Sustainable day-care for 1-4 year olds in disadvantaged urban communities in Dhaka, Bangladesh

Our partners, CIPRB, have shown, through a natural experiment, that community day-care for 1-4 year old children in rural areas is effective in reducing risk of all-cause mortality by 44%, drowning by 82% and injuries by 88%, compared to children not in day-care [9]. We wish to adapt this model so it can be appropriately, feasibly and sustainably delivered to benefit urban disadvantaged communities.
Low-income countries (LICs) are experiencing rapid and uncontrolled urbanisation. This can clearly be seen in Dhaka, Bangladesh with an annual urban population growth of 3.6% [6], and an estimated 4 million inhabitants living in slums. Urbanisation is changing gender dynamics: 22% of women in Dhaka now work outside the home (11% non-slum) [9]. With limited extended family support in slums, women must either leave children with elder siblings - often sisters who then drop-out of school - or neighbours. This limited supervision contributes to high rates of injuries, poor hygiene and limited nutrition, resulting in 50% of slum children suffering stunting (33% non-slum). Child day-care presents a holistic solution, allowing women to work whilst knowing their children are safe, cared-for and have opportunities for early childhood development (ECD).
Our partners, CIPRB, have extensive experience of delivering day-care in rural Bangladesh [9]. Building on CIPRB's rural model we plan to develop and refine a sustainable day-care model based on principles of ECD and improving nutrition and hygiene for 1-4 year olds. Financial sustainability is key for longevity and scale-up. We plan to place day-care centres adjacent to slums so services at a suitable fee can be provided to parents in non-slum neighbourhoods. This approach is designed to promote integration between the two communities, potentially facilitating social mobility for slum children.
Objectives and methods, to:
1) Understand the extent and nature of demand for day-care we will survey 200 households with children under 5 from slum and non-slum communities, and conduct qualitative interviews to understand perceptions of childcare among women, carers, men and community leaders.
2) Co-produce a proto-type integrated, self-sustaining, child day-care model we will establish a technical working group of childcare experts, community representatives, local government officials, donors and (I)NGOs. The group will draw on CIPRB's, (I)NGO models and findings of a systematic review being conducted by UWA (not included in this proposal) to develop a prototype model and all materials required. The group will also develop a draft theory of change to guide the evaluation.
3) Test and refine an integrated self-sustaining model, we will implement the day-care model for six months. During this time, we will facilitate a group of day-care users and staff to reflect on how the model is working and make changes for improvement. Our qualitative researchers will observe the process, and interview users to understand how to further improve the model. We will assess model costs and the extent that fees from non-slum day-care users can support sustainable delivery.
4) Inform the design of a pilot study for a larger evaluation to assess the cost-effectiveness of the day-care model, we will assess the feasibility and then refine methods for recruitment, assessment and follow-up among day-care users and a potential comparator group. This will involve repeating the survey among the same sample of 200 households. We will also assess children when they start at day-care and six months later. We will use our overall analysis to refine our theory of change. Throughout the study we will engage closely with local government and donors to understand and influence plans to scale up day-care across Dhaka, targeting the urban poor. We will identify the most appropriate outcome measures from our theory of change and discussions with policy makers. We expect these will include ECD, stunting and injuries.

Low-income countries are experiencing rapid and uncontrolled urbanisation [1;4]. With a population of 16 million, a quarter of whom are slum-dwellers, Dhaka, Bangladesh exemplifies this transition. The poor infrastructure and conditions of slums limit child health and development [2; 3; 9]. Increasing numbers of urban poor women are working outside the home [9], often leaving children with limited supervision. The 1-4 year age group are particularly vulnerable to injuries, poor nutrition and infections, yet intervention at this age can positively impact physical and cognitive development [2;5]. A 2011 systematic review showed day-care improved early childhood development (ECD), but also identified no robust studies of urban day-care in Asia or Africa, and insufficient quality evidence to assess health outcomes. Our partners, CIPRB, have shown that community day-care for 1-4 year olds in rural Bangladesh is effective in reducing all-cause mortality by 44% (95% CI: 20% to 61%), drowning by 82% (95% CI: 42% to 94%) and injuries by 88% (95% CI: 61% to 96%) compared to children not in day-care [9]. We wish to adapt this model so that it can be appropriately, feasibly and sustainably delivered to benefit urban disadvantaged communities.

This early phase study will: (1) use a survey and qualitative interviews to understand the extent and nature of demand for day-care amongst slum and non-slum households. (2) Co-produce, with communities, government and NGOs, a proto-type self-sustaining, child day-care model focusing on ECD, nutrition and hygiene improvement. (3) Use participatory action research to test and refine the model in one of Dhaka's largest slums. (4) Assess the feasibility and then refine methods for recruitment, assessment and follow-up among day-care users and a potential comparator group. The outcomes of this research will inform the design and pilot testing of a future evaluation to assess the cost-effectiveness of the day-care model.