This document summarizes a study that used Lot Quality Assurance Sampling (LQAS) to monitor coverage and quality of a targeted condom social marketing program in India. LQAS was used to assess geographical coverage and quality of coverage of condoms in target areas across four Indian states. Results showed a significant increase in condom availability between 2005-2008 through pharmacies and non-traditional outlets. LQAS proved to be a valuable tool for routine monitoring of geographical coverage and quality of condom delivery, allowing decision-makers to be regularly informed on progress towards targets using a small sample size and simple methods.

1. LQAS
Lot Quality Assurance Sampling
Fundaments and experience in EGPAF Uganda Program
April 2012
Juan Seclen, M.D., MHPM

2. Origins of LQAS
• LQAS first used in the Manufacturing Industry in 1920s
• Used as a quality control method in the 1920s
o To assess quality of batches (Lots)
o The Lot would either be rejected or passed based on a predetermined
criteria
• LQAS adapted in public health in mid 1980s
– Stroh 1985, Valadez 1986 and 1991, Lwanga and Lemeshow 1991

3. Terminologies from Manufacturing to Public Health
• LQAS Terminology adapted into public health
o Production Standard = Coverage target for intervention
o Production unit = Catchment area / District
o Lot = Community / Supervisor’s area of supervision

4. Fundaments of LQAS
• LQAS is used for the monitoring of programme coverage indicators,
based on a stratified simple random sample of a small number of
geographical units per stratum, also called a ‘lot’.
• It is seen as a good alternative to more complex and often more
costly sampling techniques.
• The method is particularly suitable for frequently conducted
monitoring surveys on programme coverage and other performance
indicators in settings that do not require a high level of statistical
precision.
• LQAS tests whether a given threshold value is achieved or not,
rather than producing estimates for an indicator, although different
‘lots’ can be combined in order to estimate overall programme
performance in terms of coverage.

5. Fundaments of LQAS
Lot = Supervision Area

6. Fundaments of LQAS

7. Fundaments of LQAS
LQAS: dichotomy - 19
Lot Quality Assurance Sampling
 in general small (19) RANDOM sample for acceptable precision of
at least 92% on “dichotomic” conclusions
For example, what LQAS can: just by sampling 19 farmers or
mothers in a targeted population, at least 92% of the time LQAS
will determine correctly whether yes or no the targeted farmers
have adopted the soil preparation techniques, or whether a
certain target coverage of exclusive breastfeeding is reached in a
beneficiary population
 LQAS cannot be used for coverage estimates in lot!
 Only if it’s above/below target  Decision Rule

8. Applications of LQAS
• LQAS has been used in various areas such as:
 Proportion of target population what received an intervention
 Assessing immunization coverage
 Assessing compliance with health policy and guidelines (patience
screening practices)
 Post disasters assessment
 Women’s health
 Growth and Nutrition
 Diarrheal disease control
 Quality management
 Neonatal tetanus mortality
 HIV/AIDS and STIs (for example, % of population that knows a risk
related behavior)

9. LQAS in Uganda
• Trypanosomiasis in Terego County; 1996
• HIV/AIDS, STI and TB
o World Bank, UACP project (30 districts) (HIV/AIDS, TB);
• HIV/AIDS, TB, Education
o UPHOLD (2003-2007), (29 districts)
• HIV, TB and Malaria
o NUMAT (2006, 2008) (9 Districts)
• Education
o UNICEF (2006) (13 districts)
o CSOs e.g. Family life Education program (2005)
• Other Health
o Health Partners – Uganda Health Cooperative (Bushenyi)
• HIV/AIDS, TB, Education
– STAR EC (2009) (6 districts)
• HIV/AIDS, TB, Malaria
– STAR E (2009) (4 districts)
• STAR-SW Project
o Focus in South West Region (2010 onwards) 12 districts

10. LQAS in STAR-SW Project
• One commitment of this Project is institutionalizing LQAS at
district health level
• Conducted annually since 2010
• Collect information from community level (households)
• Random sample-based study
• Lot = Districts
• Focuses on measuring:
• PMTCT/HCT
• STI
• HIV knowledge and sexual behavior
• TB
• Malaria
• Reproductive health
• Sanitation, hygiene, and feeding

