Improving Early Childhood Development in Zambia

The purpose of this study is to evaluate the impact of a community-based early childhood development (ECD) program on child physical and cognitive development. Central to the ECD program is a cadre of community-based health workers called Child Development Agents (CDAs). CDAs have four main tasks and responsibilities: 1) Biweekly screening and management (including referral) of acute malnutrition in children; 2) Encouragement of caregivers to utilize routine care services for children (immunizations, growth monitoring, and vitamin A supplementation); 3) Screening for symptoms of acute diseases including malaria, diarrhea, and pneumonia and referral for diagnosis and treatment; and 4) Organization and mentoring of weekly meetings for caregivers to discuss parenting issues and promote early childhood cognitive stimulation.

Protocols for the community-based evaluation and management of children with acute malnutrition are based on the draft Zambian Community Integrated Management of Acute Malnutrition (CIMAM) guidelines. Children with complicated severe acute malnutrition (SAM) are referred to the nearest health center for evaluation and, if SAM is confirmed based on mid-upper arm circumference (MUAC), then referred to an inpatient feeding center for management. All children with moderate acute malnutrition (MAM) and uncomplicated SAM are administered an appetite test at the health center. Children who pass the appetite test are managed locally as outpatients. Children with acute infectious diseases are treated following the Ministry of Health's adaptation of the Integrated Management of Childhood Illness (IMCI) guidelines and those with complicated SAM or feeding difficulties are referred to higher level facilities (feeding centers). As part of the ECD program, clinical staff members at study health centers receive a short training to improve their adherence to IMCI and CIMAM guidelines.

One aspect of the IECDZ program that is of particular interest from a policy and evaluation perspective is the explicit focus on improving communication between CDAs and clinical staff at facilities handling undernourished children. As part of the ECD program, CDAs meet with staff at referral health centers on a regular basis, and discuss strategies to improve nutritional outcomes of children falling behind.

In addition to these regular meetings, the ECD program strengthens the linkages between CDAs and health centers with a novel mHealth intervention. When a CDA refers a child to a health center for evaluation of acute malnutrition, danger signs, or signs/symptoms suggestive of malaria, pneumonia or diarrhea, the officer-in-charge at the health center receives an short message service (SMS) and a paper referral form to make them aware of the child and their provisional diagnosis. Once the referred child has been attended to at the facility, health center staff members will then send an SMS back to the CDA to make them aware of the final diagnosis and management plan. If the health center refers the child to a feeding center, an SMS is sent to the feeding center along with a paper referral form. All text messages within the proposed system are free of charge to the end users. The mobile health (mHealth) system is meant to improve communication between health workers operating at various levels of the health system. Caregivers themselves do not receive SMS updates. Rather, CDAs will communicate all updates on the health and nutritional status of children directly to caregivers.

The primary objectives of the ECD program are to: