Stillbirth and early neonatal mortality rates may be underestimated using recall information: A comparison of demographic surveillance methodologies.

OBJECTIVE: Child mortality and stillbirth rates (SBR) remain high in low-income countries but may be underestimated due to incomplete reporting of child deaths in retrospective pregnancy/birth histories. The aim of this study is to compare stillbirth and mortality estimates derived using two different methods: the method assuming full information and the prospective method. METHODS: Bandim Health Project's Health and Demographic Surveillance Systems (HDSS) follows women of reproductive age and children under five through routine home visits every 1, 2 or 6 months. Between 2012 and 2020, we estimated and compared early neonatal (ENMR, <7 days), neonatal (NMR, <28 days), and infant mortality (IMR, <1 year) per 1000 live births and SBR per 1000 births. Risk time for children born to registered women was calculated from birth (the method assuming full information) versus date of first observation in the HDSS (the prospective method), either at birth (for pregnancy registration) or registration. Rates were calculated using the Kaplan-Meier estimator and compared in generalised linear models allowing for within-child correlation obtaining relative risks (RR). RESULTS: We registered and followed 29,413 infants (1380 deaths; 1459 stillbirths) prospectively. An additional 164 infant deaths and 129 stillbirths were registered retrospectively and included in the method assuming full information. The ENMR was 24.5 (95%CI: 22.6-26.4) for the method assuming full information and 25.8 (23.7-27.8) for the prospective method, RR = 0.96 (0.93-0.99). Differences were smaller for the NMRs and IMRs. For SBRs, the estimates were 53.5 (50.9-56.0) and 58.6 (55.7-61.5); RR = 0.91 (0.90-0.93). The difference between methods became more pronounced when the analysis was limited to areas visited every 6 months: RR for ENMR: 0.91 (0.86-0.96) and RR for SBR: 0.85 (0.83-0.87). CONCLUSIONS: Assuming full information underestimates SBR and ENMR. Accounting for omissions of stillbirths and early neonatal deaths may lead to more accurate estimates and improved ability to monitor mortality.

Collecting mortality data via mobile phone surveys: A non-inferiority randomized trial in Malawi.

Despite the urgent need for timely mortality data in low-income and lower-middle-income countries, mobile phone surveys rarely include questions about recent deaths. Such questions might a) be too sensitive, b) take too long to ask and/or c) generate unreliable data. We assessed the feasibility of mortality data collection using mobile phone surveys in Malawi. We conducted a non-inferiority trial among a random sample of mobile phone users. Participants were allocated to an interview about their recent economic activity or recent deaths in their family. In the group that was asked mortality-related questions, half of the respondents completed an abridged questionnaire, focused on information necessary to calculate recent mortality rates, whereas the other half completed an extended questionnaire that also included questions about symptoms and healthcare. The primary trial outcome was the cooperation rate, i.e., the number of completed interviews divided by the number of mobile subscribers invited to participate. Secondary outcomes included self-reports of negative feelings and stated intentions to participate in future interviews. We called more than 7,000 unique numbers and reached 3,054 mobile subscribers. In total, 1,683 mobile users were invited to participate. The difference in cooperation rates between those asked to complete a mortality-related interview and those asked to answer questions about economic activity was 0.9 percentage points (95% CI = -2.3, 4.1), which satisfied the non-inferiority criterion. The mortality questionnaire was non-inferior to the economic questionnaire on all secondary outcomes. Collecting mortality data required 2 to 4 additional minutes per reported death, depending on the inclusion of questions about symptoms and healthcare. More than half of recent deaths elicited during mobile phone interviews had not been registered with the National Registration Bureau. Including mortality-related questions in mobile phone surveys is feasible. It might help strengthen the surveillance of mortality in countries with deficient civil registration systems. Registration: AEA RCT Registry, #0008065 (14 September 2021).

Strategies to increase downloads of COVID-19 exposure notification apps: A discrete choice experiment.

