Designing and Implementing an Early Childhood Health and Development Program in Rural, Southwest Guatemala

Advances in Pediatrics 64 (2017) 381–401

ADVANCES IN PEDIATRICS Designing and Implementing an Early Childhood Health and Development Program in Rural, Southwest Guatemala Lessons Learned and Future Directions Gretchen J. Domek, MD, MPhila,b,*, Maureen Cunningham, MD, MPHa,b, Andrea Jimenez-Zambrano, MPHb,c, Dena Dunn, PsyDb, Madiha Abdel-Maksoud, MD, PhDa,b,d, Michael Bronsert, PhD, MSb,c, Claudia Luna-Asturias, MSWb,e, Stephen Berman, MDa,b,d a

Department of Pediatrics, University of Colorado Anschutz Medical Campus, Campus Box B065, 13123 E. 16th Avenue, Aurora, CO 80045, USA; bCenter for Global Health, Colorado School of Public Health, Campus Box A090, 13199 E. Montview Boulevard, Suite 310, Aurora, CO 80045, USA; cAdult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Campus Box F443, 13199 E. Montview Boulevard, Suite 300, Aurora, CO 80045, USA; dDepartment of Epidemiology, Colorado School of Public Health, Campus Box B119, 13001 E. 17th Place, Building 500, 6th floor WS21, Aurora, CO 80045, USA; eChild Health Associate/Physician Assistant Program, University of Colorado PA Program, Campus Box F543, 13001 E. 17th Place, Room E7019, Aurora, CO 80045, USA

Keywords



Child development
Child health
Community health
Global health Guatemala

Key points


Prenatal development combined with the first 3 years of a child’s life constitute the most critical and rapid period for human brain growth and development.




Risk factors in early childhood, such as poverty, maternal depression, and stressful or traumatic experiences, can cause lasting impairments in learning, behavior, and physical and mental health. Continued

*Corresponding author. Center for Global Health, Colorado School of Public Health, Mail Stop A090, 13199 East Montview Boulevard, Suite 310, Aurora, CO 80045. E-mail address: [email protected] http://dx.doi.org/10.1016/j.yapd.2017.04.003 0065-3101/17/ª 2017 Elsevier Inc. All rights reserved.

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Continued


These risk factors are often exacerbated in low-income and middle-income countries, with multiple deprivations adding a cumulative adverse effect on the well-being of the world’s poorest children.




Community efforts to promote protective factors, such as healthy behaviors in pregnancy, nurturing caregiver relationships, and a strong developmental foundation for children, provide critical ways to buffer toxic stress and mitigate the lifelong effects of early childhood adversity.




Integrated interventions to improve early childhood development, health, and nutrition have shown promising results in low-income and middle-income countries, and are most likely to benefit the world’s most disadvantaged children.

INTRODUCTION The University of Colorado and the Colorado School of Public Health are partnering with a local private sector agricultural corporation in rural, southwest Guatemala to develop a maternal and child community health program. This article describes the early childhood part of the program, which was designed to include an integrated approach to early childhood health and development. The program combines a series of newborn home visits, community education sessions, and mother-child interactive group visits to enhance the health and development of children from birth to 3 years of age. This article uses descriptive statistics to outline findings from the initial 18 months of the program and describes important challenges faced, lessons learned, and future directions. BACKGROUND Prenatal development combined with the first 3 years of a child’s life constitute the most critical and rapid period for human brain growth and development. Advances in neuroscience, molecular biology, immunology, epigenetics, and developmental psychology have shown that early childhood adversity and negative environmental influences, called toxic stress, during this transformative period of human development have significant consequences for the long-term functioning of individuals [1]. It is well established that risk factors in early childhood, such as poverty [2,3], maternal depression [4], and stressful or traumatic experiences [5,6], can cause lasting impairments in learning, behavior, and physical and mental health. These risk factors are often exacerbated in low-income and middle-income countries (LMICs), with multiple deprivations adding a cumulative adverse effect on the well-being of the world’s poorest children [7]. Children in LMICs often face nutritional risk factors (eg, intrauterine growth restriction, childhood malnutrition, iodine deficiency, and iron deficiency), infectious diseases (eg, diarrheal diseases, malaria, and human immunodeficiency virus–acquired immune deficiency syndrome), environmental toxins (eg, contaminated drinking water, inadequate sanitation, arsenic, and lead exposure), decreased cognitive stimulation and inadequate learning opportunities (eg, maternal illiteracy,

