Validity of maternal report of care-seeking for childhood illness

Interpersonal communication, cultural norms, and community perceptions associated with care-seeking for fever among children under age five in Magoé district, Mozambique

BACKGROUND

Malaria is endemic throughout Mozambique, contributing significantly to the country's burden of disease. Prompt and effective treatment for fevers in children can limit the mortality and morbidity impacts of the disease but many children in the country are not taken for formal care when ill. Using an ideational model of behaviour, this study assesses the magnitude of the relationships for potential drivers of care-seeking, including interpersonal communication, malaria messaging, and knowledge and attitudes about malaria, with actual care-seeking behaviours for under-five children with fever in Magoé district, Mozambique.

METHODS

Data on the care-seeking behaviours for fever come from a 2019 household malaria survey in Magoé district. Households were randomly selected for interview from among those with at least one child under age five and one net for every two household members. From 1621 mother-child dyads, the analytical sample consists of 300 children under age five with a fever in the 2 weeks prior to the survey. Multilevel random effects logistic regression models are estimated to test for associations between care-seeking behaviours and hypothesized behavioural determinants, including interpersonal communication (IPC), malaria messaging, ideational factors (e.g., norms, attitudes, beliefs, risk perceptions), and community characteristics.

RESULTS

Overall, 18.5% of children under age five (N = 300) were reported to have fever in the previous 2 weeks and, of these, 68.5% were taken to a formal sector health care provider. Multivariate models highlight significant roles for interpersonal communication; care-seeking was highest among mothers who spoke only with friends/community members about malaria (94.0%, p < 0.001), followed by those who spoke only with their husband (78.6%, p = 0.015), relative to 63.3% who spoke with no one. Care-seeking decisions made by a child's grandmother were associated with a 25.0% point (p = 0.001) greater likelihood of seeking care relative to decisions made by the mother alone. Exposure to any malaria messaging was also positively associated with care-seeking (90.5% versus 62.7%, p < 0.001). In contrast, among all individual- and community-level ideational factors, only perceptions of self-efficacy to seek care were related to care-seeking behaviours.

CONCLUSIONS

These results suggest that social and behaviour change interventions that focus on encouraging families and community members to talk about malaria and the need to promptly seek treatment for fevers in children may be particularly effective at increasing this behaviour in this and similar settings. Such messaging and IPC should consider grandmothers as a target audience, as they appear to be perceived as highly influential in care-seeking decision-making in this community.

Comparing observed occurrence of mistreatment during childbirth with women's self-report: a validation study in Ghana, Guinea and Nigeria

BACKGROUND

There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria.

METHODS

Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75

RESULTS

1536 women across Ghana (n=779), Guinea (n=425) and Nigeria (n=332) were included. Most mistreatment items demonstrated better specificity than sensitivity: observation of any physical abuse (44% sensitive, 89% specific), any verbal abuse (61% sensitive, 73% specific) and presence of a labour companion (19% sensitive, 93% specific). Items for stigma (IF 0.16), pain relief requested (IF 0.38), companion present (IF 0.32) and lack of easy access to fluids (IF 0.46) showed high risk of bias, meaning labour observations would substantially underestimate true prevalence. Other items showed low or moderate bias.

CONCLUSION

Using self-report as the reference standard, labour observations demonstrated moderate-to-high specificity (accurately identifying lack of mistreatment) but low-to-moderate sensitivity (accurately identifying presence of mistreatment) among women. For overall prevalence, either women's self-report or observations can be used with low-moderate bias for most mistreatment items. However, given the dynamicity, complexity, and limitations in 'objectivity', some experiences of mistreatment (stigma, pain relief, labour companionship, easy access to fluids) require measurement via women's self-report. More work is needed to understand how subjectivity influences how well a measure represents individual's experiences.

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Key Words

• cross-sectional survey
• maternal health
• public health

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MESH Headings

• Female
• Humans
• Pregnancy
• Self Report
• Ghana
• Guinea/epidemiology
• Nigeria
• Parturition
• Pain

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Grants

• 001 World Health Organization
• UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training
• United States Agency for International Development (USAID)

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Affiliation(s)