Exposure notification apps have been developed to assist in notifying individuals of recent exposures to SARS-CoV-2. However, in several countries, such apps have had limited uptake. We assessed whether strategies to increase downloads of exposure notification apps should emphasize improving the accuracy of the apps in recording contacts and exposures, strengthening privacy protections and/or offering financial incentives to potential users. In a discrete choice experiment with potential app users in the US, financial incentives were more than twice as important in decision-making about app downloads, than privacy protections, and app accuracy. The probability that a potential user would download an exposure notification app increased by 40% when offered a $100 reward to download (relative to a reference scenario in which the app is free). Financial incentives might help exposure notification apps reach uptake levels that improve the effectiveness of contact tracing programs and ultimately enhance efforts to control SARS-CoV-2. Rapid, pragmatic trials of financial incentives for app downloads in real-life settings are warranted.

A Web-Based Tool for Quantification of Potential Gains in Life Expectancy by Preventing Cause-Specific Mortality.

Introduction: Local health departments are currently limited in their ability to use life expectancy (LE) as a benchmark for improving community health. In collaboration with the Baltimore City Health Department, our aim was to develop a web-based tool to estimate the potential lives saved and gains in LE in specific neighborhoods following interventions targeting achievable reductions in preventable deaths. Methods: The PROLONGER (ImPROved LONGEvity through Reductions in Cause-Specific Deaths) tool utilizes a novel Lives Saved Simulation model to estimate neighborhood-level potential change in LE after specified reduction in cause-specific mortality. This analysis uses 2012-2016 deaths in Baltimore City residents; a 20% reduction in heart disease mortality is shown as a case study. Results: According to PROLONGER, if heart disease deaths could be reduced by 20% in a given neighborhood in Baltimore City, there could be up to a 2.3-year increase in neighborhood LE. The neighborhoods with highest expected LE increase are not the same as those with highest heart disease mortality burden or lowest overall life expectancies. Discussion: PROLONGER is a practical resource for local health officials in prioritizing scarce resources to improve health outcomes. Focusing programs based on potential LE impact at the neighborhood level could lend new information for targeting of place-based public health interventions.

Adult death registration in Matlab, rural Bangladesh: completeness, correlates, and obstacles.

Civil registration of vital events such as deaths and births is a key part of the process of securing rights and benefits for individuals worldwide. It also enables the production of vital statistics for local planning of social services. In many low- and lower-middle-income countries, however, civil registration and vital statistics (CRVS) systems do not adequately register significant numbers of births and, especially, deaths. In this study, we aim to estimate the completeness of adult death registration (for age 15 and older) in the Matlab health and demographic surveillance system (HDSS) area in Bangladesh and to identify reasons for (not) registering deaths in the national CRVS system. We conducted a sample survey of 2538 households and recorded 571 adult deaths that had occurred in the 3 years preceding the survey. Only 17% of these deaths were registered in the national CRVS system, with large gender differences in registration rates (male = 26% vs. female = 5%). Respondents who reported that a recent death in the household was registered indicated that the primary reasons for registration were to secure an inheritance and to access social services. The main reasons cited for not registering a death were lack of knowledge about CRVS and not perceiving the benefits of death registration. Information campaigns to raise awareness of death registration, as well as stronger incentives to register deaths, may be needed to improve the completeness of death registration in Bangladesh. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41118-021-00125-7.

Neonatal and child mortality data in retrospective population-based surveys compared with prospective demographic surveillance: EN-INDEPTH study.

