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Abstract
BackgroundAn estimated 63.4 million Indian children under 5 years are at risk of poor development. Home visits that use a structured curriculum to help caregivers enhance the quality of the home stimulation environment improve developmental outcomes. However, achieving effectiveness in poor urban contexts through scalable models remains challenging. MethodsUsing a cluster randomised controlled trial, we evaluated a psychosocial stimulation intervention, comprising weekly home visits for 18 months, in urban slums of Cuttack, Odisha, India. The intervention is complementary to existing early childhood services in India and was run and managed through a local branch of a national NGO. The study ran from August 2013 to July 2015. We enrolled 421 children aged 10–20 months from 54 slums. Slums were randomised to intervention or control. Primary outcomes were children's cognitive, receptive language, expressive language and fine motor development assessed using the Bayley‐III. Prespecified intent‐to‐treat analysis investigated impacts and heterogeneity by gender. Trial registrations: ISRCTN89476603, AEARCTR‐0000169.ResultsEndline data for 378 (89.8%) children were analysed. Attrition was balanced between groups. We found improvements of 0.349 of a standard deviation (SD; p = .005, stepdown p = .017) to cognition while impacts on receptive language, expressive language and fine motor development were, respectively, 0.224 SD (p = .099, stepdown p = .184), 0.192 SD (p = .085, stepdown p = .184) and 0.111 (p = .385, stepdown p = .385). A child development factor improved by 0.301 SD (p = .032). Benefits were larger for boys. The quality of the home stimulation environment also improved. ConclusionsThis study shows that a potentially scalable home‐visiting intervention is effective in poor urban areas.
Highlights
A total of 250 million children under five in low- and middle-income countries (LMICs) are at risk of not reaching their developmental potential with more atrisk children, a total of 63.4 million, in India than in any other country (Lu, Black, & Richter, 2016)
Age in months Male, % Firstborn, % Mother’s years of education Household asset index Z-score Length-for-age WHO Z-score Weight-for-length WHO Z-score ASQ-3 problem solving Z-score ASQ-3 communication Z-score ASQ-3 fine motor Z-score Maternal knowledge of child development Z-score Quality of home environment Z-score Maternal depressive symptoms Z-score Below Urban Poverty Linea Income (Rs) per Capita per Dayb Roof made from metal sheet/thatch/polyethylene House has dirt floor House has piped water connection Household has electricity connection Household owns a fridge
Amongst those included in the analysis baseline characteristics, except maternal education, were well-balanced across treatment and control (Table S3) with the difference in maternal education not being significant once pvalues were corrected for multiple testing
Summary
A total of 250 million children under five in low- and middle-income countries (LMICs) are at risk of not reaching their developmental potential with more atrisk children, a total of 63.4 million, in India than in any other country (Lu, Black, & Richter, 2016). Lack of stimulation is a key risk factor for poor child development (Black et al, 2017) and urban slums present particular challenges: the lack of safe outdoors play spaces combined with overcrowded housing means children often have few opportunities for stimulating play (Lester & Russell, 2010). Methods: Using a cluster randomised controlled trial, we evaluated a psychosocial stimulation intervention, comprising weekly home visits for 18 months, in urban slums of Cuttack, Odisha, India. We found improvements of 0.349 of a standard deviation (SD; p = .005, stepdown p = .017) to cognition while impacts on receptive language, expressive language and fine motor development were, respectively, 0.224 SD (p = .099, stepdown p = .184), 0.192 SD (p = .085, stepdown p = .184) and 0.111 (p = .385, stepdown p = .385). Conclusions: This study shows that a potentially scalable home-visiting intervention is effective in poor urban areas.
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