Academic journal article Journal of Health Population and Nutrition

Developmental Screening Tools: Feasibility of Use at Primary Healthcare Level in Low- and Middle-Income Settings

Academic journal article Journal of Health Population and Nutrition

Developmental Screening Tools: Feasibility of Use at Primary Healthcare Level in Low- and Middle-Income Settings

Article excerpt


An estimated 150 million children suffer from some kind of disability (1), and over 200 million are not fulfilling their developmental potential (2). Prevalence data are scarce on children below 3 years due to the limited availability of tools to assess young children and the lack of simple yet reliable and valid instruments that can be used in large surveys. Most of these children live in the poorest parts of the world (1). These children often do poorly in school, are less likely to be productive adults, and are at increased risk of transferring pov- erty to the next generation (2,3). The World Health Organization has made early identification of chil- dren below 3 years with disabilities a high priority, especially as identification at this young age may reduce the impact of impairments (4). Interven- tions to promote development of young children are known (5) and are increasingly becoming avail- able in low- and middle-income countries (LMICs). These include addressing malnutrition and iron deficiency, improving caregiver-child relationship and psychosocial stimulation, and establishing community-based rehabilitation (6).

The WHO has recently launched an evidence- based clinical guideline for assessment and man- agement of priority mental, neurological and substance-abuse conditions by non-specialist pri- mary care workers through Mental Health Gap Action Program (mhGAP) Intervention Guide (7). Because of the high disability burden and the as- sociated financial costs and human rights violation associated with developmental disorders, these are among the conditions addressed by the mhGAP Intervention Guide. The guide provides decision- making flowcharts for detection and management of developmental disorders at primary healthcare level. However, the lack of tools for assessment and monitoring of child development, suitable for use by non-specialists in low-resource settings, ham- pers the possibility of mainstreaming mhGAP in child healthcare services.

Identification of infants who are in need of early intervention requires the use of a valid devel- opmental diagnostic assessment tool (8). While standardized tools from western countries pro- vide assessment tests that have been well-validat- ed in their settings, the transfer of western-based tests to non-western contexts is associated with significant limitations of score interpretation and feasibility of use in resource-constrained set- tings (9,10).

An important challenge in early identification of developmental disability is having tools that re- spond to local differences, including cultural per- ceptions in meaning of disability and can be used across countries.

When comparing test responses across popula- tions that differ in language and other aspects of culture, the comparability of the assessment pro- cedures is a special concern. Cross-cultural equiva- lence is especially problematic when assessments depend on verbal reports of individuals sampled from the population. In such instances, it is essen- tial to show that population characteristics, such as preferred language, level of education, and cul- tural values, do not affect the quality of the assess- ment (11).

Although tools can play an important role in identi- fying children who can benifit from interventions, the wisdom of applying these in settings where spe- cialized training is not widely available and contacts with the health services are constrained is highly questionable. Efforts to identify children with dis- abilities are only justified when they can lead to interventions. In the context of the increased op- portunities of access to care created by mhGAP, the present study was conducted to review the availa- ble literature to identify developmental monitoring and screening tools that have been used in LMICs for children aged 0-3 year(s) and to evaluate these tools by examining their psychometric properties (sensitivity, specificity, validity, reliability), the re- quirements for their application, and the feasibility of their use in LMICs. …

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