Perspectives of paediatricians on developmental surveillance and screening in a low- to middle-income country: a qualitative study

Abstract

Introduction

Early childhood development (ECD) is a critical global and public health issue. Worldwide, paediatricians serve as the primary point of contact between children and the healthcare system, playing a key role in promoting healthy development through routine developmental surveillance (DS) and screening (DSc). However, there is limited research on paediatricians’ perspectives regarding this matter, particularly in low-resource communities and countries such as Lebanon. This study aimed to explore the paediatricians’ perspectives on the current routine DS and DSc practices for children under 5 years of age.

Methods

Paediatricians from all five Lebanese governorates were invited to participate using purpose and convenience sampling. A total of five academic and eleven non-academic paediatricians were included in the study. Semi-structured face-to-face or online interviews were conducted in Arabic between September 2018 and August 2021. Interviews were audio-recorded, then transcribed verbatim and translated into English and thematically analysed using Quirkos V.2.5.3 software.

Results

The study revealed significant variation regarding the understanding of concepts of routine DS and DSc. Most non-academic paediatricians primarily focused on physical development, while academic paediatricians were more attuned to cognitive and psychosocial development, with variation in practice. Factors influencing the practice were multi-layered: paediatricians, parents, paediatrician–parent interaction and system level.

Conclusion

DS and DSc practices in Lebanon are inconsistent, often incomplete and not systematically integrated into routine paediatric care. Efforts should be made to raise awareness about their importance, the appropriate methods for conducting them, and address the system-level factors by developing national guidelines for ECD. Data on paediatricians’ practices in other similar low-resource countries or communities is needed to understand the common problems and have joint efforts to address them globally.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Globally, an estimated 250 million children are at risk of not reaching their full developmental potential, with the greatest burden in low- and middle-income countries (LMICs). Developmental surveillance and screening are recommended practices in paediatric care, yet implementation in LMICs remains limited due to barriers such as lack of training, standardised tools and system-level support.

WHAT THIS STUDY ADDS

• This study provides insight into paediatricians’ perspectives in an LMIC setting, revealing variability in knowledge, enthusiasm and confidence in implementing developmental surveillance and screening and highlighting perceived barriers.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Findings can guide national and regional efforts to enhance early childhood developmental services, including capacity-building initiatives, standardisation of screening tools and policy integration of developmental surveillance. These results also inform future research aimed at designing and evaluating feasible strategies to support broader implementation within resource-limited settings.

Introduction

The WHO defines early childhood development (ECD) as ‘the physical, socio-emotional, cognitive, and motor development of children between zero and eight years of age’.¹ The first 1000 days are particularly critical for the foundation of cognitive, motor and psychosocial skills.^{2 3} Having early developmental surveillance (DS) and screening (DSc) is essential for identifying delays and providing timely interventions that can prevent disabilities or improve long-term outcomes. International paediatric bodies such as the American Academy of Pediatrics define DS as a systematic process of monitoring children’s development during routine healthcare visits⁴ and DSc at 9, 18 and 30 months using validated screening tools⁵ such as the Ages and Stages Questionnaire (ASQ-3).⁶

Children younger than 5 years of age in low- and middle-income countries (LMICs) or communities are disproportionally at risk of not reaching their developmental potential.⁷ This alarming statistic highlights the urgent need to improve the quality of early childhood surveillance and screening in these countries. In Lebanon, a middle-income country where this study was conducted, clear guidelines for DS and DSc are lacking. A recent report showed that more than 20% of children under 2 years of age were not developmentally on track.⁸ Efforts to improve DS and DSc to monitor children’s developmental milestones are needed. Our aim was to explore the paediatricians’ perspectives on the current routine DS and DSc practices for children under 5 years of age and the factors that influence their practices.

