Experience in Cambodia With the Use of a Culturally Relevant Developmental Milestone Chart for Children in Low- and Middle-Income Countries

Cultural relevance of fine motor domain of the ASQ in Guatemala

Previous research suggests that the Ages and Stages Questionnaire-3rd ed. (ASQ) fine motor domain (FMD) may not be culturally relevant for developmental screening in a rural Guatemalan community, as the FMD accounts for 40% of all abnormal screenings after a needs assessment in this community. We hypothesize this is due to a lack of exposure to objects assessed in the questionnaire, such as blocks or light switches. The FMD scores of rural Guatemalan children (n = 56) participating in a child development program were compared with Spanish- and English-speaking Latinx-American children attending a US primary care clinic and screened at yearly well-child checks. Groups were matched for age gender, and socioeconomic status. Item-level analyses explored differences across the three groups. In the Guatemalan sample, the FMD abnormal score rates were 16%, 62%, and zero in the 12-, 24-, and 36-month-old children, respectively. Abnormal scores for the Guatemalan sample on the 24-month ASQ-3 significantly differed (p = .01) when compared to the Latinx-American groups. The 24-month questionnaire has more questions about objects than the 12- and 36-month questionnaires, which may explain the higher rates of abnormal scores. Developmental screening with ASQ-3 may not adequately capture the skills of children in similar communities.

Developmental delay and its associated factors among children under five years in urban slums of Nepal

INTRODUCTION

Children from low-resource settings are more likely to encounter those factors that adversely influence their ability to acquire developmental potential. This study was conducted to assess the developmental status and its associated factors among children under five years of slum areas of Butwal Sub Metropolitan City, Rupandehi, Nepal.

METHODS AND FINDINGS

We conducted a community-based cross-sectional descriptive study using Developmental Milestone Chart (DMC) among 165 children under five years. Ethical approval was obtained from Ethical Review Board of Nepal Health Research Council. R software was used for data analysis. The association between developmental status and associated factors were examined with Chi-square and followed by logistic regression. Notably, more than half of the children (56.4%) had delayed development across two or more domains of gross motor, fine motor, language/ speech, and social development. Age, sex, socio-economic status, availability of learning materials, the occurrence of infectious diseases, and height-for-age of children were found to be significantly associated with the developmental status of children under study (p<0.05).

CONCLUSIONS

More than half of the children taken under the study had delayed development on different four domains. Findings from the study suggest that there should be similar studies conducted among children living in slum-like conditions. Additionally, programs should be designed as such which aims to mitigate the effect of socio-economic status on child development and has learning and nutritional aspects embedded central to its deliverance.

Screening tools for early identification of children with developmental delay in low- and middle-income countries: a systematic review

OBJECTIVE

To systematically review, identify and report the screening tools used for early identification of developmental delay in low- and middle-income countries.

DESIGN

Systematic review.

DATA SOURCES

Four bibliographic databases: Medline (1946 to 13 July 2020), Embase (1974 to 13 July 2020), Scopus (1823 to 11 July 2020) and PsycINFO (1987 to July week 1 2020).

ELIGIBILITY CRITERIA

Peer-reviewed original articles published in English addressing validated culturally sensitive developmental screening tools among children aged <5 years were included in this review.

DATA EXTRACTION AND SYNTHESIS

One author (CK, medical librarian) developed the search strategy. Three authors conducted the database search (phase I: CK; phase II: IJ and MKI). Three authors (TF, IJ and MKI) independently screened the title and abstracts. TF, MKI and GK independently performed the full-text review of the screened articles. During each step of the study selection process, disagreements were resolved through discussion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the systematic review. Data extraction and analysis were performed using MS Excel. Meta-analysis was not possible due to heterogeneity of the study findings.

