CORE Group Global Health Practitioner Conference 2019

1. Multi-sectorial Partnerships and Innovation for
Early Childhood Development
Cristina Bisson, Director for Health
Systems Strengthening, RTI Global Health
Division
Dr. Maureen Black, Distinguished Fellow at
RTI International
Dr. Joy Noel Baumgartner, Duke University
Evidence Lab
Mohammed Ali, Nutrition Specialist with
Catholic Relief Services (CRS)
Dr. Lutter, Senior Nutrition Researcher at
RTI International
Dr. Erin Milner, USAID Nutrition Advisor

2. RTI International is a registered trademark and a trade name of Research Triangle Institute.
Multi-sectorial Partnerships
and Innovation for Early
Childhood Development
Maureen Black, Ph.D.
RTI International
maureenblack@rti.org

3. Objectives
• Nurturing Care Framework
• Early childhood development
• Metrics
• Measures

4. Why does early childhood matter?
 Birth to 3:
• Timing
• Brain highly sensitive to positive and negative
environmental inputs
1000
days

5. Why does early childhood matter?
 Birth to 3:
• Policies/programs are most impactful… but least
developed & implemented
Rate of
return on
investment
in human
capital

6. Life Course Perspective to Human Capital
Development
Birth
Early
Childhood
Childhood
Adolescence
Conception
Health, nutrition, responsive caregiving, learning opportunities,
and security & safety throughout life
Adulthood
Black et al., Lancet, 2017

7. Life Course Perspective to Human Capital
Development
Birth
Early
Childhood
Childhood
Adolescence
Conception
Health, nutrition, responsive caregiving, learning
opportunities, and security & safety throughout
life
Adulthood
Chronic health problems
Limited economic potential

8. Timing
Context
Recovery
Life-course interventionsInterventions During the Life-course

9. Nurturing Care
• Nurturing care promotes
early child development
• Nutrition
• Health
• Responsive caregiving
• Security and safety
• Early learning
• 5 components: All necessary
• No single component is sufficient
• One component out of alignment,
threatens entire system
• Applies to all children (disabilities, refugees, etc.)

10. Parent Child Interactions
PUBLIC POLICIES
CHILD
FAMILY
Parental Leave, Child Protection, etc.
COMMUNITY
Bio-Ecological Model
Bronfenbrenner & Morris, 2006

11. What the child’s brain
expects and needs
Enabling environments
for nurturing care
Nurturing Care for Early Childhood Development, WHO

12. Measurement
 Describe a global metric of early childhood
development:
• D-Score (Development Score)
• DAZ (age-adjusted Z-score )
 Describe a global measure of childhood
development for children 0-3:
• Global Scale of Early Development (GSED)

13. Metric of Early Childhood Development
 Underlying latent construct, invariant across countries
 Predictable sequence representing domains of motor,
language, cognition, personal-social development
 Interval scale (e.g., centimeters: metric for height)
 Interpretable
 Development Score (D-score)
 DAZ (age-adjusted z-score): allows
comparability across ages
Shonkoff & Phillips, 2000; Sameroff, 2009; Ertem, 201

14. Example of a D-score reference chart
Age in months
D-score unit
Source: S. Van Buuren (2014) Growth charts of human Development. Statistical Methods in Medical
Research

15. Validation
 D-score for age (DAZ)
 Concurrent validity correlation of DAZ with age
standardized score from original instruments
 Discriminant validity comparing DAZ by birth weight,
stunting and maternal education
 Predictive validity correlation of DAZ at and original
instrument with school age outcomes
Weber et al., under review

16. Summary
 D-score estimated with fewer items than used in
the original assessment.
 Interval-scale property of the D-score
comparisons across ages, as with trajectories of
height and weight.
 Estimate D-scores from pre-existing studies
or use Global Scale of Early Development
(GSED)

17. Global Scale of Early Development (GSED)
Generates D-Score
 Population (short, caregiver-report)
• Guide country-level planning & investment
• Monitor country-level progress
 Programmatic (long, direct & caregiver)
• Plan community programming
• Monitor & evaluate community programming
 Individual
• Identify individual child needs & plan intervention
• Evaluate individual child progress
WHO, BMGF

