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

BMC Pediatrics, Volume 12, Year 2012

Interpretação

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. © 2012 Kawakatsu et al.; licensee BioMed Central Ltd. This study was conducted in Gembe West, Gembe East, Rusinga West and Rusinga East, Mbita district, Nyanza province, Kenya, located on the lakeside of Lake Victoria. This is one of the poorest areas in Kenya [20] and the residents are primarily, subsistence farmers or fishermen. Moreover, this area has one of the highest prevalence rates of malaria and HIV infection [21]. Health and Demographic Surveillance System (HDSS) project in this area is being conducted by Kenya Medical Research Institute (KEMRI) – Nagasaki University Institute of Tropical Medicine (NUITM) project [22]. The research population consisted of the all 6263 children, aged 6–9 years, and their caregivers in research site. Their main tribe is the Luo tribe and their main languages are Luo language, followed by Swahili and English. The age group of 6–9 years was selected because of difficulties in identifying impairments in children younger than 6 years old and the lack of cross-cultural assessment tools for cognitive impairment in young children. In phase one, we targeted all 6263 caregivers of children aged 6–9 years in the research area. The sample size for phase two was calculated according to L.Naing [23]. With estimated prevalence of CWDs in Kenya (10%), confidence level of 95% and with a relative precision of 2.5% points on each side, a sample of 813 children was needed. This study was population based cross-sectional survey conducted from April 2009 to November 2010. There were two phases in this research. In phase one, the Ten Question Questionnaire (TQQ) was administered to all 6263 caregivers of children aged 6–9 years in April 2009 (Figure 1). In phase two, all children (413) with at least one positive response in TQQ and a similar number of children (420), randomly selected from those who had all negative response in TQQ were selected. Total 833 children were examined using the physical, neurological and cognitive assessments. A structured questionnaire on socio-demographic characteristics and potential risk factors for NI was also conducted to their caregivers in November 2010. In this study, birth difficulty was defined as any difficulties such as heavy bleeding, strange breech positioning, or asphyxia at the birth. Neonatal insult was defined by a positive history of tetanus, jaundice, sepsis or any other severe infection during the neonatal period. Study procedure. In phase one, we performed TQQ to all 6263 caregivers who has children aged 6-9 years. There were 413 children with TQQ positive and 5850 with negative. In phase two, all children with positive response (413) and a similar number of children with negative (420) were conducted physical, neurological and cognitive assessments and their caregivers were administered structured questionnaire. Finally, 41 children with disabilities were identified. The Ten Questions Questionnaire (TQQ) developed by WHO is a convenient questionnaire focusing on the child’s functional abilities and is used to detect NI among children aged 2–9 years in community settings [24]. TQQ has been used widely to screen for childhood impairment in low- and middle-income counties [9,12,14]. The validity of the TQQ has been reported in some countries such as Bangladesh [25], Jamaica [25], Pakistan [25], India [26] and Kenya [27]. We conducted one day training to research assistants to improve their understanding on this question. Although most of the participants could understand English in this area, the questionnaire was translated into Luo language in case that they could not understand English. The word of NI mentioned in this research belongs to body functions & structures part in the International Classification of Functioning, Disability, and Health (ICF) and contained cognitive impairment, physical impairment, epilepsy, hearing impairment and visual impairment. The assessments to diagnose NI included physical examination [28] including measurement of height and weight to assess motor impairment and a vision test (Landolt Chart) [29]. Hearing test by three screening tests (Behavioral Observation Audiometry (BOA): bell-tone, paper crash test, small voice) was also performed. Almost quarter subjects in phase 2 were re-checked by using an audiometer [30] (KS8: PC Werth Ltd) . In addition, the diagnosis of epilepsy was based on the history gathered from their caregivers about the child’s epilepsy-like symptoms. Cross-cultural cognitive assessment was also used [31]. This cognitive assessment included seven batteries which tested verbal and non-verbal skills, namely, “Digit span (phonological loop component of working memory)”, “Corsi Block ( operational skill of the visuospatial sketch-pad component of working memory)”, “Verbal fluency (retrieval function from long term memory)”, “Silly sentence (general intelligence and speed of access to semantic memory)”,”Visual search (speed of visual information processing)”, “Free recall (Long term memory) [32]”, and ”Vocabulary learning (prose learning) [31]”. These seven cognitive assessments were performed for the target children. These seven cognitive assessments were analyzed by using factor analysis and summarized as factor 1 and 2. Factor one significantly correlated with Digit span, Visual search, Silly sentence, and Free recall, while factor two significantly correlated with Corsi block, Verbal fluency. Finally, all suspected cases by using above assessments were re-evaluated by a physical therapist. Severe cognitive impairment was defined as the inability to successfully perform even one of the cognitive assessment batteries. Moderate cognitive impairment was defined on the basis of the two factor’s scores. The cutoff point was established as less than 1% of each factor scores in 296 children with negative response of TQQ. Since the factor scores were not associated with age and sex, age- or sex-specific cutoff points were not determined in the present study. For other domains, the definition of severity was shown in Table 1. Definitions of moderate and severe impairment a Adopted from WHO procedure manual. Data from all phases were double-entered after the verification of the data had been performed and stored using Epi info version 3.5. Statistical analysis was performed by using STATA version 10 (STATA Corporation, TX, USA). Factor analysis was used to refine factor structure in seven cognitive assessments. Thirteen variables were considered as the potential risk factors. The potential risk factors were dichotomized and coded. Moreover, these potential risk factors in children aged 6–9 years were analyzed using univariate analysis and linear logistic models with 13 potential factors as covariates. Starting with a logistic model including all of these covariates, we selected the most appropriate model on the basis of Akaike’s information criterion (AIC) [33]. Once the most appropriate model was selected, maximum likelihood estimation of the model parameters was conducted and then the odds ratio and the 95% confidence interval were calculated for each covariate in the model. Informed consents from all guardians of target children were obtained after fully explanation of the study purpose and possible consequences. This study was approved by the Ethical Review Committee of Kenya Medical Research Institute (KEMRI SSC No. 1088) and National Council for Science and Technology in Kenya (Approval number: NCST/RR1/12/1/SS/150/5). In addition, the ethical committee of the Institute of Tropical Medicine, Nagasaki University (Approval number: 06060604) and the ethics committee of International Health Development, Graduate School of Nagasaki University (Approval number: 0012) were approved this study.

