title: Measuring coverage in MNCH: a prospective validation study in Pakistan and Bangladesh on measuring correct treatment of childhood pneumonia.
abstract: BACKGROUND
  Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh.
  
  
  RESULTS
  Caregivers of 950 children under 5 y with pneumonia and 980 with "no pneumonia" were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry.
  
  
  CONCLUSIONS
  Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time.
authors.affiliation: Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan. tabishhazir@hotmail.com
authors.forename: Tabish
authors.initials: T
authors.lastname: Hazir
authors.forename: Khadija
authors.initials: K
authors.lastname: Begum
authors.forename: Shams
authors.initials: S
authors.lastname: El Arifeen
authors.forename: Amira M
authors.initials: AM
authors.lastname: Khan
authors.forename: M Hamidul
authors.initials: MH
authors.lastname: Huque
authors.forename: Narjis
authors.initials: N
authors.lastname: Kazmi
authors.forename: Sushmita
authors.initials: S
authors.lastname: Roy
authors.forename: Saleem
authors.initials: S
authors.lastname: Abbasi
authors.forename: Qazi Sadeq-Ur
authors.initials: QS
authors.lastname: Rahman
authors.forename: Evropi
authors.initials: E
authors.lastname: Theodoratou
authors.forename: Mahmuda Shayema
authors.initials: MS
authors.lastname: Khorshed
authors.forename: Kazi Mizanur
authors.initials: KM
authors.lastname: Rahman
authors.forename: Sanwarul
authors.initials: S
authors.lastname: Bari
authors.forename: M Mahfuzul Islam
authors.initials: MM
authors.lastname: Kaiser
authors.forename: Samir K
authors.initials: SK
authors.lastname: Saha
authors.forename: A S M Nawshad Uddin
authors.initials: AS
authors.lastname: Ahmed
authors.forename: Igor
authors.initials: I
authors.lastname: Rudan
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bryce
authors.forename: Shamim Ahmad
authors.initials: SA
authors.lastname: Qazi
authors.forename: Harry
authors.initials: H
authors.lastname: Campbell
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001459:Bangladesh / Q000453:epidemiology; D017028:Caregivers / Q000523:psychology; D016022:Case-Control Studies; D002662:Child Health Services / Q000592:standards*; D002675:Child, Preschool; D003906:Developing Countries; D005191:Family Characteristics; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000592:standards*; D006302:Health Services Research / Q000379:methods / Q000592:standards*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011939:Mental Recall; D010154:Pakistan / Q000453:epidemiology; D011014:Pneumonia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D015995:Prevalence; D015397:Program Evaluation; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012107:Research Design; D019035:Rural Health Services / Q000592:standards; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014741:Video Recording
chemical_list: D000900:Anti-Bacterial Agents