Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study
Identifieur interne : 002759 ( Pmc/Corpus ); précédent : 002758; suivant : 002760Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study
Auteurs : Symon M. Kariuki ; Amina Abubakar ; Martha Kombe ; Michael Kazungu ; Rachael Odhiambo ; Alan Stein ; Charles R J C. NewtonSource :
- The Lancet. Psychiatry [ 2215-0366 ] ; 2017.
Abstract
Three-quarters of the burden of mental health problems occurs in low-and-middle-income countries, but few epidemiological studies of these problems in preschool children from sub-Saharan Africa have been published. Behavioural and emotional problems often start in early childhood, and this might be particularly important in Africa, where the incidence of perinatal and early risk factors is high. We therefore aimed to estimate the prevalence and risk factors of behavioural and emotional problems in young children in a rural area on the Kenyan coast.
We did a population-based epidemiological study to assess the burden of behavioural and emotional problems in preschool children and comorbidities in the Kilifi Health and Demographic Surveillance System (KHDSS, a database formed of the population under routine surveillance linked to admissions to Kilifi County Hospital). We used the Child Behaviour Checklist (CBCL) to assess behavioural and emotional problems. We then determined risk factors and medical comorbidities associated with behavioural and emotional problems. The strength of associations between the risk factors and the behavioural and emotional problems was estimated using generalised linear models, with appropriate distribution and link functions.
3539 families were randomly selected from the KHDSS. Of these, 3273 children were assessed with CBCL. The prevalence of total behavioural and emotional problems was 13% (95% CI 12–14), for externalising problems was 10% (9–11), and for internalising problems was 22% (21–24). The most common CBCL syndrome was somatic problems (21%, 20–23), whereas the most common DSM-IV-oriented scale was anxiety problems (13%, 12–14). Factors associated with total problems included consumption of cassava (risk ratio 5·68, 95% CI 3·22–10·03), perinatal complications (4·34, 3·21–5·81), seizure disorders (2·90, 2·24–3·77), and house status (0·11, 0·08–0·14). Seizure disorders, burn marks, and respiratory problems were important comorbidities of behavioural and emotional problems.
Behavioural and emotional problems are common in preschool children in this Kenyan rural area and are associated with preventable risk factors. Behavioural and emotional problems and associated comorbidities should be identified and addressed in young children.
Wellcome Trust.
Url:
DOI: 10.1016/S2215-0366(16)30403-5
PubMed: 28137381
PubMed Central: 5285446
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study</title><author><name sortKey="Kariuki, Symon M" sort="Kariuki, Symon M" uniqKey="Kariuki S" first="Symon M" last="Kariuki">Symon M. Kariuki</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Abubakar, Amina" sort="Abubakar, Amina" uniqKey="Abubakar A" first="Amina" last="Abubakar">Amina Abubakar</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Public Health, Pwani University, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author><author><name sortKey="Kombe, Martha" sort="Kombe, Martha" uniqKey="Kombe M" first="Martha" last="Kombe">Martha Kombe</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Kazungu, Michael" sort="Kazungu, Michael" uniqKey="Kazungu M" first="Michael" last="Kazungu">Michael Kazungu</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Odhiambo, Rachael" sort="Odhiambo, Rachael" uniqKey="Odhiambo R" first="Rachael" last="Odhiambo">Rachael Odhiambo</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Stein, Alan" sort="Stein, Alan" uniqKey="Stein A" first="Alan" last="Stein">Alan Stein</name><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author><author><name sortKey="Newton, Charles R J C" sort="Newton, Charles R J C" uniqKey="Newton C" first="Charles R J C" last="Newton">Charles R J C. Newton</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Public Health, Pwani University, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28137381</idno><idno type="pmc">5285446</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5285446</idno><idno type="RBID">PMC:5285446</idno><idno type="doi">10.1016/S2215-0366(16)30403-5</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">002759</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002759</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study</title><author><name sortKey="Kariuki, Symon M" sort="Kariuki, Symon M" uniqKey="Kariuki S" first="Symon M" last="Kariuki">Symon M. Kariuki</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Abubakar, Amina" sort="Abubakar, Amina" uniqKey="Abubakar A" first="Amina" last="Abubakar">Amina Abubakar</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Public Health, Pwani University, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author><author><name sortKey="Kombe, Martha" sort="Kombe, Martha" uniqKey="Kombe M" first="Martha" last="Kombe">Martha Kombe</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Kazungu, Michael" sort="Kazungu, Michael" uniqKey="Kazungu M" first="Michael" last="Kazungu">Michael Kazungu</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Odhiambo, Rachael" sort="Odhiambo, Rachael" uniqKey="Odhiambo R" first="Rachael" last="Odhiambo">Rachael Odhiambo</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Stein, Alan" sort="Stein, Alan" uniqKey="Stein A" first="Alan" last="Stein">Alan Stein</name><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author><author><name sortKey="Newton, Charles R J C" sort="Newton, Charles R J C" uniqKey="Newton C" first="Charles R J C" last="Newton">Charles R J C. Newton</name><affiliation><nlm:aff id="aff1">KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Public Health, Pwani University, Kilifi, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Psychiatry, University of Oxford, Oxford, UK</nlm:aff></affiliation></author></analytic><series><title level="j">The Lancet. Psychiatry</title><idno type="ISSN">2215-0366</idno><idno type="eISSN">2215-0374</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Summary</title><sec><title>Background</title><p>Three-quarters of the burden of mental health problems occurs in low-and-middle-income countries, but few epidemiological studies of these problems in preschool children from sub-Saharan Africa have been published. Behavioural and emotional problems often start in early childhood, and this might be particularly important in Africa, where the incidence of perinatal and early risk factors is high. We therefore aimed to estimate the prevalence and risk factors of behavioural and emotional problems in young children in a rural area on the Kenyan coast.</p></sec><sec><title>Methods</title><p>We did a population-based epidemiological study to assess the burden of behavioural and emotional problems in preschool children and comorbidities in the Kilifi Health and Demographic Surveillance System (KHDSS, a database formed of the population under routine surveillance linked to admissions to Kilifi County Hospital). We used the Child Behaviour Checklist (CBCL) to assess behavioural and emotional problems. We then determined risk factors and medical comorbidities associated with behavioural and emotional problems. The strength of associations between the risk factors and the behavioural and emotional problems was estimated using generalised linear models, with appropriate distribution and link functions.</p></sec><sec><title>Findings</title><p>3539 families were randomly selected from the KHDSS. Of these, 3273 children were assessed with CBCL. The prevalence of total behavioural and emotional problems was 13% (95% CI 12–14), for externalising problems was 10% (9–11), and for internalising problems was 22% (21–24). The most common CBCL syndrome was somatic problems (21%, 20–23), whereas the most common DSM-IV-oriented scale was anxiety problems (13%, 12–14). Factors associated with total problems included consumption of cassava (risk ratio 5·68, 95% CI 3·22–10·03), perinatal complications (4·34, 3·21–5·81), seizure disorders (2·90, 2·24–3·77), and house status (0·11, 0·08–0·14). Seizure disorders, burn marks, and respiratory problems were important comorbidities of behavioural and emotional problems.</p></sec><sec><title>Interpretation</title><p>Behavioural and emotional problems are common in preschool children in this Kenyan rural area and are associated with preventable risk factors. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Lancet Psychiatry</journal-id><journal-id journal-id-type="iso-abbrev">Lancet Psychiatry</journal-id><journal-title-group><journal-title>The Lancet. Psychiatry</journal-title></journal-title-group><issn pub-type="ppub">2215-0366</issn><issn pub-type="epub">2215-0374</issn><publisher><publisher-name>Elsevier</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28137381</article-id><article-id pub-id-type="pmc">5285446</article-id><article-id pub-id-type="publisher-id">S2215-0366(16)30403-5</article-id><article-id pub-id-type="doi">10.1016/S2215-0366(16)30403-5</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Kariuki</surname><given-names>Symon M</given-names></name><degrees>Dr</degrees><degrees>DPhil</degrees><email>skariuki@kemri-wellcome.org</email><xref rid="aff1" ref-type="aff">a</xref><xref rid="cor1" ref-type="corresp">*</xref></contrib><contrib contrib-type="author"><name><surname>Abubakar</surname><given-names>Amina</given-names></name><degrees>PhD</degrees><xref rid="aff1" ref-type="aff">a</xref><xref rid="aff2" ref-type="aff">b</xref><xref rid="aff3" ref-type="aff">c</xref></contrib><contrib contrib-type="author"><name><surname>Kombe</surname><given-names>Martha</given-names></name><degrees>DClin</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Kazungu</surname><given-names>Michael</given-names></name><degrees>DClin</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Odhiambo</surname><given-names>Rachael</given-names></name><degrees>BSc</degrees><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Stein</surname><given-names>Alan</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff3" ref-type="aff">c</xref></contrib><contrib contrib-type="author"><name><surname>Newton</surname><given-names>Charles R J C</given-names></name><degrees>Prof</degrees><degrees>MD</degrees><xref rid="aff1" ref-type="aff">a</xref><xref rid="aff2" ref-type="aff">b</xref><xref rid="aff3" ref-type="aff">c</xref></contrib></contrib-group><aff id="aff1"><label>a</label>KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi, Kenya</aff><aff id="aff2"><label>b</label>Department of Public Health, Pwani University, Kilifi, Kenya</aff><aff id="aff3"><label>c</label>Department of Psychiatry, University of Oxford, Oxford, UK</aff><author-notes><corresp id="cor1"><label>*</label>Correspondence to: Dr Symon M Kariuki, KEMRI-Wellcome Trust Collaborative Research Programme, Kilifi 230, KenyaCorrespondence to: Dr Symon M KariukiKEMRI-Wellcome Trust Collaborative Research ProgrammeKilifi230Kenya <email>skariuki@kemri-wellcome.org</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>1</day><month>2</month><year>2017</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>2</month><year>2017</year></pub-date><volume>4</volume><issue>2</issue><fpage>136</fpage><lpage>145</lpage><permissions><copyright-statement>© 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license</copyright-statement><copyright-year>2017</copyright-year><license license-type="CC BY" xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).</license-p></license></permissions><related-article related-article-type="article-reference" id="d32e12" ext-link-type="doi" xlink:href="10.1016/S2215-0366(17)30005-6"></related-article><abstract id="ceab10"><title>Summary</title><sec><title>Background</title><p>Three-quarters of the burden of mental health problems occurs in low-and-middle-income countries, but few epidemiological studies of these problems in preschool children from sub-Saharan Africa have been published. Behavioural and emotional problems often start in early childhood, and this might be particularly important in Africa, where the incidence of perinatal and early risk factors is high. We therefore aimed to estimate the prevalence and risk factors of behavioural and emotional problems in young children in a rural area on the Kenyan coast.</p></sec><sec><title>Methods</title><p>We did a population-based epidemiological study to assess the burden of behavioural and emotional problems in preschool children and comorbidities in the Kilifi Health and Demographic Surveillance System (KHDSS, a database formed of the population under routine surveillance linked to admissions to Kilifi County Hospital). We used the Child Behaviour Checklist (CBCL) to assess behavioural and emotional problems. We then determined risk factors and medical comorbidities associated with behavioural and emotional problems. The strength of associations between the risk factors and the behavioural and emotional problems was estimated using generalised linear models, with appropriate distribution and link functions.</p></sec><sec><title>Findings</title><p>3539 families were randomly selected from the KHDSS. Of these, 3273 children were assessed with CBCL. The prevalence of total behavioural and emotional problems was 13% (95% CI 12–14), for externalising problems was 10% (9–11), and for internalising problems was 22% (21–24). The most common CBCL syndrome was somatic problems (21%, 20–23), whereas the most common DSM-IV-oriented scale was anxiety problems (13%, 12–14). Factors associated with total problems included consumption of cassava (risk ratio 5·68, 95% CI 3·22–10·03), perinatal complications (4·34, 3·21–5·81), seizure disorders (2·90, 2·24–3·77), and house status (0·11, 0·08–0·14). Seizure disorders, burn marks, and respiratory problems were important comorbidities of behavioural and emotional problems.</p></sec><sec><title>Interpretation</title><p>Behavioural and emotional problems are common in preschool children in this Kenyan rural area and are associated with preventable risk factors. Behavioural and emotional problems and associated comorbidities should be identified and addressed in young children.</p></sec><sec><title>Funding</title><p>Wellcome Trust.</p></sec></abstract></article-meta></front><body><sec id="cesec10"><title>Introduction</title><p>Behavioural and emotional problems are common in preschool children aged younger than 6 years in high-income countries.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> These problems in preschool children are classified into two broad categories: externalising problems such as aggressive behaviour and internalising problems such as emotional disturbances.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> Epidemiological and meta-analytic studies of behavioural and emotional problems in children often combine preschool estimates with those of older children, contributing to a scarcity of data in young children, particularly in Africa.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref> Childhood behavioural and emotional problems increase the risk of mental health problems later in life,<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> which could be prevented with early identification and management of these behavioural and emotional problems.</p><p>The prevalence of behavioural and emotional problems in high-income countries ranges from 3% to 40%.<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref> Estimates of behavioural and emotional problems from the Middle East, Asia, and South America range from 10% to 30%.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> Some of these low-and-middle-income studies were based on hospital samples,<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> which are biased towards greater morbidity. No reliable epidemiological studies of behavioural and emotional problems in preschool children from Africa have been published, which affects planning for preventive and therapeutic interventions such as the Triple P-positive Parenting Programme for parents.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> Identification of behavioural and emotional problems in preschool children from low-and-middle-income countries is challenging because these children are developing rapidly, and few tools exist to assess these problems.<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref></p><p>Behavioural and emotional problems in high-income countries<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> are associated with risk factors such as pregnancy and perinatal factors, social disadvantage, family factors, and environmental factors, which can be addressed through public health interventions and social policy change. Most of these risk factors are very common in Africa, where they could contribute to the burden of behavioural and emotional problems in young children. Behavioural and emotional problems co-occur with febrile seizures (in 20% of young children),<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> malnutrition, and sleep problems.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> These comorbid conditions have not been examined in African countries.</p><p><boxed-text id="cetextbox10"><caption><title>Research in context</title></caption><p><bold>Evidence before this study</bold></p><p>We searched PubMed for all English articles published up to Aug 31, 2016, using the terms “behavioural and emotional problems”, “mental health problems/disorders”, “externalising problems/disorders”, “internalising problems/disorders”, and “preschool/young children”, “infants”. Most studies of behavioural and emotional problems in preschool children were from high-income countries, with few from low-and-middle-income countries of the Middle East, Asia, and South America. There were no studies from Africa. Most studies were done after the year 2000 suggesting a recognition of the need to understand behavioural and emotional problems in preschool children. The prevalence ranged from 3% to 40% in high-income countries, and 10% to 30% in low-and-middle-income countries, although some studies from low-and-middle-income countries were hospital based. The high-income country studies identified antenatal or perinatal complications, social disadvantages, environmental factors, and family factors as the risk factors for behavioural and emotional problems. The commonest comorbidities of behavioural and emotional problems were sleep problems, upper respiratory problems, and seizures.</p><p><bold>Added value of this study</bold></p><p>This study provides robust evidence of the high burden of behavioural emotional problems in preschool children from a rural area on the Kenyan coast, and identifies seizure disorders, perinatal complications, and lifestyle factors such as consumption of cassava and soil as the most important risk factors. Most of these risk factors are easily preventable. Medical comorbidities such as seizures, burns, and respiratory infections were more frequent in those with behavioural and emotional problems than those without.</p><p><bold>Implications of all the available evidence</bold></p><p>Preschool children experience a high burden of behavioural and emotional problems similarly to older children; these problems should be assessed and addressed, alongside the associated medical comorbidities. Control of causes and risk factors for seizure disorders might reduce the burden of behavioural problems in this rural area of Kenya. The mental health problems should be addressed before children go to school.