Using Health Extension Workers for Monitoring Child Mortality in Real-Time: Validation against Household Survey Data in Rural Ethiopia

Background

Ethiopia has scaled up its community-based programs over the past decade by training and deploying health extension workers (HEWs) in rural communities throughout the country. Consequently, child mortality has declined substantially, placing Ethiopia among the few countries that have achieved the United Nations’ fourth Millennium Development Goal. As Ethiopia continues its efforts, results must be assessed regularly to provide timely feedback for improvement and to generate further support for programs. More specifically the expansion of HEWs at the community level provides a unique opportunity to build a system for real-time monitoring of births and deaths, linked to a civil registration and vital statistics system that Ethiopia is also developing. We tested the accuracy and completeness of births and deaths reported by trained HEWs for monitoring child mortality over 15 -month periods.

Methods and Findings

HEWs were trained in 93 randomly selected rural kebeles in Jimma and West Hararghe zones of the Oromia region to report births and deaths over a 15-month period from January, 2012 to March, 2013. Completeness of number of births and deaths, age distribution of deaths, and accuracy of resulting under-five, infant, and neonatal mortality rates were assessed against data from a large household survey with full birth history from women aged 15–49. Although, in general HEWs, were able to accurately report events that they identified, the completeness of number of births and deaths reported over twelve-month periods was very low and variable across the two zones. Compared to household survey estimates, HEWs reported only about 30% of births and 21% of under-five deaths occurring in their communities over a twelve-month period. The under-five mortality rate was under-estimated by around 30%, infant mortality rate by 23% and neonatal mortality by 17%. HEWs reported disproportionately higher number of deaths among the very young infants than among the older children.

Conclusion

Birth and death data reported by HEWs are not complete enough to support the monitoring of changes in childhood mortality. HEWs can significantly contribute to the success of a CRVS in Ethiopia, but cannot be relied upon as the sole source for identification of vital events. Further studies are needed to understand how to increase the level of completeness.     

Nonresponse in Household Interview Surveys

Nonresponse in Household Interview Surveys. Robert M. Groves and Mick P. Couper New York: John Wiley & Sons, Inc., 1998. 344 pp.     

Location Matters: Trends in Inequalities in Child Mortality in Indonesia. Evidence from Repeated Cross-Sectional Surveys

Background

Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography.

Methodology

Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth.

Findings

Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened.

Conclusion

Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised.     

Child Mortality Estimation: Appropriate Time Periods for Child Mortality Estimates from Full Birth Histories

Background

Child mortality estimates from complete birth histories from Demographic and Health Surveys (DHS) surveys and similar surveys are a chief source of data used to track Millennium Development Goal 4, which aims for a reduction of under-five mortality by two-thirds between 1990 and 2015. Based on the expected sample sizes when the DHS program commenced, the estimates are usually based on 5-y time periods. Recent surveys have had larger sample sizes than early surveys, and here we aimed to explore the benefits of using shorter time periods than 5 y for estimation. We also explore the benefit of changing the estimation procedure from being based on years before the survey, i.e., measured with reference to the date of the interview for each woman, to being based on calendar years.

Methods and Findings

Jackknife variance estimation was used to calculate standard errors for 207 DHS surveys in order to explore to what extent the large samples in recent surveys can be used to produce estimates based on 1-, 2-, 3-, 4-, and 5-y periods. We also recalculated the estimates for the surveys into calendar-year-based estimates. We demonstrate that estimation for 1-y periods is indeed possible for many recent surveys.

Conclusions

The reduction in bias achieved using 1-y periods and calendar-year-based estimation is worthwhile in some cases. In particular, it allows tracking of the effects of particular events such as droughts, epidemics, or conflict on child mortality in a way not possible with previous estimation procedures. Recommendations to use estimation for short time periods when possible and to use calendar-year-based estimation were adopted in the United Nations 2011 estimates of child mortality.     

Child Mortality Estimation: A Global Overview of Infant and Child Mortality Age Patterns in Light of New Empirical Data

Background

The under-five mortality rate (the probability of dying between birth and age 5 y, also denoted in the literature as U5MR and ₅ q ₀) is a key indicator of child health, but it conceals important information about how this mortality is distributed by age. One important distinction is what amount of the under-five mortality occurs below age 1 y (₁ q ₀) versus at age 1 y and above (₄ q ₁). However, in many country settings, this distinction is often difficult to establish because of various types of data errors. As a result, it is common practice to resort to model age patterns to estimate ₁ q ₀ and ₄ q ₁ on the basis of an observed value of ₅ q ₀. The most commonly used model age patterns for this purpose are the Coale and Demeny and the United Nations systems. Since the development of these models, many additional sources of data for under-five mortality have become available, making possible a general evaluation of age patterns of infant and child mortality. In this paper, we do a systematic comparison of empirical values of ₁ q ₀ and ₄ q ₁ against model age patterns, and discuss whether observed deviations are due to data errors, or whether they reflect true epidemiological patterns not addressed in existing model life tables.