AI Digest

Study Justification:

– The burden of disability is more severe among children in low-income countries.
– There are few research studies on risk factors of disabilities in sub-Saharan Africa.
– The number of children with disabilities in sub-Saharan Africa is predicted to increase with reduction in child mortality.
– The purpose of this study was to evaluate the risk factors of neurological impairment among children in western Kenya.

Study Highlights:

– The study was conducted in Mbita district, Kenya, which has high HIV infectious prevalence and is one of the poorest areas in the country.
– The prevalence of neurological impairment among children aged 6-9 years was estimated to be 29/1000.
– Cognitive impairment was the most common type of impairment (24/1000), followed by physical impairment (5/1000).
– Risk factors associated with neurological impairment included having more than five children, maternal age older than 35 years old, monthly income under 3000 ksh, and no maternal tetanus shot during antenatal care.
– Increasing coverage of antenatal care, including maternal tetanus shot, and education on how to take care of neonatal children to prevent neurological impairment are important.

Recommendations for Lay Reader and Policy Maker:

– Increase coverage of antenatal care services, including maternal tetanus shot, to reduce the risk of neurological impairment among children.
– Provide education and support to caregivers on how to take care of neonatal children to prevent neurological impairment.
– Allocate resources to improve healthcare infrastructure and services in low-income areas to ensure access to antenatal care and early interventions for children with neurological impairment.
– Implement policies and programs to reduce poverty and improve socio-economic conditions, as poverty was identified as a risk factor for neurological impairment.

Key Role Players:

– Ministry of Health: Responsible for implementing policies and programs related to maternal and child health, including antenatal care services.
– Healthcare providers: Involved in delivering antenatal care services and providing education and support to caregivers.
– Community health workers: Play a crucial role in reaching out to communities, providing education, and promoting access to healthcare services.
– Non-governmental organizations (NGOs): Can support the implementation of programs and interventions to prevent neurological impairment and improve the well-being of children with disabilities.

