16 Dec

The Nutrition Landscape in India

This post is part of a series commemorating 30 years of The DHS Program.

By Fred Arnold

Historically, India has suffered through devastating periods of famine, but due to the Green Revolution, improved food storage and distribution, and other factors, famine has been all but eradicated in the country. However, malnutrition continues to threaten the health of India’s population.

NFHS-3

NFHS-3

The National Family Health Surveys (as DHS surveys are known in India) have been documenting the nutrition situation in India since 1992 (by measuring the height, weight, and anemia status of children and adults, and by assessing infant and young child feeding practices). These surveys have brought to the nation’s consciousness the excessively high levels of stunting, wasting, underweight, and anemia that young children in India continue to suffer from. The most recent NFHS survey (NFHS-3) found that nearly half of children under five are stunted, 43% are underweight, 20% are wasted, and 7 out of every 10 children are anemic. Stunting among children was as high as 60% in the lowest wealth quintile, but was still considerable (25%) even in the highest wealth quintile. These findings were widely reported in the media, were agonized over by international organizations and NGOs, and were prominently discussed at the highest levels of government. In two national addresses, Prime Minister Manmohan Singh revealed that he had seen the results of the National Family Health Survey, and he declared the poor nutrition of India’s children to be “a national shame.” He immediately responded by writing a letter to the Chief Ministers of every state in the country, ordering them to take up the fight against malnutrition “on a war footing” and to report back to him every quarter on the progress that had been made.

Based on the NFHS-3 findings, that same year I wrote a paper on the nutrition landscape in India, which was published in Demography India and presented as the keynote speech at the Annual Meeting of the Indian Association for the Study of Population. That reached yet another important constituency that joined the national dialogue on nutrition.

Another aspect of nutrition that was documented in that paper was the emerging dual burden of simultaneous undernutrition and overnutrition among Indian adults. About one-third of women and men were abnormally thin and about 1 in 8 were overweight or obese, meaning that only about half of adults had a normal nutritional status. The figures are even more alarming in certain segments of the population. Thirty to forty percent of women were overweight or obese in some of India’s largest cities, and even in urban slums, 20-30% of women fell in that category.

Since NFHS-3, there have been encouraging signs of improvements in nutrition in some places, but discouraging signs of stagnation or deterioration in others. The results of the NFHS-4 survey, which is just about to go into the field, are eagerly awaited to provide more definitive information on the current nutrition situation. And when the next chapter in India’s nutrition history is written, NFHS will be there to monitor trends and provide vital information to guide informed policymaking and program planning.

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Fred Arnold, Technical Deputy Director—Dr. Arnold is responsible for setting the overall technical direction for The DHS Program and coordinating the design of DHS questionnaires. He has coordinated technical assistance to four large-scale National Family Health Surveys in India, which have included interviews with more than one million women and men, working with more than 40 organizations (government ministries, funding agencies, international organizations, and implementing agencies) in the conduct of the surveys. He has been involved in the design and implementation of surveys in 15 additional countries. Dr. Arnold has a Ph.D. in economics/demography from the University of Michigan. He has authored more than 150 publications in areas such as malaria; HIV; maternal, newborn and child health; nutrition; son preference; international migration; and the value of children.

10 Dec

Gender in the Demographic & Health Surveys: Past, Present, & Future

This post is part of a series commemorating 30 years of The DHS Program.

When I first started at The DHS Program in late 1993 as a Women-in-Development Specialist, the survey questionnaires contained few questions that could shed light on the impact of gender on demographic behavior and health. While the questionnaires were designed to collect all kinds of information on women’s and children’s health, women’s use of contraception, fertility, mortality and nutrition, there was virtually no information on the status of the women themselves other than information on their education and employment. In other words, there was little information that provided insights into the gendered context within which the health and demographic behavior of women and households was being determined.

