THE STATUS OF EARLY CHILDHOOD HEALTH AND DEVELOPMENT IN KIRIBATI RESULTS FROM A POPULATION WIDE CENSUS Sally Brinkman Alanna Sincovich Binh Thanh Vu 2017 THE STATUS OF EARLY CHILDHOOD HEALTH AND DEVELOPMENT IN KIRIBATI RESULTS FROM A POPULATION WIDE CENSUS Sally Brinkman Alanna Sincovich Binh Thanh Vu 2017 Report No: AUS0000127 © 2017 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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ACKNOWLEDGEMENTS The production of this report was funded through the Global Partnership for Education (GPE) and technical assistance provided by the World Bank. The development and adaptation of the instruments Kiribati Early Human Capability Index (KeHCI) was led by Sally Brinkman in consultation with the Ministry of Education, especially Mrs. Kaaro Neeti (Permanent Secretary, Ministry of Education); Nei Reetina Katokita (Director Policy, Planning & Development, Ministry of Education), Kaokatekai Kaino Riwata (Early Childhood Senior Education Officer, Ministry of Education), Mr Aboro Henry (Ministry of Health), Tannako Bwaraam (Ministry of Women, Youth & Social Affairs), Tiebane Uriam, Tekeua Taoaba, Tokarateata Buariki and Kirata Tiroia (Executive Members of the KECE Association). Special thanks to the former Hon. Minister of Education, Mr Alexander Teabo. The finalization of the KeHCI instrument was done with strong support from all concerned ministries ECE stakeholders. Sincere thanks are given to Ms MeleaTaulua (Early Childhood Education Officer, Ministry of Education) who has gone extra miles and helped the trial and validation of the KeHCI. We acknowledge support and guidance of the MOE’s management team through the whole process, including all the translations and back translation of the KeHCI instrumentation to make it relevant for the country. The data collection was managed by the consulting firm hired by the Bank, Education Technology for Development (Et4D), through preschool teachers and parents, caregivers across 21 islands of the country. We would like to acknowledge the work of all Island Education Coordinators (IECs), early childhood teachers, parent, and caregivers who collected the KeHCI data across Kiribati. Special thanks to the Ministry for their support provided to ensure data collection went smoothly across islands country. Thanks to team from the Lands Division of the Ministry of Environment, Lands & Agricultural Development, Mr Tewaea Keariki who completed the mapping and his team for the geographical mapping of eHCI result. We would also like to thank Et4D for their professionalism, dedication to work on the difficult geographical areas of the country and has successfully completed the collection of data for more than 80 percent of the target groups across all 21 islands of Kiribati. Lastly, we thank the Ministry of Education management support and coordination that helps the implementation of PEARL activities progressing ahead as scheduled, with special thanks to Mrs. Ruuta Tekeraoi (Director, Primary Education of the Ministry of Education) and Ms. Rakera Tiree (official of the Ministry of Education) who have been working closely with the PEARL and the Bank team. 1 Abbreviations ECCE Early Childhood Care and Education EGRA Early Grade Reading Assessment EHCI early Human Capability Index KeHCI Kiribati Early Human Capability Index MHMS Ministry of Health and Medical Services MoE Ministry of Education PILNA Pacific Islands Literacy and Numeracy Assessment SDG Sustainable Development Goal TeHCI Tongan early Human Capability Index WHO World Health Organization 2 3 ABSTRACT Kiribati is among the first few countries in the world to have undertaken a national census of children’s early health and development. This report presents data collected for 7,194 children aged 3 to 5 years across 21 of the country’s islands. Data were collectedon children’s health and development, their learning environments at home, and their early childhood education experience, which together, provide a snapshot of how children in Kiribati are developing in their early years and highlights factors that are playing an important role in influencing children’s outcomes. Overall, these results provide the country with valuable evidence to guide policy makers and service providers in their program planning and design, evaluation of interventions, and monitoring of children’s outcomes. It is hoped that in future, the country will drive repeat census collections, as only with repeat data over time will policy makers, service providers, and communities be able to understand if their work to support children is making a difference. 4 Introduction Kiribati is a sovereign state in the central Pacific Ocean. Comprised of 33 islands, 21 of which are inhabited, Kiribati has a population of approximately 110,000, more than half of which live on the islands of Tarawa, the country’s capital. Children make up a third of the country’s population, another half of the population are adults, and the remainder are aged 50 years and over. Kiribati’s people are Micronesian, and although English is the country’s official language, the large majority of the population speak Gilbertese. The country’s economy benefits from copra and fish exports, seaweed farming, foreign fishing licensing fees, tourism, as well as developmental aid and remittances from family overseas. The islands of Kiribati are vulnerable to changes in climate, including rising sea levels, increasing temperatures, and rainfall – indeed climate impacts almost all aspects of life in Kiribati. The Government of Kiribati has made a commitment to foster an educated, skilled, and employable population in order to achieve its