Rapid evaluation methods (REM) of health services performance: methodological observations.

The rapid evaluation method (REM) was developed by WHO in order to assess the performance and quality of health care services, identify operational problems, and assist in taking managerial action. It was tested in five developing countries (Botswana, Madagascar, Papua New Guinea, Uganda and Zambia) between 1988 and 1991. REM consists of a set of observation- and survey-based diagnostic activities, carried out mainly in health care facilities. The article describes the various steps of REM, methodological issues such as setting objectives and using an issue-information matrix, preparation of survey instruments, use of computer software (Epi Info), data quality control, fieldwork, and the use of data to produce useful information for decision-makers. REM aims at bringing prompt and relevant information to planners and decision-makers who need it for a specific purpose. In the present examples, REM provided information for preparing a programme proposal for external funding, for establishing baseline data for a situation analysis, and for assessing staff performance after extensive training in order to improve the curriculum.

PIP: The rapid evaluation method (REM) is a health management tool aimed at bringing prompt an relevant information to planners and decision makers. The method was developed by WHO's Family Health Division and was field tested in mother and child health care and family planning facilities in Botswana, Madagascar, Papua New Guinea, Uganda, and Zambia between 1988 and 1991. The purpose of this paper is to acquaint the reader with the basic components of the method and methodological problems that arise. Each of the data collection instruments employed is described: clinic exit interviews, health staff interviews, observation of task performance, community and staff focus group discussions, review of clinical records, checking of facilities and equipment and supplies, and household interviews. REM was developed because of the apparent problems of too much paperwork and insufficient time for useful analysis and fears of the expense of surveys. There was a need for a quick, accurate, and economical method of evaluation of facilities and client satisfaction. Reference is made to other REM approaches and a review of REM methods. A basic requirement is the involvement of national program managers in the control, implementation, and application of the design; outside consultants furnish information on methods, formats, and analytical techniques as a complement to national efforts. THe first action taken is to define the objectives and specify the topics and issues of concern. A core group is assigned responsibility for REM. The action plan involves the objectives, information desired, sources for information, schedule of activities, logistical arrangements, and budget preparation. The level of detail of the information desired is defined by the core group and its objectives. A matrix of information is developed which includes information requested and sources; an example is provided. The results of the 5-county evaluation revealed methodological concern about the identification of issues and pretesting of instruments, data quality control, advance notice and planning of fieldwork, the need for analysts familiar with Epi Info Software, analysis of quantitative data first and training of leaders for focus groups, and the need for basic results in 7-10 days and a draft report in several weeks.

Rapid evaluation methods (REM) of health services performance: methodological observations

The rapid evaluation method (REM) was developed by WHO in order to assess the performance and quality of health care services, identify operational problems, and assist in taking managerial action. It was tested in five developing countries (Botswana, Madagascar, Papua New Guinea, Uganda and Zambia) between 1988 and 1991. REM consists of a set of observation- and survey-based diagnostic activities, carried out mainly in health care facilities. The article describes the various steps of REM, methodological issues such as setting objectives and using an issue-information matrix, preparation of survey instruments, use of computer software (Epi Info), data quality control, fieldwork, and the use of data to produce useful information for decision-makers. REM aims at bringing prompt and relevant information to planners and decision-makers who need it for a specific purpose. In the present examples, REM provided information for preparing a programme proposal for external funding, for establishing baseline data for a situation analysis, and for assessing staff performance after extensive training in order to improve the curriculum

The relationship between birth weight, and arm and chest circumference in Egypt.

This paper is concerned with the prediction of birth weight using simple anthropometric indices, namely mid-arm and chest circumferences. Such indices are important tools in the identification of low birth weight infants in areas where scales are not widely available or where they are likely to be not robust enough to withstand rough treatment. This paper reports data from a study in Assiut, Egypt. The aim was to identify which of the two indices was the better predictor or whether measurements on both arm and chest circumference were required. The results show that chest circumference is the better predictor of birth weight, partly perhaps because its measurement is more replicable. Cut-off points for the identification of low birth weight infants are then identified.

Vaginal colonization with Staphylococcus aureus in healthy women: a review of four studies.

