Play-based family-centred psychomotor/psychosocial stimulation and the recovery of severely acutely malnourished children

Abstract

Severe acute malnutrition (SAM) remains a great health challenge in low and middle income countries (LMICs). SAM has severe short-term and long-term consequences on growth and the development of children. To mitigate the effects of SAM, the World Health Organization (WHO) recommends combining psychosocial stimulation with dietary rehabilitation. There are challenges in implementing the recommendation in some low-income settings where even basic food for survival let alone balanced diet, remains scant. In such contexts, there is a scarcity of accurate data on the magnitude of the effect of SAM on the different dimensions of child development. Psychosocial intervention studies aimed at mitigating the developmental effects of SAM are not only sparse, but also have limitations in design and use of Western child development tools in non-Western settings without adaptation. No study has so far used a randomized controlled trial during and after hospitalization, because of a belief that it is unethical to give intervention to certain participants in the same hospital ward through randomization. Therefore, there is a lack of strong scientific evidence of the contributions of psychosocial stimulation for children with SAM. Due to a lack of culturally relevant child development assessment tools in such low-income settings, little is known about the accuracy and reliability of the Western tools used to assess the developmental impacts of the interventions. The primary goal of this thesis was therefore to expound the effects of play-based family-centered psychomotor/psychosocial stimulation in mitigating the deleterious effect of SAM on child development in a low-income context. To achieve this main goal, adapting a Western child development assessment tool to the local study setting and documenting the magnitude of SAM on the different domains of child development were respectively addressed as first and second prerequisite studies. Hence, the thesis documents three studies: the adaptation and standardization processes in making a Western child development screening tool culturally relevant for use in a non-Western setting (Study 1), determining the magnitude of developmental delay among SAM children of different ages so as to undertake an insightful intervention (Study 2), and examining the effect of psychomotor/psychosocial stimulation on development, linear growth and nutritional outcomes of SAM children (Study 3). The studies were conducted in Jimma Zone, South West Ethiopia on children under six years of age. Study 1 was a three-phase process, conducted on healthy children in Jimma town: pilot survey, pilot feasibility and reliability, and final optimization and standardization on a large sample (n=1597; age= two days to six years). Of the 125 test items in the Denver II, 36 items (mostly in the personal-social domain) were adapted. The 90% age of milestones attainment on the adapted tool differ significantly from Denver II on 42 (33.6%) items (9 PS, 6 FM, 15 LA, and 12 GM). The test items in the adapted tool have good to excellent inter-rater and test retest reliabilities. Study 2 examined the magnitude of developmental delay among SAM children of different ages by comparing the developmental performances of 310 SAM children with that of age and 310 sex-matched non-malnourished healthy children (N=620, mean age=30.2, range=3-66 mo.). A more severe delay was observed on very young children on gross motor, followed by fine motor functions than on older children. Study 3 was a randomized controlled trial conducted on SAM children from different districts in Jimma Zone admitted to the Nutritional Rehabilitation Unit at Jimma University’s Specialized Referral Teaching Hospital for medical and dietary treatment (N=339; mean± SD age = 27.4±15.1mo, range=6.1—65.7mo). The SAM children were randomly assigned to control (n=170) and intervention (n=169) groups. At the hospital, both groups received standard medical and nutritional treatment but the intervention group received an additional psychomotor/psychosocial stimulation in the form of play in a playroom alone or a playroom and playground furnished with play materials. Trained clinical nurses offered the stimulation to the child (psychomotor) in the presence of the child’s caregiver. Caregivers were given education on childcare, feeding, and stimulation in addition to practical training on how to use play materials to stimulate the SAM child. After discharge from hospital, caregivers and significant others in family were involved. Through play, a child was engaged in activities that facilitate physical growth and mental, linguistic, social, and emotional development. The intervention continued at home through mediation by caregivers. Three home visits were made by intervention nurses to follow up each child. The child’s linear growth, nutritional status, and developmental performances before the start of intervention, at discharge from hospital, and after six months of home follow-up were determined. The intervention group scored significantly higher during hospital follow-up in gross motor skills (p<0.001, effect size= 0.26 SD), and during home follow-up in fine motor skills (p=0.001, effect size=0.15 SD). The effect of the intervention, however, is small. The intervention had no significant effect on linear growth and nutritional outcomes. The hospital-based follow-up was shorter than the home-based follow-up. However, it was a period when the SAM children were provided with an adequate and balanced diet, and full-time attention and support from a caregiver. During the home-based follow-up, the SAM children had no access to an adequate and diversified diet. The duration of the follow-up predicted all developmental outcomes and indicated a possibility for a significant intervention effect if prolonged. The age and sex of child and baseline developmental performance level did not affect the outcomes of the intervention on all the examined domains of development. However, compared to the control, the intervention children who started receiving the stimulation with a better nutritional status as measured in weight-for-height or body mass-index-for-age improved better in wasting status (β=0.02, p=0.012), though this did not improve any of the developmental outcomes assessed. In short, the study shows play-based child-focused psychomotor activities and family-centered psychosocial stimulation activities that address the child’s immediate social and physical environment can contribute in the developmental recovery of SAM children.