Methods and Findings

We used vital registration data from the Human Mortality Database, sample survey data from the World Fertility Survey and Demographic and Health Surveys programs, and data from Demographic Surveillance Systems. For each of these data sources, we compared empirical combinations of ₁ q ₀ and ₄ q ₁ against combinations provided by Coale and Demeny and United Nations model age patterns. We found that, on the whole, empirical values fall relatively well within the range provided by these models, but we also found important exceptions. Sub-Saharan African countries have a tendency to exhibit high values of ₄ q ₁ relative to ₁ q ₀, a pattern that appears to arise for the most part from true epidemiological causes. While this pattern is well known in the case of western Africa, we observed that it is more widespread than commonly thought. We also found that the emergence of HIV/AIDS, while perhaps contributing to high relative values of ₄ q ₁, does not appear to have substantially modified preexisting patterns. We also identified a small number of countries scattered in different parts of the world that exhibit unusually low values of ₄ q ₁ relative to ₁ q ₀, a pattern that is not likely to arise merely from data errors. Finally, we illustrate that it is relatively common for populations to experience changes in age patterns of infant and child mortality as they experience a decline in mortality.

Conclusions

Existing models do not appear to cover the entire range of epidemiological situations and trajectories. Therefore, model life tables should be used with caution for estimating ₁ q ₀ and ₄ q ₁ on the basis of ₅ q ₀. Moreover, this model-based estimation procedure assumes that the input value of ₅ q ₀ is correct, which may not always be warranted, especially in the case of survey data. A systematic evaluation of data errors in sample surveys and their impact on age patterns of ₁ q ₀ and ₄ q ₁ is urgently needed, along with the development of model age patterns of under-five mortality that would cover a wider range of epidemiological situations and trajectories. Please see later in the article for the Editors'' Summary.     

Child Mortality Estimation: Estimating Sex Differences in Childhood Mortality since the 1970s

Introduction

Producing estimates of infant (under age 1 y), child (age 1–4 y), and under-five (under age 5 y) mortality rates disaggregated by sex is complicated by problems with data quality and availability. Interpretation of sex differences requires nuanced analysis: girls have a biological advantage against many causes of death that may be eroded if they are disadvantaged in access to resources. Earlier studies found that girls in some regions were not experiencing the survival advantage expected at given levels of mortality. In this paper I generate new estimates of sex differences for the 1970s to the 2000s.

Methods and Findings

Simple fitting methods were applied to male-to-female ratios of infant and under-five mortality rates from vital registration, surveys, and censuses. The sex ratio estimates were used to disaggregate published series of both-sexes mortality rates that were based on a larger number of sources. In many developing countries, I found that sex ratios of mortality have changed in the same direction as historically occurred in developed countries, but typically had a lower degree of female advantage for a given level of mortality. Regional average sex ratios weighted by numbers of births were found to be highly influenced by China and India, the only countries where both infant mortality and overall under-five mortality were estimated to be higher for girls than for boys in the 2000s. For the less developed regions (comprising Africa, Asia excluding Japan, Latin America/Caribbean, and Oceania excluding Australia and New Zealand), on average, boys'' under-five mortality in the 2000s was about 2% higher than girls''. A number of countries were found to still experience higher mortality for girls than boys in the 1–4-y age group, with concentrations in southern Asia, northern Africa/western Asia, and western Africa. In the more developed regions (comprising Europe, northern America, Japan, Australia, and New Zealand), I found that the sex ratio of infant mortality peaked in the 1970s or 1980s and declined thereafter.

Conclusions

The methods developed here pinpoint regions and countries where sex differences in mortality merit closer examination to ensure that both sexes are sharing equally in access to health resources. Further study of the distribution of causes of death in different settings will aid the interpretation of differences in survival for boys and girls. Please see later in the article for the Editors'' Summary.     

