Parent Perspectives on the Usability and Accessibility of the Cdc Milestone Checklist and Asq-3 Questionnaire in Monitoring Early Developmental Delays

Parent Perspectives on the Usability and Accessibility of the Cdc Milestone Checklist and Asq-3 Questionnaire in Monitoring Early Developmental Delays | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Parent Perspectives on the Usability and Accessibility of the Cdc Milestone Checklist and Asq-3 Questionnaire in Monitoring Early Developmental Delays Shrisruthi Suresh, Vadivelan Kanniappan, Santhiya. G, Manju Bashini Manoharan, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7264197/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Early identification of developmental delays is pivotal for timely intervention and optimal child outcomes. Parent-administered tools such as the CDC Milestone Checklist and Ages and Stages Questionnaire–3 (ASQ-3) are globally used; however, their usability and accessibility among Indian parents, particularly those with varying literacy levels, remain underexplored Objective To evaluate and compare the usability and accessibility of the CDC Milestone Checklist and ASQ-3 among parents. Methods A sequential mixed-methods design was implemented. Phase I- a pilot study with 60 parents (30 per tool) to establish baseline usability and accessibility. Phase II- qualitative interviews with 17 parents, where both tools were administered and analysed thematically. In Phase III, a within-subject quantitative study with 84 parents, participants completed both tools were assessed using a structured Likert scale. Results The study reveals CDC Checklist was easier to understand, with 65.5% deriving more than five developmental cues, compared to the ASQ-3, where 53.5% found it difficult to understand and 39.2% required more than five cues. Familiarity with the CDC Checklist was lower initially (39% unfamiliar), but none reported unfamiliarity with the ASQ-3 when administered a second. Higher curiosity of ASQ-3 (65.5% very curious) but took longer to complete (62%: 15–20 min; 26%: >20 min). First-time mothers (46.7%) and parents of preterm infants (46.7%) faced greater challenges with comprehension and scoring, though less so with the CDC Checklist. Conclusion While both tools have value, the CDC Checklist aligned more closely with parental perspectives due to its simplicity and clarity, while practical barriers were found in using both tools in the Indian context. Findings underscore the need for a culturally sensitive and linguistically accessible developmental screening tool tailored for Indian parents. Developmental delays Usability Accessibility Parent-administered screening tools culturally sensitive Introduction Developmental delays are characterized by significant lags in attaining age-appropriate milestones across one or more domains, including motor, language, cognitive, and social-emotional development, and are estimated to affect approximately 15–18% of children worldwide 1 . Early identification of these delays is crucial, as timely intervention improves developmental outcomes, particularly in enhancing social skills, functional independence, and long-term well-being 2 . While clinical assessments by therapists play a vital role, parents often serve as the first observers of developmental differences in daily life 3 . Their observations not only initiate the pathway to early detection but also sustain the continuity of care. Importantly, the dynamic triadic relationship between child, parent, and therapist becomes central to the intervention process 4 . This collaborative structure fosters effective communication, strengthens caregiver confidence, and enhances therapeutic alignment. Recognizing the pivotal role of parents as both informants and partners in care highlights the need for tools that are accessible, culturally sensitive, and empowering—designed to guide them in tracking milestones, initiating early conversations, and engaging meaningfully in their child’s developmental journey 5 . Among the tools available (As in Table 1) for monitoring developmental milestones, the CDC (Centers for Disease Control and Prevention) Milestone Checklist and the Ages and Stages Questionnaire, Third Edition (ASQ-3) are widely used 6 . These tools are particularly valuable in home or community settings, where access to clinician-administered tools (e.g., Bayley Scales, AIMS) and early detection by specialised healthcare professionals may be limited. Evidence-based developmental checklists are designed to empower parents, improve surveillance more practical and scalable in routine care 7 . In Tamil Nadu, MCP cards (Mother and Child Protection card) have been provided to educate the parents with maternal and child services. Table 1: List of Developmental tools and their administrators Tool Name Administered By Ages and Stages Questionnaire – 3 (ASQ-3) Parent-administered CDC Developmental Checklist Parent-administered Denver Developmental Screening Test II (DDST-II) Therapist/Clinician-administered Trivandrum Developmental Screening Chart (TDSC) Therapist-administered Bayley Scales of Infant Development III Therapist/Clinician-administered Alberta Infant Motor Scale (AIMS) Therapist-administered Test of Infant Motor Profile (IMP) Therapist-administered General Movement Assessment (GMA) Therapist-administered (video-based) Hammersmith Neonatal Neurological Examination (HNNE) Therapist-administered Hammersmith Infant Neurological Examination (HINE) Therapist-administered Amiel-Tison Neurological Assessment at Term (ANAT) Therapist-administered INFANIB (Infant Neurological International Battery) Therapist-administered Griffith Mental Development Scales Therapist-administered Peabody Developmental Motor Scales (PDMS) Therapist-administered Brazelton Neonatal Behavioral Assessment Scale (NBAS) Therapist-administered Neurobehavioral Assessment of Preterm Infant (NAPI) Therapist-administered Developmental Assessment Scale for Indian Infants (DASII) Therapist-administered Battelle Developmental Inventory (BDI) Both (parent input + therapist test) Developmental Assessment of Young Children (DAYC) Both (parent interview + observation) Gesell Developmental Schedule Therapist-administered The CDC Milestone Checklist is a parent-administered tool designed to monitor child development using simple language, age-specific milestones, and a checklist format. The parent-friendly format of the CDC Developmental Milestone Checklist ensures simplicity without compromising depth—bullet points and tick boxes guide even non-medical users with ease 8,9 . Structured by age, from 2 months to 5 years, it offers a rhythm for tracking developmental milestones aligned with regular pediatric checkups. Covering four holistic domains social/emotional, communication, cognitive, and motor it paints a complete picture of a child’s early growth. Action-oriented prompts like “Don’t wait. Acting early can make a real difference” are designed to shift hesitation into empowered decision-making. Parents are not left uncertain; the tool integrates clear next-step cues, reflective questions, and direct access to early intervention resources 9 . Cultural sensitivity grounds the tone, using warm, familiar language that affirms caregiver intuition statements like “You know your baby best” and “Talk, read, and sing to your baby” guide interaction without medical jargon. Everyday moments like tummy time, peek-a-boo, and shared reading are reframed as integral to developmental stimulation. Finally, the CDC Milestone Tracker App offers digital support, promoting accessibility for tech-savvy caregivers and ensuring continuous engagement beyond clinic walls 10 . The Ages and Stages Questionnaire–3 (ASQ-3) is a developmental screening tool designed to assess children from 1 month to 5½ years of age across five core developmental domains: communication, gross motor, fine motor, problem solving, and personal-social skills. Comprising 21 age-specific questionnaires, the ASQ-3 is structured to align with a child’s developmental stage, enabling accurate and age-appropriate assessment 11 . Its design emphasizes caregiver participation, allowing parents or primary caregivers to complete the questionnaire based on their daily interactions with the child, using a simple and intuitive response format “Yes,” “Sometimes,” or “Not yet.” The tool is intentionally accessible, requiring only a fourth-grade reading level, and includes visuals in certain versions to support comprehension and reduce literacy-related barriers. The Psychometric properties sensitivity ranging from 77% to 91% and specificity from 71% to 93% demonstrates reliability and validity across diverse populations and cultural contexts 12 . The ASQ-3 has been extensively translated, adapted, and validated for use in clinical, educational, and community-based settings globally. Importantly, it provides actionable follow-up guidance for caregivers when developmental concerns are identified, ensuring as a pathway to early intervention and support. While the CDC Developmental Milestone Checklist and the ASQ-3 are established tools for early developmental monitoring. Despite this, their rich experiential knowledge gained through years of caregiving, observation, and interaction with health and education systems demonstrated a deep understanding of developmental progress and delays. This disconnect between formal tool exposure and real-world caregiving experience highlights the need to assess is quite higher. The accessibility is one such valid point that needs to be considered. From the user-centric perspective, Usability is more about how effectively and effortlessly users can operate the tool, which encompasses clarity, ease of completion, emotional tone, content relevance, contextual fit, and accessibility is about how broad that usability. The current study addresses this gap by involving such parents in a sequential comparison of the tools, acknowledging their deep familiarity with milestones despite limited formal exposure to structured checklists. To explore these perspectives, the study adopted a sequential exploratory mixed-methods design, unfolding across three phases. Both tools were assessed using variables like readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use to compare within-subjects. This methodological approach prioritized parent engagement with the tools in helping the health care provider effectively on the tools that function in practice. Most importantly, our aim is not to compare the standard tool, but rather to analyses the parental experience on how parents interpret, relate, and act upon the tools when introduced within a caregiving context. This focus aligns with broader calls in developmental and family-centered research to foreground caregiver usability over clinician-led tool assessment. Methodology Study design This study employed a sequential exploratory mixed-methods design to investigate the usability and accessibility of two developmental screening tools: the CDC Milestone Checklist and the Ages and Stages Questionnaire, Third Edition (ASQ-3). The design unfolded in three phases: An initial quantitative phase using two independent groups, an in-depth qualitative phase to explore parental perceptions, and a follow-up quantitative phase using a within-subjects design to validate and triangulate the emergent themes 13 . This multi-phase approach enabled a comprehensive understanding of parent experiences by combining in-depth, contextual insights with broader generalizability through quantitative measures. Study setting and participants The study was conducted at SRM Medical College Hospital and Research Center, Kattankulathur, Tamil Nadu, India. In the initial phase, a quantitative study was carried out with 60 participants, comprising 30 in each group. This was followed by a qualitative study involving 16 participants. Subsequently, a larger quantitative phase was conducted with 84 participants. Inclusion Criteria Parents of children diagnosed with developmental delays, within the age range of 2 months to 5 years, were included in the study. Eligibility criteria required that participating parents be able to read the English language to ensure readability of the tools. Additionally, only those parents who were available and willing to participate in both sessions were considered. Exclusion Criteria The exclusion criteria for the study included parents of typically developing children, parents who were unwilling to participate, and those who had previously undergone formal training in child development, in order to minimize potential bias in responses and ensure the authenticity of parental perspectives. Sampling Procedure Recruitment: Participants were recruited via paediatric clinics, early intervention programs, and online support groups for developmental delays. Ethical Approval Ethical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: ECR/8951/INST/TN/2013/RR-19), and conducted following the Declaration of Helsinki. A written informed consent was obtained from all participants before enrollment. Data Collection This mixed-methods study was conducted in three sequential phases to evaluate and compare the usability of two developmental screening tools—the CDC Milestone Checklist and ASQ-3—from the perspective of parents. The overall aim was to identify context-sensitive preferences, inform tool sequencing for practical use, and refine usability dimensions through a combination of quantitative and qualitative analyses. Initial Quantitative Phase (Independent Groups) The primary objective of this initial phase was to conduct a baseline comparison of tool usability across two independent participant groups (n = 60; 30 per group), in order to check for any preliminary differences in parental experience between the two tools. One group completed the CDC Milestone Checklist, while the other responded to the ASQ-3. Participants rated their experiences using Likert-scale items aligned with predetermined themes, including ease of use, readability, comprehension, tool relevance, and duration. This phase aimed to assess whether any significant differences in perceived usability existed prior to deeper investigation. Qualitative Phase To explore parental perceptions in greater depth, semi-structured interviews were conducted until data saturation was reached. This phase had two main objectives: (1) to determine which tool should be administered first in the follow-up quantitative phase, and (2) to refine and generate subcategories under each predetermined theme, capturing more nuanced aspects of tool usability. Open-ended questions probed participants’ experiences regarding ease of understanding, cultural relevance, barriers to use, and the influence of family or systemic factors on tool adoption. All interviews were audio-recorded, transcribed verbatim, and analysed thematically to develop rich, context-sensitive insights. Follow-up Quantitative Phase (Single Group – Sequential Testing) In the final phase, a within-subject design was adopted to enable a direct comparison of parental experiences with both developmental screening tools. A total of 84 parents were recruited and sequentially administered both tools—first the CDC Milestone Checklist, followed by the ASQ-3—after a one-hour interval that coincided with their child’s routine therapy session. This time gap helped reduce immediate recall bias while maintaining contextual continuity. Participants rated each tool using Likert-scale items mapped to seven overarching themes and subcategories that had been developed during the qualitative phase. For instance, under the theme of understanding ability , subcategories included: easy to understand , required 1–2 cues , required more than 5 clarifying questions , and hard to understand 14 . This sequential approach allowed for a nuanced, within-participant comparison of tool usability, enhancing insight into context-sensitive preferences and practical performance in real-world clinical settings. Overall, the study was structured across three interconnected phases: an initial quantitative phase (independent groups), a qualitative phase (semi-structured interviews), and a follow-up quantitative phase (sequential testing within a single group). The progression from baseline comparison to in-depth exploration and finally to refined testing ensured a comprehensive understanding of tool usability. Findings