Global momentum on quality of care in the health system continues to expand. The United Nations Decade of Action on Nutrition (2016-2025) recognizes that the health system is a key pillar in providing universal coverage of essential nutrition actions. Reliable data for monitoring is central to understanding and improving the health system for nutrition. In addition to data from Health Management Information Systems, Service Provision Assessment (SPA) surveys also provide nationally representative facility information that can be used to explore the quality of facility-based health services.
SPA surveys are a rich source of nutrition information providing insight on the availability and quality of services. Similarly, DHS surveys provide a significant amount of information about nutrition behaviors of populations. By linking SPA and DHS surveys, users can examine how the health facility environment contributes to these behaviors.
Two recently released DHS Working Papers examine the health service environment for key nutrition interventions: breastfeeding counseling and iron folic acid supplementation. The papers use Haiti and Malawi as case studies to describe the facility readiness, such as the availability of trained providers and essential medicines (see infographics below), and service delivery including observations of provider-client consultations of the two interventions in the context of antenatal care. The papers go on further to link SPA and DHS surveys to examine relationships between the health service environment and the nutrition behaviors.
The papers illustrate how linking SPA and DHS surveys can be useful for enhancing essential nutrition actions at the facility by identifying key programmatic gaps that can be strengthened to improve effective intervention coverage.
Download Working Papers 160 and 161 to find out more about the results in each country and their implications. And now, Analytical Briefs are available for DHS Program Analytical Reports. Download the Analytical Briefs for a shorter, more concise summary of these working papers.
Facility readiness to provide iron folic acid supplements and counseling during antenatal care.
I then transitioned from being a workshop participant to a workshop co-facilitator, facilitating the 2017 Regional Malaria Indicator Trends Workshop in Uganda. This workshop brought together NMCP monitoring and evaluation (M&E) program managers from Liberia, Malawi, Nigeria, Sierra Leone, and Uganda to examine trends in malaria indicators.
More recently, I co-facilitated the 2018 Ghana Malaria Trends Workshop. This workshop brought together district malaria health officers to analyze trends in household survey indicators in Ghana. This was a great workshop because I was able to work with the data I am most familiar with! The output from this workshop is published on The DHS Program website.
How has NMCP
used DHS data for programmatic decision making?
After the release of the 2016 GMIS, NMCP noticed a low uptake of artemisinin-based combination therapy (ACTs) in the Northern region, but the use of SP/Fansidar was high, which is not a recommended treatment for malaria in children. This triggered us to do additional research to figure out what was going on in this region and investigate which outlets were distributing SP. We realized that people were not receiving SP from public health facilities but from private clinical shops and other drug peddlers. The 2016 GMIS results provided a snapshot of the malaria case management situation in the Northern region and provided us justification to explore further. To solve this problem, NMCP implemented a sensitization activity to ensure people in the region know the recommended treatment and sources to get the correct treatment.
Another example of evidence-based decision making was the implementation of a malaria sensitization campaign using data the 2016 GMIS. Malaria prevalence by microscopy in the Eastern region increased between the 2014 GDHS and 2016 GMIS. This was a worrying trend because in Ghana we normally only see high malaria prevalence in the Northern and Upper West regions. NMCP looked more critically at the 2016 GMIS results and saw that while insecticide-treated net (ITN) ownership was high, the proportion of people who recognized the cause and symptoms of malaria was very low. As a result, NMCP implemented a community level sensitization activity in four districts of the Eastern region.
How do you use MIS
survey data during your daily job?
I recently collaborated on a research paper using DHS data. The paper, published in The Malaria Journal, used survey data from the 2014 GDHS and the 2016 GMIS to examine ITN use behavior by exploring how several household and environmental variables related to use among Ghanaians with access to an ITN. This further analysis paper has been extremely helpful for programmatic decision making here at NMCP.
What data are
you looking forward to in the upcoming 2019 GMIS?
I am interested in further examining the information about the type of nets in households. NMCP finished a mass long-lasting insecticidal net (LLIN) distribution campaign in 2018 and implemented a school-based piperonyl butoxide (PBO) net distribution campaign in 2019. The 2019 GMIS results will provide information on the reach and use of these nets across Ghana as well as where people obtained their nets.
Samuel Oppong is a Monitoring and Evaluation Specialist with the Ghana National Malaria Control Programme. He coordinators M&E activities in vector control interventions, routine data quality audits, and SMC. He is involved in capacity building of national, regional, district and health facility staff on capturing, reporting, and analyzing malaria-related data from routine health information systems as well as other malaria data sources. He also leads capacity building programs of national, regional, and district staff on conducting data quality audits as well as onsite training, supportive supervision (OTSS) on malaria data management.
