{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T23:56:33Z","timestamp":1772236593419,"version":"3.50.1"},"reference-count":36,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,2,26]],"date-time":"2025-02-26T00:00:00Z","timestamp":1740528000000},"content-version":"unspecified","delay-in-days":25,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Power of Nutrition","award":["(Award Number N\/A)"],"award-info":[{"award-number":["(Award Number N\/A)"]}]},{"DOI":"10.13039\/100004421","name":"World Bank Group","doi-asserted-by":"publisher","award":["Early Learning Partnership Grant (Award Number N\/A"],"award-info":[{"award-number":["Early Learning Partnership Grant (Award Number N\/A"]}],"id":[{"id":"10.13039\/100004421","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004421","name":"World Bank Group","doi-asserted-by":"publisher","award":["Innovation Grant (Award Number N\/A)"],"award-info":[{"award-number":["Innovation Grant (Award Number N\/A)"]}],"id":[{"id":"10.13039\/100004421","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004421","name":"World Bank Group","doi-asserted-by":"publisher","award":["Strategic Impact Evaluation Fund (Award Number N\/A"],"award-info":[{"award-number":["Strategic Impact Evaluation Fund (Award Number N\/A"]}],"id":[{"id":"10.13039\/100004421","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004421","name":"World Bank Group","doi-asserted-by":"publisher","award":["World Bank Research Budget (Award Number N\/A)"],"award-info":[{"award-number":["World Bank Research Budget (Award Number N\/A)"]}],"id":[{"id":"10.13039\/100004421","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000071","name":"National Institute of Child Health and Human Development","doi-asserted-by":"publisher","award":["F31HD105418"],"award-info":[{"award-number":["F31HD105418"]}],"id":[{"id":"10.13039\/100000071","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000071","name":"National Institute of Child Health and Human Development","doi-asserted-by":"publisher","award":["R03HD091636"],"award-info":[{"award-number":["R03HD091636"]}],"id":[{"id":"10.13039\/100000071","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Nutrition Office of Madagascar","award":["(Award Number N\/A)"],"award-info":[{"award-number":["(Award Number N\/A)"]}]},{"name":"Japan Nutrition Trust Fund","award":["(Award Number N\/A)"],"award-info":[{"award-number":["(Award Number N\/A)"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2024,12,30]]},"published-print":{"date-parts":[[2025,2]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Early child development (ECD) programs in low-resource settings can be effective when delivered through community health workers (CHWs), but there are significant challenges when moving to scale. This analysis aimed to determine the value-added, or relative effectiveness, of CHWs and communities on ECD outcomes within a home-visiting trial and examine associations between observable characteristics of the CHW or community and value-added.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We analysed data from the four treatment arms of a cluster-randomised trial conducted in 100 communities in rural Madagascar from 2014 to 2016. CHWs (one per cluster) and enrolled children (0\u201312 months) were surveyed at baseline and 2 years later. Child development scores were assessed using the Ages and Stages Questionnaire-Inventory (ASQ-I) and were internally age-standardised. We determined value-added by estimating CHW\/community-level fixed effects on ASQ-I Z-score trajectories (change from baseline to endline), conditional on baseline ASQ-I Z-score and child and household characteristics. We also assessed associations between value-added and observable CHW and community-level characteristics.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>We analysed data from 1456 children present at baseline and endline. CHW\/community fixed effects explained 26% of ASQ-I trajectory variance and estimates ranged from \u22121.68 SD to 1.31 SD. CHWs who had another income-generating position were associated with a 0.54 SD (95%\u2009CI 0.22, 0.87) increase in ASQ-I Z-score from baseline to endline. Greater increases in children\u2019s ASQ-I Z-scores were also associated with communities that had better healthcare, education and transportation infrastructure and were less geographically dispersed.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Children gained or lost over one standard deviation of ASQ-I Z-score depending on the community and CHW where they lived. Children\u2019s development trajectories benefitted from CHWs involved in an external income-generating activity and communities with better access to healthcare, education, and transportation. Careful consideration of the contexts in which child development interventions are implemented and potential correlates of improved CHW performance are crucial for improved outcomes.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjph-2024-001192","type":"journal-article","created":{"date-parts":[[2025,2,26]],"date-time":"2025-02-26T21:50:24Z","timestamp":1740606624000},"page":"e001192","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Assessing the value-added contributions of community health workers and communities to early child development: a longitudinal study in a low-income setting"],"prefix":"10.1136","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1714-1016","authenticated-orcid":false,"given":"Caitlin","family":"Hemlock","sequence":"first","affiliation":[{"name":"Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA"},{"name":"Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria","family":"Dieci","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management, Emory University, Atlanta, Georgia, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1555-4607","authenticated-orcid":false,"given":"Lia C H","family":"Fernald","sequence":"additional","affiliation":[{"name":"Division of Community Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emanuela","family":"Galasso","sequence":"additional","affiliation":[{"name":"Development Research Group, World Bank, Washington, District of Columbia, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisy","family":"Ratsifandrihamanana","sequence":"additional","affiliation":[{"name":"Centre M\u00e9dico-Educatif \"Les Orchid\u00e9es Blanches\", Antananarivo, Madagascar"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8130-5858","authenticated-orcid":false,"given":"Ann M","family":"Weber","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Biostatistics and Environmental Health, University of Nevada Reno, Reno, Nevada, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,2,26]]},"reference":[{"key":"2025083109510995000_3.1.e001192.1","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(16)31389-7"},{"key":"2025083109510995000_3.1.e001192.2","doi-asserted-by":"crossref","unstructured":"Jeong J , Franchett EE , Ramos de Oliveira CV , et al . 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