Abstract
BackgroundVisual impairment in children is common in low and middle‐income settings. Whilst visual impairment (VI) can impact on the development of children, many reach full potential with appropriate early intervention programmes. Although there is increased emphasis on early child development globally, it is not yet clear how to provide specific programmes for children with VI in low and middle‐income settings. This study aims to identify facilitators and barriers to the provision of a developmental stimulation programme for children with VI in rural and urban Malawi.MethodsWe undertook 6 focus groups, 10 home observations and 20 in‐depth interviews with carers of children with VI under 6 years in urban and rural Southern Malawi. We utilised topic guides relating to care, play, communication and feeding. Qualitative data were subject to thematic analysis that included placing themes within Bronfenbrenner's ecological framework. We established authenticity of themes through feedback from participants.ResultsWe identified themes within Bronfenbrenner's framework at five levels: (1) blindness acting as a barrier to stimulation and communication, health and complex needs all affecting the individual child; (2) understanding of VI, ability to be responsive at the microsystem level of the carer; (3) support from other carers at microsystem level within a mesosystem; (4) support from other professionals (knowledge of, identification and management of children with VI, responsibilities and gender roles, environmental safety and prejudice, stigma and child protection all at the level of the exosystem.DiscussionThis study has revealed the requirements needed in order to produce meaningful and appropriate programmes to support nutrition, care and early stimulation for children with VI in this and similar African settings. This includes supporting carers to understand their child's developmental needs, how to better communicate with, feed and stimulate their child; offering advice sensitive to carers' responsibilities and professional training to better support carers and challenge community stigma.
Highlights
The number of children aged 0–14 years living with moderate or severe disability globally is estimated at 93 million (UNICEF 2013) with 19 million (20%) of those visually impaired (World Health Organization 2014).The high rates of developmental delay in children in low and middle-income (LMIC) setting are a current major concern of the global community (McCoy et al 2016)
We report on facilitators and barriers that we identified in relation to each concentric level of Bronfenbrener’s ecological framework (Fig. 1) at (1) the level of the child; (2) the carer and family; (3) the community; (4) the teacher and other professional organisations; and (5) the level of policy and culture
This study has revealed issues to be addressed at all levels of the ecological system in order to produce meaningful and appropriate programmes to support nutrition, care and early stimulation for children with visual impairment in this African setting
Summary
The high rates of developmental delay in children in low and middle-income (LMIC) setting are a current major concern of the global community (McCoy et al 2016) Factors contributing to this are multiple, and there is consensus that investing in programmes that encourage developmental stimulation and responsiveness can improve outcomes for these children (Aboud & Yousafzai 2015) in the first 1000 days of life (Black et al 2016). Evidence from UK demonstrates that visually impaired children can significantly benefit from stimulation, and that lack of appropriate stimulation can result in developmental delay (Cass et al 1994; Dale & Sonksen 2002) Such studies have led to the development of programmes that provide information on how to support these children.
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