Longer Recall Periods Research Articles

Chronic Kidney Disease-Associated Pruritus Burden: A Patient Survey Study

Rationale & ObjectiveChronic kidney disease–associated pruritus (CKD-aP) is a common, underrecognized condition in patients with chronic kidney disease (CKD), especially those receiving hemodialysis (HD). The present study analyzed the clinical treatment journey and overall burden of pruritus among patients with CKD-aP. Study DesignCross-sectional, patient-reported online survey. Setting & ParticipantsData from adult patients undergoing HD (December 2021-May 2022) in the United States. ExposurePatients participated in an online survey and responded to questions on validated patient-reported outcome (PRO) instruments related to CKD-aP. OutcomesSelf-reported measures analyzed at the end of this survey include itch characteristics, symptom management, healthcare provider (HCP) engagement, and impact on HD, quality of life (QoL), sleep, and work productivity. Analytical ApproachBivariate analysis assessed the association of itch severity with CKD-specific QoL. ResultsOverall, 354 patients with CKD-aP were included in analyses, of which 49% and 30% had moderate and severe itch, respectively (22% were mild). Around 68% reported symptoms to HCPs, most commonly a nephrologist or primary care provider, and 55% received a treatment recommendation. The most common treatments were topical lotions/moisturizers (75%) and corticosteroids (48%); use of oral prescriptions was low (20%), with limited satisfaction with treatments. Overall, 23% of patients reported shortening and 17% reported missing HD sessions due to itch. In bivariate analysis, patients with more severe CKD-aP reported significantly worse disease and function scores [kidney disease (KD) score, cognitive function, quality of social interaction, sleep (all, P<0.001), and sexual function (P<0.05)], suggesting a direct impact of CKD-aP on QoL. LimitationsPossible recall bias, especially for questions with longer recall periods. ConclusionsCKD-aP is often inadequately treated, and disruptive of dialysis treatment, even among patients who report itch to HCPs. Worse itch severity is associated with poorer QoL, sleep quality, and functional/work impairment.

Retrospective radiographic study comparing unintentional extrusion of gutta-percha versus sealer on teeth with periapical radiolucency.

The purpose of the present study was the radiographic evaluation of endodontically treated teeth presenting periapical radiolucency and unintentional overfilling with gutta-percha or sealer on treatment outcome and persistence of the extruded materials. After assessment using periapical index (PAI), 202 roots filled with gutta-percha and zinc oxide-eugenol sealer (Roth 811, Roth International), exhibiting unintentional overfilling and periapical radiolucency were selected. All cases had at least 1 year of follow-up. Type of extruded material, periapical status, and removal/persistence of the extruded material were evaluated by two independent observers. Data were statistically analyzed using logistic and linear regression analysis. Tooth location (P .001), follow-up period (P .001), and type of extruded material (P &#61; .004) significantly influenced treatment outcomes. Specifically, posterior roots exhibited better outcomes compared to anterior, and cases with overfilling of sealer showed superior healing potential compared to those with gutta-percha overfilling. Additionally, longer recall periods were associated with improved treatment success. The type of extruded material (P .001) and follow-up period (P .001) significantly affected the presence of extruded material in the follow-up radiograph. The persistence of extruded material was greater when gutta-percha was extruded, and extruded materials were less detected when the follow-up period was longer. Teeth with periapical radiolucency and unintentional overfilling require longer follow-up intervals for effective monitoring of healing. Treatment outcome was associated with the type of extruded materials used in the present study. The persistence of those materials in the periapex did not affect healing.

Comparing estimates of psychological distress using 7-day and 30-day recall periods: Does it make a difference?

