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Centre-based day care for children under five in low- and middle-income countries

  1. Taylor W Brown1,
  2. Felix C Van Urk2,
  3. Rebecca Waller1,
  4. Evan Mayo-Wilson3,*

Editorial Group: Cochrane Developmental, Psychosocial and Learning Problems Group

Published Online: 31 MAY 2013

DOI: 10.1002/14651858.CD010543

How to Cite

Brown TW, Van Urk FC, Waller R, Mayo-Wilson E. Centre-based day care for children under five in low- and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD010543. DOI: 10.1002/14651858.CD010543.

Author Information

  1. 1

    Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, Oxfordshire, UK

  2. 2

    University of Oxford, Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, Oxford, Oxfordshire, UK

  3. 3

    University College London, Research Department of Clinical, Educational and Health Psychology, London, UK

*Evan Mayo-Wilson, Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.

Publication History

  1. Publication Status: New
  2. Published Online: 31 MAY 2013


This is not the most recent version of the article. View current version (25 SEP 2014)



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

Description of the condition

Paid female labour is a realistic means of alleviating individual and national poverty of low- and middle-income countries (LMICs) (Siraj-Blatchford 2008). Women are still the primary caregivers of children in most LMICs, which limits their ability to participate in income generation and provides them with less time for education, leisure, and social or political activities (Addati 2008; Razavi 2008; ILO 2009; Tabbert 2009). Although social mores may hinder a mother from participating in the labor force, it is likely that a lack of childcare options may also be a barrier.

Often resulting from the poverty of LMICs, many biological and psychosocial hazards compromise the development of young children (Walker 2007). Risk factors include widespread infectious diseases (Carter 2003); nutritional deficiencies (WHO 2004; Stoltzfus 2005; Walker 2007); exposure to war or community and political violence (UNICEF 2004); poor sanitation and unhygienic living conditions (Ezzati 2002); high prevalence of maternal depressive symptoms (Affonso 2000); few household resources, and a lack of cognitive stimulation and learning opportunities (Bradley 2002; Walker 2007). There is a need for early child development intervention programmes that target the physical, cognitive, and social-behavioural development of young children in LMICs (Center on the Developing Child 2007). Centre-based day care is one intervention used to address these needs.

Recently, inter- and non-governmental organisations have begun to finance loans, orchestrate development, and donate hundreds of millions of dollars to the care of young children in LMICs (Penn 2004; UNICEF 2006). In tandem with this aid, many countries have created early child development programmes - some of which contain centre-based day care (Engle 2007). Other LMICs have made political shifts to ensure that preschool education, often housed within centre-based day care, is obligatory for all children of a certain age (Meyers 2000). Still, the number of children under the age of five years who experience regular day care in LMICs is unknown. The proportion of children in LMICs currently enrolled in preschool is thought to be low, with significant variability between countries (World Bank 2011), settings (for example, rural versus urban), and age groups (Yoshikawa 2007).


Description of the intervention

A significant proportion of children in high-income countries under the age of five years experience non-parental day care within formal and informal settings (Melhuish 2004; NICHD ECCRN 2006; Smith 2010). Day care for children in LMICs takes various forms, but generally aligns with day care in high-income countries. Centre-based day care differs from informal care (for example, care by parents, private nannies, friends, or family), in that it provides group supervision of children in a publicly accessible location. In addition to supervision, this formal care may provide education; feeding; structured or unstructured play; material, toys, or playground equipment. It may be provided in the public or private sector and may be supervised by trained child development staff or by lay caregivers.

In LMICs, basic day care may be expanded to include a range of family, health, nutrition, and social services to accommodate the needs of LMIC populations. These initiatives are often subsumed under the umbrella of so called 'Early Child Development' programmes (Penn 2004; UNICEF 2006). Depending on the quality, quantity, and type of day care service provided, child outcomes can be differentially impacted (NICHD ECCRN 2005; Belsky 2007).

