Establishment of Shishu Bikash Kendra in Secondary and Tertiary Hospitals

 

Line Directorate: Improved Hospital Services Management
Directorate: Hospitals and Clinics
DGHS, Mohakhali, Dhaka

National Co-ordinator
Naila Zaman Khan
MBBS, FCPS, PhD (London)
Professor and Head, Department of Pediatric Neurosciences
Dhaka Shishu Hospital

Summary

•       Multidisciplinary (physician, psychologist, therapist) Shishu Bikash Kendra’s have been established in 10 medical college hospitals (MCHs) in 2009 and 2010, including: Dhaka MCH, Suhrawardy MCH, Salimullah MCH, Sylhet MCH, Barisal MCH, Chittagong MCH, Rajshahi MCH, Khulna MCH, Rangpur MCH, and Mymensingh MCH. Increasing numbers of children with a range of developmental problems, impairments and disabilities are benefitting from the service which emphasizes on follow up visits, and functional improvements in motor, vision, hearing, speech, cognition, behavioral domains, and comprehensive management of seizure disorders. Professionals work closely with the family to optimize every child’s developmental potential, improve their quality of life, and prevent disability. Services in the following MCHs are expected to become operational from February 2014: Cox’s Bazaar MCH, Comilla MCH, Bogra MCH, Faridpur MCH, Dinajpur MCH.
•        In January – June 2013 a country-wide epidemiological survey of autism and neurodevelopmental disorders was conducted by the government where the SBK professionals had an active field involvement. Based upon the findings of the survey a scaled up program to provide neurodevelopmental surveillance of all children across vulnerable communities, especially all metropolitan urban areas,  is planned where SBKs are to be utilized as referral centers. 

Objectives

To prevent disability, optimize development and improve quality of survival of all children in Bangladesh.

Aims

To establish child and family-friendly Shish Bikash Kendro’s (SBK) within key public hospitals across the country.
To procure and train a core team of multidisciplinary professionals, including child health physicians, child psychologists, and developmental therapists, to provide services within these centers.
To apply stardardized tools, methodologies and strategies for early screening, assessment, intervention, treatment and management of the entire range of developmental delays, disorders, impairments and disabilities.
To conduct epidemiological surveys and clinical research with the aim of providing an evidence based health service delivery system and identify causal risk factors to help towards prevention of major childhood disabilities.
To provide psychosocial services to families and empower parents and primary care-providers to optimize their child’s development.
To provide training and strategies to establish linkages with primary health care services.
To develop a digital data-base of information related to child development and disability across Bangladesh.

THE MULTIDISCIPLINARY TEAM

Office Manager/Computer Operator: for record-keeping and epidemiological surveillance,maintaining clnical records

Cleaner: for simulating the home-situation and maintaining cleanliness

Location of 15 Shishu Bikash Kendra’s by FY of establishment


1.  Dhaka Medical College Hospital, Dhaka 2.   Shahid  Shohrawardi Medical College  Hospital, Dhaka
3.  Sir Salimullah Medical College Hospital, Mitford, Dhaka 4.  Sylhet MAG Osmani Medical College Hospital, Sylhet
5.  Sher-e- Bangla Medical College Hospital, Barisal 6.  Chittagong Medical College Hospital, Chittagong
7.  Khulna Medical College Hospital 8.  Rajshahi Medical College Hospital
9.  Rangpur Medical College Hospital 10. Mymensing Medical College Hospital
11. Cox’s Bazar Medical College Hospital 12. Comilla Medical College Hospital
13. Bogra Medical College Hospital 14. Faridpur Medical College Hospital
15. Dinajpur Medical College Hospital  

WEEKLY SCHEDULE

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am
‘More Than Words’  (MTW) Clinic  Seating and Feeding Clinic (SFC) Low Vision Clinic (LVC) Speech, Language  and Communication (SLC) Clinic Epilepsy/ Encephalopathy  Clinic Well Baby Clinic (WBC)
Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA)
Tea Break: 11.30 to 12 noon
12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm
Psychological Assessment (PA)
Walk-In Clinic (WC)
Psychological Screening (PS) With

General Developmental Assessment (GDA) Clinic

Psychological Screening (PS) With

General Developmental Assessment (GDA) Clinic

Psychological Assessment (PA)
Walk-In Clinic (WC)
Psychosocial Counseling (PC)  and Mental  Health (MH)
Walk-In Clinic (WC)
Psychosocial Counseling (PC) and Mental Health (MH)
Walk-In Clinic (WC)

