1. UNICEF/WG Module on Child Functioning

2. Development of the module
Purpose
To to identify the sub-population of children and youth (aged 2-17 years) with functional difficulties. These difficulties may place children at risk of experiencing limited participation in a non-accommodating environment
Aim
To provide cross-nationally comparable data
To be used as part of national population surveys or in addition to specific surveys (e.g., health, education, etc.)

3. Development of module
WG Workgroup on Child Functioning and Disability was established fall 2009 under the leadership of ISTAT (Italy)
UNICEF joined the Workgroup in early 2011
November 2011; 11th WG meeting in Bermuda - presentation of the literature review and first draft of questions
June 2012: Technical Consultation on the Measurement of Child Disability meeting hosted by UNICEF with disability/child development experts & survey experts
October 2012: 12th WG meeting - presentation of the revised module in preparation for field work
September : validation process through cognitive and field testing
Points taken from:
WG Samoa PP

4. Construction of module
Used the ICF biopsychosocial model
Avoided a medical approach
Used, when appropriate, questions already tested and adopted by the WG
Included the reference “Compared with children of the same age…”
Considered age specificity (2-4, 5-17)
Response options reflected disability continuum
Points taken from:
WG Samoa PP

5. Selected domains Seeing Hearing Mobility Self-care Communication
Learning
Emotions
Behaviour
Attention
Coping with change
Relationships
Playing

6. Development of the module
Questions ask about difficulties the child may have in doing certain activities
Unless noted otherwise, all response categories are:
No difficulty
Some difficulty
A lot of difficulty
Cannot do at all
Questions on vision/hearing and mobility include questions on the use of glasses/hearing aids/ assistance with walking

7. Cognitive Testing Cognitive testing (2012-2016) September 2012, India
January 2013, Belize
April 2013, Oman
July 2013, Montenegro
2012/2013/2014/2015/2016 (including testing on teens), USA
March 2016, India
April 2016, Jamaica
Points taken from:
WG Samoa PP

8. Field Testing Field testing (2013-2016)
Independent field testing on earlier version of the module or subset of questions completed in Haiti (Brown University, 2013), Cameroon & India (London School of Hygiene and Tropical Hygiene, 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, NSO, 2014) and Mexico (MICS, 2016)
Dedicated methodological work in Serbia (NSO, 2016)
Points taken from:
WG Samoa PP

9. India: field test with medical follow-up
227 parent interviews between November 2012-February 2013
2 stage process:
Stage 1: Administration of Child Functioning module to a sample of parents of children from 2-17 years old
Stage 2: Clinical assessment (medical, vision, hearing, speech, motor, and psychological) of all children identified as having functional difficulties in stage 1.
Sensitivity = 100% of children who were identified as having “a lot of difficulty or cannot do at all” in stage 1 were found to have an impairment in stage 2
Specificity = 99% of children who were identified as NOT having difficulty were found to be non-disabled children in stage 2
Overall, this indicates that the module is correctly identifying children with disabilities, and is accurately differentiating between those with disabilities and those without.

10. Field test in Serbia
2,915 parent interviews in February 2016 in one Serbian province - Vojvodina
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.
The TQ module and the Washington Group short set were combined to form a control group questionnaire (CG questionnaire)

11. Field test in Serbia Two-stage stratified cluster sampling approach:
Random sample of enumeration areas from 2011 population census data, with probability proportional to size
3,852 households selected, 3,396 located, 2,905 interviewed with the response rate of 86%
2,937 children aged 2-17 were identified. Questionnaires were filled out for 2,915 children, with the response rate of 99%
Six teams
Each team consisted of four interviewers, one controller and one supervisor
The field work : 19 January February 2016
Training: 5 days in January 2016

12. Feedback from interviewers
Questions to be filled out by interviewers at the time of the survey, right after the corresponding questions were 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
For children 2 to 4
CF10= difficulty walking
CF13= difficulty being understood by you
CF14= difficulty learning things
CF15= difficulty playing
For children 5 to 17
CF35= Anxiety
CF36 = Depression
CF38 = Difficulty concentrating on an activity
CF39 = Difficulty accepting change

13. Feedback from interviewers
Note from the field: at the end of each day about what they observed in administering the questionnaires
10 questions to be filled out by interviewers at the end of the field work
Focus group discussions with interviewers and controllers (two full days, 4 group for interviewers - each group with 6 interviewers + 3 groups for controllers each group with 3 participants each).

