of Birmingham Facilitating the participation of children with disabilities in early childhood development centres in Malawi: Developing a sustainable staff training programme

: This article explores the development of a sustainable training programme supporting the inclusion of children with disabilities in early childhood, education and care (ECEC) centres in Malawi. This programme is based on a review of literature of curriculum, pedagogy and teaching approaches in ECEC in sub-Saharan Africa, alongside a review of national policy documents. The training was designed to enable sta ﬀ to value the inclusion of children with disabilities in ECEC centres, as well as suggesting practical ways to do so. We set out our response to the gap in training of ECEC sta ﬀ through the development of a supplementary integrated training programme, which, whilst respectful of the curriculum, policy and practice of Malawi, challenged sta ﬀ to consider ways of including children with disabilities (CWD) and their families. We suggest this is a pragmatic and sustainable model that could be applied to training in other ECEC settings across the region in sub-Saharan Africa. It concludes with guiding principles for training those working in ECEC with young children with disabilities in low-income countries.


Introduction
The World Report on Disability [1] stated there are approximately one billion people in the world living with a disability, with at least one in ten being children and 80% living in low-income countries. There are estimated to be 53 million children with disabilities (CWD) under the age of 5, with 95% living in low-income countries [2]. CWD are less likely to start school; indeed, disability has a greater impact on educational access than gender and household economic status [1]. Sustainable Development Goal 4 on education [3] calls for inclusive and equitable quality education and lifelong learning opportunities for all by 2030 emphasising that no-one should be left behind. The UNESCO's Guide for Ensuring Inclusion and Equity in Education [4] emphasises key aspects in the development of inclusive education systems: 'Many factors can work either to facilitate or to inhibit inclusive and equitable practices within education systems. Some of those factors are: teacher skills and attitudes, infrastructure, pedagogical strategies and the curriculum. These are all variables which education ministries either control directly, or over which they can at least exert considerable influence.' [4] (p. 13) Building on some of these factors, namely 'pedagogy', 'skills' and 'attitudes to inclusion,' we outline how a basic training programme for caregivers was developed and enhanced for caregivers (mainly volunteer nursery staff) to enable the participation and inclusion of CWD in resource constrained early childhood education and care (ECEC) settings, namely community based childcare settings (CBCCs) in the Southern Region of Malawi. The two-week training programme was based on the basic National Caregiver Training Programme and enhanced to support staff to reflect on the value of inclusion of CWD, alongside practical ways to enable this within daily activities at the CBCCs. The training was developed from both a synthesis of relevant literature on early childhood development and disability and teacher training, as well as interviews with caregivers and parents of CWD (phase one) which were conducted before carrying out a cluster-randomised controlled trial of a caregiver training intervention in Thyolo District in the Southern Region of Malawi (phase two). The purpose of the trial was to measure the impact of the augmented training programme on child language, social development and school readiness and formed part of the broader research study. The aim of the project was to provide the Economic and Social Research Council, UK Aid and the Malawi Government with a more developed understanding of the dynamics that can influence quality early childhood development and education for CWD in the rural Thyolo district of Southern Malawi [5].
We begin this article by explaining the rationale for the training, examining the political drivers to support early child development (ECD) and inclusion within early childhood education and care (ECEC) in low-income countries. Next, we explore the development of ECEC in Malawi and the opportunities and the challenges to developing inclusive ECEC within this context, including information shared by parents of CWD and CBCC caregivers within this three-year project comprising three phases. The methods section details the literature review of curriculum and pedagogy in ECEC in low-income countries and the inclusion of CWD undertaken to inform the development of an enhanced training programme on inclusive ECEC to support caregivers working in CBCCs. We then summarise the themes that arose from the review and in the final section outline the principles underpinning the approach to the development of the training taken within this research.

Definitions of Key Concepts
The concept of disability is used within the article, and while we recognise the heterogenous, individual nature of disability, we are focused on the participation of CWD as a group vulnerable to being excluded from ECEC. The International Classification of Functioning, Disability and Health [6] utilises an interactional model of disability which combines individual and social perspectives on disability. This model of disability is drawn upon in the United Nations Convention on the Rights of People with Disabilities (UNCRPD) [7] in the preamble, stating that 'disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others'. Article 1 highlights 'persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis to others.' Within the project these definitions were employed when seeking to identify CWD through parent questionnaires on their child's functioning [8] in different domains including hearing, vision, learning, mobility, playing, communication and comprehension, as these focus on the relative difficulty experienced by their child in comparison to their peers.
Whilst Article 24 'the right to education' of UNCRPD [7] does not explicitly refer to ECEC, it prohibits discrimination in education, and Article 23 of the United Nations Convention on the Rights of the Child (UNCRC) [9] emphasises the right of CWD to a full, decent, independent life and the right to participate in their community. Therefore, educational inclusion, and ECEC, is based on the pretext that all children should be taught, cared for, learn and play together, regardless of differences or disability, building on the belief that all learners have unique interests and needs [10]. The term inclusion implies transition from segregated learning settings for people with disabilities reflected in the "special education" approach to participation in the general education system [11], and this is the approach promoted within ECEC in this project.
The terms 'caregivers', 'community based childcare setting's (CBCCs) and ECD are used within Malawi. We recognise the vital roles volunteer caregivers and CBCCs play in the learning and development of children, and although these terms do not fully recognise all aspects of the work undertaken within ECEC, it is appropriate to use the terms here as they are used within Malawi. Similarly, Malawi is described as a low-income country, as it is in the lowest quartile of the Human Development Index [12] which is an index of life expectancy, education and per capita income indicators, and ranks 171 out 188.

