Assessment of infant mortality surveillance: case study

an analytical evaluative study was conducted on its implementation. It was a single-case study that correlated degree of implementation with the of the result indicators surveillance. A logic model on this strategy and a matrix of indicators and judgments according to model components were drawn up. The degree of implementation was obtained from structure and process indicators and this was then correlated with result indicators, in a deductive approach based on intervention theory.

Results:

the structure approach presented superior results to the process in all evaluated components. This strategy was considered to have been partially implemented (75. 7%), however, the components of 'identification of deaths' (85.7%), 'epidemiological research' (88.1%) and 'referral of proposals for promotion and health care and correction of official statistics' (95.8%) were classified implemented. Regarding the relation of the degree of implantation of the surveillance and its results with the logical model, only one of the 17 indicators was considered inconsistent.

Conclusions:

this strategy was considered to have been partially implemented. The model of child mortality surveillance and its assessment were shown to be adequate for signaling the consistency of the interrelations between the activities proposed and the effects expected, and would be reproducible within other scenarios.

Key words
Infant mortality; Epidemiological surveillance; Health evaluation

Components	Approach	Indicators	Parameters
Identification of deaths	Structure	Transport available for MIS activities	80 to 100%
		Technician competent to provide feedback on death certificates	Yes
		Processing power of computers used in SIM activities s	Dual core or above
		Internet speed installed at central level ath	Over 15 Mbps
		Printer or copier available for MISactivities f de	80 to 100%
		Paper available for MIS activities oture	80 to 100%
		Technician competent to sort the children's death certificates Strucation	Yes
		Number of technicians responsible for IMS at central level ific	At least 2 technicians
		Transport available for IMS activities at central level Ident	80 to 100%
		Number of technicians responsible for IMS in sanitary district	At least 1 technicians
		Persons responsible for IMS in sanitary district participated in training, lectures, courses or sought to increase awareness on surveillance	Yes
		Sufficient number of specific forms to validate home addresses in the sanitary district	Yes
	Process	Regularity of death certificate collection	52 SE
		Regularity of typing infant death certificates	52 SE
		Median days between the death notification and epidemiological surveillance at central level s	2 days
		% of deaths with corresponding birth certificates located in Sinasc oces	80 to 100%
		Regularity of submission of copies of death and birth certificate to sanitary district Pr	52 SE
		Median days between death and notification to the sanitary district	2 days
		Use of address validation form to confirm the mother's residence	Yes
		% of ESF professionals that validate home address of deaths	80 to 100%
		% of PACS professionals that validate home address of deaths	80 to 100%
	Result	SIM coverage	80 to 100%
		Coverage of deaths of mothers living in Recife Result	80 to 100%
		% of deaths with validated home address	80 to 100%
Epidemiological investigation	Structure	Persons responsible for IMS at central level participated in training, lectures, courses ion or sought to increase awareness on surveillance gat	Yes
		Sufficient number of confidential record of death investigation in sanitary district investi	Yes
		Transport available for IMS activities in sanitary district etur	80 to 100%
		% of ESF team members trained for IMS Struccal	80 to 100%
		% of PACS workers trained for IMS ogi	80 to 100%
		% of NEH trained to investigate deaths at the hospital miol	80 to 100%
		% of technicians responsible for IMS at central level with competence to investigate Epide deaths at the necropsy services	80 to 100%
Epidemiological investigation	Process	Use of confidential death enquiry sheet	Yes
		% of FHS teams that investigate deaths at the homes	80 to 100%
		% of FHS teams that investigate outpatient deaths	80 to 100%
		% of PACS teams that investigate deaths at the homes	80 to 100%
		% of PACS teams that investigate outpatient deaths	80 to 100%
		% of NEH sending hospital death investigation occurred in their facilities	80 to 100%
		% of deaths with hospital investigation reports submitted by NEH	80 to 100%
		% of NEH facilitating access to medical records for investigation	80 to 100%
		% of deaths with proper home investigation	80 to 100%
		% of deaths with appropriate investigation at the prenatal healthcare facility	80 to 100%
		% of deaths with appropriate investigation at the maternity unit where the expectant mother received care for delivery	80 to 100%
		% of deaths with appropriate investigation at the facilities where the child was assisted	80 to 100%
		% of deaths with appropriate investigation at the healthcare facility where the death occurred	80 to 100%
		% of deaths with investigation at the necropsy services	80 to 100%
