Investing in Quality in Global Early Childhood Development: Parent-Focused, Center- Based and Systems Levels Hirokazu Yoshikawa, Ph.D. Harvard Graduate.

Investing in Quality in Global Early Childhood Development:

Parent-Focused, Center-Based and Systems Levels

Hirokazu Yoshikawa, Ph.D.Harvard Graduate School of Education

August 27, 2012South Asian Regional Conference on Early Childhood Care

and EducationNew Delhi, India

Overview

• Rationale for investing in quality: Neuroscientific, biological and evaluation sciences

• Examples of quality investment in ECD:1) Parent-focused programs – investing

in the relationship2) Center-based programs – investing in

the social setting3) Systems-level – quality in governance

and finance of ECD systems

RATIONALE FOR INVESTING IN ECD QUALITY

NEUROLOGICAL AND BIOLOGICAL PERSPECTIVES

The Importance of Early Childhood

The healthy development of all young children benefits all of society by providing a solid foundation for responsible citizenship, strong communities, and a productive nation.

Core Concepts of ECD

Brains are built over time, neural circuits are wired in a bottom-up sequence, and the capacity for change decreases with age.

The interaction of genes and experience shapes the architecture of the developing brain, and a primary active agent is the “serve and return” nature of children’s relationships with the important adults in their lives.

The Rationale for Quality

New data from neuroscience, genetics and biological sciences indicate that early enriched environments can mitigate effects of disadvantage on later cognitive outcomes, mental health, and executive functioning.

The new science of the benefits of enriched early environments suggests an important rationale for investments in the quality of ECD services, with particular attention to the most vulnerable children and families (Britto, Yoshikawa, & Boller, 2011; Engle et al., 2011; Kaul & Sankar, 2009).

Socioeconomic Status and Child Development (Hackman, Farah, & Meaney, 2010, Nature Reviews: Neuroscience; Yoshikawa, Aber, & Beardslee, 2012, American Psychologist)

Mechanisms of Long-Term Effects of Enriched Early Environments (Hackman, Farah, & Meaney, 2010)

• Changes in gene expression associated with fear responses

• Changes in HPA axis functioning (more adaptive stress responses)

• Neuronal growth factors and synaptic density

• Increased fetal and infant growth

How Early Experiences Alter Gene Expression and Shape Development

Neuron

Genes Carry Instructions that Tell Our Bodies How to Work

Nucleus

Chromosome

DNA

Gene

Early Experiences Leave Lasting Chemical “Signatures” on Genes

External Experience

Gene Regulatory Proteins

Epigenetic “Signature” Turns Gene On or Off

Early Enrichment Prevents Stress-Induced Cognitive Disruption

(Cui et al., 2006, Neuroscience Letters)

Source: Cue et al. (2006)

remediation

Correct choices on memory test

Normal Normal + Enriched Environment

Early Stress + Enriched Environment

Early Stress

90

75

60

45

“normal” range

Source: Nelson et al. (2007)

“normal” range

100

90

70

60

Timing of Enrichment in the Context of Severe DisadvantageBucharest Early Intervention Program (Nelson et al.,

2007, Science)

80

0-18 18-24 24-30 30+

“normal” range

0-18 18-24 24-30 30+

IQ/DQ (Mean)

Age of placement in foster care (months)

Tested at 3 1/2 Years Old Tested at 4 1/2 Years Old

Monitoring, assessing and investing in quality (UNESCO & UNICEF, End of Decade Review)• Quality of ECD is not assessed solely

through child outcomes, but by assessing effectiveness factors in: Relationships (e.g., home visitor-parent)Settings (e.g., parent or child groups; preschools)Larger systems (of support and training; policy

implementation; finance and data systems)• A new generation of research on ECD

quality improvement is emerging: Compare services with specific investments in quality improvement to services without (rather than comparing ECD services to no services)

INVESTMENT IN THE RELATIONSHIP: ECD QUALITY IN PARENT-FOCUSED PROGRAMS[EFFECTIVENESS FACTOR: RESPONSIVENESS AND SENSITIVITY]

EXAMPLES FROM BANGLADESH, PAKISTAN AND COLOMBIA

Example from Bangladesh

• Hamadani, Huda, Kharun, & Grantham-McGregor (2006): cluster-randomized trial of community health centers

• Nutrition supplementation only • Nutrition supplementation + parent-child

stimulation component.

