Maternal care mediates the effects of nutrition and responsive stimulation interventions on young children's growth.

BACKGROUND: Undernutrition contributes to at least half the estimated six million annual childhood deaths worldwide. Furthermore, one in three children fails to meet their developmental potential because of risks including stunting, illness, under-stimulation, poor responsive interactions and maternal depressive symptoms. Our study investigates the role of caregiving processes on children's height-for-age at 2 and 4 years. METHODS: The Pakistan Early Child Development Scale-up study assessed the longitudinal effectiveness of early nutrition and responsive stimulation interventions on growth and development at 4 years of age. In total, 1302 children were followed up from birth to 4 years. We leveraged path analyses to explore potential mediators of early intervention effects on children's height-for-age at 4 years, including maternal depressive symptoms, mother-child interaction quality, diarrhoeal illness and height-for-age at 2 years. RESULTS: Our final model had excellent model fit (comparative fix index = 0.999, Tucker-Lewis index = 0.998, root mean square error of approximation = 0.008) and showed that mother-child interaction quality mediated the effects of both enhanced nutrition and responsive stimulation interventions on height-for-age at 4 years via its longitudinal stability from 2 years of age (ß = 0.016, p = 0.005; ß = 0.048, p < 0.001, respectively). Further, diarrhoeal illness mediated the effects of maternal depressive symptoms at 1 year post partum on children's height-for-age at 4 years via the longitudinal stability of height-for-age z-score from 2 years of age onwards (ß = -0.007, p = 0.019). CONCLUSIONS: The quality of early caregiving experience mediated the association between both interventions and height-for-age. The effect of maternal depressive symptoms on growth was mediated by diarrhoeal illness. Programmatic approaches to child nutrition and growth must address all these potentially modifiable factors.

Adaptation of MacArthur Communicative Development Inventory in rural Pakistan - useful tool for early childhood studies.

BACKGROUND: Given the significance of early language for later academic achievement, language development can be an important outcome measure in evaluation of early childhood intervention programmes. Language development may be challenging to assess in settings where trained personnel are hard to find; therefore, maternal report can be a reliable alternative measure. AIM: The aim of this study was to adapt a maternal report measure, the MacArthur Communicative Development Inventory II-Short Form, in the Sindhi language and to examine its psychometric properties as a measure of language outcome in 2-year-old children in rural Pakistan. METHODS: A three-phase process was followed to produce a Sindhi adaptation of the tool comprising 100 words. The first phase was a review of the original 258 words through a focus group discussion with a team familiar with the context; the second phase was testing 258 words to compile a 100-word list of easy, moderate and difficult words. The third phase was a pilot of the 100-word list followed by administration in a larger intervention study population. RESULTS: On administration with 1381 children, concurrent validity with the Bayley Scale of Infant Development III using the Pearson's correlation test showed a moderate association for comprehension (r = 0.45, p = 0.01, n = 1381) and good association for expression (r = 0.51, p = 0.01, n = 1381). Internal consistency was high with alphas of 0.98 for comprehension items and 0.96 for expression items. CONCLUSION: The authors conclude that the Sindhi adaptation of the MacArthur Communicative Development Inventory followed a feasible and rigorous methodology to create a reliable and sensitive tool to assess young children's language development for use in a child assessment battery for early childhood health, nutrition and development studies.

The development and reliability of an observational tool for assessing mother-child interactions in field studies- experience from Pakistan.

BACKGROUND: This study describes the development and reliability testing of an observational tool to measure mother-child interactions with toddlers aged 2 years in a rural low-income country setting. METHODS: The development protocol comprised five phases with iterative revisions: (1) identification of the theoretical framework for responsive behaviours and selection of items; (2) field testing; (3) expert review; (4) training of the data collection team; and (5) piloting. The final tool was a structured live observational measure assessing a 5-min interaction of a shared picture-book-reading activity. Maternal behaviours assessed included affect, touch, verbal statements and language stimulation; child behaviours assessed included affect, communication and attention. RESULTS: Following development, the mother-child interaction tool was administered on a cohort of 1390 children at 2 years of age. Using a video strategy, inter-observer reliability assessed by the Bland-Altman test for mother-child dyads suggested moderate agreement between expert and field assessors on total scores (r = 0.681**, P < 0.001, n = 154). Significant associations of the total interaction score correlations using Pearson's' correlations were found with the Responsiveness (r = 0.271**, P < 0.001, n = 1345) and Involvement (r = 0.325**, P < 0.001, n = 1345) subscales of the Home Observation for Measurement of Environment-Infant Toddler Inventory, maternal knowledge (r = 0.203**, P < 0.001, n = 1345), maternal depression (r = .-063**, P < 0.001, n = 1345), child cognitive development (r = 0.392**, P < 0.001, n = 1345) and language development (r = 0.620**, P < 0.001, n = 1345) assessed using the Bayley Scales for Infant and Toddler Development, Third Edition. CONCLUSION: The authors conclude that this tool can be reliably used by trained assessors to measure mother-child interactions in field studies.

