ArticlesEffect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial
Introduction
More than 200 million children in developing countries are at risk of not meeting their developmental potential by 5 years of age.1 Risk factors including poverty, malnutrition, and inadequate stimulation are likely to co-occur and accumulate over time, increasing the risk of early childhood mortality, morbidity, poor development, and growth.2, 3, 4 Children who are unable to fulfil their developmental and growth potential are likely to perform poorly in school and earn lower incomes as adults, thus perpetuating social inequalities and contributing to the intergenerational transmission of poverty, poor health, and development.5, 6 The first 2 years of life is an important window of opportunity to implement interventions to promote children's physical growth and development.
Early child stimulation interventions that guide parents to be sensitive (understand their child's signals) and responsive (respond in a contingent and developmentally appropriate way to these signals)7 through developmentally suitable play with their child have shown consistent benefits to children's development.8, 9, 10, 11 The enhancement of these basic caregiving skills, which are learned during play interactions, can also protect children's health by helping families to recognise and respond to the early signs of illness.7 Nutritional intervention is needed to promote healthy growth and development; however, few studies have assessed the additive benefits of combined stimulation and nutrition on child outcomes. Studies from Jamaica showed additive developmental benefits when stimulation was combined with macronutrient supplementation10 and synergistic benefits when it was combined with zinc supplementation.8
Early child development programmes in developing countries are likely to be more effective if they are comprehensive (ie, they include health, nutrition, and stimulation), run for longer, have greater intensity (ie, higher frequency and longer duration of contacts), use a structured curriculum, and enable parents and children to participate together to practise stimulation activities and receive feedback.12, 13 Knowledge gaps remain about how best to combine stimulation and nutrition interventions within existing health services to expand programmes to a large scale.13 To the best of our knowledge, the delivery of integrated early child development interventions with community health workers in public sector effectiveness settings has not been assessed so far.
Pakistan has a high burden of both child undernutrition14 and poor development.1 The National Programme for Family Planning and Primary Healthcare (often referred to as the Lady Health Worker [LHW] programme) provides an opportunity to integrate early child development services at scale (panel 1).15 The LHW programme, started in 1994, is a government-supported community health service providing care to families in rural, remote, and disadvantaged communities across Pakistan. The focus areas for health services are family planning and maternal and child health, which are delivered by LHWs. The programme does not encompass early stimulation at present, and recent assessments have emphasised the need to strengthen nutrition services.16 The aim of this study was to measure the effects of a responsive stimulation intervention delivered by LHWs to families with infants and young children from birth to 24 months of age living in rural Sindh, Pakistan, either alone or in combination with an enhanced care for nutrition intervention. The primary endpoint was child development and growth and the secondary endpoint was child morbidity; all outcomes were assessed at 24 months of age. The hypothesis to test was that, compared with either a responsive stimulation or an enhanced care for nutrition intervention delivered alone, a combined approach would have independent and additive or synergistic effects on child development, growth, and morbidity outcomes at 24 months.
Section snippets
Study design and participants
We did a pragmatic, community-based, cluster-randomised effectiveness trial in the Naushero Feroze district of Sindh, Pakistan, between June 1, 2009, and March 31, 2012. The trial had a 2 × 2 factorial design,17 and we used the cluster-randomised design to reduce the risk of contamination by ensuring that all members of each cluster received the same intervention. Each cluster was defined as an LHW catchment, and we allocated the same number of clusters to each intervention group On average,
Results
1489 mother–infant dyads were enrolled in the study for the in-depth assessment, which represents 42% of all young children receiving LHW services in the study area. 368 infants were enrolled into the control group, 364 into the enhanced nutrition group, 383 into the responsive stimulation group, and 374 into the combined enhanced nutrition and responsive stimulation group. 1391 of 1489 (93%) of the enrolled mother–infant dyads were followed up until the infants reached 24 months of age (figure
Discussion
We designed this study to investigate the effect of the delivery of a model of integrated early child development interventions with community health workers in a public sector effectiveness setting. Our results show that the responsive stimulation intervention had significant benefits on early child cognitive, language, and motor development outcomes, but not on social-emotional development. The treatment effect sizes (moderate to large) of responsive stimulation at 24 months of age were
References (39)
- et al.
Developmental potential in the first 5 years for children in developing countries
Lancet
(2007) - et al.
Inequality in early childhood: risk and protective factors for early child development
Lancet
(2011) - et al.
Child development: risk factors for adverse outcomes in developing countries
Lancet
(2007) - et al.
Zinc supplementation and psychosocial stimulation: effects on the development of undernourished Jamaican children
Am J Clin Nutr
(2005) - et al.
Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study
Lancet
(1991) - et al.
Nutritional supplementation, psychosocial stimulation, and growth of stunted children: the Jamaican study
Am J Clin Nutr
(1991) - et al.
Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries
Lancet
(2011) - et al.
Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world
Lancet
(2007) - et al.
Maternal and child undernutrition: global and regional exposures and health consequences
Lancet
(2008) - et al.
Effect of provision of daily zinc and iron with several micronutrients on growth and morbidity among young children in Pakistan: a cluster-randomised trial
Lancet
(2013)