The distribution and effects of child mortality risk factors in Ethiopia: A comparison of estimates from DSS and DHS

Objectives: To conduct a comparative analysis of the distribution and effects of under-five mortality correlates using Demographic and Health Survey (DHS) and Demographic Surveillance System (DSS) data from Ethiopia, and to investigate the methodological bias in DHS-based childhood mortality rates due to the impossibility of including children whose mothers were deceased. Methods: Using all-cause under-5 mortality as an outcome variable, the distribution and effects of risk factors weremodeled using survival analysis. All live births in rural Ethiopia in the 5-year period before the 2005 DSS+ survey and between 01/01/2000 and 31/12/2004 in the DSS in the Butajira Rural Health Program (in the Southern Nations, Nationalities, and People's (SNNP) region of Ethiopia) were included. Results: Overall, similar estimates of hazard rate ratios were derived from both DHS and DSS data and the child mortality risk profile is similar between each data source, with multiple births and living in less populous households being significant risk factors for under-five mortality. Nevertheless, some notable differences were observed. The DSS data was more sensitive to local variations in population composition and health status, whilst the more dispersed DHS approach tended to average out local variation across the country. Excluding children whose mothers were deceased from the DSS analysis had no important effect on risk profiles or estimates of survival functions at age 5 years. DHS survival functions were somewhat lower than DSS estimates (BRHP=0.87, DHS rural Ethiopia=0.67, DHS SNNP=0.66). Conclusion: Despite differing methodologies, cross-sectional DHS and longitudinal DSS data produce estimates of the distribution and effects of under-five mortality risk factors that are broadly similar. The differing methodological characteristics of DHS and DSS mean that when combined, these two data sources have the potential to provide a comprehensive picture of national population composition and health status as well as the extent of local variation –both of which are important for health monitoring and planning

Women's perceptions and self-reports of excessive bleeding during and after delivery: findings from a mixed-methods study in Northern Nigeria

OBJECTIVES: To explore lay perceptions of bleeding during and after delivery, and measure the frequency of self-reported indicators of bleeding. SETTING: Yola, North-East Nigeria. PARTICIPANTS: Women aged 15-49 years who delivered in the preceding 2 years of data collection period (2015-2016), and their family members who played key roles. METHODS: Data on perceptions of bleeding were collected through 7 focus group discussions, 21 in-depth interviews and 10 family interviews. Sampling was purposive and data were analysed thematically. A household survey was then conducted with 640 women using cluster sampling on postpartum bleeding indicators developed from the qualitative data; data were analysed descriptively. RESULTS: Perceptions of excessive bleeding fell under four themes: quantity of blood lost; rate/duration of blood flow; symptoms related to blood loss and receiving birth interventions/hearing comments from birth attendants. Young and less educated rural women had difficulty quantifying blood loss objectively, including when shown quantities using bottles. Respondents felt that acceptable blood loss levels depended on the individual woman and whether the blood is 'good' or 'diseased/bad.' Respondents believed that 'diseased' blood was a normal result of delivery and universally took steps to help it 'come out.' In the quantitative survey, indicators representing less blood loss were reported more frequently than those representing greater loss, for example, more women reported staining their clothes (33.6%) than the bed (18.1%) and the floor (6.2%). Overall, indicators related to quantity and rate of blood flow had higher frequencies compared with symptom and intervention-related/comment-related indicators. CONCLUSION: Women quantify bleeding during and after delivery in varied ways and some women do not see bleeding as problematic. This suggests the need for standard messaging to address subjectivity. The range of indicators and varied frequencies highlight the challenges of measuring excessive bleeding from self-reports. More work is needed in improving and testing validity of questions

Stillbirth should be given greater priority on the global health agenda

Stillbirths are largely excluded from international measures of mortality and morbidity. Zeshan Qureshi and colleagues argue that stillbirth should be higher on the global health agenda

Assessing the impact of mHealth interventions in low- and middle-income countries – what has been shown to work?

PKBackground: Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people’s lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders. Design: Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications. Results: There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects. Conclusions: Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base

WASH conditions in a small town in Uganda: how safe are on-site facilities?

Inadequate hygiene coupled with the conjunctive use of the shallow subsurface as both a source of water and repository of faecal matter pose substantial risks to human health in low-income countries undergoing rapid urbanisation. To evaluate water, sanitation and hygiene (WASH) conditions in a small, rapidly growing town in central Uganda (Lukaya) served primarily by on-site water supply and sanitation facilities, water-point mapping, focus group discussions, sanitary-risk inspections and 386 household surveys were conducted. Household surveys indicate high awareness (82%) of domestic hygiene (e.g. handwashing, boiling water) but limited evidence of practice. WHO Sanitary Risk Surveys and Rapid Participatory Sanitation System Risk Assessments reveal further that community hygiene around water points and sanitation facilities including their maintenance is commonly inadequate. Spot sampling of groundwater quality shows widespread faecal contamination indicated by enumerated thermo-tolerant coliforms (TTCs) (Escherichia coli) ranging from 0 to 104 cfc/100 mL and nitrate concentrations that occasionally exceed 250 mg/L. As defined by the WHO/UNICEF Joint Monitoring programme, there are no safely managed water sources in Lukaya; ∼55% of improved water sources comprising primarily shallow hand-dug wells show gross faecal contamination by E. coli; and 51% of on-site sanitation facilities are unimproved. Despite the critical importance of on-site water supply and sanitation facilities in low-income countries to the realisation of UN Sustainable Goal 6 (access to safe water and sanitation for all by 2030), the analysis highlights the fragility and vulnerability of these systems where current monitoring and maintenance of communal facilities are commonly inadequate

Visual Participatory Analysis: A qualitative method for engaging participants in interpreting the results of randomized controlled trials of health interventions

This article contributes to the field of mixed methods by introducing a new method for eliciting participant perspectives of the quantitative results of randomized controlled trials. Participants are rarely asked to interpret trial results, obscuring potentially valuable information about why a trial either succeeds or fails. We introduce a unique method called visual participatory analysis and discuss the insights gained in its use as part of a trial to prevent risk and reduce the prevalence of diabetes in Bangladesh. Findings highlight benefits such as elucidating contextualized explanations for null results and identifying causal mechanisms, as well as challenges around communicating randomized controlled trial methodologies to lay audiences. We conclude that visual participatory analysis is a valuable method to use after a trial

Digital Bangladesh: Using Formative Research to Develop Phone Messages for the Prevention and Control of Diabetes in Rural Bangladesh

mHealth, Behaviour Change, Bangladesh, Diabetes Mellitus, Formative researc

The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi

Background Verbal autopsy (VA), the process of interviewing a deceased’s family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews. Methods During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative. Results Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5–3.5) of an average 65 answered; mean inter-interviewer concordance was 92 % (IQR: 92–99 %). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather. Conclusions The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services