Cost Items for Planning Recommendations:

– Healthcare infrastructure: Budget for improving healthcare facilities and equipment in low-income areas to ensure access to quality antenatal care services.
– Training and capacity building: Allocate funds for training healthcare providers and community health workers on providing antenatal care and education to caregivers.
– Awareness campaigns: Budget for raising awareness among the community about the importance of antenatal care and early interventions for children with neurological impairment.
– Support services: Allocate resources for providing support services to caregivers of children with disabilities, including counseling, therapy, and assistive devices.
– Poverty reduction programs: Invest in poverty reduction programs to improve socio-economic conditions and reduce the risk of neurological impairment among children.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study was conducted in a specific region in Kenya, which limits its generalizability. However, the study design was cross-sectional and included a large sample size, which increases the reliability of the findings. To improve the strength of the evidence, future studies could consider conducting a longitudinal study to establish causality and include a more diverse population to enhance generalizability.

Resumo

This study was conducted in Gembe West, Gembe East, Rusinga West and Rusinga East, Mbita district, Nyanza province, Kenya, located on the lakeside of Lake Victoria. This is one of the poorest areas in Kenya [20] and the residents are primarily, subsistence farmers or fishermen. Moreover, this area has one of the highest prevalence rates of malaria and HIV infection [21]. Health and Demographic Surveillance System (HDSS) project in this area is being conducted by Kenya Medical Research Institute (KEMRI) – Nagasaki University Institute of Tropical Medicine (NUITM) project [22]. The research population consisted of the all 6263 children, aged 6–9 years, and their caregivers in research site. Their main tribe is the Luo tribe and their main languages are Luo language, followed by Swahili and English. The age group of 6–9 years was selected because of difficulties in identifying impairments in children younger than 6 years old and the lack of cross-cultural assessment tools for cognitive impairment in young children. In phase one, we targeted all 6263 caregivers of children aged 6–9 years in the research area. The sample size for phase two was calculated according to L.Naing [23]. With estimated prevalence of CWDs in Kenya (10%), confidence level of 95% and with a relative precision of 2.5% points on each side, a sample of 813 children was needed. This study was population based cross-sectional survey conducted from April 2009 to November 2010. There were two phases in this research. In phase one, the Ten Question Questionnaire (TQQ) was administered to all 6263 caregivers of children aged 6–9 years in April 2009 (Figure 1). In phase two, all children (413) with at least one positive response in TQQ and a similar number of children (420), randomly selected from those who had all negative response in TQQ were selected. Total 833 children were examined using the physical, neurological and cognitive assessments. A structured questionnaire on socio-demographic characteristics and potential risk factors for NI was also conducted to their caregivers in November 2010. In this study, birth difficulty was defined as any difficulties such as heavy bleeding, strange breech positioning, or asphyxia at the birth. Neonatal insult was defined by a positive history of tetanus, jaundice, sepsis or any other severe infection during the neonatal period. Study procedure. In phase one, we performed TQQ to all 6263 caregivers who has children aged 6-9 years. There were 413 children with TQQ positive and 5850 with negative. In phase two, all children with positive response (413) and a similar number of children with negative (420) were conducted physical, neurological and cognitive assessments and their caregivers were administered structured questionnaire. Finally, 41 children with disabilities were identified. The Ten Questions Questionnaire (TQQ) developed by WHO is a convenient questionnaire focusing on the child’s functional abilities and is used to detect NI among children aged 2–9 years in community settings [24]. TQQ has been used widely to screen for childhood impairment in low- and middle-income counties [9,12,14]. The validity of the TQQ has been reported in some countries such as Bangladesh [25], Jamaica [25], Pakistan [25], India [26] and Kenya [27]. We conducted one day training to research assistants to improve their understanding on this question. Although most of the participants could understand English in this area, the questionnaire was translated into Luo language in case that they could not understand English. The word of NI mentioned in this research belongs to body functions & structures part in the International Classification of Functioning, Disability, and Health (ICF) and contained cognitive impairment, physical impairment, epilepsy, hearing impairment and visual impairment. The assessments to diagnose NI included physical examination [28] including measurement of height and weight to assess motor impairment and a vision test (Landolt Chart) [29]. Hearing test by three screening tests (Behavioral Observation Audiometry (BOA): bell-tone, paper crash test, small voice) was also performed. Almost quarter subjects in phase 2 were re-checked by using an audiometer [30] (KS8: PC Werth Ltd) . In addition, the diagnosis of epilepsy was based on the history gathered from their caregivers about the child’s epilepsy-like symptoms. Cross-cultural cognitive assessment was also used [31]. This cognitive assessment included seven batteries which tested verbal and non-verbal skills, namely, “Digit span (phonological loop component of working memory)”, “Corsi Block ( operational skill of the visuospatial sketch-pad component of working memory)”, “Verbal fluency (retrieval function from long term memory)”, “Silly sentence (general intelligence and speed of access to semantic memory)”,”Visual search (speed of visual information processing)”, “Free recall (Long term memory) [32]”, and ”Vocabulary learning (prose learning) [31]”. These seven cognitive assessments were performed for the target children. These seven cognitive assessments were analyzed by using factor analysis and summarized as factor 1 and 2. Factor one significantly correlated with Digit span, Visual search, Silly sentence, and Free recall, while factor two significantly correlated with Corsi block, Verbal fluency. Finally, all suspected cases by using above assessments were re-evaluated by a physical therapist. Severe cognitive impairment was defined as the inability to successfully perform even one of the cognitive assessment batteries. Moderate cognitive impairment was defined on the basis of the two factor’s scores. The cutoff point was established as less than 1% of each factor scores in 296 children with negative response of TQQ. Since the factor scores were not associated with age and sex, age- or sex-specific cutoff points were not determined in the present study. For other domains, the definition of severity was shown in Table 1. Definitions of moderate and severe impairment a Adopted from WHO procedure manual. Data from all phases were double-entered after the verification of the data had been performed and stored using Epi info version 3.5. Statistical analysis was performed by using STATA version 10 (STATA Corporation, TX, USA). Factor analysis was used to refine factor structure in seven cognitive assessments. Thirteen variables were considered as the potential risk factors. The potential risk factors were dichotomized and coded. Moreover, these potential risk factors in children aged 6–9 years were analyzed using univariate analysis and linear logistic models with 13 potential factors as covariates. Starting with a logistic model including all of these covariates, we selected the most appropriate model on the basis of Akaike’s information criterion (AIC) [33]. Once the most appropriate model was selected, maximum likelihood estimation of the model parameters was conducted and then the odds ratio and the 95% confidence interval were calculated for each covariate in the model. Informed consents from all guardians of target children were obtained after fully explanation of the study purpose and possible consequences. This study was approved by the Ethical Review Committee of Kenya Medical Research Institute (KEMRI SSC No. 1088) and National Council for Science and Technology in Kenya (Approval number: NCST/RR1/12/1/SS/150/5). In addition, the ethical committee of the Institute of Tropical Medicine, Nagasaki University (Approval number: 06060604) and the ethics committee of International Health Development, Graduate School of Nagasaki University (Approval number: 0012) were approved this study.