Self-report measures are widely used in mental health research and may use different recall periods depending on the purpose of the assessment. A range of studies aiming to monitor changes in mental health over the course of the COVID-19 pandemic opted to shorten recall periods to increase sensitivity to change over time compared to standard, longer recall periods. However, many of these studies lack pre-pandemic data using the same recall period and may rely on pre-existing data using standard recall periods as a reference point for assessing the impact of the pandemic on mental health. The aim of this study was to assess whether comparing scores on the same questionnaire with a different recall period is valid. A nationally representative sample of 327 participants in Australia completed a 7-day and 30-day version of the six-item Kessler Psychological Distress Scale (K6) and a single-item measure of psychological distress (TTPN item) developed for the Taking the Pulse of the Nation survey. Linear mixed models and mixed logistic regression models were used to assess whether altering the recall period systematically changed response patterns within subjects. No substantive recall period effects were found for the K6 or the TTPN, although there was a trend towards higher K6 scores when asked about the past 30 days compared to the past 7 days (b = 1.00, 95% CI: -0.18, 2.17). This may have been driven by the “feeling nervous” item which was rated higher using the 30-day compared to the 7-day recall period. Neither the K6 nor the TTPN item were significantly affected by the recall period when reduced to a binary variable of likely severe mental illness. The results indicate that altering the recall period of psychological distress measures does not substantively alter the score distribution in the general population of Australian adults.

Recall Bias in the Assessment of Cough for Patients Discharged from Lung Surgery.

This study aimed to evaluate the presence of recall bias when patients retrospectively report cough scores. Patients who underwent lung surgery between July 2021 and November 2021 were recruited for this study. We retrospectively assessed the severity of cough within the past 24 hours and the past 7 days using a 0-10 numerical rating scale. Recall bias was defined as the difference between the scores reported on the two assessments. Patients were grouped based on the longitudinal change in cough scores from pre-operation to 4 weeks after discharge using group-based trajectory models. Using generalized estimating equation to explore the factors influencing recall bias. Overall, 199 patients were analyzed and demonstrated the three distinct trajectories of post-discharge cough: high (21.1%), medium (58.3%), and low (20.6%). Significant recall bias was found in week 2 for the high-trajectory patients (6.26 vs 5.10, P<0.01) and in week 3 for the medium-trajectory patients (2.88 vs 2.60, P=0.01). Among all recall bias, 41.8% were of underestimation, and 21.7% of overestimation. The high trajectory group (β=1.14, P<0.01) and measurement interval (β=0.36, P<0.01) were risk factors for underestimation, while post-discharge time (β=-0.57, P<0.01) and measurement interval (β=-0.13, P=0.02) were protective factors for overestimation. Retrospective assessment of post-discharge cough in patients who underwent lung surgery will introduce recall bias, with a tendency of underestimation. The high-trajectory group, interval time and post-discharge time are influencing factors of recall bias. For patients with severe cough at discharge, a shorter recall periods should be employed for monitoring, due to the large bias that results from a longer recall period.

Moderate Accuracy of Survey Responses about Infant and Young Child Feeding Counseling Reported by Mothers with Children Less than 1 Year of Age in India

BackgroundCounseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys has not yet been validated. ObjectivesWe examined the validity of maternal reports of IYCF counseling received during community-based contacts and factors associated with reporting accuracy. MethodsDirect observations of home visits conducted by community workers in 40 villages in Bihar, India served as the “gold standard” to maternal reports of IYCF counseling received during 2-wk follow-up surveys (n = 444 mothers with children less than 1 y of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and AUC. Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy. ResultsPrevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 wk was moderate (AUC: 0.60; 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, the recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Child age, maternal age, maternal education, mental stress, and social desirability were associated with reporting accuracy of multiple indicators. ConclusionsValidity of IYCF counseling coverage was moderate for several key indicators. IYCF counseling is an information-based intervention that may be received from various sources, and it may be challenging to achieve higher reporting accuracy over a longer recall period. We consider the modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.

