MOH/GTZ Reproductive Health Project Kenya & Community Based Services Sector Project

BASELINE SURVEY
An essential and rapid tool in the planning and evaluation of a CBD Program The Kenya example

Publisher: Deutsche Gesellschaft fr Technische Zusammenarbeit (GTZ) GmbH Postfach 5180, 65726 Eschborn Internet: http://www.gtz.de Author: Dr. Alan Ferguson Dr. Adiambo Omondi-Odhiambo Responsible: Dr. Henri van den Hombergh, GTZ Layout: Elisa Martin, OE 6002

Dr. Alan Ferguson B.A., Ph.D. is a social scientist who began his career as a lecturer at the University of Nairobi. Following two years as an assistant professor at Northwestern University, Illinois, he returned to Kenya, where he has lived and worked continuously since 1982. He was an evaluation and research consultant with AMREF, a medical geographer with the Medical Research Centre (a department of the Nairobi-based Kenya Medical Research Institute), and a biostatician with the GTZ Family Planning Project, Kenya, before becoming the project's Team Leader in1993. Since February 1998 he has been working as an independent health and population consultant. Dr. Ferguson can be contacted at: P.O. 25255, Lavington, Kenya; tel.: +245-2-561557; E-mail: ALANF@AFRICAONLINE.CO.KE Adiambo Omondi-Odhiambo B.A., M.A., M.Sc., Ph.D. is a demographer holding a doctorate from Florida State University. A Kenyan, Dr Omondi has vast experience of field research in the region. He, too worked at the Medical Research Centre in Nairobi (from 1978 to 1985), where he designed and carried out demographic baseline surveys. Returning from studies in 1992, Dr. Omondi worked as a Research Associate for Family Health International, based in Nairobi. Since 1994, he has been an independent consultant specialising in the design and execution of rural surveys of health and population, and has been involved in several of the surveys referred to in this manual. Dr. Omondi can be contacted at: P.O. Box 64316, Muthiaga, North Nairobi, Kenya; tel.: +245-2-860740; fax: +245-2-862573; E-mail:OMOSH@AFRICAONLINE.CO.KE Dr. Henri van den Hombergh MD, MPH is a medical doctor who has worked since 1981 in Ghana, Tanzania, Cameroon, the Gambia, Zimbabwe, Ethopia and presently Kenya. Initially active in the curative sector, after his public health training in LSHTM in 1991, he is mainly occupied with Reproductive Health, applied epidemiology and operational research, HIV/AIDS/STI prevention and control, Tuberculosis, Malaria and Health Management Information Systems. Presently he is the Team leader of the MOH/GTZ Reproductive Health Project. This project formed and still constitutes the enabling environment for the development and further elaboration of the methodology, strategy and tools documented in this "Tool" lying before you. Dr. van den Hombergh can be contacted at: P.O. Box 41607, Nairobi, Kenya; tel.:+254-2-721187 or 728252 or 561849 (home); fax: +254-2-723353; E-mail:HVDHOMBE@AFRICAONLINE.CO.KE

Acknowledgements

Acknowledgements
The manual in front of you results from a highly successful Reproductive Health Project in Kenya. It has been written and compiled by Dr. Alan Ferguson, Dr. Adiambo Omondi and myself. As the project's present team leader, I happily made the resources available to them that were required for preparing this publication and I have been pleased to assist them in their efforts. Monitoring and evaluation have played a prominent role since the inception of our project. The emphasis has rightly remained on proper fact-finding, i.e. sound baseline surveys of the target area and target population, before the actual provision of Family Planning services. Here in Kenya, we have, over the years, accumulated a great deal of experience and expertise in baseline surveys. The methodology of planning, performing and analysing these surveys has matured to the point where we feel we have a valuable body of knowhow for wider application and it would be almost unethical not to share the lessons we have learnt! By the same token, there is plenty of room for improvement: the feedback that this manual should generate will enable our techniques to attain even greater maturity, and we look forward to upgrading this reference work in the future. I take great pride in complimenting the authors on a job well done. It is with considerable satisfaction that I put this handbook and reference source onto the information market. We have here a package that will, I hope, benefit reproductive health initiatives ail over the world. Henri van den Hombergh Team Leader MOH/GTZ Reproductive Health Project, Kenya

Preface

Preface
Assistance to the Ministry of Health, Division of Family Health (Division of Primary Health Care since 1997), from German Technical Co-operation (GTZ), began in 1986, with the intention of strengthening Kenya's family planning programme. During the first phase (19861988) of the Project, most resources were invested into improvement of the management of Maternal and Child Health and Family Planning (MCH/FP) at the district level, a construction component and some operational research activities. In this first phase, the operational research component tended to be free-standing, operating more or less independently of the other Project components. By the end of 1988, the Project was in the process of re-defining some of its aims and activities, and transferring its geographical focus from the pilot districts of Kwale and Embu, to districts where a combination of high population density and low contraceptive prevalence were causing problems of over-population. One of the Project's last contributions to the first-phase pilot districts was to assist the sub-District Health Management Team (sub-DHMT) from Kinango Hospital, Kwale, to carry out a survey designed to measure contraceptive prevalence and some other aspects of MCH/FP within the catchment area of Kinango Hospital, in advance of a small programme of hospitalbased IEC and outreach clinics to provide MCH and, especially, FP services, to the people in the outlying areas. With the design and fielding of the Kinango Contraceptive Prevalence Survey in February, 1989, the Project embarked, somewhat unwittingly, on a strategy of rapid assessment of reproductive health status at the community level, producing a tool which has been extremely valuable in measuring baseline conditions, comparing local reproductive health indicators with those at national level, and evaluating Project impacts. The questionnaire used in the rapid assessment evolved from the Kinango prototype, with only a few changes, allowing comparative analysis of results to be made from one survey to the next, as the series developed. By the end of 1997, a total of thirteen baseline surveys had been completed by the Project in eleven different districts and four different provinces of Kenya. A total of 9101 women aged 15-49 had been interviewed at a time when Kenya was embarking on one of the fastest fertility transitions ever seen in the world. Fertility and family planning indicators, in particular, showed dramatic variations from one survey to the next as the transition unfolded in different places at different times, and the data collected in the surveys encapsulates many of the dynamics of this unique period of Kenya's social and demographic history. This collection attempts to share the experience of the Project with a wider audience, by making available the data sets collected in their original and amalgamated forms, providing summaries of each of the thirteen surveys in a standardised format, and by passing on the field techniques and experiences, in the form of a handbook, which should

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Preface enable organisations with similar interests to replicate or adapt the rapid assessment methodology. Each part of the collection is independent of the other, but sampling all parts to have a proper impression of the whole may be more beneficial than treating each part separately. Dr. Alan Ferguson and Dr. Adiambo Omondi

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How to use the manual

How to use the manual

This manual is intended for all managerial staff in projects with survey components. It deals with the need for measurement. How can we know what projects are required, how projects should be designed and whether projects are achieving their goals, if we don't determine what the target population is actually thinking and doing? The answer, of course, is that we can't. Especially in the reproductive health sector, it is imperative that project impacts be measured directly. And that means going out and collecting primary data. True, project managers can and must refer to a range of secondary data (available on, say, the demographic aspects of fertility), but this information is rarely tailored to the tasks of establishing the pre-intervention status in target communities and later verifying the progress made through project measures. So project managers - who do not necessarily have a background in empirical social science research - have to engage with an activity that may well appear alien and daunting: the ex-ploration of knowledge, attitudes and practices (KAP) through baseline surveys. That is where this manual comes in. It shows you how to prepare and carry out field survey operations and how to assess their findings. A series of baseline surveys from the GTZ Project Kenya exemplify the whole process of data collection and analysis. Our aim is to share experience and learn lessons. The working examples presented here will be useful both to the novice and the experienced analyst. The publication's modular structure allows the latter to refer quickly to the specialist information needed on particular techniques. As for the former, we want to help those facing challenge of field surveys for the first time to do so with confidence and get things right from the start. Our initial message to project personnel is: Baseline surveys are not too difficult, they're not too expensive, they won't take too long, and you probably have all personnel resources you'll need! Getting the most out of this manual This publication is divided into two parts. Section One is the actual handbook, providing you with a general guide to the steps involved in measuring reproductive health status. The main thrust is to demonstrate how to organise and carry out operations in the office and in the field to optimise the rapid collection and analysis of data - taking you through the aspects of questionnaire design, fieldwork organisation and data evaluation. There are also three appendices in Section 1: formulae for calculating required sample size; a model aptitude test for interviewer selection; and a useful fieldwork checklist. (A note of caution when referring back and fore: the term "module" in Section 1 is also used to denote parts of questionnaires.)

