RESUMO
Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria-tetanus-pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12-23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative-a learning initiative involving 5 consortia of 14 different organizations across 4 countries-Bangladesh, Mali, Nigeria, and Uganda-and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12-23 months as defined by the global DTP1 indicator.
RESUMO
BACKGROUND: Two probability surveys, conducted in the same districts of Bihar, India (Aurangabad and Gopalganj) at approximately the same time in 2016 using identical questionnaires and similar survey methods, produced significantly different responses for 37.2% (58/156) of the indicator comparisons. Interviewers for one survey were men while for the other they were women. Respondents were mothers of children aged 0-59 months living in a traditional rural setting. We examined the influence of interviewer gender on mothers' survey responses and their implications for interpreting survey results. METHODS: We used qualitative methods including 10 focus group discussions (FGDs) and 33 in-depth interviews (IDIs) in the same locations as the 2016 surveys. FGD participants were purposefully selected mothers with children 0-59 months, husbands and other in-law family members. IDIs were carried out with frontline health-workers, enumerators and supervisors from the two previous household surveys. RESULTS: Findings revealed a preference for female interviewers for household surveys in study districts as they facilitated access to mothers and reduced their discomfort as survey participants. However, this gender preference was related to the survey question. Regardless of age, caste and educational level, most mothers were not permitted to communicate with men (aside from husbands) about female-specific health topics, including birth preparedness, delivery, menstrual cycles, contraception, breastfeeding, sexual behaviour, sexually transmitted disease, and domestic violence. Mothers in higher castes perceived these social restrictions more acutely than mothers in lower castes. There was no systematic direction of the resulting error. Mothers were willing to discuss child health issues with interviewers of either gender. CONCLUSIONS: Interviewer gender is an important consideration when designing survey protocols for maternal and reproductive health studies and when selecting and training enumerators. Female interviewers are optimal for traditional settings in Bihar as they are more likely to obtain accurate data on sensitive topics and reduce the potential for non-sampling error due to their reduced social distance with maternal respondents.