A Multi-country Study of the Household Willingness-to-Pay for Dengue Vaccines: Household Surveys in Vietnam,Thailand, and Colombia

BackgroundThe rise in dengue fever cases and the absence of dengue vaccines will likely cause governments to consider various types of effective means for controlling the disease. Given strong public interests in potential dengue vaccines, it is essential to understand the private economic benefits of dengue vaccines for accelerated introduction of vaccines into the public sector program and private markets of high-risk countries.Conclusions/SignificanceKnowing that dengue vaccines are not yet available, our study provides critical information to both public and private sectors. The study results can be used to ensure broad coverage with an affordable price and incorporated into cost benefit analyses, which can inform prioritization of alternative health interventions at the national level.     

Child Injury Intensive Monitoring System

A system for the acquisition and recording of child injuries is described. This computer-based system is designed for implementation in three stages. Each successive stage covers wider geographical areas and provides more comprehensive facilities.Stage 1 collects basic identification information on injured children. It provides an intensive monitoring service which alerts the agencies properly concerned with child abuse to repeated or suspicious injury cases. Misleading or suppressed information increases rather than limits the precision of diagnosis. More comprehensive details of those children thought to be at risk are collected when stage 2 is introduced. The printed results of the processing of these details are circulated to certain authorized users, and they are organized for rapid information retrieval. A central office which receives a weekly copy of this cross-referenced file provides a 24-hour information service.In stage 3 a register containing fully structured, standardized case reports will be established. We believe that this system ensures medical confidentiality and respects the rights of parents and children.     

Household Demography and Early Childhood Mortality in a Rice-Farming Village in Northern Laos

This paper extends Alexandr Chayanov’s model of changing household demography (specifically the ratio of food consumers to food producers) and its influence on agricultural behavior so that it includes possible adverse effects of a rising ratio on nutritional status and early childhood mortality within the household. We apply the model to 35 years’ worth of longitudinal demographic and economic data collected in the irrigated-rice growing village of Na Savang in northern Laos. When appropriate controls are included for other household variables, unobserved inter-household heterogeneity, and changes in local conditions and national policy over the study period, the analysis suggests that a unit increase in the household’s consumer/producer ratio induces something like a nine-fold increase in the risk of death among household members aged less than five years. Monte Carlo simulation studies suggest that this may be an over-estimate but also that the effect is probably real and likely to be an important factor in household demography. At the very least, the results suggest that Chayanov’s model still has theoretical relevance and deserves to be revived.     

Child Mortality Estimation: Methods Used to Adjust for Bias due to AIDS in Estimating Trends in Under-Five Mortality

In most low- and middle-income countries, child mortality is estimated from data provided by mothers concerning the survival of their children using methods that assume no correlation between the mortality risks of the mothers and those of their children. This assumption is not valid for populations with generalized HIV epidemics, however, and in this review, we show how the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) uses a cohort component projection model to correct for AIDS-related biases in the data used to estimate trends in under-five mortality. In this model, births in a given year are identified as occurring to HIV-positive or HIV-negative mothers, the lives of the infants and mothers are projected forward using survivorship probabilities to estimate survivors at the time of a given survey, and the extent to which excess mortality of children goes unreported because of the deaths of HIV-infected mothers prior to the survey is calculated. Estimates from the survey for past periods can then be adjusted for the estimated bias. The extent of the AIDS-related bias depends crucially on the dynamics of the HIV epidemic, on the length of time before the survey that the estimates are made for, and on the underlying non-AIDS child mortality. This simple methodology (which does not take into account the use of effective antiretroviral interventions) gives results qualitatively similar to those of other studies.     

Child Centred Approach to Climate Change and Health Adaptation through Schools in Bangladesh: A Cluster Randomised Intervention Trial

Background

Bangladesh is one of the most vulnerable countries to climate change. People are getting educated at different levels on how to deal with potential impacts. One such educational mode was the preparation of a school manual, for high school students on climate change and health protection endorsed by the National Curriculum and Textbook Board, which is based on a 2008 World Health Organization manual. The objective of this study was to test the effectiveness of the manual in increasing the knowledge level of the school children about climate change and health adaptation.

Methods

This cluster randomized intervention trial involved 60 schools throughout Bangladesh, with 3293 secondary school students participating. School upazilas (sub-districts) were randomised into intervention and control groups, and two schools from each upazila were randomly selected. All year seven students from both groups of schools sat for a pre-test of 30 short questions of binary response. A total of 1515 students from 30 intervention schools received the intervention through classroom training based on the school manual and 1778 students of the 30 control schools did not get the manual but a leaflet on climate change and health issues. Six months later, a post-intervention test of the same questionnaire used in the pre-test was performed at both intervention and control schools. The pre and post test scores were analysed along with the demographic data by using random effects model.

