Prevalence and risk factors of neurological disability and impairment in children living in rural Kenya

Hearing Loss Detection and Early Intervention Strategies in Kenya

Background

Thirty-four million children globally have disabling hearing loss, with the highest prevalence in low- and middle-income countries (LMICs). Early identification and management is crucial, yet barriers to screening and treatment of hearing loss are extensive in LMICs. Unaddressed hearing loss negatively impacts individuals and communities. The WHO's 2021 World Report on Hearing urges the development of Ear and Hearing Care (EHC) programs to improve access to all aspects of care, including screening, diagnostics, management, and developmental support. A joint Nairobi- and Seattle-based group convened in 2021 to discuss strategies for program development in Kenya, as presented in this paper.

Findings

Developing a national EHC program must include the necessary support services for a child with a diagnosed hearing loss, while simultaneously promoting engagement of family, community, and healthcare workers. Existing government and healthcare system policies and priorities can be leveraged for EHC programming. Strategies for success include strengthening connections between policymakers at national, county, and municipal levels and local champions for the EHC agenda, with a concurrent focus on policy, early detection and intervention, habilitation, and family-centered care. Updates to health policy and funding to support the accessibility of services and equipment should focus on leveraging national healthcare coverage for hearing technologies and services, strengthening referral pathways, training to bolster the workforce, and metrics for monitoring and evaluation. Additional strategies to support forward progress include strategic engagement of partners and leveraging local partners for phased scale-up.

Conclusions and Recommendations

Recommendations to strengthen EHC within the Kenyan health system include concurrent leverage of existing health policies and priorities, partner engagement, and strengthening referral pathways, monitoring and evaluation, and training. These strategies may be generalized to other countries too.

Pediatric speech-language pathology in East Africa: educational opportunities and availability of speech-language services

OBJECTIVE

This paper describes the current situation of the provision of speech-language services in East Africa. An overview of the educational opportunities, workforce density, communication rehabilitation planning, caseload, and ethical and/or cultural challenges is provided.

METHOD

A narrative review was performed. All papers referring to communication disorders in East African countries were identified from EMBASE, PubMed, ISI Web of Science: Science Citation Index Expanded, and ISI Web of Science: Conference Proceedings Citation Index-Science using the following search terms: speech therapy, speech pathology, speech-language pathology, speech-language rehabilitation, speech-language therapy, logopedics, East Africa, communication disorders, communication difficulties. Two concepts were combined with a Boolean operator 'AND'.

RESULTS

At present, there is an alarming shortage of speech-language pathologists in East Africa. This issue is mainly related to the limited availability of educational programs in speech-language pathology. Although more and more universities are beginning to offer such educational programs, the number of available speech-language pathologists is still too low to meet the needs of all children with communication disorders. In addition, speech-language pathologists are often faced with different cultural and ethical obstacles when they provide intervention to East African children with communication disorders. These speech-language pathologists are therefore challenged to take a broader view of their role as a therapist. These alternative roles often include training of other individuals in the context of community-based rehabilitation.

CONCLUSION

In the future, it will be important to carefully consider the development of sustainable learning opportunities in East African contexts. Initiatives, for example, "train-the-trainer" workshops, are needed to support the speechlanguage pathologists. Existing models like the communication disability model can aid to create holistic frameworks for the development of sustainable speech-language services in the East African countries.

Viral, Bacterial, Metabolic, and Autoimmune Causes of Severe Acute Encephalopathy in Sub-Saharan Africa: A Multicenter Cohort Study

OBJECTIVES

To assess whether viral, bacterial, metabolic, and autoimmune diseases are missed by conventional diagnostics among children with severe acute encephalopathy in sub-Saharan Africa.

STUDY DESIGN

One hundred thirty-four children (6 months to 18 years) presenting with nontraumatic coma or convulsive status epilepticus to 1 of 4 medical referral centers in Uganda, Malawi, and Rwanda were enrolled between 2015 and 2016. Locally available diagnostic tests could be supplemented in 117 patients by viral, bacterial, and 16s quantitative polymerase chain reaction testing, metagenomics, untargeted metabolomics, and autoimmune immunohistochemistry screening.

RESULTS

Fourteen (12%) cases of viral encephalopathies, 8 (7%) cases of bacterial central nervous system (CNS) infections, and 4 (4%) cases of inherited metabolic disorders (IMDs) were newly identified by additional diagnostic testing as the most likely cause of encephalopathy. No confirmed cases of autoimmune encephalitis were found. Patients for whom additional diagnostic testing aided causal evaluation (aOR 3.59, 90% CI 1.57-8.36), patients with a viral CNS infection (aOR 7.91, 90% CI 2.49-30.07), and patients with an IMD (aOR 9.10, 90% CI 1.37-110.45) were at increased risk for poor outcome of disease.

CONCLUSIONS

Viral and bacterial CNS infections and IMDs are prevalent causes of severe acute encephalopathy in children in Uganda, Malawi, and Rwanda that are missed by conventional diagnostics and are associated with poor outcome of disease. Improved diagnostic capacity may increase diagnostic yield and might improve outcome of disease.

Participation of children with long-term health conditions compared to that of healthy peers: A cross-sectional comparative study

BACKGROUND

Knowledge is limited on attendance and involvement of perceived participation of children with long-term health conditions.

AIMS

To evaluate the perceived participation of children with long-term health conditions and to compare their participation with that of healthy peers.

MATERIAL AND METHODS

A cross-sectional comparative study was designed using self-reported data from 65 children with long-term health conditions and from 65 healthy peers, utilising the simplified Chinese version of Picture My Participation (PMP-C; Simplified).

RESULTS

The frequency scores of children with long-term health conditions were significantly lower than those of healthy peers in terms of attendance for the total domain and for 13 activity items. The involvement scores of children with long-term health conditions were significantly lower than those of healthy children in 3 items. There was a strong correlation between rank orders of the most important activities for the two groups (r = 0.83).

CONCLUSIONS

Children with long-term health conditions participated less in activities compared to healthy children. Further studies are required to investigate factors of the participation of children.

SIGNIFICANCE

The PMP-C (Simplified) offered an opportunity for children to express their own perspectives of participation based on their individual experience of the activity.

Behavioural and emotional comorbidities in school-aged children with neurological conditions in Kilifi, Kenya, and their long-term consequences

Background

Neurological conditions and mental health problems are common in children in low- and middle-income countries, but the risk factors and downstream impact of these problems on children with neurological conditions are not reported.

Objective

To determine the association of neurological conditions with behavioural and emotional problems in children, the prevalence and risk factors of behavioural and emotional problems, and long-term impact of these conditions.

Methods

Data on multiple neurological conditions and mental health problems were available for 1,616 children (aged 6–9 years) from Kilifi, Kenya. Neurological conditions were diagnosed using standardised tools and clinical examination. Behavioural and emotional problems assessed using Child Behaviour Questionnaire for Parents. Long-term outcomes were obtained from census data of the Kilifi Health and Demographic Surveillance System. Logistic and linear regression were used to measure associations.

Results

Mental health problems were higher in those with any neurological condition compared to those without (24% vs. 12%, p < 0.001). Cognitive (odds ratio (OR) = 2.39; 95% CI: 1.59–3.59), motor (OR = 3.17; 95% CI: 1.72–5.82), hearing (OR = 2.07; 95% CI:1.12–3.83) impairments, and epilepsy (OR = 4.18; 95% CI: 2.69–6.48), were associated with mental health problems. Prevalence of any mental health problem was 15%, with externalizing problems more common than internalizing problems (21% vs. 17%, p = 0.004). Longitudinal follow-up indicated that the disorders affected an individual’s future schooling (e.g. OR = 1.25; 95% CI: 0.14–1.46 following cognitive impairments), occupation (OR = 2.44; 95% CI: 1.09–5.44 following mental health problems), and access to household assets (OR = 2.78; 95% CI: 0.99–7.85 following epilepsy).