The DHS Program hosted a showcase of the major findings from a dozen further analysis papers based on the 2015-16 Myanmar Demographic and Health Survey in Yangon in early July. More than 50 population and health professionals in Myanmar participated in DHS data analysis trainings, resulting in the publication of 9 papers now available on The DHS Program website. Several more will be published in the coming months.
Another class of DHS Fellows has graduated! This year, 6 teams from universities in Afghanistan, Indonesia, Myanmar, Ethiopia, Ghana, and Senegal have prepared working papers in areas covering child vaccination, nutrition, malaria, contraceptive discontinuation, men’s family planning, and HIV testing.
A recent analysis workshop in Ghana linked research to action by integrating policy brief writing with statistical analysis of data from the 2017 Ghana Maternal Health Survey. Proposed policy recommendations address inequalities and advocate for programs that protect and promote the health of women. Policy briefs will be published soon on The DHS Program website.
Coming Soon in 2019!
By geographically linking SPA and DHS data, two upcoming working papers explore the relationship between the antenatal care service environment and maternal health behaviors including iron-folic acid consumption and early breastfeeding. Working Papers 160 and 161 will be published in mid-August.
What are the determinants of child marriage in Asia? In Bangladesh and Nepal, marriage by age 15 is more common in clusters where women’s acceptance of wife-beating is more prevalent. Find out more in Analytical Studies 69.
Do regional disparities in fertility preferences and family planning satisfied by modern methods persist when controlling for poverty? Analytical Report 7 will explore this question for 12 DHS Program countries and 3 groups of absolute poverty measurements.
The DHS Program explores strategies to identify potential data quality issues after data collection in Methodological Report 26.
For the first time, summary briefs will be available for almost all analytical studies and comparative reports published this year. Briefs will feature figures and maps and easily digestible bullets of key findings for a variety of audiences.
After almost 20 years, The DHS Program is thrilled to be supporting the Mauritanian Ministry of Health in the implementation of a Demographic and Health Survey. On March 26, 2019, we were honored to welcome his Excellency the Minister of Health of the Islamic Republic of Mauritania, Pr. Kane Boubacar, along with Dr. Naceredine Ouldzeidoune of the World Health Organization (WHO) in Mauritania, and Dr. Moustapha Mohamedou, Director-General of the Mauritania Institut d’Hépato-Virologie to The DHS Program office in Rockville, Maryland.
The Minister and Dr. Ouldzeidoune provided opening remarks, highlighting the great demand for DHS data in Mauritania. Sunita Kishor, the Director of The DHS Program, presented the history, objectives, and methodology of The DHS Program. Other key staff presented on the survey design and biomarker collection aspects of the upcoming 2019-20 Mauritania DHS (L’Enquête Démographique et de Santé de Mauritanie or EDSM). Madeleine Short Fabic, Public Health Advisor at USAID, also participated in the meeting.
There is a high level of interest among health stakeholders in Mauritania in this survey, as it will provide an opportunity for trend analysis as well as several new indicators. In addition to the standard DHS indicators, the survey will include maternal mortality, hepatitis B testing among those age 1-59 years, and malaria prevalence among children age 6-59 months.
The DHS Program looks forward to working with the Government of Mauritania, WHO, and other survey stakeholders to support the 2019-20 EDSM.
This blog post is part of Luminare, our blog series exploring innovative solutions to data collection, quality assurance, biomarker measurement, data use, and further analysis.
Have you ever wondered how to write a Stata program for vaccination coverage or struggled to construct mortality rates using DHS data? Well, DHS Program staff are busy writing SPSS and Stata code for all indicators listed in the Guide to DHS Statistics, and you can use this code to jump-start your exploration of the data. And as they are completed, the code will be posted on GitHub for open access to the public.
The DHS Program GitHub site contains two repositories: DHS-Indicators-Stata and DHS-Indicators-SPSS. Users can download the code from these repositories or clone the repository to their own Github site. Users can also suggest changes to the code that will be reviewed by DHS Program staff before acceptance.
