E L P GUIDANCE NOTE September 2018 Early Stimulation: E L P Supporting Parents to Help Their Children Thrive This note provides guidance on interventions that work with parents to promote child development through early stimulation. It outlines key elements of design and implementation and offers examples of effective programs from around the world. Introduction Child survival has increased dramatically, largely due to improved nutrition and healthcare. But to ensure that children thrive, we also need to promote early stimulation beginning at birth, to build the foundation for lifelong success. Children’s early experiences of warm and responsive relationships with their primary caregivers are essential to their lifelong development. What is early stimulation? Early stimulation consists of doing simple, everyday activities with a child, such as talking, singing, reading, and playing. An essential aspect of early stimulation is ongoing, attentive, and responsive interaction between the caregiver and the child (see Annex 1). This mutual interaction is sometimes referred to as “serve and return,” a concept borrowed from the game of tennis. Such interaction leads to early bonding, which is associated unlocking the ‘ordinary magic’ that builds resilience and potential in young children from birth.1 This note was written by Lucy Bassett with contributions from Amanda Devercelli, Sherrilee Le Mottee, Ibrahima Pierre Louise “Serve and Return” Giroux and Ella Humphry. Interaction between a caregiver and a child is sometimes referred to as “serve and return” as in the game of tennis. The child “serves” by indicating his or her interest to the For more information or to be caregiver—perhaps making a sound, pointing, or saying a word. The adult then “returns,” added to the ELP mailing list, acknowledging the child’s interest by nodding, smiling, or speaking and continuing the please write to earlylearningpartnership@ interaction through gestures, words, or play. As this turn-taking continues, the child gets worldbank.org support and validation from the caregiver and comes to better understand the world.2 Why is early stimulation critical? During the early years, the brain matures faster than at any other time of life and it is the most malleable it will ever be (see Figure 1). Brain development is shaped in part by genetics and in part by the child’s environment. When adults respond appropriately to a baby’s gestures, babbling, or cries, neural connections are strengthened, thereby contributing to communication and social skills. Conversely, when adults do not respond to the baby’s gestures or cries, or when their responses are inappropriate or unreliable, brain development may be disrupted, impairing mental, physical, and emotional health. All children need early stimulation, which has been shown to improve children’s cognitive function, language skills, and educational outcomes. Children who participate in early stimulation programs may be more likely to perform well in school, continue beyond primary school, and have better labor market outcomes (see Annex 2). During the first few years of life, children spend most of their time with family members and friends. Parents and caregivers in all countries and from all levels of income and education can, and should, engage in effective early stimulation with their children. FIGURE 1 Brain development during the first 20 years of life Year 1 Birth ne Number of connections Number of connections n the (synapses) in t brain (synapses) in the brain birth at bir at age 6 months dep Experience-dependent synapse formation Peak Synapse levels stabilize in adulthood 0 -.5 0 1 5 10 15 20 Age (years) Sensory pathways Language Higher cognitive function Source: World Development Report 2018, adapted with permission from Parker (2015) and Thompson and Nelson (2001). 2 EARLY LEARNING PARTNERSHIP How is early stimulation integrated into projects financed by the World Bank? Below are a few examples of Bank projects that have included early stimulation: Health/nutrition • The Madagascar Emergency Support to Critical Education, Health, and Nutrition Services Project tested the inclusion of early stimulation as part of a community- based nutrition program. Social protection • The Mauritania Social Safety Net System Project included early stimulation as part of the accompanying measures for its conditional cash transfer program, targeting parents of children under-five. • The Burkina Faso Youth Employment and Skills Development Project developed and implemented mobile creches for women beneficiaries of the Cash-for-Work program, promoting early stimulation for their young children. Education • The Guyana Early Childhood Education Project included face-to-face parenting meetings at schools (e.g., PTA meetings, parent-teacher conferences), hands- on parent coaching at community health centers, and mass media to reinforce messages role parents’ critical role in child development. • The Serbia Inclusive Early Childhood Education Project includes community grants to provide early