18. Individual
Program
Population
Global Scale of
Early
Development
(GSED, D-score)
WHO, BMGF
Individual
Measures of
Child
Development
Early Child Development Measurement

19. Intensive
Individual
Community
(Programs)
Universal
(Policies)
• Children with special
needs
• At risk community
(high rate of
poverty)
• Population
Equity
Early Child Development Interventions
Nurturing Care components
incorporated into each level

20. Thank you!!

21. Multisectoral Partnerships & Innovations for
Early Childhood Development (ECD)
JOY NOEL BAUMGARTNER, PHD
DIRECTOR, EVIDENCE LAB
7 MAY 2019

22. Early Childhood Development
250 million children
(43%) younger than 5
years in LMICs at risk
of not achieving their
developmental
potential
Black et al., 2016
Lo et al., 2017

23. Failure to meet potential
• Indicators of poor early development (stunting
and poverty) are good predictors of poor school
achievement and cognition
Hypothesized relations between poverty, stunting, child
development, and school achievement
Grantham-McGregor et al., 2007

24. Nurturing Care to close ECD gap
• Defining nurturing care: a stable environment that is
sensitive to children’s health and nutritional needs, with
protection from threats, opportunities for early learning,
and interactions that are responsive, emotionally
supportive, and developmentally stimulating
• Nurturing care includes:
– Behaviors, attitudes, and knowledge regarding caregiving
(e.g., health, hygiene care, and feeding care)
– Stimulation (e.g., talking, singing, and playing)
– Responsiveness (e.g., early bonding, secure attachment,
trust, and sensitive communication)
– Safety (e.g., routines and protection from harm)
Britto et al., 2017

25. Burden of maternal mental health
• Common perinatal mental disorders (CPMDs), which includes
depression, anxiety and somatic disorders, are a major cause of
disability during and after pregnancy
• Burden of perinatal depression (pregnancy period + 12 months
postpartum) in LMICs estimated from 18% to 25%
• Burden of CPMDs can be reduced through mental health interventions
delivered by supervised non-specialists
• Addressing maternal mental health benefits women, children and their
families
Key References:
Fisher et al., Bull World Health Organ 2012;90:139G–49G; Rahman et al., Bull World Health Organ 2013;91:593–601I ; Chisholm et al, BJP; 2004, 184(5):393-
403; Araya et al., Am J Psychiatry 2006; 163:1379–1387.;Siskind et al., J Mental Health Policy Econ; 2008;11(3):127-33.

26. Impact of perinatal depression
Impact on Mother
• Disability, poor quality of life
• Poor social functioning
• Decreased productivity
• Negative cognitions
• Suicidal ideation
Impact on Child
• Undernutrition, stunting, diarrhea
• Problems in breastfeeding
• Low academic achievement
• Socio-emotional and cognitive delays
• Childhood depression
• Behavior problems
Wachs, et al. (2009). Maternal Depression: A global threat to children’s health, development,
and behavior and to human rights. Child Development Perspectives 3(1):51-59.
Fisher, et al. (2012). Prevalence and determinants of common perinatal mental disorders in
women in LMICs: a systematic review. Bull World Health Org 90:139-149G.
Rahman, et al. (2013). Grand Challenges: Integrating Maternal Mental Health into Maternal
and Child Health Programmes. PLoS Med 10(5).

