Financing Investments in Young Children Globally: Summary of a Joint Workshop by the Institute of Medicine, National Research Council, and The Centre for Early Childhood Education and Development, Ambedkar University, Delhi (2015)

Appendix D


Poster Session Abstracts

SMART KIDS FITNESS PROJECT ON WEIGHT MANAGEMENT FOR PRIMARY SCHOOL CHILDREN ADOPTING FRAMEWORK OF HEALTH PROMOTING SCHOOLS

A. Lee, M. Ho, A. C. M. Kwong, and M. W. Keung, Centre for Health Education and Health Promotion, Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

Citation: Lee, A., Ho, M., Keung, M. W., and Kwong, A. C. M. 2014. Childhood obesity management shifting from health care system to school system: Intervention study of school-based weight management program. BMC Public Health 14:1128. doi:10.1186/1471-2458-14-1128.

Purpose: With support from the Health Care Promotion Fund, Food and Health Bureau of the government of the Hong Kong Special Administrative Region, the project aimed to help overweight and obese primary school children to develop healthy lifestyles with the goal of weight control via home-school joint venture approach under the support of health care professionals.

Design: The one-year project adopting the Health Promoting Schools approach consisting of improvement in school policies and environment in healthy lifestyles, health skills training and empowerment for teachers

and parents, involvement of family and health professionals to create a healthy culture for the benefits of all students in schools.

Setting: Primary school setting

Participants: Students aged 8–12 who were overweight or obese

Methods: The project adopted randomized control study design. Participating students were randomly assigned into intervention and control groups. Both students and their parents in both groups had pretest (T₀) at baseline, midterm test (T₁) on completion of the intervention program, and posttest (T₂) at four months after completion of program. The methods of evaluation were:

• Anthropometric assessment for students
• Survey for students on health behaviors
• Survey for parents on children’s health behaviors

Results: A total of 93 students from six participating schools completed the whole program. The key findings included:

• BMI [body mass index] and body fat percentage of the intervention group students stabilized from T₀ to T₁ whereas those of control increased significantly (BMI + 0.78kg/m², p < 0.001; body fat + 2.29 percent, p = 0.005).
• From T₁ to T₂, the intervention group showed a significant drop in mean body fat from T₁ to T₂ (–2.3 percent, p = 0.001).
• The intervention group showed an increase in the percentage of students meeting the daily recommended fruit and vegetable intake from T₀ to T₁ whereas there was no change in fruit and decrease in vegetable intake in control.
• Parents’ survey showed a significant increase in the percentage of parents who reported that their children’s dietary habits were healthy or very healthy from T₀ to T₁ (+21.2 percent, p = 0.019).
• From T₀ to T₁, an increased percentage of students from the intervention group met the basic exercise recommendation in all types of exercises, and significantly more intervention students expressed that they liked doing exercise (+29.5 percent, p = 0.02).

Implication of Research: The findings of the project affirmed that the Health Promoting Schools model is an effective way to integrate a broad range of strategies to foster a supportive environment to prevent and alleviate childhood obesity.

LITERACY RESEARCH IN INDIAN LANGUAGES: UNDERSTANDING LITERACY INSTRUCTION AND LEARNING OUTCOMES IN THE FIRST GRADE

Shailaja Menon, Azim Premji University, Bangalore; Ramchander Krishnamurthy, Azim Premji University, Bangalore; Sajitha Kutty, Azim Premji University, Bangalore; Neela Apte, Kalike, Bangalore; Abha Basargekar, QUEST, Thane; and Mounseh Nalkamani, Kalike, Yadgir

Background and Rationale: The Literacy Research in Indian Languages (LiRIL) is a longitudinal project studying early literacy development in Kannada and Marathi. This is a study initiated by Sir Ratan Tata Trust, Mumbai, in collaboration with Azim Premji University, Bangalore. Most of the theory and research related to early literacy have been generated in Western, English-speaking contexts. English uses an alphabetic script that differs considerably from the alphasyllabic or semisyllabic scripts used in most Indian languages. These linguistic differences, as well as differences in cultural and instructional contexts, make it questionable to generalize understandings generated in the West to Indian settings.

