The Adaptive Cycle As a Lens for Service Learning – Community Engagement Partnerships

This paper deploys the adaptive cycle as a construct to understand the dynamics of community engagement and partnership building during an international service-learning project. A multi-disciplinary team of USA-based university students collaborated with a local community in Zambia to build two ventilated improved pit (VIP) latrines. Post-field project reflection challenged the ‘product-first’ view commonly held in service learning projects.  Time was a central point of post-field reflection. Through critical scrutiny, the team came to recognize that contextually sensitive relationship building had been essential in enabling community ownership of the project.  The construct of the adaptive cycle provided a crucial analytical tool for tracing the process through which partners from very different backgrounds achieved a sense of common purpose and opened the way for an understanding of community engagement as weaving a thread through the complex dynamics of partnership. The adaptive cycle may be useful in the preparation and implementation framework for other service learning projects emanating from institutions of higher education

Pregnancy Surveillance Methods within Health and Demographic Surveillance Systems.

BACKGROUND: Pregnancy identification and follow-up surveillance can enhance the reporting of pregnancy outcomes, including stillbirths and perinatal and early postnatal mortality. This paper reviews pregnancy surveillance methods used in Health and Demographic Surveillance Systems (HDSSs) in low- and middle-income countries. METHODS: We searched articles containing information about pregnancy identification methods used in HDSSs published between January 2002 and October 2019 using PubMed and Google Scholar. A total of 37 articles were included through literature review and 22 additional articles were identified via manual search of references. We reviewed the gray literature, including websites, online reports, data collection instruments, and HDSS protocols from the Child Health and Mortality Prevention Study (CHAMPS) Network and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). In total, we reviewed information from 52 HDSSs described in 67 sources. RESULTS: Substantial variability exists in pregnancy surveillance approaches across the 52 HDSSs, and surveillance methods are not always clearly documented. 42% of HDSSs applied restrictions based on residency duration to identify who should be included in surveillance. Most commonly, eligible individuals resided in the demographic surveillance area (DSA) for at least three months. 44% of the HDSSs restricted eligibility for pregnancy surveillance based on a woman's age, with most only monitoring women 15-49 years. 10% had eligibility criteria based on marital status, while 11% explicitly included unmarried women in pregnancy surveillance. 38% allowed proxy respondents to answer questions about a woman's pregnancy status in her absence. 20% of HDSSs supplemented pregnancy surveillance with investigations by community health workers or key informants and by linking HDSS data with data from antenatal clinics. CONCLUSIONS: Methodological guidelines for conducting pregnancy surveillance should be clearly documented and meticulously implemented, as they can have implications for data quality and accurately informing maternal and child health programs

Women's risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa.

BACKGROUND: WHO's standard definitions of pregnancy-related and maternal deaths only include deaths that occur within 42 days of delivery, termination, or abortion, with major implications for post-partum care and maternal mortality surveillance. We therefore estimated post-partum survival from childbirth up to 1 year post partum to evaluate the empirical justification for the 42-day post-partum threshold. METHODS: We used prospective, longitudinal Health and Demographic Surveillance System (HDSS) data from 30 sites across 12 sub-Saharan African countries to estimate women's risk of death from childbirth until 1 year post partum from all causes. Observations were included if the childbirth occurred from 1991 onwards in the HDSS site and maternal age was 10-54 years. We calculated person-years as the time between childbirth and next birth, outmigration, death, or the end of the first year post partum, whichever occurred first. For six post-partum risk intervals (0-1 days, 2-6 days, 7-13 days, 14-41 days, 42-122 days, and 4-11 months), we calculated the adjusted rate ratios of death relative to a baseline risk of 12-17 months post partum. FINDINGS: Between Jan 1, 1991, and Feb 24, 2020, 647 104 births occurred in the HDSS sites, contributing to 602 170 person-years of exposure time and 1967 deaths within 1 year of delivery. After adjustment for confounding, mortality was 38·82 (95% CI 33·21-45·29) times higher than baseline on days 0-1 after childbirth, 4·97 (3·94-6·21) times higher for days 2-6, 3·35 (2·64-4·20) times higher for days 7-13, and 2·06 (1·74-2·44) times higher for days 14-41. From 42 days to 4 months post partum, mortality was still 1·20 (1·03-1·39) times higher (ie, a 20% higher risk), but deaths in this interval would be excluded from measurement of pregnancy-related mortality. Extending the WHO 42-day post-partum threshold up to 4 months would increase the post-partum pregnancy-related mortality ratio by 40%. INTERPRETATION: This multicountry study has implications for measurement and clinical practice. It makes the case for WHO to extend the 42-day post-partum threshold to capture the full duration of risk of pregnancy-related deaths. There is a need for a new indicator to track late pregnancy-related deaths that occur beyond 42 days, which are otherwise excluded from global maternal health surveillance efforts. Our results also emphasise the need for international agencies to disaggregate estimates by antepartum, intrapartum, postpartum, and extended post-partum periods. Additionally, the schedule and content of postnatal care packages should reflect the extended duration of post-partum risk. FUNDING: The UK Economic and Social Research Council

