Using routine health data to evaluate the impact of indoor residual spraying on malaria transmission in Madagascar.

INTRODUCTION: Indoor residual spraying (IRS) and insecticide-treated bed nets (ITNs) are cornerstone malaria prevention methods in Madagascar. This retrospective observational study uses routine data to evaluate the impacts of IRS overall, sustained IRS exposure over multiple years and level of spray coverage (structures sprayed/found) in nine districts where non-pyrethroid IRS was deployed to complement standard pyrethroid ITNs from 2017 to 2020. METHODS: Multilevel negative-binomial generalised linear models were fit to estimate the effects of IRS exposure overall, consecutive years of IRS exposure and spray coverage level on monthly all-ages population-adjusted malaria cases confirmed by rapid diagnostic test at the health facility level. The study period extended from July 2016 to June 2021. Facilities with missing data and non-geolocated communes were excluded. Facilities in IRS districts were matched with control facilities by propensity score analysis. Models were controlled for ITN survivorship, mass drug administration coverage, precipitation, enhanced vegetation index, seasonal effects and district. Predicted cases under a counterfactual no IRS scenario and number of cases averted by IRS were estimated using the fitted models. RESULTS: Exposure to IRS overall reduced case incidence by an estimated 30.3% from 165.8 cases per 1000 population (95% CI=139.7 to 196.7) under a counterfactual no IRS scenario, to 114.3 (95% CI=96.5 to 135.3) over 12 months post-IRS campaign in nine districts. A third year of IRS reduced malaria cases 30.9% more than a first year (incidence rate ratio (IRR)=0.578, 95% CI=0.578 to 0.825, p<0.001) and 26.7% more than a second year (IRR=0.733, 95% CI=0.611 to 0.878, p=0.001). There was no significant difference between the first and second year (p>0.05). Coverage of 86%-90% was associated with a 19.7% reduction in incidence (IRR=0.803, 95% CI=0.690 to 0.934, p=0.005) compared with coverage ≤85%, although these results were not robust to sensitivity analysis. CONCLUSION: This study demonstrates that non-pyrethroid IRS appears to substantially reduce malaria incidence in Madagascar and that sustained implementation of IRS over three years confers additional benefits.

How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations.

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia. We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation. Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

Implementation of the World's largest measles-rubella mass vaccination campaign in Bangladesh: a process evaluation.

BACKGROUND: Gavi, the Vaccine Alliance, supported a mass vaccination Measles-Rubella Campaign (MRC) in Bangladesh during January-February 2014. METHODS: We conducted a mixed-method process evaluation to understand the successes and challenges in implementation of the MRC. We reviewed documents for the MRC and the immunization programme in Bangladesh; observed meetings, vaccination sessions, and health facilities; and conducted 58 key informant interviews, 574 exit interviews with caregivers and 156 brief surveys with stakeholders involved in immunization. Our theory of Change for vaccination delivery guided our assessment of ideal implementation milestones and indicators to compare with the actual implementation processes. RESULTS: We identified challenges relating to country-wide political unrest, administrative and budgetary delays, shortage of transportation, problems in registration of target populations, and fears about safety of the vaccine. Despite these issues, a number of elements contributed to the successful launch of the MRC. These included: the comprehensive design of the campaign; strong partnerships between immunization authorities in the government system, Alliance partners, and civil society actors; and motivated and skilled health workers at different levels of the health system. CONCLUSIONS: The successful implementation of the MRC in spite of numerous contextual and operational challenges demonstrated the adaptive capacity of the national immunization programme and its partners that has positive implications for future introductions of Gavi-supported vaccines.

Assessment of a tool for measuring non-profit advocacy efforts in India, Uganda and Yemen.

To improve maternal and child health, the White Ribbon Alliance for Safe Motherhood (WRA) implemented an innovative policy advocacy project in India, Uganda and Yemen from 2009 to 2011. PATH assisted WRA in designing an approach to measure the short- and long-term results of WRA's advocacy efforts.Expert rating instruments have been widely used since 1970s to track country-level program efforts focusing on family planning, maternal and neonatal health, and HIV/AIDS. This article assesses and establishes the strength and applicability of an expert rating tool, the Maternal Health Policy Score (MHPS), in measuring and guiding a non-profit's advocacy efforts.The tool was assessed using five criteria: validity of results, reproducibility of results, acceptability to respondents, internal consistency and cost. The tool proved effective for measuring improvements in the policy environment at both the national and subnational levels that the non-profit intended to effect and useful for identifying strong and weak policy domains. The results are reproducible, though ensuring fidelity in implementation during different rounds of data collection may be difficult. The acceptability of the tool was high among respondents, and also among users of the information.MHPS provides a quick, low-cost method to measure overall changes in the policy environment, giving advocacy organizations and grant makers timely information to gauge the influence of their work and take corrective action. WRA demonstrated the use of MHPS at multiple points in the project: at the onset of a project to identify and strategize around policy domains that need attention, during and at the end of the project to monitor progress made and redirect efforts.

