Why combine infant stimulation with nutrition programmes? Dr. Lynne Jones Senior Mental Health...
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Transcript of Why combine infant stimulation with nutrition programmes? Dr. Lynne Jones Senior Mental Health...
Why combine infant stimulation with nutrition programmes?
Dr. Lynne Jones Senior Mental Health
AdviserINTERNATIONAL MEDICAL CORPS
(Research collaborators: Annamaria Berrino, Carmen Crow, Jodie Morris, Leonard Okema)
Work in 23 countries: Africa, SE Asia, Caucasus
Aim to improve the quality of life through health interventions and related activities that build local capacity in underserved communities worldwide. The integration of mental health into our services is a priority
Chad, Darfur refugee crisis, 2004
Existing evidence base for combined nutrition and psychosocial programmes
Advocated by WHO since 1999 Review of seven programs from
various parts of the world 6 improved children’s psychological
development 2 improved both growth and
psychological development. These two programs included infants
and younger children. The poorest and most malnourished
children benefited the most
Infant stimulation improves growth outcomes
DQ or IQ scores of stunted and non-stunted Jamaican children from age 9–24 months to 17–18 years
Long-term deficits associated with stunting and sustained benefits to stunted children who received a home-visiting programme providing early childhood stimulation.
Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study.
Lancet 2005; 366: 1804–07.
WHO recommends combining psychosocial stimulation with nutrition in severe food shortages
The Vicious Circle
Poorly nourished babies: timid and easily upset harder to feed less active less likely to play and
communicate less able to get the attention of
their mothers Mothers less likely to feed, play or
communicate with them
Mothers who are very worried and stressed by the problems of camp life may
not pay proper attention to babies
not communicate with them not play with them
Children become more apathetic in response and less likely to demand food when they need it
no crying orcrawling for food
Sick baby
Apathetic baby
Mother neglects baby
Other smaller baby demanding attention
Hungry baby
Mother sick/tired/worried
How to improve the situation…
Apatheticbaby
Add food and medical care
Support mother
Improve mother
child interaction
Does not cry or crawl for food
Sick baby
Hungry baby
Mother neglects baby
Other smaller baby demanding attention
Mother sick/tired
Combined Nutrition and Stimulation
Nutrition programmes provide ideal opportunity to feed the body and to feed the mind
Mother comes to get nutritional supplements for baby
Already used for education; hygiene, breastfeeding etc
Opportunity to teach infant stimulation and improve mother child interaction
No stigma Large diverse group of
vulnerable mothers
The most effective early child development programmes
Provide direct learning experiences to children and families,
Targeted toward younger and disadvantaged children
Longer duration High quality High intensity Integrated with family support, health, nutrition, or
educational systems
Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world Engle, Black et al. Lancet, 2007; 369: 229–42
Problems with existing evidence base Non emergency context (LAMI
countries: Jamaica, Brazil, south Africa
Stable population Long term interventions1- 3 yrs QUESTION: IF INTERVENTION
ADAPTED TO EMERGENCY CONTEXT, WILL IT WORK?
Examples from the Field
Northern Uganda: Kitgum and Pader
20 years of war > 10,000 dead > 95% population displaced (over 2 million) 200 IDP camps Population unable to cultivate - dependent
on food aid Infant mortality rate 165 per 1000 live births
(88 per 1000 national rate) High rates of malnutrition Population started returning to homes mid-
2007
Current nutrition programmes
Kitgum (5 sites) and Pader (4 sites) Community based therapeutic care (CTC) Stabilisation (brief inpatient care for severe
malnourishment + medical complications) Outpatient therapeutic feeding (OTP)
weekly Supplementary feeding (SFP) fortnightly Health education: Feeding practices, HIV,
contraception, hygiene, illness in the child 5000 moderately malnourished and 300
severely malnourished under five year olds treated in both districts in last quarter 2006
Main donor UNICEF
Outcomes from ethnographic research Key informant interviews with 20 mothers in a
variety of camps with different levels of education and experience
Acholi children appear to follow normal developmental norms
Physical milestones occur slightly earlier (e.g. sitting at 3/12)
Acholi mothers show love through care, nourishment and keeping them close
Hugging and kissing infants is not part of Acholi culture
Talking to children before they can talk themselves not seen as appropriate,
Speech development not delayed Buying things for their children is an important way
to show love This activity is obviously limited by few resources.
Impact of displacement
Enforced idleness leads to drunkenness in many of the men Homebrew major part of maintaining livelihoods Mothers are most often the sole provider and carer Children are back-carried from a very early age Mothers have little time to play or interact with their children
once they are mobile. Camp life has disrupted the normal patterns of transmitting
social knowledge and teaching values and skills to children All mother use coercive means of discipline and many complain
that children are spoiled. Altered social relationships and disrupted communities leaving
mothers feeling isolated and without support when things go wrong.
