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Background: Extreme poverty is severe deprivation of basic needs and services. Children living in extreme poverty may lack adequate parental care and face increased developmental and health risks. However, there is a paucity of literature on the combined influences of undernutrition and psychosocial factors (such as limited play materials, playground, playtime, interactions of children with their peers and mother-child interaction) on children’s developmental outcomes. The main objective of this study was, therefore, to ascertain the association of developmental outcomes and psychosocial factors after controlling nutritional indices. Methods: A community-based cross-sectional study design was used to compare the developmental outcomes of extremely poor children (N=819: 420 girls and 399 boys) younger than 5 years versus age-matched reference children (N=819: 414 girls and 405 boys) in South-West Ethiopia. Using Denver II-Jimma, development in personal-social, language, fine and gross motor skills were assessed, and social-emotional skills were evaluated using the Ages and Stages Questionnaires: Social-Emotional (ASQ: SE). Nutritional status was derived from the anthropometric method. Independent samples t-test was used to detect mean differences in developmental outcomes between extremely poor and reference children. Multiple linear regression analysis was employed to identify nutritional and psychosocial factors associated with the developmental scores of children in extreme poverty. Results: Children in extreme poverty performed worse in all the developmental domains than the reference children. Among the 819 extremely poor children, 325 (39.7%) were stunted, 135 (16.5%) were underweight and 27 (3.3%) were wasted. The results also disclosed that stunting and underweightness were negatively associated with all the developmental skills. After taking into account the effects of stunting and being underweight on the developmental scores, it was observed that limited play activities, limited child-to-child interactions and mother-child relationships were negatively related mainly to gross motor and language performances of children in extreme poverty. Conclusion: Undernutrition and psychosocial factors were negatively related to the developmental outcomes, independently, of children living in extreme poverty. Intervention, for these children, should integrate home-based play-assisted developmental stimulation and nutritional rehabilitation.
This research was undertaken in Jimma town, South-West Ethiopia. The population in Jimma town was estimated to be 198, 0228 in 2016 [16]. Diverse ethnic and religious groups live together and though many languages are spoken in the town, Amharic and Afan Oromo are the two dominant ones. Because of its multilingual, multicultural, and divergent socio-economic nature, Jimma town reflects, and is representative of most settings within Ethiopia [17]. A community-based cross-sectional study was conducted from March 1st to September 2nd, 2013. Children in extreme poverty were included in this study if they were (1) between 3 and 61 months of age, (2) living in Jimma town and (3) living in extreme poverty, as validated by the Office of Women’s and Children’s Affairs. However, children (1) with observable physical disabilities which hinder the performance of items in Denver II-Jimma, or (2) who were completely blind or deaf, were excluded. The eligibility of these children for the study was evaluated by pediatricians, mental health professionals, special needs experts and psychologists. Sample size estimation and power analysis: A sample of 672 children per group was required to obtain an 80% power for detection of a difference of 0.07 developmental performance ratio between the extremely poor and reference children when performing a two tailed test at significance level of 0.05. To allow a little more than 20% dropout, 823 children were recruited per group. For the power calculation, the variance in developmental performance ratio scores of 62 children in SOS village-Jimma was used. Their age ranged from 3.5–72 months (mean = 44.6; SD ± 21.2). The 823 children were randomly selected from 1496 children living in extreme poverty, using a lottery method. The 1496 children were selected and registered by Jimma town’s Women’s and Children Affairs Office. The office selected these extremely poor children using a multidimensional deprivation methodology developed by UNICEF [1]. The generally accepted multidimensional definition of extreme poverty is severe deprivation of nutrition, safe drinking water, sanitation facilities, health care, housing, access to services and protection from violence [1]. Four children were dropped because of incomplete personal data. The remaining 819 children (420 boys and 399 girls) were then enrolled for the study. All their caregivers were also requested to provide the necessary information. The developmental outcomes of these children in extreme poverty were compared to 819 (405 boys and 414 girls) age-matched reference children. They were randomly selected using a lottery method from 1, 597 children. Children in this reference group live with families of a middle or higher socio-economic level and their nutritional status varied between the Z-scores of -2SD and +2SD, implying that they were not malnourished according to WHO Child Growth Standards [18]. Both children in extreme poverty and the reference group lived in Jimma town and were assessed in the same time period. The developmental performance of each child was assessed using the Denver II-Jimma [17], a version of the Denver II [19], adapted to the sociocultural context of children under six living in the Jimma zone of Ethiopia. Denver II-Jimma has an excellent inter-rater and test-retest reliability on the majority of the