Accuracy of child morbidity data in demographic and health surveys

Education and non-communicable diseases in India: an exploration of gendered heterogeneous relationships

BACKGROUND

While the association between education and non-communicable diseases (NCDs) is well established, it remains unclear whether this association varies by gender. The aim of this study was to examine two critical research questions: whether the association of education and NCDs is conditioned by gender and, if so, what are the factors contributing to this?

METHODS

Data from the Longitudinal Aging Study in India Wave 1 (2017-2018) was used for the empirical analysis. The study employs bivariate, binary logistic regression and Oaxaca decomposition analyses.

RESULTS

The results reveal that the net likelihood of having at least one chronic NCD increases with an increase in education level for men (<5 y of schooling: odds ratio [OR] 1.18 [95% confidence interval {CI} 1.09 to 1.28]; ≥10 y of schooling: OR 1.43 [95% CI 1.33 to 1.53]). However, for women, the result showed a contrasting pattern. The decomposition analysis revealed that the distinctive roles of marital status and working status in the diagnosis of morbidity for men and women are the key factors behind the gendered heterogeneous relationship of education and NCDs in India.

CONCLUSIONS

The study found that it is important to acknowledge the potential impact of self-reporting bias in morbidity data while examining the relationship between education and NCDs.

Associations between landscape fires and child morbidity in southern Mozambique: a time-series study

BACKGROUND

Epidemiological evidence linking exposure to landscape fires to child health remains scarce. We assessed the association between daily landscape fire smoke and child hospital visits and admissions in the Manhiça district, Mozambique, an area characterised by frequent forest and cropland fires.

METHODS

In this time-series analysis (2012-20), our primary metric for exposure to landscape fires was fire-originated PM2·5 from smoke dispersion hindcasts. We also assessed total and upwind fire exposure using daily satellite-derived fire density data. Daily numbers of hospital visits and admissions were extracted from an ongoing paediatric morbidity surveillance system (children aged ≤15 years). We applied quasi-Poisson regression models controlling for season, long-term trend, day of the week, temperature, and rainfall, and offsetting by annual population-time at risk to examine lag-specific association of fires on morbidity.

FINDINGS

A 10 μg/m3 increase in fire-originated PM2·5 was associated with a 6·12% (95% CI 0·37-12·21) increase in all-cause and a 12·43% (5·07-20·31) increase in respiratory-linked hospital visits on the following day. Positive associations were also observed for lag 0 and the cumulative lag of 0-1 days. Null associations were observed for hospital admissions. Landscape fires mostly occurred in forested areas; however, associations with child morbidity were stronger for cropland than for forest fires.

INTERPRETATION

Landscape fire smoke was associated with all-cause and respiratory-linked morbidity in children. Improved exposure assessment is needed to better quantify the contribution of landscape fire smoke to child health in regions with scarce air pollution monitoring.

FUNDING

H2020 project EXHAUSTION, Academy of Finland, Spanish Ministry of Science and Innovation, Generalitat de Catalunya, and Government of Mozambique and Spanish Agency for International Cooperation and Development.

Do people with different sociodemographic backgrounds value their health differently? Evaluating the role of positional objectivity

Objective

The fundamental disconnect between the actual and the perceived health of an individual raises considerable skepticism on the self-reported health data as it may be confounded by an individual's socio-economic status. In this light, the present study aims to assess if people with different sociodemographic backgrounds value their health differently.

Methods

The health-state valuation using time-trade off was performed in a cross-sectional survey among a representative sample of 2,311 adults from India. Individuals were selected using a multistage stratified random sampling from five Indian states to elicit their present health-state, and to perform the health-state valuation exercise using computer assisted personal interviewing. A single block of standardized health-states was valued by multiple individuals, each belonging to different socio-demographic group. The difference in the valuation of health was assessed using bivariate analysis. The impact of different sociodemographic factors on the health-state valuation was evaluated using Tobit regression model.

Results

Differences in the valuation of health were observed among different groups of age, religion, family type, state of residence, substance abuse, presence of ailments at the time of valuation, and number of dependent members in the household. Even after controlling for the severity of the administered health states, factors having a significant association with the valuation of health are age, religion, state of residence, substance abuse, family type, number of dependent members in the household, and presence of chronic or both acute and chronic ailments. Younger individuals place a higher value to their health as compared to their older counterparts. As compared to a healthy individual, a person with ailments rates the same health-state as worse.

Conclusion

Inequalities in self-reported ill-health cannot be attributed to positional objectivity; age, religion, state of residence, substance abuse, family type, dependents, and ailments impact individual health valuation.

Spatial Distributions of Diarrheal Cases in Relation to Housing Conditions in Informal Settlements: A Cross-Sectional Study in Abidjan, Côte d'Ivoire

In addition to individual practices and access to water, sanitation, and hygiene (WASH) facilities, housing conditions may also be associated with the risk of diarrhea. Our study embraced a broad approach to health determinants by looking at housing deprivation characteristics as exposures of interest and confronting the latter's spatial distribution to that of diarrheal cases. We tested the hypothesis that the risk of diarrhea in informal settlements is not only associated with WASH services, but also with inadequate dwelling characteristics, and that their spatial distributions follow similar patterns. We designed a cross-sectional study and collected primary data through georeferenced household surveys in two informal settlements in Abidjan, Côte d'Ivoire. We used local join count statistics to assess the spatial distribution of events and multiple logistic regressions to calculate adjusted odds ratios between diarrhea and exposures. A total of 567 households were enrolled. We found that constant access to basic WASH services, non-durable building materials, cooking outdoors, and water service discontinuity were associated with higher risks of diarrhea in the general population. The spatial distribution of diarrheal cases coincided with that of dwelling deprivation characteristics. We observed significant heterogeneity within the study sites regarding the spatial distribution of diarrheal cases and deprived dwellings. Along with WASH infrastructure, communities also need dignified housing to effectively prevent diarrhea. We recommend that decision-makers acknowledge a "spectrum" of deprivation within the heterogeneous universe of informal settlements, adopting a site-specific approach based on high-resolution data to address diarrhea and improve people's well-being.

Environmental determinants of access to shared sanitation in informal settlements: a cross-sectional study in Abidjan and Nairobi

BACKGROUND

Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains-notably, the prevention of diarrheal diseases-may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections.

METHODS

A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d'Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment.

RESULTS

Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13-8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93-93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29-2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22-2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings' compactness, the proportion of occupied land, and angular deviation between neighboring structures.

CONCLUSIONS

Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety.

Seasonal variation in infant mortality in India

Investigating seasonal variation in health helps us understand interactions between population, environment, and disease. Using information on birth month and year, survival status within the first year of life, and age at death (if applicable) of more than 330,000 children observed in four rounds of India's Demographic and Health Surveys, I estimate period mortality rates between birth and age one (₁m₀) by calendar month. Relative to spring months, infant mortality is higher in the summer, monsoon, and winter months. If spring mortality conditions had been prevalent throughout the year, mortality below age one would have been lower by 11.4 deaths per 1,000 in the early 1990s and 3.7 deaths per 1,000 in the mid-2010s. Seasonal variation in infant mortality has declined overall but remains higher among disadvantaged children. The results highlight the multiple environmental health threats that Indian infants face and the short time of year when these threats are less salient.

Using Open-Access Data to Explore Relations between Urban Landscapes and Diarrhoeal Diseases in Côte d’Ivoire

Unlike water and sanitation infrastructures or socio-economic indicators, landscape features are seldomly considered as predictors of diarrhoea. In contexts of rapid urbanisation and changes in the physical environment, urban planners and public health managers could benefit from a deeper understanding of the relationship between landscape patterns and health outcomes. We conducted an ecological analysis based on a large ensemble of open-access data to identify specific landscape features associated with diarrhoea. Designed as a proof-of-concept study, our research focused on Côte d’Ivoire. This analysis aimed to (i) build a framework strictly based on open-access data and open-source software to investigate diarrhoea risk factors originating from the physical environment and (ii) understand whether different types and forms of urban settlements are associated with different prevalence rates of diarrhoea. We advanced landscape patterns as variables of exposure and tested their association with the prevalence of diarrhoea among children under the age of five years through multiple regression models. A specific urban landscape pattern was significantly associated with diarrhoea. We conclude that, while the improvement of water, sanitation, and hygiene infrastructures is crucial to prevent diarrhoeal diseases, the health benefits of such improvements may be hampered if the overall physical environment remains precarious.