stimulation training for parents and caregivers and a communication campaign to raise awareness about the importance of early stimulation, play, and positive interactions. Skills • The Liberia Economic Empowerment of Adolescent Girls and Young Women (EPAG) Program developed two ECD training tracks (for caregiver and teacher training) and incorporated these into an established skills program. Community-driven development (CDD) • Indonesia’s National Community Empowerment Program provided block grants to communities to establish early childhood education and development services, such as health centers, playgroups, kindergartens, community centers with integrated ECD services, home visits, and advocacy activities to raise awareness about the benefits of ECD. Integrating nutrition and early stimulation interventions to promote child development: What does the evidence tell us? It often makes good sense to address poor nutrition and lack of stimulation simultaneously because the target groups are the same and the delivery logistics can be shared. This approach is increasingly common, but does it work? A systematic review of the effectiveness of integrated early stimulation and nutrition interventions – from Jamaica, Bangladesh, Colombia, and India, among other countries – found nearly all the integrated interventions to be additive, not synergistic. That is, implementing both interventions together generally had the same effect as implementing them separately. If joint implementation does not negatively affect the impact of either intervention, the decision to integrate should then come down to delivery costs and the feasibility of shared management and logistics in the given context. Delivery costs of integrated programs are more likely to be low when the main costs are tangible inputs, but when shared inputs are primarily personnel requiring training and supervision, cost savings may be less.3 Early Stimulation: Supporting Parents to Help Their Children Thrive 3 Delivery Channels Multiple delivery channels can be used to promote early stimulation. Families are often reached individually using home visits or collectively using group sessions. These approaches can be integrated into existing service delivery mechanisms, such as health and nutrition platforms and social protection programs. Integration can provide a more sustainable mechanism for reaching families and achieving economies of scale in delivery logistics than stand-alone programs. However, when considering integration, it is important to guard against overloading the workers delivering the services, as well as the caregivers, who can absorb only so many messages. There are also cost and time implications for planning, training, and supervision. For example, the caseload per worker may need to be reduced to give them sufficient time with each family. Below are brief descriptions of the most common delivery channels and examples of programs that use them. Home visits Home visitors (often community health workers) can deliver messages to parents to promote child development and demonstrate early stimulation techniques, reaching those in their homes who do not access other services. This approach allows activities to be made age-specific and to address family-specific problems. Home visitors often leave play materials in the home that can later be replaced by different playthings in subsequent visits. Such visits are usually made weekly or biweekly. Some countries where this is working: • Jamaica: Roving Caregivers Programme • Pakistan: Lady Health Worker Programme Group sessions Group sessions are trainings held for small groups of parents along with their children in convenient locations within the community. They are often combined with home visits but are less frequent. Trained community health workers, community volunteers, or paraprofessionals lead these groups, demonstrating early stimulation activities, coaching caregivers as they practice the skills, answering questions, and leading discussions with participants. Group sessions provide peer support and can reinforce positive social norms around early stimulation. Some countries where this is working: • Bangladesh: Parenting Programme (PLAN International) • Mexico: Educacion Inicial (CONAFE) Health center waiting rooms Waiting rooms in health clinics can be used to give parents information on early stimulation, model good parenting behavior, organize activities for children, have play toys and books available, and so on. Some countries where this is working: • Antigua, Jamaica, St. Lucia: Routine primary health care with parenting intervention Community health programs In low-income settings, health workers are often the first and only service providers who have contact with the parents of young children. Community health workers can deliver messages to parents to promote early stimulation at child health check- ups, growth monitoring sessions, or community events. Some countries where this is working: 4 EARLY LEARNING PARTNERSHIP • Mozambique: Community Health Workers