Don’t see what you need? The programming for all indicators listed in the Guide to DHS Statistics will be available by September 2020. The Guide corresponds to the topics/chapters that are typically found in a DHS survey final report in addition to the modules for malaria and HIV prevalence. As of July 2019, about half of the indicators have been coded and shared in Stata including indicators covering child health, family planning, and reproductive health. SPSS code will follow later in 2019 and 2020, along with the remainder of the indicators. Review the Readme text file for more details.
If you are interested in being featured in the ‘DHS Data Users’ blog series, let us know here by submitting your example of DHS Program data use.
Over the past four years, the IPUMS-DHS program has grown substantially, in both the magnitude of available data and in use. As of June 2019, more than 2,000 users have accessed the IPUMS-DHS database, and multiple papers have been published using DHS data through IPUMS-DHS.
One of the advantages of accessing DHS data through IPUMS-DHS is that variables are harmonized across surveys, facilitating comparative research. Recent research using IPUMS-DHS data highlight innovative methods and fascinating results:
Becker conducted a comparative study looking at control of female sexuality and male absenteeism in 34 countries and found that women in historically pastoralist societies face more restrictive norms.
Boyle and Svec recently published a paper on the international transmission of gender norms and female genital cutting (FGC) in six DHS countries. Results indicate that women’s decision making status is an important factor in FGC abandonment.
Di Brisco and Farina explored the methodological challenge of measuring gender disparities through individual perceptions and enlightening the pertinence of the poset methodology for the analysis of ordinal variables and response profiles. They used IPUMS-DHS data from 16 African countries.
IPUMS-DHS is also being used to train the next generation of analysts and data users. The Quantitative Global Health Analysis course taught at the University of Minnesota this spring relied on IPUMS-DHS as a primary data source for its students. Final products were research posters using the data. Research questions explored by students analyzing IPUMS-DHS data included:
How Violence against Women Affects Fertility and Family Planning in Uganda
Changes in and Predictors of Antenatal Care for Women in Mali
Effects of Family Size and Food Insecurity on Child Mortality in Ethiopia
Understanding Variation in Vaccination Status in Ethiopia
Vitamin A Vaccination and Deficiency in Uganda
Perceptions of HIV/AIDS in India in the Context of Education
IPUMS-DHS Data Update: As of June 2019, the IPUMS-DHS database includes 156 samples from 38 countries and nearly 15,000 consistently coded variables, including all standard DHS variables from DHS Phases 1 through 7 and many country-specific variables. Learn more on our website and read our previous blogs on the IPUMS-DHS collaboration here.
This blog post is part of Luminare, our new blog series exploring innovative solutions to data collection, quality assurance, biomarker measurement, data use, and further analysis.
Two needs are often expressed by both DHS host countries and donors: 1) for data to be made available more frequently, and 2) for the continued strengthening of implementing agencies’ capacity to conduct surveys. Among various innovations that The DHS Program has pursued to respond to these needs is the Continuous Survey (CS) model.
What is a Continuous Survey?
In a CS, data are collected and reported annually by a permanently maintained office and field staff. A smaller sample size is designed to provide estimates at the national level and for urban/rural residence every year. For regional-level estimates, data are pooled over multiple consecutive phases. Through both the smaller sample and continuously maintained staff, the model can lower costs and institutionalize the implementing agency’s ability to conduct a DHS survey. In 2004, Peru became the first country to conduct a CS, and the effort is still ongoing.
How did Senegal implement a Continuous Survey?
Inspired by the Peru experience, USAID and The DHS Program piloted the CS model in Africa. Senegal was chosen for its long survey history and the capacity of the local implementing agency, Agence Nationale de la Statistique et la Démographie (ANSD). The Senegal Continuous Survey (SCS) expanded on the original model to include an annual facility-based Continuous Service Provision Assessment (C-SPA), in addition to the household-based Continuous Demographic and Health Survey (C-DHS). The SCS was conducted in five phases, spanning the period from 2012 to 2018.
Covers from final reports from each of the five phases of the SCS.
What were the successes and challenges of the SCS?
ANSD partnered with Le Soleil newspaper to create an 8-page spread highlighting results from the 2016 SCS.
The SCS demonstrated many successes. Senegal is the only country in Africa to annually collect nationally representative demographic and health data, allowing Senegal to monitor progress towards the SDGs every year. This was also the first time a country releases both facility and household data at the same time. This model of releasing C-SPA data annually and in conjunction with the C-DHS resulted in flourishing data use for both surveys.
The SCS greatly strengthened capacity in Senegal. ANSD is now capable of conducting DHS and SPA surveys with only limited technical assistance. ANSD has the initiative to move beyond the pilot to implement the 2018 SCS with limited technical assistance and is already continuing the annual surveys.