overall vision of becoming a wealthy, healthy, and peaceful nation. Further, in conjunction with countries across the world, Kiribati has committed to adopt the United Nations 2030 Agenda for Sustainable Development to end poverty, fight inequality, protect the planet and ensure inclusive and quality education for all. Sustainable Development Goal (SDG) 4.2 states that by 2030, all girls and boys should have access to quality early childhood development, care and pre-primary education so that they are ready for primary education. Similarly, the country has also ratified the United Nations Convention on the Rights of the Child, which further recommends the monitoring of children’s development within and across populations. As a result, education is one of the government’s key priorities. Historically, significant investments have been put into primary, junior, and secondary school – the first 9 years of schooling in Kiribati are compulsory and free, and as a result enrolment rates are high. Increasingly, global evidence has demonstrated the importance of children’s experiences before school, and so more recently, Kiribati has worked towards prioritising the provision, quality, and monitoring of early childhood care and education (ECCE) services across the country. Specifically, the Government of Kiribati passed an Act on ECCE in 2017, the aims of which are to (i) provide a framework for the regulation of the provision and operation of ECCE services to children from 3 to 6 years of age; (ii) establish a registration and compliance mechanism relating to the provision of ECCE services; (iii) set out requirements for the provision and operation of ECCE services; and (iv) facilitate and support ECCE services implemented at the national and local government levels. Despite such efforts, concerns remain regarding children’s levels of literacy and numeracy achievement across the country, and more broadly across the Pacific region. Results from the latest Pacific Island Literacy and Numeracy Assessment (PILNA) in 20151 indicate that at the regional level, although achievement in literacy and numeracy has improved since 2012, more than half of students in years 4 and 6 across the Pacific have still not achieved reading comprehension. Further, findings from the Early Grade Reading Assessment (EGRA) in Kiribati in 20172 demonstrate that at grade 3, 13 percent of students still have scores zero in reading comprehension. There are also causes for concern particularly regarding boys’ achievement relative to that of girls, as evidenced by results from both the PILNA and the EGRA. Subsequently, education stakeholders are urged to review the evidence and consider intervention strategies to work toward improving children’s outcomes. 1 Pacific Islands Numeracy and Literacy Assessment (PILNA) report, Pacific Community, 2015 2 Early Grade Reading Assessment (EGRA), World Bank, 2017 5 This report is a step forward in achieving these goals. Presented herein are results regarding the status of children’s early health and development in Kiribati, as well as their participation in preschool and their learning environments at home. Measuring children’s early outcomes in this way will enable the country to highlight areas of need, identify any gaps in services and supports, evaluate the effectiveness of health and ECCE sectors, and provide the evidence needed to guide program and policy development to improve the development of children across the country. 6 The early Human Capability Index The early Human Capability Index (eHCI) was used to measure children’s health and development in Kiribati. The eHCI is a population measure designed to capture the key aspects of holistic development in children aged 3 to 5 years that predict their future capabilities and outcomes. Specifically, the eHCI measures children’s physical health, verbal communication skills, perseverance and approaches to learning, early literacy and numeracy skills, cultural knowledge, and social and emotional skills. The eHCI was initially developed for use in Tonga to conduct a census of children’s development across the country, and as such the methodological details regarding the instrument’s development can be found in the original Tongan census report3. Following success and learnings from utilisation of the eHCI in Tonga, other countries across the Pacific have since committed to adapting and implementing the eHCI for population measurement, including Kiribati. The Kiribati eHCI (KeHCI) was based on the Tongan version of the eHCI (TeHCI) due to similarities in culture and language between Tonga and Kiribati. To adapt the instrument for use in Kiribati, the creator of the eHCI, Sally Brinkman, together with staff from the Ministry of Health and Medical Services (MHMS), the Ministry of Education (MoE), as well as other key stakeholders, used both Tongan and English versions of the eHCI to translate the instrument to Kiribati language and ensure the translations were capturing the true essence and intent of each item. The instrument was then piloted to ensure respondents understood the questions being asked of them, and were able to respond to each item as intended. Teachers from four preschools in South Tarawa participated in the pilot. They were trained in how to complete the instrument via the traditional pen and paper method, and were then asked to return completed KeHCI forms for the children in their class. The tool was then further revised based on the teachers’ experiences throughout the pilot. As a result of similarities in culture across islands in the Pacific, the KeHCI captures aspects of children’s development similar to that measured by the