Early Child Development and Early Childhood Education and Care in Low-Income Countries
Whilst UNESCO's Global Monitoring Report on early childhood care and education [13] does not single out one model for ECEC it instead encourages individual local approaches and identifies key features that are needed. These include working with and supporting parents, integrating educational activities with other services, including health care, nutrition and social services, and providing relevant educational experiences during the early years and helping the transition into primary school.
Whereas the United Nations' sustainable development goals [3] emphasise the central role ECD plays in ensuring young children are suitably prepared for education (e.g., target 4.2), the Organisation for Economic Co-operation and Development OECD [14] highlights the broader benefits of ECEC in promoting improved child well-being, more equitable child outcomes and reduction of poverty, increased intergenerational social mobility and better social and economic development for society at large.

The Right to Inclusive Education and Care
These broader benefits of ECEC have significance when considering the value of inclusive education and care within early childhood. Saebones et al. [15] highlight that disability is one of the prime causes of educational disadvantage, creating the largest single group of children and young people who remain out of school. The economic argument for inclusion is three-fold: (1) by educating children with disabilities, this reduces welfare costs and future dependence for the children themselves; (2) it releases other household members from caring responsibilities, allowing them to engage in employment and other productive activities; and (3) it increases children's potential productivity and wealth creation, which in turn helps to alleviate poverty [16][17][18].
In addition, the international legal frameworks on human rights, the UNCRPD and UNCRC, the International Covenant on Economic, Social and Cultural Rights, and the Universal Declaration of Human Rights, clearly include the rights of children with disabilities to education. In addition, the African Charter on the Rights and Welfare of the Child [19] Article 11 protects children from discrimination and addresses the right of the child to education, as well as Article 13 protecting the rights of children with disabilities. The right to education for all within the Incheon Declaration from the World Education Forum 2015 is clearly stated: 'No education target should be considered met unless met by all. We therefore commit to making the necessary changes in education policies and focusing our efforts on the most disadvantaged, especially those with disabilities, to ensure that no one is left behind'.
Regarding the specific area of ECEC, Saebones et al. [15] recognised that access to early childhood development is a critical entry point to reach vulnerable children within education. This access enables both early stimulation of learning, development and socialisation of children, and also supports later school performance, promotes future earnings and helps overcome social disadvantages. However, they highlight existing ECEC programmes seldom accommodate children with disabilities, and there is a lack of referral systems and services to address the needs of children identified early on with a disability. UNESCO [20] emphasises the central role of ECEC staff, as this is key to increasing quality, although untrained staff are often poorly paid, in low status positions leading to high turnover, thereby limiting the learning outcomes of all the children including those with disabilities.

The Current Context of Malawi
Malawi is one of the world's least developed countries, with a gross national income per capita of USD320 [21]. Groce et al. [22] point to the existence of a 'feedback loop' existing between poverty, disability and ill health in low-income countries. Poverty, food insecurity and malnutrition all have an impact on the numbers of children and adults with disabilities in Malawi.
Over the years, poverty has persisted in Malawi at a high rate, as in 2015, 50.7 percent of the population lived below the poverty line, on less than $1 a day, drawing on the concept of absolute poverty [23]. Groce et al. state the links between poverty and disability are complex and take a multi-dimensional view of poverty, going beyond insufficiency of income, to include inadequate coverage of needs such as food intake, education and shelter, highlighting how this lack of access impacts on the person throughout their life course and their family [24]. Groce et al. emphasise the bidirectional nature of the association, as not only does disability cause poverty, but those who are chronically poor are more likely to have a disability through reduced nutrition, ill health and injuries [24].
Food security and nutrition in Malawi is recognised as a problem, with low food productivity, income, micro-nutrient feeding content and lack of variety of foods. An estimated 85 percent of the population rely on subsistence farming to earn a living. As a result, many children are malnourished due to food insecurity in terms of access and availability at household level. Infant mortality is at 42 deaths per 1000 live births, and an under-five mortality rate of 63 per 1000 live births was recorded in the period between 2014 and 2015 [25,26]. The Government of Malawi Demographic and Health Survey states that thirty-seven percent of children under the age of five are stunted (short for their age), a sign of chronic under-nutrition; 3 percent are wasted (thin for their height), a sign of acute under-nutrition; and 12 percent are underweight for their age [25].