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unstimulating home environments, and insufficient schools), and increased exposures to armed conflict or community violence that children in higher income countries often do not experience [8,9]. Given these increased risk factors, it has been estimated that more than 200 million children under age 5 years globally are not fulfilling their developmental potential because of poverty, poor health, malnutrition, and deficient care [10]. Furthermore, this loss of developmental potential in children can lead to a substantial decrease in adult productivity and income, contributing to an intergenerational transmission of poverty with implications for national development. Fortunately, awareness of the critical period for optimal child development and the importance of interventions aimed to improve early childhood development, health, and nutrition are now recognized on a global scale [11,12]. Community efforts to promote protective factors, such as healthy behaviors in pregnancy, nurturing caregiver relationships, and a strong developmental foundation for children, provide critical ways to buffer toxic stress and mitigate the lifelong effects of early childhood adversity [13]. The most impactful and cost-effective interventions include home and community-based parenting and family support programs that address multiple risk factors, target the most disadvantaged children, provide direct services to children along with support and education for caregivers, use multiple types of interventions (eg, education, micronutrient supplementation, and skill-building), include more than 1 delivery method (eg, home visits, group counseling, and mass media), take place for longer duration and greater intensity, and are implemented prenatally or early in a child’s life [11,12]. Evidence indicates that such programs can have a beneficial impact on both child and parental wellbeing. Additionally, integrated interventions to improve early childhood development, health, and nutrition have proven more effective than any single-focused intervention [11,12,14,15]. Such interventions have the potential to enhance a child’s future physical, socioemotional, language, behavioral, and cognitive development [11,12,15–17], as well as adult economic earning potential [18]. Overview of the Trifinio Human Development Initiative The Trifinio region of southwest Guatemala is located at the intersection of 3 departments (San Marcos, Retalhuleu, and Quetzaltenango) in the coastal lowlands. This area is cultivated with crops for export, primarily bananas and palm oil, owned by large agribusiness enterprises. The rural population of approximately 30,000 inhabitants who live in more than 20 small communities struggle with poverty and lack of access to health, education, and reliable clean water. The University of Colorado and the Colorado School of Public Health are partnering with a local private sector agricultural corporation to develop a Trifinio Human Development Initiative to improve the health, education, and welfare of residents in this rural agricultural region [19]. Preliminary studies The Center for Global Health at the Colorado School of Public Health completed a community health and environmental needs assessment in October 2011 as an initial step in the long-term strategic planning process to improve the quality of life

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for residents in the Trifinio region. This rapid needs assessment found that the population experienced low levels of income and education, poor water and sanitation infrastructure, high neonatal and child morbidity and mortality, insufficient food security, and minimal access to medical care. An initial childhood developmental screening study in July 2012 [20] found that children in the Trifinio region had high rates of abnormal developmental scores in multiple domains, as defined by the Ages and Stages Questionnaire, 3rd edition (ASQ-3) [21]. This study further suggested that high-risk families who do not provide certain types of stimulation for their child would benefit from an intervention educating mothers about responsive parenting. Initial materials focusing on teaching responsive parenting techniques (eg, talking, reading, playing, and praising) received high satisfaction ratings. More comprehensive materials integrating ways to promote early childhood development, health, and nutrition were then piloted during a July 2013 study [22]. This study showed that mothers in the Trifinio region were able to significantly increase their knowledge about health and development topics following a short interactive flipchart talk. Mothers further increased their knowledge 2 weeks after the intervention, without any re-exposure to the intervention materials, presumably by assimilation and informal reinforcement with other mothers in the community. ˜ OS SANOS PROGRAM NIN Using the information obtained in the preliminary studies, investigators at the Center for Global Health designed a community-based surveillance and integrated health and development program for pregnant women and children up to 3 years of age in the Trifinio region. The program, called Creciendo Sanos (Growing Up Healthy), has 2 main segments. It starts with a maternal segment (Madres Sanas, which means Healthy Mothers) to follow outcomes and provide interventions that improve prenatal care and delivery. Once the neonate is born, the mother and child transition to an early childhood health and development segment (Nin˜os Sanos, which means Healthy Children) that focuses on integrated community interventions to improve childhood well-being. Creciendo Sanos uses community health nurses (CHNs). The 7 CHNs in this program have completed either auxiliary nursing school (n ¼ 4; 1 year after high school) or professional nursing school (n ¼ 3; 3 years after high school). All CHNs are female and average 25 years of age and 5 years after completion of nursing school. One CHN serves as a program supervisor, and the other 6 CHNs work in groups of 2 in assigned communities. Each group of 2 is responsible for approximately 200 pregnant women and mother-child dyads. The program uses an electronic data collection and registry system. CHNs complete visit forms and screening assessments on mobile devices using the Android-based platform Open Data Kit (ODK) (University of Washington, Seattle, WA) [23]. Information is then transmitted electronically through the ODK database and imported into a Statistical Analysis System (SAS 9.4, SAS Institute, Cary, NC) database for analysis. This system facilitates an overall program evaluation with targeted and timely programmatic responses and rapid cycle feedback.