Conclusions

Neurological conditions in school-aged children in Kilifi are associated with mental health problems, and both disorders have long-term consequences. Preventive and therapeutic measures for these conditions are needed to improve outcomes of these children.

Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya. Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care. Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

Neurological impairment and disability in children in rural Kenya

AIM

To investigate geographical change over time in the burden of neurological impairments in school-aged children in a demographic surveillance area.

METHOD

We investigated changes in neurological impairment prevalence in five domains (epilepsy and cognitive, hearing, vision, and motor impairments) using similar two-phase surveys conducted in 2001 (n=10 218) and 2015 (n=11 223) and determined changes in location-level prevalence, geographical clustering, and significant risk factors for children aged 6 to 9 years (mean 7y 6mo, SD 1y) of whom 50.4% were males. Admission trends for preterm birth, low birthweight (LBW), and encephalopathy were determined using admission data to a local hospital.

RESULTS

Overall prevalence for any neurological impairment decreased from 61 per 1000 (95% confidence interval [CI] 48.0-74.0) in 2001 to 44.7 per 1000 (95% CI 40.9-48.6) in 2015 (p<0.001). There was little evidence of geographical variation in the prevalence of neurological impairments in either survey. The association between neurological impairments and some risk factors changed significantly with year of survey; for example, the increased association of adverse perinatal events with hearing impairments (exponentiated coefficient for the interaction=5.94, p=0.03). Annual admission rates with preterm birth (rate ratio 1.08, range 1.07-1.09), LBW (rate ratio 1.08, range 1.06-1.10), and encephalopathy (rate ratio 1.08, range 1.06-1.09) significantly increased between 2005 and 2016 (p<0.001).

INTERPRETATION

There was a significant decline in the prevalence of neurological impairments and differential changes in the associations of some risk factors with neurological impairments over the study period. Limited geographical variation suggests that similar interventions are appropriate across the defined area.

The burden of neurological impairments and disability in older children measured in disability-adjusted life-years in rural Kenya

Neurological impairment (NI) and disability are common in sub-Saharan Africa (SSA), but the overall burden in terms of morbidity and mortality in older children remains unknown. We estimated the burden of NI in disability-adjusted life years (DALYs), years of life lost to premature mortality (YLLs), and years lived with disability (YLDs) for older children in a defined rural setting in Kenya. We used empirical and literature estimates to model the overall burden for children aged 5-14 years in five domains: epilepsy (lifetime and active) and moderate/severe cognitive, hearing, motor, and visual impairments. We obtained internally consistent estimates of prevalence, mortality, and transitional hazards using DisMod II software. Disability weights and life expectancy estimates were based on the global burden of disease (GBD) studies. We used the most plausible parameters to calculate YLLs, YLDs, and DALYs and their bootstrapped 95% uncertainty intervals (95%UI) for the defined area. NI in the five domains resulted in a total of 4587 (95%UI 4459-4715) absolute DALYs or 53 (95%UI 39-67) DALYs per 1000 children aged 5-14 years, of which 83% were YLLs and 17% YLDs. Girls had significantly more YLLs and DALYs than boys (p-values <0.001, respectively). Besides being the leading cause of fatal and non-fatal outcomes, epilepsy accounted for the greatest proportion of the total burden for a single domain (20 DALYs per 1000, 95%UI 11-26, or 38.5% of the total DALYs). Visual impairment accounted for the least proportion of the total burden (6 per 1000, 95%UI 1-17, or 12.1%). Children with NI and disability bear a significantly high burden of fatal and non-fatal outcomes. The burden is highest among girls and those with childhood-onset epilepsy. We recommend active identification, treatment, and rehabilitative support for the affected children to prevent premature mortality and improve their quality of life.

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among older children in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical and rehabilitative care by children and adolescents with NI in LMICs.

Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all studies reporting on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches.

Results: Our literature searches identified 3,258 reports of which 20 were included in the final analysis. Fifteen studies (75.0%) originated from diverse settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=17, 85.0%), geographical and physical inaccessibility (N=14, 70.0%), inadequate healthcare resources (N=14, 70.0%), prohibitive culture and beliefs (N=12, 60.0%), and inadequate education/awareness (N=11, 55.0%). Factors reported in <50% of the studies included competing domestic roles (N=4, 20%) and a lack of confidentiality for personal information (N=2, 10.0%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level.

Conclusions: Financial constraints, geographic and physical inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs.

PROSPERO registration: CRD42020165296 (28/04/2020)

Validity and reliability of the Neurodevelopmental Screening Tool (NDST) in screening for neurodevelopmental disorders in children living in rural Kenyan coast

Background: There are no data on the precise burden of neurodevelopmental disorders (NDD) in Africa, despite high incidence of risk factors. Ten Questions Questionnaire (TQQ) has been used extensively in Africa to screen neurological impairments but not autism spectrum disorders (ASD) and attention-deficit hyperactivity disorders (ADHD). The Neurodevelopmental Screening Tool (NDST) has reliably assessed NDD in Asia; its validity in Africa is unknown. Methods: Using NDST and TQQ, we screened 11,223 children aged 6-9 years in Kilifi, Kenya. We invited all screen-positives and a proportion of screen-negative children for confirmatory diagnosis of NDD using clinical history, neuropsychological assessments and interviews. Results: In total, 2,245 (20%) children screened positive for NDD. Confirmatory testing was completed for 1,564 (69.7%) screen-positive and 598 (6.7%) screen-negative children. NDST's sensitivity was 87.8% (95%CI: 88.3-88.5%) for any NDD, 96.5% (95%CI:96.1-96.8%) ASD and 89.2% (95%CI: 88.7-89.8%) for ADHD. Moderate/severe neurological impairments' sensitivities ranged from 85.7% (95%CI: 85.1-86.3%) for hearing impairments to 100.00% (100.0-100.0%) for motor impairments. NDST had higher sensitivities than TQQ for epilepsy (88.8 vs 86.7), motor impairments (100.0 vs 93.7) and cognitive impairment (88.2 vs 84.3). Sensitivities for visual and hearing impairments were comparable in both tools. NDST specificity was 82.8% (95%CI: 82.1-83.5%) for any NDD, 94.5% (95%CI: 94.0-94.9%) for ASD and 81.7% (95%CI: 81.0-82.4%) for ADHD. The specificities range for neurological impairments was 80.0% (95%CI: 79.3-80.7%) for visual impairments to 93.8% (95%CI: 93.4-94.3%) for epilepsy. Negative predictive values were generally very high (≤100%), but most positive predictive values (PPV) were low (≤17.8%). Domain specific internal consistency ranged from 0.72 (95%CI: 0.70-0.74) for ADHD to 0.89 (95%CI: 0.87-0.90) for epilepsy. Conclusions: NDST possesses high sensitivity and specificity for detecting different domains of NDD in Kilifi. Low PPV suggest that positive diagnoses should be confirmed when samples are drawn from a population with low disease prevalence.

