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  1. 1
    Peer Reviewed

    Designing HIV testing algorithms based on 2015 WHO guidelines using data from six sites in sub-Saharan Africa.

    Kosack CS; Shanks L; Beelaert G; Benson T; Savane A; Nganga A; Bita A; Zahinda JP; Fransen K; Page AL

    Journal of Clinical Microbiology. 2017 Oct; 55(10):3006-3015.

    Our objective was to evaluate the performance of HIV testing algorithms based on WHO recommendations, using data from specimens collected at six HIV testing and counseling sites in sub-Saharan Africa (Conakry, Guinea; Kitgum and Arua, Uganda; Homa Bay, Kenya; Douala, Cameroon; Baraka, Democratic Republic of Congo). A total of 2,780 samples, including 1,306 HIV-positive samples, were included in the analysis. HIV testing algorithms were designed using Determine as a first test. Second and third rapid diagnostic tests (RDTs) were selected based on site-specific performance, adhering where possible to the WHO-recommended minimum requirements of 99% sensitivity and specificity. The threshold for specificity was reduced to 98% or 96% if necessary. We also simulated algorithms consisting of one RDT followed by a simple confirmatory assay. The positive predictive values (PPV) of the simulated algorithms ranged from 75.8% to 100% using strategies recommended for high-prevalence settings, 98.7% to 100% using strategies recommended for lowprevalence settings, and 98.1% to 100% using a rapid test followed by a simple confirmatory assay. Although we were able to design algorithms that met the recommended PPV of 99% in five of six sites using the applicable high-prevalence strategy, options were often very limited due to suboptimal performance of individual RDTs and to shared falsely reactive results. These results underscore the impact of the sequence of HIV tests and of shared false-reactivity data on algorithm performance. Where it is not possible to identify tests that meet WHO-recommended specifications, the low-prevalence strategy may be more suitable.
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  2. 2
    Peer Reviewed

    Synthetic evaluation of the effect of health promotion: impact of a UNICEF project in 40 poor western counties of China.

    Bi Y; Lai D; Yan H

    Public Health. 2010 Jul; 124(7):376-91.

    OBJECTIVE: To synthetically evaluate the effects of a health promotion project launched by the Ministry of Health of China and the United Nations Children's Fund (UNICEF) in 40 poor western counties of China. STUDY DESIGN: The two surveys were cross-sectional studies. Stratified multistage random sampling was used to recruit subjects. METHODS: Data were collected through two surveys conducted in the 40 'UNICEF project counties' in 1999 and 2000. After categorizing the 27 evaluation indicators into four aspects, a hybrid of the Analytic Hierarchy Process, the Technique for Order Preference by Similarity to Ideal Solution, and linear weighting were used to analyse the changes. The 40 counties were classified into three different levels according to differences in the synthetic indicator derived. Comparing the synthetic evaluation indicators of these two surveys, issues for implementation of the project were identified and discussed. RESULTS: The values of the synthetic indicators were significantly higher in 2000 than in 1999 (P=0.02); this indicated that the projects were effective. Among the 40 counties, 11 counties were at a higher level in 2000, 10 counties were at a lower level, and others were in the middle level. Comparative analysis showed that 36% of village clinics were not licensed to practice medicine, nearly 50% of village clinics had no records of medicine purchases, nearly 20% of village clinics had no pressure cooker for disinfection, and 20% of pregnant women did not receive any prenatal care. CONCLUSIONS: The health promotion projects in the 40 counties were effective. Health management, medical treatment conditions, maternal health and child health care have improved to some extent. However, much remains to be done to improve health care in these 40 poor counties. The findings of this study can help decision makers to improve the implementation of such improvements. Copyright 2010 The Royal Society for Public Health. All rights reserved.
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  3. 3
    Peer Reviewed

    Pilot testing of WHO child growth standards in Chandigarh: implications for India's child health programmes.

    Prinja S; Thakur JS; Bhatia SS

    Bulletin of the World Health Organization. 2009 Feb; 87(2):116-22.

    OBJECTIVE: To compare the prevalence of underweight as calculated from Indian Academy of Paediatrics (IAP) growth curves (based on the Harvard scale) and the new WHO Child Growth Standards. METHODS: We randomly selected 806 children under 6 years of age from 45 primary anganwadi (childcare) centres in Chandigarh, Punjab, India, that were chosen through multistage stratified random sampling. Children were weighed, and their weight for age was calculated using IAP curves and WHO growth references. Nutritional status according to the WHO Child Growth Standards was analysed using WHO Anthro statistical software (beta version, 17 February 2006). The chi2 test was used to determine statistical significance at the 0.05 significance level. FINDINGS: The prevalence of underweight (Z score less than -2) in the first 6 months of life was nearly 1.6 times higher when calculated in accordance with the new WHO standards rather than IAP growth curves. For all ages combined, the estimated prevalence of underweight was 1.4 times higher when IAP standards instead of the new WHO standards were used. Similarly, the prevalence of underweight in both sexes combined was 14.5% higher when IAP standards rather than the new WHO growth standards were applied (P < 0.001). By contrast, severe malnutrition estimated for both sexes were 3.8 times higher when the new WHO standards were used in place of IAP standards (P < 0.001). CONCLUSION: The new WHO growth standards will project a lower prevalence of overall underweight children and provide superior growth tracking than IAP standards, especially in the first 6 months of life and among severely malnourished children.
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  4. 4
    Peer Reviewed

    Emergency obstetric care in Punjab, Pakistan: Improvement needed.

