January to June,  2010
Funded by: Planning and Research Line Directorate, DGHS

Study Children: 0-9 years old By door to door survey of underprivileged population living nearest to the MCH

Developmental Screening Questionnaire (DSQ) for 0-<2 years; Ten Questions Plus (TQP) for 2-9 year olds, asked to mothers by community workers

Children: Gender Ratio in screened children compared to those availing services in SBKs

Children: proportion <2 years versus =>2 years in survey and <2 year olds availing SBK services

% screened positive for NDIs by age group

2-9 year olds at-risk for NDIs = 8.9%
0-<2 year olds at-risk for NDIs = 6.2%
0-9 year olds at-risk for NDIs = 7.5%

% screened positive for NDIs by age group

Screen positive by child’s gender: 2-9 year olds

Prevalence of Neurodevelopmental Impairments

 
DMCH
Salimullah
Suh'wrdy
Sylhet
Barisal
Standard Error

.06

.03

.04

.02

.20

Prevalence per 1000 children

63

90

46

20

97

95% Confidence Interval, Upper - Lower

51-75

85-95

38-54

16-24

57-137

Mean Prevalence = 63 per 1000 (analysis weighted for children not assessed in second stage)

Executive Summary 1

Household Survey

41% were low income (income 3000-5000 Taka)
9.2% were ultra poor (income <3000 Taka)
36% were unskilled workers
6% were female-headed households
42% household head never had schooling
All had =>1-5 decimals of land, except 58% surveyed around Sir Salimullah MCH who had none
93% drank piped water, except in Barisal, where only 3% had this facility
95% used sanitary latrine, except Sylhet, where only 35% had this facility
98% used iodized salt in their food
 

Executive Summary 2

Mother-child Survey

42% had no schooling, lowest in Barisal (13%), highest in Sylhet (67%)
30% had attended primary school, highest in Barisal (37%), lowest in Sylhet (15%)
46% could not read, lowest in Barisal (22%), highest in Sylhet (67%)
75% ‘housewives’, highest around DMCH (82%), lowest in Barisal (64%)
77% did not earn wages, lowest in Barisal (66%), highest around DMCH (87%)
8% consanguinity, highest around Kamrangirchar, Sir Salimullah MCH (15%), lowest in Barisal (1%)
Mean live births =2; highest around Kamrangirchar (2.6), lowest in Geneva Camp (0.17)
 

Executive Summary 3

Children’s Survey Outcomes

Male: Female ratio 1.1, with most disparity in Sylhet (1.3) and negative ratio in Barisal (0.96)
9% disparity between female population in community and those availing services, with minimum disparity in Sylhet (3%), maximum in Salimullah (13%)
19% more <2 year olds, however, seeking SBK services than their proportion in the community survey
9% children aged 2-9 years screened positive for impairments, highest around Suhrawardy (12%), lowest in Sylhet (3%)
6% children aged 0-<2 years screened positive for impairments, highest around Salimullah (13%), lowest in Sylhet (1%)
 

Executive Summary 4

Children’s Survey Outcomes, continued

Higher screen-positivity within low income groups, highest in Suhrawardy (56% in the 3000 to 5000 taka group), lowest in DMCH (2% within the >15000 taka group)
11% higher likelihood of  screen positivity in female-headed households in Dhaka city, with maximum around Salimullah (18%)
No difference in screen positivity within gender categories, in both older and younger children.
 

Executive Summary 5

Risk factors for Screen Positivity

Significant risk factors were related to the following:
–DMCH:
female headed household,  unskilled worker, kutcha house, no land ownership, no source for tapped water, and no sanitary latrine.
Maternal factors: if ‘housewife’
 
–Salimullah:
low monthly income, kutcha house, no loan facilities, poor source of drinking water, and large numbers using one toilet facility
Maternal factors: poor schooling, does not work, no wages, no loans
 
–Suhrawardy:
low monthly income, no land ownership, no consumer items in the house
Maternal factors: none significant
 
–Sylhet:
Low monthly income, no bicycle
Maternal factors: none significant
 
–Barisal
No land ownership, kutcha house, no bicycle
Maternal factors: Cannot read or reads with difficulty
 

Executive Summary 6

Prevalence of Childhood Neurodevelopmental Impairments and Disabilities

63 per 1000 children were found to have => one neurodevelopmental impairment across the five study sites
Highest in Barisal (96 per 1000) and around Salimullah MCH, ie on the banks of the river Buriganga in Kamrangirchar (90 per 1000); lowest in Sylhet (20 per 1000). Data could be skewed due to less attendance of screen negatives.
Covert’ or ‘unrecognised’  impairments were most commonly diagnosed in the assessed children. These were:
   
 
–DMCH: Cognition (67%), Gross Motor (24%)
 
–Salimullah: Cognition (55%), Speech (18%)
 
–Suhrawardy: Cognition (24%), Gross Motor (19%)
 
–Sylhet: Cognition (24%), Speech (24%)
 
–Barisal: Seizures (30%), Cognition (24%)
 