Assessment of self-rated health: The relative importance of physiological, mental, and socioeconomic factors

BACKGROUND

The general self-rated health (SRH) question is the most common health measure employed in large population surveys. This study contributes to research on the concurrent validity of SRH using representative data with biomarkers from the Czech Republic, a population not previously used to assess the SRH measure. This work determines the relative contribution of biomedical and social characteristics to an individual's SRH assessment. Studies have already explored the associations between SRH and markers of physical health. However, according to a PubMed systematic literature search, the issue of the relative importance of physiological and psychosocial factors that affect individuals' assessments of their SRH has generally been neglected.

METHODOLOGY/PRINCIPAL FINDINGS

Using data from a specialized epidemiological survey of the Czech population (N = 1021), this study adopted ordinary least squares regression to analyze the extent to which variance in SRH is explained by biomedical measures, mental health, health behavior, and socioeconomic characteristics. This analysis showed that SRH variance can be largely attributed to biomedical and psychological measures. Socioeconomic characteristics (i.e. marital status, education, economic activity, and household income) contributed to around 5% of the total variance. After controlling for age, sex, location, and socioeconomic status, biomarkers (i.e. C-reactive protein, blood glucose, triglyceride, low-density lipoprotein, and high-density lipoprotein), number of medical conditions, and current medications explained 11% of the total SRH variance. Mental health indicators contributed to an additional 9% of the variance. Body mass index and health behaviors (i.e. smoking and alcohol consumption) explained less than 2% of the variance.

CONCLUSIONS/SIGNIFICANCE

The results suggested that SRH was a valid measure of physiological and mental health in the Czech sample, and the observed differences were likely to have reflected inequalities in bodily and mental functions between social groups.

Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study

OBJECTIVES

Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery.

PARTICIPANTS

Women 5-7 months pregnant with access to a phone.

SETTING

Four districts of Madhya Pradesh, India.

DESIGN

Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented.

RESULTS

Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators' and respondents' profile differences, rapport, social desirability bias, and/or enumerator's ability to adequately convey concepts or probe.

CONCLUSIONS

Phone surveys are a reliable modality for generating population-level estimates data about pregnant women's knowledge, however, should not be used for individual-level tracking.

TRIAL REGISTRATION NUMBER

NCT03576157.

Impact of mining projects on water and sanitation infrastructures and associated child health outcomes: a multi-country analysis of Demographic and Health Surveys (DHS) in sub-Saharan Africa

Background

Access to improved water and sanitation infrastructures are key determinants of health. The sub-Saharan African region in particular is lagging behind the ambitious goal of the 2030 Agenda for Sustainable Development to ensure universal access to improved and reliable water and sanitation for all (Sustainable Development Goal (SDG) 6). Large mining projects can promote economic growth and hence investments in water and sanitation infrastructures, but at the same time lead to rapid population growth and environmental degradation. In turn, these changes can pose risks and opportunities for child health (SDG 3). In this study we aim to quantify the impacts of mining projects on access to water and sanitation infrastructure as well as diarrhea and malnutrition among children using data from 131 Demographic and Health Surveys from sub-Saharan Africa.

Results

From a sample of around 1.2 million households, data within the proximity of 52 mine-panels were selected for longitudinal analyses, resulting in 41,896 households and 32,112 children. Improvements in access to modern water and sanitation infrastructures after mine opening were much larger in households near mining sites than in comparison areas located further away (adjusted relative risk ratio (aRRR) water: 18.60, 95 % confidence interval (CI): 13.08–26.46 and aRRR sanitation: 2.56, 95 % CI: 1.32–4.99). However, these associations were weaker among poorer households. In areas close to the mining sites, stunting and underweight prevalence decreased more strongly upon mine opening (adjusted odds ratio (aOR) stunting: 0.62, 95 % CI: 0.43–0.90; aOR underweight: 0.55, 95 % CI: 0.36–0.84). No differential changes were seen for wasting and diarrhea. Large impact heterogeneity was observed both within and across countries.

Conclusions

Our results suggest that the opening of mines is associated with improvements in access to modern water and sanitation infrastructures (SDG 6) as well as in some health outcomes (SDG 3). However, the large impact heterogeneity suggests that the assessment and management of mining-related impacts on communities should have an increased equity-focus, in order to “leave no one behind” in the work towards the 2030 Agenda for Sustainable Development. Overall, the findings of this study underscore that the resource extraction sector has the potential to make positive and substantial contributions towards achieving the SDGs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00723-2.

The socioeconomic dynamics of trends in female genital mutilation/cutting across Africa

BACKGROUND

The majority of women who undergo female genital mutilation/cutting (FGM/C) live in Africa. Although the UN Sustainable Development Goals call for intensified efforts to accelerate the abandonment of FGM/C, little is known about where in Africa the declines in prevalence have been fastest and whether changes in prevalence differ by women's socioeconomic status.

METHODS

We use data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys for 23 African countries, collected between 2002 and 2016, and covering 293 170 women. We reconstruct long-term cohort trends in FGM/C prevalence spanning 35 years, for women born between 1965 and 1999. We compute absolute and relative changes in FGM/C prevalence and differentials in prevalence by women's education and urban-rural residence. We examine whether socioeconomic differences in FGM/C are converging or diverging.

FINDINGS

FGM/C prevalence has declined fastest (in relative terms) in countries with lower initial prevalence, and more slowly in countries with higher initial prevalence. Although better-educated women and those living in urban areas tend to have lower prevalence, in some countries the opposite pattern is observed. Socioeconomic differentials in FGM/C have grown in the majority of countries, particularly in countries with moderate-to-higher overall prevalence.

CONCLUSIONS

The documented relationship between absolute and relative FGM/C prevalence rates suggests that in settings with higher initial prevalence, FGM/C practice is likely to be more entrenched and to change more slowly. There is substantial variation between countries in socioeconomic differentials in prevalence and their changes over time. As countries change from higher to lower overall prevalence, socioeconomic inequalities in FGM/C are increasing.

Association between Maternal High-Risk Fertility Behavior and Childhood Morbidity in Bangladesh: A Nationally Representative Cross-Sectional Survey

In this cross-sectional study, we evaluated data from the 2014 Bangladesh Demographic and Health Survey (BDHS), which consisted of 7,707 married women aged 15-49 years who lived with at least one child younger than 5 years. This study's primary aim was to examine the relationship between maternal high-risk fertility behavior and child morbidity. To define high-risk fertility behaviors, we considered three variables: maternal age at the time of delivery, birth order, and birth interval. The main outcome measures were mortality-related disease in the past 2 weeks (acute respiratory infection [ARI], diarrhea, and fever) and low birth weight (LBW). We used modified Poisson regression with generalized estimating equations to assess the relationships between the variables of interest. Results indicate that a substantial portion of women (34%) exhibited high-risk fertility patterns; 28.7% engaged in a single high-risk behavior and 5.4% engaged in multiple high-risk behaviors. After adjusting for relevant covariates, high-risk fertility behaviors were significantly associated with an increased likelihood of ARI (adjusted relative risk [ARR]: 1.22, 95% CI: 1.05-1.50), diarrhea (ARR: 1.18, 95% CI: 1.03-1.35), fever (ARR: 1.29, 95% CI: 1.11-1.58), and LBW (ARR: 1.27, 95% CI: 1.10-1.52). In addition, engaging in multiple high-risk fertility behaviors appeared to have far-reaching consequences on the outcomes measured. Maternal high-risk fertility behaviors are important predictors of morbidity in children younger than 5 years. Preventing high-risk fertility behavior may reduce childhood morbidity and mortality in Bangladesh.

Association Between Maternal Education and Childhood Mortalities in Myanmar

Maternal education is widely regarded as a core social determinant of child mortality in low-income countries. In Myanmar, the evidence related to context-specific social determinants of health including maternal education is scarce, limiting grounds to advocate for a comprehensive health policy. Employing multivariate methods, the study analyzed the 2015-2016 Demographic Health Survey data exploring independent effect of maternal education on neonatal, infant, and under-5 mortality. The study found that maternal education was not significantly associated with neonatal mortality as its effect was confounded by household wealth and geographic residence; however, it had independent effect on infant and under-5 mortality. Mothers with primary education had 23% reduction in the odds of under-5 mortality (P < .001); those with secondary level had 40% reduction (P < .001); and those at higher level had 62% reduction (P < .001). The study concluded that maternal education is a critical social determinant of childhood mortalities in Myanmar.