items in the test [17]. It consists of 125 items: 25 personal-social, 29 fine motor, 39 language and 32 gross motor. Most of these items require children to perform, and a few are based on their parents’ report. On average, testing with the Denver II-Jimma took around 20 min. For each child, the performance ratio for each developmental domain was calculated. Performance ratio simply refers to the ratio of the total number of items passed to the expected number of items a child should pass taking into account the child’s age [17]. Children performing lower than what is expected for their age, have a performance ratio below one. To test the social-emotional development of the children, ASQ: SE questionnaires were used. These are parent-report questionnaires developed to identify children whose social and emotional competences might differ from what is expected [20]. ASQ: SE is recommended for its high rate of detection of social-emotional problems among young children [21]. It has high test-retest reliability [20]. The questionnaires were culturally adapted to the study context and translated into both local languages. An ASQ: SE questionnaire only took about 10–15 min to complete for a caregiver. The child’s total score was calculated by adding up the points of all items on the questionnaire. A higher total score indicates more social-emotional problems. To characterize the nutritional status, anthropometric assessment was done following WHO guidelines [18]. The child’s weight was measured using a calibrated electronic weighing scale (SECA Uniscale, Hamburg, Germany). For children under 2 years, the length was measured using a length-measuring mat on a flat table (SECA 210, Hamburg, Germany). The height of a child above 2 years was measured by using a Seca Road Rod 214 portable Stadiometer. Age was recorded from birth certificates or immunization cards. If reliable documents for age estimation were absent, local events calendars were used to help the mother or caregiver estimate the approximate age of the child. A structured questionnaire was used to collect the demographic and psychosocial characteristics of the participants. Some of the variables measured were maternal age, education and occupation, age, sex and birth order of the child, monthly income of the household, child feeding condition, number of persons living under the same roof with the child, availability of play materials and playground, time spent on play by the child, mother-child interaction, and frequency of a child’s interaction with other children. We obtained ethical approval from The Ethical Review Board of Jimma University, Ethiopia (RPGC/36/2013, dated 13/02/2013). We also obtained written informed consents from the children’s parents. Measurements and testing were performed by four trained nurses, who spoke both Afan Oromo and Amharic languages. They were trained for 1 month by a child development expert and a nutritionist on the theoretical and practical aspects of overall child development, care, nutrition, anthropometric methods, Denver II-Jimma, the structured questionnaire and ASQ: SE. To reduce possible biases, the testers were blinded; they did not know to which group a child belonged. The testers assessed children in both groups and the assessments were performed at the children’s homes while their caregivers were present. Prior to testing, the tester created a relaxing environment with the child and its respective caregiver. Regarding the assessment order, a questionnaire, together with ASQ: SE, was administered first; the Denver II-Jimma next and finally, the anthropometric measurements. The assessment time for a child took about an hour. To guarantee data quality, double data entry was done into EpiData. The data were then exported to SPSS version 22 and analyzed. The anthropometric measures were converted into Z-scores of Weight-for-Age (WAZ), Height/Length-for age (HAZ/LAZ), and Weight-for-Height/Length (WHZ/WLZ) using WHO Anthro and Anthro plus software [22]. Based on the WHO reference standard, underweight, wasting and stunting were defined as WAZ, WHZ/WLZ and HAZ/LAZ below -2SD respectively. Z-scores between -3SD and -2SD represent moderate undernutrition; whereas, the Z-scores below -3SD signify severe undernutrition. ‘Not-malnourished’ children are the children whose Z-scores lay between -2SD and +2SD for the three nutritional indices. The data indicated a prevalence of stunting, wasting and underweight of the children in extreme poverty. To compare the psychosocial conditions of children in extreme poverty and the reference group, chi-square tests (χ2) were employed. Independent samples t-test was used to compare the developmental outcomes of children in extreme poverty and the reference group. To determine the association between the developmental scores and the nutritional/psychosocial indicators, for children in extreme poverty, multiple linear regression analyses were used for each developmental score (personal-social, fine motor, language and gross motor) separately. Two-stage approach was carried out. A regression model with the two nutritional indicators (stunting and underweight) as independent variables was fitted. Both nutritional indicators were significantly associated with each developmental score. Next, the demographic and psychosocial factors (child’s sex, birth order, feeding condition, maternal age, education, occupation, monthly family income, family size, availability of play materials, availability of playground, play time, child-to-child interaction and mother-child relationship) were added to the regression model containing the statistically significant nutritional indices. Finally, a parsimonious model was obtained by means of a stepwise selection. The significance level was set at 0.05 and all tests were two-sided.
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