THE STATUS OF EARLY CHILDHOOD HEALTH AND DEVELOPMENT IN NORTHERN LAO PDR BASELINE RESULTS FROM THE EARLY CHILDHOOD EDUCATION PROJECT Sally Brinkman Alanna Sincovich Plamen Nikolov Danchev December 2016 STANDARD DISCLAIMER COPYRIGHT STATEMENT: This volume is a product of the staff of the The material in this publication is copyrighted. International Bank for Reconstruction and Development/ Copying and/or transmitting portions or all of this The World Bank. The findings, interpretations, and work without permission may be a violation of conclusions expressed in this paper do not necessarily applicable law. The International Bank for Reconstruc- reflect the views of the Executive Directors of tion and Development/ The World Bank encourages The World Bank or the governments they represent. dissemination of its work and will normally grant The World Bank does not guarantee the accuracy of permission to reproduce portions of the work the data included in this work. The boundaries, promptly.For permission to photocopy or reprint any colors, denominations, and other information shown part of this work, please send a request with on any map in this work do not imply any judgment on complete information to the Copyright Clearance the part of The World Bank concerning the legal status Center, Inc., 222 Rosewood Drive, Danvers, MA of any territory or the endorsement or acceptance of such 01923, US A, t e l e p h o n e 978-7 5 0 - 8 4 0 0 , boundaries. fax 978-750-4470, http://www.copyright.com/. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail: pubrights@worldbank.org. TABLE OF FIGURES 6 LIST OF TABLES 7 Abbreviations 8 Executive Summary 10 PART ONE: INTRODUCTION AND BACKGROUND 12 Country Context 12 The Early Childhood Education Project 13 Project Impact Evaluation 16 Research Design 17 Sample 17 PART TWO: THE SOCIAL, DEMOGRAPHIC AND ECONOMIC SITUATION OF FAMILIES IN NORTHERN LAO PDR 27 Villages 27 Population Size 27 Ethnicity 28 Village Access 28 Income 28 Electricity 29 Sanitation 29 Rubbish Disposal 29 Water 29 Village Education Development Committees 30 Community Participation 31 Health Care Services 31 Education Services 32 Important Events 34 Households 34 Size 35 Building Materials 35 Transiency 36 Drinking Water 36 Sanitation 37 Electricity 37 Socio-economic Status 37 Aid 39 Village Education Development Committees 39 Village Environment 39 PART THREE: THE HEALTH AND DEVELOPMENT OF CHILDREN IN NORTHERN LAO PDR 40 Caretakers 40 Children 41 Child Health 43 General Health 43 Breastfeeding 43 Undernutrition 45 Diet 48 Vaccinations 50 Caretaker Knowledge on Child Health 52 Child Development 52 Verbal Communication Skills 60 Approaches to Learning 61 Early Numeracy Skills 63 Early Literacy Skills 74 Cultural Knowledge 82 Social and Emotional Skills 83 Perseverance 85 Executive Functioning 86 Stimulation in the Home Environment 89 Home Stimulation and Child Development 93 Parenting Practices and Child Development 99 Relationship Between Parenting Practices and Child Development 101 Village Amenities and Child Development 101 Health and Education Services and Child Development 103 Health Care Services 103 Relationship Between Child Health and Development 106 Early Childhood Education Services and Child Development 110 Which Factors Have the Strongest Relationship With Child Development? 114 PART FOUR: SUMMARY OF KEY FINDINGS 115 References 119 TABLE OF FIGURES Figure 1: Evaluation design and community level sample size 19 Figure 2: Provinces in Lao PDR in which baseline data was collected 20 Figure 3: Education level of village heads 27 Figure 4: Main ethnicities in villages 28 Figure 5: Village electricity sources 29 Figure 6: Villages drinking and washing/cleaning water sources 30 Figure 7: Distribution of health care services across provinces 31 Figure 8: Distribution of education services across provinces 33 Figure 9: Education level of heads of households 34 Figure 10: Distance of households to drinking water 36 Figure 11: Number of children's books in households 38 Figure 12: Household assets 38 Figure 13: Caretaker's level of education 40 Figure 14: Children's ethnicity 42 Figure 15: Child’s age when they stopped breastfeeding 44 Figure 16: Children who were exclusively breastfed until at least six months of age 45 Figure 17: Undernutrition across provinces 46 Figure 18: Prevalence of stunting by gender, age, ethnicity and caretaker's education 47 Figure 19: Prevalence of wasting by gender, age, ethnicity and caretaker's education 48 Figure 20: Average child development scores across developmental domains 53 Figure 21: Children's overall development by gender, age, ethnicity and caretaker's education 54 Figure 22: Child development by province 60 Figure 23: Children's verbal communication skills by gender, age, ethnicity and caretaker's education 61 Figure 24: Children's approaches to learning by gender, age, ethnicity, and caretaker's education 62 Figure 25: Early numeracy skills and knowledge of numeracy concepts by gender, age, ethnicity and caretaker's education 64 Figure 26: Quantitative comparison by gender, age, ethnicity, and caretaker's education 65 Figure 27: Measurement vocabulary by gender, age, ethnicity, and caretaker's education 66 Figure 28: Shape Naming by gender, age, ethnicity, and caretaker's education 67 Figure 29: Spatial vocabulary by gender, age, ethnicity, and caretaker's education 68 Figure 30: Counting ability by gender, age, ethnicity, and caretaker's education 69 Figure 31: Number identification by gender, age, ethnicity and caretaker's education 70 Figure 32: Producing a set by gender, age, ethnicity, and caretaker's education 71 Figure 33: Addition by gender, age, ethnicity and caretaker's education 72 Figure 34: Spatial visualisation by gender, age, ethnicity and caretaker's education 73 Figure 35: Early literacy (reading and writing) skills by gender, age, ethnicity, and caretaker's education 75 Figure 36: Print familiarity scores by gender, age, ethnicity and caretaker's education 76 Figure 37: Relationship between print familiarity and books in the home 77 Figure 38: Sound discrimination by gender, age, ethnicity and caretaker's education 78 Figure 39: Sound identification by gender, age, ethnicity and caretaker's education 79 Figure 40: Letter name knowledge by gender, age, ethnicity and caretaker's education 80 Figure 41: Listening comprehension by gender, age, ethnicity and caretaker's education 81 Figure 42: Children's knowledge of culture by gender, age, ethnicity and caretaker's education 82 Figure 43: Social and emotional development by gender, age, ethnicity and caretaker's education 84 Figure 41: Listening comprehension by gender, age, ethnicity and caretaker's education 81 Figure 42: Children's knowledge of culture by gender, age, ethnicity and caretaker's education 82 Figure 43: Social and emotional development by gender, age, ethnicity and caretaker's education 84 Figure 44: Children's perseverance by gender, age, ethnicity and caretaker's education 85 Figure 45: Executive function (heads toes task) by gender, age, ethnicity and caretaker's education 87 Figure 46: Executive function (forward digit span) by gender, age, ethnicity and caretaker's education 88 Figure 47: Executive function (backward digit span) by gender, age, ethnicity and caretaker's education 89 Figure 48: Caretakers' participation in home learning activities over the last 7 days 90 Figure 49: Caretakers who had played with toys/a game with their child in the past 7 days 91 Figure 50: Caretakers who had read a book with their child in the past 7 days 92 Figure 51: Relationship between home learning activities and child development 93 Figure 52: Average parenting practices across whole sample 100 Figure 53: Parental warmth across child gender, age, ethnicity and caretaker's education 100 Figure 54: Relationship between village amenities and child development 102 Figure 55: Children who received a health service in the past month by gender, age, ethnicity and caretaker's education 104 Figure 56: Relationship between health service availability and child development 105 Figure 57: Average child development scores by stunting status 107 Figure 58: Average child development scores by wasting status 108 Figure 59: Average child development scores by underweight status 110 Figure 60: ECE attendance by gender, age, ethnicity and caretaker's education 111 Figure 61: Relationship between ECE attendance and child development 112 Figure 62: Relationship between age children started kindergarten and child development 113 LIST OF TABLES Table 1: Sample by Province and District 21 Table 2: Travel time from villages to their closest health service 32 Table 3: Education and literacy levels of heads of households, by gender 35 Table 4: Caretaker's education and literacy levels by gender 41 Table 5: Age and gender of children 41 Table 6: Number and percentage of children of each ethnicity across provinces 42 Table 7: Prevalence of undernutrition and public health significance 45 Table 8: Children's food consumption in the last week 49 Table 9: School meal consumption by child age 50 Table 10: Vaccination coverage by child age and WHO vaccination recommendations 51 Table 11: Developmental domains descriptive results 53 Table 12: Child development by child age 55 Table 13: Child development by child gender 56 Table 14: Child development by child ethnicity 57 Table 15: Child development by caretaker's education level 59 Table 16: Relationship between caretaker playing a game with their child in the past 7 days and child development 94 Table 17: Relationship between caretaker reading a book to their child in the past 7 days and child development 95 Table 18: Relationship between caretaker telling a story to their child in the past 7 days and child development 96 Table 19: Relationship between caretaker drawing with their child in the past 7 days and child development 97 Table 20: Relationship between caretaker singing or dancing with their child in the past 7 days and child development 97 Table 21: Relationship between child participating in housework in the past 7 days and child development 98 Table 22: Relationship between caretaker participating in outdoor activities with child in the past 7 days and child development 99 Table 23: Relationship between parenting practices and overall child development 101 Table 24: Relationship between sanitation processes and overall child development 103 Table 25: Relationship between electricity sources and child development 103 Table 26: Relationship between stunting and child development 106 Table 27: Relationship between stunting and child development 106 Table 28: Relationship between wasting and child development 107 Table 29: Relationship between wasting and child development 108 Table 30: Relationship between being underweight and child development 109 Table 31: Relationship between being underweight and child development 109 Table 32: Relationship between ECE attendance and child development 112 Table 33: Strongest predictors of child development 114 ABBREVIATIONS CAC Community Awareness Campaign CCDG Community Child Development Group ECE Early Childhood Education EFO Externally Financed Output EHCI Early Human Capability Index IDA International Development Association Lao PDR Lao People’s Democratic Republic LEARN Lao Educational Access, Research and Networking MAT Multi-Age Teaching MELQO Measuring Early Learning Quality Outcomes MODEL Measurement of Development and Early Learning VEDC Village Education Development Committee ACKNOWLEDGEMENTS This baseline study was conducted under the overall guidance of Mr. Harry Patrinos (Practice Manager, Education Global Practice, East Asia and Pacific Region, the World Bank) and Mr. Plamen Danchev (Senior Education Specialist, Education Global Practice, East Asia and Pacific Region, the World Bank). The data collection was funded by the Early Childhood Education (ECE) Project (P145544), financed by the World Bank Group through an International Development Association (IDA) Grant, and through Credit under the Early Childhood Education Project. Data collection was undertaken by Indochina RL, under contract with the Ministry of Education and Sports of Lao PDR. The analysis of the baseline data and the production of this report has been financed through a partnership between the World Bank, Plan International and Save the Children International as part of the Lao Educational Access, Research and Networking (LEARN) Project, with funding from Dubai Cares under Externally Financed Output (EFO) Agreement EFO 990. The team would like to thank Dubai Cares and Plan International for their support and advice throughout the course of this baseline study. In particular, we would like to thank Ms. Jodie Fonseca, (LEARN Project Director, Plan International) for leading effective collaboration between the research team and key staff at Plan International and Dubai Cares. The study benefitted from the support of various officials and staff from the Ministry of Education and Sports (MoES). We would like to extend our appreciation to Mrs. Khampaseuth Kitignavong, the Education Sector Development Plan Coordination Unit (ECU) Director, MoES. We would also like to thank Ms. Boualamphan Phouthavisouk for her excellent administrative support. 9 | The Status of Early Childhood Health and Development in Northern Lao PDR EXECUTIVE SUMMARY Limited parental knowledge of what is required for This report presents baseline data from 7,520 optimal child health, coupled with inadequate children in 7,355 households, across five provinces, coverage of healthcare services is leading to poor 14 districts and 376 villages in northern Lao PDR. health outcomes for children in northern Lao PDR. These results are the starting point for the impact Children are not receiving the basic services and evaluation of the Early Childhood Education (ECE) nutrition they need for good health. In particular, the Project which seeks to support the expansion of level of stunting is of high public health significance, quality ECE services in order to improve the overall and this is having a substantial negative impact on development and school readiness of children aged children’s development and ability to learn. Despite three to five years in disadvantaged communities significant improvements in education services, Early across Lao PDR. The data provides a comprehensive Childhood Education (ECE) coverage in northern Lao picture of the current status of children’s health and is insufficient. However, where cover exists, ECE development, of the social, demographic and attendance is associated with better verbal economic contexts in which children in northern Lao communication skills, approaches to learning, early PDR are growing up, and of how all these factors are literacy and numeracy skills, perseverance, having an impact on children’s early developmental knowledge of culture, and social and emotional skills. outcomes. This is consistent with international literature around the positive impacts of ECE on children’s early Overall, children in northern Lao PDR are developing development. poorly, with disparities in child development across different ethnic groups and family backgrounds. In Finally, children are receiving very low levels of particular, Lao-Tai children are developing better than stimulation and support for their development in their Khmu and Hmong children, and children of parents home environments, and this is having a significant with some education have better development than negative impact on their learning and development. the children of parents who have never gone to Parent-child interactions are of great importance. school. According to the data collected for this study, the increase in children’s development associated with parent-child interactions was almost equal to the increases associated with ECE attendance. The ECE Project has the potential to support improvements in child health and development in Lao PDR through a range of interventions, namely: The Status of Early Childhood Health and Development in Northern Lao PDR | 10 the increased coverage and quality of existing ECE In 2018, after the project has been implemented for services and the establishment of Community Child two years, endline data will be collected in order to Development Groups (CCDGs); re-assess how well children in target villages have developed in comparison to children in villages the delivery of a community awareness campaign in without the ECE project interventions. Learnings from order to increase the knowledge and understanding of the impact evaluation will help inform future ECE parents and the wider community about the importance policy and program decisions, so that resources are of early child development, appropriate parenting used effectively and have the maximum positive skills and early stimulation required for children’s impact on children’s outcomes in Lao PDR. learning, good health and nutrition, hygiene, immunization, and childhood disability awareness; the implementation of complementary support services such as disability screening and the provision of school meals in primary schools (and kindergartens, if on the same campus) in order to encourage attendance and provide children with nutritious meals nutritious meals. 11 | The Status of Early Childhood Health and Development in Northern Lao PDR PART ONE INTRODUCTION AND BACKGROUND Country Context The Lao People’s Democratic Republic (PDR) has experienced sustained robust economic growth over the past decade; indeed, it is one of the fastest growing economies in East Asia-Paci fi c. As a reflection of such progress, the country was recently changed classification from low income country to lower-middle income country, and is on track to achieve its long-term goal of graduating from Least Developed Country status by 2020. Such growth has helped alleviate poverty, which has declined from 34% to 23% in the last decade, lifting half a million people out of poverty (World Bank, 2015). Despite these achievements, significant economic disparities persist across Lao PDR, particularly among the country’s diverse ethnic groups and between different geographical areas. The country has 49 officially recognized ethnic groups, with four In conjunction with countries across the world, Lao main linguistic families: Lao-Tai, Mong-Khmer, PDR committed to adopt the 2030 Agenda for Hmong-Mien, and Sino-Tibetan. The Lao-Tai Sustainable Development, which includes 17 experience much lower poverty rates than other Sustainable Development Goals (SDGs) to end groups: in 2012, 25% of Lao-Tai were living in poverty poverty, fight inequality and injustice, ensure inclusive compared to 42% or more for the other three groups and quality education and tackle climate change by (World Bank, 2014b). This stands in contrast with the 2030. Education(including ECE) is a particular priority fact that the three non-Lao-Tai groups make up for the Government of Lao PDR. Expanding the cover- approximately two thirds of the total population. age of and access to ECE for all children is an import- Although government support has targeted these ant goal and strategy of the government. Towards this ethnic groups and the regions they inhabit, lack of goal, the Government of Lao PDR adopted specific access to infrastructure and markets in rural and steps as part of its Education for All National Plan of remote regions remains a barrier to growth and pover- Action 2003-2015, in order to: (i) promote coordina- ty reduction. In this way, the pattern of poverty also tion between the Government, community and private has a geographical dimension. In rural areas - where sector; (ii) mobilize communities in favour of pre-pri- nearly three-quarters of the country’s almost seven mary education, and promote the development of million people live - the poverty rate of 32% is almost community pre-primary education; and (iii) promote double that of urban areas (World Bank, 2014b). access to pre-primary education for 5-year-olds by Further support is needed to reduce such disparities establishing a pre-primary class or community-based school and promote growth across Lao PDR. The Status of Early Childhood Health and Development in Northern Lao PDR | 12 readiness program to prepare them for Grade 1, The Early Childhood particularly targeting ethnic groups, girls and children from the poorest families. Moreover, the Education Project Government’s commitment to equitable and healthy development of all children is reflected in the draft National Policy on Holistic Early Child Development Against this background, World Bank Group has (2010), which was guided under the supervision and provided funding of USD 28 million through an coordination of the National Commission for Mothers International Development Association (IDA) Grant and Children. (USD 14 million) and IDA credit (USD 14 million) to the Government of Lao PDR for the Early Childhood However, although significant investments have been Education Project. The ECE Project seeks to support made in education, coverage and resources devoted the expansion of quality ECE services, with the to ECE remain insufficient. The proportion of 3 to 5 objective of improving the overall development and year old children enrolled in ECE programs increased school readiness of children aged three to five years from 23% to 33% between 2011 and 2013, and the in disadvantaged communities across the country. enrolment rate for 5 year old children rose from 32% Research conducted in both developed and in 2008/09 to 52% in 2012/13 (World Bank, developing countries demonstrates that ECE is one of 2014b). Despite these increases, enrolment rates the most cost-effective and equitable interventions in remain low compared to other countries with similar human development. Investment in ECE has been income levels. Moreover, existing ECE programs in shown to reduce school dropout and grade repetition Lao PDR predominantly cater for 5 year olds, w and rates (Davoudzadeh, McTernan, & Grimm, 2015; offer pre-primary classes attached to primary Nores & Barnett, 2010) schools. Subsequently, children of 3 and 4 years of age have especially limited access to ECE services. Coverage of ECE services also varies significantly across geographic, socioeconomic and ethnic dimensions. While almost 60% of 3 and 4 year olds attended Kindergarten in Vientiane Capital in 2011/12, just 15% of the same age group attended in Saravan province in Southern Lao PDR. Of all children enrolled in ECE, 90% are Lao-Tai while the remaining 10% are from other ethnic groups. Less than 8% of children from the lowest income quintile, from rural areas without roads or from non Lao-Tai communities, have access to ECE services (World Bank, 2014b). Lack of access, combined with poor child nutrition due to food insecurity and malnutrition, is detrimental to children’s development and their readiness to learn at school. Overall this translates into long term negative implications for the human development of Lao PDR. 13 | The Status of Early Childhood Health and Development in Northern Lao PDR (Davoudzadeh, McTernan, & Grimm, 2015; Nores & Component 2 focuses on improving the quality of ECE Barnett, 2010), increase graduation rates in services through (i) a supporting services package, post-secondary education, and improve labor force technical assistance and training; and (ii) teacher and productivity and wages (Gertler et al., 2014; Supplee education officer training. The supporting services & Meyer, 2015). More specifically, programs that package will provide a package of services to combine children’s education, parenting education targeted communities to improve the quality of ECE, and nutrition interventions have been shown to have and increase the demand for ECE services, by the largest positive impacts, particularly for children delivering: from low socioeconomic backgrounds (World Bank, 2014b). By intervening in the early years of children’s (i) a community awareness campaign to engage learning and development, the project seeks to parents in parental education, and increase the strengthen the foundations for the healthy physical, knowledge and understanding of community cognitive, emotional and social development of members about the importance of early child children. development and the first 1,000 days of a child’s life, appropriate parenting skills and early stimulation, To achieve its objective, the ECE project supports the nutrition, health, hygiene and childhood disability three key components listed below. For an in-depth awareness; description of each component and sub-component, please see World Bank (2014b). (ii) childhood disability screening and the provision of any necessary treatment or a referral for follow up Component 1 focuses on increasing the coverage of with a specialized