Abstract
Background : 50% of Malagasy children have moderate to severe stunting. In 2016, a new 10 year NationalNutrition Action Plan (PNAN III) was initiated to help address stunting and developmental delay. We report factorsassociated with risk of developmental delay in 3 and 4 year olds in the rural district of Ifanadiana in southeastern Madagascar in 2016. Methods : The data are from a cross-sectional analysis of the 2016 wave of IHOPE panel data (a population-representative cohort study begun in 2014). We interviewed women ages 15–49 using the MICS Early ChildDevelopment Indicator (ECDI) module, which includes questions for physical, socio-emotional, learning and literacy/numeracy domains. We analyzed ECDI data using standardized z scores for relative relationships for 2 outcomes: at-risk-for-delay vs. an international standard, and lower-development-than-peers if ECDI z scores were > 1 standarddeviation below study mean. Covariates included demographics, adult involvement, household environment, andselected child health factors. Variables significant at alpha of 0.1 were included a multivariable model; final modelsused backward stepwise regression, clustered at the sampling level. Results : Of 432 children ages 3 and 4 years, 173 (40%) were at risk for delay compared to international norms and68 children (16.0%) had lower-development than peers. This was driven mostly by the literacy/numeracy domain, with only 7% of children considered developmentally on track in that domain. 50.5% of children had moderate tosevere stunting. 76 (17.6%) had > = 4 stimulation activities in past 3 days.Greater paternal engagement (OR 1.5 (1.09, 2.07)) was associated with increased delay vs. international norms. Adolescent motherhood (OR. 4.09 (1.40, 11.87)) decreased children’s development vs. peers. Engagement from anon-parental adult reduced odds of delay for both outcomes (OR (95%CI = 0.76 (0.63, 0.91) & 0.27 (0.15, 0 48)respectively). Stunting was not associated with delay risk (1.36 (0.85, 2.15) or low development (0.92 (0.48, 1.78)) when controlling for other factors Conclusions : In this setting of high child malnutrition, stunting is not independently associated withdevelopmental risk. A low proportion of children receive developmentally supportive stimulation from adults, butnon-parent adults provide more stimulation in general than either mother or father. Stimulation from non-parentadults is associated with lower odds of delay.