India's integrated child development services scheme: challenges for scaling up

Background

India had around 158 million children under the age of 6 and about 26 million births in 2015. In the same year, India's Integrated Child Development Services Scheme served about 82 million children under 6 years and over 19 million pregnant women and lactating mothers. These 102 million beneficiaries received services in about 1.3 million centres.

Method

This paper reviews the growth of the Scheme and considers challenges to scaling up quality with equity based on results of large‐scale national or multistate studies.

Results

The Scheme is associated with decreased malnutrition and better child development. The size and diversity of the country, the policy context, funding mode and lack of community awareness and engagement have hindered scaling up access while the approach to service delivery, low institutional capacity and poor infrastructure have impeded scaling up of implementation quality.

Conclusions

This review illustrates the challenges associated with scaling‐up access and implementation quality of a multicomponent, integrated early childhood programme in a large, diverse country. The future success of the Integrated Child Development Services will depend on how well it adheres to quality standards and how well it evolves to address current weaknesses.     

Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru

This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.     

Scaling up Integrated Early Childhood Development programs: lessons from four countries

Background

There is still limited knowledge regarding the translation of early child development (ECD) knowledge into effective policies and large‐scale programmes. A variety of frameworks that outline the key steps in scaling up exist, but we argue that taking a complex adaptive systems (CAS) approach assists in understanding the complex, dynamic processes that result in programmes being taken to scale.

Objectives

The objective of this study is to examine the process of scaling up four major country‐level ECD programmes through the application of a CAS framework.

Methods

Nine key informants with a deep knowledge of how each ECD programme was established and brought to scale were interviewed via Skype or phone by using open‐ended interviews. The interviews were tape recorded and then transcribed verbatim for subsequent coding by using CAS domains. The coding and integration of the results to identify unique and common CAS scaling up features across the case studies involved an iterative process of reaching consensus.

Results

The scaling up of all four programmes behaved as a CAS including as follows: (i) positive feedback loops (five themes) and negative feedback loops (two themes); (ii) scale‐free networks (two themes); (iii) phase transitions (four themes); (iv) path dependence (two themes); and (v) emergent behaviour (six themes). Five additional themes were identified for sustainability, which was repeatedly mentioned as an important consideration when deciding how to scale up programmes.

Conclusions

CAS analysis is likely to improve our understanding of how effective ECD programmes become scaled up. Prospective CAS implementation research is needed to continue advancing the knowledge in the field.     

Relationship between the neighbourhood built environment and early child development

The relationship between features of the neighbourhood built environment and early child development was investigated using area-level data from the Australian Early Development Census. Overall 9.0% of children were developmentally vulnerable on the Physical Health and Well-being domain, 8.1% on the Social Competence domain and 8.1% on the Emotional Maturity domain. After adjustment for socio-demographic factors, Local Communities with the highest quintile of home yard space had significantly lower odds of developmental vulnerability on the Emotional Maturity domain. Residing in a Local Community with fewer main roads was associated with a decrease in the proportion of children developmentally vulnerable on the Social Competence domain. Overall, sociodemographic factors were more important than aspects of the neighbourhood physical environment for explaining variation between Local Communities in the developmental vulnerability of children.     

Brazilian meningococcal C conjugate vaccine: Scaling up studies

Several outbreaks caused by Neisseria meningitidis group C have been occurred in different regions of Brazil. A conjugate vaccine for Neisseria meningitidis was produced by chemical linkage between periodate-oxidized meningococcal C polysaccharide and hydrazide-activated monomeric tetanus toxoid via a modified reductive amination conjugation method. Vaccine safety and immunogenicity tested in Phase I and II trials showed satisfactory results. Before starting Phase III trials, vaccine production was scaled up to obtain industrial lots under Good Manufacture Practices (GMP). Comparative analysis between data obtained from industrial and pilot scales of the meningococcal C conjugate bulk showed similar execution times in the scaling up production process without significant losses or alterations in the quality attributes of purified compounds. In conclusion, scale up was considered satisfactory and the Brazilian meningococcal conjugate vaccine production aiming to perform Phase III trials is feasible.     