TeHCI, indicating what ‘good’ child development looks similar across the Pacific region. Specifically, the KeHCI includes 75 items designed to measure 9 different aspects of children’s development: verbal communication, approaches to learning, numeracy and concepts, cultural knowledge, formal literacy (reading), formal literacy (writing), social and emotional skills, perseverance, and physical health.Together, these aspects of development have been shown to be highly predictive of children’s later learning and educational achievement. Scores for each of the KeHCI domains range from 0 to 1, with 1 being the best score and 0 being the poorest. The data are not weighted or age standardised so older children should receive higher scores on each of the domains compared to younger children to reflect more advanced development. From these 9 domains an overall literacy and numeracy score is derived, as well as an overall development score, both ranging from 0 to 1 with 1 being the best score. In addition, the KeHCI captures basic background characteristics for each child, including their primary caregiver’s educational level, their participation in early childhood education programs, as well as their learning environments at home. Both English and Kiribati versions of the KeHCI are presented in Appendix A. 3 Brinkman, S. & Thanh Vu, B. (2017). Early Childhood Development in Tonga: Baseline Results from the Tongan Early Human Capability Index. World Bank Group, Washington, DC. 7 Data Collection Data were collected from March to June 2017 on7,194 (approximately 80 percent) of children aged 3 to 5 years old in Kiribati. Children resided in 164 villages across 21 islands, with most living in South Tarawa (N=3,154), Kiritimati (N=550), Abaiang (N=515), and North Tarawa (N=410). Data were collected from children’s primary caregivers or preschool teachers and included questions about their health and development, their learning environments at home,and their early childhood educatione xperience. Together, this information provides a snapshot of how children are developing in their early years. As demonstrated in Table 1, there were a relatively equal number of children in each age group, as well as an even number of males and females in the population sample. A small number of children were reported to have a disability, and the majority of children’s caregivers had completed at least some form of education, with levels of education reasonably similar across children’s mothers and fathers. Table 1: Sample characteristics Variable Number (percent) Gender Male 3,657 (50) Female 3,408 (47) Missing 129 (2) Age 3 years 2,184 (30) 4 years 2,128 (30) 5 years 1,992 (28) Missing 890 (12) Special needs status Yes 559 (8) No 5,883 (82) Missing 752 (10) Mother’s education Some primary school 582 (8) Completed primary school 1,251 (17) Completed junior school 2,007 (28) Completed secondary school 2,234 (32) Higher/tertiary education 696 (10) Missing 324 (5) Father’s education Some primary school 686 (10) Completed primary school 1,318 (18) Completed junior school 1,908 (27) Completed secondary school 2,168 (30) Higher/tertiary education 640 (9) Missing 474 (7) 8 Results Child Development Early childhood development is the most crucial period in life as it determines later health, wellbeing and achievement throughout the life course. Early childhood development is generally defined as children’s holistic development from conception to age 8, and this development occurs when children learn how to move, think, and interact at increasingly complex levels. There are different areas or domains of development including physical, social and emotional, language, and cognitive development, with each of these domains being influenced by a combination of biological and environmental factors. As discussed, the tool used to measure children’s development in this report is the Kiribati version of the eHCI (KeHCI). Figure 1 presents children’s average scores across the 9 KeHCI developmental domains, as well as summary indicators of overall literacy and numeracy scores and average overall development. Across the entire sample, children scored highest on domains measuring verbal communication skills, approaches to learning, and cultural knowledge, and lowest on domains that measure children’s more formal aspects of development – their early reading, writing, and maths skills. These results are consistent with those previously reported on for the children of Kiribati, with concerns regarding low levels of literacy and numeracy achievement as identified by the PILNA. Below we explore these results in more detail in order to gain an understanding of the factors that are influencing children’s development in Kiribati. Figure 1: Children’s development across domains Early language skills Good language development supports a child’s ability to communicate with others, and these skills lay the foundation for learning to read and write. Caregivers and teachers were asked about children’s early language skills; with almost all children reported to know their name (94 percent), and the majority were also able to use simple words (69 percent), a simple sentence (63 percent), and practice turn-taking in conversations (60 percent). 