THE MULTIDISCIPLINARY TEAM

Abbreviations
GDA = General Developmental Assessment Clinic
WC = Walk-in Clinic
PA = Psychological Assessment Clinic
WBC = Well Baby Clinic
MTW = More Than Words Clinic
SFC = Seating and Feeding Clinic
LVC = Low Vision Clinic
SLC = Speech Language Communication Clinic
DT = Developmental Therapy Clinic
MH = Mental Health Clinic
EP = Epilepsy Clinic
IPD = In-patients department
MDC = Multi-disability Clinic

Attendance by Clinic
First 5 SBKs: Aug '09 -Aug, 13; Last 5 SBKs: Sept '10 - Aug, 13

    Follow Up Clinic  
  GDA OPD   PA WBC IPD Total MTW MDC S+F  LV SLC DT EPI. PA OPD MH Total FU  Grand Total
Dhaka 1034 2337 939 347 36 4693 961 20 1974 915 1116 972 1995 455 612 545 9565 14258
Suhrawardi 542 2083 813 275 36 3749 44 34 55 63 237 464 511 320 453 158 2339 6088
Salimullah 886 2144 1168 118 162 4478 64 7 73 150 400 986 1334 532 66 82 3694 8172
Sylhet 1302 3624 837 76 128 5967 118 7 67 161 213 1737 153 100 321 31 2908 8875
Barisal 554 1841 770 99 31 3295 50 0 137 221 137 1858 183 1098 1851 66 5601 8896
Chittagong 405 2819 750 124 405 4503 62 0 192 200 418 1861 1701 382 1372 23 6211 10714
Rajshahi  125 3935 394 32 12 4498 59 21 22 16 41 3026 911 476 3094 27 7693 12191
Khulna  100 1617 206 20 38 1981 31 0 1 26 86 995 564 58 268 0 2029 4010
Rangpur  145 2295 278 9 9 2736 10 0 4 6 161 946 48 167 27 1 1370 4106
Mymensing  183 2729 288 64 281 3545 89 0 85 216 320 2212 300 84 2607 2 5915 9460
Total= 5276 25424 6443 1164 1138 39445 1488 89 2610 1974 3129 15057 7700 3672 10671 935 47325 86770
 

Number of Attendances in 10 SBKs by Clinic till March, 2011

note: data from 10 GDA Clinics, ie, those children who needed detailed multi-professional assessments

Do SBKs reach the ‘unreached’?

e.g., younger children, girl child, lowest income group

Name of medical college hospital

% less than two years of age

%  female

Monthly family income

<5000 Taka

Dhaka        N=303

55.44

31.9

66.67

Suhrawardy N=138

56.5

35.5

71.01

Salimullah  N=224

43.75

42.4

58.04

Sylhet         N=443

54.8

42.43

63.88

Barisal       N=137

54.7

36.5

72.99

note: data from GDA Clinics, ie, those children who needed detailed multi-professional assessments

 


sbk photo gallery

Shishu Bikash Kendra, Dhaka Medical College Hospital

   
GDA of child with cerebral palsy by Physician and Therapist    
     

Shishu Bikash Kendra, Sir Salimullah Medical College Hospital

   
Psychological Screening (PS) by Psychologist, during a GDA Clinic    
     

Shishu Bikash Kendra, Shaheed Suhrawardy Medical College Hospital

   
Well Baby Clinic (WBC): Neurodevelopmental Assessment of a newborn in the maternity ward  by therapist.  Physician and Psychologist look on.      
     

Shishu Bikash Kendra, MAG Osmany Medical College Hospital, Sylhet

More Than Words (MTW) Clinic for Autism Psychological Assessment (PA) Low Vision Clinic  (LVC)
     

Shishu Bikash Kendra, Sher-e-Bangla Medical College Hospital, Barisal

   
Family with a disabled child attending  the SBK    
     

Shishu Bikash Kendra, Chittagong Medical College Hospital

 
Developmental Therapy Clinic, with psychologist and evaluation team observing National Co-ordinator’s monitoring team in Chittagong SBK  
     

Shishu Bikash Kendra, Khulna Medical College Hospital

 
Developmental Therapist  assessing motor skills Cognitive assessment by child psychologist  
     

Shishu Bikash Kendra, Rajshahi Medical College Hospital

   
The SBK Team: Child Health Physician, Child Psychologist, Developmental Therapist, Office Manager and Cleaner    
     

Shishu Bikash Kendra, Rangpur Medical College Hospital

 
Psychometric Testing by the Child Psychologist General Developmental Assessment by Child Health Physician, Child Psychologist and Developmental Therapist in a child with suspected Autism Spectrum Disorder  
     

