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Screening in Child Health Care
Report of the Dutch Working Party
on Child Health Care
Micha de Winter
Marielle Balledux
Jose de Mare
Ruud Burgmeijer
First published 1995 by Radcliffe Publishing
Published 2016 by CRC Press

Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 1995 Micha de Winter, Marielle Balledux, Jose de Mare, Ruud Burgmeijer

CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
ISBN-13: 978-1-85775-150-5 (pbk)
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Translated by BSA Texts, © March 1994

Typeset by Marksbury Typesetting Ltd, Midsomer Norton, Bath, UK
Contents
Introduction-a critical evaluation of Dutch preventive

Child Health Care IX
1 Aims, procedures and outcome measurement in pre-school

Child Health Care 1
1.1 Aims of pre-school Child Health Care 2
1.2 Procedures in pre-school Child Health Care 3
1.2.1 The organized system of care 4

1.2.2 Methods of intervention and prevention 6
1.3 Outcome measurement 10
1.4 The structure of the report 12
2 Immunizations 15
2.1 The National Immunization Programme (R VP) 15

2.1.1 Implementation of the R VP 17
2.1.2 Financing of the R VP 18
2.2 Effects of immunization 19

2.2.1 Effects at individual level 20
2.2.2 Effects at population level 24
2.3 Costs of the R VP and the hepatitis B screening and

immunization 32
2.3.1 Costs of the R VP 32
2.3.2 Costs of hepatitis B screening and immunization 34
iv SCREENING IN CHILD HEALTH CARE
2.4 Cost-effectiveness and cost-benefit ratios 34

2.4.1 General 34
2.4.2 National Immunization Programme (RVP) 35
2.4.3 Hepatitis B screening and immunization 35
2.4.4 Haemophilus influenzae type B immunization 36
2.5 Conclusions 36
2.6 Recommendations 37
3 Screening for phenylketonuria and congenital hypothyroidism 50
3.1 Phenylketonuria (PKU) 50
3.2 Congenital hypothyroidism (CHT) 51
3.3 Organization of the screening 52
3.4 Implementation of the screening 53
3.5 Coverage of the PKU/CHT screening 54
3.6 Effectiveness of PKU screening 54
3.7 Effectiveness of CHT screening 55
3.8 Cost-benefit analysis for PKU 57
3.9 Cost-benefit analysis for CHT 59
3.10 Conclusions 60
3.10.1 The treatment of PKU 60
3.10.2 The method of screening for CHT 61
3.10.3 False positive results in the screening for CHT 62
4 Screening for hearing impairment 66
4.1 Hearing 66
4.2 Hearing impairments 66

CONTENTS V
4.3 Secretory otitis media (SOM) 67
4.4 Aim and outcome measurement of screening for hearing

impairment 69
4.5 Screening for hearing impairment 71
4.6 Screening tests 71
4.7 Conclusions 73
5 Early detection and prevention of vision defects 77
5.1 The normal development of vision 77
5.2 Visual disorders 78

5.2.1 Functional disorders 78
5.2.2 Structural defects 79
5.3 The importance of early detection (and treatment) of vision

defects 79
5.4 The aim and outcome measures of the detection of vision

defects 80
5.5 Tests for early detection of vision defects in the Netherlands 82

5.5.1 The Early Detection method 82
5.5.2 Acuity assessment 85
5.6 Other detection methods 87

5.6.1 Amblyopia and squint 88
5.6.2 Structural deviations 89
5.6.3 Visual acuity defects 89
5.7 Conclusions 90
6 Developmental surveillance 96
6.1 Development 97
vi SCREENING IN CHILD HEALTH CARE
6.2 Developmental impairments 97
6.3 Aim and outcome measures of developmental surveillance 98
6.4 Developmental surveillance methods 99
6.5 Developmental surveillance in the Netherlands 100
6.6 Conclusions 103
7 Detection of speech and language disorders 110
7.1 Normal language acquisition 111
7.2 Disorders in speech and language acquisition 111
7.3 Causes of disorders in language acquisition 112
7.4 Consequences of language acquisition disorders 113
7.5 Aim and outcome measurement of speech and language

surveillance 113
7.6 Methods for the detection of disorders in language acquisition 114

7.6.1 The Early Detection Language Project 114
7.6.2 The Language Development Survey 118
7.6.3 Method of Bax, Hart and Jenkins (1980) 118
7.6.4 Minimum speech standards 119
7.6.5 The use of parents' information 119
7.6.6 Comparing the various methods 120
7.7 The importance of an adequate follow-up route 121
7.8 Conclusions 121
8 The periodic health examination 126

CONTENTS vii
8.1 The periodic health examination: history taking, examination

and interview 129
8.1.1 History taking 129
8.1.2 The examination 130
8.1.3 The interview 131
8.2 Towards further formalization of the periodic health

examination in the Netherlands 131
8.3 The British Joint Working Party on Child Health Surveillance 139
8.4 Similarities and differences between the Netherlands and the

United Kingdom 143
8.4.1 Content and frequency 143

8.4.2 Open clinics and the role of parents 144
8.4.3 The possibilities for comparison 145
9 Prevention of psychosocial and educational problems 149
9.1 Psychosocial problems 150
9.2 Educational problems 151
9.3 Working methods in pre-school Child Health Care 154
9.4 Scientific state-of-the-art 155

9.4.1. Outcome measures 155
9.4.2. Problems in outcome measurement 156
9.5 First step towards a prevention model 158
9.6 Conclusions 160
10 Health education 166
10.1 Investigation into the effectiveness of health education 168

10.1.1 Education on nutrition 168
viii SCREENING IN CHILD HEALTH CARE
10.1.2 The Growth Book: information on child care and

child raising 169
10.1.3 Dental health education 172
10.104. Accident prevention 173
10.2 A model for the systematic setting up, implementation and

assessment of health education 176
10.3 Conclusions 179
lOA Recommendations 180
11 Activities directed at the social and physical environment of

children and parents 184
11.1 Health and environment factors 184

11.1.1. Social inequality 185
11.1.2 Physical environment 186
11.1.3 Primary lifeworld 186
11.1.4 Professionalization 187
11.2 Implications for pre-school Child Health Care: recognition,

guidance and cooperation 187
11.3 Consequences for policy, professionals and executive

organizations 189
1104 Recommendations 190
Index 193
Introduction
a critical evaluation of Dutch
preventive Child Health Care
Child Health Care for the pre-school age range has in many Western
countries increasingly grown into a subject of scientific, social and political
debate over the last few years. In Britain, the Joint Working Party on Child
Health Surveillance published a report in 1989, in which existing services
were critically examined and recommendations were made for future
practice (Hall et al. 1989). In the Netherlands as well, there were strong
reasons to do this. To put it briefly: Dutch Child Health Care, which for a
long time had enjoyed wide social support and appreciation, found itself
faced with the obligation to legitimize itself under the influence of new
political developments; society demanded a more accurate insight into the
results of its efforts. Within this context, the project called 'Integral
Evaluation of Child Health Care' was initiated. The Board of the National
Association for Community Nursing and Home Carel commissioned the
Centre for Research and Development of Youth Health Care and Youth
Social Work of the University of Utrecht to subject the Dutch Child Health
Care system to a scientific study. In this study special attention had to be
paid to quality, cost effectiveness and general effectiveness, efficiency, and
shortcomings in care. The project was financially supported by the
Ministry of Weifare, Public Health and Cultural Affairs, and the
Foundation for Research and Development of Social Services. Even before
the project was wound up in the middle of 1992, another political
discussion flared up, shaking the sector to its foundations: at the end of
1991 Christian Democrat and Labour MPs proposed a motion to transfer
the responsibility for the Child Health Care system, plus its financing, to
local authorities. The Integral Evaluation Project then took on a somewhat
different aspect. While it was initially meant to provide a better insight into
the effects of the health care system, its results were now expected to play
IFor a long time 'Cross Associations' (Kruisverenigingen) have been active in the
Netherlands in the fields of social and preventive medicine and home nursing on behalf
of their members as well as of the general public. The National Cross Association
(Nationale Kruisvereniging) represented the regional cross associations at national level. In
1990 the National Cross Association merged with the National Council for Home Help
(Centrale Raad voor de Gezinsverzorging) to form the National Association for community
Nursing and Home Care (Landelijke Vereniging voor Thuiszorg), established at Bunnik. In
this book the regional organizations will be referred to as 'Community Health Care'.
X SCREENING IN CHILD HEALTH CARE
an important part in the political decision-making process on the question

of whether the Child Health Care system remains a nationwide, guaranteed
basic facility or becomes subject to locally established priorities.
The objective of the project was formulated as follows:

'On the basis of existing national and international research material, the
project aims to arrive at a scientifically sound assessment of the present
Child Health Care system, on which proposals for changes in care, if
necessary and if possible, can be based. Should the study show, on the basis
of national and international data, that a scientifically sound assessment
cannot be made because parts of the research material are insufficient, then
recommendations for further research, such as cost-effectiveness studies,
will need to be formulated. In such a case this investigation must be
considered a preliminary study, which on the one hand ought to yield
material to reach a scientific consensus on the Child Health Care system,
and on the other hand must be viewed as a study that will enable the
programming and attuning of further research into the desirable content
and organization of the Child Health Care system. This integral study of
Dutch Child Health Care (in its relation to child health surveillance
programmes in other countries) should yield conclusions and recommenda-
tions relating to:
• the necessary and desirable content of the Dutch Child Health