Methods

This was an exploratory descriptive qualitative study. Semi-structured interviews, in-person or virtual, were conducted in two phases: phase 1 between July and August 2019 (in-person), and phase 2 (virtual) in August 2021. Interviews lasted 45–75 min each. We followed the Consolidated criteria for Reporting Qualitative research (COREQ) guidelines in reporting this study.⁹

Sample and recruitment

For phase 1, a purposive sampling approach was adopted. We obtained the list and emails of paediatricians registered with the Lebanese Orders of Physicians that included those who were practising outpatient paediatric medicine in Lebanon for at least 2 years before recruitment. Five lists, one for each Lebanese geographical area, were generated. The lists were randomised, and paediatricians were contacted and recruited on a ‘first come, first served’ basis.¹⁰ Those who consented were contacted to confirm the time and location. The recruitment for phase 1 stopped in August 2019 due to the political crisis in Lebanon and thereafter the COVID-19 pandemic.

We resumed phase 2 recruitment in August 2021. For phase 2, a convenience sample was selected from one academic centre. Paediatricians with at least 2 years of experience were invited via email found on their institutions’ official website page; those who consented were contacted to set the interview date and time. Recruiting participants stopped once we believed we reached ‘thematic saturation’.¹¹

Data collection

For phase 1, in-person interviews were conducted at the paediatricians’ clinics in a private room, at their discretion, by the first author (female medical doctor with experience in child development screening). Since phase 2 was conducted during the pandemic, all interviews were held by the first author virtually using Zoom and Microsoft Teams, ensuring that both the interviewer and the paediatrician were in a private room of their choosing. No notable differences were observed between modes in the depth or content of responses. Field notes were not taken, as the interviewer focused on probing participants’ perspectives and maintaining conversational flow.

On the day of the interview, the first author obtained consent after reading the information sheet and the points outlined in the consent form, translated into Arabic. Phase 1 participants were coded from P1–P11, and those from phase 2 were coded with P201–P205.

The topic guide included open-ended questions based on themes identified in the literature review (online supplemental appendix 1). To test the guide, one pilot interview, not included in the analysis, was conducted with a volunteer community paediatrician. The interview was transcribed and shared with the principal investigator for feedback, based on which more probing and follow-up questions were added, and the topic guide was refined for cultural sensitivity.

All interviews were audio-recorded on the researcher’s encrypted device and then translated and transcribed verbatim by the first author. The data were pseudo-anonymised, personal identifiers were removed to protect participants’ privacy and anonymity. The audio recordings were labelled with coding numbers and stored on the encrypted device. Only these coding numbers were used to refer to participants.

Data analysis

The data analysis followed a thematic analysis approach, as the study began with a preset objective and aim. The six stages of Braun and Clarke’s thematic analysis included: familiarisation with the data, generating codes, theme development, reviewing themes, defining themes and producing the report.¹²

In stage 1, the interviewer (first author) and coder (second author) listened to the audio recordings and reviewed each transcript several times to become familiar with the data. During stage 2, two coders (GH-AH and MG) went line by line to provide a label for each idea for the first transcript, then the research team met to discuss the labelling and the agreement between the coders. They then continued the coding of the remaining transcripts until an initial list of codes was created.

Stage 3 involved discussions by all authors of connections between the codes and the incorporation of definitions and quotes for each theme and subtheme. Those were recorded in a log of possible themes. In stages 4 and 5, the research team refined the list by creating clear themes and subthemes, highlighting existing connections and defining the relationships between them. In stage 6, the findings were synthesised and presented through a narrative, supported by direct quotes from beneficiaries and interviewees, to ensure a concise, logical and engaging explanation of the data.¹²

The analysis was performed using Quirkos V.2.5.3 software, a computer-based tool designed for qualitative analysis, whose only purpose was to manage the data by using graphic divisions where each concept in the data is categorised visually.¹³ Patients or members of the public were not involved in the design, or conduct, or reporting, or dissemination plans of the research.

