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Kabongo J, Mudawarima L, Majo FD, Dzikiti A, Tome J, Chasekwa B, Mutasa B, Dzapasi L, Munetsi E, Cordani I, Ntozini R, Langhaug LF, Bwakura-Dangarembizi M, Prendergast AJ. Child play and caregiver support to promote convalescence following severe acute malnutrition in Zimbabwe: The Tamba-SAM pilot study. MATERNAL & CHILD NUTRITION 2024:e13726. [PMID: 39267583 DOI: 10.1111/mcn.13726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 07/29/2024] [Accepted: 08/20/2024] [Indexed: 09/17/2024]
Abstract
Children hospitalised for severe acute malnutrition (SAM) have a high risk of mortality, relapse and rehospitalisation following hospital discharge. Current approaches fail to promote convalescence, or to address the underlying social determinants of SAM, meaning that restoration of long-term health, growth and neurodevelopment is not achieved. Although guidelines recommend play and stimulation to promote recovery, most caregivers are not supported to do this at home. We set out to evaluate the feasibility and acceptability of a codesigned intervention package aimed at providing child stimulation through play, and strengthening caregiver capabilities through problem-solving skills, peer support and income-generating activities. We evaluated the intervention in two phases, enroling 30 caregiver-child pairs from paediatric wards in Harare, Zimbabwe, once children who had been hospitalised with SAM were ready for discharge. Children were median 17.8 months old, and 28.6% had human immunodeficiency virus. Trained intervention facilitators (IFs)-lay workers whose own children had previously had SAM-delivered the intervention over 12 weeks with nurse supervision. Qualitative interviews with caregivers and IFs showed that the intervention was feasible and acceptable. Participants reported benefiting from the psychosocial support and counselling, and several started income-generating projects. Caregivers appreciated the concept of play and caregiver-child interaction, and all reported practising what they had learned. By Week 12, caregiver mental health and caregiver-child interaction improved significantly. Overall, the intervention was feasible, acceptable and showed promise in modifying caregiver knowledge, attitudes and practice. An efficacy trial is now needed to evaluate whether the intervention can improve child convalescence following complicated SAM.
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Affiliation(s)
- Jacqueline Kabongo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Louisa Mudawarima
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of Paediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Anesu Dzikiti
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | | | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lisa F Langhaug
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of Paediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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Palmer T, Clare A, Fearon P, Head R, Hill Z, Kagone B, Kirkwood B, Manu A, Skordis J. Cost-effectiveness of a radio intervention to stimulate early childhood development: protocol for an economic evaluation of the SUNRISE trial in Burkina Faso. BMJ Open 2024; 14:e080905. [PMID: 38626956 PMCID: PMC11029498 DOI: 10.1136/bmjopen-2023-080905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/14/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Approximately 250 million children under 5 years of age are at risk of poor development in low-income and middle-income countries. However, existing early childhood development (ECD) interventions can be expensive, labour intensive and challenging to deliver at scale. Mass media may offer an alternative approach to ECD intervention. This protocol describes the planned economic evaluation of a cluster-randomised controlled trial of a radio campaign promoting responsive caregiving and opportunities for early learning during the first 3 years of life in rural Burkina Faso (SUNRISE trial). METHODS AND ANALYSIS The economic evaluation of the SUNRISE trial will be conducted as a within-trial analysis from the provider's perspective. Incremental costs and health outcomes of the radio campaign will be compared with standard broadcasting (ie, 'do nothing' comparator). All costs associated with creating and broadcasting the radio campaign during intervention start-up and implementation will be captured. The cost per child under 3 years old reached by the intervention will be calculated. Incremental cost-effectiveness ratios will be calculated for the trial's primary outcome (ie, incremental cost per SD of cognitive gain). A cost-consequence analysis will also be presented, whereby all relevant costs and outcomes are tabulated. Finally, an analysis will be conducted to assess the equity impact of the intervention. ETHICS AND DISSEMINATION The SUNRISE trial has ethical approval from the ethics committees of the Ministry of Health, Burkina Faso, University College London and the London School of Hygiene and Tropical Medicine. The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference. TRIAL REGISTRATION NUMBER The SUNRISE trial was registered with ClinicalTrials.gov on 19 April 2019 (identifier: NCT05335395).
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Affiliation(s)
| | | | | | - Roy Head
- Development Media International, London, UK
| | | | | | | | - Alexander Manu
- London School of Hygiene and Tropical Medicine, London, UK, London, UK
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Wei R, Sullivan EF, Begum F, Rahman N, Tofail F, Haque R, Nelson CA. Parental communicative input as a protective factor in Bangladeshi families living in poverty: A multi-dimensional perspective. Dev Sci 2024:e13494. [PMID: 38504647 DOI: 10.1111/desc.13494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/03/2024] [Accepted: 02/25/2024] [Indexed: 03/21/2024]
Abstract
Studies from high-income populations have shown that stimulating, supportive communicative input from parents promote children's cognitive and language development. However, fewer studies have identified specific features of input supporting the healthy development of children growing up in low- or middle-income countries. The current study proposes and tests a multi-dimensional framework for understanding whether and how caregiver communicative input mediates the associations between socio-economic conditions and early development. We also examine how caregiver conceptual scaffolding and autonomy support uniquely and synergistically explain variation in child outcomes. Participants were 71 Bangladeshi families with five-year-olds who were exposed to a range of biological and psychosocial hazards from birth. Caregiver-child interactions during snack sharing and semi-structured play were coded for caregiver conceptual scaffolding, autonomy support, and child engagement. Findings indicate that the two dimensions of input were correlated, suggesting that caregivers who provided richer conceptual scaffolds were simultaneously more supportive of children's autonomy. Notably, conceptual scaffolding and autonomy support each mediated associations between maternal education and child verbal intelligence quotient (IQ) scores. Further, caregivers who supported greater autonomy in their children had children who participated in conversations more actively, and these children in turn had higher performance IQ scores. When considered simultaneously, conceptual scaffolding was associated with verbal IQ over and above autonomy support, whereas autonomy support related to child engagement, controlling for conceptual scaffolding. These findings shed new light on how environmental factors may support early development, contributing to the design of family-centered, culturally authentic interventions. A video abstract of this article can be viewed at https://youtu.be/9v_8sIv7ako RESEARCH HIGHLIGHTS: Studies from high-income countries have identified factors mitigating the impacts of socio-economic risks on development. Such research is scarce in low- and middle-income countries. The present study conceptualized and evaluated caregiver communicative input in Bangladeshi families along two interrelated yet distinct dimensions: conceptual scaffolding and autonomy support. Conceptual scaffolding and autonomy support individually mediated associations between maternal education and child verbal IQ, shedding light on protective factors in families living in poverty. Parents providing richer conceptual scaffolds were simultaneously more supportive of children's autonomy. However, the two dimensions each related to cognition and language through unique pathways.
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Affiliation(s)
- Ran Wei
- Graduate School of Education, Peking University, Beijing, China
| | - Eileen F Sullivan
- Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Brookline, Massachusetts, USA
- Harvard Graduate School of Education, Cambridge, Massachusetts, USA
| | - Fatema Begum
- Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Brookline, Massachusetts, USA
| | - Navin Rahman
- Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Brookline, Massachusetts, USA
| | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Charles A Nelson
- Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Brookline, Massachusetts, USA
- Harvard Graduate School of Education, Cambridge, Massachusetts, USA
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Ahun MN, Ali NB, Hentschel E, Jeong J, Franchett E, Yousafzai AK. A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development. Ann N Y Acad Sci 2024; 1533:99-144. [PMID: 38354095 DOI: 10.1111/nyas.15110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
This review summarizes the implementation characteristics of parenting interventions to promote early child development (ECD) outcomes from birth to 3 years. We included 134 articles representing 123 parenting trials (PROSPERO record CRD42022285998). Studies were conducted across high-income (62%) and low-and-middle-income (38%) countries. The most frequently used interventions were Reach Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were delivered as home visits. The other half used mixed settings and modalities (27%), clinic visits (12%), and community-based group sessions (11%). Due to the lack of data, we were only able to test the moderating role of a few implementation characteristics in intervention impacts on parenting and cognitive outcomes (by country income level) in the meta-analysis. None of the implementation characteristics moderated intervention impacts on cognitive or parenting outcomes in low- and middle-income or high-income countries. There is a significant need in the field of parenting interventions for ECD to consistently collect and report data on key implementation characteristics. These data are needed to advance our understanding of how parenting interventions are implemented and how implementation factors impact outcomes to help inform the scale-up of effective interventions to improve child development.
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Affiliation(s)
- Marilyn N Ahun
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nazia Binte Ali
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth Hentschel
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joshua Jeong
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Emily Franchett
- Department of Applied Psychology, New York University Steinhardt School of Culture, Education, and Human Development, New York, New York, USA
| | - Aisha K Yousafzai
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Gaidhane A, Khatib MN, Telrandhe S, Patil M, Kogade P, Gaidhane S, Choudhari SG, Holding PA, Saxena D, Syed ZQ. Design-redesign, implementation, and evaluation of effectiveness of maternal nutrition and responsive parenting program on child development at 2 years of age from rural India: a cluster RCT. Front Public Health 2023; 11:1165728. [PMID: 38035279 PMCID: PMC10682778 DOI: 10.3389/fpubh.2023.1165728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
Background To promote early childhood development (ECD), we require information not only on what needs to be addressed and on what effects can be achieved but also on effective delivery methods that can be adapted to local context. We describe design, implementation, and evaluation of a complex intervention to strengthen nurturing environment for young children. Methods Study participants were pregnant women and their children from birth to 2 years. We used design and redesign, implementation, and evaluation approaches for the study. We co-created curriculum and delivery plan with stakeholders, based on the theoretical framework, findings from formative research, and our preliminary work. We recruited 656 pregnant women and newborns, 326 (49.69%) from intervention and 330 (50.30%) from the control group. We conducted a cluster randomized controlled trial to evaluate the program's effectiveness. The outcomes of children were assessed at 12 and 24 months. Findings At recruitment, study participants from both the study arms were similar in sociodemographic characteristics. We conducted 6,665 home visits, 25 toy-making workshops, and 65 caregiver-meetings. The initial examination of program data revealed gaps in quality and coverage of interventions. The intervention was redesigned based on feedback from stakeholders in community meetings. At recruitment, participants in both study groups had similar socio-demographics. We conducted 6,665 home visits, 25 toy workshops, and 65 caregiver meetings. Initial program data showed intervention quality and coverage gaps, leading to a redesign program based on community and stakeholder feedback. Post-re-designing, session quality improved, with program coverage rising from 32 to 98%. Male participation in home visits increased from 4.3 to 32.65%, and data errors reduced from 270 to 140 per month on average. At 24 months, program showed moderate-mild impact on ECD - cognitive (0.31, 95%CI: 0.13-0.48), language (0.2, 95%CI: 0.01-0.39), and socioemotional-development (0.19, 95%CI: 0.01-0.37), moderate effect on home-environment and mother-child interaction. 96% of women initiated breastfeed within one-hour of delivery, and exclusive-breastfeeding rate of 89.80%. Interpretations The study provides an evidence-based community centered ECD curriculum and implementation strategies to enhance service providers, and caregivers' knowledge and skills for promoting ECD in low-resource settings with the potential to scale within existing Government Program. Funding The trial was funded by the Saving Brains Round 5 Initiative of Grand Challenges Canada (Grant no. SB-1707-05084), and we are grateful for their ongoing support through online sessions and orientation workshops. The trial was also supported by the Indian Council of Medical Research (File No: 5/7/1693/CH/Adhoc/RBMCH-2020).
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Affiliation(s)
- Abhay Gaidhane
- Centre of One Health, School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Mahalaqua Nazli Khatib
- Global Evidence Synthesis Initiative, Division of Evidence Synthesis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Shital Telrandhe
- Global Health Academy, Centre of Early Childhood Development - Stepping Stones Project, Wardha, India
- Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Manoj Patil
- School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Priti Kogade
- Global Health Academy, Centre of Early Childhood Development - Stepping Stones Project, Wardha, India
- Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Shilpa Gaidhane
- Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Sonali G. Choudhari
- Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Penny A. Holding
- Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Deepak Saxena
- i Health Consortium, Department of Epidemiology, Indian Institute of Public Health, Gandhinagar, Gujarat, India
| | - Zahiruddin Quazi Syed
- Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
- South Asia Infant Feeding Research Network (SAIFRN), School of Epidemiology and Public Health, Wardha, Maharashtra, India
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Buccini G, Kofke L, Case H, Katague M, Pacheco MF, Pérez-Escamilla R. Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001542. [PMID: 37556418 PMCID: PMC10411826 DOI: 10.1371/journal.pgph.0001542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/03/2023] [Indexed: 08/11/2023]
Abstract
Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.
