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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.
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