10 best resources for ... measuring population health
1 John Snow Inc., Boston, USA and 2 Harvard School of Public Health, Boston, USA
Correspondence: Patricia David, John Snow Inc., 44 Farnsworth Street, Boston, MA 02210–1211, USA. E-mail: patricia_david{at}jsi.com
 |
Introduction |
|---|
 Top Introduction ResourcesReferences |
|---|
Health information – a key ingredient in policy formation and programme planning – has often proven to be a scarce commodity in places where it is needed most. Beginning in 1978 with the declaration of the Alma Ata Conference on ‘Health for All by the Year 2000’, international momentum to monitor the performance of health programmes and hold governments accountable for progress in improving health has grown. Stimulated now by the need to measure national progress toward achieving the Millennium Development Goals and by the growing number of international initiatives such as the Global Fund to Fight AIDS, TB and Malaria, and the Global Alliance for Vaccines and Immunization, a new lens is being focused on population health information.
An important source of information on health status, behaviour, health care access and utilization amongst the general population are government-sponsored cross-sectional and longitudinal household survey programmes. In some countries, the interview is expanded to include physician assessments, tests of physical functioning, blood pressure, lung capacity, and anthropometric data, and in some, survey data may be linked to medical records or vital registers. The National Health Interview Survey (NHIS) is a cross-sectional sample survey conducted annually in the USA by the Centers for Disease Control and Prevention. The NHIS collects self-reported data on behaviours including tobacco use and physical activity, chronic disease conditions, health care utilization, and satisfaction with multiple dimensions of health. The child module includes information on asthma, allergies, immunization and days lost from school due to illness or injury. The NHIS website provides public access to primary survey data and documentation for both the child and adult questionnaires. A wide variety of such survey programmes exists around the world and at the present time valid international comparison of data from such surveys is limited (Sadana et al. 2002
).
In international public health, a prime source of health and population data is the Demographic and Health Survey (DHS) programme, headquartered at Macro International in the USA. This survey programme, which began with a 1985 survey in El Salvador, is the successor to the World Fertility Surveys and Contraceptive Prevalence Surveys. The early surveys developed and standardized methods of data collection to enable cross-country comparison of basic health and population indicators, including estimates of mortality, fertility and contraceptive behaviour. Originally designed to interview women of reproductive age, contemporary DHS often include a male sample as well. The DHS are not meant to measure illness prevalence, but obtain information on recent illness episodes in relation to care, and now cover maternal and child health practices, health knowledge, sexual behaviour, anthropometric measures, and biological testing for HIV and anaemia. Recently, the DHS expanded the socio-economic information collected in these surveys to permit construction of a ‘wealth index’ (Filmer and Pritchett 1998, 1999), providing improved discrimination between poor and non-poor. Extensions of the basic DHS survey tools include the AIDS Indicator Surveys and Malaria Indicator Surveys. The website contains reports, survey instruments and other documentation, data files, and a tool that allows the online user to create tailor-made tables from survey data.
Since 1994, UNICEF has supported development and implementation of Multiple Indicator Cluster Surveys (MICS). These national surveys were designed initially to track indicators of the goals agreed at the 1990 World Summit for Children, and since 1995 have been conducted in more than 60 countries. MICS is one of the primary vehicles for measuring population-based indicators of the Millennium Development Goals, including household access to water and sanitary facilities, educational attainment, maternal and child mortality, nutrition, and key health practices, such as exclusive breastfeeding and use of oral rehydration therapy. For 2005, the survey instrument includes modules to measure maternal and newborn health care, early childhood development interventions, prevention and treatment of presumed malaria, knowledge of HIV/AIDS, and sexual behaviour of young adult women. Reports of previous surveys, MICS2 datasets from 42 countries, and handbooks for survey coordinators can be found on the web. The handbooks contain information for planning logistics, designing questionnaires, selecting samples, conducting fieldwork, processing data and presenting results. A third handbook with new model questionnaires and analysis programmes is forthcoming.
As the role that personal health behaviours play in chronic disease and premature mortality is recognized, a number of survey instruments have been developed to track self-reported behaviours. Such information is useful for planning and evaluating health promotion and disease prevention programmes. In industrialized countries, telephone and computer-based surveys have emerged as a cost-effective alternative to face-to-face interviews, and are especially useful where the necessary expertise and resources for conducting area probability sampling are not available. Behavioural Risk Factor Surveillance System (BRFSS) surveys use telephone interviews developed by the US Centers for Disease Control and Prevention to collect state-level data on risk factors for chronic diseases. A website contains a user's guide, training materials, questionnaires, and interactive databases and maps for US data. In countries of the former Soviet Union and Eastern Europe, the BRFSS model has been used to establish similar systems (for example, see Zabina et al. 2001).
