Correction: Early childhood education and care quality and associations with child outcomes: A meta-analysis.

[This corrects the article DOI: 10.1371/journal.pone.0285985.].

Using Data Tools and Systems to Drive Change in Early Childhood Education for Disadvantaged Children in South Africa.

In line with United Nations Sustainable Development Goal (SDG) 4.2, South Africa's National Development Plan commits to providing high-quality early childhood education to all children by 2030 to drive improved child outcomes. Prior to 2016, South Africa lacked reliable, locally standardised, valid, and cross-culturally fair assessment tools for measuring preschool quality and child outcomes, suitable for use at scale within a resource-constrained context. In this paper we detail the development and evolution of a suite of early learning measurement (ELOM) tools designed to address this measurement gap. The development process included reviews of literature and other relevant assessment tools; a review of local curriculum standards and expected child outcomes; extensive consultation with government officials, child development experts, and early learning practitioners, iterative user testing; and assessment of linguistic, cultural, functional, and metric equivalence across all 11 official South African languages. To support use of the ELOM tools at scale, and by users with varying levels of research expertise, administration is digitised and embedded within an end-to-end data value chain. ELOM data collected since 2016 quantify the striking socio-economic gradient in early childhood development in South Africa, demonstrate the relationship between physical stunting, socio-emotional functioning and learning outcomes, and provide evidence of the positive impact of high-quality early learning programmes on preschool child outcomes. To promote secondary analyses, data from multiple studies are regularly collated into a shared dataset, which is made open access via an online data portal. We describe the services and support that make up the ELOM data value chain, noting several key challenges and enablers of data-driven change within this context. These include deep technical expertise within a multidisciplinary and collaborative team, patient and flexible capital from mission-aligned investors, a fit-for-purpose institutional home, the appropriate use of technology, a user-centred approach to development and testing, sensitivity to children's diverse linguistic and socio-economic circumstances, careful consideration of requirements for scale, appropriate training and support for a non-professional assessor base, and a commitment to ongoing learning and continuous enhancement. Practical examples are provided of ways in which the ELOM tools and data are used for programme monitoring and enhancement purposes, to evaluate the relative effectiveness of early learning interventions, to motivate for greater budget and inform more effective resource allocation, to support the development of enabling Government systems, and to track progress towards the attainment of national and global development goals. We share lessons learnt during the development of the tools and discuss the factors that have driven their uptake in South Africa.

Early childhood education and care quality and associations with child outcomes: A meta-analysis.

OBJECTIVES: The effectiveness of early childhood education and care (ECEC) programs for children's development in various domains is well documented. Adding to existing meta-analyses on associations between the quality of ECEC services and children's developmental outcomes, the present meta-analysis synthesizes the global literature on structural characteristics and indicators of process quality to test direct and moderated effects of ECEC quality on children's outcomes across a range of domains. DESIGN: A systematic review of the literature published over a 10-year period, between January 2010 and June 2020 was conducted, using the databases PsychInfo, Eric, EbscoHost, and Pubmed. In addition, a call for unpublished research or research published in the grey literature was sent out through the authors' professional network. The search yielded 8,932 articles. After removing duplicates, 4,880 unique articles were identified. To select articles for inclusion, it was determined whether studies met eligibility criteria: (1) study assessed indicators of quality in center-based ECEC programs catering to children ages 0-6 years; and (2) study assessed child outcomes. Inclusion criteria were: (1) a copy of the full article was available in English; (2) article reported effect size measure of at least one quality indicator-child outcome association; and (3) measures of ECEC quality and child outcomes were collected within the same school year. A total of 1,044 effect sizes reported from 185 articles were included. RESULTS: The averaged effects, pooled within each of the child outcomes suggest that higher levels of ECEC quality were significantly related to higher levels of academic outcomes (literacy, n = 99: 0.08, 95% C.I. 0.02, 0.13; math, n = 56: 0.07, 95% C.I. 0.03, 0.10), behavioral skills (n = 64: 0.12, 95% C.I. 0.07, 0.17), social competence (n = 58: 0.13, 95% C.I. 0.07, 0.19), and motor skills (n = 2: 0.09, 95% C.I. 0.04, 0.13), and lower levels of behavioral (n = 60: -0.12, 95% C.I. -0.19, -0.05) and social-emotional problems (n = 26: -0.09, 95% C.I. -0.15, -0.03). When a global assessment of child outcomes was reported, the association with ECEC quality was not significant (n = 13: 0.02, 95% C.I. -0.07, 0.11). Overall, effect sizes were small. When structural and process quality indicators were tested separately, structural characteristics alone did not significantly relate to child outcomes whereas associations between process quality indicators and most child outcomes were significant, albeit small. A comparison of the indicators, however, did not yield significant differences in effect sizes for most child outcomes. Results did not provide evidence for moderated associations. We also did not find evidence that ECEC quality-child outcome associations differed by ethnic minority or socioeconomic family background. CONCLUSIONS: Despite the attempt to provide a synthesis of the global literature on ECEC quality-child outcome associations, the majority of studies included samples from the U.S. In addition, studies with large samples were also predominately from the U.S. Together, the results might have been biased towards patterns prevalent in the U.S. that might not apply to other, non-U.S. ECEC contexts. The findings align with previous meta-analyses, suggesting that ECEC quality plays an important role for children's development during the early childhood years. Implications for research and ECEC policy are discussed.

Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.

Effectiveness of Social Inclusion Interventions for Anxiety and Depression among Adolescents: A Systematic Review.

BACKGROUND: Adolescents who are socially excluded are at increased risk of mental health problems such as depression and anxiety. Promoting social inclusion could be an effective strategy for preventing and treating adolescent depression and anxiety. METHODS: We conducted a systematic review of intervention studies which aimed to prevent or treat adolescent depression and/or anxiety by promoting social inclusion. Throughout the review we engaged a youth advisory group of 13 young people (aged 21-24) from Uganda, Turkey, Syria, South Africa, and Egypt. RESULTS: We identified 12 studies relevant to our review. The interventions tested use a range of different strategies to increase social inclusion and reduce depression and anxiety, including social skills training, psychoeducation, teaching life skills training, and cash transfers. Pooled standardised mean differences (SMDs) based on random-effects models showed medium-to-large benefits of interventions on improving depression and anxiety symptoms (n = 8; SMD = -0.62; 95% CI, -1.23 to -0.01, p < 0.05). CONCLUSION: Although there are not many studies, those which have been done show promising results that strongly suggest that social inclusion could be an important component of programmes to promote adolescent mental health.

Detecting Depression and Anxiety Among Adolescents in South Africa: Validity of the isiXhosa Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7.

PURPOSE: Screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) could potentially be used in resource-limited settings to identify adolescents who need mental health support. We examined the criterion validity of the isiXhosa versions of the PHQ-9 and GAD-7 in detecting depression and anxiety among adolescents (10-19 years) in South Africa. METHODS: Adolescents were recruited from the general population and from nongovernmental organizations working with adolescents in need of mental health support. The PHQ-9 and GAD-7 were culturally adapted and translated into isiXhosa and administered to 302 adolescents (56.9% female). The Kiddie Schedule for Affective Disorders and Schizophrenia was administered by trained clinicians as the gold standard diagnostic measure for depression and anxiety. RESULTS: For the PHQ-9, the area under the curve was 0.88 for the full sample of adolescents (10-19 years old). A score of ≥10 had 91% sensitivity and 76% specificity for detecting adolescents with depression. For the GAD-7, the area under the curve was 0.78, and cutoff scores with an optimal sensitivity-specificity balance were low (≥6). A score of ≥6 had 67% sensitivity and 75% specificity for detecting adolescents with anxiety. DISCUSSION: The culturally adapted isiXhosa version of the PHQ-9 can be used as a valid measure for depression in adolescents. Further research on the GAD-7 for use with adolescents is recommended.

Health care providers' knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study.

BACKGROUND: Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers' knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases. METHODS: This study aimed to (1) measure health care providers' knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers' knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression. RESULTS: We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69-0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79-0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores. CONCLUSION: We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.