Evaluating a Large-Scale Community-Based Intervention to Improve Pregnancy and Newborn Health Among the Rural Poor in India.

Objectives. We evaluated the effectiveness of the Sure Start project, which was implemented in 7 districts of Uttar Pradesh, India, to improve maternal and newborn health. Methods. Interventions were implemented at 2 randomly assigned levels of intensity. Forty percent of the areas received a more intense intervention, including community-level meetings with expectant mothers. A baseline survey consisted of 12 000 women who completed pregnancy in 2007; a follow-up survey was conducted for women in 2010 in the same villages. Our quantitative analyses provide an account of the project's impact. Results. We observed significant health improvements in both intervention areas over time; in the more intensive intervention areas, we found greater improvements in care-seeking and healthy behaviors. The more intensive intervention areas did not experience a significantly greater decline in neonatal mortality. Conclusions. This study demonstrates that community-based efforts, especially mothers' group meetings designed to increase care-seeking and healthy behaviors, are effective and can be implemented at large scale.

Mortality in Iraq associated with the 2003-2011 war and occupation: findings from a national cluster sample survey by the university collaborative Iraq Mortality Study.

BACKGROUND: Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011. METHODS AND FINDINGS: We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study. CONCLUSIONS: Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war. Please see later in the article for the Editors' Summary.

Age-specific and sex-specific mortality in 187 countries, 1970-2010: a systematic analysis for the Global Burden of Disease Study 2010.

BACKGROUND: Estimation of the number and rate of deaths by age and sex is a key first stage for calculation of the burden of disease in order to constrain estimates of cause-specific mortality and to measure premature mortality in populations. We aimed to estimate life tables and annual numbers of deaths for 187 countries from 1970 to 2010. METHODS: We estimated trends in under-5 mortality rate (children aged 0-4 years) and probability of adult death (15-59 years) for each country with all available data. Death registration data were available for more than 100 countries and we corrected for undercount with improved death distribution methods. We applied refined methods to survey data on sibling survival that correct for survivor, zero-sibling, and recall bias. We separately estimated mortality from natural disasters and wars. We generated final estimates of under-5 mortality and adult mortality from the data with Gaussian process regression. We used these results as input parameters in a relational model life table system. We developed a model to extrapolate mortality to 110 years of age. All death rates and numbers have been estimated with 95% uncertainty intervals (95% UIs). FINDINGS: From 1970 to 2010, global male life expectancy at birth increased from 56·4 years (95% UI 55·5-57·2) to 67·5 years (66·9-68·1) and global female life expectancy at birth increased from 61·2 years (60·2-62·0) to 73·3 years (72·8-73·8). Life expectancy at birth rose by 3-4 years every decade from 1970, apart from during the 1990s (increase in male life expectancy of 1·4 years and in female life expectancy of 1·6 years). Substantial reductions in mortality occurred in eastern and southern sub-Saharan Africa since 2004, coinciding with increased coverage of antiretroviral therapy and preventive measures against malaria. Sex-specific changes in life expectancy from 1970 to 2010 ranged from gains of 23-29 years in the Maldives and Bhutan to declines of 1-7 years in Belarus, Lesotho, Ukraine, and Zimbabwe. Globally, 52·8 million (95% UI 51·6-54·1 million) deaths occurred in 2010, which is about 13·5% more than occurred in 1990 (46·5 million [45·7-47·4 million]), and 21·9% more than occurred in 1970 (43·3 million [42·2-44·6 million]). Proportionally more deaths in 2010 occurred at age 70 years and older (42·8% in 2010 vs 33·1% in 1990), and 22·9% occurred at 80 years or older. Deaths in children younger than 5 years declined by almost 60% since 1970 (16·4 million [16·1-16·7 million] in 1970 vs 6·8 million [6·6-7·1 million] in 2010), especially at ages 1-59 months (10·8 million [10·4-11·1 million] in 1970 vs 4·0 million [3·8-4·2 million] in 2010). In all regions, including those most affected by HIV/AIDS, we noted increases in mean ages at death. INTERPRETATION: Despite global and regional health crises, global life expectancy has increased continuously and substantially in the past 40 years. Yet substantial heterogeneity exists across age groups, among countries, and over different decades. 179 of 187 countries have had increases in life expectancy after the slowdown in progress in the 1990s. Efforts should be directed to reduce mortality in low-income and middle-income countries. Potential underestimation of achievement of the Millennium Development Goal 4 might result from limitations of demographic data on child mortality for the most recent time period. Improvement of civil registration system worldwide is crucial for better tracking of global mortality. FUNDING: Bill & Melinda Gates Foundation.

