Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods

AIMS/BACKGROUND

The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation.

DESIGN/METHODS

We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported.

RESULTS

We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings.

CONCLUSION

There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.

Effects of individual differences, society, and culture on youth-rated problems and strengths in 38 societies

BACKGROUND

Clinicians increasingly serve youths from societal/cultural backgrounds different from their own. This raises questions about how to interpret what such youths report. Rescorla et al. (2019, European Child & Adolescent Psychiatry, 28, 1107) found that much more variance in 72,493 parents' ratings of their offspring's mental health problems was accounted for by individual differences than by societal or cultural differences. Although parents' reports are essential for clinical assessment of their offspring, they reflect parents' perceptions of the offspring. Consequently, clinical assessment also requires self-reports from the offspring themselves. To test effects of individual differences, society, and culture on youths' self-ratings of their problems and strengths, we analyzed Youth Self-Report (YSR) scores for 39,849 11-17 year olds in 38 societies.

METHODS

Indigenous researchers obtained YSR self-ratings from population samples of youths in 38 societies representing 10 culture cluster identified in the Global Leadership and Organizational Behavioral Effectiveness study. Hierarchical linear modeling of scores on 17 problem scales and one strengths scale estimated the percent of variance accounted for by individual differences (including measurement error), society, and culture cluster. ANOVAs tested age and gender effects.

RESULTS

Averaged across the 17 problem scales, individual differences accounted for 92.5% of variance, societal differences 6.0%, and cultural differences 1.5%. For strengths, individual differences accounted for 83.4% of variance, societal differences 10.1%, and cultural differences 6.5%. Age and gender had very small effects.

CONCLUSIONS

Like parents' ratings, youths' self-ratings of problems were affected much more by individual differences than societal/cultural differences. Most variance in self-rated strengths also reflected individual differences, but societal/cultural effects were larger than for problems, suggesting greater influence of social desirability. The clinical significance of individual differences in youths' self-reports should thus not be minimized by societal/cultural differences, which-while important-can be taken into account with appropriate norms, as can gender and age differences.

Long-Term Mental Health and Quality of Life Outcomes of Neonatal Insults in Kilifi, Kenya

We examined the mental health and quality of life (QoL) outcomes and their correlates of school-aged survivors of neonatal jaundice (NNJ), hypoxic-ischemic encephalopathy (HIE), and a comparison group. The Child Behavior Checklist and the Pediatric Quality of Life Inventory were administered to assess the mental health and QoL of 375 children (134 with NNJ, 107 with HIE, and 134 comparison group) aged 6 to 12 years [Median age 9 (interquartile range 7 to 11)]. The results showed that survivors of NNJ and HIE have mental health problems and QoL similar to the comparison group. Maternal mental health was the predominant covariate of mental health and QoL in survivors of NNJ and HIE. This result could indicate that mothers with mental health problems are more likely to have children with mental health issues, but also that caring for children with these adversities may affect mental health well-being of the caregivers. There is a need for early mental health screening and psychosocial intervention for caregivers and their children to enhance both their mental health and QoL.

Long-term neurocognitive and educational outcomes of neonatal insults in Kilifi, Kenya

BACKGROUND

There is little data on the long-term neurocognitive and educational outcomes among school-aged survivors of neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) in Africa. This study investigates the long-term neurocognitive and educational outcomes and the correlates of these outcomes in school-aged survivors of NNJ or HIE in Kilifi, Kenya.

METHODS

We conducted a cross-sectional study on neurocognitive and educational outcomes among school-aged survivors (6-12 years) of NNJ (n = 134) and HIE (n = 107) and compared them to a community comparison group (n = 134). We assessed nonverbal intelligence, planning, working memory, attention, syntax, pragmatics, word-finding, memory, perceptual-motor, mathematical, and reading abilities. We also collected information on medical history, caregivers' mental health, and family environment.

RESULTS

The survivors of NNJ had lower mean total scores in word-finding [F (1, 250) = 3.89, p = 0.050] and memory [F (1, 248) = 6.74, p = 0.010] than the comparison group. The survivors of HIE had lower mean scores in pragmatics [F (1, 230) = 6.61, p = 0.011] and higher scores higher scores in non-verbal reasoning [F (1, 225) =4.10, p = 0.044] than the comparison group. Stunted growth was associated with almost all the outcomes in HIE.

CONCLUSION

Survivors of NNJ and HIE present with impairment in the multiple domains, which need to be taken into consideration in the planning of educational and rehabilitative services.

Neonatal jaundice and developmental impairment among infants in Kilifi, Kenya

BACKGROUND

Neonatal jaundice (NNJ) is common in sub-Saharan Africa (SSA), and it is associated with sepsis. Despite the high incidence, little has been documented about developmental impairments associated with NNJ in SSA. In particular, it is not clear if sepsis is associated with greater impairment following NNJ.