UNAIDS developed a list of core indicators related to the sexual behaviour of adults and young people that are included as Millennium Development Goals and goals set by the UN General Assembly Special Session (UNGASS) on HIV/AIDS for monitoring national responses to the AIDS pandemic. One single-purpose survey tool to collect information on sexual behaviour is the Behavioral Surveillance Survey (BSS), developed by Family Health International, which goes beyond some of the other surveys mentioned to include partner-specific details. The BSS is designed for use among high-risk sub-populations who may be difficult to reach, such as sex workers and their clients, men who have sex with men, and injecting drug users. In some cases, the interview is restricted to young adult samples of men and women 15–24 years of age. A BSS survey handbook is available. A good summary of the issues surrounding measurement of sexual behaviour, as well as why such measurement is important, is found in Cleland et al. (2004).
Measuring population health after the Southeast Asian tsunami and in other disaster or conflict zones requires specialized tools that balance accuracy and flexibility. Standardized Monitoring and Assessment of Relief and Transitions (SMART) is a global inter-agency initiative – led by donors, UN agencies, NGOs and academics – to improve and harmonize monitoring and evaluation in complex emergencies. An early accomplishment of SMART was the agreement on standardized methods to measure mortality rates and nutritional status in conflict and post-conflict environments. The SMART Initiative website features case studies and tools used to measure nutrition and health in Afghanistan, Kosovo and Sudan, a new survey protocol, links to workshop reports, and a database on the human impact of conflict.
Geographic information systems (GIS) allow for the storage, analysis, modelling and presentation of spatially referenced data. GIS facilitate analysis of the relationship between population health and health services, infrastructure, and environmental, social, topographic and demographic factors. Given these properties and the visual effectiveness of mapping to present findings, many national censuses, demographic household surveys, disaster warning and management systems, and disease surveillance systems include spatial coordinates. One application of GIS is the World Health Organization's Global Atlas of Infectious Disease, an interactive tool for mapping the distribution of infectious disease statistics, demographic and socio-economic variables, and infrastructure at the country level. The WHO Health Mapper, the CDC EPI-INFO software with EPI-MAP, and a wide range of commercial software packages enable the public health practitioner to fully utilize the analytic capability of GIS.
The World Health Organization (WHO) is the international repository for data from national infectious disease surveillance systems, both passive surveillance (communicable disease reporting and confirmation of cases seen in health facilities) and active case-detection systems. The quality of passive surveillance system reporting varies considerably due to under-recognition of disease by primary care providers, omission of cases that never reach a health facility, and in poor countries especially, inadequate laboratory support for confirmation of cases. Political pressures sometimes intervene to suppress disease notification due to fear of economic consequences, as the recent SARS outbreaks demonstrate. For all these reasons, data from passive systems need to be interpreted with caution (Anker and Schaaf 2000; Murray et al. 2004). Sentinel site surveillance, while not representative of a country as a whole, is a relatively simple and cheap method of active case detection. In 1996, UNAIDS and WHO began a joint programme to improve global HIV/AIDS and sexually transmitted infection (STI) estimates through production of guidelines and tools for country surveillance activities. ‘Second generation’ surveillance systems are now being used to capture the diversity and course of mature epidemics, focusing on high-risk sub-populations and on use of data for more effective monitoring of the epidemic. Guidelines for selection of sentinel groups and sites, data collection instruments, and practical guidelines for HIV and STI testing can be found on the UNAIDS website.
Health facility-based data are a primary source of information for national and local planning and allocation of health resources. Service-based data refer only to the segment of the population that has geographic or economic access to the services, and among them, those who elect to use the services. Service statistics can provide a population health profile based on service encounters (visits to facilities or hospital stays), but the information is usually linked only to an individual's age. Area and age distributions of disease and service use are the primary outputs of such systems. In the Nordic countries, databases linking individual birth, morbidity (epidemiological registers) and death records are a valuable resource, but are expensive to maintain. In countries where health services and the information system that should serve them are under-funded, service-based data are known to be biased and incomplete and do not provide a true picture of the health of a population. Nevertheless, these data are often easily accessible, and are, perhaps, underutilized. The Routine Health Information Network (RHINO) now provides an online forum for professionals and users of health information systems to disseminate improvements in collection and use of health service data. The network's website contains links to a health information system bibliography, software and a listserv.
A number of demographic surveillance sites (DSS) have been established in less-developed countries to monitor the demographic and health status of selected sub-populations. Using an initial census, these sites register the entire population living within specified geographical boundaries. Subsequent data collection at regular intervals makes it possible to monitor population dynamics and provides a platform to collect data on other health indicators and their socio-economic correlates. The oldest and arguably the most extensively used DSS system was established in 1963 at the International Centre for Diarrhoeal Disease Research (ICDDR,B) in Matlab, Bangladesh (van Ginneken et al. 1998). In 1998, demographic surveillance sites in Africa and Asia formed the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH), with 29 sites in 16 developing countries now participating. The network aims to improve the collection and use of information from INDEPTH sites for setting health priorities, allocating resources and evaluating health programmes. The first monograph by the Network contains profiles of 22 member sites. It also presents core concepts and describes measures generated, methods of data collection, processing and quality control measures for DSS data (INDEPTH Network 2002).