Care system, if possible on the basis of cost-effectiveness data
• the frequency with which various studies are to be carried out
• the necessary expertise
• all-round or specialist district health care within the Child Health
Care system
• the procedures of quality control and quality improvement
• possibilities for greater parental involvement in Child Health Care.
In view of the breadth and complexity of the above-mentioned issues, the

project was centred around an 'expert committee', an independent expert
working party, which was composed on the basis of scientific, professional
and/or social authority in the area of youth health care or related areas.
Besides the professional groups directly involved, experts from relevant
medical and social science disciplines, the government, chief medical
inspectors, advisory bodies, medical insurance companies, Community
Health Care organizations, municipal and regional health services, and
parents associations were members of the working party. It was chaired by
Professor F. Vorst, emeritus professor of health care at the University of
Limburg. The method was analogous to that of a comparable project
relating to Child Health Surveillance, which was completed in England in
INTRODUCTION xi
1989 (Hall, 1989). Several experts who were involved in the British project
advised the Dutch working party in certain areas.
In five working conferences, the Dutch working party investigated the
above-mentioned matters with respect to Child Health Care. By means of
extensive international comparative literature studies, these conferences
were prepared by a project team from the Centre for Research and
Development of Youth Health Care and Youth Social Work of the
University of Utrecht. On the basis of the literature studies, consensus
meetings were held concerning the following subjects: the objectives of the
Child Health Care system, immunizations, phenylketonuria (PKU) and
congenital hypothyroidism (CHT) screenings, hearing examinations, visual
examinations, language/speech examinations, periodic medical examinations,
prevention of psychosocial and educational problems, health education,
activities aimed at influencing social and physical environmental factors,
and, finally, the quality and the organization of the Child Health Care
system. The final version of the report was established on the basis of
repeated discussions by the working party and advice obtained externally.
The Integral Evaluation Project was an effort to provide the best possible
survey of the effectiveness and quality of the Dutch Child Health Care
system. On the basis of its results, a great many recommendations have
been formulated which are aimed at improving quality and effectiveness
where possible. In addition, the project group has initiated a number of
research programmes, with the aid of which further insight will be gained
in the short term into effectiveness data which are not available as yet. In
particular the instrument for the determination of cost-effectiveness ratios
in the Child Health Care system, which will be developed by the Erasmus
University, must be considered an important improvement. The most
remarkable conclusion of the project is that the Dutch Child Health Care
system maybe considered a very solid kind of organized programmed
prevention. The system owes its strength to its thorough national
organization, and its firm establishment at community and district levels.
The great trust this form of preventive care enjoys with the public is an
essential precondition for an invariably high population coverage, which in
its turn is responsible for the high degree of health benefit that is obtained
with the system. The fact that there is room for improvement on many
points does not detract from this conclusion. On the contrary, the
possibility of such critical reflection on its own professional practice in this
sector may serve as an example to many other health care sectors.
Reference
Hall, D.M.B. et al. (ed.) Health for All Children. A programme for Child
Health Surveillance, New York 1989.
Aims, procedures and outcome
measurement in pre-school Child
Health Care
Outcome measurement in health care is practically always aimed at

determining the outcome of separate interventions, whether these are of a
preventive or curative nature. Think for instance of the studies into the
effects of screening programmes for breast and cervical cancer, effects of
heart transplants, or of information campaigns to influence smoking habits.
Conversely there are few, if any, examples of studies into the effects of
comprehensive and complex systems of care, such as pre-school Child
Health Care. In comparison, one could, in this connection, think of
outcome measurements of 'the' General Practice, or of 'the' Ambulatory
Mental Health Care.
Outcome measurement of a system of care differs considerably in many

respects from the evaluation of a single intervention. In studying the
outcome of a system of care, multiple objectives as well as a whole range of
intervention methods, and consequently a great diversity of outcome
measures, have to be taken into account. Moreover, in evaluating a system
of care, the possible connection or interference of the various constituent
parts must be considered; in a system the whole is more than the sum of the
parts. Owing to this complexity, outcome measurement of a system of care
will necessarily have the character of a 'programme evaluation': a series of
connected outcome studies, projected in time, the individual results of
which may have implications for several parts of the system. Next to the
study into the outcomes of its individual components, a programme
evaluation also aims at providing insight into the overall effect of the
system of care. In this way any duplications, prioritizations and gaps in the
provision of care become apparent as well as aspects of organization,
quality control and staffing policy.
In this chapter, the framework for the substance of such a programme

evaluation of pre-school Child Health Care is sketched, starting with a
description of the objectives. On the basis of the so-called ecological health
model, used by the World Health Organization in the international
programme 'Health for All by the Year 2000', a broad objective for pre-
school Child Health Care is formulated. Subsequently, subsidiary
objectives that can be made operational are derived from this. Then the
operating procedures serving to attain these specific objectives are
2 SCREENING IN CHILD HEALTH CARE
described. Finally the way to chart the effects of these procedures, related to
the objectives, is explained.
1.1 Aims of pre-school Child Health Care

What then, exactly, are the aims and functions of pre-school Child Health
Care? To begin with these do not, of course, constitute a static whole. At
the time the first Child Health Clinics were established, some 100 years ago,
the health of children was far worse than it is now. Because of poverty,
ignorance of essential hygiene and lack of facilities, rampant infectious
diseases and so on, infant mortality was very high (25% on average).
Obviously, the main objective of 'Child Health Care' then was to fight such
evils. The means used included social action, collective and individual
education of mothers, the distribution of good quality milk and the opening
of Child Health Clinics. As mortality and morbidity (from infectious
diseases) decreased, the objectives of Child Health Care shifted. Gradually
child development and 'mental hygiene' came into view as objects of care.
The main aim of pre-school Child Health Care, as expressed in 1972 by

the Netherlands League of Maternity Care and Child Health Hygiene
(Nederlandse Bond van Moederschapszorg en Kinderhygiene) was 'the
promotion and safeguarding of the health, growth and development of
young people'. In 1985 the Dutch Association of Child Health Care
(Nederlandse Vereniging voor Jeugdgezondheidszorg) widened the aim:
'Child Health Care, within the welfare and health care system, aims to
provide the longitudinal socia-medical guidance that will enable each
individual, as a young person and as an adult, to function at his/her best
individually and in a social context'. In the last few years, finally, a case has
been argued for making more room within the system of care for the
parents' responsibility for and contribution to the health and development
of their children, as well as for considering the living environment of the child
and its parents an object of Child Health Care. 1
These ideas link up with the 'ecological health model', used by the WHO
in realizing its aim 'Health for All by the Year 2000', and which in the
Netherlands served as the basis for the Memorandum 2000 (Nota 2000). In
the model, health is defined as 'a situation of equilibrium determined by the
circumstances in which people are placed and the capacity they possess, or
can acquire with the help of others, to defend themselves against
disturbances' (Ministry of Welfare, Public Health and Cultural Affairs
lSee e.g. De Winter (1990).

AIMS, PROCEDURES AND OUTCOME MEASUREMENT 3
1986). Four groups of health determinants are mentioned: physical factors;

health behaviour; social and physical environment; and the system of care
itself. A health problem (collective or individual) may arise through the
interaction of the various determinants. Specific health objectives (targets)
must therefore be pursued by influencing all relevant health determinants.
From this perspective the aim of pre-school Child Health Care can now
be defined as follows: 'The promotion and safeguarding of a healthy
physical, mental and social development of the population of pre-school
children, starting from the parents' personal responsibility, by means of
influencing the relevant health determinants, namely physical factors,
health behaviour and relevant environmental factors, including the system
of care itself'.
This general aim can be translated into four subsidiary objectives that
can be made operational.
• It is the objective of pre-school Child Health Care to improve

immunity against infectious diseases.
• It is the objective of pre-school Child Health Care to detect the
threat of individual health risks and disorders in time and, if
necessary, refer.
• It is the objective of pre-school Child Health Care to promote, at
an individual and collective level, the personal competence and the
responsibility of parents with regard to their children, if necessary
by advancing their understanding of the health condition and
(potential) development of their child and by increasing their
competence (health promoting behaviour).
• It is the objective of pre-school Child Health Care to provide
insight into the health condition of (groups of) young people, to
point out social risk factors that threaten health and to contribute
to the elimination of such factors.
1.2 Procedures in pre-school Child Health Care
Obviously it is the task of pre-school Child Health Care so to shape its

procedures (in connection with other organizations) that the above
objectives can be optimally realized. If the extent to which these objectives
are attained is to be determined, the methods to do so must be established.
These methods, after all, are the means by which the ends have to be
reached. It will then be possible to measure outcome for each method used
and also for the system of care as a whole. The latter measurement can only
be an approximation: in the first place pre-school Child Health Care is not

the only active factor (wide variables such as prosperity also influence the
state of health), and in the second place the effect of the aggregate of
methods does not equal the sum of the parts. One important reason for this
is that the methods at the service of pre-school Child Health Care are not at
all of equal order. On the one hand, for instance there are specific,
unambiguous interventions such as immunizations and screenings that
serve a well defined health target; on the other hand there are activities with
a much wider scope, such as counselling or giving advice and information
on the development of children and so on. Finally the presence, accessibility
and social roots of the system of care are major preconditions themselves.
However effective specific methods (such as immunization) are, if there is
no good organization for reaching the population the effect on health will
be considerably reduced. An adequate organization of the system itself, in
other words, is a necessary condition for the effectiveness of the whole of
pre-school Child Health Care.
Therefore, if we are to chart pre-school Child Health Care, two levels

should be distinguished. The first level is the provision of the required
conditions: the organized system of care, the extensive network of clinics
for babies and young children, from which numerous preventive and health
promotion activities are developed. Pre-school Child Health Care is carried
out by nurses and Medical Clinical Officers in clinics, in homes and for
groups. Support is given by District Medical Officers and Senior Nurses as
well as by educational experts, dieticians and health education consultants,
in their specific fields. The second level consists of the specific medical,
nursing and educational methods for prevention and intervention,
including immunization, screenings, counselling and the drawing up of
health profiles. These two levels are considered below.
1.2.1 The organized system of care

