Cohort Profile: The Haramaya Health and Demographic Surveillance System (Haramaya HDSS)

Abstract

Haramaya Health and Demographic Surveillance System (HDSS) was established in 2018 in the Haramaya district of the East Hararghe Zone in the Region of Oromia, eastern Ethiopia. The cohort was established to be a comprehensive and sustainable data source for monitoring population health and demographic events in the Haramaya district. At baseline, the total number of households in the HDSS was 17 461. The total baseline population was 99 898 (51 259 male and 48 639 female), of whom 23.86% were women of reproductive age. All households in the study area are visited and data are updated every 6 months. In the first round of follow-up data collection, there were 17 898 households and a population of 101 639 in the study area. The main data collected include information on births, deaths, immigration, emigration, pregnancies and health-related conditions, such as family planning and morbidities. The cohort is open to collaborative efforts for health and demographic studies. Requests for the existing surveillance data can be directed to the HDSS office. A demographic and health survey is a longitudinal population-based health and vital event registration system that monitors demographic and health events in a geographically defined population. Traditional sources of health information from health facilities, such as health centres and hospitals, often serve as the basis for health services planning and allocation of resources in developing countries, including Ethiopia. However, health facility-based data frequently provide fragmentary and biased information. In these countries, establishing a Health and Demographic Surveillance System (HDSS) is an important alternative to fill this information gap1. In Ethiopia, universities have a responsibility to provide evidence to policy makers. HDSSs serve as an essential source of information from the grassroots community level for making evidence-based decisions.2 Haramaya University, therefore, established the Haramaya HDSS in October 2018 to be a comprehensive and sustainable data source for monitoring population health and demographic events in the Haramaya district. The adjacent Kersa HDSS had been previously established. The Haramaya HDSS provides community-based information from the rural community of the Haramaya area. It aims to produce data on births, deaths, migration and marital status and to assess trends of demographics, health, nutrition, animal health, agriculture production and environmental changes in the area. In addition, it aims to evaluate health intervention activities and to disseminate research findings for users. Haramaya HDSS, combined with the Kersa HDSS, will give a better picture of health conditions in rural eastern Ethiopia. Most of the land in the study area is found between 2091.203923 and 2406.678431, and seems suitable for agricultural activities. Survey data show that nearly half the land in the area is usable: 36% for farming and 2.3% for pasture, with 1.5% covered with forest.3 Khat (Catha edulis), a chewable green leaf and vegetable, is the main product of the area (Table 1). Khat from Haramaya is exported to Djibouti and Somalia. Studies show that khat yields in the area range from 1500 to 1800 kg/ha through monoculture.3 Khat from Haramaya is also traded in Harar and has great socioeconomic and cultural impacts on households in this city.4,5 Besides khat farming, other vegetables and fruits are the most important cash crops in the area. Characteristics of the study kebeles (sub-districts) and their main economic activities at the baseline Haramaya district has one district hospital (located in Haramaya town), eight health centres and 38 health posts. Of these, four health centres and 14 health posts are located in the catchment area. There are also 12 private higher clinics, one village pharmacy and five traditional medical practitioners. All the health centres are accessible by road. The average distance of all health centres from the central Haramaya town is 13 km. Health extension workers are assigned to all 38 health posts. According to the data from the health centres, the average adult and child patient load per day of the health posts are 36 and 22, respectively. In addition, the average antenatal clinic (ANC) follow-up and delivery per week are 46 and 23, respectively. Eastern Ethiopia is known for high levels of social bonding among communities, and Haramaya is no different. Its people show strong relationships with one another in various community events, such as marriage, burial, communal work and day-to-day life. Marriage is of universal character although the form varies from place to place. In the Haramaya area, there are two common forms of marriage, locally known as Cabsa and Jaladeema. Cabsa is a form of marriage in which the male’s family sends elders to the female’s family to ask for a marriage between them. The female’s family then has the opportunity to decide whether or not to let their daughter marry, and they may impose preconditions if they agree. First and foremost, they ask their daughter whether she knows and likes the man and consents to marry him. The female’s family may also ask for money or gold as a gift. The second form of marriage is Jaladeema, in which the woman and man might themselves discuss marriage and decide to leave the village for several days without the permission of their parents. This is mainly to force their families, especially the woman’s family, to agree to the marriage without preconditions. This is the predominant form of marriage in the area. In terms of burial and comforting a bereaved family, Christians and Muslims in the area have similar practices. When a family loses a member, community-based organizations, called Afosha, play a significant role in comforting and supporting the family economically. Immediately after the death, they erect a tent where guests can gather to express their grief and comfort the family. After the burial ceremony, family members, neighbours and others come to the tent to chew khat, chat and stay to comfort the deceased’s family for three days. Members of the community also support each other during communal work and events such as marriage through informal organizations called Gumaata and Guuza. The former is mostly used by women during marriage, wherein the close friends and family of the bride contribute money and buy necessary home materials for her. The latter is mostly used by men to support each other during work; for instance, to harvest crops and build new houses. Haramaya HDSS was established in the Haramaya district, located in the East Hararghe