BACKGROUND: Global mortality estimates remain heavily dependent on household surveys in low- and middle-income countries, where most under-five deaths occur. Few studies have assessed the accuracy of mortality data or determinants of capturing births in surveys. METHODS: The Every Newborn-INDEPTH study (EN-INDEPTH) included a large, multi-country survey of women aged 15-49 interviewed about livebirths and their survival status in five Health and Demographic Surveillance Systems (HDSSs). The HDSSs undertake regular household visits to register births and deaths for a given population. We analysed EN-INDEPTH survey data to assess background factors associated with not recalling a complete date-of-birth. We calculated Kaplan-Meier survival estimates for both survey and HDSS data and describe age-at-death distributions during the past 5 years for children born to the same women. We assessed the proportion of HDSS-births that could be matched on month-of-birth to survey-births and used regression models to identify factors associated with matching. RESULTS: 69,176 women interviewed in the survey reported 109,817 births and 3064 deaths in children under 5 years in the 5 years prior to the survey. In the HDSS data, the same women had 83,768 registered births and 2335 under-five deaths in the same period. A complete date-of-birth was not reported for 1-7% of survey-births. Birthdates were less likely to be complete for dead children and children born to women of higher parity or with little/no education. Distributions of reported age-at-death indicated heaping at full weeks (neonatal period) and at 12 months. Heaping was more pronounced in the survey data. Survey estimates of under-five mortality rates were similar to HDSS estimates of under-five mortality in two of five sites, higher in the survey in two sites (15%, 41%) and lower (24%) in one site. The proportion of HDSS-births matched to survey-births ranged from 51 to 89% across HDSSs and births of children who had died were less likely to be matched. CONCLUSIONS: Mortality estimates in the survey and HDSS were not markedly different for most sites. However, neither source is a "gold standard" and both sources miss some events. Research is required to improve capture and accuracy to better track newborn and child survival targets.

Errors in reported ages and dates in surveys of adult mortality: A record linkage study in Niakhar (Senegal).

Sibling survival histories are a major source of adult mortality estimates in countries with incomplete death registration. We evaluate age and date reporting errors in sibling histories collected during a validation study in the Niakhar Health and Demographic Surveillance System (Senegal). Participants were randomly assigned to either the Demographic and Health Survey questionnaire or a questionnaire incorporating an event history calendar, recall cues, and increased probing strategies. We linked 60-62 per cent of survey reports of siblings to the reference database using manual and probabilistic approaches. Both questionnaires showed high sensitivity (>96 per cent) and specificity (>97 per cent) in recording siblings' vital status. Respondents underestimated the age of living siblings, and age at and time since death of deceased siblings. These reporting errors introduced downward biases in mortality estimates. The revised questionnaire improved reporting of age of living siblings but not of age at or timing of deaths.

Biases in Survey Estimates of Neonatal Mortality: Results From a Validation Study in Urban Areas of Guinea-Bissau.

Neonatal deaths (occurring within 28 days of birth) account for close to one-half of all deaths among children under age 5 worldwide. In most low- and middle-income countries, data on neonatal deaths come primarily from household surveys. We conducted a validation study of survey data on neonatal mortality in Guinea-Bissau (West Africa). We used records from an urban health and demographic surveillance system (HDSS) that monitors child survival prospectively as our reference data set. We selected a stratified sample of 599 women aged 15-49 among residents of the HDSS and collected the birth histories of 422 participants. We cross-tabulated survey and HDSS data. We used a mathematical model to investigate biases in survey estimates of neonatal mortality. Reporting errors in survey data might lead to estimates of the neonatal mortality rate that are too high, which may limit our ability to track progress toward global health objectives.

Comparative Distributional Impact of Routine Immunization and Supplementary Immunization Activities in Delivery of Measles Vaccine in Low- and Middle-Income Countries.

OBJECTIVES: In many countries, measles disproportionately affects poorer households. To achieve equitable delivery, national immunization programs can use 2 main delivery platforms: routine immunization and supplementary immunization activities (SIAs). The objective of this article is to use data concerning measles vaccination coverage delivered via routine and SIA strategies to make inferences about the associated equity impact. METHODS: We relied on Demographic and Health Survey and Multiple Indicator Cluster Surveys multi-country survey data to conduct a comparative analysis of routine and SIA measles vaccination status of children by wealth quintile. We estimated the value of the angle, θ, for the ratio of the difference between coverage levels of adjacent wealth quintiles by using the arc-tangent formula. For each country/year observation, we averaged the θ estimates into one summary measurement, defined as the "equity impact number." RESULTS: Across 20 countries, the equity impact number summarized across wealth quintiles was greater (and hence less equitable) for routine delivery than for SIAs in the survey rounds (years) during, before, and after an SIA about 65% of the time. The equity impact numbers for routine measles vaccination averaged across wealth quintiles were usually greater than for SIA measles vaccination across country-year observations. CONCLUSIONS: This analysis examined how different measles vaccine delivery platforms can affect equity. It can serve to elucidate the impact of immunization and public health programs in terms of comparing horizontal to vertical delivery efforts and in reducing health inequalities in global and country-level decision-making.