    Ali M; Ahmed KM; Kuroiwa C

    European Journal of Contraception and Reproductive Health Care. 2008 Jun; 13(2):201-207.

    This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services. In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis. No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality. The study may be taken asa baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications. (author's)
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  5. 5
    Peer Reviewed

    Intracluster correlation coefficients from the 2005 WHO Global Survey on Maternal and Perinatal Health: Implications for implementation research.

    Taljaard M; Donner A; Villar J; Wojdyla D; Velazco A

    Paediatric and Perinatal Epidemiology. 2008 Mar; 22(2):117-125.

    Cluster-based studies involving aggregate units such as hospitals or medical practices are increasingly being used in healthcare evaluation. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC). Sample size calculations for cluster-based studies need to account for the ICC, or risk underestimating the sample size required to yield the desired levels of power and significance. In this article, we present values for ICCs that were obtained from data on 97 095 pregnancies and 98 072 births taking place in a representative sample of 120 hospitals in eight Latin American countries. We present ICCs for 86 variables measured on mothers and newborns from pregnancy to the time of hospital discharge, including 'process variables' representing actual medical care received for each mother and newborn. Process variables are of primary interest in the field of implementation research. We found that overall, ICCs ranged from a minimum of 0.0003 to a maximum of 0.563 (median 0.067). For maternal and newborn outcome variables, the median ICCs were 0.011 (interquartile range 0.007-0.037) and 0.054 (interquartile range 0.013-0.075) respectively; however, for process variables, the median was 0.161 (interquartile range 0.072-0.328). Thus, we confirm previous findings that process variables tend to have higher ICCs than outcome variables. We demonstrate that ICCs generally tend to increase with higher prevalences (close to 0.5). These results can help researchers calculate the required sample size for future research studies in maternal and perinatal health. (author's)
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  6. 6
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    Knowledge, perceptions and attitudes of Islamic scholars towards reproductive health programs in Borno State, Nigeria.

    Mairiga AG; Kyari O; Kullima A; Abdullabi H

    African Journal of Reproductive Health. 2007; 11(1):98-106.

    Some reproductive health policies and activities of international development organizations continued to be criticized by some religious groups. Such criticisms can be serious obstacles in the provision of reproductive health and rights information and services in many communities. This study was conducted to find the knowledge, perception and attitude of Islamic scholars on reproductive health programs and to get some suggestions on the scholars' role in the planning and implementation of reproductive health advocacy and programming. The data were collected by in-depth interview with representative sample of selected Muslim scholars in and around Maiduguri town in Borno State, Nigeria. All the scholars had vague or no idea of what reproductive health is all about. When they were explaining reproductive health, most of the scholars mentioned some of the rights of women especially the need for maintaining the good health of women and their children as reproductive health. Even though they have poorknowledge, all the Muslim scholars interviewed believed that reproductive health is an essential component of healthy living and the programs of the international development organizations are mostly good, but they have reservations and concern to certain campaigns and programs. Scholars that promised their contributions in enhancing reproductive health have a common condition for their continuous support to any international development organization or reproductive health program. Conformity to Islamic norms and principles are prerequisites to their loyalties. The scholars also advised the international development organizations on the need to identify themselves clearly, so that people know from where they are coming, what are their background, and the program that they want to do and the reasons for doing the program in the community. (author's)
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  7. 7
    Peer Reviewed

    Assessment of ultrasound morbidity indicators of schistosomiasis in the context of large-scale programs illustrated with experiences from Malian children.

    Koukounari A; Sacko M; Keita AD; Gabrielli AF; Landoure A

    American Journal of Tropical Medicine and Hygiene. 2006 Dec; 75(6):1042-1052.

    We assessed morbidity indicators for both Schistosoma haematobium and Schistosoma mansoni infections and evaluated the appropriateness of the World Health Organization (WHO) guidelines for ultrasound in schistosomiasis in the context of large-scale control interventions. Abdominal and urinary tract ultrasonography was performed on 2,247 and 2,822 school children, respectively, from 29 randomly selected schools in Mali before the implementation of mass anthelminthic drug administration. Using two-level logistic regression models, we examined associations of potential factors with the risk of having a positive ultrasound global score (morbidity indicative of S. haematobium infection), abnormal image pattern scores, dilatation of the portal vein, and/or enlarged liver (morbidity indicative of S. mansoni infection). The WHO protocol was found useful for detection of S. haematobium pathology but overestimated the risk of portal vein dilatation and left liver lobe enlargement associated with S. mansoni infection. We conclude that ultrasonography should be included in large-scale control interventions, where logistics allow, but cautiously. (author's)
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  8. 8
    Peer Reviewed

    Sampling design for the World Health Survey in Brazil.

    de Vasconcellos MT; Silva PL; Szwarcwald CL

    Cadernos de Saude Publica. 2005; 21 Suppl:S89-S99.

