Lesotho ECCD Special Initiative Professor Mark Tomlinson

Ms Sarah Skeen Dr Jackie Stewart Ms Marguerite Marlow Ms Shoeshoe Mofokeng Professor Lorraine Sher Professor Lucie Cluver Professor Peter Cooper Professor Lynne Murray Research Team

Country Context and Background Health and HIV Outcomes Slow rates in reducing new HIV infections amongst children aged in 3 children are OVC Lowest coverage of ART amongst children in southern Africa 13% of children are moderately/severely underweight; 39 % of children are moderately/severely stunted ECD Policy Education Act (2010) recognises non-formal education centres, free and compulsory primary education and education services within 5 kilometres of every habitation provided by the MOET. ECCD provided for children between the ages of 3-5 years ECCD services in Lesotho: Privately owned, home-based or pre-primary reception classes Challenges: Low access rates, poor infrastructure, lack of training for teachers

Intervention Description Intervention delivered at preschool centre in each intervention village Targets caregivers with children between 1-5 years 2 different age groups: Infant and Toddler Intervention (12-30 months) Child Intervention (31-60 months)

Intervention Description 8-week intervention with monthly consolidation sessions Structure: Group and individual activities, video materials, visual aids and practical exercises 5/6 caregivers and their children per group 2-3 hour sessions Intervention facilitator delivers ECCD component and mentors ECCD teacher to conduct book-sharing Community-based mentor delivers key messages for health and nutrition; makes referrals and follow up; links with Village Health Workers

Partnership Framework

ECD Component: Book-Sharing Bi-directional exchange between caregiver and child using a book Active child participation; following the child’s lead; pointing and naming Doesn’t require literacy skills Each session includes a group presentation with visual aids and video material and one-on-one session with each caregiver and child Intervention facilitator models optimal behaviour

Pilot Strategy 4 preschools in urban Mokhotlong 6 weeks 6 sessions for each group Intervention Identify facilitators and barriers to implementation and delivery Cultural adaptation of intervention content Extended training and supervision for intervention staff Test referral mechanisms Feedback focus groups with pilot participants Research Translation of caregiver questionnaires Language review and adaptation of assessment measures (CDI, Mullen, Peabody) Community consultation groups (barriers to HIV testing, alcohol use, parenting, gender issues) Roles and Responsibilities SU: Training and Supervision; intervention review and adaptation MSH: M&E GROW: Orientation and Implementation

Site Description: Mokhotlong, Lesotho 32 villages in the Mokhotlong district of north-eastern Lesotho 16 control and 16 intervention villages Mountainous area with scarce arable land and high rates of extreme poverty Poor transport and road facilities, and severe weather conditions 2 community councils in the Mokhotlong district selected for inclusion in the study: Sanqebethu J03 and Menoaneng J04 Villages selected based on falling in these 2 councils; having an informal preschool and being within the geographical area receiving services from Grow Intervention takes place in local ECCD centre/preschool Considerations: geographical and climate challenges limited research capacity in terms of human resources

Study Design Cluster randomised controlled trial 16 control villages and 16 intervention villages in Mokhotlong district Wait-list control group Assessment at baseline, 3 month and 12 month follow-up points Village Mapping Determined characteristics of communities, ECCD centres and health services Villages randomly assigned to control and intervention condition based on mapping exercise Participants 1160 children between the ages of 1 and 5 years and their primary caregivers Primary Outcomes Participation increases the rate of HIV testing Participation results in better child cognitive and language outcomes. Participation increases uptake of ART for children aged months after testing. Participating results in a higher rate of adherence to ART for children Participation results in better child growth Secondary Outcomes Participation improves positive parenting and discipline practices

Key Timelines: 2015 Intervention: Village Engagement: 19 June – 10 July 2015 Mokhotlong Urban Intervention (second pilot): 27 July – 28 August 2015 Advanced Training: 7 – 25 September 2015 Intervention (Phase 1 – 8 villages): 12 October – 12 December 2015 Data Collection: Recruitment: 29 June – 13 July 2015 Data Collectors Training: 20 July – 7 August 2015 Baseline Data Collection (scaffolded): 10 August – 26 October 2015