Development, psychometric evaluation and cognitive debriefing of the rheumatoid arthritis symptom and impact questionnaire (RASIQ)

BackgroundRheumatoid arthritis (RA) is a chronic inflammatory disease often associated with persistent pain. There is a need for a patient-reported outcome measure (PROM) that is rooted in the patient experience and psychometrically validated. We describe the development of the Rheumatoid Arthritis Symptom and Impact Questionnaire (RASIQ), a novel PROM with potential to record key symptoms and impacts of RA with a 24-h recall period.ResultsA literature review identified RA concepts that patients considered most important to their disease experience, including pain, fatigue, joint swelling and stiffness. From this, an initial item pool (33 items; 27 related to symptoms, 6 related to impacts) was developed with a recall period of 24 h. Two rheumatologists evaluated each item’s relevance, and the second version of the RASIQ was refined (29 items; 21 related to symptoms, 8 related to impacts). Next, three rounds of cognitive debriefing interviews were conducted with patients with RA (n = 15 overall). The RASIQ was revised to remove items deemed irrelevant or redundant, leaving 16 items measuring symptoms (joint pain, energy/tiredness, joint stiffness) and impacts (rest, sleep). A parallel series of semi-structured concept elicitation interviews (n = 30) facilitated the design of a conceptual model of RA symptoms, impacts and treatment experiences. Post-hoc comparison of the model with RASIQ revealed that all items selected were among the most important and relevant symptoms and impacts for patients. A final round of cognitive debriefing interviews (n = 12) confirmed that the final 16-item RASIQ was relevant and easy to understand, with no further changes recommended. Psychometric evaluation using data from two Phase II RA clinical trials confirmed a 3-factor structure, as well as the reliability and validity of the scale scores, and the ability of RASIQ to detect changes in symptoms and impacts when administered at specific study timepoints, using a 24-h recall period.ConclusionsRASIQ is a novel, 16-item PROM developed with substantial patient input. Results from concept elicitation, cognitive debriefing, and psychometric evaluation confirmed the validity of the instrument, which has the potential to measure symptoms and impacts through a 24-h recall period and complement existing disease activity instruments with longer recall periods.

Validity of self-reported substance use: research setting versus primary health care setting

BackgroundSelf-reported substance use is more likely to be influenced by underreporting bias compared to the biological markers. Underreporting bias or validity of self-reported substance use depends on the study population and cannot be generalized to the entire population. This study aimed to compare the validity of self-reported substance use between research setting and primary health care setting from the same source population.Methods and materialsThe population in this study included from Rafsanjan Youth Cohort Study (RYCS) and from primary care health centers. The sample from RYCS is made up 607 participants, 113 (18.62%) women and 494 (81.38%) men and sample from PHC centers is made up 522 individuals including 252 (48.28%) women and 270 (51.72%) men. We compared two groups in respect of prevalence estimates based on self-reported substance use and urine test. Then for evaluating validity of self-reported substance use in both group, the results of reference standard, urine tests, were compared with the results of self-reported drug use using measures of concordance.ResultsThe prevalence of substance use based on urine test was significantly higher in both settings compared to self-reported substance use over the past 72 h. The sensitivity of self-report substance use over the past 72 h in research setting was 39.4, 20, 10% and zero for opium, methadone, cannabis and amphetamine, respectively and in primary health care setting was 50, 20.7, 12.5% and zero for opium, methadone, cannabis and amphetamine, respectively. The level of agreement between self-reported substance use over the past 72 h and urine test indicated fair and moderate agreement for opium in both research and primary health care settings, respectively and also slight agreement for methadone and cannabis in both settings were reported. There was no significant difference between the two groups in terms of self-reported substance use. For all substances, the level of agreement increased with longer recall periods. The specificity of self-report for all substances in both groups was more than 99%.ConclusionIndividuals in primary health care setting were more likely to self-reported substance use than in research setting, but setting did not have a statistically significant effect in terms of self-reported substance use. Programs that rely on self-reported substance use may not estimate the exact prevalence of substance use in both research and primary health care settings, especially for substances that have a higher social stigma. Therefore, it is recommended that self-report and biological indicators be used for more accurate evaluation in substance use studies. It is also suggested that future epidemiological studies be performed to reduce bias of social desirability and find a method providing the highest level of privacy.

The prominent role of informal medicine vendors despite health insurance: a weekly diaries study in rural Nigeria.

