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Background While it is recommended that childcare services implement policies and practices to support obesity prevention, there remains limited evidence to inform policy and practice. The aim of this study is to examine the effectiveness of performance review and facilitated feedback in increasing the implementation of healthy eating and physical activity-promoting policies and practices in childcare services. Methods The study was conducted with childcare services in the Hunter New England region of New South Wales, Australia. Eligible services were randomised to a wait-list control group or to receive the implementation strategy. The strategy targeted the implementation of written nutrition, physical activity, and small screen recreation policies; providing information to families regarding healthy eating, physical activity, and small screen time; providing twice weekly healthy eating learning experiences to children; providing water and plain milk only to children; providing fundamental movement skills activities for children every day; and limiting the use of electronic screen time for educational purposes and learning experiences. Intervention services received a performance review and facilitated feedback process five times over the 10 months that included an assessment of current practices, goal setting, identification of barriers to implementation, problem-solving, and resource provision. The primary outcome was the proportion of services implementing all six policies and practices, assessed by nominated supervisor completion of a computer-assisted telephone interview at baseline and 12-month follow-up. Results One hundred and eight services took part. There were no significant differences in the proportion of services implementing all six practices at 12 months (mean difference 0.51; 95% CI 0.16 to 1.58; p  = 0.24). There were also no differences between groups in the mean number of policies and practices implemented (mean difference 0.1; 95% CI − 0.4 to 0.6; p  = 0.71), or the proportion implementing each of the six individual policies and practices at 12 months (OR range 0.57 to 1.85; p  > 0.05). Conclusions Further support may be required to assist childcare services to make recommended changes to their policies and practices. Trial registration The trial was registered retrospectively on 10 September 2014 with the Australian New Zealand Clinical Trials Registry ACTRN12614000972628 .

ObjectivesToddlers are vulnerable to unintentional injuries. A safety intervention targeting low-income families of toddlers, was effective at improving home safety. The current study examined whether the effect varies by initial home safety problems.Methods277 mother-toddler dyads recruited in the Mid-Atlantic region of the United States during 2007–2010 were randomized into safety promotion (n = 91) or attention-control groups (n = 186). Observers rated participants’ homes with a 9-item safety problem checklist at baseline, and at 6- and 12-months follow-up. Initial home safety problems were categorized as multiple (≥ 4 problems) and none/few (< 4). Linear mixed models assessed the moderating effect with a three-way interaction (time, intervention, and initial safety problems).ResultsAt 12 months, the intervention effect was stronger among families with multiple initial problems than no/few initial problems, with a reduction of 1.55 more problems among the families with multiple problems, compared to the families with no/few problems (b = − 1.55, SE = 0.62, p = 0.013).ConclusionsInterventions targeting families with multiple safety problems may be more effective than universal programming.

BackgroundReal-world evaluations of complex interventions are scarce. We evaluated the effect of the Salut Programme, a universal child health promotion intervention in northern Sweden, on income-related inequalities in positive birth outcomes and healthcare utilisation up to 2 years after delivery.MethodsUsing the mother’s place of residence at delivery, the child and the mother were classified as belonging to either the control area (received care-as-usual) or the intervention area (where the intervention was implemented from 2006) and either the premeasure (children born between 2002 and 2004) or the postmeasure (children born between 2006 and 2008) period. Parents’ earned income was used as the socioeconomic ranking variable. The Relative Concentration Index was computed for six binary birth outcome indicators and for inpatient and day patient care for children and their mothers. Changes in inequality over time were compared using a difference-in-difference approach.ResultsIncome-related inequalities in birth outcomes and child healthcare utilisation were absent, except that full-term pregnancies were concentrated among the poor at premeasure in the intervention area. In contrast, mothers’ healthcare utilisation was significantly pro-poor in the control area. The extent of inequality changed differentially between premeasure and postmeasure for two birth outcomes: full-term pregnancies and infants with normal birth weight. Inequalities in healthcare utilisation did not change significantly in either area over time.ConclusionIn northern Sweden, income-related inequalities in birth outcomes and child healthcare utilisation are largely absent. However, relative inequalities in mothers’ healthcare utilisation are large. We found no evidence that the Salut Programme affected changes in inequality over time.