Concordance between GPS-based smartphone app for continuous location tracking and mother's recall of care-seeking for child illness in India

Background

Traditionally, health care-seeking behaviour for child illness is assessed through population-based national demographic and health surveys. GPS-based technologies are increasingly used in human behavioural research including tracking human mobility and spatial behaviour. This paper assesses how well a care-seeking event to a health care facility for child illness, as recalled by the mother in a survey setting using questions sourced from Demographic and Health Surveys, concurs with one that is identified by TrackCare, a GPS-based location-aware smartphone application.

Methods

Mothers residing in the Vadu HDSS area in Pune district, India having at least one young child were randomly assigned to receive a GPS-enabled smartphone with a pre-installed TrackCare app configured to record the device location data at one-minute intervals over a 6-month period. Spatio-temporal parameters were derived from the location data and used to detect a care-seeking event to any of the health care facilities in the area. Mothers were asked to recall a child illness and if, where and when care was sought, using a questionnaire during monthly visits over a 6-month period. Concordance between the mother's recall and the TrackCare app to identify a care-seeking event was estimated according to percent positive agreement.

Results

Mean concordance for a care-seeking event between the two methods (mother's recall and TrackCare location data) ranged up to 45%, was significantly higher (P-value <0.001) for care-seeking at a hospital as compared to a clinic and for a health care facility in the private sector compared to that in the public sector. Overall, the proportion of disagreement for a care-seeking event not detected by TrackCare but reported by mother ranged up to 77% and was significantly higher (P-value <0.001) compared to those not reported by mother but detected by TrackCare.

Conclusions

Given the uncertainty and limitations in use of continuous location tracking data in a field setting and the complexity of classifying human activity patterns, additional research is needed before continuous location tracking can serve as a gold standard substitute for other methods to determine health care-seeking behaviour. Future performance may be improved by incorporating other smartphone-based sensors, such as Wi-Fi and Bluetooth, to obtain more precise location estimates in areas where GPS signal is weakest.

A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions

Background

Childhood pneumonia is the single largest infectious cause of death in children under five worldwide. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) provide health information on care sought for sick children in resource poor settings. Despite not being primarily designed to identify childhood pneumonia, there are concerns that reported episodes of "symptoms of acute respiratory infection" in DHS and MICS are often interpreted by other groups as a "proxy" for childhood pneumonia. Using DHS5 and MICS5 survey tools, this study aimed to assess how accurately caregivers report of "symptoms of acute respiratory infection" reflect pneumonia episodes and antibiotic use in children under five.

Methods

Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017. Children were assessed using World Health Organization (WHO) standard criteria by study physicians to identify whether they had pneumonia. Three hundred and two matched children in each category of 'pneumonia' and "no pneumonia" were followed up at home, either two or eight weeks later, using questions from DHS5 and MICS5 surveys to assess the accuracy of caregiver recall of pneumonia.

Results

The specificity of DHS5 and MICS5 questions for identifying childhood pneumonia were 87.4 (95% confidence interval (CI) = 83.1-91.0) and 86.1 (95% CI = 81.7-89.8) respectively and the sensitivity of questions were 37.1 (95% CI = 31.6-42.8) and 37.1 (95% CI = 31.6-42.8). Correct recall of antibiotic treatment was poor (kappa statistic = 0.064) but improved with the use of medicine pill boards (kappa statistic = 0.235).

Conclusions

DHS5 and MICS5 survey questions are not designed to identify childhood pneumonia and this study confirms that they do not accurately discern episodes of childhood pneumonia from cough/cold in children under five. The proportion of pneumonia episodes appropriately treated with antibiotics cannot be accurately assessed using current DHS and MICS surveys. If these results are used to guide programmatic decisions, it is likely to encourage overuse and inappropriate prescribing of antibiotics for episodes of cough/cold. International agencies who continue to use these household data to monitor the proportion of children with pneumonia who receive antibiotic treatment should be discouraged from doing this as these data are likely to mislead national and global programmes. Medicine pill boards are used in a number of DHS surveys and should be promoted for wider use in national population surveys to improve the accuracy of antibiotic recall.

A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions

Background

Childhood pneumonia is the single largest infectious cause of death in children under five worldwide. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) provide health information on care sought for sick children in resource poor settings. Despite not being primarily designed to identify childhood pneumonia, there are concerns that reported episodes of “symptoms of acute respiratory infection” in DHS and MICS are often interpreted by other groups as a “proxy” for childhood pneumonia. Using DHS5 and MICS5 survey tools, this study aimed to assess how accurately caregivers report of “symptoms of acute respiratory infection” reflect pneumonia episodes and antibiotic use in children under five.

Methods

Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017. Children were assessed using World Health Organization (WHO) standard criteria by study physicians to identify whether they had pneumonia. Three hundred and two matched children in each category of ‘pneumonia’ and “no pneumonia” were followed up at home, either two or eight weeks later, using questions from DHS5 and MICS5 surveys to assess the accuracy of caregiver recall of pneumonia.

Results

The specificity of DHS5 and MICS5 questions for identifying childhood pneumonia were 87.4 (95% confidence interval (CI) = 83.1-91.0) and 86.1 (95% CI = 81.7–89.8) respectively and the sensitivity of questions were 37.1 (95% CI = 31.6-42.8) and 37.1 (95% CI = 31.6-42.8). Correct recall of antibiotic treatment was poor (kappa statistic = 0.064) but improved with the use of medicine pill boards (kappa statistic = 0.235).

Conclusions

DHS5 and MICS5 survey questions are not designed to identify childhood pneumonia and this study confirms that they do not accurately discern episodes of childhood pneumonia from cough/cold in children under five. The proportion of pneumonia episodes appropriately treated with antibiotics cannot be accurately assessed using current DHS and MICS surveys. If these results are used to guide programmatic decisions, it is likely to encourage overuse and inappropriate prescribing of antibiotics for episodes of cough/cold. International agencies who continue to use these household data to monitor the proportion of children with pneumonia who receive antibiotic treatment should be discouraged from doing this as these data are likely to mislead national and global programmes. Medicine pill boards are used in a number of DHS surveys and should be promoted for wider use in national population surveys to improve the accuracy of antibiotic recall.

Assessing the reactivity to mobile phones and repeated surveys on reported care-seeking for common childhood illnesses in rural India

Background

Traditionally, health care-seeking for child illness is assessed through population-based and nationally representative demographic and health surveys (DHS) that are conducted once every five to seven years and are based on maternal recall. These maternal reports are subject to recall bias. Mobile phones (with the use of GPS technology) have the potential to constantly track movements of phone owners and provide high quality and more accurate data at a population level in low and middle income countries (LMICs) to assess the validity of maternal recall. We provided a group of mothers with smartphones installed with a location-aware application and visited them monthly to administer a survey questionnaire on care-seeking for diarrhoea, fever and cough with fever. This paper assesses for any reactivity to smartphones or repeated study contacts for measuring care-seeking and if this resulted in change in health care provider preference.

Methods

We enrolled 749 mothers from rural areas of Pune district in Maharashtra, India and randomly allocated them to one of three groups – a longitudinal phone group, a longitudinal control group and a cross-sectional control group. We collected baseline information from mothers, including individual and household demographic and socio-economic characteristics and care-seeking preferences for child illness. We followed up both longitudinal groups monthly and each cross-sectional sub-group once over a period of 6 months. At each follow up, we administered questions identical to those in the National Family Health Survey (NFHS) questionnaire to determine an episode of diarrhoea, fever or cough within the last 15 days, care seeking for the same, and the type of provider. The data were analysed using the χ² test or Fisher Exact Test for categorical variables, or with the Kruskall-Wallis non-parametric test for continuous variables (due to the non-normal nature of the data). Multivariable joint models of group and visit time were analysed with logistic regression methods.

Results

All three groups were similar in their socio-demographic characteristics at baseline. We did not observe any significant difference in care seeking for diarrhoea, fever or cough with fever between groups. Also, we did not observe any significant difference in proportion of children seeking care from the private sector.

Conclusions

We did not observe any reactivity in this study due to the presence of the phone (Hawthorne effect) or repeated study visits. The study also shows the potential of using GPS enabled smartphones to enrich DHS surveys in LMICs like India. However, further studies need to be conducted in other population groups before the findings can be generalised.

Uptake of skilled attendance along the continuum of care in rural Western Kenya: selected analysis from Global Health initiative survey-2012

Background

Examining skilled attendance throughout pregnancy, delivery and immediate postnatal period is proxy indicator on the progress towards reduction of maternal and neonatal mortality in developing countries.