Executive Summary 7

Associated Factor: Stunting

41% assessed children were stunted
Highest around Salimullah (57%) and DMCH (52%), and lowest in Sylhet (18%)
 

Study Limitations

Numbers per site were too small for estimating risk factors. They need to be pooled together for further analysis.
Over half of children (screen positives and controls) could not be assessed at the SBKs as they either defaulted (parent’s could not be convinced to bring their children)
 

Study Implications 1

Door to door surveys by CWs are able to find most vulnerable populations of children, ie, lowest income/poorest, younger, girl child, and those with unrecognized developmental delays and impairments. Establish social equity.
Poverty-related factors have significant association with children at-risk for NDIs (Islam et al, 1995; Durkin et al, 2000; Grantham-McGregor et al, 2007)
Dhaka city poor have most significant associations between poverty and risk for NDIs
Children from female-headed households are more vulnerable; also whose mothers are unable to read; those without a job or source of income.
 

Study Implications 2

One in ten children  will screen positive for a NDI of whom an estimated two-third may have a definite impairment on further assessment.
Commonest impairments are ‘covert’ ‘unrecognized’ ‘not apparent’ to parents, ie, related to cognitive deficits, speech delay.
Close links with stunting (Walker et al, 2007), which is prevalent in almost half of the assessed children. 
 
–Largest implication for school enrollment and dropout, where 48% do not complete primary school (Bangladesh Education Watch, 2008)
NO SURVEY WITHOUT SERVICES: As this increases maternal stress and their psychiatric morbidity (Khan et al, 2010)
Need for services and early intervention found in this study, as ratio of <2 year olds brought to SBKs more than their ratio found in the community.
 

Study Implications 3

Multidisciplinary Shishu Bikash Kendra’s close to the community may be able to reverse >80% of these children’s impairments (Operational Plan, HNPSP, DGHS, MOHFW)
Large prospective studies are needed to provide such an evidence within Bangladesh
Field workers can be taught to administer the simple validated questionnaires  used in this study, in children’s homes, to screen children for early NDIs. For example in 13500 working from Community Clinics.
Screen-positive children can be assessed at home or within their community by CWs, using tools validated by Bangladeshi researchers (Khan et al, 2010; Khan et al, awaiting submission). Simple home-based interventions (eg. ‘positive parenting’, interactive play, story telling), validated in many studies world-wide (Maulik and Darmstadt, 2009), may be applied to these children
 

Conclusion

Home-based screening and early intervention to establish a tiered system of referral will be able to provide a ‘DEVELOPMENTAL SAFETY NET’ and an ‘INTEGRATED MANAGEMENT OF CHILD DEVELOPMENT’ (IMCD) for all children in Bangladesh
 

References

Durkin MS, Khan NZ, Davidson LL, Huq S, Munir S, Rasul E, Zaman SS. Prenatal and postnatal risk factors for mental retardation among children in Bangladesh. Am J Epidemiology 1;152(11):1024-33, December 2000.
Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369(9555):60-70.
Islam S, Durkin MS, Zaman SS. Socioeconomic Status and the Prevalence of Mental Retardation in Bangladesh. Mental Retardation. 1993; 31 (6): 412 – 417.
Khan N, Durkin M. Framework: Prevalence. In: (eds: P Zinkin and H McConachie) Disabled Childre and Developing Countries. Clinics in Developmental Medicine No. 136. Pages 1-9. MacKeith Pres.]London, 1995.
Khan NZ, Muslima H, Begum N, Begum N, Shilpi AS, Batra M, Darmstadt GD. Validation of Rapid Neurodevelopmental Assessment Instrument for under-two-year-children in Bangladesh.. Pediatrics 2010 Apr;125(4):e755-62. Epub 2010 Mar 22.
Khan NZ, Muslima H, Bhattacharya M, Darmstadt G, et al. Stress In Mothers Of Preterm Infants In Bangladesh: Associations With Family, Child And Maternal Factors And Children's Neurodevelopment. Child Care Health Dev. 16 May, 2008; 34 (5): 657- 664.
Khan NZ, Muslima H, et al. Validation of a home-based neurodevelopmental screening tool for under 2 year old children in Bangladesh. Pediatrics (submitted in Sept 2010)
Maulik PK, Darmstadt GL. Community-based interventions to optimize early childhood development in low resource settings. J Perinatol. 2009 Aug; 29(8):531-42. Epub 2009 Apr 30. Review.
Shrout PE, Newman S.  Design of two-phase prevalence surveys of rare disorders. Biometrics, 1989; 45:549-555.
UNICEF. Monitoring Child Disability in Developing Countries. Results from the Multiple Indicator Cluster Surveys. 2008. United Nations Children’s Fund. Division of Policy and Practice, New York, USA.
UNICEF. State of the World’s Children, 2007. New York.
Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007; 369(9556):145-157.
World Health Organization International Classification of Functioning, Disability and Health., Geneva, 2001.
Zaman SZ, Khan NZ, Islam S, Banu S, Dixit S, Shrout P, Durkin M. Validity of the “Ten Questions” for screening serious childhood disability: results from urban Bangladesh. Int J Epidemiology. 19: 613-620, 1990.