Objectives: The broad aims of the study are: (1) To study the acquisition of several literacy skills and sub-skills in a cohort of 360 students (per site) as they move from Grades 1–3 in Kannada and Marathi; (2) To understand the classroom contexts in which students acquire literacy by examining classroom transactions, curricular materials, and teacher knowledge and beliefs; (3) To identify the most significant predictors of literacy acquisition; and (4) To get insights into significant challenges to literacy acquisition, especially in the lives of some of the most marginalized students in the classroom.

Design and Methodology: The project combines quantitative bi-annual tracking of literacy acquisition in the cohort of 360 first-grade cohort on a battery of tests across two sites (Yadgir in Karnataka for Kannada, and Thane in Maharasthra for Marathi). The cohort of students is being followed from Grade 1 to Grade 3. Other methods that are being used include (1) classroom observations; (2) case studies of struggling readers from marginalized backgrounds; (3) teacher interviews; and (4) curricular analyses to generate a holistic understanding of literacy development in disadvantaged Indian contexts. The project has currently completed two years of piloting and is in the second year of its longitudinal study.

Results: The poster presentation will outline the “Growth and Variability in Early Literacy during First-Grade.” In this presentation, we will share

emergent insights based on the first year’s bi-annual tracking of literacy learning in 360 first graders at both sites. Specifically, the presentation focuses on three questions:

1. Literacy Acquisition of First-Graders—What have the first-graders learned in terms of reading and writing during their first year of formal schooling? We will attempt to answer this question both at a broad level in terms of capacities to read and write, as well as in terms of the difficulties and challenges they face. This analysis will be largely based on the second round of data collection conducted toward the end of Grade 1.
2. Documenting Growth during First-Grade—Since we have captured two rounds, we are able to observe growth in literacy across the year. In this part of our presentation, we will present the overall growth patterns observed across the year and demonstrate variability in this growth. This might eventually enable us to answer questions such as the following: Do the disadvantages in literacy acquisition set in early and remain firm? Or can children catch up over time?
3. Explaining Variability—In our initial analysis, we notice significant variations in achievement at least three levels: (a) between the two sites in Karnataka and Maharashtra; (b) between different classrooms included in our sample, even within the same site; and (c) between different children in the same classroom. What can we learn about the correlates of variability at each of these three levels? We draw on both data on background variables that we have collected and from the qualitative observations that we have made of the classrooms.

Implications: The presentation will briefly discuss implications of the research findings for literacy instruction in the early primary grades and the kinds of changes in curriculum and teacher education that are required.

REDUCING MALARIA BY A FACTOR OF TEN IN PART WITH ROTARY FUNDING

Naina Wodon

Purpose of Study: To document the impact of Muso’s four-step approach to malaria and child mortality in Mal and the mechanism used by Rotary International to help fund the project.

Design/Setting/Participants/Methods: Muso works in communities through a four-step approach. The first step consists of mobilizing the existing health care delivery system. This includes selecting, training, employing, and supervising local individuals who go door to door and identify children sick with malaria and other illnesses. These community health workers diagnose malaria in the household and treat simple cases. The second phase consists of removing barriers that prevent people from accessing care when needed. By eliminating point-of-care user fees, Muso ensures that even the poorest can benefit from life-saving comprehensive and universal care, whether at home, in community health centers, or in referral hospitals. The third step consists of creating rapid referral networks by training communities in identifying health risks, prioritizing rapid treatment, and navigating the health system. The final step consists of clinical capacity building. As Muso systematically removes access barriers to achieve universal health coverage, it reinforces the ability of the public sector to provide quality care to its patients.

Results: As documented by Johnson et al. (2013), at baseline, the child mortality rate in the Muso catchment area was 15.5 percent. After three years, it plummeted to 1.7 percent. During the same period, the study documented a tenfold increase in the number of patient home and clinic visits; a doubling of the rate of rapid access to malaria treatment for children in need; and a reduction by one-third in the share of children becoming sick with fever. Because the study was not based on a randomized controlled trial, but on repeated cross-sections in Muso’s area of intervention, caution is needed in assigning causality. Nevertheless, the results are very encouraging.