Most surveys encounter challenges, and, in the Senegal experience, CS-specific design challenges emerged. Some stakeholders were concerned about the approach of pooling two consecutive years of CS data to generate a large enough sample size for regional-level estimates. Additionally, a census and an updated health facility master list in Senegal during the SCS pilot period resulted in new sampling frames for both the C-DHS and the C-SPA, and subsequent challenges in data interpretation. Finally, survey dissemination activities overlapped with the next phase’s design and implementation activities, increasing the burden on ANSD.
The CS model demands an overlap of activities. While one phase moves toward dissemination, planning is already occurring for the next phase of data collection, as evidenced in the SCS pilot experience.
Lessons learned from the SCS experience will inform The DHS Program’s continued efforts to innovate in the areas of data collection and use.
This blog post is part of Luminare, our new blog series exploring innovative solutions to data collection, quality assurance, biomarker measurement, data use, and further analysis. This is the second post in the series that focuses on innovations using DHS.rates data.
Ever struggled to calculate fertility or child mortality indicators from survey data? Want to customize the reference period? DHS.rates can do it for you!
What is DHS.rates?
The DHS.rates is a user-friendly R package to calculate fertility
and childhood mortality rates based on DHS datasets. First released in March
2018, the current version of DHS.rates calculates the Total Fertility Rate,
General Fertility Rate, Age-Specific Fertility Rates, Neonatal Mortality Rate,
Post-Neonatal Mortality Rate, Infant Mortality Rate, Child Mortality Rate, Under-5
Mortality Rate and mortality probabilities. For each indicator, the package
calculates standard error, design effect, relative standard error, and
confidence intervals. Data users can customize rates:
periods other than DHS standard reference periods
Based on calendar
years so the end of the reference period is not the date of the survey
sub-populations or domains other than those produced by The DHS Program
Based on other surveys
other than DHS if the required variables are available
Not an R user? Try
theweb-application, DHS.rates Shiny
This web-application provides all the DHS.rates functions without needing to download or use R. The DHS.rates Shiny web application includes two main tabs, fert and chmort. After uploading the relevant survey dataset, the application calculates fertility or childhood mortality rates according to the DHS methodology.
Just as with the R package, Shiny web application users can customize the reference period as well as the end date of the reference period. By adding a variable to “Class of the rate”, users can do the calculations for different subpopulations other than the ones produced by The DHS Program. Users also can change any of the fields on the screen allowing them to use the application with other surveys other than the DHS.
This blog post is part of Luminare, our new blog series exploring innovative solutions to data collection, quality assurance, biomarker measurement, data use, and further analysis. This is the first post in the series that focuses on innovations to improve the quality of anthropometry data.
Anthropometry, the measurement of the human body, gives a snapshot of the malnutrition situation in a country. Yet, the collection of accurate height and weight measurements, especially for young children, is difficult during data collection. To address this challenge, The DHS Program has tested new innovations to enhance the quality of the anthropometry data in the 2018 Nigeria Demographic and Health Survey (NDHS).
The 2018 NDHS is the sixth DHS survey conducted in Nigeria. The National Population Commission (NPC), in collaboration with the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health (FMOH), implemented the survey. Thirty-seven field teams closely monitored by coordinators and quality controllers collected data from August 14, 2018, to December 29, 2018. Each field team included a supervisor, field editor, two male interviewers, three female interviewers, and a biomarker team consisting of a lab scientist and nurse.
Introducing a Biomarker Checklist to strengthen supervision
The DHS Program has developed a Biomarker Checklist to assess the performance of and provide feedback to field staff. The checklist includes a core set of tasks required to collect biomarker data. Each task is a crucial action that, if missed, can result in poor quality data. The Biomarker Checklist is administered by supervisors and coordinators during collection of biomarkers in households.
The Biomarker Checklist was tested during the 2018 NDHS pre-test and biomarker main training using a mixed-method design which included administering anonymous questionnaires and conducting key informant interviews with the supervisory staff who used the checklist to assess its’ viability and usefulness. Feedback on the Biomarker Checklist was positive, so the Biomarker Checklist was used during the 2018 NDHS data collection. A Biomarker Checklist will be publicly available at a later date.
