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?