Hedieh Mehrtash Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland Department of Global Health, University of Washington School of Public Health, Seattle, Washington, USA
Meghan A Bohren Gender and Women's Health Unit, Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
Kwame Adu-Bonsaffoh Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
Theresa Azonima Irinyenikan Department of Obstetrics and Gynaecology, University of Medical Sciences Teaching Hospital, Akure, Nigeria
Blair O Berger Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
Ernest Maya Department of Population Health, School of Public Health, University of Ghana, Accra, Ghana
Mamadou Dioulde Balde Cellulle de Recherche en Sante de la Reproduction en Guinee (CERREGUI), Conakry, Guinea
Thae Maung Maung Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
Adeniyi Kolade Aderoba National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK Department of Obstetrics and Gynaecology, Mother and Child Hospital Akure, Akure, Nigeria
Özge Tuncalp Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Hannah H Leslie Division of Prevention Science, University of California San Francisco, San Francisco, California, USA

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Exploring the accuracy of self-reported maternal and newborn care in select studies from low and middle-income country settings: do respondent and facility characteristics affect measurement?

BACKGROUND

Accurate data on the receipt of essential maternal and newborn health interventions is necessary to interpret and address gaps in effective coverage. Validation results of commonly used content and quality of care indicators routinely implemented in international survey programs vary across settings. We assessed how respondent and facility characteristics influenced the accuracy of women's recall of interventions received in the antenatal and postnatal periods.

METHODS

We synthesized reporting accuracy using data from a known sample of validation studies conducted in Sub-Saharan Africa and Southeast Asia, which assessed the validity of women's self-report of received antenatal care (ANC) (N = 3 studies, 3,169 participants) and postnatal care (PNC) (N = 5 studies, 2,462 participants) compared to direct observation. For each study, indicator sensitivity and specificity are presented with 95% confidence intervals. Univariate fixed effects and bivariate random effects models were used to examine whether respondent characteristics (e.g., age group, parity, education level), facility quality, or intervention coverage level influenced the accuracy of women's recall of whether interventions were received.

RESULTS

Intervention coverage was associated with reporting accuracy across studies for the majority (9 of 12) of PNC indicators. Increasing intervention coverage was associated with poorer specificity for 8 indicators and improved sensitivity for 6 indicators. Reporting accuracy for ANC or PNC indicators did not consistently differ by any other respondent or facility characteristic.

CONCLUSIONS

High intervention coverage may contribute to higher false positive reporting (poorer specificity) among women who receive facility-based maternal and newborn care while low intervention coverage may contribute to false negative reporting (lower sensitivity). While replication in other country and facility settings is warranted, results suggest that monitoring efforts should consider the context of care when interpreting national estimates of intervention coverage.

Reported History of Measles and Long-term Impact on Tetanus Antibody Detected in Children 9-59 Months of Age and Receiving 3 Doses of Tetanus Vaccine in the Democratic Republic of the Congo

BACKGROUND

Recent studies suggest measles-induced immune amnesia could have long-term immunosuppressive effects via preferential depletion of memory CD150+ lymphocytes, and associations with a 2-3 year period of increased mortality and morbidity from infectious diseases other than measles has been shown in children from wealthy and low-income countries. To further examine the associations previous measles virus infection may have on immunologic memory among children in the Democratic Republic of the Congo (DRC), we assessed tetanus antibody levels among fully vaccinated children, with and without a history of measles.

METHODS

We assessed 711 children 9-59 months of age whose mothers were selected for interview in the 2013-2014 DRC Demographic and Health Survey. History of measles was obtained by maternal report and classification of children who had measles in the past was completed using maternal recall and measles IgG serostatus obtained from a multiplex chemiluminescent automated immunoassay dried blood spot analysis. Tetanus IgG antibody serostatus was similarly obtained. A logistic regression model was used to identify association of measles and other predictors with subprotective tetanus IgG antibody.

RESULTS

Subprotective geometric mean concentration tetanus IgG antibody values were seen among fully vaccinated children 9-59 months of age, who had a history of measles. Controlling for potential confounding variables, children classified as measles cases were less likely to have seroprotective tetanus toxoid antibody (odds ratio: 0.21; 95% confidence interval: 0.08-0.55) compared with children who had not had measles.

CONCLUSIONS

History of measles was associated with subprotective tetanus antibody among this sample of children in the DRC who were 9-59 months of age and fully vaccinated against tetanus.

Determinants of care-seeking behaviour for fever, acute respiratory infection and diarrhoea among children under five in Nigeria

Background

Despite available, inexpensive and effective treatments, malaria, diarrhoea, and pneumonia still contribute the majority of the global burden of childhood morbidity and mortality. Nigeria has the highest absolute numbers of child deaths worldwide. Appropriate care-seeking is important for prompt diagnosis, appropriate and timely treatment, and prevention of complications. The objective of this cross-sectional study was to examine the prevalence of and factors associated with appropriate care-seeking for childhood illnesses.