	Result	% of deaths with completed home, outpatient, hospital or necropsy service investigation	80 to 100%
		% of deaths with all dimensions of the investigation report completed	80 to 100%
		Adequate completion of the confidential death enquiry sheet	80 to 100%
Discussion of deaths	Structure	Computer available for IMS activities in sanitary district	80 to 100%
		Printer or copier available for SIM activities in the sanitary district	80 to 100%
		Paper available for SIM activities in the sanitary district	80 to 100%
		Phone/Fax available for SIM activities in the sanitary district	80 to 100%
		Internet speed installed in sanitary district	Over 15 Mbps
		Sufficient number of death summary sheets in the sanitary district	Yes
		Meeting room available to discuss the death	80 to 100%
	Process	Official record (minutes) of death discussion meetings	Yes
		Alternative use to document death discussion meetings	Minutes
		% of deaths with the summaries for discussion	80 to 100%
		Summons of Technical -Management Group to discuss death via internal communication	Yes
		% of discussions with the participation of the ESF medical team	80 to 100%
		% of discussions with the participation of the ESF nursing team	80 to 100%
		% of discussions with the participation of the ACS of the ESF team	80 to 100%
		% of discussions with the participation of the PACS nurse	80 to 100%
		% of discussions with the participation of the CHA of the PACS	80 to 100%
		% of discussions with the participation of a representative of the outpatient unit involved in care	80 to 100%
		% of discussions with the participation of a representative of the hospitals involved in maternal and child care	80 to 100%
		% of discussions with the participation of a representative of the health facility where the death occurred	80 to 100%
		% of discussions with the participation of health inspection managers / technicians of the sanitary district	80 to 100%
		% of discussions with the participation of health inspection managers / technicians at central level	80 to 100%
		% of discussions with the participation of child health policy managers / technicians of the sanitary district	80 to 100%
		% of discussions with the participation of child health policy managers / technicians at central level	80 to 100%
		% of discussions with the participation of women's health policy managers / technicians of the sanitary district	80 to 100%
		% of discussions with the participation of women's health policy managers / technicians at central level	80 to 100%
		% of discussions with the participation of primary care policy managers/technicians of the sanitary district	80 to 100%
		% of discussions with the participation of primary care policy managers/technicians at central level	80 to 100%
		% of discussion with the participation of the sanitary district manager	80 to 100%
		Use of summary sheet to conclude the death after case discussion	Yes
		% of deaths with completed summary sheet	80 to 100%
		% of deaths with health promotion and care measures to prevent similar identified deaths	80 to 100%
		% of deaths with classified avoidability	80 to 100%
		% of deaths for which changes were requested to the birth certificate/Sinasc after discussion of the Technical -Management Group	80 to 100%
		% of deaths for which changes were requested to the cause of death/SIM after discussion of the Technical -Management Group	80 to 100%
		% of deaths for which changes were requested to other variables of the death certificate / SIM after discussion of the Technical -Management Group	80 to 100%
	Result	% of deaths discussed in the extended Technical -Management Group	80 to 100%
		% of deaths discussed in the restricted Technical -Management Group	<20%
		% of deaths discussed in the restricted and extended Technical -Management Group	80 to 100%
		% of deaths investigated and discussed in the Technical -Management Group in a timely manner	80 to 100%
		Average time between date of death and conclusion of the case discussion	<120 days
Submission of health promotion and care proposals and correction of official statistics	Structure	Person inputting data at central level is competent to apply with corrections proposed by the Technical -Management Team in the Sinasc and MIS databases	Yes
		% of summary sheets sent from sanitary district to central level	80 to 100%
		Technician responsible for the IMS at central level is competent to complete the summary sheet in the SIM-Online	Yes
	Process	% of deaths altered in the Sinasc database after discussion of the Technical - Management Group	80 to 100%
		% of deaths with alterations to the cause of death in the MIS after discussion of the Technical - Management Group	80 to 100%
		% of deaths with alterations to other variables of the MIS after discussion of the Technical -Management Group	80 to 100%
	Result	% of deaths discussed with discussion report prepared and submitted	80 to 100%
		% of completion of variables, of deaths, in the Sinasc	90 to 100%
		% of deaths with primary cause defined	95 to 100%
		% of completion of death variables in the SIM	90 to 100%
		% of deaths with recorded cause of death of compulsory notification of death informed to epidemiological inspection at central level	80 to 100%
		% of deaths with summary sheet entered into the SIM-Online	80 to 100%

