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Bendavid E, Boerma T, Akseer N, Langer A, Malembaka EB, Okiro EA, Wise PH, Heft-Neal S, Black RE, Bhutta ZA. The effects of armed conflict on the health of women and children. Lancet 2021; 397:522-532. [PMID: 33503456 PMCID: PMC7612212 DOI: 10.1016/s0140-6736(21)00131-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 01/16/2023]
Abstract
Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.
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Affiliation(s)
- Eran Bendavid
- Center for Population Health Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University, CA, USA.
| | - Ties Boerma
- Center for Global Public Health, University of Manitoba, Winnipeg, MB, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children (SickKids), Toronto, ON, Canada; The Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ana Langer
- Women and Health Initiative, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, Faculté de Médecine, Université Catholique de Bukavu, Bukavu, DR Congo
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Paul H Wise
- Department of Pediatrics, Stanford University, CA, USA
| | - Sam Heft-Neal
- Center on Food Security and the Environment, Stanford University, CA, USA
| | - Robert E Black
- The Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children (SickKids), Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
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Jordan K, Lewis TP, Roberts B. Quality in crisis: a systematic review of the quality of health systems in humanitarian settings. Confl Health 2021; 15:7. [PMID: 33531065 PMCID: PMC7851932 DOI: 10.1186/s13031-021-00342-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings. Methods This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain. Results We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety. Conclusion The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00342-z.
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Affiliation(s)
- Keely Jordan
- Department of Health Policy, New York University School of Global Public Health, 665 Broadway, New York, NY, 10012, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Poole DN, Raymond NA, Berens J, Latonero M, Ricard J, Hedt-Gauthier B. A combination sampling approach for epidemiologic research in humanitarian settings: a case analysis of a study of depressive disorder prevalence among refugees in Greece. BMC Public Health 2021; 21:272. [PMID: 33530961 PMCID: PMC7856792 DOI: 10.1186/s12889-021-10342-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the burden of common mental health disorders, such as depressive disorder, is the first step in strengthening prevention and treatment in humanitarian emergencies. However, simple random sampling methods may lead to a high risk of coercion in settings characterized by a lack of distinction between researchers and aid organizations, mistrust, privacy concerns, and the overarching power differential between researchers and populations affected by crises. This case analysis describes a sampling approach developed for a survey study of depressive disorder in a Syrian refugee camp in Greece (n = 135). DISCUSSION Syrian refugees face an extraordinarily high burden of depressive disorder during the asylum process (43%), necessitating population screening, prevention, and treatment. In order to preserve the informed consent process in this refugee camp setting, the research team developed a two-phase sampling strategy using a map depicting the geographical layout of the housing units within the camp. In the first phase, camp management announced a research study was being undertaken and individuals were invited to volunteer to participate. The participants' container (housing) numbers were recorded on the map, but were not linked to the survey data. Then, in the second phase, the camp map was used for complementary sampling to reach a sample sufficient for statistical analysis. As a result of the two phases of the sampling exercise, all eligible adults from half the containers in each block were recruited, producing a systematic, age- and sex-representative sample. CONCLUSIONS Combining sampling procedures in humanitarian emergencies can reduce the risk of coerced consent and bias by allowing participants to approach researchers in the first phase, with a second phase of sampling conducted to recruit a systematic sample. This case analysis illuminates the feasibility of a two-phase sampling approach for drawing a quasi-random, representative sample in a refugee camp setting.
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Affiliation(s)
- Danielle N Poole
- Neukom Institute for Computational Science, Dartmouth College, Hanover, NH, 03755, USA.
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
- Harvard Humanitarian Initiative, Harvard T.H. Chan School of Public Health, 14 Story Street, Cambridge, MA, 02138, USA.
| | - Nathaniel A Raymond
- Jackson Institute of Global Affairs, Yale University, 55 Hillhouse Avenue, New Haven, CT, 06520, USA
| | - Jos Berens
- Centre for Innovation, Leiden University, Den Haag, 2511 VA, The Netherlands
| | - Mark Latonero
- Data & Society Research Institute, New York, NY, 10011, USA
| | | | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
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Kishore N, Marqués D, Mahmud A, Kiang MV, Rodriguez I, Fuller A, Ebner P, Sorensen C, Racy F, Lemery J, Maas L, Leaning J, Irizarry RA, Balsari S, Buckee CO. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med 2018; 379:162-170. [PMID: 29809109 DOI: 10.1056/nejmsa1803972] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64. METHODS Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. RESULTS From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial. CONCLUSIONS This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.).