Zone of the Oromia Region, 500 km from Addis Ababa and 18 km west of Harar. It is bordered on the south by Kurfa Chele district, on the west by Kersa, on the north by Dire Dawa, on the east by Kombolcha, and on the southeast by the Harari Region. Its administrative centre, Haramaya town, is located at 42o3' E, 9o26' N, at an altitude of 1980 m above sea level.6 East Hararghe, which is one of 20 zones in the Oromia Region, has 20 districts, including the Haramaya district. Haramaya has 34 rural kebeles (sub-districts) and three urban kebeles in Haramaya town. The data from the district office show that the total number of residents in the district is 310 310. According to the 2019 data from the district, the area has a large population of children aged under 5 years (50 985, 16.43%). The catchment area of Haramaya HDSS includes 12 of the 34 rural kebeles in the Haramaya district (Figure 1) These kebeles were selected mainly because they did not share boundaries with Haramaya University and nearby towns—namely, Haramaya and Awaday—to avoid information contamination and to control the effect of town and university populations on the resident population (see Figure 1). Most of the kebeles in the study area range between 1600 and 2100 m above sea level. Haramaya HDSS catchment kebeles (sub-districts) At baseline, our data collectors tried to approach all of the approximately 18 000 households in the kebeles identified as the study area, by knocking at all households in rows. The community was generally welcoming and happy to be included in the study. If the data collectors accidentally missed a house, the house owners would call them to ask why they were missed. Although some participants asked a lot of questions about the benefits of the study, it could be said that there was no rejection of the study. A total of 17 461 households were interviewed and 99 898 participants were registered at baseline. A baseline enumeration for the Haramaya site began in October 2018, and the first round of data collection began in January 2019. The regular data collection rounds last for 6 months, so there are two rounds in 1 year. Data collection in the field takes a maximum of 3 months, with another 3 months spent on checking, cleaning and preparing data for the next round. Using a computer system and following the hierarchy of country, region, zone, district, sub-district and village, a nine-digit household identification number (ID) is generated to locate each household. The first three digits represent a cluster and the next six digits represent the house number in that village. A small metal sheet containing this ID number is placed on the outer side of the door of the house to mark it for a subsequent visit. This acts as a permanent location ID of the house. During each data collection round, data collectors are given a hard-copy list of households grouped by sub-districts and villages. They use this as a reference with the soft copy on their tablet. After locating the house and its ID, the interview is done with a competent person (aged 18 years or older and living permanently in the house). Data collectors read the names of the residents in the specific household and check if there has been any change in the family since the previous data collection round. Changes could occur because of immigration, emigration, birth, death or other events in the family. If an event has occurred in the family, the data collector will fill in responses to the specific questions on the tablet. If there is no one available to interview during the house visit, the data collector will re-visit the house to complete the collection of information. If the data collectors find new houses, they register these with a baseline form. In the first round of follow-up, the number of households interviewed increased from 17 461to 17 898, and in the second wave of data collection, it increased to 19 013. This was due to increases in migrations to the registered households in addition to registration of new households in the catchment area. Similarly, the number of participants increased from 99 898 at the baseline to 101 639 in the first round and to 108 557 in the second round of data collection. Our data collectors reported no dropout, but there were 1453 out-migrations in the first round and 1197 in the second round. Table 2 shows the information collected at baseline and follow-up round visits. At baseline, location, house and individual registration, marital relationships, housing conditions and economic information is completed. Events such as pregnancy outcomes, relationships of individuals to the head of the household, deaths, immigration, emigration, changes in marital status and pregnancy observations are recorded as they happen in each round. Some questions are distinctive to a particular round or year. For instance, information on child immunization, child morbidity, adult morbidity, family planning, education and economic information is collected in a staggered manner (Table 2). Verbal autopsy for a deceased family member is also completed by asking a close relative standard World Health Organization questions. Death reports from regular event registration are used for doing the verbal autopsy. Information collected during baseline enumeration and follow-up rounds in the Haramaya HDSS Baseline measures: collected during the baseline enumeration and with newly immigrated households. Follow-up measures: repeated on each data collection round. Additional measures: distinct for a data collection round or year. An electronic data collection system has been put in place using Open Health Demographic Surveillance and Open Data Kit applications. Data collectors use a tablet to collect and save data. Once data have been saved on the tablet, supervisors check for and correct errors before transferring the data to the server. A regular follow-up on the server is made by the data manager, who sends corrections to the field through the field coordinator. At baseline, the total number of households in the Haramaya HDSS catchment area was 17 461. The total population at baseline was 99 898, of whom 51 259 were male and 48 639 female. In the first round of follow-up data collection, 1046 women were pregnant and there had been 2884 live births, 441 deaths, 1453 people who had emigrated and 502 people who immigrated into the study area since baseline. The crude death and birth rates were 4.34 and 28.37, respectively. Taken together with a crude immigration rate of 4.94, the population in the study area is expected to increase in the coming years. In the last round of follow-up, round two, the total number of households has reached 19 013 and the total population has