A two-stage cluster sampling method using gridded population data, a GIS, and Google Earth(TM) imagery in a population-based mortality survey in Iraq.

BACKGROUND: Mortality estimates can measure and monitor the impacts of conflict on a population, guide humanitarian efforts, and help to better understand the public health impacts of conflict. Vital statistics registration and surveillance systems are rarely functional in conflict settings, posing a challenge of estimating mortality using retrospective population-based surveys. RESULTS: We present a two-stage cluster sampling method for application in population-based mortality surveys. The sampling method utilizes gridded population data and a geographic information system (GIS) to select clusters in the first sampling stage and Google Earth TM imagery and sampling grids to select households in the second sampling stage. The sampling method is implemented in a household mortality study in Iraq in 2011. Factors affecting feasibility and methodological quality are described. CONCLUSION: Sampling is a challenge in retrospective population-based mortality studies and alternatives that improve on the conventional approaches are needed. The sampling strategy presented here was designed to generate a representative sample of the Iraqi population while reducing the potential for bias and considering the context specific challenges of the study setting. This sampling strategy, or variations on it, are adaptable and should be considered and tested in other conflict settings.

National and subnational mortality effects of metabolic risk factors and smoking in Iran: a comparative risk assessment.

BACKGROUND: Mortality from cardiovascular and other chronic diseases has increased in Iran. Our aim was to estimate the effects of smoking and high systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC), and high body mass index (BMI) on mortality and life expectancy, nationally and subnationally, using representative data and comparable methods. METHODS: We used data from the Non-Communicable Disease Surveillance Survey to estimate means and standard deviations for the metabolic risk factors, nationally and by region. Lung cancer mortality was used to measure cumulative exposure to smoking. We used data from the death registration system to estimate age-, sex-, and disease-specific numbers of deaths in 2005, adjusted for incompleteness using demographic methods. We used systematic reviews and meta-analyses of epidemiologic studies to obtain the effect of risk factors on disease-specific mortality. We estimated deaths and life expectancy loss attributable to risk factors using the comparative risk assessment framework. RESULTS: In 2005, high SBP was responsible for 41,000 (95% uncertainty interval: 38,000, 44,000) deaths in men and 39,000 (36,000, 42,000) deaths in women in Iran. High FPG, BMI, and TC were responsible for about one-third to one-half of deaths attributable to SBP in men and/or women. Smoking was responsible for 9,000 deaths among men and 2,000 among women. If SBP were reduced to optimal levels, life expectancy at birth would increase by 3.2 years (2.6, 3.9) and 4.1 years (3.2, 4.9) in men and women, respectively; the life expectancy gains ranged from 1.1 to 1.8 years for TC, BMI, and FPG. SBP was also responsible for the largest number of deaths in every region, with age-standardized attributable mortality ranging from 257 to 333 deaths per 100,000 adults in different regions. DISCUSSION: Management of blood pressure through diet, lifestyle, and pharmacological interventions should be a priority in Iran. Interventions for other metabolic risk factors and smoking can also improve population health.

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis.