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How to use the manual Section Two then offers you working examples of data collection and collation of data sets taken from Kenya in their original form. The modules in this section will give you a clearer idea of what baseline surveys can achieve in terms of scope and outcomes, and provide a reference source for technical aspects of data analysis. An overview of the material covered by these modules is given at the head (page 5) of Section Two. Module 1 can be read as an introduction, setting the context for the examples and model procedures set out in the following modules. Newcomers to baseline surveys may benefit from browsing through the summary of the first few modules in Section Two before reading the handbook (rapid assessment guide) itself in Section One; the summary reports, in particular, supply concrete examples of what can be achieved after all the detailed steps discussed in the handbook have been followed. Moreover, Module 4 should be referred to whilst reading the handbook in Section 1 to illustrate the relevant passages.

Section 1
Rapid Assessment of Reproductive Health Status in Rural African Communities

Table of Contents Section 1

Table of Contents Section 1

Acknowledgements Preface How to use the manual Table of contents Section 1 1. Introduction 1.1 1.2 2. Operational Research and Project Implementation The Need for Measurement and the Fear of Fieldwork i ii iv 6 2 2 3 5 5 15 18 18 19 21 23 27 27 27 31 36 36 36 38 40 41 44 46

Survey Preparation 2.1 2.2 Questionnaire Design Sampling

3.

Fieldwork 3.1 3.2 3.3 3.4 Building a Field Team Selection of Interviewers Training Interviewers Fieldwork

4.

Data Management 4.1 4.2 4.3 Coding and Data Entry Data Screening and Transformations Data Analysis

5.

Costs 5.1 5.2 Introduction Example of Costs

6.

Limitations

Appendix 1 - Example of Sample Size Calculation Appendix 2 - Aptitude Test Appendix 3 - Fieldwork Checklist Index to Section 1

Introduction

1.
1.1

Introduction
Operational Research and Project Implementation

This handbook is based on the experience of the GTZ Family Planning Project, Kenya. The Project, started in 1986 in the Division of Family Health, Ministry of Health, Nairobi, has assisted the Ministry of Health (MoH) in the implementation of its family planning programme. Since February 1998, the Project, now in its fifth phase, has been renamed the MoH/GTZ Reproductive Health Project. In 1997 the Division of Family Health was renamed the Division of Primary Health Care. Perhaps unusually for a donor-assisted project mainly concerned with expanding family planning, the GTZ Project had an operational research component built in from its inception. During the first two phases of the Project, the operational research was relatively freestanding, with studies being completed on schoolgirl pregnancy in Kenya, FP needs amongst students at teacher training colleges, the dynamics of family planning adoption, method change and discontinuation and baseline studies of fertility and contraceptive knowledge and use. From the latter, a standard methodology of measuring baseline and post-implementation reproductive health conditions in rural communities in Kenya developed in response to the large-scale implementation of community-based distribution (CBD) of contraceptives, with which the MoH/GTZ co-operation was mainly concerned from 1990. Thus, the OR component became, from around 1990, much more integrated into the monitoring and evaluation of the major operation itself, the CBD programme. The methods used to acquire large and representative samples quickly and accurately, and at low cost, are neither new, nor particularly ingenious. They do, however, try to make maximum use of all the skills available within the Project, the counterpart organisation and in the communities in which the surveys take place. As noted above, the combination of project implementation with an integral programme of operational research is not common - health projects tend either to be implemented with minimal operational research incorporated, or else an intense research programme is built up round a relatively small adopted area and a series of studies carried out. The largest and best known example of the latter approach is Matlab in Bangladesh. African examples include the British-run Medical Research Centre in Gambia, the Dutch-run Joint Project Machakos in Kenya, and the Navrongo Project in Ghana, supported by the Population Council. The application described here has been carried out almost entirely in Kenya - the one exception being a baseline survey in Nyagoro District in northern Namibia in 1997 - but the questionnaire used is not culture-specific, and is easily modifiable, so there should be few problems in applying similar methodology elsewhere. Many of the questions are identical to those contained in the Demographic and Health Surveys (DHS) which are

Introduction carried out in a standard form world-wide, allowing for useful comparisons to be made between indicators over time and between different geographical scales.

1.2

The Need for Measurement and the Fear of Fieldwork

Donor-supported projects follow the norms of the donors. For project managers, the need to make a positive impact on the target group is a priority, but the need to prove authentically that the donors' money is being used to make this impact often causes even more anxiety. The means of proving a project's worth is provided through project cycle management (PCM), where a planning document (e.g., a log-frame or ZOPP) details the goals, result areas, indicators, means of verification and activities for a particular phase. Planning documents, such as log-frames, are normally produced in a "workshop" - i.e., a large comfortable room in an up-market hotel, far away from the reality of either the target area or the target population. Representatives of the latter may be present, but will tend to feel overpowered by their surroundings and their eminent colleagues. During a planning meeting, target-setting and the mean? of verification provide an apparently easy coda to the main task of defining the goals and sorting out result areas. Quantitative targets provide a short-hand, condensed means of telling the donor, and others, "We are going to aim for this much improvement...". A number of quantitative targets, if achieved, will show that the project is on the way to reaching its main objective and, at the same time, provide an easy way of communicating the effects of a range of activities undertaken to effect positivechange. The need to measure, and to measure in an accepted way, is inherent in PCM. Unfortunately, back at the workshop, it is often too easy to define quantitative targets and means of verification without considering who will do the measuring and how they will be measured. In detailing the means of verification the words "field survey" often appear, and come back later to haunt and hang over the head of the project team like the Sword of Damocles! In reproductive health, particularly in the demographic aspects of fertility, there is a vast range of secondary data available. This is convenient for defining indicators at the national or regional level. Many reproductive health projects, however, have target areas below these levels, and district information is usually less readily available, or is based on relatively small sample sizes. The Kenya Demographic and Health Survey 1993, for example, had a national sample of women aged 15-49 of 7540, but district samples varied from 60 to 355. With smaller sample sizes, the estimates of important indices are subject to wide confidence inter vals, so it becomes increasingly hard to show a significant change over time. The timing of (the "big survey" may also not fit well with the project cycle. For these reasons, the need to measure impacts of project activities directly is usually imperative. However, collection of primary data tends to be something that "other people" do: these other people tend to be professional researchers, academics from local or overseas universities or research institutes, specialists who are never burdened by the

Introduction tribulations of implementation. With certain exceptions, they do not usually interact much with the implementers, except as expensive consultants. Project managers in reproductive health do not usually come from a research background. Although they may have had some experience in research methodology and even carried out a research project at masters level, these experiences were either too short-lived or too long ago to make the manager confident that the project can successfully go into the field to collect primary data as a means of verifying the progress made. The fear of fieldwork can be legitimised in any or all of the following: It is too difficult It is too expensive It takes too long We have nobody available who can do it

If the project succumbs to such reasoning, then no fieldwork or primary data collection will take place and secondary sources and qualitative information will have to be cobbled together to evaluate the progress towards the targets of the planning document. Qualitative information is helpful, but difficulties in collection and interpretation are often underestimated1, and, when target indicators are framed quantitatively, the qualitative information available may be the proverbial square peg in the round hole. This handbook is aimed at encouraging the collection of primary data for project evaluation in reproductive health by showing that rapid assessment can be done successfully, and that it need not be expensive. As noted above, the handbook uses the series of baseline surveys from the GTZ FP Project, Kenya to exemplify the process of data collection and analysis. Although some description of the technical indicators is included, the main thrust of the handbook is to demonstrate how to organise and carry out operations in the office and in the field to optimise the rapid collection and analysis of data. Not all aspects of reproductive health are included, indeed, by definition, the GTZ Family Planning Project centred on aspects of fertility and maternal and child health and family planning. However, it is relatively easy to plug in or remove modules of the questionnaire and tailor the instrument for particular needs. The remainder of the handbook is organised in the following way, roughly corresponding to the process of planning, fieldwork and data analysis. Part 2. Survey preparation Part 3. Fieldwork Part 4. Data management Part 5. Costs Part 6. Limitations

For example, focus-group discussions require great skill in the selection of participants, moderation, processing and interpretation of results.

