Courtland Robinson

Tsunami mortality in Aceh Province, Indonesia

OBJECTIVE Nine tsunami-affected districts in Aceh, Indonesia, were surveyed between February and August 2005 to characterize tsunami mortality. METHODS The surveys employed a two-stage cluster methodology with probability proportional to size sampling, and encompassed 1653 tsunami-displaced households with a pre-tsunami population of 10 063 individuals. FINDINGS Of the original pre-tsunami population, a total of 1642 people, or 17%, were reported as dead or missing in the tsunami. Crude mortality rates in the four survey areas ranged from a high of 23.6% in Aceh Jaya district on the west coast to 5.3% on the east coast. Age-specific mortality rates followed a similar pattern across the four survey areas, with the highest mortality concentrating in the youngest children (aged 0-9 years) and oldest adults (70+). The risk of mortality was significantly greater among females than males; this difference was most pronounced among individuals between ages 10 and 69 years, and diminished among younger and older age groups. CONCLUSION Mortality risk in the 2004 Asian tsunami varied by geographic location, age and sex. The districts of Aceh Jaya, Banda Aceh and Aceh Besar experienced the greatest mortality. Risk of death was highest among females, and among the oldest and youngest population subgroups. While the full human impact of the Asian tsunami in Aceh Province, in terms of lives lost or damaged, may never be fully measured, the resulting female deficit will likely be the tsunamis most deeply felt and prolonged impact.

Tsunami Mortality Estimates and Vulnerability Mapping in Aceh, Indonesia

OBJECTIVES We aimed to quantify tsunami mortality and compare approaches to mortality assessment in the emergency context in Aceh, Indonesia, where the impact of the 2004 tsunami was greatest. METHODS Mortality was estimated using geographic information systems-based vulnerability models and demographic methods from surveys of tsunami-displaced populations. RESULTS Tsunami mortality in Aceh as estimated by demographic models was 131066 and was similar to official figures of 128063; however, it was a conservative estimate of actual mortality and is substantially less than official estimates of 168561 presumed dead, which included those classified as missing. Tsunami impact was greatest in the district of Aceh Jaya, where an estimated 27.0% (n=23862) of the population perished; Aceh Besar and Banda Aceh were also severely affected, with mortality at 21.0% (n = 61 650) and 11.5% (n = 25 903), respectively. Mortality was estimated at 23.7% for the population at risk and 5.6% overall. CONCLUSIONS Mortality estimates were derived using methodologies that can be applied in future disasters when predisaster demographic data are not available. Models could be useful in the early stages of disaster response by facilitating geographic targeting and management of humanitarian assistance.

North Korean refugee health in South Korea (NORNS) study: study design and methods.

BackgroundUnderstanding the health status of North Korean refugees (NKRs), and changes in health during the resettlement process, is important from both the humanitarian standpoint and the scientific perspective. The NOrth Korean Refugee health iN South Korea (NORNS) study aims to document the health status and health determinants of North Korean refugees, to observe various health outcomes as they occur while adapting to the westernized lifestyle of South Korea, and to explain the mechanisms of how health of migrants and refugees changes in the context of new environmental risks and opportunities.MethodsThe NORNS study was composed of an initial survey and a follow-up survey 3.5 years apart. Participants were recruited voluntarily among those aged 30 or more living in Seoul. The survey consists of a health questionnaire and medical examination. The health questionnaire comprises the following six domains: 1) demographic and migration information 2) disease history, 3) mental health, 4) health-related lifestyle, 5) female reproductive health, and 6) sociocultural adaptation. The medical examination comprises anthropometric measurements, blood pressure and atherosclerosis, and various biochemical measurements. Prevalence of several diseases able to be diagnosed from the medical examination, the changes between the two surveys, and the association between the outcome and other measurements, such as length of stay and extent of adaptation in South Korea will be investigated. Furthermore, the outcome will be compared to a South Korean counterpart cohort to evaluate the relative health status of NKRs.DiscussionThe NORNS study targeting adult NKRs in South Korea is a valuable study because various scales and medical measurements are employed for the first time. The results obtained from this study are expected to be utilized for developing a health policy for NKRs and North Korean people after unification. Additionally, since NKRs are an immigrant group who are the same race and have the same genetic characteristics as South Koreans, this study has the characteristics of a unique type of migrant health study.

