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Reproductive health indicators for China's rural areas
Social Science & Medicine 57 (2003) 217–225
Reproductive health indicators for China’s rural areas Caroline C. Wanga,*, Yan Wangb, Kaining Zhangc, Jing Fangc, Wei Liuc, Shusheng Luob, Songyuan Tangc, Shaoxian Wangb, Virginia C. Lid a
Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029, USA b Beijing Medical University, Beijing 100083, China c Yunnan Reproductive Health Research Association, P.O. Box 43, 84 West Renmin Road, Kunming, Yunnan 650031, China d School of Public Health, University of California at Los Angeles, Los Angeles, CA 90272, USA
Abstract We report community-based development of reproductive health indicators for China’s rural areas. To generate these indicators, we sequenced two participatory techniques known as nominal group process and Delphi survey methodology. Nominal group process entailed grassroots reproductive health workers’ generating indicators, followed by refinement and prioritization of these indicators through a consensus-building Delphi process among nationally and internationally known reproductive health experts. Major criteria for the indicators were practicality, feasibility, and measurability within China’s rural areas. We explain the importance of establishing these indicators for application in rural China and other developing countries as a complement to the World Health Organization’s reproductive health indicators for global monitoring; present the identified indicators; and describe lessons learned from field testing in low-, middle-, and high-income counties of China’s countryside. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Reproductive health; Indicators; Community-based; China; Rural; Developing countries; Nominal group; Delphi
Introduction In 1994, a landmark event was held in the field of reproductive health and development: the International Conference on Population and Development (ICPD) in Cairo, where participants noted, ‘‘Reproductive health is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes’’ (United Nations, 1994). Thus, indicators for reproductive health may be construed as those variables that enable health workers to assess and monitor the state of the population’s reproductive well-being and to evaluate the effects of intervention programs. The Ministry of Health of China *Corresponding author. Tel.: +1-734-936-9854; fax: +1734-763-7379. E-mail address: [email protected] (C.C. Wang).
reported a 1997 rural area maternal mortality rate of 80.4 per 100,000 live births, and an infant morality rate of 37.7 per 1000 live births, both significantly higher than in urban areas (Ministry of Health, 1998). In their struggle to eliminate this disparity, Chinese rural health workers in this vast country are hampered by the lack of practical and measurable reproductive health indicators that may underlie mortality and morbidity data. In this paper, we report one of China’s major efforts to develop and field test community-based reproductive health indicators for rural areas, as a means to address this problem. An important historical precedent prompted this research. At the 1994 Cairo ICPD and the 1995 Beijing Fourth World Conference on Women, participants declared a platform of support for women’s rights in society and their quality of life concerns. Subsequently, the World Health Organization (WHO) proposed 15 reproductive health indicators for global monitoring
0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 3 4 1 - 6
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Table 1 WHO reproductive health indicators for global monitoring 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Total fertility rate Contraceptive prevalence rate Maternal mortality ratio Percentage of women attended, at least once during pregnancy, by skilled health personnel for reasons related to pregnancy Percentage of births attended by skilled health personnel Number of facilities with functioning basic essential obstetric care per 500,000 population Number of facilities with functioning comprehensive essential obstetric care per 500,000 population Perinatal mortality rate Percentage of live births of low birth weight (o2500 g) Positive syphilis serology prevalence in pregnant women (15–24) Percentage of women of reproductive age (15–49) screened for hemoglobin levels who are anemic Percentage of obstetric and gynecology admissions owing to abortion Reported prevalence of women with female genital mutilation Percentage of women of reproductive age (15–49) at risk of pregnancy who report trying for a pregnancy for 2 years or more Reported incidence of urethritis in men (15–49) HIV prevalence in pregnant women Knowledge of HIV-related prevention practices
(World Health Organization, 1997a, b), later amending the list to 17 indicators (World Health Organization, 2001) (Table 1), and captured two currents. From a disciplinary perspective, the WHO indicators were primarily grounded in a clinical approach to reproductive health, but also began to integrate the Cairo emphasis upon social and environmental factors. From a methodological perspective, the WHO initiative emphasized that reproductive health indicators are essential to assess reproductive health needs, to monitor whether programs are implemented effectively, and to evaluate program impact. The establishment of the WHO indicators for global monitoring, helped, encouraged China’s reproductive health workers to determine whether this specific information could be, and should be, assessed within their own rural areas. Operationalizing the WHO indicators poses significant challenges. Approximately 70% of China’s 1.29 billion people reside in the countryside. Access and conditions often make it extraordinarily difficult for health managers to collect what at first glance appear to be basic data, and may require them to make a major commitment of limited resources. While the WHO reproductive health indicators do provide a useful tool for global monitoring, rural reproductive health workers need more practical, feasible, and measurable indicators designed to guide programmatic development—both at the local level so that interventions and services are most relevant, and at the national level so that goals and healthful policy are set. China represents a potentially important case study because many of the challenges its health workers face in attaining data and leveraging scarce resources across vast terrain may be common to rural workers of other developing countries. In the development of these reproductive health indicators for rural areas, we used two participatory techniques: nominal group process and Delphi survey
methodology (Van de Ven & Delbecq, 1972; Linstone & Turoff, 1975). First, the nominal group process entailed grassroots reproductive health workers’ generating an extensive list of potential indicators. Strategies that reflect grassroots values and priorities may be more likely to be culturally resonant and more effective overall (Hatch & Eng, 1984; Minkler, 1978, US Department of Health and Human Services, 1985), and provide a key rationale for adopting the nominal group process as a community-based technique to help generate reproductive health indicators for a nation with more rural villages than any other. Subsequently, the Delphi method served as a consensus-building process among nationally and internationally known reproductive health experts to prioritize these community-based indicators. The major criteria for the indicators were practicality, feasibility and measurability within China’s rural areas. Given the necessity of these indicators for rural China as an effective complement to the World Health Organization’s reproductive health indicators for global monitoring, we describe the methodology, and report the indicators generated. Because variation in economic conditions may influence resource input for reproductive health programs and influence feasibility and outcomes, we pretested the indicators in low-, middle-, and highincome counties of rural China. We note lessons learned from the field test.
