Mapping Research Evidence on Children Living with Autism Spectrum Disorders in Africa: A Scoping Review Protocol

Background: Early detection and intervention of children living with Autism Spectrum Disorders have shown a great improvement of the child's behaviour, predominantly in language and motor skills develop-pment. We are proposing to conduct a systematic scoping review that will map all evidence available on children living with Autism Spectrum Disorders in Africa. Methods and analysis: This study will be guided by Arksey and O’Malley’s framework of scoping reviews. A comprehensive literature search will be done in the following electronic databases. Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, EBSCOhost, MEDLINE, Health Sources, and Google Scholar. Primary studies, published in peer-reviewed journals and grey literature such as unpublished studies, studies in press and Theses that address our research question will be included. To reduce research bias two independent reviewers will perform title, abstract, and full article screening ers. NVivo version 12 software will be used to assist with the extraction of relevant answers to the study questions from selected studies using content thematic analysis. The results for this planned study will be presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR). Mixed Methods Assessment Tool version 2018 will be used for quality appraisal of included studies. Discussion: We anticipate that the proposed mapped evidence on Children living with Autism Spectrum Disorders in Africa will reveal indicators for early detection that would facilitate strategies for intervention. We are also anticipating that this systematic scoping review will reveal gaps that can be addressed to ensure context-sensitive interventions and identify caregiver burdens of children living with Autism. This will contribute to the reduction of a scarcity of literature on children living with Autism in Africa. syndrome


Background
Autism is a neurodevelopmental spectrum disorder that was first described by Leo Kanner in 1943 [1,2].
Three decades after his description, a study on childhood Autism in Africa by V Lotter [3] reported that the syndrome contains no descriptions of cases occurring amongst the indigenous populations of developing countries. Specialist clinics in countries with elaborate children's services, in the past recorded between seven and eight cases annually [4], but recent evidence indicates the prevalence of childhood autism is rising. A recent study shows over 50 studies from 21 countries reveal that prevalence rates of autism or Autism Spectrum Disorders (ASD) among children are on rising [5]. Over the past decade, estimates of increases between 50% to over 2000% in cases of Autistic Disorder diagnoses have been charted, studied and discussed worldwide [6]. Worldwide, population-based studies conducted before 1985 identified the prevalence of autism and related conditions among children under 18 years old to be approximately 0.5 per 1,000 children [7]. However, a recent Centers for Disease Control and Prevention's (CDC) report showed that children meeting the "Autistic Disorder" criteria has increased to about 12 per 1,000 children, worldwide. [8]. The CDC 2020 report further shows that for eight-year-old children, the likelihood of been diagnosed with Autism was one per every 54 children [9] compared to one per 59 children in 2018.
However, the reasons contributing to this recent increases in ASD in children are not known [9].
In Africa, literature on the prevalence of ASD is limited [10] partly due to diagnostic challenges [11].
Nonetheless, a study suggested that most individuals with ASDs live in low-and-middle-income countries compared to high-income countries [10,12,13] We anticipate that the results of this study will reveal research gaps for future systematic review or primary studies to inform healthcare policies direction and facilitate the creation of early inter-ventions for children living with ASD in Africa.

Overview
A scoping review is useful when it maps ranges of literature that exist in a particular topic or phenomenon of interest. This facilitates in focusing the research questions by charting existing research findings to identify research gaps [14]. The methodology used in scoping reviews is a useful approach as it aids in determining the need and value of future primary studies and systematic reviews [14].

Identifying the research question
Population, Concept and Context (PCC) as suggested by JB Institute [18] was used to elicit the eligibility of the scoping review question as shown in Table 1. The main review question will be, What research evidence exists on children living with Autism Spectrum Disorders in Africa in the last five years. The subreview questions will be as follow: • What research evidence exists on caregiver burden or experience for parents/guardians of children living with ASD in Africa within the last five years?
• What research evidence exists on detection of children living with ASD in Africa within the last five years?
• What research evidence exists on interventions for children living with ASD in Africa within the last five years?

