Factors associated with risk of developmental delay in preschool children in a setting with high rates of malnutrition: a cross-sectional analysis of data from the IHOPE study, Madagascar

Abstract

Background: 50% of Malagasy children have moderate to severe stunting. In 2016, a new 10-year National Nutrition Action Plan (PNAN III) was initiated to help address stunting and developmental delay. We report factors associated with risk of developmental delay in 3 and 4 year olds in the rural district of Ifanadiana in southeastern Madagascar in 2016. Methods: The data are from a cross-sectional analysis of the 2016 wave of IHOPE panel data (a population-representative cohort study begun in 2014). We interviewed women ages 15-49 using the MICS Early Child Development Indicator (ECDI) module, which includes questions for physical, socio-emotional, learning and literacy/numeracy domains. We analyzed ECDI data using standardized z scores for relative relationships for 2 outcomes: at-risk-for-delay vs. an international standard, and lower-development-than-peers if ECDI z scores were >1 standard deviation below study mean. Covariates included demographics, adult involvement, household environment, and selected child health factors. Variables significant at alpha of 0.1 were included a multivariable model; final models used backward stepwise regression, clustered at the sampling level. Results: Of 432 children ages 3 and 4 years, 173 (40%) were at risk for delay compared to international norms and 68 children (16.0%) had lower-development than peers. This was driven mostly by the literacy/numeracy domain, with only 7% of children considered developmentally on track in that domain. 50.5% of children had moderate to severe stunting. 76 (17.6%) had >=4 stimulation activities in past 3 days. Greater paternal engagement (OR 1.59(1.13, 2.21)) was associated with increased delay vs. international norms. Adolescent motherhood (OR3.89 (1.32, 11.48)) decreased children’s development vs. peers. Engagement from a non-parental adult reduced odds of delay for both outcomes (OR(95%CI =0.76 (0.61, 0.93) & 0.28(0.16, 0.50) respectively). Stunting was not associated with delay risk (1.33 (0.83, 2.14) or low development (0.91(0.47, 1.74)) when controlling for other factors. Conclusions: In this setting of high child malnutrition, stunting is not independently associated with developmental risk. A low proportion of children receive developmentally supportive stimulation from adults, but non-parent adults provide more stimulation in general than either mother or father. Stimulation from non-parent adults is associated with lower odds of delay