Under-five mortality estimates for low- and middle-income countries are primarily derived from detailed birth or pregnancy histories collected through in-person household surveys. Such surveys are, however, resource intensive and vulnerable to interruption during epidemic outbreaks and other crises. Remotely deployed mobile phone surveys can circumvent these disadvantages, but their suitability for measuring population-level mortality has not been demonstrated. In this contribution, we examine Malawian mobile phone survey data from the Summary Birth Histories, Truncated Pregnancy Histories, and Full Pregnancy Histories instruments for estimating under-five mortality. Considering the limited penetration and the unequal distribution of mobile phones in Malawi, quota sampling was used to ensure representation of population subgroups where mobile phone ownership is low, and poststratification methods were applied to further attenuate selection bias. Resulting probabilities of dying, or q(x)-before 28 days, 12 months, and 60 months of life-are compared against external estimates from a recent Demographic and Health Survey, a Multiple Indicator Cluster Survey, and model-based estimates from the UN Inter-agency Group of Child Mortality Estimation. Mobile phone survey estimates using the Summary Birth Histories capture the historical trends of q(12m) and q(60m) up to 2018, but they are less reliable for the most recent years. Compared with external sources, estimates from the Truncated Pregnancy Histories appear to be biased downward. Estimates of q(28d), q(12m), and q(60m) from the Full Pregnancy Histories are in line with those published by the UN Inter-agency Group, but they are also suggestive of a mortality excess during the COVID-19 outbreak in 2020‒2022. We conclude that mobile phone surveys are a promising method for collecting under-five mortality data, and particularly so via the Full Pregnancy Histories instrument.

OBJECTIVES:Bangladesh, a lower-middle-income (LMIC) South Asian country, relies on survey data for measuring adult mortality. Mobile phone surveys are an appealing alternative to in-person surveys because they are cheaper and can be deployed when enumerator mobility is hindered. In this contribution, we examined the quality of 'Parental Survival History' data collected over the phone by comparing it with data from a Health and Demographic Surveillance System. METHODS:We conducted a mobile phone survey from July to December 2021 among residents of the Matlab HDSS. Mobile phone survey data about the respondent's father and mother were individually matched to the HDSS database. Data were compared to the HDSS reference in terms of the vital status of the respondent's parents, their age, the time since death and adult mortality rates. RESULTS:A total of 2231 respondents reported information on their parents. Among these, 90.7% of fathers' names and 95.2% of mothers' names were matched between the mobile phone survey and the HDSS, and the matched dataset was used for subsequent analyses. Concordance in the vital status reports of the parent was very high (both sensitivity and specificity were above 99%). Further, we found that 50% of the parents' ages (current age for those who are alive and age at death for parents who died) were within 5 years below and 3 years above those recorded in the HDSS. Around 4% of parental deaths were erroneously located within or outside an 8-year reference period. The parents' mortality rate was 52.0 (95% CI: 49.3, 54.8) per 1000 person-years in the mobile phone survey and 52.3 (95% CI: 49.6, 55.0) in the HDSS. CONCLUSIONS:In this population, parental survival history data were reported with high accuracy in a mobile phone survey, highlighting their potential for measuring adult mortality in resource-constrained settings.

ABSTRACTBackgroundIn many African countries, there are limited representative data on HIV/AIDS mortality. We tested whether such data could be collected during household surveys periodically conducted in most African countries.MethodsWe added HIV questions to the module on adult and maternal mortality used in Demographic and Health Surveys. We conducted a validation study of the data generated by these questions in northern Malawi. We randomly assigned men and women aged 15–59 years old to a face-to-face interview or audio computer-assisted self-interviewing (ACASI). We compared survey reports of adult deaths to prospective data on mortality and HIV collected by the Karonga Health and Demographic Surveillance Site. We calculated the sensitivity and specificity of survey data in recording the HIV status of deceased siblings of respondents. We adjusted for partial verification bias using multiple imputations.ResultsWe interviewed 535 participants, who reported 885 deaths at ages 15 and older. The added HIV questions yielded largely complete data on the HIV status of respondents’ deceased siblings, particularly those who died recently. The adjusted sensitivity of survey data on HIV status of the deceased was high in both study groups (0.78–0.82). There were few false positive reports of the HIV status of deceased siblings (specificity = 0.96–0.98). ACASI did not improve the accuracy of survey data, but it required more time to collect mortality reports. Asking the HIV questions only took 0.4 minute (≈25 seconds) per deceased sibling in face-to-face interviews.ConclusionsAdding HIV questions to mortality questionnaires used in household surveys yields accurate data on the HIV status of deceased adults. These new data could aid in tracking progress towards global HIV elimination targets.MEIRU – LSHTM – JHU Partnership for improving adult mortality data1,2