Tobacco expenditures and child health and nutritional outcomes in rural Bangladesh

This study examined the relationship between tobacco prices and child health outcomes so as to assess the potential of improved child health outcomes resulting from less tobacco expenditure. In part, this paper was motivated by a study by. Efroymson et al. [(2001). Hungry for tobacco: An analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control, 10, 212-217] suggesting that for the poorest households in Bangladesh, amongst whom malnutrition is widespread, shifting tobacco expenditures to expenditures on food would significantly improve the nutritional status of the household. We used data from a survey of 956 households conducted in rural Bangladesh between June 1996 and September 1997. The households were surveyed four times at approximately 4-month intervals during the 16-month period. We restricted our sample to households with children aged 2-10, and 600 households satisfied this criterion. The primary dependent variables for this study are three anthropometric indicators of child health and nutritional status: a standardized measure of height for age, a standardized measure of weight for height, and a standardized measure of weight for age. We also used measures of self-reported morbidity, including the incidence and duration of respiratory illness. We used regression methods on data averaged across survey rounds to estimate the relationship between tobacco prices and the outcome variables. Tobacco prices were found to be a significant determinant of height for age and weight for height for both boys and girls. Furthermore, the price of tobacco products is a significant predictor of weight for age for girls and the pooled sample. Our results suggest that higher tobacco prices would, for the most part, improve child health.     

Components of successful integration in child care centres: An Ontario study

Teachers are central in the process of including children with special needs into early childhood programs. Much research and training has focused on the skills needed by teachers to make this process a success for all involved. In Ontario, Canada, the integration of children with special needs has been in practice for quite some time. This qualitative research looks at what experienced teachers in child care programs think and do in their practise of inclusion. Twenty-four teachers in seven municipal child care centres were interviewed as they watched videotapes made in their programs of children with special needs in their care. What emerged from these discussions is a model for the integration of children with special needs and the strategies the teachers used to make this process a success.     

Associations Between Parental Depression and Early Childhood Development in Indonesia: A Cross-sectional Study

ObjectivesThis study aimed to determine the associations between parental depression and early childhood development among children aged 36 months to 59 months in Indonesia.MethodsFrom Indonesia’s Basic Health Survey (RISKESDAS) 2018, this study included 6433 children aged 36 months to 59 months and their parents. Maternal and paternal depression was examined using the Mini International Neuropsychiatric Interview survey instrument, which was previously translated into Indonesian. The study also used the Early Child Development Index to measure child development and its 4 domains (cognitive, physical, socio-emotional, and learning). Multivariate logistic regression analysis was performed to determine the association between parental depression and early childhood development.ResultsOverall, 10.3% of children aged 36 months to 59 months were off-track for development. After adjusting for biological, parental, and social characteristics, children born to parents with depression were found to be 4.72 times more likely to be off-track for development (95% confidence interval, 1.83 to 12.15).ConclusionsChildren of depressed parents were more likely to be off-track for development. The findings highlight the need for early diagnosis and timely intervention for parental depression to promote early childhood development.     

7岁儿童生长发育及健康状况

目的:了解小学一年级新生的生长发育和健康状况,为采取针对性干预措施提供依据。方法:对940名7岁儿童的身高、体重、胸围、肺活量进行测量,检测血红蛋白、视力和龋患情况。结果:男生身高、体重、胸围、肺活量、血红蛋白、BM I、肺活量/体重指数显著大于女生(P<0.01)。7岁儿童乳龋患率为76.28%,乳龋充填率为7.49%,恒龋患率为7.23%,恒龋充填率为29.13%,近视率为19.36%,肥胖率为10.21%。乳龋患及矫治对生长发育有明显影响,无龋对照组和乳龋充填组的发育水平显著高于乳龋未充填组。结论:小学一年级新生口腔保健水平较低,近视率和肥胖率较高,应采取相应的干预措施。     

Child culture, play and child development

The article discusses child development in the context of child life in day care. It traces children's development of an independent, autonomous life and their creation of culture where play is a central feature. The culture produced by the children is analysed on the basis of classical notions of culture. Furthermore the emergence and development of play in the life of the child is traced and the particular way of thinking represented in play is analysed: thinking related to creating drama with pretend figures on a “stage”. The potentials for learning inherent in this particular way of thinking are discussed with reference to the child's learning in the context of early instruction.     

Developmental awareness and moral stage development in child Abuse

In an attempt to better understand why children who have been sexually assaulted commonly fail to reveal their victimization to parents or other adults, a study was undertaken in which the “engagement strategies” of 41 perpetrators were examined, exploring common rationalizations, threats, etc. aimed at insuring continued silence on the part of the victim. The “appeal” for silence offered by the perpetrator to the child was analyzed according to Kohlberg's stages of moral development.