In sub-Saharan Africa, accessibility to affordable quality care is often poor and health expenditures are mostly paid out of pocket. Health insurance, protecting individuals from out-of-pocket health expenses, has been put forward as a means of enhancing universal health coverage. We explored the utilization of different types of healthcare providers and the factors associated with provider choice by insurance status in rural Nigeria. We analysed year-long weekly health diaries on illnesses and injuries (health episodes) for a sample of 920 individuals with access to a private subsidized health insurance programme. The weekly diaries capture not only catastrophic events but also less severe events that are likely underreported in surveys with longer recall periods. Individuals had insurance coverage during 34% of the 1761 reported health episodes, and they consulted a healthcare provider in 90% of the episodes. Multivariable multinomial logistic regression analyses showed that insurance coverage was associated with significantly higher utilization of formal health care: individuals consulted upgraded insurance programme facilities in 20% of insured episodes compared with 3% of uninsured episodes. Nonetheless, regardless of insurance status, most consultations involved an informal provider visit, with informal providers encompassing 73 and 78% of all consultations among insured and uninsured episodes, respectively, and individuals spending 54% of total annual out-of-pocket health expenditures at such providers. Given the high frequency at which individuals consult informal providers, their position within both the primary healthcare system and health insurance schemes should be reconsidered to reach universal health coverage.

Biological Validation of Self-Reported Unprotected Sex and Comparison of Underreporting Over Two Different Recall Periods Among Female Sex Workers in Benin.

BackgroundSelf-reported unprotected sex validity is questionable and is thought to decline with longer recall periods. We used biomarkers of semen to validate self-reported unprotected sex and to compare underreporting of unprotected sex between 2 recall periods among female sex workers (FSW).MethodsAt baseline of an early antiretroviral therapy and pre-exposure prophylaxis demonstration study conducted among FSW in Cotonou, Benin, unprotected sex was assessed with retrospective questionnaires, and with vaginal detection of prostate-specific antigen (PSA) and Y-chromosomal deoxyribonucleic acid (Yc-DNA). Underreporting in the last 2 or 14 days was defined as having reported no unprotected sex in the recall period while testing positive for PSA or Yc-DNA, respectively. Log-binomial regression was used to compare underreporting over the 2 recall periods.ResultsUnprotected sex prevalence among 334 participants was 25.8% (50.3%) according to self-report in the last 2 (or 14) days, 32.0% according to PSA, and 44.3% according to Yc-DNA. The proportion of participants underreporting unprotected sex was similar when considering the last 2 (18.9%) or 14 days (21.0%; proportion ratio = 0.90; 95% confidence interval, 0.72–1.13). Among the 107 participants who tested positive for PSA, 19 (17.8%) tested negative for Yc-DNA.ConclusionsUnderreporting of unprotected sex was high among FSW but did not seem to be influenced by the recall period length. Reasons for discrepancies between PSA and Yc-DNA detection, where women tested positive for PSA but negative for Yc-DNA, should be further investigated.

Predictors of correspondence between self-reported substance use and urinalysis screening among a racially diverse cohort of young men who have sex with men and transgender women

It is unknown if estimates of illicit drug use among young men who have sex with men and transgender women (YMSM/TW) may be biased due to historical distrust of research or reliable due to more accepting norms for use. Research is needed to examine the validity of drug use self-reports among YMSM/TW.Data came from an ongoing longitudinal study of YMSM/TW aged 16–29 living in Chicago (analytic N = 1029). Baseline urinalysis screens for marijuana, ecstasy, amphetamine, methamphetamine, cocaine, benzodiazepine, and opiate metabolites were compared to self-reported use within different recall periods using measures of concordance. Generalized estimating equations logistic regressions were conducted on three waves of data to identify predictors of disclosing past-6-month use of marijuana and non-marijuana drugs.Past-6-month self-reported use of all non-marijuana substances was <15%. There was excellent agreement between self-reported and drug-tested marijuana use. For other substances, sensitivities within the urinalysis detection window were <0.5 but increased with longer recall periods. Black participants had lower odds of disclosing non-marijuana drug use. Gender minority participants had lower odds of disclosing marijuana use. Participants with a history of arrest had higher odds of disclosing both marijuana and non-marijuana drug use. Wave and year of first research participation were non-significant, suggesting no systematic bias or increasing honesty associated with longer research participation.Programs that rely on self-identification of non-marijuana illicit substance use may be missing a substantial portion of drug-using YMSM/TW. Future epidemiological studies should work to reduce social desirability biases and include biomarker-based drug screenings to increase validity.