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women with information and reminders about prenatal care, vaccinations, and nutrition. These tools can also be used to connect women with healthcare providers for virtual consultations or to schedule appointments.

2. Telemedicine: Implement telemedicine programs that allow pregnant women in remote or underserved areas to access prenatal care through video consultations with healthcare providers. This can help overcome geographical barriers and improve access to specialized care.

3. Community Health Workers: Train and deploy community health workers to provide education, support, and basic prenatal care to pregnant women in their communities. These workers can help identify high-risk pregnancies and refer women to appropriate healthcare facilities.

4. Maternal Health Vouchers: Introduce voucher programs that provide pregnant women with financial assistance to cover the costs of prenatal care, delivery, and postnatal care. This can help reduce financial barriers and ensure that women receive the necessary healthcare services.

5. Maternal Health Clinics: Establish dedicated maternal health clinics in underserved areas to provide comprehensive prenatal care, delivery services, and postnatal care. These clinics can be staffed by skilled healthcare providers and equipped with necessary medical equipment.

6. Transportation Solutions: Develop transportation solutions, such as mobile clinics or ambulances, to ensure that pregnant women can easily access healthcare facilities for prenatal care, delivery, and emergency obstetric care.

7. Health Education Programs: Implement community-based health education programs that focus on maternal health, including topics such as nutrition, hygiene, and the importance of prenatal care. These programs can empower women with knowledge and help them make informed decisions about their health.

8. Maternity Waiting Homes: Establish maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away and need to travel for delivery. These homes can provide a safe and comfortable place for women to stay before and after giving birth.