Methods

We used the most recent Nigeria Demographic and Health Survey (2018) to assess the prevalence of appropriate care-seeking among mothers of children under five with symptoms of common childhood illnesses. For diarrhoea, we defined appropriate care-seeking as seeking care from a formal health provider. For fever and acute respiratory infection (ARI), appropriate care-seeking was defined as seeking care from a formal provider the day of or after symptom onset. Multivariate logistic regression was carried out to assess factors associated with optimal care-seeking for each illness.

Results

At least 25% of parents did not seek any care for children with fever or ARI; this figure was over one third for diarrhoea. Only 15% and 13% of caregivers showed appropriate care-seeking for their children with fever and ARI respectively, and 27% of mothers sought care from a formal provider for diarrhoea. Predictors of appropriate care-seeking varied according to childhood illness. Previous facility delivery was the only risk factor associated with increased odds of appropriate care-seeking for all three illnesses; other risk factors varied between illnesses.

Conclusion

Overall, care-seeking for childhood illnesses was suboptimal among caregivers in Nigeria. Interventions to increase caregivers’ awareness of the importance of appropriate care-seeking are needed alongside quality of care interventions that reinforce people’s trust in formal health facilities, to improve timely care-seeking and ultimately reduce the high burden of child deaths in Nigeria.

Validation of maternal report of nutrition-related interventions and counselling during antenatal care in southern Nepal

The delivery of nutrition-related interventions and counselling during antenatal care is critical for a healthy pregnancy for both mother and child. However, the accuracy of maternal reports of many of these services during household surveys has not yet been examined. Our objectives were to assess the validity of the maternal reports of 10 antenatal nutrition interventions, including counselling, and examine associates between maternal characteristics and accuracy. Maternal report of services received collected during a post-partum survey was compared to the gold standard, the direct observation of all women's antenatal care visits. Individual-level validity was assessed by calculating indicator sensitivity, specificity and area under the operating curve (AUC). The inflation factor (IF) measured population-level bias. For five indicators, the high true coverage limited our ability to assess the validity of the maternal reports. There were no indicators that had both high individual-level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25). Indicators with greater true coverage estimates had higher sensitivity and lower specificity estimates compared to those indicators with lower true coverage. There were no maternal characteristics associated with the accuracy of the report. Maternal report of antenatal nutrition-related interventions and counselling during household surveys was found to have variable validity across indicators. Additional research in settings with varying coverage levels should be considered to best inform antenatal care coverage measurement in household surveys.

Understanding the context of healthcare utilisation for children under-five with diarrhoea in the DRC: based on Andersen behavioural model

BACKGROUND

Diarrhoea is one of the leading causes of death among children under 5 years old in the Democratic Republic of the Congo (DRC). Despite positive effects on prognosis, there is limited literature about the healthcare-seeking behaviours of children with diarrhoea, especially in the DRC. This study used the Andersen Behavioural Model, a theoretical framework, which was commonly adopted to study healthcare utilisation, to investigate and predict factors associated with the use of healthcare to treat diarrhoea in the DRC.

METHODS

Data collected from 2626 under-five children with diarrhoea in the last 2 weeks from the Multiple Indicators Cluster Survey conducted by the National Institute of Statistics in 2017-2018, in collaboration with the United Nations Children's Fund were used in this study. Both direct and indirect relationships among four latent variables: predisposing traits, enabling resources access, health needs, and health services use were measured using the structural equation modelling to test the Andersen behavioural model. The confirmatory Factor Analysis model was also modified based on the DRC context to explore this further.

RESULTS

The modified model had the goodness of fit index (GFI) of 0.972, comparative fit index (CFI) of 0.953 and RMSEA of 0.043 (95% CI: 0. 040, 0.047). Health needs (especially diarrhoea) had the largest positive direct effect on healthcare utilisation (standardized regression coefficient [β] = 0.135, P < 0.001), followed by "enabling resources" (β = 0.051, P = 0.015). Health needs also emerged as a mediator for the positive effect of predisposing on utilisation (indirect effect, β = 0.014; P = 0.009).

CONCLUSION

Access to improved water and improved sanitation, as well as socioeconomic factors like household wealth, were significantly associated with health-seeking behaviours for diarrhoea treatment in the DRC. Besides, caregivers who own higher levels of educational attainments were more inclined to have positive health services uses during the treatments. Efforts are needed to enhance the oral rehydration therapy coupled with educating caregivers on its appropriate use.