Shishu Bikash Kendra, Mymensingh Medical College Hospital

 
Child Health Physician and Developmental Therapist assessing a child’s visuo-motor functions Notice in general OPD to raise awareness regarding SBK services  
 

 


Evaluation of SBK Services

By
Prof. Helen McConachie
Professor of Clinical Psychology
Newcastle University
and
Dr. Alison Salt
Head, Clinical Neurodisability Services
Great Ormond Street Hospital for Children
Institute of Child Health
University College Hospital, London
28 April – 7 May 2011

Evaluation of Services: SBK Suhrawardy MCH, Dhaka, 30 April, 2011

     

Evaluation of Services: SBK, Osmany MCH, Sylhet, 2 May 2011

     

Evaluation of Services: SBK, Salimullah MCH, 3 May, 2011

     
     

Evaluation of Services: SBK, Dhaka MCH, 3 May, 2011

     

Evaluation of Services: SBK, Chittagong MCH, 4 May, 2011

   
     

Evaluation Feedback to the Trainers, Department of Pediatric Neuroscience, Dhaka Shishu Hospital, 5 May, 2011

   
     

Meeting at the Line Director’s Office, Improved Hospital Services Management, Hospitals and Clinics, DGHS, 5 May, 2011

   
     
 

 


Epidemiological Survey of
Childhood Impairments and
Disabilities around
5 Medical College Hospitals

January to June,  2010
Funded by: Planning and Research Line Directorate, DGHS

Study Children: 0-9 years old By door to door survey of underprivileged population living nearest to the MCH

Developmental Screening Questionnaire (DSQ) for 0-<2 years; Ten Questions Plus (TQP) for 2-9 year olds, asked to mothers by community workers

Children: Gender Ratio in screened children compared to those availing services in SBKs

Children: proportion <2 years versus =>2 years in survey and <2 year olds availing SBK services

% screened positive for NDIs by age group

2-9 year olds at-risk for NDIs = 8.9%
0-<2 year olds at-risk for NDIs = 6.2%
0-9 year olds at-risk for NDIs = 7.5%

% screened positive for NDIs by age group

Screen positive by child’s gender: 2-9 year olds

Prevalence of Neurodevelopmental Impairments

 
DMCH
Salimullah
Suh'wrdy
Sylhet
Barisal
Standard Error

.06

.03

.04

.02

.20

Prevalence per 1000 children

63

90

46

20

97

95% Confidence Interval, Upper - Lower

51-75

85-95

38-54

16-24

57-137

Mean Prevalence = 63 per 1000 (analysis weighted for children not assessed in second stage)

Executive Summary 1

Household Survey

41% were low income (income 3000-5000 Taka)
9.2% were ultra poor (income <3000 Taka)
36% were unskilled workers
6% were female-headed households
42% household head never had schooling
All had =>1-5 decimals of land, except 58% surveyed around Sir Salimullah MCH who had none
93% drank piped water, except in Barisal, where only 3% had this facility
95% used sanitary latrine, except Sylhet, where only 35% had this facility
98% used iodized salt in their food
 

Executive Summary 2

Mother-child Survey

42% had no schooling, lowest in Barisal (13%), highest in Sylhet (67%)
30% had attended primary school, highest in Barisal (37%), lowest in Sylhet (15%)
46% could not read, lowest in Barisal (22%), highest in Sylhet (67%)
75% ‘housewives’, highest around DMCH (82%), lowest in Barisal (64%)
77% did not earn wages, lowest in Barisal (66%), highest around DMCH (87%)
8% consanguinity, highest around Kamrangirchar, Sir Salimullah MCH (15%), lowest in Barisal (1%)
Mean live births =2; highest around Kamrangirchar (2.6), lowest in Geneva Camp (0.17)
 

Executive Summary 3

Children’s Survey Outcomes

Male: Female ratio 1.1, with most disparity in Sylhet (1.3) and negative ratio in Barisal (0.96)
9% disparity between female population in community and those availing services, with minimum disparity in Sylhet (3%), maximum in Salimullah (13%)
19% more <2 year olds, however, seeking SBK services than their proportion in the community survey
9% children aged 2-9 years screened positive for impairments, highest around Suhrawardy (12%), lowest in Sylhet (3%)
6% children aged 0-<2 years screened positive for impairments, highest around Salimullah (13%), lowest in Sylhet (1%)
 

Executive Summary 4

Children’s Survey Outcomes, continued

Higher screen-positivity within low income groups, highest in Suhrawardy (56% in the 3000 to 5000 taka group), lowest in DMCH (2% within the >15000 taka group)
11% higher likelihood of  screen positivity in female-headed households in Dhaka city, with maximum around Salimullah (18%)
No difference in screen positivity within gender categories, in both older and younger children.
 

