14 Jul

Linking DHS Data with Health Facility Data: Opportunities and Challenges

For 30 years, The DHS Program has asked women hundreds of questions about their utilization of various health care services, including family planning, antenatal and delivery care, vaccination and treatment of sick children, malaria treatment, and HIV prevention and treatment. In 1999, The DHS Program started collecting facility-level data through the Service Provision Assessment (SPA) survey. The SPA interviews providers and clients, takes stock of facility supplies and equipment, and observes provider-client consultations.  

© Ibou GUISSE/ANSD

© Ibou GUISSE/ANSD

Many people hoped that the two datasets would be easy to link for a deeper understanding of how people access services, the quality of services, and the association between access to services and health outcomes in a given country.  And because most recent DHS and SPA surveys are geo-coded (DHS since 2000 and SPA since 2009), that is, clusters and facilities are identified with their latitude and longitude, linking the data through a geographic information system should be easy, right?

Several studies have looked at using geospatial analysis to link DHS and SPA data to answer these larger questions about access to and utilization of health care services.  There are several challenges to this type of linkage. A major concern is sampling: the DHS and SPA surveys have different sampling frames and are rarely conducted in the same year. Most SPAs are samples of the health care facilities in the country, not a census. Many individuals surveyed in a DHS likely visit some of the health facilities that were not selected for the SPA. So just because a woman’s cluster is closest to a certain facility included in the SPA does not mean that that is the facility the woman visits.

CaseSTudy_figure_CropIn addition, to protect the identity of respondents, the GPS locations of DHS cluster points are geo-masked. In densely populated areas, this means that clusters may be moved away from their closest health facilities, making linkage based on geographic location less accurate. There’s also a practical concern: the DHS does not ask where individuals receive health care but rather only the type of facility where they sought care. While some people probably use their closest health facility, this is not always the case.  People may choose health facilities based on quality, specialty, cost, or anonymity, not just proximity.

SAR10Despite the challenges there have been several successful analyses linking DHS and SPA data, and program managers and researchers continue to explore the best use cases for DHS-SPA linkage.  This will be the topic of our upcoming DHS webinar on July 28th, “Considerations when Linking DHS Household Data to Data on Health Facilities and Infrastructure.”  Clara Burgert, The DHS Program’s GIS Coordinator and author of the recently released Spatial Analysis Report “Linking DHS Household and SPA Facility Surveys: Data Considerations and Geospatial Methods”  will be making a presentation on the DHS-SPA linkage opportunities and challenges.  Interested participants can register for the webinar here, and are encouraged to read SAR10 and post discussion questions for Clara and her co-authors on The DHS Program User Forum here.

09 Jul

Beyond Data Analysis: Collaboration and Capacity Strengthening

Participants from Nigeria, Uganda, and Malawi collaborate on interpreting malaria data.

Participants from Nigeria, Uganda, and Malawi work together to interpret malaria data.

Have you ever been to a workshop that combined interactive PowerPoints, fun hands-on activities, malaria indicator trivia games, and lots and lots of data analysis? No? Well then, you haven’t taken part in a Regional DHS/MIS Malaria Analysis Workshop hosted by The DHS Program. The malaria analysis team recently hosted two such regional workshops, one in Tanzania and the other in Senegal, with more than 30 participants representing 13 African countries.

Participants worked in country teams of 2-3 people to answer a pre-identified malaria-related research question through analysis of DHS/MIS data in Stata. While some people might cringe at the thought of an eight day data analysis workshop, in true DHS fashion there was nothing boring about this workshop. Activities throughout the workshops were designed to encompass a range of adult learning techniques – interactive PowerPoints, guided demonstrations, hands-on exercises, and small group activities were all used. The workshops culminated with each team presenting a conceptual framework, key variables, analytic methods, and preliminary results.

Chinazo Ujuju from Society for Family Health in Abuja, Nigeria reflects, “As a researcher I have the drive to analyze available data to provide relevant information for evidence-based public health interventions in my country, Nigeria. Attending the DHS/MIS data analysis workshop has equipped me with the skills to better analyze DHS and MIS datasets using Stata software. I am now competent in multivariate analysis of these datasets. I hope to use my skills to provide information for malaria programming with the ultimate goal of ensuring that relevant information are available to inform policy decisions that would improve global health.