BACKGROUND: With 4 years until 2015, it is essential to monitor progress towards Millennium Development Goals (MDGs) 4 and 5. Although estimates of maternal and child mortality were published in 2010, an update of estimates is timely in view of additional data sources that have become available and new methods developed. Our aim was to update previous estimates of maternal and child mortality using better data and more robust methods to provide the best available evidence for tracking progress on MDGs 4 and 5. METHODS: We update the analyses of the progress towards MDGs 4 and 5 from 2010 with additional surveys, censuses, vital registration, and verbal autopsy data. For children, we estimate early neonatal (0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (ages 1-4 years), and under-5 mortality. We use an improved model for estimating mortality by age under 5 years. For maternal mortality, our updated analysis includes greater than 1000 additional site-years of data. We tested a large set of alternative models for maternal mortality; we used an ensemble model based on the models with the best out-of-sample predictive validity to generate new estimates from 1990 to 2011. FINDINGS: Under-5 deaths have continued to decline, reaching 7·2 million in 2011 of which 2·2 million were early neonatal, 0·7 million late neonatal, 2·1 million postneonatal, and 2·2 million during childhood (ages 1-4 years). Comparing rates of decline from 1990 to 2000 with 2000 to 2011 shows that 106 countries have accelerated declines in the child mortality rate in the past decade. Maternal mortality has also continued to decline from 409,100 (uncertainty interval 382,900-437,900) in 1990 to 273,500 (256,300-291,700) deaths in 2011. We estimate that 56,100 maternal deaths in 2011 were HIV-related deaths during pregnancy. Based on recent trends in developing countries, 31 countries will achieve MDG 4, 13 countries MDG 5, and nine countries will achieve both. INTERPRETATION: Even though progress on reducing maternal and child mortality in most countries is accelerating, most developing countries will take many years past 2015 to achieve the targets of the MDGs 4 and 5. Similarly, although there continues to be progress on maternal mortality the pace is slow, without any overall evidence of acceleration. Immediate concerted action is needed for a large number of countries to achieve MDG 4 and MDG 5. FUNDING: Bill & Melinda Gates Foundation.

Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4.

BACKGROUND: Previous assessments have highlighted that less than a quarter of countries are on track to achieve Millennium Development Goal 4 (MDG 4), which calls for a two-thirds reduction in mortality in children younger than 5 years between 1990 and 2015. In view of policy initiatives and investments made since 2000, it is important to see if there is acceleration towards the MDG 4 target. We assessed levels and trends in child mortality for 187 countries from 1970 to 2010. METHODS: We compiled a database of 16 174 measurements of mortality in children younger than 5 years for 187 countries from 1970 to 2009, by use of data from all available sources, including vital registration systems, summary birth histories in censuses and surveys, and complete birth histories. We used Gaussian process regression to generate estimates of the probability of death between birth and age 5 years. This is the first study that uses Gaussian process regression to estimate child mortality, and this technique has better out-of-sample predictive validity than do previous methods and captures uncertainty caused by sampling and non-sampling error across data types. Neonatal, postneonatal, and childhood mortality was estimated from mortality in children younger than 5 years by use of the 1760 measurements from vital registration systems and complete birth histories that contained specific information about neonatal and postneonatal mortality. FINDINGS: Worldwide mortality in children younger than 5 years has dropped from 11.9 million deaths in 1990 to 7.7 million deaths in 2010, consisting of 3.1 million neonatal deaths, 2.3 million postneonatal deaths, and 2.3 million childhood deaths (deaths in children aged 1-4 years). 33.0% of deaths in children younger than 5 years occur in south Asia and 49.6% occur in sub-Saharan Africa, with less than 1% of deaths occurring in high-income countries. Across 21 regions of the world, rates of neonatal, postneonatal, and childhood mortality are declining. The global decline from 1990 to 2010 is 2.1% per year for neonatal mortality, 2.3% for postneonatal mortality, and 2.2% for childhood mortality. In 13 regions of the world, including all regions in sub-Saharan Africa, there is evidence of accelerating declines from 2000 to 2010 compared with 1990 to 2000. Within sub-Saharan Africa, rates of decline have increased by more than 1% in Angola, Botswana, Cameroon, Congo, Democratic Republic of the Congo, Kenya, Lesotho, Liberia, Rwanda, Senegal, Sierra Leone, Swaziland, and The Gambia. INTERPRETATION: Robust measurement of mortality in children younger than 5 years shows that accelerating declines are occurring in several low-income countries. These positive developments deserve attention and might need enhanced policy attention and resources. FUNDING: Bill & Melinda Gates Foundation.

Worldwide mortality in men and women aged 15-59 years from 1970 to 2010: a systematic analysis.