Tsunami-related injury in Aceh Province, Indonesia

Abstract The Asian tsunami, of December 2004, caused widespread loss of life. A series of surveys were conducted to assess tsunami-related mortality and injury, risk factors, care seeking and injury outcomes. Three surveys of tsunami-affected populations, in seven districts of Aceh province, were conducted between March and August 2005. Surveys employed a two-stage cluster design and probability proportional to size sampling methods. Overall, 17.7% (95% confidence interval (CI)=16.8–18.6) of the population was reported as dead/missing1 and 8.5% (95% CI=7.9–9.2) had been injured. Odds of mortality were 1.41% (95% CI=1.27–1.58) times greater in females than in males; risk of injury was opposite, with an odds of injury of 0.81 (95% CI=0.61–0.96) for females in comparison to males. Mortality was greatest among the oldest and young population sub-groups, and injuries were most prevalent among middle-aged populations (20–49). An estimated 25,572 people were injured and 3682 (1.2%) suffered lasting disabilities. While mortality was particularly elevated among females and among the youngest and oldest age groups, injury rates were the greatest among males and the working-age population, suggesting that those are more likely to survive the tsunami were also more likely to be injured.

A qualitative study of DRG coding practice in hospitals under the Thai Universal Coverage Scheme

BackgroundIn the Thai Universal Coverage health insurance scheme, hospital providers are paid for their inpatient care using Diagnosis Related Group-based retrospective payment, for which quality of the diagnosis and procedure codes is crucial. However, there has been limited understandings on which health care professions are involved and how the diagnosis and procedure coding is actually done within hospital settings. The objective of this study is to detail hospital coding structure and process, and to describe the roles of key hospital staff, and other related internal dynamics in Thai hospitals that affect quality of data submitted for inpatient care reimbursement.MethodsResearch involved qualitative semi-structured interview with 43 participants at 10 hospitals chosen to represent a range of hospital sizes (small/medium/large), location (urban/rural), and type (public/private).ResultsHospital Coding Practice has structural and process components. While the structural component includes human resources, hospital committee, and information technology infrastructure, the process component comprises all activities from patient discharge to submission of the diagnosis and procedure codes. At least eight health care professional disciplines are involved in the coding process which comprises seven major steps, each of which involves different hospital staff: 1) Discharge Summarization, 2) Completeness Checking, 3) Diagnosis and Procedure Coding, 4) Code Checking, 5) Relative Weight Challenging, 6) Coding Report, and 7) Internal Audit. The hospital coding practice can be affected by at least five main factors: 1) Internal Dynamics, 2) Management Context, 3) Financial Dependency, 4) Resource and Capacity, and 5) External Factors.ConclusionsHospital coding practice comprises both structural and process components, involves many health care professional disciplines, and is greatly varied across hospitals as a result of five main factors.

Adaptation and testing of psychosocial assessment instruments for cross-cultural use: an example from the Thailand Burma border

BackgroundThe purpose of this study was to develop valid and reliable instruments to assess priority psychosocial problems and functioning among adult survivors of systematic violence from Burma living in Thailand.MethodsThe process involved four steps: 1) instrument drafting and piloting; 2) reliability and validity testing; 3) instrument revision; and 4) retesting revised instrument.ResultsA total of N = 158 interviews were completed. Overall subscales showed good internal consistency (0.73-0.92) and satisfactory combined test-retest/inter rater reliability (0.63-0.84). Criterion validity, was not demonstrated for any scale. The alcohol and functioning scales underperformed and were revised (step 3) and retested (step 4). Upon retesting, the function scale showed good internal consistency reliability (0.91-0.92), and the alcohol scale showed acceptable internal consistency (0.79) and strong test-retest/inter-rater reliability (0.86-0.89).ConclusionsThis paper describes the importance and process of adaptation and testing, illustrated by the experiences and results for selected instruments in this population.

Large-scale "expert" mortality surveys in conflicts--concerns and recommendations.

