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Twenty-three years have passed since the end of an 11-year civil war (1991-2002) in Sierra Leone, marked by its brutality and conscription of children into armed forces. Today, many of those affected by the war as children have become parents themselves, yet face significant daily hardships including extreme poverty, few opportunities for education and employment, and scarce resources for mental health and other social services. These compound adversities can pose threats to young children’s healthy development, particularly in communities with a history of violence. The Family Strengthening Intervention for Early Child Development and Violence Prevention (FSI-ECD+VP) is an evidence-based, home-visiting intervention originally developed to support families with children under three in post-genocide Rwanda. The present study describes how evidence from a 23-year prospective study of former war-affected youth can be leveraged to adapt FSI-ECD+VP for use with Sierra Leonean families.
Methods
The Intergenerational Study of War-Affected Youth (ISWAY) is a longitudinal, prospective study of N=529 war-affected families in Sierra Leone. Using data from ISWAY, we reviewed characteristics of families with young children to identify needs. Of N=422 children surveyed, 31.3% were 36 months or younger and 26.1% were between 36-72 months of age. More than half (52.6%) were female.
Results
Among children five and under, 161 (78.9%) were flagged for developmental delay, including 64 children (31.3%) who were flagged for communication delays, 82 (40.2%) who were flagged for gross motor delays, 102 (50.0%) who were flagged for fine motor delays, 117 (57.4%) who were flagged for problem-solving delays, and 100 (49.0%) who were flagged for social emotional delays. Among children 36 months and younger 27.3% were exposed to any violent harsh discipline. This rate increased with child age, reaching 87.3% in children aged 3-6 years. There were no significant differences in the use of harsh child discipline with male or female children. In children aged 1.5-5 years, male children were significantly more likely than girls to display behavioral problems, including attention problems (p=0.006); externalizing behavior (p=0.006); and aggression (p=0.010). Just 26.1% were attending an early childhood education program. Median monthly expenditures for these programs were 45,000 SLL ($2.06 USD, or 6.0% of average monthly salaries) but ranged from 0 SLL to 800,000 SLL ($0 USD to $38.15 USD, or 0% to 93.2% of average monthly salaries). For eligible children who were not attending ECD programs, reasons given included lack of available services (30.7%); having other family watch over child (44.0%); high cost (13.8%); or the child being too young (50.5%).
Conclusions and Implications
Our analysis suggests that there is significant need for FSI-ECD+VP in families with young children. There are potentially high rates of developmental delay in children under five, some of which may be improved with greater attention to stimulation in the home; reduction of harsh disciplinary practices; and support to address behavioral problems. Structural barriers, including transportation and cost as well as lack of available services, impede caregivers from providing appropriate healthcare and engaging children in existing ECD programs.