For decades, pre-school preventive health care in the Netherlands has been
carried out by the 'Cross' organizations. 2 Amsterdam, where this care is
provided by the Municipal Health Service, is an exception to the rule. Pre-
2For a long time 'Cross Associations' (Kruisverenigingen) have been active in the
Netherlands in the fields of social and preventive medicine and home nursing on behalf
of their members as well as of the general public. The National Cross Association (National
Kruisvereniging) represented the regional cross associations at national level. In 1990 the
National Cross Association merged with the National Council for Home Help (Centrale
Raad voor de Gezinsverzorging) to form the National Association for Community Nursing
and Home Care (Landelijke Vereniging voor Thuiszorg), established at Bunnik. In this book
the regional organizations will be referred to as 'Community Health Care'.
school Child Health Care takes place in a number of different ways: in

Child Health Clinics, in home visits, group education and 'external'
activities including participation in working groups on Early Detection and
in neighbourhood networks for youth welfare work. In the course of years,
a very close national network for pre-school Child Health Care has been
built up through local organizations. Both the population and the
authorities consider the clinics and the connected activities as a basic
facility; practically every parent in the Netherlands made and makes regular
use of them. The basic character of this facility can also be seen from the
way it is financed: pre-school Child Health Care is largely paid for under
the Exceptional Medical Expenses Act (Algemene Wet op de Bijzondere
Ziektekosten AWBZ), which makes this form of care accessible to everyone
and thus provides a nationwide guaranteed basic package. Coverage figures
are an extremely important criterion for assessing the adequate functioning
of such basic preventive care. A high population coverage is after all a
conditio sine qua non for the performance of practically all functions
concerned with the aims described in section 1.1. For many years now the
coverage of pre-school Child Health Care has been accurately recorded.
The baby clinics have a stable coverage of over 95%, the clinics for pre-
school children some 85%. PKU/CHT screening covers 99.6%, the
immunization level is more than 93% (Drewes 1989), and the range of
hearing screening by the Ewing method is 86% (NSDSK 1989)3. No
percentages are known of the number of home visits made annually by
district nurses, but they are estimated at one million per year (Bos & De
Winter 1989). International comparison shows that, certainly as far as
immunizations, PKU/CHT screening and hearing screening are concerned,
these figures are among the highest in the world. Partly for these reasons,
the Netherlands has the lowest child mortality among the under-fives in the
world after Japan, Sweden and Finland.
Another important criterion for assessing the Dutch system of Child

Health Care is the quality of the system and its reaction speed. Health and
health care are not static. The health situation of the population in care
changes, old threats lessen and new risks may present themselves. Scientific
opinions change, making new forms of intervention possible. For this
reason the system of care should possess some degree of flexibility and the
ability to meet new challenges with new methods. In the past few years the
effectiveness of a soundly organized and flexibly operating pre-school Child
Health Care has been demonstrated several times. One example of this is
the introduction of a new vaccination against measles, mumps and rubella
(MMR) a few years ago, which, within a year of its introduction, achieved
the same high degree of immunization of over 90% as the long established
3The majority of the remaining children have their hearing screened by other methods. See
Chapter 4, footnote 3.
immunizations of the National Immunization Programme (Rijksvaccinatie

Programma RVp)4. Another example concerns health education: by
changing the advice about laying babies on their stomachs a quick and
sharp decrease in the incidence of cot death was brought about (De Jonge
1992).
As stated above, high coverage as well as the capacity to react quickly

and adequately to new health risks or new points of view should be
considered necessary conditions for adequate functioning of pre-school
Child Health Care. The positive score on these criteria can therefore be
considered an important outcome of Dutch pre-school Child Health Care.
1.2.2 Methods of intervention and prevention

Different criteria are used to classify prevention. Firstly, a distinction is
often made between health promotion, health protection and prevention of
sickness. The second well-known distinction, between primary, secondary
and tertiary prevention, mainly refers to the stage in the course of the
sickness or disorder at the moment of preventive intervention. Thirdly, a
distinction is usually made between collective and individual prevention, in
order to indicate whether the prevention addresses the population, or
groups of it, or the needs of individuals. Each of these classifications has
serious shortcomings for the description and evaluation of pre-school Child
Health Care. Many activities undertaken in this connection aim, for
instance, at health promotion as well as at prevention of sickness, or they
make smooth transitions between primary, secondary and tertiary
prevention. The distinction between collective and individual prevention
also causes a lot of confusion, since collective prevention is often carried
out individually and individual prevention may also have a collective
significance.
Finally, in a recent recommendation, the National Health Council

(Nationale Raad voor de Volksgezondheid NRV) focused attention on the
notion of 'programmed prevention,.5 Programmed prevention is described
as: 'systematically executed preventive activities carried out according to a
fixed division of tasks and procedure and aimed at a defined target group,
the coverage of the target group being monitored' (Van de Water &
Davidse 1992). With regard to the implementation, a distinction is made
4See Chapter 2.
sThis NR V recommendation is partly based on a preliminary report called Organizational
strengthening of prevention in primary care (Organisatiorische versterking van preventie in
de eerstelijnszorg), published by NIPG/TNO, Leiden (Van de Water & Davidse 1992).
between programmes with an individual and those with a collective

approach: 'a programme that requires individual targeting is called
individual targeted programmed prevention and programmes that entail
collective execution are called collective prevention programmes' (National
Health Council 1992). With respect to Child Health Care, a third category
could be added, namely group targeted prevention programmes (such as
group education or group clinics). Pre-school Child Health Care in its
entirety may be described as a mainly individually targeted form of
organized programmed prevention. Collectively, targeted programmed
prevention mainly takes place outside the sector's field of responsibility.
The mass media campaigns for the prevention of caries, child abuse and
accidents are examples.
The practical activities of pre-school Child Health Care may be divided,

within the framework of individually targeted programmed prevention,
into two categories, namely standardized prevention programmes and
prevention programmes geared to the individual characteristics and needs
of parent and child. In this report the latter category will be referred to as
'prevention to measure' (or individually geared 'prevention'). Examples of
standardized prevention programmes are: the National Immunization
Programme; PKU and CHT screening; hearing screening; checks for visual
disorders; developmental surveillance; detection of language and speech
disorders; as well as some types of health education (for instance Accident
Prevention Cards)6. Examples of parts of programmes that require specific
individual gearing (prevention to measure) are individual education,
guidance and counselling on the subjects of development, care, food and
education. Finally there are parts of programmes which are in the process
of being further standardized, such as the Periodical Health Examination?
The application of the 'ecological health model', as already described,

implies that the main aims of pre-school Child Health Care, the promotion
and protection of the health and development of young children, are to be
realized by influencing the relevant health determinants. Pre-school Child
Health Care has a number of methods at its disposal for this purpose. They
are classified here in two ways. In the first place a functional classification
is used, based on the subsidiary objectives of pre-school Child Health Care
described in section 1.1. This classification makes it possible on the one
hand to chart the relationships between ends and means systematically, and
6 Accident Prevention Cards are a tool to promote safety; accidents being the major cause of
death in children. Each card contains safety information aimed at a specific age group. They
are handed out at Child Health Clinics to make parents aware of accident risks at specific
stages of development of the child. This helps parents to take safety measures in time.
7Proposals for the standardized recording of the Periodical Health Examination have in the
meantime been worked out: see Chapter 8 of this report.
on the other hand to consider any gaps in the delivery of care. In the second
place a classification is made with the help of the concepts of standardized
prevention (SP) and prevention to measure (MP)8. Thus the following
overview is arrived at:
a Subs.obj.: Immunity against major infectious diseases.

Method: (SP) National Vaccination Programme.
b Subs.obj.: Detecting and identifying individual risk factors
and disorders.
Methods: (MP) Periodical Health Examination (if recorded: SP,
see Chapter 8).
(SP) Screenings (PKU/CHT, hearing, vision).
(SP) Recorded Early Detection methods (Van Wiechen
check-list9 , ED language instrument).
c Subs.obj.: Promoting parental understanding and competence
through education (collective and individual),
counselling and guidance.
Methods: (MP) Ascertaining demand for support and
information.
(MP) Individual guidance, education and counselling
(for instance as a result of examinations listed under
b above).
(SP) Group education (for instance with regard to
teaching subjects).
(SP) Printed information (by means of the Growth
Book, Toddler Information Leaflets lO , Accident
Prevention Cards and so on).
(SP) Possible introduction of a parent-held record
(Child Health Care record in the possession of
parents).
8It should be noted with regard to the classification into standardized and individually
targeted parts that this is a broad classification: in practice standardized components are
accompanied by individually targeted elements. A well known example is the extra
individual attention that has to be given to motivate some parents to take part in the
immunization programme.
9 Partly based on the Denver Developmental Scale, the 'Van Wiechen' check-list was
developed in the early eighties to promote the systematic examination of development

