WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

A WORKBOOK ON HOW TO PLAN AND CARRY OUT

RESEARCH ON THE RISK APPROACH

IN MATERNAL AND CHILD HEALTH

INCLUDING FAMILY PLANNING

TRUE POSITIVES

FALSE NEGATIVES

Experimental Edition FHE/MCH/RA 84.1

Division of Family Health World Health Organization

Geneva 1984

The issue of this document does not constitute

formal publication. It should not be reviewed,

abstracted or quoted without the agreement of

the World Health ' Organization. Authors alone

are responsible for views expressed in signed

articles.

Ce document ne constitue pas une publication.

II ne doit faire I'objet d'aucun compte rendu ou

rdsum6 ni d'aucune citation sans I'autorisation de

I'organisation mondiale de l a Sant6. Les opinions exprimees dans les articles sign& n'engagent que

leurs auteurs.

"SOMETHING FOR ALL, --

MORE FOR THOSE I N NEED,

AND I N P R O P O R T I O N T O THAT NEED"

CONTENTS

Page

P r e f a c e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

. . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

An i n t r o d u c t i o n t o t h e workbook . . . . . . . . . . . . The concept of r i s k and t h e r i s k approach . . . . . . . Heal th systems research . . . . . . . . . . . . . . . . I d e n t i f y i n g the h e a l t h problems of mothers and c h i l d r e n

. . . Epidemiological s tudy of chosen unwanted outcomes

Analysing t h e h e a l t h c a r e system . . . . . . . . . . . Planning t h e MCH/FP s t r a t e g y . . . . . . . . . . . . . Fie ld t e s t i n g . moni tor ing and e v a l u a t i n g the s t r a t e g y . Implementation . t h e wider a p p l i c a t i o n o f t h e s t r a t e g y

The Republic of F i c t i t i a . . . . . . . . . . . . . . . . . . . . . 321

P REFACE

This workbook h a s been prepared f o r those who wish t o under take s t u d i e s on t h e r i s k approach i n McH/FP c a r e a s a t o o l f o r h e a l t h systems research i n t h i s f i e l d . The r i s k approach i s based on t h e idea t h a t a measure of r i s k is a proxy f o r f u t u r e need - need f o r promotive and preven t ive c a r e - and t h e f a c t t h a t knowledge a v a i l a b l e before t h e p r e d i c t e d event a l lows t ime f o r a p r o p o r t i o n a t e response: hence we c o i n t h e s logan: "Something f o r a l l , bu t more f o r those i n need - i n proport ion t o t h a t need".

Th is approach aims t o r e d r e s s t h e i n e q u a l i t i e s i n h e a l t h t h a t a f f l i c t almost a l l s o c i e t i e s , and i s pragmatic i n t h a t i t seeks s o c i a l j u s t i c e i n h e a l t h . Human and o t h e r resources should go where t h e need is g r e a t e s t , and assessment of t h e r i s k of f u t u r e i l l n e s s , acc iden t o r dea th i s a u s e f u l s h o r t c u t t o t h e measurement of t h a t need - both f o r i n d i v i d u a l s and f o r communities. The r i s k approach should s e r v e t o c o n c e n t r a t e c a r e on t h e family i t s e l f , a s we l l a s t o ensure t h a t i n d i v i d u a l s a r e r e f e r r e d t o t h e c o r r e c t person o r i n s t i t u t i o n i n t h e c a r e s y s t m . I t should a l s o provide g u i d e l i n e s f o r t r a i n i n g , and, by f u r n i s h i n g a community p r o f i l e , a c t a s a rough-and-ready guide t o s o c i a l p o l i c i e s f o r h e a l t h .

Risk d a t a come i n d i f f e r e n t g u i s e s , t h e f a m i l i a r r e l a t i v e r i s k and t h e more e s o t e r i c a t t r i b u t a b l e r i s k being t h e b e s t known. 3f t h e s e two, t h e f i r s t is wel l s u i t e d f o r u s e a t t h e i n d i v i d u a l l e v e l i n he lp ing us t o understand and r e a c t t o danger s i g n a l s , t o r e f e r o u r s e l v e s f o r h e l p when necessa ry , o r t o guide resource use t o t h e optimum. The second type of r i s k in format ion , however, i s probably t h e most c h a l l e n g i n g , s i n c e t h i s concept of a t t r i b u t i o n (though i t must be approached with s t a t i s t i c a l and o t h e r r e s e r v a t i o n s ) provides a measure of what could happen t o t h e community's h e a l t h i f t h e r i s k f a c t o r s were removed. An inst rument of s o c i a l p o l i c y wi th t h i s ~ o t e n t i a l , even i f i t s t i l l remains t o be developed and s i m p l i f i e d , must be respec ted and i t s use i s mandatory."

The workbook provides an unders tanding of how t o c a r r y out s t u d i e s on t h e r i s k approach. I t shows how such s t u d i e s can be used a s an inst rument of change by s t i m u l a t i n g t h e r e o r g a n i z a t i o n of mate rna l and c h i l d h e a l t h and family planning c a r e w i t h i n primary h e a l t h c a r e , thus s t r e n g t h e n i n g i t s c o n t r i b u t i o n t o t h e g l o b a l t h r u s t towards Heal th f o r A l l by t h e Year 2000.

This workbook is s e l e c t i v e , combining those a s p e c t s of epidemiology, s t a t i s t i c s and h e a l t h c a r e management t h a t a r e most u s e f u l f o r t h o s e involved i n implementing r i s k approach s t u d i e s o r applying t h e i r r e s u l t s . I t i s no t in tended t o r e p l a c e t h e many e x c e l l e n t textbooks a l r e a d y a v a i l a b l e on t h e s e s u b j e c t s .

Furthermore, w h i l e t h e r i s k approach can be used t o a t t a c k such urgen t h e a l t h problems a s maternal and i n f a n t m o r t a l i t y , a c c i d e n t s and m a l n u t r i t i o n , f o r t h e sake of c l a r i t y t h e examples i n t h i s workbook have been mainly l i m i t e d t o t h e p e r i n a t a l pe r iod .

* T h e concepts and t h e p r i n c i p l e s of t h e r i s k approach have been f u l l y descr ibed i n : Backe t t , E.M., Davies, A.M. and Petros-Barvazian, A. The r i s k approach i n h e a l t h c a r e . Geneva, World Heal th Organ iza t ion , 1983. (Publ ic Heal th papers No. 76) .

The p r e s e n t workbook, deve loped over s e v e r a l y e a r s , h a s been mod i f i ed and e n r i c h e d a s a r e s u l t of t h e v a r i o u s i n t e r r e g i o n a l and i n t e r c o u n t r y workshops i n which i t was used . However, i t i s s t i l l n o t a f i n i s h e d p roduc t . The e x p e r i e n c e s of p a r t i c i p a n t s i n f u t u r e workshops w i l l c o n t r i b u t e t o i t s r e f i n e m e n t . And, t h e c o n c e p t u a l development of such a s p e c t s of t h e r i s k approach a s i n t e r s e c t o r a l a c t i o n and s e l f - and f ami ly c a r e w i l l i n e v i t a b l y l e a d t o f u r t h e r changes.

F l e a s e n o t e t h a t a s t h i s i s a n e x p e r i m e n t a l e d i t i o n , i t h a s n o t undergone d e t a i l e d e d i t o r i a l r e v i s i o n . We would he most g r a t e f u l t o r e c e i v e your comments and s u g g e s t i o n s t o h e l p u s improve f u r t h e r e d i t i o n s o f t h i s workbook. Fo r t h i s purpose you w i l l f i n d a t e a r - o u t s h e e t a t t h e end.

D r A . Pe t ros -Barvaz ian D i r e c t o r D i v i s i o n of Family Hea l th

iii

ACKNOWLEDGEMENTS

This workbook i s the r e s u l t of t h e e f f o r t s of many people both wi th in and o u t s i d e of WHO. We would e s p e c i a l l y l i k e t o thank rhe members of t h e Task Force on t h e Risk Approach f o r Improved Maternal and Child Heal th and Family Planning Care and t h e p a r t i c i p a n t s i n t h e i n t e r r e g i o n a l and i n t e r c o u n t r y workshops organized by WHO i n Nottingham (UK), Geneva (Swi tze r land) , Nairobi (Kenya), Mexico C i t y (Mexico), San Juan de Costa Rica (Costa Rica) and Cotonou (Benin).

The WHO a l s o wishes t o acknowledge with g r a t i t u d e t h e f i n a n c i a l c o n t r i b u t i o n of t h e United Nat ions Fund f o r Popula t ion A c t i v i t i e s (UNFPA) towards t h e p r e p a r a t i o n and p u b l i c a t i o n of t h i s workbook (INT/74/P16).

Chapter 1

An introduction t o the workbook

FHE/MCH/ ~A184.1 Page 2

CHAPTER 1: AN INTRODUCTION TO THE WORKBOOK

Section 1.1 General introduction and the aims of the workbook

Section 1.2 Content and structure

Section 1.3 H o w t o use the workbook

Section 1.4 Summary of the steps in the learning process

FHE/MCH/RA/84.1 Page 3

Sec t ion 1.1 General i n t r o d u c t i o n and t h e aims of t h e workbook

The workbook is a l e a r n i n g l t e a c h i n g t o o l which, i n a step-wise fash ion , d e s c r i b e s how t o c a r r y o u t research on t h e r i s k approach i n maternal and c h i l d h e a l t h c a r e inc lud ing family planning (MCH/FP). According t o the Alma Ata Dec la ra t ion on Primary Health Care , maternal and c h i l d h e a l t h c a r e inc ludes family planning. Th is i s the d e f i n i t i o n of maternal and c h i l d h e a l t h c a r e used throughout t h i s workbook.

The workbook is designed not t o provide dogmatic answers t o quest ions about " the b e s t methods of r e a l l o c a t i n g resources" , bu t r a t h e r t o provide a b a s i s f o r research o r enqui ry aimed a t f i n d i n g out what a r e the b e s t methods of doing s o i n a p a r t i c u l a r c u l t u r e o r country. The workbook c o n t a i n s a l o g i c a l sequence of c h a p t e r s with corresponding e x e r c i s e s , each of which addresses problems which could be encountered i n t h e z e a l world of experiment, survey and resource a l l o c a t i o n .

The r i s k approach i s one of s e v e r a l ways of dec id ing what i s t h e most e f f e c t i v e way t o use resources . Though i t s l o g i c is u n a s s a i l a b l e ( u n l i k e much t h a t we undertake i n d i s e a s e c o n t r o l ) , i t h a s not y e t been shown i n a l l a r e a s and i n f u l l y c o n t r o l l e d f i e l d t r i a l s t o be more e fEec t ive than o t h e r methods.

The workbook t a k e s u s through t h e development of a proper ly designed s e r i e s of s t u d i e s which make up p a r t of t h e research on t h e r i s k approach i n maternal and c h i l d h e a l t h c a r e . I t is recognised t h a t i n some s i t u a t i o n s "research" may be t o o grand a word f o r t h e e n q u i r i e s which w i l l be poss ib le . The u n a s s a i l a b l e l o g i c of a l l o c a t i n g most resources where need i s g r e a t e s t does no t always r e q u i r e "research" i n t h e academic sense of t h e word, though i t may be argued t h a t i t always r e q u i r e s some e v a l u a t i o n - however crude. It fol lows t h e p r i n c i p l e s of "no research without s e r v i c e " and t h a t " a l l h e a l t h c a r e i n t h e b e s t i n t e r e s t s of people" must be evaluated. The c o n s t r a i n t s of the " r e a l world", whi le o f t e n imposing "short cu t s" i n the development of t h e r i s k approach, must no t be allowed t o impede t h e methodical and s y s t a n a t i c s t e p s i n the argument. For t h i s reason t h e research descr ibed i s , i n one sense a t l e a s t , i d e a l i s e d and, probably, more r igorous than i s sometimes p o s s i b l e i n the f i e l d . I n o r d e r t o improvise and "cut corners" c o r r e c t l y , i t i s , however, imperat ive t o f u l l y unders tand t h e s c i e n t i f i c b a s i s f o r s t u d i e s on the r i s k approach.

How does t h i s workshop d i f f e r from t r a d i t i o n a l t r a i n i n g courses?

- Each p a r t i c i p a n t a t t h e workshop i s provided with a workbook t h a t s e r v e s a s t h e primary s u b j e c t m a t t e r . Addi t iona l r e s o u r c e s a r e a v a i l a b l e i n the form of r e f e r e n c e a r t i c l e s and t e c h n i c a l e x p e r t s ( f a c i l i t a t o r s ) .

- The m a t e r i a l s a r e designed t o a s s i s t each p a r t i c i p a n t t o develop s p e c i f i c s k i l l s . These s k i l l s a r e developed by ask ing each p a r t i c i p a n t t o apply new knowledge t o e x e r c i s e s provided i n the workbook and t o s i t u a t i o n s p resen ted i n group d i scuss ions .

- Each p a r t i c i p a n t i s encouraged t o work a t h i s own pace w i t h i n the t ime l i m i t s of t h e course .

- Each p a r t i c i p a n t is encouraged t o d i s c u s s any problems o r q u e s t i o n s with a course f a c i l i t a t o r whenever t h e s e occur and t o r e c e i v e prompt feedback on completion of e x e r c i s e s ( t h a t i s , t o be t o l d how wel l he has done the e x e r c i s e and what improvements could be made).

F H E / M C H / R A / ~ ~ .I Page 4

The aim of the workbook may be s t a t e d a s follows:

The workbook i s t o be used by i n d i v i d u a l s o r groups t o l e a r n how t o organize and c a r r y out a s tudy on t h e r i s k approach i n maternal and c h i l d h e a l t h ca re . P a r t i c u l a r emphasis i s given t o ensure t h a t such s t u d i e s a r e s o c i a l l y r e l e v a n t , s c i e n t i f i c a l l y c o r r e c t and ye t p r a c t i c a l i n terms of time, resources and method. The term "study" i s taken i n i t s widest s e n s e , inc lud ing s e t t i n g of p r i o r i t i e s , use of ep idemio log ica l da ta i n planning and programming, e v a l u a t i o n of r i s k s t r a t e g i e s and wider a p p l i c a t i o n of f i n d i n g s . The handbook i s a l s o intended t o be used dur ing the development of s tudy pro toco ls and i n the management of s t u d i e s .

The workbook, t h e r e f o r e , can be seen a s a guide t o t h e i n i t i a t i o n of change i n h e a l t h c a r e ; a guide t o t h e kinds of e n q u i r i e s which should be a p re lude t o changes i n t h e h e a l t h c a r e system and thus t o more e f f e c t i v e ca re .

The b e s t way t o l e a r n i s t o do; t h i s workbook is a t o o l t o prepare fo r the a c t u a l "doing" of t h e research .

F H E / M C I I / R A / ~ ~ . ~ Page 5

Sec t ion 1.2 Content and s t r u c t u r e

Summary

This s e c t i o n exp la ins how t h e t e x t and e x e r c i s e s have been a r ranged , i n d i c a t e s how the con ten t h a s been developed and d e s c r i b e s t h e "data base" ( F i c t i t i a ) which can be used f o r t h e e x e r c i s e s .

The workbook i s arranged i n 9 c h a p t e r s , which t o g e t h e r , form a l o g i c a l sequence t h a t t a k e s you through t h e e n t i r e process of applying and e v a l u a t i n g the r i s k approach i n a count ry s e t t i n g . The chap te rs a r e d iv ided i n s e c t i o n s , most of which correspond t o s t e p s which have t o be gone through i n a s y s t a n a t i c f a s h i o n i n o rder t o p lan and implement t h e s tudy.

Further read ing m a t e r i a l s a r e suggested on i n t e r e s t i n g and r e l a t e d bu t p e r i p h e r a l m a t e r i a l s d i v e r g i n g from t h e main theme of t h e workbook.

The e x e r c i s e s a r e problem so lv ing cha l lenges . They d i f f e r g r e a t l y i n complexity and leng th . The e x e r c i s e s a r e designed s o t h a t they form a continuum, i . e . , t h e r e s u l t s of t h e previous e x e r c i s e i s an inpu t i n t o t h e nex t e x e r c i s e . The e x e r c i s e s a r e w r i t t e n s o t h a t t h e p r i n c i p l e s a r e a p p l i c a b l e whatever t h e problems a r e t o which t h e research i s d i r e c t e d . Informat ion and da ta from any country s i t u a t i o n can , t h e r e f o r e , be used t o modify t h e e x e r c i s e s according t o d i f f e r e n t country s i t u a t i o n s . A s i t is d e s i r a b l e t o "use" a f i c t i t i o u s country a s an example, t h e count ry of F i c t i t i a has been c r e a t e d .

The document on F i c t i t i a i s d iv ided i n two s e c t i o n s :

- t h e f i r s t p a r t g i v e s a genera l d e s c r i p t i o n of t h e country and i t s h e a l t h c a r e system;

- t h e second p a r t c o n s i s t s of two appendices with d e t a i l e d s t a t i s t i c s r e l e v a n t t o t h e r i s k study.

Table and f i g u r e s a r e numbered with the number of the s e c t i o n i n which they appear , and consecu t ive ly - a , b , c , and so on.

F H E / M c H / R A / ~ ~ . ~ Page 6

Sec t ion 1 . 3 How t o use the workbook

I Summary ! The workbook can be used f o r s e l f - s t u d y , i n a

workshop s i t u a t i o n , o r a s a r e f e r e n c e book. Th is s e c t i o n d e s c r i b e s t h e arrangements f o r a workshop.

The workbook i s prepared s o t h a t i t can be used f o r t h r e e purposes:

- f o r se l f - s tudy ;

- a s l e a r n i n g m a t e r i a l f o r a workshop; and

- a s a r e f e r e n c e book f o r development, implementation and management of a s tudy on t h e r i s k approach i n maternal and c h i l d h e a l t h ca re .

The workbook assumes some knowledge about h e a l t h and h e a l t h c a r e , some unders tanding of epidemiology and sane f a m i l i a r i t y with h e a l t h s e r v i c e s research (HSR) .

By read ing through the t e x t s and using the d a t a from F i c t i t i a you should be a b l e t o answer t h e ques t ions posed i n t h e e x e r c i s e s . A l l e x e r c i s e s should be addressed i n sequence.

Workshop

The o r g a n i z e r s of the workshop w i l l have t o prepare a c a r e f u l programme, o u t l i n i n g f o r each s e s s i o n and each day t h e s e c t i o n s which w i l l be d e a l t wi th and t h e e x e r c i s e s which should be done.

The t e x t and e x e r c i s e s of t h e workbook have been prepared s o t h a t they could be covered i n t e n working days of two three-hour group s e s s i o n s . I n a d d i t i o n , p a r t i c i p a n t s would have t o do some homework: a p re l iminary reading through of t e x t s and a f i r s t a t tempt a t t h e corresponding e x e r c i s e s . I f t h e workshop is t o be undertaken i n l e s s than t e n working days, c a r e h a s t o be taken i n s e l e c t i n g t e x t s and e x e r c i s e s t o ensure t h a t t h e r e i s c o n t i n u i t y from one t o t h e next . The fol lowing is a d e s c r i p t i o n , f o r a two-week workshop, of the:

1. aims; 2. s t r u c t u r e and method; and 3. e v a l u a t i o n .

F H E / M C H / R A / ~ ~ . ~ Page 7

1. Aims

The two-week workshop i s intended t o s y n t h e s i z e and summarize the wide exper ience of t h e p a r t i c i p a n t s and h e l p them t o be a b l e to:

a ) develop t h e p r o t o c o l f o r a r i s k approach s tudy based on an unders tanding of t h e concepts of t h e r i s k approach i n maternal and c h i l d h e a l t h c a r e ; and

b ) prepare a p lan of a c t i o n f o r t h e i r own a c t i v i t i e s i n the f i e l d of r i s k approach s t u d i e s .

2 . S t r u c t u r e and method

One of t h e most important f e a t u r e s of t h e workshop i s the oppor tun i ty f o r p a r t i c i p a n t s t o p r a c t i c e s k i l l s i n problem-solving i n smal l groups. Because of t h e l i m i t e d t h e a v a i l a b l e f o r t h i s , however, assignments have been very c a r e f u l l y planned.

The workshop programme h a s been designed f o r a group of approximately twenty p a r t i c i p a n t s . A l l p a r t i c i p a n t s a r e ass igned t o a working group c o n s i s t i n g of f i v e t o seven menbers. The smal l groups w i l l be organized by t h e p a r t i c i p a n t s themselves. Each smal l group should have a l e a d e r , who could be t h e same throughout the workshop o r who could be changed f o r each s e s s i o n o r each s e c t i o n .

The d a i l y workshop process c o n s i s t s of u n s t r u c t u r e d and s t r u c t u r e d time: t h e p a r t i c i p a n t s a r e i n v i t e d t o devote t h e u n s t r u c t u r e d t ime (such a s evenings) t o i n d i v i d u a l read ing and i n d i v i d u a l p repara t ion of e x e r c i s e s (excep t a s otherwise i n d i c a t e d by t h e moderator). During the s t r u c t u r e d s e s s i o n t h e moderator w i l l give a very b r i e f summary of t h e main p o i n t s of t h e s e c t i o n . P a r t i c i p a n t s w i l l then have a n oppor tun i ty t o ask q u e s t i o n s of c l a r i f i c a t i o n concerning t h e readings. Secondly, p a r t i c i p a n t s w i l l work i n smal l groups on t h e e x e r c i s e s of the s e s s i o n . The purpose of t h e s e smal l working group d i s c u s s i o n s i s t o produce i n a l i m i t e d t h e on t h e b a s i s of t h e i n d i v i d u a l l y prepared e x e r c i s e s , a group consensus s o l u t i o n t o an e x e r c i s e ( t h i s c a n be p resen ted on a t ransparency) . A r e p r e s e n t a t i v e of each working group w i l l be requested t o p resen t t h e g roup ' s s o l u t i o n on t h e overhead p r o j e c t o r s . T h i s w i l l a l low p a r t i c i p a n t s t o compare and l e a r n from t h e s o l u t i o n s of o t h e r working groups. F i n a l l y , t h e moderator o r one of t h e ~ a r t i c i p a n t s w i l l summarise t h e main concepts and techn iques d e r i v e d from the workshop sess ion .

I t cannot be s t r e s s e d enough t h a t t h e ~ r i m a r y onus i s on t h e p a r t i c i p a n t s . The r o l e of t h e o rgan izers i s p r imar i ly t o s t i m u l a t e t h e d i s c u s s i o n s i n working groups and i n plenary s e s s i o n s among groups. The i r r o l e i s t o make s u r e t h a t t h e o b j e c t i v e s of each s e s s i o n and t h e broad o b j e c t i v e s of t h e workshop a r e achieved w i t h i n t h e t ime l i m i t s of t h e workshop. The organ izers should not be expected t o and w i l l no t express op in ions o r pass judgements on t h e p a r t i c i p a n t s ' views, bu t on ly s h a r e views wi th them.

The workshop d i r e c t o r

a ) d e c i d e s (g iven t h e adv ice of moderators and p a r t i c i p a n t s ) on the m a t e r i a l t o be included i n t h e workshop;

b ) ensures t h a t necessary m a t e r i a l i s provided t o p a r t i c i p a n t s ;

c ) ensures t h a t t h e meeting room i s p roper ly s e t up;

d) in t roduces t h e workshop approach t o p a r t i c i p a n t s ;

e ) o rgan izes a l l o c a t i o n of p a r t i c i p a n t s t o working groups;

FHE/MCH/RA/~~.~ Page 8

f ) o b t a i n s feedback from p a r t i c i p a n t s and dec ides on changes i n s e s s i o n o b j e c t i v e s , c o n t e n t , time schedule o r grouping of p a r t i c i p a n t s ;

g) a d v i s e s moderators and fac i l i t a t o r s , i f necessa ry , on e f f e c t i v e teaching methods;

h ) monitors and c o o r d i n a t e s the progress of t h e workshop.

The moderator (each s e s s i o n w i l l have a moderator)

a ) s e l e c t s which s p e c i f i c s u b j e c t s a r e t o be covered i n a given s e s s i o n ;

b ) modi f ies t h e m a t e r i a l regarding each s u b j e c t ( s e s s i o n o b j e c t i v e s , r ead ings , p r a c t i c a l e x e r c i s e s ) i n l i g h t of exper ience and i n l i g h t of the p a r t i c u l a r needs of t h e p a r t i c i p a n t s ;

C ) moni tors each s e s s i o n t o ensure o b j e c t i v e s a r e met and time schedules a r e adhered t o ;

d ) in t roduces b r i e f l y and summarises, when i n d i c a t e d , t h e s e s s i o n ;

e ) o rgan izes and c o o r d i n a t e s t h e group p r e s e n t a t i o n s .

What i s a course f a c i l i t a t o r ?

As the name impl ies , a course f a c i l i t a t o r i s one who a s s i s t s t h e p a r t i c i p a n t s i n a t r a i n i n g course t o l e a r n t h e s k i l l s p resen ted i n t h e course m a t e r i a l s , u s u a l l y through i n d i v i d u a l d i s c u s s i o n s and counse l l ing . He i s one of s e v e r a l sources of i n s t r u c t i o n ; o t h e r sources inc lude t h e workbook, r e f e r e n c e m a t e r i a l , t e c h n i c a l e x p e r t s , and o t h e r p a r t i c i p a n t s i n t h e course. S k i l l s , knowledge, or exper ience i n t h e s u b j e c t being taught e n a b l e a course f a c i l i t a t o r t o e x p l a i n i d e a s , l ead d i s c u s s i o n s , and h e l p p a r t i c i p a n t s l e a r n the s k i 11s. However, because t h e workbook i s t h e primary s u b j e c t m a t t e r resource f o r t h e course , a course f a c i l i t a t o r i s not expected t o t each the content of the course through formal l e c t u r e s o r o t h e r t r a d i t i o n a l t each ing methods.

3. Eva l u a t ion

One r e p r e s e n t a t i v e from each group w i l l meet the o rgan izers a t t h e end of each day i n o rder t o provide sugges t ions f o r modiEicat ions , i n p a r t i c u l a r r e l a t i n g t o t h e "process". Before the s t a r t of t h e nex t d a y ' s s e s s i o n , a l l p a r t i c i p a n t s w i l l be v e r b a l l y informed of t h e previous d a y ' s e v a l u a t i o n . A t t h e end of each week, a w r i t t e n eva lua t ion quest ionna i re w i l l be f i l l e d i n by p a r t i c i p a n t s and the r e s u l t s communicated t o t h e p a r t i c i p a n t s .

F H E / M C H / R A / ~ ~ . ~ Page 9

S e c t i o n 1.4 Summary of t h e s t e p s i n t h e l e a r n i n g process

The l o g i c which l i e s behind the s t e p s i n the handbook i s not a s s t r a i g h t f o r w a r d a s t h e l i s t of c o n t e n t s s u g g e s t s . Both t h e r e a l world of f i e l d research and t h e "syslans" approach r e q u i r e a number of "loops" and branched pathways i n the p rogress of l e a r n i n g , each r e f l e c t i n g t h e l i k e l y p rogress of t h e research i t s e l f . Each s t e p depends t o a l a r g e e x t e n t upon t h a t which precedes it. Thus, i f t h e top p r i o r i t y maternal and c h i l d h e a l t h problem i n an a r e a has been demonstrated through a wel l designed s t u d y t o be p e r i n a t a l m o r t a l i t y , t h e research w i l l be of a q u i t e d i f f e r e n t kind t o t h a t which would be undertaken i f t h e t o p p r i o r i t y h e a l t h problem had been, say, motor v e h i c l e acc iden ts t o c h i l d r e n .

