PAA is a nonprofit, scientific, professional organization established to promote the improvement, advancement, and progress of the human race through research of problems related to human population.
The DHS Program has been participating in the PAA Annual Meeting over the last few years and we are excited to share our recent surveys and other publications.
If you plan to attend PAA, visit booth #200 for your copy of free survey publications and tours of our new web and mobile tools. Several DHS staff will also be presenting posters, sessions, and will be available to answer any questions you may have about DHS data and results.
View the full DHS staff participation schedule here.
While we thoroughly enjoyed all of the sessions and speakers, we were particularly moved listening to Joyce Banda on challenges for women in public office, advocates from the Malala Fund inspiring conversation about the importance of education for girls and refugees, and Memory Banda describing life for girls in Malawi and taking a stand against child marriage.
At this year’s summit, it was again made clear that the collection of quality data is vital. Data will measure progress towards the SDGs. As DHS data supported collection and reporting of data for the Millennium Development Goals (MDGs), it is expected to contribute to the measurement of as many as 13 of the 17 SDGs.
Since 2013, before the SDGs were officially determined and announced, The DHS Program was involved in dozens of meetings to determine the feasibility of collecting data required to measure SDG indicators in DHS surveys. After careful review of all 230 SDG indicators, we highlighted 86 that are population-based and feasible through household or facility surveys. Of these, we have classified 32 that are already in our questionnaires and modules, and 20 that require minor additions or changes to questions and reporting. Below are just a few examples:
Goal 3: Proportion of women age 15-49 who have their need for family planning satisfied with modern methods. Learn more>>
Goal 5: Proportion of women age 15-49 who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care. Learn more>>
Goal 6: Proportion of population using safely managed drinking water services. Learn more>>
Goal 7: Proportion of population with access to electricity. Learn more>>
Goal 16: Proportion of children under 5 whose births have been registered with a civil authority, by age. Learn more>>
Dr. Ferozuddin Feroz (left), Sayed Alam Shinwari, Michael Kugelman, and Larry Sampler at The Wilson Center’s Event, “A Good Diagnosis for Afghanistan: Strengthening the Health Sector”
Working in collaboration, two Afghan government organizations– the Central Statistics Organization and the Ministry of Public Health (MOPH) – conducted Afghanistan’s first Demographic and Health Survey (AfDHS). “This in itself is an enormous milestone,” said Larry Sampler, Assistant to the Administrator for the Office of Afghanistan and Pakistan Affairs at USAID during a panel discussion at the Wilson Center, “A Good Diagnosis for Afghanistan: Strengthening the Health Sector.” Sampler, joined by the Afghanistan Minister of Public Health, Dr. Ferozuddin Feroz; Sayed Alam Shinwari, President of the Afghan Medical Professionals Association of America; and Michael Kugelman, Senior Associate for South Asia at The Wilson Center highlighted the implications of the Afghan government’s efforts to improve maternal and child health as demonstrated in the newly released 2015 AfDHS Key Indicators Report (KIR).
Of particular interest to both the MOPH and USAID, AfDHS results show progress in reducing childhood mortality. Currently, about 1 in 20 children does not survive until their 5th birthday in Afghanistan. The majority of these childhood deaths occur during the first year of life. Compared to earlier time periods, both infant and under-five mortality have declined, suggesting that child health interventions are making a difference. Dr. Feroz explains, “The DHS survey shows that there is substantial improvement in maternal health and child health. This progress has been made through high-level commitments, a productive work environment with development partners as well as non-governmental organizations (NGOs) and local NGOs, scaling up of cost effective and lifesaving interventions across the country, training of midwives, as well as attention to equity and those living in remote areas.”
“The DHS survey demonstrates how far the Afghan public health sector has come and also how far it has to go,” stated Larry Sampler. What are the challenges of Afghanistan’s health sector? “Afghanistan still faces instability and insecurity, poverty, unemployment, the few number of midwives or health staff across the country,” explains Dr. Feroz. But in spite of these challenges, the Afghan MOPH is developing a national strategy for the next five years. “We will use this recent survey as a baseline to measure progress – to increase access to remote areas, improve the quality of services, introduce cost-effective interventions, and focus on equity issues.”
Dr. Fred Arnold (left) of The DHS Program with Dr. Ferozuddin Feroz, Afghanistan Minister of Public Health
The survey covered topics including fertility and family planning, maternal and child health, childhood and maternal mortality, nutrition, malaria, HIV knowledge, and other health issues. The KIR is a short report of key indicators from the 2015 AfDHS that is meant to provide important data in a timely fashion to program managers and policy makers. Additional indicators such as the maternal mortality ratio will be included in the AfDHS Final Report, scheduled for release in late 2016.
The 2015 Afghanistan Demographic and Health Survey (2015 AfDHS) was implemented by the Central Statistics Organization and the Ministry of Public Health from June 15, 2015, to February 23, 2016. The funding for the AfDHS was provided by the United States Agency for International Development (USAID). ICF International provided technical assistance through The DHS Program, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide.