(motor development, language and speech, personality and social behaviour) and to achieve
uniform national registration. For details see Chapter 6, section 5.
lOThe 'Growth Book' has been issued to all parents of new-born babies in the Netherlands
since 1978. It aims to give the parents the information to help them care for and raise their
children. For further details see section 10.1.2. Toddler Information Leaflets are folders with
age-specific information on the development of the child. Subjects include: eating, sleeping,
play, behaviour, toilet training, obstinacy.
d Subs.obj.: Pointing out health-threatening risk factors in the social

and physical environment.
Methods: (SP) Systematic registration of the condition of the health
of (groups of) children; drawing up health profiles.
(MP and SP) Identifying and if possible influencing
factors in the surroundings that threaten health and
development, such as environmental dangers,
neighbourhood safety (including safety in traffic, lack
of play opportunities and so on).
(MP and SP) Identifying groups of children that run
extraordinary risks (owing to an accumulation of
individual and social risk factors, for instance).
If the promotion of an adequately functioning system of care is considered

to be a major precondition for achieving the above objectives (or, as in the
ecological health model, a 'health determinant'), more methods can be
specified which satisfy these preconditions. For instance, participation in
cooperative bodies and in neighbourhood networks, maintaining a quality
control and monitoring system, organizational adaptations and so on.
In day-to-day pre-school Child Health Care practice the above activities

are generally carried out in conjunction with one another. Because various
determinants may be involved, various methods are indicated, based on an
actual health target. Two examples may illustrate this.
Example I: Nutrition
Target: Promoting and safeguarding a good nutritional condition
Methods: • Physical examination of nutritional condition
• Information on age-linked nutritional needs and nutritional
habits (standardized or individually geared health education)
• Indication of risk factors at population level with regard to
nutrition (PCBs in breast milk for instance)
• Optimizing counselling opportunities (such as by dieticians).
Example 2: Psychomotor development

Target: Promoting and safeguarding optimum psychomotor
development
Methods: • Early detection (Van Wiechen check-list)
• Education on stages of development (health education,
Growth Book)
• Optimizing a system of referral of detected disorders.
1.3 Outcome measurement
For a number of reasons the determination of the outcome of pre-

school Child Health Care is not a simple and unambiguous matter. The
first problem is that the outcome of prevention often becomes visible only
in the long run. This means that the outcome of pre-school Child
Health Care could in fact chiefly be shown through longitudinal and
therefore very costly research. A timely referral in connection with a
suspected developmental disorder for instance, is an important, but by
no means isolated outcome measure. The ultimate effect should be a
decrease in the number of people suffering from developmental disorders
or their results.
This immediately gives rise to a second problem, namely the question of

how far or to what extent the effects obtained can actually be attributed to
pre-school Child Health Care. This is difficult, because quite a number of
other variables are involved, such as general prosperity and hygiene, or the
reliability and effectiveness of diagnosis and treatment that take place
outside the pre-school Child Health Care service. In other words, if long-
term outcome measures were to be used it would hardly be possible to
discern which outcomes actually result from Child Health Care activities. A
third problem is posed by the broad, differentiated aims of pre-school Child
Health Care, as set out in the previous section. Especially the fact that this
service is not only concerned with the prevention of unequivocal illnesses or
disorders, but also with such complex problem areas as psycho-social
development and teaching relationships. This results in the need to apply an
equally differentiated range of standardized and individually targeted
methods. This again gives rise to the problem that the outcome
measurement of programmed prevention is usually simpler to realize than
that of prevention to measure. Not only does systematic data recording
take place (in pre-school Child Health Care as well) with regard to such
standardized programmes but, for instance with regard to the evaluation of
screening programmes, there is also an extensive system of epidemiological
and statistical concepts available. The outcomes of prevention to measure,
on the other hand, are rather more difficult to depict, because of the
different character of the interventions for each individual situation and the
connected problems for systematic recording.
Other methodological and technical problems for the ascertaining of pre-

school Child Health Care outcomes are:
• The absence of control groups. Just because of the practically

complete coverage of the population it is not really possible to
decide what the outcomes would be of 'no prevention'.
AIMS, PROCEDURES AND OUTCOME MEASUREMENT II
• Pre-school Child Health Care not only focuses on 'health benefits',

but is also aimed at enhancing the quality of life. The question is in
how far this can be measured by the QUALY method (quality-
adjusted life-years).
• The occurrence of various forms of distortion when ascertaining
the outcomes of screening (lead-time bias, length bias, self-
selection bias and overdiagnosis bias).
As argued in the introduction to this report, the Integral Evaluation Child

Health Care project was aimed in the first place at gaining insight into
existing data on cost effectiveness of parts of pre-school Child Health Care.
For this purpose a number of literature searches have been made and
included in this report.
In the course of the project however, the conclusion was reached that a
specific set of instruments should be developed for a permanent and
comprehensive insight into the cost-effectiveness ratios within pre-school
Child Health Care. The Institute for Social Health Care (Instituut voor
Maatschappelijke Gezondheidszorg) of the Erasmus University of
Rotterdam was commissioned to undertake this. In the research project
the outcomes and costs of screening methods will be reviewed first, based
on the following broad definition of the concept of screening: 'when (at
fixed times and according to a fixed protocol) parents are asked questions
and observations are being carried out on children to ascertain whether a
number of defined health disorders (a) are probably present or threaten to
arise and/or (b) further diagnosis and/or therapy is needed, it may be said
that screening takes place for this series of defined disorders' (Van der
Maas 1991). According to Van der Maas, the outcomes of screening fall
into two main groups: bringing forward diagnosis and the health benefits
achieved by this. Once data are available with regard to the effectiveness of
parts of pre-school Child Health Care it is possible, in principle, to start
determining the ratio of cost and effectiveness. The 'cost' of pre-school
Child Health Care should include the collective means employed to
maintain clinics and so on, as well as the outlay for the training and
refresher courses of staff, and the costs incurred in the follow-up work of
pre-school Child Health Care. After all, when a diagnosis is made by
specific Early Detection activities, costs are generated in the diagnostic and
treatment circuit. On the other hand there are a number of savings: some
costs do not arise because other provisions (for instance more expensive
treatment) are not needed as a result of activities within pre-school Child
Health Care. Taking the matter even further, there may also be savings
because disablement, for instance, can be prevented. In this way, cost
profiles can be calculated for each part of pre-school Child Health Care. An
estimate of the ratio of costs and effectiveness of pre-school Child Health
Care thus becomes feasible. The instrument to be developed by Erasmus
University is being tested on hearing screening by the Ewing method and on

the new Early Detection language tool. The first results are presented in this
report. In the long run it is intended to analyse all appropriate parts of pre-
school Child Health Care.
1.4 The structure of the report

The following steps have so far been taken for the purpose of outcome
measurement:
• a main aim was formulated

• four subsidiary objectives that can be made operational were
derived from this
• a number of standardized and individually targeted prevention
programmes were organized around these subsidiary objectives.
Within the framework of the present project a number of international

literature searches were made for effectiveness data of separate components
of the programme of care. In this first stage of the project emphasis has been
placed on standardized components. The outcomes of these were expected to
be easiest to chart. Such prevention programmes are usually preceded by
scientific research and careful recording and monitoring of them will also
take place. A second argument to give priority to the evaluation of
standardized components is of an ethical nature: as against prevention to
measure, where activities are initiated within the framework of an 'interview'
between parent and professional, standardized components more or less
imply 'unsolicited' delivery by professionals. There is an even greater need for
scientific justification in such cases (Van de Water & Davidse 1992).
In Chapters 2 to 7 these standardized components are dealt with. They

are immunizations, PKU/CHT screening, hearing screening, early detection
of vision disorders, developmental surveillance and the detection of speech
and language disorders.
The central questions of the separate studies are:
• What are the target problems?
• What is known of the aetiology and the (natural) course?
• What figures on incidence and prevalence are available with regard
to the target problems?
• What methods of prevention or intervention are available?
• What are the relevant outcome measures?

• What data are available (internationally) on the effectiveness of the
various methods?
• Is additional outcome assessment necessary?
In the course of the project sufficient particulars with regard to a number of

subjects were found to be available. Several literature searches however led
to the conclusion that supplementary research was required. Authoritative
institutes have already drawn up research proposals.
Chapters 8, 9 and 10 deal with elements that so far have wholly or partly
the character of 'prevention to measure'. They are the Periodical Health
Examination (PHE), the prevention of psycho-social and teaching
problems, and health education. Whether certain activities may be suitable
for a more standardized approach is examined.
Chapter 11 has a somewhat different character. It deals with aspects that

in fact play an important part in pre-school Child Health Care, but have
not until now, been considered very explicitly. These are activities targeted
at influencing the health determinants 'social and physical environment'
and the 'system of care'. Chapter 11 considers how a contribution can be
made from pre-school Child Health Care to the detection of and
intervention in health threatening factors originating from the social and
physical environment. It is shown that extra stimulus should be given to
cooperation with organizations in the fields of health care, youth welfare
work, day care and education as well as with municipal authorities.
Finally this report gives a summary of conclusions and recommenda-

tions.
References
Bos, M.W. & Winter, M. de: Het consultatiebureau is niet van gisteren, in:
Bos, M.W. & Winter, M. de (red.): Jeugdgezondheidszorg in de toekomst,
Lisse: Swets en Zeitlinger, 1989, pp.7-13.
Drewes, J.: Kwaliteitsbewaking in de jeugdgezondheidszorg, in: Bos, M.W. &
Winter, M. de (red.): Jeugdgezondheidszorg in de toekomst, Lisse: Swets en
Zeitlinger, 1989, pp.89-104.
Jonge, G.]. de: Wiegedood in Nederland 1985-1990, Tijdschrift voor
Jeugdgezondheidszorg 24 (1992) 1, 3-6.
Maas, P.J. van der: Kosten-effectiviteits-vraagstellingen in de jeugdge-

zondheidszorg, Tijdschrift voor Jeugdgezondheidszorg 23 (1991) 3,45-46.
Ministerie van WVC: Over de ontwikkeling van het gezondheidsbeleid: feiten,
beschouwingen en beleidsvoornemens (Nota 2000), Den Haag: Sdu, 1986.
NSDSK (Nederlandse Stichting voor het Dove en Slechthorende Kind):
Jaarverslag VaG, Amsterdam 1989.
NRV (Nationale Raad voor de Volksgezondheid): Advies inzake versterking
van de preventie in de eerstelijnszorg, publ.nr. 6/92, Zoetermeer: NR V, 1992.
Water, H.P.A. van de & Davidse, W.: Organisatorische versterking van
preventie in de eerstelijns gezondheidszorg. Tweede pre-advies ten behoeve van
het door de Staatssecretaris van WVC aan de Nationale Raad voor de
Volksgezondheid gevraagde advies inzake het preventiebeleid in Nederland,
publ.nr. 92.008, Leiden: NIPG/TNO, 1992.
Winter, M. de: De kwaliteit van het kinderlijk bestaan, Bunnik 1990 (oratie).
Further reading
Lim-Feyen, J.F.: Doelstellingen in de preventieve jeugdgezondheidszorg,