Executive Summary 5

Risk factors for Screen Positivity

Significant risk factors were related to the following:
–DMCH:
female headed household,  unskilled worker, kutcha house, no land ownership, no source for tapped water, and no sanitary latrine.
Maternal factors: if ‘housewife’
 
–Salimullah:
low monthly income, kutcha house, no loan facilities, poor source of drinking water, and large numbers using one toilet facility
Maternal factors: poor schooling, does not work, no wages, no loans
 
–Suhrawardy:
low monthly income, no land ownership, no consumer items in the house
Maternal factors: none significant
 
–Sylhet:
Low monthly income, no bicycle
Maternal factors: none significant
 
–Barisal
No land ownership, kutcha house, no bicycle
Maternal factors: Cannot read or reads with difficulty
 

Executive Summary 6

Prevalence of Childhood Neurodevelopmental Impairments and Disabilities

63 per 1000 children were found to have => one neurodevelopmental impairment across the five study sites
Highest in Barisal (96 per 1000) and around Salimullah MCH, ie on the banks of the river Buriganga in Kamrangirchar (90 per 1000); lowest in Sylhet (20 per 1000). Data could be skewed due to less attendance of screen negatives.
Covert’ or ‘unrecognised’  impairments were most commonly diagnosed in the assessed children. These were:
   
 
–DMCH: Cognition (67%), Gross Motor (24%)
 
–Salimullah: Cognition (55%), Speech (18%)
 
–Suhrawardy: Cognition (24%), Gross Motor (19%)
 
–Sylhet: Cognition (24%), Speech (24%)
 
–Barisal: Seizures (30%), Cognition (24%)
 

Executive Summary 7

Associated Factor: Stunting

41% assessed children were stunted
Highest around Salimullah (57%) and DMCH (52%), and lowest in Sylhet (18%)
 

Study Limitations

Numbers per site were too small for estimating risk factors. They need to be pooled together for further analysis.
Over half of children (screen positives and controls) could not be assessed at the SBKs as they either defaulted (parent’s could not be convinced to bring their children)
 

Study Implications 1

Door to door surveys by CWs are able to find most vulnerable populations of children, ie, lowest income/poorest, younger, girl child, and those with unrecognized developmental delays and impairments. Establish social equity.
Poverty-related factors have significant association with children at-risk for NDIs (Islam et al, 1995; Durkin et al, 2000; Grantham-McGregor et al, 2007)
Dhaka city poor have most significant associations between poverty and risk for NDIs
Children from female-headed households are more vulnerable; also whose mothers are unable to read; those without a job or source of income.
 

Study Implications 2

One in ten children  will screen positive for a NDI of whom an estimated two-third may have a definite impairment on further assessment.
Commonest impairments are ‘covert’ ‘unrecognized’ ‘not apparent’ to parents, ie, related to cognitive deficits, speech delay.
Close links with stunting (Walker et al, 2007), which is prevalent in almost half of the assessed children. 
 
–Largest implication for school enrollment and dropout, where 48% do not complete primary school (Bangladesh Education Watch, 2008)
NO SURVEY WITHOUT SERVICES: As this increases maternal stress and their psychiatric morbidity (Khan et al, 2010)
Need for services and early intervention found in this study, as ratio of <2 year olds brought to SBKs more than their ratio found in the community.
 

Study Implications 3

Multidisciplinary Shishu Bikash Kendra’s close to the community may be able to reverse >80% of these children’s impairments (Operational Plan, HNPSP, DGHS, MOHFW)
Large prospective studies are needed to provide such an evidence within Bangladesh
Field workers can be taught to administer the simple validated questionnaires  used in this study, in children’s homes, to screen children for early NDIs. For example in 13500 working from Community Clinics.
Screen-positive children can be assessed at home or within their community by CWs, using tools validated by Bangladeshi researchers (Khan et al, 2010; Khan et al, awaiting submission). Simple home-based interventions (eg. ‘positive parenting’, interactive play, story telling), validated in many studies world-wide (Maulik and Darmstadt, 2009), may be applied to these children
 

Conclusion

Home-based screening and early intervention to establish a tiered system of referral will be able to provide a ‘DEVELOPMENTAL SAFETY NET’ and an ‘INTEGRATED MANAGEMENT OF CHILD DEVELOPMENT’ (IMCD) for all children in Bangladesh
 

References

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