Results

We interviewed 16 participants (11 in phase 1 and 5 in phase 2). One withdrew after consenting to participate. The participants varied in gender, years of experience and educational background. All the participants from phase 1 were community-based paediatricians whereas all those from phase 2 were affiliated with a large academic centre but practising in outpatient clinics (table 1).

Table 1. Characteristics of paediatricians interviewed during phases 1 and 2 (n=16).

	Characteristics	N (%)
Gender	Male	6 (37.5%)
	Female	10 (62.5%)
Practice location	Large urban cities	8 (50%)
	Suburban and little towns	7 (43.8%)
	Both	1 (6.2%)
Years of experience	0–10 years	2 (12.5%)
	11–20 years	7 (43.8%)
	21–30 years	5 (31.3%)
	30 and above	2 (12.5%)
Educational background	Russia	6 (37.5%)
	Lebanon and France	3 (18.8%)
	Lebanon only	4 (25%)
	USA	2 (12.5%)
	Belarus	4 (25%)
	Syria	1 (6.2%)
Academic affiliation	Yes	5 (31.3%)
	No	11 (68.7%)

Paediatricians’ practice

Most participants did not have formal education in DS or DSc. A few were mentored to practise during their training: “I learned a lot from the faculty who were our advisors/mentors, and I ended up developing a pattern that I’m very comfortable with …” (P201).

The six standards of practice steps described by Lipkin and Macias⁴ were partially used to describe the practice of DS.⁵

First: eliciting and attending to the parent’s concerns

A few paediatricians appropriately elicited parents’ concerns, “Typically I see if they [parents] have any questions …” (P12). They indicated using tools such as the ASQ to do DS, rather than using it adequately as a parent-filled screening tool “I use ASQ …, I ask [the questions] directly to the parents …” (P8).

Second: obtaining, documenting and maintaining a developmental history

Some paediatricians mentioned regularly surveying infants: “I ask them to come for a visit almost every month, during the first year of life, …” (P3). Some also often perform their DS during the regular physical assessment: “I wasn’t giving the DS its own time, I am merging it with the physical exam and history taking” (P1). During the visit, the paediatrician examines the child and makes sure the child has achieved the milestones for age: “I put the child on his stomach … if he doesn’t hold his head up and he’s 3 months old then [I know] there is some delay …” (P3).

Third: making accurate and informed observations of the child

For any alarming findings, some paediatricians mentioned they inform parents to come back for follow-up: “During the visit, I check those skills, and for the one that the child can’t do, I put a question mark and give the mother a week or two to observe and to tell me if the child is capable of doing that particular skill now” (P5).

Sixth: sharing and obtaining opinions and findings with other professionals

Whenever there were concerns, paediatricians mentioned they would often refer the child to a specialist: “if I notice someone who is not so well, I directly refer them to a specialist from the start, I don’t have to do it myself anymore” (P2), or to well-known medical centres that have more resources: “… in severe cases [I] refer the patient to big, well-known medical centers” (P5).

The fourth (identifying risks and strengths and protective factors) and fifth (maintaining an accurate record of the process and findings) stages were not reported, indicating no implementation.

Multi-layered factors influencing DS and DSc practice

Paediatricians’ factors

When asked to define DS, many paediatricians provided accurate definitions. However, some confused it with public health surveillance or perceived it as a specialty, “somebody specialized that you could refer patients to” (P204), or referred to it as monitoring the child using laboratory tests.

Regarding DSc, there were great variations in paediatricians’ understanding. Those in urban areas and academia were aware of and used screening tools. These paediatricians had diverse backgrounds, including education in countries like Russia, Lebanon and the USA. Some paediatricians used tools like the Denver Chart, but many could not recall the specific tools they used. When asked how they used them, one paediatrician said: “Before every visit, I used to send the questions to the parents’ email to fill them out and bring them for the visit. And those who did not have a computer or an email, I printed them [checklists] and gave a copy to the parents to fill out before the next visit” (P8).