</p></boxed-text></p><p>We did an epidemiological study to estimate the prevalence and risk factors of behavioural and emotional problems in young children in a rural area on the Kenyan coast. Clinical examination was done on a random sample to identify the medical comorbidities of behavioural and emotional problems.</p></sec><sec id="cesec20"><title>Methods</title><sec id="cesec30"><title>Study design and participants</title><p>This study was done within the Kilifi Health and Demographic Surveillance System (KHDSS), which is located in Kilifi County, about 60 km north of Mombasa city.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> The KHDSS is both an area (divided into enumeration zones under regular surveillance) and a database (formed of the population under routine surveillance linked to admissions to Kilifi County Hospital). The KHDSS has a population of about 280 000 residents who are predominantly of the Mijikenda tribe and has an estimated 50 000 children aged 1–6 years. The KHDSS has a northern and southern region covering an area of 891 km<sup>2</sup>. Epilepsy and neurodevelopmental clinics at Kilifi County Hospital provide therapeutic interventions and counselling services. Screening in stage 1 was done by trained fieldworkers who read out the content of the questionnaires to the parents owing to low literacy levels in this area, taking short breaks every 10 min. The three questionnaires (for risk factors, behavioural and emotional problems, and seizures) in stage 1 were administered in a random order. A random sample of those with and without behavioural and emotional problems predetermined through a sample calculation was invited in stage 2 for a clinical evaluation study to determine medical comorbidities. This study was approved by the Scientific and Ethics Review Unit of the Kenya Medical Research Institute and written informed consent was obtained from parents or carers of children participating in the study.</p></sec><sec id="cesec40"><title>Procedures</title><p>Behavioural and emotional problems were assessed in stage 1 with the Child Behaviour Checklist (CBCL), which was adapted and piloted in the local population and languages.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> The CBCL is used in children aged 1·5–5·5 years,<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> and has been applied on 1–6-year-old children; it identifies seven syndromes and five DSM-IV-oriented scales.<xref rid="bib14" ref-type="bibr"><sup>14</sup></xref> The CBCL has acceptable psychometric properties on a sample of Kenyan preschool children in this area.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref></p><p>The CBCL items had an internal consistency Cronbach's α of 0·95, and inter-informant agreement (Pearson's correlation coefficient, <italic>r</italic>>0·80), test–retest reliability (<italic>r</italic>=0·76), and the fit index of the seven-CBCL syndromes (eg, root mean square error of approximation <0·05) were within acceptable ranges.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> Because of the literacy challenges in this area, CBCL questions were read out to the respondents (parents or guardians) by trained neuropsychological assessors fluent in the local languages. The language of administration was primarily Kiswahili (lingua franca), but Giriama was also used for a few respondents who could not comprehend Kiswahili. We used a systematic approach of translation and adaptation of the tools. The initial translation was done by two independent translators fluent in the original language (English) and the target language (Kiswahili and Giriama). These translations were then back translated into English by two independent translators and inconsistencies were resolved.</p><p>The scoring system used and the grouping of the CBCL items into syndromes and externalising and internalising subscales followed recommendations by the Achenbach System of Empirically Based Assessments.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> The total score for the CBCL was formed by summing ratings from all of the 99 items. Items that formed the seven syndromes of the CBCL, externalising and internalising scores, and the DSM-oriented scales are outlined in the <xref rid="sec1" ref-type="sec">appendix</xref>.</p><p>The 90th percentile of the CBCL scores was used as the cutoff according to recommendations from the developers of the tool, and produced cutoff scores similar to those applied in children in the USA.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> These cutoffs were piloted and found to discriminate between children with and without adverse perinatal events.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref> Parents and carers of children assessed with the CBCL were interviewed using a parental risk factor questionnaire. The risk factor questionnaire consisted of the following items: maternal sociodemographic information such as employment, schooling, religion, and ethnicity; pregnancy and perinatal histories; socioeconomic status indicators such as housing status; medical histories such as seizure disorders or other chronic illnesses; and child health and nutrition habits, such as food types consumed, eating soil, and snoring at night. A thorough literature search informed the choice of risk factors included in the questionnaire.</p><p>About 20% of the children were invited to take part in stage 2 of the study. One clinician saw 243 children with CBCL scores of more than 60 and 377 children with CBCL scores of less than 60. The children were randomly selected from those screened in stage 1 using the RAND command of MySQL (Oracle Corp, USA). The clinician who was blinded to the screening status in stage 1 asked questions about the history of seizures to determine whether the seizures were acute seizures or epilepsy. The clinician was blinded to the status of the children screening positive for seizures in stage 1 in the community. The clinician did a clinical examination to assess for gross and fine motor deficits, sensory function, abnormal limb activity, cognitive or mental status, cranial nerve function, sensory ability, and skin integrity. Anthropometric measures of the child were also taken and included head circumference, mid-upper arm circumference, height, and weight.</p><p>Abnormal pregnancy was defined as premature or prolonged labour, post-dated pregnancy, pre-eclampsia, eclampsia, or any other health problems during pregnancy.<xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> Adverse perinatal events were defined as delays in crying, breathing, and breastfeeding after birth. Seizure disorders included both epilepsy and febrile acute seizures, with febrile seizures defined as seizures associated with a febrile illness or fever in those younger than 6 years, and epilepsy as a history of two unprovoked seizures.<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref> Intellectual disability was assessed by a clinician observing young children who had problems performing the standardised test of a locally adapted developmental inventory.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref> Malnutrition was defined as a weight-for-age <italic>z</italic> score value of −2 or lower or a mid-upper arm circumference less than 11·5 cm. Sensory function was considered impaired if a child could not localise touch from cotton wool or a painful stimulus. Motor impairments were defined as an inability to hold toys and walk or sit upright if of an appropriate age.</p></sec><sec id="cesec50"><title>Statistical analysis</title><p>We estimated that screening approximately 3500 children aged between 1 and 6 years, randomly selected from a surveillance database of 50 000 children using RAND command would be sufficient to identify psychopathology with a precision of 1%. We assessed whether the CBCL scores had a normal distribution by plotting quintile, Kernel density (of predicted regression residuals), and histogram plots (<xref rid="sec1" ref-type="sec">appendix</xref>) on raw and (natural) log-transformed scores.</p><p>Prevalence of behavioural problems was computed first as a probability (where those with CBCL problems are treated as positive and those without CBCL problems as negative), applying the inverse logit function to the intercept coefficient of a logistic regression model to provide outcome probabilities on the logit (log odds) scale. The probability was then multiplied by 100 to obtain the prevalence. Prevalence estimates stratified by age group and sex were computed, fitting fractional polynomial equations to smooth the prevalence by age.</p><p>Risk factors associated with behavioural and emotional problems were determined using log binomial regression models implemented in a generalised linear model, with robust variance-covariance matrix of the estimators. β coefficients for each risk factor above were then computed with log-transformed CBCL scores as the dependent variable using a generalised linear model that assumes a normal distribution and has an identity link function, and a robust variance–covariance matrix. We built penultimate models that accounted for child factors (age, sex, schooling, and region of residence) and final models that accounted for both child factors and maternal factors (age, marital status, economic or employment status, education level, ethnicity, and religion). A test for linear trend was performed for risk factors categorised into three or more levels using likelihood ratio tests. Age for the child and mother were entered into the risk factor models as first degree fractional polynomials. We measured associations between discrete variables using Pearson's χ<sup>2</sup> tests, or Fisher's exact tests, where the number of observations in a cell was less than five. Student's <italic>t</italic> test or the Mann-Whitney <italic>U</italic> test were used to compare the distribution of behavioural and emotional scores. Internal consistency was computed using the cialpha command in Stata. A p value of 0·05 or less was considered significant for exploratory comparisons, whereas associations were significant if the lower CIs did not include 1. All analyses were done with Stata, version 13.