Participants from Senegal work on their data analysis

Participants from Senegal work on their data analysis

Fankeba Souradji of Togo comments, “Je profite pour dire merci aux facilitateurs pour la qualité de la formation. Nous vous en sommes très reconnaissants.”

Though the workshop focused on strengthening data analysis skills, participants also enjoyed the opportunity to collaborate and learn from colleagues from other countries.

Nabila Hemed from the National Malaria Control Program (NMCP) in Tanzania says, “The Regional DHS/MIS analysis workshop has been a wonderful seminar that has brought together professionals of various degrees of experience. The first time I worked with DHS was two years ago. After attending this workshop I learned different issues, limits, and challenges that should be considered during analysis of DHS data. The best part was hearing various country contexts and the effects in data analysis. This helped me understand the impact of research and program decisions during analysis of DHS data. I joined this workshop under the notion that I would simply learn how to analyze to DHS data and how to use Stata. However, I got so much more than what I expected! I received a handful of knowledge and resources that I will definitely use and share with my colleagues at work.”

Participants discuss data use for decision making in a fishbowl discussion session

Participants discuss data use for decision making in a fishbowl discussion session

Though both workshops are complete, country teams are continuing work on their research proposals and abstracts. The DHS Program looks forward to seeing the final products from the workshops in upcoming scientific journals and conferences.

24 Jun

DHS Data Now Available in Integrated, Customized Package from the Minnesota Population Center

Have you ever wished that you could download just one dataset for multiple surveys with all of the data you want for your analysis in one file? And that the dataset wasn’t so huge and overwhelming? And that the variables in the dataset were all harmonized?

Integrated Demographic and Health Series

Integrated Demographic and Health Series

The Minnesota Population Center has been working on the Integrated Demographic and Health Series (IDHS), a free online database that currently includes over 2,000 integrated variables from 76 DHS surveys in 18 countries. (If you know IPUMS data, these are the DHS equivalent.) These variables are harmonized for consistency across time and across countries. The IDHS are also painstakingly documented, letting you, the researcher, know how different items have been defined and coded, with each variable’s codes and frequencies, question wording, universe, meaning, and comparability issues accessible with just a click. The variable selection tool lets you see, at a glance, which surveys have included that specific variable, allowing you to select the variables and surveys you need for your analysis. The customized datasets come packaged with the survey year and country, weights, identifiers, and other sampling variables needed for analysis, and in the format you chose (SAS, Stata, SPSS, ASCII, or CSV file).

IDHS - Use of Family Planning Variables

IDHS – Use of Family Planning Variables

IDHS data are currently available for 18 countries and 76 surveys, allowing for comparative analysis for many countries in sub-Saharan Africa as well as India and Egypt. All of the countries included have had at least 3 DHS surveys dating back to the 1980s, so these harmonized datasets are perfect for trend analysis. Researchers can select either women or children as their unit of analysis. The variables cover questions about the woman herself, such as her education, media exposure, marital history, contraceptive knowledge and use, family size desires, experience of domestic violence, and knowledge about illnesses such as HIV/AIDS, tuberculosis, and fistula. Other questions relate to the health of the woman’s children under 5, such as antenatal and delivery care, nutrition, vaccinations, and recent diarrheal and respiratory illnesses and treatment.

What’s the difference between IDHS data and DHS datasets? Who should use IDHS data? 

DHS datasets continue to be available for download from The DHS Program website by country. The datasets include all of the data collected in a survey. If you are looking to analyze a single data set, the DHS datasets are likely your best bet. But for a multi survey analysis (among the 18 countries currently included in the IDHS and limited to the women and children), try the harmonized packages from IDHS.

What’s next?

IDHS has funding to continue this project through 2016 and will seek continued funding for another five years of work. They will continue launching data from more countries, new DHS surveys as they become available, and  hope to expand to cover men and households.

17 Jun

Spotlight on New Staff: Hamdy Moussa

Hamdy Moussa

Hamdy Moussa

Name: Hamdy Moussa

Position title: Survey Manager, Service Provision Assessment (SPA) Surveys

Languages spoken: Arabic and English

When not working, favorite place to visit: New York and Cairo

Favorite type of cuisine: Mediterranean and Italian

Last good book you read: Health Systems Performance Assessment: Debates, Methods and Empiricism, WHO

Where would we find you on a Saturday? With my family for outdoor activities and exploring the Washington metropolitan area.

