Community and International Nutrition

Early Childhood Development Interventions and Cognitive Development of

Young Children in Rural Vietnam
1
Koichiro Watanabe,
2
Rafael Flores, Junko Fujiwara,* and Lien Thi Huong Tran*
Rollins School of Public Health at Emory University, Atlanta, GA 30322 and *Save the Children
JapanVietnam Ofce, Hanoi, Vietnam
ABSTRACT Little is known about the long-term benets of interventions that aim to promote early childhood
development programs. The goal of this research was to determine whether an early childhood development
intervention added to a nutrition intervention during preschool ages had lasting effects on the cognitive develop-
ment of school-age children in communes of Thanh Hoa province in rural Vietnam. The study focused on a total
of 313 children aged 6.58.5 y (grades 1 and 2 in primary school) in 2 communes that were exposed to nutrition
intervention or nutrition and early childhood development (ECD) intervention from 1999 to 2003. Measurements of
height and cognitive test scores (Ravens Progressive Matrices Test) were collected from the children; household
characteristics were determined by interviews with mothers. Longitudinal analysis was performed by integrating
the data with that collected from the same children in past surveys. Signicant effects of the ECD intervention
compared with the nutrition intervention were detected. The benecial effect of ECD intervention on the cognitive
test scores was large for the most nutritionally challenged children whose height-for-age Z-scores declined or
remained in the stunted range. The ndings help provide useful insights into the development of an effective
integrated model of ECD and nutrition intervention for children in rural Vietnam. J. Nutr. 135: 19181925, 2005.
KEY WORDS: child development growth nutrition Vietnam
In 2004 it was estimated that 162 million preschool chil-
dren, or 33% of children 5 y old in developing countries,
were stunted [height-for-age Z-scores (HAZ)
3
2] (1). The
negative effect of malnutrition on child survival has been well
documented. For example, children who are underweight have
an 2- to 8-fold higher risk of death than those who are better
nourished (2). Malnutrition in early childhood impairs func-
tional performance in adulthood; this impairment may be
physical as well as cognitive. Economic losses due to the
physical and cognitive losses are substantial. Malnutrition in
childhood decreases intellectual potential and productivity in
adulthood. Furthermore, physical losses in adulthood also have
intergenerational effects on child health and nutrition (3).
Improving the physical and cognitive development of children
in lower-income communities will have far-reaching effects
throughout the less-developed world. Effective program de-
signs for nutrition and early childhood development need a
clearer understanding of their effects on physical and cognitive
development.
The negative effect of malnutrition on cognitive develop-
ment has been demonstrated in multiple locations around the
world. Some cross-sectional studies found associations be-
tween chronic malnutrition, marked by stunting, and poor
cognitive function among school-age children (46). These
studies include one in Vietnam, although it did not control for
poverty. Other longitudinal studies showed that height-for-age
during infancy was strongly associated with cognitive perfor-
mance in late childhood (7).
The positive effect of nutrition interventions on cognitive
development has also been shown. Several supplementation
studies suggested the potential for greater cognitive develop-
ment through improved nutrition at early ages in populations
with endemic undernutrition (814). Although not conclu-
sive, it is generally agreed the rst 3 y of life constitute the
most vulnerable period, one in which nutritional status is of
particular importance (15). Several studies reported evidence
of long-lasting benets from early supplementation on cogni-
tion when the children reached school age (11,14). The ben-
ets of supplementation during early childhood on cognitive
development may not be apparent at school age, but they are
present by adolescence through interaction between schooling
and nutritional improvement (11,16).
What is much less documented, less well understood, and
thus a subject of considerable, sometimes acrimonious debate,
is whether adding an early childhood development (ECD)
intervention, dened as preschool-based activities and parent-
ing education, to a nutrition intervention in communities in
which growth stunting is endemic can improve cognitive
performance. Because a majority of the children served by
1
Supported by Joint Japan World Bank Graduate Scholarship Program and
Save the Children Japan. Any opinion, ndings, conclusion, or recommendations
expressed in this publication are those of the author(s) and do not necessarily
reect the views of the supporting agencies.
2
To whom correspondence should be addressed.
E-mail: watanabe@savechildren.or.jp.
3
Abbreviations used: ECD, early childhood development; GEE, generalized
estimating equation; GLM, generalized linear model; HAZ, height-for-age Z-
score; NERP, nutrition education rehabilitation program; PDI, positive deviance
inquiry; WAZ, weight-for-age Z-score.