    This paper describes the sample design used in the Brazilian application of the World Health Survey. The sample was selected in three stages. First, the census tracts were allocated in six strata defined by their urban/rural situation and population groups of the municipalities (counties). The tracts were selected using probabilities proportional to the respective number of households. In the second stage, households were selected with equiprobability using an inverse sample design to ensure 20 households interviewed per tract. In the last stage, one adult (18 years or older) per household was selected with equiprobability to answer the majority of the questionnaire. Sample weights were based on the inverse of the inclusion probabilities in the sample. To reduce bias in regional estimates, a household weighting calibration procedure was used to reduce sample bias in relation to income, sex, and age group. (author's)
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  9. 9
    Peer Reviewed

    Use of oral contraceptives and hormone replacement therapy in the WHO MONICA project.

    Lundberg V; Tolonen H; Stegmayr B; Kuulasmaa K; Asplund K

    Maturitas. 2004 May 28; 48(1):39-49.

    The aims were to compare menopausal age and the use of oral contraceptives (OC) and hormonal replacement therapy (HRT) between the 32 populations of the WHO MONICA Project, representing 20 different countries. Using a uniform protocol, age at menopause and the use of OC and HRT was recorded in a random sample of 25-64 year-old women attending the final MONICA population cardiovascular risk factor survey between 1989 and 1997. A total of 39,120 women were included. There were wide variations between the populations in the use of OC and HRT. The use of OC varied between 0 and 52% in pre-menopausal women aged 35-44 years, Central and East Europe and North America having the lowest and West Europe and Australasia the highest prevalence rates. Among post-menopausal women between 45 and 64 years, the prevalence of HRT use varied from 0 to 42%. In general, the use of HRT was high in Western and Northern Europe, North America and Australasia and low in Central, Eastern and Southern Europe and China. With the exception of Canada (45 years), the mean age at menopause differed only little (ranging from 48 to 50 years) between the populations. The use of OC and HRT varies markedly between populations, in general following a regional pattern. Whereas, the prevalence rates are mostly similar within a country, there are remarkable differences even between neighbouring countries, reflecting nation-specific medical practice and public attitudes that are not necessarily based on scientific evidence. (author's)
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  10. 10
    Peer Reviewed

    World Health Organization hemoglobin cut-off points for the detection of anemia are valid for an Indonesian population.

    Khusun H; Yip R; Schultink W; Dillon DH

    Journal of Nutrition. 1999; 129:1669-1674.

    The study was designed to determine whether population-specific hemoglobin cut-off values for detection of iron deficiency are needed for Indonesia by comparing the hemoglobin distribution of healthy young Indonesians with that of an American population. This was a cross-sectional study in 203 males and 170 females recruited through a convenience sampling procedure. Hemoglobin, iron biochemistry tests and key infection indicators that can influence iron metabolism were analyzed. The hemoglobin distributions, based on individuals without evidence of clear iron deficiency and infectious process, were compared with the National Health and Nutrition Survey (NHANES) II population of the United States. Twenty percent of the Indonesian females had iron deficiency, but no male subjects were iron deficient. The mean hemoglobin of Indonesian males was similar to the American reference population at 152 g/L with comparable hemoglobin distribution. The mean hemoglobin of the Indonesian females was 2 g/L lower than that of the American reference population, which may be the result of incomplete exclusion of subjects with milder form of iron deficiency. When the WHO cutoff (Hb < 120 g/L) was applied to female subjects, the sensitivity of 34.2% and specificity of 89.4% were more comparable to the test performance for white American women, in contrast to those of the lower cut-off. On the basis of the finding of hemoglobin distribution of men and the test performance of anemia (Hb < 120 g/L) for detecting iron deficiency for women, it is concluded that there is no need to develop different cut-off points for anemia as a tool for iron-deficiency screening in this population. (author's)
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  11. 11
    Peer Reviewed

    Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. [Mise en œuvre des directives de l'OMS sur la gestion de la malnutrition grave dans les hôpitaux africains]

    Deen JL; Funk M; Guevara VC; Saloojee H; Doe JY

    Bulletin of the World Health Organization. 2003; 81(4):237-243.

    Objective: To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. Methods: A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. Findings: Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. Conclusion: Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality. (author's)
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  12. 12

    Age misreporting in Malawian censuses and sample surveys: an application of the United Nations joint age and sex score.

    Palamuleni ME

    Tanzanian Journal of Population Studies and Development. 1997; 4(1):84-105.