Methods

We conducted a cross-sectional baseline survey of households of mothers with at least 1 child under-5 years in 2012 within the KEMRI/CDC health and demographic surveillance system (HDSS) area in rural western Kenya.

Results

Out of 8260 mother-child pairs, data on antenatal care (ANC) in the most recent pregnancy was obtained for 89% (n = 8260); 97% (n = 7387) reported attendance. Data on number of ANC visits was available for 89% (n = 7140); 52% (n = 6335) of mothers reported ≥4 ANC visits. Data on gestation month at first ANC was available for 94% (n = 7140) of mothers; 14% (n = 6690) reported first visit was in1^sttrimester (0-12 weeks), 73% in 2nd trimester (14-28 weeks) and remaining 13% in third trimester. Forty nine percent (n = 8259) of mothers delivered in a Health Facility (HF), 48% at home and 3% en route to HF. Forty percent (n = 7140) and 63% (n = 4028) of mothers reporting ANC attendance and HF delivery respectively also reported receiving postnatal care (PNC). About 36% (n = 8259) of mothers reported newborn assessment (NBA). Sixty eight percent (n = 3966) of mothers that delivered at home reported taking newborn for HF check-up, with only 5% (n = 2693) doing so within 48 h of delivery. Being ≤34 years (OR 1.8; 95% CI 1.4-2.4) and at least primary education (OR 5.3; 95% CI 1.8-15.3) were significantly associated with ANC attendance. Being ≤34 years (OR 1.7; 95% CI 1.5-2.0), post-secondary vs primary education (OR 10; 95% CI 4.4-23.4), ANC attendance (OR 4.5; 95% CI 3.2-6.1), completing ≥4 ANC visits (OR 2.0; 95% CI 1.8-2.2), were strongly associated with HF delivery. The continuum of care was such that 97% (n = 7387) mothers reported ANC attendance, 49% reported both ANC and HF delivery attendance, 34% reported ANC, HF delivery and PNC attendance and only 18% reported ANC, HF delivery, PNC and NBA attendance.

Conclusion

Uptake of services drastically declined from antenatal to postnatal period, along the continuum of care. Age and education were key determinants of uptake.

Escherichia coli Contamination across Multiple Environmental Compartments (Soil, Hands, Drinking Water, and Handwashing Water) in Urban Harare: Correlations and Risk Factors

Escherichia coli pathotypes (i.e., enteropathogenic and enterotoxigenic) have been identified among the pathogens most responsible for moderate-to-severe diarrhea in low- and middle-income countries (LMICs). Pathogenic E. coli are transmitted from infected human or animal feces to new susceptible hosts via environmental reservoirs such as hands, water, and soil. Commensal E. coli, which includes nonpathogenic E. coli strains, are widely used as fecal bacteria indicator, with their presence associated with increased likelihood of enteric pathogens and/or diarrheal disease. In this study, we investigated E. coli contamination in environmental reservoirs within households (N = 142) in high-population density communities of Harare, Zimbabwe. We further assessed the interconnectedness of the environmental compartments by investigating associations between, and household-level risk factors for, E. coli contamination. From the data we collected, the source and risk factors for E. coli contamination are not readily apparent. One notable exception is the presence of running tap water on the household plot, which is associated with significantly less E. coli contamination of drinking water, handwashing water, and hands after handwashing. In addition, E. coli levels on hands after washing are significantly associated with handwashing water contamination, hand contamination before washing, and diarrhea incidence. Finally, we observed that animal ownership increases E. coli contamination in soil, and E. coli in soil are correlated with contamination on hands before washing. This study highlights the complexity of E. coli contamination in household environments within LMICs. More, larger, studies are needed to better identify sources and exposure pathways of E. coli-and enteric pathogens generally-to identify effective interventions.

[Not Available]

OBJECTIFS

Évaluer le rôle des commodités familiales dans l'occurrence de la diarrhée chez les enfants de moins de 5 ans en Haïti, selon leur type (eau potable, toilettes et réfrigérateur) et leur nombre.MÉTHODE : Nous avons mis en commun les données de quatre Enquêtes démographiques et de santé réalisées en Haïti entre 1994-1995 et 2012. Nous avons retenu un échantillon de 14 481 enfants de 1-59 mois. Nous avons évalué le rôle des commodités familiales dans l'occurrence de la diarrhée selon le groupe d'âge d'enfants à risque (1-5; 6-11; 12-23; 24-59 mois), au moyen des modèles de régression logistique.RÉSULTATS : La prévalence de la diarrhée chez les enfants de 1-59 mois en Haïti est estimée à 29,31 %. Elle atteint 42,14 % chez les enfants de 6-11 mois. Elle est plus faible pour les enfants dont les familles ont accès à une eau potable améliorée, des toilettes améliorées ou un réfrigérateur. Elle est d'autant plus faible que les familles possèdent au moins deux commodités simultanément. Nous ne trouvons pas de différences significatives dans l'occurrence de la diarrhée infanto-juvénile selon l'accès à l'eau potable (p &gt; 0,10). Prenant en compte l'effet de période, une occurrence réduite de la diarrhée est significativement associée aux toilettes améliorées chez les enfants de 24-59 mois (RC : 0,62; p &lt; 0,05) et au réfrigérateur chez les 6-11 mois (RC : 0,11; p &lt; 0,05). Pour le nombre de commodités, seuls les 24-59 mois ayant au moins deux commodités ont une occurrence de la diarrhée statistiquement inférieure de celle des plus défavorisés (RC : 0,45; p &lt; 0,05).

CONCLUSION

Augmenter l'accès aux commodités familiales et leur nombre par ménage demeure essentiel dans la lutte contre la diarrhée en Haïti. Une intervention intégrée serait donc à préconiser dans l'environnement sociosanitaire haïtien.

Child Gender and Parental Reporting of Illness Symptoms in Sub-Saharan Africa

AbstractThe overwhelming majority of evidence about the health of children in low- and middle-income countries is based on reports by parents. There is limited evidence on whether these reports suffer from systematic bias, particularly related to the gender of the child. We investigate differences in symptom reporting by child gender in a sample of countries in sub-Saharan Africa. Data from 35 Demographic and Health Surveys and 10 Malaria Indicator Surveys conducted since 2005 were analyzed. Parental reports of child symptoms were compared for girls and boys. In a subsample of data from Nigeria, we also compared the accuracy of parental reports of fever between girls and boys. Then, potential explanations for observed reporting differences were explored. Finally, country-level relationships between gender differences in symptom reporting and differences in child health outcomes were estimated. Parents reported fewer episodes of fever and diarrhea for girls as compared with boys. Less frequent symptom reporting for girls does not appear to be due to reduced exposure to illness-causing agents nor increased treatment seeking. Lower fever reporting for girls relative to boys is associated with higher relative infant mortality for girls at the country level, consistent with a potential link between underreporting and health outcomes. From a measurement perspective, estimates of gender imbalances in child morbidity and treatment based on parental reports may be inaccurate. From a public health perspective, parental underreporting of symptoms in girls may indicate untreated illness that goes unnoticed.

Slow progress in diarrhea case management in low and middle income countries: evidence from cross-sectional national surveys, 1985-2012

BACKGROUND

Diarrhea remains to be a main cause of childhood mortality. Diarrhea case management indicators reflect the effectiveness of child survival interventions. We aimed to assess time trends and country-wise changes in diarrhea case management indicators among under-5 children in low-and-middle-income countries.

METHODS

We analyzed aggregate data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys done from 1986 to 2012 in low-and-middle-income countries. Two-week prevalence rates of diarrhea, caregiver's care seeking behavior and three case management indicators were analyzed. We assessed overall time trends across the countries using panel data analyses and country-level changes between two sequential surveys.

RESULTS

Overall, yearly increase in case management indicators ranged from 1 · 3 to 2 · 5%. In the year 2012, <50% of the children were given correct treatment (received oral rehydration and increased fluids) for diarrhea. Annually, an estimated 300 to 350 million children were not given oral rehydration solutions, or recommended home fluids or 'increased fluids' and 304 million children not taken to a healthcare provider during an episode of diarrhea. Overall, care seeking for diarrhea, increased from pre-2000 to post-2000, i.e. from 35 to 45%; oral rehydration rates increased by about 7% but the rate of 'increased fluids' decreased by 14%. Country-level trends showed that care seeking had decreased in 15 countries but increased in 33 countries. Care seeking from a healthcare provider increased by ≥10% in about 23 countries. Oral rehydration rates had increased by ≥10% in 15 countries and in 30 countries oral rehydration rates increased by <10%.