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Affiliation(s)
- Nishant Kishore
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Domingo Marqués
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Ayesha Mahmud
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Mathew V Kiang
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Irmary Rodriguez
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Arlan Fuller
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Peggy Ebner
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Cecilia Sorensen
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Fabio Racy
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Jay Lemery
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Leslie Maas
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Jennifer Leaning
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Rafael A Irizarry
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Satchit Balsari
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
| | - Caroline O Buckee
- From the Departments of Epidemiology (N.K., A.M., C.O.B.), Social and Behavioral Sciences (M.V.K.), and Biostatistics (R.A.I.) and the Center for Communicable Disease Dynamics (N.K., A.M., C.O.B.) and the François-Xavier Bagnoud Center for Health and Human Rights (A.F., J. Leaning, S.B.), Harvard T.H. Chan School of Public Health, Harvard University, the Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (F.R., S.B.), and the Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute (R.A.I.) - all in Boston; the Department of Psychology, Carlos Albizu University (D.M., I.R.), and the Puerto Rico Science, Technology, and Research Trust (L.M.) - both in San Juan; Keck School of Medicine, University of Southern California, Los Angeles (P.E.); and the Section of Wilderness and Environmental Medicine at the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (C.S., J. Lemery)
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Grellety E, Golden MH. Change in quality of malnutrition surveys between 1986 and 2015. Emerg Themes Epidemiol 2018; 15:8. [PMID: 29872451 PMCID: PMC5972441 DOI: 10.1186/s12982-018-0075-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 05/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Representative surveys collecting weight, height and MUAC are used to estimate the prevalence of acute malnutrition. The results are then used to assess the scale of malnutrition in a population and type of nutritional intervention required. There have been changes in methodology over recent decades; the objective of this study was to determine if these have resulted in higher quality surveys. METHODS In order to examine the change in reliability of such surveys we have analysed the statistical distributions of the derived anthropometric parameters from 1843 surveys conducted by 19 agencies between 1986 and 2015. RESULTS With the introduction of standardised guidelines and software by 2003 and their more general application from 2007 the mean standard deviation, kurtosis and skewness of the parameters used to assess nutritional status have each moved to now approximate the distribution of the WHO standards when the exclusion of outliers from analysis is based upon SMART flagging procedure. Where WHO flags, that only exclude data incompatible with life, are used the quality of anthropometric surveys has improved and the results now approach those seen with SMART flags and the WHO standards distribution. Agencies vary in their uptake and adherence to standard guidelines. Those agencies that fully implement the guidelines achieve the most consistently reliable results. CONCLUSIONS Standard methods should be universally used to produce reliable data and tests of data quality and SMART type flagging procedures should be applied and reported to ensure that the data are credible and therefore inform appropriate intervention. Use of SMART guidelines has coincided with reliable anthropometric data since 2007.
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Affiliation(s)
- Emmanuel Grellety
- Research Centre Health Policy and Systems - International Health, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Michael H. Golden
- Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland, UK
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Checchi F, Warsame A, Treacy-Wong V, Polonsky J, van Ommeren M, Prudhon C. Public health information in crisis-affected populations: a review of methods and their use for advocacy and action. Lancet 2017; 390:2297-2313. [PMID: 28602558 DOI: 10.1016/s0140-6736(17)30702-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 01/27/2017] [Accepted: 02/09/2017] [Indexed: 11/22/2022]
Abstract
Valid and timely information about various domains of public health underpins the effectiveness of humanitarian public health interventions in crises. However, obstacles including insecurity, insufficient resources and skills for data collection and analysis, and absence of validated methods combine to hamper the quantity and quality of public health information available to humanitarian responders. This paper, the second in a Series of four papers, reviews available methods to collect public health data pertaining to different domains of health and health services in crisis settings, including population size and composition, exposure to armed attacks, sexual and gender-based violence, food security and feeding practices, nutritional status, physical and mental health outcomes, public health service availability, coverage and effectiveness, and mortality. The paper also quantifies the availability of a minimal essential set of information in large armed conflict and natural disaster crises since 2010: we show that information was available and timely only in a small minority of cases. On the basis of this observation, we propose an agenda for methodological research and steps required to improve on the current use of available methods. This proposition includes setting up a dedicated interagency service for public health information and epidemiology in crises.
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Affiliation(s)
- Francesco Checchi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; Humanitarian Department, Save the Children, London, UK.
| | | | - Victoria Treacy-Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Polonsky
- Department of Health Emergency Information and Risk Assessment, World Health Organization, Geneva, Switzerland
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
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Blanchet K, Ramesh A, Frison S, Warren E, Hossain M, Smith J, Knight A, Post N, Lewis C, Woodward A, Dahab M, Ruby A, Sistenich V, Pantuliano S, Roberts B. Evidence on public health interventions in humanitarian crises. Lancet 2017; 390:2287-2296. [PMID: 28602563 DOI: 10.1016/s0140-6736(16)30768-1] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.
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Affiliation(s)
- Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Anita Ramesh
- Faculty of Public Health and Policy and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Severine Frison
- Faculty of Public Health and Policy and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Warren
- Faculty of Public Health and Policy and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mazeda Hossain
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | - James Smith
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Abigail Knight
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Nathan Post
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aniek Woodward
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | - Maysoon Dahab
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | - Alexander Ruby
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Bayard Roberts
- ECOHOST-The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK.