Early Childhood Development and Early Childhood Education and Care in Malawi
Whilst responsibility for coordinating ECD in Malawi lies between the Children's Affairs and Social Welfare Departments which are housed in the Ministry of Gender, Children, Disability and Social Welfare, the Department of Disability and Elderly Affairs also has responsibility for identifying interventions for improving the situation of children with disabilities in Malawi. This department has developed a work plan [23] to promote coordination in the development and implementation of programmes for all CWD, which includes ECD as a specific outcome (Outcome 3.2.1: Strengthened inclusive education and Special Needs Education and Outcome 3.2.2: Improved and Inclusive ECD). Much of their focus is on increasing access to nutrition alongside improving ECD services for children with disabilities through advocacy work in collaboration with different implementing partners such as the Association of Early Childhood Development in Malawi (AECDM), the Federation of Disability Organisations in Malawi, UNICEF, Parents of Disabled Children Association of Malawi and INGOs such as Save the Children and ActionAid.
The Government of Malawi and UNICEF first piloted rural ECD centres in the early 1980s, although these early pilots were not sustained by communities. Consequently, the model of CBCCs was developed to create a self-sustaining childcare system, initiated, managed and owned by the communities themselves [27]. The rise of a HIV and AIDS pandemic toward the end of the 1990s led to the rapid increase in CBCCs to attend to the growing numbers of orphaned children who required care and protection. By 1999, the government, through UNICEF, introduced the Early Childhood Care for Survival, Growth and Development program, with a focus on rural areas. In subsequent years the Malawi Government has made concerted efforts to establish the provision of CBCCs in rural and peri-urban areas [27]. As an example, a 2007 Government of Malawi and UNICEF report makes reference to: ' . . . a childcare service owned and run by parents, guardians, caregivers and the community at large. It [is] designed to promote the holistic development of all children, and particularly of those who are orphans or vulnerable for other reasons, from birth, to age five. A good CBCC will offer early learning and stimulation, and psychosocial care. It will make sure children have access to proper nutrition, health care, clean water and sanitation facilities. It will also protect the children's rights'. [28] CBCCs are part of the informal sector and so have minimal government support, relying mainly on volunteer workers who have minimal training and material contributions from the community and NGOs [29].
Munthali et al. undertook a survey locating and mapping the CBCCs in all 28 districts of Malawi and examined the quality of the facilities offered. Whilst the study indicated that CBCCs offered a key early childhood learning environment accessible to children living nearby, including orphans and other vulnerable children, the quality of most of the CBCCs fell short in terms of acceptable buildings, sanitation facilities, staff numbers and capacity and equipment [30]. Munthali et al. proposed that part of the solution to this shortfall was to bring CBCCs up to the required standard in providing training and better incentives to caregivers given that the staff members were almost all volunteers [30].
Access to CBCCs has steadily increased from 2.63% in 2000 to 45.3% in 2015 [25]. Even though the total number of children accessing CBCCs is at approximately 1.6 million, there is still a large gap in terms of access, as over half of eligible children (stipulated between the ages of three to five years) do not access CBCCs in Malawi. There is also acknowledgement that there are inadequate services for CWD within the ECD system as the focus has been on older children [31].
In recent years, ECD in Malawi has undergone a rapid transformation with developments in government policy, the validation of Early Learning and Development Standards (ELDS) and the reviewing of training protocols for volunteer ECD trainers. The current National Early Childhood Development Policy [31] aims to promote a comprehensive approach to CBCCs to fully develop children's potential. It includes recognition of the need to improve infrastructure of CBCCs and facilities for CWD alongside other key issues such as the need for adequate materials and resources, training for caregivers and improved monitoring systems.

