Baker, Helen Jane; (2003) A randomised controlled trial of psychosocial intervention with mothers of undernourished children using primary care services in Jamaica. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Previous studies have shown that psychosocial stimulation can benefit the development of undernourished children. However, these studies have been highly controlled research studies. We know of no reports of the effectiveness of integrating stimulation into existing nutrition and health services for undernourished children. There is also little information about the psychosocial function of mothers of undernourished children or on the benefit derived by the mothers of undernourished children from a stimulation program. Aims: The main aim of the research was to integrate psychosocial stimulation into existing nutrition and health services for undernourished children in Jamaica and to determine the effect of the intervention on the children's growth and development and on the mother's child-rearing knowledge and practices and frequency of depressive symptoms. At baseline, mothers of undernourished children were compared with mothers of adequately nourished children on maternal depression, parenting self-esteem, social support, exposure to stressors and stimulation provided in the home. Methods: The study was a randomised controlled trial in which 18 government health centres in the parishes Kingston, St. Andrew and St.Catherine were randomly assigned to an intervention or control group. 139 undernourished children (WAZ < -1.5z scores) aged 9 to 30 months were recruited into the study from the centres. At the beginning and end of the study all children had their development assessed on the Griffiths developmental scales, and their weight and length measured. Also the mothers' child-rearing knowledge, practices and frequency of depressive symptoms were assessed with a questionnaire and scores calculated. A case-control study was conducted at baseline and 71 adequately nourished children (WAZ [greater-than] -1z scores) from the same health centres and matched for sex and age group with the undernourished children were enrolled into the study. Questionnaires were administered to the mothers of both groups of children to determine the levels of maternal depression, parenting self-esteem, social support and daily stressors and the stimulation provided in the home was assessed. Intervention: Government health aides, already working in the centers, conducted weekly home visits for 1 year. During the visits, mothers were shown appropriate play activities to do with their young child using home made toys and books. Parenting issues were also discussed. Both groups received the standard nutrition and health care for undernourished children. Results of case-control study: Mothers of undernourished children came from poorer homes but had similar social support to mothers of adequately nourished children. They were more depressed, had lower levels of parenting self-esteem (both p < .01), reported higher levels of economic stress (p < .001) and provided a less stimulating home environment (p < .05). However, after controlling for social background variables there was no independent relationship between either psychosocial function or home stimulation and nutritional status. Undernutrition was found to be mainly explained by economic factors. Results of randomised controlled trial: The development levels (DQ) of children in both groups declined during the study. However, the intervened children declined significantly less - 7.91 points (95% confidence interval: 4.49, 11.33), than the controls. There was also a significant treatment effect on the hearing and speech subscale 10.66 (5.89, 15.44), the hand and eye subscale 6.82 (3.40, 10.24) and the performance subscale 11.10 (5.48, 16.72). There was no significant benefit of intervention on the motor subscale. Children in both groups improved modestly, though significantly in weight for age, height for age and weight for height but there was no benefit of intervention. Compared with the control group, the mothers in the intervention group improved significantly more in child rearing knowledge (p < .001) and child rearing practices (p < .01) and reduced their depressive symptoms (p < .05). Conclusions: Mothers of undernourished children had poorer psychosocial function than mothers of adequately nourished children and hence health services for undernourished children should pay attention to the psychosocial status of the mother as well as the physical condition of the child. Integrating a program of parenting education and psychosocial stimulation into primary care services was both feasible and effective and improved undernourished children's development a substantial amount (0.94 of a standard deviation for DQ). Mother's parenting knowledge and practices and frequency of depressive symptoms also improved.

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