service provider; and ECE through (i) the provision of construction grants and training for target villages, for the construction of (iii) the provision of school meals to children at pre-primary classrooms using community-based CCDGs, pre-primary and primary school to encourage contracting; and (ii) the establishment of Community the attendance of boys and girls in remote rural Child Development Groups (CCDGs). Currently, while communities, and to provide children with nutritious pre-primary classrooms are intended for 5-year-old meals in order to facilitate concentration. children, children who attend often bring their younger siblings along to class with them. CCDGs aim to provide a separate, more informal learning environment for 3 and 4-year-old children before they enter kindergarten or a pre-primary classroom. While CCDGs are the focus of the program, technical support is also being provided to develop teaching and learning materials for multi-age teaching for 3 to 5-year-olds, to support Multi-Age Teaching (MAT) existing primary schools. The Status of Early Childhood Health and Development in Northern Lao PDR | 14 Target districts have a shortage of qualified When children do not have a healthy start to life they pre-primary school teachers, and in addition, fail to reach their full potential as adults, and this is teachers are not qualified to manage the multi-age associated with a range of social and financial costs classes that are a result of 5-year-old children that place a considerable burden on a country’s bringing their younger siblings to class with them. The resources. Evidence from around the world second component of the ECE project will support demonstrates that the opportunities for preventing pre-service training of pre-primary school teachers, as such this burden lie in children’s earliest years, and well as in-service training on multi-age techniques for require significant investment throughout this period pre-primary teachers in target areas. of life. By aiming to improve children’s early health, development, and educational outcomes, the ECE Component 3 focuses on strengthening project project is not only working towards reducing poverty management, capacity development, and monitoring (and several of the SDGs), it is also working towards and evaluation at all levels of the early childhood improving the overall human capability of the country. education sector. The component’s main activities will include (i) capacity development and support for financial management, procurement, environmental and social safeguards and internal audits; and (ii) support for monitoring and evaluation activities including a results framework and monitoring system. Also included in this component is an independent evaluation of the project’s impact on a range of child outcomes. The investments that this project offers are expected to contribute to reducing poverty in project target areas by improving children’s educational attainment; higher educational attainment is associated with higher income both in urban and rural areas (World Bank, 2014a). Research around the world has also demonstrated (see for example Burger, 2010; Elango, Garcia, Heckman, & Hojman, 2015; Engle et al., 2011) that disadvantaged children (i.e. those who have larger developmental deficits) gain more benefit from ECE participation when compared to their more advantaged peers. In this way, the project is also expected to reduce the large disparities in education- al attainment of children across income groups, ethno-linguistic groups and gender, and therefore contribute to shared prosperity and educational equity. Early childhood development is the greatest enabler of human capability, allowing children to grow up to participate fully in economic, social and civic life. 15 | The Status of Early Childhood Health and Development in Northern Lao PDR Project Impact Evaluation Included within the scope of the third component of Lessons learnt from the impact evaluation regarding the ECE project is an independent evaluation of the the ability of ECE interventions to support children’s project’s impact on a range of child development health and development will help inform future ECE outcomes. The aim of the impact evaluation is to policy and program decisions, so that resources are determine the success (or failure) of the project to used effectively and have the maximum positive improve early childhood development, by comparing impact on children’s outcomes in Lao PDR. the key outcomes for children living in villages where This report presents results from the baseline data the project has been implemented with those of collection, which will subsequently be used as the children living in comparable villages where the starting point for the evaluation of the ECE project. It project has not been implemented. It is expected that provides information - prior to the project’s after the project has been implemented for two years, implementation - at the village, household and child children living in target villages will have improved level, detailing where and how children are living, their their health and development status, skills and health, nutrition and development status, their home knowledge. environments, and their access to and use of health care and ECE services. In 2018 (after the project has In order to determine impact, a clustered randomized been implemented for two years), endline data will be controlled design has been employed. A randomized collected in order to re-assess how well children in controlled trial is the most rigorous methodology for target villages have developed in comparison to determining whether inter ventions cause children in villages without the ECE project improvements in child development and school interventions. The section below, describes the steps readiness. Additionally, assessing the cost that were undertaken in the lead-up to baseline data effectiveness of the program can only be achieved collection, and details the data collection process through a randomized evaluation design. including instruments used and procedures employed. The impact evaluation will focus on three interventions implemented as part of the ECE project: CCDG (Community Child Development Groups): delivery of community-based playgroups, including training of locally recruited “teachers”, construction of a purpose-built hut and grants provided to communities to sustain implementation; MAT (Multi-age Teaching): local pre-primary teachers trained in the delivery of a purpose-designed curriculum for children aged 3-5, in one class; and CAC (Community Awareness Campaign): a 12-module ECD training course provided to the Village Education Development Committees, which in turn enables the Committees to undertake community awareness training of parents in their village. The Status of Early Childhood Health and Development in Northern Lao PDR | 16 Research Design The evaluation of the ECE project will essentially For the evaluation, comparison across the three be conducted through three pragmatic cluster different studies will also be possible, albeit under randomised controlled trials. The trials are pragmatic observational study conditions (i.e. not experimental). in that the program is being implemented by the These analyses will control for any residual confounding government within the existing service systems. by utilising data collected through this baseline study. A clustered approach was required as the program is implemented at the community level, and therefore individual recruitment was not sensible due to likely contamination (e.g., one individual's change in Sample behavior may influence another individual to do so). This pragmatic clustered design also allows for the evaluation of how communities implement the The ECE project is to be implemented in northern Lao program, from a process point of view. This PDR due to the high poverty levels and lack of existing information will help to inform the system/ services, and to avoid contamination with other governance predictors of successful implementation. programs being implemented in southern Lao PDR. Both MAT training and the establishment of CCDGs The selection of the provinces and the districts within require a pre-primary school to exist, so that after these provinces was determined by the Ministry of children go through either program, they can then Education (and, it is understood, on the basis of continue straight into pre-primary school with no gap. poverty levels and the existence of a functioning However, as there are not enough pre-primary schools district level education office). The sample of villages in Lao PDR, it is not possible to independently was calculated on the basis of population data evaluate the MAT and CCDG programs. Instead, they provided by the Educational Management Information must be compared against each other. As such, the System (EMIS), sourced in 2015, matched with randomisation occurs separately in three separate immunisation data sourced from the Ministry of trials: Health. Study 1: For communities with an existing pre-primary school, villages were randomised to receive either the CCDG (community playgroups) or the MAT (multi-age teaching) interventions. In both interventions, the local VEDC will be trained (as in study 2 and 3). Study 2: For communities with an existing kindergarten, villages were randomised to either receive community awareness training (through the local VEDC) or not. Study 3: For communities with no existing early childhood services (No ECE), were randomised to either receive community awareness training (through the local VEDC) or not. 17 | The Status of Early Childhood Health and Development in Northern Lao PDR Data provided included the number of children aged However, during data collection it was discovered that 0-5 years in each village, and the existence and type the original eligibility criteria for many villages was not of ECE service. This data was then verified by the as it was supposed to be. For example, in some local Early Childhood Unit, who phoned through to cases a community where there was supposed to be local district officials to gain an “up-to-date” list of a pre-primary school did not actually have one, or villages with the important eligibility criteria details, instead had only a kindergarten. To manage this i.e. number of children aged 0-5 in the community, problem within the evaluation design, communities and if the community had a local pre-primary or that were found not to meet the stratum criterion kindergarten. On the basis of this list, all villages in were placed back into the pool of the study stratum in the north of Lao PDR within the selected districts, and which they should have actually been allocated, and with at least 20 children residing in them, were then randomised to either arm. This then meant that allocated to one of the three studies and then there were not enough communities to meet the randomised to either arm. sample size required to be able to effectively evaluate the different aspects of the inter vention. The The fieldwork team (Indochina Research) was baseline data collection was therefore extended and provided with the randomised list of villages for each expanded into additional education districts (under study arm (and a list of substitute villages to use in the same randomised conditions). The final baseline case any of the communities were found not to have sample includes 376 villages with 20 children in each 20 children. Prior to starting the baseline study, this village adding to a total sample of 7,520 children, was considered to be the most problematic situation however this is broken into the three different that we were going to face, which was why the studies, with a sample of 2700 for study 1, 2380 for replacement lists were provided. study 2 and 2440 for study 3. The Status of Early Childhood Health and Development in Northern Lao PDR | 18 Figure 1: Evaluation design and community level sample size 376 Villages 135 Villages 119 Villages 122 Villages Study 1 Study 2 Study 3 CCDGs, Existing KG No ECE MAT and CAC and CAC and CAC Existing KG Existing KG No ECE CCDG+CAC MAT+CAC + CAC + No CAC No ECE+CAC +No CAC 73 villages 62 villages 61 villages 58 villages 74 villages 48 villages 19 | The Status of Early Childhood Health and Development in Northern Lao PDR Sampling households within the target communities In each target village, the following selection processes were employed in order to collect data at the village, household and child level. The head of each village was selected to provide village level data. If the village head was not available to participate, the deputy village head was selected, and if the deputy was also unavailable then the head of the Village Figure 2: Education Development Committee (VEDC) was selected. With assistance from the VEDC, fieldwork Provinces in Lao PDR in which teams then compiled a list of all eligible households baseline data was collected (i.e. those with a child aged 2-5 years) in each village, and random sampling methods were used to select 20 households for data collection. In the case that a village had less than 20 eligible households but at least 20 children aged 2 to 5 years (i.e. there were Phongsary several households with more than one eligible child), all households were selected to participate. In some cases, household members were out of the village Oudo mxay Huaphanh during the data collection period and the field work team were unable to make contact with them, or there had been a serious illness or death in the household. Xayabury This seldom occurred (<1% of households), and when it did the household was replaced with the next Borikhamxay randomly selected household. For households with one eligible child only, this child was selected for Viantiane. C data collection along with their primary caretaker. For households with multiple children aged 2 to 5 years, one child was randomly selected along with their primary caretaker (except in the case of villages with less than 20 households as above). Overall, data was collected from 7,520 children in 7,355 households across five provinces, 14 districts and 376 villages in northern Lao PDR. The five provinces in which data were collected are highlighted in Figure 2, and the districts, and the number of villages and children in each province are presented in Table 1 below. The final sample was distributed across the following provinces and districts: The Status of Early Childhood Health and Development in Northern Lao PDR | 20 Table 1: Sample by Province and District PROVINCE DISTRICT # OF VILLAGES # OF CHILDREN Phongsaly Khoua 26 500 Oudomxay La 14 300 Namor 40 780 Beng 17 360 Houn 12 240 Parkbeng 6 120 Houaphan Viengxay 36 720 Houa Meoung 42 840 Xam Tai 36 720 Sobbao 39 780 Meoung at 41 820 Kouan 30 600 Xaiyabouly Saysathan 20 400 Borlikhamxay Saychamphone 17 340 Development and Piloting development, experience of ECE and health services, as well as parenting practices; and (iiii) a Direct Child of Data Collection Instruments Assessment, administered to each child selected to participate, directly assessing a range of skills and abilities. Four data collection instruments were used: (i) a Village Questionnaire designed to collect data from The Village Questionnaire and Household the head of each village, including information Questionnaire were primarily developed based on regarding village residents, amenities, transport and previous census and household questionnaires used services available; (ii) a Household Questionnaire, in Lao PDR, and were adapted to suit the needs of the completed by the head of each selected household, study. The Caretaker Questionnaire and Direct Child collecting data regarding members living in the home Assessment included several internationally and household assets; (iii) a Caretaker recognised standard scale instruments, none of Questionnaire, completed by the primary caretaker of which had been utilised in the country before and so each child for whom data was collected, designed to had to be translated and adapted to suit cultural and collect information on the child’s nutrition, health and other requirements. 21 | The Status of Early Childhood Health and Development in Northern Lao PDR A series of consultations with various local stakeholders and sectors of government was conducted to ensure Early Human Capability Index (eHCI) the content and face validity of each item across the four instruments. All questionnaires were translated The tool utilised to collect information regarding and back translated a number of times, with further children’s development via the caretaker report was consultations following in order to ensure that the the Early Human Capability Index (eHCI). The eHCI is translations were capturing the true essence and a holistic measure developed to capture the key intent of each item. aspects of child development in 3 to 5-year-olds. The tool was designed to capture child development Next, instruments were piloted in order to test if the across diverse cultures and contexts; it has now been translations were working well, if village heads, used in almost 10 countries including Tonga, Tuvalu, household heads and caretakers understood the Samoa, Brazil, Australia and China. The eHCI is questions being asked of them, and how children simple to administer and can be completed by a responded to the direct assessment activities. They child’s parent, caretaker or teacher. It is not a were also tested to ensure that the child development developmental milestone test, but is a measure of measures were not too easy or too hard, but instead where a child can be placed on a developmental spec- were able to capture children’s development along a trum. As such the eHCI can determine if a child is continuum, discriminating by children’s age, gender thriving or doing poorly in relation to various aspects and caretaker’s level of education. All four draft of development, and can detect developmental questionnaires were piloted in pen and paper format change over time. in Vientiane Province (in Meun and Sanakam districts) in June 2015, which included 200 As detailed above, the eHCI was adapted for use in households across 10 villages. The questionnaires Lao PDR. This adapted version of the eHCI includes were then further revised based on experiences of 56 dichotomous items (with either yes/no, or can/- enumerators and data collected from the pilot. In can’t response options) designed to measure seven addition, an enumerator’s manual was produced to different aspects of child development: verbal aid with data collection, and a data collection communication (six items), approaches to learning database and tablet program were developed to be (six items), numbers and concepts (ten items), used for the baseline collection. cultural knowledge (five items), literacy (reading and writing) (12 items), social and emotional skills (13 Measures of Child Development items), and perseverance (four items). Together, these aspects of development have been shown to be highly predictive of children’s later learning and Child development was measured in two ways – educational achievement. indirectly through the reporting of children’s abilities from their caretaker, and directly through an assessment (conducted by an enumerator) of children’s ability to answer a range of questions and complete a number of tasks. These assessments are described in more detail below. The Status of Early Childhood Health and Development in Northern Lao PDR | 22 The index provides a score for each child on these seven developmental domains. Scores for each of the domains range from 0 to 1, with1 being the best score and 0 being the worst. This score is derived from taking the average of all items in that domain. The data are not weighted or age standardised, so older children should receive higher scores in each of the domains to reflect more advanced development. From these seven domains an overall development score is derived, also ranging from 0 to 1; with 1 being the best score. This overall score is derived from taking the average of all domain scores. Measurement of Development and Early Learning (MODEL) the instrument used to directly assess children’s development was the MODEL, developed by the Measuring Early Learning Quality and Outcomes (MELQO) initiative. The primary purpose of MODEL is to aid in the measurement of child development and learning at a population level. The tool can be used for children aged 3 to 7 years, and directly measures their pre-academic skills (through asking them to undertake tasks that include early literacy and numer- acy skills) as well as their executive function. To date, MODEL has been utilised in a range of developing countries include Bangladesh, Cambodia, Columbia, Kenya and Sudan. As with the eHCI, results from the MODEL can be used to present a nationally representative distribution of child development, which can then inform policy planning and budgeting, including resource allocation, curriculum design and teacher training programs, and ongoing monitoring of The MODEL was adapted for use in Lao PDR. The children’s development. adapted version included 18 tasks overall, measuring children’s numeracy skills and knowledge of numerical concepts (nine activities), early literacy skills and familiarity with print (six activities) and executive function (three activities). For some tasks, such as listening comprehension, scores on each question were combined and the average was taken to give an overall score of 0-1, 1 being the best score. For other tasks, a single score was given, for example whether children could or could not write their name. Further details of scoring are provided in the results section of this report. 