Category Archives: DHS-7 Questionnaire

05 May

New data available from DHS-7 Questionnaire: WASH Indicators

DHS Survey manager Joanna Lowell washes her hands in Zimbabwe during fieldwork in 2010.

This is Part 2 in the New Data Available from DHS-7 Questionnaire blog series that explores the new data that are available in DHS reports resulting from changes made to the DHS-7 questionnaire in 2014. This post focuses on changes made to improve the quality and quantity of data collected about water and sanitation.

Part 2:  Water and Sanitation

There has been increasing demand from the water, sanitation, and hygiene (WASH) community to gather more detailed information to measure the Sustainable Development Goal of access to water and sanitation for all. The major DHS-7 questionnaire enhancements in this area are outlined below.

Bottled water is now defined as an improved or unimproved source of drinking water depending on the source of water for cooking and handwashing. In the previous DHS-6 questionnaire, if a household indicated that the main source of drinking water for household members was bottled water, this was categorized as an improved source of drinking water. In the DHS-7 questionnaire (as in DHS-5), a household that uses bottled water for drinking is asked a follow-up question about the source of water used for cooking and handwashing (see questionnaire). For example, a household that uses bottled water for drinking but surface water (an unimproved source) for cooking and handwashing is considered to have an unimproved source. A household that uses bottled water for drinking and piped water (an improved source) for cooking and handwashing is considered to have an improved source. Both categories are listed in Table 2.1 (see figure).

Why? This change was made to align DHS data with recommendations from the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) which monitors progress towards Sustainable Development Goal 6: Ensure access to water and sanitation for all. It is important to note that while surveys like the DHS can assess the main source of household water, the source of water is only a proxy measure for quality. Sometimes water from an improved source is not safe to drink.

Implications: For most countries, this change will simply add insight into how households use water sources for different purposes. In countries where there is heavy reliance on bottled drinking water, reclassification of some of the bottled water users as having an unimproved water source may affect interpretation of trends in the larger “improved source” and “unimproved source” categories between surveys that include information about the source of water for cooking and handwashing and those that do not.

New category of improved source of drinking water added. Respondents to the household questionnaire can now indicate that their drinking water source is water piped to a neighbor.

Why? This response category was added because it is a common source of drinking water in some countries.

New question and table on availability of water. For households using piped water or water from a borehole or tubewell, a new question has been added asking if water was available without an interruption of at least one day in the past 2 weeks (see Table 2. 2).

Why? Scheduled or unscheduled interruptions in the water supply may force households to use unimproved sources.  All persons should have sustainable access to adequate quantities of affordable and safe water. The new question helps determine whether or not households have a sustainable supply of water.

Implications: Water availability from some improved sources, such as piped water or tubewells, is not always consistent. Intermittent and unreliable water services result in inconvenience to water users and increased risk of compromised water safety.

Sanitation and toilet facilities language clarified. The collection of data about toilet facilities has changed only marginally, however the language used to describe the different types of unimproved sanitation has been clarified. In DHS-7 reports, sanitation is divided into the categories seen in Table 2.3 from the 2015-16 Malawi DHS. Improved sanitation includes flush/pour systems, VIP latrines, and composting toilets, among others. Unimproved sanitation now includes three subcategories: a shared facility (this may still be a flush system, but by definition a shared facility is not improved); an unimproved facility, such as a pit latrine without a slab, an open pit latrine or a bucket; and open defecation, that is, the household has no facility and uses the field or bush.

Why? Improved sanitation facilities are meant to separate human excreta from human contact. If an otherwise improved sanitation facility is shared with other households, the likelihood of exposure to fecal materials is increased.

Implications: In this case, the labeling of these categories is all that has changed. The DHS STATcompiler has been updated with new labels to reflect these categories. Interpretation of data for trend analysis is not affected.

New question added on location of toilet facilities. The DHS-7 questionnaire now also asks where the toilet facility is located. Table 2.3 categorizes these locations as “in own dwelling,” “in own yard/plot,” and “elsewhere.”