Genital fistula, an abnormal hole between the vagina and rectum or bladder that causes urinary or fecal incontinence, is a devastating, preventable condition that no woman should have to endure. It usually results from inadequately managed, prolonged or obstructed labor, surgical error, or trauma [1, 2]. Although rare, it can be completely debilitating—physically, socially, and economically—particularly to women who live in remote areas without access to treatment; women with fistula are often shunned from the household or society, which can cause immense suffering .
While sexual violence can cause traumatic fistula, the vulnerable state of women with fistula gives reason to suspect that the risk of violence could also increase after the onset of fistula [4, 5, 6], though no studies have attempted to evaluate this to date. Moreover, because it is so rare, it is difficult to capture statistically significant associations with the condition.
The DHS Program provides an opportunity to study such rare events because of the inclusion of standardized questions in numerous, nationally-representative surveys with large sample sizes. In a study conducted to further examine the relationship between fistula and violence, data were pooled from 12 DHS surveys, 11 conducted in Sub-Saharan African countries and one in Haiti, where standardized modules (sets of questions) on the two topics were included.
In total, 90,276 women were included in the analysis. Among these women, the prevalence of self-reported symptoms of fistula ranged from 0.4% to 2.0%. Regression analyses confirmed an association with sexual violence: women who have experienced sexual violence, both ever as well as within the 12 months preceding the survey, have almost twice the odds of reporting symptoms of fistula. Although there are no questions posed on timing of onset of symptoms of fistula in the DHS, the association with lifetime as well as recent experience of sexual violence suggests that violence could occur both before as well as after fistula’s onset.
One other finding of interest was that women whose first experience of sexual violence was committed by a non-partner had over four times the odds of reporting symptoms of fistula than women who did not report sexual violence. Although inferences from these findings can only be made with caution, the temporality relationship between fistula and sexual violence deserves further investigation.
In light of International Day to End Fistula on May 23, it is imperative to continue to work towards minimizing occurrence of fistula by building awareness around conditions that contribute to and result from this morbidity. This study shows yet another disheartening correlation between gender-based violence and poor health outcomes for women. It provides even more impetus for training and sensitivity for women’s health care providers in this area.
Longombe AO, Claude KM, Ruminjo J. Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: case studies. Reprod Health Matters. 2008 May;16(31):132-41
Raassen TJ, Ngongo CJ, Mahendeka MM. Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries. Int Urogynecol J. 2014 Dec;25(12):1699-706.
Baloch, B.A., A. Salam, D. ZaibUnnisa, and H. Nawaz. 2014. Vesico-Vaginal Fistulae. The Professional Medical Journal, 21(5), 851-855.
ACQUIRE. 2006. Traumatic gynecologic fistula: A Consequence of Sexual Violence in Conflict Settings. A report of a meeting held in Addis Ababa, Ethiopia, September 6-8, 2005. New York, The ACQUIRE Project/EngenderHealth.
Peterman A, Johnson K. Incontinence and trauma: sexual violence, female genital cutting and proxy measures of gynecological fistula. Soc Sci Med. 2009 Mar;68(5):971-9.
Naved RT, Blum LS, Chowdhury S, Khan R, Bilkis S, Koblinsky M. Violence against women with chronic maternal disabilities in rural Bangladesh. J Health Popul Nutr. 2012 Jun;30(2):181-92.
How much time do you budget to create a data visualization? The best visualizations, though they appear to be simple and clear, are often the result of dozens of attempts.
Demographers spend countless hours crunching data and preparing journal submissions, but not all take full advantage of data visualization, either in their exploratory analysis, or in communication of their findings. Last month, data visualization enthusiasts met at the Population Reference Bureau for a hands-on workshop as part of the Population Association of America (PAA) Conference. The 4 hour interactive workshop featured presentations from DC-based data viz expert Jon Schwabish, Dr. Tim Riffe, demographer at the Max Planck Institute for Demographic Research (MPIDR), Jonas Schoeley (MPIDR), and Dr. Audrey Dorelien of the Minnesota Population Center. While each presenter had a unique focus, a common theme was clear: your first draft visualization should never be your final visualization. This lesson was put into practice as participants shared works-in-progress, received constructive feedback, and prepared “makeovers”.
Clara Burgert and I have been working on a visualization project for over a year. The original was published last summer but we’ve been reworking it for a journal submission. Our colleagues at the data viz workshop provided constructive feedback, and we have made yet another round of changes. Some of the many stages of our chart “makeover” are presented below.
Clara’s recently published analysis looks at 27 countries and 6 child health indicators. The goals of our visualization were to compare countries across these 6 indicators and to illustrate the inequity within countries, by highlighting the worst and best performing sub-national regions. While some countries have a very high measles vaccination prevalence, such as Tanzania, there are regions in Tanzania that are performing very poorly. Meanwhile, other countries have moderately good vaccination rates with very little variation among regions (like Rwanda). Our first real attempt at a publishable graphic looked like this:
One of the challenges with this first graphic was that it didn’t use color very well. Clara needed to use color to distinguish between the 6 indicators in other places in the report, so we wanted to integrate that color scheme here for consistency. Simultaneously we realized that we could also simplify our use of color in this first draft: while we had originally plotted the red circle as the lowest region, the reader doesn’t need that color to know that that plot is the lowest- it’s obvious based on the axis and the left-to-right understanding of a numerical timeline. So we tried this:
This color scheme worked better to unify the other graphics in the report, and we were feeling pretty good about it. But we still had a few concerns and questions:
Was it okay to have the axis for the stunting indicator and under-five mortality the same size as the others even though they aren’t at the same scale?