Methodology Nominal group Reproductive health researchers, practitioners, and administrators, as well as maternal and child health managers, contributed to development of the reproduc-
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tive health indicators discussed here. Many were veterans of the highly acclaimed Ford Foundationsupported Women’s Reproductive Health and Development Program of China’s Yunnan province (Li & Wang, 1998; Li et al., 2001). Focusing upon the biomedical, economic, and socio-political factors that affect reproductive health, this program garnered international praise for its success in involving provincial, township, and village leaders from the counties of Chengjiang and Luliang in a community-based approach to improving reproductive health. In the research reported here, the nominal group process brought the Women’s Reproductive Health and Development Program experience to the forefront of a community health planning process. The nominal group is a research instrument for exploratory health studies that enables participants to generate a high quality, quantity, and variety of ideas concerning problem definition (Van de Ven & Delbecq, 1972). As a participatory assessment procedure, the nominal group may involve anywhere between 6 and 8 individuals, up to several hundred, to provide study input (Gilmore, 1977; Wang, Reiter, Lentz, & Whapples, 1975). The purpose of this nominal group was to harvest the extensive experience and perspectives of those involved in the Women’s Reproductive Health and Development Program conducted in Yunnan’s counties since 1992. Not only was the nominal group process useful for qualitative problem exploration suitable to the subjective character of health planning efforts (Van de Ven & Delbecq, 1972), but it also generated the indicators that participants believed were important to reproductive health. Thirty-two women and 20 men were convened for the nominal group at the Institute of Health Science at the Kunming Medical College in the winter of 1998. Approximately half were practitioners and program managers who have been involved in the Women’s Reproductive Health and Development Program in Luliang and Chengjiang counties and townships. The remainder were members of the Yunnan Reproductive Health Research Association, among them administrators and program managers of the provincial health bureau, representatives of women’s groups, and researchers from the biomedical sciences and public health as well as social sciences and gender studies. Divided into eight groups, participants used round robin listing to generate a total of 476 potential indicators. By eliminating duplicate items, 180 individual indicators were retained and organized by group discussion into seven categories: (1) fertility and fertility regulation (i.e. Chinese family planning, 26 items); (2) pregnancy and delivery (i.e. safe motherhood, 27 items); (3) child health (7 items); (4) sexual health (25 items); (5) governmental action/policy (15 items); (6) women’s status (i.e. women’s development and empowerment, 37 items); and (7) rural community development (43
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items). Of these, the study team eliminated 18 items judged to be impractical or unfeasible as reproductive health indicators, such as health workers’ attitudes, families’ life style, ethnic minorities’ cultural conditions, and natural resources. The basis for elimination of additional indicators was low ranking by nominal group participants; 126 with highest consensus as ranked by the nominal group participants were reorganized for the Delphi I survey. Delphi survey The Delphi survey, originated at Rand Corporation in 1948, is used to explore a problem area by eliciting expert opinion in a systematic way (Linstone & Turoff, 1975). Because the Delphi survey is self-administered by mail, this approach prevents individuals from influencing one another in a group setting, and enables participation of people spread across a large geographical area. Both native Chinese and international experts were assembled for this Delphi survey questionnaire. The majority of the Chinese panel experts were identified by the study team, while most of the international experts were chosen with the help of the Ford Foundation reproductive health program officers. International experts included public health and health care specialists and social science and women’s studies scholars. To varying degrees, all had rural experience in developing nations. They lived in Australia, Brazil, Egypt, India, Jordan, Kenya, Malaysia, Mexico, Nigeria, Peru, the Philippines, Switzerland, Taiwan, Tanzania, Thailand, and the United States. The Chinese experts received their questionnaire in Chinese, while the international experts received theirs in English. The experts were asked to consider whether the indicators were practical, feasible and measurable for rural areas of developing countries, and to rank the indicators as ‘‘Important,’’ ‘‘Somewhat important,’’ ‘‘Not at all important,’’ ‘‘Uncertain as to importance,’’ or ‘‘Unfamiliar with concept.’’ In the letter of invitation to participate in the survey, the study team enclosed the definition of reproductive health adopted in the 1994 Cairo Conference and affirmed by the 1995 Fourth World Conference on Women in Beijing. The mailed Delphi survey questionnaire was administered to 63 Chinese experts and 60 international experts. To improve the response rate, first-round non-respondents were mailed surveys up to four times. In all, sixty (97%) of the Chinese experts and 43 (71.7%) of the international experts completed the first round of the Delphi survey. Only those who responded to Delphi I were mailed a Delphi II survey (described below). For Delphi II 57 (95%) of the Chinese experts and 43 (100%) of the international experts completed the survey. Table 2 summarizes the demographic characteristics by gender, professional background, and nation-
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Table 2 Number and percent of experts in Delphi survey by gender, professional background, and nationality Experts
Gender
Profession
Total
Male
Female
Biomedical
Social sciences
Chinese
International
103
39 (37.9)
64 (62.1)
41 (39.8)
62 (60.2)
60 (58.3)
43 (41.7)
ality of the experts who responded to both the Delphi I and II survey questionnaires. For Delphi I analysis, all items considered ‘‘Important’’ by a simple majority of either the Chinese experts or the international experts were included in Delphi II. Eliminating 76 indicators that did not meet the consensus standard from the original 126 in Delphi I, Delphi II retained 50 indicators from Delphi I. Because six of the original 15 WHO indicators were not generated by the nominal group process, these six were omitted from Delphi I, but they were included in the Delphi II questionnaire so as to enable the national and international experts to consider them as well. The Delphi II questionnaire also included 17 new indicators proposed by the national and international experts. Based on this process, the Delphi II was created and yielded a total of 73 potential indicators. For Delphi II analysis, an item ranked ‘‘Important’’ received a score of two; ‘‘Somewhat important’’ received a score of one; and ‘‘Not at all important,’’ received a score of zero. We included on our final list of community-based reproductive health indicators those receiving the highest mean scores. As one international expert completing the Delphi questionnaires noted, ‘‘It is important to differentiate reproductive health indicators from determinants of reproductive health behaviors.’’ We distinguished between the identified community-based reproductive health indicators for rural China and determinants for measuring achievements to improve reproductive health, and report the findings.
Community-based reproductive health indicators and determinants for China’s rural areas Through the nominal group process and the Delphi I and II surveys, we report 21 community-based reproductive health indicators for rural China, and compare them with the WHO reproductive health indicators for global monitoring (Table 3). We also report eight determinants for measuring achievements to improve reproductive health (Table 4). Items that had highest consensus from the experts were categorized as indicators or determinants. All but one of the indicators, and all of the determinants, were reviewed by the experts through the Delphi process of ranking. We added the 21st
Nationality
indicator, ‘‘HIV prevalence of reproductive age women,’’ which was hand written in by several of the international experts in the Delphi survey. For most rural communities of developing countries, indicator data on HIV prevalence of reproductive age women could not be generated, and thus fell outside the indicator criteria of practical, feasible, and measurable. Because of the global scourge of HIV infection and AIDS, the study team viewed this indicator as vital to the development of reproductive health, and urged health leaders and policy makers to allocate resources and take action to control the epidemic of HIV infection and AIDS. Comparing the indicators identified by the research participants with the WHO indicators for global monitoring, five indicators were identical, three were similar, and 13 were new (Table 3). Of the six WHO indicators excluded from Delphi I and added to Delphi II, none was selected by the national and international experts for inclusion among the final list of indicators. We did not directly ascertain Delphi survey participants’ reasons for exclusion of indicators. Field test of reproductive health indicators During April and May 2000, we field tested these reproductive health indicators identified for China’s rural areas. The purpose of the field test was to: (1) assess the feasibility and accessibility of collecting the indicators from existing records of reproductive health service organizations and governmental agencies; (2) determine the procedures and resources needed to acquire data in the absence of existing records; (3) obtain feedback from service providers and program managers about the reproductive health indicators’ utility as a program planning, monitoring, and evaluation tool. Field test site selection Counties in the provinces of Fujian, Hebei, and Yunnan representing respectively high, middle, and low socio-economic strata in China were selected for the field test. In Fujian province, Jinjiang County is located in the more developed coastal regions; in Hebei province, Laishui County in the central plains represented middle socio-economic development; and in Yunnan province, Huaning County in the mountainous southwest is less
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Table 3 Community-based reproductive health indicators for China’s rural areas and comparison with WHO reproductive health indicators for global monitoring
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
Community-based reproductive health indicators for China’s rural areas
Comparison with WHO reproductive health indicators for global monitoring
Total fertility rate Contraceptive prevalence rate Maternal mortality ratio Percentage of women attended, at least once during pregnancy, by skilled health personnel Proportion of villages with access to formally trained midwife Proportion of pregnant women who receive regular prenatal care Perinatal mortality rate Proportion of women with freedom to choose which type of contraception to use Proportion of children aged 0–5 immunized Prevalence of women who have reproductive tract infections Child mortality rate below age 5 (by age, by gender) Proportion of deliveries under antiseptic conditions Proportion of women with legal right to decide whether to bear children Neonatal mortality rate Proportion of women with high-risk pregnancy delivering at hospital Proportion of women with prenatal self-care knowledge Incidence of delivery complications Induced abortion rate Proportion of villages with emergency obstetric care Number of health care personnel who can diagnose and treat common reproductive tract infectious diseases per 100,000 HIV prevalence among reproductive age women
Identical Identical Identical Identical
Table 4 Determinants for measuring achievements in improving reproductive health 1. 2. 3. 4. 5. 6. 7. 8.