</p></sec><sec id="cesec60"><title>Role of the funding source</title><p>The funders of the study had no role in study design, data collection, data analysis, data interpretation, or the writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.</p></sec></sec><sec id="cesec70"><title>Results</title><p>3539 parents or guardians of preschool children were randomly selected from KHDSS to take part in this study. Of these, 3273 (93%) families consented to participate in the behavioural survey and were visited at home and we administered the CBCL to the parents or guardians of children in these families (<xref rid="fig1" ref-type="fig">figure 1</xref>). Of the 3273 children in the study, 1671 (51%) were males. The median age was 4 years (IQR 3–5). The sex and median age did not differ by region of the KHDSS (<xref rid="tbl1" ref-type="table">table 1</xref>). However, statistically significant differences between the northern and southern regions of the KHDSS were observed for sociodemographic factors (eg, maternal religion), socioeconomic factors (eg, livestock owned), and medical history (eg, perinatal complications) among the 2903 (89%) children who received a risk factor questionnaire (<xref rid="tbl1" ref-type="table">table 1</xref>).</p><p>The mean total CBCL scores were 33·6 (SD 22·9), and the median scores were 27 (IQR 18–42) and did not differ between sexes (p=0·593). The median and mean CBCL scores for specific CBCL syndromes and DSM-oriented scales are shown in <xref rid="tbl2" ref-type="table">table 2</xref>. The distribution of raw CBCL scores was skewed, but log transformation appeared to normalise the scores (<xref rid="sec1" ref-type="sec">appendix</xref>).</p><p>The internal consistency of the 99 items of CBCL was excellent (α=0·95 [95% CI 0·94–0·96]), and remained unchanged when administered in Kiswahili (α=0·95 [0·94–0·95]) or Giriama (α=0·94 [0·93–0·95]). The internal consistency of externalising problems, internalising problems, the six CBCL syndromes, and the five DSM-oriented scales are shown in the <xref rid="sec1" ref-type="sec">appendix</xref> and are similar to those of an earlier pilot study from the same area.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref></p><p>Total behavioural and emotional problems occurred in 420 (13%) children assessed with the CBCL—ie, a crude prevalence of 13% (95% CI 12–14). The prevalence did not differ by age (prevalence ratio [PR] 0·97, 95% CI 0·92–1·03; <xref rid="fig2" ref-type="fig">figure 2</xref>). The overall age-adjusted and sex-adjusted prevalence of behavioural and emotional problems was 11% (95% CI 10–13). Occurrence of these problems was similar in boys and girls (231 [14%] of 1671 in boys <italic>vs</italic> 189 [12%] of 1602 in girls, p=0·083).</p><p>Externalising problems occurred in 338 (10%) of 3273 children assessed with the CBCL, which is a crude prevalence of 10% (95% CI 9–11). The prevalence did not differ by age (PR 1·01, 95% CI 0·95–1·08; <xref rid="fig2" ref-type="fig">figure 2</xref>). The age and sex-adjusted prevalence of externalising problems was 9% (10–11). Externalising problems were significantly more frequent in boys than in girls (204 [12%] of 1671 in boys <italic>vs</italic> 134 [8%] of 1602 in girls, p<0·0001) but were similar in children 3 years or younger and in children older than 3 years (137 [10%] of 1353 <italic>vs</italic> 201 [11%] of 1920, p=0·751).</p><p>Internalising problems occurred in 728 (22%) children—ie, a crude prevalence of 22% (95% CI 21–24). The prevalence did not differ by age (PR 0·98, 95% CI 0·95–1·02; <xref rid="fig2" ref-type="fig">figure 2</xref>). The age-adjusted and sex-adjusted prevalence of internalising problems was 23% (95% CI 20–25). The occurrence of internalising problems was similar in boys and girls (367 [23%] of 1602 in boys <italic>vs</italic> 361 [22%] of 1671 in girls, p=0·369), and in children 3 years or younger and in children older than 3 years (306 [23%] of 1353 <italic>vs</italic> 422 [22%] of 1920, respectively, p=0·666).</p><p>The two most common CBCL syndromes were somatic problems (21%, 95% CI 20–23) and attention problems (16%, 14–17), while the two least frequent syndromes were aggressive behaviour (6%, 5–7) and sleep problems (4%, 3–4). The prevalences of other CBCL syndromes are shown in <xref rid="tbl2" ref-type="table">table 2</xref>. The commonest DSM-IV-oriented scale was anxiety problems (13%, 12–14) and the least common was oppositional defiant problems (2%, 2–3).</p><p>Factors associated with an increased risk of behavioural and emotional problems are listed by domain in <xref rid="tbl3" ref-type="table">table 3</xref>. The most important significant associations with the total score for behavioural and emotional problems among the pregnancy and birth factors were adverse perinatal events and abnormal pregnancy (<xref rid="tbl3" ref-type="table">table 3</xref>). Epilepsy and acute seizures were significantly associated with total CBCL problems among the seizure factors (<xref rid="tbl3" ref-type="table">table 3</xref>). Of the medical history factors, cassava consumption, head injury, and eating of soil were associated with total problems (<xref rid="tbl3" ref-type="table">table 3</xref>). The levels of house status, water availability, and toilet type were associated with total problems and the risk ratios for each level are shown in <xref rid="tbl3" ref-type="table">table 3</xref>. Externalising and internalising factors were associated with similar risk factors identified for total problems, but their effect size was smaller than those for total CBCL problems. (<xref rid="sec1" ref-type="sec">appendix</xref>).</p><p>There was an increased prevalence of clinically confirmed acute seizures (35 [14%] of 245 <italic>vs</italic> 85 [3%] of 2546, p<0·0001) and epilepsy (11 [5%] of 223 <italic>vs</italic> 11 [<1%] of 2476, p<0·0001) in those with total CBCL problems compared with those without. A few other comorbidities were significantly more frequent in those with behavioural and emotional problems compared with those without: burns for total problems and externalising problems, skin bruises and scars for total problems, and respiratory problems for internalising problems. The occurrence of other medical comorbidities is shown in <xref rid="tbl4" ref-type="table">table 4</xref>.</p></sec><sec id="cesec80"><title>Discussion</title><p>To our knowledge, this study is the largest epidemiological study of behavioural and emotional problems in young African children. Total behavioural and emotional problems as measured by the CBCL occurred in 13% of preschool children, with internalising problems more frequent than externalising problems (22% <italic>vs</italic> 10%). These problems were associated with multiple risk factors, and other medical problems such as seizures.</p><p>The prevalence of total problems (13%) is similar to that of preschool studies from other settings in low-and-middle-income countries such as Turkey (11·9%, assessed with the CBCL),<xref rid="bib19" ref-type="bibr"><sup>19</sup></xref> and high-income countries such as Germany (12·4%, assessed with the CBCL).<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref> The prevalence remained high even after accounting for age and sex. The prevalence was higher than in Romania (8·8%, assessed with the CBCL),<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref> and Norway (7·1%, screened with the Strengths and Difficulties Questionnaire [SDQ]).<xref rid="bib22" ref-type="bibr"><sup>22</sup></xref> The differences could be partly explained by the different assessment tools across studies or that symptoms considered behavioural and emotional problems in one culture may not be problematic in another.</p><p>Internalising problems were more prevalent than externalising problems (22% <italic>vs</italic> 10%), similar to preschool studies from New Zealand<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> and Germany.<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref> These differences might reflect the fact that the CBCL has more questions and syndromes dedicated to internalising problems,<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> which improves the sensitivity. This is a strength of the CBCL because internalising problems are less conspicuous and thus are more likely to be under-reported by parents.<xref rid="bib24" ref-type="bibr"><sup>24</sup></xref></p><p>There was a heterogeneous prevalence of specific syndromes and DSM-oriented scales as found in other studies. Somatic problems were the most common CBCL syndrome, but this finding might be confounded by inclusion of other behavioural and emotional problems that parents cannot comprehend, or by febrile illnesses, which are common in this rural population. Many caregivers in this area are women with other multiple family responsibilities and think that children requiring increased care have attention and anxiety problems, which were common. The prevalence of ADHD problems was 5%, which is similar to estimates from a meta-analysis of studies across the world (5·3%).<xref rid="bib25" ref-type="bibr"><sup>25</sup></xref> Most of these behavioural and emotional problems might be prevented by the initiation of parental interventions such as the Incredible Years Parent-Toddler programme or the Triple P-positive parenting programme.