Mothers feel worried, sad or anxious Mothers with severely malnourished children were noticeably
less interactive and responsive to their children Some mothers with marked problems expressed suicidal ideas.
Impact of camp life …
Mother 13: I don’t tell stories to my children I knew some, I have forgotten … I don’t play with my two year old. No one plays with him. I don’t have it in my head to really play. I just don’t want to play and it looks awkward for a big person to play. He does not play with his friends when he goes he fights with them and comes back crying.
What role does father play?[He has] no direct role, it is all me. In normal life he cultivates. Now he drinks. Even now he is at the drinking place, drunk. … He cuts bamboo or logs for charcoal. That’s how he gets money but there is none for me. Everyday, you will never find him sober on a single day. He used to drink but it worsened at the beginning of the year. At least before he gave me something small for the home ... (6)
War experiences…At that time I had a baby on my back. The baby was one year and five rebels took us at night. One of them told me to hit the baby against a tree to kill it. Then I told them Let me take my baby on my back. If you see me get tired you will see me throwing my baby away. Then we walked. One of the rebels said thank you for being so strong-hearted and coming up with a solution. So now you and the baby can go back home. All the mothers were told to go back [after] the men were killed. 25 people. They made them lie in a line so when they were killed: the blood flowed towards us but they told us not to move or they would cut our heads with a hoe.
Psychosocial stimulation programme
Health messaging on infant stimulation and good mother child interaction
Mother to mother groups to practice and reinforce messages
Home visits Integrated into
nutrition programme OTP and SF sites
Intervention materialsDrawn directly from the following resources and
IMC gratefully acknowledges permission for use: Learning through Play from Birth to Three years, Calendar and
Manual: the Hincks Dellcrest Centre, including Judith L. Evans and Ellen Ilfeld, authors of Good Beginnings: Mothering in the Early Years for the concept of the developmental time periods and the elements used in the Leaning Through Play Calendars)
Care for Development, UNICEF, New York Early Childhood Development (ECD) kit, Draft Guidelines for
Care providers: ECD Unit / ECD Emergency Task Force Programme Division, United Nations Children’s fund (UNICEF) New York 2005
Integrated Management of Childhood Illnesses & Comprehensive Child Care, Chart Book For Primary Health Care Level, Second Edition, 2004, Ministry Of Health, Sultanate Of Oman
Improving Mother/child Interaction To Promote Better Psychosocial Development in Children WHO/MSA/MHP/98.1 Programme on Mental Health International Child Development Programmes, Oslo and Programme On Mental Health World Health Organization, Geneva, 1997
Growing up Well in Uganda: CHILD, Uganda Nutrition and Early Childhood Development Project, Ministry of Health Uganda
Health messaging exampleQUESTION: How can we keep babies and children safe when
they play?KEY MESSAGE: Make a safe space to play: Make sure the
environment is "baby/children proof" to encourage free exploration
Children often explore by putting things into their mouths. They must be large enough not to be swallowed . Long thin or sharp objects should be avoided. Any object a baby plays with should be clean If dropped, wash it before giving back to a child. When a child wants to play with something that is not
safe or not clean, exchange the object for something that is safe and clean
Mother to mother groups Mothers attending
CTP sites Invited to join
weekly group 6 sessions Maximum ten
mothers per group Structured
interactive discussion and practice
Facilitated by nutritionist or trained mother
Experienced mothers start new groups
Home visits: using the Learning through Play
Calendar*
Adapted from Learning through Play from Birth to Three years, Calendar and Manual: the Hincks Dellcrest Centre
Love
Play
Communicate
Research EvaluationDo combined psychosocial and nutrition programmes have more effective outcomes than nutrition programmes on their own?
