Effects of Psychosocial Stimulation and Cash on Children's Development and Behaviour

Burden: In developing countries, an estimated 219 million children do not reach their maximum potentiality because of poverty and associated risk factors. More than half of the Bangladeshi children \<5 years are at risk for developmental delay due to poverty and sub-optimal home stimulation. Sometimes poor people become poorer due to catastrophic expenditure on health care and fall into the vicious cycle of poverty

Knowledge gap: Although, there is evidence that conditional cash transfer helps develop poor people' health and nutritional status, little is known about the effect of unconditional cash transfer and health education (HE) programmes along with psychosocial stimulation on children' cognition and behaviour.

Relevance: The study will bring an opportunity to evaluate the effect of transferring unconditional cash and health education programme along with psychosocial stimulation to poor families under safetynet programme of Bangladesh Govt. in rural areas. The study will also document direct and indirect cost to measure cost effectiveness that will help in decision making to implement the project if it shows benefits to children's development.

Primary Hypothesis (if any):

* Unconditional cash transfer (UCT) and health education (HE) programme will improve child's cognitive, motor and language development and behaviour compared to no intervention group.
* Adding psychosocial stimulation to an unconditional cash transfer (UCT) and health education (HE) programme will will have an additive effect on Childs's cognitive, motor and language development and behaviour compared to the control groups

Secondary Hypothesis:

Additionally the intervention will

* be cost effective,
* reduce mothers' depressive symptoms and improve their self esteem
* improve children's growth and household food security status
* reduce domestic violence
* Health seeking behaviour and health care expenditure

Long-term goal: our ultimate goal is to find a suitable infrastructure to take to scale early child development activities for the whole country.

Methods: It is a Cluster Randomized Controlled Trial with three-arms (i) UCT+HE+Psychosocial stimulation (ii) UCT+HE and iii) Comparison group.

Primary objectives:

To evaluate the effect of UCT and HE programme on children's cognitive, motor and language development and behaviour To evaluate the effect of adding psycho social stimulation to an UCT and HE program on cognitive development and behavior of young children

Secondary objectives are:

To measure effect of the program on:

cost effectiveness of the intervention mothers'mental health (depression symptoms) and their self esteem household food security status and children's growth and domestic violence health care expenditure and health seeking behaviour of the families

Introduction:

In developing countries, an estimated 250 million children younger than 5 years in low and middle income countries do not reach their maximum potentiality because of poverty and associated risk factors. More than half of the Bangladeshi children less than 5 years are at risk for developmental delay due to poverty and sub-optimal home stimulation. Sometimes poor people become poorer due to catastrophic expenditure on health care and fall into the vicious cycle of poverty. Conditional and unconditional cash transfer to the poor mothers has proved a way of reducing poverty and improving health outcomes for mothers and children worldwide. Ministry of Women and Children Affairs (MoWCA),Government of Bangladesh (GoB) introduced maternity allowance in the fiscal year 2007-2008. This is an unconditional cash transfer under safety net program for the poor mothers. The mothers also receive health education awareness program. The overall objective of the cash and health education training program is to ensure safety net in terms of morbidity, mortality and welfare during pregnancy and lactation period for both mother and child. Adding psycho social stimulation to the program will benefit children's cognition, behavior and nutritional status. On the other hand the interventions together will address family's food security and mothers' physical and mental health and self esteem because receiving extra cash as well as education on health and psycho social stimulation will enhance mothers' capacity in many aspects.

Psycho social stimulation alone and along with other health and nutrition programs was found to be effective for children's cognition and behavior \[9-13\]. Conditional Cash Transfer (CCT) alone was also found significantly effective for child development in Mexico. On the other hand, studies reported that UCT improved other health outcomes and nutrition, but little is known about the effect of unconditional cash transfer (UCT) along with health education program and psycho social stimulation on children's cognition and behavior. MoWCA is transferring cash to poor pregnant mothers along with health education training program under social safety net program. The present study group plan to conduct a randomized controlled trial to document effect of adding psycho social stimulation to the present program on children's cognition and behavior. 200 mother-child dyads in each arm will be enrolled when their child is 6-16 months old. The participants of the intervention group will receive psycho social stimulation fortnightly at home for 12 months.

However, UCT and HE program is a social safety net program under the ministry of Women and Children Affairs of Bangladesh Government. The outcomes of this program are primarily maternal and child health and does not directly focus on children's cognition and behavior. However, social safety net programs may indirectly affect other outcomes like maternal depressive symptom, violence against women, children's well being, cognition and behavior and nutrition status for both mother and child. The researchers intend to add psycho social stimulation in order to trigger the outcomes in terms of children's development. But the program needs to be cost effective to be scale able in low resources settings. If the intervention is cost effective, the package may be found attractive by respective policy makers to improve development of poor children in those settings.