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Affiliation(s)
- Gabriela Buccini
- Department of Social and Behavioral Health, University of Nevada Las Vegas School of Public Health, Las Vegas, Nevada, United States of America
| | - Lily Kofke
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Haley Case
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Marina Katague
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
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Coore-Hall J, Smith J, Kelly M, Baker-Henningham H, Chang S, Walker S. Using lessons learnt from key stakeholders to increase support for scaling the Reach Up Early Childhood Parenting program. Front Public Health 2023; 11:1151826. [PMID: 37614447 PMCID: PMC10442950 DOI: 10.3389/fpubh.2023.1151826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023] Open
Abstract
Introduction Sustainable implementation of early childhood programs requires resources, materials and methods that are adaptable, scalable and feasible for delivery through multiple sectors. Additional or modified program resources may be required to meet emerging needs, as programs go to scale. An active and effective monitoring, evaluation and learning (MEL) process may enable programs to be responsive to demands. The Reach Up: Early Childhood Parenting program, is designed primarily for disadvantaged children under 4 years of age in low- and middle-income countries (LMICs) to promote their development through playful caregiver interactions. The curriculum, training manuals and other materials and resources support implementers in the adaptation of the intervention, implementation, workforce training, monitoring and evaluation. This paper reports on how data collected from key informants drove modifications to program processes, materials and resources. Methods We conducted in-depth interviews with 14 key informants (including program managers, lead trainers, academics, consultants and workforce personnel) on their experiences with Reach Up across 15 LMICs where the program has been implemented. We also reviewed written records generated from (i) structured small group discussions at a Knowledge Exchange meeting of 31 Reach Up partners and (ii) notes from working groups formed at the meeting and tasked to continue working post-meeting to find solutions to support ongoing implementation. The transcripts from the in-depth interviews and the meeting records were analysed using thematic analysis with a mixture of pre-defined categories and data-driven sub-themes. Results The main findings indicated that there was a need to: (i) develop advocacy and communication resources and materials to aid prospective implementers and other stakeholders, to make decisions for implementation, (ii) revise and/or add to the content and format of the curriculum and add content in the training and other supporting manuals and (iii) enhance the training process. Conclusion The feedback from the key global partners informed the development of new knowledge materials, resources and processes and modifications to existing program materials and resources. These will help to support advocacy, ongoing implementations, and the process of transitioning the Reach Up early childhood intervention to scale.
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Affiliation(s)
- Jacqueline Coore-Hall
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Joanne Smith
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | | | - Helen Baker-Henningham
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
- School of Human and Behavioural Sciences, Bangor University, Bangor, United Kingdom
| | - Susan Chang
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Susan Walker
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
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Hossain SJ, Tofail F, Mehrin SF, Hamadani JD. Six-Year Follow-up of Childhood Stimulation on Development of Children With and Without Anemia. Pediatrics 2023; 151:191217. [PMID: 37125884 DOI: 10.1542/peds.2023-060221e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Previously, in 30 Bangladeshi villages, 2 groups of children with iron-deficiency anemia (IDA) and nonanemic (NA) iron sufficiency aged 6 to 24 months participated in 2 parallel cluster randomized controlled trials of the effect of psychosocial stimulation on neurodevelopment. The intervention was composed of weekly play sessions at home for 9 months. All children with anemia received iron treatment of 6 months. The intervention improved the mental development of NA but not IDA groups. Six years after end line when the children were aged 8 to 9 years, we aimed to determine if benefits were sustained in the NA group or late-onset benefits emerged in the IDA group. METHODS We relocated 372 (90%) of the initial 412 children from all the clusters (villages), and assessed their IQ with the Wechsler Abbreviated Scale of Intelligence-II, motor development, and school achievement including math, spelling, and reading. Analyses were by intention-to-treat, adjusting for clustering. RESULTS There was a significant interaction between anemia groups (IDA/NA) and intervention on IQ. The intervention benefitted the NA group's Full-Scale IQ (effect size, 0.43 [95% confidence interval, 0.08-0.79]) and Perceptual Reasoning Index (effect size, 0.48 [95% confidence interval, 0.08-0.89]) but did not affect the IDA group's outcomes. No other outcomes were significant. CONCLUSIONS The benefits from early childhood psychosocial stimulation on the NA group's IQ, 6 years after intervention ended, adds to the limited evidence on the sustainability of benefits in low- and middle-income countries. Reasons for lack of effect in children with anemia are unknown.
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Affiliation(s)
- Sheikh Jamal Hossain
- Maternal and Child Health Division
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Fahmida Tofail
- Nutrition and Clinical Science Division, icddr,b, Dhaka, Bangladesh
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Jervis P, Coore-Hall J, Pitchik HO, Arnold CD, Grantham-McGregor S, Rubio-Codina M, Baker-Henningham H, Fernald LCH, Hamadani J, Smith JA, Trias J, Walker SP. The Reach Up Parenting Program, Child Development, and Maternal Depression: A Meta-analysis. Pediatrics 2023; 151:191225. [PMID: 37125892 DOI: 10.1542/peds.2023-060221d] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Evidence is needed on effective approaches to build parents' ability to promote child development feasible in low- and middle-income countries. Our objective was to synthesize impact of the Reach Up early childhood parenting program in several low- and middle-income countries and examine moderation by family and implementation characteristics. METHODS Systematic search using PubMed and Academic Search Elite/EBSCO Host. Randomized controlled trials of the Reach Up program from 1985 to February 2022 were selected. Data were extracted by 2 independent researchers. Primary outcomes were child cognitive, language, and motor development. Secondary outcomes were home stimulation and maternal depressive symptoms. We synthesized pooled effect sizes using random effect inverse-variance weighting and effect modification by testing pooled subgroup effect estimates using the χ2 test for heterogeneity. RESULTS Average effect size across 18 studies ranged from 0.49 (95% confidence interval [CI] 0.32 to 0.66) for cognition, 0.38 (CI 0.24 to 0.51) for language, 0.27 (CI 0.13 to 0.40) for motor development, 0.37 (CI 0.21 to 0.54) for home stimulation, and -0.09 (CI -0.19 to 0.01) for maternal depressive symptoms. Impacts were larger in studies targeted to undernourished children, with mean enrollment older than age 12 months and intervention duration 6 to 12 months. Quality of evidence assessed with the Cochrane Assessment of Risk of Bias and GRADE system was moderate. Instruments used to assess child development varied. In moderator analyses, some subgroups included few studies. CONCLUSIONS Reach Up benefits child development and home stimulation and is adaptable across cultures and delivery methods. Child and implementation characteristics modified the effects, with implications for scaling.
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Affiliation(s)
- Pamela Jervis
- Universidad de Chile, Santiago, Chile
- Institute for Fiscal Studies, London, United Kingdom
| | - Jacqueline Coore-Hall
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Helen O Pitchik
- School of Public Health, University of California, Berkeley, California
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, California
| | | | | | - Helen Baker-Henningham
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
- School of Human and Behavioural Sciences, Bangor University, Bangor, Wales
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, California
| | - Jena Hamadani
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Joanne A Smith
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | | | - Susan P Walker
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
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Tofail F, Islam M, Akter F, Zonji S, Roy B, Hossain SJ, Horaira A, Akter S, Goswami D, Brooks A, Hamadani J. An Integrated Mother-Child Intervention on Child Development and Maternal Mental Health. Pediatrics 2023; 151:191220. [PMID: 37125887 DOI: 10.1542/peds.2023-060221g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 05/02/2023] Open
Abstract
OBJECTIVES To evaluate an integrated, low-cost, facility-based group intervention designed to promote child care, boost maternal mental-wellbeing, reduce harsh discipline, and improve children's health, nutrition, and early development. METHODS In Dhaka, 30 neighborhood clusters of a low-income urban community were randomized to intervention or control groups. Mothers with children between 6 and 24 months (n = 300) who self-reported negative discipline were identified and enrolled. A 1-year group intervention included integration of responsive caregiving, nutritional supplementation, caregivers' mental health, child protection, and health advice. Child outcomes were cognition (primary) and language, motor and behavioral development, growth, and hemoglobin and iron status (secondary). Maternal outcomes were depressive symptoms, self-esteem, negative discipline, and child care knowledge and practices. RESULTS Overall, 222 (74%) mother-child dyads participated in the 1-year follow-up. Intervention and control groups differed on wealth, with no other significant differences. The intervention resulted in a 0.75 SD effect on cognition, 0.77 SD on language, 0.41 SD on motor, and 0.43 to 0.66 SDs on behavior during testing (emotion, cooperation, and vocalization) in the intervention arm. Mothers in the intervention group had fewer depressive symptoms (effect size: -0.72 SD), higher self-esteem (0.62 SD), better child care knowledge (2.02 SD), fewer harsh discipline practices (0.25 SD), and better home stimulation (0.73 SD). The intervention showed no effect on child growth or hemoglobin, but significantly improved serum iron status (-0.36 SD). CONCLUSIONS A comprehensive intervention, delivered through group sessions in health facilities, was effective in promoting child development and reducing maternal depressive symptoms among mothers who reported using negative or harsh discipline.
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Affiliation(s)
| | | | | | - Shekufeh Zonji
- Early Childhood Development Action Network, Washington, DC
| | | | - Sheikh Jamal Hossain
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Abdullah Brooks
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jena Hamadani
- Maternal and Child Health Division (MCHD), International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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Nutritional status and psychosocial stimulation associated with cognitive development in preschool children: A cross-sectional study at Western Terai, Nepal. PLoS One 2023; 18:e0280032. [PMID: 36913321 PMCID: PMC10010513 DOI: 10.1371/journal.pone.0280032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 12/20/2022] [Indexed: 03/14/2023] Open
Abstract
Quality education at the age of foundation to produce dynamic manpower is a public concern in developing countries including Nepal. Preschool children do not get proper care and support from their parents due to insufficient knowledge of proper feeding habits, nutrition status and methods of psychosocial stimulation, which may affect their proper cognitive development. This study aimed to identify the factors that influence cognitive development in preschool children aged 3-5 years in Rupandehi district of western Terai, Nepal. In this school based cross-sectional survey, a total of 401 preschool children were selected using a multistage random sampling technique. The study was conducted from 4th February to 12th April, 2021 in Rupandehi district of Nepal. Data on the children's socio-economic and demographic status, level of psychosocial stimulation, nutritional status, and stage of cognitive development were collected through scheduled interviews and direct observation. Stepwise regression analysis was performed to determine the predictors of cognitive development in preschool children. A p-value less than 0.05 considered as statistical significance. Of 401 participants, 44.1% had a normal nutritional status based on height for age Z-score (HAZ). Only 1.2% of primary caregivers provided their children with high levels of psychosocial stimulation, and 49.1% of children had a medium level of cognitive development. Furthermore, cognitive development in preschoolers is positively associated with nutritional status based on the height for age z score (β = 0.280; p<0.0001), psychological stimulation from caregivers (β = 0.184; p<0.0001), and advantageous castes/ethnicity (β = 0.190; p<0.0001), but negatively associated with the child's age (β = - 0.145; p = 0.002) and family type (β = -0.157; p = 0.001). Nutritional status and psychosocial stimulation appear to be major factors affecting cognitive development of preschoolers. Nutritional promotion strategies, as well as techniques for optimal psychosocial stimulation behavior, may play an important role in enhancing preschoolers' cognitive development.