How successful are women's groups in health promotion and disease prevention? A synthesis of the literature and recommendations for developing countries.

There is a general scarcitly of resources for delivery of services to the population in all social welfare and development sectors, with the health sector being no exception. In developing countries, lack of trained manpower, illiteracy and compliance issues make health care interventions even more complex. Various community-based projects have used women as a specific group for delivery of health care interventions. The objective of this paper was to review published studies that evaluated women's groups for the promotion of health and prevention of disease. A total of 8 studies were reviewed. Women's groups have proved to be a convenient and workable option for delivering health care interventions in several developing countries.

How successful are women's groups in health promotion and disease prevention? A synthesis of the literature and recommendations for developing countries

There is a general scarcity of resources for delivery of services to the population in all social welfare and development sectors, with the health sector being no exception. In developing countries, lack of trained manpower, illiteracy and compliance issues make health care interventions even more complex. Various community-based projects have used women as a specific group for delivery of health care interventions. The objective of this paper was to review published studies that evaluated women's groups for the promotion of health and prevention of disease. A total of 8 studies were reviewed. Women's groups have proved to be a convenient and workable option for delivering health care interventions in several developing countries

HIV/AIDS and disability: differences in HIV/AIDS knowledge between deaf and hearing people in Nigeria.

PURPOSE: Studies both in North America and Europe have found that deaf individuals lack access to AIDS information, due to problems in communication, low literacy and tightly woven social networks within the deaf community. However few comparable studies are available from countries in the Developing World. The present study was undertaken in Nigeria where there is an estimated adult HIV prevalence rate of 5.4%. We sought to compare HIV knowledge among deaf and hearing individuals in order to identify how effectively deaf members of the community are being reached by HIV/AIDS messages. METHODS: A survey comparing knowledge about HIV/AIDS among deaf and hard of hearing adolescents (n = 50) and young adults (n = 50) was undertaken. RESULTS: Significant differences (p < 0.05) in levels of understanding about certain aspects of how AIDS is spread were identified as well as differences in available resources for access to accurate information among deaf members of the population. CONCLUSION: These findings from Nigeria speak strongly to the need for the development of interventions that include people with disabilities in public health and HIV/AIDS strategies and that address their specific vulnerabilities. Evaluating the adaptation of education material and the inclusion of the deaf population in HIV awareness programmes is an urgent 'next step.'

HIV/AIDS information and services: the situation experienced by adolescents with disabilities in Rwanda and Uganda.

PURPOSE: The study had two aims: (2) To explore whether knowledge about HIV and AIDS was similar among adolescents with disabilities compared with their non-disabled peers; and (2) To determine factors which may increase vulnerability of disabled adolescents to HIV infection and/or inappropriate access to HIV-related services. METHOD: A qualitative study using focus group discussions and sem-structured interviews was conducted with purposefully selected participants in Rwanda and Uganda. The participants included disabled adolescents, non-disabled adolescents, parents, teachers, members of disabled people's organisations and representatives of HIV/AIDS organisations. Interviews explored issues of HIV/AIDS knowledge, access to HIV/AIDS services and perceptions of personal risk. RESULTS: Barriers preventing adequate access to information about HIV and AIDS experienced by adolescents with disabilities depended on the nature and severity of the impairment. For example, parents and health workers were unable to communicate with deaf adolescents using sign language, adolescents with physical impairments were often unable to access community meetings about HIV and print material was not adapted for those with visual impairments. Further, assumptions by health workers and community members that people with disabilities were not sexually active led to the marginalisation of disabled people from HIV services. Adolescents with disability described low self-esteem and issues of self-efficacy affecting control of safer sexual relationships. A high level of targeted abuse, rape and exploitation was reported leading to vulnerability among this population. CONCLUSION: The impact of the HIV epidemic among people with disabilities is a neglected area. This study supports the need to develop strategies in HIV prevention programmes that include people with disabilities.

Barriers to accessing safe motherhood and reproductive health services: the situation of women with disabilities in Lusaka, Zambia.

PURPOSE: To ascertain how well health services in Lusaka, Zambia currently meet the safe motherhood and reproductive health care needs of women who have physical impairment leading to disability. METHODS: A qualitative study was conducted in Lusaka, Zambia. In-depth tape-recorded interviews were conducted with 24 purposively selected women with disabilities and with 25 safe motherhood/reproductive public sector health service providers. Qualitative analysis was conducted using NVivo software. RESULTS: Women with disabilities encounter various social, attitudinal and physical barriers to accessing safe motherhood and reproductive health (RH) services in this particular setting. The strong desire for children and affection can increase vulnerability to sexual exploitation. At the same time, a generalized assumption among reproductive health service providers that women with disabilities will not be sexually active, and not require RH services, leads to increased vulnerability to sexually transmitted infection including HIV. Once pregnant, traditional beliefs about transmission of disabilities can create barriers to integration in ante-natal clinics. Nurse-midwives' fear of delivery complications in women with physical impairments can also result in routine over-referral to a tertiary maternity facility which is outside the locality and harder for women with mobility limitations to get to. CONCLUSION: Greater understanding of the influences underpinning societal attitudes towards sexuality and disability in this setting, and more extensive communication between health care staff and women with disabilities would facilitate positive action towards improving safe motherhood and reproductive health services for women with disabilities.