Validation of Maternal Report of Receipt of Iron-Folic Acid Supplementation during Antenatal Care in Rural Southern Nepal

BACKGROUND

Coverage of iron-folic acid (IFA) supplementation is a key indicator for tracking programmatic progress within and across countries. However, the validity of maternal report of this information during household surveys has yet to be determined.

OBJECTIVES

This study aimed to examine the validity of maternal recall of receipt of IFA supplementation during antenatal care (ANC) and factors associated with accuracy of maternal recall.

METHODS

A longitudinal cohort design was employed. The direct observation of the IFA received during all ANC visits at the 5 study health posts served as the "gold standard" to the maternal report of IFA received during the postpartum interview. Individual-level validity was assessed by calculating indicator sensitivity, specificity, and AUC. The inflation factor (IF) measured population-level bias. A multivariable log-binomial model was used to assess factors associated with accurate recall.

RESULTS

The majority (95.8%) of women were observed receiving IFA during pregnancy. Women overreported the number of IFA tablets received compared with what was observed during ANC visits (mean difference: 45 tablets). Maternal report of any IFA receipt was moderate (AUC = 0.60; 95% CI: 0.50, 0.71), and population bias was low (IF = 1.01). However, the individual-level validity was poor across the 7 IFA tablet count categories; the AUC for categories ranged from misleading to moderate. Driven by the trend of maternal overreport, the IF indicated that maternal report drastically underestimated the coverage of lower tablet categories and overestimated the coverage of higher tablet counts. Accuracy of maternal report was not associated with months since last ANC observation nor any maternal characteristics.

CONCLUSIONS

Maternal report of the amount of IFA supplementation received during pregnancy produced extremely biased population coverage and performed poorly to moderately for individual-level validity. It is imperative to improve this indicator because it is used in global frameworks and national program planning.

Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review

OBJECTIVE

To assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit.

DESIGN

Systematic review of available literature.

DATA SOURCES

Medline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021.

ELIGIBILITY CRITERIA

Publications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates.

RESULTS

Of 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking).

CONCLUSIONS

Linking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.

Measles antibody levels among vaccinated and unvaccinated children 6-59 months of age in the Democratic Republic of the Congo, 2013-2014

Background

Measles is endemic in the Democratic Republic of the Congo (DRC), and 89–94% herd immunity is required to halt its transmission. Much of the World Health Organization African Region, including the DRC, has vaccination coverage below the 95% level required to eliminate measles, heightening concern of inadequate measles immunity.

Methods

We assessed 6706 children aged 6–59 months whose mothers were selected for interview in the 2013–2014 DRC Demographic and Health Survey. History of measles was obtained by maternal report, and classification of children who had measles was completed using maternal recall and measles immunoglobulin G serostatus obtained from a multiplex chemiluminescent automated immunoassay dried blood spot analysis. A logistic regression model was used to identify associations of covariates with measles and seroprotection, and vaccine effectiveness (VE) was calculated.

Results

Out of our sample, 64% of children were seroprotected. Measles vaccination was associated with protection against measles (OR: 0.15, 95% CI: 0.03, 0.81) when administered to children 12 months of age or older. Vaccination was predictive of seroprotection at all ages. VE was highest (88%) among children 12–24 months of age.

Conclusion

Our results demonstrated lower than expected seroprotection against measles among vaccinated children. Understanding the factors that affect host immunity to measles will aid in developing more efficient and effective immunization programs in DRC.

Oral rehydration solution coverage in under 5 children with diarrhea: a tri-country, subnational, cross-sectional comparative analysis of two demographic health surveys cycles

Background

More than 3 million children under 5 years in developing countries die from dehydration due to diarrhea, a preventable and treatable disease. We conducted a comparative analysis of two Demographic Health Survey (DHS) cycles to examine changes in ORS coverage in Zimbabwe, Zambia and Malawi. These surveys are cross-sectional conducted on a representative sample of the non-institutionalized individuals.

Methods

The sample is drawn using a stratified two-stage cluster sampling design with census enumeration areas, typically, selected first as primary sampling units (PSUs) and then a fixed number of households from each PSU. We examined national and sub-regional prevalence of ORS use during a recent episode of diarrhea (within 2 weeks of survey) using DHSs for 2007–2010 (1st Period), and 2013–2016 (2nd Period). Weighted proportions of ORS were obtained and multivariable- design-adjusted logistic regression analysis was used to obtain Odds Ratios (aORs) and 95% confidence intervals (CIs) and weighted proportions of ORS coverage.