First time you worked with DHS survey data: 2004 Egypt Service Provision Assessment Survey

What is on your desk (or bulletin board/wall) right now? 2014 Bangladesh Health Facility Survey (BHFS) as well as plans for the 2015 Egypt Service Provision Assessment Survey (ESPA) and 2015 Jordan Service Provision Assessment Survey (JSPA)

2012 Jordan DHS Final Report

2012 Jordan PFHS Final Report

What is your favorite survey final report cover? The 2012 Jordan Population and Family Health Survey with the wonderful photo of the monastery in the ancient city of Petra, Jordan.

Favorite chapter or indicator, and why?  Knowledge and prevalence of hepatitis C, as hepatitis C represents a major challenge to the health system in Egypt.

What’s your favorite way to access The DHS Program’s data? The website.

What population or health issue are you most passionate about?  Why?  Viral hepatitis is a critical public health issue in Egypt. The 2008 EDHS provided Egypt with the first nationally representative data on the scope of hepatitis C epidemic in Egypt. The survey found that 15% of women and men age 15-59 years had antibodies to the hepatitis C virus (HCV) in their blood, and 10% had an active HCV infection that represents a major challenge to the health system in Egypt.

What are you most looking forward to about your new position? First to be fully integrated in both SPA and DHS surveys, and second to manage more SPA surveys in different countries.

What do you look forward to bringing to The DHS Program (job-related or not!)? I am bringing my technical, consulting skills in health systems and biomarkers, and looking forward to learning more from the distinguished DHS Program staff.

11 Jun

From Population Pyramids to Ternary Plots: Visualizing Data for Demography

At this year’s Population Association of America (PAA) conference, The DHS Program staff (along with co-authors from JSI and Johns Hopkins Center for Communication Programs) presented the first paper in the data visualization session.  It was called “Why Demographers Need to be Data Visualization Experts.”  It appears we were preaching to the choir.  While this was the first year that PAA included data visualization as a topic, the session was attended by almost 200 people, and fellow presenters proved that innovation in data visualization is alive and well.

Circular plot of migration flows between and within world regions during 2005 to 2010

Dr. Nikola Sander’s Global Migration circular plot visualization

Dr. Nikola Sander, of the Vienna Institute of Demography, cited the Royal Society with the message: “Scientists must learn to communicate with the public, be willing to do so and indeed consider it their duty to do so.” (Royal Society, 1985). She is one of the creators of the Global Migration circular plot visualization that went viral in 2014.

 

 

 

 

Small multiples

Dr. Michael Bader’s small multiples

Dr. Michael Bader of American University introduced his visualizations of the distribution of racial diversity in three-dimensional tertiary plots. These 3-D animations allow the viewer to see the distribution of White, Black, Latino, and Asian neighborhoods in different cities. Small multiples (that is, multiple versions of the same graphic showing different pieces of the data) allow for the quick interpretation of change over time (see full paper here).

 

 

 

 

Lexus Surface color schemes

Jonas Schoeley’s Lexis surface qualitative color schemes

Jonas Schoeley, of the Max Planck Institute for Demographic Research, proposed solutions for presenting composite data on the Lexis surface, including a qualitative sequential color scheme to show the most prominent causes of death over time and by age group in France (see full paper here). This image contains an amazing amount of data, but fascinating data stories quickly emerge, such as the spike in 1944 of “external” deaths.  This, of course, was D-Day.

 

 

 

Still, it remains that many academic journals, institutions, and data collection projects do not prioritize data visualization, communication, and dissemination, as part of their standard process.  Why should they?

  1.  We are competing with massive amounts of data and information. A good data visualization summarizes the major findings of any scientific study in a concise and compelling way. Assume you have only a few minutes of your audience’s attention.
  2. A good data visualization is shareable and accessible to a large range of audiences.  Visualizations are shareable if they summarize a compelling data story and are beautiful to look at.
  3. If the researcher or technical expert is not involved in the data visualization process, the accuracy and integrity of the data story may be threatened. Learning the basic principles of data visualization allows the demographer to interact with a larger team, including communication professionals, graphic designers, and programmers.