BACKGROUND: Adult deaths are a crucial priority for global health. Causes of adult death are important components of Millennium Development Goals 5 and 6. However, adult mortality has received little policy attention, resources, or monitoring efforts. This study aimed to estimate worldwide mortality in men and women aged 15-59 years. METHODS: We compiled a database of 3889 measurements of adult mortality for 187 countries from 1970 to 2010 using vital registration data and census and survey data for deaths in the household corrected for completeness, and sibling history data from surveys corrected for survival bias. We used Gaussian process regression to generate yearly estimates of the probability of death between the ages of 15 years and 60 years (45q15) for men and women for every country with uncertainty intervals that indicate sampling and non-sampling error. We showed that these analytical methods have good predictive validity for countries with missing data. FINDINGS: Adult mortality varied substantially across countries and over time. In 2010, the countries with the lowest risk of mortality for men and women are Iceland and Cyprus, respectively. In Iceland, male 45q15 is 65 (uncertainty interval 61-69) per 1000; in Cyprus, female 45q15 is 38 (36-41) per 1000. Highest risk of mortality in 2010 is seen in Swaziland for men (45q15 of 765 [692-845] per 1000) and Zambia for women (606 [518-708] per 1000). Between 1970 and 2010, substantial increases in adult mortality occurred in sub-Saharan Africa because of the HIV epidemic and in countries in or related to the former Soviet Union. Other regional trends were also seen, such as stagnation in the decline of adult mortality for large countries in southeast Asia and a striking decline in female mortality in south Asia. INTERPRETATION: The prevention of premature adult death is just as important for global health policy as the improvement of child survival. Routine monitoring of adult mortality should be given much greater emphasis. FUNDING: Bill & Melinda Gates Foundation.

What can we conclude from death registration? Improved methods for evaluating completeness.

BACKGROUND: One of the fundamental building blocks for determining the burden of disease in populations is to reliably measure the level and pattern of mortality by age and sex. Where well-functioning registration systems exist, this task is relatively straightforward. Results from many civil registration systems, however, remain uncertain because of a lack of confidence in the completeness of death registration. Incomplete registration systems mean not all deaths are counted, and resulting estimates of death rates for the population are then underestimated. Death distribution methods (DDMs) are a suite of demographic methods that attempt to estimate the fraction of deaths that are registered and counted by the civil registration system. Although widely applied and used, the methods have at least three types of limitations. First, a wide range of variants of these methods has been applied in practice with little scientific literature to guide their selection. Second, the methods have not been extensively validated in real population conditions where violations of the assumptions of the methods most certainly occur. Third, DDMs do not generate uncertainty intervals. METHODS AND FINDINGS: In this paper, we systematically evaluate the performance of 234 variants of DDM methods in three different validation environments where we know or have strong beliefs about the true level of completeness of death registration. Using these datasets, we identify three variants of the DDMs that generally perform the best. We also find that even these improved methods yield uncertainty intervals of roughly +/- one-quarter of the estimate. Finally, we demonstrate the application of the optimal variants in eight countries. CONCLUSIONS: There continues to be a role for partial vital registration data in measuring adult mortality levels and trends, but such results should only be interpreted alongside all other data sources on adult mortality and the uncertainty of the resulting levels, trends, and age-patterns of adult death considered. Please see later in the article for the Editors' Summary.

Measuring adult mortality using sibling survival: a new analytical method and new results for 44 countries, 1974-2006.

BACKGROUND: For several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliably monitor the impact of such intervention programs in countries has led to significant advances in demographic methods and data sources, particularly with large-scale, cross-national survey programs such as the Demographic and Health Surveys (DHS). Although no comparable effort has been undertaken for adult mortality, the availability of large datasets with information on adult survival from censuses and household surveys offers an important opportunity to dramatically improve our knowledge about levels and trends in adult mortality in countries without good vital registration. To date, attempts to measure adult mortality from questions in censuses and surveys have generally led to implausibly low levels of adult mortality owing to biases inherent in survey data such as survival and recall bias. Recent methodological developments and the increasing availability of large surveys with information on sibling survival suggest that it may well be timely to reassess the pessimism that has prevailed around the use of sibling histories to measure adult mortality. METHODS AND FINDINGS: We present the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. Using logistic regression, our method directly estimates the probability of dying in a given country, by age, sex, and time period from sibling history data. The logistic regression framework borrows strength across surveys and time periods for the estimation of the age patterns of mortality, and facilitates the implementation of solutions for the underrepresentation of high-mortality families and recall bias. We apply the method to generate estimates of and trends in adult mortality, using the summary measure (45)q(15)-the probability of a 15-y old dying before his or her 60th birthday-for 44 countries with DHS sibling survival data. Our findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, our estimates show the risk of adult death between ages 15 and 60 y to be about 20%-35% for females and 25%-45% for males in sub-Saharan African populations largely unaffected by HIV. In countries of Southern Africa, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at age 15 y will be dead by age 60, as will six out of ten women. Adult mortality levels in populations of Asia and Latin America are generally lower than in Africa, particularly for women. The exceptions are Haiti and Cambodia, where mortality risks are comparable to many countries in Africa. In all other countries with data, the probability of dying between ages 15 and 60 y was typically around 10% for women and 20% for men, not much higher than the levels prevailing in several more developed countries. CONCLUSIONS: Our results represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The CSS method provides grounds for renewed optimism in collecting sibling survival data. We suggest that all nationally representative survey programs with adequate sample size ought to implement this critical module for tracking adult mortality in order to more reliably understand the levels and patterns of adult mortality, and how they are changing. Please see later in the article for the Editors' Summary.

