Develop. Med. Child Nerirol. 1975, 17, 605-6 I3

A Home-visiting Intervention Programme with Jamaican Mothers and Children Sallg M. Grantham-McGregor P. Desai

level of mental development found in many pre-school children from lower socioeconomic backgrounds. We therefore undertook a home-visiting project with the aim of helping mothers to interact with their three-year-old children in such a way as to improve their mental development. The study took place in suburban areas of the city of Kingston, near the University of the West Indies. The general standard of housing was low, with overcrowding and inadequate sanitation, but the areas were not among the very poorest in Kingston.

Introduction In Jamaica, as in most developing countries, very young children from poor social backgrounds are subject to varying degrees of malnutrition and considerable morbidity from infections (Miall et ul. 1970, Grantham-McGregor er a / . 1972). It has recently become apparent that, in addition, their mental development is in jeopardy: Hawke carried out developmental assessments of 65 children at one, two and three years of age and found a steady decline in their scores (GranthamMcGregor and Hawke 1971, Back et a/. 1972); and Wein ( 1 9 7 1 ~ found ) that mental development of four-year-old schoolentrants from lower socio-economic backgrounds was more than 18 months behind that of their middle-class counterparts. Scant information is available on the quality of the home environments of lower socio-economic Jamaican families (Richardson 1972; Grantham-McGregor, in preparation), but the indications are that there is a lack of toys and books in the homes and that mothers are often poorly educated and d o not provide the type of stimulation usually required to promote satisfactory psychological development. I t is almost certain that such environments are at least partly responsible for the poor

Methods The project included index and control groups of mothers and their three-year-old children. The index group was formed by conducting a complete house-to-house census in a defined area and identifying all mothers or guardians who were not in full-time employment and who had children of the appropriate age. Controls were similarly identified in an adjacent area with the same standard of housing. Children living in houses of an atypically high standard, or whose mothers or guardians had reached ‘0’-level standard of education, were not included. One child with brain damage was also excluded. ___

~

MRC Epidemiology Unit, University of the West Indies, Kingston 7, Jamaica.

605

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1975, 17

TABLE I Comparison of families, housing and children’s growth in index and control groups

I

Variable

Other children in home: older (mean) younger (mean) No. of mothers having baby during study People per room (mean) Type of lavatory: flush (inside) flush (outside) pit (outside) Education of mothers: secondary school ( 1 4 years) primary school (grade V or VI) primary school (below grade V) Children’s growth (mean & SD): weight (Ib) height (inches) head-circumference (inches)

Index group

Controlgroup

2.7 0.8 4 3.2

2.2 2.9

8

10

1

11

2 9

2 14 4

3 15 3

1.2 1

similar in the variables shown in Table J. During the course of the study we also assessed the mothers’ verbal IQ by the Peabody Picture Vocabulary Test (PPVT) (Dunn 1965) and the groups were again similar, the mean IQ of the index mothers being only four points higher than that of the control mothers. One mother in each group had part-time employment at the start of the study. Mothers and children in the index group were visited for an hour, once a week, for a maximum of 29 visits over a period of eight months, beginning in November 1972. The majority of the visits were made by a State Registered Nurse, who was given only a brief training for the work, and approximately 15 per cent of them were made by one of the authors (S.G.-M.). The general guidelines for the home visits were adapted from Gray’s programme in Tennessee (Geisy 1970, Gray 1971). Mothers were shown how to teach their children different things by playing and talking with them. The visitor at first led the playsessions, demonstrating the use of toys and books, then shared leadership with the mother, and finally encouraged the mother to take over completely. The programme was semi-structured, with general emphasis

The resulting groups each comprised 11 boys and 11 girls aged between 34 and 40 months and their mothers or guardians. The children had no gross physical handicaps. Table I gives some details of the children’s backgrounds. In Jamaica, two-thirds of children are born to parents not legally married, and young mothers frequently live with their relatives in extended family households. It is generally more meaningful to consider the total number of children in the household rather than individual sibships, therefore the average numbers of children in the household older (up to 15 years) and younger than the study children are shown. The table also shows the number of babies born to study mothers during the study. The numbers of people per room and the types of lavatory are given as indices of housing standards. Descriptions of maternal education are given: a standard below primary-school grade V usually indicated functional illiteracy, whilst mothers who had reached grades V and VI or who had been to a secondary school usually could read and write. The children’s growth is described in terms of weight, height and head-circumference. The index and control groups were very

606

SALLY

M.

GRANTHAM-MCGREGOR

P.