0022-3166/05 $8.00 2005 American Society for Nutritional Sciences.
Manuscript received 7 December 2004. Initial review completed 26 January 2005. Revision accepted 24 May 2005.
1918

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existing ECD programs in many of the developing countries
belong to the age group 12 y away from entry into primary
school, the effects of ECD interventions for this age group
should be investigated. Hence, the objectives of the present
study were to assess the existence of and potential effects of an
ECD project during the preschool years (ages 45 y) on the
cognitive development of school-age children in rural com-
munes in Vietnam where a nutrition project was implemented
when the children were 03 y old.
We hypothesized that the cognitive development of chil-
dren participating in the ECD project would improve more
than that of nonparticipating children. Nutritional status and
cognitive development of the children are often confounded
by the household environment, such as economic conditions,
age, and education level of the mothers; these were taken into
account in our assessments.
SUBJECTS AND METHODS
Population and setting. Data from 2000, the most recent data
available, showed that the prevalence of stunting (HAZ 2)
among children 5 y old in Vietnam was 36% (17). Thanh Hoa
province is located in the north central region, where the prevalence
of stunting among children 5 y old in 2000 was 40%, among the
highest in the country (18).
Save the Children Japan implemented a nutrition intervention
using Positive Deviance Inquiry (PDI) for 2 y from 1999 to 2000 at
5 communes in Vinh Loc district, Thanh Hoa province, targeting all
the children aged 036 mo in the communes. The PDI approach
identies successful child-caring practices of poor families who have
well-nourished children (19). The intervention communes were se-
lected on the basis of 4 criteria set by the implementing organization:
high prevalence of child malnutrition, poor socioeconomic condi-
tions, absence of prior or current participation in the national nutri-
tion program, and the existence of leaders interested in the project.
The main components of the nutrition intervention included bi-
monthly growth monitoring for all children and 9 sessions of a 12-d
nutrition education rehabilitation program (NERP) conducted every
month by local health volunteers in their hamlets, targeted for
severely malnourished children [weight-for-age Z-score (WAZ)
3]. Approximately half of the families participated in at least 1
NERP session, where they learned nutrition- and health-seeking
behaviors and fed the children locally available nutritious foods. In
addition, antenatal care services, home gardening, and a savings and
credit program were promoted to help strengthen and sustain the
nutritional benets.
Of the 5 communes, 2 were followed up with an early childhood
development (ECD) project for 2 y during 20022003, targeting
children of preschool age (45 y old). The 2 communes were selected
because they had less access to quality preschool services. Although
the majority of the children aged 45 y in the 2 communes attended
preschool at baseline, the attendance and the quality of preschool
teachers in the 2 communes were lower than those in the other 3
communes. The ECD intervention strengthened existing center-
based preschooling through material support and teacher training on
child-centered teaching methods. It also supported parental behaviors
through 1-d training sessions for fathers and mothers separately every
month on 10 different topics concerning child care and development.
In addition, the interventions included the establishment of a small
local library for parents and promoted play corners in the homes of
participating children.
Anthropometric measurements of height and weight were col-
lected for all of the participating children in 3 surveys conducted in
1999, 2000, and 2001; at that time, mothers were interviewed about
their behavior and knowledge of child care. The present study focused
on primary school children living in the project communes who were
aged 6.58.5 y in 2004 and were exposed directly to 1 or both of the
2 different interventions from 1999 to 2003.
Sampling. Two communes were selected as samples for this
research and represent the 2 study populations. The rst commune
represents those populations exposed only to the nutrition interven-
tion; the second commune represents those exposed to both the
nutrition intervention and early childhood development. The main
selection criteria for the 2 communes were similar socioeconomic
conditions and ecologic characteristics. Baseline data on wealth rank-
ing, ethnic composition, and ecologic characteristics collected from
the district in 1998 were used to identify the sample communes. We
studied nearly all of the children (431 of 474) listed in the sampling
frame of children aged 6.58.5 y in the 2 communes. The sampling
frame was established on the basis of the data collected in past
surveys, which were updated by the most recent census records
available at the Commune Peoples Committees. The criteria for
eligibility for the sampling frame were that the children had been
living in the commune since 1998, were currently registered in the
same commune, and were between the ages of 6.5 to 8.5 y.
Data collection. Standing height was measured to the nearest 1
mm with a standard technique that used the infant/child/adult height
measuring board (Shorr Production) (20,21). The survey team was
trained in anthropometry standardization exercises conducted by a
senior program ofcer of Save the Children Japan, to avoid interob-
server measurement bias.