Program • Pakistan: Lady Health Worker Programme Nutrition programs Nutrition programs may be particularly well suited to delivering early stimulation since they focus on children under-two, when rapid brain development is happening and when early stimulation is critical. Also, some nutrition interventions, such as breastfeeding and responsive feeding, promote warm and nurturing relationships between caregivers and children, which is also a key element of early stimulation. Some countries where this is working: • Bangladesh: National Nutrition Program • Madagascar: National Community Nutrition Program Cash transfer programs Cash transfer programs have expanded rapidly in all parts of the world and can be used to provide parents with information on nutrition, health, and early stimulation at cash delivery points or at regular gatherings for beneficiaries. This approach is particularly relevant for low- and middle-income countries, where existing early stimulation interventions may be limited and where targeted cash transfers provide a primary (and sometimes the only) vehicle for reaching vulnerable households. Some countries where this is working: • Bangladesh: Income Support Program for the Poorest • Colombia: Familias en Acción • Niger: Social Safety Net Program School-based groups Parent-Teacher Associations and other school-based groups can include training on early stimulation for parents of pre-primary students and their younger siblings. Some countries where this is working: • Guyana: Early Childhood Education Project • Pakistan: Third Punjab Education Sector Project Women’s participatory action and learning groups or microfinance groups Early stimulation has been integrated into women’s participatory action and learning groups. With the support of a facilitator, women identify and discuss parenting challenges, including maternal depression, nutrition, health, hygiene, and early stimulation, and identify solutions to overcome them. Some countries where this is working: • India: Women’s participatory action and learning groups Mass media New—and not-so-new—technologies offer opportunities to reach children and families at low cost and at scale. Radio broadcasts, mobile texting, and TV can all be used to reach parents with information promoting child development through early stimulation, positive discipline, and good health and nutrition practices. Technology is also available to tailor messages to children’s ages and levels of development, giving parents just-in-time guidance. Some countries where this is working: • Rwanda: First Steps Program • South Africa: #LovePlayTalk4 Early Stimulation: Supporting Parents to Help Their Children Thrive 5 Useful Information on Program Delivery from Four Countries The table below presents details on program design, costs and evaluation findings of selected interventions using different delivery channels to promote early stimulation. TABLE 2 Program examples from four countries, with design features, costs, and evaluation results JAMAICA MEXICO PAKISTAN NIGER Roving Caregivers Educación Inicial Lady Health Worker Niger Social Safety Net Program (CONAFE) Programme Project Home visits Group sessions Group sessions and home Group sessions and home visits (integrated into visits (integrated into an Modality community health program) unconditional cash transfer program) Caregivers and children Pregnant women, parents, Caregivers and children ages Parents and children ages Target group(s) ages 0–3 and children ages 0–4 0–2 0–5 Roving caregivers Volunteer community Paid community health NGO workers (community facilitators (promotoras) workers known as Lady Health meetings) and community Type of facilitator Workers (LHW) members (group sessions and home visits) Remuneration n/a US$50/month US$85/month US$20/month for facilitator Education level Recently completed n/a Minimum of 8 yrs of education n/a of facilitator secondary school 2 weeks preservice 2 weeks of training every 15 months training (3 in 2 weeks of initial training, training and 1-day year along with a supply classroom and 12 in the field), then a 2-wk refresher workshops every 2 of educational materials, 15 days refresher training/year. training after 6 and 12 mos Training provided weeks to discuss visits and sporadic coaching LHWs doing early stimulation for facilitator and prepare weekly by a full-time regional have additional wks of work plans supervisor training, on-the-job coaching, mentorship, and feedback. Songs, rhymes, and Activities and discussion Follows the Care for Child Training, demonstrations, play activities with focusing on language Development curriculum and games focusing on Content of the child; discussion and communication, health, nutrition, early the sessions of parenting practices, interactions with others, stimulation, and child toy-making fine and gross motor skills protection Frequency of 5 times/month (weekly 4–8 times/month (group 2–3 times/month (1–2 group 3 times/month (1 community contact with home visits; monthly sessions 1–2 times/week) sessions; at least 1 