CONCLUSIONS

Very limited progress has been made in the case management of childhood diarrhea. A better understanding of caregiver's care seeking behavior and health care provider's case management practices is needed to improve diarrhea case management in low- and-middle-income countries.

Geographical Disparities in the Health of Iranian Women: Health Outcomes, Behaviors, and Health-care Access Indicators

BACKGROUND

Women's health is a key factor affecting the health of the whole population. Tackling inequality in determinants of health is recognized as the main path toward reducing the inequality in health outcomes. This study aimed to analyze the provincial inequality in determinants of women's health and health care in Iran.

METHODS

Using the Moss's model (2002) as a comprehensive framework of determinants of women's health, including "geopolitical environment," "culture, norms, sanctions," "women's roles in reproduction and production," "health-related mediators," and "health outcome" categories, we chose 13 indicators. Afterward, using data sources including the Iranian Multiple Indicators of Demographics and Health Survey, the National Organization for Civil Registration, and Statistics Centre of Iran, we analyzed provincial inequality in these indicators in Iran (2011). Gini coefficient and Lorenz curve were used for measuring inequality.

RESULTS

Gini coefficients calculated as follows; life satisfaction level (0.027), literate women (0.398), women with proper knowledge about HIV/AIDS prevention (0.483), unemployed women (0.380), women without an income (0.384), women who use at least one type of mass media (0.389), women who used computer or internet (0.467), women who had received pregnancy care from a skill birth attendant (SBA) (0.420), women who had delivered with the help of an SBA (0.426), women who currently smoke cigarettes (0.603), women who currently consume hookah (0.561), women with at least one chronic disease (0.438), and women's deaths in 2010 and 2011 (0.393 and 0.359, respectively).

CONCLUSIONS

We found large provincial disparities in determinants of women's health in Iran. Determinants such as lifestyle, health behavior, health knowledge, and health-care services availability should be considered by health policymakers in addressing the inequality in women's health at a provincial level.

Disposal of children's stools and its association with childhood diarrhea in India

BACKGROUND

Children's stool disposal is often overlooked in sanitation programs of any country. Unsafe disposal of children's stool makes children susceptible to many diseases that transmit through faecal-oral route. Therefore, the study aims to examine the magnitude of unsafe disposal of children's stools in India, the factors associated with it and finally its association with childhood diarrhea.

METHODS

Data from the third round of the National Family Health Survey (NFHS-3) conducted in 2005-06 is used to carry out the analysis. The binary logistic regression model is used to examine the factors associated with unsafe disposal of children's stool. Binary logistic regression is also used to examine the association between unsafe disposal of children's stool and childhood diarrhea.

RESULT

Overall, stools of 79% of children in India were disposed of unsafely. The urban-rural gap in the unsafe disposal of children's stool was wide. Mother's illiteracy and lack of exposure to media, the age of the child, religion and caste/tribe of the household head, wealth index, access to toilet facility and urban-rural residence were statistically associated with unsafe disposal of stool. The odds of diarrhea in children whose stools were disposed of unsafely was estimated to be 11% higher (95% CI: 1.01-1.21) than that of children whose stools were disposed of safely. An increase in the unsafe disposal of children's stool in the community also increased the risk of diarrhea in children.

CONCLUSION

We found significant statistical association between children's stool disposal and diarrhea. Therefore, gains in reduction of childhood diarrhea can be achieved in India through the complete elimination of unsafe disposal of children's stools. The sanitation programmes currently being run in India must also focus on safe disposal of children's stool.

Exploring geographic distributions of high-risk water, sanitation, and hygiene practices and their association with child diarrhea in Uganda

Background

High-risk water, sanitation, and hygiene (WASH) practices are still prevalent in most low-income countries. Because of limited access to WASH, children may be put at an increased risk of diarrheal diseases.

Objectives

This study aims to 1) develop a new measure of WASH-induced burden, the WASH Resource Index (WRI), and estimate its correlation with child diarrhea and an additive index of high-risk WASH practices; 2) explore the geographic distribution of high-risk WASH practices, child diarrhea, and summary indices at the cluster level; and 3) examine the association between the WRI and child diarrhea at the individual level.

Design

A sample of 7,019 children from the Uganda Demographic and Health Survey 2011 were included in this study. Principal component analysis was used to develop a WRI, and households were classified as WASH poorest, poorer, middle, richer, and richest. A hot spot analysis was conducted to assess whether and how high-risk WASH practices and child diarrhea were geographically clustered. A potential association between the WRI and child diarrhea was examined through a nested regression analysis.

Results

High-risk WASH practices were clustered at geographically distant regions from Kampala. The 2-week prevalence of child diarrhea, however, was concentrated in Eastern and East Central regions where high-risk WASH practices were not prevalent. At the individual level, none of the high-risk WASH practices were significantly associated with child diarrhea. Being in the highest WASH quintile was, however, significantly associated with 24.9% lower prevalence of child diarrhea compared to being in the lowest quintile (p<0.05).

Conclusions

Only a weak association was found between the WRI and child diarrhea in this study. Future research should explore the potential utility of the WRI to examine WASH-induced burden.

Findings from a comprehensive diarrhoea prevention and treatment programme in Lusaka, Zambia

BACKGROUND

The Programme for the Awareness and Elimination of Diarrhoea (PAED) was a pilot comprehensive diarrhoea prevention and control programme aimed to reduce post-neonatal, all-cause under-five mortality by 15 % in Lusaka Province. Interventions included introduction of the rotavirus vaccine, improved clinical case management of diarrhoea, and a comprehensive community prevention and advocacy campaign on hand washing with soap, exclusive breastfeeding up to 6 months of age, and the use of ORS and Zinc. This study aimed to assess the impact of PAED on under-5 mortality.

METHODS

The study was a pre-post evaluation design. The Demographic and Health Survey style population-based two-stage approach was used to collect data at the beginning of the intervention and 3 years following the start of intervention implementation in Lusaka province. The primary outcome of interest was an all-cause, post-neonatal under-five mortality rate defined as the probability of dying after the 28th day and before the fifth birthday among children aged 1-59 months. The Kaplan-Meier time to event analysis was used to estimate the probability of death; multiplying this probability by 1000 to yield the post-neonatal mortality rate. Survival-time inverse probability weighting model was used to estimate Average Treatment Effect (ATE).

RESULTS

The percentage of children under age 5 who had diarrhoea in the last 2 weeks preceding the survey declined from 15.8 % (95 % CI: 15.2 %, 16.4 %) in 2012 to 12.7 % (95 % CI: 12.3 %, 13.2 %) in 2015. Over the same period, mortality in post-neonatal children under 5 years of age declined by 34 %, from an estimated rate of 29 deaths per 1000 live births (95 % CI: (26, 32) death per 1000 live births) to 19 deaths per 1000 live births (95 % CI: (16, 21) death per 1000 live births). When every child in the population of children aged 1-59 months is exposed to the intervention, the average time-to-death was estimated to be about 8 months more than when no child is exposed (ATE = 7.9; 95 % CI: 4.4,11.5; P < 0.001).

CONCLUSION

Well-packaged diarrhoea preventive and treatment interventions delivered at the clinic and community-level could potentially reduce probability of death among children aged 1-59 months.

Vitamin-D status is not a confounder of the relationship between zinc and diarrhoea: a study in 6-24-month-old underweight and normal-weight children of urban Bangladesh

BACKGROUND/OBJECTIVE

The role of micronutrients particularly zinc in childhood diarrhoea is well established. Immunomodulatory functions of vitamin-D in diarrhoea and its role in the effect of other micronutrients are not well understood. This study aimed to investigate whether vitamin-D directly associated or confounded the association between other micronutrient status and diarrhoeal incidence and severity in 6-24-month underweight and normal-weight children in urban Bangladesh.

SUBJECTS/METHODS

Multivariable generalised estimating equations were used to estimate incidence rate ratios for incidence (Poisson) and severity (binomial) of diarrhoea on cohorts of 446 normal-weight and 466 underweight children. Outcomes of interest included incidence and severity of diarrhoea, measured daily during a follow-up period of 5 months. The exposure of interest was vitamin-D status at enrolment.