Many were either unaware of DSc tools or confused them with physical growth charts. When asked about whether they perform DSc, one paediatrician replied with: “DSc? No not really. What do you mean by that?” (P11). Participating paediatricians acknowledged that DSc tools are an essential guide to assess a child’s development. Yet, for one paediatrician, the DSc tools were not enough to identify developmental problems.

When asked how confident they were using the DSc tools, a few indicated that it was easy to use but it can be time-consuming, according to one participant.

Parents’ factors

The delivery of DS and DSc is influenced by various parental factors:

• Parents’ awareness of developmental milestones varied from parents, who “don’t understand much of what we are talking about” (P5) to those with an adequate understanding, particularly noticed among more affluent groups.

• Family financial constraints, especially among rural and refugee populations, affected the delivery of DS and DSc. Parents avoided seeking help due to fear of additional costs. Also, early childhood interventions like speech therapy were unaffordable. Also, among Syrian refugees, the prevalence of food insecurity had a high impact and prompted parents to be more focused on growth.

• Fear of diagnosis was also a reported barrier which made parents more likely to avoid clinic visits or stay in denial when the diagnosis was made.

• Parents sometimes provided inaccurate reports, claiming their children had reached certain milestones when they had not (reporting biases). Additionally, there were reported instances of non-compliance with recommended treatments.

• There was reported community influence where neighbours or relatives were sources of information and counselling, or where religious beliefs such as the “evil eye” (P2) or taboos related to developmental challenges were still prevalent, preventing parents from being active partners in the DS and DSc. Also, grandparents played a key role in noticing developmental issues early. In addition, in more affluent areas, the reliance on migrant workers for childcare limited the ability of parents to notice details about their child’s development.

Parent–provider interaction

Generally, the parent–provider relationship was described as “a relationship of trust” (P201) and was mostly heightened in small towns and villages. One aspect that contributed to this trust relationship was honesty. Physicians seemed to be honest with the parents throughout the care of their child, even when they had to deliver bad news about their development.

Conversely, some paediatricians faced the challenge of mistrust, with some parents who tend to “seek other physicians’ opinions … This movement of patients between doctors is not allowing us to monitor 100%” (P2). Further, some paediatricians mentioned that to avoid consultation fees, parents tend to use “phone consultations” (P2) and considered that a barrier to closely monitoring development.

System-based factors

• Lebanese Pediatric Society provides a platform for continuous education on DSc and sharing cases.

• Health records given freely by the Ministry of Public Health (MoPH) to every newborn were an important reported tool for monitoring development. These records were seen as beneficial for educating parents. However, some physicians felt the records were too detailed.

• Daycares were recognised for referring children to paediatricians and contributing to diagnosis.

• Public versus private healthcare: physicians noted that in publicly funded clinics, there is less time to interact with parents due to high workloads, whereas in private clinics, doctors can spend more time with patients. Hence, children in dispensaries and social centres were often less monitored than those in private clinics.

• Access to specialists and therapies was limited outside of central Beirut.

• Lack of proper referral systems made it difficult to follow-up on specialist consultations. However, some paediatricians reported good cooperation with certain specialists.

The multi-layered factors are summarised in figure 1 and excerpts from participants’ quotes are presented in table 2. Many physicians provided recommendations on ways to improve DS; these are summarised in box 1.

Figure 1. Summary of the multi-layered factors describing the reality of DS and DSc in Lebanon. DS, developmental surveillance; DSc, developmental screening.

Table 2. Factors influencing DS and DSc practices.