As in high-income countries, parents in LMICs choose to use day care for a variety of purposes. Economically, families may utilise day care as a means to enable parents (particularly mothers) to enter or participate more fully in the labour market.  Developmentally, parents and governments may choose to utilise day care as a means of enhancing child social and academic performance before entry into formal education (Lamb 2006), or as a means to provide services for the improvement and maintenance of child health (Silva 2000). This is particularly relevant for LMICs, where an estimated two-hundred million children under the age of five years do not reach their developmental potential (Grantham-McGregor 2007).


How the intervention might work

Much of the early child development research has been conducted in high-income countries. This evidence, along with other studies of the social and economic circumstances of many children in LMICs, suggests a number of means by which centre-based care may affect the well-being of children and families.

First, day care is often offered to target children’s early cognitive development and ultimately improve long-term educational attainment. Specifically, school readiness and cognitive capacities appear to be enhanced by structured activities, psychosocial stimulation (NICHD ECCRN 2006), and responsive, verbally articulate staff (Melhuish 2004). By increasing the availability of stimulation that a child receives, centre-based care may improve the achievement of developmental milestones in a cost-effective manner (Masse 2000; Grantham-McGregor 2007; UNESCO 2010). Relatedly, language learning is likely to be facilitated in day care settings when children are afforded more opportunities to interact verbally with adults and peers. In particular, high quality centre-based care has been linked to improved language development (Clarke-Stewart 1987; Schliecker 1991). The enriched environment of a formal day care setting may be particularly important for children from deprived homes and in LMICs where academic averages consistently trend below global averages (Dearing 2009; Nakahara 2010). Longitudinal studies in high-income countries have demonstrated that early attendance at high quality day care may predict better academic outcomes, higher rates of employment, and less adult criminal activity than if children do not attend (for example, Schweinhart 1993; Campbell 2001).

Second, a considerable body of research has investigated whether day care disrupts secure mother-child attachment, which could have long-term developmental consequences for children’s socioemotional outcomes (Ainsworth 1978; Sroufe 1999). On the other hand, day care could improve children's long-term socioemotional and behavioural outcomes, with lasting consequences for adult mental health (Shonkoff 2011). Some studies have found that day care is related to positive outcomes including improved social competence (for example, Clarke-Stewart 1994; Balleyguier 1996). In contrast, other longitudinal studies have shown that greater amounts of day care predict higher levels of externalising behavior, including aggression and non-compliance (NICHD ECCRN 2006; Philips 2006; Belsky 2007).

Third, day care is provided to help facilitate parental, and specifically maternal, employment. Mothers may be able to fully participate in the labour market when they feel their children are secure and cared for (Vandell 2002; Melhuish 2004; Sclosser 2005). Provision of day care is correlated with increased female labour force participation in high-income countries, and an earlier return to the workforce after pregnancy (Brooks-Gunn 1994; Gelbach 2002; Espling-Andersen 2009). Although the relationship between paid female labour and day care has not been widely studied in LMICs, it is possible that an increase in childcare provision may correlate positively with national female labour rates (Lokshin 2004; Sclosser 2005; Tabbert 2009). In turn, increased female labour rates may result in higher family income, with collateral positive effects on child outcomes, including better nutrition and enriched home environments. However, the effect of maternal employment may vary according to socioeconomic status, culture, and ethnicity, as well as child age and gender (Masse 2000; Han 2001; NICHD ECCRN 2003; Lokshin 2004), which needs to be carefully considered in relation to child outcomes.

Finally, day care may affect children’s physical health, particularly in relation to common infectious diseases. On one hand, children in centre-based day care have been found to be at higher risk for lower respiratory tract infections (Schwartz 1994; Lu 2004) and day care may increase the prevalence of diarrhoeal disease because of the high likelihood of child-to-child transmission (Ethelberg 2006), which is of considerable concern in LMICs where the mortality rate of children under five is high, and the leading causes of death include diarrhoea, pneumonia, and other infectious diseases. On the other hand, many children in LMICs suffer from malnutrition and stunting (WHO 2009); if adequate feeding or nutritional supplementation is offered, then provision of day care may represent an important intervention to reduce the duration of acute and persistent diarrhoea (Lazzerini 2008) and improve children’s height and weight statistics (Avula 2010). Improved nutrition over time may also have collateral effects on children’s long-term educational attainment (Glewwe 2001). 