Ultimately, we are looking for our work to have impact. And measures of impact are quickly changing. We need to think outside the box of submitting papers to academic journals, but expand our toolkit to include user-friendly summaries of findings, interactive web tools, and social media. Data visualization is one of the most efficient ways to tell a complex and compelling data story. As Dr. Nikola Sander summarized, data visualization is not a luxury.  It is a requirement.

For more resources on data visualization in global health and demography, visit datavizhub.co.  Details on the PAA session and links to abstracts and papers are available here.

03 Jun

The Launch of the 2014 Egypt DHS

2014 Egypt DHS National Seminar

2014 Egypt DHS National Seminar

Very few countries have as much experience with The DHS Program as Egypt. Since 1988, Egypt has implemented seven standard DHS surveys, three Interim Surveys, one In-Depth Study, and two Service Provision Assessment Surveys (SPA).  Data collection is almost completed for a Health Indicator Survey (HIS), and plans are underway to start another SPA.

So any time a DHS is released in Egypt it is a big event. On May 10, 2015, the Minister of Health, Dr. Adel Adawy, and USAID/Egypt Mission Director Sherry Carlin along with about 300 guests gathered at the Grand Nile Towers Hotel to hear the latest findings about the health status of the Egyptian people from the 2014 Egypt DHS.

2014 Egypt DHS

2014 Egypt DHS

The news is very mixed. On the positive side, child mortality has declined and maternal health indicators have improved.  Now, 9 in 10 women receive at least 4 antenatal care visits, and 92% give birth with the assistance of a skilled provider—a far better maternal care profile than the rest of Africa. On the negative side, the 2014 EDHS reports that an astonishing  percentage of births are by Cesarean section. Nationwide, C-sections account for just over half (52%) of all deliveries in the five years before the survey—one of the highest rates in the world. Three governorates, Port Said, Damietta, and Kafr El Sheikh, report 70% or more C-section deliveries among all births. Participants at the national meeting called for more research and government action to reduce the high rate of surgical deliveries.

Another negative finding is the increase in fertility reported in the 2014 EDHS. Now, the total fertility rate, or average number of births per woman is 3.5, up from 3.0 in 2008. For a crowded country like Egypt, this is worrisome news, indeed. Family planning use has remained the same overall, but women are switching from long-acting IUDs to the pill.

Egypt has a long history of acting on the results of the DHS. The 1988 survey led to a new community health program to increase awareness of the importance of antenatal care. When the 1995 EDHS showed that 97% of ever-married women had undergone female genital circumcision (FGC), widespread calls for action led to a ban on FGC in 1996 and a national law criminalizing the practice in 2008. FGC still persists in Egypt, but the percentage of women reporting that their daughters under age 18 were or would be circumcised dropped from 70% in 2005 to 45% in 2008, and rose again to 56% in 2014. In some governorates less than one in four daughters are expected to be circumcised.

Getting this important information out to the public health community is a priority for USAID and the Ministry of Health. The DHS Program is collaborating with these organizations plus the local implementing agency El Zanaty and Associates and a local non-profit communication organization, Ask Consult for Health, to disseminate the survey results through fact sheets, policy briefs, and fact-to-face meetings.

27 May

How Many Partners Does it Take to Run The DHS Program?

Most people don’t know just how many collaborating institutions are involved in the day-to-day implementation of The DHS Program.  ICF International is the prime contractor for The DHS Program.  But 20% of us who sit at ICF’s office in Rockville, Maryland, are actually employed by other partner organizations.  Who are these partners?

Partners from Vysnova, JHUCCP, ICF, PATH, and USAID comparing maps, in “Good Map/Bad Map”

Staff from Vysnova, JHUCCP, ICF, PATH, and USAID comparing maps, in “Good Map/Bad Map.”