• Combination of supplementation and stimulation: Increased children’s overall cognitive development (Bayley MDI).

Example from Pakistan• LHW community health worker program – proven

positive impacts on infant mortality (Bhutta et al., 2011)

• Pehla Qadam (Aisha Yousafzai): • Support for lady health workers implementing

preventive and promotive nutrition and health education and links to primary care (incl. Care for Development module)

• Mentorship, coaching, community sensitization• Sensitivity and responsiveness in the facilitator –

LHW relationship parallels target of sensitivity and responsiveness in the LHW – parent relationship

• Randomized evaluation

Example from Colombia (Bernal, 2010)• Hogares Comunitarios: Challenges of community-

based child care quality given education level of the community caregivers

• Development of intensive certification / training in ECD for caregivers (ICBC, Inst Colomb de Bienestar Fam and SENA) – classes, group and individual work (3 semesters, classes 3 nights a week)

• Controlled comparison of caregivers with and without this training:

• Positive impacts on quality as measured by FDCRS; reductions in diarrhea and incidence of flu / colds; increases in communication; motor development, and socio-emotional development (ASQ reported by parents)

Didactic course only effective when accompanied by on-site coaching for center- and home-based child care providers (Neuman & Cunningham, 2009)

85

90

95

100

105

110

115

Pre Post

PD only-C

PD +Coaching-C

Control-C

Neuman & Cunningham, 2009; similar findings: Landry, Crawford, Gunnewink, & Swank, 2001

Early Childhood Language Teaching Strategies (ELLCO)

Emerging Principles from Quality Improvement of Home- and Community-Based Programs• Psychosocial and cognitive stimulation

added as component to nutritional programs improves impacts on children’s cognitive development (Engle et al., 2011)

• Effectiveness factors / active ingredients – emphasis on sensitivity, responsiveness and language interaction

• In professional development for visitors / community mothers / health promoters – incorporate same sensitivity and responsiveness in trainer relationship with visitors / mothers / promoters

INVESTMENT IN THE SOCIAL SETTING: ECD QUALITY IN CENTER-BASED PROGRAMS[EFFECTIVENESS FACTOR: EDUCATIONAL PROCESS QUALITY]

EXAMPLES FROM CAMBODIA, CHILE, BANGLADESH, USA

Cambodia: Level of Investment in preschool education matters• Rao et al., 2007, 2011 Child Development: • Comparison of children in 3 programs of

preschool education with different levels of quality investment, intensity:

• State preschool (highest training, funding)• Community preschool and Home-based

program (lower training, funding)• Children in all 3 programs – better cognitive

and motor development than those in none• Children in State preschool better outcome

than Community or Home-based

Chile: Un Buen Comienzo• Un Buen Comienzo• Teacher professional development through

coaching to improve children’s language and respiratory health outcomes

• Based on model proven in Costa Rica (Rolla, 2011)

Didactic Workshop

Acompañamiento 1:Modeling

Acompañamiento 2:

Implementing

Group

Reflection Mtg (Every 2 months)

Cycle of coaching each month

12 cycles in 2 years of program

PRE

ACOMPAÑAMIENTO

POST

ACOMPAÑAMIENTO

Design of UBC impact evaluation

• Low-income municipalities of Santiago, Chile

• 1868 4-year-olds in 64 schools; 91 classrooms; 119 teachers in total sample

• Cluster-randomized trial with 64 preschools (Moreno & Lugo-Gil, 2008) randomly assigned to:

• Condition 1) Full UBC condition• Condition 2) Comparison condition

(minimal program: stress reduction class; books provided to classrooms)

• Principal mediator: CLASS assessment of educational process quality

Focus on educational process quality as effectiveness factor, in

addition to structural• CLASS Subscales of process quality: • Emotional support:

• Shared activities, positive emotion and expectations, warm, respectful interactions

• Productive time use: • Learning activities with few disruptions, clear

instructions, brief transitions, lesson and material preparation

• Instructional support: • Open-ended questions and prompts,

responsiveness, problem solving,, elaboration, cplanning, back-and-forth exchanges

27

Statistical significance levels are indicated as ~ = .10, * = 0.05, ** = 0.01, *** = 0.001

Figure 1. Effect sizes for impacts on classroom quality: CLASS dimensions and number of books.

