Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods.

Aims/background: The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation.

Design/methods: We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported.

Results: We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings.

Conclusion: There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.