Ravens Colored Progressive Matrices test was used to measure the
cognitive performance of the children. The test measures the ability
to develop new insights and information from what is already per-
ceived or known (22). This test was used to assess the cognitive
ability of children in several international studies in developing
countries such as Guatemala (11), Kenya, Egypt, and Mexico (5).
The test generally has had high internal consistency and retest-
reliability (0.8); factor analytical studies showed that the test is a
good indicator for Spearmans g-factor (23). The standard version of
Ravens Progressive Matrices consists of 5 scales (AE), with 12 items
in each scale. Each item contains a gure with a missing piece, below
which alternative pieces are placed to complete the gure. Each set
involves a different principle for obtaining the missing piece; within
a set, the items are arranged in increasing order of difculty. Accord-
ing to the instructions given by the trainer, Ravens Colored Matrices
version was administered. The Colored Matrices version, consisting
of 3 scales, Test-A (12 items), Test-B (12 items), and Test-AB (12
items), is designed to assess with greater precision the intellectual
processes of young children (22). The same approach was taken in
similar research conducted in Guatemala (11).
Because the test has not been standardized locally, interpretations
of the scores were made only through comparisons of the group mean
scores within the study population. Field workers administered the
test one-on-one for each individual child, taking 15 min per test per
child. A trainer, afliated with the Research and Training Center for
Community Development in Hanoi, conducted training on the test
methods and use of materials made available by the Center for this
research (24). To minimize examiners biases, children were assigned
randomly to eld workers, and no information was provided to the
eld workers regarding interventions, nutritional status, and socio-
economic level of children. The workers were trained repeatedly on
skills and attitudes against biases throughout the test administration.
The training included trial test administration, which conrmed
agreement between the test results obtained by the workers and the
trainer.
In addition, selected information was gathered on maternal char-
acteristics (age, education, number of deliveries, occupation), house-
hold characteristics (number of children and family members, pres-
ence of grandparents in the household), and childcare (preschooling
history) through interviews with mothers, conducted by eld workers
in Vietnamese. Data on household monthly income were collected
from commune-level secondary data sources. A questionnaire was
developed in English, translated into Vietnamese, and pretested in
the eld before revisions and completion.
The research team consisted of 16 eld surveyors; 4 were assigned
exclusively for the Ravens tests and 2 for anthropometric measure-
ments. They worked in 2 groups under the supervision of a team
leader. Half of the eld workers were recruited for short-term work as
main surveyors from universities or nongovernment organizations,
whereas the remaining workers were recruited from local partners as
assistants to the main surveyors. They had previous experience with
data collection in rural Vietnam and were trained in data collection
COGNITIVE DEVELOPMENT OF VIETNAMESE CHILDREN 1919

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techniques before doing eld work. The eld workers were assigned
specic data collection tasks that were xed throughout the duration
of the survey to minimize interobserver errors.
Data management and analysis. Names and dates of birth of
mothers and children were obtained from the demographic record
book held in the hamlet and surveys conducted previously in the
communes by SC Japan. Then they were cross-checked at registration
points in the survey sites, double-checked by eld workers before
measurements were taken, and nally checked by the team leader
after data collection. All data collection forms were reviewed by the
team leader each evening and any discrepancies were discussed. Data
collected in the eld survey were entered into EPI Info 2000 (CDC)
immediately after collection.
The 2 main outcome variables were HAZ and Ravens test scores.
Heights were compared with the international National Center for
Health Statistics/WHO/CDC reference standards (25) and converted
to HAZ using Epi Info 2000. Ravens test scores were calculated by
summing total correct answers across the 3 scales. All data were
entered into Epi Info 2000 and analyses were performed using SAS
8.0 (SAS Institute) (26).
For data analysis, the present datasets were merged with the data
of previous surveys, which included weight/height of children at
earlier ages, household characteristics, and child feeding/caring prac-
tices of mothers. Bivariate analyses were performed using t tests for
continuous variables and
2
tests for categorical variables. The gen-
eralized linear model (GLM) was used to assess effects of interven-
tions on HAZ and Ravens tests scores. Similarly, generalized esti-
mating equations (GEEs) were used to assess the effects on
proportions. The GLM and GEE models control for potential con-
founders to compute adjusted mean scores and proportions of each
effect group for comparison. P-values 0.05 were considered signif-
icant.
