Home opportunities for the motor development of infants vertically exposed to HIVAbstract
Objective to evaluate the opportunities of the home for the motor development of vertically exposed infants according to the interdependent levels of the environment.
Methods This was a cross-sectional study which included family members who were capable of carrying out the daily care of HIV-exposed infants aged between three and 18 months who were being monitored by health services in eight municipalities in southern Brazil. Infants who were institutionalized, had lost their outpatient follow-up or were unable to be contacted by telephone were excluded. A total of 168 family members took part in the study through face-to-face and telephone data collection, characterizing the family member, the infant and the environment. The scales of opportunities in the home environment for motor development, the infant and food insecurity scales were applied. Descriptive analyses and correlations between the independent variables were carried out, followed by Poisson regression with robust variance.
Results The total opportunities of the home environment were classified as moderately adequate (37.4%), variety of stimulation as excellent (35.4%), physical space as moderately adequate (44.5%), toys for gross motor skills (38.0%) and fine motor skills (38.7%) as less than adequate. There was an association for schooling (p < 0.005), income (p < 0.013) and food security (p < 0.032) with the outcome less than adequate or moderately adequate for home opportunities.
Conclusion Poorer schooling, financial conditions and food security imply fewer opportunities for motor development, which can be exacerbated by the clinical fragility of infants with an as yet undefined serological condition and the demand for regular care to prevent vertical transmission.
Child development; Infant; HIV; Infectious disease transmission, vertical; Home environment; Child care
Resumo
Objetivo Avaliar as oportunidades do domicílio para o desenvolvimento motor de lactentes verticalmente expostos ao HIV de acordo com os níveis interdependentes do meio ambiente.
Métodos Estudo transversal que incluiu familiares capazes de realizar sozinhos os cuidados cotidianos de lactentes expostos ao HIV com três a 18 meses de idade, em acompanhamento nos serviços de saúde em oito municípios no Sul do Brasil. Foram excluídos lactentes institucionalizados, com perda de seguimento ambulatorial ou impossibilidade de contato telefônico. Participaram do estudo 168 familiares mediante coleta de dados presencial e telefônica com caracterização do familiar, do lactente e do ambiente. Foram aplicadas as escalas de oportunidades no ambiente domiciliar para o desenvolvimento motor com a escala bebê e insegurança alimentar. Foram realizadas análises descritivas e correlações entre as variáveis independentes, seguidas de regressão de Poisson com variância robusta.
Resultados As oportunidades totais do ambiente domiciliar foram classificadas como moderadamente adequadas (37,4%), variedade de estimulação excelente (35,4%), espaço físico moderadamente adequado (44,5%), brinquedos de motricidade grossa (38,0%) e de motricidade fina (38,7%) como menos que adequado. Houve associação para escolaridade (p < 0,005), renda (p < 0,013) e segurança alimentar (p < 0,032) com o desfecho menos que adequado ou moderadamente adequado para as oportunidades domiciliares.
Conclusão Menores condições escolares, financeiras e de segurança alimentar implicam em menores oportunidades para o desenvolvimento motor, as quais podem ser potencializadas pela fragilidade clínica do lactente com uma condição sorológica ainda indefinida e pela demanda de cuidados habituais para prevenção da transmissão vertical.
Desenvolvimento infantil; Lactente; HIV; Transmissão vertical de doenças infecciosas; Ambiente domiciliar; Cuidado da criança
Resumen
Objetivo Evaluar las oportunidades del domicilio para el desarrollo motor de lactantes expuestos a transmisión vertical del VIH de acuerdo con los niveles interdependientes del medio ambiente.
Métodos Estudio transversal en el que participaron familiares capaces de realizar solos los cuidados cotidianos de lactantes expuestos al VIH de tres a 18 meses de edad, atendidos en los servicios de salud de ocho municipios del sur de Brasil. Se excluyeron los lactantes institucionalizados, que perdieron el seguimiento ambulatorio o que no tenían posibilidad de contacto telefónico. Participaron en el estudio 168 familiares mediante recopilación de datos presencial y telefónica con caracterización familiar, del lactante y del ambiente. Se aplicaron las escalas de oportunidades del medio ambiente domiciliario para el desarrollo motor con la escala bebé e inseguridad alimentaria. Se realizaron análisis descriptivos y correlaciones entre las variables independientes, seguidas de regresión de Poisson con varianza robusta.