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Luz RMD, Marinho DCDB, Lima APE, Coriolano-Marinus MWL. Intervenções educativas em desenvolvimento infantil e os pressupostos do letramento em saúde: revisão integrativa. Rev Bras Enferm 2023. [DOI: 10.1590/0034-7167-2022-0116pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RESUMO Objetivos: analisar na literatura evidências científicas que abordem intervenções educativas conduzidas por profissionais de saúde sobre desenvolvimento infantil na primeira infância em contexto comunitário e identificar quais pressupostos do letramento em saúde estão presentes durante a implementação das intervenções. Método: revisão integrativa nas bases de dados PubMed, CINAHL e Web of Science. De 300 estudos encontrados, 11 foram selecionados para a amostra. Resultados: os profissionais de saúde são capacitados para implementar intervenções com pais/mães/cuidadores, para promoção do desenvolvimento infantil em contextos comunitários. Os pais são orientados a desenvolver um ambiente estimulante e propício para o desenvolvimento dos filhos. As principais dimensões do letramento em saúde encontradas foram acessar e aplicar. Conclusão: ratifica-se a importância da capacitação dos profissionais de saúde, com competências e habilidades comunicativas para orientar pais/mães/cuidadores a estimularem o desenvolvimento dos filhos em seu ambiente familiar com atividades lúdicas e interativas.
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Luz RMD, Marinho DCDB, Lima APE, Coriolano-Marinus MWL. Educational interventions in child development and health literacy assumptions: an integrative review. Rev Bras Enferm 2022; 76:e20220116. [PMID: 36542053 PMCID: PMC9749774 DOI: 10.1590/0034-7167-2022-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/02/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES to analyze scientific evidence in the literature that addresses educational interventions conducted by health professionals on early childhood development in a community context and to identify which health literacy assumptions are present during the implementation of interventions. METHOD an integrative review in PubMed, CINAHL and Web of Science databases. Of 300 studies found, we selected 11 for the sample. RESULTS health professionals are trained to implement interventions with parents/caregivers to promote child development in community settings. Parents are encouraged to develop an environment that is encouraging and conducive to the development of their children. The main dimensions of health literacy found were access and apply. CONCLUSION it confirms the importance of training health professionals, with skills and communicative skills to guide parents/caregivers to encourage the development of their children in their family environment with playful and interactive activities.
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Mahfuz M, Hossain MS, Alam MA, Gazi MA, Fahim SM, Nahar B, Ahmed T. Chronic Aflatoxin Exposure and Cognitive and Language Development in Young Children of Bangladesh: A Longitudinal Study. Toxins (Basel) 2022; 14:toxins14120855. [PMID: 36548752 PMCID: PMC9784379 DOI: 10.3390/toxins14120855] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
Aflatoxin can cross the blood-brain barrier, damage brain tissues, and have the potential to harm the development of the human brain. Although dietary aflatoxin exposure is common in children, there is a paucity of data on aflatoxin exposure and child developmental outcomes. The child's cognitive, motor, and language functions were assessed using the Bayley Scales of Infant and Toddler Development-III or BSID-III at the same time points. Association between exposure to aflatoxin and subtests of BSID-III were examined using mixed-effect linear regression. Aflatoxin assays were performed on 194, 167, and 163 children at 15, 24, and 36 months of age, and chronic aflatoxin exposure was detected in 20.6%, 16.8%, and 60.7% of children, respectively. Multi-variable analyses showed that aflatoxin exposure was independently related to the children's cognitive score (β: -0.69; 95% CI: -1.36, -0.02), receptive language score (β: -0.90; 95% CI: -1.62, -0.17), and expressive language score (β: -1.01; 95% CI: -1.96, -0.05). We did not observe any association between exposure to aflatoxin and the motor function of children. Chronic exposure to aflatoxin exposure was linked to reduced cognitive, expressive, and receptive language scores of the study children. Further research is needed in a different setting to confirm this novel finding.
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Affiliation(s)
- Mustafa Mahfuz
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
- Faculty of Medicine and Health Technology, University of Tampere, 3352 Tampere, Finland
| | - Md. Shabab Hossain
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
| | - Md. Ashraful Alam
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
- Correspondence:
| | - Md. Amran Gazi
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
| | - Baitun Nahar
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh
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Effect of parenting intervention through "Care for Child Development Guideline" on early child development and behaviors: a randomized controlled trial. BMC Pediatr 2022; 22:690. [PMID: 36461019 PMCID: PMC9716152 DOI: 10.1186/s12887-022-03752-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Several studies showed that parenting intervention programs play a core component in early child development. Considering the limited healthcare resources in developing countries, group-session intervention based on care for child development (CCD) guideline might be cost-effective. METHODS This randomized controlled trial was conducted at an outpatient public Pediatrics clinic in Isfahan, Iran. We included 210 pregnant women aged 18-45 years in their third trimester and followed their children for 18 months. The intervention group underwent 5 educational group sessions, each lasting for almost 45 minutes. The main outcomes were the children's development and socio-emotional behavior problems based on Bayley Scales of Infant and Toddler Development-III (BSID-III) at 12 months and the Children Behavior Checklist (CBCL) at 18 months. RESULTS Overall, data of 181 children were included in the current study, including 80 in the intervention group and 101 controls. The adjusted median/mean differences between intervention and control groups using median/linear regression were not significant for all BSID-III domains except for median differences for cognitive score based on BSID-III (β (SE): - 4.98(2.31), p:0.032) and mean differences for anxiety/depression score based on CBCL (β (SE): - 2.54(1.27), p:0.046). CONCLUSION In this study, parenting interventions through CCD group sessions were significantly effective on just one subscale of children's socio-emotional behavior domains based on CBCL and one domain of children's development based on BSID-III. There might be a ceiling or floor effects for the BSID-III and CBCL assessment, respectively, leaving little room for improvement as almost all children have achieved their full developmental potential in our study. TRIAL REGISTRATION IRCT20190128042533N2, Date of registration: 16/01/2020, www.irct.ir.
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16
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Mehrin SF, Hasan MI, Tofail F, Shiraji S, Ridout D, Grantham-McGregor S, Hamadani JD, Baker-Henningham H. Integrating a Group-Based, Early Childhood Parenting Intervention Into Primary Health Care Services in Rural Bangladesh: A Cluster-Randomized Controlled Trial. Front Pediatr 2022; 10:886542. [PMID: 35783319 PMCID: PMC9245711 DOI: 10.3389/fped.2022.886542] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Over 250 million children globally do not reach their developmental potential. We tested whether integrating a group-based, early childhood parenting program into government healthcare clinics improved children's development, growth, and behavior. Methods We conducted a cluster-randomized controlled trial in 40 community clinics in the Kishorganj district of Bangladesh. We randomly assigned clinics (1:1) to deliver a group-based parenting interventions or to a comparison group that received no intervention. Participants were children aged 5-24 months, with weight-for-age z-score of ≤ -1.5 SDs of the WHO standards, living within a thirty-minute walking distance from the clinic (n = 419 intervention, 366 control). Government health staff facilitated parenting sessions in the clinic with groups of four mother/child dyads fortnightly for one year as part of their routine duties. Primary outcomes measured at baseline and endline were child development assessed using the Bayley scales, child behaviors during the test by tester ratings, and child growth. The trial is registered at ClinicalTrials.gov, NCT02208531. Findings 91% of children were tested at endline (396 intervention, 319 control). Multilevel analyses showed significant benefits of intervention to child cognition (effect size 0.85 SDs, 95% CI: 0.59, 1.11), language (0.69 SDs, 0.43, 0.94), and motor development (0.52 SDs, 0.31, 0.73), and to child behaviors during the test (ranging from 0.36 SDs, 0.14, 0.58, to 0.53 SDs, 0.35, 0.71). There were no significant effects on growth. Conclusion A scalable parenting intervention, integrated into existing government health services and implemented by government health staff, led to significant benefits to child development and behavior.
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Affiliation(s)
- Syeda Fardina Mehrin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammed Imrul Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shamima Shiraji
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Jena D. Hamadani
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Kruk ME, Lewis TP, Arsenault C, Bhutta ZA, Irimu G, Jeong J, Lassi ZS, Sawyer SM, Vaivada T, Waiswa P, Yousafzai AK. Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services. Lancet 2022; 399:1830-1844. [PMID: 35489361 PMCID: PMC9077444 DOI: 10.1016/s0140-6736(21)02532-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/10/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022]
Abstract
Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.
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Affiliation(s)
- Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Center of Excellence in Women and Child Health and Institute for Global Health and Development, Aga Khan University, Karachi, Pakistan
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Jeong
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zohra S Lassi
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Susan M Sawyer
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Aisha K Yousafzai
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Čvorović J. Maternal age at marriage and child nutritional status and development: evidence from Serbian Roma communities. Public Health Nutr 2022; 25:1-34. [PMID: 35260202 PMCID: PMC9991790 DOI: 10.1017/s1368980022000544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 12/12/2021] [Accepted: 03/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to assess whether maternal age at first marriage is associated with nutritional and developmental penalties in Roma children. DESIGN Roma nationally representative population-based study. Proxies for child nutritional outcomes included children's individual-level height-for-age z (HAZ) and weight-for-age z (WAZ) scores, HAZ and WAZ scores below two standard deviations from the median of WHO's reference population (children aged 0-59 months), and Early Child Development (children aged 36-59 months). Multiple and logistic regressions were used to estimate the association between maternal age at marriage and the outcomes, and other sociodemographic determinants as possible confounders. SETTING Aggregated data from UNICEF's fifth and sixth Multiple Indicator Cluster Surveys for Serbian Roma settlements. SUBJECTS Children (n= 2652) aged 0-59 months born to ever-married women aged 15-48. RESULTS 64% of women married before age 18, 19% of children were stunted, 9% wasted, and Early Child Development score was low. Maternal age at first marriage was not associated with either nutritional status or early development of Roma children. Weight at birth (children aged 0-24) emerged as the main predictor of children's nutritional status. Boys were more likely to be shorter, more stunted and wasted than girls. Child's age, maternal parity and unimproved toilet facility negatively impacted nutritional status, while maternal literacy mitigated against poor nutritional and developmental outcomes. CONCLUSIONS Roma children up to 5 years of age bear no negative consequences of maternal early marriage. The underlying determinants of children's wellbeing include improved sanitation, child characteristics, maternal literacy and reproductive behavior, and parental investment.
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Affiliation(s)
- Jelena Čvorović
- Institute of Ethnography, Serbian Academy of Sciences and Arts, Belgrade,
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19
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Ebert C, Vollmer S. Girls unwanted - The role of parents' child-specific sex preference for children's early mental development. JOURNAL OF HEALTH ECONOMICS 2022; 82:102590. [PMID: 35139435 DOI: 10.1016/j.jhealeco.2022.102590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
We propose a novel son preference measure that relates the preference to a specific child. We find child-specific son preference to be more common among later born children and in families with fewer sons. Using the novel measure and an interaction instrumental variables approach, we estimate a penalty in early mental functions for unwanted girls of 0.7 standard deviations. This penalty appears to be partially driven by discrimination against girls and partially by pampering of boys. Children's health and parental inputs do not mediate the effect from son preference to mental development. Our findings highlight the relevance of parents' attitudes for a nurturing home environment and healthy brain development.