Evaluating pregnancy reporting in Siaya Health and Demographic Surveillance System through record linkage with ANC clinics

IntroductionHealth and Demographic Surveillance Systems (HDSS) are important sources of population health data in sub-Saharan Africa, but the recording of pregnancies, pregnancy outcomes, and early mortality is often incomplete. ObjectiveThis study assessed HDSS pregnancy reporting completeness and identified predictors of unreported pregnancies that likely ended in adverse outcomes. MethodsThe analysis utilized individually-linked HDSS and antenatal care (ANC) data from Siaya, Kenya for pregnancies in 2018-2020. We cross-checked ANC records with HDSS pregnancy registrations and outcomes. Pregnancies observed in the ANC that were missing reports in the HDSS despite a data collection round following the expected delivery date were identified as likely adverse outcomes, and we investigated the characteristics of such individuals. Clinical data were used to investigate the timing of HDSS pregnancy registration relative to care seeking and gestational age, and examine misclassification of miscarriages and stillbirths. ResultsFrom an analytical sample of 2,475 pregnancies observed in the ANC registers, 46% had pregnancy registrations in the HDSS, and 89% had retrospectively reported pregnancy outcomes. 1% of registered pregnancies were missing outcomes, compared to 10% of those lacking registration. Registered pregnancies had higher rates of stillbirth and perinatal mortality than those lacking registration. In 77% of cases, women accessed ANC prior to registering the pregnancy in the HDSS. Half of reported miscarriages were misclassified stillbirths. We identified 141 unreported pregnancies that likely ended in adverse outcomes. Such cases were more common among those who visited ANC clinics during the first trimester, made fewer overall visits, were HIV-positive, and outside of formal union. ConclusionsRecord linkage with ANC clinics revealed pregnancy underreporting in HDSS, resulting in biased measurement of perinatal mortality. Integrating records of ANC usage into routine data collection can augment HDSS pregnancy surveillance and improve monitoring of adverse pregnancy outcomes and early mortality.</jats:p

Evaluating pregnancy reporting in Siaya Health and Demographic Surveillance System through record linkage with ANC clinics.

INTRODUCTION: Health and Demographic Surveillance Systems (HDSS) are important sources of population health data in sub-Saharan Africa, but the recording of pregnancies, pregnancy outcomes, and early mortality is often incomplete. OBJECTIVE: This study assessed HDSS pregnancy reporting completeness and identified predictors of unreported pregnancies that likely ended in adverse outcomes. METHODS: The analysis utilized individually-linked HDSS and antenatal care (ANC) data from Siaya, Kenya for pregnancies in 2018-2020. We cross-checked ANC records with HDSS pregnancy registrations and outcomes. Pregnancies observed in the ANC that were missing reports in the HDSS despite a data collection round following the expected delivery date were identified as likely adverse outcomes, and we investigated the characteristics of such individuals. Clinical data were used to investigate the timing of HDSS pregnancy registration relative to care seeking and gestational age, and examine misclassification of miscarriages and stillbirths. RESULTS: From an analytical sample of 2,475 pregnancies observed in the ANC registers, 46% had pregnancy registrations in the HDSS, and 89% had retrospectively reported pregnancy outcomes. 1% of registered pregnancies were missing outcomes, compared to 10% of those lacking registration. Registered pregnancies had higher rates of stillbirth and perinatal mortality than those lacking registration. In 77% of cases, women accessed ANC prior to registering the pregnancy in the HDSS. Half of reported miscarriages were misclassified stillbirths. We identified 141 unreported pregnancies that likely ended in adverse outcomes. Such cases were more common among those who visited ANC clinics during the first trimester, made fewer overall visits, were HIV-positive, and outside of formal union. CONCLUSIONS: Record linkage with ANC clinics revealed pregnancy underreporting in HDSS, resulting in biased measurement of perinatal mortality. Integrating records of ANC usage into routine data collection can augment HDSS pregnancy surveillance and improve monitoring of adverse pregnancy outcomes and early mortality

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries

OBJECTIVES: Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage. METHODS: We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment. RESULTS: Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries. CONCLUSION: VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries

Divergent age patterns of under-5 mortality in south Asia and sub-Saharan Africa: a modelling study.

