UNICEF/WG MODULE ON CHILD FUNCTIONING: TESTING and ANALYSIS

Content and structure Questions ask about difficulties the child may have in doing certain activities Questionnaires for children 2-4 and 5-17 Response categories (with the exception of behavior (2-4) and emotions (5-17) are: No difficulty Some difficulty A lot of difficulty Cannot do at all

Domains of Functioning Seeing 2-17 years Hearing 5-17 years Mobility 2- 4 years Self-care Fine motor Communication/Comprehension Learning Remembering Emotions: anxiety and depression Controlling behaviour Focusing attention and concentrating Coping with change Relationships Playing

Cognitive Testing Cognitive testing January 2013, Belize April 2013, Oman July 2013, Montenegro 2012/13/14/15/16, USA March 2016, India April 2016, Jamaica Comparative report completed and decisions made on final set of questions included in field testing

Cognitive testing of the child functioning module Child disability questions perform differently than adult disability questions due to: Parent proxy Parent’s knowledge of “what is normal” for children of the same age Relationship between parent and child Parental frustration with child Potential for false positives. Domains most sensitive to false positives : those that generate parent frustration (learning/remembering, communication, attention/completing a task)

Cognitive testing of the child functioning module Relevance of comparison with other children of the same age: respondents do not always make this comparison/such comparison is not always possible. Domains most likely to be effected: Self-care, Emotions, Attention Responses “some difficulty” may lead to false positives Questions were modified to reduce risks of bias, clarify concepts and facilitate interview process

Example Hearing Domain: Round #1 Does [name] have difficulty hearing? This question is intended to focus on auditory hearing. Many respondents, however, focused on listening. Round #2 Does [name] have difficulty hearing sounds like peoples’ voices or music?

Example of possible constructs Compared with children of the same age, does [name] have difficulty with self-care such as feeding or dressing him/herself? Activities Considered by Respondent General Conceptualization Physical capability of child to do an array of complex activities including feeding, dressing, bathing, combing hair, getting in and out of bed Only Feeding Physical capability of child to feed themselves Willingness of child to eat what he/she is given; whether child is a “fussy” eater Only Dressing Physical capability of child to put on clothes Willingness of child to wear appropriate clothing Both Feeding and Dressing Physical capability of child to feed and dress themselves Willingness of child to eat what he/she is given coupled with the willingness of child to wear appropriate clothing Visual Representation of Thematic Schema

Field Testing Independent field testing on earlier version of the module completed in Haiti (Brown University, 2013), Cameroon & India (London School of Hygiene and Tropical Medicine, 2013), and Italy (NSO, 2013) Field testing of complete version of the module in Samoa (NSO, 2014) and El Salvador (NSO, 2015) with technical assistance from UNICEF/WG Module also used in surveys in Zambia (National Disability Survey, 2014) and Mexico (MICS, 2016) Dedicated methodological work in Serbia (NSO, 2016)

Field test in Serbia Primary goal of the field test was to assess the performance of the Child Functioning module in the field Secondary goal was to compare: the 2-4 year old questionnaire of the Child Functioning module with the 2-4 year old questionnaire of the Ten Questions (TQ) module the 5-17 year old questionnaire of the Child Functioning module with the 5-17 year old questionnaire of the Washington Group short set of questions.

Feedback from interviewers Questions to be filled out by interviewers at the time of the survey, right after the corresponding questions asked whether the interviewer had to repeat the question whether the respondent asked for clarifications of words or concepts whether the respondent had difficulties with response categories

Findings Questionnaire administered without any major problems Reactions of the respondents were mostly neutral to positive Repetitive to read out loud response categories Developed recommendations on implementation: one randomly selected child per household in countries with high levels of fertility No need to repeat responses categories after first set of questions unless needed

Cut-offs (recommended for international comparisons) For questions that use the standard WG response options: no difficulty, some difficulty, a lot of difficulty and cannot do at all – cut-off for inclusion is set at a lot of difficulty or cannot do at all For controlling behavior (2-4) cut-off for inclusion is set at a lot more For emotions (5-17) the most severe cut-off (daily) is used Overall measure: % of children with functional difficulties in at least one domain

Analysis of findings from testing Within range disability prevalence obtained across the different settings Similar patterns in terms of characteristics of the population of children with functional disability Most common functional difficulties across contexts: controlling behavior, managing emotions, learning

Prevalence rates by different cut-offs Cut-offs - at least one domain coded as: Age Prevalence Samoa Serbia Some difficulty, A lot of difficulty, or Cannot do at all Weekly or Daily (anxiety and depression: 5-17) More or A lot more (controlling behavior) MILD - SEVERE 2-4 15.5 9.4 5-17 9.0 25.0 2-17 10.4 22.7 A lot of difficulty or Cannot do at all Daily (anxiety and depression: 5-17) MODERATE - SEVERE 2.9 3.8 4.3 4.5 4.0 Samoa, 2015 / Serbia, 2016

Disability by School attendance Ever attended school Prevalence Without disability With disability YES 96.4 90.8 NO 3.6 9.2 Samoa, 2015

Child Functioning Module Results across modules   Children aged 2-4 Children aged 5-17 Child Functioning Module TQSI WG Short Set Seeing 0.5 0.6 0.3 Hearing 0.0 0.2 Walking 0.8 Learning/Cognition 9.1 0.9 Self-Care NA Understanding 2.1 Being understood/ Communicating 4.4 0.4 TOTAL PREVALENCE (using all the questions in the modules) 3.8 18.4 3.5 1.3 Serbia, 2016

Conclusions Questions carefully drafted to reflect multitude of domains and reduce risk of missing out children with different functional difficulties Domains are not meant to be looked at in isolation Questions carefully tested and cut-offs selected to reduce risk of false positives Not recommended to reduce number of questions, change response categories, modify content or change cut-offs