Theme	Quote
Paediatrician’s factors
Understanding developmental surveillance	“Watching these kids develop throughout the years and make sure that they’re following their milestones” (P203) “Because my understanding of surveillance is when you, for example, try to find how many congenital heart diseases are in the country …, it is not at the individual level anymore, it is at the public level” (P1) “We do routine tests at 3 months and 6 months of age to see if the iron level is okay [for example] or we give it to them as prevention or treatment” (P4)
Understanding developmental screening	“My understanding is that you either give them [patients] a checklist or you do it in clinic if you have a checklist; it is very detailed, [includes] everything in each stage of growth …” (P1) “We have the Denver chart. There are charts for each age phase …” (P8) “It is a screening tool, I now have it memorized, has 5 aspects: fine motor, gross motor, social, etc …” (P202) “I look at those checklists when a child comes to the clinic. I look at his checklist to see all the information concerning height, weight, body temperature, and blood pressure; the nurse does those before the child [comes to see me] so that I have all the numbers in front of me” (P5)
Perceived importance of DSc and DSc tools	“The doctors can use them as a reference to make sure not to skip anything important …” (P11) “That has nothing to do with a checklist … Checklists are not enough. The experience and self-confidence that the doctor has, is very important” (P9)
Perceived self-efficacy in DSc practice	“It is not “hard” as a process; it is very easy, you just ask the questions, or ask the parents outside in the waiting room, or in the clinic, to fill out the questionnaire. It is time-consuming, in the way that it is now, very detailed” (P1)
Parents’ factors
Parents’ awareness	“There are some parents who [request to] check with us about a developmental delay or slow development of their children more so than regarding malnutrition cases … In the last 2–3 years, parents are more aware [of developmental milestones]” (P6) parents “don’t understand much of what we are talking about” (P5) “We don’t have this awareness that you think we have, to give someone a paper to fill about their child, no. It will not work out here” (P2) “Sometimes the parents go to the neurologist on their own, they go to the neurologist or psychiatrist but then they [specialists] will ask the parents about the child (development))and vaccines so they will have to call us again” (P4)
Families financial constraints	“Mainly, in villages, everything is related to the financial capability … Sometimes, their [Parents] financial capability is very low which prevents them from any follow-up” (P6) “The psychologist charges 50$ [a large sum] per visit here in the North region, it is even more expensive in Beirut. The patient might need 1 or 2 sessions/week for 3–4 months. Many cannot afford it, so they simply don’t go at all, or they go once and then stop going” (P8)
Fear of diagnosis	“They would simply turn a blind eye … They remain silent because they are afraid that we would ask for more tests and discover a certain disease” (P11)
Reporting bias	“A mother would tell you that he walked at 1 year and 2 months, while in reality he [patient] started walking at 2 years of age” (P3)
Poor compliance	“They either ignore my instructions completely or add other things to it”. (P2) “Some parents don’t come on time they come s play a role in affecting the decision of parents after 2 months for example” (P2) “Between ages 4 and 5 years, we lose track of them [patients]. This is the pattern unless there is an illness, or notice something wrong or the nursery or school draw their [parents] attention to a problem” (P9)
Denial	“Some parents are in denial; I try to explain to them that you need to go to a specialist to understand the issue not to another doctor like me to ask them if there is a problem or not”. (P1) “They often say it is not a big deal, I was like that, or his uncle was like that, and we are fine now”. (P8) Often parents’ denial is explained by the participant as “a self-defence mechanism for herself and for the most precious thing she has which is her child …” (P3)
Community/religious influence	“But let’s say you explain to one family, okay? Then when they go to visit their neighbor or relative, they will tell them “No don’t listen to him [the doctor]” (P2) “They believe that children’s developmental concerns are due to an ‘evil eye’ so instead of seeking medical treatment, they say a prayer to dispel the sickness, referred to as ‘rakwa’” (P2) “God will cure him [the child with delay]” (P2) “After kids come back from school or nursery, they go to their grandparents who take care of them, so this also brings in another factor as to why the parents are usually more alert; they’re alerted earlier [by the grandparents] to some of the problems” (P201) “They [refugees] would come and say ‘he [my child] is not growing; he is not eating, and he needs ‘supplements’ [vitamins]” (P11) “Some have a family of 10 children, and they live in an environment where not even the minimum understanding of basic [medical concepts] exists. How is it possible to discuss or explain to them details concerning growth or development?” (P5) “The migrant worker is the one feeding the child, you see it in clinic; the mom enters the room [followed by] the migrant worker entering behind her and carrying the child, the mom will sit there and the migrant worker will answer the questions, the mom will ask the migrant worker details about the child” (P2)
Taboo	“In our culture, it is still difficult to accept going to a behavioral or psychologist. It is still considered shameful in front of people for a mother to take her son for behavioral reasons. That’s why mothers get afraid when the subject is raised … There was someone with speech delay” (P10)
Parent–provider interaction
Trust relationship	“I treat the baby like he is my baby or my grandson” (P3) “They come to me because I know the families on a personal level, and they know me … for I have known them since birth”. (P5)
Parent involvement	“I face the parents with the problem and tell them that this is the case and I explain to them. I let the parents be involved of course, they need to accept and know what is wrong”. (P1)
Parents reliance on physicians	“We must draw parents’ attention to developmental growth” (P9)
System-related factors
Lebanese Pediatric Society	“There’s the pediatric society, the LPS, it is a scientific society” (P2)
Health records	“The developmental growth health record is not just for vaccines, it is for monitoring [cognitive] development as well” (P4) “… If the mom reads this info (cognitive development, teething, etc…), she can avoid so many questions and she will be able to know how development should progress” (P2) “Many [physicians] skip filling it; if they [paediatric society] make it even more detailed, then no one will [fill it]” (P9) “With the new adjustments introduced, parents are more committed, and they can follow up [development] by themselves using the health book” (P5)
Daycares and schools	“… there is more awareness about those [delays] issues in the daycares; many children are referred to us from daycares; that along with their charts contributes to my diagnosis” (P11) “In schools, there should be more awareness about family planning, taking care of children, etc …” (P2)
Public vs private healthcare	“In private clinics, it’s different. Take your time with the patient. At the [private] clinic, the mother comes and expects more from you; more time in examining her child, more time to talk to her in detail” (P5) “The kids we see in dispensaries, in the social centers, are not well monitored like the ones we see in the [private] clinic” (P4)
Access to specialists and therapists	“There are no specialists in the villages, they are all general practitioners” (P3)
Lack of proper referral systems	“There’s a gap in the communication between the institutions and the primary healthcare physicians” (P1) “For example, the psychologist will ask me about the weight and height, if they are appropriate to(the child’s)age … and [the psychologist] will follow up the cognitive part and I follow the medical, physical part …” (P4)