home visit meeting, 1 group session, beneficiaries group meeting) every 6 weeks) and 1 home visit/mo) Duration of n/a 9 months 2 years 18 months contact US$58/child US$69/child US$48/child for early US$67/household Annual cost stimulation add-on Significant, positive Positive impacts on Higher mean scores on IQ Improved early stimulation effects on child parenting practices (+0.34 (difference +0.1), executive practices (+17 pp in and hand and eye SD on an index of parent function (difference +0.3), and early stimulation index), Results performance subscales. behaviors) and child pre-academic skills (difference but no impact on child development (+0.15 SD +0.5) for children who development; small increase in communication received early stimulation. impacts on socio-emotional and gross motor skills). development. Alderman 2011; Putcha Cardenas, Evans, and Yousafzai et al. 2016; Saima et World Bank 2016a, Barry et Source and van der Gaag 2015. Holland 2017. al. 2014. al, 2017. SD = Standard Deviations; pp = percentage points. 6 EARLY LEARNING PARTNERSHIP What is the ideal workforce for early stimulation interventions? The optimal early stimulation workforce depends on both the needs of the population and the ability a program has to train and supervise its workforce to ensure high quality. • Professional service providers can bring more technical expertise than community volunteers and have less frequent turnover, but can be more expensive. • Community volunteers may bring the benefit of relating to and understanding the cultural context of fellow members in a community. However, they might not have the desired educational level to carry out the intervention optimally, and there may be higher turnover (compared to using professionals) due to the lower level of remuneration. How do we assess the quality of early stimulation interventions? Measuring structural elements, such as dosage and content, is relatively easy to do objectively using administrative logs or checklists that collect information on the activities implemented, topics covered, and number and duration of sessions or visits. But measuring the quality of interactions—the most important aspect of good early stimulation—is more challenging and is best done by observation.5 Here are some are examples of tools to assess early stimulation: • The University of the West Indies observation checklist assesses the quality of home visits. This tool enables the assessor to gather information on the relationship between the home visitor and caregiver (such as how well the home visitor listens, responds, encourages, and gives positive/ constructive feedback), the relationship between facilitator and child (such as how well the home visitor responds and encourages child), and overall visit participation and environment (such as whether the child and caregiver participate actively).6 • The Home Observation for Measurement of the Environment (HOME) Inventory, which assesses stimulation through interview and observation of the mother-child interaction with a focus on the caregiver’s responsiveness to the child. This tool also assesses the availability and use of play materials and activities that expose the child to people and places outside the home. Evidence shows strong correlations between HOME scores and children’s cognitive development. • A shortened version of the HOME, called Family Care Indicators, can be used in national surveys. This has been validated in Sub-Saharan Africa and South Asia and has been used to evaluate children’s environments in 28 low- and middle-income countries.7 Other tools are available to measure children’s cognitive, language, motor, and socio-emotional development, which can be useful to determine whether an early stimulation intervention has had the expected impacts. See Measuring Child Development and Early Learning8 and A Toolkit for Measuring Early Childhood Development in Low and Middle-Income Countries.9 Early Stimulation: Supporting Parents to Help Their Children Thrive 7 Early stimulation in conditions of fragility and conflict Caregivers’ ability to respond to their children can be affected by stressful conditions, such as depression, domestic violence, war or displacement, or extreme poverty. It can also be difficult for caregivers to read the cues of babies who are malnourished, sick, or severely neglected. In these conditions, caregivers may need support and encouragement to provide responsive early stimulation. Some early stimulation interventions in fragile and conflict affected areas have been shown to improve interaction between caregivers and children. For example, the International Child Development Programme (ICDP) approach consists of focused efforts to gradually reestablish connections between the caregiver and child, such as eye contact, touch, smiling, and gentle vocalizations. First, facilitators try this with the child and then they support caregivers and older siblings to do so. As a result, babies become progressively more responsive, which in turn motivates caregivers to interact