Premature Mortality, Risk Factors, and Causes of Death Following Childhood-Onset Neurological Impairments: A Systematic Review

Background: Neurological impairment (NI) and disability are associated with reduced life expectancy, but the risk and magnitude of premature mortality in children vary considerably across study settings. We conducted a systematic review to estimate the magnitude of premature mortality following childhood-onset NI worldwide and to summarize known risk factors and causes of death. Methods: We searched various databases for published studies from their inception up to 31st October 2020. We included all cohort studies that assessed the overall risk of mortality in individuals with childhood-onset epilepsy, intellectual disability (ID), and deficits in hearing, vision and motor functions. Comparative measures of mortality such as the standardized mortality ratio (SMR), risk factors and causes were synthesized quantitatively under each domain of impairment. This review is registered on the PROSPERO database (registration number CRD42019119239). Results: The search identified 2,159 studies, of which 24 studies were included in the final synthesis. Twenty-two (91.7%) studies originated from high-income countries (HICs). The median SMR was higher for epilepsy compared with ID (7.1 [range 3.1-22.4] vs. 2.9 [range 2.0-11.6]). In epilepsy, mortality was highest among younger age groups, comorbid neurological disorders, generalized seizures (at univariable levels), untreatable epilepsy, soon after diagnosis and among cases with structural/metabolic types, but there were no differences by sex. Most deaths (87.5%) were caused by non-epilepsy-related causes. For ID, mortality was highest in younger age groups and girls had a higher risk compared to the general population. Important risk factors for premature mortality were severe-to-profound severity, congenital disorders e.g., Down Syndrome, comorbid neurological disorders and adverse pregnancy and perinatal events. Respiratory infections and comorbid neurological disorders were the leading causes of death in ID. Mortality is infrequently examined in impairments of vision, hearing and motor functions. Summary: The risk of premature mortality is elevated in individuals with childhood-onset NI, particularly in epilepsy and lower in ID, with a need for more studies for vision, hearing, and motor impairments. Survival in NI could be improved through interventions targeting modifiable risk factors and underlying causes.

Barriers to access and utilization of healthcare by children with neurological impairments and disability in low-and middle-income countries: a systematic review

Background: Neurological impairments (NI) and disability are common among survivors of childhood mortality in low-and middle-income countries (LMICs). We conducted a systematic review to examine the barriers limiting access and utilization of biomedical care by children and adolescents with NI in LMICs. Methods: We searched PubMed, Latin America and Caribbean Health Sciences Literature, Global Index Medicus, and Google Scholar for studies published between 01/01/1990 and 14/11/2019 to identify relevant studies. We included all reports on barriers limiting access and utilization of preventive, curative, and rehabilitative care for children aged 0-19 years with NI in five domains: epilepsy, and cognitive, auditory, visual, and motor function impairment. Data from primary studies were synthesized using both qualitative and quantitative approaches, and we report a synthesized analysis of the barriers identified in the primary studies. Results: Our literature searches identified 3,074 reports of which 16 were included in the final analysis. Fourteen studies (87.5%) originated from rural settings in sub-Saharan Africa (SSA). Factors limiting access and utilization of healthcare services in >50% of the studies were: financial constraints (N=15, 93.8%), geographical inaccessibility (N=11, 68.8%), inadequate healthcare resources (N=11, 68.8%), inadequate education/awareness (N=9, 56.3%), and prohibitive culture/beliefs (N=9, 56.3%). Factors reported in <50% of the studies related to the attitude of the patient, health worker, or society (N=7, 43.8%), poor doctor-patient communication (N=5, 31.3%), physical inaccessibility (N=3, 18.8%), and a lack of confidentiality for personal information (N=2, 12.5%). Very few reports were identified from outside Africa preventing a statistical analysis by continent and economic level. Conclusions: Financial constraints, geographic inaccessibility, and inadequate healthcare resources were the most common barriers limiting access and utilization of healthcare services by children with NI in LMICs. PROSPERO registration: CRD42020165296 (28/04/2020)

Long-term neurocognitive and educational outcomes of neonatal insults in Kilifi, Kenya

BACKGROUND

There is little data on the long-term neurocognitive and educational outcomes among school-aged survivors of neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) in Africa. This study investigates the long-term neurocognitive and educational outcomes and the correlates of these outcomes in school-aged survivors of NNJ or HIE in Kilifi, Kenya.

METHODS

We conducted a cross-sectional study on neurocognitive and educational outcomes among school-aged survivors (6-12 years) of NNJ (n = 134) and HIE (n = 107) and compared them to a community comparison group (n = 134). We assessed nonverbal intelligence, planning, working memory, attention, syntax, pragmatics, word-finding, memory, perceptual-motor, mathematical, and reading abilities. We also collected information on medical history, caregivers' mental health, and family environment.

RESULTS

The survivors of NNJ had lower mean total scores in word-finding [F (1, 250) = 3.89, p = 0.050] and memory [F (1, 248) = 6.74, p = 0.010] than the comparison group. The survivors of HIE had lower mean scores in pragmatics [F (1, 230) = 6.61, p = 0.011] and higher scores higher scores in non-verbal reasoning [F (1, 225) =4.10, p = 0.044] than the comparison group. Stunted growth was associated with almost all the outcomes in HIE.

CONCLUSION

Survivors of NNJ and HIE present with impairment in the multiple domains, which need to be taken into consideration in the planning of educational and rehabilitative services.

Neonatal jaundice and developmental impairment among infants in Kilifi, Kenya

BACKGROUND

Neonatal jaundice (NNJ) is common in sub-Saharan Africa (SSA), and it is associated with sepsis. Despite the high incidence, little has been documented about developmental impairments associated with NNJ in SSA. In particular, it is not clear if sepsis is associated with greater impairment following NNJ.

METHODS

We followed up 169 participants aged 12 months (57 cases and 112 controls) within the Kilifi Health Demographic Surveillance System. The diagnosis of NNJ was based on clinical laboratory measurement of total serum bilirubin on admission, whereas the developmental outcomes were assessed using the Developmental Milestones Checklist and Kilifi Development Inventory.

RESULTS

There were significant differences between the cases and controls in all developmental domains. Cases scored lower in language functioning (mean [M] = 6.5, standard deviation [SD] = 4.3 vs. M = 8.9, SD = 4.6; p < .001); psychomotor functioning (Mdn = 23, interquartile range [IQR] = 17-34 vs. Mdn = 31.0, IQR = 22.0-44.0; Mann-Whitney U = 4,122, p = .002); and socio-emotional functioning ([Mdn = 30.0, IQR = 27.0-33.0 vs. Mdn = 34.0, IQR = 30.0-37.0], Mann-Whitney U = 4,289, p < .001). There was no evidence of association between sepsis and psychomotor (r_pb = -.2, p = .214), language (r_pb = -.1, p = .510), and socio-emotional functioning (r_pb = .0, p = .916). Significant and medium to large portions of the variance (34-64%) in the developmental outcomes among children who survived NNJ were associated with home birth, low maternal education, and feeding problems during the first days of life.

CONCLUSIONS

NNJ is associated with developmental impairments in the early childhood years; however, NNJ associated with sepsis does not lead to more severe impairment. Prenatal and postnatal care services are needed to reduce the negative impact of NNJ for children from low resourced settings.

Pattern of Cerebral Palsy Among Sudanese Children Less Than 15 Years of Age

BACKGROUND

Cerebral palsy (CP) is a non-progressive, everlasting neurological disorder of movement, posture, and physical activities, with a prevalence of 2.2-3.3/1,000. CP is a condition that occurs globally, with a similar prevalence in both developed and undeveloped countries. However, the etiology differs according to the socioeconomic status of the countries. The objective is to determine the pattern and the contributing factors of CP among Sudanese children.

METHODS

This was a retrospective hospital-based study conducted over a period of three years in a pediatric referral hospital in Khartoum, Sudan. One hundred and eight patients of CP were enrolled, of whom 59 (54.6%) were males and 49 (45.4%) were females.

RESULTS

Spastic quadriplegic CP was the most common type. Most cases were from lower social classes. Prenatal, antenatal, and unclassified CP were found in 45 (41.7%), 31 (28.7.%), 23 (21.3%), and 9 (8.3%) cases, respectively. Birth asphyxia, neonatal jaundice, Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus infections (TORCH), and sepsis (acquired) were the main causative factors.