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Harding E, Beckworth C, Fesselet JF, Lenglet A, Lako R, Valadez JJ. Using lot quality assurance sampling to assess access to water, sanitation and hygiene services in a refugee camp setting in South Sudan: a feasibility study. BMC Public Health 2017; 17:643. [PMID: 28789627 PMCID: PMC5549393 DOI: 10.1186/s12889-017-4656-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 07/31/2017] [Indexed: 11/23/2022] Open
Abstract
Background Humanitarian agencies working in refugee camp settings require rapid assessment methods to measure the needs of the populations they serve. Due to the high level of dependency of refugees, agencies need to carry out these assessments. Lot Quality Assurance Sampling (LQAS) is a method commonly used in development settings to assess populations living in a project catchment area to identify their greatest needs. LQAS could be well suited to serve the needs of refugee populations, but it has rarely been used in humanitarian settings. We adapted and implemented an LQAS survey design in Batil refugee camp, South Sudan in May 2013 to measure the added value of using it for sub-camp level assessment. Methods Using pre-existing divisions within the camp, we divided the Batil catchment area into six contiguous segments, called ‘supervision areas’ (SA). Six teams of two data collectors randomly selected 19 respondents in each SA, who they interviewed to collect information on water, sanitation, hygiene, and diarrhoea prevalence. These findings were aggregated into a stratified random sample of 114 respondents, and the results were analysed to produce a coverage estimate with 95% confidence interval for the camp and to prioritize SAs within the camp. Results The survey provided coverage estimates on WASH indicators as well as evidence that areas of the camp closer to the main road, to clinics and to the market were better served than areas at the periphery of the camp. This assumption did not hold for all services, however, as sanitation services were uniformly high regardless of location. While it was necessary to adapt the standard LQAS protocol used in low-resource communities, the LQAS model proved to be feasible in a refugee camp setting, and program managers found the results useful at both the catchment area and SA level. Conclusions This study, one of the few adaptations of LQAS for a camp setting, shows that it is a feasible method for regular monitoring, with the added value of enabling camp managers to identify and advocate for the least served areas within the camp. Feedback on the results from stakeholders was overwhelmingly positive.
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Affiliation(s)
- Elizabeth Harding
- Médecins Sans Frontières, Plantage Middenlaan 14, 1018 DD, Amsterdam, Netherlands.,Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, Merseyside, L3 5QA, UK
| | - Colin Beckworth
- Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, Merseyside, L3 5QA, UK.
| | | | - Annick Lenglet
- Médecins Sans Frontières, Plantage Middenlaan 14, 1018 DD, Amsterdam, Netherlands
| | | | - Joseph J Valadez
- Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, Merseyside, L3 5QA, UK
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Grellety E, Golden MH. The Effect of Random Error on Diagnostic Accuracy Illustrated with the Anthropometric Diagnosis of Malnutrition. PLoS One 2016; 11:e0168585. [PMID: 28030627 PMCID: PMC5193513 DOI: 10.1371/journal.pone.0168585] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is often thought that random measurement error has a minor effect upon the results of an epidemiological survey. Theoretically, errors of measurement should always increase the spread of a distribution. Defining an illness by having a measurement outside an established healthy range will lead to an inflated prevalence of that condition if there are measurement errors. METHODS AND RESULTS A Monte Carlo simulation was conducted of anthropometric assessment of children with malnutrition. Random errors of increasing magnitude were imposed upon the populations and showed that there was an increase in the standard deviation with each of the errors that became exponentially greater with the magnitude of the error. The potential magnitude of the resulting error of reported prevalence of malnutrition were compared with published international data and found to be of sufficient magnitude to make a number of surveys and the numerous reports and analyses that used these data unreliable. CONCLUSIONS The effect of random error in public health surveys and the data upon which diagnostic cut-off points are derived to define "health" has been underestimated. Even quite modest random errors can more than double the reported prevalence of conditions such as malnutrition. Increasing sample size does not address this problem, and may even result in less accurate estimates. More attention needs to be paid to the selection, calibration and maintenance of instruments, measurer selection, training & supervision, routine estimation of the likely magnitude of errors using standardization tests, use of statistical likelihood of error to exclude data from analysis and full reporting of these procedures in order to judge the reliability of survey reports.
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Affiliation(s)
- Emmanuel Grellety
- Research Center Health Policy and Systems - International Health, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Michael H. Golden
- Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland
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Heudtlass P, Speybroeck N, Guha-Sapir D. Excess mortality in refugees, internally displaced persons and resident populations in complex humanitarian emergencies (1998-2012) - insights from operational data. Confl Health 2016; 10:15. [PMID: 27441038 PMCID: PMC4952240 DOI: 10.1186/s13031-016-0082-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 05/09/2016] [Indexed: 11/22/2022] Open
Abstract
Background Complex humanitarian emergencies are characterised by a break-down of health systems. All-cause mortality increases and non-violent excess deaths (predominantly due to infectious diseases) have been shown to outnumber violent deaths even in exceptionally brutal conflicts. However, affected populations are very heterogeneous and refugees, internally displaced persons (IDPs) and resident (non-displaced) populations differ substantially in their access to health services. We aim to show how this translates into health outcomes by quantifying excess all-cause mortality in emergencies by displacement status. Methods As standard data sources on mortality only poorly represent these populations, we use data from CEDAT, a database established by aid agencies to share operational health data collected for planning, monitoring and evaluation of humanitarian aid. We obtained 1759 Crude Death Rate (CDR) estimates from emergency assessments conducted between 1998 and 2012. We define excess mortality as the ratio of CDR in emergency assessments over ‘baseline CDR’ (as reported in the World Development Indicators). These death rate ratios (DRR) are calculated separately for all emergency assessments and their distribution is analysed by displacement status using non-parametric statistics. Results We found significant excess mortality in IDPs (median DRR: 2.5; 95 % CI: [2.2, 2.93]) and residents (median DDR: 1.51; 95 % CI: [1.47, 1.58]). Mortality in refugees however is not significantly different from baseline mortality in the host countries (median DRR: 0.94, 95 % CI: [0.73, 1.1]). Conclusions Aid agencies report the highest excess mortality rates among IDPs, followed by resident populations. In absolute terms however, due to their high share in the total number of people at risk, residents are likely to account for most of the excess deaths in today’s emergencies. Further research is needed to clarify whether the low estimates of excess mortality in refugees are the result of successful humanitarian interventions or due to limitations of our methods and data.
