Achieving Sustained Early Child Development Impacts at Scale: a Kenyan RCT

摘要 据估计，低收入和中等收入国家（LMIC）中有43%的5岁以下儿童 由于贫穷、营养不良和心理社会刺激不足，发展受到损害。许多 幼儿发展（ECD）父母干预措施已被证明是有效的，以改善幼儿发展 结果，至少在短期内，但它们a）仍然过于昂贵，无法在低资源环境中大规模实施， 和农村地区，以及B）如果没有持续的支持，它们的早期影响往往会随着时间的推移而消失。新 迫切需要提供有效的幼儿发展育儿干预措施的方法，这些方法既要成本低， 可扩展，同时也能够长期维持影响。 LMIC环境中移动的通信的快速增长和低成本呈现出潜在的有希望的 解决可扩展性和可持续性的竞争问题。然而，没有严格的研究， 移动保健（mHealth）干预措施在低收入国家环境中的幼儿发展成果。我们最近发现，一个8- 一个月的幼儿发展育儿干预，由社区卫生组织每两周举行一次小组会议 来自肯尼亚农村卫生保健系统的工作人员（CHW）显着改善了儿童的认知，语言， 社会情感发展以及育儿实践，我们基于小组的交付模式更 成本效益高于以往的幼儿发展干预措施。然而，在农村低收入国家， 特别是如果我们需要可以延长更长时间的干预措施， 他们承受冲击的能力。我们提出的研究实验测试了传统的亲自交付模式 针对两种基于移动健康的交付模式， 以远程交付取代面对面会议。肯尼亚是测试移动健康项目的理想环境， 移动的电话的高渗透率（94%）。我们将评估这些措施的相对有效性和成本 移动健康提供模式与纯粹的面对面模式相比，并将干预措施延长两年， 提高他们长期维持儿童结果变化的能力。我们的评估设计是非- 在60个社区卫生工作者和1200个家庭中进行的劣效性聚集随机对照试验，我们将使用 适应性试验设计，以便对远程交付模式进行中期审查和反馈。通过测试 这三种干预措施在远程交付替代亲自交付的程度上各不相同，我们可以评估 可替代性或互补性的程度，以告知设计更具可扩展性和可持续性 干预措施。我们的目标是确定最佳模式，以最大限度地扩大干预的范围和持续 影响，以改善儿童的成果。通过将提供服务纳入当地社区卫生工作者的持续业务， 肯尼亚的农村保健系统，利用新的低成本技术，并让当地幼儿发展决策者参与， 利益相关者作为关键合作者从项目的一开始，我们的项目有可能使重要的 为资源有限的环境发现潜在的可扩展、可持续的解决方案做出贡献。

Abstract An estimated 43% of children under age 5 in low- and middle-income countries (LMICs) experience compromised development due to poverty, poor nutrition, and inadequate psychosocial stimulation. Numerous early childhood development (ECD) parenting interventions have been shown to be effective at improving ECD outcomes, at least in the short-term, but they are a) still too expensive to implement at scale in low-resource and rural settings, and b) their early impacts tend to fade over time in the absence of continued support. New ways to deliver effective ECD parenting interventions are sorely needed that are both low-cost to be potentially scalable, while also able to sustain impacts long-term. The rapid growth and low cost of mobile communications in LMIC settings presents a potentially promising solution to the competing problems of scalability and sustainability. Yet there is no rigorous research on mobile-health (mHealth) interventions for ECD outcomes in LMIC settings. We recently showed that an 8- month ECD parenting intervention featuring fortnightly group meetings delivered by Community Health Workers (CHWs) from Kenya's rural health care system significantly improved child cognitive, language, and socioemotional development as well as parenting practices, and our group-based delivery model was more cost-effective than previous ECD interventions. Yet it is still too expensive for scaling in a rural LMIC setting such as ours, particularly if we need interventions that can be extended for longer periods of time to increase their ability to sustain impacts. Our proposed study experimentally tests a traditional in-person delivery model for an ECD parenting intervention against two mHealth-based delivery models that partially or almost fully substitute remote delivery for in-person meetings. Kenya is an ideal setting for testing mHealth programs given its high penetration of mobile phones (94%). We will assess the relative effectiveness and costs of these mHealth delivery models against a purely in-person model, and extend the interventions over two years to increase their ability to sustain changes in child outcomes longer term. Our evaluation design is a non- inferiority clustered Randomized Control Trial across 60 CHWs and 1200 households in which we will use an adaptive trial design to allow for midcourse review and feedback on the remote delivery models. By testing three interventions that vary in how much in-person delivery is substituted by remote-delivery, we can assess the degree of substitutability or complementarity to inform the design of more scalable and sustainable interventions. Our goal is to determine the best model to maximize the intervention's reach and sustained impacts to improve child outcomes. By integrating delivery into the ongoing operations of local CHWs within Kenya's rural health care system, utilizing new low-cost technology, and involving local ECD policymakers and stakeholders as key collaborators from the project's inception, our project has the potential to make important contributions towards discovering potentially scalable, sustainable solutions for resource-limited settings.