Identifying relevant studies
We will conduct a detailed keyword search to identify all relevant studies irrespective of their publication to answer the review question. ASD, Asperger's Syndrome, PDD-NOS, "detection", "intervention", "burden", "caregiver", "caregiver burden", and "Africa" will be used.  Table 2). The principal investigator (LL) will conduct the database searches. Endnotes X9 software will be used for data management of all citations.

Eligibility criteria
To ensure relevant studies are selected for this review, the eligibility criteria will be guided by the specified inclusion and exclusion criteria.

Inclusion criteria
Studies that meet the following criteria will be included: • Studies presenting evidence on ASD in Africa, • Studies reporting evidence on detection of children living with ASD, • Studies reporting evidence on intervention of children living with ASD, • Studies reporting evidence on caregiver burden of children living with ASD, • Qualitative, quantitative, and mixed methods study designs

Exclusion criteria
The following will be excluded: • Studies involving no African countries, • Studies reporting side effects of treatments, • Non-original articles

Study selection
All duplicates will be removed from the Endnote library created for this review and shared among the reviewer team for screening. Tools for the study selection will be developed a prior and piloted. Two investigators will independently sort the studies into included and excluded categories at the abstract and the full-text screening stages based on the inclusion criteria of the proposed study. We will seek the assistance of the Librarian from the University of Ghana or write to the authors for articles that we are unable to retrieve. Categorisation choices will be compared and where there is disagreement, the researchers will reach a consensus by discussing titles and content of the studies. A third investigator will be used to resolve disagreements at full article screening stage.
Articles with no abstracts available, categorisation will be based on the titles alone. The results will follow the guidelines of PRISMA as a reporting format [19] as shown on Figure 1.

Charting the data
Extraction of information relevant to the aim of this study will be performed. A data extraction form will be developed electronically using google forms piloted with ten per cent of the studies that will be included using two investigators to ensure consistency and accuracy in data extraction. Based on the feedback of the investigators, the data extraction form will be updated as and when required. Table 3 shows the data extraction form that will be used for this proposed review.

Collating, summarising, and reporting the results
Content thematic analysis approach will be used to extract data relevant to answer the proposed scoping review question as proposed by V Braun, V Clarke and N Hayfield [20]. All data regarding autism, detection, intervention and caregiver burden published in Africa will be extracted from the inclusion articles.
NVivo version 12 software will be used to facilitate the content thematic analysis. A narrative summary will be used to report emerging themes to answer the review questions. The implication of the study results for future research, education and healthcare policies will be examined and reported. The Preferred Reporting Items for Systematic reviews and Meta-Analysis: Extension for Scoping Review (PRISMA-ScR) [19], will be used to present the results of this proposed scoping review.

Quality appraisal
The Mixed Methods quality Appraisal Tool (MMAT) Version 2018 [21], will be used to assess the methodological quality of all included studies. The MMAT will be used to appraise the appropriateness of the aim of the study, adequacy of methodology, study design, participants recruitment, data collection, data analysis, and findings presented. To ensure that the study design of the included studies is appropriate for the research objectives, the quality score ranging will be graded.
Less than or equal to 50% will be considered low quality, 51 to 75%, average quality and 76 to 100% will be considered as high quality. This quality assessment will help the reviewers to report on the risk of bias of the studies included and the quality of the evidence that will be reported.

Population
• Children living with Autism Spectrum Disorders      arguably has no cure [22,23], and early detection, and proper intervention is key in improving the self-care independence of these children living with ASD [1,22]. Reported cases of ASD are exponentially skyrocketing globally [9], yet Africa with its poor healthcare infrastructure [24,25] is left without evidence of detection, interventions, caregiver burden and coping strategies. We anticipate that the mapped evidence will help provide the situation, early

Conclusion
The findings of this proposed systematic scoping review will provide useful evidence that will facilitate and guide the direction for future research including primary studies and meta-analysis. It will influence policy direction and provide caregivers with possible coping strategies.

Funding
This study is not funded

Availability of data and material
All the data generated or analysed in the course of this study will be included in the published systematic scoping review article. This will also be made available upon request.

Authors' contributions
LL conceptualised the study and prepared the draft and DK and CMB did a critical review. These three

Consent for publication
Not applicable