CONCLUSION

Spastic quadriplegia is the most common type of CP. Most of the cases had a direct positive relationship with socioeconomic status. The prenatal period was the most common period for the development of CP.

Premature mortality in children aged 6-9 years with neurological impairments in rural Kenya: a cohort study

BACKGROUND

Neurological impairments might significantly contribute to reduced life expectancy in low-income and middle-income countries (LMICs). There are no empirical studies of premature mortality in children with neurological impairments in Africa. This study estimated the risk of premature mortality in children with neurological impairments and identified risk factors and causes of death.

METHODS

We did a cohort study based on a two-stage epidemiological survey in the Kilifi Health and Demographic Surveillance System (Kilifi, Kenya). Study participants were children aged 6-9 years. In the first stage, five trained field workers administered a low-cost screening tool to a random sample of households. In the second stage, we assessed for neurological impairments in five domains (epilepsy, cognitive impairments, vision impairments, hearing impairments, and motor impairments) using comprehensive clinical evaluation and extensive neuropsychological assessments. From the two-stage survey we identified a cohort of children with neurological impairment and a cohort of matched controls. We also enrolled an age-matched sample from the general population. The primary outcome was all-cause mortality. Mortality rates, standardised mortality ratio (SMR), and hazard ratios (HR) for risk factors were estimated and causes of death identified.

FINDINGS

We enrolled 306 children with neurological impairment, 9912 survey controls, and 22 873 age-matched participants from the general population, and followed up the cohorts between June 1, 2001, and Aug 31, 2018. Median follow-up was 14·5 years (IQR 8·6-17·2). 11 (3·9%) of 284 children with neurological impairment, 92 (1·0%) of 9009 controls, and 272 (1·2%) of 22 873 participants in the general population sample died during the follow-up. Overall mortality rates were 309·8 per 100 000 person-years of observation (95% CI 126·7-492·9) in children with neurological impairment, 80·8 per 100 000 person-years of observation (64·3-97·3) in controls, and 98·8 per 100 000 person-years of observation (87·1-110·6) in the general population sample (mortality rate ratio 3·83, 95% CI 2·05-7·16, p<0·001, compared with controls; 3·13, 1·71-5·72, p<0·001, compared with the general population). Mortality risk in children with neurological impairment was not dependent on the severity of impairment (p=0·291) nor on a specific neurological impairment domain (p=0·205). The overall risk of death adjusted for age and sex was higher in children with neurological impairment compared with controls (HR 4·24, 95% CI 2·26-7·94, p=0·002). An SMR of 3·15 (95% CI 1·66-5·49) was obtained after using the general population sample as the reference for indirect standardisation. In multivariable risk factor analysis, developmental delay (adjusted HR 18·92, 95% CI 2·23-160·44, p=0·007) and severe malnutrition (20·92, 3·14-139·11, p=0·002) increased the risk of mortality in children with neurological impairment. Infections such as HIV/AIDS and accidents were common among all decedents.

INTERPRETATION

The risk of premature mortality was higher in children diagnosed with neurological impairments compared with the general population and was increased by developmental delay and severe malnutrition. Child development and nutritional status should be assessed in all children in LMICs and tailored interventions started to improve outcomes.

FUNDING

Wellcome Trust, DELTAS Africa Initiative.

Prevalence and associated factors of neurodevelopmental disability among infants in eastern Uganda: a population based study

Background

Neurodevelopmental disability (NDD) is increasingly acknowledged as one of the important causes of disease burden in low income countries. None the less, there is a dearth of data on the burden of NDD and its determinants in these settings. We aimed to establish the prevalence and factors associated with NDD among infants in Eastern Uganda.

Methods

We assessed 487 infants aged 9–12 months within Iganga-Mayuge Health Demographic Surveillance Site in Eastern Uganda using the Malawi Developmental Assessment Tool. The tool has four domains: gross motor, fine motor, language and social domains. An infant failed a domain if she/he failed more than two parameters of the expected at his/her age.

We interviewed mothers on factors that could influence the infants’ neurodevelopmental outcomes. Data were analysed using STATA version 14. We used odds ratios and 95% confidence intervals to assess statistical significance of associations.

Results

Of the 487 infants, 62(12.7%) had an NDD in at least one of the domains. The most affected was social behaviour where 52(10.7%) infants had an NDD. Severe impairment was seen among 9(1.8%) infants with NDD in either three or four domains.

Factors associated with NDD at multivariate logistic regression included: parity of more than three children (aOR = 1.8, 95% CI: 1.02–3.18); failure to cry at birth (aOR = 3.6, 95% CI: 1.46–9.17) and post-neonatal complications (aOR = 4.15, 95% CI: 1.22–14.10). Low birth weight, immediate and exclusive breast feeding were not significantly associated with NDD.

Conclusion

We found a high NDD burden among infants particularly in the social behaviour domain. To optimise the socio-neural development of infants, programs are needed to educate and work with families on how to engage and stimulate infants. Existing immunisation clinics and community health worker strategies provide an excellent opportunity for stemming this burden.

The development and testing of a module on child functioning for identifying children with disabilities on surveys. I: Background

This is the first of three papers that will document the development of a survey module on child functioning developed by UNICEF in collaboration with the Washington Group on Disability Statistics (WG), and demonstrate - both conceptually and through test results - the strengths of that module compared with alternative tools for identifying children with disabilities in household surveys. This first paper in the series sets the background and reviews the literature leading to the development of the UNICEF/WG Child Functioning Module (CFM) and presents the WG Short Set of questions (WG-SS) and the Ten Question Screening Instrument (TQSI) as precursors, outlining some of their shortcomings and how the UNICEF/WG CFM was designed to meet those challenges. Subsequent articles will summarize results from the cognitive and field testing of the CFM including comparisons with results derived from the TQSI and the WG-SS.

Prevalence of psychological distress among parents of children with intellectual disabilities in Malawi

BACKGROUND

Children with intellectual disabilities are common and are increasing in number as more children survive globally. In stark contrast to the 1-3% prevalence of intellectual disability in children globally (reported by WHO), studies from Malawi provide alarmingly high rates (26%). We know that the prevalence of psychological distress is as high as 50% in parents of children with intellectual disabilities in Europe and the US. No such studies have yet been conducted in Africa. This study is aimed at determining the prevalence and risk factors for psychological distress among parents of intellectually disabled children in Malawi.

METHODS

This quantitative cross-sectional study was conducted in January and February 2015. One hundred and seventy mothers and fathers of children with intellectual disabilities as diagnosed by psychiatric clinical officers were randomly sampled from two selected child disability clinics. The Self-Reporting Questionnaire (SRQ) was used "as measure for psychological distress and questions on socio-demographic variables were administered to all consenting participants." Data was coded, cleaned and analyzed using STATA.

RESULTS

70/170 (41.2%) of parents of children with intellectual disabilities reported psychological distress. Univariate and multivariate analysis showed that area of residence (P < 0.05), low socio-economic status (P < 0.05), knowledge of the disability of one's child (P < 0.05), low confidence in managing the disabled child (P < 0.05), increased perceived burden of care (P = 0.05), and having no sources for psychological support (P < 0.05) significantly predicted psychological distress among the parents for children with disabilities.

CONCLUSION

There is huge burden of psychological distress among parents of intellectually disabled children in Malawi. Psychosocial interventions are urgently needed to support parents of children with intellectual disability in Malawi.

The Prevalence of Speech and Language Disorders in French-Speaking Preschool Children From Yaoundé (Cameroon)

PURPOSE

The purpose of this study was to determine the prevalence of speech and language disorders in French-speaking preschool-age children in Yaoundé, the capital city of Cameroon.