OBJECTIVES:To test whether mobile phone surveys conducted remotely might generate data on deaths that are not covered by mortality surveillance systems established in laboratories and health facilities, or in institutions involved in the post-mortem management of corpses (e.g., morgues, cemeteries). METHODS:We conducted a national survey of mobile phone users in Bangladesh during the COVID-19 pandemic. Respondents were asked to list the deaths that had occurred in their household in recent years. For each death, they were also asked to indicate whether the deceased had been diagnosed with COVID-19 prior to death, whether the death occurred at home or at a health facility, and where the burial took place. Using these data, we represented the overlap between data generated by the mobile phone survey and several potential mortality surveillance systems, which focus on counting deaths in health facilities or communal cemeteries. We described the socio-demographic characteristics of the deaths that were uniquely recorded by the mobile phone survey. RESULTS:From December 2021 to July 2022, 506,659 calls were placed, resulting in 22,731 interviews completed by mobile phone. Respondents reported 1527 deaths that had occurred in their household since 2020. Among those deaths, 99 (6.5%) had received a pre-mortem diagnosis of COVID-19. The proportion of reported deaths that were not covered by other potential mortality surveillance systems, was 32.4% in the large city corporations of Dhaka and Chittagong, 36.3% in other urban areas and 49.6% in rural areas. In urban areas, deaths among men, as well as among youth and the elderly, were more likely to be covered solely by the mobile phone survey. CONCLUSION:Mobile phone surveys can potentially remedy gaps in the data generated by other recommended mortality surveillance methods.

OBJECTIVES:We evaluate the utility of mobile phone surveys (MPS) for estimating child mortality in Burkina Faso, where armed conflict and forced displacements hamper traditional face-to-face data collection on an important share of the territory. METHODS:We estimated under-five mortality from truncated birth histories collected in an MPS from September 2021 to October 2022. The sample consisted of telephone numbers collected in a prior face-to-face survey and an additional set of numbers generated through random digit dialling (RDD). We compared regionally disaggregated mortality estimates from the MPS with those from the 2021 Demographic and Health Survey (DHS), which could not cover parts of the national territory due to insecurity. RESULTS:Of 52,650 attempted phone numbers, 11,387 women of reproductive age were interviewed. Of these, 8077 were reached through RDD (36% lived in conflict-affected areas at the time of data collection) and 3310 via previously collected numbers (42% lived in conflict-affected areas). In regions not directly affected by conflict, under-five mortality rates have remained relatively stable over time: from 45 deaths per 1000 live births in 2018-2019 (95% CI: 36-54) to 58 in 2020-2022 (95% CI: 46-69). This finding mirrors the trend observed in the DHS data. In regions affected by armed conflict, however, the MPS data indicate a substantial increase in under-five mortality: From 47 deaths per 1000 live births in 2018-2019 (95% CI: 38-57) to 82 in 2020-2022 (95% CI: 67-98). This mortality reversal in conflict-affected areas is not apparent in the DHS, most likely due to the exclusion of the most insecure survey clusters from its sampling frame. CONCLUSION:MPS offers a viable alternative or complement to traditional face-to-face surveys for estimating child mortality in populations where insecurity limits face-to-face survey data collection.

Child mortality data in low- and middle-income countries are often derived from survey data prone to imprecision due to recall. Such imprecisions can affect the accuracy of date of birth (DOB) and age at death (AAD). Bandim Health Project runs two Health and Demographic Surveillance Systems (HDSSs) collecting prospective information on pregnancies, births, and deaths in Guinea-Bissau. In a survey, HDSS resident women were interviewed on their births and survival status of their children born within 5 years prior to the interview. We matched child records in the survey data to their corresponding records in the HDSS data based on sex, name, birth order, twinning status, and sibling names. We compared the risk and magnitude of displacement in DOB and AAD in regression models to identify risk factors for displacement. A total of 7679 out of 9960 survey-reported live births (78