Apoyo

em

ocio

nal

Apoyo

instru

ccio

nal

Man

ejo

de la

con

duct

a

Uso p

rodu

ctivo

del t

iem

po

Total

de lib

ros e

n sa

la

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

0.77***

0.41~

0.28

0.51**

0.61~

Instructional support Behavior management Productive time use Number of booksEmotional support

Bangladesh: Quality improvement for language and math skills

• Opel, Ameer, & Aboud, 2009, International Journal of Educational Research:

• Dialogic Reading training for preschool teachers.

• Post-test positive impact on vocabulary

• Opel, Khanom, Zanam, & Aboud, 2010: • Interactive math activity training for

preschool teachers and children: • Positive Impacts on math skills

Boston: Quality Improvement in Lang+Math at Scale with Impacts on Lang, Math, Exec Function• Weiland & Yoshikawa, 2012

• Combined language (OWL) and math curricula (Building Blocks) + coaching at scale across 76 public preschools serving largely low-income families

• Evaluation at scale using regression-discontinuity design based on birthday cutoff

• Moderate to large, positive impacts on vocabulary, letter-word identification, all dimensions of math skills

• Small, positive effects on 3 dimensions of executive function: inhibitory control, working memory, cognitive flexibility

Principles of Quality Improvement in Centers / Preschools• Curricula matter – those with

developmental relevance, implemented with activities that children and teachers enjoy (structure + play), aligned with ECD learning standards

• Process quality in ECE can be increased through in-service training provided on-site in classrooms

• Combination of developmentally focused curricula and coaching can be implemented at scale

INVESTMENT IN SYSTEMS: QUALITY IN THE GOVERNANCE AND FINANCE OF ECD

EXAMPLES FROM PERU, INDIA AND BANGLADESH

Quality Governance and Finance: Systems-Level Effectiveness Factors• Political will and collaborative policy

process (national action planning in ECD)• A causal theory for strategic investment

and intervention• Child budgeting (Kaul & Sankar, 2010;

Purkayastha, 2010) + Performance-based budgeting (Carlin & Guthrie, 2001, International Public Mgmt Reform)

• Strategic differential investments to address state, local, population disparities

• Building local and subnational data systems• Front-line provider and community

involvement in quality improvement

The fight against chronic child maltnutrition in Peru (Luna; Garatea; Abogattás)• Leadership across government and civil

society (e.g., Mesa de Concertación de la Lucha Contra la Pobreza)

• Legislation with approved budget and increased investments to achieve specific ECD goals (in context of rapidly expanding economy)

• Commitment of ministries of finance + sectoral ministries

• Ministry of finance particularly powerful – institutional integration into this ministry of ECD priority was key

Productos [Servicios] finalesintermediosinmediatos

↓ Chronic Malnutrition

Niños menores de60 meses

↓ Diarrea

↓ Infecciones Respiratorias Agudas

Niños menores de 24 meses

↑ Hand WashingHigiene

Madres de niños menores de 24 meses

CounselingEducational Sessions

Demonstration Sessions

↑ up to 6 mos: BreastfeedingMadres de niños

menores de 6 meses

↑ Calidad de lala dietaNiños de

6 a 24 meses

↑ Nutritional Suppl 6-24mos

Niños dede 6 a 24 meses

↑ CRED[control de crecimiento y desarrollo]

Anti RotavirusAnti Neumococo

↑ Vacuna

Three Key Practices

1

2

RESULTADOSKey INTERVENTIONS CAUSAL MECHANISMS AND RESULTS

… si alcanzamos coberturas mayores al 80% en las dos intervenciones claves podríamos reducir la desnutrición crónica de 49% a 35% puntos al 2016

Logic Model for Strategic Support to Reduce Chronic Malnutrition

Click aquípara regresar

Monto asignado en Enero 2008por los gobiernos regionales paraReducir la desnutrición crónica

(expresado en soles por niño menor de 5 años)

Valor de la Prevalencia de Desnutrición Crónica al 2007

2007-2008: No Alignment between Need and Spending at Regional Level re: Child Malnutrition

PrevalenciaDesnutrición Crónica (%)

PIA 2009: 1,052 MPIA 2010: 1,535 MIncremento 50%

Presupuesto por niño menor de 36 meses

Hay un IncrementoFocalizado del presupuesto

2010: Alignment between Regional Need and Spending

…. para las intervenciones que rigurosamente han sido probadas que son eficaces ….