Broadly speak ing , t h e r e a r e t h r e e groups of "s teps" ( f i r s t , in te rmedia te and f i n a l ) i n l e a r n i n g how t o apply, e v a l u a t e and implement a r i s k s t r a t e g y i n maternal and c h i l d h e a l t h c a r e inc lud ing family planning. These a r e :

---------------------------------------------------- , I l I : Steps involved i n t h e d e f i n i t i o n of the " t a r g e t "

FIRST : o r "top p r i o r i t y " h e a l t h problem and i n l e a r n i n g : STEPS : how t o do the ep idemio log ica l s t u d i e s which I

I

: r e l a t e i t t o recognisab le r i s k f a c t o r s . I I

1 I

---------------------------------------------------- 1 I

: Steps involved i n l e a r n i n g how t o organize the : preven t ion of t h e " t a r g e t " o r " top p r i o r i t y " INTERMEDIATE 1

STEPS : h e a l t h problem by m o d i f i c a t i o n of t h e resource : : use w i t h i n t h e h e a l t h c a r e system - t h e r i s k ,

I : i n t e r v e n t i o n . I

l l '----------------------------------------------------l

FINAL STEPS

,---------------------------------------------------- 1

I l : Steps involved i n l e a r n i n g how t o measure the : : e f f e c t i v e n e s s of the r i s k i n t e r v e n t i o n s and i n : : implementing and d i ssemina t ing the f i n d i n g s of : the s t u d i e s . l

I 1

* - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -1

F H E / M C H / R A / ~ & . I Page 10

F H E / M C H / R A / ~ ~ . ~ Page 11

Chapter 2

The concept of risk and the r i s k approach

F H E / M C H / R A / ~ ~ . ~ Page 12

Summary

The r i s k approach is a managerial t o o l t o improve resource u t i l i z a t i o n i n h e a l t h ca re . I t is pa r t i c u l a r l y s u i t e d t o maternal and c h i l d hea l t h and family planning ca r e , where promotive and prevent ive a c t i v i t i e s and e a r l y h e a l t h c a r e a c t i on a r e s o important. Risk i s a measure of t he p r o b a b i l i t y of a f u t u r e adverse event . A r i s k f a c t o r i s a c h a r a c t e r i s t i c of an i nd iv idua l o r a group of i nd iv idua l s with a n increased r i s k ( p r o b a b i l i t y ) of a n unwanted outcome. Risk can be measured i n terms of ab so lu t e r i s k , r e l a t i v e r i s k and a t t r i b u t a b l e r i s k . These measures a r e not pe r f ec t s i nce r i s k i s a ques t ion of p r o b a b i l i t y o r chance. The number of f a l s e p o s i t i v e and f a l s e nega t ive ca se s g ive an i nd i ca t i on of how accura te ly r i s k i s measured. That informat ion can be used t o improve organ iza t ion and management of McH/FP care .

Objec t ives

Af t e r s tudying t h i s chap t e r , you should be a b l e t o :

- exp l a in the concept of the r i s k approach;

- expla in what i s meant by r i s k o r chance;

- l ist the d i f f e r e n t types of r i s k f a c t o r s ;

- expla in 3 measures of r i s k ;

- exp l a in what i s meant by " f a l s e pos i t i ve " and " f a l s e negat ive" cases ;

- l i s t the main a r ea s where r i s k d a t a may be used f o r o rgan iza t ion and management of MCH/FP ca r e .

F H E / M C H / R A / ~ ~ . ~ Page 13

CHAPTER 2 : THE CONCEPT OF RISK AND THE RISK APPROACH

Sec t ion 2.1 The r i s k approach - concept, d a t a , research

Sec t ion 2.2 What i s meant by r i s k ?

Sec t ion 2.3 What i s a r i s k f a c t o r ? - r i s k f a c t o r s and outcomes - i n d i c a t o r s and causes - combinat ions of r i s k f a c t o r s

Sec t ion 2.4 How do we measure r i s k ?

Sec t ion 2 .5 How good a r e w e a t p r ed i c t i ng outcomes?

Sec t ion 2.6 From r i s k d a t a t o i n t e rven t i ons

FHE/McH/RA/~~. l Page 14

S e c t i o n 2.1 The r i s k approach - concept, d a t a , r esearch

I Summary I The r i s k approach i s a method f o r measuring t h e need

of i n d i v i d u a l s and groups f o r c a r e (and thus f o r a s s i s t i n g them t o determine t h e i r p r i o r i t i e s ) and a t o o l f o r the r e a p p r a i s a l and r e o r g a n i z a t i o n of h e a l t h and o t h e r s e r v i c e s t o meet t h a t need. I t s aim i s t o improve c a r e f o r a l l but t o pay s p e c i a l a t t e n t i o n t o those i n g r e a t e r need.*

Considerable e f f o r t s have gone i n t o t h e c r e a t i o n and improvement of h e a l t h s e r v i c e s , bu t t h e r e a r e s t i l l many a r e a s i n t h e world where access t o h e a l t h c a r e i s l i m i t e d f o r most of the populat ion. High q u a l i t y medical s e r v i c e s may, pa radoxica l ly , be a v a i l a b l e t o some groups w h i l e u n i v e r s a l coverage, a t t h e primary l e v e l , i s l i m i t e d by resource c o n s t r a i n t s s l r h a s l ack of money and t r a i n e d manpower. There i s t h u s a need t o seek ways of making optimal use of e x i s t i n g resources f o r the b e n e f i t of the m a j o r i t y i f t h e g o a l of "heal th f o r a l l by the year 2000" i s t o be achieved.

I n every s o c i e t y t h e r e a r e communities, f a m i l i e s and i n d i v i d u a l s whose chances of f u t u r e i l l n e s s , dea th and a c c i d e n t a r e g r e a t e r than t h o s e of o t h e r s ; t h e s e a r e s a i d t o be e s p e c i a l l y v u l n e r a b l e and the reasons f o r t h i s , though o f t e n tenuous, c a n u s u a l l y be t raced . S p e c i a l v u l n e r a b i l i t y , whether t o i l l n e s s o r h e a l t h , i s a r e s u l t of the possession of a number of i n t e r a c t i n g c h a r a c t e r i s t i c s , b i o l o g i c a l , g e n e t i c , environmental , psycho-social , which t o g e t h e r c o n f e r a p a r t i c u l a r r i s k of f u t u r e h e a l t h o r d i s e a s e . Thus the pregnant , the very young, t h e migran t , the e l d e r l y a d t h e poor a r e s p e c i a l l y vu lnerab le ; whi le t h e a d o l e s c e n t , t h e a f f l u e n t and the young a d u l t a r e genera l ly l e s s so. Within such groups, sane i n d i v i d u a l s and subgroups with s p e c i a l c h a r a c t e r i s t i c s (such a s t h e grand m u l t i p a r a ) a r e a t h igher r i s k than o t h e r members of the group. Our a b i l i t y t o measure a c c u r a t e l y t h e s e r i s k s i s r e l a t i v e l y r e c e n t and provides u s with t o o l s wi th which t o address p a r t i c u l a r l y t h e p reven t ive p a r t of h e a l t h c a r e . Because of the recen t emphasis on primary h e a l t h c a r e t h i s new knowledge may have come a t a s p e c i a l l y opportune t i m e both t o i n c r e a s e the e f f e c t i v e n e s s of primary ca re and t o se rve the Alma Ata i d e a l of Health f o r A l l by t h e Year 2000.

* See Backe t t , E.M., Davies, A.M. and Petros-Barvazian, A . The r i s k approach i n h e a l t h ca re . Geneva, World Hea l th Organ iza t ion , 1983 ( p u b l i c Health Papers , No. 76).

FHE/MCH/RA/84.1 Page 15

The possess ion by communities, f a m i l i e s o r i n d i v i d u a l s of c h a r a c t e r i s t i c s which confer a s p e c i a l " r i sk" of h e a l t h o r d i s e a s e impl ies some s o r t of c a u s a l cha in o r sequence and some of t h e s e a t t r i b u t e s can be descr ibed e a s i l y and i n d e t a i l - m a l n u t r i t i o n , teenage pregnancy and grand m u l t i p a r i t y . These r i s k s , which can be converted i n t o "scores" f o r managerial purposes , a r e i n f a c t a kind of shorthand express ion of the need f o r c a r e . Thus a pregnant mother with h igh blood pressure may be a t a very high r i s k of a complicated labour . The measured r i s k t o her and h e r c h i l d i s an express ion of h e r need f o r h e l p , t h a t i s f o r p reven t ive and c u r a t i v e c a r e now. Making some e s t i m a t e of r i s k o f , f o r example, a p e r i n a t a l d e a t h , however a c c u r a t e l y t h i s is done, is t h e r e f o r e only a s i g n a l o r i n d i c a t o r of the e x t e n t of t h e need f o r c a r e . The so-ca l led " r i s k approach s t r a t e g y " which s t a r t s wi th t h e s e s i g n a l s - t h e s e e s t i m a t e s - of the mother ' s need f o r h e l p , uses them a s gu ides t o a c t i o n , t o resource r e a l l o c a t i o n , t o h e t t e r coverage and r e f e r r a l and t o family and c l i n i c a l c a r e . T h i s is the s imple and c l a s s i c a l use of the r i s k approach u t i l i s i n g d a t a d e r i v e d mainly from t h e s tudy of i n d i v i d u a l s .

But t h e r e a re a l s o c o l l e c t i v e , community r i s k s , f o r example from the presence of mala r ia o r sch i s tosomias i s i n a reg ion , from smoke p o l l u t i o n o r poor water supp ly , from poverty o r poor h e a l t h ca re s e r v i c e s ; the degree of r i s k i n t h e s e c a s e s i s a l s o a n express ion of need, t h e measurement of which i s an e s s e n t i a l component i n the format ion of p o l i c i e s , f o r example i n the de te rmina t ion of p r i o r i t i e s and i n t h e a l l o c a t i o n of s c a r c e resources . These a r e some of t h e new uses of the r i s k approach.

The hypothes i s upon which t h e r i s k approach r e s t s t h e r e f o r e , is t h a t the more a c c u r a t e a r e t h e s e measures of r i s k t h e more c l e a r l y w i l l t h e need f o r he lp be understood and t h e b e t t e r ( o r more e f f e c t i v e ) w i l l be the response. The r i s k approach t o t h e i n d i v i d u a l i s by no means a new d i scovery , bu t i t s use a s a p o l i c y and managerial t o o l is. This t o o l has become sharper with the improvement of methods of measurement of r i s k and wi th t h e i n c r e a s i n g r i c h n e s s of informat ion.

This workbook aims t o descr ibe the method by which the t o o l s needed t o implement t h e r i s k approach i n a given count ry s i t u a t i o n can be developed. Health problems, soc ioeconomic cond i t ions and the d i s t r i b u t i o n of r i s k i n the populat ion a r e very s p e c i f i c t o l o c a l c i rcumstances . Before a r i s k s t r a t e g y can be formulated a r e l i a b l e d a t a base needs t o be developed. The ga ther ing and a n a l y s i s of the informat ion which c o n s t i t u t e s t h i s d a t a base, t h e a p p r e c i a t i o n of t h e d a t a on planning and programming and t h e e v a l u a t i o n of the modified MCH/FP s t r a t e g y i s what i s termed r i s k approach research and forms t h e s u b j e c t of t h e p r e s e n t workbook.

FHE/MCH/RA/~~.I Page 16

Sec t ion 2.2 What is meant by r i s k ?

Summary

Risk i s a measure of t h e p r o b a b i l i t y of a f u t u r e occurrence, usua l ly a n unwanted outcome. The r i s k approach i s based on t he measurement of t h e p r o b a b i l i t y which i t uses a s a proxy fo r the need f o r h e a l t h o r o t h e r

l care .

When we t a l k about the r i s k of sanething happening, we a r e r e f e r r i n g t o the p r o b a b i l i t y of t h a t event occur r ing . P r o b a b i l i t y i s a measure of unce r t a in ty . Where everything is c e r t a i n , t he r e is no roan f o r p r o b a b i l i t y s i n c e no doubts e x i s t . A t one extreme we a r e a l l ab so lu t e ly c e r t a i n t h a t we w i l l d i e one day. We can a l s o know t h a t i t is abso lu te ly impossible t h a t we w i l l l i v e t o be 200 yea r s o ld . But i f we t o s s a c o i n i n t he a i r , we have a f i f t y - f i f t y chance t h a t a co in w i l l come down head.

The top of the s c a l e of p r o b a b i l i t y represen ts ab so lu t e uncer ta in ty . The s t a t i s t i c i a n would w r i t e p = 1 ( P meaning ~ r o b a b i l i t y ) . The bottom end of the s c a l e , marked 0, r ep r e sen t s ab so lu t e imposs ib i l i t y ; most problems a r e not s o c l e a r c u t , and t he p r o b a b i l i t y of most even ts i s somewhere along t he l i n e from 0 t o 1. P e n i c i l l i n might be exce l l en t f o r a p a r t i c u l a r d i s e a s e , and cure most people with t h a t d i s ea se . But somebody, o r a very few people , might not be cured by p e n i c i l l i n .

The concept of p r o b a b i l i t y and i n p a r t i c u l a r of measurable p r o b a b i l i t y , i s fundamental t o a n understanding of r i s k .

A d i c t i ona ry d e f i n i t i o n of the word " r i sk" is:

"hazard, danger , exposure t o mischance o r per i l ' 1 .

Risk i s thus a measure of the s t a t i s t i c a l chance, the p robab i l i t y , of a fu ture occurrence - usua l ly undesired. I m p l i c i t i n t h i s no t ion i s t h e idea t h a t t he p r o b a b i l i t y of adverse consequences is increased by the presence of one or more c h a r a c t e r i s t i c s o r f a c t o r s . When t h e ~ r o b a b i l i t ~ i s known and i s of a d i s ea se , i l l n e s s , acc iden t o r dea th which can be avoided o r reduced i f an t i c i pa to ry a c t i o n i s t aken , then t h i s a c t i on uses t he r i s k approach a t an i nd iv idua l l eve l .

The no t ion of r i s k seems widely understood, p a r t i c u l a r l y when appl ied t o games. When appl ied t o personal o r family hea l t h i t i s l e s s o f t e n thought of i n numerical terms, a d l e s s i n comparative terms.

FHE/MCH/RA/84 .l Page 17

I f t h e r i s k o f , s a y , a ~ e r i n a t a l d e a t h f o r t h e e n t i r e popula t ion of newborns between the 28th week of pregnancy and the end of the f i r s t week of l i f e was on average 100 per 1000 t o t a l b i r t h s , a d e t a i l e d s tudy of t h e d i s t r i b u t i o n of t h e s e r i s k s would r e v e a l t h a t i t was anything bu t equal f o r a l l i n f a n t s . Some would have very high r i s k of dea th (and t h e method of p r e d i c t i o n of who they were and what a c t i o n s t o take i n p e r i n a t a l and o t h e r a r e a s of mate rna l and c h i l d h e a l t h is the s u b j e c t of t h i s workbook), w h i l e o t h e r s would have a very low r i s k . None would have no r i s k , w h i l e many would have a moderate r i s k . Even among those i n f a n t s with a very high r i s k of dying t h e r e w i l l be many who do n o t and, l i k e w i s e , among those most l i k e l y t o surv ive t h e r e w i l l be a few deaths . A s c r u t i n y of the records a f t e r t h e event o f t e n p o i n t s t o causes which sugges t t h a t t h e r i s k s were wrongly es t imated b u t , even a f t e r t h a t s c r u t i n y , t h e r e w i l l be i n e x p l i c a b l e surv ivors among those a t very high r i s k and unforeseen d e a t h s among t h o s e wi th t h e lowest r i s k . P a r t of t h e r i s k approach invo lves the assumption t h a t a s knowledge i n c r e a s e s s o t h e s e chance even ts w i l l become fewer and fewer. But i n t h e meantime i t i s important t o recognise t h a t no t a l l even ts can be "explained" and chance s t i l l p lays a p a r t . While we c a n p r e d i c t how many w i l l d i e i n a given popula t ion , we cannot p r e d i c t wi th anything l i k e the same confidence which i n d i v i d u a l s w i l l d i e . We can, however, examine t h e c h a r a c t e r i s t i c s of t h o s e t h a t have d i e d t o s e e whether they can show us how these i n d i v i d u a l s d i f f e r e d from those t h a t survived. I f we a r e s u c c e s s f u l , we a r e a b l e t o i d e n t i f y c h a r a c t e r i s t i c s which more a p t l y d e s c r i b e t h o s e t h a t d i e d than those who d i d not d i e . T h i s l i s t is our l i s t of p o s s i b l e r i s k f a c t o r s .

Summary

A r i s k f a c t o r i s a d e t e c t a b l e c h a r a c t e r i s t i c or c i rcumstance of i n d i v i d u a l s o r groups which i s a s s o c i a t e d wi th an inc reased chance ( r i s k ) of exper iencing an unwanted outcome. Care must be t aken i n d e f i n i n g what i s a r i s k f a c t o r and what i s an outcome, a s some c h a r a c t e r i s t i c s c a n be e i t h e r . Risk f a c t o r s can be i n d i c a t o r s o r causes of outcomes. I f they a r e causes , i n t e r v e n t i o n s could avoid the outcome. I f they a r e only i n d i c a t o r s , then they can on ly be compensated f o r by g r e a t e r ca re .

FHE/MCH/RA/~~.~ Page 18

s e c t i o n 2 .3 What is a r i s k f a c t o r ?

- r i s k f a c t o r s and outcomes - i n d i c a t o r s and causes - combinat ions of r i s k f a c t o r s

A r i s k f a c t o r i s :

any a s c e r t a i n a b l e c h a r a c t e r i s t i c o r c i rcumstance of a person o r group of persons t h a t i s known t o be a s s o c i a t e d with an abnormal r i s k of hav ing , developin o r being e s p e c i a l l y adversely a f f e c t e d by a morbid process .

Risk f a c t o r s can t h e r e f o r e be causes o r s i g n a l s but the important th ing about them i s t h a t they a r e observab le o r i d e n t i f i a b l e p r i o r t o t h e event they ~ r e d i c t . Risk f a c t o r s can be those which c h a r a c t e r i s e t h e i n d i v i d u a l , t h e fami lv , t h e group, t h e community o r t h e environment. Severa l s t u d i e s have shown t h a t f i r s t pregnancy, high p a r i t y , pregnancy a t e a r l y o r l a t e reproduc t ive age , p rev ious c h i l d l o s s , and m a l n u t r i t i o n a r e u n i v e r s a l r i s k f a c t o r s , possession of which i n c r e a s e s t h e chance of a poor outcome of pregnancy. Combinations of t h e s e and o t h e r r i s k f a c t o r s i n the same i n d i v i d u a l s f u r t h e r r a i s e t h e chance of a poor outcome. Moreover, t h e i n t e r a c t i o n of b i o l o g i c a l r i s k f a c t o r s with o t h e r s d e r i v e d from the s o c i a l and environmental s e t t i n g w i l l have an inc reased e f f e c t . For example, m u l t i p a r i t y i n mothers l i v i n g i n pover ty i s a s s o c i a t e d with a h igher r i s k of a p e r i n a t a l death t h a n m u l t i p a r i t y on i t s own.

Risk f a c t o r s a r e , t h e r e f o r e , c h a r a c t e r i s t i c s which have a s i g n i f i c a n t a s s o c i a t i o n wi th a def ined outcome. I t i s important t o s p e c i f y t h e outcome for which each r i s k f a c t o r o r group of f a c t o r s i s sought. For example, " i n f a n t death" i s no t d e t a i l e d enough because t h e c h a r a c t e r i s t i c s of mothers whose i n f a n t s have an inc reased chance of dying from hypoxia dur ing d e l i v e r y , f o r i n s t a n c e , may be q u i t e d i f f e r e n t from t h o s e of mothers whose i n f a n t s d i e from g a s t r o e n t e r i t i s .

Our own d e f i n i t i o n i s t h a t a r i s k f a c t o r is one l i n k i n a chain of a s s o c i a t i o n s l e a d i n g t o an i l l n e s s - or i t could be some i n d i c a t o r of t h a t l i n k .

F H E / M C H / R A / ~ ~ . I Page 19

Risk f a c t o r s may be s p e c i f i c f o r a p a r t i c u l a r outcome, such a s ~ r e v i o u s induced abor t ion l ead ing t o c e r v i c a l incompetence. More f r e q u e n t l y , however, one r i s k f a c t o r i n c r e a s e s t h e chances of a numher of outcomes or e n d - ~ o i n t s , o f t e n t o d i f f e r e n t degrees . An example is grand m u l t i p a r i t y with i t s inc reased r i s k of s e v e r a l compl ica t ions of pregnancy and d e l i v e r y , such a s t r a n s v e r s e l i e , postpartum haemorrhage, and premature and p r e c i p i t a t e b i r t h .

It has been emphasised t h a t r i s k f a c t o r s a r e c h a r a c t e r i s t i c s of t h e person or environment having a s t a t i s t i c a l a s s o c i a t i o n with the def ined outcome. The I, . importance" o r v a l u e of t h e r i s k f a c t o r t o ~ r e v e n t i v e medicine depends i n p a r t on the ex ten t of t h e a s s o c i a t i o n with t h e outcome, but a s w e l l , on t h e f requency of t h e outcome i n t h e community. I f a c e r t a i n r i s k f a c t o r were t o c a r r y a h igh p r o b a b i l i t y o f , s a y , f e t a l dea th , t h i s would have c o n s i d e r a b l e importance f o r the mother concerned. However, i f t h i s r i s k f a c t o r was uncommon i n t h e community, the impact on t h e t o t a l f e t a l m o r t a l i t y exper ienced by t h a t community would be smal l and t h i s f a c t would have t o be considered when formulat ing i n t e r v e n t i o n s t r a t e g i e s .

Risk f a c t o r s can be:

- b i o l o g i c a l ( a g e , s e x ) ; - environmental (water supp ly) ; - s o c i o c u l t u r a l ( l i t e r a c y , pover ty , r e l i g i o n ) ; - behavioura l (smoking, e a t i n g h a b i t s ) ; - h e a l t h c a r e r e l a t e d ( q u a n t i t y , q u a l i t y of c a r e ) .

Risk f a c t o r s and outcomes

The d i s t i n c t i o n between outcomes and r i s k f a c t o r s is not always c lea r -cu t . I t i s important t o r e a l i z e t h a t :

- what i s cons idered a r i s k f a c t o r bv sane might be cons idered a problem o r a n outcome by o t h e r s ,

- a c h a r a c t e r i s t i c might be both a problem and an i n d i c a t o r of r i s k .

For example low b i r thweigh t i s an "unwanted outcome" ( a ~ r o b l e r n ) of pregnancy, and a r i s k i n d i c a t o r f o r i n f a n t morb id i ty and m o r t a l i t y .

We f r e q u e n t l y t a l k about a c h a i n of even ts , where one problem l e a d s t o a n o t h e r , o r i n t h e r e v e r s e , where a preceding event l eads back t o another preceding event . Consider f o r example, chi ldhood m o r t a l i t y . An a n a l y s i s of who t h e dead c h i l d r e n a r e and a d e f i n i t i o n of t h e i r c h a r a c t e r i s t i c s might l ead t o a problem model such a s t h e one t h a t follows:

, l 1 - - - - - - -- - - l - -- - - - - ------ t :---A repea ted ' ' ' ' i n f a n t : : i n f e c t i o n , :--4 dehydra t ion :--4 1 -_--------- 1 c3 iarrhoea , 7 -------------, , m o r t a l i t y :

1 - - - - - ' ' -----------' l I

--------- l , 1 -- - - - - -- - - - 1 ,' ' high p a r i t y ' ' I

: poverty ,-+l I--+ m a l n u t r i t i o n : ' --------- 1 of mother I 1 -------------- 1

Any of the s t a g e s could be taken a s a problem o r a s a r i s k f a c t o r , (even i n f a n t m o r t a l i t y could be a r i s k i n d i c a t o r i n t h e sense t h a t s i b l i n g dea th is an i n d i c a t o r of s p e c i a l r i s k f o r i n f a n t dea th i n another s i b l i n g ) .

PHE/MCH/RA/~~. 1 Page 2 0

I f a s tudy on the epidemiology of r i s k i s t o be undertaken, ca re ha s t o be taken i n de f i n ing which a r e t h e outcomes and which a r e the r i s k f a c t o r s .

Ind ica tor o r cause

A c a r e f u l s tudy of the c h a r a c t e r i s t i c s of the persons experiencing a bad outcome ( a low b i r thweight , i n f a n t marasmus) and a comparison of t he se c h a r a c t e r i s t i c s with t hose of persons who d id no t experience a bad outcome ( a normal b i r thweight , a well-nourished i n f a n t ) w i l l have l ed t o t he i d e n t i f i c a t i o n of a l i s t of r i s k f a c t o r s which w i l l serve a s pa r t of the " r i s k data" needed fo r the formulat ion of t h e r i s k approach s t r a t egy . How the se d a t a w i l l be used depends c r i t i c a l l y on one c r i t e r i o n (among o t h e r s ) , namely on whether the c h a r a c t e r i s t i c is a cause of t h e outcome (smoking f o r low b i r t hwe igh t ) o r merely an i nd i ca to r ( i l l i t e r a c y ) .

I n almost a l l s o c i e t i e s l i n k s a re popular ly recognised between the outcome of pregnancy and preceding events . These a r e o f t e n held t o be causa l because they precede the outcome. This is no tor ious ly misleading s i nce events which precede o t h e r even ts d o no t nece s sa r i l y cause them. This ~ r i n c i p l e i s only accepted i n some communities and r a r e l y i n those where powerful magic and fo lk lo r e surround c h i l d b i r t h . The b e l i e f by nurses and medical s t a f f i n a western h o s p i t a l i n the 1950's t h a t r ed headed wanen f a r e badly i n c h i l d b i r t h has a c e r t a i n s i m i l a r i t y t o t h e repor ted a s s o c i a t i o n between e a t i n g eggs du r ing pregnancy and t he subsequent baldness of the ch i ld .

The no t i on of "cause" i s complex and not a l l s i g n i f i c a n t a s soc i a t i ons between t he c h a r a c t e r i s t i c s of t h e vu lnerab le and t h e unwanted outcome a r e pa r t of a chain of c ausa l i t y . Same of the most u se fu l a r e s t a t i s t i c a l only. Assoc ia t ions a r e u sua l l y descr ibed a s "causal" i f they can be seen t o be d i r e c t l y r e l a t e d t o pa tho log i ca l p rocesses , even i f the pathways a r e no t f u l l y understood. Examples inc lude p lacen ta p raev ia and f e t a l dea th from anoxia , o r f i r s t t r i m e s t e r r u b e l l a and congeni ta l malf ormat ions.

Recognition of r i s k f a c t o r s which a r e pa r t of the causa l chain of even ts l ead ing t o i l l n e s s o r death ( t h e unwanted outcome) i s t he more cha l leng ing s i nce i n t e r v e n t i o n w i l l o f t en lower the r i s k . Risk f a c t o r s which a r e s t r i c t l y speaking p a r t of t he c a u s a l cha in of even t s , such a s high maternal age, but where i n t e rven t ion t o a l t e r the pathology is e i t h e r impossible o r not understood, prompt a d i f f e r e n t response; here t he a c t i o n should be compensatory: s e rv i ce s can be a l e r t e d and made ready i n a n t i c i p a t i o n of a pos s ib l e bad outcome.

F i n a l l y , t h e r e a r e those r i s k f a c t o r s , sometimes with impressive ~ r e d i c t ive power, such a s pover ty or crowding o r membership of a p a r t i c u l a r r e l i g i o u s s e c t o r c a s t e , where a s soc i a t i ons on ly r e f l e c t t he c ausa l pathways. Others a r e even more d i s t a n t from pathology but may s t i l l be u se fu l i nd i ca to r s . Thus the absence of a b i cyc l e o r poor q u a l i t y housing of a family i n some v i l l a g e s a r e s i g n a l s of a group of i n t e r a c t i n g forces ( t h e most important oE which i s probably poverty) which render t he mother a t high and measurable r i s k .

The a t t r i b u t i o n of "cause" t o a r i s k f a c t o r t he r e fo r e w i l l only be of r e a l importance i n he lp ing t o d e f i n e what a c t i o n t o t ake . The s t a t i s t i c a l r i s k a s soc i a t ed with a r i s k f a c t o r may however, be equa l ly u se fu l as an i nd i ca to r of outcome i f i t a r i s e s from pathology o r some apparen t ly unconnected s i g n a l of r i s k such a s the absence of a b i cyc l e o r poor housing oE a househould.

FHE/MCH/ RA 84.1 Page 21

Risk f a c t o r s a r e t h e r e f o r e a s c e r t a i n a b l e i n d i c a t o r s of what i s going on i n s ide a complex i n t e r a c t i n g b i o l o g i c a l and s o c i a l systen. The d e f i n i t i o n a s wel l a s the understanding of "causes" w i th in t h i s system is nece s sa r i l y l imi ted . The p r ec i s e "causes" of poor pregnancy outcome among those with previous f e t a l o r c h i l d l o s s , t h e r e f o r e , a r e not always c l e a r , though t h e r i s k i s . A l l t h e f a c t o r s which predispose a toddle r t o excessive acc iden ts i f the mother works o u t s i d e the home a r e no t understood though a s a r i s k f a c t o r , ou t s i de work i s valuable i n some cu l t u r e s . Another common example i s the a s soc i a t i on between poverty a d in fan t g a s t r o e n t e r i t i s where t h e complex of poverty may inc lude con t r i bu t i ons t o r i s k from l a r g e f ami l i e s , crowding, e a r l y weaning and poor n u t r i t i o n , with i n f e c t i o n of the i n f an t and neg lec t of e a r l y d ia r rhoea f o r a v a r i e t y of reasons, economic, s o c i a l and c u l t u r a l . Even without e l uc ida t i ng the pathways of causa t ion , i t i s c l e a r t h a t poverty of the family i s a r i s k f a c t o r f o r g a s t r o e n t e r i t i s of t h e i n f a n t ; i t i s roba ably an even more important r i s k f a c t o r f o r dea th from g a s t r o e n t e r i t i s .