from the initial quantitative phase informed the development of the qualitative interview guide, while insights from the qualitative analysis directly shaped the subcategories used in the final phase. This integrative approach strengthened the study’s ability to capture context-sensitive perceptions and guide practical tool implementation. Interview Guide (Qualitative) A semi-structured guide was used to elicit detailed parental reflections on tool usability. Sample questions included: “How easy was it for you to understand the instructions on the CDC Milestone checklist?” “Were there any aspects of the ASQ-3 that felt confusing or difficult to complete?” “Did either of the tools help you identify concerns about your child’s development?” Statistical Analysis Data were analyzed using SPSS software version 21 (IBM SPSS Statistics, Armonk, NY) and figures were made using GraphPad Prism version 10.1 (GraphPad Software Inc., La Jolla, CA). Descriptive statistics (mean and standard deviation (SD)) were calculated. Non-parametric Mann-Whitney U for independent groups and Wilcoxon signed rank test for paired variables, with a predetermined alpha level of 0.05, were done to check the statistically significant difference present between the quantitative variables. Results Initial Quantitative Phase (Independent Groups) A total of 60 parents participated in the initial quantitative phase, with 30 parents using the CDC Developmental Checklist and 30 using the ASQ-3. Table 2 presents the demographic details of the participants. TABLE 2: Demographic Variables (Initial Quantitative) Variables CDC (N = 30) (mean ± SD or n (%)) ASQ-3 (N = 30) (mean ± SD or n (%)) Mothers Age 28.0 3.46 27.73 3.00 Parity Primi 53.3% 50% Multi 46.7% 50% Gestational Status Preterm 46.7% 46.7% Full term 53.6% 53.6% Education High School 3.33% 6.7% Graduate 96.7% 93.3% Participants rated the tools on seven dimensions: Readability, Understanding ability, Content Correlation, Level of participation, Familiarity of the tool, Curiosity of participation, and Duration of participation. Descriptive statistics revealed similar mean scores across both groups. Inferential analysis (Mann-Whitney U) showed no statistically significant differences between the two tools on any of the variables (p < 0.05) [Table in supplementary section]. These findings indicated that at the group level, parents perceived both tools similarly in terms of usability and accessibility. Qualitative Exploration A total of 17 parents of children with developmental delays participated in the qualitative phase. Participants were selected purposively to ensure diversity in educational and caregiving backgrounds. Thematic saturation was reached within this sample, as no new themes emerged in the final interviews, supporting the adequacy of the sample size for in-depth thematic analysis. Semi-structured interviews were conducted with 17 parents of children with developmental delays. All participants had exposure to both the CDC and ASQ-3 tools in monitoring the child development. Several barriers emerged from the parental narratives regarding the use of developmental screening tools such as the CDC checklist and ASQ-3 questionnaire. Awareness was limited, with many parents reporting delayed recognition of developmental concerns, a strong reliance on the MCP (Mother and Child Protection) card alone, and confusion in monitoring development. The ease of reading a tool is known to be readability. Likewise, the parents found it difficult to understand (understanding ability) and relate checklist items in their daily routines, which reduced their confidence in completing the tools accurately. Comprehensibility was also limited, with many parents unclear about the checklist's purpose and expressing a need for clearer instructions or professional guidance. In terms of usability, the tools were often perceived as overly clinical or intended for professionals, with complex formats that felt overwhelming for non-specialists. Accessibility was another concern, as the checklists were typically available only in English and not well integrated into routine pediatric or community health services. Finally, sociocultural barriers such as reliance on advice from elders, financial and caregiving stress, and the stigma associated with developmental delays further impacted parents' willingness and ability to engage with these tools effectively. A thematic analysis approach was used. Interview transcripts were coded inductively to extract recurring ideas and concepts. Seven core themes emerged and were refined into sub-themes, capturing barriers, emotional responses, and practical challenges faced by parents while using the tools. Table 3: Themes and Subthemes Qualitative Inputs Themes Clustered Themes Lack of awareness about the CDC/ASQ-3 tools Initial Awareness & Discovery Exposure & Engagement Late discovery and regret Over-reliance on the Mother and Child Protection (MCP) card Misconception that doctors alone monitor development Search for parenting info without exposure to screening tools Surprise at the existence of structured screening tools Unfamiliar and technical terms Language & Familiarity of terms Need for simpler or familiar language Terms not commonly used in the Indian context (eg: “cruising, gesture”) Difficulty relating questions to real-life contexts Understanding the questions Cognitive Processing Questions felt abstract or culturally irrelevant Lack of examples for better interpretation Difficulty understanding purpose or how to fill Tool comprehension & Navigation Needed guidance to interpret items Educational level did not ensure comprehension Overwhelming structure or length Ease of use & format barriers Practical barriers Difficulties with scoring and response formats Lack of visual or step-by- step instruction Perceived as a professional tool than a parent- friendly one Influence of family members discourages early concern Sociocultural & Family Dynamics Contextual Influences Delay due to “wait and watch” advice from elders Financial stress or social neglect affecting engagement Following Qualitative analysis, the emerged themes were extended to compare quantitative categories to check the usability and accessibility in the subsequent phase. Table 3 shows the cross matrix of alignment between the qualitative and quantitative, while protecting the complex nature of user-centric inputs. Table 4 shows the Qualitative-Quantitative theme cross matrix, which aligns together respectively and it’s classified into Strong and partial alignment. Table 4: Qualitative-Quantitative themes cross matrix ( Strong Alignment ✓ / Partial Alignment ( ✓ )) Themes Readability Understanding Ability Content Correlation Level of Participation Curiosity of Participation Familiarity of Questions Duration of Participation Initial Awareness & Discovery (✓) ✓ ✓ ✓ (✓) Language & Familiarity of words ✓ (✓) (✓) ✓ Understanding the Questions (✓) ✓ ✓ Tool Comprehension & Navigation ✓ (✓) (✓) ✓ Ease of Use & Format barriers (✓) (✓) ✓ ✓ Access & Availability ✓ ✓ ✓ Sociocultural & Family Barriers ✓ (✓) ✓ Follow-up Quantitative Phase (Single Group – Sequential Testing) To validate the qualitative themes and further investigate parental preferences, 84 parents (Table 5) were given both tools in sequence (CDC first, followed by ASQ-3 after a 1-hour gap). Table 5: Demographic variables (Quantitative - Sequential testing) Variables CDC & ASQ-3 (N = 84) (mean ± SD or n (%)) Mother’s age 27.29±2.59 Parity Primi 56% Multi 44% Gestational category Preterm 46.4% Full term 53.5% Educational Level High school 2.4% Graduate 97.6% Table 6 presents the reports of Wilcoxon signed rank test. Significant differences were noted between four sub categories namely understanding, content correlation, Level of participation and Familiarity of questions. TABLE 6: Quantitative Sequential testing- Wilcoxon signed rank test CDC vs ASQ-3 Reading skill Understanding ability Content correlation Level of participation Curiosity of participation Familiarity of questions Duration of Participation Z- value .000 -3.337 -4.094 -4.287 -3.338 -4.683 -1.561 p-values 1.000 0.001 0.000 0.000 0.736 0.000 0.118 p<0.005**,p<0.05* Further, the Wilcoxon signed rank test was carried out among the subcategories after binary coding, such as the subcategory of understanding ability - Need more than 5 cues - was tested for the presence of significant difference between CDC and ASQ-3. The results of these subcategory statistics were projected as stars and ns in Bar graphs (1 - 6), with * representing p < 0.05; ** representing p < 0.005; *** representing p<0.0005; and ns non non-significant. Bar Graph 1: Understanding Ability This bar graph illustrates the distribution of parental understanding ability, during the sequential administration of tools, subcategorized into four response groups: “ Easy to understand”, “less than 5 cues received,” “More than 5 cues received,” and “Hard to understand.” The majority of participants required more than 5 cues or felt that both the tools were hard. In the understanding ability sub category, statistically significant differences were observed for Option 2 ( Z = -3.000, p = 0.003 ) and Option 4 ( Z = -2.897, p = 0.004 ), indicating the carry over effect in sequential administration of two tools. Bar Graph 2: Familiarity of Screening Tool Questions Bar graph 2 (in additional material) represents the familiarity of questions CDC and ASQ-3 tools where five options were given to the parents, where parents rated ASQ-3 have been more familiar than CDC, with the significant differences noted in sub categories like unfamiliar (z=-4.243,p<0.001) and very familiar (Z=-4.123, p<0.001). No differences were observed in the other subcategories. This might reflect the sequential administration trend, where contents related to development milestones might overlap. ( as shown in supplementary material.10). Bar Graph 3: Comparison of parental level of Participation This bar graph (in additional material) depicts the level of parental participation subcategorized into five levels: Completely Dependent , Maximum Dependency , Moderate Dependency , Minimal Dependency , and Completely Independent . The findings show the characteristic of sequential administration, with the majority dependency in completing the CDC was gradually reduced during ASQ-3 completion, reflecting the carryover effect of learning. Bar Graph 4: Comparison of Content Correlation This bar graph (in additional material) illustrates the participants’ perceptions of content correlation in the CDC and ASQ-3 developmental screening tools. 53.5 % of participants reported that the ASQ-3 was Hard to understand , whereas the CDC tool, although requiring cues for interpretation, was perceived as comparatively clearer. Both tools showed minimal differences in the number of participants who required More than 5 Cues to understand the content, indicating that while the CDC was relatively more accessible, neither tool was entirely self-explanatory for all users. Bar Graph 5: Comparison of Curiosity of Participation This bar graph (in additional material) compares the levels of curiosity. Significant differences were observed in slightly curious ( Z = -3.317, p = 0.001 ), very curious ( Z = -3.042, p = 0.002 ), and extremely curious ( Z = -3.742, p < 0.001 ), indicating higher interest and engagement with ASQ-3 items. This suggests that ASQ-3 may encourage more active parental involvement despite being more complex. Bar Graph 6: Comparison of Duration of Participation This bar graph (in additional material) depicts the time taken by participants to complete each tool is between 15 to 20 minutes or more than 20 minutes. Demographic Influence in Scoring Four demographic variables showed statistically significant influence across the tool dimensions. The Mann-Whitney U test revealed significant differences between preterm and full-term mothers. Preterm mothers demonstrated higher scores (66.6 %) in ASQ-3 Understanding Ability (U = 669.000, Z = -2.124, p = 0.034) included in (suppl.8) , likewise 51.3 % of multi gradiva parents have reported indicating deeper familiarity with its relatively complex items—likely due to repeated prior exposure and learning through sustained engagement with developmental milestone tools,. In contrast, full-term mothers scored significantly higher in CDC Level of Participation (U = 611.500, Z = -2.560, p = 0.010) (as shown in supplementary material.6) and Curiosity of Participation (U = 589.500, Z = -2.730, p = 0.006) (as shown in supplementary material. 7), suggesting reflecting more active involvement and exploratory interest. The lower scores in these areas among preterm mothers may reflect participation fatigue. Additionally, a significant difference in CDC Familiarity was observed between primigravida and multigravida mothers. Multigravida mothers (mean rank = 49.88) scored significantly higher than primigravida mothers (mean rank = 36.69), U = 596.50, Z = -2.64, p = 0.008, indicating greater awareness and understanding of the CDC checklist content. [The Bar charts of sub-category demographic influence were included in the Supplementary. 7,8,9,10] Discussion This study aimed to evaluate and compare the usability and accessibility of the CDC Milestone Checklist and the ASQ-3 questionnaire among parents using a sequential exploratory mixed-methods design. Across three stages—independent-group quantitative baseline comparison, qualitative thematic exploration, and sequential-testing quantitative follow-up—the methodology focuses on user-centric design, A design based on Parent perspectives. The Need for Three-Stage Exploration in User-Centric Studies: This study adopted a three-stage design to ensure a genuinely user-centric exploration, a practice increasingly recommended in the development and validation of health tools across diverse populations 15,16 . Initially, quantitative data were gathered from two independent groups using pre-assumed themes derived from existing literature. However, when actual tool users, the parents, were engaged through open-ended qualitative interviews, a set of complex and entangled codes emerged. Based on these user-generated insights, categories for the final quantitative phase were confirmed, reflecting the value of embedded mixed-method designs in improving contextual fit 17 . The initial quantitative phase also served a dual purpose: it enabled a check for baseline evenness between groups. Interestingly, both groups perceived the CDC and ASQ-3 tools similarly, with no statistically significant differences — a unique feature of this study. Even if baseline disparities had been detected, they would have been preserved and treated as interpretive variables rather than exclusions, in alignment with inclusive research practices 18 . Ultimately, this stepwise and iterative design led to the emergence of user-derived complex themes inclusiveness (Table 3) — a critical shift in contexts where local cultural, linguistic, and geographic evidence is limited. By foregrounding user narratives, this study contributes novel, locally grounded insights from the English-speaking Tamil population, establishing a foundation for future work with exclusively Tamil-speaking communities and other linguistically diverse populations in India. Possible Reasons for Baseline Evenness in the First-Stage Quantitative Analysis The baseline evenness observed in the initial quantitative analysis — where independent participant groups showed no significant difference in perceiving the CDC and ASQ-3 tools — may be attributed to a convergence of demographic and contextual factors. 97.6% participants held graduate-level educational qualifications, which likely enhanced their capacity and willingness to engage with structured tools, even without prior exposure. Additionally, the study’s inclusion criteria limited participation to English-speaking members of the Tamil community — a segment better positioned to comprehend the tools, as both the CDC Milestone Checklist and ASQ-3 were designed originally in English 19,20 . In the absence of a comparator or alternative developmental screening approach, participants may have focused solely on the internal structure, clarity, and purpose of the tools, reducing the likelihood of contrast-driven bias. This may have contributed to uniform perceptions and responses across both groups. Second stage Clustered Themes Aligned with Usability and Accessibility In terms of usability, the exposure & engagement cluster reflects how inviting, discoverable, and intuitive the tools appear, directly influencing whether parents choose to engage with them — a factor also emphasized in user-interface design principles for health tools 21 . Cognitive Processing captures the depth of parental comprehension, the clarity of questions, and how well the items align with parents’ everyday understanding of child development — resonating with evidence that user comprehension is central to successful tool implementation 22 . Practical Barriers encompass challenges related to design limitations, instructional format, scoring structure, and overall user-friendliness — all of which influence the ease of tool completion and align with broader usability constraints seen in public health interventions 23,24 . Relating to accessibility, Practical Barriers also include systemic limitations such as language availability and the absence of integration into existing healthcare or Anganwadi routines ( where MCP cards are majorly used)— similar to challenges highlighted in low- and middle-income settings 25 . Contextual Influences bring attention to sociocultural beliefs, family dynamics, and financial stressors that shape a parent’s ability or willingness to use the tools. Additionally, Exposure & Engagement sheds light on disparities in information dissemination, pointing to unequal access to knowledge about developmental screening — a key equity concern in early intervention systems 26 . Together, the qualitative insights were organized into four functional clusters — Exposure & Engagement, Cognitive Processing, Practical Barriers, and Contextual Influences — each representing intertwined aspects of usability and accessibility as experienced by parents during their interaction with both the CDC Milestone Checklist and ASQ-3 Questionnaire. Quantitative Categories: Usability and Accessibility Alignment In the third stage of analysis, seven core quantitative variables were identified—readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use—as key dimensions to assess the usability and accessibility of developmental screening tools from a parent-centered lens. These dimensions were not arbitrarily chosen but derived from predetermined themes in Stage One and refined through thematic analysis in Stage Two. This cross-matrix alignment reinforces the ecological validity of the instrument framework, as each quantitative variable resonates with lived parental experiences and perceptions. Each variable contributes uniquely: readability ensures the tool is linguistically approachable, understanding relates to conceptual clarity, familiarity reflects prior exposure or alignment with known practices, content correlation checks if the tool connects with real-life child development cues, curiosity measures emotional engagement, participation level assesses the parent’s willingness to act, and duration of use speaks to tool sustainability. Together, they form a comprehensive structure that captures both the functional ease and relational depth of how parents engage with screening tools. The inclusion of curiosity and participation level as measurable categories also introduces a dynamic component into what is often a static usability framework, acknowledging parents as active participants in the child development process rather than passive respondents 27 . However, even with comprehensive coverage, the possibility remains that certain localised usability nuances—specific to linguistic, regional, or literacy contexts—might not have been captured. This insight further advocates for adaptive, user-centered tool development, wherein future screening models incorporate iterative feedback loops and modular content design to suit diverse Indian sub-populations 28,29 . Such an approach enables a mid-ground space—a collaborative interface—where parents feel empowered to engage with healthcare professionals, enhancing both developmental surveillance and caregiver confidence in supporting their child’s early health trajectory. Interpretations from Third-Stage Sequential Tool Testing: A Summary Unanimously, all 84 participants reported that both the CDC Milestone Checklist and ASQ-3 Questionnaire were easy to read. However, when it came to understanding, none of the parents found both tools equally easy to comprehend. The CDC Checklist demonstrated greater ease of comprehension, with more parents reporting that they received over five meaningful developmental cues from it. In contrast, the ASQ-3 was more frequently marked as difficult to understand, highlighting a significant gap in creating user-friendly, self-explanatory tools — a challenge echoed in other usability research on developmental assessments. This finding underscores the critical need for user-centered tool design that accommodates varying literacy and health comprehension levels 30,31 . Regarding tool familiarity, 39 % of participants reported the first-administered CDC Checklist as unfamiliar. However, none expressed unfamiliarity with the second-administered ASQ-3, indicating a carry-over learning effect between the two tools, consistent with principles of adult learning and task adaptation. Additionally, nearly equal proportions of participants rated both tools as "somewhat familiar" or "familiar." Notably, about 20% identified the second tool (ASQ-3) as very familiar, while none did so for the CDC Checklist, highlighting the need for content overlap analysis and redundancy mapping in future tool development. Such mapping should be informed by local experts who understand both contextual social environments and users’ capabilities in applying developmental tools 32 . Participation patterns further reflect adaptive learning capacities. Only 1.2 % of parents reported complete dependency while using the CDC Checklist, and a similar 2.4 % reported complete independence when using ASQ-3 — a dynamic suggesting progressive parental engagement and tool learning through sequential exposure. Most participants shifted from being maximally dependent on the CDC to moderately or minimally dependent with the ASQ-3. (Mezirow, 1997; Carpentieri et al., 2019). With rising global projections of developmental delay due to factors like increased preterm birth rates and socio-environmental stressors 33 , the demand for culturally sensitive, literacy-appropriate, and locally relevant screening tools is both urgent and foundational to early childhood care efforts. A key interpretive insight emerged from content correlation, which refers to the perceived relevance between tool items and the child’s actual development. Interestingly, none of the participants found either tool to be “easy” in terms of content correlation. For the CDC checklist, responses were almost equally distributed between “less than 5 cues,” “more than 5 cues,” and “hard to complete,” indicating a relatively balanced interpretation spectrum. However, in the case of the ASQ-3, 53.5 % of participants marked it as “hard,” while 39.2 % needed more than 5 cues, and 7.1 % found it required fewer cues to complete. This sharp contrast suggests that despite being administered after the CDC, many still found the ASQ-3 content difficult to understand. These results were also echoed in earlier qualitative feedback, which justified our decision to administer the CDC checklist first in the sequential study design. This again emphasizes the importance of culturally grounded tools 34 , especially for linguistically and contextually diverse populations such as Tamil-speaking Indian communities. Tool comprehension and perceived relevance are not merely about translation but about cultural congruence, educational suitability, and developmental literacy 35 . Thus, these findings call for the development of new tools that are both contextually relevant and developed through local expert participation, incorporating content that reflects the developmental red flags meaningful to the local caregivers. With respect to curiosity of participation, the CDC checklist evoked a wide range of responses, from “slightly curious” to “extremely curious.” On the other hand, responses for the ASQ-3 were clustered, with 65.5% of participants selecting “very curious,” and the rest marking “moderately curious.” This narrowing suggests that the ASQ-3 may have content richness or complexity that piqued participant attention, even if not fully understood. While this higher curiosity might stem from its structured design and diverse items, it does not necessarily equate to better usability. Instead, this again reinforces the need to map both tools—CDC and ASQ-3—at macro and micro levels to identify unique components worth preserving or adapting in future tool development 36 . These insights must inform the design of a hybrid, user-centric tool that balances curiosity, usability, and content relevance. Finally, regarding duration of participation, most participants reported that both tools took between 15–20 minutes or more than 20 minutes, raising critical concerns about the feasibility of using standalone tools like checklists or questionnaires for periodic developmental screening. In an era where digital referencing and modular tools are increasingly viable, the future lies in designing adaptable, age-specific, and literacy-sensitive tools that parents can refer to frequently, rather than just once 37 . Given the high levels of curiosity and the demonstrated willingness to engage, the design of future tools should capitalize on this engagement potential while addressing the gaps in comprehension and content correlation. A modular, culturally responsive design—with simplified language, frequent prompts, and intuitive feedback—may prove to be more effective for both immediate use and long-term caregiver learning. Influence of Demographic Factors on Scoring Patterns Differences in parental status and birth history significantly influenced the way participants engaged with and scored the developmental screening tools. For instance, primiparous (first-time) and multiparous (having more than one child) mothers exhibited variations in the familiarity-based scoring component of the CDC Milestone Checklist. Mothers with previous child-rearing experience were more confident in interpreting milestones, leading to more decisive scoring, whereas first-time mothers were more tentative or uncertain, reflecting their lesser exposure to developmental norms. Additionally, birth term status played a notable role. Parents of preterm infants often expressed heightened vigilance or concern when using the CDC tool, influencing both the overall milestone level and their curiosity toward developmental information. In the ASQ-3, this demographic showed more variation in the understanding and interpretation of questions, particularly where developmental norms may not align with corrected gestational age. These insights affirm that demographic context—parity and preterm/full-term history—can shape both confidence and comprehension in developmental screening 38 . Such findings point to the necessity for a new tool design that embeds these contextual influences structurally. A potential future tool should integrate parent-healthcare professional interaction features, particularly for parents of preterm infants, and align with community-level care ecosystems. Embedding supportive touchpoints like referral pathways, caregiver guidance, and infant care support groups would enhance usability and emotional preparedness. A digitally enhanced tool, when coupled with India's extensive grassroots healthcare network—including Anganwadi workers, ASHAs, and PHCs—could enable scalable, supportive early intervention across diverse settings 39 . This study evaluated and compared the usability and accessibility of the CDC Milestone Checklist and the ASQ-3 questionnaire among parents using a sequential exploratory mixed-methods design. The three-stage approach—quantitative baseline comparison, qualitative thematic exploration, and sequential quantitative follow-up—ensured a genuinely user-centric design based on parent perspectives. Baseline analysis revealed no statistically significant differences between groups, likely reflecting the sample’s high educational attainment (97.6% graduates) and English fluency. These factors may have enabled participants to engage more confidently with both tools, even without prior exposure. The qualitative stage revealed four functional clusters—Exposure & Engagement, Cognitive Processing, Practical Barriers, and Contextual Influences—that shaped how parents experienced both tools. Exposure & Engagement highlighted that tool presentation influences willingness to use developmental screening instruments. Cognitive Processing emphasized the importance of clear, relatable questions for deeper parental understanding, while Practical Barriers captured design challenges and systemic constraints such as English-only availability and lack of integration into Anganwadi and primary healthcare settings. Contextual Influences, including sociocultural norms, family dynamics, and financial stress, further determined tool acceptability and completion. The final quantitative stage validated seven measurable variables—readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use—that aligned closely with the qualitative themes. All parents (100%) reported both tools were easy to read, yet comprehension varied markedly. The CDC Checklist was easier to understand, with 65.5% of parents deriving more than five meaningful developmental cues from it. By contrast, the ASQ-3 was perceived as more difficult, with 53.5% finding it hard to understand and 39.2% requiring more than five cues to complete. Content correlation showed similar gaps: responses for the CDC Checklist were evenly distributed across “less than five cues,” “more than five cues,” and “hard to complete,” while 53.5% found the ASQ-3 “hard” overall. Patterns of familiarity and curiosity further differentiated the two tools. 39% of parents reported the CDC Checklist as unfamiliar when administered first, yet none expressed unfamiliarity with the second-administered ASQ-3, suggesting a carry-over learning effect. The ASQ-3 also evoked higher curiosity, with 65.5% marking themselves as “very curious,” compared to more variable curiosity levels for the CDC Checklist. Participation patterns reflected progressive engagement, with only 1.2% fully dependent when using the CDC Checklist and 2.4% fully independent when using the ASQ-3. However, both tools required significant time commitments, with 62% of parents spending 15–20 minutes and 26% spending more than 20 minutes, raising concerns about feasibility for routine use. Demographic factors significantly influenced parental engagement. Multiparous mothers demonstrated greater familiarity and confidence when using both tools, whereas first-time mothers (46.7%) were more tentative. Birth term status also played a role: parents of preterm infants (46.7%) expressed heightened vigilance and sometimes greater difficulty interpreting milestones, while those with full-term infants (53.3%) appeared more comfortable. These findings underscore the need for developmental screening tools that account for parental experience and infant birth history, particularly in populations with high rates of preterm birth. The study highlights the importance of culturally grounded, literacy-sensitive, and contextually relevant developmental screening tools. While the CDC Checklist demonstrated better comprehension and content relevance, the ASQ-3 engaged parents through a structured design and higher curiosity. Future tool development should leverage the strengths of both instruments, combining clarity and intuitive structure in modular, language-appropriate formats. Such a hybrid tool, designed through iterative parent feedback, would enhance usability, address literacy and cultural barriers, and align with India’s community healthcare networks (Anganwadi, ASHA, and PHCs). Embedding referral pathways and support touchpoints, particularly for parents of preterm infants and first-time mothers, would further improve caregiver confidence and participation in early developmental surveillance. Conclusions and Recommendations This study highlights the need for developmental milestone monitoring, culturally contextual, and user-friendly screening tools tailored to the Indian population, particularly in semi-rural and rural regions. The CDC Milestone Checklist and ASQ-3 questionnaire offer foundational structures. These insights collectively cluster into a strong rationale for new tool development—one that integrates the simplicity of milestone checklists with the depth of structured assessments, while addressing cultural norms, linguistic access, and health system interfaces. Future innovations in this space must prioritize caregiver comfort, reduce cognitive burden, and foster early, sustained engagement with child developmental surveillance. Abbreviations CDC Centers for Disease Control (Milestone checklist) ASQ 3-Ages and Stages Questionnaire (Edition 3) MCP Mother and Child Protection card IEC Institutional Ethical Committee Declarations Ethical Approval Ethical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: ECR/8951/INST/TN/2013/RR-19), and conducted following the Declaration of Helsinki. A written informed consent was obtained from all participants before enrollment. Clinical Trial Number : Clinical Trial number is not applicable Consent for Publication : Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conflicts of Interest: The Author declares no conflicts of interest to disclose. Funding: The authors received no funding for this study Author contributions: All authors have contributed, read, and approved the final manuscript. Acknowledgements: The authors acknowledge the parents who participated in this study. References Zablotsky B, Black LI, Maenner MJ, Schieve LA, Danielson ML, Bitsko RH, Blumberg SJ, Kogan MD, Boyle CA. Prevalence and trends of developmental disabilities among children in the United States: 2009–2017. Pediatrics. 