Focus: Lessons learned
Since 1995, UNICEF has supported countries in tracking progress in key areas of children’s and women’s well-being through the Multiple Indicator Cluster Surveys (MICS). These nationally representative household surveys have been conducted in more than 100 low- and middle-income countries, and some have included a module designed to screen child disability. This information is now being built upon to design an improved measurement tool to assess child disability.
Disability became part of the MICS questionnaires in 2000–2001 (MICS2). Since then, data on disability have been collected through more than 50 surveys, making the MICS the largest source of comparable data on child disability in low- and middle-income countries.
The standard disability module included in MICS surveys conducted between 2000 and 2010 is the Ten Questions Screen (TQ), which was developed as part of the International Pilot Study of Severe Childhood Disability in 1984. Its design reflects how disability was understood and measured at the time.
The TQ process starts with an interview with the primary caregivers of children aged 2–9 years, who are asked to provide a personal assessment of the physical and mental development and functioning of the children under their care. Questions include whether the child appears to have difficulty hearing; whether she or he seems to understand instructions, has fits or loses consciousness; and whether she or he was delayed in sitting, standing or walking compared to other children. Response categories do not accommodate nuances, and children are classified as screening positive or negative to each question.
The validity of the Ten Questions approach has been widely tested, but results must be interpreted with caution. The TQ is a screening tool, and requires follow-up medical and developmental assessment in order to yield a reliable estimate of the number of children in a given population who have disabilities. Children who have a serious disability are very likely to screen positive, but some who screen positive may be found to have no disability on further evaluation. Some children who screen positive may do so because of temporary health conditions that can be easily treated. Although the TQ comes with a recommendation that it be followed by an in-depth assessment, few countries have had the budgets or capacity to conduct the second-stage clinical assessment to validate results, and they have been further hampered by the lack of a standardized methodology for conducting the assessment.
Applying the Ten Questions Screen during the 2005–2006 MICS yielded a wide range of results across participating countries: The percentage of children who screened positive for disability ranged from 3 per cent in Uzbekistan to 48 per cent in the Central African Republic. It was not clear whether this variance reflected true differences among the populations sampled or additional factors. For instance, the low reported rate in Uzbekistan might have reflected, among other things, a large population of children with disabilities living in institutions, which are not subject to household surveys.