Measuring under-five mortality: validation of new low-cost methods.

BACKGROUND: There has been increasing interest in measuring under-five mortality as a health indicator and as a critical measure of human development. In countries with complete vital registration systems that capture all births and deaths, under-five mortality can be directly calculated. In the absence of a complete vital registration system, however, child mortality must be estimated using surveys that ask women to report the births and deaths of their children. Two survey methods exist for capturing this information: summary birth histories and complete birth histories. A summary birth history requires a minimum of only two questions: how many live births has each mother had and how many of them have survived. Indirect methods are then applied using the information from these two questions and the age of the mother to estimate under-five mortality going back in time prior to the survey. Estimates generated from complete birth histories are viewed as the most accurate when surveys are required to estimate under-five mortality, especially for the most recent time periods. However, it is much more costly and labor intensive to collect these detailed data, especially for the purpose of generating small area estimates. As a result, there is a demand for improvement of the methods employing summary birth history data to produce more accurate as well as subnational estimates of child mortality. METHODS AND FINDINGS: We used data from 166 Demographic and Health Surveys (DHS) to develop new empirically based methods of estimating under-five mortality using children ever born and children dead data. We then validated them using both in- and out-of-sample analyses. We developed a range of methods on the basis of three dimensions of the problem: (1) approximating the average length of exposure to mortality from a mother's set of children using either maternal age or time since first birth; (2) using cohort and period measures of the fraction of children ever born that are dead; and (3) capturing country and regional variation in the age pattern of fertility and mortality. We focused on improving estimates in the most recent time periods prior to a survey where the traditional indirect methods fail. In addition, all of our methods incorporated uncertainty. Validated against under-five estimates generated from complete birth histories, our methods outperformed the standard indirect method by an average of 43.7% (95% confidence interval [CI] 41.2-45.2). In the 5 y prior to the survey, the new methods resulted in a 53.3% (95% CI 51.3-55.2) improvement. To illustrate the value of this method for local area estimation, we applied our new methods to an analysis of summary birth histories in the 1990, 2000, and 2005 Mexican censuses, generating subnational estimates of under-five mortality for each of 233 jurisdictions. CONCLUSIONS: The new methods significantly improve the estimation of under-five mortality using summary birth history data. In areas without vital registration data, summary birth histories can provide accurate estimates of child mortality. Because only two questions are required of a female respondent to generate these data, they can easily be included in existing survey programs as well as routine censuses of the population. With the wider application of these methods to census data, countries now have the means to generate estimates for subnational areas and population subgroups, important for measuring and addressing health inequalities and developing local policy to improve child survival. Please see later in the article for the Editors' Summary.

Maternal and child health and neighborhood context: the selection and construction of area-level variables.

BACKGROUND: Increasingly, maternal and child health researchers are employing the statistical approach of multilevel modeling analysis to simultaneously examine the relationship between contextual and individual determinants and maternal and child health outcomes. This review addresses the following questions: (1) What categories of neighborhood characteristics have been addressed? (2) How were those neighborhood characteristics operationalized? METHODS: A literature review identified 31 relevant articles published between January 1999 and March 2004. The articles were read with special attention toward the measurement of neighborhood characteristics. RESULTS: Twelve categories of neighborhood characteristics represented in the articles include income/wealth, employment, family structure, population composition, housing, mobility, education, occupation, social resources, violence and crime, deviant behavior and physical conditions. A wide diversity of approaches was used to measure these characteristics. The most widely utilized source of data was that of administrative records from the census or local government authorities. Although most authors provided theoretical explanations of their choice to examine broad neighborhood constructs, few were explicit about why certain indicators were selected to measure these constructs. CONCLUSIONS: There are theoretical, methodological and practical barriers in the measurement of the neighborhood context which must be addressed for the field to move forward. These barriers are discussed and recommendations are made for addressing them in future research.