SEVERAL LARGE-SCALE RETROSPECTIVE MORTALITY SURveys in conflict settings in Darfur, the Democratic Republic of Congo (DRC), Northern Uganda, and Iraq have had major political implications, and, thus, were scrutinized by policy makers, researchers, and the media. The controversies they generated led to serious criticism—some well-founded, some less so—that may have undermined the credibility of mortality surveys in conflict settings. For example, a 2006 survey estimated that more than 650 000 Iraqis died mostly from violence since the USled invasion in 2003; in contrast, another study found a substantially lower estimate of violence-related deaths at approximately 151 000. A 2007 study estimated that 5.4 million have died in DRC since 1998; another report questioned the methods of this study and claimed that the excess death estimate was at least 3 times too high. Rebuttals from various sources and conflicting studies focused on sampling and nonsampling biases. Given these concerns, higher standards and improved methods are needed for undertaking and reporting large-scale mortality surveys. To track mortality prospectively, a surveillance system should be established as early as possible in humanitarian emergencies. However, humanitarian organizations often rely on cross-sectional surveys to estimate death rates retrospectively. These surveys are time consuming, costly, logistically challenging, and require technical expertise. Methodologies to measure mortality have not been sufficiently validated. Mortality surveys are useful at the beginning of emergencies to document baseline mortality rates, monitor effectiveness of programs, prioritize interventions, and advocate for funding. These surveys generally are not published in peer-reviewed journals and may not attract much attention. These are the “operational” surveys that allow humanitarian organizations to make practical field decisions. They are neither designed to meet publication standards nor to establish precise benchmarks. Although their quality can be improved, these operational surveys are essential surveys to guide field programs. Large-scale mortality surveys in conflict settings—often seeking to measure mortality at a national level and over a relatively long period—have different objectives from smaller operational surveys. These “expert” surveys are rare and primarily conducted for advocacy purposes, to document severity of crises and possible human rights violations, and to call for additional international attention and funding. Their findings are broader in nature and often do not directly effect field interventions. These surveys are complex, expensive, and time consuming to implement and to disseminate results. Sampling design and methods of retrospective mortality surveys in conflict settings are areas of unsettled science. Lack of accurate population data before the crisis is complicated by population displacement, so accurate population listings necessary for random sampling are rarely available. Thus, cluster sampling is a default method in most humanitarian settings and has often meant reliance on 30 30 cluster surveys. Given the uneven distribution of violence, sample sizes, particularly number of clusters, should be significantly larger than have previously been used; especially because many surveys attempt to interpret findings by age, sex, or location. Therefore, 30 30 cluster surveys should rarely, if ever, be used in expert mortality surveys if the purpose is to estimate mortality at a national level. Larger sample sizes with more clusters are needed. Recall periods are another important issue. Shorter periods (eg, 1-3 months) may reduce recall bias and focus results on more proximate mortality events. However, they tend to increase imprecision in estimating rates for a given sample size because the number of deaths in shorter periods is likely to be fewer. Calendar error may also prove more significant in shorter recall periods because an error of only 1 week (eg, when a death occurred) would have a greater effect on estimates. Duration of recall periods in expert surveys should be appropriate to the time dimensions of the crisis-related mortality of interest while ensuring the sample power is sufficient for precision and valid comparisons. Nonsampling errors may be particularly important in expert surveys. Surveyors and survey participants may be under pressure to increase or decrease reported deaths. Who the surveyors are, how they are trained and super-

DRG coding practice: a nationwide hospital survey in Thailand.

BackgroundDiagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored.ObjectivesThis study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice.MethodsA questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding); the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis.ResultsSCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention.ConclusionHospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan

BackgroundThe utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.MethodsThe Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.ResultsOut of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.ConclusionUtilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

The Impact of Intergenerational Cultural Dissonance on Alcohol Use Among Vietnamese and Cambodian Adolescents in the United States.

PURPOSE Rates of alcohol use may be increasing among Asian-American adolescents. Among youth from Asian-immigrant families, intergenerational cultural dissonance (ICD), a difference in acculturation between children and caregivers, is associated with adverse childhood outcomes. This study investigates the longitudinal association of ICD and alcohol use among youth from immigrant Vietnamese and Cambodian families in the United States. METHODS Two waves of annual data, wave 4 (baseline for this study) and wave 5 (follow-up), were obtained from the Cross-Cultural Families Project, a longitudinal study of 327 Vietnamese and Cambodian immigrant families in Washington State. The Asian-American Family Conflicts Scale was used to measure ICD. Adolescent alcohol use was measured as any drinking in the past 30 days. A multiple logistic regression model was estimated with the outcome, alcohol use, measured at the follow-up visit and all predictors, including ICD, measured at baseline. Sex, nationality, nativity, and acculturation were tested as modifiers of the ICD-alcohol use relationship. RESULTS Nine percent of adolescents (age range 13-18 years) reported alcohol use at baseline and this increased significantly (p < .0001) to 16% one year later. ICD was associated with increased odds of alcohol use at follow-up (odds ratio: 1.57; 95% confidence interval: 1.03-2.41; p = .04). None of the interactions were statistically significant. CONCLUSIONS ICD is a significant predictor of alcohol use among Vietnamese and Cambodian adolescents. Interventions that should be targeted toward reducing ICD through enhancing parent-child communication and teaching bicultural competence skills may help prevent alcohol use problems among youth from immigrant families.