144Identification of non-vaccinated children using decision trees

Background Non-vaccinated children are a particularly vulnerable and understudied group. Machine learning algorithms, such as decision trees, might be useful for identifying subgroups with high prevalence of zero dose (neither BCG, polio, DPT nor measles vaccines received). Methods We developed Classification and Regression Tree models using data from DHS surveys of India 2015 and Chad 2014 in order to identify risk groups of zero dose. Results The first split variable for India was the child’s place of delivery, followed by the mother’s tetanus vaccination status for the higher-risk subgroup of children born in noninstitutional facilities. For Chad, administrative region was selected, and two high zero dose regions were defined. For those regions, children whose mother did not receive any dose of tetanus vaccine were also considered a higher-risk subgroup. Conclusions Two trees were created with only two splits each. Subgroups with zero dose prevalence higher than 40% were identified. Key messages Decision trees might be valuable tools for exploratory data analysis and risk groups identification in epidemiological research.

Evaluating the Demographic and Health Surveys Mode Switch From PAPI to CAPI: An Experiment From Turkey

The Demographic and Health Surveys (DHS) have been carried out in over 90 countries since 1984, as interviewer administered household surveys conducted initially by paper and pencil interviews (PAPI). Computer assisted personal interviews (CAPI) were introduced in the 2004 Peru DHS, and since then numerous countries have also switched. However, DHS randomized mode comparisons have been limited. The 2018 Sixth Turkey DHS was conducted using CAPI but allocated one household from 21 in each of 754 clusters to PAPI. This analysis examines a wide range of potential differences between modes: interviewer attitudes toward modes; response rates, underreporting and misreporting of persons or events, number of selections to “check all that applies” questions, respondents' attitudes towards modes reflected by responses to sensitive questions, satisficing behavior such as age heaping, straight-line response patterns, and use of don’t know options; and some operational aspects of modes such as retrospective monthly contraceptive prevalence rates, presence of others during interview, and interview length. Findings show that, despite strong interviewer CAPI preference, CAPI and PAPI were on average almost identical in terms of responses. CAPI took 11 min less (total duration of 33 min). Analysis of retrospective monthly contraception use indicated potential underreporting by CAPI for past use, an issue highlighted before in DHS literature. Overall, the switch to computer technology in DHS surveys does not appear to change estimates or levels of nonsampling errors, although some differences with respect to PAPI mode may need DHS designer attention.

The tensions between comparability and locally meaningful data

In the contemporary global context where the demand for data and the calculation of indicators mean that sources of such data themselves are a powerful basis for decision making on both local and global stages, the degree to which these data are comparable takes on great importance. This chapter unpicks a number of situations and types of data where such comparability can be challenged. These can be summarized as (i) the comparability of concepts and definitions—using the household and marriage as examples which are examined in detail; (ii) the comparability of comprehensibility and answerability of questions focusing on the Demographic and Health Survey (DHS) ‘ideal family size’ and also behavioural methods of contraception; (iii) the comparability of cultural willingness to answer questions, which considers those who will and will not talk about the dead; and (iv) gendered differences in the interpretation of survey questions. The examples call into question the whole notion of comparability and what apparently comparable data sets might actually be examining. It concludes that much social behaviour is not inherently comparable cross-culturally and cross-linguistically and calls for much more care and sensitivity in analysing large data sets such as censuses and DHS surveys, especially when the analytical conclusions can have major implications for policy development and resource allocation.

Trends in fertility and fertility preferences in sub-Saharan Africa: the roles of education and family planning programs

A common explanation for the high fertility prevailing in sub-Saharan Africa (SSA) is a widespread desire for large families. This situation poses a challenge to population policy-makers in the continent. If the desired family size is high, then presumably family planning programs can only have a limited effect on fertility because these programs aim to assist women in achieving their reproductive goals. But this conclusion is based on the assumption that family planning programs do not affect the desired family size, which is questionable and is investigated here. This study examines the determinants of trends wanted and unwanted fertility in SSA using fixed-effects regressions of country-level data. The dependent variables include the total fertility rate, and its wanted and unwanted components. Explanatory variables include a family planning program score and four socioeconomic variables (women’s educational attainment, child mortality, GNI per capita, and percent urban). Data come from 103 DHS surveys in 25 countries in SSA with at least two DHS surveys between 1989 and 2019. Women’s education and family planning programs are found to be the dominant determinants of fertility decline and their effects operate by reducing both wanted and unwanted fertility. The effects of education are not surprising but the finding that family planning programs can reduce wanted fertility implies that their impact can be larger than conventional wisdom suggests. Indeed, in a few poor countries, the implementation of high-quality programs has been associated with substantial declines in wanted fertility (e.g., Ethiopia, Malawi, Rwanda). The mechanism through which this effect operates is unclear but likely involves media programs that diffuse knowledge about the benefits of smaller families.

