19 Mar

Getting data to you faster: The Key Indicators Report

In 2006 I was in Addis Ababa, Ethiopia, preparing for the release of the 2005 Ethiopia Demographic and Health Survey (EDHS). In the days leading up to the national seminar and launch of the EDHS report, two separate individuals approached me at my hotel, both looking for an “advance copy” of the report. One was writing a grant proposal for child health services and wanted to see how child health indicators had changed since 2000.  Another needed to know how to budget for family planning activities before his annual work plan was due, just days before the launch of the report. This is not a unique story, but rather an illustration of how much people rely on DHS survey data, how well they are used, and how much impact can be made by providing quality data in a timely fashion.

2014 Lesotho DHS Key Indicators Report

2014 Lesotho DHS Key Indicators Report

There is no survey manager at The DHS Program who has not been asked if data can be released in advance. We are always asking ourselves, “how can we get people the DHS survey data faster?” This month, we release the first Key Indicators Report:  a report of the most essential results from the DHS, published just three months after the completion of fieldwork. In this case, the lucky country is Lesotho.*

While The DHS Program has always published a “Preliminary Report”, the Key Indicators Report is more complete, including additional indicators, more background characteristics such as wealth quintile, and many more figures, primarily to highlight trends. In Lesotho, for example, the Key Indicators Report highlights progress towards reducing childhood mortality.

The full DHS final report will continue to be published on schedule. For Lesotho, this will likely be in late 2015. But for now, it is our hope that these key indicators provide the much needed data that policy makers and program managers need to plan, monitor, and evaluate their efforts.

Trends in Childhood Mortality in Lesotho

Trends in Childhood Mortality from the 2014 LDHS Key Indicators Report

 

*Lesotho is the first country to produce a KIR with the newly designed standard DHS KIR tabplan and cover.  Cambodia released a country-specific KIR in February 2015.  

10 Mar

Training the Next Generation of DHS Program Biomarker Consultants

In January, 2015, 11 biomarker specialists from 8 countries met in Uganda to participate in the first-ever South-to-South DHS Program Biomarker Workshop. Participants all had previous experience with DHS surveys, either as consultants or as in-country staff. The objectives of the training were to emphasize mastery of technical biomarker content and training materials, strengthen consultants training and facilitation skills, and to pilot test the newly designed DHS Program Biomarker Curriculum. Ultimately, it is hoped that many of the participants from this workshop will be able to serve as DHS Program biomarker consultants for future surveys.

There were many lessons learned from the training. For example, while DHS Program staff have been training biomarker specialists in survey countries for decades, their training has been limited to their specific role in one country. The new biomarker curriculum is broader, allowing biomarker consultants to see how biomarker data collection fits into the larger survey process, and which aspects of the standard methodologies are applied in all survey settings.

CS blog biomarkers 2

Biomarker specialists visit a Ugandan laboratory as an experiential activity.

Bakunda Kamaranzi, a Laboratory Training Coordinator from the Uganda Ministry of Health, elaborates: “I was invited from Uganda, and had a fair understanding of the DHS Program, having participated in more than one DHS survey. In as much as I thought I knew quite a bit about the program, by the end of the first day, I knew and agreed with my colleagues that there was a lot to learn, a lot more that we did not know.”

One of the challenges of training a group of future consultants is that the participants must not just be able to implement data collection protocols and practices, but they must also be able to explain them to dozens of future trainees. This requires that these consultants understand the “why” of the way we do things. Why must the blood drops be totally dry before packing? Why do we wipe away the first drop of blood during a finger prick? Why do we measure younger children lying down? The South-to-South training allowed for a discussion of all this important background information.

Zoulkarneiri Issa (Togo), Jean de Dieu Butura (Rwanda) and Tharcisse Munyaneza (Rwanda) wrote: “En effet, ils nous rappelaient à chaque moment sur notre rôle de consultant et par conséquent, nous devons maitriser tous les contours scientifiques et même épidémiologiques des thématiques à enseigner. Ce qui nous permettra de faire face aux éventuelles questions et préoccupations des autorités sanitaires et administratives des pays où nous serons appelés à consulter.”