Proportion of villages with basic essential health care available Proportion of the local government’s budget allocated to reproductive health matters Proportion of villages with safe potable water Proportion of villages with transportation from village to town/city Proportion of villages with electricity Proportion of women who share in decisions about family expenditures Existence of organization responsible for women’s crisis intervention Proportion of reproductive age women who received tetanus vaccine
developed. In 1999, per capita income for the three counties were 27,192 renminbi (RMB), 3382 RMB, and 2240 RMB, respectively. Coordination and implementation A designated coordinating body for the field test was assigned to each site. The Fujian Provincial Health Education Institute coordinated the field testing in
to to to to
WHO WHO WHO WHO
indicator indicator indicator indicator
#1 #2 #3 #4
Comparable to WHO indicator #5 Comparable to WHO indicator #6 Identical to WHO indicator #8 New New New New New New New New New New New New New Comparable to WHO indicator #16
Jinjiang County; the Beijing Medical University’s School of Public Health coordinated Laishui County field testing; and the Yunnan Reproductive Health Research Association coordinated the Huaning County field testing. Implementation of the field test in each county was conducted by that county’s Maternal and Child Health Station. The Maternal and Child Health Station was selected because it is the depository center for routine health and family planning services records. Each coordinating institution designated one or two liaisons or supervisors to train the local staff to collect data and monitor progress. The field test version of the community-based reproductive health indicators was prepared by the Yunnan Reproductive Health Research Association. The field test version included: (1) preparation instructions; (b) definitions of indicators and important terms; and (3) a questionnaire for each indicator that described sources for data, methods, time required, key informants, number of persons involved in collecting the data, and difficulties encountered in the process. One-day training was provided by Chinese reproductive health researchers of the Yunnan Reproductive Health Research Association and Beijing Medical University’s School of Public Health for the local staff responsible for data collection at each county site. The training included an explanation of the field test
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objectives, importance of adhering to specifications set forth in the field test training, and methods for record review and data collection. The average time for field testing at each site was 28 days. Because of the broad sphere of the indicators, field test investigators were encouraged to locate data from multiple sources. Field test results and lessons learned Of the 21 indicators and eight determinants, only the determinant ‘‘proportion of reproductive age women who received tetanus vaccine’’ was completely unobtainable due to irregularity in coverage and lack of records. Further, our field test experience showed that only onethird of the proposed reproductive health indicators were readily available through the Maternal and Child Health Stations. Information on the remaining indicators and determinants were obtained from family planning agencies, the Women’s Federation, and the Bureaus of Traffic, Water, and Electricity. Field testers reported that they obtained most of the indicator data from local Maternal and Child Health Stations, which emphasized clinical service and care delivered to mothers and infants. By contrast, field testers turned largely to non-health sectors and organizations to acquire data for the determinants, which focused upon women’s status, government policy and action, and rural community resources. The field test experience highlighted the necessity of intersectoral collaboration in the enhancement of women’s health. In addition, we recognized that indicator findings may be fraught with reporting bias. For example, induced abortion data are under reported because of the omission of induced abortions among unmarried women by private practitioners. In many rural areas, health workers may under report the proportion of pregnant women with anemia because of inaccessibility of hemoglobin testing for all women. Health workers may include different diseases or conditions in assessing the total reproductive tract infection rate. They may even weigh some newborn infants swaddled in embroidered blankets so as to prevent exposure to cold, or other infants not at all because of lack of a scale. To reduce reporting bias, field testers recommended that training for local reproductive health workers emphasize adherence to guidelines in the reporting of data upon which indicator findings are based. A few of the items required special assessment because data were not readily available. Field test investigators said that the indicators ‘‘proportion of women with freedom to choose which type of contraception to use,’’ and ‘‘proportion of women with legal right to decide whether to bear children,’’ as well as the determinant ‘‘proportion of women who share in decisions about family expenditures,’’ were most likely to need special assessment.
Despite these difficulties, the field testers reported that most of the indicators could be practically and feasibly obtained and measured. The data for the indicators were relatively easy to retrieve from the procedures set forth in the field test version. Program managers and administrators noted that the indicators filled an important need by providing a standardized monitoring tool to give feedback to providers on service delivery, and to decision makers in planning policy and resource allocation.