METHOD

A total of 460 participants aged 3-5 years were recruited from the 7 communes of Yaoundé using a 2-stage cluster sampling method. Speech and language assessment was undertaken using a standardized speech and language test, the Evaluation du Langage Oral (Khomsi, 2001), which was purposefully renormed on the sample. A predetermined cutoff of 2 SDs below the normative mean was applied to identify articulation, expressive language, and receptive language disorders. Fluency and voice disorders were identified using clinical judgment by a speech-language pathologist.

RESULTS

Overall prevalence was calculated as follows: speech disorders, 14.7%; language disorders, 4.3%; and speech and language disorders, 17.1%. In terms of disorders, prevalence findings were as follows: articulation disorders, 3.6%; expressive language disorders, 1.3%; receptive language disorders, 3%; fluency disorders, 8.4%; and voice disorders, 3.6%.

CONCLUSION

Prevalence figures are higher than those reported for other countries and emphasize the urgent need to develop speech and language services for the Cameroonian population.

Determinants of early child development in rural Tanzania

BACKGROUND

It has been estimated that more than 200 million children under the age of five do not reach their full potential in cognitive development. Much of what we know about brain development is based on research from high-income countries. There is limited evidence on the determinants of early child development in low-income countries, especially rural sub-Saharan Africa. The present study aimed to identify the determinants of cognitive development in children living in villages surrounding Haydom, a rural area in north-central Tanzania.

METHODS

This cohort study is part of the MAL-ED (The Interactions of Malnutrition & Enteric Infections: Consequences for Child Health and Development) multi-country consortium studying risk factors for ill health and poor development in children. Descriptive analysis and linear regression analyses were performed. Associations between nutritional status, socio-economic status, and home environment at 6 months of age and cognitive outcomes at 15 months of age were studied. The third edition of the Bayley Scales for Infant and Toddler Development was used to assess cognitive, language and motor development.

RESULTS

There were 262 children enrolled into the study, and this present analysis included the 137 children with data for 15-month Bayley scores. Univariate regression analysis, weight-for-age and weight-for-length z-scores at 6 months were significantly associated with 15-month Bayley gross motor score, but not with other 15-month Bayley scores. Length-for-age z-scores at 6 months were not significantly associated with 15-month Bayley scores. The socio-economic status, measured by a set of assets and monthly income was significantly associated with 15-month Bayley cognitive score, but not with language, motor, nor total 15-month Bayley scores. Other socio-economic variables were not significantly associated with 15-month Bayley scores. No significant associations were found between the home environment and 15-month Bayley scores. In multivariate regression analyses we found higher Bayley scores for girls and higher Bayley scores in families with more assets. Adjusted R-squared of this model was 8%.

CONCLUSION

We conclude that poverty is associated with a slower cognitive development in children and malnutrition is associated with slower gross motor development. This information should encourage authorities and other stakeholders to invest in improved welfare and nutrition programmes for children from early infancy.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia-Pacific (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for any NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

Factors associated with behavioral problems and cognitive impairment in children with epilepsy of Kinshasa, Democratic Republic of the Congo

BACKGROUND

Behavioral problems and cognitive impairment are common in children with epilepsy (CWE). In sub-Saharan Africa, little is known about these comorbidities particularly their relationships with socioeconomic features. The goal of this study was to identify clinical and socioeconomic factors associated with behavioral problems and cognitive impairment in CWE of Kinshasa (Democratic Republic of the Congo).

METHODS

This cross-sectional hospital-based study had included 104 CWE aged 6 to 17years. Behavioral problems were assessed by the child behavior checklist. The Wechsler nonverbal scale of ability was used to assess cognitive impairment.

RESULTS

At least one behavioral problem was found in 34.6% of CWE. Internalized problems were increasing with father's age (p=0.034). Externalized problems were increasing with the decreased of mother's age (p=0.009) and with a previous antiepileptic treatment (p=0.032). Total behavioral problems were increasing with a previous antiepileptic treatment (p=0.029). Cognitive impairment was present in 73.3% of CWE. It was more common in boys (p=0.013), and it was increasing with a low household daily expenses (p=0.034), with a previous antiepileptic treatment (p=0.041), with an early onset of epileptic seizures (p=0.042), and with a high frequency of epileptic seizures (p=0.011).

CONCLUSION

Behavioral problems and cognitive impairment are common in CWE. Multivariate analysis has shown that behavioral problems were associated with socioeconomic features only. Contrariwise, cognitive impairment was associated with both socioeconomic factors and clinical features. There is a need of more studies to improve knowledge of these comorbidities in the sub-Saharan Africa context.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

An overview of mental health care system in Kilifi, Kenya: results from an initial assessment using the World Health Organization's Assessment Instrument for Mental Health Systems

Background

Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilifi County. There is need to provide evidence from mental health systems research to identify priority areas in Kilifi’s mental health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilifi County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders.

Methods

This was a pilot study that used the brief version of the World Health Organization’s Assessment Instrument for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014.

Results

Kilifi county has two public psychiatric outpatient units that are part of general hospitals. There is no standalone mental hospital in Kilifi. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilifi have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilifi with only two psychiatric nurses for a population of approximately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya’s mental health policy, which is being used by Kilifi County, is outdated and does not cater for the current mental health needs of Kilifi. There is no specific legislation to protect the rights of people with mental health problems. No budget exists specifically for mental health care. There have been no efforts to integrate mental health care into primary care in Kilifi, and there is no empirical research work to evaluate its feasibility.

Conclusion

There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.

Parenting children with intellectual disabilities in Malawi: the impact that reaches beyond coping?

BACKGROUND

Rates of disability are high in resource poor settings with 85% of children with disabilities living in these settings. Long-term caregiving for disabled children is associated with fatigue, financial difficulties, parenting distress and other psychological issues. While such parents of children have repeatedly highlighted their feelings of discrimination, stigma and exclusion, leading to mental health issues, there is little research from the developing world addressing these issues.

RESEARCH OBJECTIVES

This study aims to explore psychological experiences of parents caring for children with intellectual disabilities; understand their mechanisms of coping and their psychosocial needs in Malawi.

METHODOLOGY

This study used a qualitative phenomenological design. We purposively sampled parents who had children diagnosed with intellectual disability from two clinics in two cities in Malawi. Between January 2015 and March 2015, we conducted 10 focus group discussions and four in-depth interviews. All ethical study procedures were carefully followed. All interviews were tape-recorded, transcribed and translated from vernacular to English. Thematic approach of data analysis was adopted to understand the data.

FINDINGS

Caring for intellectually disabled children comes with a number of challenges. Parents have limited access to services for their children let alone for their own psychological issues; they experience stigma and discrimination, have mental health issues resulting from the caring role, have suicidal ideas and in some cases have even been coerced by neighbours to kill their disabled child. To manage these issues, most parents cope through their spirituality.

DISCUSSION AND RECOMMENDATION

Apart from suicide and filicide, the findings of this study are similar to those performed in other countries. It is recommended that parents' psychological issues be managed concurrently when providing services for their children. There is also a need to develop psychosocial training interventions to address the needs of the parents of these children.

Evaluation of psychometric properties and factorial structure of the pre-school child behaviour checklist at the Kenyan Coast

BACKGROUND

Behavioural/emotional problems may be common in preschool children living in resource-poor settings, but assessment of these problems in preschool children from poor areas is challenging owing to lack of appropriate behavioural screening tools. The child behaviour checklist (CBCL) is widely known for its reliability in identifying behavioural/emotional problems in preschool children, but it has not been validated for use in sub-Saharan Africa.

METHODS

With permission from developers of CBCL, we translated this tool into Ki-Swahili and adapted the items to make them culturally appropriate and contextually relevant and examined the psychometric properties of the CBCL, particularly reliability, validity and factorial structure in a Kenyan community preschool sample of 301 children. It was also re-administered after 2 weeks to 38 randomly selected respondents, for the purpose of evaluating retest reliability. To evaluate inter-informant reliability, the CBCL was administered to 46 respondents (17 alternative caretakers and 29 fathers) alongside the child's mother. Generalised linear model was used to measure associations with behavioural/emotional scores. We used structural equation modelling to perform a confirmatory factor analysis to examine the seven-syndrome CBCL structure.