Results indicate that perpetrators appear to alter their engagement strategies to coincide with the developmental level of the child, thus further insuring silence by appealing to criteria for assessing “appropriate” or “inappropriate” behaviors (eg. sexual contact) which are developmentally consistent with the child's level of cognition and moral reasoning.     

Child culture,play and child development

The article discusses child development in the context of child life in day care. It traces children's development of an independent, autonomous life and their creation of culture where play is a central feature. The culture produced by the children is analysed on the basis of classical notions of culture. Furthermore the emergence and development of play in the life of the child is traced and the particular way of thinking represented in play is analysed: thinking related to creating drama with pretend figures on a “stage”. The potentials for learning inherent in this particular way of thinking are discussed with reference to the child's learning in the context of early instruction.     

Developmental awareness and moral stage development in child Abuse 1

In an attempt to better understand why children who have been sexually assaulted commonly fail to reveal their victimization to parents or other adults, a study was undertaken in which the “engagement strategies” of 41 perpetrators were examined, exploring common rationalizations, threats, etc. aimed at insuring continued silence on the part of the victim. The “appeal” for silence offered by the perpetrator to the child was analyzed according to Kohlberg's stages of moral development.

Results indicate that perpetrators appear to alter their engagement strategies to coincide with the developmental level of the child, thus further insuring silence by appealing to criteria for assessing “appropriate” or “inappropriate” behaviors (eg. sexual contact) which are developmentally consistent with the child's level of cognition and moral reasoning.

     

Care for Child Development: an intervention in support of responsive caregiving and early child development

Background

An estimated 43% of children younger than 5 years of age are at elevated risk of failing to achieve their human potential. In response, the World Health Organization and UNICEF developed Care for Child Development (CCD), based on the science of child development, to improve sensitive and responsive caregiving and promote the psychosocial development of young children.

Methods

In 2015, the World Health Organization and UNICEF identified sites where CCD has been implemented and sustained. The sites were surveyed, and responses were followed up by phone interviews. Project reports provided information on additional sites, and a review of published studies was undertaken to document the effectiveness of CCD for improving child and family outcomes, as well as its feasibility for implementation in resource‐constrained communities.

Results

The inventory found that CCD had been integrated into existing services in diverse sectors in 19 countries and 23 sites, including child survival, health, nutrition, infant day care, early education, family and child protection and services for children with disabilities. Published and unpublished evaluations have found that CCD interventions can improve child development, growth and health, as well as responsive caregiving. It has also been reported to reduce maternal depression, a known risk factor for poor pregnancy outcomes and poor child health, growth and development. Although CCD has expanded beyond initial implementation sites, only three countries reported having national policy support for integrating CCD into health or other services.

Conclusions

Strong interest exists in many countries to move beyond child survival to protect and support optimal child development. The United Nations Sustainable Development Goals depend on children realizing their potential to build healthy and emotionally, cognitively and socially competent future generations. More studies are needed to guide the integration of the CCD approach under different conditions. Nevertheless, the time is right to provide for the scale‐up of CCD as part of services for families and children.     

A comparative study of Malay-operated and Chinese-operated childcare centres in the state of Melaka, Malaysia

Demand for childcare services in Malaysia is increasing. With the changing demographic landscape and increasing knowledge of the importance of early childhood education, provision of alternative childcare services has never been more significant. Children younger than four years of age are placed in registered childcare centres while their parents work. Some children stay in the centres for half a day while others spend most of their time there. Hence, a great deal of learning takes place in these centres. The kinds of activities and how these activities are implemented may have a major influence on children's future development. Observations carried out in childcare centres in Melaka, one of the 13 states in Malaysia, revealed that there were wide variations in the services provided by Chinese and Malay childcare owners. There are 59 centres registered with the Department of Welfare, Melaka: one is Indian operated, 13 are Malay operated and the rest are Chinese operated. This paper highlights the differences in care provision between Malay-operated and Chinese-operated childcare centres along the following dimensions: (i) structured activities; (ii) toys, equipment and facilities; (iii) physical set-up; (v) division of duties among childcare providers; and (vi) availability of childcare principals or owners. This paper argues that the dimensions listed contribute to quality childcare. Recommendations are included to ensure consistency of care in these two ethnic-based childcare provision.