Why it is important to do this review

In LMICs, the proportion of children who attend day care services is unknown. However, day care may affect the developmental outcomes of children under five in LMICs. It is important to evaluate the existing evidence for the effects of day care on the cognitive and psychosocial development and health of children, and the impact on parental employment and family income. A previous Cochrane review on day care was carried out a decade ago (Zoritch 2000), but included only studies from in high-income countries, which limits its generalisability to LMIC populations (Penn 2004). That review (Zoritch 2000) also allowed for the inclusion of day care interventions with home-visit and other non-centre-based components, which limits its ability to speak particularly to the impact of centre-based care. To best understand its effects, the intervention of centre-based day care must be isolated from interventions that are not child-centred (for example, teacher or parent training) or centre-based (for example, home visits). Furthermore, possible social, economic, and biological confounding variables must be adequately controlled for, as specified in the content of this protocol. In the context of burgeoning interest in interventions and policies to improve the developmental outcomes of children in LMICs, a review of centre-based day care programmes in LMICs will serve as a guide for future research and policymakers (Walker 2007; UNESCO 2010).



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

To assess the effects of centre-based day care on the development, health, and well-being of children and their families in low- and middle-income countries (as defined by the World Bank (World Bank 2011)).



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

Criteria for considering studies for this review


Types of studies

Controlled trials, including: randomised and quasi-randomised trials, and prospective non-randomised studies with contemporaneous control groups and measuring both pre- and post-intervention.

We will include non-randomised controlled trials because centre-based care in low- and middle-income countries is unlikely to be studied using randomised controlled trials (Higgins 2011).


Types of participants

Children under five years of age (at the time of enrolment) and their families in low- and middle-income countries (as defined by the World Bank (World Bank 2011)).


Types of interventions

We will include centre-based day care, which we define as supervision of children in a publicly accessible location. It may include snack and meal provision for children or a child education component.

We will exclude studies of day care with medical or psychological co-interventions unless these are also received by participants in control groups. We will also exclude studies involving co-interventions not directed toward children or not centre-based (for example, parent programmes, home visits, and teacher training); the presence of such co-interventions would weaken the extent to which findings can be attributed to centre-based care alone. We will also exclude studies in which enrolment was limited to children with physical or intellectual disabilities (for example, autism or IQ under 80), orphans, children living in hospital, or children living with HIV/AIDS.

If some, but not all, of a study's participants are eligible for our review, then we will ask the study authors for disaggregated data. If we are unable to obtain the appropriate disaggregated data, then we will include a study if the majority (at least 51%) of participants are eligible. If we are unable to determine the exact percentage of a study’s participants who are eligible, then we will include the study if participants are eligible on average (for example, the mean participant age is less than five years).


Types of outcome measures

We will assess the effects of centre-based care by extracting data on the following child and family well-being outcomes. In studies reporting more than one measure of an outcome, we will extract data for meta-analysis using methods described below (see Measures of treatment effect). All primary outcomes and one secondary outcome (paid parental employment) will be included in 'Summary of findings' tables.


Primary outcomes

1 Child intellectual development

1.1  Cognitive ability (for example, IQ or development quotient)

1.2  Educational attainment (for example, measures of reading, writing, or mathematics, and retention in grade)

2 Child psychosocial development

2.1 Any behavioural measure (that is, self, parent, or teacher reports of externalising behaviour/aggression, prosocial or antisocial behavior)

2.2 Disrupted child attachment to mother


Secondary outcomes

3  Maternal and family outcomes

3.1 Paid parental employment

3.2 Household income

4 Incidence of infectious diseases

4.1 Incidence of diarrhoea

4.2 Prevalence of diarrhoea

4.3 Incidence of lower-respiratory tract infection (including pneumonia)

4.4 Prevalence of lower respiratory tract infections (including pneumonia)


Search methods for identification of studies

Studies will be considered regardless of publication status or language, though all searches and author communications will be conducted in English. Foreign language abstracts associated with titles of interest will be translated by fluent speakers of the relevant foreign language. Study reports will be discussed with a fluent speaker and translated if the study may meet the inclusion criteria.


