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Prev Chronic Dis ;5 4. Accessed [ date ]. Introduction High birth and immigration rates in the US-Mexico border region have led to large population increases in recent decades. Limited standardized information about health risks in this population hampers capacity to address local needs and assess effectiveness of public health programs. Methods We worked with binational partners to develop a system for reproductive health surveillance in the sister communities of Matamoros, Tamaulipas, Mexico, and Cameron County, Texas, as a model for a broader regional approach. We used a stratified, systematic cluster-sampling de to sample women giving birth in hospitals in each community during an day period August November 9 in We conducted in-hospital computer-assisted personal interviews that addressed prenatal, behavioral, and lifestyle factors.
We evaluated survey response rates, data quality, and other attributes of effective surveillance systems. We estimated population coverage using vital records data. The study sample included Differences between percentage distributions of birth certificate characteristics in the study and target populations did not exceed 2. Study population coverage among hospitals ranged from Conclusion indicate that hospital-based sampling and postpartum interviewing constitute an effective approach to reproductive health surveillance.
Such a system can yield valuable information for public health programs serving the growing US-Mexico border population. The US-Mexico border region reaches km north and km south of the international divide and is home to 14 million people 1 Figure 1. Ninety percent of the population resides in 14 pairs of economically and socially interdependent sister cities that lie on the 2,mile border 2,3. In , nearly , births occurred in these paired communities 4. High birth and immigration rates have caused a surge in population in this area in recent decades, and growth is projected to continue through at least 1.
Figure 1. Parcher, Sylvia N. Information about reproductive health in the border population is scant. Rates of health insurance coverage in US border counties are considerably lower than they are in any US state 5,6 , and the shortage of health care professionals is severe 7. Women from US border counties are less likely to receive prenatal care than are women in other counties in US border states, although their risk of infant death and preterm birth appear to be no greater 8,9.
Late or no prenatal care is particularly characteristic of adolescents in the region, who have birth rates among the highest in the United States 8,9. In Mexican border communities, adolescent birth rates are also believed to be high, and reducing maternal and infant mortality remain priorities 10, Growing concern about sexually transmitted infections and HIV risk is evident on both sides of the border US and Mexican border communities share common maternal and child health MCH goals for 15 , yet reliable baseline data are not available for many goals and related risk factors.
This information is essential for program planning and evaluation. Multiple factors contribute to the lack of reproductive health data in this dynamic region, including different data collection systems; inconsistent definitions for indicators; uneven distribution of services, such as telephone and mail delivery; low education levels; limited community resources; language barriers; and a mobile population To further complicate matters, the region includes 2 national, 10 state, and more than local and regional government entities.
On both sides of the border, these factors are obstacles to traditional survey and surveillance methods, which rely on standard definitions for health measures, complete telephone coverage, fixed residences, minimum reading levels, and data sharing among government institutions. We developed methods for reproductive health surveillance characterized by shared reproductive health goals, strong local and binational partnerships, and a bilingual approach to data collection.
Effective data collection methods developed in 1 pair of sister communities can be duplicated in other communities or used as a model for a region-wide approach. We describe the methods and operational from the pilot test conducted in 1 pair of sister communities in the US-Mexico border region. We chose Cameron County, Texas with the cities of Brownsville and Harlingen , and Matamoros, Tamaulipas, Mexico, as the paired site for this demonstration project because their population size was average among the sister communities , for Cameron County and , for Matamoros, in 19,20 and because of local interest in the project.
Starting in , we worked with University of Texas partners in Brownsville to expand partnerships and build support among local health authorities and providers of MCH services. Review of Texas birth records and discussions with health officials in Matamoros showed that most births in the Texas-Tamaulipas border region were occurring in hospitals, indicating that hospital-based sampling and postpartum interviews conducted in hospitals would yield data representative of mothers and infants in these communities.