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Affiliation(s)
- Cara Ebert
- RWI - Leibniz Institute for Economic Research, RWI Berlin Office, Invalidenstr. 112, Berlin 10115, Germany.
| | - Sebastian Vollmer
- University of Goettingen, Center for Modern Indian Studies, Waldweg 26, 37073 Göttingen, Germany
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Mihrshahi S, Ara G, Khanam M, Rasheed S, Agho KE, Kabir AI, Roy SK, Haider R, Derakhshani Hamadani J, Tofail F, Alam A, Dibley MJ. The Shishu Pushti Trial-Extended Peer Counseling for Improving Feeding Practices and Reducing Undernutrition in Children Aged 0-48 Months in Urban Bangladesh: Protocol for a Cluster-Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e31475. [PMID: 35129457 PMCID: PMC8861872 DOI: 10.2196/31475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/08/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The aim of this study is to assess if peer counseling of women improves breastfeeding, complementary feeding practices, and child growth, and thus reduces the prevalence of undernutrition in children up to 4 years of age. OBJECTIVE Lack of exclusive breastfeeding and inappropriate complementary feeding are critical factors in reducing child undernutrition, morbidity, and mortality. There are reported trials of peer counseling to improve breastfeeding; however, they did not examine the efficacy of peer counseling to improve complementary feeding or the long-term impacts on child growth and development. METHODS This study has used a community-based, cluster-randomized controlled trial with a superiority design and 2 parallel treatment arms. It is assessing the impact of peer counseling, starting in late pregnancy up to 1 year after delivery, on child feeding practices, growth, and development with follow-up until 48 months of age. The study site was Mirpur, a densely populated area in Dhaka. Using satellite maps and geographic information system mapping, we constructed 36 clusters with an average population of 5000 people. We recruited pregnant women in the third trimester aged 16-40 years, with no more than 3 living children. Trained peer counselors visited women at home twice before delivery, 4 times in the first month, monthly from 2 to 6 months, and again at 9 and 12 months. Trained research assistants collected anthropometric measurements. The primary outcome will be differences in child stunting and mean length for age at 6, 12, 15, and 18 months. Secondary outcomes will be differences in the percentage of women exclusively breastfeeding in the mean duration of any breastfeeding and in the percentage of children at 6 and 9 months of age who receive solid, semisolid, or soft foods; and the percentage of children consuming foods from 4 or more food groups at 9, 12, 15, and 18 months. We will assess the mean cognitive function scores from the Ages and Stages Questionnaire (9 and 18 months) and Bayley tests (24 and 36 months). RESULTS We identified 65,535 people in mapped residences, from which we defined 36 clusters and randomly allocated them equally to intervention or control groups stratified by cluster socioeconomic status. From July 2011 to May 2013, we identified 1056 pregnant women and 993 births in the intervention group and 994 pregnancies and 890 births in the control group. At 18 months, 692 children remained in the intervention group and 551 in the control group. From January 2015 to February 2017, we conducted the long-term follow-up of the cohort. We have now completed the data collection and processing and have started analyses. CONCLUSIONS This study will help fill the evidence gap about the short- and long-term impact of peer counseling on improving infant feeding, preventing childhood undernutrition, and enhancing child cognitive development. TRIAL REGISTRATION ClinicalTrials.gov NCT01333995; https://clinicaltrials.gov/ct2/show/NCT01333995. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/31475.
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Affiliation(s)
- Seema Mihrshahi
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, Australia.,Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Gulshan Ara
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mansura Khanam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sabrina Rasheed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | - S K Roy
- Bangladesh Breastfeeding Foundation, Institute of Public Health, Dhaka, Bangladesh
| | - Rukhsana Haider
- Training and Assistance for Health and Nutrition Foundation, Dhaka, Bangladesh
| | - Jena Derakhshani Hamadani
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ashraful Alam
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Michael J Dibley
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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Bougma S, Hama-Ba F, Garanet F, Kabre JDW, Guira F, Cissé H, Tarnagda B, Zio S, Savadogo A. Impact of Health and Nutrition Interventions in the Prevention and Recovery of Child Malnutrition in Sub-Saharan Africa from 2010 to 2020: Review Article. Health (London) 2022. [DOI: 10.4236/health.2022.147058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Hossain SJ, Roy BR, Sujon HM, Tran T, Fisher J, Tofail F, El Arifeen S, Hamadani JD. Effects of integrated psychosocial stimulation (PS) and unconditional cash transfer (UCT) on children's development in rural Bangladesh: A cluster randomized controlled trial. Soc Sci Med 2021; 293:114657. [PMID: 34942577 DOI: 10.1016/j.socscimed.2021.114657] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/23/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is evidence on benefits of psychosocial stimulation (PS) and cash transfer programmes in low- and middle-income countries on children's development. We integrated PS into an unconditional cash transfer (UCT) programme for poor Bangladeshi mothers to examine the effects on children's development. METHODS This cluster randomized controlled trial was conducted in rural Bangladesh from July 2017 to December 2018 in 33 clusters, with 11 clusters randomly assigned to each of the three arms, namely i) PS + UCT ii) UCT-only and iii) Comparison. We enrolled poor mothers and child (6-16 months) dyads eligible to receive maternity allowance by the Government of Bangladesh. Trained local women imparted training to mothers to provide psychosocial stimulation to their children for one year. Children's cognitive, language and motor development were measured with Bayley-III, behaviour with Wolke's ratings and maternal self-esteem with Rosenberg self-esteem scale. The analysis was intention-to-treat. RESULTS Of the 594 mother-child dyads, 40 (6·8%) were lost to follow-up. Compared to UCT-only, children in the PS + UCT had significant improvement in cognitive (B = 2.96, 95% CI: 0.46-5.47, Effect Size [ES] 0.24SD) and language (2.73, 0.39-5.00, ES 0.21SD) scores and were more responsive to examiner (0.30, 0.06-0.52, ES 0.27SD), while compared to comparison group, they had significantly higher cognitive (3.37, 1.27-6.19, ES 0.32SD), language (2.82, 0.53-5.10, ES 0.24SD) and motor (2.65, 0.24-5.06, ES 0.22SD) scores and were more responsive to examiner (0.30, 0.08-0.52, ES 0.26 SD). The mothers' self-esteem was significantly higher in PS + UCT (2.46, 0.94-3.98, ES 0.48 SD) and UCT-only (1.67, 0.02-3.20, ES 0.32 SD) compared to the comparison group. CONCLUSION PS integrated into an UCT programme benefited children's neurodevelopment and UCT improved mother's self-esteem. UCT programme may be an important platform for child stimulation programmes for rural poor populations.
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Affiliation(s)
- Sheikh Jamal Hossain
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh; Department of Women's and Children's Health, Uppsala University, Sweden.
| | - Bharati Rani Roy
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Hasan Mahmud Sujon
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Thach Tran
- Global and Women's Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Jane Fisher
- Global and Women's Health, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Jena Derakshani Hamadani
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
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Dulal S, Prost A, Karki S, Saville N, Merom D. Characteristics and effects of integrated nutrition and stimulation interventions to improve the nutritional status and development of children under 5 years of age: a systematic review and meta-analysis. BMJ Glob Health 2021; 6:bmjgh-2020-003872. [PMID: 34321232 PMCID: PMC8319976 DOI: 10.1136/bmjgh-2020-003872] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 06/29/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Around 250 million children in low-income and middle-income countries are at risk of not fulfilling their developmental potential. There is a need to update syntheses investigating the effects of combined nutrition and stimulation interventions on children’s growth and development and identify intervention characteristics associated with positive effects. Methods We did a systematic review to: (1) understand the effects of integrated nutrition and stimulation interventions versus (i) usual care and (ii) standalone nutrition or stimulation interventions, on the growth and development of children under five; (2) explore intervention characteristics (delivery strategies, behaviour change techniques, intensity and personnel) associated with positive effects. We searched eight databases for studies published from inception to 16 November 2020. Eligible studies were randomised and non-randomised controlled trials of integrated nutrition and stimulation interventions examining growth and developmental outcomes. We performed meta-analyses for length-for-age/height-for-age, weight-for-age and weight-for-length/weight-for-height Z scores and cognitive, motor and language development scores, and subgroup analyses by intervention characteristics. We conducted random-effects metaregression to assess potential subgroup differences in outcomes by intervention characteristics. Results Twenty trials were included in the meta-analysis. Pooled effect sizes showed significant benefits of integrated interventions on developmental outcomes compared with usual care and standalone nutrition interventions (I2 >75%) but not on growth outcomes. Moreover, integrated interventions have non-significant effects on developmental outcomes compared with standalone stimulation interventions. Integrated interventions showed greater effects on cognitive (p=0.039) and language (p=0.040) outcomes for undernourished children compared with adequately nourished children. The effects of integrated interventions on developmental outcomes did not differ by intervention characteristics. Conclusion Integrated interventions have greater benefits for children’s development than usual care or standalone nutrition interventions, especially in settings with high levels of undernutrition. Future studies should use standardised reporting of implementation processes to identify intervention characteristics linked to positive effects.
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Affiliation(s)
- Sophiya Dulal
- School of Health Sciences, Western Sydney University, Penrith South, New South Wales, Australia
| | - Audrey Prost
- Institute for Global Health, University College London, London, UK
| | - Surendra Karki
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia.,Research and Development, Australian Red Cross Lifeblood New South Wales and Australian Capital Territory, Alexandria, New South Wales, Australia
| | - Naomi Saville
- Institute for Global Health, University College London, London, UK
| | - Dafna Merom
- School of Health Sciences, Western Sydney University, Penrith South, New South Wales, Australia
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Jahir T, Winch PJ, Leontsini E, Hwang ST, Yeasmin F, Hossain K, Das JB, Amin R, Nurul Huda TM, Sultana J, Khan R, Akter F, Shoab AKM, Hasan R, Pitchik HO, Tofail F, Fernald LCH, Luby SP, Rahman M. Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157891. [PMID: 34360185 PMCID: PMC8345337 DOI: 10.3390/ijerph18157891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022]
Abstract
Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.
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Affiliation(s)
- Tania Jahir
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
- Correspondence: ; Tel.: +880-1819140900
| | - Peter J. Winch
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Elli Leontsini
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Sharon T. Hwang
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (P.J.W.); (E.L.); (S.T.H.)
| | - Farzana Yeasmin
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Khobair Hossain
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Jyoti Bhushan Das
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Ruhul Amin
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Tarique Md. Nurul Huda
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Jesmin Sultana
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Rizwana Khan
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Fahmida Akter
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - AKM Shoab
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Rezaul Hasan
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
| | - Helen O. Pitchik
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh;
| | - Lia C. H. Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, CA 94720, USA;
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Mahbubur Rahman
- Environmental Interventions Unit, Infectious Diseases Division, International Center for Diarrheal Diseases Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (F.Y.); (K.H.); (J.B.D.); (R.A.); (T.M.N.H.); (J.S.); (R.K.); (F.A.); (A.S.); (R.H.); (M.R.)
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Zhang L, Ssewanyana D, Martin MC, Lye S, Moran G, Abubakar A, Marfo K, Marangu J, Proulx K, Malti T. Supporting Child Development Through Parenting Interventions in Low- to Middle-Income Countries: An Updated Systematic Review. Front Public Health 2021; 9:671988. [PMID: 34336768 PMCID: PMC8322584 DOI: 10.3389/fpubh.2021.671988] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/15/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Over 250 million children in low- and middle-income countries are at risk of not achieving their fullest developmental potential due to co-occurring risks such as poor nutrition and inadequate learning opportunities. Early intervention programs integrating the aspects of nurturing care, that is, good health, adequate nutrition, safety and security, responsive caregiving, and learning opportunities, may ameliorate against the negative impact of these adverse conditions. Methods: This meta-analytic review updates the evidence base of parenting interventions comprising stimulation and responsive caregiving components on developmental outcomes for children under age 2 years in low- and middle-income countries. It also describes and assesses the moderation effects of population characteristics and implementation features on the intervention effectiveness. Studies were identified based on previous systematic reviews and an updated literature search in eight databases and the gray literature up to December 2020. A random-effect model was used to explore the pooled effect sizes accounted for by the intervention for developmental outcome of cognition, language, motor, and social-emotional capacities. Exploratory moderation analyses were also conducted. Results: Twenty-one randomized controlled trials representing over 10,400 children from 12 low- and middle-income countries and regions across three continents (Africa, Latin America, and Asia) were identified. The interventions showed overall small-to-moderate effects on children's cognitive development (ES = 0.44; 95% CI = [0.30, 0.57]); language development (ES = 0.33; 95% CI = [0.18, 0.49]); and motor skills (ES = 0.21; 95% CI = [0.10, 0.32]). The overall effect on social-emotional development was non-significant (ES = 0.17; 95% CI = [-0.01, 0.34]). Effect sizes (ES) varied significantly across the studies. Parenting programs that targeted vulnerable groups, including rural communities and caregivers with lower education levels, had more significant effects on children's development. Group sessions (vs. individual visits) and high program dose (≥12 sessions) were also associated with stronger effects on child development. Further research is needed to determine the effectiveness of the workforce and training on programmatic outcomes. Conclusion: The findings indicate that parenting interventions that encourage nurturing care are effective in improving the early development of children, especially among vulnerable populations. We discuss opportunities to strengthen the implementation of research-based parenting interventions in such contexts.