English: “In fact, [the facilitators] reminded us every moment of our consulting role and that we were expected to master all the scientific and epidemiological concepts and the teaching thematic concepts. This will enable us to deal with any issues and concerns of health and administrative authorities of the countries where we are called to provide technical assistance.”

Lastly, most biomarker specialists had no previous experience with adult learning techniques; few had been trained in training or facilitation. If The DHS Program hopes to use these participants as future biomarker consultants, they will, in turn, be expected to train all of the in-country biomarker survey staff on biomarker data collection. Simply knowing the technical material is not enough. They will need to know how to train people to do this correctly.

Jean de Dieu Butura, Kamarazni Bakunda, and Mike Amakyi practice storing blood samples.

For the teach back exercise, Jean de Dieu Butura, Kamarazni Bakunda, and Mike Amakyi practice proper storage of blood samples.

Bakunda Kamaranzi explains: Then came the training-of trainers. At the beginning we were introduced to new theories and names; Bloom’s taxonomy, Edgar Dale’s cone of learning, David Kolb’s experiential learning cycle, all which some of us were seeing for the very first time. By the end of the day, we were able to relate the theories to training and it all made a lot of sense.  The teaching methods learned in the TOT session were used during the teach-back sessions and, we are better trainers than we were on the 19th of January when we reported to the workshop. The trainers guide will definitely improve the way we deliver Biomarker training for DHS surveys.”

The January 2015 South-to-South Biomarker Training is one of many activities The DHS Program is undertaking to formalize our capacity strengthening efforts, and empower a wider group of experts to assist in the implementation of DHS surveys globally. The reach of these trainings is limitless:  as we train our colleagues to be trainers, they can train hundreds more. Ultimately, these South-to-South consultants will be leaders in DHS survey management, and, more broadly, will contribute to improved quality of data collection of other surveys in their region.

Biomarker specialists learning proper DBS collection.

Biomarker specialists learning proper DBS collection.

Michel Toukam, Lecturer at the Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon, summarizes: With this workshop, the consultants have acquired more knowledge on adult’s training methodology and techniques (Andragogy), on the DHS gold standards, protocols and procedures. They will form a network of DHS Program consultants in which experiences in learning techniques and follow up of DHS survey biomarker procedures will be shared. They will be more confident when they are leading training sessions in surveys.”

Nsobya Samuel Lubwama, Senior Lecturer at the Department of Pathology, School of Biomedical Science, Makerere University College of Health Sciences in Uganda, adds: “With my laboratory background experience of over 20 years, this workshop was timely to enrich me with new skills by expert facilitators…I am now able to train health laboratory technicians worldwide with very minimum supervision on other biomarkers namely:  anthropometry, DBS collection, measuring pressure, blood glucose, Hemoglobin, HIV. I have also been empowered with new knowledge how to plan for survey in advance such as advising the country policy makers on what is needed to collect biomarkers of interest in relation to country specific needs.”

 

18 Feb

Spotlight on New Staff: Kimberly Peven

This part of a series of posts introducing readers to new staff at The DHS Program. Welcome, Kimberly!

Kimberly Peven

Kimberly Peven

Name: Kimberly Peven

Position title:  Survey Manager

Languages spoken: English, French

When not working, favorite place to visit: I love to visit anywhere I can get around on a bicycle, but I have recently enjoyed visiting Myanmar and Sri Lanka.

Last good book you read: Ishmael by Daniel Quinn. The book is mostly a philosophical dialogue between a gorilla and a man examining the history of civilization and global issues.

Where would we find you on a Saturday?  On a walk or a bike ride

First time you worked with DHS survey data: I first used DHS data in graduate school, looking at female genital circumcision in the 2003 Egypt Interim DHS dataset.