We collected information on patient admissions and labor and delivery record-keeping procedures from each community hospital and used this information to de a procedure to sample and interview women who gave birth to live infants in these communities. We sought input from institutional partners throughout the process and worked closely with the Secretariat of Health in Tamaulipas to develop methods that would later be used to assess population coverage.
We met annually from through with community stakeholders to discuss progress with protocol development, solicit feedback, and plan next steps. Therefore, institutional review board approval was not required. Training materials and evaluation procedures were completed in July BMSCP collaborators include government, nongovernment, and academic institutions at the federal, state, and local levels Table 1.
We used a stratified, systematic cluster-sampling de Figure 2. The target population was women who gave birth to live infants in Matamoros and Cameron County, and the study population was women who gave birth to live infants in hospitals with or more deliveries in in each community.
A sample size of was planned for each community. Sample days were grouped as 2 consecutive days to minimize interviewer travel time and to allow staggered interviewing schedules by hospital for more efficient hospital coverage. From each of the 10 eligible hospitals 4 in Cameron County, 6 in Matamoros , we systematically selected blocks of 2 consecutive days between August 21 and November 9, All women who delivered a live infant on these days were sampled.
The sample size was expected to allow reasonable assessment of field operations, data collection, and data management activities and the opportunity for collaborative data analysis. Figure 2. Questionnaire topics were based on USMBHC Healthy Border 15 objectives related to MCH and chronic disease prevention, including lifestyle and risk behavior, family planning, prenatal health and care, HIV and cervical cancer screening, birth outcomes, child injury, and domestic violence.
Questions to obtain demographic information were also included. We reviewed survey instruments from the United States, Mexico, and elsewhere to identify relevant English- and Spanish-language questions, which were translated and modified as needed to reference the pregnancy time period. In each community, we conducted 2 focus groups among currently or recently pregnant adolescents and 2 among adult women to assess respondent ability and willingness to answer questions on the selected topics, familiarity with topic-specific terms, and views on interviews in hospital settings.
shaped the final bilingual instrument and interviewing method. Additional data collection forms developed for data and project management purposes are described in Table 2. One field coordinator FC and several interviewers 4 in Matamoros and 3 in Cameron County worked on each side of the border. All interviewers were students or medical professionals and residents of the area. Didactic training for field staff was conducted primarily in Spanish, but all training and reference materials were available in both languages and emphasized general interviewing techniques, sample identification, use of data collection forms, computer use, data entry, editing and processing, data management, and additional supervisory and managerial tasks for FCs.
At completion of the 5-day training, skills were assessed and practice interviews were scheduled as needed in hospitals the following week. Interviewers and FCs were compensated for their time in training. During data collection, FCs were employed for 4 months full-time, and interviewers were paid per completed interview. Interviewers visited each hospital for 3 consecutive days ie, the 2 sample days plus a third day to complete any outstanding interviews during each reporting period ie, the recurring cycle of sampled and nonsampled days for each hospital.
On each sample day, interviewers consulted the hospital delivery log book to identify women who had delivered a live infant during the 24 hours. As needed, field staff reviewed medical records and communicated with hospital staff to ensure that the sample contained all eligible women. Interviewers recorded information about women included in the sample on a delivery log review form DLRF , using a unique sample identification deed to protect the identity of the women. A contact sheet was then prepared for each potential respondent and used to track contact attempts and completed interviews.
Respondents who were ill or whose babies were severely ill or had died were deferred. Small gifts of appreciation were given to each respondent on completion of the interview. Interviewers entered questionnaire data into CSPro files on laptop computers, recorded tracking and respondent contact information on paper forms, and made back-up copies on diskettes Figure 3. Diskettes and paper tracking forms were given weekly to FCs.
FCs reviewed questionnaire data, keyed tracking information into electronic files, observed interviews, and provided feedback to interviewers. They checked hospital delivery log books against DLRFs to assess the completeness of the sample and monitored individual interview response rates and response rates of hospitals. The data manager created cumulative files and performed data quality checks with preprogrammed and ad hoc reports in CSPro.