RESULTS

We identified 3349 articles, of which 18 studies from 10 countries, reporting 16 screening tools, were selected for qualitative synthesis. Six cultural contexts were explored. Twelve general, two motor and two speech-language tools were identified. Seven of them found to be parent-completed ones. Five screening tools (American Speech-Language and Hearing Association, Guide for Monitoring Child Development, Infant Neurological International Battery, New Delhi-Development Screening Questionnaire and Woodside Screening Technique) reported relatively higher sensitivity (82.5%-100%) and specificity (83%-98.93%).

CONCLUSIONS

Limited number of culturally sensitive developmental screening tools were validated for children aged <5 years in low- and middle-income countries. Revising existing screening tools in different ethnic and cultural settings and subsequent validation with normative value should be a research priority.

Cambodian Developmental Milestone Assessment Tool (cDMAT): Performance reference charts and reliability check of a tool to assess early childhood development in Cambodian children

BACKGROUND

Childhood development milestones are essential skills that define how children participate in their environment socially, physically, and intellectually. A culturally-sensible and environmentally-appropriate tool is needed to assess their performance and detect disabilities at an early stage.

METHOD

This observational study aimed to create reference charts of performances among healthy rural and semi-rural Cambodian children aged 0-83 months for each milestone using the Denver II-based Cambodian Development Milestone Assessment Tool (cDMAT). Inter-observer reliability testing yielded Kappa scores.

RESULTS AND CONCLUSION

1330 children included in the analyses represented an average population sample with similar gender balance, expected poverty distribution and the illiteracy rate among their mothers (81% with no or attended <7th-grade education). While gender, poverty and the mother's education level were not found to be confounding factors, the child's school enrolment status was (p < 0.005). The performance reference charts document the PASS ratios from which age onwards <25%, 25-75%, 75-90%, 90-99% and 99-100% of the children in each monthly cohort can perform a particular milestone. The mean inter-observer reliability ranged from substantial (Kappa 0.61 for delay) to excellent (Kappa 0.84 for immediate) in all domains. The performance reference charts of a culturally-sensible and environmentally-appropriate cDMAT can be used in Cambodia with special attention given to the child's school enrolment as it was found to be a confounding factor affecting child development. Creating a small-scale pilot program linking the cDMAT to early intervention would help raise awareness and create local expertise on early childhood development.

Use of a Developmental Milestone Chart (DMC) in Rural Bangladesh to Educate Health Workers and Stimulate Referral for Early Diagnosis and Intervention

We aimed to determine the feasibility of using a simplified Developmental Milestone Chart (DMC) for assessment of neurodevelopmental status of children of age ≥1 month and ≤8 years. Participants were assessed by medical practitioners using DMC as part of regular health checkups in three sub-districts in Bangladesh between January and May 2017. Total 256 children were recruited (41.0% girls, mean age 1.3 ± 1.6 years). Total 107 children (41.8%) failed at least one and 3 (1.2%) failed all four developmental milestones. Majority missed motor milestones (75.6%, n = 81). Four medical practitioners trained on the use of DMC deemed it to be an appropriate tool for developmental screening as part of regular health checkups/care in terms of acceptability, practicality and implementation. In countries with limited facilities, a simplified instrument such as the DMC can be administered by medical practitioners in rural settings. However, further studies are required to establish the validity of DMC before it could be adopted into routine clinical practices.

The hearing screening experiences and practices of primary health care nurses: Indications for referral based on high-risk factors and community views about hearing loss

BACKGROUND

 In South Africa, primary health care is the first point of contact with the health system for at least 85% of the population, yet early hearing detection and intervention continues to be elusive in these settings. Nurses at community level may, therefore, be missing an opportunity to identify prelingual infants with hearing losses and alter their developmental trajectory.

AIM

 To determine primary health care nurses' experiences, practices and beliefs regarding hearing loss in infants.

SETTING

 The study was conducted in the eThekwini District of KwaZulu-Natal, South Africa.

METHODS

 A descriptive survey was used with quantitative methods of analysis. Fourteen primary health care clinics from the eThekwini district were selected, from which 75 nurses participated by completing a self-administered questionnaire.