Discussion In sequencing the nominal group process and the Delphi technique first and second, respectively, we sought to avoid two exclusive paradigms. The first is an extreme scholastic stance that diminishes or even ignores the grassroots expertise and wisdom of community-based workers in determining what can be achieved. The second is an extreme participatory reduction that denies the contribution of established national and international scholars in discerning what might be valuable at the local level. The nominal group process allowed us to make use of participants’ knowledge about local conditions and culture that affect reproductive health, as well as their insights about constraints upon resources needed to collect relevant data. In turn, the Delphi survey technique allowed us to tap distinguished national and international scholars’ expertise. In other words, combining the methodologies in the manner we chose allowed the selected indicators to be informed by an intimate local understanding of the difficulties that occur in collecting data in poor rural regions, as well as by national and international experts’ broad knowledge about reproductive health. Integrating the methodologies offers a composite tool to balance some of the challenges that arise in actualizing the far-sighted Cairo definition of reproductive health. By requiring many of the indicators to be filtered through the experience of people at the local level, this study serves as a modest litmus test for the usefulness and applicability of the WHO indicators to the situation of Chinese rural health workers. Speaking to burgeoning reproductive health issues affecting vast numbers of rural people, our research begins to offer a preliminary and pragmatic enhancement to the WHO indicators. While the world’s imagination is increasingly captured by visions of an industrialized China, approximately 30 million of its people live as ‘‘abject poor’’ by rigorous Chinese poverty measurement criteria, and the conditions in which they live may challenge notions about what reproductive health data are particularly pertinent or are even currently available. For example, for the excluded WHO indicators, we speculate that the research participants perceived one
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indicator as comparatively less critical (percentage of women aged 15–49 at risk of pregnancy who report trying for a pregnancy for 2 years or more); deemed it unfeasible to obtain data for two indicators [positive syphilis serology prevalence in pregnant women (15–24), percentage of women and reported incidence of urethritis in men (15–49)]; and viewed one indicator as out of line with Chinese cultural practice (reported prevalence of women with female genital mutilation). We observe additional differences of interest between the community-based indicators for rural China identified and the WHO indicators for global monitoring. We viewed one indicator, ‘‘Proportion of pregnant women who receive regular prenatal care’’ as related to the WHO indicator ‘‘Number of facilities with functioning basic essential obstetric care per 500,000;’’ a key difference is that the former is specified from the perspective of consumers, and the latter from the perspective of service providers. Two of the new indicators generated, ‘‘Proportion of women with freedom to choose which type of contraceptive to use,’’ and ‘‘Proportion of women with legal right to decide whether to bear children,’’ received high consensus scores from both the Chinese national and international experts, and may signify an expression of concern with women’s rights and status. ‘‘Proportion of children aged 0–5 immunized’’ is an unconventional reproductive health indicator. On inquiry, study participants said that given that a child not immunized has higher mortality risk, a mother whose child has died may then decide to bear another child, and endure the attendant risks and consequences to reproductive health. The indicator ‘‘Child mortality under age 5 by age, by gender’’ provides implicit recognition of the high mortality in many rural areas, and provides information about attitudes and actions towards the care or neglect of female children. Another new indicator, ‘‘Proportion of deliveries under antiseptic conditions’’ underscores that in rural areas, many or most deliveries occur at home. ‘‘Neonatal mortality rate’’ is a highly sensitive indicator for child mortality as many newborns do not survive the first 28 days of life. One major cause, and potentially related to the previous indicator, is tetanus contracted through contaminated cutting of the umbilical cord. Our past field experience has suggested that many Chinese women may not pay much attention to contraception because they have the mistaken impression that abortion is easy and painless. The indicator ‘‘Induced abortion rate’’ may provide one crude but important measure of physical, mental, and social well-being related to reproductive age women. We believe that researchers in other developing countries can usefully replicate the methodology to test the validity of our reported reproductive health indicators in their own rural areas. In adopting the methodol-
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ogy, they should be aware of several drawbacks. First, both the nominal group process and the Delphi survey technique are consensus-based methodologies. Because of pragmatic time considerations, they offer the researchers extremely limited opportunity to gain systematic insight on the reasons why any given indicator is prioritized or eliminated. This information may be partially excavated in other ways, such as by indepth interviewing of a subset of informants. Second, bias obviously exists in the selection of experts, who in turn influence final selection of the indicators. As Rufus Miles, cited by Linstone (1975), put it, ‘‘Where you stand depends on where you sit.’’ The criteria of practicality, feasibility, and measurability constrained the selection of indicators that might otherwise be deemed important to women’s reproductive health. Two rounds of the Delphi survey resulted in 20 indicators, with ‘‘HIV prevalence among reproductive age women’’ added by the study team to yield a total of 21 indicators, and eight determinants. To the study team’s surprise, many of the indicators from the nominal group process related to government policy and action, women’s education and status, sexual health, and rural community development failed to receive a consensus score high enough to be included among these final indicators and determinants. We speculate that many experts perceived these items to be important contributors to the Cairo definition of reproductive health, but that even those experts who advocate a broader definition of reproductive health may also discern a disparity between the ideal and the achievable. For example, the indicators selected do not address the reproductive health concerns of menarchal women, nor do they focus on adolescents, men, or menopausal women. Mental well-being is a significant issue within reproductive health but is difficult to measure and evaluate because of cost, the need for confidentiality, and other constraints. As a result, the majority of the indicators selected are within the more traditional scope of the maternal and child health field because of service coverage or inadequacy of reporting. Health workers applying these community-based indicators for planning, monitoring, and evaluation in other countries may encounter difficulties that were not apparent in the Chinese communities. Because each country and rural area have their distinct socio-cultural characteristics, policies, religion, and customs, the indicators defined in this study may require further modifications and adaptation. Other countries and areas undoubtedly show variation in the amount and types of existing data. Over reporting and under reporting may occur for reasons specific to the areas. The validity and utility of the indicators depends on the particular setting in which one is working and the quality of the information system itself.
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Successful field testing of the community-based reproductive health indicators in three counties of three provinces of China representing high, middle, and low socio-economic development instilled confidence that the indicators are practical, feasible, and measurable within rural China, and may have broader applicability to rural areas of other developing countries. Of all the indicators and determinants, only one—proportion of reproductive age women who received tetanus immunization—was not obtainable due to irregularities in service delivery and reporting. Additionally, individual field test sites encountered difficulties in data collection for four to eight indicators because of lack of readily available data. Systematic record keeping must be improved. The proposed reproductive health indicators for rural China, and the manner by which they were generated, play into two related issues. The first question centers on whether indicators might most usefully be global in nature, or locally defined? China itself, with its contrasts of urban versus rural, industrial versus agricultural, coastal versus inland, northern versus southern, and affluent versus poor, is a land of immense regional variation. The move toward global reproductive health indicators reflects a vision for a worldwide standard of decent reproductive health. At the same time, we argue that implementation of reproductive health indicators ought to reflect the capabilities and concerns of specific regions; the wherewithal even to generate reproductive health data differs according to economic and infrastructure considerations. The second debate returns to the parameters of the very definition of reproductive health. While some indicators for China’s rural areas might ideally reflect the Cairo definition of reproductive health, the lower priority scores of indicators focusing on government policy and action, women’s education and status, sexual health, and rural development suggests a clinical emphasis. As kin to the first debate, when criteria for indicators include practicality, feasibility, and measurability, the struggle toward the broader Cairo definition of reproductive health may give rise to reproductive health workers’ own dilemmas about where to focus and most effectively prioritize their efforts. The WHO reproductive health indicators provide an important and visionary benchmark for global monitoring. At the same time, current constraints on practicality, feasibility, and measurability diminish the potential for China’s rural health workers to use them broadly. To test the validity of the reproductive health indicators named here for their own locales, we recommend that health workers in other developing countries consider sequencing the nominal group process with the Delphi survey technique. Integrating the two methods serves to resolve the potential dilemma of the nominal group process’s yielding rich but
unwieldy data, and of the Delphi technique’s tapping the wisdom of self-referential experts without benefit of community-based insight to inform the locally focused survey content. In China’s rural areas, monitoring and evaluating the reproductive health of millions of people provides a challenge as daunting as it is urgent. We hope that the indicators reported here will enable researchers, practitioners, administrators, and program managers to move toward a more comprehensive approach to intervention, services, and healthful policy. By enhancing their reproductive health, we strive to improve the life options and the overall well-being of women, men, and children in rural populations.
Acknowledgements We would like to thank the Ford Foundation; without support from the Sexuality and Reproductive Health Program of its Beijing Office, this work would not have been possible. We are grateful to the Yunnan nominal group participants and the Chinese national and international reproductive health experts whose views provide the background for this paper, and to Dr. Guan Jihui of the Fujian Health Education Institute for her help in the field testing. We thank Zhao Jie for thoughtful input on indicators related to women’s status. The editor, reviewers, and Fong Wang provided valuable suggestions.
