Elsevier

The Lancet

Volume 374, Issue 9704, 28 November–4 December 2009, Pages 1831-1839
The Lancet

Articles
Child disability screening, nutrition, and early learning in 18 countries with low and middle incomes: data from the third round of UNICEF's Multiple Indicator Cluster Survey (2005–06)

https://doi.org/10.1016/S0140-6736(09)61871-7Get rights and content

Summary

Background

Child disability is an emerging global health priority. To address the need for internationally comparable information about the frequency and situation of children with disabilities, UNICEF has recommended that countries include the Ten Questions screen for disability in the Multiple Indicator Cluster Survey (MICS) programme. We examined child disability screening and its association with nutrition and early learning in countries with low and middle incomes.

Methods

Cross-sectional data for the percentage of children screening positive for or at risk of disability were obtained for 191 199 children aged 2–9 years in 18 countries participating in the third round of MICS in 2005–06. Screening results were descriptively analysed according to sociodemographic, nutritional, early-learning, and schooling variables. We constructed a weighted analysis to account for the sampling design in every country and tested for differences within countries using χ2 analyses.

Findings

A median 23% (range 3–48) of children aged 2–9 years screened positive for disability in the 18 participating countries. For children aged 2–4 years, screening positive for disability was significantly more likely in children who were not breastfed versus those who were (median 36% [9–56] vs 26% [4–51]) in eight of 18 countries, in children who had not received vitamin A supplementation versus those who had (36% [7–53] vs 29% [4–50]) in five of ten countries assessed, in children who met criteria for stunting (26% [6–54]) or being underweight (36% [3–61]) versus those who did not (25% [3–42] and 26% [4–43], respectively) in five of 15 countries assessed for stunting and in seven of 15 countries assessed for being underweight, and in those who participated in few early-learning activities versus others (31% [7–54] vs 24% [4–51]) in eight of 18 countries. Children aged 6–9 years who did not attend school screened positive for disability more often than did children attending school (29% [2–83] vs 22% [3–47]) in eight of 18 countries.

Interpretation

Our results draw attention to the need for improved global capacity to assess and provide services for children at risk of disability. Further research is needed in countries with low and middle incomes to understand and address the role of nutritional deficiencies and restricted access to learning opportunities as both potential antecedents of childhood disability and consequences of discrimination.

Funding

UNICEF; Department of Population Health Sciences, University of Wisconsin–Madison, USA.

Introduction

Improvements in child survival in many low-income and middle-income countries in recent decades have coincided with a growing global awareness of children's functional status and the effects of childhood disabilities on individuals, families, and populations.1, 2, 3, 4 Despite rising interest in child disability, little is known about the frequency and situation of children with disabilities in countries with low and middle incomes.3 According to the UN Convention on the Rights of Persons with Disabilities, disabilities are “long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder [a person's] full and effective participation in society on an equal basis with others.”5 Article 7 of this Convention draws attention to the rising profile of childhood disability and the need “to ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms on an equal basis with other children.”5 This view of disability is consistent with UNICEF's focus on protection of children with disabilities against discrimination6 and with the framework of the International Classification of Functioning, Disability and Health, in which disability is regarded as an interaction between individual health conditions or abilities and contextual factors such as social support, culturally influenced perceptions of disability, and access to nutrition and education.7

In response to the need for information about children with disabilities in countries with low and middle incomes, UNICEF has recommended inclusion of the Ten Questions screen for child disability (panel) as an optional module in its Multiple Indicator Cluster Survey (MICS) programme. We present results of the disability module from 18 countries (figure 1) that participated in the third round of MICS (MICS3) in 2005–06. Specifically, we aimed to estimate the percentage of children who screened positive for or were considered at risk of disability in these countries, and to assess the association between disability screening results and nutritional variables, exposure to early-learning activities, and school attendance.

Section snippets

Study design

MICS is a household survey programme that was developed by UNICEF to assist with monitoring of the health of women and children in countries with low and middle incomes. It is intended to measure progress towards an internationally agreed set of goals with use of uniform measures across countries. UNICEF provides training, materials, and support for standard methods of data collection across participating countries, although implementation of MICS3, including sample-size determination,

Results

Primary caregivers of 191 199 children completed the Ten Questions screen in 25 languages across 18 countries. Table 1 shows the characteristics of all children (aged 2–9 years) who were screened, by country. Boys and girls, and both age groups (2–4 and 6–9 years), were nearly evenly represented. The percentage of children residing in urban areas was highest in Thailand and lowest in Bangladesh (table 1). The median percentage of children meeting criteria for stunting was lowest in Montenegro

Discussion

Inclusion of the Ten Questions child disability module in UNICEF's MICS3 has provided population-based information from many countries with low and middle incomes about the proportion of young children (aged 2–9 years) screening positive for or at high risk of disability. Screening results vary across countries, with more than 10% of children screening positive for disability in 17 of the 18 countries, with a median prevalence of about one in four children. These findings are higher than are

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