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This article details the Nin˜os Sanos segment of the Creciendo Sanos program. Nin˜os Sanos was designed to include an integrated approach to early childhood health and development, combining a series of newborn home visits, community education sessions, and mother-child interactive group visits to enhance the health and development of children from birth to 3 years of age. Mothers learn through a hands-on approach emphasizing demonstration, practice, and repetition. Materials created for the mothers are based on a simple and low-literacy pictorial format. Nin˜os Sanos has 3 components: (1) 3 Neonatal Home Visits are done by CHNs in the first month of life; (2) Group Health Visits are given in small groups by CHNs when the children are 6, 12, 24, and 36 months of age; and (3) monthly mother-child interactive Care Groups start at 2 months of age and continue until each child reaches 3 years. Nin˜os Sanos program development started in January 2013 and lasted for 2 years. The CHNs then went through their initial training and implementation period from February to May 2015. The CHNs were initially trained in person by 2 US-based pediatricians in multiple 1-week training sessions, including 3 weeks of didactic training and 3 weeks of field practice and observation. The CHNs were monitored and evaluated with before and after tests throughout the training to ensure appropriate knowledge gain and field application. There were also weekly 1-hour telehealth education sessions to review and enhance early childhood health and development topics. CHNs were provided a detailed manual describing all aspects of the program. The data collection forms were then updated, and the program evaluation period commenced in June 2015. This article uses descriptive statistics to outline findings from the initial 18 months of the program evaluation (June 2015– December 2016). During this period, 486 children were enrolled in Nin˜os Sanos. Table 1 outlines demographic characteristics for the program participants, indicating high teenage pregnancy rates, a general lack of clean drinking water and reliable sanitation, frequent food insecurity, and high rates of child mortality with onethird of these children dying at home instead of receiving care at a hospital or other health care facility. Number totals do not always equal the study cohort throughout this article because some answers were left blank on the data collection forms. Neonatal Home Visits Globally, mortality occurring in the neonatal period accounts for more than 40% of deaths in children younger than the age of 5 years, a percentage that has been increasing over the past 25 years [24]. The first month of life is a critical time with high rates of morbidity and mortality, which warrants close monitoring by community health workers (CHWs) in LMICs [25–29]. Nin˜os Sanos includes 3 Neonatal Home Visits by the CHNs in the first month of life (birth, 2 weeks, and 1 month) to directly assess neonates, provide appropriate referrals for sick newborns, educate parents on recognizing signs of illness and seeking care with a short flipchart talk, observe mothers breastfeeding, and screen and refer for maternal depression using the Edinburgh Postnatal Depression Scale (EPDS) [30]. The program includes individual home visits in the first month because, culturally, mothers typically do not leave the house during this period.

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Table 1 Demographic characteristics for Nin ˜os Sanos participants Characteristic Child characteristics Child’s gender Male Female Birthweight in kg; mean (SD) Number of low-birthweight infants 2.0–2.5 kg 1.5–2.0 kg <1.5 kg Mother characteristics Mother’s age (y) Mean (SD) Age range Number of teenage mothers 18–19 y 16–17 y 14–15 y Mother is able to read and write Yes No Mother’s employment status Full-time Part-time Unemployed Mother’s marital status Married or lives with partner Divorced or separated Single Widowed Mother owns a cell phone Yes No Father characteristics Father’s age (y) Mean (SD) Age range Number of teenage fathers 18–19 y 16–17 y Father is able to read and write Yes No Father’s employment status Full-time Part-time Unemployed

Study cohort N ¼ 486, n (%)

238 (49.0) 248 (51.0) 3.0 (0.5) 57 (12.0) 44 (77.2) 7 (12.3) 6 (10.5)

23.1 (6.1) 14–42 145 (32.0) 74 (51.0) 47 (32.4) 24 (16.6) 408 (84.0) 78 (16.0) 9 (1.9) 7 (1.4) 470 (96.7) 441 (90.9) 5 (1.0) 38 (7.8) 1 (0.2) 213 (47.5) 235 (52.5)

27.0 (7.2) 16–72 33 (8.3) 24 (72.7) 9 (27.3) 384 (81.7) 86 (18.3) 257 (55.5) 176 (38.0) 30 (6.5) (continued on next page)

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Table 1 continued Characteristic

Study cohort N ¼ 486, n (%)

Father’s marital status Married or lives with partner 441 (95.2) Divorced or separated 5 (1.1) Single 17 (3.7) Father owns a cell phone Yes 121 (28.8) No 299 (71.2) Household characteristics Number of adults living in the house; mean (SD) 3.3 (1.8) Number of children living in the house; mean (SD) 2.6 (1.8) Source of drinking water Well 331 (68.1) Water pipe or tank 89 (18.3) Bottled water 36 (7.4) Multiple sources 26 (5.3) Other 4 (0.8) Human waste disposal Ground latrine 387 (79.6) Elevated latrine 62 (12.8) Washable toilet 35 (7.2) Open field 2 (0.4) Primary means of transportation Bicycle 224 (48.2) Motorcycle or tuk-tuk 193 (41.5) Car or pick-up truck 48 (10.3) In the past year, which of the following best describes the circumstances with food in your home? We eat what we want 311 (87.1) We have enough but we do not eat all we want 29 (8.1) Sometimes we do not have enough food 17 (4.8) In the past 3 mo, did you not have any food and lack enough money to buy more? Yes 47 (9.7) No 424 (87.2) Do not know 15 (3.1) In the past 3 mo, did you abstain from eating any of your daily meals due to a lack of money to buy food? Yes 23 (4.7) No 445 (91.6) Do not know 18 (3.7) In the past 3 mo, did you or any member of your family lose weight due to the lack of money to buy food? Yes 6 (1.2) No 452 (93.0) Do not know 28 (5.8) Have you had or do you have other children? Yes 322 (66.3) No 164 (33.7) (continued on next page)

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Table 1 continued Characteristic

Study cohort N ¼ 486, n (%)