9 Early maths skills Basic numeracy skills such as being able to recognise a number or a shape, understanding object size and weight, and being able to count are all important for children to become numerate and ready to learn further at school. Most caregivers and teachers reported that children could recognise shapes such as a triangle, circle and square (79 percent), could count to 10 (62 percent), and could identify 3 colours (68 percent). Fewer children were said to understand the concept of yesterday, today and tomorrow (29 percent), and were able to count to 20 (19 percent). Early literacy skills Familiarity with words, sounds, and language, as well as the more formal aspects of literacy that develop later in childhood, reading and writing, are all important skills children need to be able to further develop and learn at school. Caregivers and teachers were asked about children’s familiarity with books; 52 percent of children could hold a book and turn its page correctly, and 27 percent were able to follow the words in a book from left to right. When asked about children’s reading abilities, it was reported that 41 percent could read 4 or more familiar words. Respondents were also asked about children’s writing abilities, with 55 percent able to write 3 or more letters, and 32 percent able to write simple words. Early social and emotional skills Social and emotional skills are important for getting along with others and forming healthy relationships, and these skills enable children to adapt to their school environment. Caregivers and teachers reported that majority of children are willing to share their belongings (79 percent), willing to help others (75 percent), and are able to show respect for other children (66 percent) and adults (60 percent). However, many children were also reported to sometimes display negative social behaviours such as kicking, biting, or hitting (42 percent). Child development disparities Figure 2 below demonstrates differences in overall development according to children’s age and gender. Consistent with the international child development literature, older children were found to be developing better than younger children and girls were developing slightly better than boys, and these patterns were found to be statistically significant across all KeHCI domains. Figure 3 demonstrates small differences in children’s overall development scores based on their parent’s levels of education, with children whose parents had completed a higher level of education having slightly better development when compared to children of parents with a lower education. Further analysis revealed that this pattern was statistically significant when examining father’s education on all domains except for perseverance and writing skills. In contrast, this pattern was only statistically significant when looking at mother’s education on domains of reading, writing and numeracy skills. Generally, we would expect to see a stronger relationship between caregiver’s education and children’s development, particularly so when examining maternal education. These results suggest that in Kiribati, other factors are having a stronger influence on children’s development, and indeed, similar results have been found using the eHCI in a census of children’s development in Samoa. 10 Figure 2: Children’s overall development by gender and age Figure 3: Children’s overall development by mother’s and father’s education Figure 4 compares children’s overall development scores across 21 islands of Kiribati, and includes the number of children on each island for which data were collected. Children from Beru and Teeraina for example, have higher average overall development scores compared to children from Nonouti and Tabuaeran, and these differences are statistically significant. To further explore children’s development across islands, Figures in Appendix B demonstrate development on each KeHCI domain across the islands of Kiribati. Results demonstrate that in general, children on some islands such as Beru and Teeraina, have better scores compared to children living on other islands such as Nonouti and Abaiang. However, results are somewhat inconsistent dependant on the domain of focus. For instance, while children from Arorae had the lowest scores on the approaches to learning domain when compared to children from other islands, the same children from Arorae had the highest scores on the physical health domain relative to children from other islands. These findings indicate that programs with universal coverage, supporting the learning and development 11 of children across all islands, are required, rather than the implementation of programs that are targeted at specific geographical areas only. Throughout this report the potential drivers behind these patterns in children’s development across islands are explored. Children’s development across each island has also been compared using colour coded mapping. Islands were coloured to represent how children are developing compared to those on other islands. The bottom third of villages where children on average, have the poorest development, are coloured red, the middle third are coloured yellow and the top third performing villages are coloured green.Maps were created for each developmental domain and are available for viewing at the Ministry of Education. Presented in Figure 4 is the map for children’s overall development in North and South Tarawa. Figure 4: Children’s overall development across North and South Tarawa Child Health and Nutrition Good health and nutrition are essential not only for children’s survival, but for healthy growth and development. If children are healthy they will be more likely to develop well throughout childhood, achieve better outcomes at school and be more productive as an adult. Children’s height and weight were measured to calculate undernutrition in the forms of stunting, wasting and underweight. A child who is stunted is too short for their age, resulting from the failure to grow both physically and cognitively due to chronic or recurrent