Human subjects and ethical considerations. The project was
approved by the Emory University Institutional Review Board before
the present research was launched. Written consent was received
from parents of the children who voluntarily participated in the
research. Field workers were trained in ethical considerations and
were under strict orders not to discuss information pertaining to
subjects with members of the community or with other non-
project-related persons. All of the data collected in the research
were kept condential and used only for aggregated data analysis with
anonymity.
RESULTS
Characteristics of subjects. Of the 431children studied,
313 or 73% were matched with baseline data obtained in 1998
to construct a longitudinal data set. The remaining 118 chil-
dren were excluded from the data analysis. Main characteris-
tics of the studied children did not differ signicantly from
those excluded. Characteristics of the 313 study participants
are summarized in Table 1; each intervention had similar age
and sex structures. Children ranged from 77 to 102 mo of age
with group means of 9193. The mean number of children per
family was small (1.5) and the majority of mothers had 2
children (95%). Mothers were young (mean age 33 y) and
their education level was low; more than one-third had com-
pleted only primary school. Farming was the primary occupa-
tion of mothers in the communes (9798%); 23% of children
lived with their grandparents. Most of the household variables
were similar for the 2 interventions. They differed from each
other, however, in maternal education (P 0.05), child age
(P 0.01), parity (P 0.02), and number of children (P
0.01). The ECD-and-nutrition intervention commune had
fewer children per household, they were younger, and their
mothers had less education. Those variables were controlled
for in multiple variable analyses.
At baseline, children in the ECD-and-nutrition interven-
tion commune did not differ nutritionally from those in the
nutrition-only intervention commune on anthropometric in-
dicators measured (Table 2). Some of the key feeding practices
as well as prenatal care reported by mothers were poorer for the
ECD-and-nutrition commune. Compared with nutrition-only
mothers, ECD-and-nutrition mothers were less likely to have
had 3 prenatal checks (26 vs. 53%, P 0.01) and started
giving complementary food nearly 1 mo earlier (3.9 vs. 4.6 mo,
P 0.02).
Nutritional status in terms of linear growth at baseline and
at the time of the 2004 surveys was compared for all 313
children by GLM and GEE, which detected a signicant
decrease in the proportion of stunting over the 5 y from
baseline to 2004 for both of the interventions; the adjusted
proportions of stunted children (2 HAZ) was reduced by
TABLE 1
Characteristics of subjects and their households by study group
1,2
Variable
Intervention
P-value
ECD and nutrition
(n 141)
Nutrition only
(n 172)
Age of child, mo 93.4 6.6 90.9 7.3 0.01
Age of mother, y 32.7 5.6 33.3 5.5 0.35
Household income,
3
1000 dong 91 19 89 18 0.55
Household expenditures,
3
1000 dong 447 186 422 198 0.29
Size of family, n 4.7 1.2 4.8 1.1 0.44
Parity, n 2.3 0.8 2.6 1.0 0.02
Male sex, n (%) 74 (52.5) 83 (48.3) 0.46
2 children, n (%) 42 (29.8) 76 (44.2) 0.01
Has a younger sibling, n (%) 32 (23.0) 50 (30.3) 0.15
In 1st grade, n (%) 44 (31.2) 79 (45.9) 0.01
Mothers education primary school, n (%) 67 (48.2) 61 (37.0) 0.05
Mothers occupation, farmer, n (%) 130 (97.0) 160 (97.6) 0.77
Living with grandparents, n (%) 31 (23.0) 38 (23.3) 0.94
Had preschool experience, n (%) 135 (100.0) 160 (99.4) 0.36
1
Values are means SD or n (%).
2
P-values for continuous variables were calculated by Students 2-sided t test. P-values for categorical variables were calculated using Pearsons
2
.
3
1 US$ 16,000 Vietnamese dong.
WATANABE ET AL. 1920

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16% (P 0.01) and 13% (P 0.01) for the ECD-and-
nutrition and nutrition-only interventions, respectively (Ta-
ble 3). Severe stunting was decreased only for the ECD-and-
nutrition children, with a reduction of adjusted proportions
3 HAZ of 7.8% (P 0.01). Overall, children in the
ECD-and-nutrition intervention had a slightly larger reduc-
tion in the proportion of severe stunting. However, there was
no difference in the adjusted mean HAZ scores between the
nutrition-only and ECD-and-nutrition intervention com-
munes at baseline as well as in the 2004 surveys, indicating no
additional effects of ECD interventions on the nutritional
status of children.
