The Relative Association of Bio‐Medical and Socio‐Environmental Risk Factors with School‐Age Child Cognition in Indonesia
Authors: Prado Elizabeth L , Sebayang Susy K , Apriatni Mandri , Hidayati Nina , Adawiyah Siti R , Islamiyah Ayu , Siddiq Sudirman , Harefa Benyamin , Alcock Katie J , Ullman Michael T , Muadz Husni , Shankar Anuraj H 
Published: November 2023

Child cognitive, motor, and socio‐emotional development is affected by multiple bio‐medical and socio‐environmental factors. A better understanding of the influence and interplay of these factors is needed to inform the strategic design and integration of child development programs with existing reproductive, maternal, neonatal and child health (RMNCH) programs.We assessed the cognitive, motor, and socio‐emotional function of 2879 9–12‐year‐old children whose mothers had participated in the Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT). In multiple regression models, we assessed the relative effect size of seven bio‐medical risk factors and five socio‐environmental risk factors on each of seven cognitive, motor, and socio‐emotional scores. Six factors were measured before birth, two at birth, and four at school‐age follow‐up.The socio‐environmental factors showed stronger and more consistent associations with school‐age cognitive, motor, and socio‐emotional scores, as compared to the bio‐medical factors. Pre‐term birth, born small for gestation age, maternal anemia, and low maternal mid‐upper arm circumference and height during pregnancy were not significantly associated with any score. Child anemia at follow‐up was significantly associated with fine motor dexterity only. Children whose mothers received multiple micronutrient supplements during pregnancy and postpartum scored higher in procedural memory only. Post‐natal growth in height was significantly associated with general intellectual ability and academic achievement. In contrast, each of the socio‐environmental factors was significantly associated with three to five of the seven scores. Children in low SES households scored significantly lower in general intellectual ability, declarative memory, executive function, academic achievement, and fine motor dexterity. Both maternal and paternal education were associated with general intellectual ability, executive function, and academic achievement, while maternal education was also associated with declarative memory and fine motor dexterity. Nurturing and stimulation from the environment (HOME Inventory score) was significantly associated with general intellectual ability, declarative memory, executive function, academic achievement, and fine motor dexterity. Maternal depression was strongly associated with child socio‐emotional development, and was the only significant predictor of this score. Children of depressed mothers also scored lower in declarative memory.In order to achieve thriving populations, coverage of existing RMNCH interventions to prevent these bio‐medical conditions needs to be improved. Even with improved coverage of existing interventions, additional interventions addressing socio‐environmental risk factors are also needed.Support or Funding InformationFunded by Grand Challenges Canada Saving Brains