IntroductionIn the last decade, there has been increased global policy and program momentum to promote early childhood development. The Care for Child Development (CCD) package, developed by UNICEF and the WHO, is a key tool responding to the global demand. The CCD package comprises two age-specific evidence-based recommendations for caregivers to 1) play and communicate and 2) responsively interact with their children (0–5 years) and was designed to be integrated within existing services to strengthen nurturing care for child development. The aim of this report was to provide an up-to-date global review of the implementation and evaluation of the CCD package.MethodsIn addition to a systematic review of 55 reports, we interviewed 23 key informants (including UNICEF and WHO personnel) to better understand the implementation of CCD.ResultsThe CCD package has been or is being implemented in 54 low- and middle-income countries and territories, and it has been integrated into government services across the health, social, and education sectors in 26 countries. Across these contexts, CCD has been adapted in three primary ways: 1) translations of CCD materials (mostly counseling cards) into local language(s), 2) adaptations of CCD materials for the local context, vulnerable children, or a humanitarian/emergency setting (e.g., including local play activities, using activities that are better suited to children with visual impairments), and 3) substantive modifications to the content of CCD materials (e.g., expansion of play and communication activities, addition of new themes, creation of a structured curriculum). While there is promising evidence and examples of good implementation practice, there has been mixed experience about implementation of CCD with respect to adaptation, training, supervision, integration into existing services, and monitoring implementation fidelity and quality. For example, many users of CCD found difficulties with training the workforce, garnering buy-in from governments, and ensuring benefits for families, among others.DiscussionAdditional knowledge on how to improve the effectiveness, implementation fidelity and quality, and acceptance of CCD is needed. Based on the findings of the review we make recommendations for future efforts to implement CCD at-scale.

Care for Child Development (CCD) is one of several parenting programs implemented in low- and middle-income countries to improve child cognitive development outcomes by increasing responsive stimulation practices in caregivers of young children. Broadly, these programs have been demonstrated to be effective. However, there is markedly little high-quality evidence for the effectiveness of CCD. Despite this, CCD is promoted by UNICEF and the World Health Organisation as an evidence-based program and is implemented in many countries. We conducted a scoping review, including grey literature and a systematic search of published literature, to obtain an overview of the available evidence. We also performed an analysis of two quantitative outcomes, child cognitive development and caregiver behaviour, to investigate their correlation with behaviour change techniques used in CCD program implementation. We found no significant correlation between any behaviour change techniques and child cognitive development outcomes. There was a significant correlation between the techniques of performance and social support, as well as the total number of techniques used, and caregiver behaviour outcomes. This analysis was limited by the quality of reported data available about the program; of 27 total identified papers, only 14 reported quantitative data regarding either child cognitive development or caregiver behaviour change. Inconsistent reporting of this data required us to use a rating system to perform our analysis; we consequently lost specificity. Even those papers that did report quantitative data were subject to methodological flaws; the measures and study designs used did not always inspire confidence in their results. We concluded that CCD is not one single, well-defined program, and that there is an important distinction to be made between CCD-based and CCD-informed programs. The generic Care for Child Development Package (2012) is a framework that contains too many gaps to be easily adaptable. Not enough high-quality studies of this program are available to draw concrete conclusions concerning its effectiveness, in whole or in part.