Inclusion within Early Childhood Education and Care in Malawi
The National ECD curriculum and the ELDS [32] used together provide the basis for ensuring minimum standards of provision and quality of ECD services in Malawi. The ELDS is based on an age and stage model and sets expectations for what children should be able to do at different ages in the six domains of learning and development: physical development, social and emotional development, approaches towards learning, language, literacy and communication, cognition and general knowledge and spiritual and moral development. Whilst the ELDS have influenced the curriculum offered to children, UNICEF's Annual Report on Malawi [33] commented there has been little impact on the assessment of children's development, including CWD, which could in turn have been used to inform policy and practice.
The purpose of ECEC in Malawi, as in other countries, remains contested with some emphasising its primary function as a preparation for school, whereas others seeing ECEC as a discreet period of learning and development. For example, whilst the national ECD policy proposes a 'holistic' development of the children, Kholowa and Rose [34] report that the practice within CBCCs is perceived by 80% of the parents and guardians of children towards preparation of the children for primary schooling. The parents and guardians believed attendance at CBCCs helped the children to develop the potential to learn in school. This has implications for groups of vulnerable children such as those with disabilities who may not be perceived to be included in school and therefore do not need to attend the CBCCs.
Similarly, tensions are evident within the ELDS and its position on inclusion [32]. The standards set are the expectation for all types of children regardless of their condition or context (e.g., children with disability, urban, rural, poor or rich, etc.). This means all children in Malawi are expected to achieve the standards for optimal development, however this is positioned alongside the principle that each child will develop and learn at a different pace due to developmental and contextual differences [32]. Therefore, the dual responsibilities of achieving high standards whilst meeting the differing individual needs is placed on volunteer caregivers, through planning and implementation of developmentally and contextually appropriate experiences and activities that accommodate the diverse needs of all children whilst helping them to achieve each standard. This, in turn, has implications for those who train the caregivers.
A more recent article by Munthali et al. further examined the data collected on CBCCs in 2006-7 including information from CBCC caregivers on admission criteria for enrolling children, alongside other aspects of CBCCs [35]. Although CBCCs should register children regardless of their disability, there was a discrepancy over numbers registered, with most stating an absence of CWD in their locality. The caregivers indicated a reluctance to enrol children with special educational needs and disabilities because of 'lack of appropriate training and resources' (p. 4), including those with communication difficulties 'mainly because he or she may fail to interact well with his or her friends and caregivers' (p. 5), and those they may consider to have behaviour problems. This indicates the tension that exists between the inclusive policy promoted at the national level and practice on the ground for children with disabilities.
As part of the first phase of the 'Tikule Limodze' (Let's Grow Together) project, interviews were conducted with parents and caregivers on how children with disabilities are included in CBCCs as well as learn about the barriers that prevent their inclusion. In phase one, Gercama et al. [36] analysed primary research data gathered by community-based participatory research (CBPR) volunteers in interviews with parents of CWD and caregivers in ten CBCCs across Thyolo district in Malawi. As a methodology, CBPR aims to have respectful collaboration with the community: mutual dialogue, shared decision-making and low levels of hierarchy actively involve community-based actors in planning, data collection, analysis and dissemination (Greenwood et al., 2016) [37]. The analysis of the primary research data indicated that both parents and caregivers reported a wide range of disabilities, using descriptive terms for the child and their difficulties rather than medical labels, and had had negative experiences trying to find a diagnosis and support for their child.
For CWD, many parents reported discrimination against their child and family, alongside strong fears of stigmatisation, which impacted negatively on enrolment and attendance at CBCCs in phase one of the study [36]. Caregivers reported that parents may not enrol their CWD, particularly those with intellectual difficulties, as they perceived the children as not 'fit to learn', building on Kholowa and Rose's [34] finding that ECEC is considered by the majority of parents predominantly as preparation for school. In addition, some parents were worried about their children being a burden on staff or feared their child could risk passing on their disability, particularly epilepsy, to others. These factors sit alongside other factors that affect all children's attendance at CBCCs, for example, the provision of food could enhance attendance, and in contrast, market days, hidden fees for uniform and snacks, long distances and difficult terrain could lead to absenteeism.
It is interesting to note that whilst caregivers feared parents may not enrol their child or withdraw them due to the lack of space or other issues relating to the CBCC structure and resources, parents and guardians of CWD did not raise this as a concern [36]. Instead, parents emphasised the value of time at the CBCC to the child both in the present, in relation to interaction and learning, and also for their future. On a positive note, caregivers noted the value of CWD observing and playing with their peers and accessing toys and that all children, both disabled and non-disabled, benefitted from this interaction [36].
Overall, this highlights that whilst there is growth in the provision of ECEC through CBCCs in Malawi, there is some distance to go in terms of the participation of CWD. A number of barriers inhibit attendance, including concerns regarding resources, perceptions of parents of the function of attending a CBCC and the caregivers' confidence in how best to support CWD.

Training for Caregivers in Early Childhood Education and Care in Malawi
The OECD [38] recommendations from research into quality in ECEC states that both pre-service qualifications and in-service training result in higher quality interactions between children and the staff working with them. This, alongside exposure to appropriate developmental and educational activities, impact positively on children's outcomes including emergent literacy and numeracy, behaviour and social skills. However, it is important to note that this recommendation relates to higher level, diploma or degree, qualifications, whereas in Malawi, caregivers are offered either a basic two-week or an extended six-week training course. Nevertheless Elliott [39] and Sheridan et al. [40] state that it is not the qualification that has an impact on child outcomes, but the ability of more qualified staff members to create a 'high-quality pedagogical environment' that makes the difference as higher quality pedagogy leads to improved learning outcomes [41]. Shonkoff and Philips [42] argue that more specialised staff education and training on ECEC lead to staff engaging in more sensitive and stimulating interactions with children.
In low and middle-income countries in sub-Saharan Africa, there are concerted efforts to provide pre-service training to ECD volunteers and pre-school teachers. In Ethiopia and Tanzania, training programmes are organised by national government systems, whereas in other countries, such as Kenya, large private organisations take this role, and in South Africa, a small number of NGOs have begun to address this need. However, despite these efforts, Diawara [43] reports that many caregivers and teachers in ECEC are employed on a contract basis, receive a low salary and have little or no professional training for their role. Formal employment requirements are often not respected and staff working within ECD receive less and a shorter duration of training than their primary school counterparts. Generally, if salaries are paid, they are very low (less than $50/month in several countries). It is also important to recognise there are significant differences between countries. Fewer than one quarter of the staff received training in Cape Verde, Ghana and the United Republic of Tanzania. In contrast, the percentage of those trained in ECEC is about 90% or above in Benin, Côte d'Ivoire, Mauritius, Niger and Senegal.
As in other low-income countries, whilst standards for practice are in place in Malawi, the World Bank SABER [44] report of 2015 highlights the poor quality of ECD services due to untrained and unpaid caregivers, poor structures, lack of materials and irregular operating days and times. Whilst CBCCs are operating for the recommended minimum 15 h a week and 26,888 caregivers were employed, only 14,223 (56 percent) had received the minimum two-week training recommended by 2011 [44].
It was also noted in phase one that the caregivers, within their study, were themselves often parents of CWD [36]. However, the majority of caregivers emphasised the importance of receiving additional competency training and skill development, particularly in sign language and other special education methods. It was noted that CWD may not achieve their potential learning outcomes because caregivers did not have the required skills. This in addition to concerns about a lack of material resources, water, sanitation facilities and a safe and appropriate space was an additional challenge to providing quality care for the children.

Review of Literature
The broad aim of the research project Tikule Limodze (Let's Grow Together) was to promote the inclusion of children with disabilities through adaptation of assessment tools, teaching curricula and methods in the rural Thyolo district of Southern Malawi. The focus of this phase of the research was to review literature on curriculum and inclusive teaching approaches used in ECEC in sub-Saharan Africa, alongside a review of Malawi policy documents in order to develop the intervention for the project, i.e., a training for trainers programme, promoting inclusive early childhood education and care that could then be scaled up to be used nationally. The research questions for this phase of the project were: 1.
What inclusive teaching approaches and curriculum are most appropriate for providing ECEC in sub-Saharan Africa? 2.
What is the most effective way to train staff in ECEC on the inclusion of children with disabilities?
The literature review was conducted in 2016 based on the approach suggested by Boland, Cherry and Dickson (2017) [45] in reviewing the differing curricula and teaching approaches used in provided ECEC services in low-income countries, with a focus on sub-Saharan Africa. The initial searches used the following key terms: "early childhood", "Malawi", " vulnerable children", "sub-Saharan Africa", "low income countries", "developing countries", " special educational needs", "disability", "inclusive education", "school readiness", "early learning development standards", "curriculum", "syllabus" "teaching methods" "teaching resources" "community-based centres" and "early childhood centres". The search focused on education, psychology, early childhood and development journals within the University of Birmingham database, which includes prominent databases such as the British Education Index, Australian Education Index and Education Resources Information Centre (ERIC). Additional databases such as the World Bank, UNICEF and UNESCO were also used to provide additional documented details. A snowball approach was taken whereby reference lists were reviewed to identify further material. A total of 87 titles and abstracts were reviewed to check for relevance to the research question. Duplicates were removed and 64 articles were read in full for data extraction focusing on data for staff development on inclusion, curriculum and teaching approaches in ECEC in sub-Saharan Africa. Many of the articles emphasized the value of ECEC in sub-Saharan Africa, highlighted the importance of developing further provision and offered opinions on approaches. They were very limited in terms of offering empirical research and so all papers were included where relevant information was offered. The data within the articles was synthesised and the key themes of pedagogy, skills and attitudes to inclusion in ECEC were identified.
Given the narrow conceptualisation of the term inclusion for young children with disabilities in research studies within low-and middle-income countries (LMICs), the study drew on a bioecological systems theory of human development to provide the parameters for a broader unit of analysis [5]. The bioecological systems theory, as proposed by Bronfenbrenner [46], explicitly situates human development within a particular cultural context in which family, peers and learning settings are regarded as key in responding to young CWD. In relation to child development, the theory is commonly represented as a system of nested environments that are illustrated as a series of concentric circles situated around a developing individual to represent his or her ecology [5,46]. The individual at the centre of this complex ecology is viewed as being an active agent with the context in which such development takes place described by Bronfenbrenner with reference to the five interrelated systems (micro, meso, exo, macro; chrono).
The bioecological model of inclusive early childhood development illustrates the environmental factors that can affect the inclusion of young children with disabilities within CBCCs in Malawi. The main environmental settings of this study within the microsystem were the CBBCs in the selected district of Malawi, and the training of the caregivers was considered to be located in the mesosystem. The augmented training aimed to address the caregivers' pedagogy, skills and attitudes to inclusion through the development of an augmented training programme, which modelled a participatory pedagogic approach to teaching, learning and care and included a range of activities. The activities included opportunities to reflect on the rights of CWD, the needs of their parents and carers, demonstration of practical ways to make early literacy, maths and language activities more inclusive and guidance on how to support the participation of young CWD in the daily activities of a CBCC. The outer layers of the framework were conceptualized as being outside of the child's direct agency but nevertheless have broader relevance to the context in which the CBBCs operate. Thus, the exosystem includes the inclusive practices of a given CBCC to ensure children with particular needs are appropriately accommodated within the setting. The macrosystem includes Malawi's national early childhood development and education policies containing guidelines on ways to include children with disabilities into schools and early childhood settings.

Pedagogy-Culturally Sensitive Approaches as Opposed to Transfer of Approaches from High-Income Countries
Rogoff [47] emphasises 'cultural regularities' to help make sense of the cultural aspects of early childhood development. She argues that researchers should avoid using an imposed etic approach, making general statements or assumptions about human functioning across communities and countries based on a culturally inappropriate misunderstanding. Rather, she states the need for a 'derived etic approach', which focuses on the situated meaning of what is happening in a country, such as Malawi, through examining countries with similar community practices.
For example, high-income countries generally enrol children in age-based settings and follow age and stage practices, preparing children for later entry into school. In comparison, low-income countries involve children in everyday activities of their communities following an 'indigenous pedagogy' that permits young children to learn in participatory ways in contexts such as the home, community and religious services through 'work-play' activities, with little to no explicit didactic support [48]. Therefore, an effective ECEC programme should ensure a strong connection between home and community which takes into account the daily practices such as eating, hygiene, dressing, socialising, attending public meetings and traditional ceremonies, e.g., funerals and community rituals.

Pedagogy-Child Initiated Learning as Opposed to Adult Initiated Learning
Schweinhart and Weikart [49] suggest that a curriculum with a high level of child-initiated activities can have long-term benefits, including an increased level of community service and a wish to continue to higher education. The OECD [13] reiterates the importance of integrating exploration, play and peer interaction into the curriculum. Evidence suggests that social pretend play and child-initiated play lead to better co-operation, self-regulation and interpersonal skills [50][51][52]. Research by the Canadian Council on Learning (CCL) [53] shows that children are more competent and creative across a range of learning areas when they are encouraged to participate in different age-appropriate activities.
Despite these approaches, regions and countries hold different expectations for children in diverse societies. For example, sub-Saharan African countries place strong values on children respecting their parents and elders at an early age and being able to serve them [54]. Indeed, the African Charter on the Rights and Welfare of the Child [19] adds an extra dimension by expecting the child to work 'for the cohesion of the family, to respect his parents, superiors and elders at all times and to assist them in time of need'. This emphasis on children respecting elders is also acknowledged in the UNESCO IECCE Curriculum and Framework for Africa [55] which places a strong value on politeness and courtesy in speech and behaviour and enforcing of strong moral values. Within the National ECD curriculum, the ELDS [32], children are taught to have respect for their elders, whether or not they are related to them, which has implications in terms of children's willingness to initiate their own learning in an environment when adults should be respected and listened to.

Skills-Teaching of Children with Disabilities-Functional as Opposed to Generic Skills
Baine [56] highlights that curricula designed for young children in ECEC programmes include generic skills such as building a tower of blocks. This is based on commonly held assumptions that the 'generic' skills acquired when the children learn these tasks are prerequisite to learning higher level skills, -the acquired skills will generalise to performance of more functional activities, -CWD in low-income countries are taught skills that are frequently found in curricula of typically functioning children in high-income countries.
Tension exists between skills within the curriculum that teachers are expected to teach and the difficulties children may have being able to generalise the skills to their own environments. For example, 'it may be a waste of valuable instructional time and effort to teach village children to place pegs in a pegboard or string beads when time is being taken away from teaching other skills that are more functional in the child's daily environment' (p. 153) [56]. Brown et al. [50] emphasised the importance of reflecting on the contexts the child will use the skills taught when considering how to generalise. Rogoff [47] emphasises the opportunities to observe and participate, allowing children to learn through attention ' . . . to ongoing activities, rather than relying on lessons out of context . . . ' (p. 9).

Attitudes to Inclusion in Early Childhood Care and Education-Integrated or Stand-Alone Approach
Sharma et al. [57] undertook research in disability education across Australia, Canada, Singapore and Hong Kong. They highlight that educators who have received some disability training are more likely to have positive attitudes to inclusion, and they examined the type of approach and content that supported educators to develop this more positive attitude. Although they were not able to state whether an integrated or stand-alone model was better, they noted the central importance of the content and the pedagogy of a programme as the most significant predictors of pre-service teachers' attitudes, sentiments and concerns about inclusion. They also emphasised the importance of pre-service teachers having direct and regular contact with persons with disabilities to enhance an understanding of different disabling conditions and be aware of local policies supporting inclusion. This resulted in educators being more likely to feel positive about including students with disabilities.
There is limited research on pre-service training on inclusion in ECD/ECEC globally. Arthur-Kelly et al. [58] discussed whether inclusion should be integrated into core content on pedagogy or should be treated as a single unit, however, this research is conducted in Australia and New Zealand. The arguments for the first approach are that it models collaboration, which is essential to best practice in inclusive education. In addition, it has an improved uptake by students of attitudinal, knowledge and skill changes to create better opportunities to make informed links between theory, research and practice in relation to the diversity of student needs and contexts. In comparison, stand-alone methods may be better as those with specialist knowledge and a clear understanding of inclusion teach the relevant module.
Each of these four themes raised important arguments about the approaches taken with the training on inclusion in ECEC and therefore had implications for the training of the caregivers in Malawi. Whilst there was no clear direction in the literature as to which theme should be prioritised, we felt it was important to take a culturally sensitive approach and to build upon the pre-existing frameworks, structures, approaches and policies of Malawi as well as the bioecological systems theory of human development. This led to some inevitable tensions. For example, even though the literature review emphasised the value of child-led learning, it was important to acknowledge that this contrasted with the traditional approach taken to education, including ECEC, in sub-Saharan Africa [55]. Similarly, the literature review highlighted the importance of the teaching of functional skills to CWD, but curriculum documents such as the ELDS [32] included generic skills such as the teaching of colours, alongside functional skills, e.g., hygienic practices. It was agreed to enhance the existing training framework [59] through an integrated approach to raise awareness of and give practical strategies for inclusion of CWD within the nationally agreed two-week timetable and work using a derived etic approach first and foremost.

The Intervention-Developing an Enhanced Pre-Service Training Programme on Inclusive Education and Care in Malawi
Drawing on the themes identified in a review of literature, an Inclusion Resource Pack was developed by the University of Birmingham, in collaboration with Chancellor College, Sightsavers and National ECD trainers in Malawi, to highlight disability and promote the inclusion of CWD in the daily activities of the CBCCs. Each of the 24 CBCCs who participated in the training was given a copy of the resource pack, including items to facilitate the participation and inclusion of CWD. To be sustainable, the three-day training needed to enhance, but not extend, the existing basic two-week recommended training and to work within a resource constrained context with a limited infrastructure around ECEC. It also needed to be accessible and manageable for the caregivers, with the majority being unpaid for their work and having limited literacy skills. We outline next how the training materials and related programme were developed.
The enhanced training programme drew on the themes from the literature review, training on inclusion in ECEC, the policies and practices of both inclusion and ECEC in Malawi and the views of parents and caregivers [36] to support caregiver's pedagogy, skills and attitudes to inclusion in ECEC. The data on the views of parents/caregivers was gathered by volunteer researchers trained in community-based participatory research (CBPR) methods [37]. The CBPR component of the study took place in ten target communities in Thyolo, Malawi, over ten days in November 2016 [36]. Community researchers were trained by research assistants from Chancellor College, University of Malawi, to interview parents of CWD enrolled at ten CBCCs and the caregivers who worked there. It outlined the issues raised by participants in relation to the impact disability had on the children's capacity to interact or play and examined the perceived success of CBCC attendance, reasons for non-enrolment and absenteeism from CBCCs and barriers faced by CWD and their parents and carers. This was delivered over three days as a training for trainers, for local trainers from the Association of Early Childhood Development in Malawi (AECDM), local colleges and NGOs, who would then deliver the enhanced two-week training to the caregivers in the next phase.
To promote inclusive attitudes, the training programme utilised an integrated, as opposed to a stand-alone, approach to the issue of inclusion. Therefore, discussion, reflection and practical strategies to facilitate inclusion of CWD were threaded throughout the existing national ECD two-week pre-service training. In comparison, the original version of the two-week training had a short stand-alone unit of training on inclusion at the latter end of the course, based on the legislative framework and the rights of CWD. Whilst it is acknowledged that this knowledge is important, it contrasted with the rest of the training which had a practical focus and was therefore more useful and accessible for the caregivers.
Caregiver skills in terms of developing inclusive activities were modelled. For example, promotion of literacy and participatory storytelling techniques such as the helicopter approach were modelled alongside reflection on how to encourage the full participation of case study CWD. Collaborative activities such as parachute games were introduced to model ways to include all children. Similarly, caregiver skills in relation to working with parents and carers of CWD was developed through role play based on parent comments [36].
Practical, sustainable, inclusive activities were introduced which built upon and enhanced the existing two-week training [59] to introduce a participatory pedagogy of teaching and learning. Whilst the existing model of training tended to be in the adult-led tradition of teaching, a key theme in the literature review had been to prioritise culturally sensitive approaches, and therefore the preferred pedagogical approaches commonly adopted in Malawi ECEC [44] were built upon, such as the use of singing and storytelling for teaching. In addition, learner-led, inclusive and participatory approaches were modelled where feasible so those being trained could see the value of active involvement, encouraging an approach which mirrored children taking the lead and child-initiated learning [13]. Similarly, it was important to acknowledge the lack of resources available to the caregivers, therefore the potential of using of free, locally available materials such as sticks, stones and bottle tops was drawn upon. For example, participants were encouraged to bring their own free resources (including leaves or seed pods) to use in teaching number and quantity, and then role play was used to reflect on how to support, for example, a visually impaired child to access the play, building upon the existing training in early maths.
Sharma et al.'s [57] key point regarding attitudes to inclusion was to encourage caregivers to have direct and systematic contact with persons with disabilities, so simple case studies of children with disabilities were created. The case studies were co-constructed with those delivering the training to the caregivers and included short descriptions of children, giving their name, age, interests and special educational needs and disabilities. In addition, the trainers were supported to reflect on all the activities and experiences covered in the two weeks of training and reflect on how these could be adapted to enable the inclusion and full participation of these children. The trainers were encouraged to support the caregivers to discuss ways to support inclusion and reduce segregation. It was anticipated this would create the necessary attitudinal change noted by Arthur-Kelly et al. [58].

Discussion and Conclusions
The evidence suggests that enriched stimulating environments and high-quality pedagogy are nurtured by better qualified staff and that high-quality pedagogy leads to improved learning outcomes [14]. The Malawi Government has a revised ECD national policy [23] in place, recognising the need for further investment in the sector, particularly around developing curricula and standards. The Tikule Limodze project enhanced the basic two-week training for volunteer caregivers in a sustainable way. This was demonstrated by this change in the training being accepted by AECDM with plans to continue the adaptation and deliver it in this way in the future. This helped support a pedagogical ECEC environment that is more inclusive of all children, particularly those with disabilities.

Principles for Developing Training on Inclusion for ECD Caregivers in Malawi
The enhancement of the existing two week training cannot simply be replicated in other contexts. However key principles relating to the development of pedagogy, caregiver skills and positive attitudes to inclusion were identified which could be usefully considered when developing similar training in other low-income countries. In order to create sustainability, a key principle was the need to be respectful of how children are brought up and educated in the local culture, to build on the local practices, knowledge and strengths that exist in ECEC and collaborate with local training providers, community and ECD services. To support caregiver skills, flexible, practical and viable activities were a necessity, taking account of the vulnerability of ECEC settings such as food shortages and lack of buildings and play materials, and therefore the value of using local, easily sourced, low-cost or free resources was emphasised. Pedagogically, it was vital to integrate messages around inclusion and participation throughout the training through modelling a participatory approach to learning, challenging the traditional trainer-led approach. In addition, it was important to be inclusive of the caregivers themselves, making the training accessible, so they could replicate activities, as well as consider issues such as literacy, resource constraints and how activities could be easily integrated into the daily life of the CBCCs. Finally, in order to support positive attitudes to inclusion in early childhood education and care, repeated opportunities to reflect on and discuss case studies of CWD enabled trainers and caregivers, many of whom had CWD, to consider their own values and how to practically support the inclusion and participation of all children, including those with disabilities.
Based on these principles, we created a respectful, situated, sustainable training approach that recognised and valued the policy and practice of a low-income country, in this case Malawi. It was key that it was culturally sensitive and built on the existing policy and approaches to professional development of caregivers, consolidating the strengths of their practice whilst acknowledging and seeking to support caregivers themselves to reflect on ways around the barriers to the inclusion of CWD. The key elements included integrating the concept of inclusion throughout the training and supporting the caregivers to understand all children's rights to ECEC and to reflect on how they can practically include CWD in their activities through use of case studies. We would argue that the broad approach and the underpinning principles for developing training for caregivers outlined in this article can potentially be adapted and applied to support ECEC in other low-income countries in sub-Saharan Africa and beyond, to help ensure young CWD are fully included in ECEC and, significantly, have access to equal opportunities to learn, play and develop with their non-disabled peers.