Why? If the sanitation facility used by the household is not in the dwelling or yard/plot, it is more difficult to access when needed, and it may pose a safety issue, especially for women and children.

Implications of this addition are not yet known; analysis of future survey data may provide insight.

DHS Survey manager Joanna Lowell washes her hands in Zimbabwe during fieldwork in 2010.

DHS Survey manager Joanna Lowell washes her hands in Zimbabwe during fieldwork in 2010.

Mobile sites for handwashing now captured. In previous surveys, interviewers asked household respondents to show them where members of the household usually wash their hands. The DHS-7 questionnaire allows for interviewers to indicate whether this handwashing site was fixed (such as a sink) or mobile (such as a pitcher or basin) (see Table 2.7 from the 2015-16 Malawi DHS).

Why? Many households without piped water do not have a fixed place for handwashing. In some countries (particularly in Africa), many households rely on mobile items for handwashing. When hands need to be washed, the individual may move a jug, basin, and soap from inside the home to the outdoor courtyard in order to wash hands. The ability to determine whether handwashing relies on a fixed or mobile place helps to interpret the handwashing data and to understand the physical and social norm-related barriers to handwashing with soap.

Implications: Early review of data from DHS-7 countries suggest that adding the mobile site for handwashing increases the percentage of households that will report that they have a handwashing site. Trends in this area should be interpreted with caution, as an increase in reported handwashing sites may be a function of the questionnaire change rather than a true change in handwashing practices.

11 Apr

New Data Available from DHS-7 Questionnaire: Maternal and Pregnancy-Related Mortality

Baby Kabuche, 30 yrs old, 4 months pregnant, outside her house. Baby has 2 children: Eric, 12, living with granparents in Musoma and Judith, 6, living with her and her husband. She works in a factory manufacturing alluminium pots and iron rods. But as she becqme pregnant she took some unpaid leave as the factory uses acid and other toxic materials and she cares for the safety and health of her baby. Baby got malaria only once as she sleeps under mosquito net all the time. This new one makes her happy as it is treated with mosquito repellent and it is more effective.

© 2016 Riccardo Gangale/VectorWorks, Courtesy of Photoshare

In 2014, The DHS Program began the process of updating the standard DHS questionnaires. With input from stakeholders, feedback from in-country implementing agencies, and a host of lessons learned from the previous 5-year program, we added, modified, and, in some cases, deleted questions. For many indicators, the actual questionnaire did not require an adjustment, but the calculation of indicators or the tabulation of the data needed an update to reflect new international indicators and best practices.

While questionnaire revision started in 2014, it can take a long time to see this exercise bear fruit. The 2015-16 Malawi DHS, for example, went into the field with the DHS-7 updated questionnaires in October 2015. The final report and dataset for the 2015-16 Malawi DHS were released in March 2017, allowing us to explore the new data for the first time.

In this blog series, New Data Available from DHS-7 Questionnaire, we will be detailing, topic by topic, some of the key changes to the questionnaire, with a focus on why the changes were made, how the changes affect the tabulations, and some guidance on how the resulting data should be interpreted.

Part 1:  Maternal and Pregnancy-Related Mortality

DHS surveys now collect data to provide the maternal mortality ratio in line with the definition provided by WHO. For almost 30 years, The DHS Program has collected data on maternal mortality in a subset of countries. In previous DHS cycles, maternal mortality was defined as any death to a woman while pregnant, during childbirth, or within two months of delivery. The WHO definition of maternal mortality is more precise:  any death to a woman during pregnancy, childbirth, or within 42 days of delivery but not from accidental or incidental causes (see full WHO definition here). The new DHS-7 questionnaire allows us to calculate the maternal mortality ratio (MMR) in closer alignment with this more precise WHO definition.

As always, women interviewed in the DHS are asked to list their siblings. The interviewer then collects information about the siblings’ survival status. In the case of female siblings who have died at age 12 or older, the interviewer inquires whether or not the sister died during pregnancy, childbirth, or within the 2 months following delivery. If the sister died within 2 months after childbirth, the interviewer asks how many days after childbirth the sister died. This clarification on the number of days is a new addition to the DHS-7 questionnaire. The interviewer then asks additional questions to determine if the death was accidental or due to violence. In DHS-7 these deaths are excluded from the calculation of the MMR per the WHO definition.