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Reproductive health indicators for China’s rural areas Caroline C. Wanga,*, Yan Wangb, Kaining Zhangc, Jing Fangc, Wei Liuc, Shusheng Luob, Songyuan Tangc, Shaoxian Wangb, Virginia C. Lid a
Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029, USA b Beijing Medical University, Beijing 100083, China c Yunnan Reproductive Health Research Association, P.O. Box 43, 84 West Renmin Road, Kunming, Yunnan 650031, China d School of Public Health, University of California at Los Angeles, Los Angeles, CA 90272, USA
Abstract We report community-based development of reproductive health indicators for China’s rural areas. To generate these indicators, we sequenced two participatory techniques known as nominal group process and Delphi survey methodology. Nominal group process entailed grassroots reproductive health workers’ generating indicators, followed by refinement and prioritization of these indicators through a consensus-building Delphi process among nationally and internationally known reproductive health experts. Major criteria for the indicators were practicality, feasibility, and measurability within China’s rural areas. We explain the importance of establishing these indicators for application in rural China and other developing countries as a complement to the World Health Organization’s reproductive health indicators for global monitoring; present the identified indicators; and describe lessons learned from field testing in low-, middle-, and high-income counties of China’s countryside. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Reproductive health; Indicators; Community-based; China; Rural; Developing countries; Nominal group; Delphi
Introduction In 1994, a landmark event was held in the field of reproductive health and development: the International Conference on Population and Development (ICPD) in Cairo, where participants noted, ‘‘Reproductive health is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes’’ (United Nations, 1994). Thus, indicators for reproductive health may be construed as those variables that enable health workers to assess and monitor the state of the population’s reproductive well-being and to evaluate the effects of intervention programs. The Ministry of Health of China *Corresponding author. Tel.: +1-734-936-9854; fax: +1734-763-7379. E-mail address: [email protected] (C.C. Wang).
reported a 1997 rural area maternal mortality rate of 80.4 per 100,000 live births, and an infant morality rate of 37.7 per 1000 live births, both significantly higher than in urban areas (Ministry of Health, 1998). In their struggle to eliminate this disparity, Chinese rural health workers in this vast country are hampered by the lack of practical and measurable reproductive health indicators that may underlie mortality and morbidity data. In this paper, we report one of China’s major efforts to develop and field test community-based reproductive health indicators for rural areas, as a means to address this problem. An important historical precedent prompted this research. At the 1994 Cairo ICPD and the 1995 Beijing Fourth World Conference on Women, participants declared a platform of support for women’s rights in society and their quality of life concerns. Subsequently, the World Health Organization (WHO) proposed 15 reproductive health indicators for global monitoring
0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 3 4 1 - 6
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Table 1 WHO reproductive health indicators for global monitoring 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Total fertility rate Contraceptive prevalence rate Maternal mortality ratio Percentage of women attended, at least once during pregnancy, by skilled health personnel for reasons related to pregnancy Percentage of births attended by skilled health personnel Number of facilities with functioning basic essential obstetric care per 500,000 population Number of facilities with functioning comprehensive essential obstetric care per 500,000 population Perinatal mortality rate Percentage of live births of low birth weight (o2500 g) Positive syphilis serology prevalence in pregnant women (15–24) Percentage of women of reproductive age (15–49) screened for hemoglobin levels who are anemic Percentage of obstetric and gynecology admissions owing to abortion Reported prevalence of women with female genital mutilation Percentage of women of reproductive age (15–49) at risk of pregnancy who report trying for a pregnancy for 2 years or more Reported incidence of urethritis in men (15–49) HIV prevalence in pregnant women Knowledge of HIV-related prevention practices
(World Health Organization, 1997a, b), later amending the list to 17 indicators (World Health Organization, 2001) (Table 1), and captured two currents. From a disciplinary perspective, the WHO indicators were primarily grounded in a clinical approach to reproductive health, but also began to integrate the Cairo emphasis upon social and environmental factors. From a methodological perspective, the WHO initiative emphasized that reproductive health indicators are essential to assess reproductive health needs, to monitor whether programs are implemented effectively, and to evaluate program impact. The establishment of the WHO indicators for global monitoring, helped, encouraged China’s reproductive health workers to determine whether this specific information could be, and should be, assessed within their own rural areas. Operationalizing the WHO indicators poses significant challenges. Approximately 70% of China’s 1.29 billion people reside in the countryside. Access and conditions often make it extraordinarily difficult for health managers to collect what at first glance appear to be basic data, and may require them to make a major commitment of limited resources. While the WHO reproductive health indicators do provide a useful tool for global monitoring, rural reproductive health workers need more practical, feasible, and measurable indicators designed to guide programmatic development—both at the local level so that interventions and services are most relevant, and at the national level so that goals and healthful policy are set. China represents a potentially important case study because many of the challenges its health workers face in attaining data and leveraging scarce resources across vast terrain may be common to rural workers of other developing countries. In the development of these reproductive health indicators for rural areas, we used two participatory techniques: nominal group process and Delphi survey
methodology (Van de Ven & Delbecq, 1972; Linstone & Turoff, 1975). First, the nominal group process entailed grassroots reproductive health workers’ generating an extensive list of potential indicators. Strategies that reflect grassroots values and priorities may be more likely to be culturally resonant and more effective overall (Hatch & Eng, 1984; Minkler, 1978, US Department of Health and Human Services, 1985), and provide a key rationale for adopting the nominal group process as a community-based technique to help generate reproductive health indicators for a nation with more rural villages than any other. Subsequently, the Delphi method served as a consensus-building process among nationally and internationally known reproductive health experts to prioritize these community-based indicators. The major criteria for the indicators were practicality, feasibility and measurability within China’s rural areas. Given the necessity of these indicators for rural China as an effective complement to the World Health Organization’s reproductive health indicators for global monitoring, we describe the methodology, and report the indicators generated. Because variation in economic conditions may influence resource input for reproductive health programs and influence feasibility and outcomes, we pretested the indicators in low-, middle-, and highincome counties of rural China. We note lessons learned from the field test.