23 | The Status of Early Childhood Health and Development in Northern Lao PDR Direct assessments took place in households, with direct child assessment, this included mock enumerators assessing children on a one-on-one assessments with children. After training was basis. Most often the child’s caretaker was present, complete, enumerators were assessed on their however, enumerators requested parents not to guide understanding of the project, the questionnaires and or prompt children in their responses. Enumerators the direct assessment, and the 30 most competent framed the direct assessment as a game and worked enumerators were selected to be involved in baseline to build rapport with children in order to make them data collection. feel at ease despite the unfamiliar situation. In each team, some enumerators could speak a number of Field work took place from November 2015 to March ethnic minority languages including Hmong and 2016. Each field team consisted of five enumerators Khmu, so children who could not speak Lao were and one team leader. The Ministry of Education and assessed in their mother tongue. Sports (MOES) sent authorization letters to target provinces and districts in advance, to notify them of Enumerator Training the project and data collection activities. Senior fieldworkers coordinated with provincial education and Data Collection officers to ensure receipt of the letters, and worked closely with district officials to develop a logistical plan for collecting the data in all target villages. An experienced research firm based in Lao PDR, Based on this plan, district officials coordinated with Indochina Research, was engaged to carry out data village heads regarding the date of data collection in collection. The fieldwork team consisted of a field- each village, who in turn notified target households. work manager who had overall responsibility for all When the fieldwork team arrived in villages, the team field work activities, a fieldwork supervisor who leader conducted the village head questionnaire, and assisted the manager, six field team leaders who e n u m e r a t o r s c o n d u c t e d t h e hous ehol d were each responsible for a team of enumerators, 30 questionnaires, caretaker questionnaires and direct enumerators who administered the questionnaires, child assessments. Fieldworkers reported that on and two quality control supervisors who checked the average, village questionnaires took 30 minutes to quality of the data. complete, household questionnaires took 20 minutes to complete, caretaker questionnaires took 60 Enumerator training aimed to ensure that minutes and direct child assessments took ten standardised data collection procedures were minutes (noting that many of the children were unable employed. Training was conducted over 12 days, in or unwilling to do the tasks requested). two separate sessions, to ensure that class sizes were small and training was of high quality. Overall, 40 enumerators and nine team leaders participated in the training, which was conducted by the fieldwork manager. Training included the discussion of data collection objectives, the fieldwork and logistic plan, thorough discussion and explanation of the questionnaires, as well as practice trials of administering the questionnaires in both paper and tablet form. For the The Status of Early Childhood Health and Development in Northern Lao PDR | 24 Together, the data collected provides a Limitations comprehensive picture of the current status of children’s health and development, the social, demographic and economic contexts in which It is important to first note a few limitations to the children in northern Lao PDR are growing up, and of baseline data, so that readers are cognisant of these how these environments are having an impact on when interpreting results throughout the report. children’s early developmental outcomes. Firstly, all village level data was collected from village heads, of which 99% were male (two were female). It Quality Control is possible that the perspectives of women in the villages differ to those reported by men, particularly around services for children, as it is likely that The quality control of data was carried out by the children’s health and development is primarily the fieldwork team as well as by World Bank staff responsibility of women in this context. This is also supporting the ECE project. World Bank staff involved the case for household level data - almost two thirds in the development of the questionnaires oversaw of responses were collected from males. As such, enumerator training in order to ensure that the results reported may not be generalizable to the administration of questionnaires and the direct child perspectives of women. assessment was being taught correctly, to clarify instrument content, and to address any questions Secondly, it should be noted that almost all villages that arose regarding data collection. The same staff included in the data collection could be accessed by also visited the field during data collection in order to car in the dry season. While these villages were randomly observe and supervise the administration relatively remote, the most remote villages in of questionnaires and the direct assessment, as well Northern Lao PDR can require a combination of car, as to assist in addressing any issues that had arisen boat, motorbike and walking to be reached, and such during collection. villages were usually not captured in data collection for logistical reasons. These villages also tend to be Field team leaders randomly observed 10% of data very small, and so were also less likely to be selected collection by enumerators, and conducted random for inclusion based on the fact that they did not have post checks of 30% of each enumerator’s completed sufficient numbers of young children for whom data instruments. After completing each questionnaire or could be collected. It is likely that due to the remote- direct assessment, if it was not checked by the team ness and small size of these villages, access to leader, it was checked by another enumerator. Once services and children’s health and development is questionnaires had been completed and uploaded to poorer than the averages shown in this report, and the server from the tablets, quality control staff the inclusion of these villages in the baseline sample downloaded the data and checked it for quality using may have led to poorer overall results. logic checks. Data was downloaded from the server on a daily basis to allow for data checking to occur Finally, while the baseline sample of children included simultaneous to data collection, meaning that any a mixture of children of different ethnicities including issues identified could be corrected as soon as ethnic minorities, the majority of children (60%) were possible. Overall, these quality control measures from Houaphan province. This is important to employed ensured data collected was valid and consider when generalizing findings to provinces in reliable. northern Lao, as the situation in Houaphan province (e.g. service availability and provision) may differ to that of other provinces. 25 | The Status of Early Childhood Health and Development in Northern Lao PDR The Status of Early Childhood Health and Development in Northern Lao PDR | 26 PART TWO THE SOCIAL, DEMOGRAPHIC AND ECONOMIC SITUATION OF FAMILIES IN NORTHERN LAO PDR Villages Population Size Village level data was gathered from the head of the Villages varied in population size considerably, from village (80%), the deputy head of the village (17%) or 195 to 3,260 residents. Most villages were home to the head of the Education Development Committee less than 500 people (63%), some had 501-1000 (2%) (hereafter all referred to as village heads) in residents (30%) and few had over 1,000 residents each of the 376 villages. Village heads ranged in age (7%). Villages were home to between 33 and 652 from 22-65 years of age. The vast majority of village families; most villages had from 50-100 families heads were male; only two were female (<1%). The (52%) or between 101 and 200 families (38%) and majority of village heads had completed primary few had less than 50 families (9%) or more than 300 school (55%), a third had completed secondary families (2%). The number of households in each school (30%), with some having completed high village also varied, from 26 to 602 households. The school (4%), vocational training (3%) or a bachelor majority of villages had between 50 and 100 house- degree or similar (<1%). Few had never attended holds (54%), others had less than 50 (22%) or school (2%) or attended but did not complete primary between 101 and 300 households (24%) and just school (7%). one village had more than 600 households (<1%). Figure 3: Education level of village heads No school Attended but did not complete primary school Completed primary school Completed secondary school Completed high school Completed vocational training Completed a bachelor degree or similar 27 | The Status of Early Childhood Health and Development in Northern Lao PDR Ethnicity Village Access Village heads were asked to indicate the three main Villages were relatively remote, and while almost all ethnic groups in their village; 41% reported that could be accessed by car in the dry season (97%), Lao-Tai made up one of the three main ethnicities in only just over half could be accessed by car in the wet their village, 37% said Hmong, 34% reported Khmu, season (53%). 6% Phong, 5% each said Prai and Akha, 3% Singsili, 2% Cingmoon, and 1% each said Kmer, Toum, Ilmain, Income or Yang made up one of the three main ethnicities in All villages reported their main source of income to be their village. agriculture (100%). Some also reported additional main sources of income – commerce (25%), construction (8%), handicrafts (4%), and services (3%), while a few also repor ted mining , i n d u st r i a l jo b s, t r a n sp o r t a t i o n , fi nanc e, government employment, and forest products to be an additional main source of income for their village (all <1%). Figure 4: Main ethnicities in villages Yang Ilmain Toum Kmer Cingmoon Singsili Akha Prai phong Khmu Hmong Lao-Tai 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% % of villages The Status of Early Childhood Health and Development in Northern Lao PDR | 28 Electricity Sanitation As demonstrated in Figure 5, more than half of Villages were often using a combination of water villages accessed electricity from government sanitation processes, with 93% of villages having electrical grids (55%), 32% of villages had a mini some households using pit toilets with a water flush, hydropower turbine for each household, 8% used 21% of villages having some households using a dry solar cells, 1% used battery generators, and less than pit, and 68% of villages having some households that 1% had a private electrical generator. A small number were not using toilets. of villages did not have any access to electricity (4%). Less than half of the villages reported that all houses in their village had access to electricity (43%), while Rubbish Disposal 36% reported that 1-20 households in their village were without electricity, 16% reported that 21-50 Villages were also using a combination of rubbish households did not have electricity, with the disposal methods, with 76% of villages burning remaining 14% reporting that 51 or more households rubbish, 52% dumping rubbish in the household area, in their village were without electricity. 38% burying rubbish, 35% having rubbish collected by rubbish trucks, and 19% dumping rubbish in the river. Figure 5: Village electricity sources Water The majority of villages were using drinking water from trenches/drainage pipes (90%), while 91% also used this for washing and cleaning. Villages also reported using river water for drinking (39%) and washing/- cleaning (62%), as well as container water for drinking (23%). Few villages reported using well water for drinking (9%) and washing/cleaning (11%), underground water for drinking (4%) and washing/- cleaning (5%), and rain water for drinking (1%) and washing/cleaning (5%). Government electrical grids Mini hydropower for each household Solar cells Battery generators Private electrical generator 29 | The Status of Early Childhood Health and Development in Northern Lao PDR Village Education Development Committees The majority of villages were reported to have a for children (40%). Others said the role of the VEDC Village Education Development Committee (VEDC) was to collect information about children including (96%). VEDCs had between 1 and 92 members, with information on disabilities (29%), to provide health, the majority having less than 10 members (98%). The sanitation and nutrition advice to the community majority of VEDCs had met once (37%), twice (29%) or (20%), and to encourage parents to enrol their three times (23%) in the past three months, with few children in school (11%), while 1% of respondents did having not had met in the past three months (1%). not know what the role of the VEDC was in supporting Village heads were asked about the role of the VEDC community’s children. in promoting and supporting children in their community. The majority reported that the VEDC’s role was to promote safe environments and facilities Figure 6: Villages drinking and washing/cleaning water sources Rain Washing water Drinking Under Washing ground water Drinking Well Washing water Drinking Container Washing water Drinking River Washing water Drinking Trenches/ Washing drainage pipes Drinking 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % of villages The Status of Early Childhood Health and Development in Northern Lao PDR | 30 Community Participation Health Care Services Most villages did not have markets. Just 4% had a While the majority of villages had a village nurse regular market, and 3% had temporary market fairs. (70%), fewer villages had a health center (13%), Almost one quarter of villages had a village savings pharmacy (12%), district hospital (5%), provincial group (24%), 61% reported to be involved in a World hospital (2%), private clinic (2%) or private hospital Food Programme or School Feeding Program, 6% had (<1%). Figure 7 below shows the spread of these an aid project in their village (such as the provision or services across the five provinces in which data was repair of a school building), and 2% were involved in collected. Results suggest that there are more health both a health fund and an activity similar to early child services available in Houaphan than in any other development. province. Figure 7: Distribution of health care services across provinces 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 77.2 30.0% Phongsaly 20.0% 61.3 Oudomxay 59.4 10.0% Houaphan 52.2 Xaiyabouly 47.4 0.0% Borlikhamxay Health Village Provincial Hospital District Hospital Hospital centre nurse Private Clinic Private Pharmacy 38.6 31 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 2 below details how far villages are from the children was difficult as children often become ill nearest of each of these health services. Information afterwards (6%), that health center staff were was also collected regarding if health professionals inattentive (2%), that medicine available at health visited or live in the villages. The majority of villages centres was limited (2%), that poor households did either had a nurse living in their village or were visited not have enough money to access the center (1%), by a nurse (68%), and more than half of villages either that there were not enough vaccines available for had a doctor living in the village or were visited by a children (1%), that parents were inattentive to their doctor (55%). Many villages also either had a midwife child’s health needs (1%), or that the village health or naturopathic doctor living in or visiting the village volunteer did not have the basic necessary medicines (both 37% each). While the majority of villages did not available (<1%). As already noted, these results are have a health center, results indicate health service based on responses from males only (with the coverage appears moderate due to doctors and exception of two female village heads). Considering nurses either living in or visiting the village. While a that, in the Lao context, children’s health and large majority of village heads reported no problems development is primarily the responsibility of women, with the health services available for children in their it would be interesting to explore if women in the community over the past 12 months (85%), some same villages have a different perspective on reported that the nearest health facility was quite far problems with health services. and that the road is bad (8%), that vaccinating Table 2: Travel time from villages to their closest health service PERCENTAGE OF VILLAGES WITH A TRAVEL DISTANCE OF : HEALTH SERVICE ≤ 30 minutes > 30 ≤ 60 minutes > 60 ≤ 120 mins > 2 hours Village nurse 63% 22% 10% 5% Health centre 55% 24% 11% 11% Pharmacy 34% 19% 24% 23% District hospital 25% 22% 27% 27% Province hospital 16% 2% 11% 71% Private Clinic 30% 14% 17% 38% Private Hospital 45% 3% 10% 43% The Status of Early Childhood Health and Development in Northern Lao PDR | 32 Education Services While the majority of village heads reported no problems with the education services for children available in their community over the past 12 months (64 percent), some reported that there was not Village heads provided information regarding the enough space for children, or that the school building education services available in their village. Part of was not long-lasting/permanent (14 percent), that the selection criteria for the ECE Study was that every due to other constraints, education was not a priority village had an existing primary school. In addition, and so they did not send their children to school (10 many villages also had a kindergarten (39%). Few percent), that there were not enough teachers (7 villages had other education or ECE services, such as percent), that the school was too far away (7 percent), a preschool playgroup (2%), nursery school (1%), or that parents did not have enough money to support any other form of ECE (2%). Only 20 percent had a their children’s attendance at education services (6 lower secondary school and very few had an upper percent), that there was a lack of study equipment (6 secondary school (7%). Figure 6 below presents the percent), that teachers did not concentrate enough to spread of these services across the five provinces in teach to schedule (2 percent), that disabled children which data was collected. As with healthcare cannot study at the school (<1 percent), or that there services, these results suggest that there are more was a lack of budget to supply food for children at education services available in Houaphan than in any school (<1 percent). Again, it should be noted that other province. Again, this is unsurprising considering these results are based on responses from village that 59 percent of villages from which data was heads of whom 99 percent were male. It is therefore collected are located in Houaphan. possible that the perspectives of women in the same villages might differ to the above in relation to issues with education services for children. Figure 8: Distribution of education services across provinces 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% Phongsaly 20.0% Oudomxay 10.0% Houaphan Xaiyabouly 0.0% Borlikhamxay Kindergarten Other ECE Playgroup Nursery Lower Secondary Upper Secondary 33 | The Status of Early Childhood Health and Development in Northern Lao PDR Important Events Figure 9: Education level of heads of households While 44 percent of village heads reported that no important events had occurred in the village in the past three years, 32 percent of villages had experienced crop damage, 15 percent had new schools established, 9 percent had experienced an epidemic, another 9 percent had experienced landslides, 8 percent had new roads built, 6 percent had experienced a fire, another 6 percent had experienced a flood, and 2 percent each had experienced: the establishment of a new health centre, a storm, or aridity. The establishment of a new pre-primary classroom, a new teachers’ house, a new factory/industry, or the arrival of electricity for the community were each experienced by 1 percent of villages. A few villages had also experienced a robbery, damage to a bridge, the establishment of a canteen room for children at school, a new temple, the establishment of a market and a new village office (each <1 percent). 70 percent of these important events were reported to negatively impact on villages and 30 percent were reported as positive events. No school Completed secondary school Attended but did not Completed high school complete primary school Completed vocational training Completed primary school Completed a bachelor degree or similar Households When asked to read a simple sentence, more than half of heads of households could read well (52 Information regarding households was collected from percent), 17 percent could read some part of it, and the heads of 7,355 households. Heads of 30 percent could not it read at all. Less than 1 households ranged in age from 13 to 86 years old; percent had a disability (e.g., a vision problem) which 66 percent were male and 34 percent were female. meant they could not read. The education and literacy As shown in Figure 9, the majority of heads of house- levels for heads of households are further broken holds had received some form of education: 25 down by gender in Table 3 below. Results show that percent had attended but not completed primary male heads of households are better educated than school, 35 percent had completed primary school, 15 female household heads, and that this is then percent had completed secondary school, 3 percent reflected in the literacy levels across male and female had completed high school, 5 percent had completed heads of households. vocational training or university, and 20 percent had not been to school. The Status of Early Childhood Health and Development in Northern Lao PDR | 34 Table 3: Education and literacy levels of heads of households, by gender EDUCATION OVERALL (%) MALES (%) FEMALES (%) No school 20 10 10 Attended but did not complete primary school 25 17 8 Completed primary school 35 26 10 Completed secondary school 11 8 3 Completed high school 3 2 1 Completed vocational training 4 3 1 Completed a bachelor degree or similar 1 1 <1 LITERACY Could read well 52 38 13 Could read some part 17 12 5 Could not read at all 30 16 15 Could not read due to a disability <1 <1 <1 Size Building Materials Households ranged in size from two to 21 members, Houses were made from a range of different materials. with the majority of households comprising either The majority of roofs were made from tiles Two to five members (41 percent) or six to 10 (51 percent) or zinc-alum sheets (32 percent), while members (52 percent). A smaller number of some were also made from grass (10 percent), wood households had 10–15 members (7 percent), and (6 percent), leaves (2 percent) or concrete less than 1 percent of households had 16–21 (<1 percent). Most house walls were made from wood members. (65 percent), while some were also made from bamboo (18 percent), bricks/cement (17 percent) and zinc-alum sheets or plywood (<1 percent). Floors were made from wood (35 percent), dir t (28 percent), cement (23 percent), bamboo/leaves (9 percent), tiles (5 percent) or ceramic tiles (<1 percent). 35 | The Status of Early Childhood Health and Development in Northern Lao PDR Transiency Figure 10: Distance of households Few households had moved villages in the past four to drinking water years (3 percent). Of these, the majority had moved once only (89 percent), while a few had moved villages twice or three times (10 percent and 3 percent, respectively). Drinking Water The majority of households reported their main source of drinking water to be a gravity fed water system (74 percent), while others used piped water (11 percent), bottled water (8 percent), surface water (4 percent) or well water (3 percent)A few used water from a borehole or rain water (both <1 percent). While almost a third of households had this source of water within their house (30 percent), the majority of households (70 percent) had their main source of water located outside of their house. For most, this was relatively close by. For 32 percent of households, their main water source was 10 or fewer metres away, Within House 51-100m for 26 percent it was 11-20 metres away, for another <10m 101-200m 26 percent it was 21-50 metres away, for 9 percent it 11-20m 201-500m was 51-100 metres away, for 5 percent it was 21-50m 501-1km 101-200 metres away, for 2 percent it was 201-500 >1km metres away, for 1 percent it was 501m to 1 kilometre away, and for another 1 percent of households, it was more than a kilometre away from their house. The Status of Early Childhood Health and Development in Northern Lao PDR | 36 Sanitation Socio-economic Status When asked about sanitation, 65 percent of households Households were asked about their assets in order to reported having their own toilet, 5 percent shared assess their socio-economic status. The majority of toilets with other households, and less than 1 households (72 percent) reported owning agricultural percent of households used public toilets. Many land and at least one duck or chicken (80 percent), a households (30 percent) did not use toilets. Of the motorcycle (76 percent), a pig (71 percent) and a households that did use toilets, 74 percent were mobile or landline phone (75 percent). Many using a pit latrine, 21 percent a flush to pipe system, households also owned at least one cow or buffalo and 5 percent a dry latrine. For those that did not use (50 percent), a television (46 percent), with fewer a toilet, the majority normally defecated in an open owning a car, motor boat or tractor (26 percent). Few agricultural land or a sandy area near a river(51 households owned at least one goat (11 percent), percent), and others in a forest near the village (20 bicycle (10 percent), radio/cassette player (9 percent), in a hole that is then covered (14 percent), percent) or horse (1 percent). The majority of in a river or lake (7 percent), in a hole that is not households were reported to have separate rooms covered afterward (6 percent), or in a pond or paddy (66 percent), while 34 percent of houses did not. Just field (3 percent). 2 percent of households had experienced a food shortage for two consecutive days in the past 12 months. Similarly, 4 percent of households had been Electricity unable to purchase enough clothes for their children in the past 12 months, while another 4 percent had been unable to purchase enough books, stationery and toys for their children in the past 12 months. The majority of households had access to electricity, When asked about how many children’s books house- either from grids (53 percent), from a generator or holds owned, 40 percent had between one and three battery (4 percent), from a mini hydropower turbine for books, 11 percent had between four and six, 2 each household (20 percent), or from solar cells (4 percent had between seven and nine and 2 percent percent) – 19 percent did not have access to had between 10 and 30.The remaining 45 percent of electricity. households did not have any books for their children. 