Results

Crude ORS coverage increased from 21.0% (95% CI: 17.4–24.9) in 1st Period to 40.5% (36.5–44.6) in 2nd Period in Zimbabwe; increased from 60.8% (56.1–65.3) to 64.7% (61.8–67.5) in Zambia; and decreased from 72.3% (68.4–75.9) to 64.6% (60.9–68.1) in Malawi. The rates of change in coverage among provinces in Zimbabwe ranged from 10.3% over the three cycles (approximately 10 years) in Midlands to 44.2% in Matabeleland South; in Zambia from − 9.5% in Eastern Province to 24.4% in Luapula; and in Malawi from − 16.5% in the Northern Province to − 3.2% in Southern Province. The aORs for ORS use was 3.95(2.66–5.86) for Zimbabwe, 2.83 (2.35–3.40) for Zambia, and, 0.71(0.59–0.87) for Malawi.

Conclusion

ORS coverage increased in Zimbabwe, stagnated in Zambia, but declined in Malawi. Monitoring national and province-level trends of ORS use illuminates geographic inequalities and helps identify priority areas for targeting resource allocation.. Provision of safe drinking-water, adequate sanitation and hygiene will help reduce the causes and the incidence of diarrhea. Health policies to strengthen access to appropriate treatments such as vaccines for rotavirus and cholera and promoting use of ORS to reduce the burden of diarrhea should be developed and implemented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09811-1.

Temporal trends in coverage, quality and equity of maternal and child health services in Rwanda, 2000-2015

INTRODUCTION

Achieving the maternal and child health (MCH)-related Sustainable Development Goals (SDG) will require equitable and effective (quality-adjusted) coverage of recommended health interventions in low- and middle-income countries. We assessed effective coverage and equity of MCH services in Rwanda in the Millennium Development Goal (MDG) era to help guide policy decisions to improve equitable health gains in the SDG era and beyond.

METHODS

Using four rounds of Rwanda demographic and health surveys conducted from 2000 to 2015, we identified coverage and quality indicators for five MCH services: antenatal care (ANC), delivery care, and care for child diarrhoea, suspected pneumonia and fever. We calculated crude coverage and quality in each survey and used these to estimate effective coverage. The effective coverage should be regarded as an upper bound because there were few available quality measures. We also described equity in effective coverage of these five MCH services over time across the wealth index, area of residence and maternal education using equiplots.

RESULTS

A total of 48 910 women aged 15-49 years and 33 429 children under 5 years were included across the four survey rounds. In 2015, average effective coverage was 33.2% (range 19.9%-44.2%) across all five MCH services, 30.1% (range 19.9%-40.2%) for maternal health services (average of ANC and delivery) and 35.3% (range 27.3%-44.2%) for sick child care (diarrhoea, pneumonia and fever). This is in contrast to crude coverage which averaged 56.5% (range 43.6%-90.7%) across all five MCH services, 67.3% (range 43.9%-90.7%) for maternal health services and 49.2% (range 43.6%-53.9%) for sick child care. Between 2010 and 2015 effective coverage increased by 154.2% (range 127.3%-170.0%) for maternal health services and by 27.4% (range 4.2%-79.6%) for sick child care. These increases were associated with widening socioeconomic inequalities in effective coverage for maternal health services, and narrowing inequalities in effective coverage for sick child care.

CONCLUSION

While effective coverage of common MCH services generally improved in the MDG era, it still lagged substantially behind crude coverage for the same services due to low-quality care. Overall, effective coverage of MCH services remained suboptimal and inequitable. Policies should focus on improving effective coverage of these services and reducing inequities.

Determinants and patterns of care-seeking for childhood illness in rural Pune District, India

BACKGROUND

An estimated 1.2 million children under five years of age die each year in India, with pneumonia and diarrhea among the leading causes. Increasing care-seeking is important to reduce mortality and morbidity from these causes. This paper explores the determinants and patterns of care-seeking for childhood illness in rural Pune district, India.

METHODS

Mothers having at least one child <5 years from the study area of the Vadu Health and Demographic Surveillance System were enrolled in a prospective cohort study. Household sociodemographic information was collected through a baseline questionnaire administered at enrollment. Participants were visited up to six times between July 2015 and February 2016 to collect information on recent childhood acute illness and associated care-seeking behavior. Multivariate logistic regression explored the associations between care-seeking and child, participant, and household characteristics.

