Multiple Indicator Cluster SurveysData dissemination and further analysis workshop

Child Health

MICS4 Data dissemination and Further Analysis

Child healthImmunization, Diarrhoea, Pneumonia, Malaria

Countdown to 2015 Decade Report (2000-2010)

Child Health in MICS4 Presentation overview

Immunization

Background

WHO Expanded Programme on Immunization

It is recommended that all children receive the following immunizations:

• At birth BCG (tuberculosis) and Polio 0• At 6 weeks Polio 1 and DPT 1 (diphtheria, pertussis, tetanus)• At 10 weeks Polio 2 and DPT 2• At 14 weeks Polio 3 and DPT 3• At 9 months Measles

• Hepatitis B (HepB) and Haemophilus influenzae type B (Hib) have same schedules as Polio and DPT

• Up-to-date information on recommended vaccines can be obtained from www.who.int/immunization/documents/positionpapers/en/index.html

Indicators

In MICS4, immunization indicators are calculated as - the percentage of children aged 12-23 months who

received each specific vaccine at any time before the survey and by the age of 12 months (before their first birthday)

and- the percentage of children aged 12-23 months who

received BCG, DPT 1-3, Polio 1-3 and measles at any time before the survey and by the age of 12 months

Methodological issues

• The model schedule is adapted in some way by most countries so that it more closely meets their needs.

• Most importantly, the survey questions should reflect the national immunization schedule and take into account recent changes or vaccine introductions (if any)

Methodological issues

• In surveys, coverage estimates are obtained from information copied from observed child health cards and from maternal recall of specific immunizations.

• Immunization or child health cards are not subject to recall bias, but are not always accurate.

• Cards may not be shown to the survey interviewer, or immunizations may not have been recorded on the card.

Methodological issues

• In these cases, maternal recall may provide additional information.

• Maternal recall, however, can either over- or underestimate the true level of coverage

• Some suggest that maternal recall should not be used to determine coverage estimates, since it may introduce recall bias.

• Others maintain that inclusion of recall data yields a more accurate coverage estimate.

Methodological issues

• Indicators are calculated for children aged 12-23 months:– All children should have completed all

vaccinations by this age– Their experience is the most recent

experience which is not truncated

Calculation

Children vaccinated according to card data + Children vaccinated according to mother’s recall= Total number of children vaccinated

For children without cards (or who have cards with missing or incomplete dates), how do we compute the percentage of children vaccinated by 12 months of age (before the first birthday?

–Assume the proportion vaccinated by 12 months of age is same as for children who have cards.

Example: BCG

Percentage vaccinated according to card 85.2Percentage vaccinated according to

mother’s report +3.7Total percentage ever vaccinated 88.9

Percentage vaccinated by 12 months according to card 98.0

Apply percentage 88.9 x .98 Percentage vaccinated by 12 months 87.1

CH3: Neonatal Tetanus Protection• Estimates the percentage of women age 15-49 years

whose last live birth within the 2 years preceding the survey was protected against neonatal tetanus

• Found in women’s questionnaire• Complex calculation: women can be protected from

neonatal tetanus in a variety of circumstances based on the receipt of vaccinations in the previous years

CH3: Neonatal Tetanus Protection

• Percentage of women age 15-49 years whose last live birth within the past 2 years was protected against neonatal tetanus

• Calculation: The information contained in the first five columns of this table are calculated in a hierarchical fashion:– (Column 1) Received at least two tetanus toxoid injections during the most recent pregnancy (MN7>=2)– (Column 2) Received one tetanus toxoid injection during the last pregnancy and at least one dose prior to

the pregnancy (MN7=1 and MN10>=1) OR received at least two tetanus toxoid injections, the last of which was less than 3 years ago (MN10>=2 and MN11<3)

– (Column 3) Received at least 3 tetanus toxoid injections over lifetime, the last of which was in the last 5 years (MN10>=3 and MN11< 5)

– (Column 4) Received at least 4 tetanus toxoid injections over lifetime, the last of which was in the last 10 years (MN10>=4 and MN11< 10)

– (Column 5) Received five or more tetanus toxoid injections (MN10>=5) at any point• The last live birth for all women who fall into one of the first 5 columns is considered

‘protected against tetanus’ and should be included in the sixth column.• In many surveys, the sample sizes may be too small to present breakdowns by

background characteristics.