The maternity allowance of taka 500 ($6.25) per month is distributed through commercial banking system. Health education awareness program is conducted monthly by some Local Non Government Organizations (LNGOs) and Community Based Organizations (CBOs) on a wide range of health and social welfare issues. The NGO,/CBOs have their own curriculum approved by MoWCA for the awareness program. The Local government and community leaders can play an important role in encouraging the eligible women to participate in the program. Home based psycho social stimulation will be provided by community female Play leaders having at least 12 years of education. So the project will build capacity of the community including the Play Leaders from the community.

Study design:

This is a cluster randomized controlled trial with 3 arms: i) Psychosocial stimulation+ Health education program + Unconditional cash transfer ii) Health education program + Unconditional cash transfer and iii) Comparison arm. The comparison group will consist of those who are eligible to receive UCT but do not receive it due to resource constraints of the UCT programme.

Recruitment:

11 Unions have been selected randomly out of 14 Union at Ullapara, a sub district under Sirajgonj district in Bangladesh.The old Ward of a Union would be considered as cluster.

Since the Government is providing UCT to 79 mothers in each Union, the research team assume to get approximately 26 participants in each Ward. 18 participants will be enrolled randomly from each cluster. Restricted randomization process will be followed. There are three old Wards in each Union. the each old ward (cluster) will be allocated for each arm randomly.

For comparison arm, mother-child dyads will be enrolled from any part of the old Ward until the required sample size are fulfilled.The eligibility criteria of participants for the comparison arm would be the same as that for the UCT recipients.

Intervention and Project Execution Plan:

The study aims to integrate three distinct interventions: i) Maternity allowance ii) Health education awareness program and iii) Psychosocial stimulation.

i) Maternity Allowance: MoWCA, GoB provides maternity allowance of taka 500 ($6.25) for each poor pregnant mother up to two years through banking channel under safety net program of the GoB.

ii) Health Education Awareness Program: All mothers receiving maternity allowance receive various health education training by designated LNGOs/CBOs through MoWCA, GoB funding.

iii) Psychosocial stimulation: The participants will receive fortnightly sessions of psychosocial stimulation at home by community female play leaders for one year. The curriculum of stimulation is based on improving the mother-child interaction, and providing developmentally appropriate activities for the child. The curriculum has already been used in several projects in Bangladesh run by Child Development Unit of icddr,b and has shown significant benefits to children's development\[10-12, 22\] and growth\[11, 22\].

Training:

When the inter observer reliability coefficient will be more than 0.8 through data collection training, will be considered that the trainee to be eligible to take part in the test procedure. Quality of data collection will be checked at the field by supervisors/master trainers on 10% of the assessments.

Data collection:

All data will be collected from all groups- Group I: UCT+HE Group II: (UCT+HE)+ Psychosocial stimulation and group III: Comparison. Data will be collected at baseline, end line and some others monthly to compare the outcome between the groups.

Data Storage Data will be stored in databases saved on icddr,b servers.The databases will be password protected and only members of the study team and investigators will have access to the password.

Sample size The study requires 200 mother-child dyads in each arm with 11 clusters of 18 participants in each cluster. So in total we will have 600 participants, 33 cluster, 18 participants in each cluster considering 90% power, 5% level of significance, an intraclass correlation (ICC) of 0.05 and an effect size of previous study.

Data analysis:

Data will be checked for normality. Appropriate measures will be taken if there are any abnormal distributions. Differences between groups in socioeconomic and other background characteristics will be analyzed using t-test for continuous variables for two groups and a ANOVAforthree groups. Effect of the interventions will also be measured using intention-to-treat analysis controlling for the clustering effect.

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Cost-effectiveness Analysis:

The objective of the study is to estimate the resources used and costs associated with interventions. The research team will measure direct and indirect cost of for all the groups. Average costs per participants will be calculated by multiplying the cost of resource items by their respective unit costs. The outcomes of the study will be measured. Then the incremental cost-effectiveness ratio (ICER) will be used in cost-effectiveness analysis.

Eligibility Criteria:
Inclusion Criteria:

* Mothers with a child aged 6-16 months
* Eligible to receive UCT.

  * UCT+HE+PS arm: Receiving unconditional cash from government
  * UCT+HE arm: Receiving unconditional cash from government
  * Comparison arm: eligible to receive UCT but not under UCT programme.
* Not expected to leave the study site for more than 2 months
* Has a legally acceptable representative capable of understanding the informed consent document and providing consent on the participant's behalf.

Exclusion Criteria:

* Legal guardian unwilling or unable to provide written informed consent.
* Known congenital anomaly
* Developmental disorder or severe developmental delay
* Not possible to test the child due to physical or behavioral problems
* Children of multiple birth e.g. twin, triplets