Electronic searches

We will search the following databases.

  • Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library
  • PsycINFO
  • ERIC
  • Social Sciences Citation Index (SSCI)
  • Latin American Caribbean Health Sciences Literature (LILACS)
  • Conference Proceedings Citations Index - Social Science & Humanities (CPCI-SSH)
  • Global Health Library
  • British Library for Development Studies (BLDS)
  • World Bank (JOLIS)
  • Pan American Health Organization (PAHO)
  • WHO Library & Information Networks for Knowledge Database (WHOLIS)
  • African Index Medicus (AIM)
  • Western Pacific Region Index Medicus (WPRIM)
  • Index Medicus for South-East Asia Region (IMSEAR)
  • International Clinical Trials Registry Platform

We will use the following search strategy in MEDLINE and adapt it for other databases using appropriate controlled vocabulary and syntax. This strategy includes a filter for identifying trials in low- and middle-income countries developed by the Norwegian Satellite of the Cochrane Effective Practice and Organisation of Care Review Group (The Cochrane Collaboration 2012).

1     child day care centers/
2     Schools, Nursery/
3     "Early Intervention (Education)"/
4     ((early adj2 education$) or ECCE).tw.
5     (creche$ or nurser$ or kindergarten$ or kinder-garten$ or preschool$ or pre-primary or preprimary or playgroup$ or play-group$ or pre-school$ or (child$ adj3 centre$) or (child$ adj3 center$)).tw.
6     or/1-5
7     child care/ or child
8     (centre$ or center$ or facilit$ or "out of home" or polic$ or program$ or scheme$).tw.
9     7 and 8
10     exp child/
11     exp Infant/
12     (infant$ or baby or babies or toddler$ or child$ or boy$ or girl$ or kid$ or pre-kindergarten$ or prekindergarten$ or preschool$ or pre-school$).tw.
13     or/10-12
14     Day Care/
15     (daycare$ or day-care$ or daycentre$ or daycenter$ or (centre-based adj3 care$) or (center-based adj3 care$) or (day$ adj3 (centre$ or center$))).tw.
16     14 or 15
17     13 and 16
18     6 or 9 or 17
19     Developing,kf.
20     (Africa or Asia or Caribbean or West Indies or South America or Latin America or Central America).hw,kf,ti,ab,cp.
21     (Afghanistan or Albania or Algeria or Angola or Antigua or Barbuda or Argentina or Armenia or Armenian or Aruba or Azerbaijan or Bahrain or Bangladesh or Barbados or Benin or Byelarus or Byelorussian or Belarus or Belorussian or Belorussia or Belize or Bhutan or Bolivia or Bosnia or Herzegovina or Hercegovina or Botswana or Brasil or Brazil or Bulgaria or Burkina Faso or Burkina Fasso or Upper Volta or Burundi or Urundi or Cambodia or Khmer Republic or Kampuchea or Cameroon or Cameroons or Cameron or Camerons or Cape Verde or Central African Republic or Chad or Chile or China or Colombia or Comoros or Comoro Islands or Comores or Mayotte or Congo or Zaire or Costa Rica or Cote d'Ivoire or Ivory Coast or Croatia or Cuba or Cyprus or Czechoslovakia or Czech Republic or Slovakia or