2019;144(4). Oberklaid F, Baird G, Blair M, Melhuish E, Hall D. Children's health and development: approaches to early identification and intervention. Arch Dis Child. 2013;98(12):1008–11. Head LS, Abbeduto L. Recognizing the role of parents in developmental outcomes: A systems approach to evaluating the child with developmental disabilities. Ment Retard Dev Disabil Res Rev. 2007;13(4):293–301. Schleider JL, Weisz JR. Family process and youth internalizing problems: A triadic model of etiology and intervention. Dev Psychopathol. 2017;29(1):273–301. King G, Desmarais C, Lindsay S, Piérart G, Tétreault S. The roles of effective communication and client engagement in delivering culturally sensitive care to immigrant parents of children with disabilities. Disabil Rehabil. 2015;37(15):1372–81. Kanniappan V, Muthiah M, Abishek JR, Shrisruthi S, Chinnasami B, Sethuraman S, Muthuperumal P, Manoharan MB, Raja D, Selavaraj S. A Systematic Review of Neurodevelopmental Tools for Preterm Infants During Infancy: Mapping the Components Across Infant Age Quarters. Indian J Community Med:10–4103. Zubler JM, Wiggins LD, Macias MM, Whitaker TM, Shaw JS, Squires JK, Pajek JA, Wolf RB, Slaughter KS, Broughton AS, Gerndt KL. Evidence-informed milestones for developmental surveillance tools. Pediatrics. 2022;149(3). Zubler J, Whitaker T. CDC’s Revised Developmental Milestone Checklists. Am Family Phys. 2022;106(4):370. Abercrombie J, Wiggins L, Green KK. CDC’s Learn the Signs. Act Early. developmental milestone resources to improve early identification of children with developmental delays, disorders, and disabilities. Zero three. 2022;43(1):5. Ben-Sasson A, Jacobs K, Ben-Sasson E. Early childhood tracking application: Correspondence between crowd-based developmental percentiles and clinical tools. Health Inf J. 2023;29(1):14604582231164695. Squires J, Bricker DD, Twombly E. Ages & stages questionnaires. Baltimore: Paul H. Brookes; 2009 Jan. p. 1. Velikonja T, Edbrooke-Childs J, Calderon A, Sleed M, Brown A, Deighton J. The psychometric properties of the Ages & Stages Questionnaires for ages 2‐2.5: a systematic review. Child Care Health Dev. 2017;43(1):1–7. Yazdi-Feyzabadi V, Nakhaee N, Mehrolhassani MH, Naghavi S, Homaie Rad E. Development and validation of a questionnaire to determine medical orders non-adherence: a sequential exploratory mixed-method study. BMC Health Serv Res. 2021;21(1):136. Joshi A, Kale S, Chandel S, Pal DK. Likert scale: Explored and explained. Br J Appl Sci Technol. 2015;7(4):396. Yardley L, Morrison L, Bradbury K, Muller I. (2015). The person-based approach to intervention development: Application to digital health-related behavior change interventions. J Med Internet Res, 17(1), e3. Damschroder LJ, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Sage; 2017. Palinkas LA, et al. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Mental Health Mental Health Serv Res. 2015;42(5):533–44. Centers for Disease Control and Prevention (CDC). (2022). Developmental monitoring and screening for health professionals. https://www.cdc.gov/ncbddd/childdevelopment/screening.html Squires J, Bricker D, Twombly E. Ages & Stages Questionnaires®, Third Edition (ASQ®-3): A Parent-Completed Child Monitoring System. Paul H. Brookes Publishing; 2009. Strecher VJ, et al. Tailored health messages: Customizing communication with computer technology. Lawrence Erlbaum Associates; 2008. Sices L. Developmental screening in primary care: The effectiveness of current practice and recommendations for improvement. The Commonwealth Fund; 2007. Miller JE et al. (2014). A usability framework for health information systems. eGEMs, 2(1), Article 6. Guralnick MJ. Why early intervention works: A systems perspective. Infants Young Child. 2011;24(1):6–28. Engle PL, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet. 2007;369(9557):229–42. Halfon N, et al. The changing landscape of disability in childhood. Future Child. 2009;19(1):13–42. Rowland AS, et al. Usability of developmental screening tools in community settings. J Early Intervention. 2019;41(3):187–200. Arora NK, et al. Health system response to child development needs in India. Indian Pediatr. 2022;59(8):643–50. Chavan BS, et al. Indian assessment and intervention models in child mental health. Indian J Psychiatry. 2018;60(Suppl 4):S216–21. McCormack L, Thomas V, Lewis MA, Rudd R. Improving low health literacy and patient engagement: A social ecological approach. Patient Educ Couns. 2010;75(3):285–91. Schillinger D, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90. Gupta A, Kaur R, Malhi P. Need for culturally appropriate developmental screening tools for young children in South Asia. Indian Pediatr. 2019;56(4):325–8. Blencowe H, Cousens S, Oestergaard MZ, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162–72. Bornstein MH. Cultural approaches to parenting. Parenting: Sci Pract. 2012;12(2–3):212–21. Kaul V, Bhattacharjea S, Chaudhary AB et al. (2022). Early childhood care and education in India: Reaching marginalized children. Young Lives Working Paper. Fernald LCH, Kariger P, Engle P, Raikes A. Examining Early Child Development in Low-Income Countries. World Bank; 2009. Rahman A, Divan G, Hamdani SU, et al. Effectiveness of the parent-mediated intervention for children with autism (PASS) in South Asia: a randomised controlled trial. Lancet Psychiatry. 2018;5(8):609–20. Kuppusamy B, Krishnaveni GV, Veena SR. Preterm Birth and Neurodevelopment in India: A Community Health Perspective. J Dev Pediatr. 2020;41(4):221–9. Sharma R, Seth R, Arora S. Strengthening Community-Based Early Intervention in India: Role of Primary Healthcare and Technology. Indian Pediatr. 2023;60(3):213–8. Graphs Graphs are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials.docx Graphs.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers invited by journal 12 Sep, 2025 Editor assigned by journal 10 Sep, 2025 Editor invited by journal 21 Aug, 2025 Submission checks completed at journal 20 Aug, 2025 First submitted to journal 20 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7264197","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":518092485,"identity":"17f7906e-cfdc-4e60-b970-a1f3d80553e1","order_by":0,"name":"Shrisruthi Suresh","email":"","orcid":"","institution":"SRM College of Physiotherapy, SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Shrisruthi","middleName":"","lastName":"Suresh","suffix":""},{"id":518092486,"identity":"61358d7c-965d-4c11-8d33-34ea5b3373fa","order_by":1,"name":"Vadivelan Kanniappan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3Ooa7CMBSA4aN6zZLaM8MzHNKkQSy5r7KGBMwEEoGYGoZkmre4CwY5sgTMCLY4EKAQ4CBZCB3Bwd3AIfqLpm365RTAZvvOKAVoES+3PjxWv54gueH9Mb1HoCQlfBzq3i+yJHP6KMRqufvbFAXwn4BgO60geaeXOTlKqbtSq4jAHR0IVP4/ccOAZuMIPakZ0yokIG2mqKiCxAdDruiJeM60XxD81hGOAaWnECVBxxBmpmAt2ffS4xwFakNUJBzMzU0VYbw9OfoDrxmbj63PRaPBh+1ke6kgTznlkn4AbDabzfaiG7G4UhjgYc6OAAAAAElFTkSuQmCC","orcid":"","institution":"SRM College of Physiotherapy, SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Vadivelan","middleName":"","lastName":"Kanniappan","suffix":""},{"id":518092487,"identity":"15548d94-04da-4193-a7df-dfdaf15e3715","order_by":2,"name":"Santhiya. 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18:49:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1403529,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7264197/v1/5e45caa2-5e4a-47a5-bd0f-c4e0174cff65.pdf"},{"id":91897133,"identity":"c89bba6a-cefe-442d-a97a-6375581fee32","added_by":"auto","created_at":"2025-09-22 18:33:51","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":283167,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-7264197/v1/65e96b1147ba5c8b41ccb213.docx"},{"id":91896868,"identity":"3301f136-d785-44f9-8473-5682f342a47c","added_by":"auto","created_at":"2025-09-22 18:25:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":158580,"visible":true,"origin":"","legend":"","description":"","filename":"Graphs.docx","url":"https://assets-eu.researchsquare.com/files/rs-7264197/v1/cc703df555bb704a04291e10.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eParent Perspectives on the Usability and Accessibility of the Cdc Milestone Checklist and Asq-3 Questionnaire in Monitoring Early Developmental Delays\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDevelopmental delays are characterized by significant lags in attaining age-appropriate milestones across one or more domains, including motor, language, cognitive, and social-emotional development, and are estimated to affect approximately 15–18% of children worldwide\u003csup\u003e1\u003c/sup\u003e. Early identification of these delays is crucial, as timely intervention improves developmental outcomes, particularly in enhancing social skills, functional independence, and long-term well-being \u003csup\u003e2\u003c/sup\u003e. While clinical assessments by therapists play a vital role, parents often serve as the first observers of developmental differences in daily life \u003csup\u003e3\u003c/sup\u003e. Their observations not only initiate the pathway to early detection but also sustain the continuity of care. Importantly, the dynamic triadic relationship between child, parent, and therapist becomes central to the intervention process\u003csup\u003e\u0026nbsp;4\u003c/sup\u003e. This collaborative structure fosters effective communication, strengthens caregiver confidence, and enhances therapeutic alignment. Recognizing the pivotal role of parents as both informants and partners in care highlights the need for tools that are accessible, culturally sensitive, and empowering—designed to guide them in tracking milestones, initiating early conversations, and engaging meaningfully in their child’s developmental journey \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAmong the tools available (As in Table 1) for monitoring developmental milestones, the CDC (Centers for Disease Control and Prevention) Milestone Checklist and the Ages and Stages Questionnaire, Third Edition (ASQ-3) are widely used \u003csup\u003e6\u003c/sup\u003e. These tools are particularly valuable in home or community settings, where access to clinician-administered tools (e.g., Bayley Scales, AIMS) and early detection by specialised healthcare professionals may be limited. Evidence-based developmental checklists are designed to empower parents, improve surveillance more practical and scalable in routine care \u003csup\u003e7\u003c/sup\u003e. In Tamil Nadu,\u0026nbsp;MCP cards (Mother and Child Protection card) have been provided to educate the parents with maternal and child services.\u003c/p\u003e\n\u003cp\u003eTable 1: List of Developmental tools and their administrators\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"666\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTool Name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministered By\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAges and Stages Questionnaire – 3 (ASQ-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParent-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCDC Developmental Checklist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParent-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDenver Developmental Screening Test II (DDST-II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist/Clinician-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTrivandrum Developmental Screening Chart (TDSC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBayley Scales of Infant Development III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist/Clinician-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlberta Infant Motor Scale (AIMS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTest of Infant Motor Profile (IMP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGeneral Movement Assessment (GMA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered (video-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHammersmith Neonatal Neurological Examination (HNNE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHammersmith Infant Neurological Examination (HINE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAmiel-Tison Neurological Assessment at Term (ANAT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eINFANIB (Infant Neurological International Battery)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGriffith Mental Development Scales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePeabody Developmental Motor Scales (PDMS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrazelton Neonatal Behavioral Assessment Scale (NBAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeurobehavioral Assessment of Preterm Infant (NAPI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelopmental Assessment Scale for Indian Infants (DASII)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBattelle Developmental Inventory (BDI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBoth (parent input + therapist test)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDevelopmental Assessment of Young Children (DAYC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBoth (parent interview + observation)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGesell Developmental Schedule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTherapist-administered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe CDC Milestone Checklist is a parent-administered tool designed to monitor child development using simple language, age-specific milestones, and a checklist format. The parent-friendly format of the CDC Developmental Milestone Checklist ensures simplicity without compromising depth—bullet points and tick boxes guide even non-medical users with ease\u003csup\u003e8,9\u003c/sup\u003e. Structured by age, from 2 months to 5 years, it offers a rhythm for tracking developmental milestones aligned with regular pediatric checkups. Covering four holistic domains social/emotional, communication, cognitive, and motor it paints a complete picture of a child’s early growth. Action-oriented prompts like “Don’t wait. Acting early can make a real difference” are designed to shift hesitation into empowered decision-making. Parents are not left uncertain; the tool integrates clear next-step cues, reflective questions, and direct access to early intervention resources\u003csup\u003e9\u003c/sup\u003e. Cultural sensitivity grounds the tone, using warm, familiar language that affirms caregiver intuition statements like “You know your baby best” and “Talk, read, and sing to your baby” guide interaction without medical jargon. Everyday moments like tummy time, peek-a-boo, and shared reading are reframed as integral to developmental stimulation. Finally, the CDC Milestone Tracker App offers digital support, promoting accessibility for tech-savvy caregivers and ensuring continuous engagement beyond clinic walls \u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe Ages and Stages Questionnaire–3 (ASQ-3) is a developmental screening tool designed to assess children from 1 month to 5½ years of age across five core developmental domains: communication, gross motor, fine motor, problem solving, and personal-social skills. Comprising 21 age-specific questionnaires, the ASQ-3 is structured to align with a child’s developmental stage, enabling accurate and age-appropriate assessment \u003csup\u003e11\u003c/sup\u003e. Its design emphasizes caregiver participation, allowing parents or primary caregivers to complete the questionnaire based on their daily interactions with the child, using a simple and intuitive response format “Yes,” “Sometimes,” or “Not yet.” The tool is intentionally accessible, requiring only a fourth-grade reading level, and includes visuals in certain versions to support comprehension and reduce literacy-related barriers. The Psychometric properties sensitivity ranging from 77% to 91% and specificity from 71% to 93% demonstrates reliability and validity across diverse populations and cultural contexts \u003csup\u003e12\u003c/sup\u003e. The ASQ-3 has been extensively translated, adapted, and validated for use in clinical, educational, and community-based settings globally. Importantly, it provides actionable follow-up guidance for caregivers when developmental concerns are identified, ensuring as a pathway to early intervention and support.