<xref rid="bib7" ref-type="bibr">7</xref>, <xref rid="bib26" ref-type="bibr">26</xref></p><p>Seizure disorders, including epilepsy and acute seizures, were important risk factors for behavioural and emotional problems. This association was established in previous studies of epilepsy,<xref rid="bib27" ref-type="bibr"><sup>27</sup></xref> and the poor outcomes could be due to the seizures, underlying neurological impairment, and a shared genetic susceptibility or cause. Risk ratios for epilepsy were significantly greater than those for acute seizures, as would be expected since the former is a chronic condition with serious health and psychosocial consequences.</p><p>Only a few studies in high-income countries have found an association between behavioural and emotional problems and febrile seizures,<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> but these studies were published nearly 20 years ago. Acute seizures in our study could be symptomatic of an underlying CNS cause such as malaria,<xref rid="bib28" ref-type="bibr"><sup>28</sup></xref> which can increase the risk of developing behavioural and emotional outcomes. The role of seizure disorders in behavioural and emotional problems might be mediated or moderated by other non-seizure factors, implying that control of many risk factors would have maximum public health benefits.</p><p>The association of antenatal and perinatal problems with behavioural and emotional problems is mediated through seizures or underlying neurological impairment.<xref rid="bib29" ref-type="bibr"><sup>29</sup></xref> The associations of consumption of cassava and soil with behavioural and emotional problems are probably mediated through social disadvantage and neurological impairments including seizures, although both factors might be directly neurotoxic,<xref rid="bib30" ref-type="bibr"><sup>30</sup></xref> or are a consequence of the behavioural and emotional problems.</p><p>History of hospital admission with febrile illnesses and head injury were associated with behavioural and emotional problems, and might reflect that these problems are related to neurological insults, including those from infections such as falciparum malaria. Pets are intermediate hosts for parasitic infections such as <italic>Toxoplasma gondii</italic>, which are associated with mental health problems in humans.<xref rid="bib31" ref-type="bibr"><sup>31</sup></xref> Poor house condition is an important marker of social disadvantage and inequalities in health-care access. Mothers who cannot afford antenatal services will deliver at home, increasing the risk of perinatal complications, which were associated with behavioural and emotional problems. Initiation of interventions aimed at socioeconomic empowerment could reduce mental health problems.</p><p>Comorbidities were common in behavioural and emotional problems, but only a few children showed significant differences when compared with those without these problems. Seizure disorders were particularly common in children with behavioural and emotional problems, occurring in about 20% of children, and their association with behavioural and emotional problems is well recognised in the literature.<xref rid="bib27" ref-type="bibr"><sup>27</sup></xref> Burns were strikingly common in children with externalising problems who are often restless, increasing the risk of injuries including burns. Behavioural and emotional problems also co-occurred with respiratory problems and skin problems. Common comorbidities of behavioural and emotional problems should be assessed and managed in young children.</p><p>The strength of this study is based on a large randomly selected community sample that is adequately powered to estimate prevalence and identify underlying risk factors. The assessment was performed using the CBCL, which is an internationally recognised tool that was formally adapted and validated in the local population.</p><p>This is a cross-sectional study, in which the causal inference of associations is difficult without prospective longitudinal studies. We did not assess the family stressors, child maltreatment, and maternal mental health and HIV/AIDS status that might influence behavioural and emotional outcomes of children, although we adjusted for other maternal-related factors.</p><p>Overall, there is substantial burden of behavioural and emotional problems in young children living in rural Kenya and this should be addressed with appropriate interventions. Internalising problems were more common than externalising problems as in other studies that used the CBCL. These problems are as common as those in older children and in high-income countries.<xref rid="bib5" ref-type="bibr"><sup>5</sup></xref> The burden of behavioural and emotional problems might be reduced by controlling risk factors, for example encouraging use of antenatal services to prevent mental health problems associated with perinatal complications. Common comorbidities of behavioural and emotional problems should be assessed and managed. 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id="bib31"><label>31</label><element-citation publication-type="journal" id="sbref310"><person-group person-group-type="author"><name><surname>Flegr</surname><given-names>J</given-names></name></person-group><article-title>Influence of latent <italic>Toxoplasma</italic> infection on human personality, physiology and morphology: pros and cons of the <italic>Toxoplasma</italic>-human model in studying the manipulation hypothesis</article-title><source>J Exp Biol</source><volume>216</volume><year>2013</year><fpage>127</fpage><lpage>133</lpage><pub-id pub-id-type="pmid">23225875</pub-id></element-citation></ref></ref-list><sec id="sec1" sec-type="supplementary-material"><title>Supplementary Material</title><p><supplementary-material content-type="local-data" id="ecomp10"><caption><title>Supplementary appendix</title></caption><media xlink:href="mmc1.pdf"></media></supplementary-material></p></sec><ack id="ceack10"><sec><title>Acknowledgments</title><p>The Wellcome Trust funded this work (through a Research Training Fellowship to SMK, grant number 099782) and a Senior Research Fellowship to CRJCN (083744). We thank the field assistants who helped administer the CBCL, and the Achenbach System of Empirically-Based Assessments group for the licence (grant number 912-10-21-2013) to use the CBCL in this work. This paper is published with permission of the Director of the Kenya Medical Research Institute.</p></sec></ack><ack><title>Contributors</title><p>SMK, AS, and CRJCN designed the study. SMK, AA, and CRJCN coordinated the study. SMK, AA, MKo, MKa, RO, and CRJCN collected the data. SMK and CRJCN analysed the data and wrote the first draft. All authors reviewed the manuscript for important intellectual content and approved the manuscript for publication.</p></ack><ack><title>Declaration of interests</title><p>We declare no competing interests.</p></ack></back><floats-group><fig id="fig1"><label>Figure 1</label><caption><p>Derivation of the sample for the behavioural and emotional survey</p><p>Fieldworkers visited 3539 children in their homes, of whom 3273 (93%) consented to take part in the epidemiological survey.</p></caption><graphic xlink:href="gr1"></graphic></fig><fig id="fig2"><label>Figure 2</label><caption><p>Prevalence of total CBCL problems, externalising problems, and internalising problems among 3273 preschool children living on the Kenyan coast</p><p>The prevalence of total behavioural and emotional problems (A), externalising problems (B), and internalising problems (C) is provided by age group. Smoothened predictions of prevalence of behavioural and emotional problems (D), externalising problems (E), and internalising problems (F) were computed with a fractional polynomial equation. CBCL=Child Behaviour Checklist.</p></caption><graphic xlink:href="gr2"></graphic></fig><table-wrap id="tbl1" position="float"><label>Table 1</label><caption><p>Sociodemographic, socioeconomic, and medical characteristics of study participants by demographic surveillance area</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th></th><th colspan="2" align="left"><bold>Demographic surveillance region</bold><hr></hr></th><th align="left"><bold>Total (n=3273)</bold></th><th align="left"><bold>p value</bold><xref rid="tbl1fn1" ref-type="table-fn">*</xref></th></tr><tr><th></th><th></th><th></th><th align="left">Northern (n=1437)</th><th align="left">Southern (n=1836)</th><th></th><th></th></tr></thead><tbody><tr><td colspan="3" align="left">Child's age (months)</td><td align="left">47 (31–64)</td><td align="left">48 (32–64)</td><td align="left">48 (32–64)</td><td align="left">0·264</td></tr><tr><td colspan="3" align="left">Male sex</td><td align="left">731 (51%)</td><td align="left">934 (51%)</td><td align="left">1671 (51%)</td><td align="left">0·813</td></tr><tr><td colspan="3" align="left">Mother's age (years)</td><td align="left">29 (25–35)</td><td align="left">30 (25–35)</td><td align="left">30 (25–35)</td><td align="left">0·156</td></tr><tr><td colspan="3" align="left">Administered a risk factor questionnaire</td><td align="left">1303 (90%)</td><td align="left">1600 (87%)</td><td align="left">2903 (89%)</td><td align="left">..