Early childhood development forms the foundation for lifelong health, learning capacity, and socio-emotional well-being. Developmental delay, defined as failure to achieve age-appropriate developmental milestones in one or more domains such as gross motor, fine motor, language, cognition, or social interaction, remains a major public health concern in low- and middle-income countries, including India [1]. Children residing in urban slum settings are particularly vulnerable due to cumulative exposure to biological, social, and environmental risk factors. India has witnessed rapid urbanization over the past three decades, resulting in the expansion of informal settlements characterized by overcrowding, poor sanitation, food insecurity, inadequate healthcare access, and limited early stimulation opportunities [2]. According to national estimates, nearly one-third of India’s urban population resides in slums, with a substantial proportion being children under five years of age [3]. These conditions create an environment that adversely affects early childhood development. Developmental delays in slum-dwelling children are frequently under-recognized due to lack of routine screening, limited caregiver awareness, and inadequate integration of developmental surveillance into primary healthcare services [4]. Studies from India and other low-resource settings have demonstrated associations between developmental delay and factors such as low birth weight, recurrent infections, chronic malnutrition, maternal illiteracy, and suboptimal caregiving practices [5,6]. Additionally, psychosocial deprivation, including lack of responsive caregiving and minimal early learning stimulation, has emerged as a critical determinant of delayed cognitive and language development [7]. Qualitative approaches play a vital role in understanding contextual determinants of child development, as they capture caregiver perceptions, lived experiences, and health-seeking behaviors that quantitative tools may overlook [8]. In urban slum settings, caregivers often normalize delayed milestones due to intergenerational poverty and limited exposure to developmental norms, leading to delayed identification and intervention [9]. Furthermore, gender biases, cultural beliefs, and economic constraints frequently influence caregiving priorities and access to services [10]. Despite the magnitude of the problem, there is limited qualitative evidence exploring developmental delays among children in Indian urban slums from the perspective of caregivers and frontline health workers. Understanding these perspectives is essential for designing culturally sensitive, community-based interventions aimed at early identification and timely referral. Therefore, the present study was undertaken to evaluate the prevalence and patterns of developmental delay among children aged 6 months to 5 years residing in selected urban slum areas of India, and to qualitatively explore associated socio-demographic and caregiving factors influencing early child development.

Study Design and Setting This qualitative, community-based observational study was conducted in selected urban slum clusters of a metropolitan city in India over a period of six months. The slum areas were characterized by high population density, temporary housing structures, inadequate sanitation facilities, and limited access to organized healthcare services. Study Population Children aged 6 months to 5 years residing in the selected slum areas for at least six months were eligible for inclusion. Children with previously diagnosed genetic syndromes, congenital anomalies, or known neurological disorders were excluded to avoid confounding. Primary caregivers, predominantly mothers, were included for qualitative interviews to explore caregiving practices, awareness of developmental milestones, and health-seeking behavior. Sample Size and Sampling Technique A purposive sampling technique was employed. A total of 120 children were enrolled for developmental assessment, while 30 caregivers participated in in-depth qualitative interviews. Sample size adequacy was determined based on thematic saturation for qualitative data. Data Collection Tools 1. Developmental Screening: Developmental status was assessed using a structured, age-appropriate developmental screening checklist adapted from standard tools such as the Denver Developmental Screening Test II and Trivandrum Developmental Screening Chart. 2. Socio-Demographic Proforma: Information regarding child age, gender, birth order, parental education, family income, and housing conditions was collected. 3. Qualitative Interviews: Semi-structured interview guides were used to conduct face-to-face interviews with caregivers. Themes explored included: o Awareness of developmental milestones o Perceived causes of delayed development o Caregiving practices and early stimulation o Health-seeking behavior and barriers to care Ethical Considerations Ethical approval was obtained from the Institutional Ethics Committee prior to study initiation. Written informed consent was obtained from all caregivers. Confidentiality and anonymity were strictly maintained. Data Analysis Quantitative data were entered into Microsoft Excel and analyzed using descriptive statistics. Developmental delay was expressed as frequencies and percentages. Qualitative data from interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis. Coding was performed manually, and recurring patterns were organized into themes and sub-themes.

