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Proof of concept of the Universal Baby video innovation
for early child development in Lima, Peru
Adrianne K. Nelson ,
1,
�PHD, Christa J. Griest,
2
MA, Llubitza M. Munoz,
3
RN, Nancy Rumaldo,
3
BA,
Ann C. Miller,
4,8
PHD, Guadalupe M. Soplapuco,
3
BA, Leonid Lecca,
3
MD, Sonya S. Shin,
1,4
MD,
Llalu R. Acu~
na,
3
BA, Yesica V. Valdivia,
3
BA, Alicia R. Ramos,
3
BA, Diego G. Ahumada,
3
MA,
Blanca R.H. Ramos,
3
BA, Sarah A. Mejia,
5
PHD, Esther O. Serrano,
3
BA, William H. Castro,
3
BA,
Victoria E. Oliva,
2
MD, Annie S. Heyman,
6
MD, Lauren P. Hartwell,
7
MPH, Ronnie L. Blackwell,
5
MA,
Diego F. Diaz,
3
BA, and Martha M. Vibbert,
2,6
PHD
1
Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States
2
Boston Medical Center, Boston, MA, United States
3
Socios En Salud, Partners in Health, Lima, Peru
4
Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
5
Wheelock College of Education and Human Development, Boston University, Boston, MA, United States
6
Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
7
Boston University School of Public Health, Boston, MA, United States
8
Blavatnik Institute, Harvard Medical School, Boston, MA, United States
�Corresponding author: Adrianne K. Nelson, Department of Social, Behavioral, and Population Sciences, Tulane School of Public Health and Tropical
Medicine, 1440 Canal St, New Orleans, LA 70112, United States. Email: ahartnelson@tulane.edu
Present address: Adrianne K. Nelson is now afliated with Department of Social, Behavioral, and Population Sciences, Tulane School of Public Health and
Tropical Medicine, New Orleans, LA, United States.
Abstract
Objective: Community-based video interventions offer an effective and potentially scalable early interaction coaching tool for caregivers living
in low resource settings. We tested the Universal Baby (UB) video innovation; an early interaction coaching tool using video sourced and pro-
duced locally with early child development (ECD) expert supervision.
Methods: This proof-of-concept study enrolled 40 caregivers of children ages 10–18 months assigned to intervention and control groups by
health establishments in Carabayllo, Lima, Peru. Mother/child dyads received 12 weekly group health education sessions with social support.
Of those, 16 caregivers also received 6 UB videos featuring brain science education and local clips of responsive, reciprocal interaction, also
known as “serve and return” interaction. Survey data assessed feasibility and acceptability of the intervention. We assessed improved quality
of mother/child interaction using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO).
Results: We found the program feasible. We successfully trained the local team to produce UB videos using locally-sourced footage and deliv-
ered the videos as part of a community-based intervention. We also found it to be acceptable in that participants enthusiastically received the
UB videos, reporting they enjoyed being videotaped, and learned how to recognize and appropriately respond to their child’s nuanced sounds
and gestures. The median change in total PICCOLO scores favored the intervention group compared to the control group.
Conclusions: UB offers great potential as a sustainable, potentially scalable, and culturally appropriate tool to promote equity for child develop-
ment among young children living in low resource homes globally.
Keywords: early child development, community health workers, video, contingent interaction, PICCOLO.
Lancet’s 2016 series Advancing Early Childhood Development:
from Science to Scale estimates that 250 million children under
five are at risk of failing to attain their full developmental poten-
tial (Lu et al., 2016). These children need healthy nutrition, free-
dom from disease, a safe environment, opportunities to learn
and explore, and stimulating caregiver–child interaction to
thrive (Daelmans et al., 2015; Horton, 2017; Uchitel et al.,
2019).
Negative early experiences impede healthy neurodevelop-
ment (Benjet et al., 2010; Schilling et al., 2008; Shonkoff
et al., 2012) and can lead to delay and slow school advance-
ment (Luby et al., 2013), problems with mental health and
relationships (Benjet et al., 2010), and early onset of chronic
disease (Sonu et al., 2019). Responsive caregiving between a
caregiver and young child buffer these consequences by
increasing neural brain activity related to cognitive process-
ing, white matter connectivity, regulation of the stress
response systems, synaptic pathways, and brain volume
(Hertzman & Boyce, 2010; Stiles, 2008; Walker et al., 2011,
2007). In countries where poverty, poor nutrition and disease
pose additional threats to children’s cognitive development,
positive stimulation through parent–infant interactions is a
sustainable protective factor (Blair & Raver, 2016; Brown
et al., 2017; Horton, 2017; Luby et al., 2013; Morris et al.,
2017).
Early interventions that encourage and coach caregivers to
stimulate their child’s development show efficacy (Andrew
et al., 2020; Grantham-McGregor & Smith, 2016; Obradovic
Received: December 1, 2023. Revised: May 3, 2024. Accepted: May 3, 2024
# The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Pediatric Psychology, 2024, 00, 1–12
https://doi.org/10.1093/jpepsy/jsae035
Original Research Article
Downloaded from https://academic.oup.com/jpepsy/advance-article/doi/10.1093/jpepsy/jsae035/7693169 by guest on 22 August 2024
et al., 2016). Interventions that promote caregivers’ responses
to young children’s attention, vocalizations, play, and explora-
tion are particularly effective (Jeong et al., 2021; Morris et al.,
2017), yet sparsely provided in resource-limited areas in part
due to difficulty scaling up effective programs (Bornstein et al.,
2012; Bornstein & Putnick, 2012; Lansford et al., 2022). In
order to scale parenting programs for efficient, equitable, and
cost-effective dissemination, researchers must address challenges
of scale and specificity.