Data were transferred to CDC and stored in 2 places for cross-verification purposes: the personal hard drive of the statistician and the share drive of the Division of Reproductive Health. Figure 3. We assessed hospital participation, survey response rate, population coverage, data representativeness, and data quality and incorporated procedures to monitor potential problems in these areas during data collection. To obtain additional information about these and other attributes and feedback from community and government stakeholders about potential usefulness of the data collected, a contracting agency conducted confidential stakeholder interviews during and after the completion of data collection.
To maximize hospital participation and to reduce the burden of data collection on hospital staff, we consulted with hospital administrators and nurses early in the process of protocol development and developed procedures to communicate regularly and to identify potential problems at their onset.
We computed survey response rates among women sampled in each community and overall. Additional data collected on the respondent contact sheet provided information about the of contact attempts and reasons for nonresponse. We assessed the degree of noncoverage attributable to 1 the omission of women from the target population who delivered live infants during the study period in hospitals not included in the study and 2 the failure to identify women in the study population who delivered live infants in the study hospitals during the sample days.
For comparison and linkage purposes, we accessed Tamaulipas and Texas state records of births that occurred in each community during the study period. As a check of the completeness of birth registration in Matamoros, we merged birth data from the Civil Registry, the vital statistics agency that receives 1 copy of the birth certificate, with those from the Secretariat of Health, which receives another copy. Potential bias from noncoverage of the target population no. To evaluate noncoverage of the study population no. We estimated the study population coverage rate by hospital as follows:.
A final weight that adjusts for the sampling de, nonresponse rate, noncoverage of the target population, and noncoverage of the study population was computed for each respondent. We assessed data representativeness by comparing the distribution of selected demographic characteristics age, birth weight, and delivery method of the BMSCP weighted sample with the distribution of demographic characteristics of the target population using study period birth certificate data from both communities.
We examined responses to survey questions and any additional information recorded by the interviewer to determine whether questions appeared to have been interpreted correctly by respondents and answered without difficulty. Each of the 10 hospitals eligible for inclusion agreed to participate in the project and participated throughout the study period. The overall response rate among women sampled was Average length of hospital stay varied among hospitals from 6 to 48 hours. Refusal to participate and discharge before the interview were rare Table 3.
The study population included Among registered births that reportedly occurred in study hospitals during sample days, BMSCP data weighted for sampling de, nonresponse rate, and noncoverage of the target and study populations are compared to vital statistics data Table 5. No statistically ificant differences in percentage distributions were found for maternal age, birth weight, or delivery method. Differences between unweighted BMSCP data and vital statistics data or weighted data were minimal data not shown. The average interview required 35 minutes 29 minutes in English and 37 in Spanish.
Respondents had difficulty answering a few questions. Nearly half of respondents who did not use contraception at first sexual intercourse could not recall the frequency of intercourse before first use. Skip patterns throughout the questionnaire appeared to have been followed correctly. Interview and tracking form data were reported to the FC within 1 week of interview. During the study period, power failures, flooding, and a dengue fever outbreak occurred The last event resulted in an acute shortage of hospital rooms for postpartum women.
Interviewers conducted the required interviews at the bedside, wherever the bed was located. In-kind contributions by local institutions to support field operations and indirect costs to CDC for assistance in implementing the project were not estimated.
from this study, as measured by traditional surveillance system evaluation criteria 23,24 , indicate that this approach may be effective in similar populations. Broad-based bilateral participation was important to the success of this pilot program. Early hospital concerns regarding demands on staff time, possible patient resistance, and confidentiality were addressed through communication and partnership development. Both US and Mexican local health officials provided in-kind support, such as office space and assistance with accessing local records. Early collaboration with local institutions and the involvement of local project staff were praised by stakeholders in postpilot interviews.Matamoros sex locals
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Mexico Crime & Safety Report: Matamoros