# **S4. Vignettes: Protocol, administration, reason for use, and validation**

A vignette is a hypothetical case in which the interviewer acts as a “patient” and provides a very brief description of symptoms. The provider is informed that the “patient” will comply with the provider’s instructions, medications, and tests. The provider is then invited to proceed exactly as he or she would under normal circumstances, asking questions about the history of the illness and performing necessary examinations and tests. The “patient” provides standardized predetermined answers to the questions and examination/test procedures. The questions, examinations, and tests that a provider uses are compared to protocol checklist. Data are recorded on each of the items on the checklist the provider provided; the diagnosis given; and the treatment suggested. Four of the seven vignettes used in this study were originally developed for use in Tanzania, with the items drawn from the national protocol.<sup>4</sup> The list was subsequently expanded to include items required by the guidelines for the Integrated Management of Childhood Illnesses.<sup>5,6</sup> Vignettes were administered to a random sample of doctors, medical assistants, nurses, and nurse-midwives (i.e., any staff that provide outpatient or maternity services) who were present in the facility on the day of the first, announced visit. Absenteeism on that first visit, announced in advance, was 17.2 percent (for nurses and midwives) and 25.4 percent (for doctors).

The assessments were carried out by a team of two enumerators who were trained in the administration of vignettes. One acted as the patient and the other recorded outcomes. Normally, the recorder should have medical training: for example, in Togo the enumerators were medical students and in Niger, enumerators were medical workers with at least a university degree.

We use data from seven vignettes capturing conditions associated with the main causes of child and maternal mortality in Sub-Saharan Africa: malaria, tuberculosis, diarrhea, pneumonia, diabetes, neonatal asphyxia and post-partum hemorrhage. All seven of these conditions are major global health challenges, with three of them only – diarrhea, neonatal asphyxia, and malaria – together causing an estimated 180,000 thousand disability-adjusted life years (see Table S3).

Table S5 below shows the starting scenario for the vignettes. Beyond the starting scenario, the vignettes proceed with additional information depending on the questions asked by the health provider.

**Table S5. Initial scenarios for vignettes**

|**Vignette**|**Description **|
|---|---|
|Acute diarrhea with severe<br>dehydration|An adult presents a 1 year child with diarrhoea.|
|Pneumonia|An adultpresent a5-yearold child withcough.|
|Diabetes Mellitus|An adult presents at the facility feeling weak<br>and without energy despite feeling hungry often<br>and eating frequently. The man is 48yrs old and<br>worksasaclerk.|
|Pulmonary Tuberculosis|A pregnant woman presents at the facility after<br>being told in the community<br>that she shouldgo for antenatal care.|
|Maleria + anemia|An adult presents a child with fever for some<br>time who hasgotten worse.|
|Post partum hemorrhage|A young woman presents at the facility with<br>vaginal bleeding 24 hours after delivery in a<br>health facility|

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