BMJ  2004;329:89 (10 July), doi:10.1136/bmj.38132.503472.7C (published 24 June 2004)

Primary care

Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomised controlled trial

¹ Epidemiology Research Unit, University of the West Indies, Mona, Kingston, Jamaica, ² Department of Educational Studies, University of the West Indies, ³ Pan American Health Organization/World Health Organization, Kingston, Jamaica, ⁴ Centre for International Child Health, Institute of Child Health, London WC1N 1EH

Abstract

Objectives To assess the feasibility of integrating early psychosocial stimulation into primary care for undernourished children and to determine the effect on children's development and mothers' knowledge and practices of childrearing.

Design Cluster randomised controlled trial.

Setting 18 clinics in three Jamaican parishes.

Participants 139 undernourished children aged 9 to 30 months and their mothers enrolled in intervention or control clinics.

Interventions Weekly home visits by community health aides for one year in addition to usual duties. Parenting issues were discussed with the mothers and play activities were demonstrated with the children using homemade materials.

Main outcome measures Children's scores on the Griffiths mental development scales and mothers' knowledge and practices of childrearing.

Results Children from the intervention group showed significant improvements in development: developmental quotient, 7.8 points (95% confidence interval 4.5 to 11.1); hearing and speech, 10.7 points (5.9 to 15.4); hand and eye coordination, 6.8 points (3.4 to 10.1); and performance subscale, 11.0 points (5.6 to 16.4). No improvements were shown on the locomotor subscale. The mothers from the intervention group showed improved knowledge and practices of childrearing. Change in body mass index and height independently affected change in development.

Conclusion Integrating parenting skills and early psychosocial stimulation for undernourished children into primary care was feasible and effective in improving the children's development and mothers' knowledge and practices of childrearing.

Introduction

Undernutrition in children usually leads to poor cognitive development and school achievement.¹ Undernutrition is associated with a poor home environment, which also affects development. Small controlled trials have found sustained benefits from early psychosocial stimulation of undernourished children.^{2 3} We integrated psychosocial stimulation into the primary healthcare services for undernourished Jamaican children and examined the effect on the children's development and their mothers' knowledge and practices of childrearing.

Participants and methods

We recruited undernourished children from all 12 nutrition clinics in the urban areas of Kingston and St Andrew, Jamaica. We stratified the clinics into large and small, and numbered them. These were allocated to intervention or control according to a random number table. Fewer children were available than anticipated from the clinics' records, therefore we enrolled six clinics in the urban area of the adjacent parish of St Catherine. Four were randomly assigned to intervention and two to control to ensure similar numbers of children in each group, totalling 11 intervention clinics and seven control clinics. Inclusion criteria are listed on bmj.com. Overall, we recruited 70 mother-child dyads from intervention clinics and 69 from control clinics.

Outcome measures and intervention
The children's developmental levels were assessed with the Griffiths mental development scales at baseline and one year later.^{4 5} We used four subscales—locomotor skills, hearing and speech, hand and eye coordination, and performance. These were averaged to give a global developmental quotient. Higher scores indicate better development. The children were assessed by one of two people, blinded to allocation group.

The children's weights and lengths or heights were measured by standard procedures. Mothers' knowledge and practices of childrearing were assessed by questionnaires at baseline and one year later. The questionnaire on knowledge was specifically developed for our study. It comprises 20 questions on feeding practices and activities likely to promote language and cognitive development in children. Higher scores are associated with better knowledge. The responses were summed (maximum score 70). The questionnaire on childrearing practices comprised 15 questions to assess how often the mother involved her child in a range of activities, such as singing and playing games. The items were summed (maximum score 62).

On enrolment a researcher visited the homes and collected information on socioeconomic background, mother's height, and her verbal IQ.⁶

Over one year the community health aides visited the homes weekly and demonstrated play activities. Homemade materials were used to reduce the cost of the intervention. The aides followed a structured curriculum.^{7 8} Toys were left in the homes and exchanged at each visit. Parenting issues were discussed.

Statistical analysis
All analyses were conducted on an intention to treat basis. Multilevel multiple regression analysis was used to examine the effect of intervention, taking into account the hierarchical structure of the study. Clinic was entered as a random variable to account for the variance among clinics. Separate regressions were computed to examine the treatment effect on developmental quotient and each subscale score, mothers' knowledge and practices of childrearing, final weight, length, and body mass index. We entered the initial measure in each analysis to assess change. Covariates were offered and treatment group (intervention, n = 1; control, n = 0) entered in the final step.

Results

Overall, 129 children (93% of those enrolled) were assessed at the end of the study. Four mothers of children who had a repeat test completed did not complete the repeat questionnaire (three controls and one intervention), giving a total of 125 mothers (90% of the sample). The groups had similar characteristics on enrolment (table 1).

View this table: [in this window] [in a new window]   Table 1 Children's scores on Griffiths mental development scales and anthropometric measures, and mothers' knowledge and practices of childrearing at baseline and one year's follow up. Values are means (standard deviations)

 

The intervention had significant benefits on the children's development: 7.8 developmental quotient points (95% confidence interval 4.5 to 11.1); hearing and speech, 10.7 points (5.9 to 15.4), hand and eye coordination, 6.8 points (3.4 to 10.1), and performance, 11.0 points (5.6 to 16.4; table 2). The intervention showed a significant benefit on mothers' knowledge of childrearing (7.6 points, 5.7 to 9.4) and childrearing practices (5.0 points, 1.6 to 8.4). Growth did not modify the effects of intervention, but change in length and body mass index predicted the developmental quotient.

View this table: [in this window] [in a new window]   Table 2 Multilevel analysis of effects of intervention on children's Griffiths scores and anthropometric measurements, and mothers' knowledge and practices of childrearing

 

Discussion

Government health aides based in primary healthcare centres in Jamaica successfully delivered an intervention to promote childhood development in addition to their usual duties. On average the children were visited every 10 or 11 days. The intervention had substantial benefits on development. The decline in developmental levels shown by children from control clinics is common in children from poor backgrounds,⁹ and intervention reduced this decline. The benefits were greater than the average gain found in developed countries.¹⁰ Benefits were shown in all subscales except that for locomotor skills. The improvements in mothers' knowledge and practices of childrearing may be important for the sustainability of benefits to children and their siblings.

What is already known on this topic Children who are undernourished usually have poor cognition and school achievement Controlled trials have shown that psychosocial stimulation can have sustained benefits on their development What this study adds Child development activities were successfully integrated into primary healthcare services for undernourished Jamaican children The intervention improved the children's development and their mothers' knowledge and practices of childrearing

National governments would need to commit some resources to enable child development activities to be integrated into primary healthcare services and for them to be sustainable. Additional training, a coordinator and materials would be required. We determined that each aide could visit 3-5 children in addition to usual duties, which would take about half a day. The cost and workload of similar paraprofessionals varies by country, and the number of children served would depend on this. As there was a limit to the number of children who could be visited, the programme would be most suitable for those at high risk.

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This is the abridged version of an article that was posted on bmj.com on 24 June 2004: http://bmj.com/cgi/doi/10.1136/bmj.38132.503472.7C

We thank research assistants Pauline Alcott, Ava Mundell, Joan Thomas, and Michael Ennis, the public health nurses, the community health aides, the clinic staff, and the parents and children who participated in the study.

Contributors: See bmj.com

Funding: This study was supported by the Thrasher Research Fund, USA, with subsidiary grants from the British High Commission's Department for International Development, Jamaica, and the University of the West Indies Mona Campus Research and Publication fund. The Ministry of Health, Jamaica, supported the community health aides. This work was undertaken in collaboration with Great Ormond Street Hospital for Children NHS Trust, which receives a proportion of its funding from the NHS Executive.

Competing interests: None declared.

Ethical approval: University of the West Indies ethics committee and the Ministry of Health, Jamaica.

References

1. Pollitt E, Schurch B, eds. Undernutrition and behavioral development in children. J Nutr 1995;125: S2255-62.
2. Grantham-McGregor S, Powell C, Walker S, Chang S, Fletcher P. The long term follow up of severely malnourished children who participated in an intervention program. Child Dev 1994;65: 428-39.[CrossRef][Web of Science][Medline]
3. Walker S, Grantham-McGregor S, Powell C, Chang S. Effects of growth restriction in early childhood on growth, IQ and cognition at age 11 to 12 years and the benefits of nutritional supplementation and psychosocial stimulation. J Pediatr 2000;137: 36-41.[CrossRef][Web of Science][Medline]
4. Griffiths R. The abilities of babies. London: University of London Press, 1967.
5. Griffiths R. The abilities of young children. London: Child Development Research Centre, 1970.
6. Dunn L, Dunn L. The revised Peabody picture vocabulary test. Nashville: American Guidance Service, 1981.
7. McDonald K, Grantham-McGregor S, Chang S. Social stimulation of the severely malnourished child. A home training program. Indian J Pediatr 1989;56: 97-103.[Medline]
8. Grantham-McGregor S, Powell C, Walker S, Himes J. Nutritional supplementation, pscyhosocial stimulation and mental development of stunted children: the Jamaican study. Lancet 1991;338: 1-5.[CrossRef][Web of Science][Medline]
9. Golden M, Burns B. Social class and infant intelligence. In: Lewis M, ed. Origins of intelligence. New York: Plenum, 1976: 299-351.
10. Barnett W. Long-term cognitive and academic effects of early childhood education on children in poverty. Prev Med 1998;27: 204-7.[CrossRef][Web of Science][Medline]

(Accepted 1 April 2004)

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