1995 Egypt DHS

1995 Egypt DHS

So I had a lot of work to do. My challenge was to develop a parsimonious module of questions that in the future could potentially be used by DHS surveys across the world to better understand the role that gender plays in demographic and health outcomes. To this end I put together a set of questions on women’s status based on a thorough literature review and an examination of several studies that used questionnaires to measure women’s status and gender relations in the household. Once ready we managed to include this module of questions in the 1995 Egypt DHS. Preparing the module was challenging since the literature provided mostly proxy indicators of women’s status at the household level, but few that could directly measure empowerment. Additionally, since one of the key features of The DHS Program is that it provides comparable data across countries, I needed questions that had similar meaning across cultures with widely varying perceptions of women’s roles. The pilot of the Women’s Status Module in the Egypt DHS yielded a lot of useful information and helped determine the key indicators that would be useful to have for most countries such as the questions on women’s role in household decision making, their attitudes towards spousal violence, and barriers to accessing health care for themselves.

1998 Nicaragua DHS

1998 Nicaragua DHS

Another gender-related topic that really increased in importance during my tenure as the Senior Gender Advisor to The DHS Program is domestic violence. The women’s status module implemented in Egypt contained only a couple of questions on women’s experience of domestic violence and the 1990 and the 1995 Colombia DHS surveys included country-specific questions on domestic violence. Then in 1998, a module of questions that utilized a modified conflict tactics scale approach (Strauss 1990) to the measurement of violence was implemented in the Nicaragua DHS. It was this module that became the foundation for the core DHS Domestic Violence Module which was finalized and piloted around 2000. Overtime we also developed a protocol for the ethical collection of data on violence, particularly for the protection of female respondents and field interviewers. However, having a standardized module and protocols for its implementation, did not mean that countries were immediately interested in collecting information on domestic violence. There was first a need to try and overcome commonly held beliefs that domestic violence was not a State concern and had no place in a demographic and health survey. Additionally few believed that women would be willing to talk about their experiences of violence.

The 1995 Egypt DHS marked a new chapter in the life of The DHS Program. Questions on women’s empowerment are now part of the core questionnaire and asked in most countries. The Domestic Violence Module has been included in more than 95 surveys in over 50 countries. Survey data have been used for major legislation, advocacy efforts, and national programs to protect women in their own homes in countries as diverse as Moldova, Uganda, Timor Leste, and Zimbabwe. Analysis of DHS data has convincingly linked violence with negative reproductive health outcomes and HIV, showing that violence is an important public health issue as well as a violation of individual rights.

In the coming years, The DHS Program will continue to collect more information on women’s empowerment. The 2014 revised survey instruments now include questions on women’s ownership of mobile phones, personal bank accounts, and ownership and co-ownership of property. We have come a long way since the first pilot module on women’s status, and we will continue to be on the forefront of research into women’s lives.

Reference

Straus, M.A. 1990. Measuring intrafamily conflict and violence: the conflict tactic (CT) scales. In M.A. Straus and R.J. Gelles (eds.) Physical Violence in American families: Risk Factors and Adaptations to Violence in 8,145 Families. 29-47. New Brunswick: Transaction Publishers.

04 Dec

A look back at the 1986 Liberia DHS

Field interviewers for the 1986 LDHS

Field interviewers for the 1986 LDHS

This post is part of a series commemorating 30 years of The DHS Program.

By Annie Cross

2013 Liberia DHS

2013 Liberia DHS

The fact that Liberia is currently battling the Ebola crisis makes it harder to appreciate the fact that the recently released report on the 2013 Liberia Demographic and Health Survey (LDHS) showed improvement in most of the health-related indicators since the 2007 LDHS was carried out. I prefer to remember Liberia the way it was during the first DHS, before Ebola and before the civil war.

The 1986 LDHS was the first DHS in Africa and only the second worldwide. I was the country manager assigned to cover the survey. However, because we recruited interviewers from the local areas in which they would work and it was deemed too expensive to bring them all to one central place, we decided to hold two simultaneous training courses. I travelled the 6 hours to the town of Zwedru, while my boss (then Regional Coordinator, later DHS Director) Ann Way, was in charge of the training in Monrovia. Zwedru was a small quiet city and I was lucky to be able to stay in a USAID guest house for the month-long training. We also had a pleasant, airy new building for the training. Ann, however, was training in an old school with broken windows in Monrovia.

Annie Cross with the 1986 LDHS

Annie Cross with the 1986 LDHS

Although we had conducted a pretest several months before, this was the first DHS main interviewer training for both of us. Consequently, we had a number of questions that came up. How do you estimate a person’s age when they don’t have any documents and can’t remember who was president when they were born? Do you list someone in the household schedule who works away from home but comes home every weekend? Although we had a detailed interviewers’ manual, some of these questions had not been fleshed out. And of course, there were a slew of administrative issues too, like locating enough vehicles, getting payments wired from the U.S., etc.