Survey Preparation

2.
2.1

Survey Preparation
Questionnaire Design

Although overused as a method of elicitation, the questionnaire directed at individual respondents remains a convenient and flexible device for finding out what people know, think and do. Proper design of a questionnaire is an art which is not often well practised. Poor sequencing of questions, ambiguity (especially if the questions are to be asked in a vernacular language) and redundancy are potential problems. There is a tendency for designers of questionnaires to include far too many questions. At all stages, the designer should ask: "Why am I asking this question?". If there is no particular use for the response, then the question should not be asked. One goal of questionnaire design is, therefore, to make the questionnaire as short as possible, given the aims of the survey. The shorter the questionnaire, the easier it is to sequence, and, of course, the less time it will take to complete a single interview and the survey as a whole. The questionnaire, no matter what length, should be produced in modules. This helps the respondent to concentrate her attention on one particular topic at a time (e.g., personal background, fertility, awareness of AIDS, contraceptive knowledge and use). Modules should be arranged in a logical sequence, with the most sensitive questions at the end of each module, and the most sensitive module at the very end of the whole questionnaire. Questions in a questionnaire can be open or closed. Open questions usually allow the respondent to make a response which is recorded verbatim, in whole or part. Closed questions anticipate quantitative responses, or provide a fixed set of categories into which the interviewer marks the most appropriate to the response given. Open questions require more time for the answers to be recorded, and need to be coded after the fieldwork, but have the advantage of eliciting more free and precise responses. Closed questions channel responses into one of a number of categories which can be conveniently precoded on the questionnaire. Basically, the more exploratory the questionnaire, the greater the proportion of open questions which are necessary. There is a trade-off between speed and convenience, on the one hand, and a possible loss of detail, on the other. The fewer open questions there are, the faster the interview will progress, with the possibility that detail and elucidation will be missed. The physical design of the questionnaire is also important. Plenty of space on the paper is needed for recording. Filter questions, and instructions to the interviewer, need to be clearly marked and the possibility of the interviewer skipping questions is increased with a crowded format. The questionnaire used in April 1996 to measure baseline conditions of fertility, mortality, maternal and child health and family planning in Trans-Nzoia District, Kenya, is used to exemplify some of these points.

Survey Preparation The Trans-Nzoia survey is the 12th of its type carried out by the Project. The questionnaire, which is found in the "Forms and Tables" package, developed from the first survey of the type carried out in 1989, and the questions and the modes of recording responses have evolved through continued experience. One clue to the expansion of the original questionnaire is that the question numbering is a little odd, with much reliance on alphabetic riders, showing the emergence of new questions within the various sections. Renumbering of the questionnaire is long overdue! The questionnaire has a small header and four sections, covering four pages. It is largely pre-coded, with categories defined based on the experience of prior applications. There are very few open questions; those which are there require simple factual responses and do not require copious recording by the interviewer. The sections, or modules, are arranged in the following order: Basic Information, Fertility, Maternal Mortality and Family Planning. The sequence is a logical one and the "easy", non-controversial parts of the survey occur early. This allows rapport-building between the interviewer and respondent and makes it possible for the interviewer to ask some questions whilst other members of the family are present (later on, they will have to be out of earshot). A good, experienced interviewer can turn the fielding of this questionnaire into a natural conversation. Serial No.: Some kind of simple identification system for numbering questionnaires needs to be worked out and entered into the questionnaires as an identification code. Interviewer and Date: The interviewer and the date are noted to identify each form uniquely, and for possible follow-up at a future date. More important, the date of interview is used later to calculate the age of mothers and children at the time of survey. Sublocation/Division and Village: Some geographical identification is needed - here, it is in terms of administrative areas and village names. If a follow-up is envisaged in the future, a unique identity number which corresponds to the geographical location and respondent has to be worked out. For follow-up, the same identification number can, with the householder's permission, be written somewhere on the buildings of the compound using an indelible marker. Name of Head of Household and Name of Woman: Recording the names of the head of the household and woman responding are, strictly speaking, unnecessary, but in case a future revisit is envisaged, this is necessary. The formal exchanging of names during the introductions by the interviewer legitimises the interaction about to take place. In most African cultures, it would seem very strange to somebody for a visitor not to want to know the name of the head of the home or the name of the person who was welcoming the visitor. While interviewers must stress confidentiality, the experience of the Project has been that most people are happy to give their names, and often do so before the interview formally begins.

Survey Preparation Section 1 includes some basic information about the respondent: age, marital status, education level, religion and ethnic group. These are the only background variables used in the analysis of the data. Obviously all sorts of socio-economic information could be included here and there is a temptation to overload this section with personal details of the respondent2. From the experience of the Project, a rich set of information can be produced from the cross-tabulation of the few variables measured in this section, with the various outcome measures recorded later. Date of Birth: Most questionnaires ask the respondent to give his/her age in years. In the early versions of the questionnaire, the woman's age was directly coded into one of a set of five-year age-groups. The more recent surveys have used month and year of birth to elicit a more accurate response. Asking age directly usually results in a great deal of "heaping" of ages ending with zero or five. Asking for year of birth reduces this, although heaping can still occur round certain preferred years, especially if month of birth is not known. Many women do not know their month of birth, but the definition of age will be most accurate if this detail can be provided. How the data are treated when this information is missing is discussed in Part 4. Marital Status: Four categories of marital status are recorded - alternative classifications can be made depending on the various forms of cohabitation in the particular community. The category of "Married - Husband living away" was added after the first few surveys carried out by the project, to take account of the fact that a large proportion of households in rural Kenya have a de facto female head, with husbands working in the towns for most of the year. This can have direct and indirect effects on fertility and family planning use. The apparently odd wording of the next category in question 2, "Married - Husband died", results from the experience of confusion in recording in the case of women who have been widowed, even for several years. Such women will still tend to classify themselves as "married". In most African cultures, a woman never considers herself to be a widow in the same sense of the Western concept of the term, as she is still married to the family of her late husband. This category reminds interviewers to prompt for the current status of the women. Only Wife?: For women who do have living husbands, a filter arrow directs the interviewer to ask the respondent whether she is in a polygamous marriage, and, if so, to state whether she is the first wife, second wife, etc. Woman's level of education: Education can be recorded in number of years of schooling, or, as in the present example, by categories. Here, the four categories are: none, incomplete primary (standard 1 to standard 6), complete primary (standard 7 or 8) and secondary or above. Educational categories defined will depend on the level of
2

For example, occupation is not included (nearly all respondents are "housewives", "farmers" or "schoolgirls"). No questions regarding income are asked, as it is notoriously difficult for a rural woman to know, or to admit, the income generated and available to her in a given time period. Some indirect measures of wealth may be observed and recorded, for example, building materials, the presence of particular material goods such as a radio, bicycle, sofa-set, etc.

Survey Preparation development of female education of the area; in a neglected area, a "none-any" category may suffice. In most of rural Kenya, few women go beyond secondary education, so the highest category for recording can include girls who might have dropped out after one year of secondary school together with university graduates. Religion: Religion can be recorded as a completely open category. In the present example, Protestant churches are written-in. This allows flexibility in analysis: in Kenya, interest is usually in differences in fertility and/or family planning patterns between Catholic and Protestant families. If there are a multitude of small Protestant sects recorded, analysis can simply use (the overall Protestant category, however, if there are one or two dominant Protestant churches, these can be coded separately for analysis. Ethnic Group: Trans-Nzoia District has an unusually rich mixture of ethnic groups. Ethnic group, in this example, was pre-coded into six main groups, plus a write-in for any others. If there is a dominant ethnic group, then it is adequate to have only this and another writein category for others on the questionnaire. Section 2 covers aspects of fertility and provides information which, when combined with age, produces estimates which are very useful for assessing project achievements in family planning. Several of the questions are identical to those in the series of Demographic and Health Surveys, and can be tabulated and cross-tabulated comparatively with the DHS breakdowns for a particular country or region. Questions 7 to 10 are concerned with the birth of children to the respondent, and, like all the questions of Section 1, are simply factual. Number of children ever born / living children: Interviewers are usually taught to ask these questions together as part of a conversation. Anywhere in the world, it is painful for a mother to lose a child. In Africa, it is an unfortunately common occurrence, and it is often considered taboo to talk of children who have died. Interviewers must be trained to extract this information carefully, using a sensitive approach. Average parities by various categories and estimates of child mortality can be generated from this information. A so-called skip pattern is found after Number of living children (Question 8) for, if the woman interviewed has never given birth, then there is no sense in asking about the details of her last-born child. The next set of questions concern the last-born child. For calculations of fertility, a higher degree of accuracy would be obtained from taking a full birth history for each woman. The recording of dates of birth becomes, however, more and more difficult with increasing age of children, so, in a rapid assessment exercise, this information is restricted to the lastborn child. Date of birth of last-born child: With the expansion of immunisation coverage, many mothers, even those with minimum education, are aware of the full dates of birth of their last-born child. Some even volunteer the day of the week when the birth occurred, so a