RESULTS

Normal-weight and underweight children contributed 62 117 and 62 967 day observation, with 14.2 and 12.8 days/child/year of diarrhoea, respectively. None of the models showed significant associations of vitamin-D status with diarrhoeal morbidity. In the final model, zinc-insufficient normal-weight children had 1.3 times more days of diarrhoea than sufficient children (P<0.05). Again zinc insufficiency and mother's education (1-5 and >5 years) had 1.8 and 2.3 times more risk of severe diarrhoea. In underweight children, older age and female had 24-63 and 17% fewer days of diarrhoea and 52-54 and 31% fewer chances of severe diarrhoea.

CONCLUSION

Vitamin-D status was not associated with incidence and severity of diarrhoea in study children. Role of zinc in diarrhoea was only evident in normal-weight children. Our findings demonstrate that vitamin-D is not a confounder of the relationship between zinc and diarrhoea.

Measuring population health: costs of alternative survey approaches in the Nouna Health and Demographic Surveillance System in rural Burkina Faso

BACKGROUND

There are more than 40 Health and Demographic Surveillance System (HDSS) sites in 19 different countries. The running costs of HDSS sites are high. The financing of HDSS activities is of major importance, and adding external health surveys to the HDSS is challenging. To investigate the ways of improving data quality and collection efficiency in the Nouna HDSS in Burkina Faso, the stand-alone data collection activities of the HDSS and the Household Morbidity Survey (HMS) were integrated, and the paper-based questionnaires were consolidated into a single tablet-based questionnaire, the Comprehensive Disease Assessment (CDA).

OBJECTIVE

The aims of this study are to estimate and compare the implementation costs of the two different survey approaches for measuring population health.

DESIGN

All financial costs of stand-alone (HDSS and HMS) and integrated (CDA) surveys were estimated from the perspective of the implementing agency. Fixed and variable costs of survey implementation and key cost drivers were identified. The costs per household visit were calculated for both survey approaches.

RESULTS

While fixed costs of survey implementation were similar for the two survey approaches, there were considerable variations in variable costs, resulting in an estimated annual cost saving of about US$45,000 under the integrated survey approach. This was primarily because the costs of data management for the tablet-based CDA survey were considerably lower than for the paper-based stand-alone surveys. The cost per household visit from the integrated survey approach was US$21 compared with US$25 from the stand-alone surveys for collecting the same amount of information from 10,000 HDSS households.

CONCLUSIONS

The CDA tablet-based survey method appears to be feasible and efficient for collecting health and demographic data in the Nouna HDSS in rural Burkina Faso. The possibility of using the tablet-based data collection platform to improve the quality of population health data requires further exploration.

Geographic distribution and mortality risk factors during the cholera outbreak in a rural region of Haiti, 2010-2011

Background

In 2010 and 2011, Haiti was heavily affected by a large cholera outbreak that spread throughout the country. Although national health structure-based cholera surveillance was rapidly initiated, a substantial number of community cases might have been missed, particularly in remote areas. We conducted a community-based survey in a large rural, mountainous area across four districts of the Nord department including areas with good versus poor accessibility by road, and rapid versus delayed response to the outbreak to document the true cholera burden and assess geographic distribution and risk factors for cholera mortality.

Methodology/Principal Findings

A two-stage, household-based cluster survey was conducted in 138 clusters of 23 households in four districts of the Nord Department from April 22^nd to May 13^th 2011. A total of 3,187 households and 16,900 individuals were included in the survey, of whom 2,034 (12.0%) reported at least one episode of watery diarrhea since the beginning of the outbreak. The two more remote districts, Borgne and Pilate were most affected with attack rates up to 16.2%, and case fatality rates up to 15.2% as compared to the two more accessible districts. Care seeking was also less frequent in the more remote areas with as low as 61.6% of reported patients seeking care. Living in remote areas was found as a risk factor for mortality together with older age, greater severity of illness and not seeking care.

Conclusions/Significance

These results highlight important geographical disparities and demonstrate that the epidemic caused the highest burden both in terms of cases and deaths in the most remote areas, where up to 5% of the population may have died during the first months of the epidemic. Adapted strategies are needed to rapidly provide treatment as well as prevention measures in remote communities.

In October 2010, a large cholera outbreak was declared in Haiti and rapidly spread throughout the country, quickly overwhelming the existing health system. Specialized treatment structures were opened rapidly, generally in cities or large villages, and decentralized treatment units or rehydration points were gradually opened later on. To gain insight into the true burden of the cholera outbreak in the community and on potential geographical differences due to accessibility, we conducted a survey in April–May 2011 in a large rural area across four mountainous districts in the Nord department. We interviewed 3,187 households, corresponding to 16,900 individuals, of whom 2,034 (12%) had had diarrhea, probably cholera, since the beginning of the outbreak. The two most remote districts showed higher proportions of population affected by the disease, up to 16.2%, and higher proportions of deaths among patients with probable cholera, up to 15.2%, than the two districts with better accessibility. Remote populations, older patients, severe cases and those not seeking care were at increased risk of dying of the disease. These results show the very high burden of the cholera outbreak in remote areas, emphasizing the need to develop strategies to rapidly provide treatment and prevention measures in remote communities.

Relevance of Health Knowledge in Reporting Maternal Health Complications and Use of Maternal Health Care in India

We measured levels of women's health knowledge and their association with the reporting of maternal health complications and related health care use. We found that women with higher levels of health knowledge reported more pregnancy and postnatal complications, and used more maternal health care services. Education has a positive impact on health, but education alone is not enough to ensure recognizing and reporting of health complications and increasing the demand for maternal health care services. We conclude that the provision of health education for women will help them to identify maternal health complications and improve their reporting and related health care use.

'In general, how do you feel today?'--self-rated health in the context of aging in India

This thesis is centered on self-rated health (SRH) as an outcome measure, as a predictor, and as a marker. The thesis uses primary data from the WHO Study on global AGEing and adult health (SAGE) implemented in India in 2007. The structural equation modeling approach is employed to understand the pathways through which the social environment, disability, disease, and sociodemographic characteristics influence SRH among older adults aged 50 years and above. Cox proportional hazard model is used to explore the role of SRH as a predictor for mortality and the role of disability in modifying this effect. The hierarchical ordered probit modeling approach, which combines information from anchoring vignettes with SRH, was used to address the long overlooked methodological concern of interpersonal incomparability. Finally, multilevel model-based small area estimation techniques were used to demonstrate the use of large national surveys and census information to derive precise SRH prevalence estimates at the district and sub-district level. The thesis advocates the use of such a simple measure to identify vulnerable communities for targeted health interventions, to plan and prioritize resource allocation, and to evaluate health interventions in resource-scarce settings. The thesis provides the basis and impetus to generate and integrate similar and harmonized adult health and aging data platforms within demographic surveillance systems in different regions of India and elsewhere.

Routine vaccination coverage in low- and middle-income countries: further arguments for accelerating support to child vaccination services

BACKGROUND AND OBJECTIVE

The Expanded Programme on Immunization was introduced by the World Health Organization (WHO) in all countries during the 1970s. Currently, this effective public health intervention is still not accessible to all. This study evaluates the change in routine vaccination coverage over time based on survey data and compares it to estimations by the WHO and United Nations Children's Fund (UNICEF).

DESIGN

Data of vaccination coverage of children less than 5 years of age was extracted from Demographic and Health Surveys (DHS) conducted in 71 low- and middle-income countries during 1986-2009. Overall trends for vaccination coverage of tuberculosis, diphtheria, tetanus, pertussis, polio and measles were analysed and compared to WHO and UNICEF estimates.

RESULTS

From 1986 to 2009, the annual average increase in vaccination coverage of the studied diseases ranged between 1.53 and 1.96% units according to DHS data. Vaccination coverage of diphtheria, tetanus, pertussis, polio and measles was all under 80% in 2009. Non-significant differences in coverage were found between DHS data and WHO and UNICEF estimates.

CONCLUSIONS

The coverage of routine vaccinations in low- and middle-income countries may be lower than that previously reported. Hence, it is important to maintain and increase current vaccination levels.