Ann and I set up a plan to call each other every few days. Since this was before cell phones and even land lines were pretty scarce in Liberia, I would walk to a pay phone in Zwedru, put in several of the heavy Liberian coins (nicknamed “Doe Dollars” after the Liberian President) and call her in Monrovia. We would review various issues and catch up on news. It sounds so quaint now, but it was like a lifeline for me and I remember saving up the coins so that when the phone indicated the time was running out, I could drop another dollar in and talk a bit longer. We always had to remember to set up the time for the next call so that we would be sure to be at our respective phones. We don’t realize how much cell phones have changed the survey landscape.

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Anne Cross, former Deputy Director – Survey Operations: A demographer and survey specialist, she has extensive experience in survey research, including nearly 40 years of experience in population- and facility-based data collection, analysis, capacity building, dissemination and use of data in developing countries. Ms. Cross received her M.A. degree in Demography from Georgetown University in 1973. Prior to joining Macro in 1982 as a Demographer on various USAID-funded projects, she spent several years as a Demographer at the University of North Carolina, where she implemented a demographic survey in Somalia and assisted in the design of various survey questionnaires. Earlier in her career, Ms. Cross was a Demographic Advisor to Kenya’s Central Bureau of Statistics with responsibility for analyzing survey data.

02 Dec

Celebrating 30 years of DHS

2014 marks the 30th anniversary for the USAID-funded Demographic and Health Surveys Program and my eleventh anniversary as Senior Advisor for Communication with the project.  Much has changed over the past three decades: we’ve done many more surveys and much more complex surveys, added biomarkers, conducted more formal capacity building, and varied the kind of dissemination products and activities.  What hasn’t changed is how much people all over the world value the DHS.

When I joined The DHS Program—then MEASURE DHS—in 2003, I was a devoted DHS user, relying on surveys for background information to inform behavior change communication programs.  But I knew very little about how national governments and development partners used the surveys. It was my first trip for the project that gave me a whole new perspective on the impact of DHS findings.

2003 Nigeria DHS

2003 Nigeria DHS

I went to Abuja, Nigeria for the launch of the 2003 Nigeria DHS Final Report. More than 500 people crammed into the Sheraton Hotel Conference Centre designed to hold only about 350.  The morning session included opening prayers, introductory speeches by four government ministers, the USAID Mission Director, the head of the National Population Commission, the Chief Economic Advisor to the President, and more.  Finally, we got to the data—a short key findings presentation of the survey results highlighting childhood vaccination rates from Nigeria and from DHS surveys in other African countries (see chart below).

Percentage of children who received all basic vaccinations in select African countries from the 2003 Nigeria DHS Key Findings

Percentage of children who received all basic vaccinations in select African countries from the 2003 Nigeria DHS Key Findings

At the time, only 13% of Nigerian children had been fully vaccinated, putting Nigeria dead last in Africa.   When this statistic was presented, all 500 participants in the audience sat in shocked silence. The data told the story, and the Nigerians were not happy to be so far behind their smaller and much poorer neighbors. The DHS results were a critical factor prompting Nigerian leaders to focus on improving national immunization programs. While still not impressive, vaccination coverage for Nigerian children has doubled since 2003, reaching 25% in the 2013 DHS.

Trends in Vaccination Coverage from the 2013 Nigeria DHS Key Findings

Trends in Vaccination Coverage from the 2013 Nigeria DHS Key Findings

2013 Nigeria DHS

2013 Nigeria DHS

I heard another example of the impact of the 2003 Nigeria DHS during my trip.  The survey found that only 12% of households owned mosquito nets. As a result, a DFID-funded Society of Family Health project decided to increase malaria prevention activities and add insecticide treated nets to its roster of social marketing products.  For both the national government, private sector, and development partners, the DHS made the difference.

I’m immensely proud to introduce this blog series, which will highlight many different stories of DHS over the years. Over the course of this next month, you will hear from DHS leaders over the years, including Sunita Kishor, Martin Vaessen, Trevor Croft, Guillermo Rojas, Fred Arnold, and Annie Cross, on topics ranging from gender & women’s issues in the DHS to nutrition in India, Data Processing and collection methods to experiences from the first DHS in Liberia. I hope this series unlocks some of DHS history for you, our users. Here’s to 30 years of DHS!

