Indian Pediatr Suppl 2009;46: S55-S58
Validation of Home Screening Questionnaire
(HSQ) against Home Observation for the Measurement of
MKC Nair, GL Prasanna, L Jeyaseelan, Babu George, VR
Resmi and RM Sunitha
From Child Development Centre, Medical College,
Thiruvananthapuram 695 011, Kerala, India.
Correspondence to: Dr .MKC Nair, Director, Child
Medical College, Thiruvananthapuram 695011,
This study was done to validate the screening tool
‘Home Screening Questionnaire (HSQ)’ against the gold standard ‘Home
Observation for the Measurement of Environment (HOME)’ inventory, using
diagnostic test evaluation. Both HOME inventory and HSQ were
administered by separate observers, with children less than 3 years of
age, among 200 families belonging to 14 anganwadi areas. There was a
high sensitivity of 83 and a high specificity of 82 observed for a
cutoff point of ‘less than or equal to’ 19 on HSQ against HOME Inventory
as Gold Standard, as was also observed in the Receiver Operating
Characteristic (ROC) curve. The likelihood ratio (LR) for positive test
was 4.6 (95% CI, 3.3 to 6.9) which implies that the families with poor
home environment are 4.6 times more likely to have the HSQ score ‘less
than or equal to’ 19 as compared to normal families. The results of this
study imply that we can confidently apply the HSQ in developmental
evaluation clinics and reserve HOME inventory for research purposes.
Keywords: Home environment, Home inventory, India, Validation.
Developmental research has shown that the
home environment may serve as a protective factor for children(1). Home
environment scores were found to be significantly related to mental
development, independent of parental education and occupation(2). It is
suggested that early social environment plays a role in mediating
establishment of neural networks that regulate a child’s response to
stress and capacity for self-control(3). The quality of mother infant
interaction and the presence of age appropriate play materials may be used
as a surrogate for the evaluation of quantity and quality of stimulation
available at home. Healthy brain development depend upon the care and
support provided by individuals in the community as well as in the
The Home Screening Questionnaire (HSQ) serves as a
quick, simple and economical parent-answered questionnaire for evaluating
the quality of the family environment promoting child development(5). The
advantage of HSQ is that it can be used in routine clinical situations. It
can also be used by health, daycare and social services personnel, in
place of the Home Observation for the Measurement of Environment (HOME)
inventory, which requires time consuming home visits and direct
observations(6). The present study was done to validate the screening tool
Home Screening Questionnaire (HSQ) against Home Observation for the
Measurement of Environment (HOME) inventory, using diagnostic test
The screening tool HSQ and the gold standard HOME
inventory were administered by separate observers, among families with
children less than 3 years of age, belonging to 14 anganwadi areas
randomly selected from an ICDS block in Thiruvananthapuram district. The
sensitivity was assumed to be around 80% and in order to estimate the
sample size with the precision of 5.5%, with 95% confidence interval, we
needed to study 203 families.
HOME inventory, designed for use with families of
infants and toddlers contains 45 items and it has 6 domains, viz;
emotional and verbal responsivity of parent, acceptance of child’s
behaviour, organization of physical and temporal environment, provision of
appropriate play materials, parent involvement with child, and
opportunities for variety in daily stimulation. A single score is given to
each item and the total score is obtained by adding up the scores. As per
the HOME inventory manual, a cutoff score of less than or equal to 24 is
abnormal (poor home environment) and above 24 normal (good home
HSQ (0-3 years) is a parent–answered questionnaire
which is written at a 3rd or 4th grade reading level. It consists of 30
items; multiple choice, fill in the blanks, yes/no questions plus a toy
inventory checklist. As there is no specific cutoff score given for
denoting a poor home environment in HSQ, the same was obtained using the
following method. At each cutoff point of the HSQ scale scores, the
sensitivity, specificity and likelihood ratio of the positive test were
calculated. Receiver operating characteristics (ROC) curve was drawn to
identify the best cutoff point for the HSQ scale. The point which is
closer to the top and left most corner of the ROC curve was chosen as the
best cutoff point. Also the likelihood ratio of the positive test and its
95% confidence interval and post test probability of being abnormal were
calculated. The sensitivity, specificity, accuracy and predictive values
for the chosen cutoff point of HSQ as compared to the HOME scale were
There were 201 eligible families in the study area and
data was available for 200 families as one family refused permission.