Results

None of the various school level and student level variables were significantly different between the control and intervention group. However, the intervention group had a 17.42% (95% CI: 14.45 to 20.38, P = <0.001) higher score in the post-test after adjusting for pre-test score and other covariates in a multi-level linear regression model.

Conclusions

These results suggest that school-based intervention for climate change and health adaptation is effective for increasing the knowledge level of school children on this topic.     

The Impacts of Household Consumption and Options for Change

This introductory article situates the contributions that comprise this special issue within the field of sustainable consumption and production (SCP) studies. After a brief review of the policy history surrounding SCP, we organize our discussion and the subsequent collection of articles into two groups. The first suite of articles views the environmental impacts associated with household consumption from the perspectives of different consumer groups, income levels, and geographic areas. This work confirms and refines several insights that have been developing over the past several years, namely that food and beverages, mobility, housing, and energy-using products are the most critical consumption domains from the standpoint of environmental sustainability and that higher household income leads to greater (but less than proportional) impacts. The second subset of articles analyzes the potential for mitigating these impacts through behavioral changes and innovation strategies. Although the contributions to this special issue describe several noteworthy examples of information- and team-based initiatives to catalyze behavioral changes, the state of knowledge pertaining to this aspect of the consumption problem is much more inchoate. Research on the formulation and implementation of effective "change management for sustainable consumption" should be treated as an area of priority attention for industrial ecologists.     

Climate Change and Heat-Related Excess Mortality in the Eastern USA

Climate change will increase extreme heat-related health risks. To quantify the health impacts of mid-century climate change, we assess heat-related excess mortality across the eastern USA. Health risks are estimated using the US Environmental Protection Agency’s Environmental Benefits Mapping and Analysis Program (BenMAP). Mid-century temperature estimates, downscaled using the Weather Research and Forecasting model, are compared to 2007 temperatures at 36 km and 12 km resolutions. Models indicate the average apparent and actual summer temperatures rise by 4.5° and 3.3° C, respectively. Warmer average apparent temperatures could cause 11,562 additional annual deaths (95% confidence interval, CI: 2641–20,095) due to cardiovascular stress in the population aged 65 years and above, while higher minimum temperatures could cause 8767 (95% CI: 5030–12,475) additional deaths each year. Modeled future climate data available at both coarse (36 km) and fine (12 km) resolutions predict significant human health impacts from warmer climates. The findings suggest that currently available information on future climates is sufficient to guide regional planning for the protection of public health. Higher resolution climate and demographic data are still needed to inform more targeted interventions.     

Child Mortality Estimation: Consistency of Under-Five Mortality Rate Estimates Using Full Birth Histories and Summary Birth Histories

Background

Given the lack of complete vital registration data in most developing countries, for many countries it is not possible to accurately estimate under-five mortality rates from vital registration systems. Heavy reliance is often placed on direct and indirect methods for analyzing data collected from birth histories to estimate under-five mortality rates. Yet few systematic comparisons of these methods have been undertaken. This paper investigates whether analysts should use both direct and indirect estimates from full birth histories, and under what circumstances indirect estimates derived from summary birth histories should be used.

Methods and Findings

Usings Demographic and Health Surveys data from West Africa, East Africa, Latin America, and South/Southeast Asia, I quantify the differences between direct and indirect estimates of under-five mortality rates, analyze data quality issues, note the relative effects of these issues, and test whether these issues explain the observed differences. I find that indirect estimates are generally consistent with direct estimates, after adjustment for fertility change and birth transference, but don''t add substantial additional insight beyond direct estimates. However, choice of direct or indirect method was found to be important in terms of both the adjustment for data errors and the assumptions made about fertility.

Conclusions

Although adjusted indirect estimates are generally consistent with adjusted direct estimates, some notable inconsistencies were observed for countries that had experienced either a political or economic crisis or stalled health transition in their recent past. This result suggests that when a population has experienced a smooth mortality decline or only short periods of excess mortality, both adjusted methods perform equally well. However, the observed inconsistencies identified suggest that the indirect method is particularly prone to bias resulting from violations of its strong assumptions about recent mortality and fertility. Hence, indirect estimates of under-five mortality rates from summary birth histories should be used only for populations that have experienced either smooth mortality declines or only short periods of excess mortality in their recent past. Please see later in the article for the Editors'' Summary.