Early Childhood Development Home Visitation Program in the Dominican Republic

Monday, 30 October 2017

Alexandra Rae Nitsos, BSN1
Robin Dawson Estrada, PhD2
DeAnne K. Hilfinger Messias, PhD2
(1)Project Restauración, Foundation for International Medical Relief of Children, Restauración, Dominican Republic
(2)College of Nursing, University of South Carolina, Columbia, SC, USA

Background & Significance: Restauración is located in Dajabón, the second poorest province in the Dominican Republic. It is only 12 kilometers from the border of Haiti, the poorest country in the Western Hemisphere. The impact of poverty is particularly visible in Restauración, the poorest municipality in the province of Dajabón (Foundation for International Medical Relief of Children, 2015). Children living in such poverty-stricken areas generally experience less cognitive stimulation and enrichment in comparison to wealthier children, and have elevated rates of problems related to learning, behavior, mental health, and physical health, as well as decrements in attentional processes, working memory, planning, brain activity, and inhibitory control that persist into adulthood (Hanson, et al., 2013). Most of the brain’s neural pathways supporting communication, understanding, social development and emotional well-being grow rapidly in the first three years of life. The brain is also the most plastic and most responsive to the outside world in this time (Unicef & WHO, 2012), and cognitive stimulation in the home before the age of four years is the principal factor determining teenage brain development (Jha, 2012). Programs targeting preschool children and their families have the potential to positively impact health and educational outcomes for children living in poor and under-resourced areas.

Maternal and child education and support has traditionally been offered in home settings to allow for individualization and intimacy of meetings. There have been many successful home visitation programs established in the United States, much of Europe, and Australia. For example, nurse home coaches reduce infant deaths and child abuse and injury, while improving language development and cognitive and educational outcomes, leading to reduced healthcare costs (Spiro & Chen 2016). Home-based interventions are also starting to gain attention in third-world countries. In a randomized control trial (RCT) studying childhood stimulation in a rural part of Peru, results demonstrated that children aged 6 to 35 months whose mothers playfully interacted with them for half an hour daily performed up to 23% better, a significant improvement, in categories such as expression of feeling and emotions, fine motor skills or verbal and non-verbal communication than the control group (Hartinger et al., 2016). As early cognitive stimulation may positively affect child development, in-home programs could be an effective corrective in the early child development disparities observed between rich and poor families (Hartinger et al., 2016). Good nutrition and stimulation and caretaker emotional responsiveness affect child growth and brain development. Consequently, programs combining information about health, nutrition, and stimulation have been shown to improve growth and developmental outcomes in both the short and long term (Unicef & WHO, 2012). If parents are informed of the significance placed on the early childhood years for physical, social-emotion, and language-cognitive development, and if they are given the knowledge of how to support their children in these years, they can take the necessary steps in creating a positive environment conducive to optimal growth and development.

Objective: To create a program adaptable for a series of five home visits to educate caregivers about early childhood development and priority health topics, that will stimulate and support children developmentally, while emphasizing the significance of the first five years of a child’s life.

Method: Past Peace Corps workers whom had served in the Dominican Republic designed two manuals with information and activities for instructors to teach to primary caregivers of children zero to five years of age. Utilizing this information, as well as components of other evidence-based programs (e.g., Early Head Start), the nurse researcher created an intake sheet to assess the caregivers and children in the program and charts to track children’s physical, linguistic, and social emotional development. The researcher also compiled a comprehensive manual of instructions, information, and activities to guide the medical professional in conducting personalized home visits based on the ages, genders, concerns, and strengths of each family.

The nurse researcher and the field operations manager (FOM) then recruited participants for the program. They identified eligible caregivers through contacts at the preschool and hospital and through other FIMRC staff. Subsequently, they visited the caregivers at their homes to ensure interest, identify availability, and collect information to evaluate the probability of them living in poverty using the Progress Out of Poverty Index for the Dominican Republic (Innovations for Poverty Action, 2017). From this information, the researcher and FOM selected nine homes for the first series of visits based on need and location. Using this index, five homes that were the most likely to be living in poverty were selected for inclusion. Four additional homes in close proximity to these homes were also included. As the community is tight knit, “influencers” were among those recruited. Influencers were people whom would likely work within the community to share some of the information they would be learning in the program. The three influencers included in the first round were the local preschool director, a mother who was very passionate about childcare and had expressed desires for community changes in regards to this, and a local nurse. The Spanish-language intervention developed for this program consisted of a series of five home visits in which the intake sheet was filled out and discussed, which led into education about breastfeeding and nutrition; personal hygiene; and physical, social-emotional, linguistic, and cognitive development and associated activities that stimulate and strengthen these areas. The caregivers received a folder of simple information, child-friendly activities, and tables with the appropriate developmental milestones for each age through five years to reinforce the material being shared.

Evaluation Process: The nurse researcher created review questions based on the information shared in each of the five home visits and included objective assessment of knowledge retention immediately post-intervention. Future evaluation processes will include collection of general feedback on the program from the primary caregivers to be used for program modification, and assessment of long-term knowledge retention and understanding. FIMRC staff will return to the houses four months post-intervention for this phase of program evaluation.

Results/Preliminary Findings: Five home visits were completed in nine homes with 10 primary caregivers and 17 children five years of age and younger. A sister of a caregiver and an adult daughter of another caregiver also participated consistently in the visits. There were two fathers, two aunts, four grandmothers, and some older children in the families that participated less consistently in the visits. All participants were either Dominican or Haitian with proficient Spanish. There are still two final follow-up visits to be completed prior to beginning the program evaluation process. Preliminary qualitative feedback included one caregiver who expressed that she learned many things she had not previously incorporated into her daughter’s care. Another caregiver related that the information she obtained through the home visits helped her understand what she did not know about her children’s development, and how to expand her knowledge about the type of care best for them. One of the most involved caregivers reported that her friends enjoyed going through the materials in her folder and discussed how they could use some of the activities, especially the songs, in their own homes.

Conclusion & Discussion: Children living in poverty require appropriate developmental stimulation, support, and care, especially during the first five years of life. This time is also significant in establishing school readiness, which in turn affects adult success. These caregivers learned information that will improve the care they give their children, which has the potential to improve the health and development of the children. The time spent with a medical professional in each visit also allowed for questions and discussion, increasing the knowledge and confidence of the caregivers.

Future FIMRC staff will target unaccessed neighborhoods and communities. For the Restauración site, a strategic objective was added to reach 90 caregivers aged 15-25, with children five years of age and younger over the next two years. FIMRC staff will also be able to use names of candidates that have already met inclusion criteria but have not yet participated in the program. With the local nurse added to the staff, assistance from FIMRC interns and volunteers, and any input or guidance needed from the FOM or the nurse researcher, the program will be modified, improved, and continued.