undernutrition. Specifically, stunting as defined by the World Health Organization (WHO) growth standards is more than 2 standard deviations below the median height-for-age. Stunting is largely irreversible and has long term negative impacts throughout the life course. In contrast, a child who is wasting is too thin for their height and this is a reflection of sudden weight loss most often due to starvation or disease. Wasting is defined as more than 2 standard deviations below the median weight-for-height. Untreated, wasting can progress severely and increases the 12 risk of child mortality significantly. Lastly, if a child is classified to be underweight, this could imply that they are stunted or wasted, or both. Underweight is defined as more than 2 standard deviations below the median weight-for-age. Table 2 presents the prevalence of these three forms of undernutrition amongst children in Kiribati alongside the degree of public health significance of these prevalence rates according to the WHO classification system.4 Table 2: Undernutrition prevalenceand public health significance Form of Percent of WHO classification Undernutrition children Stunting 29.4 20-29=‘medium’ public health significance Wasting 5.8 5-9 = ‘medium’ public health significance Underweight 12.2 10-14 = ‘high’ public health significance Evidently, stunting is of considerable concern with almost a third of children in Kiribati affected, likely to be the result of having a diet that consists predominantly of foods that are poor in nutritional quality. The prevalence of wasting is also a significant concern and reflects experiences of food insecurity or disease. The number of children who are underweight in Kiribati is of high public health significance. As this indicator does not take into account a child’s height, it is not possible to determine whether these children are underweight due to acute or chronic nutrition deficiencies. Nevertheless, SDG 2 aims to end all forms of malnutrition by 2030, so while not as informative as stunting or wasting, the proportion of underweight children is still an important indicator for the country to track. Rates of wasting and underweight in Kiribati are similar to that found in other Pacific countries such as Tuvalu, while the prevalence of stunting in Kiribati is considerably lower than that in Tuvalu, and indeed lower than rates of stunting in East-Asian countries as well as sub-Sahara Africa. Yet, undernutrition in Kiribati remains a serious concern; these figures indicate that children in Kiribati require better nutrition and healthcare to develop well. Despite concerning results regarding the prevalence of undernutrition amongst children in Kiribati, children’s physical health as measured by the KeHCI appears satisfactory (see Figure 1). Considering the aspects of physical development that are assessed in this domain (e.g. if the child washes their hands after toileting, if the child takes care not to get hurt), it is clear that undernutrition prevalence and scores on the physical development KeHCI domain measure two different aspects of how a child is developing. As such, information regarding undernutrition as well as children’s physical development scores on the KeHCI should be used in combination to provide a comprehensive picture of children’s health and development as has been done in this report. While rates of undernutrition did not vary by age or gender, they did vary depending on which island a child lived on, and these differences were statistically significant. As Figure 5 shows, stunting rates ranged from as low as 8 percent in Beru to as high as 64 percent in Maiana. It should be noted that some islands had small numbers of children and so results should be interpreted with caution. For instance, while half of children in Tamana were stunted, this figure represents less than 10 children. Nonetheless, this variation in stunting suggests that some islands may be experiencing far greater problems than others, in terms of nutrition quality and diet diversity, prolonged food insecurity, or inadequate health care. To gain an understanding of early childhood nutrition practices in Kiribati, information was also collected about children’s experiences of breastfeeding. Breastfeeding provides babies 4 Further information regarding WHO growth standards, their definitions and interpretation can be found at the following links: http://www.who.int/nutgrowthdb/about/introduction/en/index2.html http://www.who.int/nutgrowthdb/about/introduction/en/index5.html 13 with the nutrition they need for healthy development, protects against disease and reduces infant mortality. The WHO recommends children be breastfed exclusively until 6 months of age (that is, that they do not consume any food or drink other than breastmilk), with continued breastfeeding with complimentary foods up until 2 years of age. Encouragingly, 94 percent of children aged 3-5 in Kiribati had been breastfed, and of these children, the majority had been breastfed for longer than 6 months (80 percent). Figure 5: Stunting prevalence by island Information was also collected on how often children fell ill, and the majority were reported to get sick often (70 percent). Illness reported by caregivers and teachers included whooping cough (16 percent), diarrhoea (8 percent), respiratory infections (6 percent), and conjunctivitis or pink eye (6 percent), with the remaining 33 percent reporting other types of sickness. Such frequent sickness could be due to a number of factors including poor hygiene and sanitation, inadequate health services, and poor nutrition and diet. Evidently, while we have observed positive breastfeeding