DS, developmental surveillance; DSc, developmental screening.

Box 1. Suggestions to improve developmental surveillance, given by physicians in practice.

1. Raising awareness using various media platforms (such as on television).

2. Having good communication channels between primary care physicians and families.

3. Organising more local conferences on the topic.

4. Need for more special education classrooms in schools, and institutions to provide needed therapies.

5. Adopting standardised surveillance and screening methods across the country.

6. Educating parents and schools on child milestones (eg, using pamphlets).

7. Empowering parents to reach out to their paediatrician with concerns.

Discussion

In its most recent estimate, UNICEF reports that around 250 million children are at risk of not reaching their full potential.¹⁴ The Global Research on Developmental Disabilities Collaborators report that more than 50 million children under the age of five are actually living with at least one developmental disability worldwide, with the vast majority of them (around 95%) living in LMICs.¹⁵ Given these numbers, paediatric visits, serving as the first point of contact between the child and the healthcare system, should be used as an opportunity for DS, DSc and anticipatory guidance, especially in LMICs. A study conducted between 2005 and 2015, gathering data from 35 LMICs, including Lebanon, found that ‘one in every three preschool-aged children living in LMICs is failing to meet basic milestones in either their cognitive or socioemotional development’.² Early detection of delays is thus very crucial for timely interventions, especially in LMICs.