Medisch Contact 43 (1988) 44, 1357.
Nederlandse Bond voor Moederschapszorg en Kinderhygiene: Jeugdgezond-
heJdszorg: inhoud en taakuitvoering, Utrecht 1972.
NVJG (Nederlandse Vereniging voor Jeugdgezondheidszorg): Functie- en taak-
omschrijving van een jeugdarts in een jeugdgezondheidszorgteam, Utrecht
1985.
NVJG: De Jeugdgezondheidszorg in 2000; beleidsplan 1330, Utrecht 1990.
Unicef: The State of the World's Children, Oxford 1991.
2 Immunizations
Internationally, the Netherlands has a name for its excellent prevention of

infectious diseases, resulting from a very high immunization uptake. Since
1979, the national average for all immunizations has been more than 90%
(GHI 1981a, 1991a, 1992). This has been accomplished thanks to excellent
computerized administration, to a great willingness (virtually 100%) on the
part of the public to make use of the National Immunization Programme
(R VP) 1, to a well-developed and easily accessible network of Child Health
Clinics and the Child Health Care Departments of the District and
Municipal Health Services (GGD). The infectious diseases against which
the population has been systematically immunized have practically
disappeared in the Netherlands, except in some communities where there
is a concentration of people who, for ideological or religious reasons, refuse
to have their children immunized.
In this chapter, the scientific foundations of immunization in the

Netherlands are reviewed. The original Dutch text has been updated for
this English edition, in which the situation as of September 1993 is
described. To put things into perspective, the R VP and the way it is
organized are outlined, followed by a synopsis of the immunization
programmes. For reasons of brevity, the diseases are not described in detail.
The reader is referred to textbooks (for example Avery et al. 1989, Ball &
Gray 1984 and, in Dutch, Stoop & Vossen 1990). Finally, the costs,
effectiveness, benefits, and the relationship between these three, are
discussed.
2.1 The National Immunization Programme (RVP)
Each year, the Minister for Welfare, Public Health and Cultural Affairs
(WVC) lays down the R VP for that year on the recommendations of the
National Health Council (N ationale Raad voor de Volksgezondheid NR V),
IThe National Immunization Programme is referred to further in this chapter by the

acronym RVP
having listened to the recommendations of the Chief Medical Inspector

(Geneeskundige Hoofdinspecteur GHI), the Director-General of the
National Institute of Public Health and Environmental Protection
(Rijksinstituut voor Volksgezondheid en Milieuhygiene RIVM) and the
Health Insurance Board (Ziekenfondsraad). Each year the Inspectorate
publishes a leaflet setting out the immunization programme for that year,
and distributes this among the officials responsible for implementation.
The Inspectorate sees to it that the R VP is carried out in accordance with
the annual programme. Only the vaccines listed in Table 1 can be provided
within the framework of the R VP; other immunizations fall outside its
coverage. The immunizations of the R VP have not always been the same:
adjustments are made from time to time as a result of new epidemiological
insights and technical possibilities.
The initial impetus for the R VP was the polio epidemic in 1956 which
claimed 2206 victims. A diphtheria-pertussis-tetanus vaccine (DPT) had
been available in the Netherlands since 1952, and was extensively used in
the child health clinics, so that 70% of the children had been immunized
with DPT by the time (1957) the RVP was introduced (Hannik 1963). At an
even earlier stage, children in the Netherlands were being immunized
against smallpox and diphtheria. With the introduction of the R VP in 1957,
inactivated triple polio vaccine (Salk vaccine) was used, initially as a
separate polio vaccine and from 1962 onwards as a combined diphtheria-
tetanus-pertussis-polio vaccine. This has continued to the present day. The
use of the Salk vaccine makes the Netherlands fairly exceptional because in
most other countries live oral polio vaccine (Sabin vaccine) is used. The
latter is only used in the Netherlands in cases of polio outbreaks. The
situation in the Netherlands differs from that in other countries
(geographically, demographically, logistically and financially) and because
of this the advantages and disadvantages of using the two vaccines are
weighed up differently in this country than elsewhere (Dutch National
Health Council; see: Gezondheidsraad 1982b).
In 1974, the immunization of ll-year-old girls against rubella (German

