Economic Evaluation of an Effective Group-based Parenting Intervention to Promote Child Development in Rural Kenya

• In Event: Family Context and Child Development in the Global South

Abstract

Introduction: Early childhood development (ECD) programs can help address early disadvantages for the 43% of children under five in low- and middle-income countries who experience compromised development. We tested the effectiveness of two group-based delivery models for an integrated ECD responsive stimulation and nutrition education intervention using Kenya’s network of community health volunteers (CHVs). Combining detailed cost data with estimated impacts on child outcomes, we also estimated the relative cost-effectiveness of each delivery model, and under different assumptions of how program impacts translate into long-term benefits, we conducted a benefit-cost analysis to estimate the long-term returns to society of scaling up the program.

Hypotheses: Group-based interventions delivered by local community health volunteers can be cost-effective to promote early child development and offer potential to implement at scale in rural, low-income settings. These interventions are effective because they induce parental behavioral change in stimulation and nutrition practices.

Study Population: Mothers or other female primary caregivers with a child between 6-24 months at baseline from the rural sub-counties of East Rachuonyo, South Rachuonyo, and Sabatia in Western Kenya.

Methods: We implemented a multi-arm cluster randomized controlled trial in three rural sub-counties across 60 villages (clusters). Villages were randomly assigned to one of three equal-sized arms: group-only delivery with 16 fortnightly sessions; mixed delivery combining 12 group sessions with four home visits; and a comparison group. Households were surveyed at baseline and immediately post-intervention. Primary outcomes were child cognitive and language development (Bayley III), socioemotional development (Wolke scale), and parental stimulation (HOME inventory). Impacts were analyzed by intention-to-treat. For the cost analysis, all direct and indirect implementation costs were collected during the 8-month intervention period using quantitative project budget and financial data reported by the local NGO implementer. Costs were analyzed using a provider’s perspective in which included costs are those that a health provider would incur if the program were to be scaled. Benefit-cost ratios and the program return-of-investment for the Government were obtained by combining societal costs with predicted gains in lifetime earnings that would result from participating in the program given intervention effects in cognition and assumptions about wage returns to cognitive ability.

Results: At endline, 1070 households were assessed with no differential attrition by intervention arm. Children in group-only villages had higher cognitive (0.52SD), receptive language (0.42SD), and socioemotional scores (0.23SD) than children in comparison villages. Children in mixed-delivery villages had higher cognitive (0.34SD) and socioemotional scores (0.22SD). Parental stimulation improved for both group-only (0.80SD) and mixed-delivery villages (0.77SD). Total costs per child were similar across the two delivery models ($99 per child in the group-only and $102 per child in the mixed-delivery). Because of higher ITT impacts at similar costs, the group-only model demonstrated greater cost-effectiveness across all child outcomes, in particular for cognition and receptive language (Table 1). Cost-effectiveness ratios are higher than many previous parenting interventions in LMIC settings. Estimated benefit-cost ratios ranged from 5.6-26.9, and the return-to-investment ranged from 68%-708% depending on assumptions about the discount rate and wage returns to cognitive ability (Table 2).

Authors

• Italo Lopez Garcia, RAND Corporation
  Presenting Author

• Jill Luoto, RAND Corporation
  Non-Presenting Author

• Frances E Aboud, Centre universitaire de santé McGill
  Non-Presenting Author

• Uzaib Saya, RAND Corporation
  Non-Presenting Author

• Nicholas Ogendo, Safe Water and AIDS Project
  Non-Presenting Author