To address these challenges, we examine video as a tool for
parent coaching. Video offers feasible, efficient, economical,
and equitable program access for many families coping with
barriers common to low resource settings (Alvarenga et al.,
2020; Feil et al., 2020). Audiovisual demonstrations are
especially effective at capturing people’s attention, engaging
emotions, and enhancing the learning of new behaviors
(Webster-Stratton, 1982, Webster-Stratton et al., 1988), and
promote peer role models who can influence attitudes,
beliefs, motivations, and behaviors (Columbo, 2001;
Magill-Evans et al., 2007; Murphy, 2001).
The use and evaluation of video viewing interventions for
parent coaching in low- and middle-income countries is rela-
tively new. Most video coaching interventions have been
developed and studied in high-income countries, and most
rely on individual feedback to a caregiver usually by a clini-
cian (Cates et al., 2018; Stegenga et al., 2018). These and
other video feedback approaches have shown the power of
visual input to influence caregiver learning, in the context of
a clinician who guides and mediates a caregiver’s viewing
experience. One trial in Salvador, Brazil found that mothers
receiving an 8-week video feedback intervention interpreted
meaning of their infants’ behavior more often, asked more
questions, and were less intrusive compared to controls
(Alvarenga et al., 2020). A meta-analysis conducted on 26
individual video feedback interventions by Fukkink et al. in
2008 found average effect sizes on parenting behaviors and
small to average on child development (Fukkink, 2008).
However, despite their power to influence caregiver knowl-
edge and child outcomes, video feedback interventions are
limited in their potential for scalability because they require
the mediation of an expert provider and individual time with
each caregiver. In contrast, video viewing interventions, if
feasible and effective, will likely have far more promise for
reaching large populations, especially in low- and middle-
income settings where staffing and resources are scarce. We
found no evidence of interventions in low-income countries
that test the impact of combined video viewing alone (with-
out individual feedback) within group health education
sessions.
We combined an innovative video-based approach—
Universal Baby (UB)—with community-based parent health
education sessions. UB consists of structured short videos
that are co-created with local families to deliver visually rich
information about early brain development and community-
specific, culturally tailored messaging and behavioral model-
ing. The objective of UB is to coach caregivers to take part in
reciprocal and contingent (“serve and return”) patterns of
interaction during daily activities with their child. We
designed a proof of concept study to determine whether UB
has potential, and merits testing in a larger randomized, pilot
design (Hilliard et al., 2021). As part of this proof of concept
study, we investigated the feasibility (whether the concept
can realistically be implemented) and acceptability (the
population’s interest and approval of the UB video interven-
tion) within the context of a community-based early interven-
tion (Hilliard et al., 2021). We also present exploratory
findings on mother/child interactions.
Methods
Study site
This study took place in the district of Carabayllo, Peru,
located north of the Lima metropolitan area. Carabayllo is
one of the largest and oldest districts in the city and is home
to over 330,000 people, 19.2% of whom live in poverty
(Ministerio de Desarollo e Inclusi�
on Social, 2023).
Carabayllo has approximately 8,800 children under 2 years
of age (Pessah et al., 2018), 70% of whom are at risk for
delay, based on prior work (Mu~
noz et al., 2017).
Carabayllo was chosen because it is the founding site of the
nongovernmental organization Partners In Health (SES—
Socios En Salud, Peru) and the base for the study team’s
work in early child development (ECD) since 2012.
Universal Baby: Intervention description
Theoretical underpinnings and formative work
Dr Martha Vibbert developed UB 10 years ago with authors
CG and ATK (Unviersal Baby Project, 2023). UB is grounded
in social learning theory, which views learning as a cognitive
process shaped by individual experience, behavioral model-
ing, and environmental factors (Bandura, 1977; Cherry,
2021). Each video incorporates mediational processes of
observational learning including attention, retention, repro-
duction, and motivation. UB combines messages to reinforce:
(a) social norming within a local context, (b) clear visual
information to provide a cognitive understanding of how a
caregiver’s responsive behaviors impact a child’s develop-
ment, and (c) motivation to intentionally practice behaviors.
Many parenting video approaches rely on studio-based
(i.e., staged), literacy-dependent, and overly generic guidance
(“play with your baby”) biased to Western, middle- and
upper-class childrearing routines. UB addresses these limita-
tions by centering culturally authentic, locally sourced video
footage of parents engaged in observable (and often nuanced)
everyday interactions with their young child during naturally
occurring activities in local caregivers’ homes. UB videos
honor local traditions while also presenting accurate brain
science with compelling visuals that link a child’s internal
brain processes to “serve and return” interaction and neuro-
developmental outcomes.