OBJECTIVES:Human resource shortages create bottlenecks to preventive maternal and child health service provision in low-resource settings, making ad-hoc service rationing at the point of care necessary. Little is known about how healthcare providers prioritise. We explored healthcare providers' rationing decisions for preventive maternal and child health services in rural Guinea-Bissau through an experimental vignette design considering situational and care-seeker characteristics and performance goals. METHODS:We implemented two vignette experiments, one for antenatal care, and one for childhood vaccinations. At 55 health facilities, providers were requested to state their willingness to provide antenatal care/vaccination given a scenario of an acute facility-level human-resource shortage and combinations of contextualised factors, summarised in 16 vignettes per experiment: provider-care-seeker relationship (stranger/related) and distance (close/far) between care-seeker residence and facility (both experiments); gestational age (2nd/3rd trimester) and consultation number (1st/4th) (antenatal care experiment); child age (5/13 months), vaccine sought (Bacillus Calmette-Guérin/3rd Pentavalent vaccine (Penta3)), and number of other children waiting (3/12) (vaccination experiment). We also inquired about facility and interviewee characteristics. Using multilevel logistic regressions, we assessed associations between the factors and providers' stated willingness for each experiment. RESULTS:We interviewed a total of 159 healthcare providers; 112 provided antenatal care, 118 vaccinations. Interviewees in the antenatal care experiment stated willingness for antenatal care provision for 94% (1691/1792) of the vignettes (range across vignettes: 88%-99%). Last pregnancy trimester, long distance, and providers' work experience were associated with stated increased willingness. In the vaccination experiment, the interviewees stated their willingness to vaccinate for 72% (1357/1887) of the vignettes (range: 54%-95%). Younger child age, long distance, a higher number of other children waiting, and inquiring Penta3 rather than Bacillus Calmette-Guérin were associated with stated increased willingness, and we found a statistically significant interaction between age and the inquired vaccine. CONCLUSIONS:Situational and care-seeker characteristics and performance goals may influence facility-based ad-hoc service rationing in rural Guinea-Bissau.

In countries with limited civil registration and vital statistics systems, mortality estimates are often derived from periodic censuses and household surveys. Mobile Phone Surveys (MPS) offer a potentially cost-effective and efficient alternative for mortality monitoring. However, their utility for this purpose still requires rigorous evaluation. The Rapid Mortality Mobile Phone Surveys (RaMMPS) project aims to develop and validate methodologies for collecting mortality data through phone-based surveys. The Malawi RaMMPS fieldwork was conducted between 24 January 2022 and 28 July 2023 and included several survey modules, including respondent background characteristics, COVID-19 vaccination status, deaths in the household in the three months prior to the interview, parental survival histories, sibling survival histories, and pregnancy histories. The resulting datasets can be used for estimating mortality and assessing the impact of the COVID-19 pandemic. Survey paradata can be used for analysing respondent engagement and the data collection process in an MPS.

BACKGROUND: In many low- and middle-income countries (LMICs), the completeness of death registration is lower among women, hampering accurate monitoring of health and mortality, gender equality, and rights. OBJECTIVE: We quantify the gender gap in death registration and examine its determinants in Guinea-Bissau, a data-scarce West African context during 2020–2023, a period of potentially high mortality. METHODS: We collected survey data from 477 urban households where deaths had occurred among regular members since January 2020. We describe the characteristics and circumstances of these deaths. We then use logistic regressions to evaluate which factors are related to the likelihood of death registration. We apply Fairlie decomposition techniques to assess how much compositional factors explain the observed gender gap in death registration. Finally, we analyse reported reasons for (non-)registration. RESULTS: Of 610 reported deaths, only 24% were registered; no infant deaths were registered. Among adult deaths (ages 15+), registration rates were higher for men (44.7%) than for women (22.1%). Gender differences in education among adult decedents explained more than 60% of the gap. Post-mortem financial transfers motivated registering male deaths, whereas non-registration was linked to low perceived benefits and limited awareness of the registration process, regardless of gender. CONCLUSIONS: The observed under-registration of female deaths has implications for accurately representing and understanding gender-specific mortality and health trends. Low completeness can increase vulnerabilities for surviving relatives lacking death certificates, which are often needed to claim rights. Addressing knowledge barriers and introducing gender-sensitive incentives could help improve coverage and reduce gender disparities. CONTRIBUTION: Findings offer insights into a neglected dimension of gender inequality: its correlates and drivers in LMICs.

Supplementary methods of mortality surveillance are needed in settings with incomplete death registration. Local perceptions of mortality levels might be useful indicators of excess deaths. Early in the COVID-19 pandemic, we developed a survey question asking respondents to evaluate the recent frequency of funerals in their community relative to a pre-pandemic baseline. We asked this question of more than 400 residents of Karonga district in Malawi, who were interviewed up to five times during a panel survey conducted by mobile phone between June 2020 and May 2021. The proportion of respondents reporting more funerals than usual in their community increased in early 2021, indicating excess mortality not otherwise detected by case-based surveillance and only partially visible in reports of inpatient deaths at health facilities. Systems assessing changes in perceptions of mortality can be rapidly established during an epidemic and may help detect excess deaths at local levels.