with, touch, and talk to them more. The ICDP approach has been implemented at feeding camps in Angola, Bosnia-Herzegovina, Colombia, and Mozambique. In Bosnia-Herzegovina, children who participated in ICDP had better psychosocial functioning and mental health and mothers had better mental health. In Mozambique, caregivers who participated in ICDP had better parenting skills, higher scores of self-efficacy, and fewer mental health problems, and they used less physical punishment. Participating children had fewer behavioral issues and showed better adjustment than children who did not participate.13 10 tips for effective interventions 1. Engage all parents and caregivers. Sometimes programs focus on mothers only, but fathers and other primary caregivers who interact with young children also play a key role in their children’s development and should learn about and practice early stimulation. 2. Start even before birth. The younger the age when early-stimulation interventions are started, the greater the impact. In the Roving Caregivers’ home visiting program in St. Lucia, children who began participating at age 6–18 months experienced improved cognitive development, whereas children who began at age 18–30 months experienced no gains.10 3. Make it participatory, with opportunities to practice and share experiences. Activities with parents and caregivers should be as practical and interactive as possible. Facilitators should model interaction with the child, practice songs and games, bring materials to use for games and toys, provide supportive and timely feedback, and encourage caregivers to practice the new skills at home. Having parents share experiences with other caregivers and service providers also facilitates learning and support. 4. Emphasize language. Caregivers, even those with low levels of education, can boost children’s language acquisition by telling stories, singing songs, describing everyday routines, and naming objects that the child can see. This should start early because language development begins even before children can speak themselves. 5. Focus on play. Play is fundamental to cognitive development and fosters critical thinking, creativity, and imagination. Caregivers and children can play games, build with blocks or boxes, or engage in pretend play, such as using a spoon, pencil, or other object to “make a phone call.” 8 EARLY LEARNING PARTNERSHIP 6. Make use of local knowledge and materials. Low-cost, readily-available materials such as plastic bottles, bottle caps, string, socks, and pebbles can easily be transformed into home-made toys such as mobiles, rattles, cars, and dolls (see Annex 1). The design and use of these toys should be based on local knowledge, practices (such as stories, songs, games), and resources. 7. Arrange for frequent contact with participants. Early stimulation interventions need to be reasonably intensive to be effective. Evidence suggests that at least two visits per month are needed to benefit child development.11 There is less evidence available on the impact of less frequent interventions, and the results are mixed. Interventions must be of high quality to have impact. 8. Supervise and support the people who provide training on early stimulation. Research indicates supportive supervision is an essential element of successful early stimulation interventions. Supervision should include observation of the person delivering the training or intervention as well as timely and supportive feedback.12 Reflection sessions can provide opportunities for peer-to-peer learning and discussions of successes and challenges. 9. Use existing delivery systems, where possible. Early stimulation interventions may not be sustainable unless they use an existing system. To mitigate the risk of overloading already busy service delivery workers and compromising the quality of services, it is important to ensure sufficient resources for training, supervision, and monitoring of the early stimulation activities and possibly additional service delivery workers. 10. Start small, ensure quality, and then expand. Scaling too quickly can be counterproductive. It is important to establish an effective approach at small scale and ensure high quality before expanding to broader coverage. Quality assurance is critical throughout the scaling process to identify any problems and address them – and provide support – in real time. Early Stimulation: Supporting Parents to Help Their Children Thrive 9 ANNEX 1 Examples of early stimulation activities and associated materials AGE GROUP SAMPLE ACTIVITIES SAMPLE MATERIALS 0-6 mos • Provide ways for your child to see, hear, • Rattle (can make using an empty plastic water bottle and bottle move freely, and touch you. caps cut into pieces inside). • Dangle bright objects for your baby to • Ring on a string (can make by cutting a plastic water bottle look at, follow with her eyes, reach for, across and stringing on a thin cord). and grasp. • Look into your baby’s eyes and talk to your baby. • Copy the sounds and gestures your child makes. • Provide your baby a rattle to shake. 