  • Avenir Health (formerly the Futures Institute) specializes in data analysis for decision making and planning. Avenir Health staff are key to The DHS Program analysis team.
  • Blue Raster is our web and GIS partner. They are instrumental in the development of the website, STATcompiler, mobile app, and API, and support mapping activities at The DHS Program.
  • EnCompass is our partner on capacity strengthening. They bring expertise in adult learning, elearning, building institutional capacity, and curriculum design.
  • Johns Hopkins University School of Public Health/Center for Communication Programs brings a long history of communicating and disseminating complex health information to a wide range of audiences.
  • Kimetrica is our only partner based in Africa, and supports DHS survey data processing and survey implementation.
  • PATH brings expertise in innovation in improving global health through their support of The DHS Program’s nutrition, laboratory and biomarker work.
  • Vysnova Partners provides technical services in many areas of global health. For The DHS Program, Vysnova provides staff with data processing and survey management skills.
EnCompass and Blue Raster staff debate how to assess an audience in the data visualization session

EnCompass and Blue Raster staff debate how to assess an audience in the data visualization session.

Twice a year, staff from all 8 institutions and members of The DHS Program’s USAID management team sit together for a day of information sharing.  This spring’s “The DHS Program Partners’ Meeting” featured presentations on updates to the DHS-7 questionnairemethodological research on data quality in DHS surveys, results from a study on nutrition and WASH indicators,  results from the 2013-14 Malawi SPA survey, an update on recent training workshops, and the “world premiere” of the newest DHS Program tutorial YouTube video on the contraceptive prevalence rate.  Several DHS survey managers provided personal perspectives on how Ebola affected survey operations in Liberia, Guinea, Sierra Leone, and Nigeria.  In addition, partners participated in hands-on activities on social media, data visualization, and mapping.

The participants summed up everyone’s sentiments quite well with the tweets they proposed in the social media session:

Sunita Kishor, DHS Program Director, drafts a Tweet in the social media session

Sunita Kishor, DHS Program Director, drafts a Tweet in the social media session. #DHSpartners #SunitasFamily

Dance with us @DHSprogram. We have great partners. #DHSpartners

Partnering to bring data & knowledge to YOU! #dataispower #DHSpartners #usedata

#DHSpartners’ family reunion today #SunitasFamily

@ICFI and #DHSpartners shine @DHSprogram.

Who ya gonna call? @DHSprogram! #DHSpartners #SunitasFamily #DataDrivesDecisions

@DHSprogram brings together #DHSpartners for knowledge sharing & innovation.

 

20 May

Your Questions on Weighting Answered: The DHS Program User Forum and Webinar

webinar_experts

The DHS Program regularly gets questions from users about sampling and weighting. “How do I apply sample weights in multilevel analyses?” or “What is the difference between self weighting data and non-self weighting data?” On June 3, 2015, three DHS experts will answer users’ questions on “Weights and other adjustments for the survey design” in our first ever live webinar. Drs. Tom Pullum, Ruilin Ren, and Mahmoud Elkasabi will be discussing common questions about sampling and weighting in DHS data collection and analysis.

Launched in 2013, The DHS Program User Forum was created to provide a transparent discussion platform for users of DHS data to ask questions and receive feedback from the broader community and DHS Program staff. To date, more than 1,700 users have registered on the user forum and posted over 3,000 messages. To quote one registered user:

“The forum is helping millions of DHS data users around the world to understand data and sort data management issues. I personally managed to merge DHS data with the help of the forum contributor.”

MemUser Forum Screen shotbers can post questions in dozens of threads in three main categories: Topics (i.e. child health, mortality, and wealth index), Countries (India and Bangladesh are currently  the most active), or Data (merging, sampling and weighting, geographic data, dataset use
in Stata and SPSS). While we encourage users to answer each other’s questions, The DHS Program staff  members do moderate the forum and provide answers when others do not. But increasingly, members are often able to find the answer to their question simply by searching the 3,000+ messages that are already in the forum. Registered users say:

“I’m likely to post again to the User Forum because, when I post not only do I get a quick and helpful answer, but also it lets me see what other users have posted and been given as answers, which opens my eyes and mind to other future research.”

Participate in the User Forum and the Webinar on June 3, 2015
To post a question on weighting for the webinar, simply visit the User Forum thread “Sampling and Weighting Webinar June 2015.” Then, on June 3, 2015, at 10am EST (UTC/GMT-4) join us live in our Adobe Connect room. A recording of the webinar will be available on the User Forum for those who cannot participate live, and a summary of the questions and answers will also be entered into the User Forum as individual messages for future reference.