Methodology Nominal group Reproductive health researchers, practitioners, and administrators, as well as maternal and child health managers, contributed to development of the reproduc-
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tive health indicators discussed here. Many were veterans of the highly acclaimed Ford Foundationsupported Women’s Reproductive Health and Development Program of China’s Yunnan province (Li & Wang, 1998; Li et al., 2001). Focusing upon the biomedical, economic, and socio-political factors that affect reproductive health, this program garnered international praise for its success in involving provincial, township, and village leaders from the counties of Chengjiang and Luliang in a community-based approach to improving reproductive health. In the research reported here, the nominal group process brought the Women’s Reproductive Health and Development Program experience to the forefront of a community health planning process. The nominal group is a research instrument for exploratory health studies that enables participants to generate a high quality, quantity, and variety of ideas concerning problem definition (Van de Ven & Delbecq, 1972). As a participatory assessment procedure, the nominal group may involve anywhere between 6 and 8 individuals, up to several hundred, to provide study input (Gilmore, 1977; Wang, Reiter, Lentz, & Whapples, 1975). The purpose of this nominal group was to harvest the extensive experience and perspectives of those involved in the Women’s Reproductive Health and Development Program conducted in Yunnan’s counties since 1992. Not only was the nominal group process useful for qualitative problem exploration suitable to the subjective character of health planning efforts (Van de Ven & Delbecq, 1972), but it also generated the indicators that participants believed were important to reproductive health. Thirty-two women and 20 men were convened for the nominal group at the Institute of Health Science at the Kunming Medical College in the winter of 1998. Approximately half were practitioners and program managers who have been involved in the Women’s Reproductive Health and Development Program in Luliang and Chengjiang counties and townships. The remainder were members of the Yunnan Reproductive Health Research Association, among them administrators and program managers of the provincial health bureau, representatives of women’s groups, and researchers from the biomedical sciences and public health as well as social sciences and gender studies. Divided into eight groups, participants used round robin listing to generate a total of 476 potential indicators. By eliminating duplicate items, 180 individual indicators were retained and organized by group discussion into seven categories: (1) fertility and fertility regulation (i.e. Chinese family planning, 26 items); (2) pregnancy and delivery (i.e. safe motherhood, 27 items); (3) child health (7 items); (4) sexual health (25 items); (5) governmental action/policy (15 items); (6) women’s status (i.e. women’s development and empowerment, 37 items); and (7) rural community development (43
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items). Of these, the study team eliminated 18 items judged to be impractical or unfeasible as reproductive health indicators, such as health workers’ attitudes, families’ life style, ethnic minorities’ cultural conditions, and natural resources. The basis for elimination of additional indicators was low ranking by nominal group participants; 126 with highest consensus as ranked by the nominal group participants were reorganized for the Delphi I survey. Delphi survey The Delphi survey, originated at Rand Corporation in 1948, is used to explore a problem area by eliciting expert opinion in a systematic way (Linstone & Turoff, 1975). Because the Delphi survey is self-administered by mail, this approach prevents individuals from influencing one another in a group setting, and enables participation of people spread across a large geographical area. Both native Chinese and international experts were assembled for this Delphi survey questionnaire. The majority of the Chinese panel experts were identified by the study team, while most of the international experts were chosen with the help of the Ford Foundation reproductive health program officers. International experts included public health and health care specialists and social science and women’s studies scholars. To varying degrees, all had rural experience in developing nations. They lived in Australia, Brazil, Egypt, India, Jordan, Kenya, Malaysia, Mexico, Nigeria, Peru, the Philippines, Switzerland, Taiwan, Tanzania, Thailand, and the United States. The Chinese experts received their questionnaire in Chinese, while the international experts received theirs in English. The experts were asked to consider whether the indicators were practical, feasible and measurable for rural areas of developing countries, and to rank the indicators as ‘‘Important,’’ ‘‘Somewhat important,’’ ‘‘Not at all important,’’ ‘‘Uncertain as to importance,’’ or ‘‘Unfamiliar with concept.’’ In the letter of invitation to participate in the survey, the study team enclosed the definition of reproductive health adopted in the 1994 Cairo Conference and affirmed by the 1995 Fourth World Conference on Women in Beijing. The mailed Delphi survey questionnaire was administered to 63 Chinese experts and 60 international experts. To improve the response rate, first-round non-respondents were mailed surveys up to four times. In all, sixty (97%) of the Chinese experts and 43 (71.7%) of the international experts completed the first round of the Delphi survey. Only those who responded to Delphi I were mailed a Delphi II survey (described below). For Delphi II 57 (95%) of the Chinese experts and 43 (100%) of the international experts completed the survey. Table 2 summarizes the demographic characteristics by gender, professional background, and nation-
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Table 2 Number and percent of experts in Delphi survey by gender, professional background, and nationality Experts
Gender
Profession
Total
Male
Female
Biomedical
Social sciences
Chinese
International
103
39 (37.9)
64 (62.1)
41 (39.8)
62 (60.2)
60 (58.3)
43 (41.7)
ality of the experts who responded to both the Delphi I and II survey questionnaires. For Delphi I analysis, all items considered ‘‘Important’’ by a simple majority of either the Chinese experts or the international experts were included in Delphi II. Eliminating 76 indicators that did not meet the consensus standard from the original 126 in Delphi I, Delphi II retained 50 indicators from Delphi I. Because six of the original 15 WHO indicators were not generated by the nominal group process, these six were omitted from Delphi I, but they were included in the Delphi II questionnaire so as to enable the national and international experts to consider them as well. The Delphi II questionnaire also included 17 new indicators proposed by the national and international experts. Based on this process, the Delphi II was created and yielded a total of 73 potential indicators. For Delphi II analysis, an item ranked ‘‘Important’’ received a score of two; ‘‘Somewhat important’’ received a score of one; and ‘‘Not at all important,’’ received a score of zero. We included on our final list of community-based reproductive health indicators those receiving the highest mean scores. As one international expert completing the Delphi questionnaires noted, ‘‘It is important to differentiate reproductive health indicators from determinants of reproductive health behaviors.’’ We distinguished between the identified community-based reproductive health indicators for rural China and determinants for measuring achievements to improve reproductive health, and report the findings.
Community-based reproductive health indicators and determinants for China’s rural areas Through the nominal group process and the Delphi I and II surveys, we report 21 community-based reproductive health indicators for rural China, and compare them with the WHO reproductive health indicators for global monitoring (Table 3). We also report eight determinants for measuring achievements to improve reproductive health (Table 4). Items that had highest consensus from the experts were categorized as indicators or determinants. All but one of the indicators, and all of the determinants, were reviewed by the experts through the Delphi process of ranking. We added the 21st
Nationality
indicator, ‘‘HIV prevalence of reproductive age women,’’ which was hand written in by several of the international experts in the Delphi survey. For most rural communities of developing countries, indicator data on HIV prevalence of reproductive age women could not be generated, and thus fell outside the indicator criteria of practical, feasible, and measurable. Because of the global scourge of HIV infection and AIDS, the study team viewed this indicator as vital to the development of reproductive health, and urged health leaders and policy makers to allocate resources and take action to control the epidemic of HIV infection and AIDS. Comparing the indicators identified by the research participants with the WHO indicators for global monitoring, five indicators were identical, three were similar, and 13 were new (Table 3). Of the six WHO indicators excluded from Delphi I and added to Delphi II, none was selected by the national and international experts for inclusion among the final list of indicators. We did not directly ascertain Delphi survey participants’ reasons for exclusion of indicators. Field test of reproductive health indicators During April and May 2000, we field tested these reproductive health indicators identified for China’s rural areas. The purpose of the field test was to: (1) assess the feasibility and accessibility of collecting the indicators from existing records of reproductive health service organizations and governmental agencies; (2) determine the procedures and resources needed to acquire data in the absence of existing records; (3) obtain feedback from service providers and program managers about the reproductive health indicators’ utility as a program planning, monitoring, and evaluation tool. Field test site selection Counties in the provinces of Fujian, Hebei, and Yunnan representing respectively high, middle, and low socio-economic strata in China were selected for the field test. In Fujian province, Jinjiang County is located in the more developed coastal regions; in Hebei province, Laishui County in the central plains represented middle socio-economic development; and in Yunnan province, Huaning County in the mountainous southwest is less
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Table 3 Community-based reproductive health indicators for China’s rural areas and comparison with WHO reproductive health indicators for global monitoring
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
Community-based reproductive health indicators for China’s rural areas
Comparison with WHO reproductive health indicators for global monitoring
Total fertility rate Contraceptive prevalence rate Maternal mortality ratio Percentage of women attended, at least once during pregnancy, by skilled health personnel Proportion of villages with access to formally trained midwife Proportion of pregnant women who receive regular prenatal care Perinatal mortality rate Proportion of women with freedom to choose which type of contraception to use Proportion of children aged 0–5 immunized Prevalence of women who have reproductive tract infections Child mortality rate below age 5 (by age, by gender) Proportion of deliveries under antiseptic conditions Proportion of women with legal right to decide whether to bear children Neonatal mortality rate Proportion of women with high-risk pregnancy delivering at hospital Proportion of women with prenatal self-care knowledge Incidence of delivery complications Induced abortion rate Proportion of villages with emergency obstetric care Number of health care personnel who can diagnose and treat common reproductive tract infectious diseases per 100,000 HIV prevalence among reproductive age women
Identical Identical Identical Identical
Table 4 Determinants for measuring achievements in improving reproductive health 1. 2. 3. 4. 5. 6. 7. 8.