PRM92 - Evaluation of Modified Item Characteristics on Item Comprehension and Psychometric Performance

A mixed methods approach was used to determine whether it is possible to shorten and simplify items for electronic clinical outcome assessment (eCOA) administration without compromising patient comprehension and item psychometric performance. From a validated bank of 75 items measuring headache impact, a revised set of items (k=91) was developed by simplifying attributes (e.g., recall period, item stem content and length, response options scales content and length) and restructuring item display. To allow unconfounded assessment of revisions, each revised item only changed a single attribute. Cognitive debriefing interviews evaluated a subset of bank items (k=39 original, k=54 revised) in adult headache sufferers (N=9). In adult headache sufferers (N=2,379), the revised items (k=90) were calibrated with the original items using item response theory (IRT) models and item performance was evaluated. Debriefing results showed that items without a recall period in the item stem (e.g., “In the past 4 weeks…”) presented problems for most respondents, who assumed a much longer recall period than specified in the survey instructions. Specificity within item stems and answer choices made items harder to read for some participants, but were helpful for others. In quantitative analyses, the addition of recall period to an item stem resulted in more information over a wider IRT score range in 77% of tests. Minor changes in response option text (i.e., “Very often” versus “Often”) or even substantial reductions (i.e. from “None of the time” to “None”) had little or no effect on item information value. Rewriting “statement” items into questions improved performance in 81% of tests. In 84% of tests conducted, shortened items performed the same or better than the original version. Items may be shortened and simplified for electronic administration without reducing item performance. However, the recall period should still be included in the item stem.

Correlates of Validity of Self-Reported Methamphetamine Use among a Sample of Dependent Adults

ABSTRACTBackground: Self-reported data are widely used in substance-use research, yet few studies have assessed the validity of self-reported methamphetamine use compared to biological assays. Objectives: We sought to assess the validity and correlates of validity of self-reported methamphetamine use compared to urine toxicology (UTOX). Methods: Using a sample of methamphetamine-dependent individuals enrolled in a randomized controlled pharmacotherapy trial in the United States (n = 327 visits among 90 participants), we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the kappa coefficient of self-reported methamphetamine use in the past 3 days compared to UTOX, as well as the NPV of self-reported methamphetamine use over an extended recall period of 1 month. We used multivariable logistic regression models to assess correlates of concordance between self-reported methamphetamine use and UTOX. Results: The sensitivity of self-reported methamphetamine use in the past 3 days was 86.7% (95% confidence intervals (95%CI): 81.4%–91.4%), the specificity was 85.3% (77.7–91.3), the PPV was 91.5% (86.9–94.8), and the NPV was 78.0% (69.4–86.1), compared to UTOX (kappa = 0.71). The NPV over the extended recall period was 70.6% (48.0–85.7). In multivariable analyses, validity of self-reported methamphetamine use was higher for older participants but lower during follow-up compared to baseline and when polysubstance use or depressive symptoms were reported. Conclusions/Importance: Our sample of methamphetamine-dependent adults reported recent methamphetamine use with high validity compared to UTOX. Validity increased with age but decreased when participants reported depressive symptoms or polysubstance use as well as later in the study timeline and during longer recall periods.

Patient-Reported Outcome Measures for Symptom Perception During a Cystic Fibrosis Exacerbation.