Core UB content and structure
Figure 1(A–C) illustrates some of the core elements common
to UB videos. Videos open with “establishing shots” of care-
givers engaging with their children using imagery of local
parents and community scenery. This imagery is intercut with
interaction images of caregivers and children from elsewhere
in order to encourage the viewer to connect with an interna-
tional community of caregivers while also identifying with
caregivers in their own community. Additional visual sequen-
ces and narration highlight internal structures and regions in
a child’s brain, synaptic connections being formed, and neu-
ronal density as these relate to caregiver–child interactions
and later child development outcomes.
Then, UB videos zero in on several minutes of locally-
sourced caregiver–child interaction, that allow for close,
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sequential observation of naturalistic responsive caregiving.
These interaction segments demonstrate, in real time, how
“serve and return” exchange moments are initiated via child
signals, how they unfold spontaneously, and how they are
sustained by ongoing reciprocal responses by caregiver and
child. Key moments of the interaction are emphasized
through slow motion, narration, visual repetition, and
graphics. These clips highlight the sequence and subtle nuan-
ces that accompany responsive interaction exchanges. Video
footage is closely vetted by local partners, and script is co-
developed with partner teams based on previously field-
tested templates adapted to local language vernacular.
Figure 1. (A–C) Sample Universal Baby video montage, Carabayllo, Peru. (A) Opening footage. Videos open with “establishing shots” of caregivers from
across the globe engaging in interaction exchanges with their children, as well as imagery of brain development phenomena related to responsive
interactions. (B) Locally-sourced caregiver–child interaction. Imagery of caregiver–child interaction allowing for close, sequential observation of
naturalistic responsive caregiving. (C) Slow motion emphasis of caregiver–child interaction and relationship to synaptic proliferation in the brain. Key
moments of the interaction are emphasized through slow motion, narration, visual repetition, and graphics such as moving arrows and pop-out font.
These visual clips also highlight the sequence and subtle nuances that often accompany responsive interaction exchanges. We received permission for
the use of all copyrighted images. Credits from left to right: [Image A (child): Universal Baby, with Socios En Salud, Image A (father and child): World
Health Organization (with UNICEF), Image A (brain imaging) Harvard Center on the Developing Child].
Journal of Pediatric Psychology (2024), Vol. 00 3
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Colorful local imagery and music are added to enhance view-
ers’ engagement and community recognition.
We co-created six UB videos with local volunteer care-
givers and their child (ages 6–24 months) identified via exist-
ing social networks and word of mouth. Volunteers were a
separate group from those enrolled in the study described
below. All videotaped caregivers completed an in-depth
informed consent process and an assent on their child’s
behalf. Each dyad received a food basket of approximately
$10 in value. Volunteers participated in a focus group about
their experience.
Group health education sessions
A locally trained community health worker (CHW) delivered
group health education sessions to all enrolled mother/child
dyads at cultural centers and health clinics. We designed the
sessions based on the Ministry of Health’s Strategies for
Health Promotion. Activities included songs to engage chil-
dren, and basic health education topics like hygiene, infec-
tious disease prevention, domestic violence prevention,
parenting, and maternal depression. CHWs facilitated loosely
structured social support where caregivers were encouraged
to share freely and respond to one another. In the UB inter-
vention arm, the group viewed bi-weekly UB videos after
group sessions.
Study design
This is not an efficacy trial and was not powered to measure
significant impact on study outcomes (Czajkowski et al.,
2015). We sought to explore the impact of UB video content
when delivered with group sessions, to inform a future effec-
tiveness trial. Therefore, we designed a nonrandomized pro-
spective study with group allocation at the health center
level. The convenience sample of 40 dyads was evenly divided
by allocation. Between April 2015 and April 2016 all partici-
pants received 12 weekly health education group sessions.
We evaluated results using video coding, self-report, and
observation tools at enrollment (baseline) and after the com-
pletion of the intervention (postintervention).
Recruitment and enrollment
We chose three Carabayllo clinics using a random drawing of
all clinics in the district. After the selection, the team assigned
two small health centers to the intervention group and one
large enough to accommodate all control participants to the
control group.
Eligibility criteria included being the primary caregiver of a
child aged 10–18 months “at risk” or “delayed” in at least
one area of the four domains of the psychomotor develop-
ment assessment instrument endorsed by the Peruvian
Ministry of Health: the Escala de Evaluaci�
on del Desarollo
Psicomotor, EEDP (Rodriguez, 1996). Children with any
known medical condition that would make them unrespon-
sive to early intervention, those >21days premature, and
those who were not at risk per the EEDP (M Schreiner, 2008)
were excluded. The team identified children through
community-based active case finding and clinician referral.
We invited all eligible dyads to participate on a first-come,
first-serve basis, reviewed the details of the study with them,
and requested the caregiver sign an informed consent.
Sociodemographic measures
We collected demographic, socioeconomic status, and mater-
nal depression data. We measured poverty using the Progress
Out of Poverty Index (Schreiner, 2008) and maternal depres-
sion using the Hopkins Symptoms Checklist (Derogatis et al.,
1974), both which we have used in previous ECD studies in
this setting (Miller et al., 2021; Nelson et al., 2018). Trained
SES staff recorded data in both paper and digital formats.
