IJE Advance Access originally published online on July 17, 2006
International Journal of Epidemiology 2006 35(4):1103; doi:10.1093/ije/dyl161
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Letter to the Editor |
Revisiting the ten questions questionnaire for developing countries
1 Developmental Paediatrician, Institute of Child Health and Primary Care, College of Medicine, University of Lagos, Nigeria.
2 Academic Unit of Audiological Medicine, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.
3 Department of Paediatrics & Community Child Health, University of Benin Teaching Hospital, Benin City, Nigeria.
* Corresponding author. E-mail: boolusanya{at}aol.com
Dear Sirs - The study by Mung'ala-Odera et al.1 is a rare and commendable attempt to establish the burden of sensory and motor disabilities/impairments in childhood in developing countries given its large sample size and the two-stage protocol.1 However, the continued use of the Ten Questions Questionnaire (TQQ), which relies on verbal reports from parents/guardians, for ascertaining the burden of impairments like hearing loss may not be appropriate for a number of reasons.
First, the TQQ was introduced in 1984 as a stop-gap for the identification of developmental disabilities in resource-poor countries in the absence of objective assessment tools and the dearth of skilled manpower. The various studies that followed over the next decade in countries like Bangladesh, Jamaica, and Pakistan justified its usefulness then as a basic screening tool and for providing baseline data. Subsequently, the World Health Assembly (WHA) in 1995 passed a resolution recognizing the urgent need for the early detection of hearing impairment in ‘babies, infants and toddlers’ in view of the vital importance of early intervention.2 The development of objective, simple-to-use and reliable tools like automated otoacoustic emissions and auditory brainstem response in the last decade has made it possible to detect hearing impairment from birth by non-specialists and also provided a basis for gathering more reliable epidemiological data. Second, as have been well documented, the TQQ is highly limited for describing the burden of sensory or hidden disabilities that are congenital or acquired soon after birth. Neither does its application at 6–9 years of age offer any window of opportunity for effective intervention, which raises a vital ethical issue about the value of detecting such impairments at this stage.3 In fact, practices towards childhood disabilities have remained largely unchanged in countries where the TQQ had long been administered. Third, within the context of the millennium development goal of ensuring that every child completes full primary education as against mere school enrolment, any tool that focuses only on children with moderate-to-severe disabilities will disenfranchise children who are likely to be impeded educationally by mild sensory impairments.4 Finally, the value of TQQ as it relates to childhood hearing impairment is also questionable in view of the growing number of developing countries already striving towards the implementation of the WHA resolution for early hearing detection and intervention.5,6 In some of these countries, the feasibility of community-based infant hearing screening by non-specialists has been demonstrated.
Given current evidence/possibilities for timely hearing detection and intervention, communities should be well-informed, guided and encouraged to develop relevant capacities towards best practices in hearing healthcare delivery.7,8 Since the WHA resolution, the World Health Organisation in partnership with some international agencies like Christofell-Blindenmission (CBM) has taken crucial steps in this direction and these need to be complemented by current research initiatives.9 The wide diversity in the income profile within and across the 164 countries that make up the developing world would suggest that modern and objective screening estimated at between US$4.00 and US$7.00 per child is affordable in many countries, particularly among the urban population. The continued reliance on TQQ without systematic efforts aimed at early hearing detection for timely and effective intervention even in rural settings may, therefore, undermine global progress in affording children in the developing world the best start in life.10
Conflict of interest: None declared.
References
1 Mung'ala-Odera V, Meehan R, Njuguna P, Mturi N, Alcock KJ, Newton CRJC. Prevalence and risk factors of neurological disability and impairment in children living in rural Kenya. Int J Epidemiol 2006;35:683–88.
2 World Health Organisation. Prevention of hearing impairment. Resolution of the 48th World Assembly, WHA 48.9. Geneva: WHO, 1995.
3 Joint Committee on Infant Hearing. Year 2000 Position Statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000;106:798–817.
4 Bess FH, Dodd-Murphy J, Parker RA. Children with minimal sensorineural hearing loss: prevalence, educational performance and functional status. Ear Hear 1998;19:339–54.[Web of Science][Medline]
5 Olusanya BO, Luxon LM, Wirz SL. Screening for early childhood hearing loss in Nigeria. J Med Screen 2005;12:115–18.[CrossRef][Web of Science][Medline]
6 Swanepoel DW, Hugo R, Louw B. Infant hearing screening at immunization clinics in South Africa. Int J Pediatric Otorhinolaryngol 2006;70:1241–49.[CrossRef]
7 Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early and later-identified children with hearing loss. Pediatrics 1998;102:1161–71.
8 Kennedy CR, McCann DC, Campbell MJ et al. Language ability after early detection of permanent childhood hearing impairment. N Engl J Med 2006;354:2131–41.
9 World Health Organisation. Guidelines for hearing aids and services for developing countries. Geneva: WHO, 2001.
10 United Nations Children's Fund (UNICEF). Facts for life. New York: UNICEF, 2002.
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