surpassed 108 557. As Table 3 shows, live births, deaths and other events showed a decreasing trend. This is especially so for live births, of which there were 2884 in the first round and 1908 in the second follow-up; crude birth rate 28.37in the first round and 17.58in the second round. Similarly total deaths, which were 441 in the first round, become 339 in the second round. On the other hand, the under-five mortality rate, women of reproductive age and in-migration increased slightly. For instance, under-five mortality rates increased from 40.57 in the first round to 56.60 in the second round; and women of reproductive age (15–49 years) rose from 23 841 in the first round to 25 419 in the second follow-up. Nevertheless, the overall crude population per 100 decreased from 2.40 to 1.45 in the second round (Table 3). Basic characteristics of Haramaya HDSS A large proportion of the adult and economically active population are farmers (35%) (Table 4). Farmers in the area mostly produce khat, maize and sorghum (Table 1). Besides farming, daily labour and trade are the other dominant forms of economic activity in the area. A large number of the population, in terms of occupation, are students (17 577, 26.82%). As a result, the young dependency ratio was 98.98 at the first follow-up (Table 3). Sociodemographic characteristics at baseline Occupation Most of the women in the area are housewives (16 009, 24.43%) in terms of occupation. With regards to literacy, most of the population (61 411, 61.47%) can neither read nor write, with only a small proportion (37 296, 37.33%) being literate. (Table 4) Among the adult population, 34 447 (52.56%) were in monogamous marriages at baseline and 274 (0.42%) were in polygamous marriages. The remainder of the population were under-age or single and had never been married. In terms of religion, 96.92% of the population at baseline were Muslim, with only 0.5% Christian (Table 4). The population pyramid and age structure of Haramaya HDSS are similar to those of the Ethiopian population and many developing countries, that is wide at the bottom, which means a large population aged under 14 years and narrow at the top, which indicates a small number aged above 60 years. The majority of the population are aged below 19 years, and most females (46.69%) are in the reproductive age group (15 to 49 years). Similarly, males aged 15 to 49 years constitute 44.85% of the male population (Figure 2). Baseline population pyramid of Haramaya HDSS In alignment with the university’s goal of being an agricultural and mechanical arts school, and with the subsequent expansion of agricultural research activities in the university, agriculture is the most researched subject. Other subjects of research include the environment, health and social sciences. There are two ongoing projects and several published research works on the Haramaya HDSS catchment area and its population. The first one is Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) Projects. This project is investigating the association of Campylobacter with environmental enteric dysfunction (EED) and stunting. In addition, it is working to fill the knowledge gap in the young children’s direct or indirect exposure to feces of animals, and sociodemographic factors that may affect this association. This project is still ongoing. Published papers connected with this project include a cross-sectional study by Chen D et.al. (2021). This study used five of the 12 sub-districts of the Haramaya HDSS and involved 102 randomly selected children.7 Another study is that of Louis KB et al. (2020). This study revealed that, despite the prevalence of stunting in the area, chicken eggs are considered too luxurious to be eaten and rather they are sold out for cash.8 The third published paper is a work of Tefere Y et al. (2020). This study focuses on the prevalence, diversity, abundance and co-occurrence of Campylobacter spp. in stools from children in a rural area of the five sub-districts of the HDSS.9 Child Health and Mortality Prevention Surveillance (CHAMPS) is another project that is still ongoing and also published several research works. CHAMPS is a global surveillance network that works to generate and share accurate causes of child mortality. It is directly working on the three sites in the area; Haramaya HDSS is one among them. Minimally invasive tissue sampling (MITS) data are gathered from children who under the age of 5 years and were found in the HDSS study There are several published research works on CHAMPS project which to the causes of child mortality. For instance, some on the of and child causes of the of overall of child the why CHAMPS is and an of demographic in the CHAMPS As the Haramaya HDSS is by the office as the previously established Kersa HDSS, all the and are The Kersa HDSS have with data and data collection and have the of the Haramaya Haramaya HDSS is located close to Haramaya University, one of the universities in Ethiopia. projects in Haramaya University have been using the Haramaya district as a of research and community activities. by and students from the university have also been done in the district, due to its to the university and university There are also some in the Haramaya The 2019 has put significant on the regular activities of the HDSS as a result, data collection rounds have not been completed on The baseline data collection months, and the first round of follow-up for months. due to and in the area data collectors not to leave their houses. As a result, there was a to data collection the available Data collectors are to a large number of households the available of although only 12 kebeles or are selected from the total of 34 the they represent the First in terms of all are that and although most of the population in the area are there are known for trade and cash which are included the study population. The Haramaya HDSS research is open to collaborative efforts health and demographic studies. Requests for the existing surveillance data can be directed to the HDSS HDSS HDSS HDSS The Haramaya HDSS was established by Haramaya University as one of its regular activities as a research field for health its the HDSS has been working with the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) it has also been with Child Health and Mortality Surveillance (CHAMPS) for and the field data collection, and monitoring and the and the and member of the the overall activities of the HDSS including the data collection and the data on and member of the HDSS and the data collection and member of the the data field the data collection and in the data manager, and the data for the

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