6-12 mos • Give your child clean household objects • Containers with lids, pots, and spoons to hold, bang, and drop. • Doll with face (can make this using a sock, needle and thread, • Call your child’s name and see if she and marker to draw the face) responds. • Tell your child the names of objects and people that you see. • Play peek-a-boo. 12-24 mos • Give your child objects to stack and • Ball things to put into and take out of • Container and clothespins containers • Objects to stack (can be water bottles cut and the tops • Provide push and pull toys. stacked) • Roll a ball back and forth. • Objects to nest (can be wat- • Let your child scribble ter bottles cut and the bottoms nested) • Ask your child simple questions (e.g. “where is the ball?” “what color is the ball?”) • Respond positively to your child’s attempts to talk. Say “that’s right, you gave me the ball.” • Tell your child a simple story every day. 2 years and up • Help your child count, name, and com- • Objects to sort pare household objects. • Puzzles • Teach your child songs and stories. • Book with pictures • Look at and talk about books and • Car and racing track pictures. • Tea set (can use cups, plates, spoons) • Make simple toys, like furniture for dolls • Lacing board (can be made using cardboard and string) or car and race track (all can be made with cardboard). • Practice lacing string through holes. Source: This table draws on Care for Child Development, Save the Children Building Brains, and REACH Up Parenting Program. 10 EARLY LEARNING PARTNERSHIP ANNEX 2: Additional early stimulation interventions JAMAICA: HOME VISITING PROGRAM14 Program design: Home visits for early stimulation and nutrition One of the best known early stimulation interventions was carried out in Kingston, Jamaica. Researchers randomly assigned 129 stunted children ages 9–24 months to one of four groups: a nutrition intervention, an early stimulation intervention, both interventions, or neither intervention over two years. The nutrition intervention consisted of weekly nutritional supplements. For the early stimulation, trained community health workers encouraged and showed mothers how to play and interact with their children. Follow-up measures were taken numerous times from baseline to adulthood. This model and curriculum is being scaled up in several other countries.15 Results • Children who received early stimulation had greater parental investment, improved cognitive skills, and lower drop-out rates than children who did not receive it. They attended 0.6 more years of school and were three times more likely to attain some college-level education. • Twenty-five years after the intervention, participants who received stimulation earned around 25 percent more than those who did not receive stimulation.16 • The nutrition intervention was found to have no impact on later life outcomes, perhaps because uptake was low and the supplement may have been shared within the family. CHINA: CARE FOR DEVELOPMENT INTERVENTION17 Program design: Counselling on early stimulation using WHO Care for Child Development 18 Trained counsellors provided two 30- to 60-minute training sessions to families with children under age two over a six-month period. The training, which was based on the WHO Care for Child Development19 guidelines, involved demonstration and practice as well as discussions of challenges and recommendations for caregivers. Mothers also received a “Mother’s Card” with age-specific messages on play and communication between caregiver and child. One hundred families were randomly allocated between intervention and control groups. Results • Among children in the intervention group, adaptive, language, and social development improved significantly. • Participating mothers demonstrated better understanding of the child development messages from the Mother’s Card and were more likely to report that the messages were feasible to implement, compared to mothers in the control group. COLOMBIA: KANGAROO MOTHER CARE20 Program design: Kangaroo Mother Care Kangaroo Mother Care (KMC) was developed as an approach to improve survival rates for premature babies. It involves 24-hour skin-to-skin contact between the caregiver and baby, with the baby nestling in an upright “kangaroo position,” exclusive breastfeeding, and early discharge from the hospital with close follow-up. A randomized controlled trial of approximately 750 low-birthweight infants compared Kangaroo Mother Care and “traditional” care at ages 3, 6, 9, and 12 months. A follow-up study 20 years later compared health status and neurological, cognitive, and social functioning with the use of neuroimaging and behavioral tests. Results • KMC had positive effects on mortality and growth in the short term. The KMC group had lower risk for death (although the difference was not significant), greater head circumference, and less severe infections Early Stimulation: Supporting Parents to Help Their Children Thrive 11 compared to the traditional group. Developmental