14. Feedback from interviewers
CF10= difficulty walking
CF13= difficulty being understood by you
CF14= difficulty learning things
CF15= difficulty playing
CF35= Anxiety
CF36 = Depression
CF38 = Difficulty concentrating on an activity
CF39 = Difficulty accepting change

15. Feedback from interviewers
CF10= difficulty walking
CF13= difficulty being understood by you
CF14= difficulty learning things
CF15= difficulty playing
CF35= Anxiety
CF36 = Depression
CF38 = Difficulty concentrating on an activity
CF39 = Difficulty accepting change

16. Feedback from interviewers
CF10= difficulty walking
CF13= difficulty being understood by you
CF14= difficulty learning things
CF15= difficulty playing
CF35= Anxiety
CF36 = Depression
CF38 = Difficulty concentrating on an activity
CF39 = Difficulty accepting change

17. Feedback from interviewers
“The findings of the qualitative survey show that the CQ questionnaire has generally been administered without any major problems; the interviewers generally managed the questionnaire well and the reactions of the respondents were mostly neutral to positive”
Repetitive to read out loud response categories : no need to repeat for each questions as respondents get to know them

18. Modification post-field work
Inclusion of the word “very” for the questions on anxiety and depression
Instruction for interviewers to stop repeating response categories after first three questions unless needed
Modifications tested in India and Jamaica

19. Data analysis
Data analysis to determine cut-offs – similar results in levels obtained in Serbia and Samoa
Module able to capture moderate to severe forms of difficulties, not mild (some difficulty leads to false positive)
Inclusion of “a lot of difficulties or cannot do at all” is the recommended cut-off for international comparison, expect for emotions (5-17) and controlling behavious (for 2-4) for which only most severe forms are included – more variations on what is considered ‘normal” for children

20. Results from the UNICEF/WG module
Table CFD.1: Child functioning Percentage of children age 2-17 years with functional difficulties, Serbia, 2016
Children age 2-4 years
Children age 5-17 years
Children age 2-17 years
Percentage of children years with functional difficulties
Number of children
Percentage of children with functional difficulties
Total
1.1
219
4.4
1250
3.9
1468
Sex
Male .5
111
623
3.8
734
Female
1.7
107
627
4.0
Area
Urban .8
127
748
3.5
875
Rural
1.5 92
5.0
501
593
Region
Vojvodina
Mother's education
None
16.7 6
17.6 52
17.5 58
Primary
2.5 33
6.3
241
5.8
274
Secondary .6 96
3.1
719
2.8
814
Higher .0 84
3.4
238
322
Ethnicity of household head
Serbian .9
149
856
3.0
1005
Hungarian 35
152
3.6
186
Bosnian 2 3
Roma
10.7 9
13.1 91
12.8
101
Other 15
4.9
116
4.3
131
Desn't want to declare 38
Missing/DK 4 .
Wealth
Poorest 60%
1.9
129
5.2
758
4.7
887
Richest 40% 90
491
2.6
582

21. Results from the TQ (children 2 to 4)
Percentage of children age 2-4 years who screen positive for indicated domains
Percentage of children aged 2-4 years with at least one reported disability
Difficulty seeing, either in the daytime or at night
Appears to have difficulty hearing
No understanding of instructions
Difficulty in walking, moving arms, weakness or stiffness
Not learning to do things like other children his/her age
No speaking / cannot be understood in words
Cannot name at least one object (2 years old) .6 .0
2.1 .8
9.1
4.4
10.2
16.0

22. Results from the WG short set
(children 5 to 17)
No difficulties
Some difficulties
A lot of difficulties
Cannot see at all
Missing
Moderate to severe
Child have difficulty seeing even when wearing glasses
96.5%
3.2%
.2%
.1%
.0%
0.3%
Child have difficulty hearing even when using a hearing aid
99.2%
.6%
0.2%
Child have difficulty walking or climbing steps
98.8%
.9%
Child have difficulty remembering or concentrating
95.7%
3.8%
.3%
Child have difficulty with self-care
98.3%
1.5%
Child have difficulty communicating
97.1%
2.4%
.4%
0.5%
1.3

23. Translation of the module
Professional translation of the Child Functioning module into six languages
Spanish
French
Arabic
Russian
Vietnamese
Chinese
Portuguese
Translation methodology:
Forward/backward translation by separate translators
Internal focus group comprising of different translators to discuss and review translations
Focus group discussions with UNICEF and the Washington Group to discuss and review translations
Review of translated questionnaires by UNICEF staff (disability focal points) who are native speakers of each language
Feedback to translators with any required changes

24. THANK YOU!