Survey Preparation high proportion of mothers are usually able to give full dates of birth. Where the dates are poorly recalled, a clinic card, or other form of record (e.g., a baptism card) can often be produced to pin-point the date. Is the child still alive now? and When did the child die?: Question 10a and 10b inquire about child deaths and, again, must be asked about gently. Indeed, if the interviewer has handled the first two questions correctly, she will be able to know if the last-born child is still alive. If this is the case, the interviewer skips Question 10b, otherwise the date of death is established. This enables estimation of infant and child mortality rates. Was the child delivered at home? / at a health facility? and Who delivered the child?: Questions 10c and 10d switch the emphasis naturally towards maternal health by finding out where the last-born child was delivered, and who the birth attendant was. If it is important to have the names of specific health facilities, these can be written in, as in this example, and coded specifically. The birth attendant is recorded in Question 10d. Often, anybody in a white coat will be perceived of as a doctor, so some probing may be required. This information should be cross-tabulated with the facility type when screening the data. Interviewers are usually instructed to write in the specific relationship between the mother and the birth attendant (usually a female relative) in the "Other" category. In earlier baseline surveys, two additional questions appeared here concerning the choice of traditional birth attendant (TBA), if this was relevant, but these were not asked in the Trans-Nzoia survey. The last questions in Section 2 concern present pregnancy and the desire for future pregnancies. Again, these questions provide very important information on the demand for children and the unmet need for contraception. There are some tricky skip patterns here which interviewers have to navigate. Are you pregnant now?: Question 11 a is the first real sensitive question in the schedule. "Are you pregnant now?" has to be asked in an agreed, appropriate way, and without the question being overheard by relatives or other bystanders. Appropriate settings for interviewing are discussed in Part 3. If the respondent answers positively to this question, information is gathered on the stage of pregnancy (Trimester), and on whether, and how often, the woman had attended an antenatal clinic. The trimester, cross-tabulated with the frequency of attendance provides a useful indicator of maternal health, and can be used to estimate the true pregnancy rate - women in their first trimester will often not admit to being pregnant, whereas the pregnancy is nearly always obvious amongst women in their third trimester. The women who answer "don't know" to Are you pregnant now? are usually young, unmarried women who are probably pregnant, although a few may be genuinely unaware of their biological status. For women not answering this question in the affirmative, the interviewer skips to ask whether the respondent wants to give birth within the next year.

Survey Preparation Do you want to give birth within the next one year?: This is a key question which influences the calculation of unmet need for family planning to a large extent, and, in aggregate, can be used as an indicator of changing levels of pro-natalism. It also causes much amusement to many older respondents. The subsequent survey in Uasin Gishu District extended this question on the desire for future births into more detail. Section 3 is a small module on the awareness of maternal mortality, which can be excluded or upgraded to the more ambitious task of estimating the rate of maternal mortality3. Do you know of any woman in this area who died when she was pregnant, whilst giving birth, or shortly afterwards?: The question simply filters out respondents who do not know of any woman who was thought to have died from pregnancy-related causes. Interviewers need to emphasise that it is information about local maternal deaths ("this area") which is being sought. From the respondents who can recall a local maternal death, some details of the woman who died are then taken, together with the timing of the death in relation to the birth of the child. The level of detail recalled can be used to classify the strength of the citations, and are necessary if a subsequent investigation of cited cases is proposed. Tabulation of responses from this question give a good general impression of how common the problem is. The simple proportion of women citing an incident of maternal mortality, plus tabulations on how recent the cited death was, can give insights into the maternal health in the area. The methodology is, however, susceptible to another type of "heaping" which occurs where somebody in the area has died very recently, and a large proportion of respondents in a locality give the same citation4. The final section of the questionnaire concerns family planning knowledge and practice. This was considered a sensitive topic when the first surveys were being fielded, so it was positioned at the end of the questionnaire, where it has since remained, despite the fact that family planning is now a common and relatively open topic of conversation amongst Kenyans. If an AIDS/STI module is to be included, it should be placed after the family planning one, as was the case when an expanded version of the questionnaire was fielded in Namibia

To do this properly requires a follow-up in the community, of all the citations of maternal deaths. The module was first used in the survey of Lake Kenyatta Settlement Scheme where follow-up of citation of maternal deaths was carried out by a Public Health Nurse who found that all the individual women mentioned in the citations were very likely to have died from pregnancyrelated causes. In the Uasin Gishu survey, exactly this problem arose when the wife of a local councillor died of obstructed labour the day before the fieldwork commenced in the area, resulting in over twenty citations of the same woman.

10

Survey Preparation The switch of topic here is signalled by a short lead-in sentence which is given by the interviewer to provide a bridge to the new subject. Which ways or methods have you heard about?: Question 14a is a replica of the knowledge question asked in the DHS series. Designed to measure basic knowledge of contraceptive methods, it includes both spontaneous and probed levels of knowledge. Earlier versions tried to classify the extent of knowledge of contraceptive methods, but there were problems of standardising knowledge levels and classifying responses, so this simpler version was fallen back on. The possibility of direct comparison with the DHS tabulations is a compensating advantage. Instructions to the interviewer are included as a reminder of the correct sequence used to elicit responses. The interviewer checks one of the three boxes for each line to note whether the method has been mentioned spontaneously, after probing, or not at all. It is, of course, possible to vary the methods in the list, and to calculate a knowledge "score", based on summation of the whole range. The latter has been calculated in all the Project surveys and the scores analysed in relation to the background variables of Section 1. Have you ever used any of these methods at any time?: Introduction of the names of the range of contraceptive methods provides an easy entry to asking about use of the methods. Ever-use of a method is recorded in Question 14b, with the interviewers asked to probe for all methods ever used. Have you heard of village people who are trained to give family planning information and contraceptives to people like yourself?: Question 14c is more recent addition to the questionnaire, aimed at measuring the level of awareness of the Project's CBD agents or, in a pre-implementation baseline survey, of any other CBD agents operating in the sample sites. Notice that the phrase "CBD agents" does not appear in the question. This is deliberate, to reduce the possibility of leading the respondent in a certain way. The question has two filters so that it is possible to determine the extent to which the respondent is familiar with CBD by classifying awareness as "heard of, "know of one" and "have talked with her/him". This gives additional depth to a simple, but important question for a project which has invested heavily in CBD. The last page contains key information on family planning users and non-users. Beginning with a filter question which separates current users from non-users, the questioning proceeds along two separate lines until the interview is over, detailing, on the one hand, the method in use, duration, source and ease of supply and approval of husband, and, on the other, the reasons for current non-use, the possibility of CBD-supply being accepted, and the general approval of family planning of the husband of the non-user. Are you presently using any method(s) of contraception?: Additional effort during interviewer training needs to be invested in this question, unambiguous though it may appear. The crucial term is the word "presently". In English, the meaning is clear and

11

Survey Preparation unambiguous, but, translated into a vernacular language of Africa, it sometimes loses its clarity. On some occasions, pregnant women or those with very small babies have claimed to be "presently using". The difficulty seems to be that a respondent may, because she has used contraceptives in the recent past, consider herself to be a "present user" of a contraceptive method, even if, at the time of interview, she is a non-user. Because the contraceptive prevalence rate (CPR), usually a key indicator, is calculated from this response, it is extremely important that interviewer and respondent both understand the exact meaning of the question. The question is not asked of pregnant women, for whom "No" is ticked, and the appropriate reason for non-use entered in the "Other" category on the right hand side. Taking the questions filtered for the users, respondents are asked a number of questions concerning the contraceptive method they are currently using. Which method(s) are you using?: It is possible to record dual methods here, for example condom-natural methods or pill-condom. Method mix is determined from the response to this question. For how many months have you used this method?: Duration of use in months is entered. Respondents who have a long continuous use of a method will tend to round the duration of use to the nearest year, resulting in heaping at multiples of 12 months. Interviewers should probe for the month and year when the user commenced using the current method. Indeed, question 17a would benefit from rewording in this way. From where do you get your source of supplies?: Question 18a records the source of supplies for users, where this is applicable. Some pre-coding by name or type of service delivery points is possible. For women who have undergone tubal ligation, the name of the facility at which the operation was performed can be entered here. Do you ever have any difficulties in obtaining supplies?: Question 19 is only asked of respondents who require resupplies and excludes users of natural methods and those who have undergone surgical procedures. It would be possible to add a filter of the type "If yes, specify the problem" if this were considered an important question. The last two questions, for married users only, probe the likely attitude of the husband towards the use of contraceptives. Does your husband know that you are using FP?: Secret use is still quite common in Kenya, particularly for users of injectables, and question 20 seeks to know whether the husband is aware of the use of contraceptives by the wife (although if a male method is being employed, this will be self-evident). If the response is negative, question 21 is not asked, since it can be implied that the husband does not approve of the use of