Have you had any children who have died? (n ¼ 321) Yes 34 (10.6) No 287 (89.4) Were they cared for in a hospital at the time they died? (n ¼ 34) Yes 22 (64.7) No 12 (35.3) Did you breastfeed your last child? (n ¼ 322) Yes 292 (90.7) No 30 (9.3) How old was your last child when you stopped breastfeeding? (n ¼ 291) Age (months); mean (SD) 16.2 (6.2) How old was your last child when you offered liquids other than breast milk? (n ¼ 291) <1 mo 22 (7.6) 1–2 mo 10 (3.4) 3–4 mo 27 (9.3) 5–6 mo 107 (36.8) >6 mo 125 (43.0) What type of liquid did you introduce first? (n ¼ 289) Water 145 (50.2) Formula 62 (21.5) Broth or soup 41 (14.2) Juice 11 (3.8) Cow’s milk 4 (1.4) Tea 1 (0.3) Other 25 (8.7) How old was your last child when you fed something other than breast milk or liquids? (n ¼ 316) <3 mo 1 (0.3) 3–4 mo 28 (8.9) 5–6 mo 126 (39.9) >6 mo 161 (50.9)

The first 2 visits focus on identifying 8 neonatal danger signs adapted from the World Health Organization (WHO) Essential Newborn Care [31] and Integrated Management of Childhood Illness [32] guidelines. These include fast breathing (defined as more than 60 breaths per minute) or severe chest indrawing, convulsions, no movement, not feeding well (defined as not latching or sucking effectively, breastfeeding fewer than 8 times per day, and having fewer than 6 wet diapers daily), feels too hot, feels too cold, has yellow palms and soles of feet, and umbilical stump is red or draining pus. Previous research has shown that CHWs in an LMIC are able to perform home-based illness recognition and management for neonates with both high validity [33] and compliance [34]. CHNs are also instructed to watch each mother breastfeed and examine the breasts for signs of mastitis, complete an EPDS postpartum depression screen, and perform anthropometric measurements. Particularly

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for home deliveries, accurate birth weights are often not known but can be successfully obtained shortly after birth at the community level [35]. Neonates are referred to a local clinic (sponsored and operated by the local private-sector agricultural corporation, University of Colorado, Colorado School of Public Health, and Children’s Hospital Colorado) for any identified danger sign or if they have not gained weight after the first visit. Mothers are referred if they are having difficulty breastfeeding, either breast is tender and red, or the EPDS score is 12 or higher. CHNs are instructed to help the family arrange transportation, and an ambulance is available at the local clinic if transportation is urgently needed. For all referrals, a paper referral form is completed and given to the mother to provide at the clinic or hospital. CHNs are instructed to follow-up with any family referred within 2 days. In the first 18 months of the program, 445 newborns received at least 1 Neonatal Home Visit. Of these, 66 (14.8%) children received 1 visit, 88 (19.8%) received 2, and 291 (65.4%) completed all 3. Visit 1 was completed for 400 (89.9%) newborns, visit 2 for 366 (82.2%), and visit 3 for 356 (80.0%). The average visit ages of the newborns were 13.8, 26.2, and 39.2 days at visits 1, 2, and 3, respectively. Almost half (n ¼ 191, 48.5%) of the first visits were completed within 3 days of birth. Danger signs were evaluated during the first 2 home visits (n ¼ 766). These were the most frequently identified: feels too hot (n ¼ 15, 2.0%), not feeding (n ¼ 12, 1.6%), fast breathing or chest in-drawing (n ¼ 10, 1.3%), yellow palms and soles (n ¼ 4, 0.5%), umbilical cord is red or draining pus (n ¼ 4, 0.5%), and feels too cold (n ¼ 1, 0.1%). No neonate presented with convulsions or no movement. Overall, 20 (4.5%) different neonates were referred for positive danger signs. Two (0.4%) mothers had postpartum depression (EPDS) scores greater than or equal to 12, necessitating referral. Both of these occurred during visit 3. Most mothers said that they could talk about their feelings with their spouse or partner (visit 1: n ¼ 341, 87.4%; visit 2: n ¼ 318, 87.8%; visit 3: n ¼ 306, 87.4%) or a family member (visit 1: n ¼ 341, 88.1%, visit 2: n ¼ 318, 90.3%; visit 3: n ¼ 292, 86.4%) but were less likely to be able to talk to a friend (visit 1: n ¼ 114, 31.8%, visit 2: n ¼ 107, 33.1%; visit 3: n ¼ 96, 31.0%). Children weighed an average of 3.2 kg, 3.9 kg, and 4.2 kg at the first 3 visits, respectively. Group Health Visits Research has shown that group visits, also called cluster visits, are an effective means of delivery for well-child care in high-income countries and have improved maternal-child interactions, child development, and health outcomes [36–39], including in families with a lower socioeconomic status [40]. Additionally, group visits have shown positive benefits when compared with more costly home visitation programs [41–43]. For these reasons, the Nin˜os Sanos program includes a series of 4 Group Health Visits given by CHNs at 6, 12, 24, and 36 months of age to teach, promote, and reinforce caregiver knowledge about age-specific topics related to child health and development. Anticipatory guidance is the foundation of well-child care. It refers to providing education to families about the expected growth and development of their child,