Poor early childhood development (ECD) in low- and middle-income countries is a major concern. There are calls to universalise access to ECD interventions through integrating them into existing government services but little evidence on the medium- or long-term effects of such scalable models. We previously showed that a psychosocial stimulation (PS) intervention integrated into a cash transfer programme improved Colombian children's cognition, receptive language, and home stimulation. In this follow-up study, we assessed the medium-term impacts of the intervention, 2 years after it ended, on children's cognition, language, school readiness, executive function, and behaviour. Study participants were 1,419 children aged 12-24 months at baseline from beneficiary households of the cash transfer programme, living in 96 Colombian towns. The original cluster randomised controlled trial (2009-2011) randomly allocated the towns to control (N = 24, n = 349), PS (N = 24, n = 357), multiple micronutrient (MN) supplementation (N = 24, n = 354), and combined PS and MN (N = 24, n = 359). Interventions lasted 18 months. In this study (26 September 2013 to 11 January 2014), we assessed impacts on cognition, language, school readiness, executive function, and behaviour 2 years after intervention, at ages 4.5-5.5 years. Testers, but not participants, were blinded to treatment allocation. Analysis was on an intent-to-treat basis. We reassessed 88.5% of the children in the original study (n = 1,256). Factor analysis of test scores yielded 2 factors: cognitive (cognition, language, school readiness, executive function) and behavioural. We found no effect of the interventions after 2 years on the cognitive factor (PS: -0.031 SD, 95% CI -0.229-0.167; MN: -0.042 SD, 95% CI -0.249-0.164; PS and MN: -0.111 SD, 95% CI -0.311-0.089), the behavioural factor (PS: 0.013 SD, 95% CI -0.172-0.198; MN: 0.071 SD, 95% CI -0.115-0.258; PS and MN: 0.062 SD, 95% CI -0.115-0.239), or home stimulation. Study limitations include that behavioural development was measured through maternal report and that very small effects may have been missed, despite the large sample size. We found no evidence that a scalable PS intervention benefited children's development 2 years after it ended. It is possible that the initial effects on child development were too small to be sustained or that the lack of continued impact on home stimulation contributed to fade out. Both are likely related to compromises in implementation when going to scale and suggest one should not extrapolate from medium-term effects of small efficacy trials to scalable interventions. Understanding the salient differences between small efficacy trials and scaled-up versions will be key to making ECD interventions effective tools for policymakers. ISRCTN18991160.

Nigeria's reproductive, maternal, newborn, child, and adolescent health indicators have remained unsatisfactory in the face of poor-quality healthcare services. Nigeria initiated the reproductive, maternal, newborn, child, and adolescent, elderly + nutrition (RMNCAEH+N) quality of care (QoC) agenda to address the challenge. The health management information system (HMIS) is integral to the agenda but there is sparse evidence on its performance so far. This study assessed the performance of routine HMIS for RMNCAEH+N QoC in Ondo and Ekiti States. This paper described the review of health facility records and health facility survey components of a multi-component study which employed a mixed-method research design. Using the routine health information system performance diagnostic tool, service data captured for over one year were critically reviewed in randomly selected sample of 169 public health facilities (Ondo:117; Ekiti:52) and information was obtained from facility heads or designates. Performance of routine HMIS for RMNCAEH+N QoC in terms of data collection, data quality, and data use were analysed using univariate and bivariate statistics. Results show that 67.3% of health facilities in Ekiti and 88.9% of facilities in Ondo had all required HMIS tools for selected RMNCAEH+N services (p<0.001). Data accuracy was 70.1% for Ondo and 40.4% for Ekiti (p <0.001); 82.9% of facilities in Ondo and 44.2% in Ekiti had complete data (p <0.001); almost all facilities (Ondo: 99.1%; Ekiti: 96.2%, p = 0.224) demonstrated data consistency; and, 82.9% of facilities in Ondo and 94.2% of facilities in Ekiti demonstrated timeliness in data submission (p = 0.048). Also, 70.1% (Ondo) and 78% (Ekiti) of facilities had quality improvement (QI) teams (p = 0.338); 53.5% (Ondo) and 77.1% (Ekiti) of QI teams regularly extracted data, calculated, and visualised prioritized indicators (p = 0.007); while 72.1% (Ondo) and 79.2% (Ekiti) regularly reviewed data and used it to make QI decisions (p = 0.367). Routine RMNCAEH+N QoC data management system in Ondo and Ekiti States vary in terms of the status of reporting forms, data quality, and data use for decision-making, and there were specific performance gaps. The routine RMNCAEH+N QoC data management system in Ondo and Ekiti States needs improvement and findings from this study can serve as the basis for evidence-based advocacy for the required efforts and investment toward improved performance.

