Video Abstract
Early childhood development (ECD) is instrumental to shaping educational, emotional, and economic trajectories; alleviating poverty; and achieving gender equality. Pediatricians are experts in children's health and trusted sources of guidance for families and clinicians and thus are optimal ECD champions. This case study describes collaboration by the American Academy of Pediatrics, Kenya Pediatric Association, and Pediatric Association of Tanzania to activate pediatricians as ECD champions in Kenya and Tanzania. From July 2020 through January 2021, the collaborators assessed ECD needs by interviewing 20 key informants per country from governmental ministries, nongovernmental organizations, and clinical practice and assessing datasets and policy documents. In 2021, the societies recruited 15 pediatricians per country as champions; surveyed their knowledge, attitudes, and practices; and trained them on 4 core competencies: understanding early brain development science; developmental and behavioral screening, surveillance, and diagnosis; integration of ECD promotion into clinical practice; and advocacy skills for ECD and nurturing care. In 2021, each society established advocacy-in-action projects to advance ECD. In Kenya, the cohort surveyed clinicians on barriers to ECD, implemented a 2-day in-person training for 90 providers, and developed a 5-week Fundamentals of ECD course, taken by 113 pediatricians from 7 African countries. In Tanzania, champions conducted ECD training workshops for 78 health managers and 189 health care providers in 9 facilities in 7 regions and established 9 ECD corners with toys and information in health care facilities. These results highlight considerations for supporting ECD, including building on existing strengths, infrastructure, and networks; strengthening ECD knowledge among pediatricians; and advocacy skill-building.
Early childhood development (ECD) is critical for supporting educational, emotional, and economic outcomes and instrumental to shaping life-course trajectories. Investing in ECD can have a multiplier effect in achieving the 2030 Sustainable Development Goals, from alleviating poverty to achieving gender equality.1 Yet almost 250 million children younger than age 5 years worldwide are at risk for not reaching their full developmental potential.1
Global efforts to advance ECD have focused on critical influences known to promote and protect ECD, which are represented in “Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential” (NCF).2 Developed by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the World Bank and informed by multidisciplinary research, the NCF guidelines highlight essential influences, including good health, adequate nutrition, safety and security, responsive caregiving, and opportunities for early learning (Fig 1). To achieve progress toward improving ECD, multisectoral approaches and collaboration are essential.
Role of child health providers in supporting nurturing care for ECD (adapted from Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential). ECD, early childhood development.
Role of child health providers in supporting nurturing care for ECD (adapted from Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential). ECD, early childhood development.
Pediatricians are frequently viewed as experts in Children’s health and wellbeing, trusted sources of guidance for families, and mentors for other child health providers. As such, pediatricians have the potential to significantly advance an ECD agenda. As clinicians and child health advocates, pediatricians are uniquely positioned to address the critical influences of ECD outcomes. As low- and middle-income countries strengthen plans for implementing guidance from the NCF and develop national strategies for optimizing ECD, opportunities arise for collaboration to strengthen and leverage pediatricians’ roles in ECD advocacy and care.
Motivated by this growing global focus on the critical role of ECD in building and sustaining healthy communities, we describe a collaboration with the American Academy of Pediatrics (AAP), the Pediatric Association of Tanzania (PAT), and the Kenya Pediatric Association (KPA) focused on supporting pediatricians and pediatric societies in advocacy for building sustainable capacity for promotion of optimal ECD. This collaboration grew from a prior partnership between AAP and these pediatric societies focused on immunization advocacy. The 650 pediatricians in Kenya and 300 in Tanzania engage in diverse activities, including public and private health care delivery, medical education, mentorship of other health care providers, and service as child health experts within civil society and government. We aimed to leverage these diverse roles to activate pediatricians in ECD advocacy.
In both Kenya and Tanzania, children face significant challenges to optimal health and development. Although both countries have experienced recent gains in child survival (under-5 mortality rates of 41 per 1000 live births in Kenya and 43 per 1000 live births in Tanzania),3,4 proxy measures for children at risk for not reaching their developmental potential remain elevated including high rates of stunting (17.6% in Kenya and 30% in Tanzania) and extreme poverty (27% in Kenya and 49% in Tanzania).3–6 Although direct measures of child developmental are limited, both countries recently conducted Demographic Health Surveys including the Early Childhood Development Index 2030, a global population level indicator of child development which reflects the proportion of children aged 24 to 56 months achieving key developmental milestones.7 The proportion of children meeting this minimum standard for on track development was 78% in Kenya and 47% in Tanzania, reflecting much opportunity to improve ECD.3,4
The overarching goal of the collaboration between the AAP, KPA, and PAT was to strengthen the pediatric societies and pediatricians in Tanzania and Kenya to strategically support cross-sector engagement and national planning for ECD policies and guidelines. The objectives were to (1) recruit a cohort of pediatric ECD champions, (2) develop the champions’ capacity to advocate for ECD programs and policies, (3) support implementation of ECD advocacy-in-action plans, and 4) create a sustainability plan for continued ECD efforts at the pediatric society level.
Methods and Process
We used a multiphased approach (Fig 2) from January 2020 through April 2022. Phase 1 included 3 main activities focused on building a cohort of trained pediatricians in ECD and laid the foundations toward implementing advocacy initiatives in phases 2 and 3.
Overview of multiphased approach for supporting ECD initiatives in pediatric societies. ECD, early childhood development.
Overview of multiphased approach for supporting ECD initiatives in pediatric societies. ECD, early childhood development.
Phase 1: Assess, Prepare, Train
Assess
To understand the ECD landscape and define advocacy priorities in Kenya and Tanzania, AAP staff and technical advisors collaborated with each society’s leadership to conduct a comprehensive needs assessment. All meetings were conducted virtually because of the COVID-19 pandemic. We began with a focus on pediatricians and pediatric societies’ current ECD capacity and priorities. Following this, in-depth interviews were conducted with key external stakeholders, including individuals across regional WHO offices, government ministries of health and education, technical working groups, nongovernmental organizations, and clinical child development specialists. Across both countries, 20 structured interviews with key informants were conducted remotely from July 2020 through January 2021. ECD regional and national policy documents were reviewed, including datasets on ECD indicators. Primary themes were compiled from written summaries, interview recordings, and policy reviews by AAP ECD technical advisors. These themes were reviewed and edited by ECD project leads from both societies and served as key priorities for pediatrician advocacy within KPA and PAT (Fig 3).
Prepare
Pediatricians across Tanzania and Kenya were recruited to serve as ECD champions. Applicants were eligible to be an ECD champion if they were a current pediatric society member and board-certified pediatrician committed to full participation in project activities. Selection criteria included a history of developing cross-sector collaborations, current geographical practice location, and clinical practice type (eg, private, public). The application received 25 submissions from Kenya and 24 in Tanzania; 15 pediatricians were selected from each country.
Pediatric champions were surveyed to understand their knowledge, attitudes, and practices in supporting ECD. Based on identified gaps, 4 core competencies with corresponding learning objectives were developed: (1) understanding the science of early brain development; (2) developmental and behavioral screening, surveillance, and diagnosis; (3) integration of ECD promotion into clinical practice; and (4) advocacy for ECD and nurturing care.
Train
The survey results informed development of an interactive online course to improve champions’ foundational knowledge of ECD and address competencies 1 and 2 before an in-person advocacy and clinical skills workshop on competencies 3 and 4. The online curriculum included 6 content sessions and 1 introductory meeting (60-90 minutes each) delivered over a 4-month period. Although the societies shared competencies, each developed their own presentations, discussions, online learning platform, and ECD webpage in collaboration with the AAP.
Following remote learning, societies hosted champions for an in-person 3-day advocacy workshop. The workshop focused on integration of ECD promotion into clinical practice and advocacy for ECD and nurturing care and included lectures, discussions, and simulation activities. The workshop culminated with developing advocacy-in-action ECD proposals for phase 2.
Outcomes
Phase 2: Implement
Following the advocacy workshops, each society submitted an advocacy-in-action proposal to the AAP. Societies received US$35 000 to complete the projects within 6 months.