BACKGROUND Mobile phone surveys (MPSs) have gained traction as a tool for gathering survey data, especially following the emergency of COVID-19. However, our understanding of MPS data quality in contexts with limited mobile phone penetration is still modest. OBJECTIVE This study evaluates (1) the circumstances under which mobile phone survey interviews were conducted and how these might influence the completion and quality of interviews, and (2) whether mortality-related questions upset respondents. METHODS We present descriptive statistics on respondents' locations and a few debriefing questions, complemented by an analysis of audio recordings from a selection of interviews. RESULTS Findings indicate that interviews conducted while respondents are in public places are more likely to be interrupted or take longer compared to interviews conducted when respondents are at home. Furthermore, mortality questions only rarely trigger emotional distress among respondents. We observed no discernible shifts in respondents' tone when answering mortality questions relative to other questions. CONCLUSION It is less desirable to conduct MPS interviews when respondents are in public places, especially on topics that require privacy. Additionally, although sensitive, mortality questions should be treated like any other, as they are largely not as upsetting as commonly perceived. CONTRIBUTION As MPSs continue to gain ground in low- and middle-income countries, establishing good practices related to the circumstances wherein respondents take interviews is crucial. Aside from being sensitive and respectful when asking survey questions, enumerators should treat mortality questions like any other. Only in a few instances do these questions typically trigger negative emotional reactions.

Guidelines for conducting surveys by mobile phone calls in low- and middle-income countries suggest keeping interviews short (<20 minutes). The evidence supporting this recommendation is scant, even though limiting interview duration might reduce the amount of data generated by such surveys. We recruited nearly 2,500 mobile phone users in Malawi and randomly allocated them to 10-, 20-, or 30-minute phone interviews, all ending with questions on parental survival. Cooperation was high in all groups, and differences in completion rates were minimal. The extent of item nonresponse, age heaping, and temporal displacement of deaths in data on parental survival generally did not vary between study groups, but reports of maternal age at death were more reliable in longer interviews. Recommendations about the duration of mobile phone interviews might be too restrictive. They should not preclude additional modules, including ones on mortality, in mobile phone surveys conducted in LMICs.

We recently highlighted the rapidly deteriorating circumstances faced by young children in Venezuela between 2008 and 2016.1 This reversal of a decades-long trend towards better health in the country occurred in the middle of a sharp economic downturn and a collapsing health system.2 Since then, the socioeconomic crisis affecting Venezuela has continued, leading to the greatest population displacements in the recent history of the Americas. Several vaccine-preventable diseases have also re-emerged,3 and multiple waves of the COVID-19 pandemic have further disrupted health services over the past 3 years.

La mortalité aux âges élevés reste peu documentée dans les pays où les systèmes d’enregistrement et les statistiques de l’état civil sont incomplets. Les enquêtes comportant des questions sur la survie des parents peuvent contribuer à combler cette lacune en fournissant des estimations de la mortalité des plus de 50 ans. Notre article évalue si des biais de sélection pourrait altérer la qualité de ces estimations. Nous analysons les données de trois observatoires de population et de santé regroupant 9 600 femmes et 8 500 hommes. Nous appliquons des modèles de Cox afin d’estimer la mortalité des femmes et des hommes âgés de 50 à 89 ans en fonction du nombre de leurs filles adultes (qui sont généralement les répondantes aux enquêtes). Les résultats indiquent que les personnes sans enfant vivant au moment de l’enquête font face à un risque de décès plus important. Les estimations de mortalité déduites des déclarations sur la survie des parents sont donc susceptibles de sous-estimer les niveaux de mortalité après 50 ans, même si aucun biais systématique n’apparaît clairement. La collecte de données sur la survie des parents constitue finalement un outil prometteur pour mesurer la mortalité aux âges élevés, étant donné le faible risque de biais de sélection.