Staff automatically uploaded digital data into the SES infor-
mation system, a password-controlled internal database with
built-in quality control mechanisms.
Feasibility measures
Core feasibility and acceptability measures are presented in
Figure 2. We determined the study feasible if: (1) we success-
fully transferred production of UB videos to the Peru produc-
tion team, (2) CHWs successfully delivered UB videos to the
target audience as part of a broader parent/child intervention,
and (3) we were able to use the PICCOLO instrument to assess
the impact of UB on mother/child interaction. We developed
four criteria for success for each of these goals (Figure 2).
Acceptability measures
We defined acceptability as follows: (1) the UB videos are
acceptable from the perspective of the video volunteers who
were filmed, and (2) the UB videos are acceptable according
to the women who viewed them.
To learn about acceptability from the video volunteers, we
developed a semi-structured survey with forced choice and
open-ended questions. We asked, for instance, “what could
the team do to make the [videotaping] process more
comfortable?” To further examine community acceptability
of being videotaped, we included all participants who were
videotaped for the PICCOLO.
Mothers who received the UB intervention responded to
another set of semi-structured survey questions about their
experience watching UB videos. For instance, “how did you
feel about watching the videos of other caregivers?”. We
asked about their opinions of the video content, “what did
you like/not like about the videos of other caregivers?”.
Finally, we asked, “would you like to be featured in a future
UB video?”.
Preliminary impact measures
In order to understand whether caregivers placed more
importance on child development after viewing UB videos,
the study team designed a questionnaire using a 4-point
Likert scale. We asked caregivers to rate the importance of
each area of their child’s health, including learning & educa-
tion, physical health, social skills, interactions with adults,
nutrition, happiness, obedience, and the child’s brain devel-
opment. We then asked participants to rank these areas of
their child’s health from most important to least important at
baseline and postintervention timepoints using forced choice
response.
We were not powered to assess impact, however, in order to
assess potential impact for a future effectiveness trial, we meas-
ured the quality and frequency of caregiver–child interactions at
baseline and within 1 month of the last 12-week session using
the Parenting Interactions with Children: Checklist of
Observations Linked to Outcomes (PICCOLO) instrument
(Roggman et al., 2013; Vilaseca et al., 2019). The PICCOLO
uses detailed coding of raw naturalistic footage to
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comprehensively assess caregiver–child interaction behaviors in
four “developmental domains of parenting” shown to predict
better child development outcomes: affection, responsiveness,
encouragement, and teaching. The rating system is based on 0-2
scale, defined by frequency of observed behavior: 0 (no behavior
observed), 1 (emerging/rarely observed) and 2 (strongly, fre-
quently observed) (Roggman, 2009).
Data analysis
For qualitative analyses, we chose thematic analysis because
our qualitative data involve an applied health intervention, we
are interested in comparing and contrasting participant per-
spectives, and its clear and organized approach fitted our semi-
structured interview tool (Nowell et al., 2017). First, we saved
open-ended survey responses in an excel file. A group of three,
two students and a qualitative researcher, then identified emer-
gent themes using thematic analysis. We created a codebook,
coded qualitative data using open coding and assigned
excerpts to codes. We then wrote short paragraphs for each
code and wove them into the narrative. After creating a narra-
tive, we shortened the content to focus on the acceptability of
the UB intervention as presented here (Clarke et al., 2019).
Excerpts were chosen based on their relevance to the study
objective and their illustrative quality. We also included con-
trary, unusual, or surprising perspectives. We replaced partici-
pant numeric identifiers with pseudonyms for this report.
We analyzed quantitative data using Stata 15 (College
Park, TX). We calculated frequency distributions in
PICCOLO score change from baseline to 3-month follow-up
between the two study arms, and measured the association
between intervention status and PICCOLO score change
using linear regression, adjusting for baseline covariates that
significantly differed (p<.05) between intervention and con-
trol arms.
Ethical considerations
This study was approved by the Ethics Review Board at
Harvard Medical School, Boston University, and the Instituto
Nacional de Salud (National Institute of Health) in Peru.
Grand Challenges Canada provided seed funding for this
study.
Results
Study participants
We screened 80 children for eligibility; 43 mother–-child dyads
from the cohort met eligibility criteria (Figure 3). Of those, four
mothers declined participation and one could not be located. The
remaining 38 were enrolled into the study (18 interventions, 20
controls). Among intervention participants, one was lost to
follow-up and another chose to leave (n¼16 analyzed). Among
control participants, three were lost to follow-up (n¼17 ana-
lyzed). Among the remaining 33 dyads, 30 dyads had complete
PICCOLO data at baseline and postintervention.
Table 1 shows baseline characteristics of the study popula-
tion. Mean child age at study initiation was 14.2 months and
60% were female. Primary caregivers were exclusively female
and the child’s mother. We did not request any racial or eth-
nic data. Caregivers in the control arm had a higher propor-
tion of education past secondary school (35.7% vs. 6.25%).