    The paper is divided into four parts. The first part, the introduction, discusses the importance of age in demographic analysis and some factors associated with age misreporting. The second section describes the UN's procedure of evaluating age statistics. The third part is the main section of the paper and deals with the application of the procedure described in the second section to the Malawian database. The fourth section, the conclusion, presents the major findings of the study in a summary form. The study has revealed that although age reporting still remains inaccurate, there is some evidence to suggest a slight improvement in the quality of age reporting. It has further been shown that age misreporting varies from one region or district to another. It appears these differentials can be explained in terms of existing social, historical and cultural factors differences within the country. (author's)
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  13. 13
    Peer Reviewed

    Evaluation of the WHO / UNICEF algorithm for integrated management of childhood illness between the ages of one week to two months.

    Gupta R; Sachdev HP; Shah D

    Indian Pediatrics. 2000 Apr; 37:383-90.

    This prospective observational study aimed to evaluate the utility of the WHO/UN International Children's Emergency Fund algorithm for integrated management of childhood illness (IMCI) between the ages of 1 week-2 months admitted at the outpatient department and emergency room of a medical college hospital. 129 infants presenting to the outpatient department (n = 70) or emergency room (n = 59) were assessed and classified as per IMCI algorithm and treatment required was identified…The final diagnoses made and therapies instituted on this basis served as a 'gold standard.’ The diagnostic and therapeutic agreement between the 'gold standard' and the IMCI was computed. More than one illness was present in 97 (75.2%) of subjects as per 'gold standard' (mean 2.1). Subjects having any referral criteria as per IMCI algorithm had a greater (p = 0.002) co- existence of illnesses (mean 2.3 vs. 1.8 illnesses per child, respectively). The IMCI algorithm covered the majority (81-84%) of the recorded diagnoses either partly (40-41%) or fully (40-44%)…A total agreement with IMCI was found in 60-66% cases… Upper respiratory infection (URI) emerged as an important cause resulting in unnecessary referrals (13 out of 21 cases). Of the 43 cases identified as diarrhea by the algorithm, 6 had breastfed stools, which do not require any therapy. The IMCI algorithm had a provision for preventive services of immunization and breast-feeding counseling (18% possibility of availing missed opportunities in both). There is a sound scientific basis for adopting IMCI approach even in young infants as co-existence of morbidities is frequent and severe illnesses are assessed with good sensitivity. However, there is a need to improve the specificity of referral criteria. Two important conditions identified for possible refinement are URI and breastfed stools. (author's, modified)
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  14. 14

    Survey of parents' ability to answer questions on family life.

    Association Zairoise pour le Bien-Etre Familial; Population Council

    In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar. [2] p. (ZAI-16)

    In 1987, the Zairian International Planned Parenthood affiliate, AZBEF, researched adolescents' reproductive health information needs, at a cost of US $2,739, by interviewing more than 10,000 students aged 15 to 27 in schools in the Kinshasa and Bas-Zaire regions. Of approximately 2,000 questions the students asked about sexuality, AZBEF selected 160, representing physiological knowledge, sexually transmitted disease (STD), and contraceptives (including sterility and abortion), to design a booklet on family life education for young people. In February 1991, the national family planning (FP) association, PSND, joined with AZBEF to explore parents' ability to respond to children's concerns about sexuality. In March 1991, they approached The Population Council to design and carry-out a sample survey to determine the proportion of parents open to providing family life education for their children, their capacity to provide it, reasons they would disapprove of such education, and the impact of sexual taboos on the dissemination and understanding of reproductive health information. To collect the data, 30 questions were chosen from AZBEF's list of 160 and a random sample of 500 parents (50% mothers) aged 25 to 55 was selected from 22 of 24 zones (231 neighborhoods) in Kinshasa. Information was gathered during 10 days in April and May 1991. Questions were categorized as: sexual experiences; knowledge about reproductive health, adolescent sexuality, and STDs; attitudes towards contraceptive use by adolescents; and appropriate scholastic programs for introducing family life education. The results provide the basis for an information, education, and communication (IEC) strategy in FP for both PSND and AZBEF. Levels of knowledge about contraceptive methods were 91% in fathers and 84% in mothers. Yet, approximately 75% of parents thought that educating girls about contraception encouraged promiscuous sexual behavior. Abstinence was the most recommended method for both sexes to avoid pregnancy, followed by the condom for boys and the rhythm method for girls. Surprisingly, 62% of the respondents were willing to speak with their children about sex education; 50% of mothers and 20% of fathers stated that they had already done so. Of the 38% who were reluctant to speak with their children about this subject, 58% of males and 60% of females had distinct reasons for not doing so, age being the primary factor. Many deferred this responsibility to other members of the family or community; husbands would often assign this role to their wives, and vice versa, and parents saw the aunt as an important information source for the youth. 36.4% of fathers indicated that youths could go to the FP center to obtain this information, while 59.6% of the mothers preferred youths to visit a local minister. Most parents were aware of STDs, while holding false information about their transmission; 86% believed that kissing is a major form of transmission of STDs, along with handshakes, exchange of clothes, and use of the same latrines. This study provides the basis for future development of a family life education program tailored for the young people of Zaire.
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  15. 15

    [Child health in the states of Ceara, Rio Grande do Norte and Sergipe, Brazil: description of a methodology for community diagnosis] A saude das criancas dos estados do Ceara, Rio Grande do Norte e Sergipe, Brasil: descricao de uma metodologia para diagnosticos comunitarios.