Medical c a r e i n t he pa s t has concentrated upon those a s s o c i a t i o n s where t he pa tho log ica l processes could be i n t e r rup t ed . This preoccupat ion has l ed t o neg lec t of t he more tenuous l i n k s i n t h e causa l cha in , which, l i k e poverty, a r e d i f f i c u l t "non medical" cha l lenges . One f ea tu r e of the use of the r i s k approach i s t h a t i t prompts a t t e n t i o n t o a l l "causes" r ega rd l e s s of t h e i r "medical", " i n t e r s ec to r a l " , emotional, p o l i t i c a l , economic o r even magic o r i g in s . I t cannot , of course, unrave l a l l of t he se a s s o c i a t i o n s bu t may go some way t o de f i n ing t h e i r r e l a t i v e importance.

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S e c t i o n 2.4 How d o we measure r i s k ?

I Summary

There a r e d i f f e r e n t ways of measuring t h e r e l a t ionship between a problem and the correspond ing r i s k f a c t o r s :

- a b s o l u t e r i s k - r e l a t i v e r i s k - a t t r i b u t a b l e r i s k

The a b s o l u t e r i s k i s simply t h e inc idence of t h e outcome (problem) among the whole popula t ion , which of c o u r s e inc ludes t h o s e with and those wi thou t d e f i n a b l e r i s k f a c t o r s .

The r e l a t i v e r i s k is the r a t i o of the inc idence of t h e outcome i n those wi th t h e f a c t o r t o t h e inc idence i n those without the f a c t o r and shows t h e r i s k t o i n d i v i d u a l s wi th t h e r i s k f a c t o r .

The a t t r i b u t a b l e r i s k is a more complex measure. I t g i v e s an i n d i c a t i o n of how t h e t o t a l problem would be reduced i f the f a c t o r d i sappeared from each i n d i v i d u a l i n t h e populat ion.

Risk o r the p r o b a b i l i t y of an event o c c u r r i n g , can be measured i n a t l e a s t t h r e e ways depending on who o r what we c o n s i d e r t o be " a t r i s k " ( r i s k " t o whom"). This can b e s t be i l l u s t r a t e d by means of an example such a s p e r i n a t a l m o r t a l i t y i n Cuba a s s e t ou t i n Table 2.4a.

Table 2.4a

Some uses f o r r i s k informat ion: P e r i n a t a l dea th r a t e s i n four high r i s k groups: A l l b i r t h s , Cuba, 1973

1 I Risk f a c t o r s : % of : P e r i n a t a l m o r t a l i t y : R e l a t i v e : A t t r i b u t a b l e : I : a l l b i r t h s : per 1000 b i r t h s r i s k r i s k % : ;---------------------- ------------1---------------------t t----------I--------------'

: Mother p a r i t y 4+ 1 I 1 18.1 : 40.4 1.69 : 11 I

I l I I I l : Maternal age of l 1 I 9.1 : 30.7 1.16 : 2 I : l e s s than 18 y e a r s ', I I I I I I I l 1 I

: Sing le mother I l V 35.8 : 32.8 1.39 : 12 v

I 1 1 1 l l : Non h o s p i t a l I 1 7.5 : 40.9 1.54 : 1 1 I

: d e l i v e r y I I I I I t I I I I - - - - - - - - - - - - -_ l

I I I A l l mothers 100.0 : 26.9 1.00 : - I

Source: B a c k e t t , E.M., Davies , A.M. and Petros-Barvazian, A. The r i s k approach i n h e a l t h c a r e , Geneva, World Health Organ iza t ion , 1983 ( P u b l i c Heal th Papers , No. 76) .

F H E / M C H / R A / ~ ~ . ~ Page 2 3

F i r s t , t h e r e i s t h e r i s k of t h e outcome occur r ing t o t h e whole populat ion. Th is includes those with and those without d e f i n a b l e r i s k f a c t o r s and is sometimes c a l l e d t h e a b s o l u t e r i s k . Since i t expresses t h e a c t u a l chances of an e v e n t , i t i s va luab le . I t expresses the f requency, i . e . t h e r e a l p r o b a b i l i t y of t h e i l l n e s s , acc iden t o r dea th occur r ing i n a given time. Thus i n Tahle 2.4a, t h e r i s k of a p e r i n a t a l dea th f o r t h a t p a r t i c u l a r community was 26.9 f o r every 1000 b i r t h s .

Next t h e r e i s t h e r i s k of t h e outcome occur ing t o t h o s e with one o r more r i s k f a c t o r s . For t h e i n d i v i d u a l s concerned t h i s i s t h e most important concept. What i s t h e p r o b a b i l i t y t h a t t h e i n f a n t of t h i s p a r t i c u l a r woman w i l l d i e ? The most usua l measure of i n d i v i d u a l r i s k i s r e l a t i v e r i s k . Th is i s among the most u s e f u l and s imple of measures and expresses t h e r a t i o between t h e inc idence of t h e i l l n e s s o r cause of dea th i n t h e popula t ion with the r i s k f a c t o r ( o r f a c t o r s ) and i t s inc idence i n t h e populat ion wi thou t them. I t i s t h e r e f o r e a l s o a measure of t h e s t r e n g t h of t h e a s s o c i a t i o n between r i s k f a c t o r and outcome. I n our Cuba example s i n g l e mothers have a r e l a t i v e r i s k of 1.39, i . e . t h e i r chances of exper ienc ing a p e r i n a t a l dea th a r e 39% h i g h e r t h a n those of a marr ied mother.

While t h e importance of a r i s k f a c t o r depends t o a l a r g e e x t e n t upon t h e s t r e n g t h of i t s a s s o c i a t i o n wi th t h e even tua l outcome, from t h e community's po in t of view i t a l s o depends upon t h e frequency of t h e occurrence of t h e unwanted outcome i n the community. I f a c e r t a i n r i s k f a c t o r were t o c a r r y a h igh p r o b a b i l i t y o f , s a y , f e t a l dea th b u t was very r a r e i n t h e community, t h e impact of i t s removal on t o t a l f e t a l m o r t a l i t y would be smal l . Th is impact on t h e community's exper ience is measured by a t t r i b u t a b l e r i s k . I t i s expressed a s a percentage reduc t ion of t h e adverse outcome.

A t t r i b u t a b l e r i s k b r i n g s t o g e t h e r t h r e e ideas : t h e f requency of t h e unwanted outcome with and wi thou t t h e r i s k f a c t o r p r e s e n t ( t h e r e l a t i v e r i s k ) , and t h e frequency of occurence of the r i s k f a c t o r i n the community. I t i n d i c a t e s t h e r e f o r e what might be expected t o happen t o t h e o v e r a l l outcome i n t h e community i f t h e r i s k f a c t o r were removed. Figure 2.4a shows g r a p h i c a l l y how both r e l a t i v e r i s k and frequency of occurence c o n t r i b u t e t o a t t r i b u t a b l e r i s k . The importance of t h i s concept i n terms of p o l i c y making can hard ly be exaggerated.

Figure 2.4a

A t t r i b u t a b l e r i s k : e f f e c t on t h e community of t h e removal of two r i s k f a c t o r s

l 1 1

COMMON 1 l 1 1 - - ----

1 1 t , 1 I H I G H I , I I 1 !

! ! 1 1 1 I , I , I 1 I l ! I 1 1 I 1 1 I l I I I 1 t 1 , I LOW l I I t 1 1

----- B RARE 1

; ;++++++l ; *---12z:?t?:---I

THEIR P REVALENCE THEIR RELATIVE RISK THEIR ATTRI RUTABLE RISK

Note: A t t r i b u t a b l e r i s k i s based on the assumption of a c a u s a l r e l a t i o n s h i p between r i s k f a c t o r and outcome.

FUE/MCH/RA/84.1 Page 24

When several factors are present, and are influencing each other, the s t a t i s t i c a l handling of the data becomes more complicated. But concepts of absolute r i s k , r e la t i ve r i sk and at tr ibutable r i sk remain unchanged even when dealing with a number of r i sk factors added together.

F H E / M C H / R A / ~ ~ . ~ Page 25

Sec t ion 2.5 How good a r e we a t p r e d i c t i n g outcomes?

Summary

A r i s k f a c t o r only p r e d i c t s t he chances of an unwanted outcome. How good t h i s p r ed i c t i on is can be measured by the number of f a l s e ~ o s i t i v e s and the number of f a l s e nega t ives . As one goes up, the o the r w i l l go down. The prevalence of t he outcome i n t h e populat ion in f luences the r a t e of f a l s e p o s i t i v e s and f a l s e nega t ives .

Once r i s k f a c t o r s have been i d e n t i f e d and quan t i f i ed i t i s pos s ib l e t o make an e s t ima t e of the l i ke l i hood t h a t a given outcome w i l l occur t o a given group of people. We cannot , however, p r e d i c t with c e r t a i n t y t o whom the outcome w i l l occur. Because we a r e dea l ing with chance we a r e bound t o make wrong pred ic t ions . These wrong p r ed i c t i ons can be of two types.

1. We can p r e d i c t an unwanted outcome which w i l l not occur ( t h e smoker who does no t g e t lung cancer) . The i nd iv idua l s f o r whom t h e outcome is p r ed i c t ed - who were deemed "a t r i sk " - and who do not experience t h a t unwanted outcome a r e c a l l e d " f a l s e pos i t i ve s " .

2. We can p r e d i c t a good outcome when i n f a c t an unwanted outcome occurs ( t h e non-smoker who g e t s lung cancer ) . The i nd iv idua l s concerned, who were f a l s e l y deemed "not a t r i sk " , a r e c a l l e d " f a l s e negatives".

The e f f e c t i v e n e s s of t he r i s k f a c t o r o r f a c t o r s a t p r e d i c t i n g t h e outcome w i l l depend upon the propor t ion of "cor rec t" o r t r u e assoc ia t ions . An " idea l" r i s k f a c t o r , i f p r e sen t , would always be a s soc i a t ed with t h e unwanted outcome and i f ab sen t , never. However, dea th s from g a s t r o e n t e r i t i s sometimes occur among breas t fed i n f a n t s (though much l e s s commonly than among t he b o t t l e fed) and smoking and poverty do no t always p r e d i c t low bir thweight - and s o on. I n s h o r t , r i s k f a c t o r s a r e c l u e s , s i g n a l s and, a t b e s t , s t ep s i n a complex o f "causes". Fa l se pos i t i ve s and f a l s e nega t ives abound and may be s o frequent t h a t the p r a c t i c a l a spec t s of sc reen ing and d e l i v e r y of c a r e according t o r i s k become very d i f f i c u l t .

The b a s i s of the r i s k approach s t r a t e g y ( a t the i nd iv idua l l e v e l ) is the i d e n t i f i c a t i o n of i nd iv idua l s who a r e " a t r i sk " and t h e a l l o c a t i o n of g r e a t e r ca re t o them. But by i t s very na ture " r i sk" i s not a c lea r -cu t yes/no va r i ab l e . There a r e always degrees of r i s k and t h e l e v e l t h a t i s deemed t o warrant e x t r a c a r e i s a mat te r of choice. The more people a re included i n the r i s k group the fewer " f a l s e negat ives" bu t t h e more " f a l s e pos i t ives" t h e r e w i l l be. Fa l s e p o s i t i v e s overload the system and may cause inconvenience and even possibly harm t o i nd iv idua l s . Fa l s e nega t ives may e n t a i l t he unnecessary l o s s of l i f e . The dec i s i on on how much "r isk" warrants an i nd iv idua l being included i n the "a t r i s k " group i s thus c r u c i a l and involves a pay-off between t h e two types of mistake and t he resources ava i l ab l e .

When we pose the ques t i on of how many mare f a l s e p o s i t i v e s can be "afforded" by t h i s community f o r t h e de s i r ed reduc t ion i n undiagnosed need o r f a l s e nega t ives , t he answer w i l l depend, of course, upon a balance between the s e r i ousnes s of the undiagnosed need and t he poss ib le damage done by i n t e rven t i ons t o i nd iv idua l s no t a t r i s k and the unnecessary use of h e a l t h resources .

FHE/MCH/RA/84 .l Page 26

Sect ion 2 - 6 From r i s k d a t a t o i n t ervent ions

Summary

The r i s k approach can be used t o improve t h e h e a l t h of mothers and c h i l d r e n a t s e v e r a l l e v e l s both w i t h i n and o u t s i d e t h e h e a l t h c a r e system.

The use of informat ion der ived from examinat ion of r i s k can be used f o r h e a l t h educa t ion and t o improve personal and family h e a l t h ca re . Involvement of the community i n t h e knowledge of i n d i v i d u a l and group r i s k f a c t o r s should l ead t o increased awareness of h e a l t h problems and community a c t i o n programs. Within t h e h e a l t h c a r e s y s t e n , inc reased coverage should be followed by b e t t e r r e f e r r a l p r a c t i c e s t o i n c r e a s e congruence between needs and s k i l l s . Manipulation of r i s k f a c t o r s comes n e x t , both by t rea tment of i n d i v i d u a l s , change i n l i f e - s t y l e and improvement of the environnent . This w i l l r e q u i r e t h e changing of f a c i l i t i e s and s k i l l s t o meet t h e d i f f e r e n t needs both a t l o c a l l e v e l s and a t r e g i o n a l and n a t i o n a l l e v e l s .

The r i s k approach w i l l po in t t o the c o n t r i b u t i o n of o t h e r s e c t o r s t o h e a l t h and d i sease .

Up t o t h i s point the d e s c r i p t i o n of the r i s k approach has involved community d e c i s i o n s a s t o what a r e t h e p r i o r i t y problems t o be addressed i n the promotion of the h e a l t h of mothers and c h i l d r e n , the d e t e c t i o n of r i s k f a c t o r s and groups of r i s k f a c t o r s and t h e i r i n t e r r e l a t i o n s h i p s , t h e i r power a s p r e d i c t o r s and t h e c a l c u l a t i o n of the r e l a t i v e and a t t r i b u t a b l e r i s k s a s s o c i a t e d wi th them. Also known would be t h e incidence and perhaps prevalence of t h e unwanted outcomes and of t h e r i s k f a c t o r s and perhaps something of t h e i r inc idence and t rends over t ime.

Before t h e s e t o o l s of t h e r i s k approach can be used i n t h e improvement of t h e o r g a n i s a t ion of h e a l t h c a r e , p a r t i c u l a r l y a t the i n d i v i d u a l l e v e l , t h r e e a d d i t i o n a l t e c h n i c a l problems must be faced. A f i n a l s t e p w i l l be t o ask whether t h e l o c a l h e a l t h c a r e s y s t e n is a b l e t o support innova t ions of the kind proposed.

F i r s t , an answer must be found t o t h e ques t ion of how t o convert r i s k d a t a , and p a r t i c u l a r l y r e l a t i v e r i s k , i n t o simple measures which c a n be used a t the l e v e l of t h e c l i n i c and l o c a l h o s p i t a l . Th is i s u s u a l l y achieved by some form of scor ing.

The nex t t e c h n i c a l q u e s t i o n concerns cut-off p o i n t s f o r r i s k f a c t o r s . Th is p r e s e n t s no problem when t h e r i s k f a c t o r i s e i t h e r p r e s e n t o r a b s e n t , nor where t h e r e are such sharp changes of r e l a t i v e r i s k t h a t dichotomy i s r e l a t i v e l y obvious and easy. Where, however, t h e change i n r e l a t i v e r i s k i s g r a d u a l , t h e o f t e n opposing c o n s i d e r a t i o n s of "y ie ld" and of r e s o u r c e s t o d e a l with t h a t y i e l d impose c o n s t r a i n t s upon t h e r i s k approach ( t h e r e i s , f o r example, l i t t l e advantage i n a s t r a t e g y which c l a s s i f i e s 80% of wanen a s "very h igh r i s k " u n l e s s massive resources a r e a v a i l a b l e ) . F i n a l l y , t h e l a s t t e c h n i c a l problem i s t h a t of " t r a d e o f f s " i n sc reen ing f o r r i s k . By t h i s i s meant the o f t e n p a i n f u l d e c i s i o n s which t u r n upon f o r example, how many f a l s e ~ o s i t i v e s a r e t o be t o l e r a t e d i n o r d e r t o reduce t h e f a l s e n e g a t i v e s t o a c c e p t a b l e proport ions. Essent i a l l y t h i s i s the quest ion (mentioned above) of how many and what kind of "mistakes" can we accept i n prevent ive medicine and how a c c u r a t e we have t o be.

F H E / M C H / R A / ~ ~ . ~ Page 27

The h e a l t h c a r e system: how can i t be changed?

The community and i t s s e r v i c e s a r e a t t h i s point poised ( a s i t were) on the b r i n k of t r y i n g some new uses f o r a l l t h e inEormation about r i s k . There i s , however, one f i n a l quest ion which must be asked and t h a t i s whether t h e e x i s t i n g h e a l t h c a r e system can change enough t o accommodate t h e innovat ions which w i l l be proposed.

So many v a r i a t i o n s i n t h r o rgan isa t ion of h e a l t h c a r e e x i s t t h a t i t is l i k e l y t h a t not a l l could use t h e r i s k approach. Systems without a coord ina ted r e f e r r a l chain o r those r u n without r e g i o n a l o r o t h e r coord ina t ion a r e a t a p a r t i c u l a r disadvantage. P lans t o use t h e r i s k approach would, of c o u r s e , be f u l l y adapted t o l o c a l p a t t e r n s of c a r e , l o c a l v a l u e systems, l o c a l r e l i g i o n s and l o c a l methods of payment. But such a d a p t a t i o n has l i m i t s ( f o r example f i n a n c i a l o r o p e r a t i o n a l l h i t s ) beyond which accommodation i s impossible. Before planning t h e innovat ion i t i s t h e r e f o r e necessa ry t o d e s c r i b e i n some d e t a i l t h e ways i n which c a r e i s c u r r e n t l y d e l i v e r e d ( p a r t i c u l a r l y a s regards the " t a r g e t " outcomes) a s wel l a s the p o l i c i e s which e x i s t f o r t h e promotion and maintenance of h e a l t h . The main determinants ( l aws , customs, e t c . ) of these p a t t e r n s would a l s o be descr ibed. The purpose of t h e s e d e s c r i p t i o n s i s a t every s t a g e t o seek t o answer such q u e s t i o n s a s : "Is the h e a l t h c a r e system (and i t s a s s o c i a t e d laws, customs, e t c . ) capable of accommodating t h e r i s k approach i . e . can i t be changed enough?" O r , " Is it l i k e l y t h a t t h e a d d i t i o n of the r i s k approach w i l l h e l p ? " "Are the h e a l t h d a t a which a r e a v a i l a b l e good enough t o make t h e approach v i a b l e ? " "Is t h e r e s u f f i c i e n t l o c a l , r e g i o n a l and nat i o n a l support f o r t h e educa t iona l and t r a i n i n g programmes involved t o g i v e them a reasonable chance of success?" , and s o on.

The r i s k approach c a n be app l ied a t a l l Levels of c a r e from s e l f and home t o i n t e r s e c t o r a l ~ o l i c y . E igh t such uses of t h e r i s k approach s t r a t e g y of resource r e a l l o c a t i o n and c a r e i n p ropor t ion t o need a r e suggested ( s e e Table 2.6a). Each seems l i k e l y t o have a p o s i t i v e e f f e c t upon t h e h e a l t h c a r e of mothers and c h i l d r e n .

Table 2.6a

E igh t uses of t h e r i s k approach

.................................................................. I

l 1 , : 1. Self and family c a r e : Screening s e l f and family f o r r i s k , : 0 1 @ : family h e a l t h educa t ion I

1 : 2. Local community c a r e : Community development, l o c a l c a r e : : 3 . I n c r e a s i n g coverage : Risk sc reen ing increases coverage !

I : 4. Improving r e f e r r a l 1 Risk d a t a o r s c o r e s mean needs and : 1 : s k i l l s a r e b e t t e r m a t c h e d I

9 l a

: 5. Modifying r i s k f a c t o r s : T r e a t i n g high blood pressure or 1 I

t I 1 : d i a b e t e s , f o r example I l l I : 6. Local r e o r g a n i z a t i o n : Changing s k i l l s and f a c i l i t i e s I

I I I I and t r a i n i n g : t o match needs

I

: 7 . Regional and n a t i o n a l : Changing s k i l l s and f a c i l i t i e s l I

I l V r e o r g a n i z a t i o n and t o match needs e I 1 @ t r a i n i n g 9 I l 8 : 8. I n t e r s e c t o r a l p o l i c y : R e f l e c t s d i s t r i b u t i o n of need and : 0 : r i s k f a c t o r s such a s pover ty , 1

1 , I I : overcrowding and m a l n u t r i t i o n I , , 1

'-------------------.---------1-------------------------------------'

F H E / M C H / R A / ~ ~ -1 Page 28

Three of the i n t e r w n t ions proposed i n Table 2.6a a r e ou t s i de the formal hea l t h c a r e system - t h e f i r s t two a t the l e v e l of s e l f , family and community ca r e and the l a s t a t the most d i s t a n t l e v e l , t h a t of i n t e r s e c t o r a l pol icy. Between these t h r e e a r e f i v e suggested uses of t he r i s k approach wi th in the formal h e a l t h c a r e system ( i n increas ing coverage, improving r e f e r r a l p a t t e r n s and i n matching hea l t h p ro f e s s iona l s k i l l s and i nd iv idua l needs, i n the a t t a c k on r i s k f a c t o r s , and l o c a l , r eg iona l and na t i ona l reorgan iza t ion and t r a i n i n g ) .

These uses of t he r i s k d a t a , f o r purposes of i l l u s t r a t i o n , a r e t r e a t ed a s i f s epa r a t e each from the o the r . This would not be the case i n the " rea l" world, nor would t he " r e f e r r a l chain" be a s simple a s is suggested. I t is a l s o recognised t h a t hea l t h c a r e sy s t ans , where they e x i s t a t a l l a s organised sy s t ans , a re o f t e n chao t i c ; a mixture of good and bad c a r e , c o s t l y and f r e e c a r e and sometimes no ca r e a t a l l f o r t hose a t high r i s k and t oo much f o r the r e l a t i v e l y hea l thy . I t i s with t h i s kind of " r ea l l i f e " system t h a t t he r i s k approach i s concerned and i n which the following a p p l i c a t i o n s seem appropr ia te .

Appl ica t ions o u t s i d e t h e organised system of c a r e

Appl ica t ions of the r i s k approach (Table 2.6a) a r e l i k e l y t o be e a s i e r w i th in t h e organised system of c a r e than ou t s i de . However, most hea l t h behaviour, most e a r l y ca re of i l l n e s s and most prevent ive a c t i o n of a l l k inds take p lace i n the home o r l o c a l community before passing along t he r e f e r r a l cha in and i n t o t he organised system.

Se lf and family

S t r a t e g i e s which use the r i s k d a t a a t the l e v e l of s e l f and family care w i l l depend upon t r a n s l a t i n g and communicating t he t e chn i ca l information about r i s k and the a s soc i a t ed need for p revent ive a c t i o n i n a form which can be understood.

Apart from genera l s e n s i t i z a t i o n t o what i s important and what unimportant i n the maintenance of t h e i r h e a l t h , the use of r i s k d a t a a t s e l f and family l e v e l might be thought of a s having t h r e e overlapping ob j ec t i ve s :

F i r s t and most important would be a n improved a b i l i t y t o recognise h e a l t h p r i o r i t i e s and hea l t hy l i f e s t y l e s and behaviour s o t h a t , i n terms which t he family uses normally, a more r a t i o n a l approach t o s e l f and family care would r ep l ace i r r a t i o n a l i n t e r p r e t a t i o n s of r i s k s . This could l e a d , f o r example, t o a b e t t e r understanding of the b e n e f i t s of family planning o r of immunisation aga in s t t e t anus , and of t h e r i s k of no t doing s o , of n u t r i t i o n a l c a r e i n pregnancy o r the e a r l y r e cogn i t i on of r i s k f a c t o r s f o r i n f a n t g a s t r o e n t e r i t i s . Recognition of r e a l i s t i c p r i o r i t i e s i n family h e a l t h would f o s t e r g r e a t e r a t t e n t i o n t o p revent ive r a t h e r than cu ra t i ve care .

The e a r l y r e cogn i t i on of r i s k f a c t o r s does no t nece s sa r i l y imply a n anxious preoccupat ion with i l l n e s s but r a t h e r t he gradual s o p h i s t i c a t ion of s e l f and family care s o t h a t , wi th in the family group, r i s k s i t u a t i o n s a r e recognised e a r l y and a t tended t o before o t h e r s of l e s s importance.

Increas ing ly informed and respons ib le h e a l t h management of the family would involve e a r l y recogni t ion of danger s i g n a l s , s e l e c t i v e r e f e r r a l , and a more c r i t i c a l a p p r a i s a l of f a c i l i t i e s .

FHE/MCH/RA/EG.~ Page 29

Appl ica t ions of t he r i s k approach a t t h i s l e v e l would seek t o spread new informat ion about the na ture and ex ten t of the r e l a t ionships which e x i s t between environment and family h e a l t h and between behaviour and family hea l t h . Properly i n t e r p r e t e d r i s k d a t a could become a v e h i c l e f o r the demonstrat ion of cause and e f f e c t i n t he development of d i s ea se and he lp t o develop i n t e rven t i ons appropr ia te t o the l o c a l s i t u a t i o n . T t would a l s o seek t o f o s t e r community a c t i o n i n the c o n t r o l of r i s k f a c t o r s i n accordance with t h e i r importance f o r family and community hea l t h .

Appl ica t ions w i th in the organized sy s t an of ca re

The r i s k approach has been t he sub j ec t of research mainly a t t he l o c a l level where r e f e r r a l sy s t ans , scor ing and medical i n t e rven t ions t o modify r i s k f a c t o r s a r e , i n maternal and c h i l d h e a l t h a t l e a s t , reasonably wel l known and where l o c a l resources can usua l ly be r ea l l oca t ed . However, a s cons ide r a t i on of how the r i s k approach might be used passes from the i nd iv idua l s i n t h e i r homes and v i l l a g e c l i n i c s t o pos s ib l e a s s i s t a n c e i n the r eo rgan i za t i on of h e a l t h s e rv i ce s , the i s s u e s become more complex. The information needed changes from f ami l i a r medical records and r e l a t i v e r i s k s t o c o s t s , b e n e f i t s , a t t r i b u t a b l e r i s k s and p o l i t i c a l concerns.

Increas ing coverage

The va lue of the r i s k approach i n increas ing coverage is discussed s epa ra t e ly because i n a l l t h e primary h e a l t h c a r e l i t e r a t u r e improvements i n coverage - t h a t i s , increas ing the number of persons who rece ive care of any kind i s r i g h t l y given g r e a t prominence: Heal th f o r a l l r equ i r e s access t o h e a l t h c a r e f o r a l l .

Of a l l the f a c t o r s which i n f l uence coverage, t h r e e have rece ived pa r t i cu l a r a t t e n t i o n and a l l may be a f f ec t ed by the r i s k approach. A v a i l a b i l i t y , access and what has been c a l l e d " threshold" and a c c e p t a b i l i t y a r e important determinants of bo th formal and informal ca re .

Increas ing the a v a i l a b i l i t y ( o r t he ex i s t ence ) of app rop r i a t e ca re i s a n o b j e c t i v e of t h e r i s k approach which, i n theory a t l e a s t , o f f e r s a method f o r r e a l l o c a t i n g r e sources accord ing t o need, and t hus should increase coverage. The s t ep s involved a r e , f i r s t , a saving of resources formerly expended upon those a t low r i s k and t h e i r t r a n s f e r so t h a t they become a v a i l a b l e t o those i n g r e a t e r need - among whom would be some of those no t "covered" by formal o r informal h e a l t h c a r e . I n r e a l i t y , i t is doubt fu l i f t h i s r e a l l o c a t i o n could immediately take p lace s o a s t o r e f l e c t t h e need and i nc r ea se coverage; when i t does i t i s l i k e l y t o be most e f f e c t i v e i n c l i n i c s and h o s p i t a l s . The sc reen ing of the populat ion f o r r i s k and t he c a r e of those found t o be i n need of i t would, i n i t i a l l y a t l e a s t , use more resources , pa r t i cu l a r l y community resources newly mobil ised, the o v e r a l l a v a i l a b i l i t y of c a r e being cons iderab ly increased. L a t e r , when the p r i n c i p l e was understood and appl ied , new resources would be gradual ly and i nc r ea s ing ly a l l o c a t e d according t o need.