Components/Indicators (n=29)	Values found	Judgment
Identification of infant deaths (12 indicators with weight 10)
Transport available for MIS activities	80 to 100%	1
Technician competent to provide feedback on death certificates	Yes	1
Processing power of computers used in MIS activities	1 to 2 GHz with dual core	0.75
Internet speed installed at central level	11 to 15 Mbps	0.75
Printer or copier available for MIS activities	80 to 100%	1
Paper available for MIS activities	80 to 100%	1
Technician competent to sort the children's death certificates	Yes	1
Number of technicians responsible for IMS at central level	2 technicians	1
Transport available for IMS activities at central level	80 to 100%	1
Number of technicians responsible for IMS in sanitary district	1 technician	1
Persons responsible for IMS in the sanitary district participated in training, lectures, courses or sought to increase their awareness of this surveillance	Yes	1
Sufficient number of specific forms to validate home addresses in the sanitary district	Yes	1
Scores obtained		11.5=95.8% (weight 10 = 115.00)
Epidemiological investigation of child deaths (7 indicators with weight 30)
Persons responsible for IMS at central level participated in training, lectures, courses or sought to increase their awareness of this surveillance	Yes	1
Sufficient number of confidential record of death investigation in sanitary district	Yes	1
Transport available for IMS activities in sanitary district	60 to 79%	0.75
% of FHS team members trained for IMS	80 to 100%	1
% of PACS workers trained for IMS	80 to 100%	1
% of NEH trained to investigate deaths at the hospital	80 to 100%	1
% of technicians responsible for IMS at central level with competence to investigate deaths at the necropsy services	80 to 100%	1
Scores obtained		6.75=96.4% (weight 30=202.50)
Discussion of infant deaths (7 indicators with weight 40)
Computer available for IMS activities in sanitary district	60 to 79%	0.75
Printer or copier available for MIS activities in the sanitary district	60 to 79%	0.75
Paper available for MIS activities in the sanitary district	80 to 100%	1
Phone/Fax available for MIS activities in the sanitary district	80 to 100%	1
Internet speed installed in sanitary district	11 to 15 Mbps	0.75
Sufficient number of death summary sheets in the sanitary district	Yes	1
Meeting room available to discuss the death	60 to 79%	0.75
Scores obtained		6=85.7% (weight 40=240.00)
Submission of health promotion and care proposals and correction of official statistics (3 indicators with weight 20)
Person inputting data at central level is competent to apply with corrections proposed by the Technical -Management Team in the Sinasc and SIM databases	Yes	1
% of summary sheets sent from sanitary district to central level	97.9%	1
Technician responsible for IMS at central level is competent to enter data in the summary sheet at the MIS-Online	Yes	1
Scores obtained		3=100.0% (weight 20=60.00)
Total score obtained		27.25 (pondered=6.18)
Pondered result		92.2%