Resultados Las oportunidades totales del ambiente domiciliario fueron clasificadas como moderadamente adecuadas (37,4 %), la variedad de estimulación fue excelente (35,4 %), el espacio físico moderadamente adecuado (44,5 %), los juguetes de motricidad gruesa (38,0 %) y de motricidad fina (38,7 %) como menos que adecuados. Hubo relación de escolaridad (p<0,005), ingresos (p<0,013) y seguridad alimentaria (p<0,032) con el resultado menos adecuado o moderadamente adecuado de oportunidades domiciliarias.
Conclusión Menores condiciones escolares, financieras y de seguridad alimentaria conllevan menores oportunidades para el desarrollo motor, que pueden potencializarse por la fragilidad clínica del lactante con una condición serológica aún indefinida y por la demanda de cuidados habituales para la prevención de la transmisión vertical.
Desarrollo infantil; Lactante; VIH; Transmisión vertical de enfermedad infecciosa; Ambiente en el hogar; Cuidado del niño
Introduction
The home represents the first environment of opportunity for promoting child motor development (CMD), where parents and caregivers provide domestic resources and exploration of physical space. The interaction with family members and other children and the variety of stimulation (games and toys) develops fine and gross motor skills, as well as the cognitive and social skills of young children.1,2
However, inadequate resources in this environment have been associated with an increased risk of developmental delay in babies (3 to 11 months).3In low/middle-income countries, low scores were observed for maternal age, maternal and paternal schooling and variety of stimuli.4 Thus, these environmental conditions for families were linked to restrictions in physical spaces and in the variety of toys.5,6
Research into the cognitive, linguistic and motor development of babies (8 to 10 months) found that biological and environmental risk factors have a similar impact. The accumulation of these factors increases the likelihood of delays and the absence of quality environments hinders child development.7If CMD is conditioned by the supply of environmental opportunities and the individual’s biological conditions,8exposure and vertical transmission (VT) to the human immunodeficiency virus (HIV) stand out.
This fact persists even though TV prevention programs have been agreed globally to achieve the Sustainable Development Goals (SDGs). Overall, 3.4 million new HIV infections per year have been averted in children since 2000. But this decline has almost stagnated in recent years; by 2022, an average of 130,000 children (aged 0-14) had contracted HIV.9
Specific care to prevent HIV transmission should be taken by the family,10as well as the provision of environmental opportunities and regular care.11It should be noted that children living with HIV are vulnerable, including socially, as they depend on their families10initially so that the prevention of VT is guaranteed, after usual care11 and the provision of environmental opportunities to promote CMD. The research problem is therefore the following: What are the opportunities at home for the motor development of infants vertically exposed to HIV?
This research is justified on the grounds that the first thousand days of life are an opportune time to stimulate CMD, which requires attention to the usual demands of the age group and the specificities of the condition of exposure to HIV, as well as adding environmental aspects to health service guidelines, which are still mostly focused on the clinical dimension, which could increase the chances of a healthy life.
This study is based on the Bioecological Theory of Human Development,12the process is structured in four interrelated elements: person, process, context and time. In this paper, the person is the developing individual, the HIV-exposed infant, and the process consists of the reciprocal interactions between the infant, family members and the structure of the home. The context is defined as the environmental levels: microsystem, the environment closest to the infant’s insertion (home); mesosystem, the relationship between home and the child’s other environments, the family’s relationship with the daycare center and the health service; exosystem, the places where the infant does not participate directly, but affects or is affected by it, the parents’ work and the conditions derived from it (leave, etc.); and macrosystem, the infant’s work and the conditions derived from it (leave, etc.); and macrosystem, the social, cultural and global influence expressed by the sociodemographic and clinical characteristics of family members and the infant. Time is the age group of the infant and the social period experienced.
The aim was therefore to assess the opportunities in the home for the motor development of infants vertically exposed to HIV according to the interdependent levels of the environment.