\u003c/p\u003e\n\u003cp\u003eWhile the CDC Developmental Milestone Checklist and the ASQ-3 are established tools for early developmental monitoring. Despite this, their rich experiential knowledge gained through years of caregiving, observation, and interaction with health and education systems demonstrated a deep understanding of developmental progress and delays. This disconnect between formal tool exposure and real-world caregiving experience highlights the need to assess is quite higher. The accessibility is one such valid point that needs to be considered.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the user-centric perspective, Usability is more about how effectively and effortlessly users can operate the tool, which encompasses clarity, ease of completion, emotional tone, content relevance, contextual fit, and accessibility is about how broad that usability. The current study addresses this gap by involving such parents in a sequential comparison of the tools, acknowledging their deep familiarity with milestones despite limited formal exposure to structured checklists.\u003c/p\u003e\n\u003cp\u003eTo explore these perspectives, the study adopted a sequential exploratory mixed-methods design, unfolding across three phases. Both tools were assessed using variables like readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use to compare within-subjects. This methodological approach prioritized parent engagement with the tools in helping the health care provider effectively on the tools that function in practice.\u003c/p\u003e\n\u003cp\u003eMost importantly, our aim is not to compare the standard tool, but rather to analyses the parental experience on how parents interpret, relate, and act upon the tools when introduced within a caregiving context. This focus aligns with broader calls in developmental and family-centered research to foreground caregiver usability over clinician-led tool assessment.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a sequential exploratory mixed-methods design to investigate the usability and accessibility of two developmental screening tools: the CDC Milestone Checklist and the Ages and Stages Questionnaire, Third Edition (ASQ-3).\u003c/p\u003e\n\u003cp\u003eThe design unfolded in three phases: An initial quantitative phase using two independent groups, an in-depth qualitative phase to explore parental perceptions, and a follow-up quantitative phase using a within-subjects design to validate and triangulate the emergent themes\u003csup\u003e13\u003c/sup\u003e. This multi-phase approach enabled a comprehensive understanding of parent experiences by combining in-depth, contextual insights with broader generalizability through quantitative measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at SRM Medical College Hospital and Research Center, Kattankulathur, Tamil Nadu, India. In the initial phase, a quantitative study was carried out with 60 participants, comprising 30 in each group. This was followed by a qualitative study involving 16 participants. Subsequently, a larger quantitative phase was conducted with 84 participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParents of children diagnosed with developmental delays, within the age range of 2 months to 5 years, were included in the study. Eligibility criteria required that participating parents be able to read the English language to ensure readability of the tools. Additionally, only those parents who were available and willing to participate in both sessions were considered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria for the study included parents of typically developing children, parents who were unwilling to participate, and those who had previously undergone formal training in child development, in order to minimize potential bias in responses and ensure the authenticity of parental perspectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecruitment: Participants were recruited via paediatric clinics, early intervention programs, and online support groups for developmental delays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: ECR/8951/INST/TN/2013/RR-19), and conducted following the Declaration of Helsinki. \u0026nbsp;A written informed consent was obtained from all participants before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis mixed-methods study was conducted in three sequential phases to evaluate and compare the usability of two developmental screening tools—the CDC Milestone Checklist and ASQ-3—from the perspective of parents. The overall aim was to identify context-sensitive preferences, inform tool sequencing for practical use, and refine usability dimensions through a combination of quantitative and qualitative analyses.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eInitial Quantitative Phase (Independent Groups)\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe primary objective of this initial phase was to conduct a baseline comparison of tool usability across two independent participant groups (n = 60; 30 per group), in order to check for any preliminary differences in parental experience between the two tools. One group completed the CDC Milestone Checklist, while the other responded to the ASQ-3. Participants rated their experiences using Likert-scale items aligned with predetermined themes, including ease of use, readability, comprehension, tool relevance, and duration. This phase aimed to assess whether any significant differences in perceived usability existed prior to deeper investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo explore parental perceptions in greater depth, semi-structured interviews were conducted until data saturation was reached. This phase had two main objectives: (1) to determine which tool should be administered first in the follow-up quantitative phase, and (2) to refine and generate subcategories under each predetermined theme, capturing more nuanced aspects of tool usability. Open-ended questions probed participants’ experiences regarding ease of understanding, cultural relevance, barriers to use, and the influence of family or systemic factors on tool adoption. All interviews were audio-recorded, transcribed verbatim, and analysed thematically to develop rich, context-sensitive insights.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFollow-up Quantitative Phase (Single Group – Sequential Testing)\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eIn the final phase, a within-subject design was adopted to enable a direct comparison of parental experiences with both developmental screening tools. A total of 84 parents were recruited and sequentially administered both tools—first the CDC Milestone Checklist, followed by the ASQ-3—after a one-hour interval that coincided with their child’s routine therapy session. This time gap helped reduce immediate recall bias while maintaining contextual continuity.\u003c/p\u003e\n\u003cp\u003eParticipants rated each tool using Likert-scale items mapped to seven overarching themes and subcategories that had been developed during the qualitative phase. For instance, under the theme of \u003cem\u003eunderstanding ability\u003c/em\u003e, subcategories included: \u003cem\u003eeasy to understand\u003c/em\u003e, \u003cem\u003erequired 1–2 cues\u003c/em\u003e, \u003cem\u003erequired more than 5 clarifying questions\u003c/em\u003e, and \u003cem\u003ehard to understand\u0026nbsp;\u003c/em\u003e\u003csup\u003e14\u003c/sup\u003e. This sequential approach allowed for a nuanced, within-participant comparison of tool usability, enhancing insight into context-sensitive preferences and practical performance in real-world clinical settings.\u003c/p\u003e\n\u003cp\u003eOverall, the study was structured across three interconnected phases: an initial quantitative phase (independent groups), a qualitative phase (semi-structured interviews), and a follow-up quantitative phase (sequential testing within a single group). The progression from baseline comparison to in-depth exploration and finally to refined testing ensured a comprehensive understanding of tool usability. Findings from the initial quantitative phase informed the development of the qualitative interview guide, while insights from the qualitative analysis directly shaped the subcategories used in the final phase. This integrative approach strengthened the study’s ability to capture context-sensitive perceptions and guide practical tool implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Guide (Qualitative)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA semi-structured guide was used to elicit detailed parental reflections on tool usability. Sample questions included:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“How easy was it for you to understand the instructions on the CDC Milestone checklist?”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Were there any aspects of the ASQ-3 that felt confusing or difficult to complete?”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Did either of the tools help you identify concerns about your child’s development?”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS software version 21 (IBM SPSS Statistics, Armonk, NY) and figures were made using GraphPad Prism version 10.1 (GraphPad Software Inc., La Jolla, CA). Descriptive statistics (mean and standard deviation (SD)) were calculated. Non-parametric Mann-Whitney U for independent groups and Wilcoxon signed rank test for paired variables, with a predetermined alpha level of 0.05, were done to check the statistically significant difference present between the quantitative variables. \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch4\u003e\u003cstrong\u003eInitial Quantitative Phase (Independent Groups)\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eA total of 60 parents participated in the initial quantitative phase, with 30 parents using the CDC Developmental Checklist and 30 using the ASQ-3. Table 2 presents the demographic details of the participants.\u003c/p\u003e\n\u003cp\u003eTABLE 2: Demographic Variables (Initial Quantitative)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"634\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 252px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(N = 30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(mean \u0026plusmn; SD or n (%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASQ-3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(N = 30)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(mean \u0026plusmn; SD or n (%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 252px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMothers Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e28.0\u0026nbsp;3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e27.73\u0026nbsp;3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimi\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e53.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMulti\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e46.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreterm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e46.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e46.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e53.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e53.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh School\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e3.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e6.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGraduate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e96.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e93.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants rated the tools on seven dimensions: Readability, Understanding ability, Content Correlation, Level of participation, Familiarity of the tool, Curiosity of participation, and Duration of participation. Descriptive statistics revealed similar mean scores across both groups. Inferential analysis (Mann-Whitney U) showed no statistically significant differences between the two tools on any of the variables (p \u0026lt; 0.05) [Table in supplementary section]. These findings indicated that at the group level, parents perceived both tools similarly in terms of usability and accessibility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Exploration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 17 parents of children with developmental delays participated in the qualitative phase. Participants were selected purposively to ensure diversity in educational and caregiving backgrounds. Thematic saturation was reached within this sample, as no new themes emerged in the final interviews, supporting the adequacy of the sample size for in-depth thematic analysis.\u003c/p\u003e\n\u003cp\u003eSemi-structured interviews were conducted with 17 parents of children with developmental delays. All participants had exposure to both the CDC and ASQ-3 tools in monitoring the child development.\u003c/p\u003e\n\u003cp\u003eSeveral barriers emerged from the parental narratives regarding the use of developmental screening tools such as the CDC checklist and ASQ-3 questionnaire. Awareness was limited, with many parents reporting delayed recognition of developmental concerns, a strong reliance on the MCP (Mother and Child Protection) card alone, and confusion in monitoring development. The ease of reading a tool is known to be readability. \u0026nbsp;Likewise, the parents found it difficult to understand (understanding ability) and relate checklist items in their daily routines, which reduced their confidence in completing the tools accurately. Comprehensibility was also limited, with many parents unclear about the checklist\u0026apos;s purpose and expressing a need for clearer instructions or professional guidance. In terms of usability, the tools were often perceived as overly clinical or intended for professionals, with complex formats that felt overwhelming for non-specialists. Accessibility was another concern, as the checklists were typically available only in English and not well integrated into routine pediatric or community health services. Finally, sociocultural barriers such as reliance on advice from elders, financial and caregiving stress, and the stigma associated with developmental delays further impacted parents\u0026apos; willingness and ability to engage with these tools effectively.\u003c/p\u003e\n\u003cp\u003eA thematic analysis approach was used. Interview transcripts were coded inductively to extract recurring ideas and concepts. Seven core themes emerged and were refined into sub-themes, capturing barriers, emotional responses, and practical challenges faced by parents while using the tools.