measles) was started as a separate immunization, followed by a separate
immunization against measles in 1976. In 1987, both disappeared again
from the R VP with the introduction of the combined immunization against
mumps, measles and rubella (MMR). Within the scope of the R VP, it is
possible to immunize against measles and rubella only by means of the
MMR-vaccine. On 1 April 1993, the immunization against Haemophilus
Influenzae type b was added to the RVP. This will not necessarily mark the
end of the list of diseases against which prevention can be offered in the
form of immunization (Ruitenberg et al. 1984, Huisman 1985, Ruitenberg
1989). However, before any further additions are made, it must be quite
clear that the practicability of the programme will not be jeopardized, and
that the motivation of parents and professionals will not diminish as a
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she is not shut up like an Arab woman.
Whilst the man journeys afar with the caravans, or on freebooting
expeditions, she remains at home to direct affairs. But this is not all,
for she studies old traditions, is highly enlightened, and far in
advance of the men in knowledge of old customs and manners, and
also of the art of reading and writing the Tuareg language. In short, it
is she who preserves their traditions and is acquainted with their
literature, and indeed sometimes ranks as the highest authority of
the tribe.
Duveyrier relates that amongst the eastern Tuareg the women
take part in the councils when the tribes assemble, just as did the
Iberian women in ancient days.
In the battlefield it is often dread of the women’s scorn which
drives the men to make the utmost efforts to return victorious.
“This trait reminds one of the Iberian maidens, who chose their
husbands from amongst the bravest warriors.”
Descent on the mother’s side alone ennobles, and the children
belong to the family of the wife.
For instance, the son of a nobly born woman and a slave is
acknowledged as free born, whereas the son of a slave and a free
man remains a slave. But, in favour of the latter, certain tribes have
created a particular caste called “Iradjenat,” who, though yet slaves,
are exempt from certain heavy labour.
It must be added that the women have entire control over their
own property.
Inheritance in the tribes goes from a man to his brother, and, in
default, to the son of a sister, but never to the direct progeny.
In such communities misconduct on the part of women is not
tolerated, it is simply punished with death. Captain Bissuel relates
that a native of the province of Setif killed his sister by order of his
father, they having learnt that she was leading a dissolute life. Both
father and brother mourned for the poor culprit, but were convinced
that they had only done their duty.
On the other hand, according to Duveyrier, the Tuareg lawfully
claim le droit du seigneur from their female slaves, before these
marry.
The same custom is mentioned by Herodotus as obtaining
amongst the Adyrmachidæ in the neighbourhood of Egypt.
The western Tuareg regard this custom as despicable.
The Tuareg have to give their wives a dowry, which varies in
amount. The western Tuareg, for instance, give at least six camels, a
negress, and a complete costume.
These are the principal features of Tuareg customs. They have
many points in common with those of the mystical Amazons and the
Iberians of antiquity.
Even now among the Basques the man plays a subordinate part.
The woman rules and controls the house. “The husband is her head
servant,” who brings to the house only himself and his labour,
together with a stipulation for progeny.
The Arabs.
The Arabs in Tunisia are, like those in Algeria, nearly all nomads.
They reside chiefly in the southern and central portions of the
Regency.
They are recognisable by their tall, slender figures, their lean,
muscular build, and by their dignified nobility of carriage.
The Arab cast of countenance is narrow, the nose curved, the lips
thin and graced by a delicate black beard, the black eyes are lively,
but the expression crafty.
The Arab woman is endowed with a pretty, well-formed figure, but
she is of small stature. She is, on the whole, attractive, but fades
early, being old and ugly through hard work by the time she attains
her twentieth year. Unlike the Berber woman, she is usually obliged
to go abroad veiled.
As the Bey was too weak to collect his own taxes, he united the
various groups of nomad Arabs to form his auxiliary troops. These
tribes were thence designated “Mahzen,” were almost exempt from
taxation, or only paid in kind, such as oil, dates, etc. In return they
bound themselves to fight the robber bands (Jish) who frequently
harassed the country. Were they victorious, all spoils were theirs.
Their ostensible duty was to assist the Bey’s own soldiers to recover
the taxes. This collection resolved itself into sheer plunder. The least
of their perquisites was the right to “diffa” and “alfa,” which means
hospitality for themselves and their horses; of this they took
advantage to the greatest extent, often pillaging wherever they
appeared.
For instance, the holy city of Kairwan was often compelled to raise
forced contributions under this pretext.
Their morals, as a rule, are very lax. The abduction of married
women and girls is common, and adultery a matter of course.
The upbringing that an Arab woman receives in a tent is not
exactly calculated to ensure in any way a moral tone. A young girl is
from the very outset of her innocent life apt to see and learn much
that to us appears offensive.
Whereas the man has every possible right of control over his wife,
she has only the “justice of God” (el hak Allah), meaning that he
must fulfil his obligations towards her as her husband, failing which
she can demand a divorce, not an infrequent occurrence.
After the enactment of the law emancipating slaves, the men in
some tribes married their negresses, with a view to thus evading the
law. But it befell that the former went into court and complained that
they were defrauded of their rights as wives.
Although the Arabs, as aliens, have always been in a minority in
the land of the Berbers, yet they were the masters until the arrival of
the French. They had steadily spread themselves over all the open
plains and lower tablelands, moving ever from east to west. Thus
each tribe continually changed its territory, one tribe ever pressing
another before it farther westward.
Long before Mohammed’s day this immigration had already
begun, but it was not until after his time that it made any real
headway, and the conquest of the country and its conversion to
Mohammedanism took place.
Not until much later, in the middle of the eleventh century, was the
great migration accomplished, in which both Mongols and Egyptians
were included. Such great waves, however, always cause a counter
wave. When the tribes reached the shores of the Atlantic on the
most distant coasts of Morocco, the tide turned. Thus the tribe that
claims to be the chief of all the tribes, namely, the Shorfa, or
“Followers of the Prophet,” is precisely that which, having been to
Morocco, returned eastwards.
Yet another receding wave brought back the “Arabs” who had
conquered Spain, and who were afterwards driven forth again.
These Spanish “Arabs” were for the most part Berbers who had
been carried westward by the tide, and who returned, after a long
sojourn on the Iberian peninsula, blended with other races—
Ligurians, Iberians, Celts, and Western Goths.
The greater proportion of these refugees, who are known in
Barbary as “Andaluz,” established themselves in the towns, where
they introduced a new strain into the already mixed race of Moors.
These Spanish Moors are more especially represented in Tunis.
It is quite natural that, in a country so often invaded and peopled
by foreigners who to this day have never really amalgamated, there
should be an entire lack of patriotism such as is found in Europe. It is
as Mussulmans that these races have united to make war against
the Christian. Amongst themselves they are often at enmity.
Mohammedanism.
Though it is an undoubted fact that the various races of Berbers
and Arabs have preserved much of their identity, it is also noticeable
that, to a stranger arriving in the country for the first time, the
inhabitants appear, as it were, to be fused into one race. This fusion
is the result of their creed, for Mohammedanism has been drawn like
a veil over the whole country.
Mohammed, through the Koran, gave to even daily labour the
stamp of religion, and in a marvellous way moulded all the various
races, who thus became “the faithful,” into one mode of thought and
life, which gradually shaped them all to one pattern, although
hereditary inclinations and customs contended, and are still
contending, against such constraint.
The features which appear most strongly marked in these various
races who have become Mussulmans, are their individual absorption
in their religion and their family organisation.
The stubborn influence of Islamism on the community is entirely
expressed in the phrase “Mektub” (it is written). Fatalism has
destroyed all initiative, all progress. How men may act is immaterial.
“It is written.”
To the Mussulmans, authority is of divine origin. Their creed
ordains that everyone must bow to authority. This has given rise to
the most complete absolutism, alike from the Bey, whose title is “The
chosen of God and the owner of the kingdom of Tunisia,” down to
the lowest of officials.
But yet the yoke may prove too heavy—then the oppressed revolt,
as has so often happened.
The influence of religion is manifest in the treatment of the insane,
whose utterances are held as sacred. The number of real and
pretended lunatics is consequently very great. Hospitality is not
exactly gladly offered to such afflicted persons, but they are
permitted to take whatever they please from a house, a liberty often
very widely interpreted. Latterly a madman in Tunis declared several
houses to be under a ban. All the inmates at once fled, and could not
be persuaded to return. This individual was also inspired with the
sublime idea of erecting a barricade in one of the most populous
streets, by means of doors which he lifted from their hinges.
The Prophet organised the family on the lines best adapted to the
nomad tribes, who were destined to be great conquerors. He
ordained the absorption of the vanquished into the family; while the
males were killed or, if fortunate, made slaves, the women were
allowed to enter the family.
This was the foundation of the rapid conquest of North Africa by
Islam.
To ensure unity in the family, composed of so many and varied
elements, the man is invested with the most absolute authority. He
does not marry but he buys his wife, who becomes his property. He
is unquestionably her lord and master, he can maltreat her, kill her if
she is untrue to him, without risking injury to a hair of his own head.
All that he owes her is the “hak Allah.”
Crimes against women are more rare now through fear of the
French; but as there is no legal census, many murders may be
committed which are never brought to light.
Religious influence first and foremost, also life in common under
equal conditions of many generations of different extraction, have
obliterated many of the characteristics of the natives of Tunisia.
Many Berber tribes have been entirely transformed into Arabs, and,
on the other hand, many Arab tribes have been Berberised. Indeed,
there are tribes forming a subdivision, of which it is well known some
are Berbers, some Arabs.
Of the religious brotherhoods, so numerous elsewhere under
Islam, there are comparatively few in Tunisia. We find the
“Tidyanya,” “Medaniya,” and the “Aissaua,” and, besides these,
many scattered “Shorfa.”
In the towns there is more fanaticism than in the country. In this
respect “those who can read and write are the worst.”
Yet many customs and reminiscences may be found of a former
age before Mohammedanism was forced on the Tunisians.
For instance, the people hang bits of rag all over sacred trees;
many fear the “evil eye,” or honour five as a peculiarly lucky number.
For this reason they set the mark of their own five fingers on their
houses to protect the latter. Indeed, it is not uncommon for a man
who has more than five children, if questioned as to their number, to
reply that he has five, rather than be obliged to name an unlucky
number.
If rain is long delayed, they take refuge in exorcism, and will on
occasion even dip their kaid in a fountain so that his beard may be
wetted—that surely brings rain.
The Moors.
Nowhere has all origin of race been so entirely effaced as in the
towns. There have sprung up the Moors—quite a new race of town
dwellers, which may be said to have absorbed all others.
Whereas the population of the interior of the country to a great
extent escaped intermixture with the new elements, up to the time of
the arrival of the Arabs, it has been quite otherwise in the towns,
where foreign traders settled and intermingled with the native
inhabitants.
Amongst the Moors in the towns are found, as has been said, the
so-called “Andaluz,” who were driven out of Spain. Several of these
distinguished families have carefully preserved the records of their
genealogy, and some of them still possess the keys of their houses
in Seville and Granada. They have certainly intermarried with other
families of different origin, but still cling to their traditions, and retain
and exercise to a certain extent the handicrafts and occupations of
their forefathers in Spain. The gardeners of “Teburka,” for instance,
are descendants of the gardeners of the Guadalquivir, and the
forefathers of the potters near Nebel were potters at Malaga.
The blood of slaves of all nationalities has also been introduced
into the people known as Moors.
The complexion of the Moor is fair, or, more rarely, olive; it
resembles that of the Southern Italian or Spaniard. The shape of the
head is oval the nose long, and they have thick eyebrows and very
black beards. Of medium height, they are well built, and their
carriage is easy and graceful. They are considered more honourable
than either Jews or Christians, and were noted formerly for their kind
treatment of their slaves. Though clever workmen and well educated,
their moral tone is not high. In old days the town of Tunis was the
great market frequented by the people of the Sudan; nothing was
considered worth having that had not been made by a Tunisian.
The Turkish element, as represented by the Bey and his
surroundings, has long since ceased to have any influence on the
Moorish race in Tunisia. No real Turks are now to be found in the
country. In the towns, however, are a few descendants of Turkish
soldiers and Tunisian women; they are called “Kurughis,” and are
lazy, vain, and ignorant, and consequently not much respected.
The Moors, or the town dwellers, on the whole, are, however, not
so vigorous and energetic as the nomads and the mountaineers;
their manners are more effeminate, and they are lazier.
Crimes against the person, such as assault or murder, are rare in
the towns, but drunkenness on the sly is common, and immorality is
prevalent.
The Jews.
The ancient conquerors of the country, the Carthaginians and
Romans, who covered it with towns, forts, and monuments, have left
no impress of themselves on the appearance of the present
inhabitants, nor do there survive amongst the tribes any traditions
concerning them.
No more remains to recall the Vandals and Goths, yet the latest
researches prove the existence in early days of other Semitic
peoples besides the Arab.
The earliest importation to the country of Semitic blood was
doubtless the Phœnician. To this is due the fact that many of the
types portrayed on Chaldaic and Assyrian ruins are now found
scattered throughout Tunisia.
At the same time as the Phœnicians may be mentioned the Jews,
the earliest of whom probably came to Barbary at the same time as
the former, but their number was largely added to later, after the
conquest of Jerusalem by Titus. Moreover, it is known that many
Berber tribes were converted to Judaism and remained Jews, even
after the Arab conquest. The classic type of European Jew is
therefore rarely met with in Tunisia.
After the Mohammedans the Jews are, numerically, most strongly
represented in Barbary. They form somewhat important
communities, not only in the town of Tunis, but also in all other
towns, even in the island of Jerba. Possibly with theirs has mingled
the blood of the ancient Carthaginians.
There are also a great number of Jews whose ancestors were
ejected from Spain and Portugal; these are called “Grana,” from their
former most important trading city in Spain.
These “Grana” were under the protection of the foreign consuls,
and therefore have had nothing to complain of; but the old Jews
were in a disastrous condition in former days, and suffered much, so
much that some isolated families abjured Judaism and became
Mohammedans; such they are still, but they always associate with
their former co-religionists. Other Jews—those of Jerba, for instance
—have modified their religious forms, pray to Mohammedan saints,
and hold their Marabouts in honour.
A peculiar head-dress distinguishes those Jews who are under no
protection, from those who are protected by the consuls. It is an
irony of fate that many Jews have placed themselves under Spanish
protection, because they knew that Spain was their home in old
days. Now they are protected by the country that formerly drove
them forth. Somewhat similar is the case of the Algerian Jews in
Tunis who seek French protection.
All the Jews of Tunis retain the ancient Spanish ritual. They are
peaceful and well behaved, and not so grasping as others of their
faith, but they are clever at taking advantage of a good opportunity
when there is a prospect of making money, or when their trade may
be extended. Commerce is therefore in great measure in their
hands.
In the whole Regency of Tunisia there are over fifty thousand
Jews, and their numbers increase rapidly. In the town of Tunis there
is a “ghetto,” the quarter formerly devoted to them, and where they
were compelled to dwell. It has long since become too small, and the
Jews have now spread over all the other quarters, and in the
bazaars have wrested from the Moors many of their shops.
This Jewish community is an interesting study, and one is
astonished to find how in many respects they so little resemble their
co-religionists in other countries.
COSTUMES
The Dress of the Countrywomen (Arabs—
Berbers)
Over the whole of Tunisia the countrywomen, whether Arab or