Why?  These changes were made to improve the precision of the MMR, as well as to align the DHS estimation of the MMR with the standard definition provided by the WHO.

Implications:  While the newly added questions allow for a more precise and up-to-date measure of maternal mortality, the change does present challenges for interpretation. DHS has reported on maternal mortality for 30 years, but estimates obtained using the new definition of maternal mortality cannot be directly compared to the old definition of maternal mortality which included deaths up to 2 months after delivery and did not exclude deaths due to accidents and violence.

And yet, one of the main objectives for conducting DHS surveys is to provide trend data. Fortunately, the old definition of maternal mortality can still be applied to calculate the mortality ratio estimate comparable to estimates from previously collected mortality data. This less precise measure of mortality is referred to as the pregnancy-related mortality ratio (PRMR).

DHS reports that include the maternal mortality module will now contain both the maternal mortality ratio and the pregnancy-related mortality ratio. The maternal mortality ratio will be used as the primary point estimate, but the pregnancy-related mortality ratio will be shown in an additional table and in figures to illustrate the trend. Keep in mind that the new measure of maternal mortality, by definition, will result in a lower maternal mortality ratio than the old measure because the accidental and violence-related deaths to women during the maternal period and deaths occurring between 42 days and 2 months after childbirth are being excluded from maternal deaths while using the new definition but included while using the old definition.

Summary of Maternal Mortality and Pregnancy-related Mortality:

Maternal Mortality Ratio The number of maternal deaths to any woman during pregnancy, childbirth, or within 42 days of delivery excluding accidents and acts of violence per 100,000 live births More precise Not comparable to surveys before DHS-7
Pregnancy-related Mortality Ratio The number of pregnancy-related deaths (deaths to a woman during pregnancy or delivery or within 2 months of the termination of a pregnancy, from any cause, including accidents or violence per 100,000 live births Less precise Comparable to previous surveys; shown to allow for trend  interpretation

The DHS-7 questionnaire includes additional prompts to fully capture more siblings and siblings’ deaths. In previous DHS questionnaires, women were asked to list their siblings in order and then were asked follow-up questions about their survival status. In the DHS-7 adult mortality module, respondents are asked to list their siblings without worrying about their order but are then asked a list of probing questions to ensure that all siblings have actually been recorded. This change is likely to produce a more complete list of siblings for which information on adult and maternal mortality is collected. Once a complete list is produced they are then ordered and the questions on their survival status and age or age at death and years since death, as well as the maternal mortality related questions, are then asked as applicable. 

Why?  Several studies have suggested that respondents’ lists of siblings are not always complete. This often happens when the sibling is a half-brother or sister, when the sibling did not live with the respondent as a child, or when the sibling has died. A pre-test in Ghana indicated that the addition of these probing questions resulted in capturing additional siblings for about 10% of women.

Implications:  Omissions in the sibling history can affect the adult and maternal mortality ratios in different ways. The inclusion of more siblings tends to increase the adult mortality rate. This is because often the siblings who were previously omitted were not spontaneously mentioned because they have already died. However, studies suggest that these deaths are not disproportionately maternal deaths, so a more complete sibling listing might result in a lower maternal mortality ratio.

Key Take-Aways

The changes described above may sound confusing for non-demographers.  The major points to remember for DHS data users include:

  • The new Maternal Mortality Ratio is not comparable with previous measures of maternal mortality in DHS surveys
  • For trends, look at Pregnancy-related Mortality Ratio
  • Despite the different names, both measures include deaths during pregnancy. The MMR is a more precise measure as it excludes some of the deaths during pregnancy that were not related to pregnancy (i.e. accidents and acts of violence).
  • Maternal mortality is still a relatively rare event, and therefore both MMR and PRMR have wide confidence intervals. Both measures are always presented with their confidence interval so that the user can draw their own conclusions about the relative certainty of the point estimate.

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