METHODS

We followed up 169 participants aged 12 months (57 cases and 112 controls) within the Kilifi Health Demographic Surveillance System. The diagnosis of NNJ was based on clinical laboratory measurement of total serum bilirubin on admission, whereas the developmental outcomes were assessed using the Developmental Milestones Checklist and Kilifi Development Inventory.

RESULTS

There were significant differences between the cases and controls in all developmental domains. Cases scored lower in language functioning (mean [M] = 6.5, standard deviation [SD] = 4.3 vs. M = 8.9, SD = 4.6; p < .001); psychomotor functioning (Mdn = 23, interquartile range [IQR] = 17-34 vs. Mdn = 31.0, IQR = 22.0-44.0; Mann-Whitney U = 4,122, p = .002); and socio-emotional functioning ([Mdn = 30.0, IQR = 27.0-33.0 vs. Mdn = 34.0, IQR = 30.0-37.0], Mann-Whitney U = 4,289, p < .001). There was no evidence of association between sepsis and psychomotor (r_pb = -.2, p = .214), language (r_pb = -.1, p = .510), and socio-emotional functioning (r_pb = .0, p = .916). Significant and medium to large portions of the variance (34-64%) in the developmental outcomes among children who survived NNJ were associated with home birth, low maternal education, and feeding problems during the first days of life.

CONCLUSIONS

NNJ is associated with developmental impairments in the early childhood years; however, NNJ associated with sepsis does not lead to more severe impairment. Prenatal and postnatal care services are needed to reduce the negative impact of NNJ for children from low resourced settings.

Long-term outcomes of survivors of neonatal insults: A systematic review and meta-analysis

BACKGROUND

The Millennium Developmental Goals ensured a significant reduction in childhood mortality. However, this reduction simultaneously raised concerns about the long-term outcomes of survivors of early childhood insults. This systematic review focuses on the long-term neurocognitive and mental health outcomes of neonatal insults (NNI) survivors who are six years or older.

METHODS

Two independent reviewers conducted a comprehensive search for empirical literature by combining index and free terms from the inception of the databases until 10th October 2019. We also searched for additional relevant literature from grey literature and using reference tracking. Studies were included if they: were empirical studies conducted in humans; the study participants were followed at six years of age or longer; have an explicit diagnosis of NNI, and explicitly define the outcome and impairment. Medians and interquartile range (IQR) of the proportions of survivors of the different NNI with any impairment were calculated. A random-effect model was used to explore the estimates accounted for by each impairment domain.

RESULTS

Fifty-two studies with 94,978 participants who survived NNI were included in this systematic review. The overall prevalence of impairment in the survivors of NNI was 10.0% (95% CI 9.8-10.2). The highest prevalence of impairment was accounted for by congenital rubella (38.8%: 95% CI 18.8-60.9), congenital cytomegalovirus (23.6%: 95% CI 9.5-41.5), and hypoxic-ischemic encephalopathy (23.3%: 95% CI 14.7-33.1) while neonatal jaundice has the lowest proportion (8.6%: 95% CI 2.7-17.3). The most affected domain was the neurodevelopmental domain (16.6%: 95% CI 13.6-19.8). The frequency of impairment was highest for neurodevelopmental impairment [22.0% (IQR = 9.2-24.8)] and least for school problems [0.0% (IQR = 0.0-0.00)] in any of the conditions.

CONCLUSION

The long-term impact of NNI is also experienced in survivors of NNI who are 6 years or older, with impairments mostly experienced in the neurodevelopmental domain. However, there are limited studies on long-term outcomes of NNI in sub-Saharan Africa despite the high burden of NNI in the region.

TRIAL REGISTRATION

Registration number: CRD42018082119.

Patterns of neurobehavioral functioning in school-aged survivors of neonatal jaundice and hypoxic-ischemic encephalopathy in Kilifi, Kenya: A cross-sectional study

Background: Studies in high-income countries have reported that school-aged children who survive neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) develop long-term neurocognitive problems. However, less is known about the patterns of functioning in school-aged survivors of NNJ and HIE in sub-Saharan Africa. This study examined patterns of functioning in school-aged children who survived NNJ and HIE in Kilifi, Kenya. Methods: This is a cross-sectional study that included 107 survivors of NNJ/HIE (64 with NNJ, 43 with HIE), aged 6-12 years, admitted to Kilifi County Hospital on the Kenyan Coast. The Gross Motor Function Classification System (GMFCS), Adapted Communication Profile, Raven’s Coloured Progressive Matrices (RCPM) and an epilepsy screening tool were used to assess gross motor function, communication function, intellectual functioning, and epilepsy, respectively. Results: Most of the survivors of NNJ (95.2%) and HIE (95.3%) had no impairments in gross motor functioning. A small percentage of the children in the NNJ and HIE groups had profound problems in their communication (4.7% and 4.7%); expressive communication function (4.7% and 4.7%); social functions (3.1% and 2.3%); receptive communication (4.7% and 2.3%); and communicative effectiveness (4.7% and 2.3%). Cognitive impairment was reported in 10.9% and 11.9% for NNJ and HIE survivors, respectively. Active epilepsy was detected in 1.6% of survivors of NNJ and 2.3% of survivors of HIE. All children had normal hearing and visual functioning except one participant who presented with mild visual acuity problems. Conclusions: Most school-aged children who survive with NNJ and HIE have normal motor and communication function; however, one in ten are likely to present with lowered intellectual functioning compared to the normative sample.