Components/Indicators (n=54)	Values found	Julgamento
Identification of infant deaths (9 indicators with weight 10)
Regularity of death certificate collection	98.1%	1
Regularity of entries of infant death certificates	63.5%	0.75
Median days between the death notification and epidemiological surveillance at central level	15 days	0
% of deaths with corresponding birth certificates located in Sinasc	94.3%	1
Regularity of submission of copies of death and birth certificate to sanitary district	73.1%	0.75
Median days between death and notification to the sanitary district	37 days	0
Use of address validation form to confirm the mother's residence	Yes	1
% of FHS professionals that validate home address of deaths	80 to 100%	1
% of PACS professionals that validate home address of deaths	80 to 100%	1
Scores obtained		6.5=72.2% (weight 10=65.00)
Epidemiological investigation of infant deaths (14 indicators with weight 30)
Use of confidential death enquiry sheet	Yes	1
% of FHS teams that investigate deaths at the homes	80 to 100%	1
% of FHS teams that investigate outpatient deaths	80 to 100%	1
% of PACS teams that investigate deaths at the homes	80 to 100%	1
% of PACS teams that investigate outpatient deaths	80 to 100%	1
% of HEU sending hospital death investigation occurred in their facilities	57.1%	0.5
% of deaths with hospital investigation reports submitted by HEU	55.1%	0.5
% of HEU facilitating access to medical records for investigation	80 to 100%	1
% of deaths with proper home investigation	71.7%	0.75
% of deaths with appropriate investigation at the prenatal care unit	75.0%	0.75
% of deaths with appropriate investigation at the maternity unit where the expectant mother delivered the infant	84.2%	1
% of deaths with appropriate investigation at the healthcare services where the child received care	66.7%	0.75
% of deaths with appropriate investigation at the healthcare facility where the death occurred	96.7%	1
% of deaths with investigation at the necropsy services	55.6%	0.5
Scores obtained		11.75=83.9% (weight 30=352.50)
Discussion of infant deaths (28 indicators with weight 40)
Official record (minutes) of death discussion meetings	Yes	1
Alternative use to document death discussion meetings	Minutes	1
% of deaths with the summaries for discussion	80 to 100%	1
Summons of Technical -Management Group to discuss death via internal communication	Yes	1
% of discussions with the participation of the FHS medical team	20 to 39%	0.25
% of discussions with the participation of the FHS nursing team	80 to 100%	1
% of discussions with the participation of the ACS of the FHS team	80 to 100%	1
% of discussions with the participation of the PACS nurse	80 to 100%	1
% of discussions with the participation of the ACS of the PACS	80 to 100%	1
% of discussion with the participation of the outpatient representatives involved in care	<20%	0
% of discussion with the participation of the hospital representatives involved in maternal/child care	<20%	0
% of discussions with the participation of a representative of the health facility where the death occurred	60 to 79%	0.75
% of discussions with the participation of health inspection managers/technicians of the sanitary district	80 to 100%	1
% of discussions with the participation of health inspection managers/technicians at central level	80 to 100%	1
% of discussions with the participation of child health policy managers/technicians of the sanitary district	80 to 100%	1
% of discussions with the participation of child health policy managers/technicians at central level	60 to 79%	0.75
% of discussions with the participation of women's health policy managers/technicians of the sanitary district	80 to 100%	1
% of discussions with the participation of women's health policy managers/technicians at central level	<20%	0
% of discussions with the participation of primary care policy managers/technicians of the sanitary district	80 to 100%	1
% of discussions with the participation of primary care policy managers/technicians at central level	<20%	0
% of discussion with the participation of the sanitary district manager	<20%	0
Use of summary sheet to conclude the death after case discussion	Yes	1
% of deaths with completed summary sheet	96.5%	1
% of deaths with health promotion/care measures for the prevention of similar deaths	59.5%	0.5
% of deaths with avoidability classification	66.3%	0.75
% of deaths in which changes were requested to the birth certificates/Sinasc after discussion of the Technical - Management Group	20.4%	0.25
% of deaths with request to alter the cause of death/SIM after discussion of Technical -Management Group	56.6%	0.5
% of deaths with request to alter other variables of the death certificate after discussion of Technical - Management Group	33.5%	0.25
Scores obtained		19=67.9% (weight 40=760.00)
Submission of health promotion and care proposals and correction of official statistics (3 indicators with weight 20)
% of deaths in which changes were made to the Sinasc database after discussion of the Technical - Management Group	62.0%	0.75
% of deaths with changes to the cause of death in the IMS after discussion of the Technical -Management Group	86.0%	1
% of deaths with changes to other variables of the IMS after discussion of the Technical -Management Group	93.0%	1
Scores obtained		2.75=91.7% (weight 20=55.00)
Total score obtained		40 (pondered=12.33)
Pondered result		72.9%

Instituto de Medicina Integral Prof. Fernando Figueira Rua dos Coelhos, 300. Boa Vista, 50070-550 Recife PE Brasil, Tel./Fax: +55 81 2122-4141 - Recife - PR - Brazil
E-mail: revista@imip.org.br

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[TFN1] Degree of implementation parameter/score

- Results in the proportions 80-100%=1; 60-79%=0.75; 40-59%=0.5; 20-39%=0.25, and <20%=0.

Yes=1 or No=0.

- Computer capacity: dual core or above=1; 1 to 2 Gigahertz (GHz) with dual core=0.75; 1 to 2 GHz with single core=0.5; 1 GHz or less with dual core=0.25; 1 GHz or less with single core=0.

- Internet capacity: above 15 Megabytes second (Mbps)=1; 11 to 15 Mbps=0.75; 6 to 10 Mbps=0.5; 1 to 5 Mbps=0.25; 1 Mbps or less=0.

- Meeting record Minute=1 or other document=0

DC=death certificate; BC=live birth certificate; SD=sanitary district; NC=central level; MIS= Mortality Information System; HEU=hospital epidemiology unit; FHS=family health strategy; PACS=Community Health Agent Programme; IMS=infant mortality surveillance; Sinasc=Live Births Information System.