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Affiliation(s)
- Linlin Zhang
- Key Laboratory of Learning and Cognition, School of Psychology, Capital Normal University, Beijing, China
| | - Derrick Ssewanyana
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Marie-Claude Martin
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Stephen Lye
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Greg Moran
- Department of Psychology, Western University, London, ON, Canada
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Kofi Marfo
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Joyce Marangu
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Kerrie Proulx
- Alliance for Human Development, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Tina Malti
- Centre for Child Development, Mental Health, and Policy, University of Toronto Mississauga, Mississauga, ON, Canada
- Department of Psychology, University of Toronto, Toronto, ON, Canada
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Improvement in appetite among stunted children receiving nutritional intervention in Bangladesh: results from a community-based study. Eur J Clin Nutr 2021; 75:1359-1367. [PMID: 34045689 PMCID: PMC8416653 DOI: 10.1038/s41430-020-00843-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/15/2020] [Accepted: 12/09/2020] [Indexed: 11/08/2022]
Abstract
Background/objectives Stunted children often have poor appetite, which may limit their response to nutritional interventions. We investigated the effect of a nutritional intervention on the appetite status of stunted children. Methods A longitudinal prospective intervention study was conducted with 50 stunted (length for age; LAZ < −2) (age and sex matched) aged 12–18 months and their mothers in Bauniabadh slum of Dhaka city. The stunted children received the following intervention package: one boiled egg and 150 ml milk daily 6 days a week for 3 months; psychosocial stimulation including structured play activities and parental counseling for 6 months; routine clinical care. Appetite status was measured using an interview-based tool “Early Childhood Appetite and Satiety Tool.” Results Over the period of nutritional intervention, the mean appetite score increased from 49 to 60 in the stunted children and was associated with increased food consumption. Over the intervention period, both egg and milk consumption increased (40.3–49.6 g and 83.8–138.5 ml, respectively). Conclusions Assessment of appetite status using EACST appears to be a useful tool for monitoring a nutritional intervention in stunted children. This tool may be useful for programs in managing child stunting in low-income countries and an important way to assess the efficacy of a nutritional intervention in these children.
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Jeong J, Franchett EE, Ramos de Oliveira CV, Rehmani K, Yousafzai AK. Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis. PLoS Med 2021; 18:e1003602. [PMID: 33970913 PMCID: PMC8109838 DOI: 10.1371/journal.pmed.1003602] [Citation(s) in RCA: 207] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Parents are the primary caregivers of young children. Responsive parent-child relationships and parental support for learning during the earliest years of life are crucial for promoting early child development (ECD). We conducted a global systematic review and meta-analysis to evaluate the effectiveness of parenting interventions on ECD and parenting outcomes. METHODS AND FINDINGS We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for peer-reviewed, published articles from database inception until November 15, 2020. We included randomized controlled trials (RCTs) of parenting interventions delivered during the first 3 years of life that evaluated at least 1 ECD outcome. At least 2 reviewers independently screened, extracted data, and assessed study quality from eligible studies. ECD outcomes included cognitive, language, motor, and socioemotional development, behavior problems, and attachment. Parenting outcomes included parenting knowledge, parenting practices, parent-child interactions, and parental depressive symptoms. We calculated intervention effect sizes as the standardized mean difference (SMD) and estimated pooled effect sizes for each outcome separately using robust variance estimation meta-analytic approaches. We used random-effects meta-regression models to assess potential effect modification by country-income level, child age, intervention content, duration, delivery, setting, and study quality. This review was registered with PROSPERO (CRD42018092458 and CRD42018092461). Of the 11,920 articles identified, we included 111 articles representing 102 unique RCTs. Pooled effect sizes indicated positive benefits of parenting interventions on child cognitive development (SMD = 0.32, 95% CI [confidence interval]: 0.23, 0.40, P < 0.001), language development (SMD = 0.28, 95% CI: 0.18 to 0.37, P < 0.001), motor development (SMD = 0.24, 95% CI: 0.15 to 0.32, P < 0.001), socioemotional development (SMD = 0.19, 95% CI: 0.10 to 0.28, P < 0.001), and attachment (SMD = 0.29, 95% CI: 0.18 to 0.40, P < 0.001) and reductions in behavior problems (SMD = -0.13, 95% CI: -0.18 to -0.08, P < 0.001). Positive benefits were also found on parenting knowledge (SMD = 0.56, 95% CI: 0.33 to 0.79, P < 0.001), parenting practices (SMD = 0.33, 95% CI: 0.22 to 0.44, P < 0.001), and parent-child interactions (SMD = 0.39, 95% CI: 0.24 to 0.53, P < 0.001). However, there was no significant reduction in parental depressive symptoms (SMD = -0.07, 95% CI: -0.16 to 0.02, P = 0.08). Subgroup analyses revealed significantly greater effects on child cognitive, language, and motor development, and parenting practices in low- and middle-income countries compared to high-income countries; and significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent-child interactions for programs that focused on responsive caregiving compared to those that did not. On the other hand, there was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias. Study limitations include considerable unexplained heterogeneity, inadequate reporting of intervention content and implementation, and varying quality of evidence in terms of the conduct of trials and robustness of outcome measures used across studies. CONCLUSIONS Parenting interventions for children during the first 3 years of life are effective for improving ECD outcomes and enhancing parenting outcomes across low-, middle-, and high-income countries. Increasing implementation of effective and high-quality parenting interventions is needed globally and at scale in order to support parents and enable young children to achieve their full developmental potential.
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Affiliation(s)
- Joshua Jeong
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Emily E. Franchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Clariana V. Ramos de Oliveira
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Karima Rehmani
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Aisha K. Yousafzai
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Aizawa T. Dynamic variation in receptive vocabulary acquisitions: Further evidence from the Young Lives study. COGNITIVE DEVELOPMENT 2021. [DOI: 10.1016/j.cogdev.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mehrin SF, Hamadani JD, Salveen NE, Hasan MI, Hossain SJ, Baker-Henningham H. Adapting an Evidence-Based, Early Childhood Parenting Programme for Integration into Government Primary Health Care Services in Rural Bangladesh. Front Public Health 2021; 8:608173. [PMID: 33537282 PMCID: PMC7848202 DOI: 10.3389/fpubh.2020.608173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022] Open
Abstract
This paper describes the process of adapting an early childhood development programme, with proven effectiveness in Bangladesh, for integration into government health services in rural Bangladesh. Through a three-stage process, we adapted an evidence-based, home-visiting, programme (Reach-Up and Learn) for delivery in government health clinics by government health staff as part of their regular duties. Stage one involved preparing an initial draft of two parenting interventions for use with: (1) pairs of mother/child dyads, and (2) small groups of mother/child dyads. In stage two, we piloted the adapted interventions in nine clinics with a total of twenty-seven health staff and 357 mother/child dyads. We used data from mothers' attendance, feedback from participating mothers and health staff and observations of parenting sessions by the research team to revise the interventions. Stage three involved piloting the revised interventions in six clinics with eighteen health staff and 162 mother/child dyads. We gathered additional data on mothers' attendance and used observations by the research team to finalize the interventions. Through this three-stage process, adaptations were made to the intervention content, process of delivery, materials, and engagement strategies used. The largest challenges were related to incorporating the parenting programme into health staff's existing workload and promoting mothers' engagement in the programme. We also simplified the content and structure of the curriculum to make it easier for health staff to deliver and to ensure mothers understood the activities introduced. This iterative piloting was used prior to implementing and evaluating the interventions through an effectiveness trial.
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Affiliation(s)
- Syeda Fardina Mehrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Nur-E Salveen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammed Imrul Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sheikh Jamal Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Hamadani JD, Mehrin SF, Tofail F, Hasan MI, Huda SN, Baker-Henningham H, Ridout D, Grantham-McGregor S. Integrating an early childhood development programme into Bangladeshi primary health-care services: an open-label, cluster-randomised controlled trial. LANCET GLOBAL HEALTH 2020; 7:e366-e375. [PMID: 30784637 DOI: 10.1016/s2214-109x(18)30535-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/21/2018] [Accepted: 11/14/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Poor development in young children in developing countries is a major problem. Child development experts are calling for interventions that aim to improve child development to be integrated into health services, but there are few robust evaluations of such programmes. Previous small Bangladeshi trials that used individual play sessions with mothers and their children (at home or in clinics), which were predominantly run by employed women, found moderate improvements on child development. We aimed to integrate an early childhood development programme into government clinics that provide primary health care and to evaluate the effects of this intervention on child cognition, language, and motor development, growth, and behaviour in a subsample of the children. METHODS In this open-label cluster-randomised controlled trial, we recruited individuals from community clinics in Narsingdi district, Bangladesh. These clinics were randomly selected from a larger sample of eligible clinics, and they were assigned (1:1) to either deliver an intervention of 25 sessions, in which mothers of eligible children were shown how to support their child's development through play and interactions, or to deliver no intervention (control group). Participants were underweight children, defined as a weight-for-age Z score of -2 SDs of the WHO standard, who were aged 5-24 months and who lived near the clinic (defined as a walk of less than 30 min). Government health workers ran these sessions at the clinics as part of their routine work, and mothers and children attended fortnightly in pairs (instead of individual weekly home visits that were specified in the original programme). A subsample of children from each clinic was randomly selected for impact evaluation, and these children were assessed on the Bayley Scales of Infant and Toddler Development for their cognitive, language, and motor performance and for their behaviour with Wolke's ratings, before and after implementation of the intervention. The primary outcomes were the performance of this evaluation subsample on the Bayley and Wolke scales and their anthropometric measurements (weight, length or height, and head circumference) after 1 year of the intervention. This study is registered with ClinicalTrials.gov, number NCT02208531. FINDINGS Between Nov 29, 2014, and April 30, 2015, 12 054 children in 90 clinics were screened, and between six and 25 underweight children were enrolled from each clinic. From the 2423 (20%) underweight children, we excluded 656 (27%) children who lived more than 30-min walking distance from the community clinics, and 30 (1%) children whose mothers did not consent to participate. We therefore enrolled 1737 (72%) children from these 90 clinics. After randomisation, the control group clinics included 878 (51%) children (who all received no intervention) and the intervention group clinics included 859 (49%) children (who all received the child development programme sessions). Eight children from each clinic (360 [41%] children from the control group clinics and 358 [42%] children from the intervention group clinics) were randomly selected for inclusion in the evaluation subsample. Between Feb 24, 2016, and Sept 7, 2016, 344 (96%) children in control group clinics and 343 (96%) children in intervention group clinics were assessed for the primary outcome. 16 (5%) children in the control group clinics and 15 (4%) children in the intervention group clinics did not provide all data and were not included in final analyses. An intention-to-treat analysis showed that the intervention significantly improved children's cognition (effect size 1·3 SDs, 95% CI 1·1 to 1·5; p=0·006), language (1·1 SDs, 0·9 to 1·2; p=0·01), and motor composite scores (1·2 SDs, 1·0 to 1·3; p=0·006) and behaviour ratings (ranging from 0·7 SDs, 0·5 to 0·9; p=0·02; to 1·1 SDs, 1·0 to 1·2; p=0·007), but the intervention had no significant effect on growth (p values ranged from 0·05 to 0·74). Three (1%) children in the intervention group died, but their deaths were not related to the intervention. INTERPRETATION The extent and range of benefits of our intervention are encouraging. Health workers ran most of the sessions effectively and attendance was good, which is promising for scale-up of the intervention model. However, researchers trained and supervised the health workers, and the next step will be to determine whether the Bangladeshi ministry of health can perform these tasks. In future programmes, more attention needs to be paid to the nutrition of the children. FUNDING Grand Challenges Canada (Saving Brains).