37 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 11: Number of children's books in households None 1-3 books 4-6 books 7-9 books 10-30 books Figure 12: Household assets Buffalo Pig Duck or chicken Horse Goat Bicycle Radio or casette player Television Mobile or landline phone Car, motor boat or tractor Motorcycle Agricultural land % of households 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% The Status of Early Childhood Health and Development in Northern Lao PDR | 38 Aid Households were asked about their receipt of different types of aid – 2 percent had received financial aid in the form of cash, and 11 percent had received aid in the form of rice (or other food) or goods (2 percent), clothing (5 percent), equipment to clean their latrine (4 percent), or agricultural tools, household equipment and articles, livestock, education equipment and filtered water (each less than 1 percent). Village Education Development Committees Household heads were also asked about the VEDC in their community; 74 percent reported that a VEDC existed in their village, 17 percent said that there was no VEDC, and 10 percent did not know if there was a VEDC. Village Environment The majority of household heads reported that it was safe for children to play outside of the house (75 percent), while 24 percent thought it was not safe and some did not know (1 percent). The majority of villages reported that they did not have open areas for children to play outside of their houses (95 percent). 39 | The Status of Early Childhood Health and Development in Northern Lao PDR PART THREE THE HEALTH AND DEVELOPMENT OF CHILDREN IN NORTHERN LAO PDR Information on children’s health and development Figure 13: was gathered from the primary caretakers of 7,520 Caretaker's level of education children. Additional information on children’s development was obtained through a direct assessment of children’s capabilities. Caretakers The majority of caretakers surveyed were female (88 percent) and identified themselves as the mothers of the children being assessed (85 percent). The remainder were the children’s fathers (11 percent), grandparents (3 percent), aunts, uncles and siblings (<1 percent). Caretakers ranged in age from 14-78 years old, with the majority aged 20-29 years (57 percent) or 30-39 years (28 percent).Much smaller percentages of caretakers were aged less than 20 (4 percent), between 40-49 years old (8 percent), or over No school 50 years of age (4 percent). Caretakers had low Attended but did not complete primary school education and literacy levels - 30 percent of Completed primary school caretakers had never been to school, 27 percent had Completed secondary school attended but not completed primary school, 29 Completed high school percent had completed primary school, 8 percent had Completed vocational training completed secondary school, 2 percent had Completed a bachelor degree completed high school, 3 percent had completed or similar vocational training and less than 1 percent had a bachelor degree. When asked to read a short Caretaker’s education and literacy levels are further sentence in Lao language, 45 percent of caretakers broken down by gender in Table 4 below. Again, were not able to read at all, 17 percent could read a results show that male caretakers were generally little, and 36 percent could read well. better educated than females, with a greater proportion of males than females having completed some education. This is then reflected in levels of literacy – the majority of females could not read at all, while the majority of males could read well. The Status of Early Childhood Health and Development in Northern Lao PDR | 40 Table 4: Caretaker's education and literacy levels by gender EDUCATION OVERALL (%) MALES (%) FEMALES (%) No school 30 2 28 Attended but did not complete primary school 27 4 24 Completed primary school 29 4 25 Completed secondary school 8 2 6 Completed high school 2 1 2 Completed vocational training 3 1 2 Completed a bachelor degree or similar <1 <1 <1 LITERACY Could read well 36 7 31 Could read some part 17 3 13 Could not read at all 45 3 42 Could not read due to a disability <1 <1 <1 Children Children ranged in age from two to five years; 51% were male and 49% female. As shown in Table 5, there was a roughly equivalent number of children in each age group, as well as a roughly even number of males and females in each age group. Table 5: Age and gender of children AGE OVERALL (%) MALES (%) FEMALES (%) 2 years 1,540 (21%) 52% 48% 3 years 2,005 (27%) 51% 49% 4 years 2,148 (29%) 51% 49% 5 years 1,827 (24%) 51% 49% Total 7,520 51% 49% Figure 14 below shows that the majority of children were Lao-Tai (30 percent), Khmu (25 percent) and Hmong (27 percent). Other children were Prai (5 percent), Phong (4 percent) and Akha (4 percent), while each of the Lao, Leu, Yang, Cingmoon, Kmer, Toum, Singsili, Hor and Ilmain ethnic groups had 1 percent or fewer. Table 6 below presents children’s ethnicities across the five provinces. Khmu children make up the majority of the samples in Phongsaly and Oudomxay, while almost all children in Xayaboury were of Prai ethnicity. The sample in Houaphanh was made up of predominantly Lao-Tai and Hmong children, while children in Borlikhamxay were predominantly Lao-Tai, Hmong or Khmu. 41 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 14: Children's ethnicity Lao-tai Khmu Hmong Prai Phong Akha Other Table 6: Number and percentage of children of each ethnicity across provinces ETHNICITY PHONGSALY (%) OUDOMXAY (%) HOUAPHANH (%) XAYABOURY (%) BORLIKHAMXAY (%) Lao-Tai 89 (18%) 204 (11%) 1806 (40%) 5 (1%) 123 (36%) Khmu 215 (43%) 1079 (60%) 530 (12%) 2 (<1%) 69 (20%) Hmong 4 (1%) 227 (13%) 1738 (39%) 1 (<1%) 73 (22%) Prai - - 1 (<1%) 368 (92%) - Phong - - 249 (6%) - 11 (3%) Akha 163 (33%) 167 (9%) - - - Lao - 17 (1%) - - - Leu 3 (1%) 53 (3%) - - 1 (<1%) Yang 16 (3%) - - - - Cingmoon 1 (<1%) - 79 (2%) 24 (6%) - Kmer - 27 (2%) - - 21 (6%) Toum - - - - 42 (12%) Singsili 9 (2%) 21 (1%) - - - Hor - 1 (<1%) - - - Ilmain - 3 (<1%) 77 (2%) - - Total 500 (100%) 1800 (100%) 4480 (100%) 400 (100%) 340 (100%) The Status of Early Childhood Health and Development in Northern Lao PDR | 42 Child Health Good health and nutrition are essential not only for children’s survival, but for healthy development and growth. Health and nutrition lay the foundations for development throughout childhood, in turn having a positive impact on later learning, educational achievement and adult productivity. To promote holistic child development, good health and nutrition for the country’s children is critical. General Health Breastfeeding Caretakers were asked about what they thought the Not only does breastfeeding provide infants with current health status of the child in their care was. nutrition for healthy growth and development, it also The majority (67 percent) reported the child to be very reduces infant mortality and provides protection healthy, some believed the child had normal health against disease and infection. It is recommended by (32 percent), and very few believed the child to be the World Health Organization (WHO) that children be either unhealthy or often sick (1 percent). These exclusively breastfed (i.e., fed nothing other than findings are interesting considering results regarding breastmilk including food or water) for the first six children’s health and nutrition presented below. In the months of life. Thereafter, children should receive past 12 months, the majority of children had worms complimentary foods with continued breastfeeding up (65 percent), with some also having experienced until two years of age. diarrhoea (33 percent). In the past month, 9 percent of children had an illness or health problem (excluding Almost all children (99 percent) surveyed had been worms and diarrhoea) that needed to be treated. breastfed at some stage. For the small number of children that had not been breastfed, this was mainly due to their mother not having enough milk (<1 percent), or because they had been adopted by anoth- er family (<1 percent). For children who had been breastfed, the majority were breastfed until they were 7–12 months old (27 percent) or 13–24 months old (62 percent). The remainder were breastfed from 1–6 months old (4 percent), 25–36 months old (7 percent) and 37–60 months old (1 percent). The most common reasons mothers stopped breastfeeding were that the child reached an age when they felt that they should no longer be breastfed (50 percent), because the mother had to work (23 percent), was either pregnant or wanted to be pregnant (12 percent), or because the child did not want their mother’s milk anymore (6 percent). 43 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 15 below shows length of breastfeeding time Hmong or other ethnicities, and uneducated parents across age, gender, ethnicity and caretaker’s breastfed their children for longer than parents who education. Interestingly, Lao-Tai children were on had some level of education. average not breastfed for as long as children of Khmu, Figure 15: Child’s age when they stopped breastfeeding 25 20 15 10 5 0 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong school or above No school Did not complete primary school primary school Caretaker’s Gender Age Ethnicity Education Figure 16 below shows that when looking more and Hmong children, and children of other ethnicities. closely at exclusive breastfeeding rates, there are Further, educated parents were more likely to disparities across ethnicity and family background. In exclusively breastfeed their children for at least six particular, more Lao-Tai children were exclusively months compared with parents who had never been breastfed until at least six months of age than Khmu to school. The Status of Early Childhood Health and Development in Northern Lao PDR | 44 Figure 16: Children who were exclusively breastfed until at least six months of age 70% 60% 50% 40% 30% 20% 10% 0% completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education Undernutrition recurrent undernutrition. Wasting refers to a child who is too thin for their height, reflecting recent sudden weight loss or acute undernutrition, usually as a Children’s height and weight was measured to result of starvation or severe disease. Being calculate the incidence of stunting, wasting and being underweight can imply stunting, wasting or both. underweight. Stunting refers to a child being too short Table 7 presents the overall prevalence of these for their age; it is the failure to grow both physically three forms of undernutrition alongside the degree of and cognitively and is the result of chronic or public health significance according to the WHO classification system. FORM WHO Table 7: OF UNDERNUTRITION CHILDREN (%) CLASSIFICATION Prevalence of undernutrition 40+ = ‘very high’ Stunting 50 and public health significance public health significance 5-9 = ‘medium’ Wasting 9 public health significance 20-29 = ‘high’ public Underweight 27 health significance 45 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 17 below shows the prevalence of child under- proportion of children affected by wasting was highest nutrition across the five provinces. Evidently, stunting in Borlikhamxay, which was almost double the average was most prevalent amongst children in Phongsaly, of the sample (15 percent). The propor tion of with 60 percent of children affected, while the rate underweight children was highest in Borlikhamxay was lowest in Xaiyabouly (42 percent). In contrast, the (40 percent) and Phongsaly (33 percent). Figure 17: Undernutrition across provinces 60% 50% 40% 30% 20% 10% Stunting Wasting 0% Underweight Borlikhamxay Phongsaly Oudomxay Houaphan Xaiyabouly Child stunting is classified as a very high public being provided to young children, resulting in such health concern in northern Lao PDR, with half of all high rates of stunting. Further, it is also possible that children surveyed being stunted. Stunting is largely stunting is beginning in utero due to poor maternal irreversible, and can have detrimental consequences nutrition. When examining stunting in greater detail, in later life, such as poor motor and cognitive skills, disparities across age, gender, ethnicity and family leading to reduced adult productivity. These findings background emerge, as shown in Figure 18 below. are interesting to reflect on when considering that More children from Khmu, Hmong and other only 2 percent of households reported food ethnicities were stunted than Lao-Tai children, and shortages for more than two consecutive days over children whose parents had some form of education the last 12 months. It is possible that households were less likely to be stunted than children whose were unwilling to admit to their level of food insecurity, parents had never gone to school. or that there is a lack of variation and quantity of food The Status of Early Childhood Health and Development in Northern Lao PDR | 46 Figure 18: Prevalence of stunting by gender, age, ethnicity and caretaker's education 60% 50% 40% 30% 20% 10% 0% completed secondary 2 - 3 years 3 - 4 years 4 - 5 years completed Female Other Male Lao-Tai Khmu Hmong Did not complete school or above No school primary school primary school Caretaker’s Gender Age Ethnicity Education Wasting at the level found in this sample is As shown by Figure 19 below, the wasting data does considered a medium public health concern not reveal gender differences, but there were according to the World Health Organisation (WHO) differences across age, ethnicity and family back- universal growth standards. If wasting goes ground. Children from other ethnicities were more unidentified and untreated, the condition progresses likely to be wasting. Slightly more Lao-Tai children severely, requires specialized nutritional rehabilitation were found to be wasting than Khmu and Hmong and greatly increases the risk of child mortality. The children. Finally, while fewer children whose parents WHO has set a global target to reduce and maintain had completed secondary school or above were wast- childhood wasting to less than 5 percent - wasting in ing, there was very little variation in the proportion of northern Lao PDR is currently almost double this. children wasting among those whose parents had Coupled with the stunting rate, this tells us that either not gone to school, had gone to school but not children are not receiving nutrition (and access to completed primary school, or had completed primary healthcare) that they should be. school. 47 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 19: Prevalence of wasting by gender, age, ethnicity and caretaker's education 35% 30% 25% 20% 15% 10% 5% 0% completed secondary completed Female Male Other 2 - 3 years 3 - 4 years 4 - 5 years Lao-Tai Khmu Hmong No school Did not complete primary school school or above primary school Caretaker’s Gender Age Ethnicity Education The prevalence of underweight children in northern Lao PDR is considered to be of high public health Diet significance. As this indicator does not take into account a child’s height, it is not possible to Caretakers were asked to report on the food their determine whether a child is underweight due to child had consumed in the past week. All children had acute or chronic nutritional de fi ciencies. eaten rice (100 percent), almost all had consumed Nevertheless, ending all forms of malnutrition by vegetables (96 percent), meat (92 percent), and fruit 2030 is one of the Sustainable Development (83 percent).The majority had eaten sweets such as Goals - so while not as informative as stunting or cakes, crackers or bread (77 percent), raw fish (74 wasting, the proportion of underweight children is still percent), eggs (72 percent), instant noodles (58 an important indicator to track. percent), roots such as cassava or taro (56 percent), and candy or chocolate (51 percent).Some had also consumed carbohydrates such as corn or sago (26 percent), dry fish (15 percent), and milk (not including breast milk) (13 percent) in the past week. Table 8 shows the frequency with which children consumed each of these foods: from not at all, to three times per week, to every day of the week. The Status of Early Childhood Health and Development in Northern Lao PDR | 48 Table 8: Children's food consumption in the last week NUMBER OF DAYS CHILDREN CONSUMED THIS FOOD TYPE (% CHILDREN) FOOD None 1 2 3 4 5 6 7 Milk 87% 2% 4% 3% 1% 1% <1% 2% Eggs 28% 11% 26% 18% 4% 5% 1% 5% Meat 8% 9% 24% 24% 9% 11% 2% 9% Raw fish 26% 14% 23% 16% 6% 6% 2% 5% Dry fish 85% 5% 6% 2% 1% 1% <1% 1% Rice 0% <1% <1% <1% <1% <1% <1% 99% Carbohydrates 74% 8% 9% 4% 1% 2% <1% 1% Roots 44% 10% 20% 13% 4% 5% 1% 3% Vegetables 4% 4% 10% 10% 6% 16% 9% 39% Fruit 17% 11% 28% 17% 6% 8% 2% 8% Instant noodles 13% 30% 11% 3% 4% 4% 1% 4% Cakes/breads 23% 6% 11% 9% 5% 8% 5% 30% Candy/chocolate 49% 8% 14% 7% 4% 4% 2% 11% These findings highlight that, overall, children in (<1 percent) or seven times in the week (5 percent). northern Lao PDR are not getting a balanced diet. Table 9 below explores school meal consumption by They have high consumption of carbohydrates (rice, children’s age among the 17 percent of children who taro, cakes etc.), and low consumption of milk were reported to have a school meal in the past products, proteins and fats. This could in part help to week. Evidently, children of all ages are benefitting explain the high stunting rates reported earlier. While from the school meals program. Of the children who children in northern Lao PDR are not food insecure, it had school meals five times in the past week, 46 is clear that they are not eating enough of the right percent were five years of age, 33 percent were four, kinds of foods to obtain the necessary nutrients for 17 percent were three and 3 percent were two years healthy growth. old. As mentioned earlier, 61 percent of village heads reported that there is a World Food Programme or Caretakers also reported that 17 percent of children school food program in their village. Because data had received/eaten a school meal in the past week: was collected on 20 children from each village, it is the majority (79 percent) had received a school meal difficult to determine if children are receiving school five days that week, with the remainder having a meals as expected, as children selected to school meal once (2 percent), twice (2 percent), three participate may not accurately represent the number times (7 percent), four times (5 percent), six times of children receiving school meals in the village. 49 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 9: School meal consumption by child age 2 YEARS (N, %) 3 YEARS (N, %) 4 YEARS (N, %) 5 YEARS (N, %) Had a school meal in the past week 48 (4%) 229 (19%) 414 (34%) 544 (44%) Once in the past week 3 (17%) 4 (22%) 6 (33%) 5 (28%) Twice in the past week 3 (10%) 5 (17%) 10 (33%) 12 (40%) 3 times in the past week 3 (3%) 25 (29%) 31 (36%) 28 (32%) 4 times in the past week 1 (2%) 16 (26%) 22 (35%) 23 (36%) 5 times in the past week 31 (3%) 169 (17%) 323 (33%) 450 (46%) 6 times in the past week 0 (<1%) 0 (<1%) 1 (<1%) 0 (<1%) 7 times in the past week 7 (11%) 10 (16%) 21 (33%) 26 (41%) Vaccinations Immunization is one of the most cost-effective health against Measles, 22 percent had been fully vaccinated investments – it controls and eliminates life-threatening against both Polio and DPT (three doses of each). infectious disease, and is estimated to prevent up to While 12 percent of children had received two doses three million deaths annually. of the Hepatitis B vaccine, no children had received all three doses and were therefore not fully More than half of caretakers reported they had their vaccinated against the infection. It is likely that child’s vaccination card (56 percent); 29 percent were children of families who did not have(or who were able to present their child's vaccination card but with- unable to provide) an immunization card have either out any details recorded on it, and 28 percent had no immunizations at all, or have lower coverage presented a vaccination card that did have informa- than families who were able to present an tion recorded on it. Examining only the responses immunization card. Table 10 below presents from caretakers who were able to present their child’s vaccination results by age, with an upper and lower vaccination card, we are able to estimate that up to estimate of the coverage. This information is 24 percent of children had received their BCG vaccine presented alongside the WHO recommended routine for tuberculosis, 20 percent had been vaccinated vaccinations for all children. The Status of Early Childhood Health and Development in Northern Lao PDR | 50 Table 10: Vaccination coverage by child age and WHO vaccination recommendations WHO AND UNICEF OFFICIAL IMMUNISATION STATISTICS VACCINATION AGE LOWER ESTIMATE UPPER ESTIMATE FOR LAOS PDR – RATES WHO OF CHILDREN VACCINATED OF CHILDREN VACCINATED AT 23 MONTHS RECOMMENDATION (WHOLE COUNTRY) BCG 2 10% 34% Age of first and 3 8% 27% only dose – as soon 83% as possible after birth 4 6% 20% 5 5% 19% Measles 2 8% 18% Age of first and 3 6% 21% only dose – 9 No estimate 4 5% 17% or 12 months 5 4% 15% Polio (3 dosages) 2 9% 31% Minimum 6 weeks old 3 7% 24% at first does, then 89% minimum 4-8 week intervals 4 5% 18% between second and 5 5% 16% third dosages. DPT (3 dosages) 2 9% 31% Minimum 6 months old 3 7% 24% at first dose, then 89% minimum 4-week intervals 4 5% 19% between second and 5 5% 17% third dosages. Hepatitis B 2 5% 13% First dose as soon as possible after birth, (2 dosages only) 3 4% 17% No estimate then minimum 4-week 4 3% 9% intervals between second 5 % 9% and third dosages. These rates of immunization that we found in As detailed in the WHO Global Vaccine Action Plan our study area (northern rural and remote) are 2011-2020, equitable access to immunization is a well below international standards and well core component of the right to health. Countries below the of fi cial statistics for the whole of themselves have ownership and responsibility for Laos. In 2015, at a global level, coverage of three establishing good governance for immunization, and doses of Hepatitis B vaccine was approximately for providing effective and quality immunization 83 percent, 85 percent of children had received a services for all. Evidently, Lao PDR has much work to measles vaccination by their second birthday, and do in order to increase immunization rates, and to 86 percent of infants had received three doses of provide access to safe, effective, quality and affordable Polio vaccine. In addition, 126 countries had reached medicines and vaccines as outlined in SDG 3. at least 90 percent coverage of DTP vaccine (three doses). 