Access t o the care made a v a i l a b l e would be improved f o r the same reasons a s a v a i l a b i l i t y was improved and a l s o because t he r i s k approach seeks ou t those a t r i s k r a t h e r than wai t ing fo r them t o apply t o the s e r v i c e s f o r he lp . Persons with understanding of t h e r i s k f a c t o r s i n family hea l t h w i l l respond e a r l i e r and more r e a d i l y , recognis ing the need f o r c a r e ( fo rmal , informal and s e l f c a r e ) when appropr ia te . They w i l l probably seek hea l t h c a r e when needed. In some f ami l i e s , the need fo r h e a l t h c a r e i s not recognised. The reasons f o r t h i s l ack of recogni t ion of need a r e poorly understood and a r e of course , d i f f i c u l t t o s epa ra t e from a r e luc t ance t o use s e rv i ce s .

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The e f f e c t on community h e a l t h of such an i n c r e a s e i n coverage could w e l l be a d i s p r o p o r t i o n a t e improvement. Th is is because t h e r e i s a marked excess of high r i s k persons always t o be found among those who h i t h e r t o have not sought c a r e a t a l l . For t h e f i r s t t ime some of t h i s hidden need w i l l be met.

Improving r e f e r r a l

By "improving r e f e r r a l " i s meant t h a t the movement of i n d i v i d u a l s along the r e f e r r a l c h a i n i s f a c i l i t a t e d s o t h a t a l l people reach t h e l e v e l and kind of c a r e which t h e y need. I t i s t o be hoped t h a t t h e r e i s , a t the same time, g r e a t e r coverage s o t h a t more of t h e p e o p l e ' s "needs" a r e met by community and h e a l t h s e r v i c e s k i l l s which a r e appropr ia te . The f i r s t o b j e c t i v e is t o achieve the "best f i t " i n t h e e x i s t i n g r e f e r r a l cha in without a l t e r i n g t h e cha in i t s l f , thus ensur ing t h a t people a r e r e f e r r e d t o t h e b e s t a v a i l a b l e s k i l l s , f a c i l i t i e s , e t c . according t o t h e i r needs.

A score based upon the r e l a t i v e r i s k i s o f t e n used t o improve r e f e r r a l . I t i s an e f f e c t i v e , i f c r u d e , i n d i c a t o r of t h e urgency and s e r i o u s n e s s of i n d i v i d u a l need. Such a r i s k score i s , l i k e the r e l a t i v e r i s k i t s e l f , only a proxy f o r need; i t w i l l subsequent ly be necessa ry t o examine i n d e t a i l t h e n a t u r e of the need, t h e r i s k f a c t o r s involved and the f a c i l i t i e s and s k i l l s a v a i l a b l e and needed. I n t h i s way t h e o b j e c t of t h i s p a r t of t h e r i s k approach s t r a t e g y , a matching of need and s k i l l may even tua l ly be achieved. I n such a sys tan , mothers with the same r i s k of a de f ined outcome w i l l be r e f e r r e d t o t h e same i n s t i t u t i o n with t h e same f a c i l i t i e s , t echnolog ies and s k i l l s on the r e f e r r a l chain. T h i s does not mean t h a t a l l t h e i r needs w i l l be e x a c t l y t h e same bu t they w i l l f a l l w i t h i n t h e same broad group and, i d e a l l y , the i n s t i t u t i o n o r c l i n i c w i l l have the c a p a c i t y , s k i l l s a d technology necessa ry t o meet them.

Modifying r i s k f a c t o r s

I n t e r v e n t i o n i n t h e causes of i l l n e s s by v a c c i n a t i o n , h e a l t h educa t ion , t reatment of i n t e r c u r r e n t i l l n e s s i n pregnancy o r by family planning have always been among the c l a s s i c a l p reven t ive approaches i n maternal and c h i l d h e a l t h . Risk d a t a add t o t h e va lue of t h e s e i n t e r v e n t i o n s by g i v i n g a ~ r i o r i t y t o r i s k f a c t o r s a t the i n d i v i d u a l l e v e l . The a t t r i b u t a b l e r i s k sugges t s how t h e community would b e n e f i t i f t h e r i s k f a c t o r s were removed.

Examples of r i s k f a c t o r s which can be l o c a l l y and d i r e c t l y modified inc lude b o t t l e - f e e d i n g , i n f e c t e d w a t e r , c e r t a i n kinds of m a l n u t r i t i o n , dehydra t ion and o t h e r p recursors of severe d i s e a s e , h igh p a r i t y , s h o r t b i r t h i n t e r v a l and pregnancy a t the extremes of reproduc t ive l i f e . Heal th workers can be t r a i n e d t o monitor and t o in te rvene when such r i s k f a c t o r s a r e p r e s e n t .

Appl ica t ions a t r e g i o n a l and n a t i o n a l l e v e l

The value of r i s k d a t a i n r e g i o n a l and n a t i o n a l planning must depend upon how w e l l they can supplement in format ion which comes from o t h e r , more r o u t i n e sources . These a r e usua l ly v i t a l s t a t i s t i c a l d a t a , i n s t i t u t i o n a l a d s e r v i c e d a t a , and d a t a about t h e use of h e a l t h c a r e . I t i s u n l i k e l y t h a t such d a t a w i l l be adequate. However, a d d i t i o n a l sample popula t ion d a t a of some kind could probably be ob ta ined and t h e r e may a l s o be some census m a t e r i a l from which denominators Eor v i t a l r a t e s may be der ived.

FHEIMCHIRAI84.1 Page 31

A t t h e i n t e r s e c t o r a l l e v e l

Because of the independent ways i n which the execu t ive arms - u s u a l l y m i n i s t r i e s - of c o u n t r i e s f u n c t i o n , t h e c o l l a b o r a t i o n of one s e c t o r with ano ther i n j o i n t e n t e r p r i s e s r e l a t e d t o h e a l t h i s r a r e . Thus the h e a l t h m i n i s t r y r a r e l y c o l l a b o r a t e s with , s a y , a g r i c u l t u r e i n o rder t o i n c r e a s e t h e product ion of a s p e c i f i c item of food and t h u s promote h e a l t h . Transport and telecommunications which a l s o c o n t r i b u t e t o t h e h e a l t h s e r v i c e s a r e , l i k e educa t ion f o r l i t e r a c y , r a r e l y thought of a s a s s i s t i n g i n h e a l t h promotion p a r t i c u l a r l y of t h e young family. Yet i n each of t h e s e examples t h e i n t e r s e c t o r a l e f f e c t s on h e a l t h a r e massive. They suggest t h a t more informat ion about t h e e x t e n t of t h e s e e f f e c t s should be of i n t e r e s t t o t h e m i n i s t r i e s concerned and t h a t they might even s t i m u l a t e c o l l a b o r a t i o n by showing the e f f e c t of one upon the o ther . The shar ing and j o i n t e x p l o i t a t i o n of r i s k d a t a by d i f f e r e n t m i n i s t r i e s even i f they d id no t immediately se rve t h e s e ends should be a p r e r e q u i s i t e t o c o l l a b o r a t i o n . The use of r i s k d a t a by a number of m i n i s t r i e s ( a t n a t i o n a l l e v e l ) o r execu t ive branches of government ( a t r e g i o n a l l e v e l ) o f f e r s o p p o r t u n i t i e s f o r c o l l a b o r a t i o n which have no t h i t h e r t o been a v a i l a b l e . The d a t a o f f e r e d must however, provoke t h i s c o l l a b o r a t i o n , i . e . they must show c l e a r l y t o " a g r i c u l t u r e " o r " t ranspor t " the b e n e f i c i a l e f f e c t s of t h e i r a c t i o n s on t h e h e a l t h of mothers and c h i l d r e n . Meanwhile t h e complex p o l i t i c s of c o l l a b o r a t i o n must not be fo rgo t ten .

I n t e r s e c t o r a l c o l l a b o r a t i o n i n , s a y , the r e d u c t i o n of maternal m o r t a l i t y , o r childhood d e a t h from a c c i d e n t s w i l l l e a n h e a v i l y upon t h e v i t a l s t a t i s t i c s a v a i l a b l e a s w e l l a s the r i s k f a c t o r s involved. I n each example r i s k d a t a w i l l g ive f u r t h e r exp lana t ions of t h e p rocesses concerned and w i l l i l l u m i n a t e "causes" by d e s c r i p t i o n s of r i s k f a c t o r s and measures of r e l a t i v e r i s k s . A t t r i b u t a b l e r i s k s m a y se rve c o l l a b o r a t i v e s o c i a l po l icy development by i n d i c a t i n g ( f o r t h e f i r s t time i n many c a s e s ) t h e l i k e l y e f f e c t s on mate rna l m o r t a l i t y o f , f o r example, a r e d u c t i o n i n i l l i t e r a c y , t h e p rov is ion of t r a n s p o r t o r a reduc t ion i n n u t r i t i o n a l anaemia. Risk f a c t o r a n a l y s i s of maternal m a l n u t r i t i o n might thus l ead t o a r e v i s i o n of a g r i c u l t u r a l p r i o r i t i e s . For chi ldhood d e a t h s from a c c i d e n t s t h e c o n t r i b u t i o n s of l a r g e f a m i l i e s , crowding, pover ty , lack of play f a c i l i t i e s o r t r a n s p o r t r e g u l a t i o n s could be given numerical weights upon which t o base cho ices i n p o l i c y development.

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I

Exerc i s e 2 . 6

2 .6 .1 Based on your understanding of the r i s k concept, g ive one example of how you think the r i s k approach could be used for MCHIFP care i n your own country s e t t i n g for each of the 8 areas out l ined i n Table 2 .6a.

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Chapter 3

Health systems research

FHE/McH/RA/84.1 Page 34

Slnnmary

Primary Health Care (PHC) is the approach which countr ies have agreed t o use i n heal th development. Health Systems Research (HSR) i s an important tool i n t h i s development. HSR should aim t o produce r e l i a b l e information quickly and re l a t ive ly inexpensively while maintaining s c i e n t i f i c standards. The r e s u l t s of HSR should d i r e c t l y influence p o l i t i c a l , managerial and technical dec ision-making and must, therefore, be both responsive t o the needs of the community and r e a l i s t i c . Thus the community and health workers should be involved i n the research. Their par t ic ipat ion should be prepared and organized - i t does not happen spontaneously.

The ways i n which studies on the r i sk approach a r e carr ied out w i l l vary from place t o place, depending on loca l problems, objec t ives , and resources avai lable both for services and research. But the main stages of the study a r e s imi lar everywhere.

Obj ec t ive S

After studying t h i s chapter you should be able to:

- explain the r o l e of s tudies on the r i s k approach i n MCH/FP care in the context of a c t i v i t i e s leading towards "health for a l l by the year 2000";

- list the main steps i n organizing community and s t a f f part ic ipa t ion in r e search;

- l ist the main phases of a r i s k study, estimate resource needs and s t a t e the main pr incip les of applying for a research grant.

F H E / M c H / R A / ~ ~ . ~ Page 35

CHAPTER 3: HEALTH SYSTEMS RESEARCH

Section 3.1 Primary health care, MCH/FP and health systems research

Section 3.2 Community and s ta f f participation

Section 3.3 The main steps in a risk study

Section 3.4 The research proposal and re source needs

FHE/MCH/RA/84.1 Page 36

S e c t i o n 3.1 Primary h e a l t h c a r e , McH/FP and h e a l t h systems r e s e a r c h

Summary

Primary Health Care i s THE approach t o t h e development of h e a l t h c a r e fo r a l l c o u n t r i e s . MCH/FP i s one of i t s e i g h t e s s e n t i a l elements. Health Systems Research i s no t academic research bu t p a r t of the development and management of h e a l t h c a r e . I t i s research aimed d i r e c t l y a t producing progress a d change. S c i e n t i f i c and purely "academic" c o n s i d e r a t i o n s , t h e r e f o r e , have t o be weighed a g a i n s t o t h e r elements such a s t ime, money, t h e ~ o l i t i c a l s e t t i n g and t h e f e a s i b i l i t y of applying the f ind ings .

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The I n t e r n a t i o n a l Conference on Primary Heal th Care. Alma-Ata, USSR, 6-12 September 1978, agreed t h a t Primary Health Care i s THE approach which c o u n t r i e s of the world should adopt t o reach the goal of "Health f o r A l l by t h e Year 2000". The r e p o r t of the Alma-Ata Conference* o u t l i n e s what i s meant by Primary Heal th Care:

Primary Health Care is essential health care made univer- sally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country's health system of which it is the nucleus and of the overall social and econ- omic development of the community.

Primary Health Care addresses the main health problems in the community, providing promotive, preventive, curative and rehabili- tative services accordingly, Since these services reflect and evolve from the economic conditions and social values of the country and its communities, they will vary by country and community, but will in- clude at least: promotion of proper nutrition and an adequate supply of safe water; basic sanitation; maternal and child care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; education con- cerning prevailing health problems and the methods of preventing and controlling them; and appropriate treatment for common diseases and injuries.

" WHO and UNICEF. Primary h e a l t h ca re : a j o i n t r e p o r t . Geneva and New York, WHO, 1978 , p. 2 .

F H E / M C H / R A / ~ ~ - 1 Page 38

In order to make Primary Health Care universally accessible in the community as quickly as possible, maximum community and indi- vidual self-reliance for health development are essential. To attain such self-reliance requires full community participation in the planning, organization and management of Primary Health Care. Such partici- pation is best mobilized through appropriate education which enables communities to deal with their real health problems in the most suit- able ways. They will thus be in a better position to take rational decisions concerning Primary Health Care and to make sure that the. right kind of support is provided by the other levels of the national health system. These other levels have to be organized and strengthened so as to support Primary Health Care with technical knowledge, training, guidance and supervision, logistic support, sup- plies, information, financing and referral facilities including insti- tutions to which unsolved problems and individual patients can be referred.

Primary Health Care is likely to be most effective if it employs means that are understood and accepted by the community and applied by community health workers at a cost the community and the country can afford. These community health workers, including traditional practitioners where applicable, will function best if they reside in the community they serve and are properly trained socially and technically to respond to its expressed health needs.

Since Primary Health Care is an integral part both of the country's health system and of overall economic and social development, without which it is bound to fail, it has to be coordinated on a national basis with the other levels of the health system as well as with the other sectors that contribute to a country's total development strategy.

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The acceptance of Primary Health Care (PHc) a s THE approach t o reach "hea l th f o r a l l by the year 2000" ha s g r ea t impl ica t ions fo r the way i n which MCH/FP programmes a r e organized and implemented. The o ld approach, which concentrated on spec i a l i z ed MCH c e n t r e s and standard r o u t i n e s and technologies i s g radua l ly becoming a more problem-solving o r i en t ed approach based on t he p r i n c i p l e s of PHC. l

Health Systems Research

Health Systems Research (HSR) is recognized a s an essen t i a l t o o l i n developing Primary Health Care. For t h e purposes of t h i s book,

"Health systems research i s the sys temat ic s tudy of the means by which ba s i c medical and o t h e r r e l evan t knowledge is brought t o bear o n the hea l t h of i nd iv idua l s and communities under a given s e t of conditions".

HSR i s a c t i o n research using s c i e n t i f i c methods t o provide informat ion and i n s i g h t s which w i l l :

- make pos s ib l e the improved understanding of h e a l t h problems and the r o l e and i n f l uence of h e a l t h c a r e ;

- a s s i s t i n more r a t i o n a l h e a l t h planning;

- r e s u l t i n more e f f e c t i v e and e f f i c i e n t h e a l t h c a r e which a t t he same time is b e t t e r adapted t o the c u l t u r a l and emotional needs of people;

- encourage g r e a t e r persona l , family and community s e l f - r e l i a n c e i n hea l t h mat te r s by a c t i v e l y involving people i n the s tudy of t h e i r own problems.

HSR has wide scope and involves hea l t h workers and s c i e n t i s t s from many d i s c i p l i n e s . Health systems research p ro j ec t s may range i n s i z e from major mu l t i na t i ona l c o l l a b o r a t i v e s t u d i e s concerned, f o r i n s t ance , with t h e f inanc ing of hea l t h s e r v i c e s t o small s t u d i e s involving one or two workers i n a v i l l a g e o r a n urban neighbourhood.

Addit ional information on t h i s sub i ec t i s contained in : WHO Technical <

Report S e r i e s , No. 600, 1976 ( ~ e w t r ends and approaches i n t he de l i ve ry of maternal and c h i l d ca re i n hea l t h s e rv i ce s ) .

FHE/MCH/ RA/84.1 Page 40

HSR i s u s u a l l y concerned wi th a given c u l t u r e i n a p a r t i c u l a r s e t t i n g and hence, a l though methods may be g e n e r a l l y u s e f u l , the r e s u l t s have low t r a n s f e r a b i l i t y . The concep t u a l i z a t ion and fo rmula t ion of the problems addressed w i l l emerge from wi th in each count ry and cannot be imposed from o u t s i d e . The time element i n HSR i s c r u c i a l because the r e s u l t s must be a v a i l a b l e when they a r e needed; hence, unconventional approaches have t o be developed. Crude approximations provided promptly and s t a t e d i n broad terms may have a g r e a t e r va lue than r e f i n e d and a c c u r a t e r e s u l t s which, because they can only be produced s lowly, may become a v a i l a b l e t o o l a t e . While t h i s i s a v a l i d way t o proceed i f the informat ion i s needed q u i c k l y , i t must be remembered t h a t by s a c r i f i c i n g " s c i e n t i f i c s tandards" one i s i n c r e a s i n g the chances of making wrong d e c i s i o n s . S c i e n t i f i c s t andards a r e s e t f o r t h e purpose of ensur ing t h a t t h e conc lus ions drawn a r e c o r r e c t . The s t r i c t e r t h e s t a n d a r d s , the more complex, c o s t l y and time-consuming t h e research u s u a l l y is. (HSR i s sometimes considered " u n s c i e n t i f i c " o r "unacademic" s i n c e i t "cuts corners" on convent iona l r e s e a r c h pr inc i p l e s . ) However, maintaining a l l s c i e n t i f i c s t andards w i l l o f t e n r e s u l t i n s t u d i e s t h a t may be impossible t o c a r r y out because they a r e t o o expensive and time-consuming. The cha l lenge of HSR i s t o s t r i k e a ba lance between s c i e n t i f i c r i g o u r and p r a c t i c a l requirement S.

The main po in t is t h a t HSR should produce r e l i a b l e in format ion on p e r t i n e n t problems and t h u s i n f l u e n c e p o l i t i c a l and managerial d e c i s i o n s which w i l l improve the coverage and q u a l i t y of h e a l t h ca re .

HSR i s a powerful t o o l which could change the p o l i t i c a l d e s i r e f o r primary h e a l t h c a r e t h a t a l r e a d y e x i s t s i n many c o u n t r i e s i n t o t h e p o l i t i c a l w i l l and o p e r a t i o n a l 'know-how' needed t o p rov ide it. The u l t h a t e success of HSR must be measured both i n terms of improvements i n h e a l t h s e r v i c e s and i n t h e h e a l t h of t h e populat ion.

E t h i c a l c o n s i d e r a t ions

E t h i c a l c o n s i d e r a t i o n s a r e a s important i n h e a l t h s e r v i c e s r e s e a r c h a s i n biomedical research . E t h i c a l i s s u e s must be considered when t h e s tudy pro toco l i s developed and the s tudy implenented. I f we s i n c e r e l y be l ieve t h a t the r i s k approach w i l l h e l p t o c o n t r o l t o p p r i o r i t y MCH problems i t might be argued t h a t research is then u n e t h i c a l and was te fu l . Th is i s p r e c i s e l y the s i t u a t i o n of t h e t h e r a p i s t who b e l i e v e s t h a t t h e drug he is asked t o t e s t i s i n f a c t t h e drug of cho ice . He would then have no e t h i c a l r i g h t t o u rder take a c o n t r o l l e d c l i n i c a l t r i a l . I t i s e s s e n t i a l t h a t t h i s i s s u e be faced a t t h e o u t s e t . However, most h e a l t h c a r e programmes a r e not based on any research i n the l o c a l s e t t i n g . They a r e f requen t ly a mere a p p l i c a t i o n of what "seems t o have worked" somewhere e l s e , with l i t t l e o r no sc i en t if i c e v a l u a t i o n of the r e s u l t s . The a p p l i c a t i o n of new o r modif ied s t r a t e g i e s without research could t h u s be considered more u n e t h i c a l than t e s t i n g them through a r e search process .

Serv ice research h a s ano ther e t h i c a l aspect : r esources a r e f requen t ly provided dur ing an exper imental a p p l i c a t i o n of a new s t r a t e g y . I t would be u n e t h i c a l t o withdraw such s e r v i c e r e s o u r c e s from the s t u d y a r e a s when the research i s completed. Th is impl ies t h a t t h e resources put i n t o the s e r v i c e a s p e c t dur ing t h e s tudy should n o t be g r e a t e r t h a n can be s u s t a i n e d a f t e r the research h a s been completed. Another i m p l i c a t i o n i s t h a t a c l e a r d i s t i n c t i o n should be made between the resources used fo r providing c a r e and those needed t o c a r r y o u t the research . The problem becomes unsolvable when, f o r example, t h e research s t a f f provides c a r e a t the same t h e . By withdrawing the research s t a f f , t h e care p rov is ion would thus s top .

Problems i n t h i s a r e a should be reso lved before the s tudy s t a r t s .

F H E / M C H / R A / ~ ~ . ~ Page 41

Exerc i ses 3.1

3.1.1 The Primary Heal th Care approach h a s i m p l i c a t i o n s f o r t h e way MCH/FP c a r e is organized.

L i s t 3 changes which would have t o be made t o a MCH/FP s t r a t e g y t h a t you know w e l l s o t h a t i t fo l lows the p r i n c i p l e s of primary h e a l t h c a r e .

3.1.2 Some very "basic" ques t ions must be d i scussed p r i o r t o t h e launching of a r e s e a r c h p r o j e c t . These concern items such a s t h e appropr ia teness of the r e s e a r c h , t h e use of s k i l l s a s wel l a s r e s o u r c e s , and t h e s tandards t h a t can be maintained. The p h i l o s o p h i c a l o r t h e o r e t i c a l b a s i s of t h e proposed research should be d i scussed p r i o r t o launching t h e p r o j e c t .

Discuss t h e fol lowing q u e s t i o n s i n your group:

a ) How can h e a l t h systems research he lp us s o l v e our MCH/FP problems?

b ) What i s meant when i t i s s a i d t h a t research i s " too academic"?

c ) What do we mean by " s c i e n t i f i c s t andards" i n h e a l t h s e r v i c e s research?

d ) Is i t p o s s i b l e , o r a d v i s a b l e , t o "re lax" t h e s e s c i e n t i f i c s t andards?

What a r e we los ing i n r e l a x i n g t h e s e s t a n d a r d s ?

e ) I f we a r e forced by ci rcumstances t o r e l a x s tandards of s c i e n t i f i c accuracy, would i t be b e t t e r not t o do t h e research a t a l l ?

3.1.3 E t h i c a l a s p e c t s a r e a s important i n h e a l t h systems research a s i n biomedical r e s e a r c h . The argument is sometimes heard t h a t t h e r i s k approach t o resource a l l o c a t i o n i s t h e b e s t approach, and t h a t we do not have any r i g h t t o experiment.

What arguments would you use t o defend a research proposa l on t h e r i s k approach i n MCH/FP c a r e ?

3.1.4 I n one count ry , t h e s tudy design proposed t o d i v i d e pregnant women i n t o "high r i s k " and "low r i s k " groups. I n t h e s tudy a r e a s s p e c i a l a t t e n t i o n would he given t o the i n d i v i d u a l s i n t h e "high r i s k " group. I n t h e c o n t r o l a r e a s no s p e c i a l c a r e would be provided t o t h e "high r i s k " group.

The nurses and d o c t o r s i n t h e c o n t r o l a r e a s s a i d t h a t i t would be u n e t h i c a l not t o g ive s p e c i a l c a r e t o a wanan c l a s s i f i e d a s "high r i sk" . They, t h e r e f o r e , r e fused t o p a r t i c i p a t e i n t h e s tudy.

I n your op in ion , were they r i g h t ? Explain your answer.

FHE/MCH/RA/84.1 Page 42

Sec t ion 3.2 Canmunity and s t a f f p a r t i c i p a t i o n

Summary

HSR is an instrument of change. I t must be responsive t o the needs of the connnuni t y and r e a l i s t i c i n terms of t he f e a s i b i l i t y of app l i c a t i on of its f ind ings . The community, a s we l l a s h e a l t h a d hea l t h - r e l a t ed workers must p a r t i c i p a t e i n t he research. '

Canmunity and s t a f f p a r t i c i p a t i o n does no t "happen". I t should be promoted and programmed. This r equ i r e s t a c t , understanding, a d the w i l l i ngnes s t o share r e s p o n s i b i l i t i e s and decision-making on the p a r t of t he r e search organ izers .

Addit ional informat ion on community pa r t i c i p a t ion is contained in: WHO a d . . UNICEF. Cormnunitv involvement i n ~ r i m a r v hea l t h care: a study of the Drocess of

F H E / M C H / R A / ~ ~ . ~ Page 43

Alma Ata and community involvement

The participation of the community i n the development and management of health care (and, therefore, presumably i n research aimed a t i t s improvement) i s one of the p i l l a r s of Primary Health Care:

43. Self-reliance and social awareness are key factors in human development. Community participation in deciding on policies and in planning, implementing and controlling development programmes is now a widely accepted practice. However, it is understood and interpreted in different ways in different countries, being greatly influenced by the overall political structure and the social and economic situation. The case studies on community participation conducted by the UNICEF/ WHO Joint Committee on Health Policy have helped to draw attention to and clarify the role of community participation in primary health care.

44. Community participation is the process by which individuals and families assume responsibility for their own health and welfare and for those of the community, and develop the capacity to contribute to their and the community's development. They come to know their own situation better and are motivated to solve their common prob- lems. This enables them to become agents of their own development instead of passive beneficiaries of development aid. They therefore need to realize that they are not obliged to accept conventional sol- utions that are unsuitable but can improvise and innovate to find sol- utions that are suitable. They have to acquire the capacity to appraise a situation, weigh the various possibilities and estimate what their own contribution can be. While the community must be willing to learn, the health system is responsible for explaining and advising, and for providing clear information about the favourable and adverse conse- quences of the interventions being proposed, as well as their relative costs.

FHE/MCH/RA/S4. I Page 44

Communi t y invo lvement

Research on the r i s k approach, l i k e a l l h e a l t h systems r e s e a r c h , r e l i e s heav i ly on t h e c o l l a b o r a t i o n of t h e community. For example, t h e community may be involved by asking f o r t h e i r :

- agreement t o submit t o research q u e s t i o n i n g ;

- p a r t i c i p a t i o n i n development of t h e r i s k s t r a t e g y ;

- agreement t o t e s t new approaches i n MCH/FP c a r e and t o support the even tua l implementation of t h e new s t r a t e g y ;

- p a r t i c i p a t i o n i n the e v a l u a t i o n s tudy (such a s s e l e c t i n g the e v a l u a t i o n i n d i c a t o r s , and performing t h e f i n a l e v a l u a t i o n ) ; and

- d e c i s i o n upon t h e top p r i o r i t y h e a l t h problem t o be a t t a c k e d - t h e so-ca l led t a r g e t h e a l t h problem.

A f i r s t s t e p i n e n l i s t i n g community p a r t i c i p a t i o n is t o make a b r i e f d e s c r i p t i v e a n a l y s i s of t h e community. Some of t h e i tems t o be considered a r e :

1. The formal o r g a n i z a t i o n s r e p r e s e n t i n g groups of people , e.g. wanen's c l u b s , community development a s s o c i a t i o n s , e l e c t e d ~ o l i t i c a l bod ies , t r a d e s unions, coopera t ive groups, v i l l a g e c o u n c i l s , r e l i g i o u s groups;

2 . The informal groups o r important i n d i v i d u a l s , p o l i t i c a 1, s o c i a l and r e l i g i o u s l e a d e r s , t r a d i t i o n a l b i r t h a t t e n d a n t s , t r a d i t i o n a l h e a l e r s , "opinion leaders" , " t rend s e t t e r s " ; and

3. The i n t e r e s t s , a t t i t u d e s and concerns of groups and key i n d i v i d u a l s .

For each of t h e important groups and i n d i v i d u a l s , a s h o r t ' ' p ro f i l e" of i n t e r e s t s , a t t i t u d e s and concerns should be prepared. I t i s no t , of course , proposed t h a t a formal " r e g i s t e r t ' of t h e s e p r o f i l e s be e s t a b l i s h e d , bu t t h e research group should d i s c u s s them. This w i l l f a c i l i t a t e c o n t a c t and c o l l a b o r a t i o n , and give an i n d i c a t i o n of t h e type and degree of ~ a r t i c i p a t i o n ( o r r e s i s t a n c e ) which could be ob ta ined or should be expected.

