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编号:11356029
Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomised controlled trial
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     1 Epidemiology Research Unit, University of the West Indies, Mona, Kingston, Jamaica, 2 Department of Educational Studies, University of the West Indies, 3 Pan American Health Organization/World Health Organization, Kingston, Jamaica, 4 Centre for International Child Health, Institute of Child Health, London WC1N 1EH

    Correspondence to: C Powell christine.powell@uwimona.edu.jm

    Abstract

    Around 150 million children aged under 5 years are undernourished.1 Undernutrition in early childhood usually leads to poor cognitive development and poor school achievement.2

    Undernutrition is usually associated with poverty and non-stimulating home environments, which affect children's development. In small controlled trials, psychosocial stimulation produced sustainable benefits in the development of undernourished children.3 4 Yet little attempt has been made to integrate psychosocial stimulation into routine care of undernourished children.

    Although many international agencies and governments promote child development programmes, little information is available on the design and effectiveness of such programmes in countries with low resources.5-7 Health services are often the only government sector routinely making contact with children aged under 3 years. We integrated psychosocial stimulation into the primary healthcare services for undernourished Jamaican children and examined the effect on the children's development and mothers' knowledge and practices of childrearing.

    Participants and methods

    Overall, 129 children (93% of those enrolled) were assessed at the end of the study. Five of the families had moved (three from control clinics), three mothers from intervention clinics refused to take part, one child from a control clinic was not available for testing, and one child from a control clinic could not be tested. Four mothers of children who had a repeat test completed did not complete the repeat questionnaire (three controls and one intervention), giving a total of 125 mothers (90% of the sample).

    On enrolment the groups were similar for socioeconomic background and parental characteristics, sex of child, initial age, nutritional status, Griffith's scores, anthropometry, and mothers' knowledge and practices of childrearing (tables 1 and 2).

    Table 1 Characteristics of children and family on enrolment. Values are means (standard deviations) unless indicated otherwise

    Table 2 Children's scores on Griffiths mental development scales and anthropometric measures, and mother's knowledge and practices of childrearing at baseline and one year's follow up. Values are means (standard deviations)

    Treatment effects

    The intervention had significant benefits on the children's development: 7.8 developmental quotient points (95% confidence interval 4.5 to 11.1); hearing and speech, 10.7 (5.9 to 15.4 points), hand and eye coordination, 6.8 (3.4 to 10.1 points), and performance, 11.0 (5.6 to 16.4 points; table 3). We found no significant effect of the intervention on locomotor skills. The intervention showed a significant benefit on mothers' knowledge of childrearing (7.6, 5.7 to 9.4 points) and childrearing practices (5.0, 1.6 to 8.4 points; table 3). The intervention had no effect on gain in length or body mass index. Growth did not modify the effects of intervention, but change in length and body mass index predicted the developmental quotient (length B = 1.0, 95% confidence interval 0.1 to 1.9; body mass index B = 2.8, 0.9 to 4.7).

    Table 3 Multilevel analysis of effects of intervention on children's Griffiths scores and anthropometric measurements, and mothers' knowledge and practices of childrearing

    Out of an intended 50 visits, the median number of home visits to mothers and children from intervention clinics was 32.5 (interquartile range 22.5-43.0). The number of visits had no significant effect on child and maternal outcomes.

    Discussion

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