12

Survey Preparation contraception. If this assumption is considered doubtful, there is no need to filter out the "No" responses. Does he approve?: The "don't know" category tends to identify the situation where no discussion about the use of family planning has taken place between the husband and wife, and is therefore a more important response than might initially be imagined. For current users, the interview ends at this point. Why are you not using any method?: Following the filter for non-users, the important question of why the respondent is not currently using a method is asked. Here, the interviewers should prompt for as many reasons as the respondent can give. Even pregnant women may have other reasons for not being current users. Based on the experience of previous surveys in Kenya, 11 named reasons for non-use are set out, and a final write-in "other" category is added. Cross-checks for consistency are possible for some of the reasons given. In the section on data management, some of these are presented. Interviewers must be encouraged to identify inconsistent answers during the interview, and to review the inconsistencies with the respondent before progressing. One recurring example, is the response that breastfeeding is a reason for not using a contraceptive method. While breastfeeding is an important spacing mechanism in rural Africa, it is often over-relied upon. Interviewers should always check on the age of the child who is being breast-fed, and find out if menses have returned. If so, then breastfeeding is not a valid reason for non-use of a method, and the respondent should be probed further. Under the response category "abstaining from sex", a reason for this has to be recorded by the interviewer, who should, again, be ready to look back at previous responses to ensure consistency. This identifies one of the problematic areas of the questionnaire, for the "abstention" response is commonly cited by teenage girls. Since interviews take place at the homes of the respondents, it is obviously quite hard for a young girl to admit to premarital sexual activity, even when the interviewer has emphasised confidentiality and is interviewing out of earshot of other members of the household. Interviewers should be trained to press the "abstention" respondent more strongly to defend her response, hence the qualifying "reason for abstention". If an AIDS/STI module is used, the same type of problem may occur in eliciting positive responses on experience of STIs. Others citing abstention are likely to be older married women, particularly women in polygamous marriages, women whose husbands have died or who are usually living away. The reasons for non-use are usually of interest in themselves as they tend to identify the barriers to expansion of family planning use which a programme has to overcome. In combination with information from the earlier sections of the questionnaire, the reasons for non-use can be used to calculate the proportions of women having an immediate unmet need for contraception.

13

Survey Preparation If contraceptives could be supplied to you at your home, would you use them?: Question 17b is a very direct question designed to give a rough idea of how acceptable a CBD program would be. Notice that the term "CBD agent" is, again, left out of the question. Positive responses to this question are usually above the proportions expected, and some contradictory patterns appear. The question probably needs modification, for example by specifying pills and condoms instead of the less direct term "contraceptives", or by making it more reflective of the information-diffusion role of the CBD agent. Does your husband approve of family planning?: Finally, the married non-user is asked whether her husband approves of family planning. The proportion of negative responses is usually higher than the proportion citing this spontaneously as a reason for non-use. Several cross-tabulations involving this variable can be explored, for example, cross-tabulation by religion, education, ever-use of a method, parity and age group. This questionnaire takes an average of only 10 minutes to complete in a typical household, once an interviewer is experienced. When the respondent is an unmarried teenager with no children, completion is usually even shorter, as there are several questions which can be skipped altogether. Depending on the population density and the terrain, a typical interviewer will be able to complete 20-25 interviews in one field day. Physical production of blank questionnaires is worth mentioning. Although a decidedly obsolete technology, the cheapest way of producing the questionnaire is to cut stencils and copy the required numbers using a duplicating machine, and to compile and staple the sheets manually. Using a photocopier with a sorter is, of course, much neater and quicker, but con siderably more expensive. Remember to produce about 20% more questionnaires than the target number of completed interviews, to cater for interviewer training, wastage, etc. With an untested questionnaire, only a small number should be produced for field-testing in case of the need for revision. If the questionnaire is being used for the first time, it is well worth formally translating everything into the vernacular language to be used, and then having it translated back into English or another European language by a second translator. Questions with ambiguities will be revealed in the re-translated version, and a small team of people skilled in the vernacular language can revise the terminology of these questions. Even with a questionnaire which has been checked like this, consistency in phrasing must still be emphasised during interviewer training. Although, as stated earlier, the questionnaire seems fairly robust and impervious to cultural variations in rural Africa, pre-testing a draft form may be desirable. A pre-test will also give an inexperienced team an idea of how to organise the logistics of the survey, and how much time will be required to reach a given target number. A pre-test may also build confidence and defeat the "fear of fieldwork". It is a dress-rehearsal for the main survey.

14

Survey Preparation A pre-test should be carried out in an area similar to the one targeted. The language used in the pre-test should be the language to be used in the main survey. Rigorous sampling is not necessary, and the completion of around 30 questionnaires should be sufficient to identify any major problems. Areas of the questionnaire giving problems should be revised and a decision made as to whether a second pre-test is necessary. The questionnaire should then be finalised and produced.

2.2

Sampling

Where is the survey to be carried out? This is an obvious question, to which the answer will usually be "In such-and-such a district". Presuming that a specific administrative area is chosen as the target, the survey must seek to sample the area in a representative way. In a standard piece of research, a sampling frame will have to be constructed, composed of all the units - for example, households - in the area. Such frames are usually available from the technical department of the Ministry which plans and carries out the national census. Two- or three-stage sampling from such a frame will then ensure an unbiased sample. In a rapid assessment, it will not be possible to follow this procedure: sampling individual households scattered throughout a rural area is expensive and very time consuming. Instead, procedure described below has been used successfully in the GTZ/MoH surveys. No revisits are carried out in the rapid assessment exercise, so, even if a household has eligible women, if they are not present at the time of visit, they are not included. This is a main difference with a survey in which a proper household sampling frame has been used. In practice, the main drawback of the rapid method is the tendency to under-sample schoolgirls, and the main advantage is speed of coverage. Firstly, liaison with a counterpart organisation in the district is essential. A good local knowledge of the district by the project team is also important. The key question to be discussed is whether the area in which the survey is to be carried out is homogenous in terms of its geographic and socio-economic status. The less homogenous an area is, the greater is the requirement for stratification into separate sample clusters. The settlement pattern, for example, dispersed or clustered, is an important aspect with respect to sampling, and information of this kind should be built into the sampling procedure. A survey being carried out in the catchment area of a health centre may not need to sample widely-separated sites, but, if the target is a larger geographical area, for example, an administrative district, then the definition of separate sample clusters will give a better representation of the whole area than a single site. Discussion of sample sites with local counterparts should lead to an agreement about the number of clusters and their location. In health projects, it is often convenient to define clusters within the catchment area of particular health facilities, especially if the proposed or actual intervention involves the service delivery point. Most of the later baseline surveys carried out by the Project have used multi-cluster samples when new districts were being brought into the CBD program.