A randomized control trial of phototherapy and 20% albumin versus phototherapy and saline in Kilifi, Kenya

Objective

The study evaluated the efficacy of phototherapy and 20% albumin infusion to reduce total serum bilirubin (TSB) in neonates with severe hyperbilirubinemia. The primary outcome was a reduction of TSB at the end of treatment. The secondary outcomes were the need for exchange transfusion, inpatient mortality, neurological outcomes at discharge, and development outcomes at 12-months follow-up.

Results

One hundred and eighteen neonates were randomly assigned to phototherapy and 20% albumin (n = 59) and phototherapy and saline (n = 69). The median age at admission was 5 (interquartile range (IQR) 3–6) days, and the median gestation was 36 (IQR 36–38) weeks. No significant differences were found in the change in TSB (Mann–Whitney U =609, p = 0.98) and rate of change in TSB per hour after treatment (Mann–Whitney U = 540, p = 0.39) between the two groups. There were no significant differences between the two groups in the proportion of participants who required exchange transfusion (χ² (2) = 0.36, p = 0.546); repeat phototherapy (χ² (2) = 2.37, p = 0.123); and those who died (χ² (2) = 0.92, p = 0.337). Trial registration The trial was registered in the International Standardized Randomized Controlled Trial Number (ISRCTN); trial registration number ISRCTN89732754.

Patterns of neurobehavioral functioning in school-aged survivors of neonatal jaundice and hypoxic-ischemic encephalopathy in Kilifi, Kenya: A cross-sectional study

Background: Studies in high-income countries have reported that school-aged children who survive neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) develop long-term neurocognitive problems. However, less is known about the patterns of functioning in school-aged survivors of NNJ and HIE in sub-Saharan Africa. This study examined patterns of functioning in school-aged children who survived NNJ and HIE in Kilifi, Kenya. Methods: This is a cross-sectional study that included 107 survivors of NNJ/HIE (64 with NNJ, 43 with HIE), aged 6-12 years, admitted to Kilifi County Hospital on the Kenyan Coast. The Gross Motor Function Classification System (GMFCS), Adapted Communication Profile, Raven’s Coloured Progressive Matrices (RCPM) and an epilepsy screening tool were used to assess gross motor function, communication function, intellectual functioning, and epilepsy, respectively. Results: Most of the survivors of NNJ (95.2%) and HIE (95.3%) had no impairments in gross motor functioning. A small percentage of the children in the NNJ and HIE groups had profound problems in their communication (4.7% and 4.7%); expressive communication function (4.7% and 4.7%); social functions (3.1% and 2.3%); receptive communication (4.7% and 2.3%); and communicative effectiveness (4.7% and 2.3%). Cognitive impairment was reported in 10.9% and 11.9% for NNJ and HIE survivors, respectively. Active epilepsy was detected in 1.6% of survivors of NNJ and 2.3% of survivors of HIE. All children had normal hearing and visual functioning except one participant who presented with mild visual acuity problems. Conclusions: Most school-aged children who survive with NNJ and HIE have normal motor and communication function; however, one in ten are likely to present with lowered intellectual functioning compared to the normative sample.

Emotional and Behavioral Problems in Children and Adolescents in Central Kenya

Emotional and behavioral problems (EBP) during childhood and adolescence are a common concern for parents and mental health stakeholders. However, little has been documented about their prevalence in Kenyan children and adolescents. This study aimed to close this gap. The study included Child Behavior Checklist reports from 1022 Kenyan parents on their children (ages 6-18 years) and Youth Self-Reports from 533 adolescents (ages 12-18) living in Kenya's Central Province. EBP in Kenya are highly prevalent compared to multi-cultural standards for parent reports, with 27 and 17% scoring in the borderline and clinical range, respectively. Based on parent reports, younger children scored higher on EBP than older children, and higher on internalizing problems. Based on self-reports girls scored higher than boys, particularly on internalizing problems. The study provides evidence on elevated parent-reported EBP in Kenyan youths. Mental health providers should focus on interventions that reduce EBP in Kenyan youths.