51 | The Status of Early Childhood Health and Development in Northern Lao PDR Caretaker Knowledge on Child Health Caretakers were asked how long they thought children should be fed only breastmilk– 2 percent responded less than three months, 50 percent 3-6 months, 27 percent more than 12 months, 21 percent more than 12 months and 1 percent did not know. When a child has diarrhoea, 46 percent of caretakers answered that children should consume the same amount of food as normal, 19 percent said that they should have more food than normal, 31 percent said less food than normal, 2 percent believed the child should not be fed anything, and another 2 percent did not know. Similarly, when a child has diarrhoea, 38 percent of caretakers reported children should drink the same amount of water as normal, 41 percent said that they should drink more than normal, 19 percent As discussed earlier, the indicator used to measure said less than normal, 1 percent said they should not child development is based on the Early Human drink any water, and another 1 percent did not know. Capability Index (eHCI), which has been used internationally. The version of the eHCI index used in Lao PDR provides a score for each child on seven Child Development different developmental domains: verbal communication, approaches to learning, numbers and concepts, cultural knowledge, literacy (reading and writing), social and Early childhood development is generally defined as emotional skills, and perseverance. Scores for each the holistic development of children from conception. of the domains range from 0 to 1; 1 being the best Development is the result of the process of change in score and 0 being the poorest. The data is not which the child comes to master increasingly complex weighted or age standardised, so older children levels of moving, thinking, feeling and interacting with should receive higher scores on each of the domains, people and objects in his/her environment. There are to reflect more advanced development. From these various aspects of development, such as physical, seven domains an overall development score is derived, so c i a l, e m o t io n al , l anguage and cogni t i v e also ranging from 0 to 1, with 1 being the best score. development. Early childhood development is consid- ered to be the most important phase in life, which For each of the domains, Table 11 presents the determines later health, wellbeing, learning, behavior highest and lowest score (scale range), the 25th and and achievements across the life course. It is a time 75th percentile (interquartile range), the mean of both opportunity and vulnerability and each child’s (average score), and the standard deviation around development is dependent on a combination of the mean. Valid scores were available for all 7,520 biological and environmental factors. children on all domains. The Status of Early Childhood Health and Development in Northern Lao PDR | 52 Table 11: Developmental domains descriptive results DOMAIN MIN 25TH MEAN STANDARD 75TH MAX PERCENTILE DEVIATION PERCENTILE Verbal Communication 0 .75 .84 .26 1 1 Approaches to Learning 0 .57 .67 .28 .86 1 Numeracy and Concepts 0 .20 .37 .26 .50 1 Literacy (reading and writing) 0 .00 .14 .18 .17 1 Cultural Knowledge 0 .60 .71 .21 .80 1 Social and Emotional Skills 0 .36 .48 .20 .64 1 Perseverance 0 .50 .56 .33 .75 1 Figure 20 below presents average scores for each of age of the children assessed and the items assessed the seven developmental domains for all children, as in these domains – for example, it is expected that , well as an average overall development score. the majority of children aged 2-5 years would have the Evidently, children in northern Lao PDR have ability to communicate their needs using a simple particularly poor maths, reading and writing skills. In word or sentence, or be able to participate in tradi- contrast, children’s verbal communication skills and tional cultural events. Each of these aspects of devel- knowledge of culture appear to be developing well opment is explored in more depth below. though these results are expected considering the Figure 20: Average child development scores across developmental domains .90 Average child development score .80 .70 .60 .50 .40 .30 .20 .10 .00 Perseverance and Concepts Cultural (Reading and Writing) Social and Emotional Skills Overall Verbal Communication Approaches to Learing Numeracy Development Knowledge Literacy 53 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 21 below and Tables 12-15 explore disparities pronounced difference in development is between in children’s development across children’s gender, children with educated or uneducated parents. age, ethnicity and family background – specifically, Children with parents who had not completed any their caretaker’s level of education. When examining school performed consistently poorer than children overall child development, the results demonstrate whose parents attended and/or completed primary only small differences in development between boys school. Children of parents with a higher level of and girls. As expected, overall child development education, having completed secondary school or improves as children grow older: the older the child, above, had better development again. Overall, these the more advanced their stage of development. When disparities in developmental scores are expected, examining ethnicity, Lao-Tai children generally appear and consistent with the international literature on to be developing better than children of other child development. ethnicities, with Hmong children usually demonstrating the poorest performance. Another Figure 21: Children's overall development by gender, age, ethnicity and caretaker's education .70 Average child development score .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 54 Table 12 below shows results from a univariate related to scores in all domains of development, with general linear model demonstrating the relationship older children performing better than younger between child age and scores on each developmental children. This association is strongest for early domain. As expected, children’s age is strongly numeracy skills, followed by early literacy skills. Table 12: Child development by child age DOMAIN MEAN SD MEAN SQ F 2 years .69 .32 Verbal 3 years .85 .24 15.88 265.27** Communication 4 years .89 .22 5 years .91 .20 2 years .54 .30 3 years .65 .28 Approaches 13.96 198.00** to Learning 4 years .72 .25 5 years .75 .24 2 years .18 .19 Numeracy 3 years .31 .21 41.47 810.55** and Concepts 4 years .42 .23 5 years .54 .25 2 years .06 .09 Literacy 3 years .10 .12 11.97 460.13** (reading and writing) 4 years .15 .17 5 years .25 .23 2 years .58 .25 Cultural 3 years .69 .20 14.59 363.59** Knowledge 4 years .75 .18 5 years .79 .18 2 years .37 .18 Social 3 years .46 .19 13.41 368.13** and Emotional Skills 4 years .51 .19 5 years .58 .20 2 years .43 .33 3 years .54 .33 Perseverance 13.65 132.52** 4 years .60 .32 5 years .58 .20 2 years .41 .16 Overall 3 years .51 .14 16.28 791.21** Development 4 years .58 .13 5 years .64 .15 Note : *p,.05, **p<.01 55 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 13 below presents results from a univariate significant differences on approaches to learning, general linear model demonstrating how children’s literacy skills, and social and emotional development. gender is related to performance on each Boys performed better than girls in the approaches to developmental domain. Results demonstrate a small learning domain, and girls scored higher than boys on but statistically significant difference between boys reading and writing, and on social and emotional and girls on overall development, and larger statistically development. Table 13: Child development by child gender DOMAIN MEAN SD MEAN SQ F Male .84 .26 Verbal Communication .01 .08 Female .84 .25 Male .84 .25 Approaches to Learning 1.21 15.91** Female .66 .28 Male .37 .26 Numeracy and Concepts .15 2.24* Female .37 .26 Male .13 .17 Literacy (reading and writing) .56 18.36** Female .15 .18 Male .70 .21 Cultural Knowledge .24 5.27** Female .71 .22 Male .47 .20 Social and Emotional Skills 1.91 45.97** Female .50 .21 Male .55 .33 Perseverance .75 6.91** Female .57 .33 Male .53 .16 Overall Development .17 6.14* Female .54 .17 Note : *p,.05, **p<.01 Table 14 below presents results from a univariate slightly higher), social and emotional skills (for which general linear model demonstrating the relationship children of other ethnicities score the same as between children’s ethnicity and scores in each Lao-Tai children), and perseverance (for which Khmu developmental domain.This relationship was and children of other ethnicities score higher than statistically signi fi cant across all domains of Lao-Tai children). Conversely, Hmong children score development, particularly so when examining reading the least well of all ethnicities on all domains of and writing skills. On average, Lao-Tai children development, with the exception of social and perform better than Hmong, Khmu and children of emotional development (for which Khmu children other ethnicities on all domains except verbal score the same, on average). communication (for which Khmu children score only The Status of Early Childhood Health and Development in Northern Lao PDR | 56 Table 14: Child development by child ethnicity DOMAIN MEAN SD MEAN SQ F Lao-Tai .86 .25 Khmu .87 .24 Verbal Communication 1.45 22.14** Hmong .81 .27 Other .82 .27 Lao-Tai .71 .25 Khmu .69 .28 Approaches to Learning 2.87 38.27** Hmong .63 .29 Other .66 .27 Lao-Tai .42 .28 Khmu .35 .24 Numeracy and Concepts 3.34 50.28** Hmong .33 .23 Other .37 .27 Lao-Tai .20 .20 Khmu .12 .16 Literacy (reading and writing) 5.14 178.68** Hmong .09 .12 Other .16 .18 Lao-Tai .75 .20 Khmu .72 .21 Cultural Knowledge 3.31 74.11** Hmong .65 .21 Other .71 .24 Lao-Tai .51 .21 Khmu .46 .20 Social and Emotional Skills Hmong .46 .20 1.72 41.78** Other .51 .21 Lao-Tai .56 .31 Khmu .59 .35 Perseverance 4.27 40.05** Hmong .49 .33 Other .60 .31 Lao-Tai .57 .17 Khmu .54 .16 Overall Development 2.22 84.61** Hmong .49 .18 Other .55 .17 Note : *p,.05, **p<.01 57 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 15 below presents results from a univariate general linear model exploring how children’s development scores are associated with their care- taker’s level of education. Again, there was a statisti- cally significant relationship across all domains of development, with the strongest association observed between caretaker’s education and children’s scores in the literacy domain. This is consistent with international evidence – caretakers who are able to read and write are more likely to try to foster these skills in the children they are caring for, while it is very difficult for illiterate caretakers to teach their children early literacy skills that they do not have themselves. The Status of Early Childhood Health and Development in Northern Lao PDR | 58 Table 15: Child development by caretaker's education level DOMAIN MEAN SD MEAN SQ F No School .83 .27 Primacy School (incomplete) .83 .26 Verbal .50 4.50** Communication Completed Primary School .85 .25 Completed Secondary School or above .87 .23 No School .63 .30 Primacy School (incomplete) .65 .28 Approaches 4.77 64.25** Completed Primary School .70 .26 to Learning Completed Secondary School or above .76 .21 No School .32 .24 Primacy School (incomplete) .36 .25 Numeracy 3.41 51.43** and Concepts Completed Primary School .40 .27 Completed Secondary School or above .43 .28 No School .10 .14 Primacy School (incomplete) .13 .16 Literacy 4.22 144.74** Completed Primary School .17 .19 (reading and writing) Completed Secondary School or above .22 .22 No School .67 .22 Primacy School (incomplete) .69 .22 Cultural 2.40 53.40** Completed Primary School .73 .21 Knowledge Completed Secondary School or above .76 .20 No School .45 .20 Primacy School (incomplete) .48 .20 Social Completed Primary School .50 .21 1.68 40.84** and Emotional Skills Completed Secondary School or above .52 .20 No School .55 .34 Primacy School (incomplete) .52 .34 Perseverance 1.93 17.91** Completed Primary School .58 .32 Completed Secondary School or above .58 .31 No School .51 .16 Primacy School (incomplete) .52 .16 Overall 2.23 85.49** Completed Primary School .56 .16 Development Completed Secondary School or above .59 .16 Note : *p,.05, **p<.01 59 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 22 below shows average child development aligned with the levels of poverty found in these areas scores across the five different provinces in which – Xaiyabouly has the lowest score on the poverty data was collected. Results demonstrate statistically severity index (1.5) whilst Houaphan has the highest significant differences in how children are developing of these five provinces (2.8). This is consistent with overall, across provinces (F(4 )= 9.15, p = .000), with the international literature demonstrating that poverty child development highest in Xaiyabouly (.58), and and poor child development go hand in hand. lowest in Phongsaly and Houaphan (both 53). This is Figure 22: Child development by province .59 Average child development score .58 .57 .56 .55 .54 .53 .52 .51 .50 Borlikhamxay Phongsaly Oudomxay Houaphan Xaiyabouly Verbal Communication Skills Children communicate from birth through sounds, as would be expected for children of this age range. facial expressions and gestures, and from here a Figure 23 below shows that there is not a great deal child’s communication skills grow rapidly throughout of difference between children’s communication skills their first years of life. To be ready for school and to across different demographic groups, unlike the learn successfully in a classroom, it is crucial that greater differences seen in other domains of children are able to communicate their needs and development (refer to Tables 12 to 15 for significance thoughts to adults and other children alike. values). However, there is a steep improvement in the communication skills of two and three year olds, Examples of items measured in this domain include which re fl ects the expected developmental children’s ability to communicate their needs, speak milestones of children this age. There are only small simple sentences, and stop an activity when told to differences between the communication skills of do so. As previously noted, the data shows that children of different ethnicities and children of children’s verbal communication skills are quite good, educated and uneducated parents. The Status of Early Childhood Health and Development in Northern Lao PDR | 60 Figure 23: Children's verbal communication skills by gender, age, ethnicity and caretaker's education 1.00 .90 Average child development score .80 .70 .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete school or above No school primary school primary school Gender Age Ethnicity Caretaker’s Education Approaches to Learning Children’s approaches to learning include how they interact with people and objects. With adult support, learn and develop new skills, and their attitude children feel safe and confident to try new things and towards learning experiences. For infants and take risks. When parents nurture their children’s toddlers, this begins with their interest in the world natural curiosity by playing games, talking to them around them, and their curiosity and willingness to about their experiences, counting, reading and so on, this lays a foundation for future learning and success. 61 | The Status of Early Childhood Health and Development in Northern Lao PDR Examples of items measured in this domain include compared to children with less educated parents. children’s demonstrated interest to learn new things, Further testing for interaction effects demonstrated play new games and pay attention when completing that there is a statistically significant relationship an activity. Overall, children in northern Lao received between a caretaker’s education and children’s good scores. Figure 24 shows small disparities gender when examining scores on approaches to across age, ethnicity and family background which are learning (F= 3.61, p = .013). There was no difference statistically significant (refer to Tables 12 to 15). between the scores of boys and girls of caretakers Hmong children received the lowest scores relative to who had completed secondary school or above (both Lao-Tai, Khmu and children of other ethnicities, while M = .76), but a significant difference between the children whose parents completed secondary school scores of boys and girls whose caretakers who had or above scored the highest on this domain, never gone to school (M = .66, M = .60, respectively). Figure 24: Children's approaches to learning by gender, age, ethnicity, and caretaker's education .80 Average child development score .70 .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete school or above No school primary school primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 62 Early Numeracy Skills Basic numeracy skills and knowledge of numeracy concepts – such as being able to recognize a number, having knowledge of smaller objects and heavier objects, and the ability to count – are important for children to be ready to learn at school. Children will have a greater interest in learning at school when they have already developed an interest in counting, recognising numbers and shapes. As mentioned above, results demonstrate that children in northern Lao PDR have particularly poor numeracy skills, relative to other domains of development. Figure 25 below shows that when examining indicators of early numeracy skills as reported by caretakers, there are significant disparities across age, ethnicity and family background (refer to Tables 12 to 15 for significance values). As would be expected, children’s score in this domain of development increased significantly with age. Furthermore, while still low overall, Lao-Tai children’s maths skills were better developed than those of Khmu and Hmong children, or children of other ethnicities, while children with better educated parents had higher scores in this domain than children whose parents did not go to school. Despite these significant main effects, no interaction effects between children’s gender, caretaker’s education, and children’s ethnicity were found. 63 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 25: Early numeracy skills and knowledge of numeracy concepts by gender, age, ethnicity and caretaker's education Average child development score .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school school or above primary school Gender Age Ethnicity Caretaker’s Education Nine different aspects of children’s numeracy skills rapport with children to make them feel at ease. were explored further via a direct assessment of Quantitative comparison: Children were asked to children’s abilities. It is important to note that for identify the picture with the greater number of these direct assessment tasks, there were a large tomatoes. No response was received from 30 number of children who gave no response, or gave an percent of children, 1 percent of children said they did ‘I don’t know’ response, rather than answering the not know the answer, 62 percent of children answered question correctly or incorrectly. Details of the correctly, and 8 percent answered incorrectly. Of the missing data for each direct assessment measure is 70 percent of children who responded to this included below. The responses given are likely due to question, Figure 26 below shows that five year olds children feeling uncomfortable in the assessment were most likely to answer this question correctly, situation with an unfamiliar person, despite the great along with Lao-Tai children and children whose efforts made by enumerators to play with and build parents completed secondary school or above. The Status of Early Childhood Health and Development in Northern Lao PDR | 64 Figure 26: Quantitative comparison by gender, age, ethnicity, and caretaker's education .90 % of children who answered correctly .80 .70 .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete school or above No school primary school primary school Gender Age Ethnicity Caretaker’s Education 65 | The Status of Early Childhood Health and Development in Northern Lao PDR Measurement Vocabulary These items measured children’s knowledge of score of 1, although no response was received from measurement terms such as smallest and largest. 29 percent of children. Of the 71 percent of children Items were combined and the average was taken to who responded, Figure 27 shows significant give an overall score of 0-1, 1 being the best score. disparities in ability by age only, with older children The majority of children (51 percent) received a top having a better measurement vocabulary than younger children. Figure 27: Measurement vocabulary by gender, age, ethnicity, and caretaker's education 1.00 .90 Average measurement vocabulary score .80 .70 .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong school or above No school Did not complete primary school primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 66 Shape Naming This task required children to name a number of across age, ethnicity and parent’s education. Older geometrical shapes. Items were combined and the children were significantly more familiar with shapes average was taken to give an overall score of 0-1, 1 than younger children, Lao-Tai children performed being the best score. The results demonstrated that better than Khmu, Hmong and children of other children’s knowledge of shapes was very poor. No ethnicities, and children whose parents completed response was received from 58 percent of children, secondary school or above also received a and another 34 percent received a score of 0. For the significantly higher score on this scale when 42 percent of children who did respond, Figure 28 compared to children of parents with a lower below shows significant disparities in development education level. Figure 28: Shape naming by gender, age, ethnicity, and caretaker's education .20 .18 Average shape naming score .16 .14 .12 .10 .08 .06 .04 .02 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school school or above primary school Gender Age Ethnicity Caretaker’s Education 67 | The Status of Early Childhood Health and Development in Northern Lao PDR Spatial Vocabulary Figure 29 below shows that older children had a These items measured children’s knowledge of better developed spatial vocabulary than younger spatial terms such as ‘on top of’ and ‘underneath of’. children, males scored slightly better than females, Items were combined and the average was taken to Lao-Tai children received a higher score than Khmu, give an overall score of 0-1, 1 being the best score. Hmong and children of other ethnicities, and children No response was received from 36 percent of with parents who completed primary school did better children, and another 20 percent received a top score than children with less educated parents. of 1. Of the 64 percent of children who did respond, Figure 29: Spatial vocabulary by gender, age, ethnicity, and caretaker's education .80 Average spatial vocabulary score .70 .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 68 Counting This item sought to determine how high children significant disparities across age, indicating that (as could count. Almost half of children (45 percent) did would be expected) older children’s counting skills not respond, another 1 percent responded that they are more developed than those of younger children. did not know, 39 percent could count to at least three, Though smaller, we also see disparities by ethnicity, 19 percent could count to at least 10, 7 percent could with Lao-Tai children on average being able to count count to at least 20 and 4 percent of children could higher than children of other ethnicities, and children count to 30. Of the 55 percent of children who with uneducated parents having worse counting skills provided a response, Figure 29 below shows than those of children with educated parents. Figure 30: Counting ability by gender, age, ethnicity, and caretaker's education 16 14 Average number the child 12 could count to 10 8 6 4 2 0 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education 69 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 31: Number identification by gender, age, ethnicity and caretaker's education 4 4 of numbers identified 3 Average number 3 2 2 1 1 0 completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education Number Identification This task involved showing children a series of all 20 numbers correctly. Of the 18 percent who numbers and asking them to name them. Children responded, Figure 31 above demonstrates the performed quite poorly on this task – the large average number of correct responses across gender, majority of children did not respond, or could not age, ethnicity and caretaker’s education. Older name any of the numbers (82 percent). Of children were able to identify more numbers than remaining 18 percent of children, 4 percent identified younger children, Lao-Tai children performed better one correct number, 6 percent identified between 2-5 than children of Khmu, Hmong and other ethnicities, correct numbers, 3 percent identified between 6-10 and children of parents who completed secondary correct numbers, 4 percent identified between 11-19 school also did better than children with less correct numbers, and 2 percent of children identified educated parents. The Status of Early Childhood Health and Development in Northern Lao PDR | 70 Producing a Set This task involved children producing sets of counting set of objects. Of the 34 percent who did respond, objects based on enumerator instruction (e.g. Figure 32 below shows that age was an important “please give me three pieces of macaroni”). Items factor in being able to complete this task were combined and the average was taken to give an competently. Disparities in performance by ethnicity overall score of 0-1, 1 being the best score. The are apparent, with Hmong children performing more majority of children did not respond (66 percent), but poorly than Lao-Tai, Khmu and children of other 34% of children able to produce at least one correct ethnicities. Figure 32: Producing a set by gender, age, ethnicity, and caretaker's education .70 Average producing a set score .60 .50 .40 .30 .20 .10 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong No school Did not complete primary school school or above primary school Gender Age Ethnicity Caretaker’s Education 71 | The Status of Early Childhood Health and Development in Northern Lao PDR Addition with Two Sets This item assessed children’s basic addition, asking percent said they did not know the answer. Figure 33 them to add 2 + 3 together using counting objects. shows that, of the 45 percent of children who More than half of children (55 percent) did not provided a response, the best predictor of being able respond, 15 percent gave the correct answer, 6 to answer this question correctly was age. When percent answered correctly but got to the total by looking at results by ethnicity, Lao-Tai children counting to five, <1 percent