15

Survey Preparation Sample size is a question which tends to worry project managers. Put quite simply, assuming that the sample is free from bias, the larger the sample, the closer the estimated rates and values will be to the true situation. Statisticians normally pre-define an acceptable range around the estimated rate of the main variable to be measured, and compute the required sample size from this range5. In rapid evaluations, this strict procedure can be relaxed without being completely abandoned. Usually, as is obvious from the example we are dealing with here, the values of a series of variables, not just one, need to be estimated. In this case, the required sample sizes for estimation of each variable with different expected values may be quite different. Also, strict adherence to a particular acceptable range may often result in required sample sizes being very large, defeating the purpose of carrying out a rapid and economical survey. The compromise used in this case, is to take the contraceptive prevalence rate (CPR) as the variable used to set target sample sizes (this was one of the specific objectively verifiable indicators of past Project plans). In the Trans-Nzoia survey, for example, three separate clusters were defined, each with a target of 250 women aged 15 to 49. With a pre-survey estimation that the true CPR for Trans-Nzoia would be 25% and a sample size of 750, confidence intervals would be 3.1% (see footnote 5). In other words, we would be confident that, employing this sample size and with an expected CPR of 25%, 19 times out of 20 the true CPR would lie between 21.9% and 28.1%. This was taken to be sufficiently accurate as a baseline measure which would allow any change as a result of the CBD program to be measured reasonably accurately at a subsequent survey. For the individual clusters, the sample size of 250 produce less precise limits for the CPR - at 95% confidence intervals, the expected range would be 5.37% from the estimate. The numerical calculations of these ranges, using the formula given in footnote 5, are set out in Appendix 1. Sampling on the ground can be done in various ways. The fastest methods use cluster sampling: all households in a particular sub-area are visited in turn, and all eligible persons interviewed. Where there is almost 100% of enrolment of boys at primary schools, a formal, but time-consuming, way of doing this is to draw up a list of primary schools in the sample cluster or clusters, visit the schools to obtain a list of boys in the lowest grade, then randomly choose one boy from the list. The team then takes the boy home and begins interviewing at this household. Subsequent interviews are carried out with members of the nearest households to the random starting point. The survey team then move out in all directions from the initial household to the nearest neighbours,

This procedure makes use of the formula : n = {z SUP 2p(1-p)} OVER d SUP 2 Where: n = sample size z = standard normal deviate corresponding to 95% confidence intervals p = expected proportion of variable under consideration d = acceptable range (plus or minus) round 'p'

16

Survey Preparation interviewing eligible women, until a pre-arranged number for that cluster has been reached. This cluster method has been used to determine immunisation coverage in Kenya. While it ensures unbiased sampling of households in a cluster, it adds logistical requirements and involves considerable preparation time (for example, visits to schools, compilation of enrolment lists, liaison with officials and parents). The alternative methodology used in most of the surveys carried out in the Project, is to define the cluster area on a base-map; if one does not exist, then a rough map should be drawn using local expertise. Starting points for interviewers at particular, easily traceable points, e.g., schools, markets, crossroads, should be defined, and the survey team then works in particular directions going from one household to its nearest neighbour in the manner described above. Roads or tracks, rivers etc. can be defined as boundaries to keep the interviewers separate and to allocate their work areas for a particular day. Provided that roadside bias is avoided, this procedure will provide, in a homogenous rural area, a good representative sample of the whole population.

17

Fieldwork

3.

Fieldwork

Good fieldwork is key to the quality of the final product. Unfortunately, senior staff tend not to become too involved in the minutiae of fieldwork, and too much delegation to junior or less experienced staff can have detrimental and probably un-noticed results on the quality of the data being collected. In Module 1, for example, the story is told of the follow-up survey in Nyamira where interviewers strayed well out of the catchment area defined for one of the sampling sites, an error which was only noticed months later, and resulted in a costly recollection exercise. A Fieldwork Checklist, covering the main points discussed in this section, and some of the pre-fieldwork stages, is attached as Appendix 3, and should be consulted when embarking on a rapid assessment survey for the first time.

3.1

Building a Field Team

It is obvious from the discussion of sampling, that rapid assessment relies greatly on local knowledge. Where a counterpart organisation has a local structure, it should be integrated into the whole research process. The implementing agency for the GTZ FP Project is the Ministry of Health, Kenya, so the counterpart is the main consumer of the information to be produced by the survey, and must be intimately involved. Even where the relationship is not so direct, local knowledge is usually available and must be incorporated. Key counterparts should be identified early in planning the survey: they will need to make certain preparations before the survey takes place. For fieldwork, the most useful team members may not necessarily be the most senior. Public health technicians, for example, often have a more intimate knowledge of the district than the more desk-bound members of the health teams, and are often invaluable when sampling sites are under discussion (see above). Tasks which the counterpart team should carry out prior to fieldwork should include the following: Selection of possible sample clusters and timing of the survey Giving advance notice of the survey to local leaders in the areas to be sampled Identifying potential interviewers Preparing background information (maps, district-level health data) Allocating staff for the fieldwork Securing a suitable place for training and preparation

If these preparations are carried out in advance, then time in the field can be reduced considerably. The fieldwork is then much more a joint effort, rather than being completely controlled by outsiders. Timing may be dictated by the needs of the project team, but especially busy times (e.g., planting or harvesting) and obviously unsuitable times (e.g., the middle of the rainy season) should be avoided. One particular problem occurs when a survey is timed during school terms. This usually means that much lower than expected proportions of teenagers, and to some extent, those aged 20-24, are interviewed, requiring weighting of some important indicators to take account of the bias. If it is feasible

18

Fieldwork to time the survey during school holidays, so much the better. The problem of age bias is dealt with in Part 4.

3.2

Selection of Interviewers

Good interviewers are essential for obtaining good results. Working in a rural African community, interviewers need to be sympathetic and non-threatening towards respondents, intelligent, diplomatic and in good physical condition. To make it easier to communicate the needs of the survey, there may be a temptation to select interviewers who have the highest educational qualifications, e.g., university students, teachers or nurses. This temptation should be avoided: in our experience, the best interviewers are not necessarily those who speak best English or who look most confident. To begin with, certain exclusion criteria for interviewers must be applied. For a survey of reproductive health with women aged 15-49 as the target population, interviewers have to be female, and should be mature in age and disposition. A minimum qualification of four years of secondary education can be set in most of the agricultural areas of Kenya, although it may be difficult to find sufficient numbers at this level in some parts. School leavers with below four years of secondary education usually have difficulties in learning quickly enough, in understanding enough English, and in recording with sufficient accuracy. University students can usually do all these things well, but quickly become bored and may anticipate responses too much. Teachers tend not to listen well, and nurses may be overpowering or bias the respondent towards "correct" answers. Most of the GTZ/MoH surveys have utilised Form 4 leavers6, resident in the sampled areas, as interviewers. Most have never been able to further their education, for reasons of poverty or lack of high enough grades. Most are married and have one or two children. There are obvious advantages in using local interviewers. The most important one is their acceptability to respondents and the ease with which they can initiate and complete the interview. Local knowledge of the area, language and cultural protocols, and the enhanced ability to put respondents at ease improve the quality of the data collected. Costs and time are saved by not having to transport interviewers or to accommodate them, and some small direct benefits and goodwill are gained through the temporary employment of local people. There are also a few disadvantages: a locally knowledgeable interviewer can bias the sampling towards or away from particular types of household unless she is properly supervised7, and respondents may be reluctant to give out intimate knowledge to someone who is known to them. The problem of inadvertently selecting the relatives of locally-prominent people as interviewers is dealt with below.

6 7

Form 4 leavers have had eight years of primary and four years of secondary education. During one of the baseline surveys, an otherwise excellent interviewer missed a house on the grounds that the people inside practiced witchcraft.

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Fieldwork Where more than one sample cluster has been defined, it is usually better to train a set of interviewers for each site, although there are savings in costs and time by only training one set of interviewers and retaining them for all sites8. Some time savings can be made in this situation by training all interviewers simultaneously. To begin the selection process, the local counterparts should have passed messages to key people in the survey sites that temporary interviewers are required from such-andsuch a date. Announcements at church services can be used to spread such messages. Typically, they should specify the minimum qualifications required, e.g., "Survey team is seeking to recruit six ladies over 23 years of age with Form 4 education for a period of one week." The number of interviewers to be selected should be decided on beforehand, depending on the sample size and strategy, the availability of supervision and the transport logistics. Some flexibility should be allowed for in case of particularly easy or difficult areas, or varying quality of candidates. Typically, the Project surveys have been carried out with six to eight interviewers per cluster - more than eight interviewers are hard to supervise in the field and logistics are more complicated. Fewer than six interviewers lengthens the duration of fieldwork and increases the likelihood of fatigue or boredom amongst the interviewers. Having gathered the prospective interviewers together in the pre-arranged location, the first step is to administer an aptitude test. This is absolutely essential, for it is almost certain that local leaders and counterparts will have sent many of their relatives to vie for the position of interviewer. Exclusion through failure in an aptitude test is probably the only acceptable antidote to a local chief who calls to enquire why his daughter has not been picked as an interviewer in his area. The aptitude test does not need to be particularly complicated, but should be able to weed out those whose knowledge of language is insufficient, whose attention to detail is lacking, and who take too long to complete the questions. The aptitude test attached as Appendix 2 has been used successfully for several years as a means of ranking candidates. Project managers should adapt this or devise their own. The test is quick to administer (20 minutes are allowed, but a sharp person can finish it in five) and score, and it lends fairness and transparency to the recruitment exercise. Scoring the test can vary according to the weight given to each question. Overall, the lowest proportion of correct answers are found in the question requiring the identification of the mis-spelt word written backwards, and the calculation of the baby's date of birth. All candidates should then be interviewed and the purpose of the survey explained. Shyness and self-consciousness are common amongst young women in Africa, and the task is to get beyond the initial deference to decide whether or not the candidate would be confident enough to ask women of an older age set the very personal questions contained

In one instance, local chiefs refused to co-operate with the survey team unless "their people" were hired as interviewers.