    Victora CG; Barros FC; Tomasi E; Ferreira FS; MacAuliffe J; Silva AC; Andrade FM; Wilhelm L; Barca DV; Santana S

    Revista de Saude Publica / Journal of Public Health. 1991 Jun; 25(3):218-25.

    From 1987 to 1989, UNICEF collaborated with state and municipal health organs of the Brazilian states of Ceara (C), Rio Grande do Norte (R), and Sergipe (S) in order to realize a community diagnosis of maternal-child health care. The estimation of mortality required investigating women aged 15-49 visiting 8000 households, examining 4513 children <3 years old. In R and S, a sample of 1000 children <5 was used to estimate most common health problems. In these states, 1920 households were visited, and a questionnaire served for collection of demographic and socioeconomic data. Children were weighed, and a modified AHRTAG anthropometer served for measuring body length. About 1/4 to 1/3 of children were first-born. In C, 19.3% of children were seventh-born or higher, almost double the rate of the other 2 states. Income, literacy rate of parents, living conditions, and availability of running water indicators were much worse in C. 34.8% of the women in C had not received prenatal care; this figure was 15.7% in S an R, respectively. In C, only 24.3% of the mothers had received 6 or more prenatal care checkups vs. about 1/2 in the other states. Hospital deliveries reached 64.8% in C vs. almost 90% in the other states. In C, breast feeding was more prevalent: 83% were breast feeding for 1 month and 27.1% for 12 months. Malnutrition indicated by height and age was 27.6% in C vs. 16.1% in S and 14/2% in R. There was a clear association between family income and nutritional deficits of height/age and weight/age indicators. In C, malnutrition was higher in all income groups. Diarrhea incidence was 12% in C vs. 7.3% in S and 6/4% in R. A lower percentage used rehydration in C. 9.9% of children in C had been hospitalized in the previous 12 months vs. 6.2% in S and 6.9% in R. Coughing, fever and respiratory difficulties ran to 8.6% in C. Only 42.4% had full vaccination in C vs. 61.7% in S and 71.3% in R. 30/5% had been weighed in C in the previous 3 months vs. 45.1% in S and 44.2% in R.
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  16. 16

    Lot quality assurance sampling techniques in health surveys in developing countries: advantages and current constraints.

    Lanata CF; Black RE


    Costly, time-consuming, traditional survey methods usually provide information only at national or regional levels. Information from the health center and community levels is, however, also of interest particularly in managing and directing supervisory activities. An industrial method is described with practical applications for conducting health surveys to monitor health programs in developing countries. This lot quality assurance sampling (LQAS) methodology was developed in industry for quality control, and allows the use of small sample sizes when surveying small geographical or population-based areas. The paper describes the method, explains how to build a sample frame, and how to conduct the sampling necessary for field application of LQAS. Sampling unit selection for health program monitoring is described in detail. Simple- and double-sampling schemes are discussed, as well as interpretation of survey results and the planning of subsequent rounds. Constraints limiting use by health planners are explored with suggestions provided on modes of overcoming obstacles through future research.
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  17. 17

    A simplified general method for cluster-sample surveys of health in developing countries.

    Bennett S; Woods T; Liyanage WM; Smith DL


    Emphasizing methods for practitioners with little expertise and no background in sampling, this paper presents a set of guidelines to follow in planning cluster-sample surveys of appropriate size in developing countries without undue bias. A self-weighting design based upon the World Health Organization's Expanded Program on Immunization is employed. The paper covers the topics of sample design, methods of random selection of areas and households, sample-size calculation, and estimating proportions, ratios, and means with standard errors appropriate to the survey design. Extensions, including stratification and multiple stages of selection, are also discussed. Giving guidance on possible values, the authors pay close attention to allow for survey structure in estimating sample size, using the design effect and the rate of homogeneity. A spreadsheet is finally included to aid in calculating standard errors.
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  18. 18

    Measuring childhood mortality: a guide for simple surveys.

    David PH; Bisharat L; Hill AG; Bennett S

    Amman, Jordan, United Nations Children's Fund, Regional Office of the Middle East and North America, 1990. 172 p.