28. Partnering to evaluate ECD interventions
implemented by Catholic Relief Services
Photo credit: CRS

29. Need for more evidence-based
ECD programming
• Evidence Lab at Duke partners with CRS-Cameroon,
CRS-Ghana and CRS-Kenya to evaluate ECD
programs focused primarily on ages 0-2
• Primary outcomes include child development and
maternal mental health
• ECD behavior assessments inclusive of early
stimulation, positive parenting and nutrition
• Opportunity to help drive evidence-based ECD
programming

30. Recommendations for
Care for Childhood Development
WHO. Care for Child Development: Participant Manual. 2012.

31. Recommendations for
Care for Childhood Development
WHO. Care for Child Development: Participant Manual. 2012.

32. Counseling for the Family
WHO. Counsel the Family on Care for Child Development Counselling Cards. 2012.

33. • Intervention: Home visiting component
of ECD intervention that utilizes
culturally adapted UNICEF & WHO ECD
materials
• Focus on Positive Parenting & Early
Stimulation
• Cohort of 228 HIV+ mother-baby dyads
followed for 21 months Yaoundé
• Cluster RCT design
• Data collection ongoing
Evaluation of an Early Childhood Development
Intervention for HIV-exposed Children in Cameroon

34. Intervention is the Integrated Mothers and Babies
Course (iMBC) which addresses maternal mental
health with integrated ECD messages
Cluster RCT (32 communities
in rural northern Ghana)
Cohort of 378 mother-baby
dyads (enrolled during
pregnancy) followed for 21 months
(data collection ongoing)
Evaluation of integrated maternal mental health &
early childhood development intervention in Ghana

35. Intervention is the Integrated Mothers and Babies Course
(iMBC) which addresses maternal mental health with integrated
ECD messages
Longitudinal cohort study
with comparison group of
428 mother/baby dyads
to be followed for 24 months
(data collection ongoing)
Evaluation of integrated maternal mental health &
early childhood development intervention in Kenya

36. Partnering for ECD program evaluations
• Duke-CRS collaborations will result in 3 impact
evaluations of specific ECD programs
• But, we are also trying to better understand early
stimulation behaviors among rural and/or high-risk
populations in low-resource settings—significant gap in
the literature
• Implementation Research is key—researchers need deep
understanding of program content, delivery mechanisms,
and contextual challenges so we can
– 1) explain findings, and
– 2) share lessons learned with stakeholders

37. Multi-sectorial Partnerships and Innovation
for Early Childhood Development
2019 Core Group, Global Health Practitioner
Conference, Bethesda, USA
May 7, 2019
Mohammed Ali, MPH, PhD
Health Technical Lead, CRS Ghana
mohammed.ali@crs.org

38. Outline of Presentation
Ghana’s ECD Profile
Partnership and ECD: Why & How?
CRS Partnership model in support of ECD
Partnership model and its influence on
Key ECD outcomes
Challenges & Next steps
38

39. Ghana’s ECD Profile- highlights of basic indicators
39
Though
underestimated,
more than 25%
of Ghanaian
children U5 risk
not achieving
their full
development
potentials
87% 4 plus ANC visits
56% PW with HIV access
treatment
81% Early PNC
2
21% Children have support for
learning
6% of children have play items at
home
68% attendance in early
childhood educ
14% access to basic sanitation
71% of Births are registered
56% Early Initiation of BF
52% Exclusive BF
GDHS, 2014

40. Partnershipfor EarlyChildhood Development
40
CRS define Partnership as A relationship based on mutual
commitment, complementary purpose and values that results
in positive change and increased social justice.
Why CRS Invest in Partnerships:
Transformational Change
Local Leadership
Successful outcomes

41. Why Partnershipfor ECD Matters
41
 Multi-dimensional nature
Pool expertise and
resources
 Add diversity
 Facilitate cost
effectiveness
 Share evidence and best
practices
 Sustainability

42. Integrated ECD
programming in Ghana – the PartnershipModel
42
• Participation
and support
• Lead
research
institutio
n
• Field level
implementatio
n
• Technical lead
& Assistance
Catholic
Relief
Services
Government-
Schools &
Health
facilities
Communit
y and
other
actors
University
for
Developmen
t Studies

43. 43
• Government,
communities
and actors
• Joint:
• Planning
• Assessment
• Design
COLLABORATIVE
• Technical
Assistance
• Resource
mobilization
• Public spaces-
church/mosqu
es, schools and
health facilities
SUPPORTIVE • Implementation
• MEAL -
documentation
• Shadowing
• Mentoring
ACCOMPANIMENT
The PartnershipModel for ECD
programming– CRS Ghana’s approach

44. Developing Meaningful Partnerships for ECD
programming: the process
.
5. JOINT MEAL
Process and final
evaluations
1.PREPARE
Identify partner
assets & capabilities
Clarify roles
&responsibilities
2. JOINT
PLANNING,
ASSESSMENT &
DESIGN
All to be involved right
from inception stage
3. BUILD CAPACITY
& PROVIDE TOOLS
-Close gaps and
empower
participation
4. JOINT
IMPLEMENTATION
Facilitate availability and
commitment of all
INFLUENCE AND
OPPORTUNITY
TO SCALE-UP
5. SHARING OF
LESSONS
LEARNED/BEST
PRACTICES

45. Checklist in Assessing MeaningfulPartnership
for ECD
45
 Connect partners based on purpose
with the right stakeholders'
 Clarify purpose of the partnership
 Congruency of objectives,
strategies, values
 Creation of value
 Communication among partners
 Continued learning
 Commitment to build trust in the
partnership

46. Implementation of PartnershipsModel for ECD
–keyoutcomesfromanintegratedhealthandWASHproject inruralGhanafrom
May2014–June2017
46
• 4 Plus antenatal care visits (52% to
86%)
• Skilled assisted deliveries (36% to 78%)
• Early Postnatal care (58% to 92%)
• * For all, p < 0.001
HEALTH
• Early initiation of breastfeeding↑(38%
to 82%)*
• Exclusive breastfeeding ↑(47% to
74%)
• Stunting- 2SD-↓(29% to 22%)*
• Underweight –2SD↓ (43% to 11%)*
• * p<0.001 & **P = 0.002
NUTRITION

47. Implementation of PartnershipsModel for ECD
–keyoutcomesfromanintegratedhealthandWASHproject inruralGhana
fromMay2014–June2017
47
• Birth registration (12% to 86%)
• Access to improved drinking water (30% to
70%)
• Access to improved sanitation (5 % to 68%)
• *p < 0.005
SAFETY
AND
SECURITY
• Attendance in early childhood
education (2% to 16%)
• Children have play materials (0%
to 100%)**
• ** Provided in selected schools
EARLY
LEARNING
RESPONSIVE
CAREGIVING
• Parental mental health ????
• Parental knowledge of child
stimulation??
• Parental support groups for ECD ????

48. Challenges encountered
48
 No national policy/strategy
framework on ECD
 Poor coordination of efforts in
support of ECD
 Vague or no idea of ECD and its
importance among strategic
actors
 Staff attrition
 Absence of data on key
elements of ECD

49. Next steps
49
Foster new partnerships to implement and
evaluate an integrated mothers and babies
course(IMBC) with ECD
– the bases for an ongoing collaboration
between CRS and; Duke University, Ghana
Health Services with other actors

50. 50

51. www.rti.orgRTI International is a registered trademark and a trade name of Research Triangle Institute.
Child nutrition and feeding and
early childhood development: a two
way street
Dr Chessa Lutter
Senior Nutrition Researcher
Division of Food Security and Agriculture
Photo credit: PAHO/WHO

52. Periods of greatest risk for undernutrition coincide
with most sensitive periods for brain development
Source: Victora et al., Timing of growth faltering: revisiting
implications for interventions. Pediatrics 2010.
Fifth year

53. Conceptual framework for nutrition & ECD
.
Socio-
cultural
Poverty
Home/
Caregiver
Interactions
Nutrition
Brain
Development/
Functioning
Motor
Social
Emotional
Growth
Cognitive
Language
Early learning opportunities
Responsive caregiving
Include indirect effects:
1) Impact of nutrition intervention may vary by quality of home & caregiver interactions
2) Impact of early child development intervention may vary by nutritional status
Slide courtesy of Dr Maureen Black