Outcomes
Feasibility
Transfer of UB production to Peru team
Trained Peru team in video capture
Boston-based collaborators successfully trained the SES team
to collect naturalistic footage from caregiver–child dyads
interacting in their homes and piloted with two volunteer
families. The SES team collected video when the parent and
child were together and alert and brainstormed ways to
encourage mothers to take part in their typical daily activ-
ities, suggesting she should “do what you would normally be
doing at this time”. Some mothers expected the video team to
tell her what to do or to “play” with her child during the vid-
eotaping. Mothers typically fed, bathed, cooked, and/or
cleaned with her child during video sessions. The videogra-
pher collected footage with a small, unobtrusive camera and
minimized intrusions into the mother/child’s interactions by
staying out of view and maintaining a “non-responsive”
stance.
Achieved bi-cultural and bi-linguistic understanding of “serve
and return”
The Peru and Boston-based teams worked in close coordina-
tion throughout the entire six-video production phase, to
Transfer UB production to Peru team CHWs delivered UB videos Use of PICCOLO for measurement of
mother/child interaction
Trained Peru team in video capture with volunteer
caregiver/child dyads Equipment was available and functional Successfully collected pre and post
intervention naturalistic footage from
participants
Achieved bi-cultural and bi-linguistic
understanding of “serve and return” Participants attended and watched UB videos Transferred all footage to Boston-based team
for coding
Developed technology sharing platforms UB content measured as an added but stand-
alone intervention in the context of health
education group sessions
Coded footage with blinded, bilingual/
bicultural team
Provided on-going assistance with editing
suggestions and integration of animation graphics
and narration track for local language tnemeergaredoc-retni%58deveihcA
Figure 2. Core feasibility elements of UB
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make sure that visual imagery and script translations were
vetted for accuracy and fidelity to core messages. Cultural
adaptations were made collaboratively. For example, the
Boston-based, SES, and CHW teams engaged in extended
conversations to translate the term “serve and return” in a
culturally and linguistically appropriate way. The CHW’s,
SES team, and Boston-based team agreed on “dar y
responder” because it was easy to remember and implies
ongoing back and forth engagement. Locally composed
music and images of the district were added to enhance cul-
tural specificity and identification.
Developed technology sharing platforms
The SES team successfully transferred all digital video
files to the Boston-based team via WeTransfer, a secure
cloud-based storage and transfer platform. The SES team
ensured all video files were password-protected and
encrypted, both for transit across networks (TLS) as well
Recruited (N=80)
EEDP screening instrument
Eligible (N=43)
Ineligible
(N=37)
No risk of delay = 36
Did not complete
evaluation (child
diagnosed with hearing
problems) = 1
Not enrolled (N=5)
Refused participation: N=4
Unable to be located: N=1
Intervention (N=18) Control (N=20)
Completed the study (N=33)
INTERVENTION (N=16) CONTROL: (N=17)
LTFU (n=1)
Not responsive to team’s
attempts to arrange study
meetings (n=3)
Chose to leave the study
(n=1)
For analysis (complete baseline
and follow-up primary outcome
data): N=16
For analysis (complete baseline
and follow-up primary outcome
data): N=14
Figure 3. Study enrollment ow diagram.
Table 1. Baseline characteristics, N¼30.
Child characteristics N (%) or mean [SD] Intervention arm, n¼16 Control arm, n¼14
Female 18 (60.0) 8 (50%) 10 (71.4%)
Number of weeks gestation at birth 39.0 [0.99] 39.3 [0.93] 38.7 [1.05]
Age in months 14.2 [2.41] 14.4 [2.31] 13.9 [2.58]
Ever breast fed 27 (90.0) 14 (87.5%) 13 (92.9%)
Two or more primary caregivers 5 (16.7%) 3 (18.7%) 2 (14.3%)
Self-reported alcohol during pregnancy 0 0 0
Family history of developmental delay 16 (4533%) 10 (62.5%) 6 (42.8%)
Baseline EASQ z score, vs. World Bank norms mean [SD] −0.34 [0.81] −0.32 [0.94] −0.35 [0.70]
Baseline total PICCOLO median [IQR] 27.5 [18–42] 26.0 [16.5–45] 30.5 [19–42]
Caregiver characteristics N (%) or mean [SD] Intervention arm, n516 Control arm, n514
Female 30 (100.0) 16 (53.3) 14 (46.7)
Mean age 26.6 [5.6] 26.6 [6.1] 26.5 [5.3]
Married or living together 25 (83.3) 14 (87.5) 11 (78.6)
Education
Primary or less 4 (13.3) 4 (25.0) 0
Some secondary 20 (66.7) 11 (68.8) 9 (64.3)
Any technical or university 6 (20.0) 1 (6.25) 5 (35.7)
Identifies as Amerindian 27 (90.0) 15 (93.7) 12 (85.7)
No history of depression 26 (86.7) 3 (18.75) 1 (7.1)
Employed outside of household 2 (6.7) 2 (12.5) 0 (0)
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as in storage (AES-256). Access links expired 7 days after
transfer.
Provided ongoing assistance with video capture and
production
During production, the Boston UB team traveled to Peru
twice to guide SES staff on video production, shifting greater
responsibility to SES staff each time. For the first video,
Boston-based film editors guided video capture directions,
animation details, and actual editing using AVID technology.