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Affiliation(s)
- Peter Heudtlass
- Institut de Recherche Santé et Société, Université catholique de Louvain, Brussels, Belgium
| | - Niko Speybroeck
- Institut de Recherche Santé et Société, Université catholique de Louvain, Brussels, Belgium
| | - Debarati Guha-Sapir
- Institut de Recherche Santé et Société, Université catholique de Louvain, Brussels, Belgium
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Heudtlass P, Speybroeck N, Guha-Sapir D. Monitoring mortality in forced migrants--can Bayesian methods help us to do better with the (little) data we have? PLoS Med 2015; 12:e1001887. [PMID: 26485006 PMCID: PMC4617888 DOI: 10.1371/journal.pmed.1001887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In crisis situations, data are scarce-Peter Heudtlass and colleagues explore ways of best understanding the extra risk of death borne by forced migrants.
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Affiliation(s)
- Peter Heudtlass
- Institut de Recherche Santé et Société (IRSS), Université catholique de Louvain, Brussels, Belgium
- * E-mail:
| | - Niko Speybroeck
- Institut de Recherche Santé et Société (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Debarati Guha-Sapir
- Institut de Recherche Santé et Société (IRSS), Université catholique de Louvain, Brussels, Belgium
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Davis WW, Mullany LC, Shwe Oo EK, Richards AK, Iacopino V, Beyrer C. Health and Human Rights in Karen State, Eastern Myanmar. PLoS One 2015; 10:e0133822. [PMID: 26308850 PMCID: PMC4550474 DOI: 10.1371/journal.pone.0133822] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/02/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Decades of conflict in eastern Myanmar have resulted in high prevalence of human rights violations and poor health outcomes. While recent ceasefire agreements have reduced conflict in this area, it is unknown whether this has resulted in concomitant reductions in human rights violations. METHODS AND FINDINGS We conducted a two-stage cluster survey of 686 households in eastern Myanmar to assess health status, access to healthcare, food security, exposure to human rights violations and identification of alleged perpetrators over the 12 months prior to January 2012, a period of near-absence of conflict in this region. Household hunger (FANTA-2 scale) was moderate/high in 91 (13.2%) households, while the proportion of households reporting food shortages in each month of 2011 ranged from 19.9% in December to 47.0% in September, with food insecurity peaking just prior to the harvest. Diarrhea prevalence in children was 14.2% and in everyone it was 5.8%. Forced labor was the most common human rights violation (185 households, 24.9%), and 210 households (30.6%) reported experiencing one or more human rights violations in 2011. Multiple logistic regression analysis identified associations between human rights violations and poor health outcomes. CONCLUSION Human rights violations and their health consequences persist despite reduced intensity of conflict in eastern Myanmar. Ceasefire agreements should include language that protects human rights, and reconciliation efforts should address the health consequences of decades of human rights violations.
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Affiliation(s)
- William W. Davis
- Center for Public Health and Human Rights, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Luke C. Mullany
- Center for Public Health and Human Rights, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Adam K. Richards
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, United States of America
- Community Partners International, 2550 Ninth St. Suite 111, Berkeley, California, 94710, United States of America
| | - Vincent Iacopino
- Physicians for Human Rights, New York City, New York, United States of America
- University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Human Rights Center, University of California, Berkeley, California, United States of America
| | - Chris Beyrer
- Center for Public Health and Human Rights, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Altare C, Guha-Sapir D. The Complex Emergency Database: a global repository of small-scale surveys on nutrition, health and mortality. PLoS One 2014; 9:e109022. [PMID: 25333954 PMCID: PMC4204814 DOI: 10.1371/journal.pone.0109022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/02/2014] [Indexed: 11/18/2022] Open
Abstract
Evidence has become central for humanitarian decision making, as it is now commonly agreed that aid must be provided solely in proportion to the needs and on the basis of needs assessments. Still, reliable epidemiological data from conflict-affected communities are difficult to acquire in time for effective decisions, as existing health information systems progressively lose functionality with the onset of conflicts. In the last decade, health and nutrition humanitarian agencies have made substantial progress in collecting quality data using small-scale surveys. In 2002, a group of academics, non-governmental organizations, and UN agencies launched the Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. Since then, field agencies have conducted thousands of surveys. Although the contribution of each survey by itself is limited by its small sample and the impossibility to extrapolate results to national level, their aggregation can provide a more stable view of both trends and distributions in a larger region. The Complex Emergency Database (CEDAT) was set up in order to make best use of the collective force of these surveys. Functioning as a central repository, it can provide valuable information on trends and patterns of mortality and nutrition indicators from conflict-affected communities. Given their high spatial resolution and their high frequency, CEDAT data can complement official statistics in between nationwide surveys. They also provide information of the displacement status of the measured population, pointing out vulnerabilities. CEDAT is hosted at the Centre for Research on the Epidemiology of Disasters, University of Louvain. It runs on voluntary agreements between the survey implementer and the CEDAT team. To date, it contains 3309 surveys from 51 countries, and is a unique repository of such data.