responded correctly but performed significantly better than their peers, and could only show five fingers rather than saying the children whose parents completed secondary school word ’five’, 19 percent answered incorrectly, and 5 or above also performed better than children with parents who had never attended school. Figure 33: Addition by gender, age, ethnicity and caretaker's education 40% 35% % of children who answered 30% 25% correctly 20% 15% 10% 5% 0% completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school school or above primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 72 Spatial Visualisation This task asked children to complete a five-piece that, of the 73 percent of children who provided a picture puzzle, assessing their ability to visualize response, males were more likely to complete the spatially. No response was received from 37 percent puzzle than females, and five year olds were most of children, 8 percent said they did not know how to likely to be able to complete the puzzle. Lao-Tai complete the puzzle, 4 percent got all five puzzle children performed the best, while Hmong children pieces correct, 1 percent got four correct pieces, 3 performed the poorest. Children whose parents percent got three correct pieces, 10 percent got two completed secondar y school or above did matching pieces, and 38 percent were not able to significantly better than children with parents who had match any puzzle pieces together. Figure 34 shows never attended school. Figure 34: Spatial visualisation by gender, age, ethnicity and caretaker's education 12% % of children who answered 10% 8% correctly 6% 4% 2% 0% completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school school or above primary school Gender Age Ethnicity Caretaker’s Education 73 | The Status of Early Childhood Health and Development in Northern Lao PDR Early Literacy Skills Literacy skills are a vital part of overall child While still very low overall, Lao-Tai children had better development. Familiarity with words, sounds, literacy skills when compared to Khmu, Hmong and language and books, as well as the formal aspects of children of other ethnicities, with Hmong children literacy that develop later in childhood – being able to showing the poorest levels of development in this read and write – are all crucial skills children need in domain. Further, as would be expected, children with order to be able to further learn and develop. better educated parents had significantly higher scores in this domain than children whose parents The data shows that of all aspects of development, did not go to school. children in northern Lao PDR performed most poorly on literacy skills, despite the fact that many Further testing for interaction effects demonstrated caretakers believed children should start reading and that there is statistically significant interaction writing by the age of three (43 percent and 32 between caretaker’s education and children’s gender percent, respectively). Considering the majority of when examining scores for early literacy skills caretakers could not read at all, or only a little, (F= 3.81, p = .010). Specifically, there was no unfortunately it is unsurprising that such illiteracy is difference between the scores of boys and girls of being passed down to children. Figure 35 below caretakers who had never gone to school (both M = shows that when examining indicators of early literacy .10), but a significant difference between the scores skills as reported by caretakers, again there are of boys and girls of caretakers who have completed significant disparities across gender, age, ethnicity secondary school or above (M = .21, M = .24, respec- and family background (see Tables 12 to 15 for tively). This interaction effect is opposite to that seen significance values). Girls outperformed boys, and above in the approaches to learning domain. older children had significantly better literacy development than younger children. The Status of Early Childhood Health and Development in Northern Lao PDR | 74 Figure 35: Early literacy (reading and writing) skills by gender, age, ethnicity, and caretaker's education .30 Average child development score .25 .20 .15 .10 .05 .00 Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Did not complete Khmu Hmong completed school or above No school primary school completed secondary primary school Gender Age Ethnicity Caretaker’s Education Six different aspects of children’s literacy skills were literacy direct assessment items than for the direct explored further via a direct assessment of children’s assessment numeracy items. This is likely a abilities. Again, it should be noted that there were a reflection of children feeling uncomfortable in the large number of children who gave no response, or assessment situation, as well as the very low literacy gave an ‘I don’t know’ response, rather than skills and understanding of literacy concepts of the answering the question correctly or incorrectly. The children assessed. number of missing responses were considerably higher for the literacy direct assessment the 75 | The Status of Early Childhood Health and Development in Northern Lao PDR Familiarity with Print Concepts These items assessed children’s familiarity with books; how to open them, where to start reading and so on. Items were combined and the average was taken to give an overall score of 0-1, 1 being the best score. The majority of children (53 percent) did not provide a response when asked these questions –a reflection of the fact that 45 percent of households had no books, so children had likely not come across a book before. Just over a third of children (35 percent) had at least some knowledge of books. Of the 47% of children who provided a response, Figure 36 below shows that age was an important factor in being able to complete these tasks competently. Small disparities in performance by ethnicity are also apparent, with Lao-Tai children performing better than children of all other ethnicities, and children of parents who completed secondary school being more familiar with books and print concepts than children with less educated parents. Figure 36: Print familiarity scores by gender, age, ethnicity and caretaker's education .45 .40 Average print familiarity score .35 .30 .25 .20 .15 .10 .05 .00 Female 2 years 3 years 4 years 5 years Male Hmong Other Lao-Tai Khmu No school Did not complete completed primary school completed secondary school or above primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 76 Figure 37: Relationship between print familiarity and books in the home 0.4 Average print familiarity score 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 0 1 to 3 4 to 6 7 to 9 10+ Books at home Figure 37 above examines children’s print familiarity relative to the presence of books in their household. Evident- ly, having at least one to three books in the home is helpful for the promotion of children’s early literacy skills. Initial Sound Discrimination These tasks involved asking children to identify, from a 23% provided incorrect responses, leaving just 2% of choice of three words, which word started with a children who responded correctly at least once. particular sound. Items were combined and the Figure 38 below shows disparities across gender, average was taken to give an overall score of 0-1, 1 age, ethnicity and parent’s education level, although being the best score. A large majority of children (76%) the data should be interpreted with caution as it is did not provide a response, and an additional based on very few children overall (n=137). 77 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 38: Sound discrimination by gender, age, ethnicity and caretaker's education .09 .08 .07 Average sound discrimination score .06 .05 .04 .03 .02 .01 .00 completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Caretaker’s Gender Age Ethnicity Education Initial Sound Identification These tasks involved asking children which sound incorrect responses, leaving just 2% of children who words started with. Items were combined and the responded correctly at least once. Figure 39 below average was taken to give an overall score of 0-1, 1 presents disparities across gender, age, ethnicity and being the best score. Again, most children (77%) did parent’s education level. As above, the data should not provide a response, and another 21% provided be interpreted with caution as it is based on very few children overall (n=178). The Status of Early Childhood Health and Development in Northern Lao PDR | 78 Figure 39: Sound discrimination by gender, age, ethnicity and caretaker's education .20 .18 .16 sound discrimination .14 .12 .10 .08 .06 .04 .02 .00 completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education Letter Name Knowledge This task involved showing children a series of Figure 40 below shows the average number of correct letters, and asking them to name them. The majority responses across gender, age, ethnicity and of children did not respond or were not able to identify caretaker’s education. Older children were able to any letters correctly (88%). Of the remaining 12% of identify more letters than younger children, Lao-Tai children, 2% were able to identify one letter only, 4% children performed better than children of Khmu, identified between 2-5 correct letters, 1% identified Hmong and other ethnicities, and children of parents between 6-10 correct letters, 3% identified between who completed secondary school also did better than 11-19 correct letters and 2% identified all 20 letters children with less educated parents. correctly. Of the children who responded, 79 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 40: Letter name knowledge by gender, age, ethnicity and caretaker's education 3.00 2.50 Average number of letters identified 2.00 1.50 1.00 .50 .00 Female Other Male 2 years 3 years 4 years 5 years Lao-Tai Khmu Hmong Did not complete primary school completed completed secondary school or above No school Gender Age Ethnicity Caretaker’s primary school Education Name Writing Children were asked to write their name any way they knew how. Almost half of children did not respond (49%), 3% of children said that they did not know how to write their name, 23% did not write anything, 18% made some scribbles with no discernible symbols, and 7% were able to write some symbols or letters, albeit incorrectly. No children were able to correctly write their name. The Status of Early Childhood Health and Development in Northern Lao PDR | 80 Listening Comprehension This scale assessed children’s ability to listen to a disparities in results across children’s gender, age, story, and then answer descriptive questions about ethnicity and parent’s education. Older children had details of the story. Items were combined and the better listening comprehension than younger children, average was taken to give an overall score of 0-1, 1 Lao-Tai children performed significantly better than being the best score. Most children (71%) did not children of Khmu, Hmong or other ethnicities, and provide a response; another 10% provided incorrect children with parents who had completed secondary responses, leaving 20% of children who responded school had better listening comprehension than correctly at least once. Of the 30% of children who children of parents with a lower level of education or provided a response, Figure 41 below explores no education. Figure 41: Listening comprehension by gender, age, ethnicity and caretaker's education .50 .45 Average listening comprehension score .40 .35 .30 .25 .20 .15 .10 .05 .00 completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education 81 | The Status of Early Childhood Health and Development in Northern Lao PDR Cultural Knowledge Culture is important because we learn to education. Again, these are the results that are to be communicate and understand our world through the expected, as it is assumed that the majority of context of our languages, traditions, behaviours, children aged 2-5 years would have grasped a good beliefs and values. Children’s knowledge of culture, understanding of their culture. Only small including for example knowledge of important improvements would be expected as children grow traditions and culturally appropriate ways in which to older, due to increased exposure to cultural traditions. behave, is important because it shapes the way they see themselves and what is important. Further testing for interaction effects demonstrated that there is statistically significant interaction Examples of items measured in this domain include between caretaker’s education and children’s gender children’s knowledge of common animals, traditional when examining children’s knowledge of culture food dishes, and ability to participate in traditional (F= 3.78, p = .010). Specifically, girls of caretakers cultural events. Overall, children scored well in this aspect of who had never gone to school on average scored development, second only to verbal communication. lower than boys of caretakers who had never gone to Figure 42 below demonstrates significant disparities school (M = .66 versus M = .68). This pattern was across age, ethnicity and parent’s level of reversed for children of caretakers who had completed secondary school or above, with girls scoring higher than boys (M = .78 versus M = .75). Figure 42: Children's knowledge of culture by gender, age, ethnicity and caretaker's education .80 Average child development score .70 .60 .50 .40 .30 .20 .10 .00 Female 2 years 3 years 4 years 5 years Male Lao-Tai Other Did not complete completed completed secondary Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 82 Social and Emotional Skills Social and emotional skills are important as they help Examples of items measured in this domain include children get along with others and form healthy children’s ability to share with others, respect adults relationships throughout life. Children develop these and other children, and be considerate of other social skills through their earliest relationships. people’s feelings. Results demonstrate that overall Positive and supportive relationships teach children children received low scores on social and emotional how to get along with others, and they also help skills. The scores were higher only than scores in the children learn that they are capable and important. literacy and numeracy domains. Figure 43 below These skills are important for children to have when shows that, when examining children’s social and they reach school, as they are best able to adapt to a emotional skills, there are significant disparities classroom environment when they can consider across ethnicity and parent’s level of education. others, have patience, and are beginning to manage Again, it is not surprising that the largest differences their emotions. in children’s social and emotional development are seen with age, with older children’s social and emotional skills further developed than that of younger children (refer to Tables 12 to 15 for significance values). Further testing for interaction effects demonstrated no significant interaction effect between caretaker’s education and children’s gender when examining children’s social and emotional skills. There was however, a statistically significant interaction between children’s ethnicity and children’s gender (F= 3.12, p = .025). Specifically, the difference in social and emotional development between boys and girls of Lao Tai children (M = .48, M = .54, respectively) and between boys and girls of all other ethnicities (M = .49, M = .52, respectively) is significantly larger than differences in scores between boys and girls of Khmu ethnicity (M = .45, M = .47, respectively) and between boys and girls of Hmong ethnicity (M = .45, M = .47, respectively). 83 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 43: Social and emotional development by gender, age, ethnicity and caretaker's education .70 Average child development score .60 .50 .40 .30 .20 .10 .00 Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong Did not complete completed No school completed secondary school or above primary school primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 84 Perseverance Perseverance refers to a child’s ability to persist or shows disparities in perseverance scores, mainly stick to an activity without losing interest too quickly, across children of different ages and ethnicities (refer and to pursue goals or tasks through to their to Tables 12 to 15 for significance values). Older completion despite any difficulties experienced. children had higher perseverance scores than young- Perseverance is important for children’s overall learn- er children, and Hmong children received significantly ing and future success as it enables them to perse- lower scores in this developmental domain than vere through challenges, therefore fostering a strong Lao-Tai, Khmu and children of other ethnicities. work ethic and resilience. Examples of items mea- Interestingly, there does not appear to be a clear sured in this domain include children’s ability to work pattern of disparity in perseverance scores across at something independently, their tendency to finish a caretakers’ educational backgrounds. Despite these task, and their ability to stay focused. Overall, significant main effects, no interaction effects children in northern Lao PDR were found to have between children’s gender, caretaker’s education, and mid-range perseverance scores. Figure 44 below children’s ethnicity were found. Figure 44: Children's perseverance by gender, age, ethnicity and caretaker's education .70 Average child development score .60 .50 .40 .30 .20 .10 .00 Female 2 years 3 years 4 years 5 years Other Male Did not complete Lao-Tai Khmu Hmong No school primary school completed completed secondary primary school school or above Gender Age Ethnicity Caretaker’s Education 85 | The Status of Early Childhood Health and Development in Northern Lao PDR Executive Functioning Executive function skills are the mental processes that enable planning, memory, the focus of attention, and management of multiple tasks. Good executive functioning is important for children to be able to remember instructions, plan their actions, solve problems, and complete tasks – all of which a child will need to do at school and throughout life. Poor executive function can negatively impact a child’s ability to learn new things, and therefore their overall development. Development of a child’s executive function was measured via three direct assessments. Again, it should be noted that there were a large number of children who gave no response to these direct Heads Toes Task assessments, or gave an ‘I don’t know’ response, rather than answering the question correctly or incorrectly. This is likely due to children feeling In this task children were asked to play a game in uncomfortable that they were in an assessment which they must do the opposite of what the situation with an unfamiliar person, despite the enumerator asks. For example, the enumerator efforts enumerators made to make children feel at instructs children to touch their head, but instead of ease. The number of missing data for each direct following the instructions, the children are supposed assessment measure is included below. to do the opposite and touch their toes. This task is designed to measure a range of aspects of executive function including inhibitory control, working memory and attention focusing. Children receive one point for each correct answer they provide. The scale ranges from 1-10, with 10 being the best score. The large majority of children (81%) did not respond. Of those who did, 7% scored from 1-5, 12% scored from 6-10, with 7% getting a top score of 10. Figure 45 below explores disparities in these results across children’s gender, age, ethnicity, and parent’s education. On average, older children had better executive function than younger children, Lao-Tai children performed significantly better than children of Khmu, Hmong or other ethnicities, and children with educated parents had better executive functioning scores than children of uneducated parents. The Status of Early Childhood Health and Development in Northern Lao PDR | 86 Figure 45: Executive function (heads toes task) by gender, age, ethnicity and caretaker's education 3.00 Average executive 2.50 function score 2.00 1.50 1.00 0.50 0.00 Female 2 years 3 years 4 years 5 years Other Male Did not complete Lao-Tai Khmu Hmong No school completed school or above primary school completed secondary primary school Gender Age Ethnicity Caretaker’s Education Forward Digit Span This task asked children to repeat numbers read respond), older children had better executive function aloud to them, in the order that they were read. This than younger children, Lao-Tai children performed was a test of memory, which is an important aspect significantly better than children of Khmu, Hmong or of executive function. The majority of children (56%) other ethnicities, and children with educated parents did not respond or get any items correct. 14% of had better executive functioning scores than children children did however receive a top score of 1. Figure of uneducated parents. 46 below shows that on average (for those who did 87 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 46: Executive function (forward digit span) by gender, age, ethnicity and caretaker's education .60 Average executive .50 function score .40 .30 .20 .10 .00 completed secondary completed Female Other Male 2 years 3 years 4 years 5 years Lao-Tai Khmu Hmong No school Did not complete primary school school or above Caretaker’s primary school Gender Age Ethnicity Education Backward Digit Span Similar to forward digit span, in this task children were used to assess children’s development, which is were read a string of numbers, although this time they reflected by the fact that 96% of children provided no were required to repeat them backward to the order in response or no correct answers. Of the small number which they heard them. This task measures not only of children who did respond, Figure 47 below shows a child’s memory, but also their ability to mentally disparities across gender, age, ethnicity and parent’s transform or manipulate the information presented to education level. This information should however be them. This is the most difficult task of all items that interpreted with caution as it is based on very few children overall (n=328). The Status of Early Childhood Health and Development in Northern Lao PDR | 88 Figure 47: Executive function (backward digit span) by gender, age, ethnicity and caretaker's education .05 .05 .04 Average executive .04 function score .03 .03 .02 .02 .01 .01 .00 completed secondary completed Male Female 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education Stimulation in the Home Environment A nurturing home environment that provides safety, very low.71% of caretakers had not read a book to love and opportunities to learn, explore and play is their child, 75% had not told their child a story, 70% essential for healthy child development. It is therefore had not engaged in drawing with their child, 71% had important for parents to tell stories, sing and play not listened to music, sung or danced with their child, with their children. While almost all caretakers (97%) 82% had not played any games with their child, and agreed that it is important that parents interact with 76% had not engaged in any outdoor activities with and stimulate their children to help them learn well their child in the last seven days. In addition, 75% of before they go to kindergarten, unfortunately these children had not participated in housework (e.g., beliefs were not reflected in responses to questions cooking, cleaning). Compared to other countries, regarding stimulation in the home environment. these results indicate that children in northern Lao Caretakers were asked about seven different PDR are receiving very low levels of stimulation and activities that families commonly engage in with their support for their development in their home children, and if they had undertaken any of these environments. activities with their child in their home over the past week. Rates of caretaker and child interaction were 89 | The Status of Early Childhood Health and Development in Northern Lao PDR As previously noted, the large majority (88%) of had sung or danced with their child compared to 28% caretakers in this study were female. When exploring of females; 33% of male caretakers reported that children’s participation in the above activities, differences their child participated in housework compared to can be observed between male and female caretakers. 