By the second video, the SES team led the process; subse-
quently producing and editing the final five videos using
Adobe Premier CC2014. Upon culmination of the project,
the SES staff collected high quality, naturalistic footage in the
field, picked key “serve-and-return” moments for use, edited
footage into didactic excerpts while preserving the brain sci-
ence, and produced sharable videos of 8–12 min each. Since
this project, the SES team successfully trained another team
at SES who produced three nutrition related UB videos.
CHWs delivered UB videos
Equipment was available and functional
CHWs were able to access videos via a USB stick, which the
Peru team prepared on the computers at their office and
show them on a television available at the location of the
group sessions.
Participants attended and watched UB videos
Mother–child dyads received the health education sessions in
four groups of 8–10. Mothers in the intervention group
watched the six UB videos over the course of 3 months (one
video every 2 weeks) as a stand-alone activity. In the case
that a mother missed a session, she saw the video privately at
the following session. None of the mothers who finished the
sessions missed any UB videos.
UB content measured as a stand-alone intervention
CHWs were trained to avoid any child development teaching
during sessions to prevent confounding the impact of the vid-
eos. For example, CHWs praised caregivers and children, but
did not direct them to child-led or interactive play, or correct
behavior that was not developmentally appropriate, unless
dangerous to the child. CHWs also confirmed that they did
not discuss UB videos with caregivers after delivery.
Use of PICCOLO for measurement of mother/child
interaction
We collected nearly 23hr of PICCOLO video interaction
data via hand-held high-definition cameras and digitally
uploaded them to secure SES computers. Per PICCOLO crite-
ria, we discarded the first 5 min of each clip and used the
next 10 min for coding.
The UB team scored in consultation with the instrument’s
designer, Lori Roggman. Boston-based native Spanish speak-
ers trained in early education and psychology (SM) and (DA)
conducted the coding blind to study arm. CGN and MV
mediated inter-coder discussions.
During three, 6-hr training sessions, coders scored 18 prac-
tice videos (10 from the User Guide, 8 from Carabayllo) inde-
pendently and compared findings. By training end, the coding
team successfully achieved 75% interrater reliability utilizing
the expanded item-level scoring descriptions provided in the
PICCOLO User Guide and an internal set of “rules”. Then,
coders followed recommendations by Roggman et al. and
coded two video clips per hour, 2 hr at a time, per day, to
prevent fatigue. The team watched each 10-min clip of raw
participant footage once through without stopping, and
scored it during the second viewing, spending approximately
25 min on each.
The Boston-based team successfully conducted coder
“calibration” meetings at a 20% rate (every 6 videos) during
coding to prevent drift. When the coding team encountered
an unfamiliar colloquial expression or gesture, the UB team
cross-checked with the SES team, maintaining participant
anonymity. During a final series of meetings, the coders and
mediators discussed discrepancies and resolved each instance
to create one final database.
Acceptability
Volunteer caregivers being videotaped
Overall, caregivers (n¼38) expressed pride in their child dur-
ing videotaping and enjoyed seeing their child on video. For
most participants it was the first time they were videotaped
interacting with their child. They were happy to receive a
copy of the video, saying it would be very meaningful to see
in the future and could help other mothers learn to interact
with their children.
Several participants mentioned they were able to perceive
reactions from their child in the video that they had missed
during the interaction and identify moments they could have
reacted differently. “See how I interact and am with my chil-
dren. [In the video] I see what I am doing wrong and can
improve on.” (Yesica, 26 years old)
When asked whether their activities were typical of daily
activities, 100% of the women responded positively.
Of 38 participants, 27 (71.1%) would like to share the
video with family members to show them that they were
patient, loving, or busy with their children at home, suggest-
ing videos boosted pride in their caregiving role. Almost all
(35/38, 92.1%) said they would share the video with other
caregivers. Several want to share the video to help others: “so
they are a little more loving with their children” (Estela,
24 years old), and “because we don’t realize what we are
doing with our children. With the video we can see and
learn” (Serena, 28 years old). This indicates mothers gained
valuable insight and felt comfortable enough with the repre-
sentation of their culture to appropriate the content and share
within their social networks.
Most participants said they felt uncomfortable when video
capture began 28/38 (73.7%), but 31/38 (81.6%) said they
became more comfortable. Those that expressed discomfort
mentioned embarrassment about their house (3/38, 7.9%),
the length of the visit (2/38, 5.3%), the number of visitors (1/
38, 2.6%), or discomfort with a male visitor (1/38, 2.6%).
One caregiver worried a criminal could use the video to hurt
her child (1/38, 2.6%).
Four participants shared ideas for improved video capture,
including planning ahead, appearing at the home without
warning, self-video capture, and having a fixed camera with-
out a videographer. Three participants suggested requesting
permission to use the video following the capture rather than
in advance (3/38, 7.9%). Findings suggest high variability in
video capture preferences.
Journal of Pediatric Psychology (2024), Vol. 00 7
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Caregivers watching UB videos
Mothers in the UB intervention group (n¼16) spoke exten-
sively about skills they learned from the videos. They
acquired awareness of “serve and return” interactions and
said content helped them identify the child’s subtle signals,
realize the importance of interaction, and acquire knowledge
about children’s brain development.