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with recommendations specific to a child’s age. Research has shown that anticipatory guidance can lead to improved child and family functioning [44]. The study group adapted early childhood education materials from the Colorado Bright by Three program [45] that was developed by faculty at the University of Colorado, as well as health and nutrition recommendations from the WHO, to create a series of age-specific 30-page interactive flipchart talks that are given at these visits. Educational topics include age-appropriate anticipatory guidance regarding nutrition, recognition and treatment of malnutrition, home management of common illnesses such as diarrhea and fever, hygiene and handwashing [46,47], timely immunizations, prevention of childhood unintentional injuries [48], child development, and responsive parenting techniques (eg, talking, reading, playing, and praising). The flipcharts were designed with a front side viewable by the mother that contains basic information and illustrative photographs of local mothers and children. The reverse side is viewable by the CHN and provides more in-depth written information about the topic being discussed. The flipcharts were written in English with a third grade or less Flesch-Kincaid readability level and were then translated into Spanish by a bilingual native Guatemalan. The talks provide an interactive educational environment through the use of demonstrations and open-ended questions that prompt mothers to raise concerns on topics for which they would like more targeted guidance. The Group Health Visits also include growth monitoring and promotion [49] with referrals for children who are not gaining weight or are showing signs of malnutrition. Weight, length-height, head circumference, and mid-upper arm circumference (MUAC; for children 6 months and older) are recorded at every visit. Length (children <2 years) or height (children >2 years) is measured to the nearest 0.1 cm using a portable Seca measuring board for infants (Seca, Hamburg, Germany) or an infant-child ShorrBoard (Weigh and Measure LLC, Olney, MD). Weight is recorded to the nearest 0.1 kg using a Salter Brecknell hanging scale (Avery Weigh-Tronix LLC, Fairmont, MN). A growth card and protective plastic sleeve are provided to each mother to document and monitor the child’s plotted weight over time, providing a graphic representation of a child’s weight-for-age and allowing for the early detection of growth faltering. Communication and motivational counseling about the growth curves are key elements to growth monitoring and promotion and are provided to the mothers to encourage better feeding and improve growth. These growth cards are brought to each visit and also allow for immunization documentation and verification. Children who are delayed in their vaccinations are referred to the local health post. Developmental screening with the ASQ-3 [21] is done at each Group Health Visit with referrals for children with abnormal scores in multiple developmental domains (eg, communication, gross motor, fine motor, problem solving, personal-social) who appear severely delayed. In the first 18 months of the program, 30 children participated in a Group Health Visit, with 18 (60.0%) children completing visit 4 at a mean age of 6.8 months and 12 (40.0%) children completing visit 5 at a mean age of 13.4 months. No child had completed more than 1 Group Health Visit. Almost

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half of the children (n ¼ 13, 43.3%) were not up-to-date with their immunizations. Some mothers (n ¼ 3, 10.0%) had concerns about their child’s development, but no mothers were concerned about their child’s hearing or vision. More than half of children at both visits 4 and 5 scored within the borderline or abnormal ranges for at least 1 of the 5 developmental domains on the ASQ-3, placing them at risk for developmental delays (Figs. 1 and 2). At visit 4, mothers reported first offering liquids other than breastmilk when their child was less than 1 month (n ¼ 1, 5.6%), 1 to 2 months (n ¼ 2, 11.1%), 3 to 4 months (n ¼ 8, 44.4%), 5 to 6 months (n ¼ 4, 22.2%), and greater than 6 months (n ¼ 3, 16.7%). The most common liquids were water (n ¼ 7, 38.9%), broth or soup (n ¼ 4, 22.2%), formula (n ¼ 3, 16.7%), and tea (n ¼ 1, 5.6%). The authors have found that, culturally, many mothers give water to their newborns to combat dehydration in the hot environment; however, this lacks nutritional value and places infants at risk of infection. Although most mothers breastfed, most did not exclusively breastfeed until the recommended 6 months of age. Mothers first fed solid foods at 3 to 4 months (n ¼ 7, 38.9%), 5 to 6 months (n ¼ 6, 33.3%), or greater than 6 months (n ¼ 5, 27.8%). This information is now being used to create targeted intervention messages promoting exclusive breastfeeding with the introduction of complementary feeding at 6 months of age. Care Groups Nin˜os Sanos includes monthly mother-child interactive Care Groups that start at 2 months of age and continue until the child reaches 3 years. These small groups of 3 to 10 mother-child dyads use participatory learning to promote child development, provide peer support for the mothers, reinforce caregiver 100 90 80

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knowledge of health topics, and perform growth monitoring and promotion. Each group starts with a check-in question for the mothers about their child (eg, ‘‘What is 1 thing your child does that makes you happy?’’ or ‘‘What is something new that your child is doing, saying, or exploring?’’), followed by a review question from the last Care Group. Information and a brief discussion about a child development topic are provided before the main interactive stimulatory activity (Box 1). Each session then closes with a brief health topic review, a language-promoting activity called language power (ie, baby talk with finger puppets or reading books), a group song, and growth monitoring and promotion. The entire group session lasts for about 60 minutes. The Care Group curriculum is based on promoting positive and stimulating mother-child interactions through the use of responsive parenting techniques [50] and developmentally appropriate activities. Research in LMICs has consistently found that interventions incorporating psychosocial stimulation and responsive parenting techniques benefit child development outcomes [11,12,15–17,51], and there are several specific examples of LMIC interventions that have shown success in promoting early childhood stimulation [52–63]. The importance of talking, reading, playing, and praising is reinforced during each Care Group session. Stimulating play is recognized as critical to early childhood development [64] and is demonstrated and practiced during the sessions with items such as finger puppets, building blocks [65], mirrors, balls, and board books. Care Groups use low-cost and culturally appropriate toys, including handmade toys and household items when possible. Mothers are given finger puppets at the 2 month session as well as introductory picture books in Spanish donated by the Colorado Bright by Three program [45] at the 12 and 24 month