RESULTS

During the first phase we found that most of the items could be adequately translated and easily understood by the participants. The inter-informant agreement for CBCL scores was excellent between the mothers and other caretakers [Pearson's correlation coefficient (r) = 0.89, p < 0.001] and fathers (r = 0.81; p < 0.001). The test-retest reliability was acceptable (r = 0.76; p < 0.001). The scale internal consistency coefficients were excellent for total problems [Cronbach's alpha (α) = 0.95] and between good and excellent for most CBCL sub-scales (α = 0.65-0.86). Behavioural/emotional scores were associated with pregnancy complications [adjusted beta coefficient (β) = 0.44 (95 % CI, 0.07-0.81)] and adverse perinatal events [β = 0.61 (95 % CI, 0.09-1.13)] suggesting discriminant validity of the CBCL. Most fit indices for the seven-syndrome CBCL structure were within acceptable range, being <0.09 for root mean squared error of approximation and >0.90 for Tucker-Lewis Index and Comparative Fit Index.

CONCLUSION

The CBCL has good psychometric properties and the seven-syndrome structure fits well with the Kenyan preschool children suggesting it can be used to assess behavioural/emotional problems in this rural area.

Clinical Profile of Pediatric Neurological Disorders: Outpatient Department, Khartoum, Sudan

BACKGROUND

There is no available data from Sudan reflecting the magnitude of the neurological disorders and disabilities in the pediatric age-group. This study aims to evaluate the pattern of neurological disorders among Sudanese children.

PATIENTS AND METHODS

This is a retrospective survey of children with epilepsy and other neurodisability disorders seen at pediatric neurology outpatient clinic, during the period from January 2007 to August 2013. The data of 9600 patients were analyzed.

RESULTS

A total of 6019 patients were included in the study. The majority of the patients had epilepsy that amounted to 52.8%, followed by cerebral palsy (19.1%), congenital anomalies of the central nervous system (6.2%), neuromuscular disorders (3.2%), stroke (2.4%), ataxia and movement disorders (1.9%), assumed genetic syndromes (1.2%), and others.

CONCLUSION

Neurological disorders constitute a major cause of chronic morbidity in pediatric age-group.

"It means you are grounded" - caregivers' perspectives on the rehabilitation of children with neurodisability in Malawi

PURPOSE

Rates of childhood disability are estimated to be high in African settings; however, services to provide information and support are limited. This study aims to explore perspectives and experiences of caregivers of children with disabilities (CWD) from acquired brain injury to inform the development of training packages for health-workers (HW) in hospital settings.

METHODS

The study was conducted in a tertiary hospital using qualitative methods. Fourteen in-depth interviews (IDIs) were conducted with parents/carers (PC), and 10 IDIs and 4 focus-group discussions (FGDs) with HW. Data were audio-recorded, transcribed, translated and analysed using thematic approaches.

RESULTS

HWs and PCs held varying perspectives on aetiology and prognosis for CWD. HWs raised concerns about impact on families, risks of neglect and abuse. Barriers to care and support included prioritisation of acute illness, lack of HW knowledge and confidence, stigma, poor communication, focus on physical disability, and poor availability of services. Among ideas for improvement, good communication and counselling was seen as a priority but not often achieved.

CONCLUSION

A range of family, health service and wider contextual factors affect care for CWD. Training for HW should emphasise disability rights, access to services, a range of disabilities and specific training on counselling.

IMPLICATIONS FOR REHABILITATION

To create good training programmes for workers who manage children with neurodisability, workers' views on their training needs, as well parents' views of what feel they need to know most, must be taken into account. The need for training regarding communication skills is a priority for health-workers (HW), who manage children with neurodisability in Malawi and confidence in this area is likely to be vital in providing support for these families. Disability rights and inclusion should be imperative in any training programme for managing children with neurodisability in hospital settings. Even in low-resource settings such as Malawi, it is vital that the links between hospital management and the limited resources in the community are updated and maintained.

Prevalence of motor developmental disorders in children in alborz province, iran in 2010

BACKGROUND

Unlike developed countries, data from the developing world regarding motor developmental disorders is scarce.

OBJECTIVES

In the present study, we used the Infant Neurological International Battery (Infanib) test to determine the prevalence of motor impairment in 4-18 month-old infants in Alborz province, Iran, in 2010.

PATIENTS AND METHODS

This study was a descriptive-analytic study performed on 6150 infants in Iran. The sample was recruited by convenience sampling from all 4-18 month-old children attended healthcare centers in different districts of Alborz province. Sampling was continued until reaching the desired sample size.

RESULTS

The sample included 3129 boys and 3021 girls. There was no significant difference between the scores of girls and boys (P = 0.403). The number of children with motor developmental abnormality varied depending on the considered cut-off points. In normative cut-off points, 3.7% had motor disorder, whereas based on the Iranian cut-off points, it was 6.5%.

CONCLUSIONS

Providing an early detection and intervention system is an urgent public health problem due to the prevalence of motor developmental delay in infants living in Alborz province, because it indicates that most infants had been previously undiagnosed and untreated.

Caregiver perceptions of children who have complex communication needs following a home-based intervention using augmentative and alternative communication in rural Kenya: an intervention note

A high level of unmet communication need exists amongst children with developmental disabilities in sub-Saharan Africa. This study investigated preliminary evidence of the impact associated with a home-based, caregiver-implemented intervention employing AAC methods, with nine children in rural Kenya who have complex communication needs. The intervention used mainly locally-sourced low-tech materials, and was designed to make use of the child's strengths and the caregiver's natural expertise. A pretest-posttest design was used in the study. Data were gathered using an adapted version of the Communication Profile, which was based on the International Classification of Functioning, Disability, and Health (ICF) framework. The non-parametric Wilcoxon signed-rank test was applied to data from the first two sections of the Communication Profile-Adapted. Qualitative analysis was conducted on the final section. The data provided evidence of statistically significant positive changes in caregiver perceptions of communication at the levels of Body Structure and Function, and Activities for Communication. Also, analysis of the Participation for Communication section revealed some expansion to the children's social activities. The potential impact of the home-based intervention would benefit from investigation on a larger scale. Limitations of the study are discussed.

Prevalence of undetected developmental delays in Iranian children

BACKGROUND

Regarding the short- and long-term benefits of early intervention for childhood developmental disorders, this study was carried out to determine the prevalence of undetected developmental delays by the standardized form of the Persian version of the Ages and Stages Questionnaires (ASQ) in Iranian children.

METHODS

This was a cross-sectional study. The study was carried out on 11 000, 4- to 60-month-old children; in 19 age groups, in 41 selected cities throughout the country. Ninety physicians were invited from each of the selected cities to Tehran in groups, and trained about the ASQ scoring, during a 2-day workshop. The questionnaires were completed at healthcare settings by parents of children who were apparently normal (lacking any gross developmental disorders) under the supervision of the physicians who consequently scored each child. The response rate was 95% (10 516 parents).

RESULTS

Among the 10 516 children studied, 5035 (47.87%) were girls. The average percentage of children delayed in the communication, gross motor, fine motor, problem-solving and social-personal domains was 3.87%, 4.04%, 4.31%, 4.15% and 3.69%, respectively, when considering the Iranian cut-off points. In the 19 age-domain groups, most frequently in the personal-social and fine motor domains (in terms of domains), and also most frequently at 36 and 48 months of age (in terms of age ranges), girls showed significantly higher scores than boys. Boys showed significantly higher scores in two age-domain groups (gross motor domain at 20 and 22 months of age).

