On January 9, 2008 the World Health Organization reported the results of the "Iraq Family Health Survey" published in the New England Journal of Medicine. The study surveyed 9,345 households across Iraq and was carried out in 2006 and 2007. It estimated 151,000 deaths due to violence (95% uncertainty range, 104,000 to 223,000) from March 2003 through June 2006.
The study was done by the "Iraq Family Health Survey Study Group", a collaborative effort of six organizations: the Federal Ministry of Health, Baghdad; Kurdistan Ministry of Planning, Erbil; Kurdistan Ministry of Health, Erbil; Central Organization for Statistics and Information Technology, Baghdad; World Health Organization Iraq office, Amman, Jordan; World Health Organization, Geneva.
Methods
The Iraq Family Health Survey (IFHS) was a cross-sectional, nationally representative survey of 9345 households that was conducted by relevant federal and regional ministries in Iraq in collaboration with the World Health Organization (WHO). The sampling frame that was used in the southern and central provinces was derived from the 1997 Iraq census, which had been updated for the 2004 Iraq Living Conditions Survey. The sampling frame used in Kurdistan was based on information provided by the Statistical Offices in the region. Population estimates for Iraq for the survey period were projected by Iraq's Central Organization for Statistics and Information Technology (COSIT).
Training of central and local supervisors from all 18 governorates was conducted in Amman, Jordan. Training of interviewers was done separately in each governorate for one week during May and June 2006 and a one-day refresher training session was conducted the day before the start of the survey in each governorate. Following interviewer training, the survey instruments and procedures were pilot tested in all governorates. The survey fieldwork was conducted during August and September 2006 in the 14 South/Centre governorates. In Anbar governorate, the fieldwork was conducted in October and November 2006, while fieldwork for the Kurdistan region was conducted during February and March 2007. Overall, 407 personnel participated in the implementation of the survey, consisting of 100 central, local and field supervisors, 224 interviewers evenly split between males and females, and 83 central editors and data entry personnel.
The survey had an original target sample size of 10,080 households. Interviewers visited 89.4% of 1086 household clusters during the study period and the household response rate was 96.2%. 115 clusters (10.6%) were not visited due to security problems. The IFHS argues that past mortality is likely to be higher in these missed clusters. Ratios derived from comparing their surveyed clusters to corresponding data from Iraq Body Count were used to impute elevated mortality rates to these missed clusters. Using this method, the IFHS derives death rates for the missed clusters in Baghdad that are 4.0 times as high as the clusters visited by the survey in Baghdad. The same procedure in Anbar derived rates that are 1.7 times as high as clusters visited in Anbar.
The IFHS also argues that underreporting is likely to be common in household surveys, particularly due to household dissolution after the death of a household member. On this basis the authors used several demographic assessments such as the growth balance method to derive an adjustment for reporting bias. This adjustment raised the violence-related death rate by roughly 50%, from 1.09 (95% CI, 0.81 to 1.50) to 1.67 (95% uncertainty range 1.24 to 2.30).
Results
The number of violent deaths derived from the household survey, plus the adjustments for missing clusters and reporting bias, was estimated to be 151,000 (95% uncertainty range, 104,000 to 223,000) from March 2003 through June 2006. This estimate suggests that violence was a leading cause of death for Iraqi adults and was the main cause of death in men between the ages of 15 and 59 during the reporting period.
The results were also compared to the 2006 survey by Burnham et al. reported in the Lancet, and to the Iraq Body Count project (IBC). Naeema Al Gaseer, the WHO Representative to Iraq noted, "Our survey estimate is three times higher than the death toll detected through careful screening of media reports by the Iraq Body Count project and about four times lower than a smaller-scale household survey conducted earlier in 2006," referring to the survey by Burnham et al. reported in the Lancet journal in October 2006.