25 Nov

DHS Curriculum Training in Kenya

Participants in the DHS Curriculum Training in Mombasa, Kenya

Participants in the DHS Curriculum Training in Mombasa, Kenya

By Peninah K. Masibo

The Demographic and Health Survey (DHS) curriculum is a course that builds the capacity of faculty and students in African universities to understand and use DHS surveys. The course covers a general introduction to the DHS, basic statistics and demographic health terms, indicators in the DHS, conducting a DHS, collecting data on HIV/AIDS and malaria as well as dissemination and use of DHS data.

In May 2014, 40 participants from the Technical University of Mombasa and Pwani University went through a five day training on the DHS curriculum course. Participants were an interesting mix of senior university professors, deans of schools, heads of academic departments, members of various faculties, and graduate students. The participants came from various fields of specialization including medical sociology, public health, environmental science, laboratory management, entomology, epidemiology, and medicine.This range of scholars made it so much fun and generated very hearty debates regarding the DHS curriculum and the applicability of the materials in university teaching, learning, and research.

The DHS curriculum training spurred participants into finding ways of integrating DHS into their university teaching. Applicable fields include statistics, epidemiology, research methods, vector control, parasitology, human nutrition, medical laboratory, HIV/AIDS, research methods, and medical sociology. The graduate students from the Master of Public Health (MPH) programs at both universities found the training very applicable to their course and field work activities.

2008-09 Kenya DHS

One of the prominent areas of discussion was the new malaria module. The Kenyan coastal region is a malaria endemic zone, and the module is very relevant for research and academic teaching in the institutions of higher learning. The malaria trivia game made it a very memorable learning experience. Other interesting discussions centered on emerging health issues such as cervical cancer. Participants were thrilled to learn of the inclusion of cervical cancer knowledge questions in some DHS countries.

The training created a lot of interest in learning how to use DHS data for individual and group research activities. Working in small groups made the training very exciting allowing the graduate students to lead discussions along with senior faculty.

The training was well organized with full participation from the two public universities. The Deputy Vice Chancellor (DVC) of Academics, Research, and Extension at Technical University of Mombasa made the official opening speech. She highlighted the importance of DHS in informing health and development policy in Kenya and globally. The closing ceremony and the certificate award were conducted by the DVC of Academics and Student Affairs at Pwani University. He observed the need for participants to apply the newly acquired knowledge and skills from the training to enhance the universities’ training activities.

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Dr. PM.photoPeninah K. Masibo is a lecturer at the Moi University School of Public Health, Department of Epidemiology and Nutrition, Kenya.

 

 

 

19 Nov

GIS Resources at The DHS Program

gis

By Clara Burgert

The first DHS survey to use geographic location data was the 1996 Benin DHS. At that time, Geographic Information Systems (GIS) Day didn’t even exist (it was first started in 1999)! But over the years, we’ve collected location data in more and more surveys—over 120 to date. Our offerings in terms of GIS tools for understanding the data we’ve collected have also become richer. These data serve the important role of helping us to understand the linkage between health behavior or outcomes and physical location.

One of the key GIS tools that The DHS Program has created is the Spatial Data Repository (SDR). The Spatial Data Repository provides geographically-linked health and demographic data from The DHS Program and the U.S. Census Bureau for mapping in a GIS.  The SDR has gone through many iterations before it arrived at its present design. Originally, the site was just a host for users to download .zip packages of information. When we launched the current SDR last year, it had been completely redesigned to include several new functionalities, including the Boundaries page, which allows users to take a look at ways in which boundaries have changed over time in DHS surveys. The SDR is one of the first USAID-funded sites that is fully open data, that is, any user can go to the site and download information for free, without having to go through a process of registration or requesting.

As of September this year, the SDR has added even more resources. The boundary page has a comparison page, and we’ve added more maps and search functions to the SDR Gallery, where users can peruse maps that were created from the SDR data. Users can submit their own maps, and they may also be featured on the site.

We’ve also created several video tutorials that explain more about how to use GIS resources (and three SDR-specific videos) at DHS.

Be it today for GIS Day or any day of the year, The DHS Program GIS resources are available to assist you in visualizing and analyzing DHS data.