RESULTS

We enrolled 743 mothers with 1066 eligible children, completing 2585 follow-up interviews (90% completion). Overall acute illness prevalence in children was 26% with care sought from a health facility during 71% of episodes. Multivariable logistic regression showed care-seeking was associated with the number of reported symptoms (Odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.5-3.9) and household insurance coverage (OR = 2.2, 95% CI = 1.1-4.3). We observed an interaction between the associations of illness severity and maternal employment on care-seeking. Somewhat-to-very severe illness was associated with increased care-seeking among both employed (OR = 5.0, 95% CI = 2.2-11.1) and currently unemployed mothers (OR = 7.0, 95% CI = 3.9-12.6). Maternal employment was associated with reduced care-seeking for non-severe illness (OR = 0.3, 95% CI = 0.1-0.7), but not associated with care-seeking for somewhat-to-very severe illness. Child sex was not associated with care-seeking.

CONCLUSIONS

This study demonstrates the importance of illness characteristics in determining facility-based care-seeking while also suggesting that maternal employment resulted in decreased care-seeking among non-severe illness episodes. The nature of the association between maternal employment and care-seeking is unclear and should be explored through additional studies. Similarly, the absence of male bias in care-seeking should be examined to assess for potential bias at other stages in the management of childhood illness.

Childhood vaccines and antibiotic use in low- and middle-income countries

Vaccines may reduce the burden of antimicrobial resistance, in part by preventing infections for which treatment often includes the use of antibiotics1-4. However, the effects of vaccination on antibiotic consumption remain poorly understood-especially in low- and middle-income countries (LMICs), where the burden of antimicrobial resistance is greatest5. Here we show that vaccines that have recently been implemented in the World Health Organization's Expanded Programme on Immunization reduce antibiotic consumption substantially among children under five years of age in LMICs. By analysing data from large-scale studies of households, we estimate that pneumococcal conjugate vaccines and live attenuated rotavirus vaccines confer 19.7% (95% confidence interval, 3.4-43.4%) and 11.4% (4.0-18.6%) protection against antibiotic-treated episodes of acute respiratory infection and diarrhoea, respectively, in age groups that experience the greatest disease burden attributable to the vaccine-targeted pathogens6,7. Under current coverage levels, pneumococcal and rotavirus vaccines prevent 23.8 million and 13.6 million episodes of antibiotic-treated illness, respectively, among children under five years of age in LMICs each year. Direct protection resulting from the achievement of universal coverage targets for these vaccines could prevent an additional 40.0 million episodes of antibiotic-treated illness. This evidence supports the prioritization of vaccines within the global strategy to combat antimicrobial resistance8.

Measuring coverage of infant and young child feeding counselling interventions: A framework and empirical considerations for survey question design

Most countries implement nutrition counselling interventions as part of programmes to support breastfeeding and complementary feeding. However, data to track coverage of counselling interventions are rarely available. As a result, little is known about the coverage of counselling on infant and young child feeding (IYCF). Survey-based data collection systems generally collect data on IYCF practices but do not collect data on coverage of interventions to support IYCF, and those surveys that do collect this information do not do so consistently. We present a framework to guide the design of survey questions to measure IYCF counselling coverage. We provide examples of how large-scale surveys for programme evaluation and national monitoring have included survey questions to address these data gaps. Our review suggests that elements relevant to designing survey questions to capture coverage of counselling interventions include timing of contact, target behaviour and message content, place of contact, type of service provider, frequency of contact and mode of intervention. Application of this framework may help strengthen harmonized measurement of IYCF counselling coverage to enable better tracking of programme investments, document progress in scaling up nutrition services and allow for cross-country comparisons. Thus, improving measurement of counselling coverage may lead to improved reach of programmes to support optimal IYCF practices.

Validity of self-reported receipt of iron supplements during pregnancy: implications for coverage measurement

Background

Iron-deficiency anemia during pregnancy is an underlying cause of maternal deaths, and reducing risk through routine iron supplementation is a key component of antenatal care (ANC) programs in most low- and middle income countries. Supplementation coverage during pregnancy is estimated from maternal self-reports in population-based household surveys, yet recall bias and social desirability bias lead to errors of unknown magnitude.