indices were similar between the groups. • KMC has significant, long-lasting social and behavioral protective effects 20 years after the intervention. Children who had benefited from KMC had greater cerebral development, spent more time in school, were less aggressive, stressed, and hyperactive, and earned higher wages (equivalent to US$ 0.40) compared to the traditional group. SOUTH AFRICA: BOOK-SHARING TRAINING PROGRAMME21 Program design: Book sharing Book sharing between caregivers and young children, particularly when parents are trained in ways of actively engaging the child, has been shown to be an effective intervention for promoting child language development. In South Africa, a book sharing program provided training on a weekly basis for 8 weeks to small groups of caregivers of children 14-16 months of age. The trainer shared information on how to read with young children and modeled how to do this, using a Powerpoint presentation and example videos. After the presentation, each caregiver had 15 minutes to share a book with their child, during which the trainer provided support and made suggestions. Ninety-one caregivers and their children were randomized into book-sharing training and control groups. Results: • The intervention showed positive results on children’s language development. Caregivers who received the training reported a greater increase in the number of words their children understood and could vocalize, compared to the control group. • Participating children also showed improved sustained attention, which predicts future IQ and cognitive performance. ANNEX 3: Program Resources There are numerous excellent resources for early stimulation activities that can be adapted to different country contexts. Below are a few examples. REACH UP EARLY CHILDHOOD PARENTING PROGRAMME http://www.reachupandlearn.com The Reach Up Early Childhood Parenting Programme provides a structured training course for home visitors to help parents improve their child’s development. It is based on the successful Jamaica home visiting program. Users must register at http://www.reachupandlearn.com/register to access materials. Materials include: • Manuals o Adaption and Planning o Training Manual o Toy Manual o Supervisor Manual • Curriculum o Weekly visit guide ages 6-11 months o Weekly visit guide ages 12-23 months o Weekly visit guide ages 24-36 months • Videos 12 EARLY LEARNING PARTNERSHIP SAVE THE CHILDREN BUILDING BRAINS TOOLKITS This toolkit provides operational and technical guidance for implementing early stimulation programs for children 0-3. It includes: • Recommendations for conducting a situational analysis to understand the 0-3 landscape • Guiding principles for interventions • Sample radio program scripts • Sample group session content • Sample games and activities for children of different ages • Case studies WHO/UNICEF CARE FOR DEVELOPMENT https://www.unicef.org/earlychildhood/index_68195.html The Care for Child Development training package, developed by UNICEF and WHO, provides age–based recommendations for parents on how to play (supporting cognitive development) and communicate (supporting language and social development) with their children from birth through age 2, as well as how to deal with problems that caregivers may bring up. Studies in Tajikistan, Kyrgyzstan, and Kazakhstan where health staff used Care for Child Development found improvements in children's language, gross– motor, and social–emotional development.22 Materials include: • Participant manual - English - French • Counseling cards - English - French • Facilitator notes - English - French • Guide for clinical practice - English - French • Framework for M&E - English - French NURTURING CARE FRAMEWORK http://nurturing-care.org/resources/ Nurturing care is defined as “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. The Nurturing Care Framework provides a roadmap for action to implement nurturing care. It includes guiding principles, strategic actions, and ways of monitoring progress. Additional resources available include: • Media resources (media toolkit, social media tiles) • Country reports and profiles • Resources from partners RESOURCE MODULES FOR HOME VISITORS https://www.issa.nl/modules_home_visitors UNICEF and the International Step by Step Association (ISSA) have developed resource modules for home visitors, focusing on nurturing care. 18 modules are available, including such topics as The Art of Parenting – love, talk, play, read and Supervision, supporting professionals and enhancing services quality. There is also a trainer guide. Early Stimulation: Supporting Parents to Help Their Children Thrive 13 REFERENCES Alderman, H. 2011. No Small Matter: The Impact of Poverty, Shocks, and Human Capital Investments in Early Childhood Development. Human Development Perspectives. Washington DC: World Bank. Barry, O., A. Maïdoka, and P. Premand. 2017. “Promoting Positive Parenting Practices in Niger Through a Cash Transfer Programme.” Bernard van Leer Foundation. https://bernardvanleer.org/app/ uploads/2017/06/ECM17_12_Niger_Barry.pdf Cardenas, S., D. Evans, and P. Holland. 