</td></tr><tr><td colspan="7" align="left">Sociodemographic information</td></tr><tr><td></td><td colspan="2" align="left">Mother's marital status</td><td></td><td></td><td></td><td align="left">0·017</td></tr><tr><td></td><td></td><td align="left">Single</td><td align="left">178 (14%)</td><td align="left">188 (12%)</td><td align="left">366 (13%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Separated or divorced</td><td align="left">80 (6%)</td><td align="left">73 (5%)</td><td align="left">153 (5%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Widowed</td><td align="left">8 (1%)</td><td align="left">22 (1%)</td><td align="left">30 (1%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Married</td><td align="left">1037 (80%)</td><td align="left">1317 (82%)</td><td align="left">2354 (81%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Mother's religion</td><td></td><td></td><td></td><td align="left"><0·0001</td></tr><tr><td></td><td></td><td align="left">None</td><td align="left">318 (24%)</td><td align="left">373 (23%)</td><td align="left">691 (24%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Traditional</td><td align="left">77 (6%)</td><td align="left">111 (7)</td><td align="left">188 (6%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Islam</td><td align="left">116 (9%)</td><td align="left">227 (14%)</td><td align="left">343 (12%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Christian</td><td align="left">792 (61%)</td><td align="left">889 (56%)</td><td align="left">1681 (58%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Mother's education level</td><td></td><td></td><td></td><td align="left">0·720</td></tr><tr><td></td><td></td><td align="left">None</td><td align="left">447 (34%)</td><td align="left">558 (35%)</td><td align="left">1005 (35%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Primary</td><td align="left">753 (58%)</td><td align="left">930 (58%)</td><td align="left">1683 (58%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Secondary</td><td align="left">83 (6%)</td><td align="left">86 (5%)</td><td align="left">169 (6%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Tertiary</td><td align="left">20 (2%)</td><td align="left">26 (2%)</td><td align="left">46 (2%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Mother's ethnicity</td><td></td><td></td><td></td><td align="left"><0·0001</td></tr><tr><td></td><td></td><td align="left">Mijikenda</td><td align="left">59 (5%)</td><td align="left">97 (6%)</td><td align="left">156 (5%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Other Mijikenda</td><td align="left">55 (4%)</td><td align="left">120 (8%)</td><td align="left">175 (6%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Kauma</td><td align="left">72 (6%)</td><td align="left">198 (12%)</td><td align="left">270 (9%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Chonyi</td><td align="left">183 (14%)</td><td align="left">693 (43%)</td><td align="left">876 (30%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Giriama</td><td align="left">934 (72%)</td><td align="left">492 (31%)</td><td align="left">1426 (49%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Economic activity (mother)</td><td align="left">955 (73%)</td><td align="left">1159 (72%)</td><td align="left">2114 (73%)</td><td align="left">0·607</td></tr><tr><td></td><td colspan="2" align="left">Economic activity (father)</td><td align="left">1111/1196 (93%)</td><td align="left">1371/1488 (92%)</td><td align="left">2482/2684 (92%)</td><td align="left">0·461</td></tr><tr><td></td><td colspan="2" align="left">Number of children</td><td align="left">4 (3–6)</td><td align="left">4 (3–6)</td><td align="left">4 (3–6)</td><td align="left">0·841</td></tr><tr><td colspan="7" align="left">Socioeconomic status and household information</td></tr><tr><td></td><td colspan="2" align="left">Water availability</td><td></td><td></td><td></td><td align="left"><0·0001</td></tr><tr><td></td><td></td><td align="left">Infrequent</td><td align="left">328 (25%)</td><td align="left">487 (30%)</td><td align="left">815 (28%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Weekly</td><td align="left">153 (12%)</td><td align="left">48 (3%)</td><td align="left">201 (7%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Daily</td><td align="left">328 (25%)</td><td align="left">364 (23%)</td><td align="left">692 (24%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Always</td><td align="left">494 (38%)</td><td align="left">701 (44%)</td><td align="left">1195 (41%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">House status</td><td></td><td></td><td></td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Dilapidated</td><td align="left">130 (10%)</td><td align="left">178 (11%)</td><td align="left">308 (11%)</td><td align="left">0·053</td></tr><tr><td></td><td></td><td align="left">Major repairs needed</td><td align="left">90 (8%)</td><td align="left">84 (5%)</td><td align="left">183 (6%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Incompletely built</td><td align="left">24 (2%)</td><td align="left">25 (2%)</td><td align="left">49 (2%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Minor or no repairs needed</td><td align="left">1050 (81%)</td><td align="left">1313 (82%)</td><td align="left">2363 (81%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Toilet type</td><td></td><td></td><td></td><td align="left"><0·0001</td></tr><tr><td></td><td></td><td align="left">Bush or none</td><td align="left">522 (40%)</td><td align="left">479 (30%)</td><td align="left">1001 (34%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Traditional pit</td><td align="left">624 (48%)</td><td align="left">913 (57%)</td><td align="left">1537 (53%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Ventilated pit</td><td align="left">86 (7%)</td><td align="left">133 (8%)</td><td align="left">219 (8%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">Flush</td><td align="left">71 (5%)</td><td align="left">75 (5%)</td><td align="left">146 (5%)</td><td align="left">..</td></tr><tr><td></td><td colspan="2" align="left">Livestock owned</td><td></td><td></td><td></td><td align="left"><0·0001</td></tr><tr><td></td><td></td><td align="left">None</td><td align="left">516 (40%)</td><td align="left">841 (53%)</td><td align="left">1357 (47%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left"><5</td><td align="left">324 (25%)</td><td align="left">265 (17%)</td><td align="left">589 (20%)</td><td align="left">..</td></tr><tr><td></td><td></td><td align="left">>5</td><td align="left">463 (36%)</td><td align="left">494 (31%)</td><td align="left">957 (33%)</td><td align="left">..</td></tr><tr><td colspan="7" align="left">Pregnancy and birth history</td></tr><tr><td></td><td colspan="2" align="left">Pregnancy problems</td><td align="left">112 (9%)</td><td align="left">78 (5%)</td><td align="left">190 (7%)</td><td align="left"><0·0001</td></tr><tr><td></td><td colspan="2" align="left">Mother's age at first birth</td><td align="left">18 (17–20)</td><td align="left">18 (17–20)</td><td align="left">18 (17–20)</td><td align="left">0·334</td></tr><tr><td></td><td colspan="2" align="left">Delivery at home</td><td align="left">833 (64%)</td><td align="left">923 (58%)</td><td align="left">1756 (60%)</td><td align="left">0·001</td></tr><tr><td></td><td colspan="2" align="left">Adverse perinatal events</td><td align="left">37 (3%)</td><td align="left">28 (2%)</td><td align="left">65 (2%)</td><td align="left">0·048</td></tr><tr><td colspan="7" align="left">Medical history</td></tr><tr><td></td><td colspan="2" align="left">Family history of seizures</td><td align="left">127 (10%)</td><td align="left">125 (8%)</td><td align="left">252 (9%)</td><td align="left">0·066</td></tr><tr><td></td><td colspan="2" align="left">Family history of febrile seizures</td><td align="left">95 (7%)</td><td align="left">147 (9%)</td><td align="left">242 (8%)</td><td align="left">0·066</td></tr><tr><td></td><td colspan="2" align="left">Previous hospital admission</td><td align="left">124 (10%)</td><td align="left">146 (9%)</td><td align="left">270 (9%)</td><td align="left">0·72</td></tr><tr><td></td><td colspan="2" align="left">Head injury</td><td align="left">24 (2%)</td><td align="left">24 (2%)</td><td align="left">48 (2%)</td><td align="left">0·47</td></tr><tr><td></td><td colspan="2" align="left">Dogs or cats in compound</td><td align="left">541 (42%)</td><td align="left">697 (44%)</td><td align="left">1238 (43%)</td><td align="left">0·27</td></tr><tr><td></td><td colspan="2" align="left">Eats cassava</td><td align="left">990 (76%)</td><td align="left">1179 (74%)</td><td align="left">2169 (75%)</td><td align="left">0·16</td></tr><tr><td></td><td colspan="2" align="left">Eats soil</td><td align="left">175 (13%)</td><td align="left">153 (10%)</td><td align="left">328 (11%)</td><td align="left">0·001</td></tr><tr><td></td><td colspan="2" align="left">Eats pork</td><td align="left">134 (10%)</td><td align="left">134 (8%)</td><td align="left">268 (9%)</td><td align="left">0·077</td></tr><tr><td></td><td colspan="2" align="left">Bednet use</td><td align="left">1116 (86%)</td><td align="left">1329 (83%)</td><td align="left">2445 (84%)</td><td align="left">0·057</td></tr><tr><td></td><td colspan="2" align="left">Snores at night</td><td align="left">259 (20%)</td><td align="left">319 (20%)</td><td align="left">578 (20%)</td><td align="left">0·97</td></tr><tr><td></td><td colspan="2" align="left">Deceased father</td><td align="left">35/1110 (3%)</td><td align="left">43/1362 (3%)</td><td align="left">78/2472 (3%)</td><td align="left">0·97</td></tr></tbody></table><table-wrap-foot><fn><p>Data are median (IQR), n (%), or n/N (%). CBCL=Child Behaviour Checklist.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl1fn1"><label>*</label><p id="cenpara10">Comparison of characteristics between the northern demographic surveillance area and southern demographic surveillance area. The questionnaire for sociodemographic characteristics, socioeconomic status, and medical history was administered to 2903 (89%) of the 3273 individuals screened with CBCL.