practices in Kiribati, children are experiencing sickness frequently. Further analyses were conducted to explore if both of 14 these factors were influencing children’s stunting, wasting and underweight rates, but no statistically significant associations were found. As such, further work is required in order to better understand what is influencing the considerable rates of undernutrition in Kiribati. Figures 6-8 explore associations between undernutrition prevalence and children’s development across the 9 KeHCI domains, as well as their average overall literacy and numeracy score and their average overall development score. There are statistically significant differences in developmental outcomes between children who are experiencing either stunting, wasting or are underweight, and those who are not. Stunting in particular, has the strongest negative relationship with children’s development, especially so for more formal, cognitively driven processes of development including literacy and numeracy skills. These results provide further evidence for the need to understand and address the factors that are influencing undernutrition amongst children in Kiribati. Figure 6: Children’s development across domains by stunting prevalence Figure 7: Children’s development across domains by wasting prevalence 15 Figure 8: Children’s development across domains by underweight prevalence Preschool Participation Access to quality early education promotes positive child development and prepares children for a successful transition to school. Encouragingly, most children in Kiribati (92 percent) had attended preschool. Figure 9 below demonstrates that preschool attendance varies by children’s age and gender; increasing as children grow older and get closer to school age, with participation rates higher for girls than boys. Figure 10 demonstrates statistically significant differences across all domains of development between children who had and had not attended preschool – that is, preschool has a clear and consistent positive influence on children’s development. These differences are largest when looking at children’s approaches to learning, cultural knowledge, social and emotional skills and early literacy and maths skills, which is to be expected considering that these are the types of skills and capabilities that are enhanced by participating in a preschool environment. It should be noted that these results do not take into account important factors such as how much preschool children attended or the quality of preschool that children were exposed to. It is likely that the relationship between preschool attendance and children’s development would be stronger if dose and quality were considered, and collecting such data would be useful in future. Figure 9: Preschool attendance by children’s age and gender 16 Figure 10: Children’s development across domainsby preschool attendance Figure 11 explores preschool attendance across the islands of Kiribati. Encouragingly, preschool attendance rate in Kiribati is quitter high (between 85 and 100 percent). The results also indicate that children attended preschool are doing better. However, results also suggest that preschool could do more to contribute better in child development domains, especially in numeracy and concepts, reading and writing which are lower than other domains (see figure 10 above). Interestingly, despite the positive association between preschool attendance and children’s development, the pattern of preschool attendance across islands does not align well with the pattern of child development outcomes across islands as explored above. For instance, although Kirimati had the lowest preschool attendance rates amongst all islands, children’s average overall development in Kirimati was seventh highest amongst islands – and further analyses determine these patterns are not due to the age of children on the island. Patterns in development outcomes and facilitators of child development appear complex, and we continue to discuss potential drivers of this further in the next section of the report. 17 Figure 11: Preschool attendance by island of residence Home stimulation A nurturing home environment that provides love, support, and opportunities to learn and explore is essential to promote a child’s healthy development. Parents need to interact with their children frequently through playing together, reading books, singing songs, counting, drawing, and telling stories, in order to provide them with the opportunities they need to learn and develop. Children’s caregivers and teachers were asked about 6 different parent-child engagement activities, and if children’s parents or somebody else in the family over 15 years of age had engaged in these activities with each child in the past 3 days. Overall, levels of home stimulation activities in Kiribati were low to moderate – less than half of all children had been read a book in the past 3 days (47 percent), 71 percent had been told a story, 60 percent had sung songs, 42 percent had played somewhere other than home, 58 percent had played in general, and 41 percent had named, counted and drawn objects. Figure 12 below demonstrates how these home stimulation activities have an important influence on children’s outcomes. Evidently, each of the parent-child engagement activities had a statistically significant positive relationship with children’s overall development. The children of parents who engaged in these activities with them were developing better than children whose parents did not read to them, tell stories, sing, play, draw, and so on. Indeed, this pattern is evident across each developmental domain, with few