Do referrals improve the representation of women in mobile phone surveys?

Random digit dial surveys with mobile phones risk under-representation of women. To address this, we compare the characteristics of women recruited directly with those of women recruited through referrals from male household members. The referral process improves representation of vulnerable groups, such as young women, the asset poor, and those living in areas with low connectivity. Among mobile phone users, we show a referral (rather than a direct dial) protocol includes more nationally representative proportions of women with these attributes. While seeking intra-household referrals may improve representation, we show that it does so at a higher cost.

The Unintended Consequences of Information Provision: The World Health Organization and Border Restrictions during COVID-19.

Why do some international agreements fail to achieve their goals? Rather than states' engaging in cheap talk, evasion, or shallow commitments, the World Health Organization's (WHO) International Health Regulations (IHR)-the agreement governing states' and WHO's response to global health emergencies-point to the unintended consequences of information provision. The IHR have a dual goal of providing public health protection from health threats while minimizing unnecessary interference in international traffic. As such, during major outbreaks WHO provides information about spread and severity, as well as guidance about how states should respond, primarily regarding border policies. During COVID-19, border restrictions such as entry restrictions, flight suspensions, and border closures have been commonplace even though WHO recommended against such policies when it declared the outbreak a public health emergency in January 2020. Building on findings from the 2014 Ebola outbreak, we argue that without raising the cost of disregarding (or the benefits of following) recommendations against border restrictions, information from WHO about outbreak spread and severity leads states to impose border restrictions inconsistent with WHO's guidance. Using new data from COVID-19, we show that WHO's public health emergency declaration and pandemic announcement are associated with increases in the number of states imposing border restrictions.

Resumen: ¿Por qué motivo algunos acuerdos internacionales no logran alcanzar sus objetivos? El Reglamento Sanitario Internacional (RSI) de la Organización Mundial de la Salud (OMS)­el acuerdo que rige la respuesta de los Estados y la OMS a las emergencias sanitarias mundiales­señala como motivo las consecuencias imprevistas del suministro de información, en lugar del discurso trivial, la evasión o los compromisos superficiales por parte de los Estados. El RSI tiene como doble objetivo proteger la salud pública de las amenazas sanitarias y minimizar las interferencias innecesarias en el tráfico internacional. Como tal, durante brotes importantes, la OMS proporciona información sobre la propagación y la gravedad, así como orientación sobre cómo deben responder los Estados, principalmente en lo que respecta a las políticas fronterizas. Sin embargo, durante la COVID-19, las restricciones fronterizas, tales como las restricciones de entrada, las suspensiones de vuelos y los cierres de fronteras, han sido habituales, a pesar de que la OMS recomendó no aplicar estas políticas cuando declaró el brote epidémico como emergencia de salud pública en enero de 2020. Basándonos en los resultados del brote de ébola de 2014, argumentamos que, sin aumentar el coste de ignorar (o los beneficios de seguir) las recomendaciones contra las restricciones fronterizas, la información de la OMS sobre la propagación y la gravedad del brote lleva a los Estados a imponer restricciones fronterizas que no son coherentes con las orientaciones de la OMS. Utilizando nuevos datos de la COVID-19, mostramos que la declaración de emergencia de salud pública de la OMS y el anuncio de pandemia están asociados con el aumento del número de estados que imponen restricciones fronterizas.