Innovative Funding: Thanks to fundraising by a network of Rotarians in Mali, the United States, and India, Muso benefitted from a $60,000 grant from the Rotary (International) Foundation. The focus of this grant was on malaria prevention and treatment for the community of Yirimadjo. The funds were used to buy high-quality insecticide bed nets and provide diagnosis and treatment for more than 3,500 patients. During the course

In March 2014 the Rotary Foundation awarded Muso an additional $151,500 global grant. The new initiative, put together by the Rotary Club of Washington, DC, is called “Thrive for Five: Improving Child Mortality and Survival in Mali.” It will benefit 13,500 children over two years. To date, close to two dozen Rotary Clubs in 11 countries across four continents have supported Muso’s work. The Muso team recently received two global awards. The 2013 GSK Global Healthcare Innovation Award recognized Muso as one of five effective new models for better chances of child survival. The Caplow Children’s Prize named Muso one of eight finalists for its global award that identifies high-impact new models for saving children’s lives.

Implications: Grassroots private fundraising for innovative service delivery health care models with first-rate implementation capacity can be highly successful for demonstrating the value of pilots, which can then be replicated by larger organizations at scale.

Reference for the Impact Assessment: Johnson, A. D., et al. 2013. Assessing early access to care and child survival during a health system strengthening intervention in Mali: A repeated cross sectional survey. PLoS ONE 8(12):e81304.

THE LATIKA ROY FOUNDATION

Shubha Nagesh and Jo Chopra

The Latika Roy Foundation (LRF) has established itself as a major player in the field of disability in North India. The quality of specialized services offered for children and adults (birth to adulthood) is unparalleled in the region, and our comprehensive approach to early childhood development (ECD) is innovative and family centered and based on parent empowerment.

LRF works with parents and ECD providers (Anganwadi centers) to identify at-risk children early, prevent acquired disability in typical children, and mitigate the impact of developmental disabilities on children and their families, while helping all of them become ready for school.

Engaging with the government is the only practical way to achieve scale and effect change within the system. We are already working successfully and extensively in a public–private partnership with the National Rural Health Mission at Gubbara; our assessment and diagnostics center located at the government Doon Hospital; and Chhota Gubbara, our follow-up program for high-risk newborns, located in the Doon Women’s Hospital.

Assessment and diagnosis is only the first step in a very long process, and parents need much more input to truly make a difference in their children’s lives. In addition to assessments and diagnoses, these programs provide parents intensive training to creatively engage and work with their child at home. A pilot program, initially funded by Sight Savers UK, now self-funded, provides follow-up care in the community for children assessed at Gubbara.

Mama EIC [early intervention center] is a center-based therapy program for young children with disability from 0 to 5. Children attend sessions with their parents, who are trained to continue the program, including speech therapy and physiotherapy at home. We follow a family centered and holistic approach based on the belief that every child, regardless of ability, has the potential to develop and grow in a positive way. Free and structured play sessions form an important part of the curriculum at all levels. We believe in developing the whole child, and personality development is as important as teaching a child to perform specific tasks. Strong emphasis is placed on consistent, nonthreatening behavior management and the development of good social skills.

Currently, we are seeing children with significant disabilities, and the majority need help over an extended period; most still have special needs at five years of age. These children move on to Karuna Vihar School or the Child Development Centre or other schools able to meet their continuing needs. A growing number of children have been admitted to mainstream schools and have been supported there by on-going interaction with the LRF outreach team.

Our rights-based approach challenges injustice and demonstrates how inclusion works. By training grassroots and professional personnel and mentoring hundreds of children with special needs, we are bringing the disability perspective to mainstream health and education, thereby raising standards for everyone. Our focus now lies on training and capacity building as the best ways to scale up and demonstrate our belief that when we plan for the most vulnerable, the world works better for everyone. Our mission is to make Uttarakhand a model state where people with disabilities have access to education, employment, and full inclusion in the community.