Methods
This cross-sectional study collected data from December 2015 to August 2020 in Rio Grande do Sul, Brazil. Municipalities in the Metropolitan Region (Novo Hamburgo, Cachoeirinha, Sapucaia do Sul and Viamão) and in the countryside (Erechim, Santa Cruz, Santa Maria and Passo Fundo) were selected, according to the classification of the 100 Brazilian municipalities with more than 100,000 inhabitants with the highest composite HIV rate.13
The inclusion criteria were: being a family member of an infant (3 to 18 months) vertically exposed to HIV and capable of carrying out daily care on their own. Exclusion criteria were: institutionalization of the infant, loss of outpatient follow-up (≥ 1 year without access) or impossibility of telephone contact (after ten attempts on different days and shifts). A total of 168 family members took part in the study. Based on this sample, it is possible to estimate with 95% confidence any outcome that occurs with a frequency of 50%, with margins of error of between 7 and 8 percentage points.
Access to the population was gained through a face-to-face meeting with managers and professionals from the specialized public health services in each municipality, when the logistics of data collection were discussed. Participants were recruited using a list (names of children/mothers and appointment days) provided by the services.
Data collection training was carried out by the researcher in charge for a team of five people, scientific initiation scholarship holders and a postgraduate student. Face-to-face and telephone data collection was supervised in weekly meetings. Potential participants were called beforehand to explain the project’s objectives. Upon acceptance, they were informed that a physical copy of the informed consent form (ICF) would be available for the nurses to sign on the day of the appointment. After signing, the nurses informed the team of the second telephone contact to apply the research instrument.
Previous experience with the telephone technique and with sensitive topics indicated the use of an exclusive telephone number for the survey and the call in a private room. As the topic was sensitive, the collectors were trained to always ask about the family member’s relationship with the child, where the participant was at the time of the call, and to make sure that the call was not on speakerphone, to avoid exposure or embarrassment. The average self-reported response time to the instrument was 30 minutes.
The survey instrument consisted of questions about the characterization of the family member and the infant. Family member variables: age, gender, marital status, schooling, income, number of people living on the income, number of children, occupation, employment, attendance at appointments and perception of being monitored. Infant variables: the respondent’s bond with the baby, whether there is another child in the household under special care, whether the child has an exposed sibling, when the infant was first seen by an infectious disease specialist, number of appointments, missed appointments and perception of keeping the infant monitored.
Two scales were used: 1) Affordances in the home environment for motor development - Infant Scale (AHEMD-IS),1 composed of six items characterizing the environment and 35 assessment items for the 3 to 11 month and 12 to 18 month age groups. For the telephone survey, the respondents were shown the toys in the images contained in the scale, indicating that they were examples and that the infant did not necessarily need to have all the items mentioned. 2) Brazilian Food Insecurity Scale - short version (EBIA),14 assesses people’s perception of the availability of food in the household, with five questions referring to the three-month period prior to the interview, where at least one positive answer means the presence of food insecurity (FI) in the household. The pilot test was developed in a previous study, when the instrument was refined.
The data was entered into EpiInfo version 7.2, with independent double entry. After correcting errors and inconsistencies, they were exported to SPSS version 22.0. The opportunities of the home environment were considered as dependent and the sociodemographic and clinical characterization of the family member and the infant, the environment, and the total AI as independent. Qualitative variables were associated using Pearson’s chi-square test and Fischer’s exact test. For the non-parametric quantitative variables, according to the Kolmogorov-Smirnov test, the Mann-Whitney test was used for variables with two categories and the Kruskal-Wallis test for variables with three or more categories. Poisson regression analysis with robust variance was carried out. The significance level adopted was 5% (p ≤ 0.05). The research was approved by the Research Ethics Committee of the Federal University of Santa Maria, under opinion: 1.348.256/2015, CAAE: 50609615.1.0000.5346. For the quality and transparency of the writing, the Strengthening the Reporting of Observational studies in Epidemiology (STROBE).
Results
The study population of 168 family members is predominantly female (n=165, 98.2%), aged ≥30 years (n=88, 52.4%), in a stable union (n=108, 64.3%), with a high school education (n=72, 43.1%). The number of children was between two and four (n=109, 64.9%). The majority reported being unemployed (n=101, 60.8%), with a monthly family income of up to two salaries (n=81, 48.8%), with between three and five dependents (n=129, 76.6%).