Kenya
In Kenya, the champions aimed to improve developmental surveillance and counseling on responsive caregiving and opportunities for early learning among health care workers providing services for children younger than age 5 years in Kisumu, Nyeri, and Kitui counties. Champions surveyed health care workers in primary to referral-level facilities in these counties to understand their current practices in delivering ECD services. Nearly 200 respondents identified barriers to conducting ECD-promoting activities, including staffing shortages, knowledge gaps, stigma against developmental delays, and lack of materials to conduct surveillance and counseling. These findings informed development of a training curriculum for a 2-day workshop that was introduced to local county health managers to facilitate county-level support. Supporting use of an existing Ministry of Health (MOH) Maternal Child Health handbook designed to provide parents and health care workers guidance for positive parenting and practices for maternal and child health was a key component of the training. The handbook incorporates developmental surveillance questions and adapted activities from Care for Child Development. Additionally, champions promoted use of MOH Registers, which are databases in local public health clinics that include developmental milestone indicators to document the scope of developmental delays. Ninety health care workers participated in the workshop.
Tanzania
In Tanzania, the champions sought to create enabling environments for ECD in selected health facilities by (1) training health managers and clinicians on ECD and (2) establishing ECD corners in health care facilities supplied with locally sourced toys and caregiver counseling materials. The champions collaborated with national stakeholders to develop a 2-day ECD training for health managers and health care providers (pediatricians, nurses, and other clinicians) that included the science of ECD, an overview of the national ECD multisectoral program, and coaching on counseling to promote child growth and development. Guidelines for maintaining, supplying, and staffing ECD corners were also developed.
From January to October 2021, ECD champions conducted ECD training workshops in 9 facilities across 7 regions. Overall, 78 health managers and 189 clinicians participated in the training. PAT reported pretest and posttest scores for 8 of 9 facilities (mean improvement in ECD knowledge, 18%). PAT champions also established 9 ECD corners in outpatient departments, inpatient wards, and well-baby clinics.
Phase 3: Sustain
After completing their advocacy-in-action project, the societies convened a regional workshop focused on sustainability of existing ECD work and opportunities for regional collaboration. Champions shared details from their respective advocacy-in-action projects and explored opportunities for sustaining and expanding ECD work with tools such as strength, weakness, opportunity, and threat analyses and trend-mapping. To institutionalize advocacy efforts at the society level, champions codeveloped a sustainability framework that provides guidance on incorporating ECD advocacy within the core functions of a pediatric society: membership services, professional practice advancement, quality-of-care standard promotion, and practice and health policy influences (Table 1).
Sustainability Framework for ECD
| Membership Services | Advancement of Professional Practice | Promote Quality and Care Standards | Influence Practice and Health Policy |
|---|---|---|---|
| Represent interests of pediatricians at local, regional, national, and international levels | Promote/protect common goals of pediatricians | Ensure highest standards of care for patients/public | Influence local and national policy to improve access to preventive services and quality of care |
| ↓ Sample activities to integrate early childhood development into core functions ↓ | |||
| □ Convene a subcommittee or working group on promoting ECD | □ Modify or create standardized monitoring tools for developmental screening and surveillance | □ Provide coaching to caregivers on how they can support child’s development in home settings | □ Work with regional or national ECD network to understand current and in-progress policies addressing ECD |
| □ Include a subpage on how organization supports ECD on association Web site | □ Develop preservice curriculum for pediatric trainees on the science of early brain development and nurturing care in practice | □ Identify gaps in existing referral services for children with suspected developmental differences | □ Lobby for pediatric society member(s) on national ECD working groups |
| □ Share information on local, regional, and global conferences on ECD | □ Identify opportunities to promote nurturing care during contact points with families and children (ie, antenatal, immunization, well-child) | □ Include ECD concepts (ie, science of brain development, nurturing care) in continuing education courses offered to members | □ Submit comments to public consultations on ECD frameworks and reports by WHO, UNICEF, etc |
| □ Include a track on ECD during annual scientific conference | □ Launch and maintain a regional learning collaborative network to allow pediatricians to share resources, experiences, and expertise | □ Sponsor ECD corners at health facilities with educational posters, books, toys, and other resources for responsive caregiving and early learning | □ Meet with Ministry officials responsible for implementing national ECD policy/programs |
| □ Provide talking points and mentorship support to members who are interested in expanding ECD programs in their institutions | □ Publish evidence-based guidance and policy statements on the role of pediatricians in supporting child development from antenatal to adolescence | □ Assess current practices for developmental screening and surveillance in health facilities where pediatric society members work | □ Support conduct of research to close data gaps |