CONCLUSIONS

The prevalence of undetected developmental delays in Iranian children screened by the ASQ questionnaires ranged from 3.69% to 4.31% in different developmental domains.

Pediatric cerebral palsy in Africa: a systematic review

Cerebral palsy is a common neurologic problem in children and is reported as occurring in approximately 2-2.5 of 1000 live births globally. As is the case with many pediatric neurologic conditions, very little has been reported on this condition in the African context. Resource-limited settings such as those found across the continent are likely to result in a different spectrum of etiologies, prevalence, severity as well as management approaches. This review aims to establish what has been reported on this condition from the African continent so as to better define key clinical and research questions.

Public health and research funding for childhood neurodevelopmental disorders in Sub-Saharan Africa: a time to balance priorities

Sub-Saharan African (SSA) population consists of about 45% children, while in Europe and North America children population is 10-15%. Lately, attention has been directed at mitigating childhood infectious and communicable diseases to reduce under-five mortality. As the under-five mortality index in Sub-Saharan Africa has relatively improved over the last two decades, more Sub-Saharan African children are surviving beyond the age of five and, apparently, a sizeable percentage of this population would be living with one or more childhood neurodevelopmental disorders (NDD). The distribution of child mental health service resources across the world is unequal. This manifests in the treatment gap of major childhood onset mental health problems in SSA, with the gap being more pronounced for childhood NDD. It is important to balance the public health focus and research funding priorities in Sub-Saharan Africa. We urgently need to define the burden of childhood NDD in the region for healthcare planning and policy formulation.

Investigation of practices to support the complex communication needs of children with hearing impairment and cerebral palsy in a rural district of Kenya: a case series

BACKGROUND

Rehabilitation services are scarce in low-income countries, where under-representation of some specialist professions has led to the role extension of others. An example of this can be found in Kilifi in Kenya where the role of speech and language therapy has been taken on by occupational therapists and teachers.

AIMS

To investigate the communication practices used by these professional groups to support children with complex communication needs in a rural part of Kenya and to explore the ways in which this might be seen to facilitate or obstruct improved communication by asking the following questions: What are the critical features of interactional discourse in practitioner-child dyads with caregiver-child dyads providing a natural comparison? What communicative modalities and practice techniques are invoked? And how does this information relate to extending professional roles?

METHODS & PROCEDURES

An in-depth, descriptive study of a case series was conducted in a school for deaf children and the occupational therapy department of a district general hospital. A mixed methodology was used involving naturalistic observation and applied linguistics analysis. A convenience sample was established comprising six practitioner-child dyads assigned to partnership types: (A) three children with hearing impairment and their teachers; and (B) three children with cerebral palsy and their occupational therapists. As a natural comparator, the same three children in B were also observed with their mothers (partnership type C). Dyadic interaction was video recorded on three occasions. The video data were sampled, transcribed into standard orthography and translated. Codes were applied to determine turn structure, linguistic move types and communicative modalities. Sequential analysis was conducted on the move types.

OUTCOMES & RESULTS

Partnership type A dyads showed a fairly even turn distribution between teacher and child. A common pattern was teacher-initiated Instruct and Model/Prompt, followed by child response in the form of an Action. The most frequently used modality was Sound Production and Hands-on-Articulators, which corresponded to articulation drill practice. Partnership type B dyads revealed a tendency towards adult domination of turns. The majority of adult-initiated moves required no response from the child. The practice technique Hands-on-Articulators involved manipulating the oral musculature of the child. Partnership type C dyads showed resonances of type B dyads, although focused more on Motor-Action in relation to task performance.

CONCLUSIONS & IMPLICATIONS

The assignment of speech and language therapy duties to teachers and occupational therapists has resulted in suboptimal practice for children with complex communication needs.

Burden of surgical congenital anomalies in Kenya: a population-based study

BACKGROUND

Congenital malformations are a significant component of the global burden of disease among children, accounting for 25 million disability-adjusted life years (DALYs) worldwide. Unfortunately, efforts to estimate the burden of pediatric surgical disease in Africa are limited by the absence of population-based data. The objective of this study was to estimate both the prevalence and the disease burden of several common congenital surgical malformations among children in Kenya.

METHODS

Community volunteers randomly surveyed households at sites across Kenya. Caretakers were asked to identify on a photographic portfolio, several congenital malformations present among the children in their household, including club foot, hypospadias, hydrocephalus, spina bifida/encephalocele, cleft lip, bladder exstrophy and imperforate anus. DALYs were then calculated based on life expectancy tables and published and estimated disability weights for the conditions encountered.

RESULTS

The caregivers of 5559 children (54% female) were surveyed in 1909 households, 56% of which were rural, 31% suburban and 12% urban. The overall prevalence of congenital malformations was 6.3 per 1000 children, amounting to 54-120 DALYs per 1000 children, depending on the life tables used. The most prevalent condition in the survey was club foot, whereas spina bifida had the highest burden of disease.

DISCUSSION

This study is the first to document the prevalence of selected surgical congenital malformations among children in Kenya and the burden of disease associated with them. The results will serve to inform strategies aimed at reducing the unmet burden of surgical disease in resource-limited regions.

Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health

BACKGROUND

The health of a carer is a key factor which can affect the well-being of the child with disabilities for whom they care. In low-income countries, many carers of children with disabilities contend with poverty, limited public services and lack assistive devices. In these situations caregiving may require more physical work than in high-income countries and so carry greater risk of physical injury or health problems. There is some evidence that poverty and limited access to health care and equipment may affect the physical health of those who care for children with disabilities. This study seeks to understand this relationship more clearly.

METHODS

A mixed methods study design was used to identify the potential physical health effects of caring for a child with moderate-severe motor impairments in Kilifi, Kenya. Qualitative data from in-depth interviews were thematically analysed and triangulated with data collected during structured physiotherapy assessment.

RESULTS

Carers commonly reported chronic spinal pain of moderate to severe intensity, which affected essential activities. However, carers differed in how they perceived their physical health to be affected by caregiving, also reporting positive benefits or denying detrimental effects. Carers focussed on support in two key areas; the provision of simple equipment and support for their children to physically access and attend school.

CONCLUSIONS

Carers of children with moderate-severe motor impairments live with their own physical health challenges. While routine assessments lead to diagnosis of simple musculoskeletal pain syndromes, the overall health status and situation of carers may be more complex. As a consequence, the role of rehabilitation therapists may need to be expanded to effectively evaluate and support carers' health needs. The provision of equipment to improve their child's mobility, respite care or transport to enable school attendance is likely to be helpful to carers and children alike.

Prevalence and risk factors for neurological disorders in children aged 6 months to 2 years in northern India

AIM

To study prevalence and risk factors for neurological disorders--epilepsy, global developmental delay, and motor, vision, and hearing defects--in children aged 6 months to 2 years in northern India.

METHOD

A two-stage community survey for neurological disorders was conducted in rural and urban areas of Lucknow. After initial screening with a new instrument, the Lucknow Neurodevelopment Screen, screen positives and a random proportion of screen negatives were validated using predefined criteria. Prevalence was calculated by weighted estimates. Demographic, socio-economic, and medical risk factors were compared between validated children who were positive and negative for neurological disorders by univariate and logistic regression analysis.

RESULTS

Of 4801 children screened (mean age [SD] 15.32mo [5.96]; 2542 males, 2259 females), 196 were positive; 190 screen positives and 269 screen negatives were validated. Prevalence of neurological disorders was 27.92 per 1000 (weighted 95% confidence interval 12.24-43.60). Significant risk factors (p≤0.01) for neurological disorders were higher age in months (p=0.010), lower mean number of appliances in the household (p=0.001), consanguineous marriage of parents (p=0.010), family history of neurological disorder (p=0.001), and infants born exceptionally small (parental description; p=0.009). On logistic regression, the final model included age (p=0.0193), number of appliances (p=0.0161), delayed cry at birth (p=0.0270), postneonatal meningoencephalitis (p=0.0549), and consanguinity (p=0.0801).