EARLY CHILDHOOD EDUCATION INITIATIVE: PROVIDING AFFORDABLE HIGH-QUALITY EDUCATION FOR CHILDREN FROM LOW-INCOME FAMILIES IN URBAN INDIA

Monitor Inclusive Markets, a mission-driven nonprofit unit of Deloitte

Aroon Vijaykar, Tom Blathwayt, Ashish Karamchandani

Purpose of Study: To determine the state of the early childhood education (ECE) market in urban India and the potential for a private-sector intervention to provide good quality ECE at scale for low-income families earning INR 10–25K per month.

Design/Setting/Participants/Methods: Monitor Inclusive Markets (MIM) conducted an eight-week scan of the ECE sector in India with a four-member team. The research process involved interviews with 11 experts, 12 investors/grant makers, and 8 ECE providers. The team also conducted site visits with 10 ECE providers and reviewed 12 industry reports. Coming out of the research, MIM designed a six-year program for a private-sector intervention and refined it based on input from six experts and one funder.

Results: An increasing number of the 14 million households in urban India earning ~INR 10–25K are paying ~4–6 percent of their monthly household income (~INR 6–15K per annum) to send their children to private ECE centers as they believe this will help them get into good private schools. However, most ECE being provided to low-income children today is of a low quality due to teachers employing rote learning methods in teaching English/math as well as teaching writing at an early age when motor skills are not yet sufficiently refined. This low-quality standard for ECE is due to a few different factors. Parents want children to learn English, math, and writing in order to gain admission into good private schools. For admissions testing, schools use criteria such as English/math as a proxy for evidence of academic capability. As a result, ECE teachers use methods they are familiar with (e.g., rote learning) to teach to the demands of parents and schools. In addition, low-quality ECE is cheaper to deliver because it requires a lower teacher-to-student ratio.

However, there exists the potential for a sustainable and scalable model that can deliver high-quality ECE while serving low-income households. Such a model would include more play-based and interactive learning, focusing on age-appropriate skills and the full suite of priority development areas (e.g., physical, social, emotional, and cognitive). The model is commercially viable because one can get low-cost rental space in low-

income neighborhoods, and teachers are open to working at reasonable wages. Parents could be convinced of the need for high-quality ECE, and school admission criteria could be changed to incentivize market adoption of high-quality ECE. Teachers too can be educated and trained to deliver high-quality ECE.

Implications of Research: MIM is embarking on a six-year program to catalyze the market for lower-cost high-quality ECE. Activities include:

• Defining and disseminating a business model blueprint
• Assembling supporting elements (e.g., teacher training curricula, quality assessment systems)
• Running pilots through four to six partners in approximately three cities
• Supporting three to five scale adopters
• Addressing cross-cutting ecosystem barriers (e.g., lack of standardized quality assessment tools, policy obstacles)

MIM aims to impact 18 lakh children annually by 2025.

THE UMMEED EARLY CHILDHOOD DEVELOPMENT AND DISABILITIES PROGRAM

Rucha Shelgikar, MBBS; Vibha Krishnamurthy, M.D.; Pervez Daver, M.Sc.

Ummeed Child Development in partnership with Forbes Marshall, Pune

There is ample research that documents why young children in low- and middle-income countries do not develop optimally due to multiple risk factors like malnutrition, anemia, and poor awareness amongst caregivers about early child development (ECD).

Early intervention for children at risk of and with developmental disabilities leads to improved developmental outcomes for the children as well as benefits for the community in terms of maximizing human potential and return on investment.

In India, the best access to families with children under the age of three is through community health workers (CHWs) who have direct contact with them. Ummeed designed and piloted a prototype intervention in collaboration with Forbes Marshall (FM) for their projects with CHWs in urban slums in Pune.

Objectives:

• To create a training program that gives CHWs the skills to
• Promote and monitor ECD in their community
• Identify children with disabilities early
• Teach families simple play and communication-based interventions to address developmental delays
• Identify local resource bases for referral of children with developmental disabilities and to actively advocate for children with disabilities
• To pilot the training program with 15 CHWs and their supervisors in three urban slum communities in Pune

Methods: Fifteen CHWs and two supervisors were selected as trainees for the pilot. Baseline assessments for FM, CHWs, and the community were conducted. Ummeed conducted the training in four modules of three to four days, over a period of 15 months. In between modules, supervisors and CHWs went into the community to engage with the families one day a week, every week. For effective mentorship, Ummeed had regular meetings and telephonic conversations with the supervisors.