| □ Community of practice regarding ECD and screening for developmental delays | □ Invest in creation of digital tools for monitoring child development and growth | □ Encourage use of existing tracking tools (ie, Mother/Child Handbooks) | □ Work to minimize siloes between health and education |
| □ Creation of online platform that disseminates information regarding ECD | □ Offer guidance to Early Childhood Centers and preprimary schools on ways to support ECD and identify existing developmental delays | □ Implement a social media campaign focused on promoting ECD, nurturing care, and inclusion | |
| □ Identify strategies to integrate developmental monitoring and surveillance into screening into clinical workflow | □ Educate community leaders and parenting groups on how stigma and some cultural beliefs can negatively impact a child’s development | □ Collect data and implement research on ECD and factors impacting child developmental outcomes to inform policy | |
| □ Identify opportunities to collaborate with educational sectors | □ Promote inclusion of children with developmental differences in school and community settings | ||
| □ Identify opportunities to support training in developmental and behavioral pediatric care to general pediatricians and in supporting fellowship training opportunities | |||
| Membership Services | Advancement of Professional Practice | Promote Quality and Care Standards | Influence Practice and Health Policy |
|---|---|---|---|
| Represent interests of pediatricians at local, regional, national, and international levels | Promote/protect common goals of pediatricians | Ensure highest standards of care for patients/public | Influence local and national policy to improve access to preventive services and quality of care |
| ↓ Sample activities to integrate early childhood development into core functions ↓ | |||
| □ Convene a subcommittee or working group on promoting ECD | □ Modify or create standardized monitoring tools for developmental screening and surveillance | □ Provide coaching to caregivers on how they can support child’s development in home settings | □ Work with regional or national ECD network to understand current and in-progress policies addressing ECD |
| □ Include a subpage on how organization supports ECD on association Web site | □ Develop preservice curriculum for pediatric trainees on the science of early brain development and nurturing care in practice | □ Identify gaps in existing referral services for children with suspected developmental differences | □ Lobby for pediatric society member(s) on national ECD working groups |
| □ Share information on local, regional, and global conferences on ECD | □ Identify opportunities to promote nurturing care during contact points with families and children (ie, antenatal, immunization, well-child) | □ Include ECD concepts (ie, science of brain development, nurturing care) in continuing education courses offered to members | □ Submit comments to public consultations on ECD frameworks and reports by WHO, UNICEF, etc |
| □ Include a track on ECD during annual scientific conference | □ Launch and maintain a regional learning collaborative network to allow pediatricians to share resources, experiences, and expertise | □ Sponsor ECD corners at health facilities with educational posters, books, toys, and other resources for responsive caregiving and early learning | □ Meet with Ministry officials responsible for implementing national ECD policy/programs |
| □ Provide talking points and mentorship support to members who are interested in expanding ECD programs in their institutions | □ Publish evidence-based guidance and policy statements on the role of pediatricians in supporting child development from antenatal to adolescence | □ Assess current practices for developmental screening and surveillance in health facilities where pediatric society members work | □ Support conduct of research to close data gaps |
| □ Community of practice regarding ECD and screening for developmental delays | □ Invest in creation of digital tools for monitoring child development and growth | □ Encourage use of existing tracking tools (ie, Mother/Child Handbooks) | □ Work to minimize siloes between health and education |
| □ Creation of online platform that disseminates information regarding ECD | □ Offer guidance to Early Childhood Centers and preprimary schools on ways to support ECD and identify existing developmental delays | □ Implement a social media campaign focused on promoting ECD, nurturing care, and inclusion | |
| □ Identify strategies to integrate developmental monitoring and surveillance into screening into clinical workflow | □ Educate community leaders and parenting groups on how stigma and some cultural beliefs can negatively impact a child’s development | □ Collect data and implement research on ECD and factors impacting child developmental outcomes to inform policy | |
| □ Identify opportunities to collaborate with educational sectors | □ Promote inclusion of children with developmental differences in school and community settings | ||
| □ Identify opportunities to support training in developmental and behavioral pediatric care to general pediatricians and in supporting fellowship training opportunities | |||
ECD, early childhood development; UNICEF, United Nations Children’s Fund; WHO, World Health Organization.
Applying the framework, each society developed a sustainability plan to continue their advocacy efforts. The Kenyan team focused on expanding ECD training opportunities by developing and delivering a regional virtual ECD course for pediatricians. Information regarding the course was disseminated through various social platforms and invitations to East African regional pediatric associations. The course was offered from January 24 to February 27, 2022, and completed by 113 pediatricians across 7 African countries. There were 5 modules covering neurobiology, developmental milestones, developmental screening, atypical development, and the ecology of childhood. Each module ran for 1 week with pretest and posttest assessments.
In Tanzania, the champions focused on strengthening sustainability of the existing ECD corners. Toward this goal, they established an ECD committee and supervisory and mentorship structure for the original nine ECD corners. The program was also expanded to include 10 additional facilities.
Lessons Learned
Pediatricians worldwide are well-positioned to strengthen all components of the Nurturing Care Framework (health, nutrition, safety and security, responsive caregiving, and early learning) through direct clinical care delivery and as respected child health experts and advocates, although the best mechanisms for leveraging these roles to build ECD capacity are undetermined. We outlined our process for leveraging pediatric societies to support ECD in institutions and communities. Our results highlight considerations to aid pediatric societies and pediatricians in supporting ECD: (1) building on existing strengths, infrastructure, and networks within pediatric societies and among pediatricians; (2) establishing multisectoral collaboration; (3) strengthening pediatricians’ ECD knowledge; (4) advocacy skill-building; (5) establishing pediatric societies’ sustainability mechanisms; and (6) leveraging remote training and collaboration strategies.
Leveraging the Position of Pediatric Societies and Pediatricians
Pediatricians in Kenya and Tanzania embrace a diversity of roles that uniquely position them to promote nurturing care for ECD by reaching children, caregivers, clinicians, educators, and organizational leaders across systems. Most pediatricians are members of their national pediatric societies that have engaged in prior successful national advocacy activities. Although neither society had an ECD committee, leveraging existing organizational infrastructure (eg, physical structure, staff, advocacy initiative history) in our project made conducting ECD work feasible.
Engaging existing pediatric leadership in advocating for ECD promotion and supporting children with developmental delays and disabilities are important next steps. Leveraging each society’s educational platform may be important to increase ECD knowledge among members who can then disseminate this information to communities and networks.
Multisectoral Collaboration
As highlighted by socioecological theory8 and supported by a wealth of multidisciplinary research, child development is influenced by relationships and interactions between a child’s immediate context (family, friends, and early childhood programs) and larger environmental systems (economic, political, legal, value-based, and culture).9,10 To improve ECD, interventions must extend beyond individual-level factors and immediate health care settings. Multisectoral collaboration was essential throughout each project phase. Needs assessment meetings with key stakeholders across sectors were instrumental in understanding the ECD national landscape and setting the pediatric societies' training and implementation priorities. The contribution of varying viewpoints during the advocacy workshop laid the foundation for the advocacy-in-action project implementation in phase 2. For instance, during KPA’s workshop, invited speakers from MOH, Ministry of Education, WHO, and Africa Early Childhood Network highlighted the need to build capacity among health care workers surrounding the NCF, while also collecting data to inform future national efforts. In Tanzania, a national multisectoral ECD program was under development as this project was initiated, and newly trained ECD champions from PAT were able to join its corresponding technical working group, strengthening cross-sectoral relationships and planning. As the ECD program was launched in December 2021, PAT ECD champions aligned their advocacy strategy with strategic goals outlined in the plan. ECD leaders from the MOH, UNICEF, Tanzania Early Childhood Development Network, and other nongovernmental organizations joined the PAT advocacy workshop; some partners collaborated during the implementation phase. Future work will continue to foster multidisciplinary relationships by encouraging mutual learning/sharing opportunities to improve ECD regionally.
Strategies to Support ECD Knowledge Among Pediatricians
Medical training on ECD is currently nonstandardized and variable in Tanzania and Kenya. Although pediatricians recognize a need to become more knowledgeable about child development, training opportunities are limited. Pediatric societies can play an important role in disseminating information on ECD promotion and dispelling myths about developmental delays and disabilities. Using existing educational platforms may be 1 strategy to increase knowledge among society members.
Clinical practice of delivery of anticipatory ECD guidance and developmental screening can vary within and across private and public sectors, which may exacerbate existing income-level developmental disparities, highlighting a need to support the implementation of standardized ECD anticipatory guidance content within well-child visits. The use of culturally relevant standardized checklists for pediatricians, general physicians, and mid level clinicians to conduct developmental screening are important next steps to support healthcare providers’ training.