P l a n f o r f i r s t c o n t a c t s

The research group should prepare a b r i e f p l a n of a c t i o n f o r c o n t a c t s wi th the community. For example:

- Who should be con tac ted?

- How should they be con tac ted : p e r s o n a l l y , by l e t t e r , mee t ing , household v i s i t ?

- Who from the research group should d e a l with t h e c o n t a c t ?

- Which s p e c i f i c i s s u e s should be p resen ted on t h i s f i r s t c o n t a c t ?

I n some communities, c e r t a i n groups might o f f e r l e a d e r s h i p i n the o r g a n i z a t i o n of community p a r t i c i p a t i o n . I t i s more l i k e l y , however, t h a t t h e research group w i l l have t o take the i n i t i a t i v e .

FHE/MCH/RA/84.1 Page 45

S t a f f p a r t i c i p a t i o n

HSR i s f requen t ly e v a l u a t i v e i n na ture and may understandably meet r e s i s t a n c e from government o f f i c i a l s , managers and h e a l t h workers; y e t u n l e s s i t i n f l u e n c e s p o l i c y and p r a c t i c e i t is wor th less . Therefore , every e f f o r t should be made t o i n t e r e s t and educa te decis ion-makers , i n government and t h e community a l i k e , i n t h e importance of HSR and, i f p o s s i b l e , t o involve them i n t h e research .

The l o c a l h e a l t h workers , a s w e l l a s s t a f f from o t h e r s e c t o r s and t r a d i t i o n a l h e a l t h workers and t h e i r r e p r e s e n t a t i v e o r g a n i z a t i o n s , should, of course , be involved from t h e very heginning of t h e research .

A s tudy of the h e a l t h c a r e system is f r e q u e n t l y (and with reason) seen a s a t h r e a t by t h e h e a l t h s t a f f , whose h o s t i l i t y can be expressed through open animosi ty and dec la red non-col laborat ion, o r a grudging acceptance with h a l f - h e a r t e d and p a r t i a l c o l l a b o r a t ion.

I t i s only n a t u r a l t h a t s t a f f should f e e l th rea tened . The research group should unders tand and sympathize w i t h t h i s . The o n l y way t o overcome r e s i s t a n c e is through f r a n k d i s c u s s i o n , f u l l informat ion and, of course , c o l l a b o r a t i o n i n d e c i s i o n making.

"No r e s e a r c h e r should f o o l himself i n t o th ink ing t h a t h e a l t h s e r v i c e research can be c a r r i e d ou t wi thout s t a f f and popular consent ."

FHE/MCH/RA/84 .l Page 46

Exerc i ses 3 .2

For the f i r s t t h e i n t h i s workbook you a r e dea l ing with a count ry which i s c a l l e d F i c t i t i a . La t e r i n t h i s workbook you w i l l l e a r n more about F i c t i t i a . For t h i s exe r c i s e , imagine t h a t you a r e planning a s tudy on t h e Risk Approach i n MCH/FP ca r e i n some of the v i l l a g e s of F i c t i t i a ' s c o a s t a l region.

I n t he se v i l l a g e s , t h e r e a r e many groups of varying in f luence and a few ind iv idua l s who a r e very important. I n each of the v i l l a g e s , t h e r e i s a v i l l a g e counc i l with a headman. This i s the t r a d i t i o n a l form of government i n t h i s p a r t of F i c t i t i a . One of t he o l d e r persons from each of t he f ami l i e s s i t s on t he Council which e l e c t s the headman. Since Independence, these l o c a l t r a d i t i o n a l counc i l s no longer have any o f f i c i a l power because a system, based on gene ra l e l e c t i o n with p o l i t i c a l p a r t i e s , ha s been c rea ted . The country has been d iv ided i n t o commmunes and, f o r each commune, t he r e is a communal counc i l and a mayor. I n the c o a s t a l a r ea , on ly two p o l i t i c a l p a r t i e s have ever succeeded i n g e t t i n g r e p r e s e n t a t i v e s on the communal counc i l . In the commune i n which t he v i l l a g e s a r e s i t u a t e d , t he Blue Pa r ty has t he ma jo r i t y of vo t e s and the mayor, of course , i s from t h a t party.

The v i l l a g e s a r e q u i t e t r a d i t i o n a l i n t he sense t h a t women do no t take pa r t i n o f f i c i a l decision-making. However, wanen have an important r o l e i n s o c i a l a f f a i r s . There i s a very a c t i v e vo lun ta ry wanen's a s s o c i a t i o n where h e a l t h and o ther problems a r e d i scussed and many a c t i v i t i e s of development and information a r e undertaken. I t s o happens t h a t the pres iden t of the wanen's a s s o c i a t i o n i s t he wife of the l e ade r of t he Green P a r t y , t he minor i ty party.

Most d e l i v e r i e s i n the v i l l a g e s a r e undertaken by t r a d i t i o n a l b i r t h a t t endan t s (TBAs). TBAs do no t have a high s o c i a l s t a t u s . However, they a r e very important i n family dec ision-making s i nce , i n a d d i t i o n t o t h e i r r o l e i n c h i l d b i r t h , they a r e c l o s e l y r e l a t ed t o l o c a l t r a d i t i o n a l b e l i e f s . There a r e about 15 TBAs i n the v i l l a g e s you a r e dea l i ng w i th , bu t they have no a s s o c i a t i o n and no group and t he r e is no obvious leader amongst them.

Rel igious b e l i e f s do no t p lay a key r o l e i n t he p o l i t i c a l sys tan , b u t many people a r e profoundly r e l i g i o u s and a r e t hus very in f luenced by t he r e l i g i o u s l e ade r s . Although t h e r e i s no r e l i g i o u s h i e r a r chy , i t i s known t h a t one of the r e l i g i o u s l e ade r s has a personal i n f l uence which goes f a r beyond h i s v i l l a g e .

There a r e sane h e a l t h c l i n i c s i n these v i l l a g e s . The nurses and t he midwives a r e p a r t of t he Nurse/Midwife Union, which i s q u i t e p r e s t i g i o u s i n the country, but the union i s not very a c t i v e i n t he c o a s t a l region. The hea l t h a s s i s t a n t s and t he d r e s s e r s i n the c l i n i c s a re members of a l i t t l e known h e a l t h worker 's union. The p r e s iden t of t he l o c a l h e a l t h worker 's union i s the son-in-law of the mayor.

F H E / M C H / R A / ~ ~ . ~ Page 47

Exerc i ses 3 . 2 (con t inued)

One of t h e farmers i n t h e v i l l a g e has had advanced t r a i n i n g i n a g r i c u l t u r e and is running h i s farm according t o modern p r i n c i p l e s . He tends t o be r a t h e r aggress ive i n ~ u s h i n g h i s i d e a s o n t o h i s neighbours and f r i e n d s . One of t h e o t h e r farmers , who i s n o t p a r t i c u l a r l y s u c c e s s f u l , i s known throughout t h e v i l l a g e t o be a very wise man; a l l the v i l l a g e r s come t o him f o r advice.

The above i s on ly a quick d e s c r i p t i o n of some of t h e a s p e c t s of communal l i f e i n the c o a s t a l r eg ion of F i c t i t i a , b u t should provide enough m a t e r i a l f o r you t o answer t h e fol lowing e x e r c i s e s :

3.2.1 L i s t 5 persons from the community whom you would involve i n t h e s tudv from t h e beginning.

3 . 2 . 2 How would you approach each one of them f o r t h e f i r s t c o n t a c t ?

3 . 2 . 3 What type of p a r t i c i p a t i o n would you expect from each of them?

ME/MCH/RA/84.1 Page 48

S e c t i o n 3.3 The main s t e p s i n a r i s k s tudy

Summary

Although research needs and p o s s i b i l i t i e s vary g r e a t l y from one country t o another t h e r e a r e c e r t a i n b a s i c elements i n t h e design of t h e r i s k approach s tudy t h a t a r e u n i v e r s a l l y app l icab le . I n a l l s i t u a t i o n s i t i s extremely important t h a t research g o a l s a r e well-defined before embarking on the s tudy. Careful ly-formulated hypotheses w i l l be very h e l p f u l i n s t r u c t u r i n g t h e research .

S t u d i e s on t h e r i s k approach i n MCH/FP c a r e c o n s i s t of a s e r i e s of s e q u e n t i a l s t e p s , inc lud ing , review of a v a i l a b l e d a t a , ep idemio log ica l research , review of the s t r u c t u r e and func t ion ing of t h e h e a l t h c a r e system, development and f i e l d - t e s t ing of the new s t r a t e g y , and e v a l u a t i o n .

S t u d i e s on the r i s k approach can be designed i n d i f f e r e n t w q s t o provide answers t o d i f f e r e n t q u e s t i o n s . Those with more t h e o r e t i c a l i n t e r e s t s might l i k e t o prove t h a t the r i s k approach does o r does not work. A more o p e r a t i o n a l approach would be t o t e s t whether s t r a t e g i e s based on t h e r i s k approach g i v e r e s u l t s t h a t a r e b e t t e r t h a n those obtained under e x i s t i n g c a r e systems.

I n t h i s workbook, t h e s t u d i e s a r e designed a s t o o l s i n h e a l t h development, where the r i s k approach i s only one of the elements of a r a t i o n a l MCH/FP s t r a t e g y . What we propose t o t e s t i s whether a MCH/FP s t r a t e g y based on t h e r i s k approach, (which i s a well-planned approach encompassing items such a s t r a i n i n g , technology and o r g a n i z a t i o n ) w i l l improve t h e h e a l t h s i t u a t i o n i n a s p e c i f i c s e t t i n g .

The l o c a l s i t u a t i o n w i l l d i c t a t e what type of s tudy can be undertaken. A sys temat ic approach t o t h e development of t h e research pro toco l is e s s e n t i a l . Thus, c e r t a i n s c i e n t i f i c methods and approaches based on the exper ience of a number oE research p r o j e c t s have been descr ibed i n t h i s workbook. I n a p a r t i c u l a r count ry s i t u a t i o n , you may choose t o depar t from some of the methods descr ibed . The design may a l s o have t o be modified d u r i n g t h e s tudy i f , f o r example, c e r t a i n h e n e f i t s o r "spin of f s" t h a t might a f f e c t the h e a l t h c a r e system a r e encountered. The e s s e n t i a l element i s knowing what you want t o g e t ou t of t h e s tudy b e f o r e t h e s tudy s t a r t s . The methods and approaches used should be a b l e t o provide t h e informat ion wanted. One of t h e important messages of t h i s workbook i s t h a t every i tem of informat ion c o l l e c t e d , and every a n a l y s i s of d a t a t h a t i s made should r e l a t e t o a s p e c i f i c ques t ion . Too o f t e n t h e d a t a c o l l e c t i o n phase of s t u d i e s ends wi th p l e a s t o s t a t i s t i c i a n s t o "Come and t e l l us how we can use t h e s e data".

F ~ E / MCHI RA/84. l Page 49

The hypotheses f o r t h e s tudy a s a whole, a s w e l l a s f o r each p a r t of t h e s tudy, must he c l e a r from the o u t s e t ( f o r f u r t h e r informat ion about hypotheses s e e Chapter 5 ) . The main hypotheses f o r a s tudy on t h e r i s k approach i n MCH/FP care could be :

- I t is p o s s i b l e t o i s o l a t e - through the use of s p e c i a l i n t e r a c t i n g r i s k i n d i c a t o r s , f a c t o r s and scores - subgroups of t h e popula t ion o r i n d i v i d u a l s who a re more l i k e l y t o exper ience f u t u r e morbid processes than the r e s t of t h e populat ion;

- Such subgroups, though r e l a t ive ly smal l , w i l l c o n t a i n a s u b s t a n t i a l p r o p o r t i o n of a l l f u t u r e morb id i ty and m o r t a l i t y occur r ing i n t h e popula t ion descr ibed ;

- By the r e d i s t r i b u t i o n of e x i s t i n g r e s o u r c e s towards the s p e c i a l c a r e of the i n d i v i d u a l s and subgroups a t r i s k , t h e o v e r a l l e f f e c t i v e n e s s and e f f i c i e n c y of MCH/FP s e r v i c e s w i l l be inc reased , wi thout s e r i o u s e f f e c t s on the groups cons idered n o t t o be a t r i s k and away from whom some resources w i l l have t o be r e d i r e c t e d ; a d

- A system can be e s t a b l i s h e d by which " r i sk" can be used e f f e c t i v e l y t o o rgan ize and manage t h e a c t i v i t i e s of t h e MCH/FP s e r v i c e s a t d i f f e r e n t l e v e l s .

The major p a r t s of such a s tudy include:

- a review of e x i s t i n g in format ion on t h e problems of mothers and c h i l d r e n ; ranking of t h e s e problems; s e l e c t i o n of one a s a " t a r g e t " f o r t h e r i s k approach (Chapters 3 and 4 ) ;

- a n ep idemio log ica l s tudy of the t a r g e t h e a l t h problem arid a s s o c i a t e d r i s k f a c t o r s ; q u a n t i f i c a t i o n of t h e r i s k f a c t o r s and of t h e i r i n t e r r e l a t i o n s h i p s ; development of a scor ing system (Chapter 5 );

- a survey of t h e o r g a n i z a t i o n and f u n c t i o n i n g of t h e e x i s t i n g h e a l t h c a r e system t o s e e whether i t is capable of accommodating t h e r i s k approach (Chapter 6) ;

- t h e development of the new MCH/FP s t r a t e g y based on the r i s k approach us ing r i s k s c o r e s and o t h e r informat ion i n a sys temat ic way (Chapter 7) ;

- a f i e l d t r i a l and e v a l u a t i o n of the new MCH/FP r i s k s t r a t e g y (Chapter 8); and,

- a wider a p p l i c a t i o n of t h e f ind ings (Chapter 9 ) .

A u s e f u l i n t r o d u c t o r y s t e p would be t h e p r e p a r a t i o n o f a "flowchart" i n d i c a t i n g l i k e l y a c t i v i t i e s dur ing the research phase. Th is w i l l h e l p i n e s t i m a t i n g t ime arid resource needs , and w i l l s e r v e a s a g u i d e l i n e f o r t h e l a t e r development of a more d e t a i l e d protocol . ( I t c a n a l s o be used l a t e r i n prepar ing a g ran t a p p l i c a t i o n . ) Knowledge of l o c a l a t t i t u d e s , r esources and c o n s t r a i n t s , t o g e t h e r with a knowledge of research methods are important i n prepar ing a r e a l i s t i c f lawchart and t i m e t a b l e f o r research .

The fol lowing f lowchart i n d i c a t e s same of the a c t i v i t i e s which w i l l probably have t o be undertaken i n t h e planning and implementation of a s tudy on r i s k approach i n MCH/FP c a r e :

FHE/MCH/RA 184.1 Page 50

Flowchart of a risk approach research project in MCH/FP care

-------------A-------- ---------------------- ---------------I I-_---_---------

I , 1 I , I I I , ,

Main health problems : : Main risk indicators : : care : : care : I I : (perinatal study) : : (perinatal study) ; system l system : I , , , (study areas) :(control areas):

*----------------------l ~--------------_-------~ t 8 , 1--------------_1 1---_-----__----1

! !

, ---------- t t--- -------- I I

------- t ------- ------- + -------, 1 1

, I 1 I

EPIDEMIOLOGICAL BASELINE : BASELINE BASELINE : I U I I

: Problems/risl< indicators : : - quantity : - quantity : l v , , of care of care : I I 1 I : - frequency : : - quality of : : - quality of :--- 1 , I I care care t I : - distribution t I 1 I 1 9 1 ,

' : - vital : : - vital I 1 : - interrelationships with perinatal outcome : , 1 1 , , statistics : statistics : ........................................ 1 I , v 8 1---------------1 1---------------1 t

---------------v--------------- *-----------------' : (New) risk approach strategy ; *------------------------- t 1 t

:--------------------------------------m-------- * I 1 m , I t 8 0

+ ---------------, , - --- - - -+ -- - -- - - , : Preparation of manuals :------------+f MONITORING : : Training of service staff :

0 , - services : : projected :

---------------v--------------- # , : - staff I I I I ; performance ; ,-------------- ' ' : Testing of risk strategy : , S t 8 I I a #

: Testing of data collection :------------ 4 - etc. : RESEARCH : : : 1 I I I ,

m , - Data t I , : and data analysis I I ) : - 4 collection : : : 1-------------------------------1 1 I

I 0 , (control : : : t o I ~ I : + study) : : :

---------------i-------------~- ( I * I I I 1 1 1 1-----------------1 I I

1--------------1 1 1

I I 1 I

I I I I : Implementation with "dry run" : I I T m ( 1

:-------------------------------+---------------* : ,------ + ------- I t I 1 8 , . . , . . . , EVALUATION ' : : b..' ; ' - ~eforel ,

1 ---W- +i after I ,

I ,

- study/ W---' : control :

, ----- t ---- , : Report : I--_-_-----(

: National application : : offindings (--------------____----~

FHE/MCH/RA/84 .l Page 51

Exerc i ses 3.3

3.3.1 Are a l l of t h e s t ep s i n t he f lowchart on t he prev ious page necessary i n F i c t i t i a ? I f not, which one(s ) can be dropped? Explain why.

Are any e s s e n t i a l s t ep s missing? I f so , i n d i c a t e which.

3.3.2 Considering t h a t some of t h e major a c t i v i t i e s can be undertaken s imultaneously, how long do you th ink such a s tudy would take?

3.3.3 A t what t h r e e po in t s i n the development and implenentat ion of t h e s tudy i s i t , i n your opinion, e s s e n t i a l t h a t r e p r e s e n t a t i v e s of community and s t a f f meet with the reseach group and why?

Mark t he se on the f l m c h a r t with an (*) a s t e r i s k .

Sec t ion 3.4 The r e s e a r c h proposal and r e s o u r c e needs

1 Summary I I A research p r o j e c t s t a r t s wi th an idea t h a t is

developed through d i s c u s s i o n . l

I n order t o s t a r t a s tudy , money, manpower, government and e t h i c a l c lea rance , and a c o r r e c t research approach a r e needed. The research proposal w i l l h e l p t o ensure t h e s e i f i t i s c a r e f u l l y prepared. Th is s e c t i o n o u t l i n e s what t o inc lude i n a research proposa l and g i v e s some s p e c i f i c i d e a s on how the research budget should be developed and presen ted .

The research proposal

A r e s e a r c h proposa l should provide a complete and a c c u r a t e d e s c r i p t i o n of what i s proposed and why. I t i s used f o r s e v e r a l purposes:

- t o o b t a i n i n i t i a l approval from h igher a u t h o r i t i e s ;

- t o e x p l a i n t o co l leagues and o t h e r s what i s proposed;

- t o o b t a i n fund ing , o r a t l e a s t i n i t i a l funding;

- t o f o r c e t h e r e s e a r c h e r o r r e s e a r c h group t o s p e c i f y what i s t o be done and why, and t o d e f i n e p o s s i b l e o b s t a c l e s and ways of overcoming them; and

- t o o b t a i n t e c h n i c a l approval o r advice.

Thus, the research proposal i s a key document which should be a s complete and convincing a s poss ib le . Funders, a d m i n i s t r a t o r s , s c i e n t i s t s o r p o l i t i c i a n s may have t o be consu l ted ; t h e i r d i f f e r i n g informat ion needs must be cons idered i n prepar ing t h e proposal .

The proposal should no t be a d e t a i l e d p ro toco l . The development of the d e t a i l e d p ro toco l should be undertaken when funding and a d m i n i s t r a t i v e approval a r e a v a i l a b l e and acceptance is almost assured.

mE/McH/~A/84.1 Page 52

FHEIMCHI RAI84.1 Page 53

Although proposa l s vary g r e a t l y , some g e n e r a l p r i n c i p l e s can be c i t e d . The fol lowing is an example of an o u t l i n e of a research proposal:

PART I - ADMINISTRATIVE INFORMATION (P lease type o r p r i n t c l e a r l y i n Engl i sh)

1. THE PROJECT

1.1 P r o j e c t t i t l e

1.2 Objec t ives of p r o j e c t (summary)

1.3 P r o j e c t d u r a t i o n

1.4 Funds requested (Year ( s ) and amount i n US$)

2. PRINCIPAL INVESTIGATOR

2 . 1 Name (Family name/surname - F i r s t namelother names)

2 . 2 Complete p o s t a l address and te lephone number

3. INSTITUTION RESPONSIBLE FOR RESEARCH PROJECT

3.1 Give name, p o s t a l address , te lephone, t e l e x number and c a b l e address .

3.2 Ind i c a t e Department ( S ) and I n v e s t i g a t o r ( S ) c o l l a b o r a t i n g wi th andlor accommodating t h e p r o j e c t .

4 . OTHER RESEARCH ACTIVITIES

4.1 Other research a c t i v i t i e s i n p rogress f o r which the a p p l i c a n t i s r e s p o n s i b l e a s P r i n c i p a l I n v e s t i g a t o r .

5 . OTHER SUPPORT FOR THE PROPOSED RESEARCH

5.1 I f t h i s research i s c u r r e n t l y being supported by any o t h e r body( ies ) , p l e a s e i n d i c a t e the o r g a n i z a t i o n and summarize t h e amount and d u r a t i o n of suppor t provided.

5.2 I f t h i s a p p l i c a t i o n is c u r r e n t l y being cons idered elsewhere, i n d i c a t e the o r g a n i z a t i o n ( s ) and t h e d a t e a d e c i s i o n i s expected.

FHE/MCH/ RA184.1 Page 54

6. ETHICAL CLEARANCES

A document ind i c a t ing i n s t i t u t iona l e t h i c a l approval must accompany proposa l s f o r research invo lv ing human s u b j e c t s . S i m i l a r l y , i f a n a t i o n a l body e x i s t s f o r t h e purpose, a document i n d i c a t i n g t h e i r approva l must a l s o be submitted.

7. NATIONAL APPROVAL

I f approval of a n a t i o n a l body i s r e q u i r e d f o r submission of t h e proposal , documentation i n d i c a t i n g t h e approval must accompany t h e proposal .

8. RESEARCH DESIGN

8 .1 Var iab les

S t a t e t h e hypothes i s . I f t h e r e is more than one hypothes i s ( o r research q u e s t i o n ) , a d e s c r i p t i o n of t h e r e l e v a n t v a r i a b l e s should be provided f o r each. L i s t t h e s p e c i f i c v a r i a b l e s t o be s t u d i e d , i d e n t i f y i n g which a r e independent (background) v a r i a b l e s and which a r e dependent (outcome) v a r i a b l e s . F'rovide o p e r a t i o n a l d e f i n i t i o n s of a l l "derived" v a r i a b l e s (e .g . variables deduced o r i n f e r r e d from t h e responses t o s e v e r a l q u e s t i o n s ) .

8.2 Respondentslsubj e c t s / s t u d y a r e a

Define t h e popula t ion t o be s t u d i e d , p a r t i c u l a r l y i n terms of the fol lowing v a r i a b l e s : ( a ) gender , ( b ) age, ( c ) m a r i t a l s t a t u s , d ) e t h n o c u l t u r a l background, ( e ) r e l i g i o n , and ( £ 1 o t h e r a p p l i c a b l e l i f e exper ience v a r i a b l e s (e.g. educa t ion and u r b a n l r u r a l r es idence) . J u s t i f y t h e choice o f populat ion t o be s t u d i e d i n terms of t h e o b j e c t i v e s of t h e research .

I n d i c a t e t h e s tudy a r e a and g i v e a d e s c r i p t i o n o f , o r r e f e r e n c e t o , geography and cl imate .

Describe the s o c i o l o g i c a l and c u l t u r a l background of the popula t ion involved. When their a c t i v e coopera t ion w i l l be sought , i n d i c a t e e a s e of l i n g u i s t i c communication o r language t r a i n i n g needs, a s w e l l a s how the proposed s t u d i e s w i l l be explained t o them.

8.3 Sampling procedures

Descr ibe and j u s t i f y t h e type of s m p l i n g procedures t o be followed (e.g. quota sampling, s imple random sampling, s t r a t i f i e d random sampling and c l u s t e r sampling). Spec i fy the sample s i z e , and e x p l a i n why i t is needed.

8.4 Research ins t ruments

Describe t h e ins t rument ( s ) t o be used (e .g . q u e s t i o n n a i r e , in te rv iew schedule , p r o j e c t i v e t e s t s ) . I f p o s s i b l e , inc lude a complete copy of t h e ins t rumcnt ( s ) i n the appendix. If t h e e n t i r e instrument h a s not y e t been developed, provide i l l u s t r a t i v e examples of ques t ion types , s c a l e fo rmats , o r o t h e r measurement techniques . Provide any informat ion a v a i l a b l e regarding the r e l i a b i l i t y and v a l i d i t y of t h e i n s t r u m e n t ( s ) , p a r t i c u l a r l y wi th r e s p e c t t o any p i l o t s t u d i e s o r p r e - t e s t ing.

FHE/MGH/RA/~~.~ Page 55

8.5 Procedures

Out l ine each of the s t e p s t o be taken i n the proposed study.

I n d i c a t e t h e es t imated du ra t i on of:

( i ) planning and p r epa ra t i on phase (p r e - t e s t ing quest ionnaire S, purchase and o rgan i za t i on of m a t e r i a l , l o g i s t i c s ) ;

( i i ) a c t u a l da t a c o l l e c t i o n i n the f i e l d ;

( i i i ) compilat ion of d a t a from l abo ra to ry s t u d i e s (e.g. se ro logy) ; and

( i v ) da t a ana ly s i s .

8.6 Data c o l l e c t i o n

' h e methods of da t a c o l l e c t ion (e . g. s t andard ized ques t ionna i re S, phys ica l examination and s e r o l o g i c a l t e s t s ) should be explained i n d e t a i l .

A f lowchar t , t r a c ing each of the s t e p s from the beginning t o t he completion of t he p r o j e c t , can be a very u se fu l appendix t o t h i s s ec t i on .

8.7 Data processing and s t a t i s t i c a l a n a l y s i s

Data coding and process ing

Describe how t h i s w i l l be done, where, and on what equipment.

S t a t i s t i c a l a n a l y s i s

B r i e f l y descr ibe the s t a t i s t i c a l ana lyses which a r e proposed f o r examining t he r e l a t i o n s h i p s among t he v a r i a b l e s , and whether t he se ana lyses w i l l be performed by hand o r on a computer.

8.8 Descr ibe t h e c r i t e r i a f o r eva lua t ion .

8.9 Describe how the s tudy w i l l be organized and how the community and hea l t h workers w i l l be involved.

Resource needs

One of the major stumbling b locks i n s t a r t i n g research i s lack of funding. Therefore , an important func t ion of a research manager i s t o o b t a i n t h e necessary funds. Imagination must be used i n seeking funding sources. Once t he se have been i d e n t i f i e d , a g r a n t app l i c a t i on must be prepared t h a t w i l l convince t he p o t e n t i a l donor t o support the study. P r e c i s e ob j ec t i ve s , a r e a l i s t i c t ime t ab l e , good j u s t i f i c a t i o n f o r undertaking t he r e sea r ch , i n d i c a t i o n s of an app rop r i a t e research approach, and a reasonable reques t f o r funds a r e important elements f o r success i n ob t a in ing funds. A c a r e f u l l y prepared budget wi th f u l l j u s t i E i c a t i o n w i l l prove t o be t ime-saving and e f f e c t i v e .

F H E / M C H / R A / ~ ~ .l Page 56

One way of proceeding i s a s follows:*

1. Analyse resource needs

1.1 Review s t a f f i n g requirements

Types of s t a f f needed f o r d i f f e r e n t purposes When and where such s t a f f w i l l be needed Can e x i s t i n g ( a v a i l a b l e ) s t a f f be used? Is o u t s i d e s t a f f needed? Can e x i s t i n g s t a f f be used without s p e c i a l arrangements? Is f u l l - t i n e research s t a f f needed? Does t h e s t a f f need research t r a i n i n g ? For how long a r e s t a f f members a v a i l a b l e ( important f o r t h e c o n t i n u i t y of t h e s tudy)?

