Message-ID: <36404EF1.34A0983F@akron.infi.net> Date: Wed, 4 Nov 1998 07:56:18 -0500 From: Bob Pyke Jr <mailto:repyke@AKRON.INFI.NET> Subject: Why Children Die To: mailto:DEVEL-L@AMERICAN.EDU
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> November 1998 Contents:
>
> I. Why do Children Die? Hugo Diaz, SASHR
>
>
> I. Why do children die? Hugo Diaz, SASHR
>
> This seminar was conducted by Dr. Rene Salgado, Senior Technical Officer at the BASICS (Basic
> Support for Institutionalizing Child Survival) Project, which has funding from the USAID's Child
> Survival Project. Dr. Salgado presented a methodology for assessing why children die, using three
> case studies for Bolivia, Guatemala and Kazakhstan. The population groups studied in Bolivia and
> Guatemala consisted of American Indians with high rates of illiteracy and poverty. The Kazakhstan
> population was less deprived, with high literacy rate.
>
> "Why children die" refers not merely to the actual causes of death of children under 5 (in the case of
> the Guatemala study, only deaths in the first seven days of life were included), such as pneumonia or
> diarrhea, but also to certain characteristics in the chain of events from the onset of illness until the time
> of death that explain why the death was not prevented. More specifically, the studies had the
> following objectives:
> -Identify causes of death of children less than five years old (perinatal period in the case of
> Guatemala).
> -Identify the process (identification of illness, care seeking behavior, and quality of care) that
> influenced the final result (death), and identify points of intervention that might, in the future, prevent
> these deaths.
> -Determine predictors of childhood mortality (in Kazakhstan only).
>
> The studies use a framework referred to as the "Pathway to Survival". This is a diagram which
> depicts various events, decisions and outcomes following onset of the disease. For example,
> immediately following onset of the disease, the caretaker (usually the mother) may or may not
> recognize that this is a serious problem requiring intervention. If she does recognize this fact, she may
> either decide to provide care herself, or look for outside help. If she seeks outside help, she may
> either go to a government clinic, a qualified private provider, or a traditional healer. The care
> provided by either the caretaker or any outside source may or may not be of good quality, i.e.,
> appropriate to the disease in question.
>
> The investigators identify a number of recent deaths of children (e.g., 271 in the Bolivia study) and,
> using the above framework, attempt to reconstruct the story of what happened in each case.
> Identification of the deaths can be done from civil registries, from neighbors/relatives, from the
> records of cemeteries, etc. A random sample is then drawn from the population of identified deaths,
> for inclusion in the study. Once the set of deaths to be studied has been selected, the investigators
> use several instruments to gather information:
> -Ethnographic studies, to be able to understand the local terminology for various events, types of
> providers, and other elements of the analysis [this information is used to adapt the instruments to local
> conditions].
> -Verbal autopsy [uses questions for signs and symptoms during illness that lead to death; uses
> algorithms and expert panel to determine most probable cause of death; it gives generally reliable
> results for the major causes of childhood deaths, notably pneumonia and diarrhea].
> -Social autopsy [reconstructs on a day-to-day basis all signs, symptoms, care seeking decisions and
> actions, and treatments for the illness that caused death].
> -Medical records abstraction forms.
>
> Once the data/qualitative information have been gathered, it can be organized in many different ways
> to throw light on the problem. Many of the conclusions thus reached are of direct relevance for the
> design of interventions or projects.
> In Bolivia, for example, it was found that of all cases of ARI & diarrhea deaths studied (N=146), in
> only 43% of the cases did the caretaker recognize that there was a serious problem. All of those
> caretakers who recognized that there was a serious problem sought outside help from various types
> of providers. Appropriate care was provided in only about one-fifth of all the cases for which
> outside help was sought, however.
>
> In Kazakhstan the nature of the problem was found to be different from that in Bolivia. In
> Kazakhstan, only in less than 10% of all the deaths from ARI & diarrhea did the caretaker fail to
> seek outside help. In most cases in which outside help was sought, either formal sector providers, or
> a combination of formal and informal sector providers, was used. The main problem here was the
> abysmally poor quality of the medical care provided to these children. This problem was present in
> Bolivia also, but in that country an even greater problem was the lack of awareness of the severity of
> the problems on the part of the caretakers.
>
> The above findings suggest different strategies for the two countries. In Bolivia, the results of the
> study prompted the Government to emphasize community mobilization and IEC interventions (mainly
> in the form of serialized, "soap opera" type radio programs, using material from the cases included in
> the study). The Ministry of Health also introduced a Mortality Survey/ Surveillance Manual, in order
> to keep track of childhood deaths on a systematic basis (hopefully as a first step to improving quality
> of care). In the case of Kazakhstan there is obviously no need to increase awareness or motivation
> of the population to seek care, but efforts should concentrate on improving the quality of care. Thus
> the information collected and analyzed through studies of this nature can be very helpful in setting
> priorities for various types of interventions to reduce under-5 deaths. The cost of the Bolivia study
> was about US$50,000 and it took about four months to be completed. A manual for conducting
> studies of this nature has been prepared by Johns Hopkins in cooperation with CDC. However,
> expert assistance would almost certainly be required in order to conduct the studies.