\u003c/p\u003e\n\u003cp\u003eTable 3: \u003cstrong\u003eThemes and Subthemes\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"660\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative Inputs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClustered Themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLack of awareness about the CDC/ASQ-3 tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eInitial Awareness \u0026amp; Discovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eExposure \u0026amp; Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLate discovery and regret\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eOver-reliance on the Mother and Child Protection (MCP) card\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eMisconception that doctors alone monitor development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eSearch for parenting info without exposure to screening tools\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eSurprise at the existence of structured screening tools\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eUnfamiliar and technical terms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLanguage \u0026amp; Familiarity of terms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eNeed for simpler or familiar language\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eTerms not commonly used in the Indian context (eg: \u0026ldquo;cruising, gesture\u0026rdquo;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eDifficulty relating questions to real-life contexts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eUnderstanding the questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive Processing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eQuestions felt abstract or culturally irrelevant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLack of examples for better interpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eDifficulty understanding purpose or how to fill\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eTool comprehension \u0026amp; Navigation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eNeeded guidance to interpret items\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eEducational level did not ensure comprehension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eOverwhelming structure or length\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eEase of use \u0026amp; format barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractical barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eDifficulties with scoring and response formats\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eLack of visual or step-by- step instruction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003ePerceived as a professional tool than a parent- friendly one\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eInfluence of family members discourages early concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eSociocultural \u0026amp; Family Dynamics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContextual Influences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eDelay due to \u0026ldquo;wait and watch\u0026rdquo; advice from elders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eFinancial stress or social neglect affecting engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Following Qualitative analysis, the emerged themes were extended to compare quantitative categories to check the usability and accessibility in the subsequent phase. Table 3 shows the cross matrix of alignment between the qualitative and quantitative, while protecting the complex nature of user-centric inputs. Table 4 shows the Qualitative-Quantitative theme cross matrix, which aligns together respectively and it\u0026rsquo;s classified into Strong and partial alignment.\u003c/p\u003e\n\u003cp\u003eTable 4: Qualitative-Quantitative themes cross matrix\u003c/p\u003e\n\u003cp\u003e(\u003cstrong\u003eStrong Alignment\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;/ Partial Alignment (\u003c/strong\u003e\u003cstrong\u003e✓\u003c/strong\u003e\u003cstrong\u003e))\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReadability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderstanding Ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent Correlation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCuriosity of Participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamiliarity of Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial Awareness \u0026amp; Discovery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLanguage \u0026amp; Familiarity of words\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderstanding the Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTool Comprehension \u0026amp; Navigation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEase of Use \u0026amp; Format barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccess \u0026amp; Availability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociocultural \u0026amp; Family Barriers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e(✓)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eFollow-up Quantitative Phase (Single Group \u0026ndash; Sequential Testing)\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eTo validate the qualitative themes and further investigate parental preferences, 84 parents (Table 5) were given both tools in sequence (CDC first, followed by ASQ-3 after a 1-hour gap).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Demographic variables (Quantitative - Sequential testing)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 433px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDC \u0026amp; ASQ-3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(N = 84)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(mean \u0026plusmn; SD or n (%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 433px;\"\u003e\n \u003cp\u003e27.29\u0026plusmn;2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003ePrimi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eMulti\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003ePreterm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e46.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eFull term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e53.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eGraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e97.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 6 presents the reports of Wilcoxon signed rank test. Significant differences were noted between four sub categories namely understanding, content correlation, Level of participation and Familiarity of questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 6: Quantitative Sequential testing- Wilcoxon signed rank test\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"698\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eCDC vs ASQ-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eReading skill\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUnderstanding ability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eContent correlation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eLevel of participation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCuriosity of participation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eFamiliarity of questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eDuration of Participation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eZ- value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e-3.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-4.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e-4.287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-3.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-4.683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-1.561\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ep-values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026lt;0.005**,p\u0026lt;0.05*\u003c/p\u003e\n\u003cp\u003eFurther, the Wilcoxon signed rank test was carried out among the subcategories after binary coding, such as the subcategory of understanding ability - Need more than 5 cues - was tested for the presence of significant difference between CDC and ASQ-3. The results of these subcategory statistics were projected as stars and ns in Bar graphs (1 - 6), with * representing p \u0026lt; 0.05; ** representing p \u0026lt; 0.005; *** representing p\u0026lt;0.0005; and ns non non-significant.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eBar Graph 1: Understanding Ability\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis bar graph illustrates the distribution of parental understanding ability, during the sequential administration of tools, subcategorized into four response groups: \u0026ldquo;\u003cem\u003eEasy to understand\u0026rdquo;, \u0026ldquo;less than 5 cues received,\u0026rdquo; \u0026ldquo;More than 5 cues received,\u0026rdquo; and \u0026ldquo;Hard to understand.\u0026rdquo;\u003c/em\u003e\u0026nbsp; The majority of participants required more than 5 cues or felt that both the tools were hard. In the understanding ability sub category, statistically significant differences were observed for Option 2 (\u003cem\u003eZ = -3.000, p = 0.003\u003c/em\u003e) and Option 4 (\u003cem\u003eZ = -2.897, p = 0.004\u003c/em\u003e), indicating the carry over effect in sequential administration of two tools.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eBar Graph 2: Familiarity of Screening Tool Questions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eBar graph 2 (in additional material) represents the familiarity of questions CDC and ASQ-3 tools where five options were given to the parents, where parents rated ASQ-3 have been more familiar than CDC, with the significant differences noted in sub categories like \u003cem\u003eunfamiliar\u003c/em\u003e (z=-4.243,p\u0026lt;0.001) and \u003cem\u003every familiar\u003c/em\u003e (Z=-4.123, p\u0026lt;0.001). No differences were observed in the other subcategories. This might reflect the sequential administration trend, where contents related to development milestones might overlap. ( as shown in supplementary material.10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBar Graph 3: Comparison of parental level of Participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis bar graph (in additional material) depicts the level of parental participation subcategorized into five levels: \u003cem\u003eCompletely Dependent\u003c/em\u003e, \u003cem\u003eMaximum Dependency\u003c/em\u003e, \u003cem\u003eModerate Dependency\u003c/em\u003e, \u003cem\u003eMinimal Dependency\u003c/em\u003e, and \u003cem\u003eCompletely Independent\u003c/em\u003e. The findings show the characteristic of sequential administration, with the majority dependency in completing the CDC was gradually reduced during ASQ-3 completion, reflecting the carryover effect of learning.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eBar Graph 4: Comparison of Content Correlation\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis bar graph (in additional material) illustrates the participants\u0026rsquo; perceptions of content correlation in the CDC and ASQ-3 developmental screening tools. 53.5 % of participants reported that the ASQ-3 was \u003cem\u003eHard to understand\u003c/em\u003e, whereas the CDC tool, although requiring cues for interpretation, was perceived as comparatively clearer. Both tools showed minimal differences in the number of participants who required \u003cem\u003eMore than 5 Cues\u003c/em\u003e to understand the content, indicating that while the CDC was relatively more accessible, neither tool was entirely self-explanatory for all users.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eBar Graph 5: Comparison of Curiosity of Participation\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis bar graph (in additional material) compares the levels of curiosity. Significant differences were observed in slightly curious (\u003cem\u003eZ = -3.317, p = 0.001\u003c/em\u003e), very curious (\u003cem\u003eZ = -3.042, p = 0.002\u003c/em\u003e), and extremely curious (\u003cem\u003eZ = -3.742, p \u0026lt; 0.001\u003c/em\u003e), indicating higher interest and engagement with ASQ-3 items. This suggests that ASQ-3 may encourage more active parental involvement despite being more complex.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eBar Graph 6: Comparison of Duration of Participation\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis bar graph (in additional material) depicts the time taken by participants to complete each tool is between 15 to 20 minutes or more than 20 minutes.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDemographic Influence in Scoring\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eFour demographic variables showed statistically significant influence across the tool dimensions. The Mann-Whitney U test revealed significant differences between preterm and full-term mothers. Preterm mothers demonstrated higher scores (66.6 %) in ASQ-3 Understanding Ability (U = 669.000, Z = -2.124, p = 0.034) included in (suppl.8) , likewise 51.3 % of multi gradiva parents have reported indicating deeper familiarity with its relatively complex items\u0026mdash;likely due to repeated prior exposure and learning through sustained engagement with developmental milestone tools,. In contrast, full-term mothers scored significantly higher in CDC Level of Participation (U = 611.500, Z = -2.560, p = 0.010) (as shown in supplementary material.6) and Curiosity of Participation (U = 589.500, Z = -2.730, p = 0.006) (as shown in supplementary material. 7), suggesting reflecting more active involvement and exploratory interest. The lower scores in these areas among preterm mothers may reflect participation fatigue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, a significant difference in CDC Familiarity was observed between primigravida and multigravida mothers. Multigravida mothers (mean rank = 49.88) scored significantly higher than primigravida mothers (mean rank = 36.69), U = 596.50, Z = -2.64, p = 0.008, indicating greater awareness and understanding of the CDC checklist content. [The Bar charts of sub-category demographic influence were included in the\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSupplementary. 7,8,9,10]\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to evaluate and compare the usability and accessibility of the CDC Milestone Checklist and the ASQ-3 questionnaire among parents using a sequential exploratory mixed-methods design. Across three stages—independent-group quantitative baseline comparison, qualitative thematic exploration, and sequential-testing quantitative follow-up—the methodology focuses on user-centric design, A design based on Parent perspectives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Need for Three-Stage Exploration in User-Centric Studies:\u003c/p\u003e\n\u003cp\u003eThis study adopted a three-stage design to ensure a genuinely user-centric exploration, a practice increasingly recommended in the development and validation of health tools across diverse populations\u003csup\u003e15,16\u003c/sup\u003e. Initially, quantitative data were gathered from two independent groups using pre-assumed themes derived from existing literature. However, when actual tool users, the parents, were engaged through open-ended qualitative interviews, a set of complex and entangled codes emerged. Based on these user-generated insights, categories for the final quantitative phase were confirmed, reflecting the value of \u003cem\u003eembedded mixed-method designs\u003c/em\u003e in improving contextual fit\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe initial quantitative phase also served a dual purpose: it enabled a check for baseline evenness between groups. Interestingly, both groups perceived the CDC and ASQ-3 tools similarly, with no statistically significant differences — a unique feature of this study. Even if baseline disparities had been detected, they would have been preserved and treated as interpretive variables rather than exclusions, in alignment with inclusive research practices\u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eUltimately, this stepwise and iterative design led to the emergence of user-derived complex themes inclusiveness (Table 3) — a critical shift in contexts where local cultural, linguistic, and geographic evidence is limited. By foregrounding user narratives, this study contributes novel, locally grounded insights from the English-speaking Tamil population, establishing a foundation for future work with exclusively Tamil-speaking communities and other linguistically diverse populations in India.