1.2 Review requirements f o r equipment and s u p p l i e s

- A r e a v a i l a b l e equipment and s u p p l i e s s u f f i c i e n t ? - Can a v a i l a b l e equipment and s u p p l i e s be used without payment? - Are e x t r a equipment and s u p p l i e s needed? I f y e s , - How long i s needed f o r d e l i v e r y , i n s t a l l a t i o n and t r a i n i n g of s t a f f i n

t h e i r use? - Maintenance - L i s t s e p a r a t e l y any s p e c i a l equipment t h a t might be needed - Check p o s s i b i l i t i e s of f inanc ing and d e l i v e r y time

1.3 Review l o g i s t i c s

- Are s u i t a b l e roans and f a c i l i t i e s a v a i l a b l e ? - I s a d d i t i o n a l space needed? - Is an a d d i t i o n a l budget needed f o r roans and f a c i l i t i e s ? - Do r o o m s / f a c i l i t i e s need m o d i f i c a t i o n s ? I f yes , how long w i l l t h i s

t a k e ? - Are s p e c i a l arangements/permission needed t o use the r o a n s / f a c i l i t i e s ? - When a r e t h e r o o m s / f a c i l i t i e s needed?

2 . Es t imate t o t a l c o s t s f o r s tudy

E s t imat e (wi th h e l p of knowledgeable a d m i n i s t r a t o r s ) the t o t a l c o s t s f o r each item: s t a f f , c a p i t a l , s u p p l i e s , maintenance and s e r v i c e , d a t a handl ing , and i n d i r e c t .

3. Financing

Review:

- a v a i l a b l e resources ; - a d d i t i o n a l funds needed; - p o s s i b l e sources of funds (government, p r i v a t e , i n t e r n a t i o n a l ) ; - t iming of funding r e q u e s t s ; and - t h e format and content of funding reques t s .

* T r a n s l a t e d and modified from "Spri rappor t 19, V'irdering av medicinska metoder". ( S p r i i s the Planning and R a t i o n a l i z a t i o n I n s t i t u t e f o r Health and Health Care i n Sweden, P.O. Box 27310, S-102 54 Stockholm, Sweden).

FHE/MCH/RA/84.1 Page 57

4 . Budget p r e p a r a t i o n and monitoring

Prepare :

- your budget and budget review s y s t a n - book-keeping system ( income/expenses) - a s imple account ing system, f o r example:

- c a p i t a l c o s t - supply c o s t - maintenance/service - t r a v e l - document a t ion - s a l a r y

C o l l e c t a l l b i l l s and o t h e r i n v o i c e s s y s t e m a t i c a l l y .

S t a f f c o s t s a re es t imated according t o t h e average s a l a r y of t h e s t a f P type with a d d i t ion of poss ib le s p e c i a l compensation f o r over t ime, weekend work, and l o s t h o l i d a y s , a s we l l a s d a i l y allowance and t r a v e l insurance a s appropr ia te .

C a p i t a l c o s t s a r e those c a l c u l a t e d f o r amort i z i n g equipment which w i l l be used f o r more t h a n one year .

The buying c o s t must be d i s t r i b u t e d over t h e number of y e a r s the equipment i s es t imated t o be used.

Supply c o s t s and s e r v i c e c o s t s a r e usua l ly es t imated a s a percentage of t h e corresponding c a p i t a l investment.

Maintenance c o s t s inc lude r e n t and a d m i n i s t r a t i v e c o s t s (such a s paper and stamps).

Research c o s t s ve rsus s e r v i c e c o s t s

S tud ies on t h e r i s k approach i n MCH/FP c a r e inc lude modi f ica t ions i n h e a l t h c a r e s t r a t e g y . Such m o d i f i c a t i o n s o f t e n cos t money t o implement, both i n terms of one-time investments and i n terms of ongoing expendi tu res (e.g. d rugs) . Although t h e s e expenses cannot be s p e c i f i e d a t t h i s s t a g e , c o s t e s t i m a t e s should be undertaken e a r l y on i n o rder t o s e e whether t h e new s t r a t e g y i s r e a l i s t i c . Th is w i l l enab le n d e c i s i o n t o be taken on t h e p o t e n t i a l a p p l i c a t i o n of t h e s t r a t e g y .

l Manpower

This item is f requen t ly given i n s u f f i c i e n t c o n s i d e r a t ion, which l e a d s t o problems and de lays . Knowledge i n v a r i o u s d i s c i p l i n e s i s needed t o c a r r y out a s u c c e s s f u l study: s t a t i s t i c s , computer programming, research management and d a t a processing. A c a r e f u l review of manpower requ i rements , inc lud ing t r a i n i n g needs and the p o s s i b l e use of o u t s i d e c o n s u l t a n t s , should be made. A plan of manpower requirements f o r t h e d u r a t i o n of the s tudy should be prepared.

F H E / M C H / R A / ~ ~ . ~ Page 58

Exerc i s e s 3.4

3.4.1 Based on your knowledge of F i c t i t i a (main text of F i c t i t i a document) and of t h e major a c t i v i t i e s of a r i s k approach s tudy ( s ee t he flowchart a t t he end of Sec t ion 3.3) l i s t t h e a d d i t i o n a l resources t h a t w i l l be needed under each of the fol lowing headings:

- research s t a f f ; and

- o t h e r resources .

3.4.2 L i s t four of the most important types of knowledge needed f o r your study.

W i l l persons with t h e r equ i r ed s k i l l s be a v a i l a b l e i n the country you a r e dea l i ng wi th? I f no t , how w i l l you dea l with t he s i t ua t ion?

F H E / M C H / R A / ~ ~ . ~ Page 59

CHAPTER 4

Identifying the health problems of

mothers and chi ldren

FHEIMCHI RA184 .l Page 60

Summary

This chap t e r d e a l s with t he search f o r and a n a l y s i s of e x i s t i n g informat ion on the h e a l t h problems of mothers and ch i l d r en . On t h e b a s i s of ex t r apo l a t i on from p a s t t rends , it w i l l be pos s ib l e t o f o r eca s t the evolu t ion of t he se problems. The outcome of t h i s a n a l y s i s i s what planners c a l l "a problem statement". It q u a n t i f i e s , a s f a r a s p o s s i b l e a d i n a number of d i f f e r e n t ways, the magnitude, d i v e r s i t y and probable f u t u r e t r ends of h e a l t h problems. The problem statement s e r v e s a s a b a s i s t o formulate a b r i e f l ist of problems, i n p r i o r i t y order . These p r i o r i t y problems become the focus of the r i s k approach s tudy and t h e t a r g e t of t h e r e s u l t i n g s t r a t egy .

This chap te r g i v e s an o u t l i n e of the procedure t o fol low i n ana lys ing t he hea l t h problems of mothers and ch i l d r en and an i n d i c a t i o n of d i f f e r e n t methods which could be used. The e s s e n t i a l i s t h a t any research on t he r i s k approach i n MCH/FP c a r e should be based on the sys temat ic a n a l y s i s of r e l evan t in fonna t ion and no t o n preconceived ideas .

Some n a t i o n a l p l ans a d programmes c l e a r l y s t a t e , i n quan t i f i ed terms, t he p r i o r i t y hea l t h problems of mothers and ch i l d r en . I n t h i s ins tance , it would only be necessary t o review t h e re levant in fonna t ion and presen t i t i n a c l e a r way. This chap te r assumes t h a t no p r i o r i t i e s have been def ined , but t h a t . most people knowledgeable i n t h e h e a l t h f i e l d w i l l have an i dea of the top f i v e o r t e n most s e r i o u s causes of morbidi ty o r m o r t a l i t y among mothers and ch i ld ren . Our " ta rge t" h e a l t h problem w i l l be chosen from among these.

Obj ec t ive S

Af t e r s tudying t h i s chap t e r , you should be a b l e to:

- review e x i s t i n g p o l i c i e s and progralmnes i n a s y s t w a t i c manner

- ana lyse e x i s t i n g da ta , and develop a d d i t i o n a l d a t a using "rapid app ra i s a l techniquesw

- s e l e c t , q u a n t i f y and p lace i n p r i o r i t y order the h e a l t h prohlems of women and ch i l d r en

- ensure t h a t t he se p r i o r i t i e s take account of cornmuni t y p r i o r i t i e s and c o m u n i t y development, and a r e framed wi th in a broad po l i t i co-soc i a l con tex t .

FHE/MCH/RA/84.1 Page 61

CHAPTER 4: IDENTIFYING THE HEALTH PROBLEMS OF MOTHERS AND CHILDREN

S e c t i o n 4.1 S e t t i n g t h e scene: review of r e l e v a n t p o l i c i e s and programmes

S e c t i o n 4.2 I d e n t i f y the d a t a r e q u i r e d and those t h a t a r e a v a i l a b l e

S e c t i o n 4 - 3 I d e n t i f y t h e p o s s i b l e sources of d a t a . Are t h e r e q u i r e d da ta a v a i l a b l e ?

Sec t ion 4.4 E x t r a p o l a t i o n and "guestimates": Have we s u f f i c i e n t inf otmat ion now?

Sec t ion 4.5 Undertaking " rap id assessment surveys"

S e c t i o n 4.6 P r e s e n t a t i o n of d a t a such a s r a t e s and t rends

S e c t i o n 4.7 Ranking McH/FP problems i n o rder of importance

FHE/MCH/RA/84 .l Page 6 2

S e c t i o n 4.1 S e t t i n g the scene: review of r e l e v a n t p o l i c i e s and programmes1

l Summary I I d e n t i f y i n g t h e h e a l t h problems of mothers and

c h i l d r e n r e q u i r e s t h a t the n a t i o n a l MCH/FP s t r a t e g y - p r e s e n t and f u t u r e - be reviewed wi th respec t t o e x i s t i n g p o l i c i e s and programmes. Many b e l i e v e they know t h e s e without making a s p e c i a l survey. However, exper ience has shown t h a t a l though one may a l r e a d y be f a m i l i a r wi th t h e s e s t r a t e g i e s i t is s t i l l u s e f u l t o summarize t h e r e l e v a n t p o l i c i e s and programmes i n an o r d e r l y and sys temat ic way.

The i d e n t i f i c a t i o n of problems has t o be undertaken i n a s p e c i f i c n a t i o n a l c o n t e x t and with c o n s i d e r a t ion of the p r i o r i t i e s of t h e community. I t can no t be a t h e o r e t i c a l o r academic e x e r c i s e . One should not t r y t o a t t a c k problems which cannot r e a l i s t i c a l l y be so lved i n t h e s p e c i f i c con tex t i n which one i s working. The s o c i o - p o l i t i c a l s i t u a t i o n i n f l u e n c e s not on ly t h e problem d e f i n i t i o n , but t h e o r g a n i z a t i o n of research and the p o s s i b i l i t i e s f o r changes i n h e a l t h c a r e s t r a t e g y . The h e a l t h c a r e s t r a t e g y is o f t e n expressed i n w r i t t e n p o l i c i e s , but unwr i t t en "understand ingsl ' a r e sometimes more important. The w r i t t e n and unwr i t t en p o l i c i e s f r e q u e n t l y c o n t r a d i c t each o t h e r . The w r i t t e n p o l i c y might s t a t e t h a t on ly d o c t o r s can give i n j e c t i o n s , while i t i s understood, a d widely p r a c t i c e d , t h a t a s s i s t a n t nurses g i v e them. I t i s t h e r e f o r e e s s e n t i a l t h a t t h e u n w r i t t e n p o l i c i e s r e l a t i n g t o MCHIFP programmes and research be d i scussed , analyzed and summarised i n w r i t i n g .

Statements of r e l e v a n t n a t i o n a l h e a l t h p o l i c i e s , p r i o r i t i e s , and h e a l t h c a r e g o a l s should be c o l l e c t e d f o r review. The a s s i s t a n c e of government p lanners and a d m i n i s t r a t o r s of r e l a t e d m i n i s t r i e s should be sought.

Supporting s ta tements of va lue can o f t e n be found in:

- i n t e r n a t i o n a l agreements;

- h e a l t h c a r e p r o v i s i o n s of t h e n a t i o n a l c o n s t i t u t i o n ;

- d e s c r i p t i o n s of h e a l t h and o t h e r m i n i s t e r i a l f u n c t i o n s , inc lud ing a r e a s of r e s p o n s i b i l i t y and i n t e r r e l a t i o n s h i p s ;

- c o n s t i t u t i o n a l func t ions and r e s p o n s i b i l i t i e s of s t a t e and l o c a l a d m i n i s t r a t i o n s and s p e c i a l agenc ies ;

You can f i n d more about how svstemat i c a l l y t o review r e l e v a n t p o l i c i e s and programmes i n : Bainbridge, J . & S a p i r i e , S. Hea l th p r o j e c t management - a manualof procedures f o r formulat ing and implementing h e a l t h p r o j e c t s . Geneva, World Health Organ iza t ion , 1974 (Offse t P u b l i c a t i o n , No. 1 2 ) , pp. 39-40.

F H E / M C H / R A / ~ ~ . ~ Page 63

- t h e n a t i o n a l development plan ( a good source of p l a n s , ~ o l i c i e s , g o a l s , and p r i o r i t i e s ) ;

- t h e n a t i o n a l p l a n f o r "Heal th f o r a l l by the year 2000" ( a good source of p o l i c i e s and t a r g e t s ) ;

- t h e Country Health Programme ( i f one e x i s t s ) .

Th is review of e x i s t i n g p o l i c i e s should provide answers t o such ques t ions as :

- How w i l l t h e e x i s t i n g p o l i c i e s i n f l u e n c e the major h e a l t h problems of mothers and c h i l d r e n ?

- Do e x i s t i n g p o l i c i e s d e s i g n a t e any s p e c i a l populat ion groups a s needing p a r t i c u l a r a t t e n t i o n ?

- W i l l the p o l i c i e s make i t e a s i e r o r more d i f f i c u l t f o r t h e research team t o work w i t h i n t h e e x i s t i n g l o c a l h e a l t h c a r e system?

- How w i l l e x i s t i n g p o l i c i e s i n f l u e n c e the manner i n which t h e research f i n d i n g s might be used t o change t h e h e a l t h c a r e and r e l a t e d systems?"

The presen t o r planned h e a l t h and development programmes should be s i m i l a r l y reviewed s o t h a t t h e re levance of t h e proposed research t o those programmes can be e s t a b l i s h e d . The fol lowing ques t ions might be used i n deciding which of them i s re levan t :

- I s the programme l i k e l y t o a l t e r t h e s o c i a l and/or economic c o n d i t i o n s which a f f e c t t h e h e a l t h problems of mothers and c h i l d r e n ?

- Are t h e r e any p o t e n t i a l b e n e f i t s t o be d e r i v e d from c o o r d i n a t i o n between t h e programme and t h e planned r e s e a r c h p r o j e c t ?

A t t h i s po in t i t would be u s e f u l f o r t h e s tudy group t o make summary l i s t s of r e l e v a n t p o l i c i e s and programmes wi th comments about t h e i r re levance f o r MCH/FP and the research p r o j e c t . Cont rad ic to ry o r c o n f l i c t i n g p o l i c i e s o r programmes, o r those t h a t a r e obviously i n a p p r o p r i a t e , should be noted. Decis ions w i l l have t o be made about which p o l i c i e s a re o v e r r i d i n g and thus d i r e c t the emphasis o r o b j e c t i v e of the planned s tudy , and which programmes deserve g r e a t e s t a t t e n t i o n d u r i n g subsequent research . With t h e s e summary l i s t s the research team can proceed t o t h e fol lowing s e c t i o n s wi th a good unders tanding of t h e atmosphere and genera l d i r e c t i o n of t h e s o c i a l system i n which t h e y a r e working.

" I t is easy t o imagine a s i t u a t i o n i n which, whi le t o l e r a t i n g t h e research , t h e n a t i o n a l a u t h o r i t i e s would never a l l o w implementation of t h e f i n d i n g s .

WE/MCH/RA/~~. 1 Page 64

Exerc i ses 4 .l

4.1.1 Opera t iona l p o l i c i e s i n F i c t i t i a a r e l i s t e d under the item 'P lann ing f o r t h e r i s k approach' a t t h e end of t h e main t e x t i n t h e document on F i c t i t i a . Give an example of a p o l i c y which you t h i n k might change a s a r e s u l t of a s tudy on t h e r i s k approach. (Do n o t d i s c u s s whether i t should be changed, b u t whether it could be changed a s a r e s u l t of research .)

4.1.2 Give a n example of a p o l i c y which you t h i n k would not change a s a r e s u l t of t h e research .

4.1.3 Give an example of a n MCH/FP policy/programme which might h inder t h e research which you p lan t o under take. Also, give an example of how t h e l a c k of a policy/progrannne might h i n d e r research.

4.1.4 From your persona l exper ience , d e s c r i b e a n unwr i t t en MCH/FP p o l i c y which would i n f l u e n c e your research.

4.1.5 L i s t 3 f a c t o r s o t h e r than r e s e a r c h which i n f l u e n c e h e a l t h p o l i c i e s and programmes.

FHE/MCH/RA/84.1 Page 65

Sec t ion 4.2 I d e n t i f y t h e d a t a requ i red and those t h a t a r e a v a i l a b l e 1

Summary

The d a t a requirements must be s p e c i f i e d s o t h a t only the d a t a t h a t a r e r e a l l y needed a r e c o l l e c t e d . To h e l p i n spec i fy ing d a t a needs, t h e main c r i t e r i a f o r s e l e c t i o n of problems should be agreed upon. Data can be q u a n t i t a t i v e and q u a l i t a t i v e : both a r e u s e f u l i n dec id ing p r i o r i t i e s . Though d a t a may be incomplete they should not be d i sca rded . They may prove t o be very u s e f u l when they a r e "enriched" and c a r e f u l l y i n t erpre ted.

The d e t a i l e d s tudy pro toco l which must be developed r e q u i r e s t h a t we must determine which s p e c i f i c h e a l t h problems a r e t o be d e a l t with.' What a r e t h e s e problems? What informat ion do we need i n o rder t o f ind ou t?

Hoarding of masses of d a t a should be avoided s o a s n o t t o waste t ime and e f f o r t . We need only those d a t a which w i l l h e l p u s i n l i s t i n g t h e major h e a l t h prohlems of mothers and /or c h i l d r e n according t o t h e i r importance o r p r i ~ r i t y . ~ These problems ( o r t h i s problem) a r e the ones which w i l l be f u r t h e r s t u d i e d and f o r which a n i n t e r v e n t i o n s t r a t e g y w i l l even tua l ly be developed.

The review of d a t a must be made i n a sys temat ic way. T h i s chap te r d e s c r i b e s i t a s a s t e p by s t e p p rocess . I n r e a l i t y t h e group w i l l go back and f o r t h between t h e s t e p s a s i d e a s develop. But, n e v e r t h e l e s s , t h i s should be done i n a n o r d e r l y fashion. The process of p u t t i n g problems t h a t have been i d e n t i f i e d i n t h e i r o rder of importance ( " p r i o r i t i z i n g " ) i s d e a l t with i n d e t a i l i n S e c t i o n 4.7 and depends on the c r i t e r i a 4 t o be used i n problem s e l e c t i o n . These c r i t e r i a i n t u r n w i l l determine t h e d a t a needs.

For more d e t a i l e d informat ion on how t o assemble d a t a from which t o choose t h e most important h e a l t h problems of women and c h i l d r e n , you may wish t o c o n s u l t : Bainbridge, J . 6 S a p i r i e , S. H< formulat ing and implement ing h e a l t h p r o j e c t s . Geneva, World Heal th Organ iza t ion , 1974 (Offse t P u b l i c a t i o n No. l ' ) , pp. 77-83.

' Note: T h i s workbook is tak ing a systems approach t o t h e development of the p r o t o c o l . Each s t e p i n t h e p rocess w i l l be c l e a r l y d e f i n e d , and d e f i n i t i o n s of words a r e important. We a r e i n t h i s chap te r d e a l i n g with h e a l t h problems and not with t h e problems of t h e h e a l t h c a r e system o r those of economic, s o c i a l , c u i t u r a l o r p o l i t i c a l c h a r a c t e r . These w i l l be considered i n l a t e r c h a p t e r s , e i t h e r a s r i s k f a c t o r s , a s c o n s t r a i n t s t o t h e development of t h e h e a l t h c a r e and i n t e r s e c t o r a l s t r a t e g i e s o r a s o b s t a c l e s which cannot be overcome and which one t h e r e f o r e h a s t o " l i v e with" .

Note: the word p r i o r i t y can be used when d e s c r i b i n g p r i o r i t y h e a l t h problems, p r i o r i t y concerns , p r i o r i t y a c t i v i t i e s , p r i o r i t y s t r a t e g y among o t h e r s . I n t h i s chap te r we a re dea l ing wi th t h e l i s t i n g of the main o r most important h e a l t h problems i .e . t h e h e a l t h problems.

C r i t e r i o n : A s tandard of judgement.

FHE/MCH/RA/R~ . l Page 66

C r i t e r i a f o r s e l e c t i o n of p r i o r i t y problems

D i f f e r e n t persons have d i f f e r e n t pe rcep t ions of what the p r i o r i t y problems of mothers and c h i l d r e n a r e and how t h e d e c i s i o n on what i s important should be made. The research group can reduce such persona l b i a s e s by agree ing on a l i s t of c r i t e r i a which w i l l determine whether a given ~ r o b l e m is t o be included o r excluded i n t h e p r i o r i t y s e l e c t i o n process .

The fol lowing c r i t e r i a a r e commonly used i n i d e n t i f y i n g the main h e a l t h problems t o be "attacked":

1. The e x t e n t of the problem - how "big" i s i t ?

2 . The s e r i o u s n e s s of t h e problem.

3 . The " p r e v e n t a b i l i t y " of the problem - by how much can the problem be reduced through h e a l t h and r e l a t e d a c t i o n s ? Is i t worth spending scarce resources t r y i n g t o so lve i t ? I s t h e technology a v a i l a b l e ?

4. The concerns of t h e l o c a l community - does t h e l o c a l popula t ion t h i n k i t a major problem?

5. Time t rends .

The f i r s t two c r i t e r i a r e f e r t o the "medical" importance of the problem; how "se r ious" i s t h e d i s e a s e , and how much of i t i s t h e r e ?

The e x t e n t of the problem

Measures of the e x t e n t of h e a l t h problems a r e r a r e l y a v a i l a b l e i n the form requ i red - t h a t i s a s age , sex and /or cause s p e c i f i c r a t e s . However, f a i r l y a c c u r a t e guesses a re usua l ly p o s s i b l e from a v a i l a b l e informat ion ( u s u a l l y the number of d e a t h s per annum).

The s e r i o u s n e s s of a h e a l t h problem

Although t h e "se r iousness" of a h e a l t h problem is o f t e n (and popula r ly ) the b a s i s of s e t t i n g p r i o r i t i e s , t h e i d e a i s a complex one. The s e r i o u s n e s s of a h a d i c a p , a dea th o r a d i s e a s e can be measured i n terms of t h e number of years of expected l i f e l o s t , t h e economic l o s s t o t h e community, t h e dependency imposed by the handicap, the g r i e f i n f l i c t e d o r t h e d u r a t i o n of t h e pain exper ienced. For many of t h e s e t h e r e w i l l be no d a t a and t h e importance a t t r i b u t e d t o each w i l l va ry from p lace t o place. I n p r a c t i c e , measures of crude m o r t a l i t y , and medical and nurs ing exper ience a r e o f t e n t h e b a s i s f o r such d e c i s i o n s . The e s t i m a t e of se r iousness should be made a f t e r l o c a l d i s c u s s i o n s .

The p r e v e n t a b i l i t y of t h e h e a l t h problem

This c r i t e r i o n r e l a t e s t o the b e n e f i t s (problem reduc t ion) ob ta ined f o r every u n i t of a c t i o n o r resource we spend on i t s c o n t r o l . Some h e a l t h problems ( f o r example, t e t a n u s neonatorum) a r e s imple and easy t o c o n t r o l . Others ( s p i n a b i f i d a , f o r example) a r e c o s t l y and d i f f i c u l t , i f no t imposs ib le , t o do any th ing about . The p r i o r i t y should be higher t h e b e t t e r t h e r e t u r n f o r a given inpu t of resources .

Concerns of t h e l o c a l community

Guidance on what a re the important l o c a l a r e a s of concern, might be a v a i l a b l e from v i l l a g e l e a d e r s , r e g i o n a l a u t h o r i t i e s , count ry h e a l t h programmes, n a t i o n a l h e a l t h p l a n s , t h e Min is t ry of Hea l th , vo lun ta ry agenc ies , o r from o t h e r sources .

FHE/MCH/RA/84 .l Page 67

Some a t l e a s t of t h e l o c a l concerns can be c rude ly measured o r e s t i m a t e s made of t h e i r s t r e n g t h using s c a l e s . Flowever, what i s important a t t h i s s t a g e is whether l o c a l p r i o r i t i e s c o n f l i c t wi th t h o s e obtained on t h e b a s i s of e x t e n t , se r iousness and l i k e l y response t o p reven t ive e f f o r t .

The four c r i t e r i a desc r ibed a r e of a g e n e r a l n a t u r e and a r e open t o d i f f e r e n t i n t e r p r e t a t i o n s . I n o r d e r t o be u s e f u l , c r i t e r i a must be s p e c i f i c s o t h a t everybody agrees on what they mean.

Time t r e n d s

Health problems a r e not s t a t i c and changes over t ime must be taken i n t o c o n s i d e r a t i o n . Some h e a l t h problems, l i k e m o r t a l i t y from measles may be d e c l i n i n g f a s t , whi le o t h e r s may be inc reas ing o r , a t b e s t , s t e a d y over a number of years .

An examination of p a s t t r e n d s w i l l u s u a l l y show whether t h e problem is i n c r e a s i n g o r decreas ing and the probable f u t u r e t rends can of t en be foreseen. Trends must be t aken i n t o account i n our " p r j o r i t i z i n g " . Hea l th problems which look a s though t h e y w i l l be inc reas ing must be given a h i g h e r p r i o r i t y t h a n those t h a t look s teady o r a r e d e c l i n i n g . A problem which seems t o be s o l v i n g i t s e l f over t ime would normally be considered l e s s important than one t h a t i s l i k e l y t o inc rease .

Informat ion can be of two b a s i c types: Q u a l i t a t i v e o r q u a n t i t a t i v e . Both a r e important f o r our purpose.

Qual i t a t ive informat ion is inva luab le a s background informat ion and a l s o i n dec id ing t h e s e r i o u s n e s s of a h e a l t h problem.

Example

What i s happening t o t h e h e a l t h of mothers i n your v i l l a g e s ?

Women i n our v i l l a g e s have t o o many c h i l d r e n and a r e c o n s t a n t l y t i r e d .

Q u a l i t a t i v e informat ion i s a l s o h e l p f u l i n ga in ing i n s i g h t s i n t o t r e n d s over time and t h e l i k e l y means of c o n t r o l . I t enab les u s t o have a b e t t e r understan- of the problems i n t h e p o l i t i c a l , human, socio-economic and env i ronnenta l s e t t i n g s of t h e count ry and a l s o of t h e i r i n t e r r e l a t i o n s h i p s . Th is kind of informat ion w i l l a l s o t e l l u s something about the func t ion ing of the h e a l t h c a r e system and h e l p s t o i d e n t i f y i n t e r s e c t o r a l c o n s i d e r a t i o n s which can be used i n s u g g e s t i n g resource r e a l l o c a t i o n .

FHE/MCH/ RAl84.1 Page 6 8

Q u a l i t a t i v e problem a n a l y s i s

The development of such q u a l i t a t i v e d a t a about h e a l t h problems can be formal ised. S t a r t i n g wi th one h e a l t h problem (such a s i n f a n t m o r t a l i t y ) , ques t ions and answers a r e used t o b u i l d up a "model". "Why i s t h i s a concern?" "Because. . . . . . . ."l Then the quest ion t o be asked is:

"What i s t h e outcome ( r e s u l t ) of t h i s ? " To h e l p i n a s y s t e m a t i c review, the answers can be e n t e r e d on a diagram.

The e n t r i e s on the diagram are then reviewed and t h e i r probable i n t e r r e l a t i o n s h i p s shown. This formal or " i n depth8 ' ~ r o b i n g l e a d s t o a sys temat ic y e t anecdota l view of l o c a l h e a l t h problems, t h e i r causes and consequences, t h e i r s e r i o u s n e s s and t h e i r i n t e r r e l a t i o n s h i p s . Such a n a n a l y s i s might i n d i c a t e t o t h e group the problems which need f u r t h e r documentation. I t w i l l a l s o p rov ide ideas about p o s s i b l e r i s k f a c t o r s .

Using t h i s modified Delphi o r concensus d i s c u s s i o n , t h e team w i l l now a t t m p t t o i d e n t i f y t h e cause and e f f e c t r e l a t i o n s h i p s t h a t e x i s t between t h e v a r i o u s h e a l t h problems under review. The r e l a t i o n s h i p s vary i n s t r e n g t h . I t may be h e l p f u l t o d i f f e r e n t i a t e between s t r o n g and weak l inkages .