24% of female caretakers; and 25% of male 32% of male caretakers (N=942) had played a game caretakers had engaged in outdoor activities with with their child in the past seven days, compared to their child compared to 24% of female caretakers. An 16% of all female caretakers (N=6578); 30% of male equal amount of male and female caretakers (29%) caretakers had told their child a story compared reported having read a book to their child in the past to 25% of female caretakers; 34% of male caretakers week. These results suggest that male caretakers are had drawn with their child compared to 30% interacting with their children at home considerably of female caretakers; 38% of male caretakers more than female caretakers. Figure 48: Caretakers' participation in home learning activities over the last 7 days 20% 18% 16% 14% % of chidren 12% 10% 8% 6% 4% 1-2 days 2% 3-5 days 0% 6-7 days Told story Read a book Drew Listened to music, sung or danced Played with toy Child participated Played outside or a game in housework The Status of Early Childhood Health and Development in Northern Lao PDR | 90 For those who did participate in these activities with Figure 49 shows that that better educated parents their child, Figure 48 above shows the frequency with and Lao-Tai parents were more likely to have played which each of these activities occurred. Evidently, games with their child in the past week. Parents who reading a book, telling a story, drawing or listening to had not attended any school were much less likely to music, singing and dancing were activities that have played with their child. Despite these significant parents more commonly did with their children at main effects, no interaction effects between children’s least once or twice throughout the week. Fewer gender, caretaker’s education, and children’s ethnicity parents played with toys or games, played outside, or were found. let their child participate in housework.When exploring these patterns of activity further, Figure 49: Caretakers who had played with toys/a game with their child in the past 7 days 30% 25% % of chidren 20% 15% 10% 5% 0% completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong school or above No school Did not complete primary school primary school Gender Age Ethnicity Caretaker’s Education 91 | The Status of Early Childhood Health and Development in Northern Lao PDR Similarly, Figure 50 below shows that Lao-Tai parents general linear models showed that the relationship were more likely to have read a book to their child in between parents’ education and engagement in the past week, with Hmong parents being the least learning activities at home was statistically significant likely to have engaged in this activity. There is also a across all seven activities. Again, despite these strong link between parent’s education and whether significant main effects, no interaction effects or not they read to their child, with educated parents between children’s gender, caretaker’s education, and reading to their children more than those who had children’s ethnicity were found. never attended school. Testing using univariate Figure 50: Caretakers who had read a book with their child in the past 7 days 60% 50% % of chidren 40% 30% 20% 10% 0% completed secondary completed Female 2 years 3 years 4 years 5 years Other Male Lao-Tai Khmu Hmong school or above No school Did not complete primary school primary school Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 92 Home Stimulation and Table 16 below presents descriptive analyses as well as results from a univariate general linear model Child Development showing the relationship between caretakers having played a game with their child in the past week and children’s development. Evidently caretakers playing Each of the seven caretaker-child engagement games with their children had a strong statistically activities had a significant positive relationship with significant relationship with all domains of child’s overall development. As shown in Figure 51 development, with the magnitude of the relationship below, the children of caretakers who had read a book largest for children’s reading and writing skills, as well to their child, told their child a story, drawn with their as their social and emotional development. This anal- child, listened to music, sung or danced with their ysis focuses on the development of children whose child, played games with their child, participated in caretakers played with them at least once in the past housework with their child, or engaged in outdoor week, and so it is likely that the magnitude of this activities with their child in the last seven days all had relationship would be larger still for children whose better development than children whose caretakers caretakers played them multiple times over a week. had not engaged in these activities with them in the This is the case for the following analyses examining past week. The relationship between each of these parent-child engagement and child development stimulation activities and different aspects of child below. development is further explored below. Figure 51: Relationship between home learning activities and child development 0.7 Average print familiarity score 0.6 0.5 0.4 0.3 0.2 0.1 0 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Played a Read Told Drew Sung Child Outdoor game with a book a story a picture or danced participated activities child with child to child with child with child in housework with child 93 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 16: Relationship between caretaker playing a game with their child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .80 .26 Verbal Communication 2.25 34.12** Did not do .85 .26 Did do .74 .22 Approaches to Learning 8.10 108.05** Did not do .66 .28 Did do .44 .26 Numeracy and Concepts 9.25 139.16** Did not do .35 .26 Did do .21 .21 Literacy (reading and writing) 8.21 276.32** Did not do .13 .16 Did do .74 .21 Cultural Knowledge 1.58 34.57** Did not do .70 .21 Did do .56 .20 Social and Emotional Skills 9.01 222.05** Did not do .47 .20 Did do .59 .27 Perseverance 1.73 16.01** Did not do .55 .34 Did do .58 .15 Overall Development 3.36 126.18** Did not do .53 .16 Note : *p,.05, **p<.01 The Status of Early Childhood Health and Development in Northern Lao PDR | 94 Table 17: Relationship between caretaker reading a book to their child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .87 .23 Verbal Communication 2.68 40.74** Did not do .82 .27 Did do .75 .22 Approaches to Learning 18.20 247.17** Did not do .64 .29 Did do .50 .26 Numeracy and Concepts 54.39 899.51** Did not do .32 .24 Did do .24 .21 Literacy (reading and writing) 26.45 969.75** Did not do .11 .14 Did do .77 .18 Cultural Knowledge 12.45 281.15** Did not do .68 .22 Did do .56 .19 Social and Emotional Skills 16.82 425.50** Did not do .45 .20 Did do .59 .31 Perseverance 4.31 39.99** Did not do .54 .33 Did do .61 .15 Overall Development 16.15 648.15** Did not do .51 .16 Note : *p,.05, **p<.01 Table 17 above presents descriptive analyses as well as results from a univariate general linear model showing the relationship between caretakers having read a book to their child in the past week and children’s development. Evidently caretakers reading to their children has a strong statistically significant relationship with all domains of development, with the magnitude of the relationship largest for children’s reading, writing and maths skills, but also for their social and emotional development. 95 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 18 below presents descriptive analyses as well show that caretakers telling their child a story had a as results from a univariate general linear model strong statistically significant relationship with all showing the relationship between caretakers having domains of development. Again, the magnitude of told their child a story (without a book) in the past this relationship was largest for children’s reading, week and children’s development. Again, results writing and maths skills, then for their social and emotional development. Table 18: Relationship between caretaker telling a story to their child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .88 .22 Verbal Communication 2.91 44.24** Did not do .83 .27 Did do .75 .22 Approaches to Learning 14.86 200.60** Did not do .65 .29 Did do .49 .27 Numeracy and Concepts 36.04 572.98** Did not do .33 .25 Did do .222 .22 Literacy (reading and writing) 15.17 527.13** Did not do .17 .15 Did do .77 .18 Cultural Knowledge 9.50 212.69** Did not do .69 .22 Did do .55 .19 Social and Emotional Skills 12.35 307.88** Did not do .46 .20 Did do .61 .31 Perseverance 6.89 64.10** Did not do .54 .33 Did do .61 .15 Overall Development 12.43 489.34** Did not do .51 .16 Note : *p,.05, **p<.01 Next the study examined the relationship between Table 20 below presents descriptive analyses and caretakers drawing with their child in the past week results from a univariate general linear model and child development scores. Table 19 below showing the relationship between caretakers having presents descriptive analyses and results from a sung or danced with their child in the past week and univariate general linear model, showing that children’s development. Again, results reveal a strong caretakers drawing with their children had a strong statistically significant relationship with all domains statistically significant relationship with all domains of development, with the magnitude of this of development. Again, the magnitude of this relationship largest for children’s reading, writing and relationship was largest for children’s reading, writing maths skills, and also for their social and emotional and maths skills, and then for their social and development. emotional development. The Status of Early Childhood Health and Development in Northern Lao PDR | 96 Table 19: Relationship between caretaker drawing with their child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .87 .23 Verbal Communication 2.66 40.39** Did not do .83 .27 Did do .76 .21 Approaches to Learning 26.47 364.84** Did not do .63 .29 Did do .49 .26 Numeracy and Concepts 49.26 805.57** Did not do .32 .24 Did do .24 .21 Literacy (reading and writing) 30.91 1158.43** Did not do .10 .14 Did do .77 .18 Cultural Knowledge 12.44 280.89** Did not do .68 .22 Did do .56 .19 Social and Emotional Skills 22.43 578.50** Did not do .45 .20 Did do .60 .30 Perseverance 6.48 60.25** Did not do .54 .34 Did do .61 .14 Overall Development 18.57 755.02** Did not do .51 .16 Note : *p,.05, **p<.01 Table 20: Relationship between caretaker singing or dancing with their child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .85 .24 Verbal Communication 0.28 4.24** Did not do .84 .26 Did do .75 .22 Approaches to Learning 17.31 234.68** Did not do .64 .29 Did do .47 .27 Numeracy and Concepts 31.03 488.07** Did not do .33 .25 Did do .22 .21 Literacy (reading and writing) 18.13 638.91** Did not do .11 .16 Did do .76 .19 Cultural Knowledge 9.13 204.18** Did not do .69 .22 Did do .55 .19 Social and Emotional Skills 15.39 387.43** Did not do .45 .20 Did do .59 .30 Perseverance 4.74 44.01** Did not do .54 .34 Did do .60 .15 Overall Development 11.41 446.56** Did not do .51 .16 Note : *p,.05, **p<.01 97 | The Status of Early Childhood Health and Development in Northern Lao PDR The relationship between children participating in significant relationship with all domains of develop- housework in the past week and child development ment except for verbal communication. In contrast to was also examined. Table 21 below presents the other home stimulation activities, the magnitude descriptive analyses and results from a univariate of this relationship was largest for children’s social general linear model, showing that children’s and emotional skills and well as their literacy skills. participation in housework had a strong statistically Table 21: Relationship between child participating in housework in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .85 .23 Verbal Communication 0.11 1.71 Did not do .84 .26 Did do .74 .24 Approaches to Learning 12.25 164.59** Did not do .65 .28 Did do .45 .26 Numeracy and Concepts 18.08 276.85** Did not do .34 .25 Did do .22 .21 Literacy (reading and writing) 12.90 443.76** Did not do .12 .16 Did do .77 .19 Cultural Knowledge 8.25 183.89** Did not do .69 .22 Did do .58 .20 Social and Emotional Skills 22.74 587.05** Did not do .45 20 Did do .62 .29 Perseverance 12.06 112.89** Did not do .53 .34 Did do .60 .15 Overall Development 10.61 413.35** Did not do .52 .26 Note : *p,.05, **p<.01 Finally, Table 22 below presents descriptive analyses Overall, these results make it clear that parental stim- and results from a univariate general linear model ulation, engagement and interaction in a range of showing the relationship between caretakers having activities with children at home is very important for participated in outdoor activities with their child in the child development. In particular, parents reading and past week, and children’s development. Results drawing with their children was strongly associated reveal a statistically significant relationship with all with better child development. domains of development except for cultural knowledge, though the magnitude of these relationships is relatively smaller than was observed across the other six parent-child interaction activities. The Status of Early Childhood Health and Development in Northern Lao PDR | 98 Table 22: Relationship between caretaker participating in outdoor activities with child in the past 7 days and child development DOMAIN MEAN SD MEAN SQ F Did do .83 .25 Verbal Communication 0.28 4.26* Did not do .85 .26 Did do .73 .24 Approaches to Learning 7.89 105.21** Did not do .66 .28 Did do .42 .25 Numeracy and Concepts 5.26 78.49* Did not do .35 .26 Did do .18 .19 Literacy (reading and writing) 3.13 102.92** Did not do .13 .17 Did do .71 .20 Cultural Knowledge 0.02 0.46 Did not do .71 .22 Did do .52 .20 Social and Emotional Skills 3.37 81.44** Did not do .47 .20 Did do .61 .28 Perseverance 7.10 66.05** Did not do .54 .34 Did do .57 .15 Overall Development 2.46 92.08** Did not do .53 .17 Note : *p,.05, **p<.01 Parenting Practices and Child Development Parenting behaviours and practices characterise how parenting, with scores ranging from 0-5, 5 being the parents interact with their children every day, and highest. Across the whole sample, parents scored research shows that parenting plays a crucial role in highest on the warmth dimension. When examining children’s development. Nurturing, warm parenting parenting practices across gender, age, ethnicity and that is sensitive and responsive provides the family background, significant differences between foundation for a child’s wellbeing and healthy develop- groups could only be seen on parental warmth. As ment. In contrast, hostile, punitive parenting can Figure 53 below shows, parents of Hmong children contribute to or worsen behavioural problems in showed less parental warmth than those of other children. ethnicities, and more educated parents received higher scores on the warmth scale than parents who Caretakers responded to questions designed to did not attend school or complete primary school. measure their parenting practices. Figure 52 below Despite these significant main effects, no interaction presents average scores on four dimensions of effects between children’s gender, caretaker’s parenting: warmth, consistency, hostility, and hostile education, and children’s ethnicity were found. 99 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 52: Average parenting practices across whole sample 4.00 Average parenting practice score 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Warmth Consistency Hostillty Hostile Parenting Figure 53: Parental warmth across child gender, age, ethnicity and caretaker's education 3.7 3.7 3.6 Average score 3.6 3.5 3.5 3.4 3.4 3.3 3.3 3.2 Female 2 years 3 years 4 years 5 years Male Other Lao-Tai Khmu Hmong Did not complete completed completed secondary No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education The Status of Early Childhood Health and Development in Northern Lao PDR | 100 Relationship Between Parenting Practices and Child Development The relationship between parenting practices and hostility and hostile parenting and child development children’s development was also examined. Of the were weak. Hostile parenting was the only practice four parenting practices measured, parental warmth negatively correlated with child development, had the strongest correlation with overall child indicating that increases in hostile parenting are development scores as shown in Table 23 below associated with decreases in overall child (r = .32). Parental warmth and consistency had weak development scores. Subsequent regression analysis to moderate relationships with overall child confirmed that parental warmth had the strongest development, while the relationships between relationship with children’s development. Table 23: Relationship between parenting practices and overall child development OVERALL DEVELOPMENT PARENTING PRACTICE r B SE B β Warmth .32 .065 .003 .247** Consistency .24 .030 .004 .103** Hostility .14 .023 .004 .059** Hostile Parenting -.15 -.019 .003 -.083** R 2 .123 F 262.88** Note : *p,.05, **p<.01 Village Amenities and accessed by car in the wet season (53%). More than half of the villages accessed electricity from Child Development government electrical grids (55%), and only a small number of villages (4%) did not have access to electricity from any source. The majority of villages Village access and amenities are important for basic were using drinking water from trenches/drainage health and hygiene of the population, and are likely to pipes (90%), but many also had some households influence the development of children in the village. using river water for drinking (39%). Villages often As discussed, the villages in the study were relatively used a combination of water sanitation processes; remote, and while almost all could be accessed by car most villages had some households using pit toilets in the dry season (97%), only just over half could be with a water flush (93%), although some villages had households that were still using dry pits (21%). 101 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 54 below indicates the relationship between sophisticated electricity and sanitation processes are village access, electricity, water and sanitation with developing better than children from villages with child development. The results show that children poor access, that do not have electricity and that do living in more accessible villages that utilize more not use toilets. Figure 54: Relationship between village amenities and child development No Electricity Solar Cell Electricity Mini Hydropower Battery Generator Private Generator Government Grids Container water Drinking Trenches & Drainage Pipes Water River Water Well water No toilet Sanitation Water Dry Pit Flush Toilet Access Cannot access in wet season Can access in wet season Average child development score 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Of these variables, sanitation and electricity appear were found to have a better overall development to be particularly important for child development score than children from households using other elec- scores and so these relationships were further tricity sources, and testing using a univariate general explored. Testing using a univariate general linear linear model determined that this result was model (as presented in Table 24 below) statistically signi fi cant. These results are demonstrates that having no toilet at all has the unsurprising, as having a toilet and a private strongest relationship with poor overall child generator are most likely associated with lower levels development scores. As presented in Table 25, of poverty and thus better child development scores. children living in households with a private generator The Status of Early Childhood Health and Development in Northern Lao PDR | 102 Table 24: Relationship between parenting practices and overall child development OVERALL DEVELOPMENT SANITATION PROCESS Mean SD Mean Sq F Yes .54 .16 Flush Toilet 1.47 55.23** No .48 .15 Yes .62 .32 Dry Pit 1.54 57.35** No .53 .16 Yes .52 .16 No Toilet 3.89 146.59** No .57 .17 Table 25: Relationship between parenting practices and overall child development OVERALL DEVELOPMENT ELECTRICITY SOURCE Mean SD Mean Sq F Government grids .56 .16 Private generator .61 .15 Battery generator .55 .15 1.10 41.64** Mini hydropower .51 .16 Solar cell .52 .15 Note : *p,.05, **p<.01 Health and Education Health Care Services Services and Child Development Caretakers reported that 22% of children had received some form of health service in the past month – most often a health check-up, treatment or Universal healthcare and education coverage is vaccination. Only 13% of children had visited a health crucial for supporting the health and development of center, 9% a district hospital, 1% a provincial hospital, a nation. Access to quality healthcare services, as and less than 1% had visited a private clinic, tradition- well as the opportunity to participate in quality ECE, al healer or village health volunteer. Figure 55 below gives children the best start in life and the foundation shows that fewer Hmong children had received a they need to enjoy learning at school. health service compared to children of Lao-Tai, Khmu and other ethnicities, though disparities across age and caretaker’s education are less clear. 103 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 55: Children who received a health service in the past month by gender, age, ethnicity and caretaker's education 12% 10% % of chidren 8% 6% 4% 2% 0% completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Lao-Tai Khmu Hmong No school Did not complete primary school school or above primary school Gender Age Ethnicity Caretaker’s Education In the past 12 months, 38% of children had their while some also received Vitamin A from a midwife weight measured – the majority of whom had this (2%), at a hospital (4%), or at school or child care done at a health centre (14%) or by a mobile medical (2%). Just 33% of children had received a health team (12%), while others were weighed by a midwife check in the past 12 months, the majority of whom (4%), at a hospital (7%), or at school or child care received the check at a health centre (13%), hospital (2%). In the past 12 months, 27% of children were (9%) or from a mobile medical team (8%), with the reported to have taken Vitamin A supplements, the remaining children receiving their health check from a majority of whom received the supplements from a midwife (2%) or at school or child care (1%). mobile medical team (11%) or health centre (9%), The Status of Early Childhood Health and Development in Northern Lao PDR | 104 Figure 56: Relationship between health service availability and child development Naturopath No lives in or visits village Yes Midwife lives No in or visits village Yes Nurse lives No in or visits village Yes Doctor lives No in or visits village Yes No Pharmacy Yes No Hospital Yes No Private Clinic Yes Village No Nurse Yes No Health Centre Yes 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Average child development score The availability of health services was shown to have a positive relationship with child development – that is, increased availability of health services was linked to improved child development, as shown in Figure 56 above. 