What is on your desk (or bulletin board/wall) right now?  Hanging on my wall are the infographics from the Women’s Lives and Challenges report and postcards picturing artistic signage in Ghana.

2007 DR Congo Final Report

2007 Democratic Republic of Congo DHS Final Report

What is your favorite survey final report cover?   République Démocratique du Congo, 2007. Okapi!

What’s your favorite way to access The DHS Program’s data? The DHS Program website is one of my most used bookmarks, and I find it easiest to use for looking at complete reports or documents. When I want some quick information or information for many countries at once, STATcompiler can’t be beat.

What population or health issue are you most passionate about?  Why?  Maternal and Child Health is my favorite public health area. I see it as this window of opportunity where interventions can have a huge impact. Women who are healthy pre-conception have healthy pregnancies. They know how to take care of their children in the critical, early part of life and have children that grow up to be healthy adults who then go on to have healthy babies.

What are you most looking forward to about your new position?  I am looking forward to working on different kinds of surveys in varied working environments.

What has been your biggest surprise so far?  How many people are involved in a DHS survey!

22 Jan

Spotlight on New Staff: Shireen Assaf

This part of a series of posts introducing readers to new staff at The DHS Program. Welcome,Shireen!

Shireen Assaf, Senior Research Associate

Shireen Assaf, Senior Research Associate

Name: Shireen Assaf

Position title:  Senior Research Associate

Languages spoken: English, Arabic and basic Italian

When not working, favorite place to visit:  Lebanon and Italy

Favorite type of cuisine: Mediterranean food (especially Middle-Eastern and Italian) but I also love Thai and Japanese.

Last good book you read: The Shoemaker’s Wife.

Where would we find you on a Saturday?  Either in some sort of exercise class or visiting my sister and her family in Arlington.

First time you worked with DHS survey data: During my Masters studies.

What is on your desk (or bulletin board/wall) right now?  Pictures of family and old pictures of Palestine.

Special Report on Intervention Zones in Niger based on the 2012 DHS

Special Report on Intervention Zones in Niger based on the 2012 DHS

What is your favorite survey final report cover?  The Special Report on Intervention Zones in Niger based on the 2012 DHS. Just look at that  face!

Favorite chapter or indicator, and why?  If I had to choose one indicator perhaps it would be modern contraceptive use. This one indicator can give you a lot of insight about a country, from demographics to gender issues.

What’s your favorite way to access The DHS Program’s data? STATcomplier for quick access to indicators and trends, and The DHS Program website for the final reports and other published material.

What population or health issue are you most passionate about?  Why?

Family planning and gender issues. So much still needs to be achieved in these areas and studying the factors associated with them is one of the issues I am passionate about. I am also very passionate about studying trends in various health indicators both temporal and spatial.

What are you most looking forward to about your new position?

I look forward to working on different analytical and research studies each year for different countries and topics. I love research and analysis and I am happy to be in a position that allows to me conduct analysis on new topics using new data each year. I am also looking forward to learning from my work here and from my colleagues who are all very cooperative and great to work with.

What has been your biggest surprise so far?

The national diversity of The DHS Program team. Also the amount of work required to manage the DHS in all its aspects; survey management, training, data processing, analysis, and dissemination.

What do you look forward to bringing to The DHS Program (job-related or not!)?

I look forward to bringing my research and analytical skills and to contributing the best of my abilities to The DHS Program research activities.

13 Jan

Harnessing Technology to Streamline Data Collection

By Guillermo Rojas

The survey process at The DHS Program takes an average of 18-20 months and goes through several steps: survey preparation and questionnaire design, training and fieldwork, data processing, and finally, writing the final report and dissemination. But how do the data get from respondents’ households into the tables you see in the final report?