Résumé: Pourquoi certains accords internationaux n'atteignent-ils pas leurs objectifs? À l'inverse d'États se perdant dans des discussions superficielles, des pirouettes ou des engagements insignifiants, le Règlement sanitaire international (RSI) de l'Organisation mondiale de la santé (OMS), à savoir l'accord encadrant la réponse des États et de l'OMS aux situations d'urgence sanitaire internationales, évoque les conséquences imprévues de la transmission d'informations. Le RSI a un objectif double : protéger les populations contre les menaces pour la santé publique, tout en minimisant les interactions non nécessaires dans le trafic international. Par conséquent, lors des grandes épidémies, l'OMS fournit des informations relatives à la transmission et à la gravité des maladies, ainsi que des conseils quant aux mesures que les États doivent mettre en œuvre, principalement en ce qui concerne les politiques aux frontières. Pourtant, durant la pandémie de COVID-19, les restrictions aux frontières, telles que les limitations des entrées, les suspensions de vols et les fermetures, ont été monnaie courante, et ce bien que l'OMS ait déconseillé de telles pratiques lorsqu'elle a déclaré que l'épidémie constituait une urgence sanitaire, en janvier 2020. S'appuyant sur des travaux portant sur l'épidémie d'Ebola en 2014, nous soutenons, sans exagérer l'impact d'une non-conformité (ou les avantages d'une conformité) aux recommandations de l'OMS en matière de restrictions aux frontières, que les informations transmises par l'organisation en matière de transmission et de gravité de la maladie ont conduit les États à imposer des restrictions aux frontières non conformes auxdites recommandations. Grâce à de nouvelles données relatives au COVID-19, nous montrons que la déclaration d'urgence sanitaire et l'annonce de la pandémie par l'OMS se sont accompagnées d'une augmentation du nombre d'États imposant des restrictions aux frontières.

Understanding the societal factors of vaccine acceptance and hesitancy: evidence from Hong Kong.

OBJECTIVES: Vaccination is considered to be an important public health strategy for controlling the COVID-19 pandemic. Besides subjective evaluations of the vaccine and the health threat, societal factors have been seen as crucial to vaccination decisions. Based on a socioecological perspective, this study examines the role of societal factors in COVID-19 vaccine hesitancy in Hong Kong. STUDY DESIGN AND METHOD: An online survey was fielded between 25 and 28 June 2021, collecting 2753 complete responses. Multinomial logistic regression was conducted to examine how subjective evaluations of the vaccine (summarised by the 5C model - Confidence, Collective responsibility, Constraints, Complacency and Calculation), threat perception, interpersonal influences and institutional trust contribute to explaining three types of decision - acceptant (vaccinated, scheduled or indicated 'Yes'), hesitant (unvaccinated and indicated 'Maybe' on intention) and resistant (unvaccinated and indicated 'No'). RESULTS: A total of 43.2%, 21.7% and 35.1% of respondents were acceptant, hesitant and resistant. Although the 5C model remained useful in explaining vaccination decisions, respondents were heavily influenced by the decisions of their family, although they were less influenced by friends. Second, respondents tended to accept the vaccine when they had a weaker perception that the act is supportive of the government and were less resistant if they had stronger institutional trust. CONCLUSION: Under the low-incidence and low-trust environment such as Hong Kong, vaccination decisions are heavily influenced by family's decision and the perception of vaccination as socially and politically desirable. Our findings highlight the importance of a nuanced conception of interpersonal and political influence towards vaccine acceptance/hesitancy.

Is the lack of smartphone data skewing wealth indices in low-income settings?

BACKGROUND: Smartphones have rapidly become an important marker of wealth in low- and middle-income countries, but international household surveys do not regularly gather data on smartphone ownership and these data are rarely used to calculate wealth indices. METHODS: We developed a cross-sectional survey module delivered to 3028 households in rural northwest Burkina Faso to measure the effects of this absence. Wealth indices were calculated using both principal components analysis (PCA) and polychoric PCA for a base model using only ownership of any cell phone, and a full model using data on smartphone ownership, the number of cell phones, and the purchase of mobile data. Four outcomes (household expenditure, education level, and prevalence of frailty and diabetes) were used to evaluate changes in the composition of wealth index quintiles using ordinary least squares and logistic regressions and Wald tests. RESULTS: Households that own smartphones have higher monthly expenditures and own a greater quantity and quality of household assets. Expenditure and education levels are significantly higher at the fifth (richest) socioeconomic status (SES) quintile of full model wealth indices as compared to base models. Similarly, diabetes prevalence is significantly higher at the fifth SES quintile using PCA wealth index full models, but this is not observed for frailty prevalence, which is more prevalent among lower SES households. These effects are not present when using polychoric PCA, suggesting that this method provides additional robustness to missing asset data to measure underlying latent SES by proxy. CONCLUSIONS: The lack of smartphone data can skew PCA-based wealth index performance in a low-income context for the top of the socioeconomic spectrum. While some PCA variants may be robust to the omission of smartphone ownership, eliciting smartphone ownership data in household surveys is likely to substantially improve the validity and utility of wealth estimates.