Berber, wear a similar costume, which must be almost identical with
that worn by the Grecian women in olden days.
The dress of the women of ancient Greece consisted of what was
known as the “peplos”[8] (πέπλος), a white wrapper gathered in by a
belt about the waist (ζώνη), and supported on the shoulders by pins
(περόναι and ἐνεται). As head-dress, or for ornament, they wore a
kind of forehead band (χρήδεμνον) or veil, and, in addition to these,
earrings, necklets, bracelets, etc. etc.
The “peplos” was a large piece of stuff without seam, which was
folded round the body from one side.
The dress of a Tunisian woman of to-day is the same. It consists
of a “m’lhalfa,” which resembles the “peplos,” being a long narrow
piece of stuff, wound round the body in such a manner that it entirely
covers the back and shoulders. One end is brought over the breast,
and hangs down in front; the other end covers the lower limbs, and
forms a skirt. The piece is so long that it hangs in folds, which partly
conceal the sides. Whilst the Greek “peplos” was held together by
“fibulæ” on the shoulders, the clasps that confine the “m’lhalfa” are
placed rather forward—over the breast. The Grecian woman’s neck
was bare, her chest covered. But it is the contrary with the Tunisian
woman. In other words, the “m’lhalfa” is merely a “peplos” which has
been drawn forward. Many Tunisian women draw the “m’lhalfa” over
the breast, and arrange one end to form a full drapery; others, as in
the Matmata villages, omit this, but wear over their bosom a thin
square of stuff called “katfia.” This is secured by the clasps already
mentioned.
In a few places, such as the Khrumir mountains, the “m’lhalfa” is
composed of two pieces of stuff worn one in front and one behind,
held together by the breast clasp. Over the neck and shoulders is
laid a rather large towel. The “m’lhalfa” is always bound in at the
waist by a long woollen belt, generally white or of some bright colour.
The clothes for daily wear are, as a rule, of a dark blue woollen
material, but for festivals or weddings they wear red, yellow, or parti-
coloured garments of silk, cotton, or wool.
In most regions a kerchief is worn on the head (tadchira); round
this is wound a turban (assaba), composed of a long piece of stuff
ornamented with coins or trinkets. Over this again is thrown a large,
often embroidered, cloth, in which the face is enveloped (begnuk).
Generally speaking, the Tunisian women wear no underclothing,
at all events not in daily life in the country. On festive occasions,
especially in the towns of the oases, they assume a white shirt
(suïera). It has very short or no sleeves. A bride, as a rule, wears
one. The bridal shirt (gomedj) is generally embroidered about the
opening at the neck in silk or cotton, in stripes of black, yellow, blue,
and red.
In daily life they do not wear shoes, but go barefoot. At the feasts
the women put on yellow shoes without heels (balgha).
The ornaments worn by the poor are mostly of brass, copper, or
horn; by those in better circumstances, of silver; or sometimes by the
rich, of gold.
Round the neck are worn strings of glass beads, and in the ears
large slight earrings (“khoras,” from cross); on the wrists, broad open
bracelets (addide). Finally, they wear large heavy anklets called
“kralkral,” that are generally made not to meet.
To fasten the “m’lhalfa” on the shoulders large brooches are
commonly employed. These are in the form of an open circle,
through which passes a pin (khlel).
On the breast they wear a silver chain (ghomra), from which
depend coins or flat plates of metal. These chains are fastened to
the breast-pins. All these ornaments are made by the Jews of the
towns or oases, and are really artistic productions.
The women do not usually wear straw hats, though some may
amongst the Berbers of the island of Jerba. These hats are precisely
similar to those depicted on some of the Tanagra figures found in
Greece.
In Jerba are worn crescent-shaped breast ornaments, said to
come from Tripoli; also ornaments in filagree work from Zarsis.
The women often carry a little looking-glass tied to their breast-
pins, and also the requisites for applying henna and kohol.
When they fetch water in their great pitchers they carry these
slung on their backs by means of a wide band round the forehead, or
in the end of their turban, loosened for the purpose.
Their hair is never plaited, but is covered by the cloth or turban. A
woman is rarely seen in stockings. In a few places where the roads
are bad they wear wooden shoes. The Khrumirs are proficient in
making these.
Much of the material employed in the women’s dress is woven or
made by themselves in the region in which it is worn, but some is
brought from Tripoli, the Sudan, or from Europe. As a rule, however,
the countrywomen wear only their own handiwork.
In the Matmata mountains and the neighbouring oases I was able
to collect and buy a complete costume, the whole of which had been
made in that region, and chiefly of native materials.
It must be mentioned that the Berber women have everywhere
more freedom than their Arab sisters, and are therefore often
unveiled. Yet many of the tribes have gradually adopted Arab
customs, and in this particular follow their example—at all events in
the vicinity of a town, for in the country the women all go unveiled,
only hiding their faces on occasion.
We will now examine the dress of the men, both Arabs and
Berbers.
In contradistinction to the Kabail of Algeria, the Arabs always
cover their heads. In Tunis, where the races are so mixed, nearly all
the men go covered. They wear white cotton caps under the red
“shashia,” allowing a narrow edge of white to appear beneath the
latter.
The Arabs always wear a haik or burnous; the Berbers, generally.
The burnous, as is known, consists of a cape united at the breast.
The “haik” is a piece of thinner stuff, which is worn as a drapery,
usually under the burnous, but also alone.
In the southern mountains of Tunisia I found that many of the
mountaineers wore, instead of burnous or haik, a piece of stuff
without hood or seam. In this they draped themselves so that the
head was covered. It was usually of brown or grey wool. The
burnous is as a rule white, as is also the haik. Many of the poorer
folk, especially amongst the Berbers, wear nothing else in daily life;
but they assume a shirt, waistcoat, and coat, as also a gala burnous
(sjebba) on festive occasions. This last is shorter than the real
burnous, and is made with short wide sleeves, of bright coloured
stuff, often embroidered in silk.
The people on the coast near Susa and to the south have a still
shorter brown-hooded garment in place of a haik or burnous, and
they wear trousers. This costume is convenient for fishermen.
A large broad-brimmed straw hat is worn by the denizens of the
plains. Shoes or sandals of morocco leather or hide are worn by
many.
Red morocco leather boots, worn inside a shoe, are used by
riders, also spurs.
The purse is a long, narrow, knitted or woven bag.
The Berber often wears a shirt, and, in such cases, only a haik
over it, and no burnous.
The usual costume of the Arab is that worn in Algeria—the
burnous and the haik, the latter bound on with a camel’s-hair cord;
shoes (or boots). Of the Berber, shirt, haik, burnous, bare legs, and
uncovered head.
Such variations of these costumes as may exist in Tunisia have
been brought about by an altered mode of life and the admixture of
races.
Dr. Bertholon declares that most of the costumes are of very
ancient origin. That of the Jews, for instance, he dates back to the
days of the Carthaginians; the burnous, he says, resembles the
hooded Roman cloak.
The Moorish woman’s dress is very pretty, but extremely
coquettish. It is overladen with ornaments.
“In the morning she wears a very scanty costume. If one has the
luck to catch a glimpse of her at an early hour as she moves hither
and thither in the harem, she is not easily forgotten. She is clad in a
simple shirt, with short sleeves, which leave her plump arms
exposed. Under this she wears trousers, so short that they scarcely
reach the knees; a little shawl, of which the ends are knotted in front
at the waist, replaces a skirt, and enfolds her pretty form. Her
bosoms are supported by a narrow bodice, and about her hair is
bound a silk kerchief, but her locks fall down over her neck” (Des
Godins de Souhesnes).
When she leaves the house she wears a “gandura,” a kind of
cloak of transparent material, fastened on the shoulders by gold or
silver pins. Besides this she has put on wrinkled white linen trousers
reaching to her ankles; over her head she throws a white kerchief;
and, lastly, she conceals her face with a long embroidered veil.
The Moorish woman blackens her eyebrows, enhances the
beauty of her eyes with antimony (khol), and stains with orange-red
henna the nails of her fingers and toes and the palms of her hands.
The dress of the Moor much resembles that of the Jew. He wears
a tasselled cap (shashia), surrounded by a turban, and a silken vest
or coat, embroidered in gold or silver.
The trousers are very wide, and fall in heavy folds; the lower part
of the leg is uncovered, and on his bare feet he wears broad shoes
of red or yellow morocco leather (babush).
The costume of the Jews, as worn by them before they were free,
to distinguish them from the Arabs, is very picturesque, and,
fortunately, still universal.
The men, who are generally handsome, wear a tasselled shashia,
often surrounded by a turban. Their wide, pleated Turkish trousers
reach a little below the knee, and are secured at the waist by a belt.
They wear also coat and waistcoat, stockings, and shoes.
Many have now adopted European attire, but the characteristic
Jewish type is easily distinguished.
The Jewish women are not veiled. They wear shirts, narrow
embroidered silk trousers, cotton stockings, shoes, and on their
heads a pointed cap.
These women, when young, are very pretty, but also very
immoral. They are generally spoilt by being too stout, young girls
being fed up to make them attractive for their wedding.
There is no native industry peculiar to Tunisia, but there are a few
which may be considered worth notice.
The holy town of Kairwan is famed for its beautiful carpets. In
Gefsa and Jerba also curious and beautiful carpets are woven.
Clay ware is a speciality of Nebel, where, to this day, pottery is
made that recalls that found in the Phœnician and Roman tombs
near Carthage. Pottery is also made at Jerba in the form of jars,
vases, etc., which are sent to different parts of the country—northern
Tunisia obtaining its pottery from Nebel; southern, from Jerba.
Amongst the tribes, pottery is also made by the women and
negresses, but generally without the aid of the potter’s wheel. The
Khrumir in particular are noted for their peculiar ornamented pottery.
In the towns, moreover, and especially in Tunis, there are
numbers of shoemakers, leather workers, saddlers, harness and
pouch makers, etc. etc. There are also excellent dyers and makers
of perfumes.
In the oases are made fans, and baskets of palm leaves and of
alfa straw; baskets, hats, and great crates for corn, which take the
place in these regions of the clay jars of the Kabail.
Tripoli lies quite close to Tunis, and there manufactures attain a
high level; a great quantity therefore of stuffs—carpets and worked
leather articles—are imported thence. The Jews are the goldsmiths,
and, even in the interior and in the southern oases, possess the art
of making pretty bracelets and ornaments.
The inhabitants of Zarsis are renowned for their peculiar filigree
work.
POSTSCRIPT
The information adjoined regarding the number of souls included in