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Affiliation(s)
- Chiara Altare
- Centre for Research on the Epidemiology of Disaster, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
- * E-mail:
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disaster, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
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Caleo GM, Sy AP, Balandine S, Polonsky J, Palma PP, Grais RF, Checchi F. Sentinel site community surveillance of mortality and nutritional status in southwestern Central African Republic, 2010. Popul Health Metr 2012; 10:18. [PMID: 22947146 PMCID: PMC3477098 DOI: 10.1186/1478-7954-10-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 08/27/2012] [Indexed: 11/15/2022] Open
Abstract
Background During 2010, a community-based, sentinel site prospective surveillance system measured mortality, acute malnutrition prevalence, and the coverage of a Médecins Sans Frontières (MSF) intervention in four sous-préfectures of Lobaye prefecture in southwestern Central African Republic. We describe this surveillance system and its evaluation. Methods Within 24 randomly selected sentinel sites, home visitors performed a census, weekly demographic surveillance of births, deaths, and in- or out-migration, and weekly anthropometry on a sample of children. We evaluated the system through various methods including capture-recapture analysis and repeat census. Results The system included 18,081 people at baseline. Over 32 weeks, the crude death rate was 1.0 (95% confidence interval [CI]: 0.8-1.2) deaths per 10,000 person-days (35 deaths per 1,000 person-years), with higher values during the rainy season. The under-5 death rate was approximately double. The prevalence of severe acute malnutrition (SAM) was 3.0% (95% CI: 2.3-4.0), almost half featuring kwashiorkor signs. The coverage of SAM treatment was 29.1%. The system detected >90% of deaths, and >90% of death reports appeared valid. However, demographic surveillance yielded discrepancies with the census and an implausible rate of population growth, while the predictive value of SAM classification was around 60%. Discussion We found evidence of a chronic health crisis in this remote region. MSF's intervention coverage improved progressively. Mortality data appeared valid, but inaccuracies in population denominators and anthropometric measurements were noted. Similar systems could be implemented in other remote settings and acute emergencies, but with certain technical improvements.
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Mason JB, White JM, Heron L, Carter J, Wilkinson C, Spiegel P. Child acute malnutrition and mortality in populations affected by displacement in the Horn of Africa, 1997-2009. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2012; 9:791-806. [PMID: 22690164 PMCID: PMC3367278 DOI: 10.3390/ijerph9030791] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 02/23/2012] [Accepted: 02/28/2012] [Indexed: 11/16/2022]
Abstract
Drought and conflict in the Horn of Africa are causing population displacement, increasing risks of child mortality and malnutrition. Humanitarian agencies are trying to mitigate the impact, with limited resources. Data from previous years may help guide decisions. Trends in different populations affected by displacement (1997-2009) were analyzed to investigate: (1) how elevated malnutrition and mortality were among displaced compared to host populations; (2) whether the mortality/malnutrition relation changed through time; and (3) how useful is malnutrition in identifying high mortality situations. Under-five mortality rates (usually from 90-day recall, as deaths/10,000/day: U5MR) and global acute malnutrition (wasting prevalences, < -2SDs of references plus edema: GAM) were extracted from reports of 1,175 surveys carried out between 1997-2009 in the Horn of Africa; these outcome indicators were analyzed by livelihood (pastoral, agricultural) and by displacement status (refugee/internally displaced, local resident/host population, mixed); associations between these indicators were examined, stratifying by status. Patterns of GAM and U5MR plotted over time by country and livelihood clarified trends and showed substantial correspondence. Over the period GAM was steady but U5MR generally fell by nearly half. Average U5MR was similar overall between displaced and local residents. GAM was double on average for pastoralists compared with agriculturalists (17% vs. 8%), but was not different between displaced and local populations. Agricultural populations showed increased U5MR when displaced, in contrast to pastoralist. U5MR rose sharply with increasing GAM, at different GAM thresholds depending on livelihood. Higher GAM cut-points for pastoralists than agriculturalists would better predict elevated U5MR (1/10,000/day) or emergency levels (2/10,000/day) in the Horn of Africa; cut-points of 20-25% GAM in pastoral populations and 10-15% GAM in agriculturalists are suggested. The GAM cut-points in current use do not vary by livelihood, and this needs to be changed, tailoring cut points to livelihood groups, to better identify priorities for intervention. This could help to prioritize limited resources in the current situation of food insecurity and save lives.