Our study showed that there is confusion in the understanding of the concepts of DS and DSc among Lebanese paediatricians. Generally, it appears there are two groups of paediatricians: those who prioritise the physical aspects, and those who recognise the importance of cognitive, psychosocial and emotional development alongside the physical. This was also reflected when paediatricians discussed the MoPH’s Health Record whose primary goal is to centralise all health information in one document. So, parents are expected to bring it with them to every well-child visit, while paediatricians are responsible for updating it, including the growth charts, vaccines given, medications/supplements prescribed and developmental milestones achieved. However, there is often a focus on physical growth over cognitive development, leading to incomplete entries in the record.

This emphasis on physical growth could be attributed to the state of transition that Lebanon is going through, much like most LMICs.¹⁶ Ever since the Millennium Development Goals era and into the post-Sustainable Development Goal (SDG) era, decreasing under-five mortality rates has been a global priority, with multiple international, regional and national initiatives aiming at improving nutrition and vitamin supplementation, controlling and preventing infectious diseases and increasing vaccination uptake levels in LMICs.¹⁶ Therefore, countries with now improved levels of child survival are faced with higher numbers of children who need constant follow-up.¹⁶ This has put LMICs under a ‘dual burden’ to ensure: (1) continuing efforts to increase child survival rates all while (2) keeping up with the post-2015 SDG target to improve childhood development by 2030.¹⁷ Added to that, Lebanon has been going through a series of crises in recent years, from political instability to economic collapse, the Beirut port explosion and the pandemic, which shifted the attention again towards safety, security and nutrition. Consequently, ECD was moved down in priority.

Interestingly, among those who prioritised the physical aspect were paediatricians with more than 10 years’ experience, whereas newer graduates included both DS and DSc in their encounters. One of those paediatricians also defined surveillance as a public health measure, rather than a responsibility for the paediatricians on the individual level. This interesting distinction might be at the root of the lack of surveillance and therefore paediatricians’ responsibilities should be redefined on a national level to ensure a more systematic and universal approach to development for all children. Therefore, it seems that paediatric training is moving in parallel with SDG targets. Accordingly, more awareness of the concept of ECD and the practices of surveillance and screening should be spread among the older generation physicians, especially since some noted that they waited for obvious delays before referring patients to ECD services. By implementing proper methods, delays can be detected earlier, allowing interventions to take place within an appropriate timeframe, preventing further disabilities and, in some cases, potentially reversing such delays.

Also, there was confusion in the concepts of ‘surveillance’ and ‘screening’, with paediatricians often grouping both under the same term. Although both serve the same end goal, screening requires the usage of validated tools, unlike surveillance. This misperception might stem from the lack of validated screening tools in Arabic.¹⁸ Interestingly, refugee parents who were participants in a study conducted in the Center for Refugee Health in Rochester, New York, were unsure of a word for ‘development’ in their primary language. They also demonstrated limited awareness of developmental milestones and raised their concern only when speech or behaviour problems were present.¹⁸ It is therefore essential to validate culturally appropriate screening tools and empower paediatricians to use them.

Another key finding of our study was the lack of guidelines for ECD. In the last decade, several initiatives have been introduced in Lebanon to understand the reality of ECD practices and advocate for policy change, but the country has just started these national discussions on the issue of ECD (personal communication) so there is a lot of progress to still be made. A recent report published in August 2024 emphasised the absence of a multisectoral national vision for ECD and the urgent need for policy mapping and targeted investment decisions. Similarly, in 2018, the MoPH in collaboration with multiple stakeholders organised a national Knowledge to Policy (K2P) dialogue on ECD. Stakeholders agreed that there is a lack of evidence on the subject and emphasised the need for further research to inform policies.¹⁹ This suggests a clear gap in the literature with different aspects related to ECD that should still be investigated.