BACKGROUND: Understanding the age pattern of under-5 mortality is essential for identifying the most vulnerable ages and underlying causes of death, and for assessing why the decline in child mortality is slower in some countries and subnational areas than others. The aim of this study is to detect age patterns of under-5 mortality that are specific to low-income and middle-income countries (LMICs). METHODS: In this modelling study, we used data from 277 Demographic and Health Surveys (DHSs), 58 Health and Demographic Surveillance Systems (HDSSs), two cohort studies, and two sample-registration systems. From these sources, we collected child date of birth and date of death (or age at death) from LMICs between 1966 and 2020. We computed 22 deaths rates from each survey with the following age breakdowns: 0, 7, 14, 21, and 28 days; 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, and 21 months; and 2, 3, 4, and 5 years. We assessed how probabilities of dying estimated for the 22 age groups deviated from predictions generated by a vital registration model that reflects the historical mortality of 25 high-income countries. FINDINGS: We calculated mortality rates of 81 LMICs between 1966 and 2020. In contrast with the other regions of the world, we found that under-5 mortality in south Asia and sub-Saharan Africa was characterised by increased mortality at both ends of the age range (ie, younger than 28 days and older than 6 months) at a given level of mortality. Observed mortality in these regions was up to 2 times higher than predicted by the vital registration model for the younger-than-28 days age bracket, and up to 10 times higher than predicted for the older-than-6 months age bracket. This age pattern of under-5 mortality is significant in 17 countries in south Asia and sub-Saharan Africa. Excess mortality in children older than 6 months without excess mortality in children younger than 28 days was found in 38 countries. In south Asia, results were consistent across data sources. In sub-Saharan Africa, excess mortality in children younger than 28 days was found mostly in DHSs; the majority of HDSSs did not show this excess mortality. We have attributed this difference in data sources mainly to omissions of early deaths in HDSSs. INTERPRETATION: In countries with age patterns of under-5 mortality that diverge from predictions, evidence-based public health interventions should focus on the causes of excess of mortality; notably, the effect of fetal growth restriction and infectious diseases. The age pattern of under-5 mortality will be instrumental in assessing progress towards the decline of under-5 mortality and the Sustainable Development Goals. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health

Age patterns of under-5 mortality in sub-Saharan Africa during 1990-2018: A comparison of estimates from demographic surveillance with full birth histories and the historic record.

BACKGROUND: Estimates of under-5 mortality (U5M) for sub-Saharan African populations often rely heavily on full birth histories (FBHs) collected in surveys and model age patterns of mortality calibrated against vital statistics from other populations. Health and Demographic Surveillance Systems (HDSSs) are alternate sources of population-based data in much of sub-Saharan Africa, which are less formally utilized in estimation. OBJECTIVE: In this study we compare the age pattern of U5M in different African data sources (HDSSs, Demographic and Health Surveys (DHS), and Multiple Indicator Cluster Surveys (MICS)), and contrast these with the historical record as summarized in the Human Mortality Database and model age patterns. METHODS: We examined the relative levels of neonatal, postneonatal, infant, and child mortality across data sources. We directly compared estimates for DHS and MICS subnational regions with HDSS, and used linear regression to identify data and contextual attributes that correlated with the disparity between estimates. RESULTS: HDSS and FBH data suggests that African populations have higher levels of child mortality and lower infant mortality than the historic record. This age pattern is most explicit for Western African populations, but also characterizes data for other subregions. The comparison between HDSS and FBH data suggests that FBH estimates of child mortality are biased downward. The comparison is less conclusive for neonatal and infant mortality. CONTRIBUTION: This study questions the practice of using model age patterns derived from largely high-income settings for inferring or correcting U5M estimates for African populations. It also highlights the considerable uncertainty around the consistency of HDSS and FBH estimates of U5M

Community-Led Sanitation in Simoonga, Zambia

Abstract – This paper describes a sanitation project conducted by students from th

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries

ObjectivesVitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage.MethodsWe used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment.ResultsChildren who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries.ConclusionVAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries