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

摘要 据估计，在低收入和中等收入国家(LMIC)，43%的5岁以下儿童经历了 由于贫困、营养不良和心理社会刺激不足而损害发展。数不胜数 早期儿童发展(ECD)父母干预已被证明在改善ECD方面是有效的 结果，至少在短期内，但它们仍然太昂贵，无法在低资源的情况下大规模实施 B)在没有持续支持的情况下，它们的早期影响往往会随着时间的推移而逐渐减弱。新的 提供有效的ECD育儿干预的方法是迫切需要的，既要低成本，又要有潜力 可扩展，同时也能够长期维持影响。 LMIC环境中移动通信的快速增长和低成本提供了一个潜在的前景 解决可伸缩性和可持续性方面的相互矛盾的问题。然而，还没有严格的研究表明 移动健康(MHealth)干预措施对LMIC环境中的ECD结果的影响。我们最近展示了一个8- 由社区卫生组织提供的以每两周一次的小组会议为特色的一个月的ECD育儿干预 来自肯尼亚农村卫生保健系统的工作人员显著改善了儿童的认知、语言和 社会情绪发展和育儿实践，我们的基于群体的交付模式更多 比以往的幼儿发展干预措施更具成本效益。然而，在农村LMIC环境中进行扩展仍然成本太高 就像我们这样，特别是如果我们需要可以延长更长时间的干预措施来增加 他们承受冲击的能力。我们提议的研究通过实验测试传统的面对面交付模式 针对部分或几乎完全基于mHealth的两种交付模式的ECD育儿干预 用远程交付取代面对面会议。肯尼亚是测试移动健康计划的理想环境 其手机的高渗透率(94%)。我们将评估这些措施的相对有效性和成本。 与纯粹的面对面模式进行比较，并将干预措施扩展到两年以上 提高他们长期维持儿童结局变化的能力。我们的评估设计是一种非 我们将在60个CHW和1200个家庭中进行劣势群集化随机对照试验 适应性试验设计，允许对远程交付模式进行中期审查和反馈。通过测试 在面对面交付被远程交付取代的程度上，我们可以评估三种不同的干预措施 替代性或互补性的程度通知设计更具可伸缩性和可持续性 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性 对改善儿童结果的影响。通过将交付整合到当地社区卫生服务中心的持续运营中 肯尼亚的农村保健系统，利用新的低成本技术，并让当地的幼儿发展政策制定者和 利益相关者从项目一开始就是关键的协作者，我们的项目有可能使重要的 有助于为资源有限的环境发现潜在的可扩展、可持续的解决方案。

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.