Th is q u a l i t z t i v e problem a n a l y s i s h e l p s t o focus t h e a t t e n t ion of the research team on t h e more important , r e c t i f i a b l e problems.

Quant i t a t ive d a t a

Such d a t a a r e r a r e l y a v a i l a b l e i n the form requ i red . Moreover, i f a v a i l a b l e , they a r e o f t e n no t very good. They may, however, be q u i t e s u f f i c i e n t f o r t h e l e v e l of d e c i s i o n making which i s necessa ry a t t h i s s t a g e .

Q u a n t i t a t i v e d a t a may be a v a i l a b l e on , f o r example:

1. s p e c i f i c cond i t i o n s o r happenings, e.g. pregnancy and d e l i v e r y , a c c i d e n t s ;

2 . s p e c i f i c symptoms, e.g. f e v e r s , d i a r r h o e a s , upper r e s p i r a t o r y i n f e c t i o n ;

3 . s p e c i f i c outcomes, e . g. dea th , temporary d i s a b i l i t y , permanent impairment ;

4. t h e e f f e c t s on s o c i e t y of s p e c i f i c d i s e a s e s and c o n d i t i o n s - work o r school days l o s t , ea rn ings o r p r o d u c t i v i t y lawered, r u r a l development;

5. d i s e a s e s and c o n d i t i o n s having s p e c i f i c environmental p r e c u r s o r s such a s unsafe water , poor waste and sewage d i s p o s a l , poor housing, prevalence of p e s t s , h igh d e n s i t y of popula t ion o r v e h i c l e s ;

6. d i s e a s e and c o n d i t i o n s c o n t r i b u t i n g t o o r a f f e c t e d by s p e c i f i e d h e a l t h s e r v i c e d i f f i c u l t i e s - s h o r t a g e of o u t - p a t i e n t and c l i n i c c a p a c i t y , shor tage of s p e c i f i e d types of s t a f f , l ack of coverage by s p e c i f i e d t y p e s of c a r e .

For example, a high i n f a n t and t o d d l e r m o r t a l i t y r a t e may be a concern l o c a l l y no t on ly because i n f a n t l i f e i s p rec ious b u t because more boys d i e than g i r l s . One r e s u l t might be a r e l u c t a n c e t o a c c e p t family planning i n t h i s country.

FHE/MCH/ RA/84.1 Page 69

For each of t h e types of q u a n t i t a t i v e in format ion i n t h e above l i s t , some of t h e fol lowing d a t a would be needed: raw d a t a ( a b s o l u t e numbers) and the der ived f r a c t i o n s , r a t i o s and propor t ions ; crude inc idence and prevalence r a t e s whether ad jus ted o r s p e c i f i c ; t r e n d s , c o e f f i c i e n t s and i n d i c e s . A l l t h e s e terms a r e def ined and i l l u s t r a t e d by examples i n Sec t ion 4 . 6 : resenta at ion of d a t a a s r a t e s and t rends which c a n be r e f e r r e d t o .

What d a t a a r e a v a i l a b l e ? p--

I n r e a l l i f e d a t a c o l l e c t i o n i s no t a t a l l simple. Many of the d a t a which a r e needed a r e no t a v a i l a b l e . Those t h a t a r e , a r e o f t e n n o t t h e d a t a most needed.

Before s e t t i n g out on a d a t a c o l l e c t i o n e x e r c i s e i t i s worthwhile making a thorough search of a l l p o s s i b l e sources of in format ion . I n many o r most s i t u a t i o n s mare d a t a a r e a v a i l a b l e than i s immediately apparent . Spec ia l s t u d i e s , vo lun ta ry agenc ies , u n i v e r s i t i e s , non-health government i n s t i t u t i o n s such a s m i n i s t r i e s of planning o r t h e i n t e r i o r , and the recording and r e p o r t i n g systems of the h e a l t h c a r e system w i l l o f t e n provide u s e f u l d a t a . These may have t o be i n t e r p r e t e d with c a u t i o n , b u t they should c e r t a i n l y be considered a s sources of p o t e n t i a l l y u s e f u l d a t a .

F i g u r e 4 . 2 a

Diagram o f C r i t i c a l Problems

E n v i r c m e n t a l F a c t o r

D i s e a s e o r Cond i t i o n

Consequence

I l c ~ l t l i S e r v i c e

Socioeconomic F a c t o r

FHE/MCH/RA/~~.~ Page 7 1

Exercises 4 . 2

4 . 2 . 1 Develop a problem model, s imi lar t o that given on the previous page, for the problem of infant mortal i ty .

4 . 2 . 2 Make a l i s t o f raw data you would require i n order t o describe the problem chosen under 4 . 2 . 1 above.

FHE/MCH/RA/f34.1 Page 72

Sec t ion 4.3 Zdent i f y the poss ib le sources of da ta . Are the requi red da ta a v a i l a b l e ?

Summary

Having i d e n t i f i e d d a t a needs, t he pos s ib l e sources of d a t a w i l l have t o be i den t i f i ed . With some imagination and p a t i e n t search one o f t e n f i n d s a s u r p r i s i n g amount of unused da t a .

This s e c t i o n is concerned with the sources of s t a t i s t i c a l d a t a i n ~ e n e r a l and wi th t h e "missing" d a t a &I p a r t i c u l a r .

In i den t i f y ing sources of d a t a , the s tudy group would not only r e f e r t o wel l known documents. An imaginat ive search f o r t he r e s u l t s of surveys , through personal con t ac t s , l e t t e r s t o i n s t i t u t i o n s and i nd iv idua l s , sea rches of l i b r a r i e s , and i f pos s ib l e , computer searches of t he l i t e r a t u r e * should a l s o be undertaken. Documentat ion on r e l a t e d cu r r en t research a c t i v i t i e s should a l s o be consul ted.

Any and a l l sources of d a t a should be considered.

Government s t a t i s t i c s and ad hoc r e p o r t s , r e p o r t s ( p e r i o d i c a l o r ad hoc) from i n s t i t u t i o n s , p r i v a t e and p ro f e s s iona l o rgan i za t i ons , agencies f o r i n t e r n a t i o n a l c o l l a b o r a t ion ( b i l a t e r a l -mu l t i l a t e r a l ) , s c i e n t i f i c pub l i c a t ions, medical o r o the r j ou rna l s , country hea l t h p r o f i l e s , n a t i o n a l h e a l t h plans and programmes, s tudent p r o j e c t s , a s we l l a s l o c a l l y kep t records from h o s p i t a l s , c l i n i c s , p r i v a t e a d publ ic agencies and b i r t h and dea th r e g i s t r a t i o n a l l provide u se fu l information.

Too o f t en one hears t h a t there i s "no information ava i lab le" . I n r e a l i t y , more o f t en than no t masses of information a r e a v a i l a b l e ; t he problem i s t h a t few people know of o ther people ' s informat ion. Many informat ion systems a r e very much i n chaos - and i n many coun t r i e s t h e r e i s no r e a l system a t a l l . The information might be of doubt fu l exac tness , l im i t ed t o sane s tudy a r ea s , o r sometimes outdated. I n any ca se , i f used wi th c a r e , some information i s b e t t e r than none.

Di f fe r ing informat ion on the same sub j ec t may be a v a i l a b l e from the same source o r from d i f f e r e n t sources . Then c a r e f u l cons ide r a t i on has t o be given a s t o which should be used. I f the same information i s given from d i f f e r e n t sources , one may th ink i t i s more l i k e l y t o be c o r r e c t , but t ake c a r e , they may a l l be quot ing the same informat ion ( r i g h t o r wrong) from the same source. Always quote the source of information.

* We may be lucky and find survey r epo r t s of da t a such a s s t i l l b i r t h r a t e s , t odd l e r m o r t a l i t y o r b i r thweights .

FHE/MCH/RA/84.1 Page 73

Exercises 4 . 3

4 . 3 . 1 Suggest poss ib le sources from which the data l i s t e d i n Exerc i s e 4 . 2 . 2 might be obtained.

4 . 3 . 2 I f you come t o the conclusion that some of the missing d a t a a r e not avai lable from the sources suggested in Exercise 4 . 3 . 1 , describe 3 ways i n which t o obtain more information.

FHE/MCH/RA/84.1 Page 74

Sec t ion 4.4 Ext rapo la t ion and "guestimates"; Have we suf f i c i e n t informat ion now?

Ext rapo la t ion : Some d a t a may be a v a i l a b l e f o r a few vears . By extending t h e observed p a t t e r n t h e f i g u r e s f o r t h e next y e a r s can be es t imated . The e a s i e s t way t o do t h i s is t o p l o t the d a t a on a graph a g a i n s t time. A l i n e i s drawn through t h e p o i n t s and extended or "ex t rapo la ted" t o g e t informat ion f o r t h e fol lowing o r previous years .

P- ---- ----

Summary

I n s p i t e of a l l t h e e f f o r t s of t h e s tudy group, some necessary informat ion w i l l , i n most s i t u a t i o n s , not be a v a i l a b l e . The miss ing d a t a which were considered as e s s e n t i a l i n the previous s t e p must be d i scussed again.

There a r e i n d i r e c t ways of e s t i m a t i n g informat ion. Th is s e c t i o n d e s c r i b e s some such methods: E x t r a p o l a t i o n , a n a l y s i s of anecdota l in format ion and Delphi e s t i m a t e s .

Example

I

You know t h a t i n 1970 t h e r e were 85 bab ies born i n your v i l l a g e , i n 1975 t h e r e were l 0 0 and i n 1978 t h e r e were 110. P l o t t h e s e on a graph and draw a l i n e through t h e po in t s .

of 75 7

b i r t h s I

Year

By extending t h e l i n e ( e x t r a p o l a t i n g ) we g e t an e s t i m a t e of 118 b i r t h s f o r 1982.

F H E / M C H / R A / ~ ~ . ~ Page 75

Anecdota 1 informat ion

Older members of the community, inc lud ing h e a l t h p r o f e s s i o n a l s , can usua l ly t a l k knowledgeably of c h i l d b i r t h over t h e l a s t t e n y e a r s o r s o . Confirmation of t h e s e memories is o f t e n a v a i l a b l e from o t h e r sources . Th is informat ion may be c a l l e d "anecdotal1'*. That i s , i t i s based on impressions r a t h e r than on f a c t s and f i g u r e s . It may, f o r example, be expressed a s follows: "The c h i l d r e n i n our v i l l a g e normally a r e w e l l till around t h e age of 6 months. But from t h a t age on thev seem t o s u f f e r a l o t from d i a r r h o e a , and may d i e from it". Such informat ion can s t i l l be very u s e f u l , bu t has t o be i n t e r p r e t e d wi th cau t ion .

I n f e r e n c e s from o t h e r in format ion

We can of t en i n f e r o r d e r s of magnitude of t h e unknown r a t e s from o t h e r , r e l a t e d informat ion. For example we d o not know t h e maternal m o r t a l i t y r a t e . By looking a t t h e sex r a t i o of the o lder age groups you s e e t h e r e a r e more men t h a n wanen, which i s unusual . We can thus guess t h a t a l a r g e number of t h e women who d i e before reaching these age groups do s o from causes r e l a t e d t o pregnancy and de l ivery . We may be a b l e t o p ick t h i s up more d i r e c t l y by f i n d i n g t h a t more women than men aged 15 t o 45 y e a r s have d ied over t h e l a s t years .

A high i n f a n t m o r t a l i t y can be i n f e r r e d i f t h e r e i s a d i s p r o p o r t i o n a t e l y l a r g e number of young c h i l d r e n among those t h a t have died i n the l a s t years . Other examples a r e t h a t high p e r i n a t a l m o r t a l i t y u s u a l l y means t h a t t h e r e is a high maternal m o r t a l i t y ( t h e causes a r e s i m i l a r ) , and t h a t high young c h i l d m o r t a l i t y u s u a l l y means t h a t t h e r e i s a high pos tneona ta l m o r t a l i t y ( t h e causes a r e a l s o s i m i l a r ) .

Delphi e s t i m a t e s

The Delphi method i s a n organized c o l l e c t i o n and a n a l y s i s of people 's "guesst imates" or "informed opinions" about a n i s s u e . Ten people may be asked: "What i s i n your op in ion the i n f a n t m o r t a l i t y r a t e i n F i c t i t i a ? Give a f i g u r e which you th ink i s c l o s e s t t o t h e r e a l f igure" . The answers a r e analyzed and a new q u e s t i o n i s made t o t h e same group of people based on the previous answers. "The i n f a n t m o r t a l i t y r a t e i n F i c t i t i a h a s been e s t i m a t e d t o be between 130 and 250 per 1000. Rased on t h i s informat ion, give a f i g u r e which you t h i n k i s c l o s e s t t o t h e r e a l f igure" . The answers t o t h e second q u e s t i o n u s u a l l y converge more than prev ious ly . The process can be repea ted i f necessary. I n the end, a n e s t h a t e can be made, based on such a group consensus by "informed ind iv idua l s" . The prbcess can be undertaken by group d i scuss ion . Usually i t is p o s s i b l e t o reach agreement on a "good guess".

Observat ion

One of the most u s e f u l methods f o r ob ta in ing in format ion when d a t a a r e l a c k i n g , i s r a r e l y d e s c r i b e d and formal ized. The method i s OBSERVATION. I f p r a c t i c a l l y every c h i l d we s e e on our t r a v e l s i n t h e d i s t r i c t i s obviously malnourished, we may s a f e l y conclude t h a t m a l n u t r i t i o n i n c h i l d r e n i s a common c o n d i t i o n even i f i t i s r a r e l y o r never recorded on c l i n i c ca rds . Somebody might cha l lenge u s on the accuracy of t h a t observa t ion . Our answer t o t h a t person would be t o reques t him t o provide more a c c u r a t e informat ion NOW.

* Anecdote: S e c r e t , p r i v a t e o r h i t h e r t o ~rnpubl i shed n a r r a t i v e s o r d e t a i l s of h i s t o r y . The Oxford Engl ish D i c t i o n a r y , 1933.

F~IE /MCH/RA/~~ .~ Page 76

Exercises 4.4

4.4.1 Based on a s e r i e s of sample surveys and o the r i n v e s t i g a t i o n s , t he fol lowing e s t ima t e s have been made of i n f an t and pos tneona ta l m o r t a l i t y i n F i c t i t i a :

------T-------------------------- 1 I : In fan t : Pos tneona ta l : : Year : mor t a l i t y : m o r t a l i t y I l I r a t e r a t e I *------~-e---------~ll-ll-l-ll-lll~

I I I I : 1961 : 132 : 79 1 l

1 I 1 : 1972 : 120 ! 68 I I 1 I : 1975 115 : I

63 I I I I I l

: 1981 : 103 55 I I 1 I I I

'------1-,--------,*--------------1

Use a graph t o e s t ima t e what t he i n f a n t m o r t a l i t y r a t e might be i n 1985 and 1990 i f the p resen t trend cont inues.

4.4.2 Est imate t he neona ta l m o r t a l i t y r a t e f o r those yea r s using the da ta s e t ou t i n Exercise 4.4.1

4.4.3 Using t h e above information, de sc r i be t he presen t t r ends i n i n f an t m o r t a l i t y , neona ta l and pos tneona ta l m o r t a l i t y i n F i c t i t i a .

4.4.4 How do t h e s e t rends serve t o narrow the range of problems of mothers and ch i l d r en i n F i c t i t i a ? Which of those problems would seem be the most important problem?

FHE/MCH/RA/84. l Page 77

Sec t ion 4 . 5 Undertaking " rap id assessment surveys"

Summary

I f and when t h e d a t a a v a i l a b l e a r e n o t s u f f i c i e n t t o i d e n t i f y and d e s c r i b e t h e p r i o r i t y MCH/FP problems, i t might be p o s s i b l e t o o b t a i n a d d i t i o n a l informat ion through a " r a p i d assessment survey". Such r a p i d surveys a r e l e s s c o s t l y , qu icker and i n e v i t a b l y l e s s e x a c t than more orthodox surveys. Rut they may provide s u f f i c i e n t and p r e c i s e enough informat ion f o r our purposes.

I n most c o u n t r i e s the s t a t i s t i c a l informat ion r e q u i r e d t o i d e n t i f y p r i o r i t y MCH/FP problems is not very complete o r exac t . A so-cal led " rap id assessment" survey can be h e l p f u l i n p rov id ing informat ion i n a d d i t i o n t o t h a t obtained by t h e approaches descr ibed i n Sec t ion 4.4. The in format ion requ i red might be , f o r example, maternal m o r t a l i t y by age and p a r i t y o r t h e use of the h e a l t h c a r e system by pregnant women. The d a t a a r e needed qu ick ly . A survey looking i n t o t h e f a c t s of the pas t must then be undertaken, s i n c e a follow-up of f u t u r e even ts w i l l take a long time (and be d i f f i c u l t and c o s t l y ) . The survey depends upon t h e memories of headmen, TBAs, h e a l t h p r o f e s s i o n a l s and the " i n f l u e n t i a l women" of the v i l l a g e s and whatever w r i t t e n in format ion i s a v a i l a b l e . We would probably seek in format ion f o r a maximum of 3 years back, s i n c e memories a r e s h o r t . We would need t o e s t a b l i s h a f r i e n d l y approach t o t h e popula t ion and t o t h e h e a l t h workers. The survey would use a very s imple c h e c k - l i s t which probes f o r informat ion through in te rv iews : f i r s t l y , f a c t s about even ts which can be confirmed - b i r t h s and maternal d e a t h s , secondly in format ion about the women who gave b i r t h i n the v i l l a g e dur ing the per iod concerned such a s t h e i r age (approximately) and t h e i r p a r i t y , and t h i r d l y ques t ions which w i l l g ive ( l e s s a c c u r a t e ) informat ion about the use of h e a l t h c a r e .

I n a d d i t i o n , c l i n i c records can be s y s t e m a t i c a l l y reviewed. Even though they may n o t be complete, the in format ion ob ta ined though t h e in te rv iews might be confirmed. A quick a n a l y s i s of t h e p a t t e r n of a t t endance a t t h e c l i n i c can r e v e a l u s e f u l informat ion.

But one h a s t o be c a r e f u l about drawing conc lus ions about a l l t h e wanen i n t h e a r e a from t h e smal l group which a t t e n d s t h e h e a l t h c e n t r e .

FHE/MCH/RA/84.1 Page 78

Exerc i s e s 4.5

4.5.1 Examine the fol lowing d a t a from a r a p i d survey taken from two h o s p i t a l s i n t h e urban d i s t r i c t s of t h e c o a s t a l region of F i c t i t i a .

C a l c u l a t e the b i r thweigh t s p e c i f i c neona ta l m o r t a l i t y r a t e f o r each h o s p i t a l .

What conc lus ions can you draw from comparisons of t h e o t h e r d a t a f o r t h e s e two h o s p i t a l s ?

See nex t page ]

F H E / M C H / R A / ~ ~ . ~ Page 79

,---.-------------------------------------------------- I 1 C h a r a c t e r i c s of s e l e c t e d v a r i a b l e s I

l l

I i n Hosp i ta l A and H o s p i t a l B l

1 t

I i n t h e Coas ta l r eg ion of F i c t i t i a , 1981 1 I

I I : Hospi ta l A : H o s p i t a l B : I 1 C h a r a c t e r i s t i c ; ------ I I : N o . : X N o . : % : : Maternal age ( y r s ) l I 1 I l

I l I I 1 I l I l l 1

10-17 : 4 5 : 1.1 : 678 : 19.3 : 18-19 : 117 : 2.9 : 698 : 19.9 : 20-29 : 2911 : 71.1 : 1821 : 51.8 : : 30-34 : 6 5 8 : 1 6 . 1 : 1 4 4 : 4 . 1 : 35+ : 3 4 6 : 8 . 4 : 1 5 4 : 4 . 4 : Unknown : 1 8 : 0 . 4 : 1 4 : 0 . 4 :

~-------------------------l------f------~------~------~

: Ethnic A : 3922 : 95.8 : 515 : 14.7 : : Ethnic B : 173 : 4.2 : 2994 : 85.3 ; I-------------------------1------1------~------~------~

: Urmarried : 52 : 1.1 : 1385 : 28.8 : I-------------------------*------1------~------~------*

: I l l i t e r a t e : 420 : 10.3 : 1859 : 53.0 : I-------------------------I------*------*------~------*

: Birthweight (grams) I I I I I 1 I I I I

l l

1 1 I l

-1499 : 5 7 : 1 . 4 : 2 4 8 : 7 . 1 : : 1500-2499 : 2 3 1 : 5 . 6 : 4 8 2 : 1 3 . 7 ;

2500+ : 3 8 0 4 : 9 2 . 9 : 2 7 6 7 : 7 8 . 9 : Unknown : 3 : 0 . 1 : 1 2 : 0 . 3 :

:-------------------------:------:------:------:------: : Number of i n f a n t s l I l

l I I l I 1 1

: dying i n neona ta l l I I l 1 I 1 1 : p e r i o d l I I l I

I I I I I

: Birthweight (grams) I I I I I I I l l I I

: Deaths I I l l l

I l

I I 1 l

1 l I 1

-2499 : 59 : 66 227 : 71 2500+ : 31 : 34 : 92 : 29 ;

: Area of mate rna l l l l I I

1 l 1 l l : r e s i d e n c e I I I I I

l 1 I l l

1 1 1 1 : Rural : 455 : 11.1 ; 258 : 7.4 j

,' Slum : 371 : 9.1 : 3096 : 88.2 : : Urban (excluding slums) : 3269 : 79.8 : 155 ; 4.4 : ;-------------------------;------;------ ;------;------l

: Caesarean s e c t i o n s : 902 : 22.0 : 359 : 10.2 : ;-------------------------;------;------;------t------1

: No p r e n a t a l c a r e : 699 ; 17.1 : 1043 : 29.7 : ;-------------------------~------~------~------~------~ / T o t a l b i r t h s : 4095 : : 3509 : I I

'-------------------------t------1------~------~------*

FHE/MCH/ RA/R4.1 Page 80

S e c t i o n 4.6 P r e s e n t a t i o n of d a t a such a s r a t e s and t rends

Summary

Data must be p resen ted c l e a r l y and c o r r e c t l y i n o r d e r t o be u s e f u l . Th is s e c t i o n g i v e s some d e f i n i t i o n s a d exp la ins some methods of p r e s e n t i n g d a t a - l I t p a r t i c u l a r l y emphasizes t h a t the r a t e s , r a t i o s and propor t ions which a r e used t o d e s c r i b e even ts a r e f r e q u e n t l y mispresented and m i s i n t e r p r e t e d . The t rans format ion of "raw" d a t a i n t o more u s e f u l and more meaningful in format ion i s sanet imes r e f e r r e d t o a s the t r a n s l a t i o n of d a t a i n t o " in te l l igence" .

I n o r d e r t o be u s e f u l t h e numerical d a t a we have c o l l e c t e d have t o be expressed i n a form which a l lows u s t o make comparisons between popula t ion groups, geographical a r e a s , t h e same populat ion group o r a r e a a t d i f f e r e n t p o i n t s i n t ime, between d i s e a s e s o r happenings, o r between any of t h e s e and any norm t h a t we may, consciously o r unconsciously, use a s a measure of magnitude.

When a l l necessary d a t a have been c o l l e c t e d e i t h e r from t h o s e which were a v a i l a b l e , o r by s p e c i a l su rveys , e x t r a p o l a t i o n o r gues t imates , we a r e ready t o p resen t t h e d a t a i n a form i n which they can be meaningful ly i n t e r p r e t e d .

Absolute numbers

Sometimes i t i s s u f f i c i e n t t o d e s c r i b e people and even ts i n a c t u a l o r "absolute" numbers. The numbers of c a s e s wi th a p a r t i c u l a r h e a l t h problem might be i d e n t i c a l i n two d i f f e r e n t popula t ions , b u t i f the popula t ions were d i f f e r e n t the p r o p o r t i o n s and t h e r e f o r e t h e importance of t h e c o n d i t i o n would be d i f f e r e n t . I f we were concerned wi th t h e c a s e load i n a c l i n i c , f o r i n s t a n c e , we would want the a b s o l u t e number of persons who a t t ended . But i f we a r e i n t e r e s t e d i n t h e coverage of h e a l t h c a r e , we need t o know the p ropor t ion of persons who con tac td t h e h e a l t h worker a t l e a s t once o u t of t h e t o t a l number of persons i n t h e a rea .

To know more about how t o p resen t d a t a , c o n s u l t : Descr ip t ive S t a t i s t i c s - Tables and Ra tes , R a t i o s , Proposals and Ind ices - Graphs and Charts . Publ ished by US D e ~ a r t m e n t of Heal th . Educat ion and Welfare. P u b l i c Health Serv ice . Center fo r Disease Control , A t l a n t a , Georgia 30033, United S t a t e s of America.

FHE/MCH/ RA/84.1 Page 81

Propor t ions , r a t i o s and r a t e s

The most u s e f u l form i n which t o a p p r a i s e d a t a i s t h a t of a r e l a t i v e number, i . e . a number which expresses t h e magnitude of one event i n terms of ano ther . This i s u s u a l l y i n the form of a f r a c t i o n where the t o p , the numerator, i s t h e event and t h e bottom, t h e denominator, i s t h e populat ion of i n d i v i d u a l s t o whom t h a t event could have occurred. An example might be female i l l i t e r a c y where the numerator i s t h e number of a d u l t women i n t h e v i l l a g e who cannot read and t h e denominator i s a l l a d u l t women i n the v i l l a g e . T h i s type of f r a c t i o n where the numerator is included i n t h e denominator i s known a s a p r o p o r t i o n . A s l i g h t l y l e s s u s e f u l measure bu t one t h a t we have t o r e s o r t t o f requen t ly i n p r a c t i c e i s the f r a c t i o n where the numerator i s ,& included i n t h e denominator. An example of t h i s i s maternal m o r t a l i t y . L o g ~ c a l l y maternal dea ths should be r e l a t e d t o pregnancies . The numerator should be t h e number of women who d i e from causes r e l a t e d t o pregnancy and c h i l d b i r t h . The popula t ion t o whom t h i s event could occur i s obviously t h a t of a l l pregnant wanen. ( I f you a r e no t pregnant you cannot d i e from maternal causes . ) However, i n p r a c t i c e i t i s u s u a l l y impossible t o o b t a i n t h i s denominator and we have t o use a proxy measure, t h e number of b i r t h s . Th is type of f r a c t i o n i s no t a p ropor t ion , i t is a r a t i o , the r a t i o of maternal d e a t h s t o b i r t h s .

Many, bu t no t a l l , of t h e measures we s h a l l be us ing i n t h e r i s k approach a n a l y s i s a r e e v e n t s , such a s t h e dea ths of i n f a n t s , which occur over a space of t ime. Th is means t h a t our f r a c t i o n has t o be converted t o a rate, t h e number of even ts occur r ing i n a given popula t ion over a given span of time (e.g. t h e number of dea ths t o c h i l d r e n aged 1 t o 4 y e a r s among a l l t h e c h i l d r e n aged 1 t o 4 y e a r s i n one y e a r ) . When g iv ing r a t e s one must d e f i n e the t ime ( 1 y e a r ) , the popula t ion ( a l l c h i l d r e n aged 1 t o 4 y e a r s ) and t h e p lace (count ry , r e g i o n , m u n i c i p a l i t y ) .

A common source of e r r o r a r i s e s where the numerator and the denominator d o no t come from t h e same p lace . Th is can a r i s e , f o r example, when c a s e s of a d i s e a s e seen a t the h e a l t h c e n t r e , which a l s o a t t r a c t s c a s e s from neighbouring v i l l a g e s , a r e r e l a t e d t o t h e popula t ion of t h e v i l l a g e i n which t h e h e a l t h c e n t r e happens t o be loca ted .

Crude r a t e s

Rates expressed i n terms of a t o t a l p o p u l a t i o n a r e descr ibed a s &; They do not a l low f o r d i f f e r e n c e s i n t h e age and s e x s t r u c t u r e between popula t lons being compared. Crude r a t e s a r e used f o r many purposes because they a l low popula t ion c h a r a c t e r i s t i c s t o be summarised i n a s i n g l e f i g u r e . Furthermore they can be c a l c u l a t e d from a minimm amount of in format ion , e.g. t o t a l number of d e a t h s and t o t a l number i n t h e popula t ion , i r r e s p e c t i v e of t h e o t h e r c h a r a c t e r i s t i c s i n t h e group. Th is i s a l s o a disadvantage because they may be misleading. I t does mean, however, t h a t two populat ions wi th t h e same age-spec i f i c m o r t a l i t y bu t d i f f e r e n t age s t r u c t u r e s w i l l have d i f f e r e n t crude death r a t e s .