The need to monitor progress and measure health outcomes has stimulated development of the Health Metrics Network (website: http://www.who.int/healthmetrics/en/), a new collaboration between ministries of health, statistical bureaux, international organizations, donor agencies, foundations and academic institutions. Facilitated by WHO, the Health Metrics Network aims to bring together producers and users of health information, cutting across different areas of measurement, a range of tools and methods, and the needs of diverse users. While this and other promising initiatives get underway, efforts to harmonize population measurement tools and improve cross-country comparisons of data are on the increase. The MICS and DHS have harmonized survey instruments to make their results more comparable, and countries covered by the two survey programmes will not intentionally overlap. Striving to better coordinate donor support with country needs, the nascent Health Metrics Network holds great promise in our efforts to strengthen national health information systems. These efforts should lead to improved information on which to build sound health policies for the 21st century.
|
Resources |
|---|
|
TopIntroductionResourcesReferences |
|---|
- The National Health Interview Survey website [http://www.cdc.gov/nchs/nhis.htm] contains data and survey documentation, including survey instruments.
- The website for Demographic and Health Survey reports and data files: [http://www.measuredhs.com/]. Earlier versions of survey tools and other documentation can be found at this site under Publications, Basic Documentation, but for the latest questionnaires contact DHS directly at measure{at}orcmacro.com.
- Multiple Indicator Cluster Survey handbooks, reports and data files from 42 countries are available on the web at: [http://www.childinfo.org].
- The Behavioral Risk Factor Surveillance System website contains a user's guide, training materials, questionnaires and interactive databases and maps for US data at [http://www.cdc.gov/brfss].
- Behavioral Surveillance Surveys (BSS): Amon J, Brown T, Hogle J et al. 2000. Behavioral Surveillance Surveys BSS: Guidelines for repeated behavioral surveys in populations at risk of HIV. Washington, DC: Family Health International. Available on the web at: [http://www.fhi.org/en/HIVAIDS/pub/guide/bssguidelines.htm].
- The Standardized Monitoring and Assessment of Relief and Transitions (SMART) Initiative website: [http://www.smartindicators.org].
- WHO Global Atlas of Infectious Disease: [http://globalatlas.who.int/globalatlas/InteractiveMap/].
CDC's EPI-INFO software, including EPI-MAP, which permits mapping and simple spatial analysis, can be downloaded free at: [http://www.cdc.gov/epiinfo/].
Information about WHO's Health Mapper software package is available on the web at: [http://www.who.int/csr/mapping/tools/en/].
- Guidelines for ‘second generation’ surveillance: World Health Organization and Joint United Nations Programme on HIV and AIDS. 2000. Second Generation Surveillance for HIV: The next decade. WHO/CDS/CSR/EDC2000.5 and UNAIDS/00.03E and on the web: [http://www.unaids.org/en/resources/epidemiology/epi_recent_publications/secondgensurveillance2000.asp].
- The Routine Health Information Network's website: [http://www.rhinonet.org].
- INDEPTH Network. 2002. Population and Health in Developing Countries, Volume 1: Population, health and survival at INDEPTH sites. Ottawa: IDRC. Download e-book free at: [http://www.idrc.ca/en/ev-9435-201-1-DO_TOPIC.html]. More information is found in the INDEPTH founding document at [http://www.indepth-network.net].
|
References |
|---|
|
TopIntroductionResourcesReferences |
|---|
Anker M, Schaaf D. 2000. WHO report on global surveillance of epidemic-prone infectious diseases. WHO/CDS/CSR/ISR/2000.1. Geneva: World Health Organization, Department of Communicable Disease Surveillance and Response.
Cleland J, Boerma JT, Carael M, Weir SS. 2004. Monitoring sexual behaviour in general populations: a synthesis of lessons of the past decade. Sexually Transmitted Infections 80 (Suppl. II): ii1–7.
Filmer D, Pritchett L. 1998. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in States of India. World Bank Policy Research Working Paper No. 1994. Washington, DC: World Bank. Available at: [http://www.worldbank.org/html/dec/Publications/Workpapers/WPS1900series/wps1994/wps1994.pdf].
Filmer D, Pritchett L. 1999. The effect of household wealth on educational attainment: evidence from 35 countries. Population and Development Review 25: 85–120.
Murray C, Lopez A, Wibulpolprasert S. 2004. Monitoring global health: time for new solutions. British Medical Journal 329: 1096–100.
Sadana R, Mathers CD, Lopez AD, Murray CJL, Iburg K. 2002. Comparative analyses of more than 50 household surveys on health status. In: Murray CJL, Salomon J, Mathers C, Lopez A (eds). Summary measures of population health: concepts, ethics, measurement and applications. Geneva: World Health Organization.
van Ginneken J, Bairagi R, de Francisco A, Sarder AM, Vaughan P. 1998. Health and demographic surveillance in Matlab: past, present and future. ICDDR,B Special Publication No. 72. Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh.
Zabina H, Schmid TL, Glasunov I et al. 2001. Monitoring behavioral risk factors for cardiovascular disease in Russia. American Journal of Public Health 91: 1613–16.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||