\u003c/p\u003e\n\u003cp\u003ePossible Reasons for Baseline Evenness in the First-Stage Quantitative Analysis\u003c/p\u003e\n\u003cp\u003eThe baseline evenness observed in the initial quantitative analysis — where independent participant groups showed no significant difference in perceiving the CDC and ASQ-3 tools — may be attributed to a convergence of demographic and contextual factors. 97.6% participants held graduate-level educational qualifications, which likely enhanced their capacity and willingness to engage with structured tools, even without prior exposure. Additionally, the study’s inclusion criteria limited participation to English-speaking members of the Tamil community — a segment better positioned to comprehend the tools, as both the CDC Milestone Checklist and ASQ-3 were designed originally in English\u003csup\u003e19,20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn the absence of a comparator or alternative developmental screening approach, participants may have focused solely on the internal structure, clarity, and purpose of the tools, reducing the likelihood of contrast-driven bias. This may have contributed to uniform perceptions and responses across both groups.\u003c/p\u003e\n\u003cp\u003eSecond stage Clustered Themes Aligned with Usability and Accessibility\u003c/p\u003e\n\u003cp\u003eIn terms of usability, the exposure \u0026amp; engagement cluster reflects how inviting, discoverable, and intuitive the tools appear, directly influencing whether parents choose to engage with them — a factor also emphasized in user-interface design principles for health tools\u003csup\u003e21\u003c/sup\u003e. Cognitive Processing captures the depth of parental comprehension, the clarity of questions, and how well the items align with parents’ everyday understanding of child development — resonating with evidence that user comprehension is central to successful tool implementation\u003csup\u003e22\u003c/sup\u003e. Practical Barriers encompass challenges related to design limitations, instructional format, scoring structure, and overall user-friendliness — all of which influence the ease of tool completion and align with broader usability constraints seen in public health interventions\u003csup\u003e23,24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eRelating to accessibility, Practical Barriers also include systemic limitations such as language availability and the absence of integration into existing healthcare or Anganwadi routines ( where MCP cards are majorly used)— similar to challenges highlighted in low- and middle-income settings\u003csup\u003e25\u003c/sup\u003e. Contextual Influences bring attention to sociocultural beliefs, family dynamics, and financial stressors that shape a parent’s ability or willingness to use the tools. Additionally, Exposure \u0026amp; Engagement sheds light on disparities in information dissemination, pointing to unequal access to knowledge about developmental screening — a key equity concern in early intervention systems\u003csup\u003e26\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTogether, the qualitative insights were organized into four functional clusters — Exposure \u0026amp; Engagement, Cognitive Processing, Practical Barriers, and Contextual Influences — each representing intertwined aspects of usability and accessibility as experienced by parents during their interaction with both the CDC Milestone Checklist and ASQ-3 Questionnaire.\u003c/p\u003e\n\u003cp\u003eQuantitative Categories: Usability and Accessibility Alignment\u003c/p\u003e\n\u003cp\u003eIn the third stage of analysis, seven core quantitative variables were identified—readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use—as key dimensions to assess the usability and accessibility of developmental screening tools from a parent-centered lens. These dimensions were not arbitrarily chosen but derived from predetermined themes in Stage One and refined through thematic analysis in Stage Two. This cross-matrix alignment reinforces the ecological validity of the instrument framework, as each quantitative variable resonates with lived parental experiences and perceptions.\u003c/p\u003e\n\u003cp\u003eEach variable contributes uniquely: readability ensures the tool is linguistically approachable, understanding relates to conceptual clarity, familiarity reflects prior exposure or alignment with known practices, content correlation checks if the tool connects with real-life child development cues, curiosity measures emotional engagement, participation level assesses the parent’s willingness to act, and duration of use speaks to tool sustainability. Together, they form a comprehensive structure that captures both the functional ease and relational depth of how parents engage with screening tools.\u003c/p\u003e\n\u003cp\u003eThe inclusion of curiosity and participation level as measurable categories also introduces a dynamic component into what is often a static usability framework, acknowledging parents as active participants in the child development process rather than passive respondents\u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHowever, even with comprehensive coverage, the possibility remains that certain localised usability nuances—specific to linguistic, regional, or literacy contexts—might not have been captured. This insight further advocates for adaptive, user-centered tool development, wherein future screening models incorporate iterative feedback loops and modular content design to suit diverse Indian sub-populations\u003csup\u003e28,29\u003c/sup\u003e. Such an approach enables a mid-ground space—a collaborative interface—where parents feel empowered to engage with healthcare professionals, enhancing both developmental surveillance and caregiver confidence in supporting their child’s early health trajectory.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eInterpretations from Third-Stage Sequential Tool Testing: A Summary\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnanimously, all 84 participants reported that both the CDC Milestone Checklist and ASQ-3 Questionnaire were easy to read. However, when it came to understanding, none of the parents found both tools equally easy to comprehend. The CDC Checklist demonstrated greater ease of comprehension, with more parents reporting that they received over five meaningful developmental cues from it. In contrast, the ASQ-3 was more frequently marked as difficult to understand, highlighting a significant gap in creating user-friendly, self-explanatory tools — a challenge echoed in other usability research on developmental assessments. This finding underscores the critical need for user-centered tool design that accommodates varying literacy and health comprehension levels\u003csup\u003e30,31\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eRegarding tool familiarity, 39 % of participants reported the first-administered CDC Checklist as unfamiliar. However, none expressed unfamiliarity with the second-administered ASQ-3, indicating a carry-over learning effect between the two tools, consistent with principles of adult learning and task adaptation. Additionally, nearly equal proportions of participants rated both tools as \"somewhat familiar\" or \"familiar.\" Notably, about 20% identified the second tool (ASQ-3) as very familiar, while none did so for the CDC Checklist, highlighting the need for content overlap analysis and redundancy mapping in future tool development. Such mapping should be informed by local experts who understand both contextual social environments and users’ capabilities in applying developmental tools\u003csup\u003e32\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eParticipation patterns further reflect adaptive learning capacities. Only 1.2 % of parents reported complete dependency while using the CDC Checklist, and a similar 2.4 % reported complete independence when using ASQ-3 — a dynamic suggesting progressive parental engagement and tool learning through sequential exposure. Most participants shifted from being maximally dependent on the CDC to moderately or minimally dependent with the ASQ-3. (Mezirow, 1997; Carpentieri et al., 2019). With rising global projections of developmental delay due to factors like increased preterm birth rates and socio-environmental stressors\u003csup\u003e33\u003c/sup\u003e, the demand for culturally sensitive, literacy-appropriate, and locally relevant screening tools is both urgent and foundational to early childhood care efforts.\u003c/p\u003e\n\u003cp\u003eA key interpretive insight emerged from content correlation, which refers to the perceived relevance between tool items and the child’s actual development. Interestingly, none of the participants found either tool to be “easy” in terms of content correlation. For the CDC checklist, responses were almost equally distributed between “less than 5 cues,” “more than 5 cues,” and “hard to complete,” indicating a relatively balanced interpretation spectrum. However, in the case of the ASQ-3, 53.5 % of participants marked it as “hard,” while 39.2 % needed more than 5 cues, and 7.1 % found it required fewer cues to complete. This sharp contrast suggests that despite being administered after the CDC, many still found the ASQ-3 content difficult to understand. These results were also echoed in earlier qualitative feedback, which justified our decision to administer the CDC checklist first in the sequential study design. This again emphasizes the importance of culturally grounded tools\u003csup\u003e34\u003c/sup\u003e, especially for linguistically and contextually diverse populations such as Tamil-speaking Indian communities. Tool comprehension and perceived relevance are not merely about translation but about cultural congruence, educational suitability, and developmental literacy\u003csup\u003e35\u003c/sup\u003e. Thus, these findings call for the development of new tools that are both contextually relevant and developed through local expert participation, incorporating content that reflects the developmental red flags meaningful to the local caregivers.\u003c/p\u003e\n\u003cp\u003eWith respect to curiosity of participation, the CDC checklist evoked a wide range of responses, from “slightly curious” to “extremely curious.” On the other hand, responses for the ASQ-3 were clustered, with 65.5% of participants selecting “very curious,” and the rest marking “moderately curious.” This narrowing suggests that the ASQ-3 may have content richness or complexity that piqued participant attention, even if not fully understood. While this higher curiosity might stem from its structured design and diverse items, it does not necessarily equate to better usability. Instead, this again reinforces the need to map both tools—CDC and ASQ-3—at macro and micro levels to identify unique components worth preserving or adapting in future tool development\u003csup\u003e36\u003c/sup\u003e. These insights must inform the design of a hybrid, user-centric tool that balances curiosity, usability, and content relevance.\u003c/p\u003e\n\u003cp\u003eFinally, regarding duration of participation, most participants reported that both tools took between 15–20 minutes or more than 20 minutes, raising critical concerns about the feasibility of using standalone tools like checklists or questionnaires for periodic developmental screening. In an era where digital referencing and modular tools are increasingly viable, the future lies in designing adaptable, age-specific, and literacy-sensitive tools that parents can refer to frequently, rather than just once\u003csup\u003e37\u003c/sup\u003e. Given the high levels of curiosity and the demonstrated willingness to engage, the design of future tools should capitalize on this engagement potential while addressing the gaps in comprehension and content correlation. A modular, culturally responsive design—with simplified language, frequent prompts, and intuitive feedback—may prove to be more effective for both immediate use and long-term caregiver learning.\u003c/p\u003e\n\u003cp\u003eInfluence of Demographic Factors on Scoring Patterns\u003c/p\u003e\n\u003cp\u003eDifferences in parental status and birth history significantly influenced the way participants engaged with and scored the developmental screening tools. For instance, primiparous (first-time) and multiparous (having more than one child) mothers exhibited variations in the familiarity-based scoring component of the CDC Milestone Checklist. Mothers with previous child-rearing experience were more confident in interpreting milestones, leading to more decisive scoring, whereas first-time mothers were more tentative or uncertain, reflecting their lesser exposure to developmental norms.\u003c/p\u003e\n\u003cp\u003eAdditionally, birth term status played a notable role. Parents of preterm infants often expressed heightened vigilance or concern when using the CDC tool, influencing both the overall milestone level and their curiosity toward developmental information. In the ASQ-3, this demographic showed more variation in the understanding and interpretation of questions, particularly where developmental norms may not align with corrected gestational age. These insights affirm that demographic context—parity and preterm/full-term history—can shape both confidence and comprehension in developmental screening\u003csup\u003e38\u003c/sup\u003e. Such findings point to the necessity for a new tool design that embeds these contextual influences structurally. A potential future tool should integrate parent-healthcare professional interaction features, particularly for parents of preterm infants, and align with community-level care ecosystems. Embedding supportive touchpoints like referral pathways, caregiver guidance, and infant care support groups would enhance usability and emotional preparedness. A digitally enhanced tool, when coupled with India's extensive grassroots healthcare network—including Anganwadi workers, ASHAs, and PHCs—could enable scalable, supportive early intervention across diverse settings\u003csup\u003e\u0026nbsp;39\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThis study evaluated and compared the usability and accessibility of the CDC Milestone Checklist and the ASQ-3 questionnaire among parents using a sequential exploratory mixed-methods design. The three-stage approach—quantitative baseline comparison, qualitative thematic exploration, and sequential quantitative follow-up—ensured a genuinely user-centric design based on parent perspectives. Baseline analysis revealed no statistically significant differences between groups, likely reflecting the sample’s high educational attainment (97.6% graduates) and English fluency. These factors may have enabled participants to engage more confidently with both tools, even without prior exposure.\u003c/p\u003e\n\u003cp\u003eThe qualitative stage revealed four functional clusters—Exposure \u0026amp; Engagement, Cognitive Processing, Practical Barriers, and Contextual Influences—that shaped how parents experienced both tools. Exposure \u0026amp; Engagement highlighted that tool presentation influences willingness to use developmental screening instruments. Cognitive Processing emphasized the importance of clear, relatable questions for deeper parental understanding, while Practical Barriers captured design challenges and systemic constraints such as English-only availability and lack of integration into Anganwadi and primary healthcare settings. Contextual Influences, including sociocultural norms, family dynamics, and financial stress, further determined tool acceptability and completion.\u003c/p\u003e\n\u003cp\u003eThe final quantitative stage validated seven measurable variables—readability, understanding, familiarity, content correlation, curiosity, level of participation, and duration of use—that aligned closely with the qualitative themes. All parents (100%) reported both tools were easy to read, yet comprehension varied markedly. The CDC Checklist was easier to understand, with 65.5% of parents deriving more than five meaningful developmental cues from it. By contrast, the ASQ-3 was perceived as more difficult, with 53.5% finding it hard to understand and 39.2% requiring more than five cues to complete. Content correlation showed similar gaps: responses for the CDC Checklist were evenly distributed across “less than five cues,” “more than five cues,” and “hard to complete,” while 53.5% found the ASQ-3 “hard” overall.