Children under five living in extreme poverty in South West Ethiopia: Developmental profile and home-based developmental stimulation

Abstract

Worldwide, over 385 million children under five are living in extreme poverty. Half of them currently live in Sub-Saharan Africa and are at high risk of suboptimal development. The main risk factors are undernutrition, lack of safe water, poor sanitation, restricted learning opportunities and lack of adequate care, as well as inadequate stimulation at home. Because of the intergenerational transmission of extreme poverty, the risks these children are exposed to could even be transferred to the next generations. Rigorous and effective interventions are, thus, vital to curb such intergenerational influences. Nevertheless, to design and implement these interventions, the specific problems of these children need to be identified and documented. Particularly in Sub-Saharan African countries such as Ethiopia, the extent of developmental problems of these children has not been identified and documented for appropriate intervention. Hence, this doctoral dissertation documents two published studies which emerged from a preliminary exploratory study. The former study was also published, but not included in this dissertation. The first study discussed in this dissertation focused on profiling children (3 - 59 months in age; n= 819) in South-West Ethiopia living in extreme poverty by analyzing their developmental, nutritional and psychosocial problems (Study 1; Chapter 2). This information was essential to design the home-based play-assisted developmental stimulation, which was implemented and evaluated in the second study of this dissertation (Study 2; Chapter 2). This second study targeted children living with their foster families in the context of extreme poverty; because 112 (14%) of the 819 children in study 1 were foster children and, these children carry double burdens. The design of this intervention study was a randomized controlled trial (RCT), with two arms: intervention (n=39) and control (n=39). Both groups received the basic services (such as a family home, food, clothing, health care, protection and education). Children in the intervention group received home-based play-assisted stimulation in addition to these basic services. Provision of the basic services and stimulation started simultaneously. The intervention consisted of an hour of play stimulation conducted during a weekly home visit for six months. The stimulation activities were carried out by experienced clinical nurses at the children’s home, in collaboration with the primary caregivers. At every visit, play materials were brought to the home and left for the caregiver and the child to use. The intervention focused on activities to promote developmental skills and emphasized direct caregiver-child interactions. Caregivers were regularly reminded and motivated to continue practicing the activities and cultural games learned during the home visits. This intervention study deliberately took into account a child’s contextual factors (personal and home-environmental factors), activity and participation in the WHO’s International Classification of Functioning, Disability and Health (ICF). We preferred home visits and closely working with children’s caregivers because we thought their responsive interactions with their children could promote development and wellbeing. We also believed that focusing on caregivers’ child-rearing practices could make benefits to the children more likely to be sustainable. Development in personal-social, language, fine and gross motor skills were assessed using the culturally adapted and standardized developmental screening tool, the Denver II-Jimma, and social-emotional outcomes (self-regulation, adaptive functioning, affect, compliance, autonomy, interaction with people and communication behaviors) were obtained using an adapted Ages and Stages Questionnaire: Social-Emotional (ASQ:SE). Information about psychosocial conditions and sociodemographic characteristics were collected using a structured questionnaire. Anthropometric methods were used to determine nutritional status. The results (of Study 1) showed that children in extreme poverty (n=819) performed worse in all the tested developmental outcomes when compared with age-matched reference children (n=819). Again, in contrast to the reference children, they experienced higher psychosocial problems, such as limited child-child interaction (χ² = 90.7, p<0.001), limited mother-child interaction (χ² = 116.1, p<0.001), limited play materials (χ² = 243, p<0.001), limited playground (χ² = 194.2, p<0.001) and limited play time (χ² = 12.8, p<0.001). Among the 819 extremely poor children, 325 (39.7%) were stunted, 135 (16.5%) were underweight and 27 (3.3%) were wasted. Stunting and being underweight were negatively associated with all the developmental outcomes. After controlling for the effects of stunting and being underweight on the developmental outcomes, it was observed that limited play activities, limited child-child interactions and mother-child relationships were negatively related mainly to language and gross motor outcomes. This means that these increased psychosocial problems reduced the language and gross motor performances of the children (Study 1; Chapter 2). At three months (midline) of the intervention study (Study 2), language (P=0.0151, effect size (es) = 0.34) and social-emotional (P<0.0001, es = -0.603) benefits had already been observed for the children in the intervention group. The negative (-) sign of the effect size indicates the reduction in social-emotional problems. At six months (endline), significant intervention effects were found for language (P=0.0014, es = 0.55), personal-social (P=0.0087, es = 0.56) and social-emotional (P<0.0001, es = -1.28) outcomes. For language, the intervention effect depended on the child’s sex (P=0.0100); that is, boys benefited more from the intervention than girls (Study 2; Chapter 2). In conclusion, some children living in extremely poor households were not only undernourished, but they were also experiencing higher psychosocial problems. Both conditions negatively affected their developmental outcomes independently. Further, quality home-based play-assisted developmental stimulation, integrated into basic services, developmentally benefited these children under five in a resource-poor context. On the basis of these results, an implementation of this type of intervention is suggested at the national level.