Improving the demand for birth registration: a discrete choice experiment in Ethiopia.

INTRODUCTION: Birth registration remains limited in most low and middle-income countries. We investigated which characteristics of birth registration facilities might determine caregivers' decisions to register children in Ethiopia. METHODS: We conducted a discrete choice experiment in randomly selected households in Addis Ababa and the Southern Nations, Nationalities, and People's Region. We interviewed caregivers of children 0-5 years old. We asked participants to make eight choices between pairs of hypothetical registration facilities. These facilities were characterised by six attributes selected through a literature review and consultations with local stakeholders. Levels of these attributes were assigned at random using a fractional design. We analysed the choice data using mixed logit models that account for heterogeneity in preferences across respondents. We calculated respondents' willingness to pay to access registration facilities with specific attributes. We analysed all data separately by place of residence (urban vs rural). RESULTS: Seven hundred and five respondents made 5614 choices. They exhibited preferences for registration facilities that charged lower fees for birth certificates, that required shorter waiting time to complete procedures and that were located closer to their residence. Respondents preferred registration facilities that were open on weekends, and where they could complete procedures in a single visit. In urban areas, respondents also favoured registration facilities that remained open for extended hours on weekdays, and where the presence of only one of the parents was required for registration. There was significant heterogeneity between respondents in the utility derived from several attributes of registration facilities. Willingness to pay for access to registration facilities with particular attributes was larger in urban than rural areas. CONCLUSION: In these regions of Ethiopia, changes to the operating schedule of registration facilities and to application procedures might help improve registration rates. Discrete choice experiments can help orient initiatives aimed at improving birth registration.

Measuring unmet need for contraception as a point prevalence.

BACKGROUND: This study proposes a framework to address conceptual concerns with the standard indicator of unmet need for contraception. We define new point prevalence measures of current status (CS) unmet need and CS unmet demand, by linking contraceptive behaviours to pregnancy exposure and to women's future contraceptive intentions. We explore the difference between standard and CS unmet need and estimate the proportion of women with CS unmet demand, who may be more likely to adopt contraception. METHODS: We use Demographic and Health Survey data from 46 low-income and middle-income countries released between 2010 and 2018. We assess differences in women's classification between standard and CS unmet need indicators and estimate the percentage of women with CS unmet demand for contraception, defined as the percentage of women with CS unmet need who intend to use contraception in the future. FINDINGS: We find substantial country-level differences between standard and CS estimates of unmet need, ranging from -8.3% points in Niger to +11.1% points in Nepal. The average predictive value of the standard measure across the 46 countries for identifying prevalent cases of unmet need is 53%. Regardless of indicator (standard or CS), only half of women with unmet need intend to use contraception. INTERPRETATION: The results of this study suggest that the standard measure of unmet need has low predictive value in identifying women with current unmet need. Thus, the standard indicator does not reflect a prevalence estimate of unmet need.

Evaluating Sampling Biases from Third-party Reporting as a Method for Improving Survey Measures of Sensitive Behaviors.

Survey participants often misreport their sensitive behaviors (e.g., smoking, drinking, having sex) during interviews. Several studies have suggested that asking respondents to report the sensitive behaviors of their friends or confidants, rather than their own, might help address this problem. This is so because the "third-party reporting" (TPR) approach creates a surrogate sample of alters that may be less subject to social desirability biases. However, estimates of the prevalence of sensitive behaviors based on TPR assume that the surrogate sample of friends is representative of the population of interest. We used sociometric data on social networks in Likoma, Malawi to examine this assumption. Specifically, we use friendship network data to investigate whether friends have similar socio-economic characteristics as index respondents, and to measure possible correlations between the likelihood of inclusion in the surrogate sample and sensitive behaviors. From these results, we suggest approaches to strengthen estimates of the prevalence of sensitive behaviors obtained from TPR.