</p></fn></table-wrap-foot></table-wrap><table-wrap id="tbl2" position="float"><label>Table 2</label><caption><p>Behavioural and emotional scores and problems for the CBCL seven-syndrome scales and the DSM-IV-oriented scales</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th align="left"><bold>Median score (IQR)</bold></th><th align="left"><bold>Mean scores (SD)</bold></th><th align="left"><bold>Number of children with problems (n=3273); n (%; 95% CI)</bold></th></tr></thead><tbody><tr><td colspan="4" align="left"><bold>CBCL syndromes</bold></td></tr><tr><td align="left">Emotionally reactive</td><td align="left">2 (1–3)</td><td align="left">2·4 (2·4)</td><td align="left">331 (10·1%; 9·1–11·2)</td></tr><tr><td align="left">Anxious or depressed</td><td align="left">2 (0–4)</td><td align="left">2·8 (3·1)</td><td align="left">417 (12·7%; 11·6–13·9)</td></tr><tr><td align="left">Somatic problems</td><td align="left">2 (1–3)</td><td align="left">3·1 (2·6)</td><td align="left">695 (21·2%; 19·8–22·7)</td></tr><tr><td align="left">Withdrawn</td><td align="left">2 (0–3)</td><td align="left">2·1 (2·0)</td><td align="left">360 (11·0%; 9·9–12·1)</td></tr><tr><td align="left">Sleep problems</td><td align="left">2 (1–3)</td><td align="left">2·3 (2·2)</td><td align="left">114 (3·5%; 2·9–4·2)</td></tr><tr><td align="left">Attention problems</td><td align="left">3 (2–5)</td><td align="left">3·4 (2·0)</td><td align="left">507 (15·4%; 14·3–16·8)</td></tr><tr><td align="left">Aggressive behaviour</td><td align="left">6 (3–10)</td><td align="left">7·5 (6·6)</td><td align="left">189 (5·8%; 5·0–6·6)</td></tr><tr><td colspan="4" align="left"><bold>DSM-IV-oriented</bold></td></tr><tr><td align="left">Affective problems</td><td align="left">1 (0–3)</td><td align="left">1·9 (2·5)</td><td align="left">189 (5·8%; 5·0–6·6)</td></tr><tr><td align="left">Anxiety problems</td><td align="left">4 (2–6)</td><td align="left">4·5 (3·5)</td><td align="left">413 (12·6%; 11·5–13·8)</td></tr><tr><td align="left">Pervasive developmental problems</td><td align="left">2 (1–4)</td><td align="left">3·1 (2·9)</td><td align="left">173 (5·3%; 4·5–6·1)</td></tr><tr><td align="left">Attention-deficit hyperactivity disorder problems</td><td align="left">5 (3–7)</td><td align="left">5·5 (2·9)</td><td align="left">163 (5·0%; 4·3–5·8)</td></tr><tr><td align="left">Oppositional problems</td><td align="left">2 (0–3)</td><td align="left">2·2 (2·3)</td><td align="left">76 (2·3%; 1·8–2·9)</td></tr></tbody></table><table-wrap-foot><fn><p>CBCL=Child Behaviour Checklist. DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, 4th edn.</p></fn></table-wrap-foot></table-wrap><table-wrap id="tbl3" position="float"><label>Table 3</label><caption><p>Factors associated with total behavioural and emotional problems in 2903 children who received the risk factor questionnaire</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th colspan="2" align="left"><bold>Frequency distribution</bold><hr></hr></th><th align="left"><bold>Penultimate adjusted model</bold><xref rid="tbl3fn1" ref-type="table-fn">*</xref><hr></hr></th><th align="left"><bold>Final adjusted model</bold><xref rid="tbl3fn2" ref-type="table-fn">†</xref><hr></hr></th><th align="left"><bold>Penultimate adjusted model</bold><xref rid="tbl3fn1" ref-type="table-fn">*</xref><hr></hr></th><th align="left"><bold>Final adjusted model</bold><xref rid="tbl3fn2" ref-type="table-fn">†</xref><hr></hr></th></tr><tr><th></th><th></th><th align="left">Number of children with no problems (n=2623)</th><th align="left">Number of children with problems (n=280)</th><th align="left">Risk ratio (95% CI)</th><th align="left">Risk ratio (95% CI)</th><th align="left">β coefficient (95% CI)</th><th align="left">β coefficient (95% CI)</th></tr></thead><tbody><tr><td colspan="8" align="left"><bold>Pregnancy and birth information</bold></td></tr><tr><td colspan="2" align="left">Mother's age at first birth (years)</td><td align="left">18 (17–20)</td><td align="left">18 (16–20)</td><td align="left">0·98 (0·96 to 1·01)</td><td align="left">1·01 (0·98 to 1·06)</td><td align="left">–0·01 (–0·01 to 0·00)</td><td align="left">0·00 (–0·01 to 0·01)</td></tr><tr><td colspan="2" align="left">Pregnancy problems</td><td align="left">155 (6%)</td><td align="left">35 (13%)</td><td align="left">2·03 (1·46 to 2·81)</td><td align="left">2·11 (1·55 to 2·88)</td><td align="left">0·25 (0·15 to 0·36)</td><td align="left">0·27 (0·17 to 0·38)</td></tr><tr><td colspan="2" align="left">Delivery at home</td><td align="left">1583 (60%)</td><td align="left">173 (62%)</td><td align="left">1·07 (0·85 to 1·34)</td><td align="left">1·00 (0·78 to 1·29)</td><td align="left">0·00 (–0·05 to 0·04)</td><td align="left">–1·57 (–3·34 to 0·20)</td></tr><tr><td colspan="2" align="left">Adverse perinatal events</td><td align="left">34 (1%)</td><td align="left">31 (11%)</td><td align="left">5·41 (4·07 to 7·20)</td><td align="left">4·34 (3·21 to 5·87)</td><td align="left">0·69 (0·55 to 0·84)</td><td align="left">0·67 (0·53 to 0·82)</td></tr><tr><td colspan="8" align="left"><bold>Seizure information</bold></td></tr><tr><td colspan="2" align="left">Any seizure disorder</td><td align="left">157 (6%)</td><td align="left">68 (24%)</td><td align="left">3·83 (3·02 to 4·85)</td><td align="left">2·90 (2·24 to 3·77)</td><td align="left">0·42 (0·33 to 0·51)</td><td align="left">0·39 (0·30 to 0·49)</td></tr><tr><td colspan="2" align="left">Acute seizures</td><td align="left">85/2546 (3%)</td><td align="left">35/245 (14%)</td><td align="left">3·72 (2·74 to 5·08)</td><td align="left">2·62 (1·89 to 3·64)</td><td align="left">0·36 (0·24 to 0·49)</td><td align="left">0·33 (0·21 to 0·46)</td></tr><tr><td colspan="2" align="left">Epilepsy</td><td align="left">11/2476 (<1%)</td><td align="left">11/223 (5%)</td><td align="left">6·31 (4·11 to 9·70)</td><td align="left">4·71 (2·65 to 8·35)</td><td align="left">0·68 (0·38 to 0·99)</td><td align="left">0·60 (0·28–0·93)</td></tr><tr><td colspan="2" align="left">Family history of seizures</td><td align="left">204 (8%)</td><td align="left">48 (17%)</td><td align="left">2·19 (1·65 to 2·91)</td><td align="left">2·00 (1·46 to 2·62)</td><td align="left">0·18 (0·10 to 0·27)</td><td align="left">0·21 (0·11 to 0·30)</td></tr><tr><td colspan="2" align="left">Family history of febrile seizures</td><td align="left">146 (6%)</td><td align="left">96 (34%)</td><td align="left">5·73 (4·65 to 7·07)</td><td align="left">4·07 (3·21 to 5·18)</td><td align="left">0·63 (0·55 to 0·71)</td><td align="left">0·61 (0·52 to 0·70)</td></tr><tr><td colspan="8" align="left"><bold>Medical history information</bold></td></tr><tr><td colspan="2" align="left">Previous hospital admission</td><td align="left">211 (8%)</td><td align="left">59 (21%)</td><td align="left">2·63 (2·03 to 3·41)</td><td align="left">2·25 (1·72–2·95)</td><td align="left">0·25 (0·17 to 0·33)</td><td align="left">0·24 (0·15 to 0·34)</td></tr><tr><td colspan="2" align="left">Head injury</td><td align="left">26 (1%)</td><td align="left">22 (8%)</td><td align="left">5·14 (3·68 to 7·19)</td><td align="left">3·11 (2·19 to 4·43)</td><td align="left">0·64 (0·47 to 0·81)</td><td align="left">0·56 (0·38 to 0·74)</td></tr><tr><td colspan="2" align="left">Eats cassava</td><td align="left">1905 (73%)</td><td align="left">264 (94%)</td><td align="left">5·58 (3·40 to 9·18)</td><td align="left">5·68 (3·22 to 10·03)</td><td align="left">0·30 (0·26 to 0·35)</td><td align="left">0·33 (0·28 to 0·39)</td></tr><tr><td colspan="2" align="left">Dogs or cats in compound</td><td align="left">1103 (42%)</td><td align="left">135 (48%)</td><td align="left">1·25 (0·99 to 1·56)</td><td align="left">1·30 (1·04 to 1·64)</td><td align="left">0·06 (0·02 to 0·11)</td><td align="left">0·06 (0·01 to 0·12)</td></tr><tr><td colspan="2" align="left">Eats soil</td><td align="left">251 (10%)</td><td align="left">77 (28%)</td><td align="left">3·14 (2·44 to 4·03)</td><td align="left">2·80 (2·16 to 3·64)</td><td align="left">0·42 (0·35 to 0·50)</td><td align="left">0·40 (0·32 to 0·48)</td></tr><tr><td colspan="2" align="left">Snores at night</td><td align="left">462 (18%)</td><td align="left">116 (41%)</td><td align="left">2·83 (2·28 to 3·53)</td><td align="left">2·23 (1·77 to 2·81)</td><td align="left">0·32 (0·26 to 0·38)</td><td align="left">0·29 (0·23 to 0·37)</td></tr><tr><td colspan="2" align="left">Eats pork</td><td align="left">228 (9%)</td><td align="left">40 (14%)</td><td align="left">1·65 (1·21 to 2·52)</td><td align="left">1·74 (1·28 to 2·37)</td><td align="left">0·13 (0·04 to 0·22)</td><td align="left">0·06 (0·02 to 0·11)</td></tr><tr><td colspan="2" align="left">Bednet use</td><td align="left">2198 (84%)</td><td align="left">247 (88%)</td><td align="left">1·38 (0·97 to 1·97)</td><td align="left">1·35 (0·91 to 1·99)</td><td align="left">0·07 (0·01 to 0·14)</td><td align="left">0·02 (–0·05 to 0·09)</td></tr><tr><td colspan="2" align="left">Malnutrition</td><td align="left">13/377 (6%)</td><td align="left">6/243 (2%)</td><td align="left">0·72 (0·36 to 1·52)</td><td align="left">1·01 (0·47 to 2·16)</td><td align="left">–0·18 (–0·53 to 0·16)</td><td align="left">–0·05 (–0·42 to 0·33)</td></tr><tr><td colspan="8" align="left"><bold>Socioeconomic information</bold></td></tr><tr><td colspan="8" align="left">Water availability</td></tr><tr><td></td><td align="left">Infrequent</td><td align="left">662 (25%)</td><td align="left">153 (55%)</td><td align="left">1·00</td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00</td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td></tr><tr><td></td><td align="left">Weekly</td><td align="left">167 (6%)</td><td align="left">34 (12%)</td><td align="left">0·90 (0·63 to 1·29)</td><td align="left">1·41 (0·99 to 2·00)</td><td align="left">−0·25 (−0·36 to −0·13)</td><td align="left">−0·13 (−0·24 to −0·02)</td></tr><tr><td></td><td align="left">Daily</td><td align="left">670 (26%)</td><td align="left">22 (8%)</td><td align="left">0·17 (0·11 to 0·26)</td><td align="left">0·25 (0·15 to 0·41)</td><td align="left">−0·38 (−0·44 to −0·32)</td><td align="left">−0·36 (−0·43 to −0·29)</td></tr><tr><td></td><td align="left">Always</td><td align="left">1124 (43%)</td><td align="left">71 (25%)</td><td align="left">0·31 (0·24 to 0·41)</td><td align="left">0·42 (0·31 to 0·56)</td><td align="left">−0·27 (−0·32 to −0·22)</td><td align="left">−0·23 (−0·29 to −0·18)</td></tr><tr><td colspan="8" align="left">House status</td></tr><tr><td></td><td align="left">Dilapidated</td><td align="left">159 (6%)</td><td align="left">149 (53%)</td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td></tr><tr><td></td><td align="left">Major repairs needed</td><td align="left">149 (6%)</td><td align="left">34 (12%)</td><td align="left">0·38 (0·28 to 0·53)</td><td align="left">0·51 (0·35 to 0·74)</td><td align="left">−0·62 (−0·75 to −0·50)</td><td align="left">−0·58 (−0·73 to −0·43)</td></tr><tr><td></td><td align="left">Incompletely built</td><td align="left">45 (2%)</td><td align="left">4 (1%)</td><td align="left">0·17 (0·07 to 0·43)</td><td align="left">0·18 (0·06 to 0·54)</td><td align="left">−0·77 (−0·97 to −0·57)</td><td align="left">−0·84 (−10·5 to −0·62)</td></tr><tr><td></td><td align="left">Minor or no repairs needed</td><td align="left">2270 (87%)</td><td align="left">93 (33%)</td><td align="left">0·08 (0·06 to 0·10)</td><td align="left">0·11 (0·08 to 0·14)</td><td align="left">−0·84 (−0·91 to −0·78)</td><td align="left">−0·85 (−0·93 to −0·78)</td></tr><tr><td colspan="8" align="left">Toilet type</td></tr><tr><td></td><td align="left">Bush or none</td><td align="left">816 (31%)</td><td align="left">185 (66%)</td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td></tr><tr><td></td><td align="left">Traditional pit</td><td align="left">1466 (56%)</td><td align="left">71 (25%)</td><td align="left">0·24 (0·19 to 0·32)</td><td align="left">0·31 (0·23 to 0·41)</td><td align="left">−0·26 (−0·31 to −0·21)</td><td align="left">−0·27 (−0·32 to −0·21)</td></tr><tr><td></td><td align="left">Ventilated pit</td><td align="left">202 (8%)</td><td align="left">17 (6%)</td><td align="left">0·41 (0·25 to 0·65)</td><td align="left">0·55 (0·33 to 0·93)</td><td align="left">−0·28 (−0·38 to −0·18)</td><td align="left">−0·30 (−0·40 to −0·19)</td></tr><tr><td></td><td align="left">Flush</td><td align="left">139 (5%)</td><td align="left">7 (3%)</td><td align="left">0·25 (0·12 to 0·53)</td><td align="left">0·46 (0·20 to 1·04)</td><td align="left">−0·18 (−0·28 to −0·09)</td><td align="left">−0·16 (−0·27 to −0·05)</td></tr><tr><td colspan="8" align="left">Livestock owned<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td></tr><tr><td></td><td align="left">None</td><td align="left">1214 (46%)</td><td align="left">143 (51%)</td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">1·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td><td align="left">0·00<xref rid="tbl3fn3" ref-type="table-fn">‡</xref></td></tr><tr><td></td><td align="left"><5</td><td align="left">522 (20%)</td><td align="left">67 (24%)</td><td align="left">1·07 (0·82 to 1·42)</td><td align="left">0·95 (0·70 to 1·27)</td><td align="left">−0·04 (−0·10 to 0·03)</td><td align="left">0·05 (−0·11 to 0·03)</td></tr><tr><td></td><td align="left">>5</td><td align="left">887 (34%)</td><td align="left">70 (25%)</td><td align="left">0·69 (0·52 to 0·91)</td><td align="left">0·66 (0·50 to 0·89)</td><td align="left">−0·07 (−0·12 to −0·02)</td><td align="left">−0·05 (−0·11 to −0·00)</td></tr><tr><td colspan="2" align="left">Number of siblings</td><td align="left">4 (3–6)</td><td align="left">4 (3–6)</td><td align="left">1·01 (0·97 to 1·05)</td><td align="left">0·95 (0·88 to 1·01)</td><td align="left">0·00 (−0·01 to 0·01)</td><td align="left">−0·02 (0·03 to 0·00)</td></tr><tr><td colspan="2" align="left">Deceased father</td><td align="left">73 (3%)</td><td align="left">5 (4%)</td><td align="left">1·15 (0·48 to 2·73)</td><td align="left">1·49 (0·61 to 3·61)</td><td align="left">−0·09 (−0·22 to 0·04)</td><td align="left">0·04 (−0·15 to 0·23)</td></tr></tbody></table><table-wrap-foot><fn><p>Data are median (IQR), n (95% CI), n (%), n/N (%).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl3fn1"><label>*</label><p id="cenpara20">Adjusted for child factors (age, sex, schooling, and region of residence).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl3fn2"><label>†</label><p id="cenpara30">Adjusted for both child factors (age, sex, schooling, region of residence) and maternal factors (age, marital status, education level, economic or employment status, religion, and ethnicity).</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl3fn3"><label>‡</label><p id="cenpara40">The test for linear trend for the levels of the factor was statistically significant. Associations for categorical variables (eg, behavioural and emotional problems) were reported as risk ratios, whereas for continuous scores regression coefficients were used.</p></fn></table-wrap-foot></table-wrap><table-wrap id="tbl4" position="float"><label>Table 4</label><caption><p>Medical and neurocognitive comorbidities of behavioural and emotional problems by age group in children randomly selected for clinical assessment</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th align="left"><bold>All children (n=620)</bold></th><th colspan="3" align="left"><bold>Total problems</bold><hr></hr></th><th colspan="3" align="left"><bold>Externalising problems</bold><hr></hr></th><th colspan="3" align="left"><bold>Internalising problems</bold><hr></hr></th></tr><tr><th></th><th></th><th align="left">No (n=377)</th><th align="left">Yes (n=243)</th><th align="left">p value</th><th align="left">No (n=424)</th><th align="left">Yes (n=196)</th><th align="left">p value</th><th align="left">No (n=266)</th><th align="left">Yes (n=354)</th><th align="left">p value</th></tr></thead><tbody><tr><td align="left">Hypoaesthesia<xref rid="tbl4fn1" ref-type="table-fn">*</xref></td><td align="left">29 (5%)</td><td align="left">13 (3%)</td><td align="left">16 (6%)</td><td align="left">0·071</td><td align="left">17 (4%)</td><td align="left">12 (6%)</td><td align="left">0·247</td><td align="left">8 (3%)</td><td align="left">21 (6%)</td><td align="left">0·088</td></tr><tr><td align="left">Abnormal limb function<xref rid="tbl4fn2" ref-type="table-fn">†</xref></td><td align="left">8 (1%)</td><td align="left">3 (1%)</td><td align="left">5 (2%)</td><td align="left">0·174</td><td align="left">4 (1%)</td><td align="left">4 (2%)</td><td align="left">0·260</td><td align="left">2 (1%)</td><td align="left">6 (2%)</td><td align="left">0·303</td></tr><tr><td align="left">Motor impairments<xref rid="tbl4fn3" ref-type="table-fn">‡</xref></td><td align="left">86 (14%)</td><td align="left">46 (12%)</td><td align="left">40 (16%)</td><td align="left">0·134</td><td align="left">56 (13%)</td><td align="left">30 (15%)</td><td align="left">0·482</td><td align="left">36 (14%)</td><td align="left">50 (15%)</td><td align="left">0·833</td></tr><tr><td align="left">Intellectual disability</td><td align="left">27 (4%)</td><td align="left">12 (3%)</td><td align="left">15 (6%)</td><td align="left">0·075</td><td align="left">15 (4%)</td><td align="left">12 (6%)</td><td align="left">0·143</td><td align="left">8 (3%)</td><td align="left">19 (5%)</td><td align="left">0·154</td></tr><tr><td align="left">Otitis and ear canal abnormalities</td><td align="left">26 (4%)</td><td align="left">18 (5%)</td><td align="left">8 (3%)</td><td align="left">0·418</td><td align="left">22 (5%)</td><td align="left">4 (2%)</td><td align="left">0·084</td><td align="left">12 (5%)</td><td align="left">14 (4%)</td><td align="left">0·840</td></tr><tr><td align="left">Cardiovascular problems</td><td align="left">4 (1%)</td><td align="left">3 (1%)</td><td align="left">1 (<1%)</td><td align="left">1·000</td><td align="left">4 (1%)</td><td align="left">0 (0%)</td><td align="left">0·313</td><td align="left">1 (<1%)</td><td align="left">3 (1%)</td><td align="left">0·639</td></tr><tr><td align="left">Respiratory problems</td><td align="left">11 (2%)</td><td align="left">6 (2%)</td><td align="left">5 (2%)</td><td align="left">0·759</td><td align="left">6 (1%)</td><td align="left">5 (3%)</td><td align="left">0·337</td><td align="left">1 (<1%)</td><td align="left">10 (3%)</td><td align="left">0·023</td></tr><tr><td align="left">Malnutrition</td><td align="left">19 (3%)</td><td align="left">13 (3%)</td><td align="left">6 (2%)</td><td align="left">0·490</td><td align="left">16 (4%)</td><td align="left">3 (2%)</td><td align="left">0·132</td><td align="left">9 (4%)</td><td align="left">10 (3%)</td><td align="left">0·690</td></tr><tr><td align="left">Skin scars or bruises</td><td align="left">20 (3%)</td><td align="left">8 (2%)</td><td align="left">12 (5%)</td><td align="left">0·053</td><td align="left">11 (3%)</td><td align="left">9 (5%)</td><td align="left">0·191</td><td align="left">7 (4%)</td><td align="left">13 (4%)</td><td align="left">0·468</td></tr><tr><td align="left">Burn marks</td><td align="left">65 (10%)</td><td align="left">32 (8%)</td><td align="left">33 (14%)</td><td align="left">0·043</td><td align="left">32 (8%)</td><td align="left">33 (17%)</td><td align="left"><0·0001</td><td align="left">26 (10%)</td><td align="left">39 (11%)</td><td align="left">0·619</td></tr></tbody></table><table-wrap-foot><fn id="tbl4fn1"><label>*</label><p id="cenpara50">Reduced sensation to touch or painful stimuli.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl4fn2"><label>†</label><p id="cenpara60">Reduced or increased reflex activity.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tbl4fn3"><label>‡</label><p id="cenpara70">Both general and fine motor skills assessed.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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