Four studies assessed the frequency of vaginal Staphylococcus aureus colonization in healthy women and associated risk factors. An association was found between S. aureus vaginal colonization and colonization at the labia minora and the anterior nares. Significant risk factors associated with an increased risk of vaginal S. aureus in at least one study were a history of genital herpes simplex infection, insertion of tampons without an applicator, and the use of Rely (Procter & Gamble) tampons. The use of systemic antibiotics within 2 weeks of the vaginal culture decreased the risk of recovery of S. aureus. The overall frequency of vaginal S. aureus in the 808 women in the four studies was 9.2%.

Fatal amniotic fluid embolism during legally induced abortion, United States, 1972 to 1978.

Amniotic fluid embolism (AFE) has emerged as an important cause of death from legally induced abortion. In the period 1972-1978, 12 probably and three autopsy-confirmed cases of fatal AFE during legally induced abortion were identified in the United States (12% of all deaths from legal abortion). Fourteen deaths from AFE were associated with labor-inducing techniques, and one with hysterotomy. The risk of death appears to be related to gestational age: the death-to-case rate for AFE increases progressively from nil at less than or equal to 12 weeks' gestation to 7.2 deaths per 100,000 abortions at greater than or equal to 21 weeks' gestation. Because treatment is frequently ineffective, prevention of AFE is critical. Performing abortions early in pregnancy and using curettage techniques whenever feasible should reduce the risk of death from this obstetric accident during legally induced abortion.

PIP: Amniotic fluid embolism (AFE) has increased in importance as a cause of maternal death. During 1968-75 454 women died of AFE in the U.S., or 9% of all maternal deaths. AFE has recently been found to be an important cause of abortion-related deaths; since 1972 AFE has accounted for 12% of all deaths related to legally induced abortion; the overall estimated death-to-case rate for AFE is 0.2/100.000 legal abortions. 15 cases of fatal AFE associated with legally induced abortion were reported in 1978-79, according to the Center for Disease Controls; 3 of these cases were confirmed by autopsy. Age ranged from 16 to 35 years; 7 patients were white, 6 blacks, and 2 were Asian. Gestational age went from 14 to 35 weeks. 5 women had preexisting conditions; 14 women underwent instillation of hypertonic solution, hyperosmolar urea, or PGF2alpha; 1 woman underwent hysterotomy. All women were in labor when manifestations of AFE became evident; death usually occurred soon after the appearance of signs. Risk of death from AFE seems to increase progressively with advancing gestational age; risk at 21 weeks gestation is about 24 times higher than from abortion at 13-15 weeks' gestation. During the same period of time no deaths were associated with curettage abortions. Estimated death-to-case rate for instillation was not significantly different than for hysterotomy; the estimated death-to-case rate for black women and minority women was 2 times higher than for white women. Age did not make a difference in relationship to death. AFE is caused by the forcing of amniotic fluid into the maternal vascular system during the period of intense uterine contractions. The amount of amniotic fluid is much larger during the second and third trimester of pregnancy; this probably explains the increased risk of death from AFE afer 12 weeks' gestation. Prevention rather than treatment of AFE is of paramount importance. 2 measures may reduce the risk of abortion-related AFE: 1) abortion before the 12-15 week, and 2) curettage at about 13 weeks' gestation. Curettage, presumably by avoiding labor contractions, lowers the risk of AFE.

Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases.

To determine the risk factors associated with toxic-shock syndrome (TSS) in menstruating women, we conducted a retrospective telephone study of 52 cases and 52 age-matched and sex-matched controls. Fifty-two cases and 44 controls used tampons (P < 0.02). Moreover, in case-control pairs in which both women used tampons, cases were more likely than controls to use tampons throughout menstruation (42 of 44 vs. 34 of 44, respectively; P < 0.05). There were no significant differences in brand of tampon used, degree of absorbency specified on label, frequency of tampon change, type of contraceptive used, frequency of sexual intercourse, or sexual intercourse during menstruation. Fourteen of 44 cases had one or more definite or probable recurrences during a subsequent menstrual period. In a separate study, Staphylococcus aureus was isolated from 62 of 64 women with TSS and from seven of 71 vaginal cultures obtained from healthy controls (P < 0.001).