1. MICS4 Survey Design Workshop Multiple Indicator Cluster Surveys Survey Design Workshop Questionnaire for Children Under Five: Care of Illness

2. MICS4 Survey Design Workshop Presentation overview Pneumonia Diarrhoeal diseases Safe disposal of childrens stools

3. MICS4 Survey Design Workshop Leading causes of child deaths Pneumonia and diarrhoea are the leading causes of under-five deaths – causing an estimated 40% of child deaths each year globally Source: WHO Global Burden of Disease estimates (2004) Note: Globally more than one-third of under-five deaths is attributable to under-nutrition

4. MICS4 Survey Design Workshop Pneumonia

5. MICS4 Survey Design Workshop Background (Pneumonia) Refers to cases of suspected pneumonia (previously referred to as acute respiratory illness) Suspected pneumonia includes children reported to have an illness with a cough accompanied by fast and/or difficult breathing in the previous 2 weeks Simple cases of cold are filtered out with a second question: Were these (symptoms) due to a problem in the chest or a blocked or runny nose?

6. MICS4 Survey Design Workshop MICS Indicators (Pneumonia) Pneumonia (no change from MICS3) #3.9 Care seeking for suspected pneumonia % under fives with suspected pneumonia in the previous 2 weeks who were taken to an appropriate health provider #3.10 Antibiotics treatment of suspected pneumonia % under fives with suspected pneumonia in the previous 2 weeks who received antibiotics

7. MICS4 Survey Design Workshop –Prevalence of suspected pneumonia –Care-seeking for suspected pneumonia

8. MICS4 Survey Design Workshop –Antibiotic use for suspected pneumonia

9. MICS4 Survey Design Workshop Method issues (Pneumonia) Seasonality of suspected pneumonia may affect comparisons over time and across countries Does not measure timing or dosage of treatment, or type of antibiotic used Methodological work underway to assess validity of caregivers responses regarding treatment by drug type for major childhood illnesses (CHERG)

10. MICS4 Survey Design Workshop Diarrhoeal diseases

11. MICS4 Survey Design Workshop Background (Diarrhoea) Treatment recommendations have changed several times over past few decades Current treatment recommendations include fluid replacement (including breastfeeding) with continued feeding and zinc treatment ORS packets (specifically low-osmolarity ORS) are most effective for preventing & treating life-threatening dehydration due to diarrhoea

12. MICS4 Survey Design Workshop Background (diarrhoea) If ORS packets not available, recommended homemade fluids or increased fluids of any type also help prevent dehydration Continued feeding supports fluid absorption and improves nutritional status Zinc treatment reduces stool volume, including diarrhoea severity and duration

13. MICS4 Survey Design Workshop MICS Indicators (Diarrhoea) #3.8: ORT with continued feeding - % under fives with diarrhoea in the previous 2 weeks receiving ORT (ORS packet or recommended homemade fluid or increased fluids) and continued feeding Compound indicator reflects multiple components of treatment recommendations (except zinc treatment since data are largely unavailable at present) Previously reported ORT indicators not included (e.g. home management of diarrhoea and ORT use)

14. MICS4 Survey Design Workshop MICS Additional Indicators (Diarrhoea) Components of treatment recommendation (indicators) ORS packets % under fives with diarrhoea receiving an ORS packet (includes pre-packaged ORS fluids or fluids from an ORS packet) Recommended homemade fluids % under fives with diarrhoea receiving recommended homemade fluids (customized to national guidelines) Increased fluids % under fives with diarrhoea receiving more to drink during the illness Continued feeding % under fives with diarrhoea receiving either more, same or somewhat less to eat than usual during the illness Zinc treatment % under fives with diarrhoea receiving zinc

15. MICS4 Survey Design Workshop –Prevalence of diarrhoea –Fluids and foods

16. MICS4 Survey Design Workshop –ORS packet or recommended home fluid –Treatment for diarrhoea

17. MICS4 Survey Design Workshop Method issues (diarrhoea) Customization of survey questionnaire Adapt locally to include common names/brands used for ORS packets (including pre-packaged ORS fluids and fluids from ORS packets) If no pre-packaged ORS fluid available in the country, delete this category Adapt locally to include country-specific recommendations for homemade fluids based on national or medical guidelines. Ingredients promoted by government to make these fluids should be included in this category.

18. MICS4 Survey Design Workshop Method issues (diarrhoea) Other methodological issues Compound indicator – current treatment indicator reflects multiple components of recommendation (except zinc). Evaluate components to help interpret overall coverage value. Changing recommendations, changing indicators – lack of comparable data to measure progress in diarrhoea treatment –ORT use (1980s to early 1990s) - % U5s with diarrhoea receiving either an ORS packet or recommended homemade fluid –Home management of diarrhoea (early 1990s to early 2000s) - % U5s with diarrhoea receiving increased fluids and continued feeding –ORT with continued feeding (early 2000s to present) - % U5s with diarrhoea receiving ORT (ORS packet, RHF or increased fluids) with continued feeding

19. MICS4 Survey Design Workshop Method issues (diarrhoea) Other methodological issues (continued) Diarrhoea prevalence varies by season and timing of outbreaks, and caregivers understanding of what constitutes a diarrhoea episode. Does not measure duration or severity of diarrhoea, nor extent of dehydration accompanying episode. Does not measure number or timing of interventions used during episode, or whether ORS or homemade fluids were correctly prepared

20. MICS4 Survey Design Workshop Method issues (diarrhoea) Other methodological issues (continued) Customization of survey questionnaire often not done. For some countries, national guidelines for home fluids may not be defined or readily available to survey managers. Wording changes for ORT questions over time may affect responses (although surveys translated into many languages which also may lead to slight differences in question wording) Zinc included as response category, not as separate question – more work needed to see how this affects response

21. MICS4 Survey Design Workshop Method issues (diarrhoea) Other methodological issues (continued) Methodological work underway to assess issues outlined above, including whether accuracy of zinc responses improves if separate question included (CHERG) Forthcoming UNICEF and WHO report on diarrhoeal diseases to assess prevention and treatment coverage; set for release in Oct/Nov 2009

22. MICS4 Survey Design Workshop Safe disposal of childrens stools

23. MICS4 Survey Design Workshop Background (Child stools) Childrens stools tend to carry a higher pathogen load than adults stools Many children defecate in or around home, as well as play in areas where stools are found Safely disposing childrens stools is critical for reducing the number of diarrhoea cases

24. MICS4 Survey Design Workshop MICS Indicators (Child stools) # 4.4: Disposal of childs faeces - % under threes whose (last) stools were disposed of safely Adequate disposal includes used a toilet/latrine, rinsed in a toilet/latrine or buried stools. Adequacy of throwing in garbage depends on solid waste collection.

25. MICS4 Survey Design Workshop