11. LQAS study cover all STAR-SW Project’s districts
STAR-SW DISTRICTS
IBANDA
KIRUHURA
RUBIRIZI
BUHWEJU
BUSHENYI
MITO OMA
SHEEMA
RUKUNGIRI
ISINGIRO
KANUNGU NTUNG AMO
KABALE
KISORO

13. Data collection:

14. Data processing:

15. Results of Indicators aggregated at STAR-SW catchment area
Indicators Youth (15-24 Men (15-54 Women (15-49 Mothers of
years) years) years) Children 0-11
Months
Percentage of individuals n=1,237 n=1,237 n=1,237 n=1,237
identifying at least 2 ways of 74.5 (72.1-76.9) 78 (75.7-80.3) 78.8 (76.5-81.1) 80.8 (78.6-
preventing sexual transmission 83.1)
of HIV
Percentage of individuals who n=1,237 n=1,237 n=1,237 n=1,237
reject all misconceptions about 45.8 (43.0-48.6) 49.7 (46.9-52.5) 43.2 (40.5-46.1) 43.8 (41.1-
HIV transmission 46.6)
Percentage of individuals who n=1,237 n=1,237 n=1,237 n=1,237
both correctly identify ways of 32.3 (29.6-34.9) 36.1 (33.4-38.8) 31.7 (29.2-34.4) 33.3 (30.7-
preventing the sexual 35.9)
transmission of HIV and reject
major misconceptions about
HIV transmission

16. Result by STAR-SW districts
Performance Buhw Bush Iband Isingir Kabal Kanu Kisoro Mito Ntunga Rubiri Rukun Shee
indicator eju enyi a o e ngu n=114 ma mo zi giri ma
n=96 n=95 n=11 n=95 n=133 n=95 n=95 n=114 n=96 n=95 n=95
4
Percentage of 65.6 93.7 75.4 73.7 88.0 81.1 93.9 93.7 83.3 92.7 82.1 87.4
mothers of (55.2- (86.8- (66.5- (63.6- (81.2- (71.7- (87.8- (86.8- (75.2- (85.5- (72.9- (79.0-
children (0-11 75.0) 97.6) 83.0) 82.1) 92.9) 88.3) 97.4) 97.6) 89.6) 96.9) 89.2) 93.2)
months) who
were counselled
and received an
HIV test during
the last
pregnancy and
know their
results

17. Uses of LQAS findings in STAR-SW Project:
• Program improvement: A current challenge
• Dissemination of results:
• Documentation: Official reports to MOH, district reports,
abstracts

18. Sex Transm Infect. 2010 Feb;86 Suppl 1:i56-61.
Lot quality assurance sampling for monitoring coverage and quality of a targeted condom social
marketing program in traditional and non-traditional outlets in India.
Piot B, Mukherjee A, Navin D, Krishnan N, Bhardwaj A, Sharma V, Marjara P.
Source
Population Services International, Research & Metrics Department, Washington, DC, USA.
Abstract
OBJECTIVES:
This study reports on the results of a large-scale targeted condom social marketing campaign in and
around areas where female sex workers are present. The paper also describes the method that was used
for the routine monitoring of condom availability in these sites.
METHODS:
The lot quality assurance sampling (LQAS) method was used for the assessment of the geographical
coverage and quality of coverage of condoms in target areas in four states and along selected national
highways in India, as part of Avahan, the India AIDS initiative.
RESULTS:
A significant general increase in condom availability was observed in the intervention area between 2005
and 2008. High coverage rates were gradually achieved through an extensive network of pharmacies and
particularly of non-traditional outlets, whereas traditional outlets were instrumental in providing large
volumes of condoms.
CONCLUSION:
LQAS is seen as a valuable tool for the routine monitoring of the geographical coverage and of the quality
of delivery systems of condoms and of health products and services in general. With a relatively small
sample size, easy data collection procedures and simple analytical methods, it was possible to inform
decision-makers regularly on progress towards coverage targets.