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Affiliation(s)
- John B. Mason
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA 70118, USA; (J.M.W.); (L.H.); (J.C.)
- Author to whom correspondence should be addressed; ; Tel.: +1-504-988-4533; Fax: +1-504-988-3540
| | - Jessica M. White
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA 70118, USA; (J.M.W.); (L.H.); (J.C.)
| | - Linda Heron
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA 70118, USA; (J.M.W.); (L.H.); (J.C.)
| | - Jennifer Carter
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA 70118, USA; (J.M.W.); (L.H.); (J.C.)
| | - Caroline Wilkinson
- United Nations High Commissioner for Refugees, Case Postale 2500, CH-1211 Geneva 2 Dépôt, Switzerland; (C.W.); (P.S.)
| | - Paul Spiegel
- United Nations High Commissioner for Refugees, Case Postale 2500, CH-1211 Geneva 2 Dépôt, Switzerland; (C.W.); (P.S.)
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Prudhon C, de Radiguès X, Dale N, Checchi F. An algorithm to assess methodological quality of nutrition and mortality cross-sectional surveys: development and application to surveys conducted in Darfur, Sudan. Popul Health Metr 2011; 9:57. [PMID: 22071133 PMCID: PMC3231955 DOI: 10.1186/1478-7954-9-57] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 11/09/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Nutrition and mortality surveys are the main tools whereby evidence on the health status of populations affected by disasters and armed conflict is quantified and monitored over time. Several reviews have consistently revealed a lack of rigor in many surveys. We describe an algorithm for analyzing nutritional and mortality survey reports to identify a comprehensive range of errors that may result in sampling, response, or measurement biases and score quality. We apply the algorithm to surveys conducted in Darfur, Sudan. METHODS We developed an algorithm based on internationally agreed upon methods and best practices. Penalties are attributed for a list of errors, and an overall score is built from the summation of penalties accrued by the survey as a whole. To test the algorithm reproducibility, it was independently applied by three raters on 30 randomly selected survey reports. The algorithm was further applied to more than 100 surveys conducted in Darfur, Sudan. RESULTS The Intra Class Correlation coefficient was 0.79 for mortality surveys and 0.78 for nutrition surveys. The overall median quality score and range of about 100 surveys conducted in Darfur were 0.60 (0.12-0.93) and 0.675 (0.23-0.86) for mortality and nutrition surveys, respectively. They varied between the organizations conducting the surveys, with no major trend over time. CONCLUSION Our study suggests that it is possible to systematically assess quality of surveys and reveals considerable problems with the quality of nutritional and particularly mortality surveys conducted in the Darfur crisis.
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Affiliation(s)
| | | | - Nancy Dale
- Department of International Health, University of Tampere, Finland
| | - Francesco Checchi
- Faculty of Infectious and Tropical Diseases, London School of Hygiene &Tropical Medicine, London, UK
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Roberts B, Morgan OW, Sultani MG, Nyasulu P, Rwebangila S, Sondorp E, Chandramohan D, Checchi F. Economic feasibility of a new method to estimate mortality in crisis-affected and resource-poor settings. PLoS One 2011; 6:e25175. [PMID: 21949879 PMCID: PMC3176324 DOI: 10.1371/journal.pone.0025175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 08/29/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Mortality data provide essential evidence on the health status of populations in crisis-affected and resource-poor settings and to guide and assess relief operations. Retrospective surveys are commonly used to collect mortality data in such populations, but require substantial resources and have important methodological limitations. We evaluated the feasibility of an alternative method for rapidly quantifying mortality (the informant method). The study objective was to assess the economic feasibility of the informant method. METHODS The informant method captures deaths through an exhaustive search for all deaths occurring in a population over a defined and recent recall period, using key community informants and next-of-kin of decedents. Between July and October 2008, we implemented and evaluated the informant method in: Kabul, Afghanistan; Mae La camp for Karen refugees, Thai-Burma border; Chiradzulu District, Malawi; and Lugufu and Mtabila refugee camps, Tanzania. We documented the time and cost inputs for the informant method in each site, and compared these with projections for hypothetical retrospective mortality surveys implemented in the same site with a 6 month recall period and with a 30 day recall period. FINDINGS The informant method was estimated to require an average of 29% less time inputs and 33% less monetary inputs across all four study sites when compared with retrospective surveys with a 6 month recall period, and 88% less time inputs and 86% less monetary inputs when compared with retrospective surveys with a 1 month recall period. Verbal autopsy questionnaires were feasible and efficient, constituting only 4% of total person-time for the informant method's implementation in Chiradzulu District. CONCLUSIONS The informant method requires fewer resources and incurs less respondent burden. The method's generally impressive feasibility and the near real-time mortality data it provides warrant further work to develop the method given the importance of mortality measurement in such settings.