INTERPRETATION

Perinatal factors, lower socio-economic status, and consanguinity emerged as predictors of neurological disorders. These factors are largely modifiable.

Prevalence and risk factors of neurological impairment among children aged 6-9 years: from population based cross sectional study in western Kenya

Background

The burden of disability is more severe among children in low income countries. Moreover, the number of children with disabilities (CWDs) in sub-Saharan Africa is predicted to increase with reduction in child mortality. Although the issue on CWDs is important in sub-Saharan Africa, there are few researches on risk factors of disabilities. The purpose of this study was to evaluate the risk factors of neurological impairment (NI) among children in western Kenya.

Methods

The present study was conducted in Mbita district (which has high HIV infectious prevalence), Kenya from April 2009 to December 2010. The study consisted of two phases. In phase 1, the Ten Question Questionnaire (TQQ) was administered to all 6362 caregivers of children aged 6–9 years. In phase two, all 413 children with TQQ positive and a similar number of controls (n=420) which were randomly selected from children with TQQ negative were examined for physical and cognitive status. In addition, a structured questionnaire was also conducted to their caregivers.

Results

The prevalence was estimated to be 29/1000. Among the types of impairments, cognitive impairment was the most common (24/1000), followed by physical impairment (5/1000). In multivariate analysis, having more than five children [adjusted odds ratio (AOR): 2.85; 95%IC: 1.25 – 6.49; p=0.013], maternal age older than 35 years old [AOR: 2.31; 95%IC: 1.05 – 5.07; p=0.036] were significant factors associated with NI. In addition, monthly income under 3000 ksh [AOR: 2.79; 95%IC: 1.28 – 6.08; p=0.010] and no maternal tetanus shot during antenatal care [AOR: 5.17; 95%IC: 1.56 – 17.14; p=0.007] were also significantly related with having moderate/severe neurological impairment.

Conclusion

It was indicated that increasing coverage of antenatal care including maternal tetanus shot and education of how to take care of neonatal children to prevent neurological impairment are important.

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.

Validation of a culturally modified short form of the McCarthy Scales of Children's Abilities in 6 to 8 year old Zimbabwean school children: a cross section study

BACKGROUND

The burden of cognitive impairment among school children from developing communities is under reported due to lack of culturally appropriate screening tools. The objective of this study was to validate a culturally modified short form of the McCarthy Scales of Children Abilities (MSCA) in school children aged 6-8 years from varied backgrounds.

METHODS

One hundred and one children aged 6-8 years attending mainstream classes were enrolled cross-sectionally from three schools: one rural and two urban. Two assessments were conducted on each child and the Short form MSCA was compared to an independent assessment by the educational psychologist.

RESULTS

When comparing the results of the MSCA to local standard at -2SD, -1.5 SD and -1SD the sensitivity rates ranged from 17 to 50% with lower sensitivity at -2SD cut-off point. Specificity rates had less variation ranging from 95% to 100%. The number of children identified with cognitive impairment using -2SD, -1.5SD and -1SD below the mean for MSCA as a cut-off point were 3(3%), 7(7%) and 13(13%) respectively while the psychologist identified 18 (18%). The overall mean score on MSCA was 103 (SD 15). The rural children tended to score significantly lower marks compared to their peers from urban areas, mean (SD) 98(15) and 107(15) respectively, p=0.006. There was no difference in the mean (SD) scores between boys and girls, 103(17) and 103(15) respectively, p=0.995.

CONCLUSION

The culturally modified short form MSCA showed high specificity but low sensitivity. Prevalence of cognitive impairment among 6 to 8 year children was 3%. This figure is high when compared to developed communities.

Validity of a screening instrument for neurologic disability in resource-poor African communities

BACKGROUND

There have been no recent population-based studies on all-cause adult neurological morbidity in sub-Saharan Africa. We have developed a screening survey to improve the feasibility in performing these studies.

METHODS

Our screening instrument contains both history questions and examination items. We pilot tested this instrument in the Hai District, Tanzania, and Butajira, Ethiopia using trained individuals from the local communities. To measure sensitivity, we applied the instrument blindly to 25 previously-identified subjects with Parkinson's disease, stroke or epilepsy. To measure specificity, we examined 42 randomly selected previously screened subjects. We also compared the validity of the entire instrument to the history-only section.

RESULTS

There were 669 adult subjects screened in both communities (150 screen-positives, and 519 screen-negatives). The sensitivity of the instrument was 100% (95% CI 84.2-100%) and the specificity was 82.4% (95% CI 66.1-92.0%). However, when restricting the instrument to the history-only section, the sensitivity remained unchanged, but the specificity became 91.2% (95% CI 76.3-97.7%; p=0.48).

CONCLUSIONS

We have created a valid tool to screen adults for neurologic morbidity in resource-poor communities. The use of the history-only section of the tool is adequate as a screen and will improve feasibility.

Behavioral problems in children with epilepsy in rural Kenya

The aims of this study were to record behavioral problems in children with epilepsy (CWE), compare the prevalence with that reported among healthy children without epilepsy, and investigate the risk factors. A child behavioral questionnaire for parents comprising 15 items was administered to the main caregiver of 108 CWE and 108 controls matched for age in Kilifi, Kenya. CWE had a higher mean score for reported behavioral problems than controls (6.9 vs 4.9, t=4.7, P<0.001). CWE with active epilepsy also recorded more behavioral problems than those with inactive epilepsy (8.2 vs 6.2, t=-2.9, P=0.005). A significantly greater proportion of CWE (49% vs 26% of controls) were reported to have behavioral problems. Active epilepsy, cognitive impairment, and focal seizures were the most significant independent covariates of behavioral problems. Behavioral problems in African CWE are common and need to be taken into consideration in planning comprehensive clinical services in this region.

Childhood disability and socio-economic circumstances in low and middle income countries: systematic review

BACKGROUND

The majority of children with disability live in low and middle income (LAMI) countries. Although a number of important reviews of childhood disability in LAMI countries have been published, these have not, to our knowledge, addressed the association between childhood disability and the home socio-economic circumstances (SEC). The objective of this study is to establish the current state of knowledge on the SECs of children with disability and their households in LAMI countries through a systematic review and quality assessment of existing research.

METHODS

Electronic databases (MEDLINE; EMBASE; PUBMED; Web of Knowledge; PsycInfo; ASSIA; Virtual Health Library; POPLINE; Google scholar) were searched using terms specific to childhood disability and SECs in LAMI countries. Publications from organisations including the World Bank, UNICEF, International Monetary Fund were searched for. Primary studies and reviews from 1990 onwards were included. Studies were assessed for inclusion, categorisation and quality by 2 researchers.

RESULTS

24 primary studies and 13 reviews were identified. Evidence from the available literature on the association between childhood disability and SECs was inconsistent and inconclusive. Potential mechanisms by which poverty and low household SEC may be both a cause and consequence of disability are outlined in the reviews and the qualitative studies. The association of poor SECs with learning disability and behaviour problems was the most consistent finding and these studies had low/medium risk of bias. Where overall disability was the outcome of interest, findings were divergent and many studies had a high/medium risk of bias. Qualitative studies were methodologically weak.

CONCLUSIONS

This review indicates that, despite socially and biologically plausible mechanisms underlying the association of low household SEC with childhood disability in LAMI countries, the empirical evidence from quantitative studies is inconsistent and contradictory. There is evidence for a bidirectional association of low household SEC and disability and longitudinal data is needed to clarify the nature of this association.