Utilization of non-Ebola health care services during Ebola outbreaks: a systematic review and meta-analysis.

BACKGROUND: Beyond their direct effects on mortality, outbreaks of Ebola Virus Disease (EVD) might disrupt the provision of health care services in affected countries, possibly resulting in an increase in the number of deaths from non-EVD causes. We conducted a systematic review and meta-analysis of studies documenting the impact of EVD outbreaks on health care utilization. METHODS: We searched PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Health, Pascal and grey literature to identify observational studies that compared indicators of health care utilization before and during the outbreak. We identified 14 752 unique citations, 22 of which met inclusion criteria. All were related to the 2013-2016 West African EVD outbreak. From the 22 studies, we extracted 235 estimates of the relative change in health care utilization during the EVD outbreak. We used multivariate regression to estimate the average effect of the outbreak on health care utilization, and to assess heterogeneity across study characteristics. FINDINGS: On average, health care utilization declined by 18.0% during the outbreak (95% Confidence Interval: -26.5%, -9.5%). The observed declines in health care utilization were largest in settings affected by higher levels of EVD incidence (>2.5 cases per 100 000 per week) whereas utilization did not change in settings with EVD incidence less than 0.5 cases per 100 000 per week. Declines in utilization were greater for inpatient care and for deliveries than for outpatient care. They were also larger in studies based on small samples of health facilities, suggestive of publication bias. However, several studies based on larger samples of facilities also observed declines in health care utilization. CONCLUSIONS: During the West African EVD outbreak, the utilization of health services declined significantly. During outbreaks of EVD, attention needs to be paid to the disruption of the health services, which can have large indirect health impacts.

The impact of supplementary immunization activities on routine vaccination coverage: An instrumental variable analysis in five low-income countries.

BACKGROUND: Countries deliver vaccines either through routine health services or supplementary immunization activities (SIAs), usually community-based or door-to-door immunization campaigns. While SIAs have been successful at increasing coverage of vaccines in low- and middle-income countries, they may disrupt the delivery of routine health services. We examine the impact of SIAs on routine vaccine coverage in five low-income countries. METHODS: Data on the number and timing of SIAs conducted in various countries was compiled by WHO and obtained through UNICEF. Information on the coverage of vaccines not targeted by SIAs (e.g., DPT) was extracted from the Demographic and Health Surveys. We focus on SIAs that took place between 1996 and 2013 in Bangladesh, Senegal, Togo, Gambia, and Cote d'Ivoire, and examine outcomes for children aged 12-59 months. To avoid biases resulting from non-random placement and timing of SIAs, we use age of a child at her first SIA as an instrumental variable for total exposure to SIAs. RESULTS: We find that SIA exposure reduced the likelihood of receiving routine vaccines in all the countries included in the study; the coefficients of interest are however statistically insignificant for Gambia and Cote d'Ivoire. In countries that witnessed statistically significant SIA-induced declines in the likelihood of obtaining DPT 3, measles as well as BCG, reductions ranged from 1.3 percentage points (Senegal) to 5.5 percentage points (Bangladesh). CONCLUSION: SIA exposure reduced routine vaccination rates in study countries. Efforts should be made to limit the detrimental impact of SIAs on the services provided by routine health systems.

Differences in barriers to birth and death registration in Guinea-Bissau: implications for monitoring national and global health objectives.