54. Guiding Principal #3. Responsive feeding
Practice responsive feeding, applying the
principles of psycho-social care:
1. Feed infants directly and assist older
children when the feed themselves,
being sensitive to their hunger and
satiety cues
2. Feed slowly and patiently, and
encourage children to eat, but do not
force them
3. If children refuse many foods,
experiment with different food
combinations, tastes, textures and
methods of encouragement
4. Minimize distractions during meals if the
child loses interests easily
5. Remember that feeding times are
periods of learning and love – talk to
them during feeding, with eye to eye
contact
PAHO/WHO, 2003

55. Responsive and non-responsive feeding
Photo credits: Pan American Health Organization/WHO

56. Breastfeeding and cognitive development
Horta et al., Acta Paediatrica, 2015 Concurso de fotografía de la Iniciativa
Maternidad Segura, PAHO/WHO 2011

57. Egg nutrition and brain development
Iannotti et al. Nutrition Reviews 2014

58. Role of nutrition and mental stimulation in ECD
• Systematic review and
meta analysis of 21
interventions aimed at
enhancing stimulation
and 18 interventions that
provided better nutrition
• Nutrition interventions
had a small effect size
(0.09) on mental
development
• Psychosocial
interventions had a
medium effect size on
language development
(0.47) and cognitive
development (0.42)

59. Evidence for combining nutrition and ECD interventions
• Penny et al., Effectiveness of an educational intervention delivered
through the health services to improve nutrition in young children: a
cluster-randomized controlled trial. Lancet 2005
• Vazir et al., Cluster-randomized trail on complementary and
responsive feeding education to caregivers found improved dietary
intake, growth, and development among rural Indian toddler. MCN
2012
• Yousafzai et al., Effect of integrated responsive stimulation and
nutrition interventions in Lady Health Worker programme in Pakistan
on child development, growth, and health outcomes: a cluster-
randomized factorial effectiveness trail. Lancet 2014 and Global
Lancet Health 2016
• National programs: Chile Crece Contigo

60. Key messages
• Good nutrition is not only a function of what children are
fed, but also how they are fed
• Early childhood nutrition and feeding practices are key
components of ECD
• Responsive feeding and responsive parenting go hand in
hand
• Evidence starting to emerge on the joint effects of
interventions to improve nutrition and ECD on nutrition
and developmental outcomes

61. More Information
Thank you
Chessa Lutter, PhD
Senior Researcher, Nutrition
Food Security and Agriculture, International Development Group
clutter@rti.org

62. USAID’s
ECD
Endeavors
Erin Milner, Ph.D.
Nutrition Advisor
USAID Bureau for Global Health,
Office of Maternal and Child Health and Nutrition
May 7, 2019
PhotoCredit:KateConsavage,USAID

63. What is USAID doing in the ECD space?
• USAID ECD interest group
• USAID Multi-Sectoral Nutrition Strategy
• U.S. Government Strategic Framework:
Advancing Protection and Care for
Children in Adversity
• Demographic and Health
Surveys (DHS)
• Collaboration with WHO
and UNICEF
1

64. ECD Integration with Health
2
Newbor
n
Health
Child
Health
Infectious
Diseases
• Reviewing evidence and drafting standards on
nurturing care for small or sick newborns
• Conducting case studies on how countries implement
nurturing care
• Providing Zika developmental support in Latin
America and the Caribbean
• Monitoring development of children and counseling
caregivers on responsive care and stimulation as part
of routine health services in Mozambique

65. Nutrition
Vulnerable
Children
Education
ECD Integration with Other Sectors
• Facilitating integrated SBC messaging
• Engaging and training community health staff
• Promoting nurturing care for the most vulnerable
newborns and young children
• Putting family care first
• Protecting children from violence
• Programming at the pre-primary level
3

66. Ghana ECD 0-3 Program
4

67. Future Directions
5
• USAID Advancing Nutrition
• Mapping and coordination
• Working with WHO to complete a guide for health care workers
to monitor children’s health and development from age 0-3 years
• ECD behaviors
PhotoCredit:DaveCooper,USAID
PhotoCredit:ErinMilner,USAID

68. Thank
you!
Erin Milner
emilner@usaid.go