Symptom burden increases during pulmonary exacerbations of cystic fibrosis (CF), and patient-reported outcome measures (PROMs) are often used to evaluate symptoms as either primary or secondary outcomes. However, there is currently no guidance on the use of PROMs to assess symptom burden during pulmonary exacerbations. A systematic literature search was conducted to identify PROMs measuring symptom experience, management, or influencing factors, which were developed for CF patients and had been used at least once during pulmonary exacerbations. The PROMs included were assessed for relevance and psychometrics, according to the criteria of the United States FDA guideline and the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Five PROMs were identified, all measuring symptom perception. The CF Respiratory Symptom Diary (CFRSD) and the Symptom Scoring System were developed to assess symptom severity during pulmonary exacerbations. Of the other 3, which also included symptom scores of 2 quality of life measures, one assessed symptom severity exclusively, and 2 measured symptom severity in addition to other dimensions (such as symptom distress). All 5 instruments measured respiratory symptoms. Other relevant symptoms, such as energy and emotions, were covered by 4 instruments; pain and gastrointestinal symptoms were covered by 2 measures. All of the instruments demonstrated good internal consistency and sensitivity to change over a period up to 4 weeks. The symptom scores of the 2 quality of life measures with longer recall periods are not suitable for measuring assessed changes in a period of < 2 weeks. Criterion validity for gastrointestinal subscores has not been established. Discriminant validity was established in all of the instruments reviewed except for the Symptom Score System. Of the current PROMs used during CF pulmonary exacerbations, only 2 have been developed for this purpose, and only the CFRSD fulfilled all FDA guideline criteria. To date, there is no instrument that assesses exacerbation-specific symptom distress.

Long-term memory in older children/adolescents and adults with autism spectrum disorder.

This study extends prior memory reports in autism spectrum disorders (ASD) by investigating memory for narratives after longer recall periods and by examining developmental aspects of narrative memory using a cross-sectional design. Forty-seven older children/adolescents with ASD and 31 youth with typical development (TD) and 39 adults with ASD and 45 TD adults were compared on memory for stories from standardized measures appropriate for each age group at three intervals (immediate, 30 min, and 2 day). Both the youth with and without ASD had difficulty with memory for story details with increasing time intervals. More of the youths with ASD performed in the range of impairment when recalling the stories 2 days later as compared to the TD group. The adults with ASD had more difficulty on memory for story details with increasing delay and were poorer at recall of thematic information (needed to create a gist) across the three delay conditions as compared to the TD group. Analyses of the individual results suggested that memory for details of most of the adults with ASD was not impaired when applying a clinical standard; however, a significant percentage of the adults with ASD did not make use of thematic information to organize the narrative information, which would have helped them to remember the stories. The youth with and without ASD performed similarly when both were at a stage of development when memory for details is the primary strategy. The adults with ASD had difficulty with use organizational strategies to support episodic memory. Autism Res 2017, 10: 1523-1532. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Forgetting to remember or remembering to forget: A study of the recall period length in health care survey questions

Self-reported data on health care use is a key input in a range of studies. However, the length of recall period in self-reported health care questions varies between surveys, and this variation may affect the results of the studies. This study uses a large survey experiment to examine the role of the length of recall periods for the quality of self-reported hospitalization data by comparing registered with self-reported hospitalizations of respondents exposed to recall periods of one, three, six, or twelve months. Our findings have conflicting implications for survey design, as the preferred length of recall period depends on the objective of the analysis. For an aggregated measure of hospitalization, longer recall periods are preferred. For analysis oriented more to the micro-level, shorter recall periods may be considered since the association between individual characteristics (e.g., education) and recall error increases with the length of the recall period.

Agreement between SISPRENATAL and mother's recall for gestational age at prenatal care initiation

We compared the initiation of prenatal care during the first trimester of pregnancy (adequacy of initiation) between mother’s recall and the prenatal health information system (SISPRENATAL). We asked 238 women that received prenatal care at Family Health Units in Vespasiano, Minas Gerais their gestational age at first prenatal visit. Both recall and SISPRENATAL indicated that 30% of women had inadequate initiation. There was fair agreement in the adequacy of initiation (Kappa=0.35, 95% CI: 0.22-0.48) between recall and SISPRENATAL. Through regression models, we found that agreement was more likely with mother’s shorter recall period and non-use of the private sector. Use of the private sector (16.4%) was also correlated with a later date of initiation by SISPRENATAL than by mother’s recall. In sum, differences in the adequacy of initiation between recall and SISPRENATAL were associated with longer recall periods and with use of the private sector. Despite the limitation of recall bias, mother’s recall is preferable to SISPRENATAL for capturing the public use by the pregnant women.

Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency Cesarean Sections in Ghana and the Dominican Republic

BackgroundCesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR).Methods and FindingsThis study compares hospital-based data, considered the reference standard, against women’s self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%, and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results than decision time in Ghana and slightly more favorable results in the Dominican Republic.ConclusionsQuestions used in this study to identify emergency cesarean section are promising but insufficient to promote for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based indicators in advance of data collection and which use a longer recall period are warranted.

Evaluation of Key Design Elements of Long-Distance Survey of Front Range Travel Counts

An evaluation of two key design aspects of a long-distance survey conducted as part of the 2009–2012 Front Range Travel Counts effort is documented. The Front Range Travel Counts project is a cooperative effort across four adjacent Colorado metropolitan regions to document travel behavior within and across regions. The effort included household, commercial vehicle, and external station surveys. Consistent with the state of the practice in the United States, the long-distance survey was administered as a supplement to the household survey sample. Respondents were asked to record all trips made to a location 50 mi or more from home during the 2-week period before the 24-h travel day. Households reporting no long-distance travel were asked to report details of their most recent long-distance trips, regardless of when the trip occurred. The analysis focuses on two design aspects: (a) the selection of a 2-week recall period, with the request for the most recent trip from those who reported zero long-distance trips, and (b) the definition of a long-distance trip. The results suggest that future surveys should use a longer recall period. In addition, the practice of asking for the most recent trip from only those respondents who reported zero long-distance trips within the recall travel period should be expanded to asking that question of all respondents. Finally, the definition as used resulted in the capture of shorter-distance trips, suggesting that refinement is needed.

Estimating the Effect of Recurrent Infectious Diseases on Nutritional Status: Sampling Frequency, Sample-size, and Bias

There is an ongoing interest in studying the effect of common recurrent infections and conditions, such as diarrhoea, respiratory infections, and fever, on the nutritional status of children at risk of malnutrition. Epidemiological studies exploring this association need to measure infections with sufficient accuracy to minimize bias in the effect estimates. A versatile model of common recurrent infections was used for exploring how many repeated measurements of disease are required to maximize the power and logistical efficiency of studies investigating the effect of infectious diseases on malnutrition without compromising the validity of the estimates. Depending on the prevalence and distribution of disease within a population, 15-30 repeat measurements per child over one year should be sufficient to provide unbiased estimates of the association between infections and nutritional status. Less-frequent measurements lead to a bias in the effect size towards zero, especially if disease is rare. In contrast, recall error can lead to exaggerated effect sizes. Recall periods of three days or shorter may be preferable compared to longer recall periods. The results showed that accurate estimation of the association between recurrent infections and nutritional status required closer follow-up of study participants than studies using recurrent infections as an outcome measure. The findings of the study provide guidance for choosing an appropriate sampling strategy to explore this association.

Validity of average, minimum, and maximum end-of-day recall assessments of pain and fatigue

End-of-day (EOD) diary assessments of symptoms have the potential to reduce recall bias associated with longer recall periods, and therefore be useful for generating accurate patient reported outcomes (PROs). In this report we examine the relative validity of diary questions about the experience of daily pain and fatigue, including several questions about experience for the entire day and questions about minimum and maximum daily levels, with previously collected data [1]. Validity estimates are based on comparisons of EOD reports with momentary recordings of pain and fatigue from the same days. One hundred and six participants with rheumatologic diseases yielded 2852 days for analysis. Differences in levels as assessed by EOD and momentary reports were small (just a few points), although in many instances were significantly different. Correlational analyses indicated that “how much,” “how intense,” and “on average” EOD questions were more strongly associated with momentary reports ( rs = 0.85–0.90 for pain and 0.81–0.83 for fatigue) than were minimum and maximum questions ( rs = 0.73–0.80 for pain and 0.67–0.75 for fatigue). Overall, the pain measures had higher EOD-momentary correspondence than the fatigue measures. Analyses of difference scores between EOD and momentary reports confirmed the better correspondence of the average questions compared with minimum and maximum questions. There was little evidence of individual differences in level and correspondence analyses. The implication of these results is that over-the-day diary measures may yield superior PROs than those based on minimum or maximum daily levels.