Methods

We linked data from household and health facility surveys from 16 countries to estimate input-adjusted coverage of iron supplementation during pregnancy. We assessed the validity of reported receipt of iron supplements in client exit interviews using direct observation as the gold standard across 9 countries with a recent Service Provision Assessment (SPA). Using a sample of 227 women who participated in the Nepal Oil Massage Study (NOMS), we also assessed the validity of self-reported receipt of iron folic acid (IFA) supplements. We used Poisson regression models to explore the association between client and health facility characteristics and agreement of self-reported receipt of iron supplements compared to direct observation.

Results

Across the 16 countries, iron supplements were in supply at most of the 9215 sampled health facilities offering ANC services (91%). We estimated that between 48 and 93% of women attended at least one ANC visit at a health facility with iron supplements available. The specificity of recall of receipt of iron supplementation immediately following a visit was 79.3% and the sensitivity was 88.7% for the entire sample. Individual-level accuracy was high (Area under the curve > 0.7) and population bias low (0.75 < inflation factor < 1.25) across all countries. By contrast, in the NOMS sub-study, the accuracy of self-reported receipt of IFA supplements after 1–2 years was poor (sensitivity 86.1%, specificity 34.3%). Adjusted regression analyses indicated that older age and higher level of education were associated with poorer agreement between self-reports and direct observation.

Conclusions

These findings suggest the need for caution when using self-reported measures with an extended recall period. Further validation studies using conditions similar to widely used population-based household surveys are warranted.

Prospective Relations Between Prenatal Maternal Cortisol and Child Health Outcomes

OBJECTIVE

The aim of the study was to investigate prospective, longitudinal associations between maternal prenatal cortisol response to an interpersonal stressor and child health for the subsequent 3 years.

METHODS

One hundred twenty-three women expecting their first child provided salivary cortisol samples between 12 and 32 weeks of gestation (M (SD) = 22.4 (4.9) weeks) before and after a videotaped couple conflict discussion with their partner. Mothers reported on overall child health and several indicators of child illness (sick doctor visits, fevers, ear, and respiratory infections) when children were 6 months (n = 114), 1 (n = 116), and 3 (n = 105) years old. Associations between maternal prenatal cortisol reactivity and recovery and later child health at each of the three time points were analyzed using longitudinal regression models.

RESULTS

Greater cortisol reactivity in response to the couple conflict discussion was associated with maternal self-report of better overall child health (p = .016, 95% CI = 0.06-1.30, Cohen's f = 0.045) across the study period. Greater cortisol reactivity was also associated with lower incidence rate ratios for maternal reports of sick doctor visits (incidence rate ratio 95% CI = 0.25-0.83, p = .006), fevers (95% CI = 0.25-0.73, p = .002), ear infections (95% CI = 0.25-0.58, p < .001), and respiratory infections (95% CI = 0.08-1.11, p = .073). Cortisol recovery was unrelated to study outcomes (all p's > 0.05). Maternal prenatal depressive symptoms moderated the association between cortisol reactivity and overall child health (p = .034, 95% CI = 0.07-1.87 for interaction term) but no other health outcomes (p's > 0.05). Among women with lower depressive symptoms, cortisol reactivity was not associated with overall child health; among women with higher levels of depressive symptoms, greater cortisol reactivity was associated with better overall child health.

CONCLUSIONS

This study provides longitudinal evidence that greater maternal cortisol reactivity to a salient interpersonal stressor during pregnancy is associated with fewer child health problems and better maternal report of overall child health during infancy and into early childhood.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT01901536.

Linking household survey and health facility data for effective coverage measures: a comparison of ecological and individual linking methods using the Multiple Indicator Cluster Survey in Côte d'Ivoire

Background

Population-based measures of intervention coverage are used in low- and middle-income countries for program planning, prioritization, and evaluation. There is increased interest in effective coverage, which integrates information about service quality or health outcomes. Approaches proposed for quality-adjusted effective coverage include linking data on need and service contact from population-based surveys with data on service quality from health facility surveys. However, there is limited evidence about the validity of different linking methods for effective coverage estimation.

Methods

We collaborated with the 2016 Côte d'Ivoire Multiple Indicator Cluster Survey (MICS) to link data from a health provider assessment to care-seeking data collected by the MICS in the Savanes region of Côte d'Ivoire. The provider assessment was conducted in a census of public and non-public health facilities and pharmacies in Savanes in May-June 2016. We also included community health workers managing sick children who served the clusters sampled for the MICS. The provider assessment collected information on structural and process quality for antenatal care, delivery and immediate newborn care, postnatal care, and sick child care. We linked the MICS and provider data using exact-match and ecological linking methods, including aggregate linking and geolinking methods. We compared the results obtained from exact-match and ecological methods.