Sensitivity, specificity and likelihood ratios for different scores of HSQ
against HOME inventory were calculated. A sensitivity of 83 and a
specificity of 82 was observed for a cutoff point of
on HSQ (Fig. 1), as also observed in the ROC curve.
Fig. 1 ROC curve for Home Screening
Table I shows that the likelihood ratio
(LR) for positive test was 4.6 (95% CI, 3.3-6.9), which implies that the
families with poor home environment were 4.6 times more likely to have the
HSQ score £19
as compared to normal families. Therefore this point was considered to
‘rule in’ abnormality. The posttest probability of being abnormal family,
if score is £19
is 0.84. According to the HOME inventory, 103 families out of 200 were
diagnosed to have poor home environment. It was also observed that for the
screening test HSQ against the gold standard HOME inventory, the
sensitivity was 83%, specificity 82%, positive predictive value 83.3%,
negative predictive value 81.6%, and accuracy 82.5%. Both the HSQ and HOME
inventory identified 85 families as of poor environmental status (true
positive) and 80 families as of good environmental status (true negative).
Validity Statistics for ‘Ruling in’ and ‘Ruling out’ Cutoff Points of HSQ
Rule out ‘abnormal’ family
||93.2 - 98.7
||55.2 - 68.7
||2.1 - 3.2
||87 - 94.9
||67.9 - 80
||2.7 - 4.7
Rule in ‘abnormal’ family
||77.7 - 88.2
||76.6 - 87.3
||3.3 - 6.9
||61.5 - 74.4
||85.8 - 94.1
||4.3 - 12.7
||45 - 58.9
||93.2 - 98.7
||6.7 - 45.8
Likelihood ratio for positive test
A screening test should ideally be one with high
sensitivity and specificity but in practical situations, we usually go for
high sensitivity for screening test and high specificity for the
confirmatory test. But a tradeoff between sensitivity and specificity
becomes often necessary. In this study, the best cutoff point taken for
HSQ score was less than or equal to 19, because it offered an acceptably
high sensitivity of 83% and a high specificity of 82%.
The observed high negative predictive value of 81.6%
indicates that with a negative test result, it is very unlikely that the
home is abnormal (poor home environment), a welcome quality for a
screening test. This result implies that we could apply with confidence
the HSQ in developmental evaluation clinics and reserve HOME inventory for
research purposes. The HOME inventory requires that a trained interviewer
visit the home to complete it, which is both costly and time consuming.
The advantage of HSQ is that it may be completed by a parent or health
worker. Similar observations have also been made in validation studies
done in other populations(7-9).
It is also recommended that whenever we do
developmental assessment, home environment assessment, an important factor
determining the developmental outcome, should be included.
Shyamalan K, Indira MS, functionaries of Vattiyoorkavu
ICDS Block; and, Asokan N, Child Development Centre, Medical College,
Contributors: MKCN was involved in designing the
study and preparation of the manuscript and will act as guarantor. GLP was
involved in data collection, LJ was involved in analysis of data and BG,
VRR and RMS supervised the data collection process.
Funding : None.
Competing interests: None stated. The findings and
conclusions of this article are those of the authors and do not
necessarily represent the views of the funding agency.
What This Study Adds?
• HSQ against HOME inventory has a high
sensitivity (83%) and specificity (82%) observed for a cutoff point
• Families with poor home environment are 4.6
times more likely to have HSQ score
as compared to normal families.
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