We investigated behavioral responses to COVID-19 in Malawi, where a first wave of the pandemic occurred between June and August 2020. Contrary to many countries on the African continent, the Government of Malawi did not impose a lockdown or a stay-at-home order in response to the initial spread of SARS-CoV-2. We hypothesized that, in the absence of such requirements to restrict social interactions, individuals would primarily seek to reduce the risk of SARS-CoV-2 transmission during contacts, rather than reduce the extent of their social contacts. We analyzed 4 rounds of a panel survey spanning time periods before, during and after the first wave of the COVID-19 pandemic in Malawi. Five hundred and forty-three participants completed 4 survey interviews between April and November 2020. We found that the likelihood of attending various places and events where individuals work and/or socialize remained largely unchanged during that time. Over the same time frame, however, participants reported adopting on a large scale several behaviors that reduce the transmissibility of SARS-CoV-2 during contacts. The percentage of panel participants who reported practicing physical distancing thus increased from 9.8% to 47.0% in rural areas between April-May 2020 and June-July 2020, and from 11.4% to 59.4% in urban areas. The percentage of respondents who reported wearing a facial mask to prevent the spread of SARS-CoV-2 also increased, reaching 67.7% among rural residents in August-September 2020, and 89.6% among urban residents. The pace at which these behaviors were adopted varied between population groups, with early adopters of mask use more commonly found among more educated office workers, residing in urban areas. The adoption of mask use was also initially slower among women, but later caught up with mask use among men. These findings stress the importance of behavioral changes in containing future SARS-CoV-2 outbreaks in settings where access to vaccination remains low. They also highlight the need for targeted outreach to members of socioeconomic groups in which the adoption of protective behaviors, such as mask use, might be delayed.

ABSTRACTMany African countries have experienced a first wave of the COVID–19 pandemic between June and August of 2020. According to case counts reported daily by epidemiological surveillance systems, infection rates remained low in most countries. This defied early models of the potential impact of COVID–19 on the continent, that projected large outbreaks and massive strain on health systems. Theories proposed to explain the apparently limited spread of the novel coronavirus in most African countries have emphasized 1) early actions by health authorities (e.g., border closures) and 2) biological or environmental determinants of the transmissibility of SARS-CoV-2 (e.g., warm weather, cross-immunity). In this paper, we explored additional factors that might contribute to the low recorded burden of COVID–19 in Malawi, a low-income country in Southeastern Africa. To do so, we used 4 rounds of panel data collected among a sample of adults during the first 6 months of the pandemic in the country. Our analyses of survey data on SARS-CoV-2 testing and COVID-related symptoms indicate that the size of the outbreak that occurred in June-August 2020 might be larger than recorded by surveillance systems that rely on RT-PCR testing. Our data also document the widespread adoption of physical distancing and mask use in response to the outbreak, whereas most measured patterns of social contacts remained stable during the course of the panel study. These findings will help better project, and respond to, future waves of the pandemic in Malawi and similar settings.

BACKGROUND In many low- and middle-income countries, the mortality of adults over 50 years of age poorly monitored because death registration systems are deficient. Nationally representative surveys currently focus on the survival of children or adults aged 15 to 49 years. OBJECTIVE We propose to measure adult survival beyond age 50 via parental survival histories, which survey respondents provide data on their parents' ages at the time of the survey, and if deceased, their age at death and date of death. We evaluate the magnitude possible selection bias in parental survival histories and quantify the sample sizes needed to estimate mortality at ages 50 to 79 with varying levels of precision. METHODS We created a population with known parental survival histories using the 2013 national census of Senegal augmented with microsimulations. Using a stratified two-stage sampling procedure, we then conducted household surveys of this artificial population. We compared reference mortality levels in the artificial population of adults aged 50 to 79 years with those inferred from parental survival histories. We also analyzed selection bi ases in simulated populations where mortality above age 50 is correlated with the number of adult children. RESULTS The inclusion of modules on parental survival in large-scale surveys, such as the Demographic and Health Surveys, could provide accurate and precise estimates of old-age mortality and capture time trends and age patterns. Estimates derived from parental survival histories are affected by an upward bias when mortality is positively correlated with fertility, and vice versa, but the bias is modest and can be partially corrected. CONTRIBUTION Parental survival histories are a promising method to fill important data gaps around mortality at older ages, although more research is needed on possible reporting errors.

Not enough is known about old-age mortality in countries with limited civil registration and vital statistics systems. Surveys using parental survival histories (PSH) could help bridge this gap, providing estimates on deaths over age 50. We assess the potential for sample selection biases in these mortality estimates with data from three Health and Demographic Surveillance Systems in Senegal, covering around 9,600 women and 8,500 men. We use Cox models to estimate variation in mortality of men and women aged 50-89 according to the number of their adult daughters (typical survey respondents). Results indicate that older adults without surviving children are associated with a higher risk of mortality. PSH-based mortality estimates might therefore be lower than the 'true' levels of mortality over age 50, though we found no systematic bias. PSH is thus a promising instrument for measuring mortality in old ages, with sample selection bias likely minimal.