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Clara R. Burgert is the GIS Coordinator for The DHS Program. She oversees all  geographic data, mapping, and geospatial analysis activities at The DHS Program.  Additionally, she facilitates workshops in partner countries on using maps for better decision making using open source GIS software.

 

 

 

 

30 Oct

A Perspective on the DHS Fellows Program from a 2013 Fellow

2013 DHS Fellows

2013 DHS Fellows

By Simon Peter Kibira

In 2013, I was a member of a three-person team from Makerere University selected to participate in the DHS Fellows Program along with four other teams from African universities. The DHS Fellows program is designed to increase the capacity of countries to conduct further analysis of DHS data. Over the course of two intensive, yet enlightening, workshops, DHS staff mentored and encouraged us in our research endeavours.

DHS Fellows including Simon at the 2nd 2013 Fellows workshop in Kenya.

From L to R: 2013 DHS Fellows Madeleine Wayack- Pambè (Burkina Faso), Elizabeth Nansubuga (Uganda), and Simon Kibira at the 2nd 2013 Fellows workshop in Kenya.

The first workshop in Uganda focused on technical skills in using DHS data. The workshop consisted of various technical sessions that allowed participants to learn survey data analysis skills from the DHS researchers, to exchange research ideas among Fellows, and to hear about former Fellows’ experience working with DHS data.  The second workshop, held in Kenya, focused on writing our working papers. We refined analysis, addressed reviewers’ comments from DHS subject experts, and polished our final drafts.

The hands-on experience of working with DHS data through further analyses was such a remarkable experience.  The DHS facilitators and co-facilitators provided one-to-one assistance that made working through dataset challenges much easier. We had sessions where we listened to each team’s presentation about research findings. It was amazing to see how much we evolved over the course of two workshops to be able to positively critique each other’s work from very informed viewpoints. In my own perspective, we were turning into “DHS experts.”

Apart from the working paper, the workshop facilitators organized us to visit DHS implementers in Uganda–the Uganda Bureau of Statistics–through which we had a better understanding how DHS data were collected. We were also encouraged to disseminate our fellowship paper further through conferences and peer-reviewed journals. My team’s work resulted in three presentations at international conferences in Uganda, South Africa, and the US, and a peer-reviewed journal article. After the Fellowship ended I collaborated with other faculty at Makerere University, including a 2012 DHS Fellow, on a new study using DHS data. We recently published our findings in a peer-reviewed journal.

Further, we were encouraged to use DHS Program materials for capacity building trainings at our institutions. It is fulfilling to see that data collected nationally can be fully and properly utilised to benefit African university students and researchers, but also bring out results beyond what is published in DHS survey final reports. The onus is on all Fellows to take an extra step to ensure vital recommendations from published papers are utilised by health programs.

I am proud of the invaluable collegial network I have among the DHS Fellows. I know future collaboration can be based on such networks in different countries and universities. These are immeasurable benefits beyond the one year fellowship.

When the DHS Program asked me to co-facilitate the 2014 fellowship, my decision was a no-brainer. Aside from helping teams, I learned a lot as a co-facilitator from the Fellows. It was also very fulfilling to see Fellows’ papers in the DHS working paper series.

The mark the fellowship program has left on my academic and research career will endure throughout my career. The DHS Fellows program is an experience every early or mid-career professional in research and academia will find rewarding.  I hope many more people from DHS countries will benefit from the DHS Fellows program.







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2015 DHS Fellows Program

Applications are now being accepted for the 2015 DHS Fellows Program through December 1, 2014. Applications must be from teams comprised of three faculty members from the same university who teach in departments of demography, public health, economics, sociology, geography, or other social sciences. Applications are only being accepted from faculty members at universities in Malawi, Namibia, Nigeria, Tanzania, Uganda, Zambia, or Zimbabwe. Read more>>

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Simon Peter Kibira is an Assistant lecturer at Makerere University in the School of Public Health. He started his career at the Uganda Bureau of Statistics (UBOS) in 2006 as a regional supervisor in the implementation of the 2006 UDHS. In 2008, he joined the faculty at Makerere University and in the 2011 UDHS he was part of the external team from the School of Public Health that did quality control during data collection. He authored the chapter on Family Planning in the 2011 UDHS final report.  Simon is a 2013 DHS Fellow and co-facilitated the 2014 Fellows workshops. He is currently pursuing further studies in International Health at University of Bergen and part of his study is based on Uganda AIDS Indicator Survey data, inspired by his participation in the 2013 DHS Fellows Program.

24 Oct

Introducing: Sampling & Weighting at DHS

In my travels as a DHS sampling statistician, I have met countless people who want to hear about the sampling techniques and procedures we use in DHS surveys. Recognizing this fact, we are working to incorporate more sampling-related capacity strengthening activities at The DHS Program. The feedback we get after these activities has only encouraged us to produce more learning tools highlighting basic sampling-related concepts and topics used in DHS surveys.

2012 Tajikistan DHS

2012 Tajikistan DHS

We created a 4-part video series (the next two will be coming within the year) designed to introduce DHS sampling concepts, two of which were launched around World Development Information Day. In the videos, we present the sampling design and procedures used in the 2012 Tajikistan DHS survey as an example of sampling procedures in DHS surveys.

The first video, Introduction to DHS Sampling Procedures, explains the basic concepts of sampling, introduces the stages of designing a sample in a DHS survey, and discusses the key factors to consider when calculating sample sizes for a DHS survey.







The second video, Introduction of Principles of DHS Sampling Weights, introduces the concept of weighting survey data.  You will understand the goals and the importance of weighting as well as the concepts of over- and under-sampling.






Both videos introduce you to the basic sampling definitions, concepts, and procedures followed in a standard DHS survey. If you are interested in more information about the sampling procedures in the DHS surveys, you can check out the DHS Sampling and Household Listing Manual. If you have more questions, check out the user forum!

What did you learn from the sampling & weighting videos? What would you like to explore further? Comment below!

14 Oct

Reflections on the DHS Curriculum workshop in Malawi

DHS Curriculum Workshop participants after a successful training.

DHS Curriculum Workshop participants after a successful training

By James Kaphuka

In July, I facilitated my fourth DHS Curriculum workshop. It was also the second time I had trained graduate students from the University of Malawi, Chancellor College.

The DHS Curriculum Facilitator’s Guide is a comprehensive package of ready-made training materials about understanding and using Demographic and Health Survey reports.  The curriculum is designed for use in African universities and with public health program staff.  Over 25 hours of instruction are divided into eight stand-alone modules designed to be a course on its own or customized and integrated into existing curricula.

This particular workshop was a stand-alone course held in Zomba, Malawi, from 21- 25 July 2014. Participants were students at Chancellor College, University of Malawi, pursuing master’s degrees in Development Studies.

2010 Malawi DHS

2010 Malawi DHS

A majority of the participants did not know anything about Demographic and Health Surveys until this workshop—and most surprisingly, quite a few of them indicated that they had never seen the results of the 2010 Malawi DHS until they worked with it during the workshop. A majority of the participants struggled to understand Module 4, Conducting a DHS, especially Sessions 2 and 3, because of their background. Session 2 describes the sampling procedures used in the DHS, while Session 3 goes over the principles of Sampling Weights. However, the group showed great interest and everyone was very eager to learn more about DHS and enjoyed group work and exercises.  The group really enjoyed the Malaria Trivia Game (Module 7)!

Malaria trivia game

Malaria trivia game

After the workshop,  many participants expressed  that this course should be a must for all graduate students at Malawian universities because the course material is very helpful in their school work. A number of them have indicated that they will use DHS results in their project work or dissertation.  There is a great demand among the students, both undergraduate and graduate.

I am very passionate about my DHS survey work, and I look forward to continuing to collaborate with DHS Program staff so that together we can help train (and mentor) as many undergraduate and graduate students using DHS in Malawian universities.

For more photos of the training, check out the Facebook album.

James Kaphuka is a survey specialist with more than 5 years of professional experience providing technical assistance in all phases of survey implementation, from questionnaire and training manual design to report writing and data dissemination. Kaphuka has been directly involved  (as a consultant) in the implementing and completing Demographic and Health surveys in Swaziland, Namibia, Zambia, Malawi, and Liberia. Kaphuka has a Master of Science degree in Demography and Health from the London School of Hygiene and Tropical Medicine, University of London and an MSc in Social Research Methods and Statistics from the University of Manchester.

You can learn more about his work with The DHS Program here:

 

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