Managing borders during public health emergencies of international concern: a proposed typology of cross-border health measures.

BACKGROUND: The near universal adoption of cross-border health measures during the COVID-19 pandemic worldwide has prompted significant debate about their effectiveness and compliance with international law. The number of measures used, and the range of measures applied, have far exceeded previous public health emergencies of international concern. However, efforts to advance research, policy and practice to support their effective use has been hindered by a lack of clear and consistent definition. RESULTS: Based on a review of existing datasets for cross-border health measures, such as the Oxford Coronavirus Government Response Tracker and World Health Organization Public Health and Social Measures, along with analysis of secondary and grey literature, we propose six categories to define measures more clearly and consistently - policy goal, type of movement (travel and trade), adopted by public or private sector, level of jurisdiction applied, stage of journey, and degree of restrictiveness. These categories are then brought together into a proposed typology that can support research with generalizable findings and comparative analyses across jurisdictions. Addressing the current gaps in evidence about travel measures, including how different jurisdictions apply such measures with varying effects, in turn, enhances the potential for evidence-informed decision-making based on fuller understanding of policy trade-offs and externalities. Finally, through the adoption of standardized terminology and creation of an agreed evidentiary base recognized across jurisdictions, the typology can support efforts to strengthen coordinated global responses to outbreaks and inform future efforts to revise the WHO International Health Regulations (2005). CONCLUSIONS: The widespread use of cross-border health measures during the COVID-19 pandemic has prompted significant reflection on available evidence, previous practice and existing legal frameworks. The typology put forth in this paper aims to provide a starting point for strengthening research, policy and practice.

The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.

Using routine health information data for research in low- and middle-income countries: a systematic review.

BACKGROUND: Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. METHODS: Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. RESULTS: We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. CONCLUSIONS: Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

Measuring and explaining changing patterns of inequality in institutional deliveries between urban and rural women in Ghana: a decomposition analysis.

BACKGROUND: Despite recent progress in improving access to maternal health services, the utilization of these services remains inequitable among women in developing countries, and rural women are particularly disadvantaged. This study sought to measure i) disparities in the rates of institutional births between rural and urban women in Ghana, ii) the extent to which existing disparities are due to differences in the distribution of the determinants of institutional delivery between rural and urban women, and iii) the extent to which existing disparities are due to discrimination in resource availability. METHODS: Using Demographic and Health Survey data from 2003, 2008, and 2014, this study decomposed inequalities in institutional delivery rates among urban and rural Ghanaian woman using the Oaxaca, the Blinder, and related decompositions for non-linear models. The determinants of the observed inequalities were also analyzed. RESULTS: Institutional delivery rates in urban areas exceeded those of rural areas by 32.4 percentage points due to differences in distribution of the determinants of institutional delivery between the two areas. The main determinants driving the observed disparities were wealth, which contributed to about 16.1% of the gap, followed by education level, and number of antenatal visits. CONCLUSION: Relative to urban women, rural women have lower rates of institutional deliveries due primarily to lower levels of wealth, which results in financial barriers in accessing maternal health services. Economic empowerment of rural women is crucial in order to close the gap in institutional delivery between urban and rural women.

Evaluating Quality of Contraceptive Counseling: An Analysis of the Method Information Index.

The Method Information Index (MII) is calculated from contraceptive users' responses to questions regarding counseling content-whether they were informed about methods other than the one they received, told about method-specific side effects, and advised what to do if they experienced side effects. The MII is increasingly reported in national surveys and used to track program performance, but little is known about its properties. Using additional questions, we assessed the consistency between responses and the method received in a prospective, multicountry study. We employed two definitions of consistency: (1) presence of any concordant response, and (2) absence of discordant responses. Consistency was high when asking whether users were informed about other methods and what to do about side effects. Responses were least consistent when asking whether side effects were mentioned. Adjusting for inconsistency, scores were up to 50 percent and 30 percent lower in Pakistan and Uganda, respectively, compared to unadjusted MII scores. Additional questions facilitated better understanding of counseling quality.

Aligning Funding and Need for Family Planning: A Diagnostic Methodology.

With limited international resources for family planning, donors must decide how to allocate their funds to different countries. How can a donor for family planning decide whether countries are adequately prioritized for funding? This article proposes an ordinal ranking framework to identify under-prioritized countries by rank-ordering countries by their need for family planning and separately rank-ordering them by their development assistance for family planning. Countries for which the rank of the need for family planning is lower than the rank of its funding are deemed under-prioritized. We implement this diagnostic methodology to identify under-prioritized countries that have a higher need but lower development assistance for family planning. This approach indicates whether a country is receiving less compared to other countries with similar levels of need.

Child diarrhoea and nutritional status in rural Rwanda: a cross-sectional study to explore contributing environmental and demographic factors.

OBJECTIVE: To explore associations of environmental and demographic factors with diarrhoea and nutritional status among children in Rusizi district, Rwanda. METHODS: We obtained cross-sectional data from 8847 households in May-August 2013 from a baseline survey conducted for an evaluation of an integrated health intervention. We collected data on diarrhoea, water quality, and environmental and demographic factors from households with children <5, and anthropometry from children <2. We conducted log-binomial regression using diarrhoea, stunting and wasting as dependent variables. RESULTS: Among children <5, 8.7% reported diarrhoea in the previous 7 days. Among children <2, stunting prevalence was 34.9% and wasting prevalence was 2.1%. Drinking water treatment (any method) was inversely associated with caregiver-reported diarrhoea in the previous 7 days (PR = 0.79, 95% CI: 0.68-0.91). Improved source of drinking water (PR = 0.80, 95% CI: 0.73-0.87), appropriate treatment of drinking water (PR = 0.88, 95% CI: 0.80-0.96), improved sanitation facility (PR = 0.90, 95% CI: 0.82-0.97), and complete structure (having walls, floor and roof) of the sanitation facility (PR = 0.65, 95% CI: 0.50-0.84) were inversely associated with stunting. None of the exposure variables were associated with wasting. A microbiological indicator of water quality was not associated with diarrhoea or stunting. CONCLUSIONS: Our findings suggest that in Rusizi district, appropriate treatment of drinking water may be an important factor in diarrhoea in children <5, while improved source and appropriate treatment of drinking water as well as improved type and structure of sanitation facility may be important for linear growth in children <2. We did not detect an association with water quality.

China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?

BACKGROUND: There is a growing recognition of China's role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China's engagement as a donor with that of more traditional global health donors. METHODS: Using newly released data from AidData on China's development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000-2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China's activities to projects from traditional donors using data from the OECD's Development Assistance Committee (DAC) Creditor Reporting System. RESULTS: Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China's contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries. CONCLUSIONS: China is an important global health donor to Africa but contrasts with traditional DAC donors through China's focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China's approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Unmasking the truth: Experimental evidence of facemask compliance in Bangladesh, Kenya, and Nigeria during the COVID-19 pandemic.

High levels of compliance with public health measures are critical to ensure a successful response to the COVID-19 pandemic and other public health emergencies. However, most data on compliance are self-reported and the tendency to overreport due to social desirability could yield biased estimates of actual compliance. A list experiment is a widely used method to estimate social desirability bias in self-reported estimates of sensitive behaviours. We estimate rates of compliance with facemask mandates in Kenya, Nigeria, and Bangladesh using data from phone surveys conducted in March-April 2021. Data on compliance were collected from two different survey modules: a self-reported compliance module (stated) and a list experiment (elicited). We find large gaps between stated and elicited rates of facemask wearing for different groups depending on specific country contexts and high levels of overreporting of facemask compliance in self-reported surveys: there was an almost 40 percentage point gap in Kenya, 30 percentage points in Nigeria, and 20 percentage points in Bangladesh. We also observe differences in rates of self-reported facemask wearing among key groups but not using the elicited responses from the list experiment, which suggest that social desirability bias may vary by demographics. Data collected from self-reported surveys may not be reliable to monitor ongoing compliance with public health measures. Moreover, elicited compliance rates indicate levels of mask wearing are likely much lower than those estimated using self-reported data.

Data flows during public health emergencies in LMICs: A people-centered mapping of data flows during the 2018 ebola epidemic in Equateur, DRC.

In infectious outbreaks, rapid case detection and reporting, coordination, and context-specific strategies are needed for rapid containment. Data sharing between actors, and the speed and content of data flows, is essential for expediting epidemic response. In this study, researchers mapped data flows during the 2018 Ebola Virus Disease (EVD) outbreak in Equateur Province in the Democratic Republic of the Congo using semi-structured interviews, ethnographic research, and focus groups with EVD response actors. During this research, we mapped and tracked data collection, transmission, storage, sharing, and use patterns. Target participants included: key organizational actors in the EVD outbreaks responses, including local (primary health, community-based, hospital), provincial (MoPH, DRC Red Cross), and international (WHO, UN organizations, international first-responders) stakeholders. We found that a community-based surveillance system enabled the rapid detection of a hemorrhagic fever outbreak, resulting in the rapid laboratory confirmation of EVD. With the arrival of international organizations to provide support to the EVD response, routine surveillance systems continued to function robustly. However, the establishment of a vertical EVD response architecture created challenges for the response. Data flows during the Equateur outbreak were hampered by numerous challenges in the domains of early warning, line lists of cases, and contact tracing, which impeded surveillance and data flows. We therefore argue that structuring health information systems for preparedness requires taking a person-centered approach to data production, flow, and analysis.

Identifying barriers to the production and use of routine health information in Western Province, Zambia.

Recent decades of improvements to routine health information systems in low- and middle-income countries (LMICs) have increased the volume of health data collected. However, countries continue to face several challenges with quality production and use of information for decision-making at sub-national levels, limiting the value of health information for policy, planning and research. Improving the quality of data production and information use is thus a priority in many LMICs to improve decision-making and health outcomes. This qualitative study identified the challenges of producing and using routine health information in Western Province, Zambia. We analysed the interview responses from 37 health and social sector professionals at the national, provincial, district and facility levels to understand the barriers to using data from the Zambian health management information system (HMIS). Respondents raised several challenges that we categorized into four themes: governance and health system organization, geographic barriers, technical and procedural barriers, and challenges with human resource capacity and staff training. Staff at the facility and district levels were arguably the most impacted by these barriers as they are responsible for much of the labour to collect and report routine data. However, facility and district staff had the least authority and ability to mitigate the barriers to data production and information use. Expectations for information use should therefore be clearly outlined for each level of the health system. Further research is needed to understand to what extent the available HMIS data address the needs and purposes of the staff at facilities and districts.

The impact of COVID-19 and national pandemic responses on health service utilisation in seven low- and middle-income countries.

BACKGROUND: The COVID-19 pandemic has disrupted health services worldwide, which may have led to increased mortality and secondary disease outbreaks. Disruptions vary by patient population, geographic area, and service. While many reasons have been put forward to explain disruptions, few studies have empirically investigated their causes. OBJECTIVE: We quantify disruptions to outpatient services, facility-based deliveries, and family planning in seven low- and middle-income countries during the COVID-19 pandemic and quantify relationships between disruptions and the intensity of national pandemic responses. METHODS: We leveraged routine data from 104 Partners In Health-supported facilities from January 2016 to December 2021. We first quantified COVID-19-related disruptions in each country by month using negative binomial time series models. We then modelled the relationship between disruptions and the intensity of national pandemic responses, as measured by the stringency index from the Oxford COVID-19 Government Response Tracker. RESULTS: For all the studied countries, we observed at least one month with a significant decline in outpatient visits during the COVID-19 pandemic. We also observed significant cumulative drops in outpatient visits across all months in Lesotho, Liberia, Malawi, Rwanda, and Sierra Leone. A significant cumulative decrease in facility-based deliveries was observed in Haiti, Lesotho, Mexico, and Sierra Leone. No country had significant cumulative drops in family planning visits. For a 10-unit increase in the average monthly stringency index, the proportion deviation in monthly facility outpatient visits compared to expected fell by 3.9% (95% CI: -5.1%, -1.6%). No relationship between stringency of pandemic responses and utilisation was observed for facility-based deliveries or family planning. CONCLUSIONS: Context-specific strategies show the ability of health systems to sustain essential health services during the pandemic. The link between pandemic responses and healthcare utilisation can inform purposeful strategies to ensure communities have access to care and provide lessons for promoting the utilisation of health services elsewhere.