Results: The CHWs have monitored and supported the development of 717 children under the age of 3 by visiting their homes regularly over the past 18 months. Twenty-eight children under the age of 3 and six older children were identified to have significant delays. Ten children requiring further assessment and treatment were sent to locally identified resource centers.

Qualitative changes were seen in the communities’ attitude and practices related to ECD. Communities included ECD as part of the agenda for community meetings and events and proactively sought CHWs for advice and support related to children. The CHWs have become strong advocates for ECD and for children with disabilities. Operational costs in the field of Rs.48,000/month (USD 800) were borne by FM. This roughly translates into an investment of Rs.100 (USD 1.6) per child being monitored in a given month.

Implications: The Ummeed FM ECD prototype provides a model that can be used for ECD interventions for children at risk and with developmental disabilities. It has the potential to be replicated, through partnerships between organizations that have expertise in ECD, with community-based organizations. Government policy and funding need to be in place that promote such partnerships.

THE ODISHA IMPACT ASSESSMENT STUDY: MOTHER TONGUE–BASED MULTILINGUAL EDUCATION

Anubha Rajesh, Shefali Pai-Samant, Vini Gupta, and Manvika Sharma

ICF International

The program “Successful Transition for Young Tribal Children in Odisha,” supported by the Bernard van Leer Foundation, is a part of India’s strategy to provide “increased access to quality multilingual pre-school education services for 3–5 year old tribal children in Odisha.” The foundation through the current study wants to establish empirical evidence that can be shared with the policy makers to improve opportunities for disadvantaged children. The objectives of this longitudinal study are to measure the impact of mother tongue–based multilingual education by tracking children from early childhood education (ECE) centers through Class II with respect to enrollment, retention, and performance.

Research Design: A quasi-experimental research design was utilized. Purposive sampling was used to select the intervention (PREM [People’s Rural Education Movement] and ICDS + PREM) group. Subsequently, a comparable control group (ICDS) sample was selected. Rigorous measures were employed to create/adapt contextually appropriate tools (center observations, child assessments, child height and weight, social skills, facilitator/AWW [Anganwadi worker] interview, parent interviews, family demographic survey, and focus group discussions) and train field staff.

Sample: This poster presentation is focused on the data collected and analyzed for Time 1 and Time 2, when the children were enrolled in ECE centers. The sample from Time 1 included 455 children from 78 ECE centers of the Kandhamal and Rayagada districts of Odisha. A total of 150 parents and 79 facilitators/AWWs were interviewed to gain an understanding of their opinion. In addition, 30 focus group discussions were conducted with the community.

Research Questions Focused for the Presentation:

1. How do the three ECE program models (PREM, ICDS + PREM, and ICDS) compare in terms of program quality (classroom, teacher, and curriculum)?
2. What is the relationship between the type of ECE program model (PREM, ICDS + PREM, and ICDS centers) and changes in children’s physical, language, literacy, math, and socioemotional outcomes from the beginning to the end of the preschool year?

Major Findings from Time 1 and Time 2: The findings from the study indicate that there were no significant differences between PREM, ICDS + PREM, and ICDS centers with regard to center quality, which was generally average. The language spoken for the majority of the day in ICDS centers was Odiya (85.8 percent), whereas in PREM centers, both Kui and Saora were spoken along with Odiya. AWWs from ICDS + PREM and ICDS centers had higher education qualifications and longer tenures than PREM facilitators. More PREM facilitators reported receiving mother-tongue-approach training as compared to their counterparts.

The key findings for the performance of children below 4.5 years and children in 4.6–5.11 years indicate that both age groups of children from both ICDS and PREM improved in total scores over time. Mixed ANOVAs [Analyses of Variance] conducted on the older age group showed PREM children performed better in the overall total child assessment score, school readiness items, and language items. However, the children’s performance is far from ideal.

Implications: This is a unique longitudinal study in India with a quasi-experimental research design to focus on mother tongue programming and ECE in a tribal context. The findings throw light on how grassroots efforts and mother tongue programming can help increase access to ECE services to marginalized children and families.