Outcomes to be evaluated: Improved nutritional outcomes in infants
between 6months and 30 months Improved mother child interaction Improved maternal mood Improved maternal knowledge of ECD
Ethical approval from Uganda National Council for Science and Technology
Measures
Standard nutritional measures Default rate Length of time to
recovery Mother child interaction
measure Culturally appropriate
maternal mood scale Pre and post
intervention KAP test
Kitgum Maternal Mood scale
Object: to determine any shift in maternal mood achieved by intervention-does not measure depression
Qualitative ethnographic enquiry as to problems and feelings generated (while conducting assessment)
Pile sort concepts attached to mood and feelings Develop scale using local language of distress Pilot, adjust language Back translated, re translated for conceptual
clarity
Acholi HOME
Observation and questionnaire to assess mother child interaction
Yes/no answers or likert scales Naturalistic- conducted in home setting 53 items-7 subscales (maternal involvement,
variety, discipline and punishment, play, emotional and verbal responsivity, acceptance, organisation)
Adapted to Acholi culture Translated and back translated Tested for acceptability
Knowledge Attitudes and Practice
10 item scale Simple statements on child development True or false
K1: PNNutrition + psychosocial support
K2: PNNutrition+
psychosocial support
K3: PNNutrition+
psychosocial support
K4: NOnutrition
only
K5: NOnutrition
only
100 new admissions who are receiving both psychosocial and nutritional support
100 new admissions who receive nutritional support alone
Complete evaluation measures: Kitgum maternal mood Acholi HOMEStandard infant nutritional measures on infant
After discharge (4/12) repeat all measures
Compare outcomes to determine which programme achieves a greater beneficial change in outcome
measure
Complete evaluation measures: Kitgum maternal mood Acholi HOMEStandard infant nutritional measures infant
After discharge (4/12) repeat all measures
May 2007
September 2007
Data analysis Quantitative data analysed using SPSS Compare in PN and NO groups pre and post
intervention Nutritional outcomes (length of admission, default
rate) KAP test Mother child interaction Maternal mood Limited amount of qualitative data will be analysed
using thematic analysis. If funding were available: Spread of knowledge
through community
NO group (control group) PN intervention group
Number N= 105 N=131
Completed follow up
79 (75.2%) 78 (59.5%)
Drop out 26 (24.8%) 52 (39.7%) 1 (0.4%) refused to complete the follow up
Child Age 14.1 months (s.d. 8.4; range 6-40)
14.5 months (s.d. 6.8; range 6-41)
Maternal Age
24.1 years (s.d.4.3; range 17-36)
26.5 years (s.d.7.0; range 16-50 )
Number of children
3.3 (s.d. 2.0; range 0-9) 3.5 (s.d. 2.3; range 1-12)
Marital status
81% married 10.5% separated3.8% divorced4.8% widowed
74.2% married 13.6% separated 9.8% divorced 2.3% widowed
Years in camp
4.4. (s.d. 1.8; range 1-10) 4.0 (s.d. 2.4; range 1-10)
Years of education
no schooling 44.8%lower primary 21.9%upper primary 30.5% O' level and tertiary level: 2.9%
no schooling 34.8%lower primary 18.9%upper primary 43.2% O' level and tertiary level: 3.0%
Preliminary Results
Mothers receiving combined intervention had significantly
Improved maternal mood Improved maternal involvement Better use of play materials
Self sustaining activity
9 continuing mother to mother groups across the 3 PN sites
25 mothers expressed interest in establishing their own groups in the various localities
Mothers who pioneered group activity in these areas train their colleagues who are interested in furthering group activity.
In addition to training their fellow mothers, the pioneer mothers are currently sharing health education cards with the leaders of the newer groups.
The nutrition support staff routinely monitor and supervise these new groups.
Implications for MDG 4 and 5
Population based intervention Brief and relatively easy to do Does not require highly educated
group facilitators Impact on maternal mood and
involvement Improves maternal mental health Could predict impact on maternal
general health (5), child health and nutrition and thus child survival (4)
Difficulties of conducting research in emergencies
Mobile fragmented population- may move before research completed
Weather- floods Insecurity access barred Capacity of NGO local staff Programme donors time frame
short Programme donors priority is
service provsion Research funders don’t
understand emergency contexts
Ethical Issues Informed consent:
Refusal should not compromise access to aid Drop out always possible
Confidentiality: private space to interview impossible to find in camp setting
Do no harm: better if intervention already has positive evidence base in other settings
Beneficience: wait list controlsAddressing basic needs and security are
obviously the priority, however it is also unethical to provide interventions that have not beeen evaluated for that setting
Research methods in emergencies
Individual randomisation almost impossible Creates conflict Contamination
Cluster randomisation requires LARGE scale intervention in homogenous community- not always available- multiple confounding variables
Wait list controls need more time for intervention Ethical review needs fast track process by
culturally relevant, internationally recognised body Service providers and data collectors must be
separate (will still get bias to negative) What to do with inconsistent data
Other emergency contexts where intervention could be applied Carers of babies in institutional care Rape victims with attachment problems MCH clinics PHC clinics Stabilisation centres Safe spaces in camps Anywhere where women gather ….
Further research…Lessons learned
Focus on one intervention- e.g mother to mother group More groups go more slowly (10 sessions) Detach from nutrition site in order to measure impact
on nutritional status- Is psychosocial intervention protective? Do babies receiving intervention have lower rates of
malnutrition? Train key mothers as facilitators Do cluster based RCT using parallel camps or
communities in conflict or disaster setting Separate intervention team from research team
Programme replication with Somali refugees in Ethiopia
Colombia with WFP TOT programme for local partners
In summary, combined psychosocial and nutrition programmes
Long term programmes: Improve developmental outcomes in short and long
term Improve maternal mood if using groups and home
visits Emergency programmes:
Improve maternal mood and maternal involvement (Uganda)
Increase knowledge (Colombia) Increase networks of social support Provide a non-stigmatising way of supporting
vulnerable women and children exposed to violence Nutrition is an easy point of access Are fun to do!
Any questions?