Results

We linked 731 of 786 care-seeking episodes (93%) from the MICS to a structural quality score for the provider named by the respondent. Effective coverage estimates computed using exact-match methods were 13%-63% lower than the care-seeking estimates from the MICS. Absolute differences between exact match and ecological linking methods were ±7 percentage points for all ecological methods. Incorporating adjustments for provider category and weighting by service-specific utilization into the ecological methods generally resulted in better agreement between ecological and exact match estimates.

Conclusions

Ecological linking may be a feasible and valid approach for estimating quality-adjusted effective coverage when a census of providers is used. Adjusting for provider type and caseload may improve agreement with exact match results. There remain methodological questions to be addressed to develop guidance on using linking methods for estimating quality-adjusted effective coverage, including the effect of facility sampling and time displacement.

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.

Validation studies for population-based intervention coverage indicators: design, analysis, and interpretation

Background

Population-based intervention coverage indicators are widely used to track country and program progress in improving health and to evaluate health programs. Indicator validation studies that compare survey responses to a “gold standard” measure are useful to understand whether the indicator provides accurate information. The Improving Coverage Measurement (ICM) Core Group has developed and implemented a standard approach to validating coverage indicators measured in household surveys, described in this paper.

Methods

The general design of these studies includes measurement of true health status and intervention receipt (gold standard), followed by interviews with the individuals observed, and a comparison of the observations (gold standard) to the responses to survey questions. The gold standard should use a data source external to the respondent to document need for and receipt of an intervention. Most frequently, this is accomplished through direct observation of clinical care, and/or use of a study-trained clinician to obtain a gold standard diagnosis. Follow-up interviews with respondents should employ standard survey questions, where they exist, as well as alternative or additional questions that can be compared against the standard household survey questions.

Results

Indicator validation studies should report on participation at every stage, and provide data on reasons for non-participation. Metrics of individual validity (sensitivity, specificity, area under the receiver operating characteristic curve) and population-level validity (inflation factor) should be reported, as well as the percent of survey responses that are “don’t know” or missing. Associations between interviewer and participant characteristics and measures of validity should be assessed and reported.

Conclusions

These methods allow respondent-reported coverage measures to be validated against more objective measures of need for and receipt of an intervention, and should be considered together with cognitive interviewing, discriminative validity, or reliability testing to inform decisions about which indicators to include in household surveys. Public health researchers should assess the evidence for validity of existing and proposed household survey coverage indicators and consider validation studies to fill evidence gaps.

Evaluation of methods for linking household and health care provider data to estimate effective coverage of management of child illness: results of a pilot study in Southern Province, Zambia

Background

Existing population-based surveys have limited accuracy for estimating the coverage and quality of management of child illness. Linking household survey data with health care provider assessments has been proposed as a means of generating more informative population-level estimates of effective coverage, but methodological issues need to be addressed.

Methods

A 2016 survey estimated effective coverage of management of child illness in Southern Province, Zambia, using multiple methods for linking temporally and geographically proximate household and health care provider data. Mothers of children <5 years were surveyed about seeking care for child illness. Information on health care providers’ capacity to manage child illness, or structural quality, was assessed using case scenarios and a tool modeled on the WHO Service Availability and Readiness Assessment (SARA). Each sick child was assigned the structural quality score of their stated (exact-match) source of care. Effective coverage was calculated as the average structural quality experienced by all sick children. Children were also ecologically linked to providers using measures of geographic proximity, with and without data on non-facility providers, to assess the effects of these linking methods on effective coverage estimates.

Results

Data were collected on 83 providers and 385 children with fever, diarrhea, and/or symptoms of ARI in the preceding 2 weeks. Most children sought care from government facilities or community-based agents (CBAs). Effective coverage of management of child illness estimated through exact-match linking was approximately 15-points lower in each stratum than coverage of seeking skilled care due to providers’ limited structural quality. Estimates generated using most measures of geographic proximity were similar to the exact-match estimate, with the exception of the kernel density estimation method in the urban area. Estimates of coverage in rural areas were greatly reduced across all methods using facility-only data if seeking care from CBAs was treated as unskilled care.

Conclusions

Linking household and provider data may generate more informative estimates of effective coverage of management of child illness. Ecological linking with provider data on a sample of all skilled providers may be as effective as exact-match linking in areas with low variation in structural quality within a provider category or minimal provider bypassing.