>
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--------------0CA5EA728B726AD750751326--November 1998 Contents: I. Why do Children Die? Hugo Diaz, SASHR I. Why do children die? Hugo Diaz, SASHR This seminar was conducted by Dr. Rene Salgado, Senior Technical Officer at the BASICS (Basic Support for Institutionalizing Child Survival) Project, which has funding from the USAID's Child Survival Project. Dr. Salgado presented a methodology for assessing why children die, using three case studies for Bolivia, Guatemala and Kazakhstan. The population groups studied in Bolivia and Guatemala consisted of American Indians with high rates of illiteracy and poverty. The Kazakhstan population was less deprived, with high literacy rate. "Why children die" refers not merely to the actual causes of death of children under 5 (in the case of the Guatemala study, only deaths in the first seven days of life were included), such as pneumonia or diarrhea, but also to certain characteristics in the chain of events from the onset of illness until the time of death that explain why the death was not prevented. More specifically, the studies had the following objectives: -Identify causes of death of children less than five years old (perinatal period in the case of Guatemala). -Identify the process (identification of illness, care seeking behavior, and quality of care) that influenced the final result (death), and identify points of intervention that might, in the future, prevent these deaths. -Determine predictors of childhood mortality (in Kazakhstan only). The studies use a framework referred to as the "Pathway to Survival". This is a diagram which depicts various events, decisions and outcomes following onset of the disease. For example, immediately following onset of the disease, the caretaker (usually the mother) may or may not recognize that this is a serious problem requiring intervention. If she does recognize this fact, she may either decide to provide care herself, or look for outside help. If she seeks outside help, she may either go to a government clinic, a qualified private provider, or a traditional healer. The care provided by either the caretaker or any outside source may or may not be of good quality, i.e., appropriate to the disease in question. The investigators identify a number of recent deaths of children (e.g., 271 in the Bolivia study) and, using the above framework, attempt to reconstruct the story of what happened in each case. Identification of the deaths can be done from civil registries, from neighbors/relatives, from the records of cemeteries, etc. A random sample is then drawn from the population of identified deaths, for inclusion in the study. Once the set of deaths to be studied has been selected, the investigators use several instruments to gather information: -Ethnographic studies, to be able to understand the local terminology for various events, types of providers, and other elements of the analysis [this information is used to adapt the instruments to local conditions]. -Verbal autopsy [uses questions for signs and symptoms during illness that lead to death; uses algorithms and expert panel to determine most probable cause of death; it gives generally reliable results for the major causes of childhood deaths, notably pneumonia and diarrhea]. -Social autopsy [reconstructs on a day-to-day basis all signs, symptoms, care seeking decisions and actions, and treatments for the illness that caused death]. -Medical records abstraction forms. Once the data/qualitative information have been gathered, it can be organized in many different ways to throw light on the problem. Many of the conclusions thus reached are of direct relevance for the design of interventions or projects. In Bolivia, for example, it was found that of all cases of ARI & diarrhea deaths studied (N=146), in only 43% of the cases did the caretaker recognize that there was a serious problem. All of those caretakers who recognized that there was a serious problem sought outside help from various types of providers. Appropriate care was provided in only about one-fifth of all the cases for which outside help was sought, however. In Kazakhstan the nature of the problem was found to be different from that in Bolivia. In Kazakhstan, only in less than 10% of all the deaths from ARI & diarrhea did the caretaker fail to seek outside help. In most cases in which outside help was sought, either formal sector providers, or a combination of formal and informal sector providers, was used. The main problem here was the abysmally poor quality of the medical care provided to these children. This problem was present in Bolivia also, but in that country an even greater problem was the lack of awareness of the severity of the problems on the part of the caretakers. The above findings suggest different strategies for the two countries. In Bolivia, the results of the study prompted the Government to emphasize community mobilization and IEC interventions (mainly in the form of serialized, "soap opera" type radio programs, using material from the cases included in the study). The Ministry of Health also introduced a Mortality Survey/ Surveillance Manual, in order to keep track of childhood deaths on a systematic basis (hopefully as a first step to improving quality of care). In the case of Kazakhstan there is obviously no need to increase awareness or motivation of the population to seek care, but efforts should concentrate on improving the quality of care. Thus the information collected and analyzed through studies of this nature can be very helpful in setting priorities for various types of interventions to reduce under-5 deaths. The cost of the Bolivia study was about US$50,000 and it took about four months to be completed. A manual for conducting studies of this nature has been prepared by Johns Hopkins in cooperation with CDC. However, expert assistance would almost certainly be required in order to conduct the studies.