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Affiliation(s)
- Jena D Hamadani
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
| | - Syeda F Mehrin
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Fahmida Tofail
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad I Hasan
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, London, UK
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Prado EL, Larson LM, Cox K, Bettencourt K, Kubes JN, Shankar AH. Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis. Lancet Glob Health 2019; 7:e1398-e1413. [PMID: 31537370 DOI: 10.1016/s2214-109x(19)30361-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/13/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Faltering in linear growth and neurobehavioural development during early childhood are often assumed to have common causes because of their consistent association. This notion has contributed to a global focus on the promotion of nutrition during pregnancy and childhood to improve both conditions. Our aim was to assess whether effects of interventions on linear growth are associated with effects on developmental scores and to quantify these associations. METHODS In this systematic review and meta-analysis, we included randomised trials done during pregnancy and in children aged 0-5 years that reported effects of any intervention on length-for-age or height-for-age Z scores (LAZ or HAZ) and on any of the following outcomes: motor, cognitive or mental, language, and social-emotional or behavioural development. We searched MEDLINE (Ovid), CINAHL (EBSCO), and PsycINFO (EBSCO) from database inception to June 25, 2019. Study-level data were extracted and, when required, authors were contacted for missing information. We calculated weighted meta-regression coefficients of the association between standardised effect sizes of interventions on LAZ or HAZ and developmental outcome scores and calculated pooled effect sizes for different types of intervention. FINDINGS Of the 7207 studies identified, we included 75 studies with 122 comparisons between intervention and control groups and outcomes reported for 72 275 children. Across all interventions, effect sizes on LAZ or HAZ were significantly associated with effect sizes on social-emotional scores (β 0·23, 95% CI 0·05 to 0·41; p=0·02), but not on cognitive (0·18, -0·36 to 0·72; p=0·51), language (0·12, -0·07 to 0·31; p=0·21), or motor development scores (0·23, -0·05 to 0·50; p=0·11). In studies that provided nutritional supplements, we observed positive significant pooled effect sizes on all five outcomes of LAZ or HAZ (effect size 0·05, 95% CI 0·01-0·09; p=0·01; n=50), cognitive or mental (0·06, 0·03-0·10; p<0·01; n=38), language (0·08, 0·03-0·13; p=0·01; n=21), motor (0·08, 0·04-0·12; p<0·01; n=41), and social-emotional (0·07, 0·02-0·12; p=0·01; n=20) scores. The effect sizes of nutritional supplementation on LAZ or HAZ scores were significantly associated with effect sizes on cognitive (β 0·40, 95% CI 0·04-0·77; p=0·049) and motor (0·43, 0·11-0·75; p=0·01) scores. In the 14 interventions promoting responsive care and learning opportunities, the pooled effect size on LAZ or HAZ score was not significant (-0·01, 95% CI -0·07 to 0·05; p=0·74), but pooled effect sizes on cognitive, language, and motor scores were 4 to 5 times larger (range 0·38-0·48) than the pooled effect sizes of nutritional supplementation (0·05-0·08). INTERPRETATION In nutritional supplementation interventions, improvements in linear growth were associated with small improvements in child development, whereas nurturing and stimulation interventions had significant effects on child development but no effects on linear growth. The determinants of linear growth and neurodevelopment are only partly shared. To nurture thriving individuals and communities, interventions should specifically target determinants of neurodevelopment and not simply linear growth. FUNDING University of California Davis, US Department of Agriculture National Institute of Food and Agriculture.
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Affiliation(s)
- Elizabeth L Prado
- Department of Nutrition, University of California Davis, Davis, CA, USA.
| | - Leila M Larson
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Katherine Cox
- Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Kory Bettencourt
- Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Julianne N Kubes
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Anuraj H Shankar
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Abessa TG, Worku BN, Wondafrash M, Girma T, Valy J, Lemmens J, Bruckers L, Kolsteren P, Granitzer M. Effect of play-based family-centered psychomotor/psychosocial stimulation on the development of severely acutely malnourished children under six in a low-income setting: a randomized controlled trial. BMC Pediatr 2019; 19:336. [PMID: 31521161 PMCID: PMC6744679 DOI: 10.1186/s12887-019-1696-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends incorporating psychosocial stimulation into the management of severe acute malnutrition (SAM). However, there is little evidence about the effectiveness of these interventions for SAM children, particularly when serious food shortages and lack of a balanced diet prevail. The objective of this study was to examine whether family-based psychomotor/psychosocial stimulation in a low-income setting improves the development, linear growth, and nutritional outcomes in children with SAM. METHOD Children with SAM (N = 339) admitted for treatment to the Jimma University Specialized Hospital, Ethiopia, were randomized to a control (n = 170) or intervention (n = 169) group. Both groups received routine medical care and nutritional treatment at the hospital. The intervention group additionally received play-based psychomotor/psychosocial stimulation during their hospital stay, and at home for 6 months after being discharged from hospital. The fine motor (FM) and gross motor (GM) functions, language (LA) and personal-social (PS) skills of the children were assessed using adapted Denver II, the social-emotional (SE) behavior was assessed using adapted Ages and Stages Questionnaires: Social-Emotional, and the linear growth and nutritional status were determined through anthropometric assessments. All outcomes were assessed before the intervention, upon discharge from hospital, and 6 months after discharge (as end-line). The overtime changes of these outcomes measured in both groups were compared using Generalized Estimating Equations. RESULTS The intervention group improved significantly on GM during hospital follow-up by 0.88 points (p < 0.001, effect size = 0.26 SD), and on FM functions during the home follow-up by 1.09 points (p = 0.001, effect size = 0.22 SD). Both young and older children benefited similarly from the treatment. The intervention did not contribute significantly to linear growth and nutritional outcomes. CONCLUSION Psychomotor/psychosocial stimulation of SAM children enhances improvement in gross motor functions when combined with standard nutrient-rich diets, but it can enhance the fine motor functions even when such standard dietary care is not available. TRIAL REGISTRATION The trial was retrospectively registered on 30 January 2017 at the US National Institute of Health (ClinicalTrials.gov) # NCT03036176 .
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Affiliation(s)
- Teklu Gemechu Abessa
- Department of Special Needs and Inclusive Education, College of Behavioral Sciences and Education, Jimma University, Jimma, Ethiopia
- REVAL Rehabilitation Research Center, Biomedical Research Institute, Faculty of Rehabilitation Sciences and Physiotherapy, Hasselt University, Hasselt, Belgium
| | - Berhanu Nigussie Worku
- REVAL Rehabilitation Research Center, Biomedical Research Institute, Faculty of Rehabilitation Sciences and Physiotherapy, Hasselt University, Hasselt, Belgium
- Department of Psychology, College of Behavioral Sciences and Education, Jimma University, Jimma, Ethiopia
| | - Mekitie Wondafrash
- Department of Population and Family Health, Jimma University, Jimma, Ethiopia
| | - Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
| | - Johan Valy
- Department of Healthcare, PXL University College, Hasselt, Belgium
| | - Johan Lemmens
- Department of Healthcare, PXL University College, Hasselt, Belgium
| | | | - Patrick Kolsteren
- Department of Food Safety and Food Quality, University of Gent, Ghent, Belgium
| | - Marita Granitzer
- REVAL Rehabilitation Research Center, Biomedical Research Institute, Faculty of Rehabilitation Sciences and Physiotherapy, Hasselt University, Hasselt, Belgium
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Hossain M, Nahar B, Haque MA, Mondal D, Mahfuz M, Naila NN, Gazi MA, Hasan MM, Haque NMS, Haque R, Arndt MB, Walson JL, Ahmed T. Serum Adipokines, Growth Factors, and Cytokines Are Independently Associated with Stunting in Bangladeshi Children. Nutrients 2019; 11:nu11081827. [PMID: 31394828 PMCID: PMC6723106 DOI: 10.3390/nu11081827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
Growth in young children is controlled through the release of several hormonal signals, which are affected by diet, infection, and other exposures. Stunting is clearly a growth disorder, yet limited evidence exists documenting the association of different growth biomarkers with child stunting. This study explored the association between different growth biomarkers and stunting in Bangladeshi children. A quasi-experimental study was conducted among 50 stunted (length-for-age Z-score (LAZ) < -2 SD) and 50 control (LAZ ≥ -2 SD) children, aged 12-18 months, residing in a Bangladeshi slum. The enrolled stunted children received an intervention package, which included food supplementation for three months, psychosocial stimulation for six months, and routine clinical care on community nutrition center at the study field site. The controls received routine clinical care only. All children were clinically screened over the study period. Length, weight, fasting blood and fecal biomarkers were measured. All biomarkers levels were similar in both groups except for oxyntomodulin at enrolment. Leptin (adjusted odds ratio, AOR: 4.0, p < 0.01), leptin-adiponectin ratio (AOR 5.07 × 108, p < 0.01), insulin-like growth factor-1 (IGF-1) (AOR 1.02, p < 0.05), and gamma interferon (IFN-γ) (AOR 0.92, p < 0.05) levels were independently associated with stunting at enrolment. Serum leptin, leptin-adiponectin ratio, interleukin-6 (IL-6), IL-10, tumor necrosis factor-alpha (TNF-α), and fecal alpha-1-antitrypsin (AAT) levels increased significantly (p < 0.001), while IFN-γ levels significantly decreased among stunted children after six months of intervention. Leptin, leptin-adiponectin ratio, IGF-1, and IFN-γ are independently associated with stunting in Bangladeshi children. This trial was registered at clinicaltrials.gov as NCT02839148.
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Affiliation(s)
- Muttaquina Hossain
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh.
| | - Baitun Nahar
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Md Ahshanul Haque
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Dinesh Mondal
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Nurun Nahar Naila
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Md Amran Gazi
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Md Mehedi Hasan
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | | | - Rashidul Haque
- Enteric and Respiratory Infections, icddr,b, Dhaka 1212, Bangladesh
| | - Michael B Arndt
- PATH, Seattle, WA 98109, USA
- Department of Global Health, University of Washington, Seattle, WA 98109, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA 98109, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98109, USA
- Childhood Acute Illness and Nutrition Network, Nairobi 00200, Kenya
- Departments of Medicine, University of Washington, Seattle, WA 98109, USA
- Department of Epidemiology, University of Washington, Seattle, WA 98109, USA
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
- Department of Global Health, University of Washington, Seattle, WA 98109, USA
- James P. Grant School of Public Health, BRAC University, Dhaka 1212, Bangladesh
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Nahar B, Hossain M, Mahfuz M, Islam MM, Hossain MI, Murray-Kolb LE, Seidman JC, Ahmed T. Early childhood development and stunting: Findings from the MAL-ED birth cohort study in Bangladesh. MATERNAL AND CHILD NUTRITION 2019; 16:e12864. [PMID: 31237738 PMCID: PMC7038907 DOI: 10.1111/mcn.12864] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 01/20/2023]
Abstract
Information on the association between stunting and child development is limited from low‐income settings including Bangladesh where 36% of children under‐ 5 are stunted. This study aimed to explore differences in early childhood development (ECD) between stunted (length‐for‐age z‐score [LAZ] < −2) and nonstunted (LAZ ≥ −2) children in Bangladesh. Children (n = 265) aged 6–24 months who participated in the MAL‐ED birth cohort study were evaluated by trained psychologists at 6, 15, and 24 months of age using the Bayley Scales of Infant and Toddler Development‐III; child length and weight were measured using standard procedures. ECD scores (z‐scores derived from cognitive, motor, language and socio‐emotional skills) were compared between stunted, underweight (weight‐for‐age z‐score < −2), and wasted (weight‐for‐length z‐score < −2) children, controlling for child age and sex and maternal age, education, body mass index (BMI), and depressive symptoms. Stunted children had significantly lower ECD scores than their nonstunted peers on cognitive (P = .049), motor (P < .001), language (P < .001) and social–emotional (P = .038) scales where boys had significantly lower fine motor skills compared with girls (P = .027). Mother's schooling and BMI were significant predictors of ECD. Similar to stunting, underweight children had developmental deficits in all domains (cognitive: P = .001; fine motor: P = .039, and P < .001 for both gross motor and total motor; expressive communication: P = .032; total language: P = .013; social–emotional development: P = .017). Wasted children had poor motor skills (P = .006 for the fine motor; P < .001 for both gross motor and total motor development) compared with the nonwasted peers. Early childhood stunting and underweight were associated with poor developmental outcomes in Bangladesh.
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Affiliation(s)
- Baitun Nahar
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Muttaquina Hossain
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Munirul Islam
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Laura E Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, Pennsylvania
| | - Jessica C Seidman
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.,James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Ara G, Khanam M, Papri N, Nahar B, Kabir I, Sanin KI, Khan SS, Sarker MSA, Dibley MJ. Peer Counseling Promotes Appropriate Infant Feeding Practices and Improves Infant Growth and Development in an Urban Slum in Bangladesh: A Community-Based Cluster Randomized Controlled Trial. Curr Dev Nutr 2019; 3:nzz072. [PMID: 31334480 PMCID: PMC6635820 DOI: 10.1093/cdn/nzz072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/14/2019] [Accepted: 06/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Undernutrition and poor cognitive development affect many children in developing countries. Good nutrition and health care are essential for optimal child development and growth. OBJECTIVES We assessed the impact of peer counseling combined with psychosocial stimulation on feeding practices and child growth and development in slums in Bangladesh. METHODS We performed a community-based cluster randomized controlled trial in selected slums; 350 mother-infant pairs were allocated to receive peer counseling on feeding practices plus psychosocial stimulation (PC + PCS; n = 175) or usual health messages (control; n = 175) using restricted randomization. Data were collected at enrollment and 1, 3, 5, 7, 9, and 12 mo after delivery. We collected data on infant and young child feeding practices and anthropometric measurements from birth until 12 mo to assess the main outcomes, including feeding practices and growth. We used the Bayley Scale III at 12 mo to assess child development. The effects of the PC + PCS intervention were assessed by using regression models. RESULTS More mothers in the PC + PCS group than in the control group reported early initiation of breastfeeding (in the first hour: 89% compared with 78%, respectively; P < 0.05) and exclusive breastfeeding at 5 mo (73% compared with 27%, respectively; P < 0.001). Peer counseling had positively impacted infant length gain at 12 mo (P < 0.005). Children in the PC + PCS group were found to be more socially and emotionally active compared with controls at 12 mo (standardized score: 0.165 compared with -0.219, respectively; P < 0.05). CONCLUSION Combining peer counseling with psychosocial stimulation had positive effects on infant feeding practices and growth at 12 mo and on the social-emotional development of young children. This trial was registered at clinicaltrial.gov as NCT03040375.