Skills-Building in Advocacy
Although many primary health services in low- and middle-income countries are delivered by general clinicians, pediatricians are trusted child health experts with the potential to be powerful voices for the health of children. To fulfill this potential, pediatricians and pediatric societies require additional support in identifying opportunities and building advocacy skills. A prior advocacy collaboration between AAP and several pediatric societies focused on improving routine immunization demonstrated this approach’s power.11
This ECD program was grounded in similar methodology, with a strong focus on building pediatricians’ and pediatric societies’ advocacy capacity. The workshops supported participants in developing core advocacy skills while designing programs for broader impact. The agendas included key multisectoral stakeholders assuring a broader vision focused on how to influence institution-level, community-level, and policy-level changes. Participants had the opportunity to develop key advocacy messages and practice communication strategies. Pediatric societies also gained organizational capacity for advocacy as they developed online resources to disseminate ECD information and training. Grounding pediatricians' and pediatric societies’ support for nurturing care for ECD in advocacy strengthens the work’s scope and impact.
Sustainability Mechanism
With many competing priorities for child health, maintaining motivation and establishing a framework for sustaining support for ECD activities is crucial. Messaging during training and workshops aimed to emphasize the long-term impact of healthy development as a critical building block for educational achievement, economic productivity, lifelong health, strong communities, and successful parenting of the next generation. The program described here also included specific goals and funding for sustainability activities. A post implementation sustainability workshop allowed champions to share lessons learned to expand their work and strengthen regional collaborations. Participants reviewed project outcomes, shared best practices, discussed challenges and solutions for sustainability, and identified new priorities during the workshop.
To institutionalize advocacy efforts at the society level, champions codeveloped an ECD sustainability framework providing guidance on incorporating ECD advocacy within the core functions of a pediatric society. A regional learning collaborative, which started in late 2022 and will extend until 2024 aims to maintain and accelerate the champions’ momentum. The collaborative serves as an opportunity to increase ECD knowledge among each society’s members through educational webinars, information-sharing, and implementation of a regional advocacy project. The latter will focus on strategies to expand ECD training to pediatricians and other health care workers including developing preservice and in-service curriculum with a train-the-trainer approach.
Leveraging Strategies for Remote International Collaborations
In the initial planning for this project, the needs assessment and advocacy workshop were intended to be in person, with participation from AAP staff and technical advisors. Because of the COVID-19 pandemic, the needs assessment was completed remotely with key stakeholders, pediatric society leadership, and AAP staff and technical advisors. Although we were initially concerned about limitations of scope and quality, we noted several benefits to the remote format. Instead of a 1-week interview period with a convenience sample of available key informants, we used an extended timeframe. Although the pivot to a remote approach did limit our ability to observe (eg, community health workers, early childhood education settings), the extended timeframe allowed us to build on contacts identified early in the process and expand key informant networks, ultimately including a much broader cadre. AAP staff and technical advisors could not physically attend the respective advocacy workshops; however, open communication and collaboration on the agenda allowed AAP to be present nonetheless.
Conclusions
This case study highlights the importance of engaging pediatricians and pediatric societies in the promotion of nurturing care for ECD. Pediatricians are trusted community members and can be strong advocates for ECD in clinical and community settings. Our work provides 1 model for how pediatric societies can successfully engage in efforts to promote clinical ECD education, advocacy, skill-building, and partnerships with stakeholders across sectors.
Dr Shah conceptualized and designed the study, collected data, analyzed and interpreted data, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Wamithi, Gachie Lopokoiyit, and Masenge conceptualized and designed the study, collected data, analyzed and interpreted data, reviewed the initial manuscript for critical informational content, and critically reviewed and revised the manuscript; Ms Carter, Ms Patel, and Ms Smith conceptualized and designed the study, analyzed, and interpreted data, and critically reviewed and revised the manuscript; Dr Wilson conceptualized and designed the study, analyzed, and interpreted data, drafted the initial manuscript, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: This project was funded by a grant to the American Academy of Pediatrics from the Conrad N. Hilton Foundation. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
- AAP
American Academy of Pediatrics
- ECD
early childhood development
- KPA
Kenya Paediatric Association
- MOH
Ministry of Health
- NCF
Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential
- PAT
Pediatric Association of Tanzania
- UNICEF
United Nations Children’s Fund
- WHO
World Health Organization
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