105 | The Status of Early Childhood Health and Development in Northern Lao PDR Relationship Between Child Health and Development As discussed, a child’s health status - and in testing of this relationship using a univariate general particular the extent to which they experience linear model (Table 27) demonstrated that stunting undernutrition - can hinder early development and go has a statistically significant relationship with all on to have detrimental consequences throughout domains of development except perseverance, with their life. Table 26 below presents descriptive analyses the magnitude of the relationship especially high for showing the relationship between children’s stunting numeracy skills. Unsurprisingly, this effect was stronger status (severely stunted, stunted, or not stunted) and when comparing development scores of severely child development scores. As expected, stunting is stunted children with children who were not stunted, associated with poorer development. Subsequent and this is presented in Figure 57 below also. Table 26: Relationship between stunting and child development SEVERELY STUNTED STUNTED NOT STUNTED DOMAIN Mean SD Mean SD Mean SD Verbal Communication .78 .30 .81 .28 .84 .25 Approaches to Learning .61 .29 .64 .28 .67 .27 Numeracy and Concepts .30 .23 .30 .24 .35 .25 Literacy (reading and writing) .09 .13 .10 .13 .13 .16 Cultural Knowledge .64 .24 .67 .23 .71 .21 Social and Emotional Skills .42 .20 .45 .20 .47 .20 Perseverance .50 .34 .53 .34 .54 .32 Overall Development .47 .16 .50 .16 .53 .16 Table 27: Relationship between stunting and child development SEVERELY STUNTED STUNTED DOMAIN Mean Square F Mean Square F Verbal Communication 3.11 44.36** 1.14 16.16** Approaches to Learning 2.89 37.39** 1.18 15.18** Numeracy and Concepts 5.96 101.38** 3.70 62.63** Literacy (reading and writing) 1.21 55.32** 1.29 59.30** Cultural Knowledge 4.32 92.85** 1.70 36.24** Social and Emotional Skills 2.32 59.61** 0.66 16.87** Perseverance 2.16 19.89** 0.06 .51 Overall Development 2.98 120.41** 1.17 46.73** Note : *p,.05, **p<.01 The Status of Early Childhood Health and Development in Northern Lao PDR | 106 Figure 57: Average child development scores by stunting status .90 Severely stunted Stunted Not stunted Average child development score .80 .70 .60 .50 .40 .30 .20 .10 .00 Numbers and Cultural Literacy (reading and writing) Communication Approaches to Learning and Concepts Emotional Skills Overall Development Verbal Knowledge Social and Emotinal Skills Social and Next the relationship between children’s wasting that this relationship was not statistically significant. status (severely wasted, wasted, not wasted) and Figure 58 below shows that in terms of overall child development scores was explored. Again, development scores, there is almost no difference wasting was associated with poorer development between children who are severely wasted, wasted scores (Table 28).However, further testing using a and not wasted. univariate general linear model (Table 29) demonstrated Table 28: Relationship between stunting and child development SEVERELY STUNTED WASTED NOT STUNTED DOMAIN Mean SD Mean SD Mean SD Verbal Communication .79 .27 .82 .27 .83 .27 Approaches to Learning .63 .27 .63 .27 .66 .28 Numeracy and Concepts .32 .25 .34 ..25 .33 .24 Literacy (reading and writing) .13 .17 .12 .15 .12 .15 Cultural Knowledge .70 .21 .70 .21 .69 .22 Social and Emotional Skills .44 .20 .45 .19 .46 .20 Perseverance .53 .32 52 .33 .54 .33 Overall Development .51 .15 .51 .16 .52 .16 Note : *p,.05, **p<.01 107 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 29: Relationship between wasting and child development SEVERELY WASTED WASTED DOMAIN Mean Square F Mean Square F Verbal Communication 0.20 2.75 0.08 1.08 Approaches to Learning 0.07 0.87 0.42 5.43* Numeracy and Concepts 0.02 0.29 0.05 0.81 Literacy (reading and writing) 0.05 2.44 0.01 0.36 Cultural Knowledge 0.02 0.43 0.04 0.86 Social and Emotional Skills 0.09 2.23 0.09 2.14 Perseverance 0.01 0.06 0.24 2.24 Overall Development 0.01 0.56 0.03 1.16 Note : *p,.05, **p<.01 Figure 58: Average child development scores by wasting status .90 Severely stunted Stunted Not stunted Average child development score .80 .70 .60 .50 .40 .30 .20 .10 .00 (reading and writing) Numbers and and Concepts Cultural Literacy Communication Approaches to Learning Emotinal Skills Emotional Skills Overall Verbal Knowledge Social and Social and Development The relationship between children’s underweight linear model (Table 31) demonstrated that this status (severely underweight, underweight, and not relationship was statistically significant, with being underweight) and child development scores was also underweight having a particularly negative effect on examined. Again, data showed that being underweight children’s numeracy skills and approaches to was associated with poorer development scores learning. This relationship is also demonstrated by (Table 30). Further testing using a univariate general Figure 59 below. The Status of Early Childhood Health and Development in Northern Lao PDR | 108 Overall, these results demonstrate that of all forms of a negative effect on their development. Efforts need undernutrition examined, stunting is the most to be made in order to reduce the prevalence detrimental to children’s development. Half of the stunting in children in northern Lao PDR, so that they children for which data were collected were stunted; are able to develop to their full potential. this is a serious public health concern that is having Table 30: Relationship between being underweight and child development SEVERELY UNDERWEIGHT UNDERWEIGHT NOT UNDERWEIGHT DOMAIN Mean SD Mean SD Mean SD Verbal Communication .80 .29 .81 .28 .83 .26 Approaches to Learning .63 .29 .63 .28 .66 .28 Numeracy and Concepts .30 .24 .31 .24 .33 .25 Literacy (reading and writing) .11 .14 .11 .14 .12 .15 Cultural Knowledge .67 .24 .68 .23 .69 .21 Social and Emotional Skills .43 .20 .45 .19 .46 .20 Perseverance .52 .34 .54 .34 .54 .33 Overall Development .49 .16 .51 .16 .52 .16 Table 31: Relationship between being underweight and child development SEVERELY UNDERWEIGHT UNDERWEIGHT DOMAIN Mean Square F Mean Square F Verbal Communication 0.39 5.42* 0.52 7.31* Approaches to Learning 0.31 4.00* 1.02 13.07** Numeracy and Concepts 0.42 6.99* 0.63 10.50** Literacy (reading and writing) 0.01 0.41 0.11 5.12* Cultural Knowledge 0.12 2.45 0.22 4.70* Social and Emotional Skills 0.32 8.17* 0.16 3.99* Perseverance 0.12 1.11 0.00 0.01 Overall Development 0.21 8.12** 0.28 10.99** Note : *p,.05, **p<.01 109 | The Status of Early Childhood Health and Development in Northern Lao PDR Figure 59: Average child development scores by underweight status Severely stunted Stunted Not stunted .90 Average child development score .80 .70 .60 .50 .40 .30 .20 .10 .00 Communication Numbers and and Concepts Cultural Literacy (reading and writing) Approaches to Learning Social and Emotinal Skills Social and Emotional Skills Overall Development Verbal Knowledge Early Childhood Although ECE attendance is low, results show that children who had attended ECE were developing Education Services better across all domains of development when com- and Child Development pared to children who had never attended, which is consistent with the international literature on the impact of ECE on child development. Table 32 below presents descriptive analyses as well as results from Despite the fact that 97% of caretakers agreed that a univariate general linear model. Evidently, ECE children who attend some form of ECE will do better attendance has a statistically significant relationship in school, just 25% of children had done so at some with all domains of development, with the magnitude point in their lives – either a baby care center (<1%), of this relationship largest for children’s reading, group learning through play (<1%), kindergarten (23%) writing and early maths skills. This relationship is or pre-primary class (1%). As Figure 59 below shows, also depicted in Figure 60 and 61 below. Despite more older children had attended some form of ECE. these significant main effects, no interaction effects Further, it shows that significantly more Lao-Tai between children’s gender, caretaker’s education, and children had attended ECE than Khmu, Hmong or children’s ethnicity were found. children of other ethnicities. Surprisingly, there was no clear pattern between caretaker’s education and their children’s ECE attendance. The Status of Early Childhood Health and Development in Northern Lao PDR | 110 Again, these results are to be expected considering how much ECE children have attended. It is likely that low levels of caretaker literacy and education, the amount of time children attend ECE would have coupled with the notion that these more formal an impact on their development. The graph below aspects of development (maths, reading and writing) shows whether a child had attended any ECE at all, are fostered in early childhood education. It is and does not take into account the “dose” or length important to note that this does not take into account of time that he/she might have attended. Figure 60: ECE attendance by gender, age, ethnicity and caretaker's education 14.0% 12.0% % of children 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% completed secondary completed Female Male 2 years 3 years 4 years 5 years Other Did not complete Lao-Tai Khmu Hmong No school primary school primary school school or above Gender Age Ethnicity Caretaker’s Education 111 | The Status of Early Childhood Health and Development in Northern Lao PDR Table 32: Relationship between ECE attendance and child development DOMAIN MEAN SD MEAN SQ F Attended .89 .21 Verbal Communication 6.71 102.69** Did not attend .82 .27 Attended .73 .23 Approaches to Learning 9.12 121.87** Did not attend .65 .29 Attended .51 .26 Numeracy and Concepts 45.92 745.87** Did not attend .32 .24 Attended .26 .21 Literacy (reading and writing) 32.03 1207.14** Did not attend .11 .14 Attended .79 .21 Cultural Knowledge 17.23 394.70** Did not attend .68 .22 Attended .56 .20 Social and Emotional Skills 16.24 410.11** Did not attend .46 .20 Attended .61 .30 Perseverance 6.23 57.94** Did not attend .54 .34 Attended .62 .15 Overall Development 16.84 678.37** Did not attend .51 .16 Note : *p,.05, **p<.01 Figure 61: Relationship between ECE attendance and child development 1 Attended ECE No ECE 0.9 Average child development score 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Perseverance Cultural Social and Emotional Skills Learning Numbers and Concepts Literacy Communication Knowledge Approaches to Overall Development The Status of Early Childhood Health and Development in Northern Lao PDR | 112 As the number of caretakers who responded with the research into the influence of ECE regarding their children attending baby care centers, attendance on child development, Figure 62 below group learning through play and pre-primary class was shows a relationship between when children started too small, only kindergarten attendance could be attending kindergarten and their development, with explored in more detail. Of the 23% of children who children attending kindergarten earlier (at age two or had attended kindergarten, 4% started attending at younger) receiving significantly better development age two or younger, 13% started attending between scores than children who started going to the ages of 2-3, 6% between 3-4, and the remaining kindergarten from when they were older than two. 1% started attended after the age of four. Consistent Figure 62: Relationship between age children started kindergarten and child development .64 Average child development .63 .62 .61 score .60 .59 .58 .57 2 years 2-3 years 3-4 years older than or less 4 years The majority of children (19%) attended kindergarten of caretakers, most of whom explained that this was at least once per week, while some attended 2-3 because their child was still young (12%). Others said times per month (1%), or less than once every three it was because the kindergarten was too far (2%), months (2%). Each time they went to kindergarten, because the caretakers were too busy (1%), because the majority of children (20%) attended for more than the child was too old (1%), because the child did not three hours, while 1% attended for 2-3 hours and like to attend (1%), because they did not have enough under 1% attended for less time than this. money to pay for attendance (<1%), because there For children who had attended kindergarten but were not enough teachers (<1%), or because of child stopped going, or had never attended kindergarten, health or disability issues (<1%). caretakers were asked why they stopped or had never used the service. Responses were received from 18% 113 | The Status of Early Childhood Health and Development in Northern Lao PDR Overall, results indicate that ECE coverage in northern Lao PDR is insufficient. Encouragingly, where Which Factors Have the there are kindergartens available, results show that families are utilising them and that they are having a Strongest Relationship positive influence on children’s early development. with Child Development? Work is needed in order for Lao PDR to achieve access to quality ECE for all children, as per SDG 4. Findings throughout this report have highlighted a range of factors that are influencing children’s early development in northern Lao PDR. A series of multiple regression analyses were conducted in order to determine which of these factors have the strongest relationship with child development. Table 33 below presents the range of variables shown to best predict overall child development scores, all of which are highly statistically significant. Naturally, children’s age was the strongest predictor, followed by caretaker warmth, severe stunting, and a range of parent-child engagement activities. Caretaker consistency was also a significant predictor, and a caretaker’s literacy level had a stronger relationship with child development than their education level. These results (and those presented throughout the report) demon- strate that children’s development in northern Lao PDR is being influenced by a variety of factors at both the individual level and the level of the broader environment. Table 33: Strongest predictors of child development OVERALL DEVELOPMENT VARIABLES B SE B β Caretaker’s education level .002 .001 .029** Caretaker’s literacy level .020 .004 .063** Child’s age .071 .002 .407** Read books with child .020 .005 .055** Told stories to child .018 .005 .047** Drew with child .025 .005 .071** Child participates in housework .033 .004 .089** Child is severely stunted (-3SD) .036 .004 .094** No toilet -.013 .004 -.039** Caretaker warmth .053 .003 .206** Caretaker consistency .023 .003 .081** Caretaker hostility .013 .004 .034** R2 .365 F 287.882** Note : *p,.05, **p<.01 The Status of Early Childhood Health and Development in Northern Lao PDR | 114 PART FOUR: SUMMARY OF KEY FINDINGS The results presented in this report indicate that overall, children in northern Lao PDR have poor health Child Health and Nutrition and development. Encouragingly however, the data also demonstrates that there are a range of factors which are having a significantly positive influence on Children are not receiving the services and nutrition children’s development. With the implementation of they need for good health. Despite meeting the WHO the ECE Project underway, the government and global target for exclusive breastfeeding until six non-government service providers have the potential months of age, there is still significant room for to improve these results and the lives of young improvement in the breastfeeding rates in northern children in Lao PDR through the positive factors Lao PDR. The prevalence of stunting amongst identified. children is of high public health significance, and this is having a significant negative impact on children’s development and ability to learn. Additionally, the Child Development rates of immunization are well below international standards. It is also important to note that results reflect the notion that caretakers believe their Overall, children in northern Lao PDR are developing children are healthy, which points to a lack of under- poorly, with disparities in child development across standing around what exactly good child health looks different ethnic groups and family backgrounds. In like. Evidently, poor parental knowledge and under- particular, Lao-Tai children are developing better than standing around what is required for optimal child Khmu and Hmong children, and children of parents health, coupled with inadequate health care services with some education have better development than coverage is leading to poor health outcomes for children of parents who have never gone to school. children in northern Lao PDR. Furthermore, the While children’s communication skills and knowledge relationships observed between children’s health and of culture appear to be developing well, their early development outcomes highlight the need for literacy and numeracy skills are particularly poor. This integrated approaches inclusive of both health and appears to be influenced by a combination of poor education services, in order to effectively promote the health and nutrition; very low ECE attendance; lack of holistic development of children. parental education and understanding of how to promote good child health and development; and very low levels of parental stimulation in the home environment. 115 | The Status of Early Childhood Health and Development in Northern Lao PDR Early Childhood Education that providing a warm, nurturing environment for children is strongly related to positive development. Despite low levels of parental engagement, caretakers expressed that they believe it is important Results indicate that, despite signi fi cant to provide a stimulating home environment for their improvements in the access and quality of education children. However, almost half of all households did services, ECE coverage in northern Lao PDR is not have any children’s books. It appears parents insufficient. This is evident from the finding that while want to support the learning and development of their all caretakers agreed that ECE was important for their children, but that they require guidance around how to children’s learning, ECE attendance was very low. do so effectively, as well as assistance with learning Despite these low attendance rates, the children who materials to further promote activities at home. had attended ECE had better scores across all domains of development compared to children who had never attended. Furthermore, results show that Next Steps for the ECE Project the earlier children participated in ECE, the greater positive influence ECE had on their development. These findings are consistent with international The ECE Project has the potential to support improve- literature about the positive impacts of ECE on ments in child health and development in Lao PDR children’s early development, and they demonstrate through a number of mechanisms. The project will that further work is needed in order for Lao PDR to considerably increase coverage of ECE services achieve universal access to quality ECE for all through the construction of pre-primary classrooms, children. as well as through the establishment of Community Child Development Groups that will provide a separate, more informal learning environment for Home Stimulation younger children before they begin pre-primary. This will aim to support increased ECE attendance across northern Lao PDR and the positive effect on children’s Compared to other countries, children in northern Lao development that is associated with ECE. PDR are receiving very low levels of stimulation and support for their development in their home environments, and this is having a significant negative impact on their learning and development. Children whose parents engaged in simple yet stimulating activities with them, such as storytelling, drawing, reading, and playing, were developing better than children whose parents had not been interacting with them at home. The great importance of these parent-child interactions is highlighted by the fact that these activities were associated with increases in children’s development almost as large as the influence ECE attendance had on development. These findings are consistent with the international evidence regarding the importance of providing a stimulating home environment for the promotion of children’s early development. Results also highlight The Status of Early Childhood Health and Development in Northern Lao PDR | 116 Next, the project will deliver a community awareness In 2018/2019, endline data will be collected in order campaign in order to engage parents in parental to re-assess how well children in target villages have education, and to increase the knowledge and developed in comparison to children in villages understanding of community members about the without the ECE project interventions. It is expected importance of early child development and the first that after the project interventions have been 1,000 days of a child’s life. The campaign will cover implemented for around two years, children will have appropriate parenting skills and early stimulation improved their health and development status, skills required for children’s learning and development, and knowledge. The success (or failure) of the good health and nutrition, hygiene, immunization, and different project modalities to improve early childhood childhood disability awareness. This caretaker developmental outcomes will be evaluated by education component of the project will aim to comparing key outcomes of the children living in support children’s overall health and development by target villages, with outcomes of children living in guiding caretakers through what their child needs to other similar villages where the project has not been develop well, and how they can meet those needs for implemented. Learnings from the impact evaluation their children. Results show that home stimulation is will inform the Government of Lao PDR about what a mechanism through which children’s development works, and what does not work, to support child could be improved significantly. As such, the project health and development. Furthermore, results will will also support the provision of toy libraries in each help inform future ECE policy and program decisions village, designed to enable parents to stimulate and so that resources are used effectively and have the promote their children’s learning and development by maximum positive impact on children’s outcomes in providing toys and age appropriate books which Lao PDR. families otherwise would not have access to. Finally, the ECE project will also implement complementary support services such as disability screening and the provision of school meals to children at primary school to encourage the attendance of boys and girls in remote rural communities, and to provide children with nutritious meals in order to facilitate healthy balanced diets and concentration in class. For these interventions to be successful, it will be extremely important that the education of parents, teachers and community members is implemented effectively, and that the key messages around improving child development are delivered clearly and successfully to families living in the communities of northern Lao PDR. 117 | The Status of Early Childhood Health and Development in Northern Lao PDR REFERENCES Burger, K. (2010). How does early childhood care Gertler, P., Heckman, J., Pinto, R., Zanolini, A., and education affect cognitive development? An Vermeersch, C., Walker, S., . . . Grantham-McGregor, international review of the effects of early interven- S. (2014). Labor market returns to an early childhood tions for children from different social backgrounds. stimulation intervention in Jamaica. Science, Early Childhood Research Quarterly, 25, 140-165. 344(6187), 998-1001. doi: 10.1126/- science.1251178 Davoudzadeh, P., McTernan, M. L., & Grimm, K. J. (2015). Early school readiness predictors of grade Nores, M., & Barnett, S. W. (2010). Benefits of early retention from kindergarten through eighth grade: A childhood interventions across the world: (Under) multilevel discrete-time survival analysis approach. Investing in the very young. Economics of Education Early Childhood Research Quarterly, 32, 183-192. Review, 29(2), 271-282. doi: 10.1016/j.ecresq.2015.04.005 Supplee, L. H., & Meyer, A. L. (2015). The Intersection Elango, S., Garcia, J. L., Heckman, J., & Hojman, A. Between Prevention Science and Evidence-Based (2015). Early Childhood Education. IZA Discussion Policy: How the SPR Evidence Standards Support Paper No. 9476: Institute for Study of Labor. Human Services Prevention Programs. Prevention Science, 16(7), 938-942. doi: Engle, P. L., Fernald, L. C. H., Alderman, H., Behr- 10.1007/s11121-015-0590-7 man, J. R., O'Gara, C., Yousafzai, A., . . . Iltus, S. (2011). Strategies for reducing inequalities and World Bank. (2014a). Lao Development Report improving developmental outcomes for young children 2014: Expanding Productive Employment for in low-income and middle-income countries. The Broad-Based Growth. Washington DC: World Bank Lancet, 378(9799), 1339-1353. Group. World Bank. (2014b). Lao People's Democratic Republic - Early Childhood Education Project. Washington DC: World Bank Group. World Bank. (2015). Lao PDR Poverty Policy Notes: Drivers of Poverty Reduction in Lao PDR. Washington, D.C: World Bank Group. The Status of Early Childhood Health and Development in Northern Lao PDR | 118 The World Bank Country Office Education Global Practice Xieng Ngeun Village, Chao Fa Ngum Road The World Bank P.O. Box. UN345, Chanthabouly District 1818 H Street, NW Vientiane, Lao PDR Washington D.C. 20433, USA Tel: (856-21) 266200 Tel: (202) 473 1000 Fax: (856-21) 266299 Fax: (202) 477 6391 www.worldbank.org/lao www.worldbank.org www.facebook.com/worldbanklaos www.facebook.com/worldbank