Table CH.3: Neonatal tetanus protection

Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Country, Year

      

Percentage of women who received at least 2 doses during

last pregnancy

Percentage of women who did not receive two or more doses during last pregnancy but received:

Protected against tetanus1

Number of women with a live birth in the last 2

years 2 doses, the last within prior

3 years3 doses, the last within

prior 5 years4 doses, the last within prior

10 years5 or more doses during

lifetimeRegion  

Region 1  

Region 2  

Region 3  

Region 4  

Region 5  

Area  

Urban  

Rural  

Education  

None  

Primary  

Secondary  

Higher  

Wealth index quintile  

Poorest  

Second  

Middle  

Fourth  

Richest  

Religion/Language/Ethnicity of household head  

Group 1  

Group 2  

Group 3  

   

Total                

1 MICS indicator 3.7

Child Health in MICS4 Presentation overview

Care of illness tables– Diarrhoea (3 tables)– Pneumonia (4 tables)– Malaria (6 tables)

Beyond the tables

Diarrhoea treatment

Table CH.4: Oral rehydration solutions and recommended homemade fluidsPercentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Country, Year 

Had diarrhoea in last two

weeks

Number of

children age 0-59 months

Children with diarrhoea who received:Number of

children age 0-59 months

with diarrhoea in last two

weeks

 

ORS(Fluid from

ORS packet or pre-packaged

ORS fluid)

Recommended homemade fluids ORS or any

recommended

homemade fluidFluid X Fluid Y Fluid Z

Any recommended

homemade fluid                    

                   

• Diarrhoea prevalence – varies by season and caretaker reporting

• ORS (Oral Rehydration Salts) – recent push to scale up • Recommended home fluids vary according to country

Diarrhoea treatment

• Preventing dehydration is key to child survival• Feeding should continue during the diarrhoea

episode

Table CH.5: Feeding practices during diarrhoeaPercent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Country, Year 

Had diarrhoea

in last two

weeks

Number of

children age 0-

59 months

Drinking practices during diarrhoea: Eating practices during diarrhoea:

Number of children age 0-59 months

with diarrhoea in last two

weeks

Given much less to drink

Given some-what

less to drink

Given about

the same

to drink

Given more

to drink

Given noth-ing to drink

Missing/DK

Given much less to

eat

Given somewhat

less to eat

Given about

the same to eat

Given more to eat

Stop-ped food

Had never been given food

Miss-ing/DKTotal Total

Diarrhoea treatment

• ORT = Oral rehydration therapy = ORS and/or recommended home fluids and/or increased fluids

• Key diarrhoea indicator in this table – ORT with continued feeding (based on four components)

• Zinc is another key intervention

Table CH.6: Oral rehydration therapy with continued feeding and other treatmentsPercentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments, Country, Year

  Children with diarrhoea who received:   Other treatments:

Not given any

treatment or drug

Number of

children age 0-59 months

with diarrhoea

in last two

weeks

ORS or increased fluids

ORT (ORS or

recommended

homemade fluids or

increased fluids)

ORT with continued feeding1

Pill or syrup Injection

Intra-venou

s

Home remed

y, herbal medici

ne Other

No other

treatment 

Anti- biotic

Anti- motili

ty Zinc OtherUn-

known  Anti- biotic

Non-antibiot

icUnkno

wn

Key diarrhoea indicators

ORT + continued feeding

ORT

ORS

RHF

Increased fluids

Continued feeding 0 10 20 30 40 50 60 70 80 90 100

61.6

85.4

60.9

57.7

39.4

70.8

Bhutan MICS 2010

Percentage of children with diarrhoea in the two weeks preceding the survey, who received:

Child Health in MICS4 Presentation overview

Care of illness modules– Diarrhoea (3 tables)– Pneumonia (4 tables)– Malaria (6 tables)

Beyond the tables

Pneumonia

• Definition of suspected pneumonia = cough + rapid/difficult breathing + problem in the chest

• Suspected pneumonia prevalence – varies by season and caretaker reporting• Appropriate health providers includes public and private sources (excludes

private pharmacy)• Two key pneumonia indicators = careseeking and antibiotics

Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumoniaPercentage of children age 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider and percentage of children who were given antibiotics, Country, Year

 

Had suspected pneumonia in the last two weeks

Number of

children age 0-59 months

Children with suspected pneumonia who were taken to:

Any appro-priate

provider1

Percentage of children

with suspected pneumonia

who received

antibiotics in the last

two weeks2

Number of children age 0-59 months with

suspected pneumonia in the last two

weeks

Public sources Private sources Other source

Govt. hospit

al

Govt. health centre

Govt. health post

Village

health work-

er

Mobile/ out-reach clinic

Other publi

c  

Private hospit

al/ clinic

Private physici

an

Private pharm

acyMobile clinic

Other private medic

al

Relative or

friend Shop

Trad. Practi- tioner

Antibiotic treatment

Total Urban Rural0

10

20

30

40

50

60

70

80

90

100

4958

47

Bhutan MICS 2010

Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

Antibiotic treatment

Total Urban Rural0

10

20

30

40

50

60

70

80

90

100

Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

Antibiotic treatment

Total Urban Rural0

10

20

30

40

50

60

70

80

90

100

Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

Based on 54 unweighted cases!

Antibiotic treatment

Total Urban Rural0

10

20

30

40

50

60

70

80

90

100

Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

Based on 54 unweighted cases!

Note that *all* treatment indicators based on a subset of children!

Pneumonia

• Note this table is based on mothers/caretakers of all children under-five

• The two danger signs are fast breathing and difficult breathing• Open-ended questions can lead to challenges during data

collection

Table CH.8: Knowledge of the two danger signs of pneumoniaPercentage of mothers and caretakers of children age 0-59 months by symptoms that would cause the to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Country, Year

 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/

caretakers who recognize the

two danger signs of pneumonia

Number of mothers/caretakers of children

age 0-59 months 

Is not able to drink or breastfeed

Becomes sicker

Develops a fever

Has fast breathing

Has difficult breathing

Has blood in

stool

Is drinking poorly

Has other

symptoms

Pneumonia

MICS4 tables cover three essential steps needed to reduce deaths among children under five with pneumonia:

1. Recognize a child is sick2. Seek appropriate care3. Treat appropriately with antibiotics

Essential steps for reducing pneumonia deaths among children

Caretaker knowledge -both signs

Fast breathing

Difficulty breathing

Any appropriate provider

Antibiotic treatment

0 10 20 30 40 50 60 70 80 90 100

8

21

23

62

71

1

2

3

Mongolia MICS 2005

Pneumonia

• Inhaling smoke from solid fuels is hazardous

• Variation by region

• How valid are data in CH10?

Table CH.9: Solid fuel usePercent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Country, Year  Percentage of household members in households using:

Number of household members

 

Elec-tricity

Liquefied Petroleum Gas (LPG)

Natural Gas

Bio-gas Kerosene

Solid fuels

Other fuel

No food cooked in

the househol

d Total

Solid fuels for cooking1   

Coal, lignite

Char-coal Wood

Straw, shrubs, grass

Animal dung

Agricultural crop

residueRegion                                  Urban-rural  Education of household head  Wealth index quintiles  Religion/Language/Ethnicity of household head     Total                             100.0    

1 MICS indicator 3.11

Table CH.10: Solid fuel use by place of cookingPercent distribution of household members in households using solid fuels by place of cooking, Country, Year

 

Place of cooking:Number of household

members in households

using solid fuels for cooking

In a separate

room used as kitchen

Elsewhere in the house

In a separate building Outdoors

At another place Total

Region              Urban-rural  Education of household head  Wealth index quintiles  Religion/Language/Ethnicity of household head     Total           100.0  

Child Health in MICS4 Presentation overview

Care of illness modules– Diarrhoea (3 tables)– Pneumonia (4 tables)– Malaria (6 tables)

Beyond the tables

Standard MICS4 malaria tables

• Household availability of insecticide treated nets and protection by a vector control method

• Children sleeping under mosquito nets

• Pregnant women sleeping under mosquito nets

• Anti-malarial treatment of children with anti-malarial drugs

• Malaria diagnostics usage

• Intermittent preventive treatment for malaria

Take advantage of increasing focus on health for dissemination, advocacy

and analysis!

Further use of data

Health interventions across the continuum of care

Countdown to 2015 Decade Report (2000-2010)

From Diarrhoea: Why children are still dying and what can be done

A second look at diarrhoea-related data?

A second look at pneumonia-related data?

Treatment• Careseeking behavior• Antibiotics

Key prevention measures• Adequate nutrition (including breastfeeding and zinc) • Immunization (measles, Hib and pneumococcal

conjugate)• Reducing indoor air pollution• Water, sanitation and hygiene

Thank You!