Proportion of villages with basic essential health care available Proportion of the local government’s budget allocated to reproductive health matters Proportion of villages with safe potable water Proportion of villages with transportation from village to town/city Proportion of villages with electricity Proportion of women who share in decisions about family expenditures Existence of organization responsible for women’s crisis intervention Proportion of reproductive age women who received tetanus vaccine
developed. In 1999, per capita income for the three counties were 27,192 renminbi (RMB), 3382 RMB, and 2240 RMB, respectively. Coordination and implementation A designated coordinating body for the field test was assigned to each site. The Fujian Provincial Health Education Institute coordinated the field testing in
to to to to
WHO WHO WHO WHO
indicator indicator indicator indicator
#1 #2 #3 #4
Comparable to WHO indicator #5 Comparable to WHO indicator #6 Identical to WHO indicator #8 New New New New New New New New New New New New New Comparable to WHO indicator #16
Jinjiang County; the Beijing Medical University’s School of Public Health coordinated Laishui County field testing; and the Yunnan Reproductive Health Research Association coordinated the Huaning County field testing. Implementation of the field test in each county was conducted by that county’s Maternal and Child Health Station. The Maternal and Child Health Station was selected because it is the depository center for routine health and family planning services records. Each coordinating institution designated one or two liaisons or supervisors to train the local staff to collect data and monitor progress. The field test version of the community-based reproductive health indicators was prepared by the Yunnan Reproductive Health Research Association. The field test version included: (1) preparation instructions; (b) definitions of indicators and important terms; and (3) a questionnaire for each indicator that described sources for data, methods, time required, key informants, number of persons involved in collecting the data, and difficulties encountered in the process. One-day training was provided by Chinese reproductive health researchers of the Yunnan Reproductive Health Research Association and Beijing Medical University’s School of Public Health for the local staff responsible for data collection at each county site. The training included an explanation of the field test
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objectives, importance of adhering to specifications set forth in the field test training, and methods for record review and data collection. The average time for field testing at each site was 28 days. Because of the broad sphere of the indicators, field test investigators were encouraged to locate data from multiple sources. Field test results and lessons learned Of the 21 indicators and eight determinants, only the determinant ‘‘proportion of reproductive age women who received tetanus vaccine’’ was completely unobtainable due to irregularity in coverage and lack of records. Further, our field test experience showed that only onethird of the proposed reproductive health indicators were readily available through the Maternal and Child Health Stations. Information on the remaining indicators and determinants were obtained from family planning agencies, the Women’s Federation, and the Bureaus of Traffic, Water, and Electricity. Field testers reported that they obtained most of the indicator data from local Maternal and Child Health Stations, which emphasized clinical service and care delivered to mothers and infants. By contrast, field testers turned largely to non-health sectors and organizations to acquire data for the determinants, which focused upon women’s status, government policy and action, and rural community resources. The field test experience highlighted the necessity of intersectoral collaboration in the enhancement of women’s health. In addition, we recognized that indicator findings may be fraught with reporting bias. For example, induced abortion data are under reported because of the omission of induced abortions among unmarried women by private practitioners. In many rural areas, health workers may under report the proportion of pregnant women with anemia because of inaccessibility of hemoglobin testing for all women. Health workers may include different diseases or conditions in assessing the total reproductive tract infection rate. They may even weigh some newborn infants swaddled in embroidered blankets so as to prevent exposure to cold, or other infants not at all because of lack of a scale. To reduce reporting bias, field testers recommended that training for local reproductive health workers emphasize adherence to guidelines in the reporting of data upon which indicator findings are based. A few of the items required special assessment because data were not readily available. Field test investigators said that the indicators ‘‘proportion of women with freedom to choose which type of contraception to use,’’ and ‘‘proportion of women with legal right to decide whether to bear children,’’ as well as the determinant ‘‘proportion of women who share in decisions about family expenditures,’’ were most likely to need special assessment.
Despite these difficulties, the field testers reported that most of the indicators could be practically and feasibly obtained and measured. The data for the indicators were relatively easy to retrieve from the procedures set forth in the field test version. Program managers and administrators noted that the indicators filled an important need by providing a standardized monitoring tool to give feedback to providers on service delivery, and to decision makers in planning policy and resource allocation.