    This handbook is intended to aid the United Nations International Children's Emergency Fund (UNICEF) handle surveys of childhood mortality added to vaccination coverage surveys (expanded program of immunization- -EPI) surveys or to diarrheal mortality and morbidity surveys (MMT). By including all women of reproductive ages in each household as part of EPI coverage surveys, the survey window has widened. The core modality module (CMM) locks neatly into this flow. It is not intended to be a substitute for other ways to measure child mortality. Infant and under- age-5 mortality are indicators of social welfare. The reasons why these surveys are called "simple" or "rapid" are listed. Measurement of mortality is covered in Chapter 1. The Brass method, the birth history, the preceding births technique, and the design and execution of a simple mortality survey are discussed here. Formulating the questionnaire is covered in the next chapter. Discussed here are the mortality module; translation, layout and pretesting of the questionnaire; the screening questionnaire, and the mortality questionnaire (Modules A and B). Chapter 3 discusses the design of a sample survey to measure childhood mortality. Discussed here are cluster and stratified sampling, modifying EPI surveys for purposes of mortality estimation, selecting the sample and the clusters, determining sample size, and the requirements of a good sample. Collecting the data is discussed in chapter 4. Topics discussed include field work, preparation of the interview instructions, field supervisor and interviewers, selection and training of field staff, training course outline, selecting households in the sample, quality control; supervisor's responsibilities, how to handle an interview, and how to fill in the questionnaire. The 5th chapter discusses data analysis. Under data analysis, data tabulation of the mortality data, the Brass estimates of childhood mortality and trends, preceding birth technique estimates, estimates from the short birth history, technical note: calculating sampling error for proportions and points to remember are described. How to write the report is discussed in chapter 6.
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  19. 19

    Diarrheal diseases morbidity, mortality and treatment rates in Bahrain (1986).

    Al-Khateeb M

    [Unpublished] 1988. Presented at the 13th World Conference on Health Education, Houston, Texas, August 28 - September 2, 1988. 60 p.

    This study is the report of a 1986 baseline survey, guided by the World Health Organization's "Guidelines for a Sample Survey of Diarrheal Diseases Morbidity, Mortality, and Treatment Rate." The survey method was the Expanded Program on Immunization 30 cluster 2-stage method. Baseline data were also gathered on the status of immunization against diphtheria, tetanus, whooping cough, poliomyelitis, measles, and tuberculosis. Primary health care services in Bahrain are generally good. The archipelago of 670 sq km has a population of 417,210 including 55,000 children under 5. There are 18 health centers and 480 physicians or 1 physician for every 860 people. All inhabitants of a catchment area live within 5 km of a health center, and medical care is free. Diarrhea is due to a number of different organisms, including typhoid, paratyphoid, salmonellosis, Escherichia coli, rotaviruses, and giardiasis, but there has been no cholera in Bahrain since 1979. The national diarrheal diseases control program, drafted by the World Health Organization in 1985, emphasized the use of oral rehydration therapy, breast feeding, and feeding during diarrhea. No vaccinations are compulsory in Bahrain, but immunization coverage has been reported annually since 1981, and vaccinations are in line with the World Health Organization's criteria. Diphtheria-Typhoid-Paratyphoid vaccinations were 1st given in Bahrain in 1957; polio vaccination began in 1958 with Salk vaccine and in 1962 with the Sabin vaccine. Measles vaccination began in 1974. BCG vaccination has been given to children entering school since 1972. All health centers in the country offer vaccination services. Vaccines are stored under refrigeration, and the central supply is at the Public Health Directorate. Adverse effects of vaccinations are monitored. The 1986 diarrheal diseases survey, using the 30 cluster method, looked at a sample of 4114 children under 5 from 2515 households. 378 (9.2%) of the children suffered from diarrhea, and 200 (52.9%) were treated with oral rehydration salts. The under-5 diarrheal mortality rate was .97/1000. The estimated number of episodes of diarrhea per child per year is 2.4, with a high of 8.7 episodes in the Northern Region and a low of 1.2 episodes in the Muharraq Region. Vaccination coverage of children under 2 for other diseases was found to be 96.5% for diphtheria, paratyphoid, and typhoid; 95% for polio; 82.5% for measles; and 59.8% for the trivalent mumps, measles and rubella vaccine. 96.4% of all vaccinations were given in government hospitals. 98.7% of mothers have been examined during pregnancy, and 98.9% of all deliveries are in hospitals. It is recommended that a health education campaign be concentrated on diarrhea, breast feeding, feeding during diarrhea, and hygiene; that both medical staff and mothers be trained in the use of oral rehydration salts; that they should also be informed of the adverse effects of treating diarrhea with antibiotics; that a system for reporting cases of diarrhea be developed; that health education campaigns emphasize the importance of receiving booster doses of vaccines and of vaccination against measles; that staff at health centers adjust their schedules so as to be available for immunizations as needed; and that this survey be repeated every 2 years.
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  20. 20

    Neonatal tetanus: strategies for disease control.

    Frank DL

    [Unpublished] 1987 Apr 30. [4], 53 p.