06 May

Spotlight on Implementing Agencies: The Gambia

(L-R) Gambian visitors Saikou Trawally, Alieu Saho, Momodou L. Cham  & DHS staff member Zhuzhi Moore at The  DHS Program Headquarters

(L-R) Gambian visitors Saikou Trawally, Alieu Saho, Momodou L. Cham & DHS Program staff member Zhuzhi Moore at The  DHS Program Headquarters in Rockville, MD

Name(s):  Saikou Trawally, Alieu Saho, and Momodou L. Cham

Country of origin:  The Gambia

Position titles and organizations:  Officials of The Gambia Bureau of Statistics and National Population Commission Secretariat

When not working, favorite place to visit:  Shopping sites, relatives and friends, and site seeing cultural centers.

First time you worked with The DHS Program’s data:

Momodou: I first used the Data in 2001 for my MSC. Medical Demography Dissertation at the London School of Hygiene and Tropical Diseases, University of London.

What has been the nicest surprise visiting The DHS Program headquarters? 

The infrastructure, expertise of staff, the wonderful reception, and the knowledge sharing.

What do you miss most about home when you are here? Family

What is the biggest difference between The DHS Program headquarters office and your office at home?

Reliable communication facilities, furniture, the office space and environment.

2013 Gambia DHS

2013 The Gambia DHS

What is your favorite DHS final report cover?  2013 The Gambia DHS cover with a green background with flora and fauna in the middle of the page.

Favorite DHS chapter or indicator, and why?

Mortality (infant, child, and maternal mortality) and HIV/AIDS. This is the first time we are getting accurate data on these indicators. The data will help The Gambia know the level of progress towards addressing such issues.

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

Reproductive health is important because the health of the mother determines the health of the newborn.

How do you hope the DHS data from your country will be used?  

The data should be used for planning, monitoring, and informing national policies on health and population.

What have you learned from the DHS experience?

We have learned a lot about survey design, sampling, data collection and processing, analysis, and producing a standard technical report that is internationally comparable.

22 Apr

Kufa au Kupona (Fever Road)

2011-12 Tanzania HIV and Malaria Indicator Survey

2011-12 Tanzania HIV and Malaria Indicator Survey

Malaria kills more than 500,000 Africans every year.  Consistent use of insecticide-treated mosquito nets (ITNs), early diagnosis and treatment, and prophylactic use of antimalarials during pregnancy can save thousands of lives. But according to the 2011-12 Tanzania HIV and Malaria Indicator Survey (THMIS), many families are not practicing these life saving measures.

To get the message about malaria prevention practices out to Tanzanian communities, The DHS Program collaborated with USAID, the President’s Malaria Initiative, the National Malaria Control Programme, and Media for Development International to produce a film showcasing real life stories of Tanzanians dealing with malaria. Filmed in Dar es Salaam with local actors, Kufa au Kupona (Fever Road), tells three stories. The first is about a young boy who almost dies of malaria because his parents take him to a witch doctor instead of a health care facility when he gets sick. The second story focuses on Jazira who contracts malaria during pregnancy because she does not take IPTp. Five-year-old Brighton, the subject of the third story, is mistakenly treated for malaria when his symptoms are actually due to a urinary tract infection.

Kufa au Kupona (Fever Road)

Kufa au Kupona (Fever Road)

Kufa au Kupona has been broadcast on 6 national television stations in Tanzania and widely disseminated in high malaria prevalence areas through a partnership with the Tanzania Video Library Association, at health care facilities with video equipment, and through mobile video vans. Now, through an arrangement with FilmAid, Kufa au Kupona will be publicly screened at refugee camps in Africa reaching tens of thousands of people at risk for malaria.

Does Kufa au Kupona have an impact? A follow-up survey of more than 800 women and men leaving the video showings in Tanzania found that virtually all respondents liked the film, and many wished it had been longer. All but two of the respondents said that the film influenced them to take action: 20% said they would get tested for malaria the next time they got sick; 22% said they would use mosquito nets; and 18% planned to discuss the film with other people.

 

Watch the movie with English subtitles>>

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