Second, scores on the Ravens tests were modeled with
GLM to assess the main effects (Table 4). The results showed
that test scores were signicantly higher for the ECD-and-
nutrition than for the nutrition-only intervention group (ad-
justed mean scores 16.5 vs. 14.9, P 0.05). The difference in
the scores was particularly greater among stunted children
(adjusted mean scores 16.8 vs. 12.8, P 0.01). Test scores of
stunted and nonstunted children differed for the nutrition-
only intervention (adjusted mean scores 17.0 vs. 12.8, P
0.01), whereas almost no difference was detected for chil-
dren exposed to the nutrition-and-ECD intervention.
Additional models were also applied to assess whether
initial height, change in height, and their interactions modi-
ed the effects (Table 4). Adjusting for initial height did not
change the effect, showing that the effects were not biased by
the different distributions of stunting at baseline in the 2
groups. Further adjustment for change in height and the in-
teractions between the change and initial height slightly re-
duced the difference in scores between the interventions (P
0.06). Even after this adjustment, however, the effect of the
ECD intervention on cognitive test scores among stunted
children remained signicant (P 0.01).
Finally, scores on the Ravens tests were modeled with
GLM to compare how changes in the nutritional status of
children from baseline to 2004 affected cognitive test scores
between the 2 interventions (Table 5). Nutritional status at
baseline and in 2004 were cross-tabulated to form 4 groups:
drop (HAZ dropped from 2 to 2), remained
stunted (HAZ stayed 2), never stunted (HAZ stayed
2), and catch up (HAZ improved from 2 to 2).
Adjusted differences in cognitive test scores between the
groups were detected only for the nutrition-only intervention
(P 0.0010.06). Mean scores from the 4 groups (Fig. 1)
illustrate the dose-response relation between the change in
nutritional status over time and cognitive test scores for the
nutrition-only intervention commune, which was not present
for the ECD-and-nutrition intervention.
DISCUSSION
This study examined the effects of an early childhood
development project for children aged 45 y on the cognitive
TABLE 2
Nutritional status and key maternal behaviors at baseline and 2000 surveys in school-aged children
previously exposed to ECD-and-nutrition or nutrition-only intervention
1,2
Variable
Intervention
P-value
ECD and nutrition
(n 141)
Nutrition only
(n 172)
WAZ 1.93 0.84 1.89 0.77 0.68
HAZ 1.59 1.22 1.54 0.98 0.70
WHZ
3
1.19 0.75 1.20 0.69 0.88
Underweight (WAZ 2), n (%) 70 (49.7) 81 (47.1) 0.65
Stunting (HAZ 2), n (%) 53 (37.6) 54 (31.4) 0.25
Wasting (WHZ 2), n (%) 16 (11.4) 19 (11.1) 0.93
Premature birth, n (%) 11 (7.9) 15 (9.1) 0.71
Smaller at birth, n (%) 62 (44.6) 60 (36.4) 0.14
3 antenatal care visits, n (%) 36 (25.5) 91 (52.9) 0.01
Stop breast-feeding, mo 17.7 4.8 18.6 6.7 0.16
Start complementary feeding, mo 3.9 1.9 4.6 3.1 0.02
Participation in NREP, n (%) 62 (44.6) 91 (55.2) 0.07
Participation in growth monitoring, within 3 mo, n (%) 97 (71.3) 87 (54.7) 0.01
1
Values are means SD or n (%).
2
P-values for continuous variables were calculated by Students 2-sided t test. P-values for categorical variables were calculated using Pearsons
2
.
3
WHZ, weight-for-height Z-score.
TABLE 3
Anthropometric status of children exposed to
ECD-and-nutrition or nutrition-only intervention,
at the 2004 survey and change over 5 y
1
Variable
Intervention
Difference
2
ECD and nutrition
(n 141)
Nutrition only
(n 172) P-value
2004
Mean HAZ 1.42 0.74 1.36 0.83 0.12 0.18
% 2 HAZ 21.3 18.0 4.8 0.30
% 3 HAZ 0.7 4.1 3.1 0.19
Change
3
Mean HAZ 0.17 1.00 0.18 0.84
(% 2 HAZ) 16.3* 13.4*
(% 3 HAZ) 7.8* 1.2
1
Values are means SD or %.
2
Differences between interventions were adjusted for initial height
at baseline, household income, and age of the child. P-values were
calculated using the GLM for continuous variables and GEE for pro-
portions.