    Neonatal tetanus, caused by the toxin of Clostridium tetani, is transmitted via unclean instruments used to cut the umbilical cord or contaminated dressings applied to the stump. The symptoms are inability to suck, trismus, convulsions, and (in 80-90% of cases) death on the 7th or 8th day. In the US between 1982 and 1984 only 2 cases of neonatal tetanus were reported; in the developing world an estimated 800,000 infants die of neonatal tetanus every year. The survey methodology used to determine the neonatal tetanus death rate was a 2-stage sampling method, known as the Expanded Program on Immunization 30 cluster sampling method, followed by questionnaires. Such surveys contain a certain amount of built-in bias due both to fact that the final selection of households is never completely random and that retrospectively gathered information is subject to recall bias. The surveys indicated that neonatal tetanus incidence was highest in rural areas, especially where animals were present; in the slums of cities; among families with many children; where mothers received no prenatal care; and where birth attendants were untrained. The best preventive strategy against neonatal tetanus is provided through immunization of the mother with tetanus toxoid, since the antibodies cross the placenta and protect the infant through the neonatal period. Unfortunately, the tetanus vaccination program lags at least 30% behind other World Health Organization Expanded Program on Immunization coverage. The World Health Organization recommends an initial immunization with .01 antitoxin International Units per milliliter of serum, a 2nd dose 4 weeks later (at least 2 weeks before delivery) and booster doses on each successive pregnancy up to 5; the 5th booster provides lifetime protection. Immunization should also be carried out among nonpregnant women of childbearing age and children. The World Health Organization has proposed that neonatal tetanus be made a reportable disease, which should be combatted by prenatal immunization of mothers and training of traditional birth attendants. Between 60% and 80% of all births in developing countries are attended by traditional birth attendants, but, except in China, the training of traditional birth attendants has not contributed as much to reduction of neonatal tetanus as has immunization. Alternative strategies for carrying out tetanus immunization programs include integrating them into prenatal clinics, schools, family planning programs, maternal food distribution programs, well-baby care centers, mass campaigns (especially in urban areas), and mobile team outreach strategies in rural areas. Tetanus immunization could also be linked to other Expanded Program on Immunization programs even though these are mainly targeted at children rather than mothers and other women of childbearing age. Indonesia initiated a tetanus immunization program in 1977 and a traditional birth attendant training program with assistance from the UN Childrens Fund in 1978. However, 3 neonatal tetanus surveys, conducted in 19 provinces, the city of Jakarta, and Java, estimated the total number of deaths/year from neonatal tetanus as 71,150--a neonatal tetanus mortality rate of 11/1000. 3 provincial level studies, also using the Expanded Program on Immunization 30 cluster sampling method, in Nusa Tenggara Barat, West Sumatra Province, and Daerah Istemewah Aceh revealed neonatal tetanus mortality rates of 8.3/1000, 18.5/1000, and 8.4/1000 respectively. In the Health portion of Indonesia's 4th 5-year plan (Pelita IV), the 1st priority is given to reducing the neonatal death rate of 93/1000 live births; the 7th priority is reduction of mortality due to neonatal tetanus by ensuring adequate immunization as part of routine health services and by requiring 2 tetanus immunizations of all women applying for a marriage certificate.
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  21. 21

    Handbook of population and housing census methods, part VI: sampling in connection with population and housing censuses.

    United Nations. Department of Economic and Social Affairs. Statistical Office

    New York, New York, United Nations Department of Economic and Social Affairs, 1971. v, 34 p. (Studies in Methods, Series F, No. 16.; ST/STAT/SER.F/16 (Part VI).)

    This is the 6th part of a 7-part HANDBOOK OF POPULATION AND HOUSING CENSUS METHODS. This handbook is intended to give assistance to governments in the implementation of the PRINCIPLES AND RECOMMENDATIONS FOR THE 1970 POPULATION CENSUSES and the PRINCIPLES AND RECOMMENDATIONS FOR THE 1970 HOUSING CENSUSES. Accordingly, it elaborates on the various aspects of census work that are briefly presented in the 2 sets of recommendations, and offers suggested approaches to problems frequently encountered in the planning and execution of population and housing censuses. Part VI of the handbook is concerned with sampling in connection with population and housing censuses. Chapter I on sampling a an integral part of the census covers general considerations, advantages and disadvantages of sampling and conditions of acceptable sample operations, and applications of sampling methods. Chapter II deals with the census as a basis for subsequent sample inquiries.
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  22. 22

    Surveys to measure programme coverage and impact: a review of the methodology used by the expanded programme on immunization. Enquetes sur la couverture et l'impact des programmes: methodes quantitative utilisees par le programme elargi de vaccination.

    Lemeshow S; Robinson D

    World Health Statistics Quarterly. Rapport Trimestriel de Statistiques Sanitaires Mondiales. 1985; 38(1):65-75.