Slovak Republic or Djibouti or French Somaliland or Dominica or Dominican Republic or East Timor or East Timur or Timor Leste or Ecuador or Egypt or United Arab Republic or El Salvador or Eritrea or Estonia or Ethiopia or Fiji or Gabon or Gabonese Republic or Gambia or Gaza or Georgia Republic or Georgian Republic or Ghana or Gold Coast or Greece or Grenada or Guatemala or Guinea or Guam or Guiana or Guyana or Haiti or Honduras or Hungary or India or Maldives or Indonesia or Iran or Iraq or Isle of Man or Jamaica or Jordan or Kazakhstan or Kazakh or Kenya or Kiribati or Korea or Kosovo or Kyrgyzstan or Kirghizia or Kyrgyz Republic or Kirghiz or Kirgizstan or Lao PDR or Laos or Latvia or Lebanon or Lesotho or Basutoland or Liberia or Libya or Lithuania or Macedonia or Madagascar or Malagasy Republic or Malaysia or Malaya or Malay or Sabah or Sarawak or Malawi or Nyasaland or Mali or Malta or Marshall Islands or Mauritania or Mauritius or Agalega Islands or Mexico or Micronesia or Middle East or Moldova or Moldovia or Moldovian or Mongolia or Montenegro or Morocco or Ifni or Mozambique or Myanmar or Myanma or Burma or Namibia or Nepal or Netherlands Antilles or New Caledonia or Nicaragua or Niger or Nigeria or Northern Mariana Islands or Oman or Muscat or Pakistan or Palau or Palestine or Panama or Paraguay or Peru or Philippines or Philipines or Phillipines or Phillippines or Poland or Portugal or Puerto Rico or Romania or Rumania or Roumania or Russia or Russian or Rwanda or Ruanda or Saint Kitts or St Kitts or Nevis or Saint Lucia or St Lucia or Saint Vincent or St Vincent or Grenadines or Samoa or Samoan Islands or Navigator Island or Navigator Islands or Sao Tome or Saudi Arabia or Senegal or Serbia or Montenegro or Seychelles or Sierra Leone or Slovenia or Sri Lanka or Ceylon or Solomon Islands or Somalia or South Africa or Sudan or Suriname or Surinam or Swaziland or Syria or Tajikistan or Tadzhikistan or Tadjikistan or Tadzhik or Tanzania or Thailand or Togo or Togolese Republic or Tonga or Trinidad or Tobago or Tunisia or Turkey or Turkmenistan or Turkmen or Uganda or Ukraine or Uruguay or USSR or Soviet Union or Union of Soviet Socialist Republics or Uzbekistan or Uzbek or Vanuatu or New Hebrides or Venezuela or Vietnam or Viet Nam or West Bank or Yemen or Yugoslavia or Zambia or Zimbabwe or Rhodesia).hw,kf,ti,ab,cp.
22     ((developing or less* developed or under developed or underdeveloped or middle income or low* income or underserved or under served or deprived or poor*) adj (countr* or nation? or population? or world)).ti,ab.
23     ((developing or less* developed or under developed or underdeveloped or middle income or low* income) adj (economy or economies)).ti,ab.
24     (low* adj (gdp or gnp or gross domestic or gross national)).ti,ab.
25     (low adj3 middle adj3 countr*).ti,ab.
26     (lmic or lmics or third world or lami countr*).ti,ab.
27     transitional countr*.ti,ab.
28     or/19-27
29     18 and 28


Searching other resources

We will examine reference lists from previous studies, and contact the authors of all included studies to request details of ongoing and unpublished studies. We will also search for grey literature in the following.

  • 3ie: International Initiative for Impact Evaluation
  • Bernard van Leer Foundation
  • OpenGrey
  • Oxfam
  • Aga Khan Foundation
  • Save the Children
  • Christian Child's Fund (ChildFund)
  • World Bank
  • Eldis
  • Consultative Group for Early Child Care and Development
  • United Nations Children's Fund (UNICEF)


Data collection and analysis


Selection of studies

Two review authors will independently screen all titles and abstracts. Relevant articles will be collected and independently screened to determine which studies meet the inclusion criteria. We will contact study authors if further information is required. Disagreements will be resolved through discussion and consultation with other review authors.


Data extraction and management

Two review authors will independently extract the following data from all included studies. Disagreement will be resolved through discussion and consultation with other review authors.


  • Year of study
  • Country
  • Study design (that is, case control, cohort)
  • Unit of analysis (for example, individual- or cluster-randomized)
  • Methods used to control for confounding factors
  • Setting (that is, urban or rural, specific region or city if provided)


  • Number of study participants and clusters randomized to each included group
  • Age
  • Sex
  • Inclusion and exclusion criteria

For each intervention or comparison group of interest

  • Dose of centre-based care
  • Duration of centre-based care
  • Frequency of centre-based care
  • Co-interventions (if any)
  • Quality of care (if measured)

For each study, we will use the Cochrane recommended lists for identifying study design and will report the characteristics of study designs in a ‘Characteristics of included studies’ table (Higgins 2011, section 4.6.1).


Assessment of risk of bias in included studies

Two review authors (TWB and FVU) will code each included study using the Cochrane tool for assessing risk of bias (Higgins 2011 8.5.a), including: sequence generation; allocation concealment; blinding of study participants, personnel, and outcome assessors; incomplete outcome data; selective outcome reporting; and other sources of bias. In addition to these, we will assess the risk of bias due to confounding and for outcome validity. Risk of bias will be judged in each category by a rating of low, high, or unclear. A rating of 'low' shall indicate that evidence was sufficient to judge that study authors used appropriate methods to avoid bias, as determined by the Cochrane Handbook for Systematic Reviews of Interventions criteria for judging risk of bias in the 'Risk of bias' assessment tool (Higgins 2011, section 8.5.c); a rating of 'high' shall indicate that evidence was sufficient to judge that study authors did not use appropriate methods to avoid bias; and a rating of 'unclear' shall indicate that there was insufficient information to judge the extent to which study authors used appropriate methods to avoid bias. Disagreements will be discussed and resolved with a third author (EMW) and, if necessary, a fourth author (BW).

We will report assessments of confounders using additional tables that will identify which confounding factors were considered and controlled for in each study. Confounding factors that we will explicitly assess and report include: child age, child sex, neighborhood, socioeconomic status, water availability, water (drinking) quality, excreta disposal, number of children under five years in the household, malnutrition at baseline, mother's education, father's employment, mother's employment outside the home, distance from home to day care centre, transportation costs to day care centre, fees at day care centre, quality of day care centre, child history of illness, other. We will assess each study, as above, with a rating of low, high, or unclear in terms of their control for each of these confounding variables. See also Sensitivity analysis.


Measures of treatment effect

Studies often report outcomes using multiple definitions and outcome measures. We will give preference to data that involved the least manipulation by authors or inference by review authors; that is, we will extract raw values (for example, means and standard deviations) rather than calculated effect sizes (for example, Cohen’s d). If outcomes are reported as final values and as changes from baseline, we will extract the final values.  

For studies with multiple time points, we will include the latest time point. If possible, we will also conduct an analysis of prespecified time points: up to 25 months, 25 months or greater.  

We will report outcomes with a 95% confidence interval.

Dichotomous data

We will calculate relative risks or rate ratios (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. When risk ratios or rate ratios cannot be calculated (when total sample size is unknown), we will calculate odds ratios (OR). If we cannot calculate RR for all studies included in an analysis, but can calculate OR for all studies, we will report OR for all studies included in that analysis. RR and OR will not be meta-analysed together. We will give preference to denominators in the following order: events per person-year, events per person with definite outcome known (or imputed, as described in Dealing with missing data), events per person randomised.

Continuous data

We will use Hedges' (adjusted) g (a standardised mean difference) for each outcome for which there is continuous data.


Unit of analysis issues

Some data in this review may come from cluster-randomised trials, which randomise groups of people rather than individuals. For each cluster-randomised trial, we will first determine whether or not its data incorporate sufficient controls for clustering (such as robust standard errors or hierarchical linear models). If the data do not have proper controls, then we will attempt to obtain an appropriate estimate of the intracluster correlation coefficient (ICC). If we cannot find an estimate in the report of the trial, then we will request an estimate from the trial report authors. We will use the ICC estimate to control for clustering, according to procedures described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, section 16.3.4).


Dealing with missing data

For all analyses, we will attempt to include all study participants, and we will contact authors to request data including all participants randomised for all outcomes. When analyses are reported for completers as well as controlling for dropout, we will extract the latter. If participant data are missing in a study, or if reasons for dropout are not included, then we will contact authors for additional information. For studies with dichotomous data, if no information can be gathered from authors, we will assume that participants in all groups for whom data are missing experienced negative outcomes. All missing data will be recorded on the data extraction sheet and reported in the 'Risk of bias' tables.