Discussion In sequencing the nominal group process and the Delphi technique first and second, respectively, we sought to avoid two exclusive paradigms. The first is an extreme scholastic stance that diminishes or even ignores the grassroots expertise and wisdom of community-based workers in determining what can be achieved. The second is an extreme participatory reduction that denies the contribution of established national and international scholars in discerning what might be valuable at the local level. The nominal group process allowed us to make use of participants’ knowledge about local conditions and culture that affect reproductive health, as well as their insights about constraints upon resources needed to collect relevant data. In turn, the Delphi survey technique allowed us to tap distinguished national and international scholars’ expertise. In other words, combining the methodologies in the manner we chose allowed the selected indicators to be informed by an intimate local understanding of the difficulties that occur in collecting data in poor rural regions, as well as by national and international experts’ broad knowledge about reproductive health. Integrating the methodologies offers a composite tool to balance some of the challenges that arise in actualizing the far-sighted Cairo definition of reproductive health. By requiring many of the indicators to be filtered through the experience of people at the local level, this study serves as a modest litmus test for the usefulness and applicability of the WHO indicators to the situation of Chinese rural health workers. Speaking to burgeoning reproductive health issues affecting vast numbers of rural people, our research begins to offer a preliminary and pragmatic enhancement to the WHO indicators. While the world’s imagination is increasingly captured by visions of an industrialized China, approximately 30 million of its people live as ‘‘abject poor’’ by rigorous Chinese poverty measurement criteria, and the conditions in which they live may challenge notions about what reproductive health data are particularly pertinent or are even currently available. For example, for the excluded WHO indicators, we speculate that the research participants perceived one
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indicator as comparatively less critical (percentage of women aged 15–49 at risk of pregnancy who report trying for a pregnancy for 2 years or more); deemed it unfeasible to obtain data for two indicators [positive syphilis serology prevalence in pregnant women (15–24), percentage of women and reported incidence of urethritis in men (15–49)]; and viewed one indicator as out of line with Chinese cultural practice (reported prevalence of women with female genital mutilation). We observe additional differences of interest between the community-based indicators for rural China identified and the WHO indicators for global monitoring. We viewed one indicator, ‘‘Proportion of pregnant women who receive regular prenatal care’’ as related to the WHO indicator ‘‘Number of facilities with functioning basic essential obstetric care per 500,000;’’ a key difference is that the former is specified from the perspective of consumers, and the latter from the perspective of service providers. Two of the new indicators generated, ‘‘Proportion of women with freedom to choose which type of contraceptive to use,’’ and ‘‘Proportion of women with legal right to decide whether to bear children,’’ received high consensus scores from both the Chinese national and international experts, and may signify an expression of concern with women’s rights and status. ‘‘Proportion of children aged 0–5 immunized’’ is an unconventional reproductive health indicator. On inquiry, study participants said that given that a child not immunized has higher mortality risk, a mother whose child has died may then decide to bear another child, and endure the attendant risks and consequences to reproductive health. The indicator ‘‘Child mortality under age 5 by age, by gender’’ provides implicit recognition of the high mortality in many rural areas, and provides information about attitudes and actions towards the care or neglect of female children. Another new indicator, ‘‘Proportion of deliveries under antiseptic conditions’’ underscores that in rural areas, many or most deliveries occur at home. ‘‘Neonatal mortality rate’’ is a highly sensitive indicator for child mortality as many newborns do not survive the first 28 days of life. One major cause, and potentially related to the previous indicator, is tetanus contracted through contaminated cutting of the umbilical cord. Our past field experience has suggested that many Chinese women may not pay much attention to contraception because they have the mistaken impression that abortion is easy and painless. The indicator ‘‘Induced abortion rate’’ may provide one crude but important measure of physical, mental, and social well-being related to reproductive age women. We believe that researchers in other developing countries can usefully replicate the methodology to test the validity of our reported reproductive health indicators in their own rural areas. In adopting the methodol-
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ogy, they should be aware of several drawbacks. First, both the nominal group process and the Delphi survey technique are consensus-based methodologies. Because of pragmatic time considerations, they offer the researchers extremely limited opportunity to gain systematic insight on the reasons why any given indicator is prioritized or eliminated. This information may be partially excavated in other ways, such as by indepth interviewing of a subset of informants. Second, bias obviously exists in the selection of experts, who in turn influence final selection of the indicators. As Rufus Miles, cited by Linstone (1975), put it, ‘‘Where you stand depends on where you sit.’’ The criteria of practicality, feasibility, and measurability constrained the selection of indicators that might otherwise be deemed important to women’s reproductive health. Two rounds of the Delphi survey resulted in 20 indicators, with ‘‘HIV prevalence among reproductive age women’’ added by the study team to yield a total of 21 indicators, and eight determinants. To the study team’s surprise, many of the indicators from the nominal group process related to government policy and action, women’s education and status, sexual health, and rural community development failed to receive a consensus score high enough to be included among these final indicators and determinants. We speculate that many experts perceived these items to be important contributors to the Cairo definition of reproductive health, but that even those experts who advocate a broader definition of reproductive health may also discern a disparity between the ideal and the achievable. For example, the indicators selected do not address the reproductive health concerns of menarchal women, nor do they focus on adolescents, men, or menopausal women. Mental well-being is a significant issue within reproductive health but is difficult to measure and evaluate because of cost, the need for confidentiality, and other constraints. As a result, the majority of the indicators selected are within the more traditional scope of the maternal and child health field because of service coverage or inadequacy of reporting. Health workers applying these community-based indicators for planning, monitoring, and evaluation in other countries may encounter difficulties that were not apparent in the Chinese communities. Because each country and rural area have their distinct socio-cultural characteristics, policies, religion, and customs, the indicators defined in this study may require further modifications and adaptation. Other countries and areas undoubtedly show variation in the amount and types of existing data. Over reporting and under reporting may occur for reasons specific to the areas. The validity and utility of the indicators depends on the particular setting in which one is working and the quality of the information system itself.
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Successful field testing of the community-based reproductive health indicators in three counties of three provinces of China representing high, middle, and low socio-economic development instilled confidence that the indicators are practical, feasible, and measurable within rural China, and may have broader applicability to rural areas of other developing countries. Of all the indicators and determinants, only one—proportion of reproductive age women who received tetanus immunization—was not obtainable due to irregularities in service delivery and reporting. Additionally, individual field test sites encountered difficulties in data collection for four to eight indicators because of lack of readily available data. Systematic record keeping must be improved. The proposed reproductive health indicators for rural China, and the manner by which they were generated, play into two related issues. The first question centers on whether indicators might most usefully be global in nature, or locally defined? China itself, with its contrasts of urban versus rural, industrial versus agricultural, coastal versus inland, northern versus southern, and affluent versus poor, is a land of immense regional variation. The move toward global reproductive health indicators reflects a vision for a worldwide standard of decent reproductive health. At the same time, we argue that implementation of reproductive health indicators ought to reflect the capabilities and concerns of specific regions; the wherewithal even to generate reproductive health data differs according to economic and infrastructure considerations. The second debate returns to the parameters of the very definition of reproductive health. While some indicators for China’s rural areas might ideally reflect the Cairo definition of reproductive health, the lower priority scores of indicators focusing on government policy and action, women’s education and status, sexual health, and rural development suggests a clinical emphasis. As kin to the first debate, when criteria for indicators include practicality, feasibility, and measurability, the struggle toward the broader Cairo definition of reproductive health may give rise to reproductive health workers’ own dilemmas about where to focus and most effectively prioritize their efforts. The WHO reproductive health indicators provide an important and visionary benchmark for global monitoring. At the same time, current constraints on practicality, feasibility, and measurability diminish the potential for China’s rural health workers to use them broadly. To test the validity of the reproductive health indicators named here for their own locales, we recommend that health workers in other developing countries consider sequencing the nominal group process with the Delphi survey technique. Integrating the two methods serves to resolve the potential dilemma of the nominal group process’s yielding rich but
unwieldy data, and of the Delphi technique’s tapping the wisdom of self-referential experts without benefit of community-based insight to inform the locally focused survey content. In China’s rural areas, monitoring and evaluating the reproductive health of millions of people provides a challenge as daunting as it is urgent. We hope that the indicators reported here will enable researchers, practitioners, administrators, and program managers to move toward a more comprehensive approach to intervention, services, and healthful policy. By enhancing their reproductive health, we strive to improve the life options and the overall well-being of women, men, and children in rural populations.
Acknowledgements We would like to thank the Ford Foundation; without support from the Sexuality and Reproductive Health Program of its Beijing Office, this work would not have been possible. We are grateful to the Yunnan nominal group participants and the Chinese national and international reproductive health experts whose views provide the background for this paper, and to Dr. Guan Jihui of the Fujian Health Education Institute for her help in the field testing. We thank Zhao Jie for thoughtful input on indicators related to women’s status. The editor, reviewers, and Fong Wang provided valuable suggestions.
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