Trend of malaria in Senegal from 2010 to 2017

Background In Senegal, many interventions have been carried out in the fight against malaria. Thus, the prevalence of malaria has clearly declined from 2010 to the present day. The objective of this study is to study the factors associated with malaria. Methods Senegal is a country in West Africa. The analyses in this study were based on DHS data from 2010 to 2017 from Senegal. Data from 5 DHS surveys were used (2010-2011, 2012-2013, 2014, 2015, 2016). Malaria prevalence had been studied on the basis of RDT positivity. A multivariate analysis with an adjustment over the years was done. The variables studied were socio-demographic characteristics such as age, socioeconomic level and dwelling place (rural vs. urban), variables related to the type of habitat and the use of mosquito nets. The analyses were done using STATA.15. Results The results showed a reduction in malaria prevalence from 3.01% to 0.8% from 2010 to 2016. The protective factors are belonging to a well-off socio-economic background (middle OR:046 [0.24-0.90], richer OR = 0.37 [0.15-0.93]). The other factors associated with malaria are the fact of living in rural area (OR: 1.7 [1.06-2.89]). Conclusions Despite the decline in malaria prevalence over the years in Senegal, its persistence could be feared if factors related to the socio-economic level are not addressed. Key messages Special attention must be paid to people living in rural areas as part of the fight against malaria. The fight against malaria will necessarily involve the fight for the socio-economic emergence of countries in West Africa.

Are Data Available to Measure Progress in the Coverage of Essential Nutrition Actions in South Asia? A Review of Demographic and Health Surveys in Seven Countries, 2005–2018

Objectives South Asian countries carry the largest burden of undernutrition globally. The World Health Organization has recommended a set of Essential Nutrition Actions (ENA) to tackle all forms of malnutrition. Limited evidence exists on the availability of data in nationally representative surveys to analyse coverage patterns and to track progress on these actions. Methods We reviewed household and woman questionnaires from DHS surveys conducted in South Asia—Afghanistan (2014), Bangladesh (2011 and 2014), India (2006 and 2016), Maldives (2009 and 2017), Nepal (2011 and 2016), Pakistan (2013 and 2018), and Sri Lanka (2006 and 2016)—to assess the availability of data to track coverage of the ENAs in South Asia region. For each ENA, we examined questionnaires to identify the availability of questions that could be used to construct coverage indicators. Results For adolescents and women of reproductive age, DHS questionnaires ask about prenatal iron folic acid (IFA) supplementation in zero countries and use of iodized salt in five countries. For pregnant women, out of six recommended ENAs, five are measured in at least one country: health and nutrition education, energy and protein supplementation, IFA supplementation, calcium supplementation, and multiple micronutrients that contain IFA. For postpartum women, data on iron supplementation and breastfeeding counselling are collected in only four countries. For early childhood, DHS surveys only measure 6 of 25 ENAs; only vitamin A supplementation is being tracked in DHS across all seven countries, while children who were breastfed early, had immediate skin to skin contact and zinc supplementation are measured in most countries. Conclusions Data for more than half of the ENAs across the continuum of care are not collected in the South Asian DHS questionnaires; gaps exist both for interventions and among countries. Coverage data from household surveys are critical to enable countries to track progress towards national coverage goals and to examine equity in the reach of interventions. To support national efforts to scale-up the coverage of ENAs, national survey instruments should be reviewed to include indicators on the coverage of a broader set of ENA indicators. Funding Sources Data for Decisions to Expand Nutrition Transformation (DataDENT) project, supported by the Bill and Melinda Gates Foundation.

An Agricultural Wealth Index for Multidimensional Wealth Assessments

Social scientists have increasingly used asset-based wealth scores, like the DHS wealth index, to assess economic disparities. However, current indices primarily capture wealth in globalized market economies, thus ignoring other forms of prosperity, such as success in agricultural activities. Using a simple extension to the standard estimation of the DHS Wealth Index, we describe procedures for estimating an Agricultural Wealth Index (AWI) that complements market-based wealth indices by capturing household success in agricultural activities. We apply this procedure to household data from 129 DHS surveys from over 40 countries with sufficient land and livestock data to estimate a reliable and consistent AWI. We assess the construct validity of the AWI using benchmarks of growth in both adults and children. This alternative measure of wealth provides new opportunities for understanding the causes and consequences of wealth inequality, and how success along different dimensions of wealth creates different social opportunities and constraints for health and well-being.

The association between female genital fistula symptoms and gender-based violence

Aims: This study examined the association between self-reported female genital fistula symptoms and experience of gender-based violence (GBV) among women interviewed in Demographic and Health Surveys (DHS) surveys. Methods: This study pooled data from 13 recent DHS surveys with both fistula and domestic violence modules. Multivariable logistic regressions controlled for maternal and demographic factors. Results: In this sample of 95,625 women, the prevalence of self-reported fistula symptoms ranges from 0.3% to 1.8% across countries. Among women reporting fistula symptoms,56% report past experience physical violence, more than among women with no symptoms (38%). Twice as many women with fistula symptoms report either lifetime (27%) or recent (16%) experience sexual violence than women not reporting symptoms (13% and 8%, respectively). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with those who never experienced sexual violence. Conclusions: These findings must be interpreted with caution given the inability to identify temporal and causal relationships through DHS data. However, the increased risk of violence among women with fistula symptoms suggests that fistula treatment programs should incorporate GBV screening, referral, and services into their pre-discharge care.

The Price of Labor: Evaluating the Impact of Eliminating User Fees on Maternal and Infant Health Outcomes

Since 2001, several sub-Saharan African countries have eliminated user fees for childbirth. Although intended to improve maternal and infant health outcomes, service quality also fell as facilities became overburdened. In this paper I combine DHS surveys on births from countries eliminating user fees. I identify the effect of user fee elimination using (i) a maternal fixed effect and (ii) an event study within a small geographic area. I find that user fees increase the likelihood of delivery at public sector facilities by 2-7 percentage points. I also find that user fee elimination reduces maternal mortality but may increase neonatal mortality.