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Affiliation(s)
- Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Watson F, Negussie B, Dolan C, Shoham J, Hall A. Quality and potential use of data collected during nutrition surveys: an analysis of surveys in Ethiopia. Int Health 2011; 3:85-90. [PMID: 24038180 DOI: 10.1016/j.inhe.2011.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Humanitarian agencies regularly carry out nutrition surveys to estimate the prevalence of acute malnutrition (wasting) and mortality as well as to collect data on a wide range of contributory or aggravating factors in order to identify interventions and to direct aid where it is most needed. In this study, the case of Ethiopia was used (i) to assess the proportion of 291 nutrition surveys conducted between 2003 and 2008 that used the recommended sampling method to estimate the prevalence of wasting, (ii) to assess how and what data on indicators of aggravating factors were collected, (iii) to examine whether data on such factors can be used to establish priorities for emergency assistance based on Ethiopian Government guidelines and (iv) to discuss the general value of such data. All but one survey used the recommended methods to estimate the prevalence of wasting. Data were collected on more than 40 indicators of aggravating factors related to health, caring practices, food security and coping strategies, but no consistent methods or indicators were used, resulting in inconsistent data. This illustrates the need to develop and agree upon a set of core indicators of aggravating factors and then thresholds to describe the humanitarian situation in Ethiopia and elsewhere and to indicate priorities for interventions.
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Affiliation(s)
- Fiona Watson
- NutritionWorks, P.O. Box 53616, London SE24 9UY, UK
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Roberts B, Morgan OW, Sultani MG, Nyasulu P, Rwebangila S, Myatt M, Sondorp E, Chandramohan D, Checchi F. A new method to estimate mortality in crisis-affected and resource-poor settings: validation study. Int J Epidemiol 2010; 39:1584-96. [PMID: 21044978 PMCID: PMC2992632 DOI: 10.1093/ije/dyq188] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2010] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Data on mortality rates are crucial to guide health interventions in crisis-affected and resource-poor settings. The methods currently available to collect mortality data in such settings feature important methodological limitations. We developed and validated a new method to provide near real-time mortality estimates in such settings. METHODS We selected four study sites: Kabul, Afghanistan; Mae La refugee camp, Thailand; Chiradzulu District, Malawi; and Lugufu and Mtabila refugee camps, Tanzania. We recorded information about all deaths in a 60-day period by asking key community informants and decedents' next of kin to refer interviewers to bereaved households. We used the total number of deaths and population estimates to calculate mortality rates for 60- and 30-day periods. For validation we compared these rates with a best estimate of mortality using capture-recapture analysis with two further independent lists of deaths. RESULTS The population covered by the new method was 76 ,476 persons in Kabul, 43,794 in Mae La camp, 54,418 in Chiradzulu District and 80,136 in the Tanzania camps. The informant method showed moderate sensitivity (55.0% in Kabul, 64.0% in Mae La, 72.5% in Chiradzulu and 67.7% in Tanzania), but performed better than the active surveillance system in the Tanzania refugee camps. CONCLUSIONS The informant method currently features moderate sensitivity for accurately assessing mortality, but warrants further development, particularly considering its advantages over current options (ease of implementation and analysis and near-real estimates of mortality rates). Strategies should be tested to improve the performance of the informant method.
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Affiliation(s)
- Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver W Morgan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mohammed Ghaus Sultani
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Nyasulu
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sunday Rwebangila
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Myatt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Egbert Sondorp
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Chandramohan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Francesco Checchi
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK, United States Centers for Disease Control and Prevention, Atlanta, GA, USA, Médecins Sans Frontières France, Malawi Programme, Chiradzulu, Malawi, United Nations High Commissioner for Refugees, Tanzania Office, Kigoma, Tanzania, Brixton Health, Plymouth, UK and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Weaver H, Roberts B. Drinking and displacement: a systematic review of the influence of forced displacement on harmful alcohol use. Subst Use Misuse 2010; 45:2340-55. [PMID: 20469970 DOI: 10.3109/10826081003793920] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This paper systematically reviews evidence about factors associated with harmful alcohol use amongst forcibly displaced persons, including refugees and internally displaced persons. Bibliographic and humanitarian-related databases were searched. The number of quantitative and qualitative studies that were screened and reviewed was 1108. Only 10 studies met inclusion criteria. Risk factors identified included gender, age, exposure to traumatic events and resulting posttraumatic stress disorder, prior alcohol consumption-related problems, year of immigration, location of residence, social relations, and postmigration trauma and stress. The evidence base was extremely weak, and there is a need to improve the quantity and quality of research about harmful alcohol use by forcibly displaced persons.