Mothers were moved by video interactions and identified
with the caregivers shown. This suggests the videos accu-
rately captured daily activities and interactions widely shared
in this context: “The mother who was bathing her child, my
son does the same thing when he doesn’t want to get out, he
also splashes.” (Claudia, 22 years old).
They particularly appreciated the scientific part of the
video with the image of the child’s brain. They were
impressed at how much growth occurred at such a young
age.
“I liked more where they talked about the development of
child’s brain. At 3 years old their brain is developing.”
(Olivia, 23 years old).
All but one mother (15/16, 93.8%) reported they learned
something new by watching the videos. They highlighted
messages about the importance of interacting with their chil-
dren. “It’s important to interact with our children during
their first years of life, without knowing we have to under-
stand what they need.” (Julieta, 19 years old).
Mothers spoke eloquently about being more attuned to
their child after seeing the videos. They were enthusiastic
about their new ability to interpret subtle signals from their
child’s nonverbal behaviors and vocalizations: “I felt good
because I learned new things, I saw how the mothers inter-
acted with their children and I learned how to understand my
son without him being able to tell me.” (Julieta, 19 years
old).
Mothers repeatedly emphasized patience as a caregiver
quality they admired in others and felt more equipped to
embody after seeing the videos: “We have to be patient. Their
development is important and [so is] what they capture when
they’re children.” (Maria, 21 years old).
The mother’s focus on patience may demonstrate greater
awareness of the child’s needs. Several mothers referenced a
video in which a grandmother cares for the baby while the
mother is occupied as exemplifying caregiver patience:
Because in that moment the grandma understood him, she
had the patience despite him throwing a tantrum. I didn’t
do it with my son, I didn’t play with him, when I fed him I
thought that he should take everything now, that I have to
feed him from 10 to 12 spoonfuls. Before, I insisted a lot
and he would throw up. The grandma didn’t insist and
now I don’t do it. (Maria, 21 years old)
All mothers said they would benefit from watching videos
of themselves and videos created with footage from other
mothers. They were interested in sharing videos (13/16,
81.3%, TV being the most popular way to share videos).
They also emphasized the benefits of discussing the videos
among peers in a group format.
Exploratory findings on UB impact
Overall, caregivers from the intervention group rated devel-
opmental areas of higher priority postintervention compared
to preintervention, except “interaction with adults”. This
was not the case with the control group, who rated only
“learning and education” and “physical health” higher post-
intervention. With the exception of “interaction with adults”,
the intervention group rated all areas higher than the control
group postintervention.
When asked to rate areas of their child’s health from most
important to least important, two mothers in the intervention
group rated brain development as the most important area of
their child’s health preintervention compared to nine postin-
tervention. Only one rated brain development as the most
important area in the control group postintervention.
PICCOLO scores at baseline between study arms were sim-
ilar (26 in the intervention arm and 30.5 in control arm)
(Table 1), and more widely spread at follow-up (intervention
total median score 41.0, control total median score 31.5)
(Figure 4). The intervention arm improved their mean score
significantly more than the control arm in adjusted analysis
(beta 13.6, 95%CI 0.2 to 27.4, p¼.05, R
2
¼0.14, F(2,27) ¼
2.21) (Supplemental Table S1).
Discussion
We found that UB was feasible in that the video production
was successfully transferred to a local team and delivered to
parents using locally available technology via CHW-led
group health education sessions. The PICCOLO was a feasi-
ble instrument to measure parent–child interactions through
naturalistic video footage and scored by a cross-cultural
team. We learned that significant attention invested in
exchange around UB video script and PICCOLO coding was
necessary for a successful outcome. Since this study was
undertaken, the User Guide has been finalized in Spanish,
meaning the local team can now conduct on-site scoring.
UB was acceptable, inspiring enthusiastic engagement
among caregivers. Both video volunteers and intervention
group participants found footage of local community mem-
bers empowering, relatable, and effective in conveying mes-
sages about ECD and healthy parenting. They expressed
interest in capturing their own parenting interactions through
similar footage. Investigators collecting video footage may
find providing participants with capture options increases
participant comfort.
PICCOLO findings support future randomized assessment
with a sample size powered to detect statistically significant
improvements in mother/child outcomes, including UB’s
impact on individual PICCOLO sub-domains. Should
mother/child interaction improve in piloting, we could fur-
ther explore UB’s impact on ECD outcomes.
UB carries advantages over current video interventions.
Childrearing practices and norms for interaction are known
to vary widely across cultures and contexts (Bornstein et al.,
2015). Nonetheless, early interaction “exchanges” across
most cultures share some basic commonalities: they rely on
infant cues interpreted by a caregiver, and they evolve into
sustained moments of shared focus, or bouts of “joint
attention” to a third focal point (Bard et al., 2022). These
bouts of joint engagement play a key role in helping the
young brain make and proliferate neuronal connections. UB
8 Nelson et al.
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uses caregivers as peer experts and our data show that local
examples of joint engagement in peer dyads make accessible
content that participants can easily mirror in their own lives.