9. Public-Private Partnerships: Foster collaborations between government agencies, non-profit organizations, and private sector companies to improve access to maternal health services. These partnerships can leverage resources, expertise, and technology to address the challenges faced in delivering maternal healthcare.

10. Data Collection and Monitoring Systems: Implement robust data collection and monitoring systems to track maternal health indicators, identify gaps in service delivery, and measure the impact of interventions. This data can inform evidence-based decision-making and help improve the quality and accessibility of maternal healthcare services.

AI Innovations Description

The study mentioned in the description focuses on the prevalence and risk factors of neurological impairment among children aged 6-9 years in western Kenya. The study found that cognitive impairment was the most common type of impairment, followed by physical impairment. The study identified several significant risk factors associated with neurological impairment, including having more than five children, maternal age older than 35 years old, monthly income under 3000 ksh, and no maternal tetanus shot during antenatal care.

Based on the findings of this study, a recommendation to improve access to maternal health and potentially reduce the risk of neurological impairment among children could be to increase the coverage of antenatal care, specifically emphasizing the importance of maternal tetanus shots. This could be achieved through various strategies, such as:

1. Strengthening healthcare systems: Improving the availability and accessibility of antenatal care services in low-income areas, like the study site in western Kenya, by increasing the number of healthcare facilities and trained healthcare providers.

2. Health education and awareness: Conducting health education campaigns to raise awareness among pregnant women and their families about the importance of antenatal care and the benefits of receiving maternal tetanus shots. This could include community outreach programs, workshops, and information dissemination through various media channels.

3. Collaboration and partnerships: Collaborating with local organizations, community leaders, and stakeholders to promote and support antenatal care services. This could involve establishing partnerships with community health workers, traditional birth attendants, and local clinics to ensure that pregnant women have access to the necessary care and vaccinations.

4. Financial support: Providing financial assistance or subsidies to pregnant women who may face financial barriers to accessing antenatal care services, including maternal tetanus shots. This could help alleviate the financial burden and encourage more women to seek the necessary care.

5. Monitoring and evaluation: Implementing a robust monitoring and evaluation system to track the coverage and impact of antenatal care services, including the administration of maternal tetanus shots. This would help identify any gaps or challenges in the implementation and allow for timely adjustments and improvements.

By implementing these recommendations, it is hoped that access to maternal health services, including maternal tetanus shots, can be improved, leading to a potential reduction in the risk of neurological impairment among children.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Increase coverage of antenatal care: This study found that not receiving a maternal tetanus shot during antenatal care was significantly related to having moderate/severe neurological impairment in children. Therefore, increasing the coverage of antenatal care services, including the provision of maternal tetanus shots, can help prevent neurological impairment in children.

2. Education on neonatal care: The study also indicated that education on how to take care of neonatal children is important in preventing neurological impairment. Providing education to expectant mothers and caregivers on proper neonatal care practices can help improve maternal and child health outcomes.

3. Improve access to healthcare services: The study was conducted in one of the poorest areas in Kenya, where access to healthcare services may be limited. Improving access to healthcare facilities, including maternal health clinics and hospitals, can ensure that pregnant women have timely access to necessary care and interventions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on improving access to maternal health. For example, indicators could include the percentage increase in antenatal care coverage, the percentage of women receiving maternal tetanus shots, or the reduction in the prevalence of neurological impairment among children.

2. Collect baseline data: Gather data on the current status of access to maternal health services and the prevalence of neurological impairment among children in the target population. This data will serve as a baseline for comparison.

3. Implement the recommendations: Implement the recommended interventions, such as increasing antenatal care coverage and providing education on neonatal care.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through surveys, interviews, or health facility records.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health. Compare the post-intervention data with the baseline data to determine any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas for improvement and make further recommendations for future interventions.

7. Disseminate findings: Share the findings of the impact assessment with relevant stakeholders, such as policymakers, healthcare providers, and community members. This can help inform decision-making and guide future efforts to improve access to maternal health.

Autor

Dima Health

Statistics:

Citations: 13

Identifiers:

DOI: 10.1186/1471-2431-12-186

Research Areas:

Community Interventions, Disability, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Social Determinants, Technology and Innovations

Study Countries:

Kenya

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

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