Effectiveness of an intervention with mothers to stimulate children under two years

Objective: To analyze the effectiveness of an educational intervention with mothers to stimulate children under two years of age at risk for neuropsychomotor development. Method: Before-after intervention study, conducted with 52 mothers of children under two years old, enrolled in reference centers in early childhood education. Initially, maternal knowledge regarding child development and stimulation was assessed through a structured instrument. Then, workshops were held with the mothers and, after three months, maternal knowledge was revised, reapplying the data collection instrument. In the analysis, descriptive and inferential statistics were used, applying the McNemar and Wilcoxon tests and the Rasch Model from the Item Response Theory. Results: after the intervention, there was a significant increase in scores regarding the following aspects: knowledge of mothers about child development and stimulation from 5.77 ± 1.85 to 18.60 ± 1.94 (p <0.001); reduction of the maternal difficulty index in answering the instrument questions from 1.17 ± 0.57 to -1.98 ± 1.63 (p 0.01). Conclusion: the educational intervention contributed to the improvement of maternal knowledge regarding the development and forms of child stimulation, corroborating the importance of this action to advance the health of children at risk under maternal care at home.


Introduction
Child development, initiated in intrauterine life, is defined as a complex and dynamic process related to physical growth, neurological maturation, and progressive acquisition of motor and psychocognitive skills in children (1) .
Although continuous, qualitative and sequential, development may present its chronological course compromised in different domains due to the influence of risk factors, making the child more vulnerable to facing the evolutionary tasks of their life cycle (2) . Risk factors for child development are those of genetic, biological origin and those associated with poor health and housing conditions, inadequate care and education practices, and an affectively disrupted home environment (environmental risk) (3) .
Cumulative exposure to these risk factors still in childhood may reflect negatively on maturing brain function, increasing the chances of motor, cognitive, behavioral and/or language disorders, which notably affect overall development and the child's learning process (4) .
Estimates show that 200 million children under the age of five worldwide are at risk of not achieving their developmental potential (5) . A study found that 43% of children under five (about 250 million) living in low-and middle-income countries are at risk of developmental delays that, early in life, may lead to health and learning problems and inadequate nutrition, reflecting in low wages in adulthood, as well as social tensions, with negative consequences not only for the present generation, but also for the future ones (6) .
Risk factors may also precede socioeconomic variables in adulthood, such as crime, negative influence on school performance, especially of women, and intergenerational transmission of poverty (7)(8) . Thus, early identification of changes in neuropsychomotor development is fundamental for decision-making regarding referral to specialized treatment in a timely manner, which will reflect a greater chance of reversal of delays in children and a better future for them (9) .
In this context, the importance of child health surveillance actions is highlighted, including different programs, specifically child development surveillance. In recent decades, the focus of child stimulation transcends actions centered solely on children, expanding to the construction of a support network for development, as a poorly stimulating environment exposes them to risk factors and different developmental delays (10) .
In addition, adverse childhood experiences will have consequences in the course of life, including parental experiences and trauma (11) , hence the importance of guiding families to care.
Undoubtedly, mothers are primarily responsible for providing direct care to their children (9) . Thus, health professionals need to support this mother so that stimulating acts, including playful and affective actions, especially for children at risk for development, may be understood by them as presupposed to the practice of care, including to enhance child development (12) , and thus try to reduce the negative effects of risk factors.
In this sense, the establishment of educational interventions with close relatives, namely mothers, about the evolution of development and the orientation regarding the use of auditory, visual, sensory, social and daily motor stimuli are fundamental strategies for the optimization of the development potential of the child, especially in the first 24 months (13) . Orienting the primary caregiver, in theory the mother, on aspects of development, valuing their empirical knowledge about child stimulation, will facilitate the construction of new opportunities for experimentation at home (14) .
Therefore, it is necessary to guide and exchange information with mothers about the correct use of activities that promote a healthy development.
Communication, the fundamental axis of popular health education, is an essential aspect for them to learn to implement stimuli correctly and successfully, considering the characteristics and needs of the child (15) . The workshop started with a dynamic presentation.
After this, the activities began, which were developed based on active methodologies, with problematization as the main teaching-learning strategy.
In this sense, anchored in the theoretical framework of popular education (19)(20) , we sought to provide a space for dialogue in workshops. The intervention sought to instigate reflection in all mothers so that they could talk about their children's child development.
It also served as a space for listening, resignification

Results
All mothers, as shown in Table 1 Those who did paid work did so sporadically and received as day laborers. Most mothers had one child (67.3%), whose age ranged from 13 to 24 months (59.6%).  According to the data shown in Table 3, there is a significant difference in maternal information regarding the general aspects of child development and stimulation before and after the educational intervention, that is, we   (21) .  (22) and Brazil (23)  This hypothesis corroborates a study that used educational materials to guide parents and relatives on child stimulation in order to improve or reverse motor development delays (25) . However, it should be emphasized that the educational materials must have in their purpose objectivity and accessible language on the theme addressed, because the lower the level of education of the individual, the clearer its content should be, otherwise, when poorly designed, these resources may also make it difficult for the user to understand (11)(12) .
Similarly to intervention studies (22)(23) , to be seen as moments of sharing ideas that respect diversity, being the health professional a true facilitator and a link between the community for the promotion of child development (27) .
In this sense, it is understood that, the presence of those who help facilitate their development properly is as important as the structuring and organization of the physical space for the child to develop (15) .
Therefore, it is necessary to value the educational approach offered by the health professional to parents and family (28) .
The data shown strengthen the idea that teaching is not established by mere knowledge transfer, but by active listening and creation of possibilities that facilitate its construction based on pre-existing knowledge (26) .
It is conjectured, however, that the substitution of The number of correct answers after the educational intervention is considered to be of fundamental relevance to foster popular education and its methodology as an indispensable strategy for reorienting health practices (29) . In this context, it is necessary to reflect and plan despite the type of approach that will be used during educational interventions, as each group may have specificities that require different interventions, but direct contact has the potential to make knowledge more effective.
This is what was observed in an Iranian study (30) portrayed with caregivers of children under the age of three, which found that one of the preferred educational approaches by caregivers to improve their knowledge on stimulating their development was faceto-face contact. practices. According to a study, mothers over the age of twenty and with more than five years of study had a greater capacity for emotional involvement and stimulation, as well as a better ability to organize their home environment to stimulate their children (31) .
However, it is noteworthy that, although high education is considered an important aspect for improving maternal knowledge (14) , the data from this research project reveal that mothers with low educational level are also able to improve their knowledge about child development and learn to properly stimulate children.
Family income, according to a research conducted in Pakistan, also seems to influence the quality of the physical environment and, consequently, the quality of child development stimulation (32) . This is also what another study revealed, in which families with lower purchasing power had low rates for offering stimuli to children in the gross and fine motor dimensions (33) .
However, contradicting the findings mentioned, although family income is an important aspect for the supply of toys, this does not guarantee that a greater amount of material resources provides an adequate home environment, as revealed by research developed with children whose average age was 42 months. In this study, it was found that a better social class is not a sufficient condition to structure a home environment that provides opportunities for children's motor performance in basic tasks (34)(35) . These data In addition to the active methodology, the mothers' initiative to be present in the educational workshops may also have contributed to the positive results, since, when they became aware of the workshops, they showed interest in participating and a desire to improve their knowledge about the theme addressed.
This aspect is very relevant, because the change of attitude is only possible from the personal will of each individual to learn something new related to previous knowledge, because otherwise all learned content will be quickly forgotten (27) . Education is suggested, in order to help parents and caregivers to apply appropriate stimuli for the promotion of child development in the home context.