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, 2012 South Asian Regional Conference on Early Childhood Care and Education New 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 relationship 2) Center-based programs – investing in the social setting 3) 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 childrens 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 NormalNormal + Enriched Environment Early Stress + Enriched Environment Early Stress normal range

Source: Nelson et al. (2007) normal range Timing of Enrichment in the Context of Severe Disadvantage Bucharest Early Intervention Program (Nelson et al., 2007, Science) normal range IQ/DQ (Mean) Age of placement in foster care (months) Tested at 3 1 / 2 Years OldTested 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 childrens 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) 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 childrens 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 childrens 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 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, *** = Figure 1. Effect sizes for impacts on classroom quality: CLASS dimensions and number of books. Emotional 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 de 60 meses Diarrea Infecciones Respiratorias Agudas Niños menores de 24 meses Hand Washing Higiene Madres de niños menores de 24 meses Counseling Educational Sessions Demonstration Sessions up to 6 mos: Breastfeeding Madres de niños menores de 6 meses Calidad de la la dieta Niños de 6 a 24 meses Nutritional Suppl 6-24mos Niños de de 6 a 24 meses CRED [control de crecimiento y desarrollo] Anti Rotavirus Anti Neumococo Vacuna Three Key Practices 1 2 RESULTADOS Key INTERVENTIONSCAUSAL 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 aquí para regresar

Monto asignado en Enero 2008 por los gobiernos regionales para Reducir la desnutrición crónica (expresado en soles por niño menor de 5 años) Valor de la Prevalencia de Desnutrición Crónica al : No Alignment between Need and Spending at Regional Level re: Child Malnutrition

Prevalencia Desnutrición Crónica (%) PIA 2009: 1,052 M PIA 2010: 1,535 M Incremento 50% Presupuesto por niño menor de 36 meses Hay un Incremento Focalizado del presupuesto 2010: Alignment between Regional Need and Spending

…. para las intervenciones que rigurosamente han sido probadas que son eficaces …. Intervention [Product/ Service] Increase Children with Complete Vaccinations For Age Introducción de nuevas vacunas para prevenir las infecciones respiratorias agudas y las diarreas en menores de 24 meses 165 M420 M+254% Children with CRED (complete growth and development monitoring charts) completo según edad Incrementar 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 M86 M+432% + Increases in funding for component products / services, …. 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 2009 se 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 Perus 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 years 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 Perus Children, 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 respecto a los que nacieron en es del 60%

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 UNICEFs 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 DSa, Constanza Gonzalez Parrao