Assessment of heterogeneity

Differences among included studies are discussed in terms of their participants, interventions, outcomes, and methods. For each meta-analysis, we will visually inspect forest plots to see if the confidence intervals of individual studies have poor overlap, conduct a Chi2 test, and calculate the I2 statistic. We will consider meta-analyses to have heterogeneity when the P value for Chi2 is less than 0.10 and I2 is greater than 25%.

Due to the likelihood of variability in participants and co-interventions across different sites, there is a chance that this review will include studies that are clinically heterogeneous. If studies are determined to be too clinically heterogeneous, we will not conduct a primary meta-analysis but will discuss results narratively, including detailed descriptions of the interventions of all included studies.


Assessment of reporting biases

For each meta-analysis that includes 10 or more studies, we will draw a funnel plot and look for asymmetry to assess the possibility of small study or reporting bias (see Sensitivity analysis).


Data synthesis

The primary meta-analysis will include centre-based day care versus any non centre-based childcare (for example, home care by a parent). We will conduct subgroup analysis as detailed below in Subgroup analysis and investigation of heterogeneity.

As recommended in the Cochrane Handbook for Systematic Reviews of Interventions, we will analyse and present results of randomised and non-randomised study designs separately (Higgins 2011, section and will report individual study results for studies with similar design features using forest plots. We will use Review Manager (RevMan) Version 5.1 (Review Manager 2011) to conduct all meta-analyses. Relative risks or rate ratios and 95% confidence intervals will be calculated for dichotomous outcomes and combined using Mantel-Haenszel methods.  When risk ratios or rate ratios cannot be calculated (when total sample size is unknown), we will calculate ORs. If studies report dichotomous data in multiple formats that cannot be combined in RevMan, we will use Comprehensive Meta-Analysis Version 2 software (Borenstein 2005) to calculate log risk ratios and standard errors for the data, and enter these log risk ratios and standard errors into RevMan. If we cannot calculate RR for all studies included in an analysis, but can calculate OR for all studies, we will report OR for all studies included in that analysis. RRs and ORs will not be meta-analysed together.

We will use random-effects models because studies may include different interventions and populations.


Subgroup analysis and investigation of heterogeneity

We will conduct the following subgroup analyses.

  1. Age: under three years versus three to five years.
  2. Setting: urban versus rural (as identified by authors).
  3. Co-intervention: centre-based day care alone versus no intervention; centre-based day care with a co-intervention (for example, nutritional intervention) versus the same co-intervention without centre-based day care.
  4. Household income: high-income versus low-income households.


Sensitivity analysis

Sensitivity analysis will be used as follows.

  1. We will repeat the primary meta-analysis excluding quasi- and non-randomised trials.
  2. We will repeat the primary meta-analysis excluding studies that reported outcomes for completers only.
  3. For cluster-level studies, if the authors do not provide an ICC for relevant outcomes, then we will obtain one from a similar study and conduct sensitivity analyses assuming high and low effects of clustering, to determine if the results are robust.



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

All authors received internal support from the Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford (UK). EMW also received support from the Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London (UK).

This protocol was produced within the Cochrane Developmental, Psychosocial and Learning Problems Group.


Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

All authors contributed to drafting the protocol.


Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

Taylor Brown - none known
Evan Mayo-Wilson - none known
Felix Van Urk - none known
Rebecca Waller - none known


Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

Internal sources

  • Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, UK.
  • Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford, UK.
    Salary, graduate stipends


External sources

  • No sources of support supplied



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Contributions of authors
  7. Declarations of interest
  8. Sources of support
  9. Notes

The authors are publishing another related protocol: Van Urk FC, Brown TW, Waller R, Mayo-Wilson E. Centre-based day care for children under five in high-income countries. Cochrane Database of Systematic Reviews, Issue 5, 2013.


Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Acknowledgements
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
  10. Notes
  11. Additional references
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