exceptions 18 (singing songs did not significantly influence children’s writing skills, and playing did not significantly influence children’s reading and writing scores). Figure 12: Children’s overall development by home stimulation activities 19 Figure 13: Home stimulation activities by island of residence Figure 13 explores children’s engagement in home learning activities across the islands of Kiribati to better understand what is driving disparities in children’s development across islands. Results show statistically significant differences in caregiver-child engagement 20 across islands, and results are consistent with differences in child development outcomes across islands also. For instance, stimulation in the home environment is lowest for children in Tamana, Marakei, and Tabuaeran, and in line with this, it is also the children on these islands that have some of the lowest KeHCI development scores in the country. These results indicate that home stimulation may be a significant driver behind differences in children’s development across islands. School readiness of 5-year old Closely linked to children’s development, school readiness focuses on a particular time in a child’s life, generally around the age of 5 years, and enables children to begin school with the skills, capabilities, health, and development required to successfully transition into a school learning environment. These skills develop cumulatively, and as such, learning achievement in school is the product of a process of acquiring skills from birth and building advanced skills based upon the mastery of former, more basic skills. For example, a child needs to be able to understand letter names and sounds in order to learn to read. Importantly, school readiness has been linked to positive long-term social and behavioural outcomes, as well as improved academic outcomes. As a result, we also explored the developmental outcomes of children aged 5 years old to gain an understanding of school readiness in Kiribati. Figure 14 demonstrates children’s development across domains separately for boys and girls. Again, consistent with previous results, amongst 5-year old children only, girls outperform boys across all domains of development, even on those for which boys traditionally score higher than girls according to the international literature, such as numeracy and concepts and approaches to learning. Further, gender differences across each developmental domain are statistically significant. Interesting also is that the gender gap in development appears to be increasing with age – that is, as children grow older, boys are falling further behind girls. Again, these results reflect those of the PILNA, which highlighted concerns in achievement for boys, in particular. Figure 14: Child development across gender for 5 year old 21 As with results for children aged 3-5 years, Figure 15 below shows that children aged 5 years of age who engaged in home learning activities with their caregivers, and particularly those who attended preschool, had overall better development scores relative to those who were not given these interaction opportunities. Evidently, preschool helps children prepare for school, and this is consistent with the literature around the positive influence of preschool attendance on children’s school readiness. Results suggest action should be taken to ensure all 5 yearolds in Kiribati are attending preschool before they commence school in order to prepare them for a successful transition into the school learning environment. 22 Which factors have the strongest relationship with child development? Findings throughout this report have highlighted a range of factors that are influencing children’s early development in Kiribati. As such, next we explored which of these are most important for children’s development. A series of regression analyses were conducted to determine which of these factors have the strongest relationship with children’s overall development. Table 3 below presents the range of variables shown to best predict overall child development scores, all of which are highly statistically significant. Figure 15: Overall development by preschool attendance and home stimulation activities for 5 year old Naturally, a child’s age has a strong influence on their developmental outcomes, and so too did gender, again reflecting the existence of a considerable gap in development between boys and girls in Kiribati. Stunting had a considerable negative influence on children’s outcomes, and while interactions in the home environment – in particular caregivers reading, naming, counting and drawing with their children – positively predict children’s development, preschool attendance had the strongest relationship with children’s development. Encouragingly, these three factors are modifiable, and can be improved in order to better support children’s development and readiness for school. 