With regard to health monitoring, the women reported that they attended their appointments (n=153, 93.9%) and considered the difficulty of keeping up with their monitoring to be more or less (n=68, 41.5%), easy (n=64, 39.0%), difficult (n=30, 18.3%).
With regard to the bond with the infant, most were mothers (n=160, 95.2%), who have other children under their care (n=109, 65.3%), with no siblings exposed to HIV (n=101, 60.1%). The child’s first visit to the infectology service took place within one month of life (n=102, 60.1%), with visits ranging from one to four (n=75, 49.7%). Keeping track of the infant’s health was considered easy (n=73, 43.7%), and they denied missing any appointments in the last year (n=132, 83.0%).
Regarding the characterization of the environment, there was a predominance of houses (n=155, 94.5%), with up to two bedrooms (n=114, 69.5%), living with up to two adults (n=122, 74.4%) and up to two children (n=114, 69.5%). Of the children in the study, the majority did not attend nursery school (n=131, 86.2%).
The opportunities in the home environment were classified as moderately adequate (37.4%). In terms of dimensions, the physical space was moderately adequate (44.5%), gross and fine motor toys were less than adequate (38.0% and 38.7%, respectively) and the variety of stimulation was excellent (35.4%) (Table 1).
The association between the variables characterizing the participants and the AHEMD-IS scale was statistically significant for income (p<0.001) and schooling (p=0.005) in the total score for home environment opportunities. The variables: relationship with the infant, first consultation, number of consultations, maintaining follow-up and, again, income and schooling were associated differently between the four dimensions of the instrument (Table 2).
Distribution of sociodemographic and clinical variables and the opportunities of the home environment for the motor development of infants vertically exposed to HIV, from municipalities in the state of Rio Grande do Sul
In the regression model, there was a significant association between schooling, income and EBIA, with the outcome ≤ moderately adequate (Table 3). People who had not studied had 1.84 times (crude prevalence ratio) the prevalence of less than adequate AHEMD-IS when compared to those with secondary or higher education. Those with primary education had 1.24 times this prevalence in the sample, but there was no significant difference. Two adjusted models were made, one with EBIA and schooling, the other with EBIA and income, since income and schooling are highly associated variables. After adjusting for EBIA and schooling, family members who have not studied have 1.54 times the prevalence of having AHEMD-IS ≤ moderately adequate when compared to those with secondary or higher education, regardless of their EBIA score, and those with FI have 1.67 times the prevalence of AHEMD-IS ≤ moderately adequate when compared to those who have food security (FNS), regardless of schooling. (Table 3).
Discussion
The home is the closest environment to the developing person, the first level of context to which the infant is inserted, in other words, the microsystem12 Most of the homes of HIV-exposed infants were classified as moderately suitable for CMD opportunities. This same classification was obtained for 36.5% of the homes of Brazilian children (6-18 months) with typical development7 and for 36.1% of households with healthy infants (3-18 months).15There is a similarity in that the children in this study have an increased health risk, which has not increased the risk of having homes that are unsuitable for CMD opportunities.
The variety of stimulation dimension was the only dimension with an excellent rating in this study. This dimension assesses whether the child is carried by adults; whether they use some kind of equipment that keeps them sitting or standing; whether they stay in a playpen or crib; whether they play lying on their stomach; and whether they remain free to move around the house. For children (0-24 months), 58% of households obtained the maximum score,16 considered to be protective for CMD. In children (3-18 months) with Down’s Syndrome, there was a positive correlation between motor performance and the variety of stimuli.17
There were two statistically significant associations for this dimension: first consultation (<1 month of life) and number of consultations1-4 in a specialized service. In order to meet the needs arising from both usual childhood care and clinical characteristics, the interaction environment of these infants was expanded, possibly from health services to the home, which is a protective factor identified at the mesosystem level. This level refers to the links between two or more environments in which the person is inserted.12
The importance of specialized care before the age of two months stands out, as it was statistically associated with prophylactic measures. When the first visit took place after two months of age, there was a 3.2 to 31.5 times greater chance of HIV transmission.10 In countries with human development indices (HDI) such as Kenya and Uganda,18 Brazil19 e Italy20 identified multiple missed opportunities for HIV prevention and the delay in testing. Therefore, there are still challenges at the global level to achieve the SDG target of eliminating VT.
Another significant association for the variety of stimulation was family ties. In this study, the main ties were mainly to mothers, which was also evidenced in a study of Ugandan children exposed to HIV.21
Income was a factor with a statistically significant association with opportunities for physical space in the home, demonstrating the influence of the macrosystem12 and offering CMD opportunities. The low-income characteristics of the population in this study are in line with evidence from other developing countries, such as India,22 and with an HDI considered low, such as Ethiopia.23 It can be inferred that a better financial situation can lead to better housing conditions.
The dimensions toys for fine and gross motor skills were classified as less than adequate opportunities, which is a risk factor for acquiring motor skills in childhood.24 Study shows that enriched home environment improves CMD.25
Among the variables significantly associated with the availability of toys, income and schooling showed the influence of the macrosystem.12 This is similar to what has been reported with Brazilian children not exposed to HIV,5in which there was a positive correlation between socioeconomic class and fine and gross motor toys.15 In a survey of children (03 to 42 months), it was found that income alone can affect the quality and quantity of resources available in the household, including the relationship between this and parental education.26Therefore, there is evidence that better income and educational level increase the acquisition and use of toys for motor stimulation in families at risk of HIV infection.
The results of this study correlate maintaining infectious disease follow-up with better results in the AHEMD-IS, including significant associations for the toy dimensions, demonstrating the influence of the mesosystem12 in opportunities for CMD. The variability of stimulation is explained both by the environment and by the parents’ knowledge and practice, indicating the implementation of educational and parental training programs to guide the use, substitution or improvisation of age-appropriate toys.
The regression analysis showed that among the environmental factors that influenced lower household opportunities were lower income, schooling and FI, increasing the family’s risk factors, which may be linked to a lack of resources to provide safe and adequate food. In this study, FI was associated with lower AHEMD-IS scores (less than adequate and moderately adequate). In sub-Saharan Africa, a review mapped the association of FNS with positive development outcomes, while exposure to HIV was among indicators of low CMD.27
The established COVID-19 pandemic scenario is a limitation of this study, as social isolation and changes in care flows interrupted data collection. The need for longitudinal studies directly at home is recognized, as CMD is continuous and multifaceted.
The contributions of this study include advancing the frontier of knowledge on the assessment of CMD in the first thousand days of life, with evidence that lower school, financial and FNS conditions imply fewer opportunities for CMD. It also contributes to filling gaps in the HIV field by considering that this evidence can be strengthened by the clinical fragility of infants with a yet undefined serological status and by the demand for regular care to prevent VT.
Conclusion
The classification of the households of HIV-exposed children in terms of opportunities to promote CMD reinforces the influence of the microsystem (household), the mesosystem (health services-family) and the macrosystem (social, cultural and economic characteristics of the family member) on development. It was concluded that the household microsystem influenced opportunities for CMD, since AI, lower income and schooling were associated with fewer household opportunities. The latter two variables were also related to the dimensions of physical space and toys, and to the mesosystem, given the association between first care, before one month of life, and between one and four visits to the infectology service for an excellent variety of stimulation for the infant. It can be inferred that the presence of environmental factors (inadequate nutrition and fewer opportunities at home, in terms of quantity and quality) plus the clinical condition (vertical exposure to HIV) represent immediate and/or late developmental risks.
Acknowledgements
PPGEnf/UFSM funding sources with DS/CAPES grants. And from the PPSUS/FAPERGS and Universal/CNPq calls, and PQ/CNPq, PIBIC/CNPq and PROBIC/FAPERGS scholarships.
References
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Edited by
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Associate Editor
Kelly Pereira Coca (https://orcid.org/0000-0002-3604-852X) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil
Publication Dates
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Publication in this collection
04 Oct 2024 -
Date of issue
2024
History
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Received
23 June 2023 -
Accepted
7 May 2024