DESAI

nor was aware whether they were index or control chldren. At the end of the study all mothers were asked a brief series of questions on childrearing. Before final evaluations, the nurse graded the index mothers into three categories according to how well they had co-operated with the programme.

on increasing the verbal interaction between mother and child and developing the child’s self-confidence and imagination. Specific emphasis was given to teaching basic concepts such as size, colour, shape and quantity. The concept-teaching was based on the curriculum developed by Palmer (1971) whilst working with deprived children in New York. The books and toys used at each session were left in the home for a week, then exchanged and rotated to other families. Care was taken to select play materials relevant to the children’s environment; other than this the toys were similar to those found in most well-equipped nursery schools or play-groups, i.e. jigsaws, blocks, tea-sets, dolls and beads. Equipment found in the homes was also used when possible. Towards the end of the study mothers and children were taken in small groups to a nearby zoo to demonstrate the educational value of such an outing. The control group of mothers and children were visited three times during the intervention period, to maintain contact and to make arrangements for evaluation sessions. The IQS of all index and control children were assessed before and after intervention with the Griffiths Mental Development Scales for Babies and Young Children (Griffiths 1970), and the PPVT.Only four of the six component scales of the Griffiths Scales were used, namely Hearing and speech, Eye and hand co-ordination, Performance and Praciical reasoning. Partway through the study the IQS of about half the index and half the control children were estimated, using the Grifiths test only (limited resources prevented the testing of the remaining ones). S.G.-M. performed all initial and intermediate tests, but the final Griffiths tests were administered by a psychologist who neither knew the children’s former scores

Results Three boys were lost from the study: one index and one control whose families moved from the area, and one index child whose mother went out to work full-time. The number of visits made to the remaining 20 index families ranged from 22 to 29. Some of these visits were made in the absence of the mother or child. Five children had fewer than 20 visits with both mother or guardian and child present. However, a suitable substitute who lived with the child was found for four of them, so except for one boy who only had 14 satisfactory visits, all the children had at least 20 visits with both the child and a suitable adult present. IQs and Changes in IQs Table I1 and Figure 1 show the IQ scores of the index and control children before and after the intervention programme. Mean IQS of both groups were initially very similar, but after intervention the mean scores of the index children had risen by 13 points relative to the controls in both the Griffiths test and the PPVT. In both tests there was a tendency for index girls to improve more than boys, which was significant in the PPVT scores only (two-way analysis of variance: GriF fiths test-experimental effect p< .01 experiment-sex interaction not significant; PPvr-experimental effect p< .01, experiment-sex interaction p < .05). Before intervention there were disparities in the mean scores on the four sub-scales of the Griffiths test in both

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1975, 17

DEVELOPMENTAL MEDICINE A N D CHILD NEUROLOGY.

TABLE 1I IQs of index and control children before and after intervention Group

i

1 1

Gri’ths

Mean Index 9 92 Males 11 91 Females Both sexes 20 92

Control 10 I 9 0 Males i i 90 Females Both sexes 21 90

1

Change

Afrer

Before SD

Mean

PP VT

Scales

SD

Mean

+10

- 2 - 4

9 7

- 3

8

70 70 70

14 9 11

+ 8

6

88 86 87

14

12 12

8

Mean

74

100 103 102

9

SD 8 6 7

14 8 11

+12

1

Before SD

Afrer Mean

12 71 6 84 9 78

70 72

9 6 7

63 63 63

Change

SD

Mean SD

16 20 19

- 3 $14 6

+

14 16 17

10 10 10

- 7 - 7 -7

9 8

8

p < -01). After intervention, the control children’s mean scores remained heterogeneous but the index children’s scores had become almost uniform in each of the sub-scales; their greatest gains had been made where originally their scores were lowest, and vice versa (Fig. 2). The results of testing part-way through the programme indicated that the index children’s Griffiths scores were still improving after six months of intervention (Fig. 3). It is uncertain whether improvement was still taking place at the end of the project. Mean

groups of children. They scored relatively highly in F (Practical reasoning) and D (Eye and hand co-ordination) and poorly in C (Hearing and speech) and E (Performance) (difference among four means in index and control groups combined

Index

IQ 105’ 3efore intervention

After intervention

100

95 90

85 80

75

-co-oLnomo 7 --m I l l

II C

D

E F c D E Subscale of Griffiths test

F

Fig. 2. Mean scores of index and control children

Change in IQ

in the four subscales of the Griffiths test, before and after intervention. (C=Learning and speech, D=Eye and hand co-ordination, E=Performance, F= Practical reasoning.)

Fig. 1. Changes in IQ (Griffiths test) among index and control children during intervention period.

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SALLY M. GRANTHAM-MCGREGOR

Reliability of Tests Over the six-month period between the initial and interim tests, the scores on the Griffiths scales showed satisfactory testretest correlations (r = .94) for the 11 control children. A similarly high correlation (r = -94) was found between the interim and final scores for the 11 control children, indicating consistency between the two testers. At the final evaluations, the children’s scores on the Griffiths Mental Development Scales were significantly correlated with those on the PPVT (r = .75, p

on this small sample was satisfactory. The children’s Griffiths scores correlated satisfactorily with their PPVT scores at four years of age (r = .75, p

A home-visiting intervention programme with Jamaican mothers and children.

In order to promote better mental development in three-year-old children from poor Jamaican families, a home-visiting project was carried out with the...
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