Health care seeking for childhood diarrhea in developing countries: evidence from seven sites in Africa and Asia

We performed serial Health Care Utilization and Attitudes Surveys (HUASs) among caretakers of children ages 0–59 months randomly selected from demographically defined populations participating in the Global Enteric Multicenter Study (GEMS), a case-control study of moderate-to-severe diarrhea (MSD) in seven developing countries. The surveys aimed to estimate the proportion of children with MSD who would present to sentinel health centers (SHCs) where GEMS case recruitment would occur and provide a basis for adjusting disease incidence rates to include cases not seen at the SHCs. The proportion of children at each site reported to have had an incident episode of MSD during the 7 days preceding the survey ranged from 0.7% to 4.4% for infants (0–11 months of age), from 0.4% to 4.7% for toddlers (12–23 months of age), and from 0.3% to 2.4% for preschoolers (24–59 months of age). The proportion of MSD episodes at each site taken to an SHC within 7 days of diarrhea onset was 15–56%, 17–64%, and 7–33% in the three age strata, respectively. High cost of care and insufficient knowledge about danger signs were associated with lack of any care-seeking outside the home. Most children were not offered recommended fluids and continuing feeds at home. We have shown the utility of serial HUASs as a tool for optimizing operational and methodological issues related to the performance of a large case-control study and deriving population-based incidence rates of MSD. Moreover, the surveys suggest key targets for educational interventions that might improve the outcome of diarrheal diseases in low-resource settings.

Associations between Infant Feeding Practices and Length, Weight, and Disease in Developing Countries

The health benefits of exclusive breastfeeding are well-known, but the relative detrimental impacts of other foods on infant health are unknown. Because infants in developing countries are fed a wide range of food, quantifying the burden of these diverse feeding practices on infant health is essential for public health policy. We used data from the Demographic Health Survey from 20 developing countries over multiple years to examine the independent association of six different types of food (exclusive breastfeeding, non-exclusive breastfeeding, infant formula, milk liquids, non-milk liquids, and solid foods) with five measures of infant health (length, weight, diarrhea, fever, and cough). We estimated associations with regression analysis, controlling for confounding factors with infant, mother, and household factors and community-year fixed effects. We used these estimates in a simulation model to quantify the burden of different combinations of food on infant health. We show that for an infant younger than 6 months old, following current guidelines and exclusively breastfeeding instead of giving the infant solid foods may increase length by 0.75 cm and weight by 0.25 kg and decrease diarrhea, fever, and cough prevalence by 8, 12, and 11%, respectively. We found that the burden on infant health of some feeding practices is less than others. Although all other feeding practices are associated with worse health outcomes than exclusive breastfeeding, breastfeeding supplemented with liquids has a lower burden on infant health than solid foods and infant formula has a lower burden than milk or non-milk liquids as measured by four of five health metrics. Providing specific quantified burden estimates of these practices can help inform public health policy related to infant feeding practices.

Validity of vaccination cards and parental recall to estimate vaccination coverage: a systematic review of the literature

Immunization programs frequently rely on household vaccination cards, parental recall, or both to calculate vaccination coverage. This information is used at both the global and national level for planning and allocating performance-based funds. However, the validity of household-derived coverage sources has not yet been widely assessed or discussed. To advance knowledge on the validity of different sources of immunization coverage, we undertook a global review of literature. We assessed concordance, sensitivity, specificity, positive and negative predictive value, and coverage percentage point difference when subtracting household vaccination source from a medical provider source. Median coverage difference per paper ranged from -61 to +1 percentage points between card versus provider sources and -58 to +45 percentage points between recall versus provider source. When card and recall sources were combined, median coverage difference ranged from -40 to +56 percentage points. Overall, concordance, sensitivity, specificity, positive and negative predictive value showed poor agreement, providing evidence that household vaccination information may not be reliable, and should be interpreted with care. While only 5 papers (11%) included in this review were from low-middle income countries, low-middle income countries often rely more heavily on household vaccination information for decision making. Recommended actions include strengthening quality of child-level data and increasing investments to improve vaccination card availability and card marking. There is also an urgent need for additional validation studies of vaccine coverage in low and middle income countries.

Epidemiological methods in diarrhoea studies--an update

BACKGROUND

Diarrhoea remains a leading cause of morbidity and mortality but is difficult to measure in epidemiological studies. Challenges include the diagnosis based on self-reported symptoms, the logistical burden of intensive surveillance and the variability of diarrhoea in space, time and person.

METHODS

We review current practices in sampling procedures to measure diarrhoea, and provide guidance for diarrhoea measurement across a range of study goals. Using 14 available data sets, we estimated typical design effects for clustering at household and village/ neighbourhood level, and measured the impact of adjusting for baseline variables on the precision of intervention effect estimates.

RESULTS

Incidence is the preferred outcome measure in aetiological studies, health services research and vaccine trials. Repeated prevalence measurements (longitudinal prevalence) are appropriate in high-mortality settings where malnutrition is common, although many repeat measures are rarely useful. Period prevalence is an inadequate outcome if an intervention affects illness duration. Adjusting point estimates for age or diarrhoea at baseline in randomized trials has little effect on the precision of estimates. Design effects in trials randomized at household level are usually <2 (range 1.0–3.2). Design effects for larger clusters (e.g. villages or neighbourhoods) vary greatly among different settings and study designs (range 0.1–25.8).

CONCLUSIONS

Using appropriate sampling strategies and outcome measures can improve the efficiency, validity and comparability of diarrhoea studies. Allocating large clusters in cluster randomized trials is compromized by unpredictable design effects and should be carried out only if the research question requires it.

Towards universal health coverage: the role of within-country wealth-related inequality in 28 countries in sub-Saharan Africa

OBJECTIVE

To measure within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators in sub-Saharan Africa and quantify its contribution to the national health service coverage gap.

METHODS

Coverage data for child and maternal health services in 28 sub-Saharan African countries were obtained from the 2000-2008 Demographic Health Survey. For each country, the national coverage gap was determined for an overall health service coverage index and select individual health service indicators. The data were then additively broken down into the coverage gap in the wealthiest quintile (i.e. the proportion of the quintile lacking a required health service) and the population attributable risk (an absolute measure of within-country wealth-related inequality).

FINDINGS

In 26 countries, within-country wealth-related inequality accounted for more than one quarter of the national overall coverage gap. Reducing such inequality could lower this gap by 16% to 56%, depending on the country. Regarding select individual health service indicators, wealth-related inequality was more common in services such as skilled birth attendance and antenatal care, and less so in family planning, measles immunization, receipt of a third dose of vaccine against diphtheria, pertussis and tetanus and treatment of acute respiratory infections in children under 5 years of age.

CONCLUSION

The contribution of wealth-related inequality to the child and maternal health service coverage gap differs by country and type of health service, warranting case-specific interventions. Targeted policies are most appropriate where high within-country wealth-related inequality exists, and whole-population approaches, where the health-service coverage gap is high in all quintiles.

Prenatal docosahexaenoic acid supplementation and infant morbidity: randomized controlled trial

OBJECTIVE

Long-chain polyunsaturated fatty acids such as docosahexaenoic acid (DHA) influence immune function and inflammation; however, the influence of maternal DHA supplementation on infant morbidity is unknown. We investigated the effects of prenatal DHA supplementation on infant morbidity.

METHODS

In a double-blind randomized controlled trial conducted in Mexico, pregnant women received daily supplementation with 400 mg of DHA or placebo from 18 to 22 weeks' gestation through parturition. In infants aged 1, 3, and 6 months, caregivers reported the occurrence of common illness symptoms in the preceding 15 days.

RESULTS

Data were available at 1, 3, and 6 months for 849, 834, and 834 infants, respectively. The occurrence of specific illness symptoms did not differ between groups; however, the occurrence of a combined measure of cold symptoms was lower in the DHA group at 1 month (OR: 0.76; 95% CI: 0.58-1.00). At 1 month, the DHA group experienced 26%, 15%, and 30% shorter duration of cough, phlegm, and wheezing, respectively, but 22% longer duration of rash (all P ≤ .01). At 3 months, infants in the DHA group spent 14% less time ill (P < .0001). At 6 months, infants in the DHA group experienced 20%, 13%, 54%, 23%, and 25% shorter duration of fever, nasal secretion, difficulty breathing, rash, and "other illness," respectively, but 74% longer duration of vomiting (all P < .05).

CONCLUSIONS

DHA supplementation during pregnancy decreased the occurrence of colds in children at 1 month and influenced illness symptom duration at 1, 3, and 6 months.

Health care seeking behavior for diarrhea in children under 5 in rural Niger: results of a cross-sectional survey

BACKGROUND

Diarrhea remains the second leading cause of death in children under 5 years of age in sub-Saharan Africa. Health care seeking behavior for diarrhea varies by context and has important implications for developing appropriate care strategies and estimating burden of disease. The objective of this study was to determine the proportion of children under five with diarrhea who consulted at a health structure in order to identify the appropriate health care levels to set up surveillance of severe diarrheal diseases.