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Box 1: Examples of child development topics and interactive mother-child activities for Care Group sessions Child Development Topics

Interactive Mother-Child Activitiesa

Body awareness

Singing Head, Shoulders, Knees and Toes Singing The Hokey Pokey Drawing faces Exploring toys Playing peek-a-boo Nesting objects Matching colors Learning to count Encouraging baby talk with finger puppets Looking at pictures and books Making a picture book with personal photos Making animal noises using picture books Naming objects using a word box Using a picture book to ask questions (who, what, when, where, and why) Telling stories with finger puppets Demonstrating responsive feeding Cooking demonstration Practicing calming techniques Teaching time-out Exploring toys with music Creating rattles with water bottles and seeds Rolling and throwing balls Drawing lines and scribbling Drawing and tracing shapes Exploring in, out, and around with boxes or crates Playing hide-and-seek with finger puppets, towels, and furniture Showing approval (with activities such as stacking building blocks) Providing safe and clean toys Calming your baby techniques Expressing and responding to feelings or emotions Exploring with a mirror Creating faces and showing feelings

Cognitive development and the importance of play

Communication and early literacy

Complementary feeding Developing self-control and managing temper tantrums Gross and fine motor development

Independence and separation Praise and encouragement Safety and accident prevention Sleep Social-emotional development

a

Activities vary by child age.

sessions to keep and practice with at home. The program teaches mothers about the importance of early childhood development and encourages families to incorporate playing, talking, reading, and praising into daily activities as a means to promote learning and attachment. Care Groups also provide nutritional education, including the introduction of complementary foods at 6 months of age, responsive feeding techniques [66,67], and cooking demonstrations. The authors believe that the group nature of these visits is vital to their success for multiple reasons. The importance of social networks to support families

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experiencing stress is well known [68]. Research has shown that community participation and mobilization can be a cost-effective way to improve maternal, newborn, and child health in low-resource settings [69], especially women’s groups that practice participatory learning and action [70]. Additionally, a group format can serve as a sort of support group, allowing mothers to share individual experiences and feelings surrounding motherhood while they engage and encourage other mothers, some of whom may be experiencing symptoms of depression. Interestingly, during the Neonatal Home Visits, most mothers reported not being able to talk to a friend about their feelings. It will be important to track this at later visits to see if mothers feel differently after being part of the Care Group experience. Furthermore, a body of evidence exists showing that maternal depression can negatively affect the cognitive, social-emotional, and physical development of children [4,71]. Depressed mothers may have difficulty attending to their child’s needs and engaging their child in play and other interactive activities. These parenting deficits were found to be more profound with younger infants and socioeconomically disadvantaged mothers [72]. LMIC interventions aimed at improving child development have shown significant benefits for maternal depression, including a home visitation early stimulation intervention in Jamaica [73]. Aboud and colleagues [53] also found that mothers who met in groups for a parenting program in rural Bangladesh had significantly fewer depressive symptoms than mothers who had mostly home or clinic visits. In the first 18 months of the Nin˜os Sanos program, 294 mother-child dyads participated in a Care Group session, with 31.0% (n ¼ 91) participating in 1 session, 19.7% (n ¼ 58) in 2, 20.7% (n ¼ 61) in 3, 9.9% (n ¼ 29) in 4, 7.8% (n ¼ 23) in 5, 6.5% (n ¼ 19) in 6, and 4.4% (n ¼ 13) in 7 or more sessions (total encounters, n ¼ 835). Several children were identified as having some degree of malnourishment during the Care Group visits. For population-based anthropometric assessments, the z-score system is widely used in global health, including by the WHO, and expresses the anthropometric value as a number of standard deviations below or above the reference mean or median value. Eighteen (6.1%) children were identified as having severe acute malnutrition, also known as severe wasting, which is defined as a weight-for-height below 3 z-scores or standard deviations of the median WHO child growth standards. MUAC values were obtained in children older than 6 months of age, with 1 child identified as having severe wasting (defined as a MUAC <11.5 cm). Twenty-six (8.8%) children were identified as having moderate acute malnutrition with a weight-for-height between 3 and 2 z-scores, whereas 27 children were identified with moderate acute malnutrition by a MUAC value between 11.5 and 12.5 cm. Severe stunting was found in 21 (7.1%) children, which is defined as a height-for-age below 3 z-scores. Twenty-five (8.5%) children had moderate stunting, which is defined as a height-for-age between 3 and 2 z-scores. Before each Care Group session, mothers were asked if their child was sick with diarrhea, cough, or fever in the previous 2 weeks. Mothers reported diarrhea 9.4% (n ¼ 78) of the time and brought their child to see someone 48.7% (n ¼ 38) of the time, most often to a pharmacy (n ¼ 17, 44.7%), health post