\u003c/p\u003e\n\u003cp\u003ePatterns of familiarity and curiosity further differentiated the two tools. 39% of parents reported the CDC Checklist as unfamiliar when administered first, yet none expressed unfamiliarity with the second-administered ASQ-3, suggesting a carry-over learning effect. The ASQ-3 also evoked higher curiosity, with 65.5% marking themselves as “very curious,” compared to more variable curiosity levels for the CDC Checklist. Participation patterns reflected progressive engagement, with only 1.2% fully dependent when using the CDC Checklist and 2.4% fully independent when using the ASQ-3. However, both tools required significant time commitments, with 62% of parents spending 15–20 minutes and 26% spending more than 20 minutes, raising concerns about feasibility for routine use.\u003c/p\u003e\n\u003cp\u003eDemographic factors significantly influenced parental engagement. Multiparous mothers demonstrated greater familiarity and confidence when using both tools, whereas first-time mothers (46.7%) were more tentative. Birth term status also played a role: parents of preterm infants (46.7%) expressed heightened vigilance and sometimes greater difficulty interpreting milestones, while those with full-term infants (53.3%) appeared more comfortable. These findings underscore the need for developmental screening tools that account for parental experience and infant birth history, particularly in populations with high rates of preterm birth.\u003c/p\u003e\n\u003cp\u003eThe study highlights the importance of culturally grounded, literacy-sensitive, and contextually relevant developmental screening tools. While the CDC Checklist demonstrated better comprehension and content relevance, the ASQ-3 engaged parents through a structured design and higher curiosity. Future tool development should leverage the strengths of both instruments, combining clarity and intuitive structure in modular, language-appropriate formats. Such a hybrid tool, designed through iterative parent feedback, would enhance usability, address literacy and cultural barriers, and align with India’s community healthcare networks (Anganwadi, ASHA, and PHCs). Embedding referral pathways and support touchpoints, particularly for parents of preterm infants and first-time mothers, would further improve caregiver confidence and participation in early developmental surveillance.\u003c/p\u003e"},{"header":"Conclusions and Recommendations","content":"\u003cp\u003eThis study highlights the need for developmental milestone monitoring, culturally contextual, and user-friendly screening tools tailored to the Indian population, particularly in semi-rural and rural regions. The CDC Milestone Checklist and ASQ-3 questionnaire offer foundational structures. These insights collectively cluster into a strong rationale for new tool development\u0026mdash;one that integrates the simplicity of milestone checklists with the depth of structured assessments, while addressing cultural norms, linguistic access, and health system interfaces. Future innovations in this space must prioritize caregiver comfort, reduce cognitive burden, and foster early, sustained engagement with child developmental surveillance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenters for Disease Control (Milestone checklist)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e3-Ages and Stages Questionnaire (Edition 3)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMother and Child Protection card\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIEC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInstitutional Ethical Committee\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Ethics Committee (IEC) of SRM Medical College Hospital and Research Centre (Approval No: ECR/8951/INST/TN/2013/RR-19), and conducted following the Declaration of Helsinki. \u0026nbsp;A written informed consent was obtained from all participants before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e: Clinical Trial number is not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe Author declares no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no funding for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eAll authors have contributed, read, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the parents who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZablotsky B, Black LI, Maenner MJ, Schieve LA, Danielson ML, Bitsko RH, Blumberg SJ, Kogan MD, Boyle CA. Prevalence and trends of developmental disabilities among children in the United States: 2009\u0026ndash;2017. Pediatrics. 2019;144(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOberklaid F, Baird G, Blair M, Melhuish E, Hall D. Children's health and development: approaches to early identification and intervention. Arch Dis Child. 2013;98(12):1008\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHead LS, Abbeduto L. Recognizing the role of parents in developmental outcomes: A systems approach to evaluating the child with developmental disabilities. Ment Retard Dev Disabil Res Rev. 2007;13(4):293\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchleider JL, Weisz JR. Family process and youth internalizing problems: A triadic model of etiology and intervention. Dev Psychopathol. 2017;29(1):273\u0026ndash;301.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKing G, Desmarais C, Lindsay S, Pi\u0026eacute;rart G, T\u0026eacute;treault S. The roles of effective communication and client engagement in delivering culturally sensitive care to immigrant parents of children with disabilities. Disabil Rehabil. 2015;37(15):1372\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanniappan V, Muthiah M, Abishek JR, Shrisruthi S, Chinnasami B, Sethuraman S, Muthuperumal P, Manoharan MB, Raja D, Selavaraj S. A Systematic Review of Neurodevelopmental Tools for Preterm Infants During Infancy: Mapping the Components Across Infant Age Quarters. Indian J Community Med:10\u0026ndash;4103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZubler JM, Wiggins LD, Macias MM, Whitaker TM, Shaw JS, Squires JK, Pajek JA, Wolf RB, Slaughter KS, Broughton AS, Gerndt KL. Evidence-informed milestones for developmental surveillance tools. Pediatrics. 2022;149(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZubler J, Whitaker T. CDC\u0026rsquo;s Revised Developmental Milestone Checklists. Am Family Phys. 2022;106(4):370.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbercrombie J, Wiggins L, Green KK. CDC\u0026rsquo;s Learn the Signs. Act Early. developmental milestone resources to improve early identification of children with developmental delays, disorders, and disabilities. Zero three. 2022;43(1):5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBen-Sasson A, Jacobs K, Ben-Sasson E. Early childhood tracking application: Correspondence between crowd-based developmental percentiles and clinical tools. Health Inf J. 2023;29(1):14604582231164695.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSquires J, Bricker DD, Twombly E. Ages \u0026amp; stages questionnaires. Baltimore: Paul H. Brookes; 2009 Jan. p. 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVelikonja T, Edbrooke-Childs J, Calderon A, Sleed M, Brown A, Deighton J. The psychometric properties of the Ages \u0026amp; Stages Questionnaires for ages 2‐2.5: a systematic review. Child Care Health Dev. 2017;43(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYazdi-Feyzabadi V, Nakhaee N, Mehrolhassani MH, Naghavi S, Homaie Rad E. Development and validation of a questionnaire to determine medical orders non-adherence: a sequential exploratory mixed-method study. BMC Health Serv Res. 2021;21(1):136.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoshi A, Kale S, Chandel S, Pal DK. Likert scale: Explored and explained. Br J Appl Sci Technol. 2015;7(4):396.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYardley L, Morrison L, Bradbury K, Muller I. (2015). The person-based approach to intervention development: Application to digital health-related behavior change interventions. J Med Internet Res, 17(1), e3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDamschroder LJ, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Sage; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalinkas LA, et al. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Mental Health Mental Health Serv Res. 2015;42(5):533\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention (CDC). (2022). \u003cem\u003eDevelopmental monitoring and screening for health professionals.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/ncbddd/childdevelopment/screening.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/ncbddd/childdevelopment/screening.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSquires J, Bricker D, Twombly E. Ages \u0026amp; Stages Questionnaires\u0026reg;, Third Edition (ASQ\u0026reg;-3): A Parent-Completed Child Monitoring System. Paul H. Brookes Publishing; 2009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStrecher VJ, et al. Tailored health messages: Customizing communication with computer technology. Lawrence Erlbaum Associates; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSices L. Developmental screening in primary care: The effectiveness of current practice and recommendations for improvement. The Commonwealth Fund; 2007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiller JE et al. (2014). A usability framework for health information systems. eGEMs, 2(1), Article 6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuralnick MJ. Why early intervention works: A systems perspective. Infants Young Child. 2011;24(1):6\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEngle PL, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet. 2007;369(9557):229\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHalfon N, et al. The changing landscape of disability in childhood. Future Child. 2009;19(1):13\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRowland AS, et al. Usability of developmental screening tools in community settings. J Early Intervention. 2019;41(3):187\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArora NK, et al. Health system response to child development needs in India. Indian Pediatr. 2022;59(8):643\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChavan BS, et al. Indian assessment and intervention models in child mental health. Indian J Psychiatry. 2018;60(Suppl 4):S216\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCormack L, Thomas V, Lewis MA, Rudd R. Improving low health literacy and patient engagement: A social ecological approach. Patient Educ Couns. 2010;75(3):285\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchillinger D, Grumbach K, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta A, Kaur R, Malhi P. Need for culturally appropriate developmental screening tools for young children in South Asia. Indian Pediatr. 2019;56(4):325\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlencowe H, Cousens S, Oestergaard MZ, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBornstein MH. Cultural approaches to parenting. Parenting: Sci Pract. 2012;12(2\u0026ndash;3):212\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaul V, Bhattacharjea S, Chaudhary AB et al. (2022). Early childhood care and education in India: Reaching marginalized children. Young Lives Working Paper.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFernald LCH, Kariger P, Engle P, Raikes A. Examining Early Child Development in Low-Income Countries. World Bank; 2009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahman A, Divan G, Hamdani SU, et al. Effectiveness of the parent-mediated intervention for children with autism (PASS) in South Asia: a randomised controlled trial. Lancet Psychiatry. 2018;5(8):609\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuppusamy B, Krishnaveni GV, Veena SR. Preterm Birth and Neurodevelopment in India: A Community Health Perspective. J Dev Pediatr. 2020;41(4):221\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharma R, Seth R, Arora S. Strengthening Community-Based Early Intervention in India: Role of Primary Healthcare and Technology. Indian Pediatr. 2023;60(3):213\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Graphs","content":"\u003cp\u003eGraphs are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Developmental delays, Usability, Accessibility, Parent-administered screening tools, culturally sensitive","lastPublishedDoi":"10.21203/rs.3.rs-7264197/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7264197/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEarly identification of developmental delays is pivotal for timely intervention and optimal child outcomes. Parent-administered tools such as the CDC Milestone Checklist and Ages and Stages Questionnaire\u0026ndash;3 (ASQ-3) are globally used; however, their usability and accessibility among Indian parents, particularly those with varying literacy levels, remain underexplored\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate and compare the usability and accessibility of the CDC Milestone Checklist and ASQ-3 among parents.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA sequential mixed-methods design was implemented. Phase I- a pilot study with 60 parents (30 per tool) to establish baseline usability and accessibility. Phase II- qualitative interviews with 17 parents, where both tools were administered and analysed thematically. In Phase III, a within-subject quantitative study with 84 parents, participants completed both tools were assessed using a structured Likert scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe study reveals CDC Checklist was easier to understand, with 65.5% deriving more than five developmental cues, compared to the ASQ-3, where 53.5% found it difficult to understand and 39.2% required more than five cues. Familiarity with the CDC Checklist was lower initially (39% unfamiliar), but none reported unfamiliarity with the ASQ-3 when administered a second. Higher curiosity of ASQ-3 (65.5% very curious) but took longer to complete (62%: 15\u0026ndash;20 min; 26%: \u0026gt;20 min). First-time mothers (46.7%) and parents of preterm infants (46.7%) faced greater challenges with comprehension and scoring, though less so with the CDC Checklist.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWhile both tools have value, the CDC Checklist aligned more closely with parental perspectives due to its simplicity and clarity, while practical barriers were found in using both tools in the Indian context. Findings underscore the need for a culturally sensitive and linguistically accessible developmental screening tool tailored for Indian parents.\u003c/p\u003e","manuscriptTitle":"Parent Perspectives on the Usability and Accessibility of the Cdc Milestone Checklist and Asq-3 Questionnaire in Monitoring Early Developmental Delays","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 18:17:46","doi":"10.21203/rs.3.rs-7264197/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"276125999174058660979460972832577271940","date":"2025-09-22T02:11:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T00:13:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109822740783099222028185521641085187950","date":"2025-09-15T21:09:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T22:11:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-10T05:51:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-21T12:28:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-21T03:13:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-21T03:10:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8792ebca-9578-4efc-be9f-194366185c26","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T18:17:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-22 18:17:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7264197","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7264197","identity":"rs-7264197","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}