METHODS

A cluster survey was done on 35 clusters of 21 children under 5 years of age in each of four districts of the Maradi Region, Niger. Caretakers were asked about diarrhea of the child during the recall period and their health seeking behavior in case of diarrhea. A weighted cluster analysis was conducted to determine the prevalence of diarrhea, as well as the proportion of consultations and types of health structures consulted.

RESULTS

In total, the period prevalence of diarrhea and severe diarrhea between April 24th and May 21st 2009 were 36.8% (95% CI: 33.7 - 40.0) and 3.4% (95% CI: 2.2-4.6), respectively. Of those reporting an episode of diarrhea during the recall period, 70.4% (95% CI: 66.6-74.1) reported seeking care at a health structure. The main health structures visited were health centers, followed by health posts both for simple or severe diarrhea. Less than 10% of the children were brought to the hospital. The proportion of consultations was not associated with the level of education of the caretaker, but increased with the number of children in the household.

CONCLUSIONS

The proportion of consultations for diarrhea cases in children under 5 years old was higher than those reported in previous surveys in Niger and elsewhere. Free health care for under 5 years old might have participated in this improvement. In this type of decentralized health systems, the WHO recommended hospital-based surveillance of severe diarrheal diseases would capture only a fraction of severe diarrhea. Lower levels of health structures should be considered to obtain informative data to ensure appropriate care and burden estimates.

Effects of state-level public spending on health on the mortality probability in India

This study uses the second National Family Health Survey of India to estimate the effect of state-level public health spending on mortality across all age groups, controlling for individual, household, and state-level covariates. We use a state's gross fiscal deficit as an instrument for its health spending. Our study shows a 10% increase in public spending on health in India decreases the average probability of death by about 2%, with effects mainly on the young, the elderly, and women. Other major factors affecting mortality are rural residence, household poverty, and access to toilet facilities.

Molecular epidemiological investigation of a typhoid fever outbreak in South Africa, 2005: the relationship to a previous epidemic in 1993

In 2005, over 600 clinically diagnosed typhoid fever cases occurred in South Africa, where an outbreak had been previously described in 1993. Case-control and molecular investigations, including Salmonella enterica serovar Typhi (S. Typhi) isolates from that area from 1993, 2005 and later, were undertaken. Controls were significantly older than cases (P=0·003), possibly due to immunity from previous infection, and a significantly larger proportion had attended a gathering (P=0·035). Exposure to commercial food outlets and person-to-person transmission was not significant. Pulsed-field gel electrophoresis and multi-locus tandem repeat analysis revealed common clusters of S. Typhi strains identified in 1993 and 2005 as well as in 2007 and 2009. This outbreak probably occurred in a non-immune population due to faecally contaminated water. S. Typhi strains appeared to be related to strains from 1993; failure to address unsafe water may lead to further outbreaks in the area if the current population immunity wanes or is lost.

Diarrhoea morbidity and mortality in older children, adolescents, and adults

Diarrhoea is a leading cause of morbidity and mortality yet diarrhoea specific incidence and mortality rates for older children, adolescents, and adults have not been systematically calculated for many countries. We conducted a systematic literature review to generate regional incidence rates by age and to summarize diarrhoea specific mortality rates for regions of the world with inadequate vital registration data. Diarrhoea morbidity rates range from 29·9 episodes/100 person-years for adults in the South East Asian region to 88·4 episodes/100 person-years in older children in the Eastern Mediterranean region and have remained unchanged in the last 30 years. Diarrhoea mortality rates decline as the child ages and remain relatively constant during adulthood. These data are critical for improving estimates worldwide and further highlight the need for improved diarrhoea specific morbidity and mortality data in these age groups.

Heterogeneity in the validity of administrative-based estimates of immunization coverage across health districts in Burkina Faso: implications for measurement, monitoring and planning

Background Data aggregation in national information systems begins at the district level. Decentralization has given districts a lead role in health planning and management, therefore validity of administrative-based estimates at that level is important to improve the performance of immunization information systems.

Objective To assess the validity of administrative-based immunization estimates and their usability for planning and monitoring activities at district level.

Methods DTP3 and measles coverage rates from administrative sources were compared with estimates from the EPI cluster survey (ECS) and Demographic and Health Survey (DHS) carried out in 2003 at national and regional levels. ECS estimates were compared with administrative rates across the 52 districts, which were classified into three groups: those where administrative rates were underestimating, overestimating or concordant with ECS estimates (differences within 95% CI of ECS rate).

Results National rates provided by administrative data and ECS are similar (74% and 71% for DTP3 and 68% and 66% for measles, respectively); DHS estimates are much lower. Regional administrative data show large discrepancies when compared against ECS and DHS data (differences sometimes reaching 30 percentage points). At district level, geographical area is correlated with over- or underestimation by administrative sources, which overestimate DTP3 and measles coverage in remote areas. Underestimation is observed in districts near urban and highly populated centres. Over- and underestimation are independent of the antigen under consideration.

Conclusions Variability in immunization coverage across districts highlights the limitations of using nationally aggregated indicators. If district data are to be used in monitoring and planning immunization programmes as intended by decentralization, heterogeneity in their validity must be reduced. The authors recommend: (1) strengthening administrative data systems; (2) implementing indicators that are insensitive to population mobility; (3) integrating surveys into monitoring processes at the subnational level; (4) actively promoting the use of coverage information by local personnel and district-level staff.

Morbidity and mortality disparities among colonist and indigenous populations in the Ecuadorian Amazon

Rural populations living in the northern Ecuadorian Amazon (NEA) experience the highest health burden of any region in the country. Two independent studies of colonist and indigenous groups living in the NEA are used to compare their morbidity and mortality experiences. Colonist data are from a probability sample of land plots in 1999, while indigenous data are from a representative sample of the five largest ethnicities (Quichua, Shuar, Huaorani, Cofan, Secoya) collected in 2001. Poisson regression was used to compare morbidity. Results indicate clear differences in health between populations. Indigenous groups had 30% higher probability of mortality and 63% higher incidence rate of all-cause morbidity compared to colonists. Vector-borne, chronic, gastrointestinal, and diseases of unknown origin were particularly high among indigenous groups. Factors associated with morbidity varied: morbidity rates were similar for the two youngest age groups (0-4 and 5-9), but indigenous people aged 15-39 and 40+ had almost double the morbidity compared to colonists; larger households, later months of data collection and less pollution were associated with less morbidity in both groups; better infrastructure access (electricity and roads) was generally associated with lower morbidity in both groups; and associations of land use were different by group with more cultivation of perennials and fewer annuals associated with less morbidity for colonists, but more for indigenous groups. These results demonstrate the health disparities that exist among indigenous and non-indigenous populations even when living in the same geographic region. Land use itself exemplifies the cultural and contextual differences that are evident in health, since land use decisions are related to broader demographic and economic factors that influence overall ecological and human health. Ongoing population-environment and/or environment-health research needs to recognize the broader factors involved when studying relationships between population health, development and deforestation.

Recall errors in a weekly survey of diarrhoea in Guatemala: determining the optimal length of recall

We measured the recall error, optimal recall length and factors associated with diarrhoea in a weekly survey. Data was taken from a year-long randomized controlled trial in which characteristics of diarrhoeal episodes were recorded weekly. We labelled the recall period as days 1–6; day 1 being the day before the visit. Recall error was the percentage difference between the number of episodes reported to begin on a particular day and the mean for days 1 and 2. Generalized estimating equations were used to determine associations. Recall error was 37% on day 3 and 51% on day 5. The error was less in younger children (by 10%), severe episodes (by 29%) and when blood was present in the stool (by 18%). Diarrhoea was underreported when the recall period extended beyond 2 days. Surveys that use longer recall periods risk underestimating diarrhoea incidence and selectively capturing more severe episodes.

Measuring outcomes in a longitudinal birth cohort

Longitudinal studies are often focussed on specific outcomes to address predetermined hypotheses. Nevertheless, many discoveries have been made with data collected that were not part of the original design. Measurement of a broad range of outcomes is therefore important. Here we describe examples of the types of outcome that a birth cohort should collect, with emphasis on accuracy. We emphasise the use of continuous traits as well as of dichotomous outcomes, using a variety of examples.

Are self-reports of health and morbidities in developing countries misleading? Evidence from India

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual's assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross-sectional logistic regression analyses were carried out on a nationally representative population-based sample from the 1998 to 1999 Indian National Family Health Survey (INFHS); and 1995-1996 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill-health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.