We employ field interviewers to ask respondents the questions included in the DHS questionnaires – household, woman’s, man’s, and biomarkers. But the way we record their answers changes based on the data collection methodology. At The DHS Program, we employ three types of methodologies to collect data: paper questionnaires, Computer Assisted Field Editing (CAFE), and Computer Assisted Personal Interviews (CAPI).

DHS Model Household Questionnaire, Page 1

DHS Model Household Questionnaire, Page 1

The vast majority of DHS surveys in the past 30 years have used paper questionnaires to collect data. With physical paper questionnaires in hand, field interviewers go from house to house, ask the questions of the respondents, and manually fill out the questionnaires. After interviewers visit all households within a cluster, supervisors ship the questionnaires to the survey central office. Upon arrival, the data processing begins for that particular cluster.

The Computer Assisted Field Editing (CAFE) system allows for editing to happen as interviews are taking place. With CAFE, interviewers still use paper questionnaires, but Field Editors enter the questionnaires into computers while the team is still in the cluster. Essentially, questionnaires are fully field edited by an intelligent data entry program. With this type of data collection approach, Field Editors provide feedback to interviewers on any anomaly identified by the program such as interviewers missing full sections of the questionnaire or wrongly executing critical skip patterns. At this point in the survey process, it is relatively easy to send the interviewer back to the household to resolve any problems. With this approach, there is no need for main data entry as the data entered in the field is sent via the internet to the central office. Therefore, CAFE speeds up the survey process as cluster data files are available as soon as the data arrive to the central office for further processing.

The 2005 Colombia DHS was the first DHS survey to utilize the Computer Assisted Personal Interview (CAPI) methodology. CAPI does not involve any type of paper questionnaire—it is entirely digital. Back in 2005, field interviewers used bulky laptops, though nowadays we use lighter tablets and notebook computers.

Fieldwork in the 2005 Colombia DHS

Fieldwork in the 2005 Colombia DHS

The DHS CAPI data collection system consists of three comprehensive subsystems:

1. A system for interviewers to facilitate the interview process

2. A system for supervisors to centralize the data collected by interviewers

3. A system for the central office to monitor the fieldwork operation and to further process the data

The DHS CAPI system uses Bluetooth technology to transfer and share data among members of the same fieldwork team. Supervisors then send data to the central office headquarters using the Internet File Streaming System (IFSS), a cloud-based electronic file delivery system developed by The DHS Program. The primary objective of the service is to deliver files from one user to another in an exceptionally fast and secure way.

In the past 30 years, we’ve witnessed an incredible change in technology, especially with both hardware and software. When I first started at The DHS Program, running the program to impute the woman’s events dates could easily take more than six hours for a survey with a sample size of 2,000 to 3,000 households! Nowadays, with sample sizes of 20,000 to 30,000, this program takes just one to two minutes to run. CAFE and CAPI allow us to use the power of these newer innovations in technology to make sure that we carry out DHS surveys as efficiently and accurately as possible.

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Guillermo Rojas is Chief of Data Processing at The DHS Program. He has more than 35 years of experience in computer science and survey data processing, and has provided data processing technical assistance and training for more than 20 surveys. Since the early stages of The Demographic and Health Surveys (DHS) program, Mr. Rojas has been involved in the design and development of the data processing methodology currently being used to process and analyze DHS surveys. He is the primary writer of the master programs for implementing the evolving data processing methodology. Mr. Rojas coordinates all DHS data-processing activities and supervises personnel to ensure the accuracy and quality of the processes implemented.

07 Jan

Video: Interview with Martin Vaessen, Former Director of The DHS Program

We sat down with Martin Vaessen, former director of The DHS Program, to hear his thoughts about the past 30 years of The DHS Program. Martin is a demographer and survey specialist with more than 35 years of experience providing technical assistance in all phases of survey implementation in developing countries. He was instrumental in achieving the incorporation of HIV testing in the  Demographic and Health Surveys (DHS), an innovation that led to a revision of the estimated number of people living with HIV from 40 million to 33 million in 2007.

 

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.

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