“it [Biomarker Checklist] has helped a lot because you are able to monitor what the biomarkers are doing so [you] can actually give corrective action”
Reducing errors while still in the field through re-measurement of children
The shift from paper questionnaires to a CAPI-based data collection approach provides an opportunity to easily identify children who may have been mismeasured and return to the household to measure these children again. To identify children with incorrect measurements requires performing a complicated calculation – a child’s body measurements are compared against a healthy population by transforming their measurements into anthropometry Z-scores. Extreme measurement results are then detected by calculating anthropometry Z-scores and flagging cases with higher or lower Z-scores than expected. The DHS Program has developed a program to automatically calculate anthropometry Z-scores and flag extreme cases in the CAPI system. A user-friendly interface on the tablet produces a report with the children who need to be re-measured.
The DHS Program relies on field check tables that are run periodically during data collection. While an important data quality tool, a major limitation of the field check tables is that enough data need to accumulate before problems can be identified. At that point, the information can only be used to improve collection of data moving forward; these corrections do not fix data previously collected. The real-time ability to re-measure children while still in the field is a major step forward and can easily be applied to other CAPI surveys.
Re-measuring anthropometry in a random subsample of children
A random re-measurement of height and weight in a subsample of children was also piloted in Nigeria. The DHS Program has developed a CAPI program that randomly selects one household in each cluster for the biomarker team to revisit. The program then compares differences between measurements and reports precision, or how close the first measurement is to the second measurement, as acceptable or unacceptable.
The aim is measurements will be of better quality as a result of instituting random re-measurement. The biomarker team may be more careful and not rush measurements if they know poor measurements will be exposed. The data produced on precision can be used as a motivational tool for biomarker teams and provide an opportunity to identify and re-train in cases where there is a high degree of discrepancy between measurements.Precision estimates will also help better assess data quality post-data collection.
A review of the anthropometry data from the 2018 NDHS indicates it meets data quality targets. Results from the 2018 NDHS Key Indicators Report (KIR) show that 37% of children under 5 are stunted. Stunting generally increases with age, peaking at 47% for children age 24-35 months. Overall, 7% of children under 5 are wasted, while 23% of children are underweight.
Lessons learned in the implementation of the quality assurance activities in Nigeria are being used to conduct similar activities in DHS surveys in other countries.
About the survey
The 2018 NDHS was implemented by the National Population Commission (NPC) in collaboration with the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health, Nigeria. Funding for the 2018 NDHS was provided by the United States Agency for International Development (USAID), Global Fund, Bill and Melinda Gates Foundation (BMGF), the United Nations Population Fund (UNFPA), and World Health Organization (WHO). ICF provided technical assistance through The DHS Program, a USAID-funded project that provides support and technical assistance in the implementation of population and health surveys in countries worldwide.
Additional information about the 2018 NDHS may be obtained from the headquarters of the National Population Commission (NPC), Plot 2031, Olusegun Obasanjo Way, Zone 7, Wuse, P.M.B. 0281, Abuja, Nigeria (telephone: 234-09-523-9173; fax: 243-09-523-1024; email: firstname.lastname@example.org; internet: www.population.gov.ng).
This blog post is part of Luminare: The DHS Program Blog Series on Innovation. You can find additional posts in the Luminare series here.
While The DHS Program is known for comparability and standard methods, it would not be relevant today without innovation. We’ve made big leaps – like moving from paper to tablet-based interviewing and from basic print publications to web and mobile data dissemination. We’ve integrated complex biomarker testing and developed weeks-long curricula in data analysis and use. We’ve also made hundreds of smaller, less flashy improvements, such as use of WhatsApp to communicate with field teams and the use of checklists to improve biomarker collection. Innovation – large and small – is part of life at The DHS Program, as we are constantly seeking new ways to solve problems, increase efficiency, and improve data quality while meeting the needs of an increasingly diverse audience.
Over the course of the next several years, we will be undertaking a systematic review of new ideas, from new biomarker assays to non-traditional partnerships. This new blog series is just one of the ways that we will be exploring and sharing innovations. We will also be holding topical consultations with experts, reviewing the academic literature, attending key conferences, and interviewing key informants such as external survey experts, staff, consultants, and implementing agency representatives.
In DHS-8, we have an even stronger mandate to innovate, and for the first time ever, we have a formal innovation strategy which is led by our new Senior Science Advisor, Joanna Lowell. Her job, in part, is to lead the “deliberate exploration and strategic incorporation of state-of-the-art advances in survey tools methodologies, and partnerships.”
We welcome your ideas. You can reach out to Joanna directly at Innovations@dhsprogram.com and look out for announcements regarding other ways to contribute.