Intervention [Product/ Service] 2009 2010 Increase

33254 Children with Complete Vaccinations For AgeIntroducción de nuevas vacunas para prevenir las infecciones respiratorias agudas y las diarreas en menores de 24 meses

165 M 420 M +254%

33255 Children with CRED (complete growth and development monitoring charts) completo según edadIncrementar sustancialmente la cobertura del control del crecimiento y desarrollo de los niños para promover en el hogar las tres prácticas claves de cuidado y alimentación del menor de 36 meses: lavado de manos, lactancia materna exclusiva y la adecuado alimentación del menor .

20 M 86 M +432%

+ Increases in funding for component products / services, 2009-2010

…. Conditioned on:

• Programming and budgeting on the part of health centers • Standardized “recipe” for services with room for local adaptation

En el 2008 no se observa

cambios

En el 2009se observa

cambios lentos

En el 2010 crece rápidamente

Investment in Human Resources to Support Products/Services (Growth in Hiring of Nurses for Local Health Centers)

… el indicador de ejecución presupuestal vinculado con el PRODUCTO y con su insumo crítico, se mide desde el inicio del año, mes por mes..

INSUMO

The Role of Data in Governance and Finance of Peru’s Child Malnutrition Policies• Dissemination of new data platform for

reporting numbers of children in need of preventive measures re: malnutrition – at the local level (each health center)

• Transparency of data allocation and expenditures by budget line (Transparencia Económica website updated daily; % of the year’s allocation spent to date visible to public)

• Data available for each budget line for nation and for each region

Results: Reductions in Rates of Chronic Malnutrition in Peru’s Children, 2007-

2010

La probabilidad de un niño promedio de sufrir de desnutrición crónica disminuye significativamente para los niños que nacieron a partir del 2008, controlando por otras características del niño, del hogar, de la comunidad y de intervenciones como juntos y SIS. La reducción en la probabilidad de sufrir de desnutrición de los niños que nacieron en 2010-2 respecto a los que nacieron en 2007-4 es del 60%

2007-1 2007-2 2007-3 2007-4 2008-1 2008-2 2008-3 2008-4 2009-1 2009-2 2009-3 2009-4 2010-1 2010-20%

5%

10%

15%

20%

25%

Prob. desnutrición (y=1) Cohorte de nacimiento

PpR

Community and provider involvement in quality improvement (Kaul & Sankar, 2009; UNICEF & UNESCO, End of Decade Review, 2012)• 1) Community involvement in service

provision and improvement: Local Resource Groups in UNICEF’s Dular project, building on ICDS (Dubowitz et al., 2007, Food and Nutrition Bulletin); Mother-tongue instruction in Bangladesh (Vijayakumar et al., 2010)

• 2) Continuous Quality Improvement approaches (Institute for Healthcare Improvement; Berwick, 2003 JAMA): Involvement of providers, local stakeholders in

rapid PDSA (Plan-Do-Study-Act) cycles utilized in Un Buen Comienzo expansion, Region VI of Chile)

Next directions in the quality imperative in ECD* Parent human capital development + ECD services• Bhutan – UNICEF-supported non-formal

education (NFE) + ECD program• Tulsa, Oklahoma – CareerAdvance program –

parent sector-specific workforce development + Head Start ECE (King, Glover, Chase-Lansdale, Yoshikawa)

* Integration of social protection / income support and CCT with ECD* Integration of intensive attention to children with disabilities

Conclusions• From increasing access to improving quality: The next

challenge in global ECD. • Rationale for improving quality – from neuroscience,

biological and evaluation sciences• At the level of parent or center-based programs: Focus on

responsiveness of interactions between trainer and community mother; community mother and parent as well as didactic content; educational process quality in centers as well as developmentally focused curricula.

• At the level of ECD governance and finance: Strategic investments in capacity building at state and local levels; results-based budgeting; data system development; community involvement

Thanks• Core Funder of UBC: Fundación Educacional

Oportunidad (seed funding: World Bank; UNICEF Chile office; Harvard Center on the Developing Child and HGSE); thanks to collaborators at Universidad Diego Portales and Mathematica Policy Research

• Funders of Governance and Finance in Early Childhood Development project: UNICEF Innocenti Research Centre; Bernard Van Leer Foundation; and thanks to collaborators Pia Britto and Jan Van Ravens

• Students / advisees: Soojin Oh, Ana Maria Nieto, Diana Leyva, Mary Catherine Arbour, M. Clara Barata, Christina Weiland, Celia Gomez, Nikhit D’Sa, Constanza Gonzalez Parrao