Despite these sporadic initiatives, there is a critical need for sustained, coordinated efforts by governmental institutions and non-government organisations (NGOs) to design, implement and fund comprehensive local and national projects aimed at strengthening ECD. For instance, in Jordan, the implementation of the Positive Parenting Programme has delivered large-scale childcare skills training to hundreds of thousands of parents and caregivers, ultimately enhancing the well-being and development of nearly half a million children.¹⁴ Other initiatives include the ‘Teachers with a Tablet’ in Mongolia, where teachers in classrooms provide educational activities to both children and their parents, the innovative ECD programmes in Rwanda that help children grow in a safe environment while empowering their mothers to work, and the National Parenting Education programme in Bhutan, to name a few.¹⁴ Lebanon should build on the lessons learnt from these initiatives and engage in strategic collaboration with international partners and NGOs to facilitate knowledge exchange, with the objective of formulating a comprehensive national plan adapted to Lebanon’s institutional framework and socio-political context.

Also, this study revealed the inequity in the Lebanese healthcare system, which is likely due to the ‘out-of-pocket’ spending and the unfair distribution of services, which is governed by the rules of the private sector. This is impacting mainly those with worse social determinants of health.^{8 20} Despite numerous efforts to improve primary healthcare services nationwide through reforms suggested by the World Bank, efforts remain too general and do not appropriately target vulnerable populations.^{8 20} Given the increased financial burden on both citizens and refugees in Lebanon due to the poly-crises, securing funding for ECD services should be central to any proposed vision.

The challenges affecting DS and DSc in Lebanon, as well as paediatricians’ perceptions of these practices, are not unique to this country but are shared across other contexts worldwide, including high-income countries. There is a limited number of studies that explore perceptions of healthcare workers on this topic, but a similar qualitative study was conducted in Australia exploring the perceptions of 36 frontline workers on the topic of child development.²¹ The study focused mainly on the usage of screening tools and found that healthcare professionals are aware of the various screening tools available; however, they continue to face many barriers. Of which, they mention difficulties with transportation and the language barrier, given that the tools are not widely translated.²¹ Although not widely discussed by participants in our study, the availability of validated screening tools translated in Arabic (the official spoken and written language in Lebanon) might increase the usage of these tools. Individual efforts have been made to translate and validate the ASQ into Arabic; however, nationwide implementation would require a governmental decision.¹⁸

Strengths and weaknesses

This is the first study conducted in Lebanon and the MENA region exploring the perspectives of paediatricians regarding DS and DSc. By taking a qualitative approach, this study provides an in-depth analysis and presents nuances that cannot be detected using quantitative research methods.

We ensured the credibility, reflexivity and confirmability of our study by adhering to COREQ guidelines. To ensure credibility, we used transcribed audio-recorded interviews as the primary data repository. As in most qualitative studies, small samples are usually not representative of the target population; however, choosing paediatricians from the different geographical areas was expected to yield results that might infer the cultural and socioeconomic differences between the areas. To enhance rigour, data analysis was conducted collaboratively by two independent researchers, reducing the potential for biased interpretation and ensuring a more balanced perspective on the findings.

Regarding the reflexivity, the interviewer maintained a prior professional relationship with the participants, which helped build rapport and foster open communication. However, participants were not informed about the researcher’s personal objectives to minimise bias.

To ensure confirmability, a semi-structured interview guide was employed to standardise the data collection process, ensuring consistency across interviews while allowing flexibility to explore emerging themes. Additionally, we maintained an audit trail documenting all methodological decisions and analyses to provide transparency and enable verification of the study’s findings. Our study adheres to the COREQ checklist, aiming to establish a rigorous and trustworthy qualitative research process (online supplemental appendix 2).⁹

Conclusion

This study reveals significant gaps in the implementation of DS and DSc in Lebanon, primarily due to the absence of standardised practices, insufficient training and systemic barriers within the healthcare system. Overall, DS and DSc practices in Lebanon are inconsistent, often incomplete and not systematically integrated into routine paediatric care, highlighting the need for comprehensive improvements. It is therefore crucial to enhance awareness, introduce culturally appropriate screening tools and prioritise policy reforms that ensure equitable access to services nationwide.

Data availability statement

Data are available upon reasonable request.