2017. Estimating the Effects of a Low-Cost Early Stimulation and Parenting Education Programme in Mexico, 3ie Impact Evaluation Report 57. New Delhi: International Initiative for Impact Evaluation (3ie). Putcha, V., and J. van der Gaag, 2015. “Investing in Early Childhood Development: What Is Being Spent, and What Does It Cost?” Washington, DC: Brookings Institution. Saima, G., A. Yousafzai, R. Armstrong, and Z. A. Bhutta. 2014. “Cost Effectiveness of Responsive Stimulation and Nutrition Interventions on Early Child Development Outcomes in Pakistan.” Annals of the New York Academy of Sciences 1308: 149–61. World Bank. 2016a. 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Retrieved from www.developingchild.harvard.edu. 3 Grantham-McGregor et al., “Effects of Integrated Child Development and Nutrition Interventions on Child Development and Nutritional Status,” Annals of the New York Academy of Sciences 1308: 11–32; H. Alderman and L. Fernald, “The Nexus between Nutrition and Early Childhood Development,” Annual Review of Nutrition 37: 7.1–7.30. 4 http://angielazaro.com/blog/?p=665. 5 F. López-Bóo, M. C. Araujo, and R. Tome, “How is Child Care Quality Measured?” (February 11, 2016) (available at SSRN: https://ssrn.com/abstract=2762057). 6 J. Leer and F. Lopez-Boo, “Assessing the Quality of Home Visit Parenting Programs in Latin America and the Caribbean.” Early Child Development and Care (March 14, 2018), DOI: 10.1080/03004430.2018.1443922. 7 F. E. Aboud, and A. K. Yousafzai, “Very Early Childhood Development,” Chapter 13 in Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third edition (Volume 2), edited by R. E. Black, R. Laxminarayan, M. Temmerman, et al. (Washington, DC: World Bank, 2016). 8 World Bank, Measuring Child Development and Early Learning (Washington, DC: Early Learning Partnership, World Bank, 2016). 9 L. Fernald, E. Prado, P. Kariger, and A. Raikes, A Toolkit for Measuring Early Childhood Development in Low and Middle-Income Countries (Washington, DC: World Bank, 2017), https://openknowledge.worldbank. org/handle/10986/29000. 10 H. Baker-Henningham and F. López Bóo, Early Childhood Stimulation Interventions in Developing Countries: A Comprehensive Literature Review, IZA Discussion Paper No. 5282 (IZA, 2010), (available at SSRN: https:// ssrn.com/abstract=1700451). 11 A study of home-visiting frequency in Jamaica found that at least biweekly visits were required to show impact on child development (C. Powell and S. Grantham-McGregor, “Home Visiting of Varying Frequency and Child Development,” Pediatrics 84:157–64). A review of nine studies found the magnitude of benefits from weekly visits to be twice that of biweekly visits (S. Walker, “Promoting Equity through Early Child Development Interventions for Children from Birth through Three Years of Age,” in No Small Matter: The Impact of Poverty, Shocks and Human Capital Investments in Early Childhood Development, edited by H. Alderman [Washington, DC: World Bank, 2011]). 12 Save the Children, Building Brains: Early Stimulation for Children from Birth to Three (2017). 13 Center on the Developing Child, Five Numbers to Remember About Early Childhood Development; L. Richter, S. Lye, and K. Proulx, “Nurturing Care for Young Children under Conditions of Fragility and Conflict.” in Towards a More Peaceful World: The Promise of Early Child Development Programmes, edited by J. F. Leckman and P. R. Britto, New Directions for Child and Adolescent Development 159 (2018), 13–26. 14 “Early Childhood Engagement for Lifelong Learning,” J-PAL Policy Bulletin (July, 2016). https://www. povertyactionlab.org/sites/default/files/publications/early-childhood-engagement-for-lifelong-learning. pdf 15 http://www.reachupandlearn.com/ 16 P. J. Gertler, R. Heckman, A. Pinto, et al., “Labor Market Returns to an Early Childhood Stimulation Intervention in Jamaica,” Science 344 (6187). 17 X. Y. Jin, F.Sun, J. Jiang, et al., “‘Care for Development’ Intervention in Rural China: A Prospective Follow- Up Study.” Journal of Developmental and Behavioral Pediatrics 28(3): 213–18. 18 http://www.who.int/maternal_child_adolescent/documents/care_child_development/en/ 19 https://www.unicef.org/earlychildhood/index_68195.html 20 N. Charpak, J. Ruiz-Peláez, Z. Figueroa, and Y. Charpak, “A Randomized, Controlled Trial of Kangaroo Mother Care: Results of Follow-Up at 1 Year of Corrected Age,” Pediatrics 108(5): 1072– 79; N. Charpak et al., “Twenty-year Follow-up of Kangaroo Mother Care Versus Traditional Care,” Pediatrics 139(1). 21 P. Cooper, L. Murray, M. Tomlinson, and Z. Vally, 2014-15, Early Literacy in South Africa: The Promise of Book-Sharing (Commonwealth Education Partnerships). 22 P. L. Engle, Care for Development in Three Central Asian Countries: Report of a Process Evaluation in Tajikistan, Kyrgyz Republic, and Kazakhstan (UNICEF, 2011), http://www.unicef.org/ceecis/Care_for_ChDev_in_3_ Central_Asian_Countries.pdf. Early Stimulation: Supporting Parents to Help Their Children Thrive 15