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(n ¼ 10, 26.3%), private clinic (n ¼ 7, 18.4%), or hospital (n ¼ 2, 5.3%). The most common treatment of diarrhea was antibiotics (n ¼ 20, 52.6%), with only 10.5% (n ¼ 4) receiving oral rehydration solutions, 10.5% (n ¼ 4) antiparasitic medication, 7.9% (n ¼ 3) Pepto-Bismol, and 7.9% (n ¼ 3) acetaminophen. Mothers reported cough 15.0% (n ¼ 125) of the time and brought their child to see someone 68.8% (n ¼ 86) of the time, most often to a pharmacy (n ¼ 33, 38.4%), health post (n ¼ 25, 29.1%), private clinic (n ¼ 24, 27.9%), or hospital (n ¼ 3, 3.5%). The most common treatments for cough were antibiotics (n ¼ 29, 33.7%) and expectorant or mucolytic agents (n ¼ 23, 26.7%), with only 15.1% (n ¼ 13) receiving acetaminophen. Mothers reported fever 11.9% (n ¼ 99) of the time and brought their child to see someone 52.5% (n ¼ 52) of the time, most often to a pharmacy (n ¼ 17, 32.7%), health post (n ¼ 17, 32.7%), private clinic (n ¼ 15, 28.8%), or hospital (n ¼ 2, 3.8%). The most common treatment of fever was acetaminophen (n ¼ 45, 86.5%), with only 5.8% (n ¼ 3) receiving antibiotics and 3.8% (n ¼ 2) ibuprofen. This information is being used to create targeted intervention messages to promote health post and clinic utilization (instead of a pharmacy), decrease antibiotic use specifically for diarrhea and cough, and encourage oral rehydration solutions for diarrheal treatment. CHALLENGES, LESSONS LEARNED, AND FUTURE DIRECTIONS Nin˜os Sanos has experienced important challenges and lessons learned during program development and implementation. During the initial 2-year program development period, CHWs with very little nursing or medical experience were employed. The CHWs included social workers and teachers. Turnover was high, with most CHWs leaving for other positions within months of being hired. Teaching nonclinicians how to diagnose and treat neonatal and childhood illnesses proved to be difficult. During the implementation period, new CHNs with previous training and experience in nursing were hired. In the nearly 2 years since that time, CHN retention has been much better, possibly due to the healthspecific nature of the program that lends itself better to frontline health workers with specific nursing training. This has been critical for promoting program continuity, building rapport with families, and limiting the amount of training and retraining that has been necessary for program implementation and evaluation. Transportation for the nurses was also a problem. CHNs were initially given motorcycles by the program. However, it remained difficult to carry heavy flipcharts, scales, measuring boards, and Care Group supplies on the motorcycles. The program then purchased tuk tuks (3-wheeled auto rickshaws) to solve this problem. Additionally, CHNs were individually assigned to communities at the beginning of the program. Due to safety concerns, they were switched to groups of 2 CHNs working together in assigned communities. This significantly increased their morale, safety, and teamwork because they were no longer out in the rural community working alone but instead now had a coworker to help coordinate and run the program visits. There were difficulties during the development and implementation phases of the program getting Neonatal Home Visits done on time. CHNs

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experienced difficulty communicating with traditional birth attendants and were not being notified of home deliveries or hospital discharges. An incentive plan was implemented that provided each CHN with a monetary bonus based on whether the first visit occurred during the first 3 days of life and if all 3 Neonatal Home Visits were completed by 1 month of age. There was an immediate and sustained improvement in these parameters with 65.4% (n ¼ 291) of neonates receiving all 3 visits and 48.5% (n ¼ 191) completing the first visit within 3 days of life after 18 months of program evaluation. It will be important to explore the use of incentives for other parts of the program that have experienced poorer adherence, such as completing Group Health Visits and documenting follow-up visits for referrals. The costs of frequent faculty trips to train CHNs and monitor program implementation have been a monetary challenge given the limited budget. During the development phase of the program, the introduction of the ODK [23] mobile telephone-based data collection and surveillance system had important advantages over the paper-based system that was initially used. Data are only entered once into the cellular telephone, improving promptness of data collection and decreasing errors made and additional staff costs in transcribing paper forms to a computer for analysis. Data are also monitored for errors from afar on a regular basis, reducing error rates and improving data completeness. Additionally, a telehealth education program was implemented between faculty in the United States and CHNs in Guatemala in response to the expressed needs of the CHNs to expand generalized child health topics targeted to their current field work [74]. These weekly lectures include didactic teaching, community case presentations, and interactive discussions. Using telehealth technology has proven to be an efficient means of training CHNs by increasing communication between CHNs and program developers, as well as decreasing faculty travel costs to Guatemala. A few key areas have been identified for future program development and expansion of Nin˜os Sanos. Given the importance of developmental programs combined with nutritional interventions [11,12,14,15], program developers are working to obtain and distribute nutritional supplements for growth faltering and iron deficiency anemia, including food, iron, and micronutrient supplementation. Furthermore, a malnutrition refeeding program for the community treatment of clinically stable children identified with severe and moderate acute malnutrition is currently being developed as part of the program. Another important area for future expansion is increasing the involvement of experienced community mothers, called madres monitoras. These volunteer women often host Group Health Visits and Care Groups in their homes. It is hoped that their roles will be expanded to areas such as helping identify pregnant women and newborns, supporting women who are struggling with depression, coordinating program visits, teaching cooking classes, and promoting educational topics (eg, breastfeeding, infant care, child development, and the provision of oral rehydration solution). Trained volunteer peer counselors have been shown to be an important method for improving child health