Integrated care is about joining things up in order to meet health needs, and in ways that make sense to children and families. [...]it should make an important contribution towards improving child health. A plethora of government and non-government documents, policies and initiatives about integrated care have been produced in recent years. 10 Most of the national discourse on integration, however, focuses on the needs of the elderly. Since many older people are reliant on social care, and the effects of inefficient or over stretched social services are distinctly felt in healthcare, much of the policy around integration emphasises better join-up between health and social care.

To evaluate the cost-effectiveness of results-based financing and input-based financing to increase use and quality of maternal and child health services in rural areas of Zambia. In a cluster-randomized trial from April 2012 to June 2014, 30 districts were allocated to three groups: results-based financing (increased funding tied to performance on pre-agreed indicators), input-based financing (increased funding not tied to performance) or control (no additional funding), serving populations of 1.33, 1.26 and 1.40 million people, respectively. We assessed incremental financial costs for programme implementation and verification, consumables and supervision. We evaluated coverage and quality effectiveness of maternal and child health services before and after the trial, using data from household and facility surveys, and converted these to quality-adjusted life years (QALYs) gained. Coverage and quality of care increased significantly more in results-based financing than control districts: difference in differences for coverage were 12.8% for institutional deliveries, 8.2% postnatal care, 19.5% injectable contraceptives, 3.0% intermittent preventive treatment in pregnancy and 6.1% to 29.4% vaccinations. In input-based financing districts, coverage increased significantly more versus the control for institutional deliveries (17.5%) and postnatal care (13.2%). Compared with control districts, 641 more lives were saved (lower-upper bounds: 580-700) in results-based financing districts and 362 lives (lower-upper bounds: 293-430) in input-based financing districts. The corresponding incremental cost-effectiveness ratios were 809 United States dollars (US$) and US$ 413 per QALY gained, respectively. Compared with the control, both results-based financing and input-based financing were cost-effective in Zambia.

Early childhood interventions have potential to offset the negative impact of early adversity. We evaluated the impact of a community-based parenting group intervention on child development in Zambia. We conducted a non-masked cluster-randomized controlled trial in Southern Province, Zambia. Thirty clusters of villages were matched based on population density and distance from the nearest health center, and randomly assigned to intervention (15 clusters, 268 caregiver-child dyads) or control (15 clusters, 258 caregiver-child dyads). Caregivers were eligible if they had a child 6 to 12 months old at baseline. In intervention clusters, caregivers were visited twice per month during the first year of the study by child development agents (CDAs) and were invited to attend fortnightly parenting group meetings. Parenting groups selected \"head mothers\" from their communities who were trained by CDAs to facilitate meetings and deliver a diverse parenting curriculum. The parenting group intervention, originally designed to run for 1 year, was extended, and households were visited for a follow-up assessment at the end of year 2. The control group did not receive any intervention. Intention-to-treat analysis was performed for primary outcomes measured at the year 2 follow-up: stunting and 5 domains of neurocognitive development measured using the Bayley Scales of Infant and Toddler Development-Third Edition (BSID-III). In order to show Cohen's d estimates, BSID-III composite scores were converted to z-scores by standardizing within the study population. In all, 195/268 children (73%) in the intervention group and 182/258 children (71%) in the control group were assessed at endline after 2 years. The intervention significantly reduced stunting (56/195 versus 72/182; adjusted odds ratio 0.45, 95% CI 0.22 to 0.92; p = 0.028) and had a significant positive impact on language (β 0.14, 95% CI 0.01 to 0.27; p = 0.039). The intervention did not significantly impact cognition (β 0.11, 95% CI -0.06 to 0.29; p = 0.196), motor skills (β -0.01, 95% CI -0.25 to 0.24; p = 0.964), adaptive behavior (β 0.21, 95% CI -0.03 to 0.44; p = 0.088), or social-emotional development (β 0.20, 95% CI -0.04 to 0.44; p = 0.098). Observed impacts may have been due in part to home visits by CDAs during the first year of the intervention. The results of this trial suggest that parenting groups hold promise for improving child development, particularly physical growth, in low-resource settings like Zambia. ClinicalTrials.gov NCT02234726.

Audrey Prost and colleagues discuss how best to enable families and communities to improve child health

Despite advances in child health over the past 20 years, children are still failing to reach their full health and development. Marian Jacobs and Michael Merson examine what the 2016 strategic review tells about how IMCI and iCCM have contributed to gains in child health, as well as the changes in child health epidemiology, health systems, technology and innovations, and health science