Adjusted Rates

To c o r r e c t f o r t h i s , a d j u s t e d r a t e s may be d e r i v e d a s fol lows:

The m o r t a l i t y r a t e s a t d i f f e r e n t ages i n t h e two populat ions t o be compared a r e a p p l i e d t o a s tandard populat ion1 t o determine what the o v e r a l l dea th r a t e would be i n t h a t popula t ion i f i t was exposed t o t h e r a t e s i n t h e two s e l e c t e d popula t ions .

A h y p o t h e t i c a l popula t ion with a given age and sex s t r u c t u r e

FHE/MCH/RA/84.1 Page 82

S p e c i f i c r a t e s

When t h e problem we a r e i n v e s t i g a t i n g only concerns a smal l s e c t i o n of the populat ion i t i s more u s e f u l t o d e a l wi th age, sex o r cause s p e c i f i c r a t e s of morb id i ty and m o r t a l i t y . Our example of the number of d e a t h s of c h i l d r e n aged one t o f o u r y e a r s d i v i d e d hy t h e mid-year populat ion aged one t o f o u r y e a r s g i v e s an "age s p e c i f i c " d e a t h r a t e . Th is i s usua l ly c a l l e d "young ch i ld" dea th r a t e . Female m o r t a l i t y 15-49 y e a r s i s a sex and age s p e c i f i c r a t e . The number of d e a t h s from t u b e r c u l o s i s per 1 ,000 popula t ion i s a d i s e a s e (cause) s p e c i f i c r a t e .

Inc idence and prevalence

Whilst m o r t a l i t y r a t e s a r e u s e f u l i n p inpo in t ing p r i o r i t y h e a l t h problems by measuring t h e l o s s of l i f e , they t e l l u s no th ing about t h e h e a l t h s t a t u s of those who do not d i e . Two measures which a r e f requen t ly used t o q u a n t i f y the r e l a t i v e importance of d i s e a s e s , c o n d i t i o n s o r happenings (such a s m a l a r i a , anaemia o r childhood a c c i d e n t s , f o r example) a r e inc idence and prevalence r a t e s . The inc idence r a t e i s def ined a s t h e number of i n s t a n c e s of i l l n e s s commencing ( o r of persons m i n g i l l ) dur ing a given time per iod i n a s p e c i f i e d popula t ion d iv ided by the number of i n d i v i d u a l s i n t h a t populat ion. For i l l n e s s we can s u b s t i t u t e o t h e r happenings we wish t o measure, l i k e fo r example c h i l d r e n having a c c i d e n t s , wanen becoming pregnant.

Example

58 c h i l d r e n aged one t o f o u r y e a r s developed measles i n 1981. The t o t a l number of c h i l d r e n aged one t o four i n t h e popula t ion from which t h e s e c h i l d r e n come is 700. The incidence r a t e i s then:

5 8 700 X 1000 = 83 p e r thousandL

While inc idence measures t h e frequency of a happening over t ime , prevalence i s a p i c t u r e of t h e s i t u a t i o n reva ailing a t one s i n g l e i n s t a n c e i n time: how many of the women i n t h i s v i l l a g e a r e anaemic now? The prevalence r a t e , which measures t h i s is def ined a s t h e number of ins tances of i l l n e s s , o r persons ill i n a s p e c i f i e d popula t ion d iv ided by the number of i n d i v i d u a l s i n t h a t populat ion.

I Example l I f 75 of t h e 640 pregnant women a t t e n d i n g t h e

p r e n a t a l c l i n i c a r e anaemic, the prevalence of anaemia i n pregnancy i s s a i d t o be:

Rates c a n be expressed a s a r a t e per thousand o r a r a t e percent depending on t h e f a c t o r used t o m u l t i p l y t h e f r a c t i o n .

FHE/MCH/RA/84.1 Page 83

A common mistake is t o use t h e term "incidence" a s a g e n e r a l express ion of f requency, or t o use i t f o r what i s i n f a c t prevalence. Th is i s important t o avoid because inc idence d e s c r i b e s t h e r i s k of acqu i r ing a d i s e a s e i n a populat ion.

Trend S

One of the c r u c i a l quest ions t o be asked i n s e l e c t i n g p r i o r i t y problems is what i s happening over t ime. Is t h e prohlem g e t t i n g b i g g e r , is i t c o n s t a n t , o r is i t d iminishing?

I n order t o g e t some measure of t h e changes t ak ing p l a c e over t ime we need t o o rder our d a t a i n such a way t h a t comparisons can be made between d i f f e r e n t p o i n t s i n time.

Exampl e

The number of c a s e s of measles among c h i l d r e n aged 1-4 was 58 i n 1981: wi th a popula t ion of 700 such c h i l d r e n t h e inc idence r a t e was c a l c u l a t e d t o be 8 3 per thousand. I n 1978 t h e r e were 40 c a s e s among 500 c h i l d r e n ( i n c i d e n c e of 130 per thousand) and i n 1975 t h e r e were 30 c a s e s among 400 c h i l d r e n ( i n c i d e n c e of 75 per thousand) .

The inc idence r a t e i s thus seen t o be r i s i n g .

1975: 75 per thousand 1978: 80 per thousand 1981: 83 per thousand

Time t rends c a n be d i sce rned by c a l c u l a t i n g r a t e s f o r d i f f e r e n t p o i n t s i n t ime o r even sometimes by comparing raw d a t a over t ime. There a r e v a r i o u s ways of making time t rends emerge more c l e a r l y :

A. The s imples t way i s t o p l o t the d a t a , e i t h e r t h e raw d a t a o r t h e r a t e s , o r a graph and then t o make a v i s u a l assessment of t h e t rends .

Incidence of measles 80 per 1000 c h i l d r e n aged 1-4

75

1 - - * - - * - - 1 - - 1 - - 1 - - 1 - - * - - ' - - I - - t

1975 1978 1981

Year

FHE/MCH/ W 8 4 . 1 Page 84

B . An a l t e r n a t i v e way is t o express a l l the f i g u r e s a s percentages of the f i r s t year . Such percentages a r e known a s index numbers.

Example l Year Measles Index Number

Inc idence

1975 7 5 75 : 75 X 100 = 100 1978 80 80 : 75 X 100 = 107 1981 8 3 83 : 7 5 X 100 = 111

This method al lows you t o judge how Past t h e problem i s i nc r ea s ing ( o r decreas ing) .

I n our c a s e the incidence of measles can be seen t o have increased by 11% i n 6 years .

This s e c t i o n h a s only descr ibed how "raw data" can be transformed i n t o "information". The dec i s i on on what d a t a t o use , and how t o p resen t them i s c r u c i a l f o r the development of the study. The tendency i s t o ask f o r t oo much informat ion. There should be a reason f o r each p iece of information. Before c o l l e c t i n g and processing d a t a i t is u se fu l t o w r i t e d m n the se reasons i n a sys temat ic way.

FHE/ MCH/RA/84.1 Page 85

Exerc i ses 4.6

4.6.1 The team i n F i c t i t i a decided t o ob t a in more information about dea ths t o c h i l d r e n under one year of age through a rapid assessment survey. They were a b l e t o ob t a in the following information from the v i l l a g e h e a l t h workers:

There were 755 pregnant women who had been seen by the v i l l a g e h e a l t h workers during the l a s t two years . 730 had given b i r t h t o l i v e c h i l d r e n , t he o t h e r s had experienced a f e t a l death. Of the l iveborn bab ies , 20 per cen t were small ("not b ig enoughq'). They had no t been weighed but they were thought t o have a b i r thweight of 2500 grams o r l e s s . Of t he se small bab ies , 24 d ied before they were four weeks old. Of the l a r g e ("big enough") bab ies , 5 3 d i ed before they were one year old - 28 of them before they were four weeks old. I n a l l , 95 bab ies died before reaching t h e i r f i r s t b i r thday . Two women d ied dur ing b i r t h . The causes of dea th dur ing the f i r s t four weeks, a s recorded on t he ca rd s , were a s follows:

t 1 Nmber of dea ths of Cause death smal l bab ies l a r g e bab i e s j

l I I I

: Tetanus I 3 I I I 9 l

: Other i n f e c t i o n s : 4 1 I I 8 t : Jaundice I 1 l

1 2 l 0 I : Abnormal baby : 1 1 l l 1 I : Bi r th i n j u r i e s : 1 I 1 l 7 l : Immature 1 t I

9 10 l 1 l : Other l 1 1 1 0 1 1 l

Unknown l 1 I I 3 1 1 1

l 1 I l

I I I I

: A l l causes l 1 t 1 24 28 ! 1

FHE/MCH/RA/84.1 Page 86

Exerc i ses 4.6 (cont inued)

Use t h e above informat ion t o c a l c u l a t e a s u i t a b l e measure of the h e a l t h problems l i s t e d i n t h e t a b l e below. ( F e t a l dea th r a t e i s given a s an example).

I I I Type l

I Nmbers l

Health Problem I : Measurement : t o be used !

: F e t a l dea th l : Low bi r thweigh t I : I n f a n t m o r t a l i t y

Rate : 755-730 100 = I I

I : 755

I I : Neonatal m o r t a l i t y I

I 1

: Pos tneona ta l m o r t a l i t y : 1 I : M o r t a l i t y from t e t a n u s : I I

,' Maternal m o r t a l i t y I l

l t : Neonatal m o r t a l i t y f o r : I I I l : l a r g e ("big enough") : I I : babies I

1 I

1 I

l I

t I l

I

~-------------------------'-------------~-----------------~

4.6.2 Using t h e d a t a s e t out i n E x e r c i s e 4.6.1 prepare a t a b l e showing n e o n a t a l , postneonatal and i n f a n t m o r t a l i t y r a t e s by b i r thweigh t . Explain how a n a l y s i s of these m o r t a l i t y r a t e s can be used t o d e f i n e t h e problems.

4.6.3 What conc lus ions about the p r i o r i t y problems i n F i c t i t i a a r e you beginning t o make?

F H E / M C H / R A / ~ ~ . ~ Page 87

S e c t i o n 4.7 Ranking McH_/FP problems i n o rder of importance

Summary

I Personal b i a s e s a r e e a s i l y and f r e q u e n t l y involved when p r i o r i t y problems f o r a c t i o n a r e i d e n t i f i e d . I The personal b i a s o r s u b j e c t i v i t y can be reduced by applying a s e r i e s of agreed c r i t e r i a f o r p r i o r i t y s e l e c t i o n t o t h e l i s t of problems. Refinements of t h i s method a r e descr ibed . The methods descr ibed must be used wi th c a u t i o n and common sense . They a r e on ly t o o l s and do no t provide i n f a l l i b l e answers.

The group must now dec ide which i s t h e most important h e a l t h problem t o a t t a c k using t h e r i s k s t r a t e g y . I n dec id ing r e l a t i v e p r i o r i t i e s we s h a l l have t o be p r a c t i c a l , use a v a i l a b l e in format ion and, probably, i n s p i r e d guesswork. There a r e a number of guiding p r i n c i p l e s :

- obviously the more common problems should have a higher p r i o r i t y t h a n t h e more r a r e ( a l l o t h e r c o n s i d e r a t i o n s a p a r t ) ;

- t h e more "se r ious" h e a l t h problems should have h igher p r i o r i t y t h a n t h e l e s s s e r i o u s ;

- t h e more e a s i l y p reven tab le h e a l t h problems should have a h igher p r i o r i t y than t h o s e t h a t a r e more d i f f i c u l t t o prevent ;

- those with upward t rends over t ime must have h i g h e r p r i o r i t y t h a n those which a r e s teady , and t h e s e must have a h i g h e r p r i o r i t y than t h o s e t h a t a r e diminshing;

- we must r e s p e c t and a c c e p t community concerns , community p r i o r i t i e s and pre fe rences .

A l l c o u n t r i e s w i l l have n a t i o n a l h e a l t h p o l i c i e s , s t r a t e g i e s and p lans of a c t i o n i n w r i t t e n form. These w i l l r e f l e c t o f f i c i a l n a t i o n a l h e a l t h p r i o r i t i e s . I n a d d i t i o n , unwr i t t en p r i o r i t i e s w i l l a l s o e x i s t - t h e s e may be r e f l e c t e d i n the emphasis given t o c e r t a i n a s p e c t s of h e a l t h c a r e i n t h e h e a l t h budget. For example, t h e n a t i o n a l h e a l t h p l a n may give top p r i o r i t y t o h e a l t h problems of mothers and c h i l d r e n , bu t on ly provide a minimal budget t o d e a l wi th those problems. Pressure groups of many k inds a r e in f luenc ing both t h e w r i t t e n and the unwr i t t en p o l i c i e s , and p r i o r i t i e s a r e t h e r e f o r e changing over t ime. The s tudy group should review a l l a v a i l a b l e express ions of n a t i o n a l p r i o r i t y MCHfFP problems. These can be found i n n a t i o n a l h e a l t h p l a n s , p lans f o r h e a l t h f o r a l l by t h e y e a r 2000, y e a r l y budgets , speeches of the Min is te r of Hea l th , e t c . The s t u d y group should c o n t a c t the l o c a l popula t ion , l o c a l h e a l t h s t a f f and l o c a l decision-makers t o d i s c u s s l o c a l h e a l t h problems. Through d i s c u s s i o n s , p r i o r i t y h e a l t h problems would emerge. I f t h e s e a r e very d i f f e r e n t from t h e n a t i o n a l p r i o r i t y problems, t h e group would have t o cons ider e i t h e r t o :

- look f o r another s tudy a r e a which i s more r e p r e s e n t a t i v e f o r the count ry ;

FHE/MCH/ RA/84. l Page 88

- f u r t h e r d i s c u s s the m a t t e r l o c a l l y t o s e e i f a compromise between the n a t i o n a l and l o c a l express ions of p r i o r i t i e s may be merged;

- c a r r y ou t the s tudy on t h e l o c a l p r i o r i t y problems which might r e s u l t in :

- a b e t t e r unders tanding of t h e divergence of h e a l t h problems i n t h e country ;

- non-appl ica t ion of the research f i n d i n g s a t the n a t i o n a l l e v e l .

I t would be wise t o d i s c u s s t h e m a t t e r f u l l y wi th t h e S t e e r i n g Committee of t h e Study, a s w e l l a s with the funder , s o t h a t a n agreement can be reached by a l l concerned.

The s t u d y group should fol low the p o l i c y guidance from the Minis t ry of Health. P r i o r i t i e s a r e u s u a l l y s e t a s a compromise between t h e d i f f e r i n g p r i o r i t i e s of d i f f e r e n t persons and groups. There is more t o p r i o r i t y s e l e c t i o n t h a n t e c h n i c a l a s p e c t s : t h e s tudy group must be s e n s i t i v e t o economic, s o c i a l , psychological and p o l i t i c a l a s p e c t s of h e a l t h . A canpromise between t h e d i f f e r e n t i n t e r e s t s must be reached i f t h e s tudy i s t o be r e a l l y u s e f u l i n t h e development of t h e MCH/FP a s p e c t of Primary Heal th Care i n the country.

One sys temat ic way of s e l e c t i n g p r i o r i t y h e a l t h problems i s through t h e use of c r i t e r i a . The fol lowing t e x t d e s c r i b e s d i f f e r e n t ways of u s i n g c r i t e r i a . Note t h a t the method descr ibed is no t a mathematical t o o l t o o b t a i n a CORRECT answer; i t i s a way of o rgan iz ing a d i s c u s s i o n and t o merge t h e op in ions of d i f f e r e n t persons and groups.

Making a p r i o r i t y mat r ix

There a re s e v e r a l ways i n which t o a l l o c a t e s c o r e s t o problems and weights t o c r i t e r i a from which a rank order w i l l emerge. A l l a r e b e t t e r than t h e wild guesses o r t h e " p o l i t i c a l l y " i n s p i r e d p r i o r i t y a l l o c a t i o n which a r e s o o f t e n found. The advantage of t h e methods proposed i s t h a t t h e ranking i s t h e r e s u l t of a l o g i c a l l y o rdered process . But even t h e s e methods a r e n o t e n t i r e l y o b j e c t i v e , they depend on t h e s u b j e c t i v e cho ice of c r i t e r i a , s c o r e s and weights .

Method 1 - The s imple m a t r i x

The s imple m a t r i x l ists t h e c r i t e r i a a c r o s s the top and t h e h e a l t h problems down t h e s i d e . ( I n t h e fol lowing examples we use t h e 5 c r i t e r i a of e x t e n t , s e r i o u s n e s s , prevantabi l i t y , l o c a l concern a d time t r e n d . )

You now t e s t each of t h e problems a g a i n s t each c r i t e r i o n t o s e e i f they apply. Only "yes" o r "no" is used. Each c r i t e r i o n can be s p e c i f i e d , f o r example: A d i s e a s e i s s e r i o u s i f i t i s among t h e f i v e major causes of m o r t a l i t y . O r i t may be l e f t vague: "There is a l o c a l concern because t h a t i s our impression". For example i f a problem ranks among t h e f i v e major causes of m o r t a l i t y , t h e answer under t h e c r i t e r i o n of " se r iousness" i s "yes", and a check i s made i n the a p p r o p r i a t e box.

When each problem has been reviewed a g a i n s t each c r i t e r i o n , the number of checks ( o r "yes" marks) given t o each problem can be counted. The h e a l t h problem wi th t h e h i g h e s t number of marks w i l l be t h e f i r s t p r i o r i t y problem; t h e problem wi th t h e second h ighes t number of marks w i l l be t h e second p r i o r i t y problem, a d s o on. I n our example, t o d d l e r a c c i d e n t s g e t a r a t i n g of 4 , equa l t o d i a r r h o e a , measles comes t h i r d with 2 .

F H E / M C H / R A / ~ ~ . ~ Page R 9

METHOD 1

9 8 9 1 I 1 v C r i t e r i a f o r p r i o r i t y a l l o c a t i o n 1 I 1 1 I

V 1 ' Local : Time : T o t a l : : Extent : Ser iousness : P r e v e n t a b i l i t y i : trend : score : I I I l , : Heal th problem : I l 1 I I

1 t I , , l I l 1 1 l 1 : Measles : X : I I X 1 t I : 2 :

l I l l l

: Diarrhoea : X : X 1 I X : X : : 4 : I I I U 1 : Toddler 1 I 1

l t X 1 X : X x 4 : : road a c c i d e n t s : I I l ! 1 I 1 I 1 1 1 I

This method h a s sane weaknesses: equa l weights a r e given t o each c r i t e r i o n and "yes/nol' assessments do no t t a k e i n t o account t h e d i f f e r e n c e s i n incidence and m o r t a l i t y .

Two ref inements c a n be used: a ) t h e c r i t e r i a can be given d i f f e r e n t weights which r e f l e c t t h e i r importance i n t h a t p a r t i c u l a r c u l t u r e , and /or b ) ~ e s / n o r a t i n g s can be rep laced by s a y , 10 po in t s c a l e s .

Method 2 - The m a t r i x with weighted c r i t e r i a

The weighted model i s based on t h e assumption t h a t n o t a l l t h e c r i t e r i a a r e of equa l importance. One way t o a s s i g n weights i s t o reach group consensus through d i s c u s s i o n on a weight ing from 1 t o 4 . For example:

- very important , is ass igned a r e l a t i v e weight of 4 - important , i s ass igned a r e l a t i v e weight of 3 - f a i r l y important , i s a ss igned a r e l a t i v e weight of 2 - l e s s important , i s a ss igned a r e l a t i v e weight of 1

The m a t r i x i s c o n s t r u c t e d a s i n Method 1 above. Rut before t h e t i c k s a r e added, each i s mri l t ip l ied by t h e weight of t h e column i n which i t appears .

I f you have decided t h a t :

Weight

- Exten t i s very important = - Ser iousness i s very important = - P r e v e n t a b i l i t y i s f a i r l y important = - Local concern i s important = - Time t rend i s l e s s important =

FHE/MCH/ RAI84.1 Page 90

The m a t r i x w i l l now look l i k e t h i s :

METHOD 2

I----------------

I I

t C r i t e r i a f o r p r i o r i t y a l l o c a t i o n I 1 1 I

l----------------I---------------------------------------------------------l-------*

I I : Local : Time : T o t a l : : Exten t : Ser iousness : P r e v e n t a b i l i t y , I I I , concern : t rend : score :

1 1

Weights : h : 4 I I 2 : 3 l ; - ; 1----------------1--------~-------------~----------------@---------*-------~-------f

I , I I I l l : Heal th problem : I I I

l l

I l I I

1 I I I t I 1

I

: Measles : 4 : 2 ! ! ! h ! l I I l l l I l

: Diarrhoea : 4 : 4 I 2 ! 3 ! : 13 ! 1 I l I 1 l l I

Toddler I l

1 1 4 I 2 : 3 1 1 0 :

I

: road a c c i d e n t s ', I I I I I I I I

I 1

I I

I I I I I I I l

1----------------~--------'-------------~----------------*---------~-------~-------~

The ranking h a s now changed - d i a r r h o e a comes f i r s t with 13, t o d d l e r road a c c i d e n t s second wi th 1 0 and measles l a s t wi th 6.

Method 3 - The m a t r i x with weighted c r i t e r i a and problem s c o r e s

This approach i s a f u r t h e r ref inement i n ' t h a t each problem is given a r a t i n g i n r e l a t i o n t o each c r i t e r i o n .

We can f o r example modify our s ta tement , "yes, measles i s preventable" t o "measles i s e a s i l y preventable" . The e a s e of p reven t ion can be r a t e d between 0 and 10. Measles would r a t e 10 ou t of 10 f o r p r e v e n t a b i l i t y . Diarrhoea i s l e s s e a s i l y p reven tab le and might on ly r a t e 5 o u t 10 f o r p r e v e n t a b i l i t y . We must determine the r a t i n g fo r each of our problems under each c r i t e r i o n before completing t h e mat r ix . For example:

l 1 Health I Score : I : C r i t e r i o n a l l o t e d : I problem , : ( o u t of 1 0 ) : l I I l

Measles : Exten t I 5 I l

l I

1 : Seriousness ; 5 I

, I

I : P r e v e n t a b i l i t y : 10 I

I I : Local concern 3

l

l I

1 : Time t rend I 2 I I

1 I I 1 : Diarrhoea : Extent I I 4 1

l I

I : Seriousness : 9 , I

I : P r e v e n t a b i l i t y : 5 I 1

I

I : Local concern 6 I

l I

I : Time t rend I 4 1 I

l I t I I : Toddler : Extent t 2 l I 1

: Road Accidents : Seriousness ; 9 I

1 I

1 : P r e v e n t a b i l i t y : 4 l

1 l

1 : Local concern ; 7 I

1 l

I : Time t rend 9 7 , I

I 1 I I I

FHE/MCR/RA/84.1 Page 91

Each of t h e s e r a t i n g s i s then e n t e r e d i n t o t h e r e l e v a n t box i n t h e mat r ix and m u l t i p l i e d by the weight of the c r i t e r i o n . The row t o t a l s of t h e s e products ( r a t i n g X weight) g i v e s a t o t a l score f o r each problem. I n our example t h e mat r ix now looks l i k e t h i s :

METHOD 3

1 I

C r i t e r i a f o r p r i o r i t y a l l o c a t i o n I I I I I I

I I I Local Time : T o t a l : : Exten t : Ser iousness : P r e v e n t a b i l i t y : I I I I Concern Trend : Score : 1 1

I I

: Weights 4 I 1 4 I I 2 3 ; l : - I I I l l l l I I l I

: H e a l t h : problem : 1 I : Measles : 5x4 = 2 0 : 5x4 = 20 10x2 = 20 : 3x3 = 9 : 2x1 = 2 : 71 ; I I l I l I I I : Diar rhoea : 4x4 = 16 : 9x4 = 36 5x2 = 10 : 6x3 = 18 : 4x1 = 4 : 84 : I l l I 1 1 l : Toddler : I I I 1 1 I I 1 I

l : road I I : 2x4 = 8 9x4 = 36 4x2 = 8 : 7x3 = 21 : 7x1 = 7 : 80 : : a c c i d e n t s : V I I I t I 1 I 1 I I

l l

I l 1 1 I l I 1 I 1 I l l l I '-----------1----------~-------------1----------------~----------f---------l-------l

Diarrhoea s t i l l emerges a s t h e t o p p r i o r i t y . But meas les , has moved up because we now inc lude a r a t i n g f o r s e r i o u s n e s s , l o c a l concern and time t r e n d , which we had n o t done when i t was on a "yes" or "no" answer.

But: Any m a t r i x is only a s good a s the numbers you put i n t o i t . Common sense has t o p r e v a i l . I f t h e r e s u l t s of your m a t r i x a n a l y s i s go a g a i n s t "common sense" we should review our m a t r i x , our method and our d a t a . Maybe we made a mistake, o r f o r g o t some th ing?

FHE/MCH/RA/84.1 Page 92

Exerc i ses 4.7

I n Exercise 4.6 t h e group made i t s t e c h n i c a l assessment of problems i n F i c t i t i a .

Naw you would l i k e t o know how the people s e e t h e i r own problems. You have spen t a cons iderab le amount of time d i s c u s s i n g the m a t t e r wi th t h e people i n a v i l l a g e . The i r views can be summarized a s follows:

"Ours i s a happy s o c i e t y with s t u r d y c h i l d r e n , bu t t o o few bab ies l i v e . Our women a r e worn o u t wi th c h i l d b e a r i n g and saddened by the l o s s of s o many babies . Many of our b a b i e s d i e b e f o r e they a r e born and many o t h e r s on ly l i v e a few days b e f o r e they g e t the " s t i f f n e s s " . I t i s only when our c h i l d r e n surv ive one moon t h a t we g ive them a name and b e l i e v e t h a t they w i l l grow up t o adulthood. Many of our young c h i l d r e n have d i a r r h o e a and become weak; some d i e . There have been seasons when our c h i l d r e n g e t s i c k with t h e mott led fever and aga in sane d i e . When they grow o l d e r and ven ture f u r t h e r a f i e l d , down t o t h e roadways, they a r e maimed o r k i l l e d by the l o r r i e s t h a t pass . Our wanen a r e t i r e d and weak and cannot look a f t e r our sons and some d i e dur ing c h i l d b i r t h . . . . ."

4.7.1 Use the r e s u l t s of t h e s e meet ings , t h e r e s u l t s of the previous d a t a c o l l e c t i n g , guesswork and rap id surveys t o list the h e a l t h problems t o be considered.

Prepare a mat r ix showing, on t h e h o r i z o n t a l a x i s , t h e 5 c r i t e r i a you a r e u s i n g , t o g e t h e r wi th t h e i r weights , and on t h e v e r t i c a l a x i s l i s t t h e h e a l t h problems.

4.7.2 Use the m a t r i x and Method 3 a s desc r ibed i n S e c t i o n 4.7 t o d e r i v e a score from which t h e p r i o r i t i e s a r e t o be der ived. Rank t h e problems. Name your " t a r g e t " h e a l t h problem.

4.7.3 Compare your m a t r i x with t h e m a t r i x of the F i c t i t i a s tudy group (g iven o v e r l e a f ) . Is your l i s t i n g of p r i o r i t i e s d i f f e r e n t ? I f yes , e x p l a i n how and why.

-

FHE/MCH/ W 8 4 .l Page 93

The matrix of t h e F i c t i t i a study g r o u p is:-

Criterin for priority allocation ' - - - - - _ _ _ _ _ _ _ _ - - - _ - - - - - - - @ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - V - - - - - - - 3

j Extent j Srriousness i Preventability i ' Time : , concern : trend : j

' - - _ _ - _ _ - - _ _ _ _ _ _ _ _ - - - - - - - ~ - - - - - - - - ~ - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - ~ - - - - - ~ - - - ~ - - ~ ~ ~ - ~ ~ ~ 3 ~ ~ ~ ~ - - - ,

Weights : 4 1 4 2 : 3 : 1 : ~------_---_______-------~--------~_------------~----------------~---------~---------.-~~~~--, : llcnlth problem : Toddler deaths. ; from measles : 4x5=20 : 4x9=36 : 2xb=12 : 3x3-9 : lxl=l : I8 ;

I Short birth interval : ix8-32 : 4x6~24 : 2 ~ 7 ~ 1 4 : 3x6=18 : 1x5=5 : 93 : : Postneonatal mortality : 4x7=28 : 4x9=36 2x8=16 : 3x5=15 : Ixl=l 96 : 1 Perinatal mortality : 4x8=32 1 4x9=36 : 2x7~14 : 3x8~24 : 1x10=10 : 116 : : Maternal mortality : 4x8=32 : 4~9.36 2x5~10 : 3x8=24 : 1x8-8 ; 110 : I----------_-___---------~--------I-------------+----------------~---------~---------*-------*

FHE/MCH/RA/84.1 Page 94