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Take this to the big leagues.
$64 MILLION QUESTION

We know how to make programs that help poor kids. The hard part is scaling up

By Jenny Anderson

In the 1970s, three groundbreaking studies—in Jamaica, North Carolina and Michigan—changed the way the world thought about helping poor kids. The studies suggested that one way of reducing inequality and supporting families was to create high-quality infant and early childhood programs in homes and in child care centers, which had a dramatically positive impact on the kids involved,  (and in some cases, on the parents too).

In one study in Jamaica, for example, trained workers visited 129 mothers and their babies, who were developmentally delayed, their stunted children (babies smaller than well-nourished children of the same age and gender who show persistent developmental delays as they grow up) once a week for two years, coaching the mothers about the importance of talking, singing and interacting with their children. After two years, the infants who’d received home visits caught up to kids who were not developmentally stunted—a remarkable feat. Twenty-two years later, the kids who’d had the home visits had higher incomes, better social skills, and less violent tendencies than the control group.

In the decades since, the positive effects of these programs have been used as a rallying cry to mobilize governments (pdf) everywhere. Invest in your youngest citizens, the thinking goes, both because it is cost effective and because doing so can help close the gap between rich and poor kids, support babies’ brain development, and better prepare children to reap the benefits of formal schooling.

But recent research published in PLOS Medicine suggests that’s easier said than done. The research, following up on a promising Colombian study, reveals some of the challenges to making early childhood programs available to large parts of a country’s population. We know that parent coaching works in small, tightly controlled studies. The question is how to scale up.

The case of Colombia

From 2009 to 2011, researchers in Colombia studied 1,419 children between the ages of 12 to 24 months to see whether coaching their mothers on interactions with their babies could help the children’s development. For 18 months, trained local women made weekly home visits, using a curriculum meant to promote nurturing care and parent-child attachment. Afterward, the researchers found a host of benefits: the children whose mothers had received coaching got smarter. Their language skills improved, and their home environments were judged to be more stimulating.

But the new PLOS Medicine study reveals that when researchers went back two years later, they found the children—now about five years old—had not maintained those benefits. “Two years after the intervention ended, we found no effects on children’s cognition, language, school readiness, executive functioning, or behavioural development,” the study reports.

The authors, including Alison Andrew, an economist at the Institute for Fiscal Studies and at University College London, London, cited many possible explanations as to why the coaching didn’t have a longer-lasting effect. The original gains, though significant, were small, so potentially harder to sustain over time, especially if kids return to less-than-stimulating environments. Since there was no continued effort to improve stimulation, the effects might have just faded out.

The program also relied on local women to coach mothers in their homes. The supervisors had to travel long distances to train and give feedback to the home visitors, meaning they did not get the support that workers in the Jamaica studies received. In the Jamaica study, supervisors met with home visitors weekly, and the supervisors themselves were highly trained. In the Colombian study, by contrast, visitors were meant to meet with supervisors once every six weeks; they were actually able to do so once every nine weeks. Staff turnover was high.

Andrew said the results of the study were disappointing, but unsurprising. It’s very hard to ramp up small-scale programs while staying faithful to their original design. “We are really thinking the on-the-ground staff have to be supported much more,” she said. She also noted that if the program got big enough, some of the problems might solve themselves. If every community had parent coaching, and if it was tied to a national welfare program, supervisors could presumably be local, which would mean they could spend more time training workers and offer more feedback.

Finally, there is the so-called “resurrection effect” to be considered: The benefits of coaching could seem to go away for a while, only to show up again later in the children’s lives. In the Jamaica study, children who were part of the home visiting group showed strong short-term effects, many of which faded by age seven or eight—only to reappear again around ages 11 and 12. Tested again at age 22, researchers found that the kids maintained a battery of benefits.

One thing is clear: “Whether it’s the quality of implementers, the quality of supervision, or ability to make quick corrections, implementing at scale brings a host of new complications,” said Dave Evans, an economist at the World Bank who was not involved in the study. “So we learn whether a program can work from pilots, but we have to test at some level of scale to know if those results will translate.”

The future of parent coaching

The original parent-coaching program in Colombia included 1,419 kids, but was intentionally designed to be applied much more widely in the future. It operated through Colombia’s large national welfare program, Familias en Acción, which gives the poorest 20% of Colombian households monthly transfers of between US$8 and US$16 per child. Cash transfer programs have proven to be surprisingly effective at helping poor families, and some believe that pairing parent coaching with cash transfers could be an effective way to make coaching widely available.

Other countries, including Peru and Bangladesh, have successfully brought such programs to scale. And the Brazilian government is currently building the most ambitious (paywall) parent-coaching program in the world. Promising programs are flourishing around the world.

Marta Rubio-Codina, a senior economist at the Inter-American Development Bank who was involved with the study, draws several  useful lessons from the follow-up study. Researchers know how important the home visitors are, and they suspect coaches need more training, support, and supervision. “There’s no magic formula,” she said. “You are developing an intervention that aims to change behavior and change the way parents interact with their children; that’s not something you achieve one day to another.”

Rubio-Codina also noted that in some low-income environments, where mothers lack time and resources, gentle, nurturing care for babies is often not the norm. Singing, talking, and playing with young children, which have been proven critical to a baby’s brain development, may be perceived as frivolous.

Coaching programs must battle these perceptions, such as one Rubio-Codina heard “that children were like chicken, and we had to just feed them.” If the mothers feel this way, the home visitors—recruited from the same communities— may well have similar views, which only highlights the importance of effective education, training and support.

Mothers were receptive to the program, Rubio-Codina said, and grateful. They could see their children thriving in ways others had not. “I wish you had been here for the other children,” was a common refrain the home visitors heard from parents. “We wish we had known this earlier.”

In commentary published in PLOS Medicine alongside Andrew’s study, Mark Tomlinson, lead investigator at the Centre of Excellence in Human Development at the University Witwatersrand, South Africa, said that there is still limited evidence about the best way to scale programs up. It may be that families who receive coaching and support need to then be entered into effective preschool or early learning programs, as well as decent schools. He also said researchers do not yet know what age benefits the most from interventions, or how frequently to make the visits.

Helping new mothers understand how to best support their child’s social, emotional, and cognitive development is no small task. This study will help refine how to implement future programs, Codina said. “It doesn’t mean everything is a failure ,” she said matter of factly. “We just need to keep trying.”

This reporting is part of a series supported by a grant from the Bernard van Leer Foundation.

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