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Affiliation(s)
- Gulshan Ara
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mansura Khanam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nowshin Papri
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Baitun Nahar
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Iqbal Kabir
- Bangladesh Breastfeeding Foundation, Institute of Public Health, Dhaka, Bangladesh
| | - Kazi Istiaque Sanin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sihan Sadat Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Michael J Dibley
- Sydney School of Public Health, University of Sydney, Sydney, Australia
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Ma Y, Sudfeld CR, Kim H, Lee J, Cho Y, Awoonor-Williams JK, Degley JK, Cha S. Evaluating the impact of community health volunteer home visits on child diarrhea and fever in the Volta Region, Ghana: A cluster-randomized controlled trial. PLoS Med 2019; 16:e1002830. [PMID: 31199792 PMCID: PMC6568387 DOI: 10.1371/journal.pmed.1002830] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 05/20/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although there is mounting evidence demonstrating beneficial effects of community health workers (CHWs), few studies have examined the impact of CHW programs focused on preventing infectious diseases in children through behavior changes. We assessed the preventive effects of community health volunteers (CHVs), who receive no financial incentive, on child diarrhea and fever prevalence in Ghana. METHODS AND FINDINGS We conducted a cluster-randomized controlled trial in 40 communities in the Volta Region, Ghana. Twenty communities were randomly allocated to the intervention arm, and 20 to the control arm, using a computer-generated block randomization list. In the intervention arm, CHVs were deployed in their own community with the key task of conducting home visits for health education and community mobilization. The primary outcomes of the trial were diarrhea and fever prevalence at 6 and 12 months among under-5 children based on caregivers' recall. Secondary outcomes included oral rehydration treatment and rapid diagnostic testing for malaria among under-5 children, and family planning practices of caregivers. Generalized estimating equations (GEEs) with a log link and exchangeable correlation matrix were used to determine the relative risk (RR) and 95% confidence intervals (CIs) for diarrhea, fever, and secondary outcomes adjusted for clustering and stratification. Between April 18 and May 4, 2015, 1,956 children were recruited and followed up until September 20, 2016. At 6 and 12 months post-randomization, 1,660 (85%) and 1,609 (82%) participants, respectively, had outcomes assessed. CHVs' home visits had no statistically significant effect on diarrhea or fever prevalence at either time point. After a follow-up of 12 months, the prevalence of diarrhea and fever was 7.0% (55/784) and 18.4% (144/784), respectively, in the control communities and 4.5% (37/825) and 14.7% (121/825), respectively, in the intervention communities (12-month RR adjusted for clustering and stratification: diarrhea, RR 0.73, 95% CI 0.37-1.45, p = 0.37; fever, RR 0.76, 95% CI 0.51-1.14, p = 0.20). However, the following were observed: improved hand hygiene practices, increased utilization of insecticide-treated bed nets, and greater participation in community outreach programs (p-values < 0.05) in the intervention group. In a post hoc subgroup analysis, the prevalence of diarrhea and fever at 6 months was 3.2% (2/62) and 17.7% (11/62), respectively, in the intervention communities with ≥70% coverage and a ≥30-minute visit duration, and 14.4% (116/806) and 30.2% (243/806) in the control communities (RR adjusted for clustering, stratification, baseline prevalence, and covariates: diarrhea, RR 0.23, 95% CI 0.09-0.60, p = 0.003; fever, RR 0.69, 95% CI 0.52-0.92, p = 0.01). The main limitations were the following: We were unable to investigate the longer-term effects of CHVs; the trial may have been underpowered to detect small to moderate effects due to the large decline in diarrheal and fever prevalence in both the intervention and control group; and caregivers' practices were based on self-report, and the possibility of caregivers providing socially desirable responses cannot be excluded. CONCLUSIONS We found no effect of CHVs' home visits on the prevalence of child diarrhea or fever. However, CHV programs with high community coverage and regular household contacts of effective duration may reduce childhood infectious disease prevalence. TRIAL REGISTRATION International Standard Randomised Controlled Trial Registry, ISRCTN49236178.
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Affiliation(s)
- Yeunji Ma
- Independent Consultant, Seoul, Republic of Korea
| | - Christopher R. Sudfeld
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Heunghee Kim
- Korea International Development Institute, Seoul, Republic of Korea
| | - Jaeeun Lee
- Korea International Cooperation Agency, Seongnam-si, Republic of Korea
| | - Yinseo Cho
- Korea International Cooperation Agency, Seongnam-si, Republic of Korea
| | | | | | - Seungman Cha
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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Milner KM, Bernal Salazar R, Bhopal S, Brentani A, Britto PR, Dua T, Gladstone M, Goh E, Hamadani J, Hughes R, Kirkwood B, Kohli-Lynch M, Manji K, Ponce Hardy V, Radner J, Rasheed MA, Sharma S, Silver KL, Tann C, Lawn JE. Contextual design choices and partnerships for scaling early child development programmes. Arch Dis Child 2019; 104:S3-S12. [PMID: 30885961 PMCID: PMC6557220 DOI: 10.1136/archdischild-2018-315433] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/18/2018] [Accepted: 01/18/2019] [Indexed: 12/29/2022]
Abstract
Translating the Nurturing Care Framework and unprecedented global policy support for early child development (ECD) into action requires evidence-informed guidance about how to implement ECD programmes at national and regional scale. We completed a literature review and participatory mixed-method evaluation of projects in Saving Brains®, Grand Challenges Canada® funded ECD portfolio across 23 low- and middle-income countries (LMIC). Using an adapted programme cycle, findings from evaluation related to partnerships and leadership, situational analyses, and design for scaling ECD were considered. 39 projects (5 'Transition to Scale' and 34 'Seed') were evaluated. 63% were delivered through health and 84% focused on Responsive Caregiving and Early Learning (RCEL). Multilevel partnerships, leadership and targeted situational analysis were crucial to design and adaptation. A theory of change approach to consider pathways to impact was useful for design, but practical situational analysis tools and local data to guide these processes were lacking. Several RCEL programmes, implemented within government services, had positive impacts on ECD outcomes and created more enabling caregiving environments. Engagement of informal and private sectors provided an alternative approach for reaching children where government services were sparse. Cost-effectiveness was infrequently measured. At small-scale RCEL interventions can be successfully adapted and implemented across diverse settings through processes which are responsive to situational analysis within a partnership model. Accelerating progress will require longitudinal evaluation of ECD interventions at much larger scale, including programmes targeting children with disabilities and humanitarian settings with further exploration of cost-effectiveness, critical content and human resources.
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Affiliation(s)
- Kate M Milner
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Raquel Bernal Salazar
- Economics Department, Universidad de los Andes, Bogota, Colombia
- Centro de Estudios de Desarrollo Economico (CEDE), Universidad de los Andes, Bogota, Colombia
| | - Sunil Bhopal
- Maternal & Child Health Intervention Research Group, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Northern School of Paediatrics, Newcastle-upon-Tyne, UK
| | - Alexandra Brentani
- Departamento de Pediatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Tarun Dua
- Department of Mental Health and Substance Abuse, World Health Organisation, Geneva, Switzerland
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Esther Goh
- Bernard van Leer Foundation, The Hague, The Netherlands
| | - Jena Hamadani
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Dhaka District, Bangladesh
| | - Rob Hughes
- Maternal & Child Health Intervention Research Group, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Children's Investment Fund Foundation, London, UK
| | - Betty Kirkwood
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Maya Kohli-Lynch
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Victoria Ponce Hardy
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - James Radner
- Munk School of Global Affairs and Public Policy, University of Toronto, Toronto, Ontario, Canada
- Center on the Developing Child, Harvard University, Cambridge, Massachusetts, USA
| | | | | | | | - Cally Tann
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
- Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
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Hossain SJ, Roy BR, Salveen NE, Hasan MI, Tipu SMMU, Shiraji S, Tofail F, Hamadani JD. Effects of adding psychosocial stimulation for children of lactating mothers using an unconditional cash transfer platform on neurocognitive behavior of children in rural Bangladesh: protocol for a cluster randomized controlled trial. BMC Psychol 2019; 7:13. [PMID: 30836984 PMCID: PMC6402152 DOI: 10.1186/s40359-019-0289-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/20/2019] [Indexed: 11/26/2022] Open
Abstract
Background There is sufficient evidence that psychosocial stimulation (PS) benefits children’s neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh. Methods The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union, the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union. These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly (n = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke’s behavior rating scale. The secondary outcomes will be children and mothers’ growth, family food security status, health seeking behavior, mothers’ depressive symptoms and self-esteem and violence against mothers. Discussion The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh. Trial registration number ClinicalTrials.gov NCT03281980, registered on September 13, 2017.
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Affiliation(s)
- Sheikh Jamal Hossain
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh.
| | - Bharati Rani Roy
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Nur-E Salveen
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Mohammad Imrul Hasan
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - S M Mulk Uddin Tipu
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Shamima Shiraji
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Fahmida Tofail
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
| | - Jena D Hamadani
- Maternal and Child Health Division (MCHD), Internationational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, 1212, Bangladesh
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Andrews K, Gonzalez A. Contextual risk factors impacting the colonization and development of the intestinal microbiota: Implications for children in low- and middle-income countries. Dev Psychobiol 2019; 61:714-728. [PMID: 30663777 DOI: 10.1002/dev.21823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/09/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022]
Abstract
Early adversities, such as poverty, maternal stress, and malnutrition, can affect the structure and functioning of the developing brain with implications for biological systems such as the intestinal microbiota. To date, most studies examining the impact of these risk factors on the development and functioning of the intestinal microbiota have primarily been conducted in high-income countries. However, arguably, children in low- and middle-income countries may be at increased risk given cumulative biological and psychosocial adversities during their development. Accumulating evidence in low- and middle-income countries has linked dysbiosis of the intestinal microbiota to child health outcomes such as stunting, malnutrition, and diarrheal diseases characterized by reduced microbial diversity and elevated pathogenic bacteria, which has implications for psychosocial outcomes. This review summarizes empirical findings that highlight the association between risk factors prevalent in low- and middle-income countries and the intestinal microbiota of children. Additionally, we briefly survey the current evidence regarding the effect of nutritional interventions on the microbial composition of children in low- and middle-income countries. We conclude that these empirical studies have the capacity to inform future research investigating the influence of preventive interventions on biological systems by targeting the predominant risk factors faced by children in low- and middle-income countries.
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Affiliation(s)
- Krysta Andrews
- Neuroscience Graduate Program, McMaster University, Hamilton, Ontario, Canada.,Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Gonzalez
- Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada.,Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
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Ahner-McHaffie TW, Guest G, Petruney T, Eterno A, Dooley B. Evaluating the impact of integrated development: are we asking the right questions? A systematic review. Gates Open Res 2018; 1:6. [PMID: 29984355 PMCID: PMC6034098 DOI: 10.12688/gatesopenres.12755.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors? We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.
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Affiliation(s)
| | - Greg Guest
- FHI 360, 359 Blackwell St Suite 200; Durham, NC, USA
| | | | | | - Brian Dooley
- FHI 360, 1825 Connecticut Avenue, NW; Washington, DC, USA
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Ahner-McHaffie TW, Guest G, Petruney T, Eterno A, Dooley B. Evaluating integrated development: are we asking the right questions? A systematic review. Gates Open Res 2017. [DOI: 10.12688/gatesopenres.12755.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors? We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design, the only design capable of statistically detecting synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.
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Perkins JM, Kim R, Krishna A, McGovern M, Aguayo VM, Subramanian S. Understanding the association between stunting and child development in low- and middle-income countries: Next steps for research and intervention. Soc Sci Med 2017; 193:101-109. [DOI: 10.1016/j.socscimed.2017.09.039] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/01/2017] [Accepted: 09/21/2017] [Indexed: 02/05/2023]
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Developmental delay in the Amazon: The social determinants and prevalence among rural communities in Peru. PLoS One 2017; 12:e0186263. [PMID: 29023517 PMCID: PMC5638337 DOI: 10.1371/journal.pone.0186263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/28/2017] [Indexed: 11/19/2022] Open
Abstract
The consequences of poor child development are becoming increasingly recognized. Programs are being put in place around the world to improve child development by providing healthy and stimulating environments for children. However, these programs often have limited reach and little is known about the prevalence of developmental delay in under-developed communities. The current study set-out to better understand the prevalence of developmental delay in rural communities in the Amazon region of Peru. Also, it explores social determinants that are associated with any delay. Cross-sectional study by evaluating developmental delay in children under 4 years utilizing Ages and Stages Questionnaire (ASQ-3). Additionally, conducting a social determinants questionnaire answered by caretakers to identify social drivers for developmental delay. The data was analyzed with multi-variant analysis to measure association. The prevalence of developmental delay in the Amazonian communities was 26.7% (19.3% in communication, 11.4% in gross motor skills, 8% in both) (N = 596). The multivariate logistic regression analysis revealed significant associations between developmental delay and; level of education (OR 0.64, p = 0.009), age of mother during child's birth (OR 0.96, p = 0.002), visits by community health agents (OR 0.73, p = 0.013), and river as primary water source (OR 2.39, p = 0.001). The social determinants questionnaire revealed that 39% of the mothers had their first child before the age of 17, nearly half stopped going to school before the age of 12 (52%), 29% gave birth at home, 13% breast fed for less than 7 months, and 50% of the children had diarrhea in the last month. There is still a great need to improve the conditions for child development in the Amazon region of Peru. One-fourth of the children suffer from developmental delay, which will likely impede their potentials for life unless something is done. The impact of education, age of mother at birth of the child, community health agents, and access to clean drinking water were important findings. Improvements can be made in these areas to create a large, cost-effective impact on the well-being of the communities.
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Designing and Implementing an Early Childhood Health and Development Program in Rural, Southwest Guatemala: Lessons Learned and Future Directions. Adv Pediatr 2017; 64:381-401. [PMID: 28688599 DOI: 10.1016/j.yapd.2017.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Worldwide, children are often not meeting their developmental potential owing to malnutrition, infection, lack of stimulation, and toxic stress. Children with disabilities are more likely to experience poverty, neglect, and abuse, and are less likely to have adequate access to education and medical care. Early childhood developmental stimulation can improve language, learning, and future participation in communities. Therapeutic supports and endeavors to reduce stigma for people of all abilities strengthen communities and allow for human thriving.
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Abstract
This article looks at both nutrition and early childhood stimulation interventions as part of an integrated life cycle approach to development. We build on recent systematic reviews of child development, which are comprehensive in regard to what is currently known about outcomes reported in key studies. We then focus particularly on implementation, scaling, and economic returns, drawing mainly on experience in low- and middle-income countries where undernutrition and poor child development remain significant public health challenges with implications across the life course.
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Affiliation(s)
- Harold Alderman
- International Food Policy Research Institute, Washington, DC 20006;
| | - Lia Fernald
- Community Health Sciences, School of Public Health, University of California, Berkeley, California 94720;
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Herba CM, Glover V, Ramchandani PG, Rondon MB. Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries. Lancet Psychiatry 2016; 3:983-992. [PMID: 27650772 DOI: 10.1016/s2215-0366(16)30148-1] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 12/15/2022]
Abstract
Studies examining mechanisms underlying associations between maternal depression and adverse child outcomes (including behaviour, socioemotional adjustment, and emotion regulation) indicate that during pregnancy, maternal depression could affect child outcomes through altered placental function, epigenetic changes in the child, and stress reactivity. Infection and dietary deficiencies in the mother and the child, together with the child's genetic vulnerability, might also affect outcome. Postnatally, associations between maternal depression and child outcome are influenced by altered mother-child interactions, sociodemographic or environmental influences, and social support. Knowledge is scarce on mechanisms in low-income and middle-income countries where maternal depression is highly prevalent, and stressful factors that influence the development of perinatal maternal depression and adverse child outcome (eg, food insecurity, perinatal infections, crowded or rural living conditions, and interpersonal violence) are both more intense and more common than in high-income countries. We reviewed evidence and use the biopsychosocial model to illustrate risk factors, mediators and moderators underlying associations between maternal depression and child outcomes in low-income and middle-income countries.
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Affiliation(s)
- Catherine M Herba
- Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada; CHU Sainte-Justine Research Center, Montréal, QC, Canada.
| | - Vivette Glover
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | | | - Marta B Rondon
- Mental Health and Psychiatry Unit, Department of Medicine, Cayetano Heredia Peruvian University, Lima, Peru
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Larson LM, Yousafzai AK. A meta-analysis of nutrition interventions on mental development of children under-two in low- and middle-income countries. MATERNAL AND CHILD NUTRITION 2015; 13. [PMID: 26607403 DOI: 10.1111/mcn.12229] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 12/26/2022]
Abstract
Interventions to improve nutritional status of young children in low- and middle-income countries (LMIC) may have the added benefit of improving their mental and motor development. This meta-analysis updates and goes beyond previous ones by answering two important questions: (1) do prenatal and postnatal nutritional inputs improve mental development, and (2) are effects on mental development associated with two theoretically interesting mediators namely physical growth and motor development? The meta-analysis of articles on Medline, PsycINFO, Global Health and Embase was limited to randomized trials in LMICs, with mental development of children from birth to age two years as an outcome. The initial yield of 2689 studies was reduced to 33; 12 received a global quality rating of strong. Of the 10 prenatal and 23 postnatal nutrition interventions, the majority used zinc, iron/folic acid, vitamin A or multiple micronutrients, with a few evaluating macronutrients. The weighted mean effect size, Cohen's d (95% CI) for prenatal and postnatal nutrition interventions on mental development was 0.042 (-0.0084, 0.092) and 0.076 (0.019, 0.13), respectively. Postnatal supplements consisting of macronutrients yielded an effect size d (95% CI) of 0.14 (0.0067, 0.27), multiple micronutrients 0.082 (-0.012, 0.18) and single micronutrients 0.058 (-0.0015, 0.12). Motor development, but not growth status, effect sizes were significantly associated with mental development in postnatal interventions. In summary, nutrition interventions had small effects on mental development. Future studies might have greater effect if they addressed macronutrient deficiencies combined with child stimulation and hygiene and sanitation interventions.
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Affiliation(s)
- Leila Margaret Larson
- Emory University, Nutrition and Health Sciences Program, Laney Graduate School, Atlanta, Georgia, USA
| | - Aisha K Yousafzai
- Aga Khan University, Department of Paediatrics and Child Health, Division of Women and Child Health, Karachi, Sindh, Pakistan
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Nahar B, Hossain I, Hamadani JD, Ahmed T, Grantham-McGregor S, Persson LA. Effect of a food supplementation and psychosocial stimulation trial for severely malnourished children on the level of maternal depressive symptoms in Bangladesh. Child Care Health Dev 2015; 41:483-93. [PMID: 25040164 DOI: 10.1111/cch.12176] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Maternal depression is associated with poor child development and growth in low-income countries. This paper evaluates the effect of a community-based trial providing psychosocial stimulation and food supplements to severely malnourished children on maternal depressive symptoms in Bangladesh. METHODS Severely underweight (weight-for-age Z-score < -3) hospitalized children aged 6-24 months (n = 507), were randomly assigned to: psychosocial stimulation (PS), food supplementation (FS), PS+FS, clinic control (CC) and hospital control (CH) at discharge. PS included play sessions with children and parental counselling to mothers during fortnightly follow-up visit at community clinics, conducted by trained play leaders for 6 months. FS involved cereal-based supplements (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplements and growth monitoring. We used Bayley scales, Home Observation for Measurement of Environment (HOME) inventory and a parenting questionnaire to assess child development, home stimulation and mothers' child-rearing practices, respectively. We assessed mothers' depressive symptoms using a modified version of Centre for Epidemiologic Studies Depression Scale at baseline and at 6 months post intervention. RESULTS Maternal depressive symptoms were significantly lower in the CH group at baseline (P = 0.014). After 6 months of intervention there was no significant effect of intervention after adjusting for baseline scores and all possible confounders. Maternal depressive symptoms were higher among poorer (P = 0.06), older (P = 0.057) and less educated (P = 0.019) mothers, who were housewives (P = 0.053), and whose husbands had more unstable jobs (P = 0.058). At 6 months post intervention, children's cognitive (P = 0.045) and motor (P = 0.075) development, HOME (P = 0.012) and mother's parenting score (P = 0.057) were higher among mothers with lower depressive symptoms. CONCLUSION The study did not show a significant effect of the intervention on the level of maternal depressive symptoms. Interventions with higher intensity and/or of longer duration focusing directly on maternal psychosocial functioning are probably needed to reduce maternal depressive symptoms.
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Affiliation(s)
- B Nahar
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014; 384:1282-93. [PMID: 24947106 DOI: 10.1016/s0140-6736(14)60455-4] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stimulation and nutrition delivered through health programmes at a large scale could potentially benefit more than 200 million young children worldwide who are not meeting their developmental potential. We investigated the feasibility and effectiveness of the integration of interventions to enhance child development and growth outcomes in the Lady Health Worker (LHW) programme in Sindh, Pakistan. METHODS We implemented a community-based cluster-randomised effectiveness trial through the LHW programme in rural Sindh, Pakistan, with a 2 × 2 factorial design. We randomly allocated 80 clusters (LHW catchments) of children to receive routine health and nutrition services (controls; n=368), nutrition education and multiple micronutrient powders (enhanced nutrition; n=364), responsive stimulation (responsive stimulation; n=383), or a combination of both enriched interventions (n=374). The allocation ratio was 1:20 (ie, 20 clusters per intervention group). The data collection team were masked to the allocated intervention. All children born in the study area between April, 2009, and March, 2010, were eligible for enrolment if they were up to 2·5 months old without signs of severe impairments. Interventions were delivered by LHWs to families with children up to 24 months of age in routine monthly group sessions and home visits. The primary endpoints were child development at 12 and 24 months of age (assessed with the Bayley Scales of Infant and Toddler Development, Third Edition) and growth at 24 months of age. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT007159636. FINDINGS 1489 mother-infant dyads were enrolled into the study, of whom 1411 (93%) were followed up until the children were 24 months old. Children who received responsive stimulation had significantly higher development scores on the cognitive, language, and motor scales at 12 and 24 months of age, and on the social-emotional scale at 12 months of age, than did those who did not receive the intervention. Children who received enhanced nutrition had significantly higher development scores on the cognitive, language, and social-emotional scales at 12 months of age than those who did not receive this intervention, but at 24 months of age only the language scores remained significantly higher. We did not record any additive benefits when responsive stimulation was combined with nutrition interventions. Responsive stimulation effect sizes (Cohen's d) were 0·6 for cognition, 0·7 for language, and 0·5 for motor development at 24 months of age; these effect sizes were slightly smaller for the combined intervention group and were low to moderate for the enhanced nutrition intervention alone. Children exposed to enhanced nutrition had significantly better height-for-age Z scores at 6 months (p<0·0001) and 18 months (p=0·02) than did children not exposed to enhanced nutrition. Longitudinal analysis showed a small benefit to linear growth from enrolment to 24 months (p=0·026) in the children who received the enhanced nutrition intervention. INTERPRETATION The responsive stimulation intervention can be delivered effectively by LHWs and positively affects development outcomes. The absence of a major effect of the enhanced nutrition intervention on growth shows the need for further analysis of mediating variables (eg, household food security status) that will help to optimise future nutrition implementation design. FUNDING UNICEF.
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Affiliation(s)
- Aisha K Yousafzai
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Muneera A Rasheed
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Zulfiqar A Bhutta
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
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