each of the Berber tribes, and of their domestic animals, came to
hand only after the first portion of my book had gone to press. I
therefore add it here. This information has been collected with great
pains throughout the Government of El Arad by the kindly help of M.
Destailleur, Contrôleur Civil to that Government. It is positively
reliable, the calculations which I was able to make in person during
my stay in several of the villages, with the same view, corresponding
exactly to those in the table. Only—as an outsider—I must aver that
the number of horses may not be quite correct, but for some places
appears computed too low. As for instance in Hadeij, where, it is
said, none are to be found, which was certainly not the case.
Possibly the explanation may be that the sheikhs feared that the
inquiry made by the Government arose from a desire to know how
many mounted men this tribe could place in the field in time of war.
Number of Sheep and
Names of Tribes and Villages. Asses. Oxen. Horses. Camels. Mules
Inhabitants. Goats.
Jara 1925 500 40 100 40 700 40
Menzel 2200 600 60 35 40 410 90
Shenini 1040 300 2 25 30 185 30
Ghenush 350 100 4 3 8 200 40
Bu Shma 50 20 10 30
Udref 750 280 70 8 120 450 2
Metuia 1800 200 20 10 100 600 60
Tebulbu 235 45 25 4 38 350 1
Zarat 165 45 55 3 12 1000
Ghraïra 450 100 8 390 1450
Alaia 232 30 20 351
Hazem 1229 210 4 36 240 2880
Hamernas 2100 600 57 37 300 2100 1
⎧ Gassur 900 140 70 20 50 350 10
⎪ Debdaba 1390 115 22 40 92 520 19
⎪ El Begla 1455 432 41 535 1830
Beni-Zider, ⎪ Shelahsha 1689 400 95 1400 10,000 4
South of ⎨
Matmata 1000 120 8 20 400 1800
the Shott. ⎪
⎪ Shehel 1100 150 25 1200 2500
⎪ El Heurja 1000 140 30 420 2000
⎩ Zauia 868 320 35 800 8000 4
Tujud 210 15 30 2 55 520
⎧
Zarua 604 55 27 1 207 713 2
⎪
⎪ Dehibat 100 20 3 2 50 1000
⎪ Ben Aissa 340 25 25 3 65 311
⎪ Guelaa Ben Aissa 495 40 45 3 115 410
Matmata
⎨ Smerten 105 10 1 25 265
Mountains.
⎪ Beni Sultan 632 43 73 1 55 200 2
⎪ Tujan 1071 51 80 3 169 1000 1
⎪ Uled-Sliman-Hadeij 1300 200 200 300 2700 8
⎪
Lasheish 1020 120 223 6 263 2036 2
⎩
Tamezred 1082 50 100 7 400 4600 4
Urghamma. ⎧ Neffat 3830 826 46 221 3371 9926 3
⎪ Accara 5496 750 250 110 1335 6060
⎪ Tuasin 2461 1203 15 600 6945 15,263
⎪ Khezur 3411 890 150 142 1353 9745
⎪
Ghomrasen 1376 565 3 43 684 2848
⎪
Shenini-Duirat 410 80 20 3 300 1960 1
⎪
⎪ Guermasa 460 80 30 8 170 1150
⎪ Uderma. ⎧ Hamidia 287 60 25 255 890
⎪ ⎨ Uled-Debab 389 150 20 200 2000
⎨ ⎩
⎨ of Tribes and
⎩ Villages. Number of Sheep and
Names Asses. Oxen. Horses. Camels. Mules
⎪ Inhabitants. Goats.
⎪ Deghagha 585 250 10 34 300 300
⎪ Uled Shada 330 125 42 320 1200
⎪ Suabria-Duirat 153 7 2 2 32 800
⎪ Beni Barka 125 25 7 2 60 240
⎪ Zedra 117 25 12 1 14 360
⎪ Gatufa 130 30 15 4 11 400
⎪
⎧ Uled-Lazareg
⎪
Jelidat ⎨ Uled-Aun 302 100 4 50 300 1100
⎩
⎩ Uled-Ashiri
Quadid 125 30 4 4 80 600
Duiri 1357 63 54 10 280 3400

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Screening in Child Health Care Report

of the Dutch Working Party on Child

Health Literacy and Child Health Outcomes: Promoting

Variation in Health Care Spending Target Decision

Maternal Child Nursing Care 6th Edition Shannon E.

Child health a population perspective 1st Edition Blair

Parental Care and the Best Interests of the Child in

Paediatrics a Core Text on Child Health Second Edition

The Encyclopedia of Elder Care The Comprehensive

India's Public Health Care Delivery: Policies for

Published 2016 by CRC Press

© 1995 Micha de Winter, Marielle Balledux, Jose de Mare, Ruud Burgmeijer

No claim to original U.S. Government works

ISBN-13: 978-1-85775-150-5 (pbk)

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

British Library Cataloguing in Publication Data

Library of Congress Cataloging-in-Publication Data is available.

Translated by BSA Texts, © March 1994

Introduction-a critical evaluation of Dutch preventive

1 Aims, procedures and outcome measurement in pre-school

1.1 Aims of pre-school Child Health Care 2

1.2 Procedures in pre-school Child Health Care 3

1.2.1 The organized system of care 4

1.3 Outcome measurement 10

1.4 The structure of the report 12

2.1 The National Immunization Programme (R VP) 15

2.2 Effects of immunization 19

2.3 Costs of the R VP and the hepatitis B screening and

2.4 Cost-effectiveness and cost-benefit ratios 34

3 Screening for phenylketonuria and congenital hypothyroidism 50

3.1 Phenylketonuria (PKU) 50

3.2 Congenital hypothyroidism (CHT) 51

3.3 Organization of the screening 52

3.4 Implementation of the screening 53

3.5 Coverage of the PKU/CHT screening 54

3.6 Effectiveness of PKU screening 54

3.7 Effectiveness of CHT screening 55

3.8 Cost-benefit analysis for PKU 57

3.9 Cost-benefit analysis for CHT 59

4 Screening for hearing impairment 66

4.2 Hearing impairments 66

4.3 Secretory otitis media (SOM) 67

4.4 Aim and outcome measurement of screening for hearing

4.6 Screening tests 71

5 Early detection and prevention of vision defects 77

5.1 The normal development of vision 77

5.2 Visual disorders 78

5.3 The importance of early detection (and treatment) of vision

5.4 The aim and outcome measures of the detection of vision

5.5 Tests for early detection of vision defects in the Netherlands 82

5.6 Other detection methods 87

6.2 Developmental impairments 97

6.3 Aim and outcome measures of developmental surveillance 98

6.4 Developmental surveillance methods 99

6.5 Developmental surveillance in the Netherlands 100

6.6 Conclusions 103

6.7 Recommendations 105

7 Detection of speech and language disorders 110

7.1 Normal language acquisition 111

7.2 Disorders in speech and language acquisition 111

7.3 Causes of disorders in language acquisition 112

7.4 Consequences of language acquisition disorders 113