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Fieldwork in the questionnaire. Often the level of understanding of English is too weak to qualify a candidate, and this will be obvious during the interview. Sometimes otherwise suitable candidates may have religious beliefs which make them uncomfortable with handling the questions to be asked, but try to conceal this. Born-again Christians are usually unsuitable for this reason. The survey team in the Project make liberal use of condoms, penis models, packets of pills and other family planning artefacts during these interviews to observe any particularly squeamish reactions from the candidates. While chronic shyness will disqualify many, those who are over-confident or have a domineering manner must also be excluded, for this type do not make good interviewers. Health workers may be thought of as suitable interviewers, but their professional knowledge of the topics covered in the questionnaire, and their status are actually disadvantages. From the aptitude test and the interview notes, the final choice is made. Before dismissing the unsuccessful candidates, the working conditions - rates of pay, hours of work, duration of assignment - must be explained clearly to the group, and any who cannot agree replaced by another candidate. Some expenses should be paid to the unsuccessful group who can then leave, and the training session can begin.

3.3

Training Interviewers

To reach a competent level of interviewing on the above questionnaire, one full day is usually sufficient for training, although this may have to be extended, depending on the quality of the interviewers varies from place to place. Unless there are few candidates, selection of interviewers will take a whole morning, so training can commence in the afternoon and be carried through until the middle of the following day. The training session starts with self-introductions, introduction of the purpose of the survey and how it is to be carried out. Most recruits will not have had any experience of field surveys, particularly those involving reproductive health, so all details should be covered, including the fact that a considerable amount of walking should be anticipated. Rapid internalisation of the questionnaire is a major objective of the training The questionnaire is introduced, question by question (in much the same way as in the above section), and agreements reached about the rendering of some of the sensitive questions in the local vernacular. As noted when reviewing the questionnaire, there are a few points which require particular care. For example, Questions 7 and 8, inquiring about numbers of children ever-born and surviving, need to be asked in an acceptable way to ensure that the respondent is not upset, and that she does not undercount the children who have died. The question "Are you pregnant now?" is almost never asked in this direct form. In the Siaya Baseline Survey, for example, the interviewers agreed on a vernacular form of the question which translated back as "Is it possible that God is going to bless you with a gift?", a question which would mystify English speakers, but which was unambiguous in Dholuo, the local language. If the questionnaire has been subjected to prior formal

21

Fieldwork translation to, and back from, a vernacular language, questions which need this type of treatment will have been identified. Most interviewers are in their early twenties. Although, from the selection procedure, a group with some knowledge of and positive attitudes towards family planning should have been selected, it may be necessary during training to review the range of contraceptive methods available, and how they work. Passing examples of packets of pills, injection vials, condoms and foam tablets, Norplant sets and lUCDs with their applicators generates interest in the group and helps the interviewers to describe these methods when probing for knowledge of contraceptive methods during the interviews. This area of training can be delegated to one or two of the counterpart staff, who will have much experience in explaining contraceptive methods and how they work. This also helps to integrate the two components of the survey team. Interviewing techniques not directly associated with the questionnaire must also be learned. These include the etiquette of introductions, rapport-building and, most important, confidentiality during the interview. Since interviewers should have been selected from the local community, there should be no problems about the approach. If the local leaders have informed the community in advance about the survey, then less explanation and persuasion will be necessary. Interviewers should, however, be told to anticipate the occasional refusal, and to accept this without protest9. One recurring problem in the field is the inability of interviewers to ensure confidentiality. The visit of strangers to a compound attracts attention, particularly if Europeans are amongst the group, and considerable efforts are needed by the interviewers to separate the respondent from the others without causing offence. This technique must be practised during interviewer training. Possible strategies for ensuring confidentiality in these circumstances are discussed in the next section. These points are then reinforced by role play as interviewers practice the questionnaire on each other and weaknesses and problem areas are identified and revised. Once interviewers feel more confident, some "live" interviews should be carried out with respondents drawn from the neighbourhood of the training area - this has usually been a health facility, so clients from the MCH clinic or others who are waiting for preventive care, can be selected. Each interviewer needs to carry out three or four complete interviews before proceeding to the field, and particular attention has to be taken with these, and the early "live" interviews, that the answers are being recorded properly - often, until a rhythm is established, the inter viewer will ask a question, receive an answer, and ask another question without first recording a response. The tendency to miss questions or to fail to

The refusal rate in this series of surveys is 1% to 2%. Refusals tend to occur in pockets where a negative rumour has spread or where a small fundamentalist religious group is concentrated.

22

Fieldwork record answers reduces with in creased experience as the questions, and their order, become more and more committed to memory. If the training session carries over to the next day, interviewers can be given some blank questionnaires and asked to carry out some interviews with their friends or neighbour before attending the next day's session. Supervisors can then scrutinise the completed questionnaires for errors in recording, inconsistencies and other problems, and discuss the details with each interviewer. Completed questionnaires used for training purposes should be discarded before embarking on the fieldwork proper, otherwise a few might appear among the set to be analysed. At this stage, it should be clear whether or not the group as a whole are ready to start the work. If there are still significant problems, these should be eliminated by further training and practice; at the extreme, interviewers who do not appear to be able to reach a sufficiently high standard must be dismissed, although, if the screening process has been carried out properly, this should not be necessary. Materials required for the field are few: clipboards, questionnaires, pencils and pencil sharpeners, pens, erasers and notebooks should be distributed to the interviewers when training commences. Some box files are handy. Survey managers usually prefer recording to be done in ink, with errors crossed through; interviewers, in Kenya at least, are addicted to pencils and erasers, although the filled questionnaires are often more difficult to read in pencil. It is possible to enter data in the field using a notebook computer. While this may seem an attractive proposition, the experience of the GTZ Project in Kenya is that basic data cleaning is more of a priority in the field than data entry, and that, unless an additional team-member is included in the field team solely for data entry, there is simply no time or energy remaining at the end of a field day for this step. An sturdy box is useful for storing blank and completed questionnaires, maps and other papers, keeping the inevitable dust off the materials.

3.4

Fieldwork

Before commencing interviews, a courtesy call to the local administrative leaders is a sensible step, even if information about the survey has been passed in advance. Local chiefs are compendiums of knowledge, and it is useful to consult with them when planning the sampling strategy. They will also know of any local events which might affect the availability of the target group. For example, if there is a local market day, fewer women than usual will be at home, so it is better to work in another area on that particular day. The chief will also know about any big funerals taking place which would drain women away from the surrounding households, a particular problem in western Kenya. On occasions, a chief may even decide to accompany the field team. Some care is required, however, that the survey team sticks to the sampling strategy, for local leaders are often tempted to conduct visitors to their "showpiece" households.

23

Fieldwork The field team - or teams, if more than one cluster is being surveyed at the same time meet at a pre-arranged time and place to start work. Early starts are usually advantageous in that it is often easier to find women at home before 10 a.m. It is better to work with a targeted number of interviews for a day's work, giving out a sufficient number of blank questionnaires to each interviewer, than to work to a time-schedule. Correspondingly, it is better to carry on without a break until the target has been reached, or until a pre-arranged stopping time, than to have a "lunch-hour", which breaks the rhythm, and can lead to afternoon somnolence in the team! Drinking water should be carried, especially for those from outside the area who may not have tolerance of the local drinking water. Rural people are usually generous to visitors, and offers of food and drink will often be made, and it is discourteous to refuse. If the hospitality is slowing down the work, however, interviewers must explain the problem and push on. At the pre-arranged starting point, the team should be divided up according to the areas to be covered, ensuring that there will be no overlaps. (On one occasion, where this had not been done properly, one women was interviewed twice within an hour by two different interviewers, and was too polite to point this out until after the second interview had been completed!). After agreeing on a place and time to collect after the day's work, the team can then move to their first households. (At the outset, it is a good idea to put interviewers into pairs, pairing a strong interviewer with a relatively weak one, and trying to have one supervisor allocated to each pair. The pair should carry out the first few interviews together to check each other's progress, and to build up confidence. Once the interviewers have gained in confidence and competence - usually after only a few questionnaires have been completed - the pair should be allowed to interview simultaneously, with the supervisor moving from one to the other. Quite often, there will be more than one eligible woman in each household, so two interviews can take place close to each other. On arrival at the household, greetings and introductions having been exchanged, the first task is to identify women 15-49 in the household. Identifying women in the main childbearing age groups is easy, but mistakes can be made with incorrect inclusion or exclusion of women of the youngest and oldest eligible ages. Interviewers tend, particularly, to exclude young girls because "they are still at school", even although the inclusion criteria have been explained during training. Some women in their late forties may not know their year of birth, and some questions may have to be asked to establish whether the woman is eligible interview10. It is an important task of the supervisor to ensure that the women interviewed have been correctly identified.