    To improve the health status of their populations, most countries are developing their ability to provide primary health care. This ultimately depends on information for planning, supervision and monitoring of health activities. Data are needed to define the need for health services, the efficiency of existing services, as well as their impact on morbidity and mortality. Such imformation can best be obtained from surveys. The WHO and other international agencies have been active in promoting the use of surveys and as an example, through its Expanded Program on Immunization (EPI), WHO aims to ensure the availability of immunization for all children in the world by the year 1990. This is a vital effort towards the goal of health for all by the year 2000. EPI developed an appropriate system for data collection which could be implemented in a relatively standardized manner from 1 country to another. The primary purpose of the methodology was to assess the level of immunization coverage, but becasue of its success, it was also adopted for other purposes and suggests limitations, modifications and alternatives to meet the needs of different health programs. The sampling strategy utilized was the probability proportionate to size (PPS) cluster sampling. The EPI survey, as it is currently carried out for determining immunization coverage, involves the detailed review of immunization status of about 210 children by trained reviewers. Field methodology involve identifying precisely what the population is and which age groups within the population are of particular interest and determining which individuals within the cluster to study. Random selection methods are explained. A distinct problem with the EPI methodology is the risk that surveys of adjacent households could either over or underestimate the true population coverage depending on where the starting households happen to be. Leaving selection of successive households to the interviewer creates another opportunity for bias. With some modifications, the EPI methodology has been applied to studies of the incidence of poliomyelitis, neonatal tetanus, diarrhea and studies of morality due to measles. Careful consideration of sample size is necessary. An evaluation of the EPI sampling strategy via computer simulation is presented. An alternative method is the Lot Quality Assurance Sampling (LQAS) technique.
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  23. 23

    Need for and acceptability of long-acting steroidal contraception.

    Shain RN; Potts M

    In: Zatuchni GL, Goldsmith A, Shelton JD, Sciarra JJ, ed. Long-acting contraceptive delivery systems. Philadelphia, Pa., Harper and Row, 1984. 1-19. (PARFR Series on Fertility Regulation)

    Depo-Provera (depomedroxy-progesterone acetate, or DMPA) and NORPLANT (the Population Council's registered trade name for subdermal implants) are focused on in this literature review. Over the past 17 years, more than 1 million individual doses of Depo-Provera have been supplied in Thailand. Currently 6,000 women a month use the method. Depo-Provera has proved outstandingly successful in Bangladesh for years. The basic disadvantage of long-acting steroid systems is that return to fertility is slow and unpredictable. Other disadvantages include menstrual distrubances and weight gain. Acceptability of injectable contraceptives has been studied primarily by the World Health Organization (WHO). In 1976, the Task Force on Acceptability of Research and Family Planning explored preferences among 3 routes of contraceptive administration: 1)oral; 2)intravaginal; and 3)injection. The study was conducted in Indonesia, Korea, Pakistan, and Thailand. Although the oral route was generally preferred by most women, many respondents still chose the injectable. A WHO III multicentered trial comparing the use, effectiveness, side effects and bleeding patterns of Depo-Provera and norethisterone enanthate (NET-EN) was terminated after only 1 year because of excessively high pregnancy rates with NET-EN. A total sample of about 250 women in Manila and Alexandria were interviewed. Results indicated that the 2 most important considerations were effectiveness and menstrual bleeding. Depo-Provera did not affect menstruation. Various types of subdermal implants releasing a contraceptive Silastic implant, is placed beneath the skin of the forearm or upper arm and provides 5 or more years' protection against pregnancy. The 6 capsules are not biodegradable and require surgical removal under local anesthesia.
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  24. 24

    [UN/WHO Working Group on Data Bases for Measurement of Levels, Trends and Differentials in Mortality, Bangkok, 20-23 October 1981] Groupe de Travail ONU/OMS sur les Bases des Donnees Destinees a la Mesure des Niveaux, Tendances et Differences dans la Mortalite, Bangkok, 20-23 octobre 1981.

    World Health Statistics Quarterly. Rapport Trimestriel de Statistiques Sanitaires Mondiales. 1981; 34(4):239-40.

    The meeting was jointly organized by the UN and the World Health Organization (WHO) to discuss the experience of various governments and national institutions in the collection, analysis, and use of mortality data relevant to the establishment of policies in the health and development sectors of their countries in order to make governments aware of the potential uses of the data. Topics covered included: 1) use of mortality data for health and development programs, 2) use of continuous registration systems, 3) approaches for collection of mortality data, 4) collection of mortality data through multipurpose surveys, 5) birth or death records as a sampling frame for studies of mortality, and 6) special data collection systems for studying health processes. Recommendations concerned vital registration, censuses and surveys, other data needs, research strategies, data management and the role of international organizations and funding agencies, stressing the achievement of "birth and death registration for all by the year 2000" as the final goal.
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  25. 25

    Improved data for demographers.

    Taeuber C

    In: Husain IZ, ed. Population analysis and studies: Rodhakamal Mukerjee commemoration volume. Bombay, India, Somaiya Publications, 1972. 104-11.

    The census is a basic element in any integrated national statistical system. Although it supplies only part of the demographic information needed, it is often the 1st step in any statistics collection process. It is limited in time, providing information for 1 static period. The value of census information increases when comparisons can be made with previous censuses. In recent years, various economic and political international organizations have taken responsibility for fostering international census activities. There has been an increase in the number of countries performing censuses. In addition, there have been changes in the approach to censuses, the importance attached to them, and census methodolgy itself. Sampling techniques are becoming more widely used. Evaluation, both of the data collecting techniques in the field and the actual processing of the data, is becoming more widespread also. Computers were 1st used for processing large scale census data in 1951; the importance of this tool for data processing has been universally recognized. As census-taking becomes more widespread, the types of data being collected increase as well. More information useful for social and economic planning is being collected in national censuses.
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