3
Change between baseline and 2004. P-values were calculated
using McNemars tests. * Different from baseline, P 0.05.
COGNITIVE DEVELOPMENT OF VIETNAMESE CHILDREN 1921

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development of the children who were previously exposed to
a nutrition intervention at the age of 03 y. We collected
measurements of heights and cognitive test scores of children
when they reached school age in the 2 intervention communes
in rural Vietnam. Overall, children exposed to Save the Chil-
drens ECD interventions had signicantly better scores on
Ravens progressive matrix tests than their counterparts who
experienced only nutrition intervention. Effects were particu-
larly large for currently malnourished children.
Overall, the current level of stunting among school-age
children who were exposed to the Save the Childrens nutri-
tion program was 20% in terms of the proportion of children
2 HAZ. Age-specic nutrition status by height-for-age is
not available for this age group in Vietnam. A recent national
survey reported the prevalence of undernutrition among chil-
dren 610 y old as 27% nationally and 28% for rural regions
(27). Although these data provide only an overview, it could
be argued that nutritional improvement has occurred in these
TABLE 4
Mean Ravens test scores of children exposed to ECD-and-nutrition or nutrition-only intervention, by current nutritional status
1
Variable
Intervention
Difference
ECD and nutrition Nutrition only
n Score n Score
Unadjusted
All 141 16.6 5.4 170 16.1 6.1
Normal
2
111 16.7 4.9 140 17.0 5.5
Stunted
3
30 16.1 7.2 30 11.8 6.9
Adjusted for confounders
4
All 128 16.46 0.58 152 14.91 0.56 1.55*
Normal 101 16.10 0.53 124 17.03 0.48
a
0.93
Stunted 27 16.82 1.03 28 12.80 1.02
b
4.03*
Adjusted for initial height
5
All 128 16.62 0.59 152 15.08 0.57 1.54*
Normal 101 15.96 0.54 124 16.96 0.48
a
1.01
Stunted 27 17.28 1.07 28 13.20 1.05
b
4.08*
Adjusted for initial height and
change in height
6
All 128 16.68 0.60 152 15.17 0.61 1.51
Normal 101 15.91 0.55 124 16.91 0.50
a
1.00
Stunted 27 17.44 1.14 28 13.43 1.19
b
4.01*
1
Values are means SD for unadjusted data and SEM for adjusted data. * Different between the interventions, P 0.05.
2
HAZ 2.
3
HAZ 2.
4
PROC GLM was applied to compute least-squares means for different interventions, adjusted for household income, maternal education, childs
age, and the presence of grandparents. Means in a column without a common letter differ, P 0.05.
5
Adjusting for initial height in addition to 4.
6
Adjusting for change in height from baseline to 2004 and its interaction with initial height, in addition to 5.
TABLE 5
Mean difference in Ravens test scores of groups by nutritional status change in school-aged children previously exposed to
ECD-and-nutrition or nutrition-only intervention
Variable
Intervention
ECD and nutrition Nutrition only
n Coefcient
1
SE 95% CI n Coefcient
1
SE 95% CI
Unadjusted (reference group catch up)
Drop 6 0.35 2.53 (4.63, 5.33) 8 7.78* 2.23 (12.12, 3.39)
Remained stunted 24 0.73 1.56 (2.34, 3.79) 22 5.88* 1.56 (8.96, 2.81)
Never stunted 82 1.63 1.22 (0.77, 4.03) 108 1.54 1.14 (3.77, 0.70)
Catch up 29 32
Adjusted
2
(reference group catch up)
Drop 4 1.03 2.85 (6.65, 4.59) 8 7.16* 1.56 (11.43, 2.90)
Remained stunted 23 1.53 1.52 (1.46, 4.52) 20 5.40* 1.15 (8.46, 2.34)
Never stunted 75 0.62 1.22 (1.78, 3.01) 96 2.15 2.85 (4.42, 0.11)
Catch up 26 28
1
Coefcients from linear regression models in which the Ravens test score is the dependent variable; coefcients represent the mean decit in
the Ravens test score relative to the reference group. * Different from the reference, P 0.05.
2
PROC GLM was applied, adjusted for household income, maternal education, childs age, and the presence of grandparents.
WATANABE ET AL. 1922

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communes. The difference was not signicant, however, be-
tween the 2 communes in terms of the amount of change over
time in mean HAZ scores. Those results indicate that there
were no additional effects of ECD interventions on the nutri-
tional status of children.
With the nutritional improvement program, the nutritional
change among children exposed to nutrition-only interven-
tions had a linear association with cognitive development.
This nding, consistent with other studies that detected sig-
nicant associations between cognitive performance among
school-age children and their current or early nutritional sta-
tus (57,11), suggests that continuing malnutrition is detri-
mental to the cognitive development of children.
Children exposed to Save the Childrens ECD interven-
tions had signicantly better test scores than their counter-
parts who experienced only the nutrition intervention. Differ-
ences in test scores between stunted and nonstunted children
were minimal among children who had ECD interventions,
whereas they were signicantly larger in the nutrition-only
intervention commune in which better-nourished children
had higher scores than malnourished children. Signicant
effects of the ECD intervention were thus most noticeable for
currently malnourished children whose test scores were signif-
icantly higher than similarly malnourished children who were
exposed only to the nutrition intervention.
Furthermore, additional analyses controlling for initial
height, change in height over time, and their interactions did
not alter the ndings without the adjustments, suggesting that
the effect of the ECD intervention was separate from the
effects on physical growth. All of this evidence supports the
protective effect of ECD intervention against the negative
cognitive effects of growth failure; it is possible that the effects
of Save the Childrens ECD intervention compensated for
the loss caused by poor physical growth in the earlier years.
Reviews of early childhood development programs for chil-
dren in low-income families in the United States reported
evidence that the programs produced large effects on IQ dur-
ing the early childhood years and sizable persistent effects on
school achievement (28). Those included longitudinal studies,
which found signicant positive effects on IQ scores (29,30),
achievement test scores (2932), school repetition (29,32),
attendance (33), and special education (2931). For popula-
tions in developing countries with endemic undernutrition,
many studies assessed the effects of food supplementation on
the cognitive development of children. In contrast, very few
examined the additional effects of psychological stimulation.
A longitudinal study in Cali, Colombia assessed the effects
of integrated interventions of varying duration, consisting of
nutrition supplementation, health care, and an early education
program, on the cognitive development of preschool children
aged 4284 mo who were chronically malnourished. The
results showed that nutrition supplementation alone before
initiation of the preschool program had no effect on psycho-
logical development measured by various intellectual ability
tests at several ages from 4 to 7 y, whereas the combined
interventions of nutrition and early education had larger ef-
fects if they were started earlier and lasted longer (34). The
study design, however, did not allow us to compare the effects
of nutrition supplementation alone with the combined inter-
ventions of supplementation and stimulation. Another study
in Bogota, Colombia compared the effects of supplementation
only, stimulation only, supplementation and stimulation, and
no intervention on cognitive development of children aged
036 mo. It detected clear effects of nutrition supplementa-
tion on the cognitive performance of children as measured by
the Grifth test. However, no added benets of psychological
stimulation were found (12).
Evidence concurrent with this studys ndings was provided
by a study of stunted Jamaican children, aged 924 mo, who
were randomly assigned to nutrition-only, stimulation-only,
nutrition-and-stimulation, and control groups (10) After the
2-y intervention, the benets from a combination of supple-
mentation and stimulation were additive, and the children
receiving both treatments caught up to the nonstunted control
group in developmental levels. A follow-up study of those
children at 7 y of age showed small, but signicant, global
benets of the interventions (9). That study indicated a plau-
sible mechanism that the lower activity levels of undernour-
ished children may not affect their development when they are
in a stimulating environment.
The greater effect of the combined interventions in im-
proving both physical growth and psychological development
than the effect of either one alone may be explained by their
interactions at 3 different critical points: at the child level,
between the child and his or her family or caregivers, and in
the design and delivery of programs (35). At the level of the
child, the negative cognitive effects of growth failure were
evident, as shown in the nutrition-only commune in this
study, which was protected by exposure to the ECD interven-
tion. Psychosocial stimulation programs, although improving
cognition, would also have positively affected physical growth
(36), which was not detected in this study. This was possibly
due to the late timing of the ECD intervention (ages of 45 y).
Effective timing and duration of ECD interventions warrant
further investigation. As illustrated by similar studies in Co-
lombia (32), the effects of psychological stimulations were
larger if the interventions were applied earlier and for a longer
period. A follow-up study on younger children aged 03 y at
the time of this study, who were exposed to the ECD inter-
vention at younger ages and for a longer period, may provide
useful insights.
At the level of interaction between child and caregivers,
better-nourished children tend to be more active and explor-
atory and more able to elicit parental interaction. ECD inter-
FIGURE 1 Mean test scores by change in nutritional status be-
tween baseline and 2004 in school-aged children previously exposed to
nutrition-only intervention or nutrition-and-ECD intervention. Values are
means and SEM, n 313. The 4 groups are dened as follows: 1) Drop
HAZ 2 at baseline and 2 in 2004, 2) Stunt HAZ 2 at
baseline and in 2004, 3) Norm HAZ 2 at baseline and in 2004; 4)
Up HAZ 2 at baseline and 2 in 2004.
COGNITIVE DEVELOPMENT OF VIETNAMESE CHILDREN 1923

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vention may have stimulated parents to acquire more respon-
sive behaviors toward malnourished children than parents
with nutrition-only intervention. This study, however, cannot
provide information to further examine the critical points due
to lack of data on parental behaviors and child-parent inter-
actions. It is of interest to determine which components of the
ECD interventions worked most effectively on child-parent
interactions. The ECD interventions combined the center-
based approach with the parental support component, which
cannot be separated in this study design. The preschool-based
activities could have stimulated active learning and social
interactions between the child and his or her environment,
and the parental education component may have enhanced
parents knowledge, attitude, and practices regarding child
care at home.
The nonverbal cognitive ability measured by Ravens Col-
ored Progressive Matrices test is dened as eductive, which
refers to the ability to make meaning out of confusion. It is not
within the scope of this study to detail the interpretation
beyond the one summarized by Raven that eductive ability,
compared with other cognitive abilities, is promoted when
parents involve their children in their own attempts to make
sense of difcult situations (37). This aspect of ability has
relevance in assessing effects of ECD interventions. However,
we can by no means assume that Ravens progressive matrix is
the single best tool with which to assess cognitive develop-
ment in rural Vietnam. It would have been preferable to
perform several other tests that have been used for different
purposes in studies measuring childrens cognitive perfor-
mance. School test scores and teacher ratings were of partic-
ular interest because the effect is modied by access and
quality of education at preschool and primary schools. Never-
theless, the study provided a unique example of the utility of
Ravens tests in assessing the cognitive development of chil-
dren in developing countries.
We acknowledge several other limitations to this study in
addition to the points raised above. Unlike intervention trials
using direct high-energy food supplementation or intensive
provision of psychological stimulation, this study involved
interventions designed for a real-life project with a primary
focus on behavioral changes in feeding and child-care prac-
tices by parents as well as the community. The absence of data
on the key behavioral factors did not allow us to investigate
intermediate variables. If the Ravens test had been conducted
at baseline, it would have provided stronger evidence that the
differences could be attributed to the ECD intervention.
Larger samples randomly selected from the entire project com-
munes would have provided a statistically more valid estima-
tion of measurements. Measurements of potential confounders,
particularly regarding educational opportunities available for
children and mothers, would have helped to better explain
study outcomes and interpretations. The optimal study design
was beyond the resources of this study.
In summary, this study documented evidence that during a
period of nutritional change, children who failed to catch up
in linear growth are likely to lose the opportunity for cognitive
betterment in the early primary school years if appropriate
interventions are not given. The ndings suggest that early
childhood program interventions for preschool-age children
(45 y) increase the potential for cognitive development,
particularly for malnourished children, whose growth failure
prevents proper cognitive development. All of these ndings
support the importance of an integrated program of nutrition
and ECD to optimize the potential for holistic development of
children in an equitable manner.
The Government of Vietnam, in collaboration with inter-
national donors, has initiated efforts to develop an effective
integrated model of ECD and nutrition for preschool children.
Save the Children is expanding its ECD program to have a
wider scope with particular focus on the northern mountain-
ous regions where people belonging to an ethnic minority live.
These regions have fallen behind during the current trend of
widening regional disparity, and children there suffer from
chronic poverty and inferior access to health and education
services, as well as food insecurity. Such a context allows these
disadvantaged children to lose their chance for physical and
intellectual development. It is here that the contributions
from nutrition and ECD programs are expected to be most
important. It is recommended, therefore, that the effects of the
integrated nutrition and ECD interventions be examined fur-
ther through community intervention trials.
ACKNOWLEDGMENTS
The authors thank the following people who contributed to the
success of this study: eld survey team members of Save the Children
JapanVietnam Ofce, who participated in the data collection; Tuan
Tran, Thach Duc Tran, and Van Ha of Research and Training
Center for Community Development, who provided training and
tools for the Ravens tests and other technical assistance.
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