Comparison of armspan, arm length and tibia length as predictors of actual height of disabled and nondisabled children in Dharavi, Mumbai, India.

OBJECTIVES: To investigate appropriate measurements to predict height in children with physical impairments to facilitate the accurate assessment of nutritional status in field studies. DESIGN: Case-control cross-sectional study. SETTING: Dharavi, a large slum in Mumbai, India. SUBJECTS: In total, 141 children with mixed disabilities and 162 nondisabled control children, aged 2-6 y. METHODS: Height/length, armspan, arm length and tibia length were measured to the nearest 0.1 cm using standard procedures. The relations between armspan, arm length and tibia length with height in controls were investigated using linear regression. RESULTS: Armspan (R(2)=0.93, P<0.001, n=158), arm length (R(2)=0.81, P<0.001, n=162) and tibia length (R(2)=0.72, P<0.001, n=161) were found to be strong predictors of height based on data from nondisabled control children. These measurements could be used to determine a more accurate height for children with physical impairments where the nature of the impairment may interfere with height measurements. CONCLUSIONS: Armspan, arm length and tibia length can be used to determine accurate height for children with physical impairments, for example, children with a nonambulatory status or those with kyphosis or scoliosis of the spine.

Serum leptin in disabled and non-disabled children in an Indian slum population.

OBJECTIVE: To assess the concentration of serum leptin in a population of malnourished children and to compare the leptin levels of disabled and non-disabled children in this population. DESIGN: Case-control study. SUBJECTS: Eighty-one children, comprising 41 children with mixed disabilities and 40 non-disabled controls, were selected from 425 children involved in a case-control study assessing the nutritional status of children with disabilities in an Indian slum population. METHODS: Leptin was measured in the serum samples and was compared with anthropometry (weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ), weight-for-height Z-scores (WHZ), body mass index (BMI), mid-upper-arm circumference (MUAC), sub-scapular skinfold thickness and triceps skinfold thickness) and serum acute phase proteins. RESULTS: The children were very malnourished with WAZ=-2.07 (s.d. 1.15), HAZ=-2.15 (s.d. 1.85) and WHZ=-1.07 (s.d. 0.83). Leptin was extremely low in both the disabled (1.44 ng/ml; 95% confidence interval, CI, 1.23-1.69) and the non-disabled (1.19 ng/ml; 95% CI 1.04-1.35) children. There were no differences between the disabled and non-disabled groups as a whole but 15 children with neurological disabilities had significantly higher (P<0.05) serum leptin (1.65 ng/ml; 95% CI 1.29-2.06) than the non-disabled children. Girls (1.55 ng/ml; 95% CI 1.29-1.87) had significantly higher concentrations of leptin than boys (1.11 ng/ml; 95% CI 1.02-1.22; P=0.002). Leptin did not correlate with any biochemical or anthropometric measures. CONCLUSIONS: In this population, where malnutrition was common, serum leptin levels were very low and did not correlate with anthropometry. SPONSORSHIP: UK Department for International Development; Virgin Airways through the Great Ormond Street Hospital Trustees.

The nutritional status of disabled children in Nigeria: a cross-sectional survey.

OBJECTIVE: To compare the nutritional status of disabled children in Nigeria with their non-disabled siblings and neighbours. A second aim was to investigate anthropometric techniques appropriate for disabled children in this situation. DESIGN: A cross-sectional survey. SETTING: Nasarawa and Plateau States and the Federal Capital Territory in Central Nigeria. SUBJECTS: 311 children under 10 years of age were studied: 112 with various disabilities, 87 siblings and 112 neighbours. METHODS: Selected anthropometric measurements, (height, weight, mid-upper arm circumference (MUAC), demispan and halfspan), and blood haemoglobin levels were assessed by trained personnel. All measurements of disabled subjects were compared to the non-disabled controls. RESULTS: The disabled subjects had mean height for age (ht/age) and weight for age (wt/age) significantly lower than the control group (P<0.05). These differences were due largely to the very low Z scores in children with neurological impairments, (ht/age= 3.07 (s.d.=1.6); wt/age= 2.0 (s.d.=1.2)). Measurement difficulties contributed to low height values in disabled children and halfspan was found to be a useful proxy for height in these children. MUAC results were higher for the children with disabilities due to polio than for controls. The mean haemoglobin levels were slightly but significantly higher (P<0.05) in the disabled and sibling groups compared to the neighbourhood group. CONCLUSION: Disabled children with neurological impairments and consequent feeding difficulties are nutritionally at risk, but others are no worse off than their non-disabled peers in this area. Halfspans may serve as a useful proxy indicator for estimating height in some children with physical impairments. SPONSORSHIP: The study was funded by a TEAR fund grant to JT for her MSc studies.