RESULTS

 At least one-third of primary health care nurses had never screened a child for hearing loss, and most clinics did not have access to basic hearing screening equipment or materials. Only 49% of nurses had access to an otoscope, while 31% used the Road to Health Development screener to check for hearing loss. None of the clinics had access to an otoacoustic emission screener nor the Swart questionnaire. Although nurses reported that they would refer to audiology services for some of the risk factors, as indicated on the Joint Committee on Infant Hearing (JCIH) 2007 list, they were less likely to refer if the child was in a neonatal intensive care unit (ICU) longer than five days, had neurodegenerative disorders, meningitis, hyperbilirubinaemia requiring blood transfusion or were undergoing chemotherapy. Less than a third of nurses always referred if the child displayed additional non-JCIH risk factors or those pertinent to the South African context. Approximately 38% reported that communities believed that hearing loss could be because of some form of spiritual or supernatural causes.

CONCLUSION

 This study demonstrates that hearing screening and referral practices at primary health care clinics need to be strengthened. Nurses need to be capacitated to conduct basic screening, make necessary referrals, provide information to caregivers and understand community beliefs about hearing loss in order to counsel caregivers appropriately and facilitate the process of early hearing detection and intervention.

Piloting a Developmental Screening Tool Adapted for East African Children

There is a need for developmental screening that is easily administered in resource-poor settings. We hypothesized that known risk factors would predict failed developmental screening on an adapted screening tool in East African children living in poverty. The sample included 100 healthy Ugandan children aged 6–59 months. We adapted a parent-reported developmental screener based on the Child Development Review chart. The primary outcome was failure to meet age-appropriate milestones for any developmental domain. Venous blood was analyzed for lead, and caregivers completed a demographics questionnaire. We used multivariate logistic regression models to determine if elevated blood lead and stunting predicted failure on the screener, controlling for maternal education level, age in months past the lower bound of the child’s developmental age group, and absence of home electricity. In the sample, 14% (n = 14) of children failed one or more milestones on the screener. Lead levels or stunting did not predict failing the screener after controlling for covariates. Though this tool was feasibly administered, it did not demonstrate preliminary construct validity and is not yet recommended for screening in high-risk populations. Future research should include a larger sample size and cognitive interviews to ensure it is contextually relevant.

The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Global perspective on early diagnosis and intervention for children with developmental delays and disabilities

Low- and middle-income countries are experiencing a significant reduction in mortality of children under 5 years of age. This reduction is bringing in its wake large numbers of surviving children with developmental delays and disabilities. Very little attention has been paid to these children, most of whom receive minimal or no support. Thus, there is an urgent need to recognize that improving the quality of life of the survivors must complement mortality reduction in healthcare practice and programs. The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention.

Creating a Cambodia-specific developmental milestone screening tool - a pilot study

BACKGROUND

Approximately 600 million people are living with various types of disabilities throughout the world and over 200 million children under age of 5 years old not reach their developmental potential. These adverse outcomes can be prevented through early detection and treatment. To accurately assess the development of children, a culturally appropriate screening tool must be used. Cambodia lacks such tool and other studies have shown that western tools are not valid in other cultures.

AIMS

This study aimed at creating a culturally appropriate screening tool - called the Angkor Hospital for Children Developmental Milestone Assessment Tool (AHC DMAT) - for screening neurodevelopmental disability in Cambodian children. STUDY DESIGN, SUBJECT, OUTCOME MEASURES: Western milestones from the DDST II were used with cultural modifications. Children of both genders and aged from 1 month to 6 years assumed to have normal development were included in two pilot screenings (N=100 and N=63) with further modifications to the AHC DMAT made as necessary after each screening.

RESULTS

The final AHC DMAT consists of 140 milestones (49% directly from DDST II, 17% modified DDST II, 34% added through expert opinion).

CONCLUSION

Extensive revision of the DDST II was needed in order to create a more valid Cambodian screening tool. This study was the first step to create a Cambodian-specific screening tool but further large-scale testing of the AHC DMAT is needed to strengthen the tool's validity and to identify the age-range percentiles of each milestone before it can be used for neurodevelopment screening.