A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions

Abstract

A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions Background Childhood pneumonia is the single largest infectious cause of death in children under five worldwide. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) provide health information on care sought for sick children in resource poor settings. Despite not being primarily designed to identify childhood pneumonia, there are concerns that reported episodes of "symptoms of acute respiratory infection" in DHS and MICS are often interpreted by other groups as a "proxy" for childhood pneumonia. Using DHS5 and MICS5 survey tools, this study aimed to assess how accurately caregivers, report of "symptoms of acute respiratory infection" reflect pneumonia episodes and antibiotic use in children under five.Methods Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017. Children were assessed using World Health Organization (WHO) standard criteria by study physicians to identify whether they had pneumonia. Three hundred and two matched children in each category of 'pneumonia' and "no pneumonia" were followed up at home, either two or eight weeks later, using questions from DHS5 and MICS5 surveys to assess the accuracy of caregiver recall of pneumonia. ResultsThe specificity of DHS5 and MICS5 questions for identifying childhood pneumonia were 87.4 (95% confidence interval (CI) = 83.1-91.0) and 86.1 (95% CI = 81.7-89.8) respectively and the sensitivity of questions were 37.1 (95% CI = 31.6-42.8) and 37.1 (95% CI = 31.6-42.8). Correct recall of antibiotic treatment was poor (kappa statistic = 0.064) but improved with the use of medicine pill boards (kappa statistic = 0.235).Conclusions DHS5 and MICS5 survey questions are not designed to identify childhood pneumonia and this study confirms that they do not accurately discern episodes of childhood pneumonia from cough/cold in children under five. The proportion of pneumonia episodes appropriately treated with antibiotics cannot be accurately assessed using current DHS and MICS surveys. If these results are used to guide programmatic decisions, it is likely to encourage overuse and inappropriate prescribing of antibiotics for episodes of cough/cold. International agencies who continue to use these household data to monitor the proportion of children with pneumonia who receive antibiotic treatment should be discouraged from doing this as these data are likely to mislead national and global programmes. Medicine pill boards are used in a number of DHS surveys and should be promoted for wider use in national population surveys to improve the accuracy of antibiotic recall. Electronic supplementary material:The online version of this article contains supplementary material.

Care seeking behaviour and aspects of quality of care by caregivers for children under five with and without pneumonia in Ibadan, Nigeria

“…A total of 360 children without pneumonia were recruited into the study. This recruitment is detailed in a separate study [17]. 302 children of those without pneumonia were included as a control group having been matched to cases of pneumonia; 168 males and 137 females, age 0-52 months (Mean = 15.9, SD = 13.7).…”

“…This sample may also not entirely represent those normally surveyed by DHS and MICS in the community as they may have different characteristics. There was also some loss to follow up in those recruited and therefore this may have introduced some bias [17]. OPC physicians were aware of the study and referred children to the study physicians.…”

“…This was done as per the study protocol of the larger prospective observational study which randomly assigned matched cases to either two or eight week follow up [17]. Doctors, who had completed training on how to carry out these demographic surveys, interviewed the caregiver of each child in their home using DHS5 and MICS5 questionnaires to elicit care seeking information for the episode of respiratory illness.…”

“…The matching procedure is described in more detail in the study protocol of the wider observational study [17]. …”

Methodological Considerations for Linking Household and Healthcare Provider Data for Estimating Effective Coverage: A Systematic Review

“…Estimation of intervention need may require solely population demographics such as age (e.g., for prevention and health promotion interventions) or may require defining specific illnesses or conditions The latter is more subject to reporting bias [6]. Multiple studies have shown poor association or biases between maternally-reported symptoms and clinical pneumonia [7,8], malaria [9], and diarrhea [10] in children under five. A handful of studies (n=3) showed maternal report of both maternal and newborn birth complications is variable [11–13].…”