The majority of children belonged to the 13–36-month age group (46.7%), representing the most critical period for developmental monitoring. Male children constituted 56.7% of the study population. A significant proportion of mothers had low educational attainment, with 38.3% being illiterate and only 18.4% having secondary or higher education, highlighting socio-educational vulnerability (Table 1). Table 1: Socio-Demographic Profile of the Study Children (n = 120) Variable Category Frequency Percentage Age group 6–12 months 24 20.0 13–36 months 56 46.7 37–60 months 40 33.3 Gender Male 68 56.7 Female 52 43.3 Maternal education Illiterate 46 38.3 Primary 52 43.3 Secondary or above 22 18.4 Overall, 45% of children demonstrated delay in at least one developmental domain. Language delay was the most prevalent (38.3%), followed by social-personal delay (28.3%). Gross and fine motor delays were observed in approximately one-fourth of the children, indicating widespread multi-domain vulnerability (Table 2). Table 2: Prevalence of Developmental Delay by Developmental Domain Developmental Domain Children with Delay (n) Percentage Gross motor 32 26.7 Fine motor 28 23.3 Language 46 38.3 Social-personal 34 28.3 Any domain 54 45.0 Developmental delay was strongly associated with poor nutritional status. Children with severe undernutrition showed the highest prevalence of developmental delay (66.7%), followed by moderately undernourished children (57.1%). In contrast, only 25.9% of children with normal nutritional status exhibited delay, emphasizing nutrition as a key determinant (Table 3). Table 3: Association of Developmental Delay with Nutritional Status Nutritional Status Total Children Developmental Delay n (%) Normal 54 14 (25.9) Moderate undernutrition 42 24 (57.1) Severe undernutrition 24 16 (66.7) Caregiver awareness regarding developmental milestones was low, with only 31.7% reporting any knowledge of age-appropriate development. Less than one-third of caregivers engaged in verbal stimulation activities such as storytelling. Limited early stimulation practices were commonly reported, reflecting psychosocial deprivation in the slum environment (Table 4). Table 4: Caregiver Awareness and Stimulation Practices Variable Yes n (%) No n (%) Awareness of milestones 38 (31.7) 82 (68.3) Regular play interaction 44 (36.7) 76 (63.3) Storytelling/talking to child 32 (26.7) 88 (73.3)

The present qualitative study highlights a high burden of developmental delay among children residing in urban slum areas, with nearly half of the study population exhibiting delay in one or more developmental domains. These findings align with previous community-based studies from low-resource urban settings that report disproportionately high rates of developmental vulnerability among socio-economically marginalized children [11]. Language delay emerged as the most prevalent developmental concern in this study. Similar observations have been reported in Indian and global slum-based research, where limited caregiver–child interaction, reduced verbal stimulation, and low parental literacy adversely impact early language acquisition [12]. The predominance of language delay underscores the importance of responsive caregiving and early learning opportunities during the critical window of brain development. The strong association between undernutrition and developmental delay observed in this study corroborates existing evidence linking chronic malnutrition to impaired cognitive and motor development [13]. Undernourished children are more susceptible to infections, reduced exploratory behavior, and delayed myelination, all of which contribute to suboptimal developmental outcomes [14]. The high prevalence of undernutrition in urban slums thus acts as both a biological and environmental risk factor. Maternal education emerged as an important contextual determinant. Children of illiterate mothers exhibited higher rates of developmental delay, consistent with studies demonstrating that maternal education influences health-seeking behavior, feeding practices, and stimulation activities [15]. Educated mothers are more likely to recognize developmental concerns early and seek appropriate care. Qualitative interviews revealed that many caregivers perceived delayed development as “normal” or attributed it to familial traits, poverty, or fate. Such perceptions have been documented in other qualitative studies, where normalization of developmental delay leads to delayed help-seeking and missed opportunities for early intervention [16]. Additionally, caregivers often prioritized immediate survival needs over developmental concerns due to financial constraints. The lack of awareness regarding developmental milestones and limited engagement in play-based stimulation observed in this study reflects psychosocial deprivation inherent to slum environments. Overcrowding, maternal workload, and absence of safe play spaces were frequently cited barriers. Previous research has emphasized that early stimulation interventions integrated into community and primary healthcare settings can significantly improve developmental outcomes even in low-resource contexts [17]. Gender differences in developmental outcomes were not pronounced in the present study; however, qualitative narratives suggested subtle preferential caregiving practices favoring male children. Similar gender-based disparities have been reported in other Indian studies and may influence long-term developmental trajectories [18]. The findings highlight critical gaps in urban primary healthcare delivery, where routine developmental screening is often overlooked. Integration of developmental surveillance into existing maternal and child health programs, along with caregiver education, is essential for early identification [19]. Community health workers can play a pivotal role in raising awareness and facilitating referrals. Overall, this study reinforces the multifactorial nature of developmental delay in urban slum children and emphasizes the need for holistic interventions addressing nutrition, caregiver education, and early stimulation within the socio-cultural context of slum communities [20-25].

The study demonstrates a substantial burden of developmental delay among children living in urban slum areas of India, with language and social-personal domains being most affected. Undernutrition, low maternal education, and inadequate caregiver awareness emerged as key contributing factors. Qualitative insights revealed normalization of delayed development and significant barriers to early stimulation and health-seeking behavior. These findings underscore the urgent need for integrated, community-based strategies focusing on nutritional support, caregiver education, and routine developmental screening within urban slum settings. Strengthening primary healthcare services and empowering caregivers through culturally appropriate interventions can facilitate early identification and timely intervention, thereby improving developmental outcomes and reducing long-term disability among vulnerable urban children.

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