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outcomes [75]. The authors believe that madres monitoras could serve a critical role in increasing program coverage, visit attendance, and educational reinforcement. Additionally, using a mobile telephone-based electronic registry such as ODK provides several advantages that should be further explored and expanded. Interestingly, more mothers in these rural communities own a cellular phone compared with fathers (47.5% vs 28.8%, P<.0001) (see Table 1). This suggests that mothers in the program may have an encouraging reach and accessibility using mobile technology. Mobile telephones create the ability to send and receive telephone calls, voice messages, and text messages between CHNs, mothers, madres monitoras, traditional birth attendants, and health care professionals. This technology could be used to send reminders and alerts for things such as group visits, pregnancy due dates, vaccinations, and poor growth, as well as using mobile consultation between CHNs and health care professionals (eg, physicians at the local clinic or hospital) for advice as part of home visits [76]. Mobile telephones also allow for the use of the Global Positioning System (GPS) to identify locations, cameras to send photographs or videos, and Internet and numerous other applications that can improve CHN training, treatment guideline adherence, data collection, performance feedback, emergency referrals, supervision, and communication and motivation [77]. Previous studies have shown success using mobile health (mHealth) technologies by frontline health workers in LMICs [77,78], and the use of mHealth as part of this program certainly warrants further exploration. Finally, a more rigorous pragmatic trial of the Nin˜os Sanos program will be an important future goal to demonstrate program effectiveness that can promote further expansion and ongoing funding. SUMMARY The prenatal and early childhood period is the most critical time for child development and lays the foundation for future physical, emotional, social, and intellectual well-being. Children in LMICs face multiple and cumulative risks, including poverty, malnutrition, maternal depression, adverse childhood experiences, poor health, and unstimulating home environments, that negatively affect their development. Early childhood development programs have shown promising results and are most likely to benefit the world’s most disadvantaged children. Despite convincing evidence for these cost-effective investments, global coverage for early childhood development programs is lacking. Efforts must now be focused on reaching these most vulnerable children through programs such as Nin˜os Sanos. Acknowledgments The authors thank the community health nurses, especially their manager Claudia Rivera, at the Center for Human Development in Guatemala for their hard work and dedication to the Creciendo Sanos program. The authors also thank the many mothers and children who have participated in the program. The authors thank Drs Edwin Asturias, Gretchen Berggren, John Brett, Sheana Bull,

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Saskia Bunge Montes, Bonnie Camp, Marco Celada, Gretchen Heinrichs, and Susan Niermeyer for their invaluable advice and support. The authors thank Dr Maya Bunik and Maureen Lenssen for their CHN breastfeeding training program. The authors greatly appreciate the help of several medical students who have performed pilot studies to inform the design of this program, including Brittney MacDonald, Catherine Cooper, Lauren Mehner, and Darren Eblovi, as well as our Global Health Fellow Dr Kelly McConnell. The authors also thank the Colorado Bright by Three program for donating picture books for every mother-child dyad in our program. Funding for this program was provided by the Fundacion de Salud Integral de Guatemalatecos CU. References [1] Johnson SB, Riley AW, Granger DA, et al. The science of early life toxic stress for pediatric practice and advocacy. Pediatrics 2013;131(2):319–27. [2] Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child 1997;7:55–71. [3] Johnson SB, Riis JL, Noble KG. State of the art review: poverty and the developing brain. Pediatrics 2016;137(4):e20153075. [4] Wachs TD, Black MM, Engle PL. Maternal depression: a global threat to children’s health, development, and behavior and to human rights. Child Dev Perspect 2009;3(1):51–9. [5] Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998;14(4): 245–58. [6] Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129(1):e232–46. [7] Gorman KS, Pollitt E. Does schooling buffer the effects of early risk? Child Dev 1996;67(2): 314–26. [8] Walker SP, Wachs TD, Gardner JM, et al, International Child Development Steering Group. Child development: risk factors for adverse outcomes in developing countries. Lancet 2007;369(9556):145–57. [9] Walker SP, Wachs TD, Grantham-McGregor S, et al. Inequality in early childhood: risk and protective factors for early development. Lancet 2011;378:1325–38. [10] Grantham-McGregor S, Cheung YB, Cueto S, et al. International Child Development Steering Group. Developmental potential in the first 5 years for children in developing countries. Lancet 2007;369(9555):60–70. [11] Engle PL, Black MM, Behrman JR, et al, International Child Development Steering Group. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet 2007;369(9557):229–42. [12] Engle PL, Fernald LC, Alderman H, et al, Global Child Development Steering Group. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet 2011;378(9799):1339–53. [13] Garner AS. Home visiting and the biology of toxic stress: opportunities to address early childhood adversity. Pediatrics 2013;132:S65. [14] Black MM, Dewey KG. Promoting equity through integrated early child development and nutrition interventions. Ann N Y Acad Sci 2014;1308:1–10. [15] WHO. A critical link: interventions for physical growth and psychological development. A review. Geneva (Switzerland): Department of Child and Adolescent Health, World Health Organization; 1999. [16] Aboud FE, Yousafzai AK. Global health and development in early childhood. Annu Rev Psychol 2015;66:433–57.

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