In contrast to video-feedback interventions, UB is delivered
at low cost with trained CHWs. High-quality educational
content and explicit dyadic interactions are shared to reach
large caregiver and/or trainee audiences without specialist
involvement. Delivery options for UB videos include existing
public-health interventions, clinical waiting rooms,
community-based group meetings, and broad public health
TV or social media messaging. In addition to this project and
further efforts in Peru, UB has been developed locally to
reach viewers in diverse communities with scarce health care
infrastructure, such as Uganda, Cherokee Nation, Zambia,
South Africa and clinically oriented parenting programs in
the USA.
Limitations
We had some study dropout (15%) and missing PICCOLO data
due to file corruption (n¼3). Enrolled children who did not
complete the study could be more vulnerable to the ill effects of
developmental delay. However, as most dropouts were from the
control arm, their inclusion would likely increase the effect.
Conclusion
This study suggests that the innovative approach of UB—using
local naturalistic video footage to co-create structured short
Figure 4. Distribution of parent outcome scores (PICCOLO) at baseline and follow-up, N¼30.
Journal of Pediatric Psychology (2024), Vol. 00 9
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videos grounded in a theoretical framework—is feasible, accept-
able, and may increase uptake of responsive parent–child inter-
actions. Future research will test the effectiveness of this UB
intervention embedded within a community-based group health
education session as part of a randomized pilot study. Proof of
concept studies such as this should also investigate the cross-
cultural import of UB as a potential scalable tool delivered
through social media or television to achieve global equity in
advancing healthy child development.
Supplementary material
Supplementary material is available online at Journal of
Pediatric Psychology (https://academic.oup.com/jpepsy/).
Data availability
Data are available upon request.
Author contributions
Adrianne K. Nelson (Conceptualization [equal], Data curation
[equal], Formal analysis [equal], Funding acquisition [lead],
Investigation [lead], Methodology [lead], Project administration
[lead], Supervision [lead], Writing—original draft [equal],
Writing—review & editing [equal]), Christa J. Griest
(Conceptualization [lead], Formal analysis [supporting],
Funding acquisition [supporting], Investigation [equal],
Methodology [equal], Software [equal], Supervision [support-
ing], Validation [lead], Visualization [equal], Writing—original
draft [equal], Writing—review & editing [equal]), Llubitza M.
Munoz (Conceptualization [equal], Funding acquisition [equal],
Investigation [equal], Project administration [lead], Resources
[equal], Supervision [lead], Visualization [lead], Writing—
review & editing [supporting]), Nancy Rumaldo
(Conceptualization [equal], Funding acquisition [equal], Project
administration [lead], Supervision [equal], Validation [equal],
Writing—review & editing [equal]), Ann C. Miller
(Conceptualization [equal], Data curation [lead], Formal analy-
sis [lead], Investigation [lead], Methodology [lead], Writing—
original draft [equal], Writing—review & editing [equal]),
Guadalupe M. Soplapuco (Conceptualization [equal],
Methodology [supporting], Project administration [lead],
Supervision [equal], Visualization [equal], Writing—review &
editing [equal]), Leonid Lecca (Funding acquisition [lead],
Project administration [equal], Supervision [equal], Writing—
review & editing [equal]), Sonya S. Shin (Funding acquisition
[equal], Investigation [equal], Methodology [equal], Resources
[equal], Supervision [equal], Validation [equal], Writing—
review & editing [equal]), Llalu R. Acu~
na (Data curation
[equal], Project administration [equal], Validation, Writing—
review & editing), Yesica V. Valdivia (Data curation [equal],
Project administration [equal], Validation, Writing—review &
editing [equal]), Alicia R. Ramos (Data curation [equal], Project
administration [equal], Supervision, Validation, Writing—
review & editing [equal]), Diego G. Ahumada (Data curation
[equal], Formal analysis [equal], Investigation, Methodology,
Validation, Writing—review & editing [equal]), Blanca R.H.
Ramos (Project administration [equal], Validation, Writing—
review & editing [equal]), Sarah A. Mejia (Data curation
[equal], Formal analysis [equal], Methodology, Validation),
Esther O. Serrano (Data curation [equal], Project administration
[equal], Validation, Writing—review & editing [equal]),
William H. Castro (Conceptualization [equal], Project adminis-
tration [equal], Software [lead], Visualization[equal]), Victoria
E. Oliva (Data curation [equal], Project administration [equal],
Validation, Writing—review & editing [equal]), Annie S.
Heyman (Data curation [equal], Formal analysis [equal],
Methodology, Validation), Lauren P. Hartwell (Data curation
[equal], Formal analysis [equal], Methodology, Validation),
Ronnie L. Blackwell (Data curation [equal], Formal analysis
[equal], Methodology, Validation), Diego F. Diaz
(Conceptualization [equal], Project administration [equal],
Software [lead], Visualization [equal]), and Martha M. Vibbert
(Conceptualization [lead], Data curation [equal], Formal analy-
sis [equal], Funding acquisition [lead], Investigation [lead],
Methodology [equal], Resources, Supervision [lead], Validation,
Visualization [equal], Writing—original draft [equal],
Writing—review & editing [equal])
Funding
Grand Challenges Canada provided funding for this study via
grant #0671-01-10, Stars in Global Health Round 7.
Conflicts of interest: The authors report no conflicts of
interest.
Acknowledgments
This paper is dedicated to our dear colleague and friend
Guadalupe Soplapuco who dedicated her life to the children
and families of Carabayllo.
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