23 Table 3: Strongest predictors of child development Children’s overall development Variables B SE B β Child’s age 0.078 0.327 27.566** Child’s gender 0.030 0.077 6.773** Stunting -0.041 .006 -7.151** Attended preschool 0.109 0.148 12.977** Read books at home 0.078 0.121 9.681** Vocalised/counted/drew 0.029 0.074 5.929** R2 0.207 F 268.148** Note: *p < .05, **p < .01 24 Key findings and recommendations Results from the KeHCI national census have provided a snapshot of the early health and developmental outcomes of children aged 3-5 years in Kiribati, and have highlighted the factors that are influencing development outcomes for children across the country. According to results, children in Kiribati are not receiving the nutrition and health care they need to grow and develop. Almost a third of children are affected by stunting, and this is likely to be negatively impacting children’s development outcomes now and in the future. To promote positive development, a basis of good health, nutrition and care for the country’s children is critical, and so it is of great importance that undernutrition amongst children in Kiribati is addressed and reduced. Encouragingly, preschool enrolment and attendance rates in Kiribati are high, and results show that this is having a significant positive influence on all domains of children’s development. The country should work to ensure that all children attend preschool before school so that these developmental benefits are maximised. Further, what is not well understood is how often children are attending preschool and for how long, as well as the quality of the early education children are receiving. It is likely that these relationships will be strengthened if preschool attendance and quality were considered. Collecting such data would be useful for program planning and evaluation in future. Further, results show that nurturing, stimulating home environments are an important mechanism through which children’s development can be improved. Increasing the levels of stimulation and support children are receiving at home by enhancing the capacity of caregivers should also be prioritised, and will likely positively influence children’s outcomes. Finally, results demonstrate interesting differences in children’s outcomes across 21 of the country’s inhabited islands. Exploration of the drivers behind these differences revealed that engagement in learning activities between children and their caregivers in particular varied considerably across islands, influencing children’s outcomes. Disparities in children’s outcomes across islands are likely a reflection of more resources and greater accessibility and availability of services and supports in some areas compared to others. It is encouraged that this evidence be acted upon by determining where more supports are needed, and implementing intervention strategies to work toward improving children’s outcomes. There are several evidence-based interventions that could be implemented in Kiribati to work towards reducing stunting prevalence amongst children, increasing preschool attendance and enriching child-caregiver interactions in the home environment. An example that has been successfully applied in another Pacific country, Tonga, is the delivery of community- based playgroups. Aimed at children from birth to 5 years of age, these playgroups aim to engage caregivers and their children in play-based activities on a weekly basis to promote positive child development by engaging caregivers in improving home stimulation activities which will help prepare children for school. Furthermore, community playgroups can integrate parenting programs to improve caregiver’s knowledge of the importance of good health, nutrition, and age-appropriate stimulation activities to promote their child’s development. Nutrition supplementation (such as vitamin A, iodine, worming tablets etc.) can also be distributed via the community playgroups as a means of improving children’s health and working to reduce rates of stunting. Finally, community-based playgroups can also incorporate toy libraries, whereby families can borrow toys and books to take home and play with their children, further promoting stimulating home environments. Although it is important to ensure that such interventions are evidence-based, it is equally important to ensure that any interventions employed in future are also aligned with the local community, culture and traditions of Kiribati. Along with Australia, Tonga, Samoa, and Tuvalu, Kiribati is now one of the very few countries in the world to have undertaken a population wide census of children’s development. 25 Results produced findings that we would expect considering the international evidence, as well as some surprising ones, and the country now has comprehensive data that captures the early health and development outcomes of children across the entire country. This provides the country with valuable evidence on which policy makers and service providers can base their planning around, and program evaluation and policy monitoring can be measured against. Repeated implementation of the KeHCI will provide the country with data at multiple time points, and will thus enable Kiribati to evaluate any policy shifts, changes to service delivery, and community action implemented to support early child development. It is hoped that the country will drive repeat KeHCI collections, as only with repeat data over time will policy makers, service providers, and communities be able to understand if their work to support children is making a difference. 26 APPENDIX A English and Kiribati versions of the KeHCI Dissemination materials 27 28 29 30 31 32 33 34 APPENDIX B Development on each KeHCI domain across the islands of Kiribati 35 Figure 17: Children’s physical health by island of residence 36 Figure 18: Children’s general verbal communication by island of residence   37 Figure 19: Children’s approaches to learning by island of residence   38 Figure 20: Children’s numeracy and concepts by island of residence   39 Figure 21: Children’s cultural knowledge by island of residence   40 Figure 22: Children’s formal literacy (reading) by island of residence   41 Figure 23: Children’s formal literacy (writing) by island of residence   42 Figure 24: Children’s social and emotional development by island of residence   43 Figure 25: Children’s perseverance by island of residence 44