OBJECTIVE: Improving civil registration and vital statistics (CRVS) systems is essential to monitoring health objectives locally and globally. The barriers to birth and particularly death registration in low- and middle-income countries are however poorly understood. METHODS: We conducted a survey among women of reproductive age in Bissau, the capital of Guinea-Bissau. We asked women with a birth in the past two years whether their child had been registered and had obtained a birth certificate. We elicited the sources of information about birth registration and asked respondents to list their reasons for (not) registering a birth. If their child had died, we asked similar questions about death registration. RESULTS: Most women (86%) had received messages about birth registration, but few women whose child had died had heard about the need to register deaths (22%). The primary sources of information about birth registration were messages broadcast on the radio or displayed at health facilities. Information about death registration was primarily obtained through informal social networks. Only 16% of births, and 2% of deaths, had been registered. The main barriers to birth registration were administrative pre-requisites and paternal absence. The main reasons for not registering a death were lack of knowledge about death registration and lack of perceived benefits. CONCLUSION: Strengthening CRVS systems requires addressing the specific barriers preventing birth and death registration. In Bissau, interventions to improve knowledge about death registration are needed. Simplifying registration procedures, as well as providing additional incentives, might help improve the coverage of birth registration.

A pilot trial of the peer-based distribution of HIV self-test kits among fishermen in Bulisa, Uganda.

BACKGROUND: HIV self-testing (HIVST) addresses barriers to HIV diagnosis among men, but current approaches to distributing HIVST kits only reach a subset of the men requiring testing. METHODS: We conducted a pilot trial of the secondary distribution of HIVST kits through peer networks in fishing communities of Buliisa district (Uganda). We recruited distributors ("seeds") among male patients of a health facility, and among community members. Seeds were trained in HIVST and asked to distribute up to five kits to their peers ("recruits"). Recruits were referred to the study using a coupon, and asked to return the HIVST kit (used or unused). The accuracy of HIVST was measured against a confirmatory test conducted by a health worker. We conducted audio computer assisted self-interviews to measure the occurrence of adverse events, and evaluate the potential yield of peer-delivered HIVST. We also assessed how seeds and recruits rated their experience with peer-distributed HIVST. RESULTS: Nineteen seeds offered an HIVST kit to 116 men, and 95 (81.9%) accepted the offer. No recruit reported coercion, but two seeds experienced hostility from recruits or their family members. The sensitivity of peer-distributed HIVST, as interpreted by recruits, was 100%, and its specificity was 92.8%. Among recruits, 29 had never tested (25.8%), and 42 (44.2%) had tested more than a year ago. Three men living with HIV learned their status through peer-distributed HIVST (yield = 1 new diagnosis per 6.3 seeds). Most recruits (85/88) and seeds (19/19) reported that they would recommend HIVST to their friends and family. All seeds stated that they would accept acting as peer distributors again. CONCLUSIONS: This novel peer-based distribution model of HIVST is safe, and has high uptake. It could help reduce the gender gap in HIV testing in under-served fishing communities in Uganda and elsewhere.

Impact of measles supplementary immunisation activities on utilisation of maternal and child health services in low-income and middle-income countries.

BACKGROUND: Measles supplementary immunisation activities (SIAs) are an integral component of measles elimination in low-income and middle-income countries (LMICs). Despite their success in increasing vaccination coverage, there are concerns about their negative consequences on routine services. Few studies have conducted quantitative assessments of SIA impact on utilisation of health services. METHODS: We analysed the impact of SIAs on utilisation of selected maternal and child health services using Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 28 LMICs, where at least one SIA occurred over 2000-2014. Logistic regressions were conducted to investigate the association between SIAs and utilisation of the following services: facility delivery, postnatal care and outpatient sick child care (for fever, diarrhoea, cough). RESULTS: SIAs do not appear to significantly impact utilisation of maternal and child services. We find a reduction in care-seeking for treatment of child cough (OR 0.67; 95% CI 0.48 to 0.95); and a few significant effects at the country level, suggesting the need for further investigation of the idiosyncratic effects of SIAs in each country. CONCLUSION: The paper contributes to the debate on vertical versus horizontal programmes to ensure universal access to vaccination. Measles SIAs do not seem to affect care-seeking for critical conditions.