Was it okay that we were sorting lowest to highest, instead of ordering countries in a consistent way?
How should we handle ordering of the data when for 4 of our indicators, a high data value is “good”, like vaccination coverage, while for 2 of our indicators, a high data value is bad, like mortality?
Were there any formatting tweaks we could make to improve readability?
It was this version that was shared at the PAA data visualization workshop. Through the feedback of experts and colleagues, we made some final decisions:
Change the axis of the stunting indicator to go to 100% so that it is consistent with the other percentages in the graphic. Some suggested that we move stunting and under-five mortality to a separate page to visually remind readers that the interpretation of these indicators is different (i.e., high values are bad). Ultimately, we decided that the layout of the 6 indicators was better for us in terms of publication, but agree that this is a trade-off and may confuse some less technical audiences.
We decided to keep our sorting from low to high, as the main audience for this paper is looking at general trends, not for data for a specific country. However, reports by The DHS Program often have many audiences, and with that in mind, we created an additional graphic (not shown) that summarizes each of the indicators by country so that a stakeholder in Ghana can see his or her relevant data in one view, without searching for Ghana in each of the above graphics.
Jon Schwabish had some quick and practical suggestions for making this graphic easier to read. His critique that it felt “heavy” resonated with us as the creators. He suggested thinning out the lines and substituting the big “X” marking the national average with a smaller circle.
There is a science to data visualization, but there is also a lot of subjectivity. Many solutions can be found only through trial and error. Often it takes time, several new sets of eyes, and dozens of drafts to settle on the best possible visualization for your data. While this is a big investment, there is growing evidence that it’s worth it. We are competing for just 1 or 2 minutes of our audience’s attention in a world filled with data and information. We hope to create a few visualizations that are worth stopping to explore.
It’s that time of year again! The end of September marked the UN General Assembly and the Social Good Summit, the latter of which we attended this year (read about our trip last year). We were witness to a remarkable group of speakers, including UN Secretary-General’s Special Advisor Amina J. Mohammed, Executive Director of UNFPA Babatunde Osotimehin, and former U.S. Secretary of State Madeleine Albright – just to name a few.
Twesigye Kaguri (Nyaka AIDS Orphans Project), Waislitz Award Winner
We listened to compelling (and at times, heart-wrenching) stories about children, women and girls, and refugees, and heard appeals for gender equality, greater efforts for climate control, and improved funding for and access to education. We were also shown numerous examples of how technology has the potential to aid all of the above. This year’s summit was especially important and relevant to The DHS Program because of the recent adoption of the Sustainable Development Goals (SDGs) during the UN Sustainable Development Summit 2015.
The SDGs replace the Millennium Development Goals (MDGs), which guided poverty reduction, health, education, and equality initiatives from 2000 through 2015. The SDGs that follow aim not only to continue efforts, but to broaden them. Where there were 8 MDGs, there are 17 SDGs with 169 targets. The SDGs are “action oriented,” “universally applicable,” and “take into account different national realities, capacities, and levels of development,” building on the MDGs before them.
@DHSprogram (that’s us!) live-tweeting at the Social Good Summit.
The DHS Program supported the measurement of the MDGs initiatives, and our data currently include indicators that will contribute to the monitoring of several SDGs:
Zero Hunger: End hunger, achieve food security and improved nutrition and promote sustainable agriculture.
Gender Equality: Achieve gender equality and empower all women and girls.
DHS data look at many women’s status indicators, including female genital cutting, domestic violence, child marriage, and access to education and other resources.
Clean Water and Sanitation: Ensure availability and sustainable management of water and sanitation for all.
DHS surveys include data on household drinking water and sanitation facilities.
Throughout the summit, many speakers emphasized data’s key role in monitoring the SDGs and impact on social good:
“Data is at the heart of the SDG agenda.” — Ricardo Fuentes, Executive Director of Oxfam Mexico
“Data is the lifeblood of decision making & key component of SDGs.” — Haile Owusu, Chief Data Scientist at Mashable
“Let’s take data and make it useful for social good”. — Shamina Singh, Executive Director of MasterCard Center for Inclusive Growth
We strongly identify with Target 17.18 to “enhance capacity-building support to developing countries”, and to “increase the availability of high-quality, timely and reliable” disaggregated data. As always, the collection of DHS data is part of a capacity strengthening process. And while DHS surveys aren’t designed to capture all of the SDG targets or each detail, the skills learned through survey implementation – data collection, processing, analysis, and use – contribute to international capacity towards achieving these goals, thus enabling social good!