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Affiliation(s)
- Heather Weaver
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Affiliation(s)
- Francesco Checchi
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Bilukha OO. Old and new cluster designs in emergency field surveys: in search of a one-fits-all solution. Emerg Themes Epidemiol 2008; 5:7. [PMID: 18611276 PMCID: PMC2474831 DOI: 10.1186/1742-7622-5-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 07/08/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Cluster surveys are frequently used to measure key nutrition and health indicators in humanitarian emergencies. The survey design of 30 clusters of 7 children (30 x 7) was initially proposed by the World Health Organization for measuring vaccination coverage, and later a design of 30 clusters of 30 children (30 x 30) was introduced to measure acute malnutrition in emergency settings. Recently, designs of 33 clusters of 6 children (33 x 6) and 67 clusters of 3 children (67 x 3) have been proposed as alternatives that enable measurement of several key indicators with sufficient precision, while offering substantial savings in time. This paper explores expected effects of using 67 x 3, 33 x 6, or 30 x 7 designs instead of a "standard" 30 x 30 design on precision and accuracy of estimates, and on time required to complete the survey. ANALYSIS The 67 x 3, 33 x 6, and 30 x 7 designs are expected to be more statistically efficient for measuring outcomes having high design effects (e.g., vaccination coverage, vitamin A distribution coverage, or access to safe water sources), and less efficient for measuring outcomes with more within-cluster variability, such as global acute malnutrition or anemia. Because of small sample sizes, these designs may not provide sufficient levels of precision to measure crude mortality rates. Given the small number (3 to 7) of survey subjects per cluster, it may be hard to select representative samples of subjects within clusters.The smaller sample size in these designs will likely result in substantial time savings. The magnitude of the savings will depend on several factors, including the average travel time between clusters. The 67 x 3 design will provide the least time savings. The 33 x 6 and 30 x 7 designs perform similarly to each other, both in terms of statistical efficiency and in terms of time required to complete the survey. CONCLUSION Cluster designs discussed in this paper may offer substantial time and cost savings compared to the traditional 30 x 30 design, and may provide acceptable levels of precision when measuring outcomes that have high intracluster homogeneity. Further investigation is required to determine whether these designs can consistently provide accurate point estimates for key outcomes of interest. Organizations conducting cluster surveys in emergency settings need to build their technical capacity in survey design to be able to calculate context-specific sample sizes individually for each planned survey.
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Affiliation(s)
- Oleg O Bilukha
- International Emergency and Refugee Health Branch, Division of Emergency and Environmental Health Services, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA 30341, USA.
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Abstract
Francesco Checchi and Les Roberts discuss how mortality among crisis-affected populations is currently documented, barriers to better documentation, and how these barriers might be overcome.
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Affiliation(s)
- Francesco Checchi
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Deitchler M, Deconinck H, Bergeron G. Precision, time, and cost: a comparison of three sampling designs in an emergency setting. Emerg Themes Epidemiol 2008; 5:6. [PMID: 18454866 PMCID: PMC2412846 DOI: 10.1186/1742-7622-5-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 05/02/2008] [Indexed: 12/03/2022] Open
Abstract
The conventional method to collect data on the health, nutrition, and food security status of a population affected by an emergency is a 30 × 30 cluster survey. This sampling method can be time and resource intensive and, accordingly, may not be the most appropriate one when data are needed rapidly for decision making. In this study, we compare the precision, time and cost of the 30 × 30 cluster survey with two alternative sampling designs: a 33 × 6 cluster design (33 clusters, 6 observations per cluster) and a 67 × 3 cluster design (67 clusters, 3 observations per cluster). Data for each sampling design were collected concurrently in West Darfur, Sudan in September-October 2005 in an emergency setting. Results of the study show the 30 × 30 design to provide more precise results (i.e. narrower 95% confidence intervals) than the 33 × 6 and 67 × 3 design for most child-level indicators. Exceptions are indicators of immunization and vitamin A capsule supplementation coverage which show a high intra-cluster correlation. Although the 33 × 6 and 67 × 3 designs provide wider confidence intervals than the 30 × 30 design for child anthropometric indicators, the 33 × 6 and 67 × 3 designs provide the opportunity to conduct a LQAS hypothesis test to detect whether or not a critical threshold of global acute malnutrition prevalence has been exceeded, whereas the 30 × 30 design does not. For the household-level indicators tested in this study, the 67 × 3 design provides the most precise results. However, our results show that neither the 33 × 6 nor the 67 × 3 design are appropriate for assessing indicators of mortality. In this field application, data collection for the 33 × 6 and 67 × 3 designs required substantially less time and cost than that required for the 30 × 30 design. The findings of this study suggest the 33 × 6 and 67 × 3 designs can provide useful time- and resource-saving alternatives to the 30 × 30 method of data collection in emergency settings.
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Affiliation(s)
- Megan Deitchler
- Food and Nutrition Technical Assistance Project, Academy for Educational Development, 1825 Connecticut Ave. NW, Washington, DC 20009, USA.
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Bostoen K, Bilukha OO, Fenn B, Morgan OW, Tam CC, ter Veen A, Checchi F. Methods for health surveys in difficult settings: charting progress, moving forward. Emerg Themes Epidemiol 2007. [PMCID: PMC1892016 DOI: 10.1186/1742-7622-4-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Health surveys are a very important component of the epidemiology toolbox, and play a critical role in gauging population health, especially in developing countries. Research on health survey methods, however, is sparse. In particular, current sampling methods are not well adapted for certain 'difficult' settings, such as emergencies, remote regions without easily available sampling frames, hidden and vulnerable population groups, urban slums and populations living under strong political pressure. This special issue of Emerging Themes in Epidemiology is entirely devoted to survey methods in such settings, and builds upon a successful conference in London highlighting problems with current approaches and possible ways forward. Greater investment in research on health survey methods is needed and will have beneficial effects for populations in need.
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