10

For example, the year of birth of the first- and last-born children, whether the woman had children in the year of independence, whether she has an identity card, etc.

24

Fieldwork The issue of isolation of the respondent is important. As mentioned above, the arrival of strangers will cause a great deal of curiosity, and a small crowd may assemble to hear what is going on. The interviewers can introduce themselves and explain what is happening to this audience, but, once the women to be interviewed have been selected, more privacy is needed. Most often, interviews will take place inside the main room of the house, but several may have to be carried out outside. In both locations, there may be interference. Husbands and mothers-in-law are the most common "intruders" to an interview, mothers-in-law being especially intractable. Husbands are usually happy to leave when told that the questions concern "the health of women and children"; many may have positive attitudes to reproductive health, in which case, the supervisor, if present, can go to another part of the compound and discuss this, or anything else, with the husband. Mothers-in-law, however, are not so easily moved. If it is difficult to attain privacy, the interviewer can begin the questionnaire in the company of mothers-in-law or other adults, but, once the sensitive questions are imminent, privacy must be assured, and either the interview will have to be continued at another part of the compound, or a diplomatic way of asking the listener to leave will have to be found. Increasingly, the topics of reproductive health, especially family planning, are discussed in families, and there may be no fear by the respondent about answering questions, but privacy must still be ensured as far as possible. In the discussion of the questionnaire, the problem of shyness amongst teenage women was mentioned. Privacy when interviewing teenagers is particularly important. Here, too, if the supervisor is a male, he should be out of earshot, otherwise the delicate thread of rapport between interviewer and respondent will be broken. Interviewing then proceeds, from household to next nearest household. Sometimes the next household cannot be seen, in which case the interviewer usually asks direction. More often than not, a child from the previous compound is allocated as a guide to the next household. Between households, eligible women may be met along the paths or in the fields. Provided that they are identified as resident in one of the households of the area, they can be interviewed, although it is more difficult to ensure privacy in a public place. In an area of dispersed settlement, market centres should be avoided, except as starting points, as people who live outside the sampled area are often found there. If, on the other hand, the settlement pattern consists of significant amounts of nucleated settlement, such as market centres, this should have been taken account of when developing the sampling strategy. The baseline survey carried out in Makueni, in eastern Kenya, in 1996, included sampling in market centres and dispersed households for this reason. The role of field supervisors is also very important, especially in the initial stages of fieldwork. Supervisors need to make sure that the interviewers are carrying out instructions properly, are not straying out of the arranged area, and be prepared to deal with any contingencies which occur. Often, these involve patient explanation of the

25

Fieldwork purpose of the survey and what may be the results. A supervisor must be able to spot contradictions and omissions quickly in the completed questionnaires, and to help an interviewer decide on how to categorise a particular response. The supervisor needs to note, in writing, any procedures which are not being carried out properly, so that the field manager can review these when all the interviewers are collected together. Supervisors should check questionnaires as soon as possible after completion. If a question has been missed, or a response is contradictory or obviously incorrect, then the interviewer can return on the spot to correct the error (an example of why recording names is a useful procedure). Dates of birth of mothers and numbers of live births, should, in particular be checked for feasibility. Table 1, in the following section, indicates some of the cross-checks for consistency which can be performed in the field on one set of questions. Observation of interviews by a supervisor can usually detect whether the "flow" is good, and if the respondent is having trouble in remembering dates or other details. Unless the interviewer has made an obvious mistake, missed a contradictory response, or is in intractable difficulties, however, the supervisor should not interrupt the interview. After the day's fieldwork has been concluded, supervisors should meet briefly to discuss progress and problems, and the remaining questionnaires should be checked and initialled. Any with errors should be put aside for revision with the interviewers on the following morning. With six or more interviewers in the field, this may be quite a timeconsuming task, as upwards of 120 completed questionnaires will be generated each field day, and double this figure if simultaneous interviewing is being carried out in more than one cluster. It is important not to let fatigue affect quality assurance, and a fair allocation of the supervisory tasks must be made within the team.

26

Data Management

4.
4.1

Data Management
Coding and Data Entry

Once the survey team has returned from the field, the first stage is to code the data. In the questionnaire reviewed in Part 2, coding is relatively simple. Most data analysis packages (e.g., SPSS, Epi Info) accept either numeric or alphanumeric codes. In our experience, numeric codes should be used wherever possible, even when a variable is alphanumeric, and variable labels assigned to the alphanumeric variables. For example, rather than assigning "Y" and "N" for "Yes" and "No", it is better to code these as "1" and "0" or "2" and "1" and to label the values alphanumerically. Coding of some responses will depend on the detail required during the analysis. For example, in question 10d, on the birth attendant of the last-born child, birth attendants other than health workers, TBAs and the woman herself, can be coded according to who they are, or can be left together as a blanket category. When in doubt, it is always better to give many separate codes, which can be receded into a single value later, as the opposite process is not possible. Once all the codes have been allocated, data entry can begin. The Project has used SPSS Data Entry II as the entry medium, although any spreadsheet, data base or statistics package can be used. The advantage of SPSS Data Entry is that entry can be semi-automated by the use of "skip and fill" patterns, and entry errors are minimised by defining the range of possible values which a variable can take. A validation mode, where re-entry of data is performed and non-identical entries are flagged, is also a useful feature. These options are available in Epi-lnfo, but not in the most recent Windows-based versions of SPSS. As mentioned above, it is possible to enter data in the field. The main advantages of doing this are speed, and the possibility of trapping and correcting errors which have escaped the supervisory process. The main disadvantages are that an extra person in the field team is needed, and that the economic repair of faulty recording may not be possible if the field team are sampling from fairly widely-scattered areas. Data entry is not a major constraint; a reasonably quick data entry operator will be able to complete around 150 questionnaires in a day. Double entry of data to screen for entry errors is advisable if no entry templates defining skip patterns and range rules have been established.

4.2

Data Screening and Transformations

When the data have been entered, the first step is to screen for any entry or other errors. The easiest way to do this is to produce frequency tables of every variable entered and to examine the values. Transformation of some data to produce additional variables should be done beforehand. For example, to establish the age in years of a respondent, a calculation involving the month and year of birth and the month and year of the survey has to be performed. Similar calculations to establish the age (in months) of the last-born 27

Data Management child, and, if it has not survived, its age at death, should be performed, and new variables defined to hold these values. Most statistical packages allow easy creation of new variables and modification of data. Examination of frequency tables can often identify data or entry errors. Age frequencies should be examined for values over 49 and under 15; if these are found, then the case has to be removed from the data set as age is a key variable. Most other cases with missing values can be retained, and the package used will give the choice of a generic missing value (a dot) or a user-defined code, and tabulations will include numbers and proportions with and without inclusion of missing values. Negative values are sometimes found in the frequency distribution of ages of last-born children, usually the result of the interviewer entering the current year rather than the previous year as the date of birth. Referral to the original questionnaire will help decide whether this is an obvious mistake which can be rectified. If there is any doubt, the substitution of a missing code for the particular value is the only solution. Some cross-tabulations should also be performed explicitly for screening purposes. Table 1 shows some of the most commonly-performed examples.

28

Data Management Table 1 Examples of cross-tabulations for data screening Variable 2 (Question No.) Consistency Check Live births surviving children unless twins present Doctors and nurses should not appear with home deliveries; TBAs should not deliver in health facilities No examples of current users not being ever-users Should be non-user Low parity or long birth interval should be found Overall score low, or few methods known even after prompting Most responses should be in mothers with babies under six months old Must be currently married to answer this question Variable 2 must always be "No" Surgical, natural methods should not appear here Must be currently-married to answer this question Method must be specified

Variable 1 (Question No.)

No. of children ever born (7) No. of living children (8) Birth attendant (10d) Place of delivery (10c)

Ever-use of FP (14b) Desire for birth within year following survey (11 b) Reason for non-use: Gynaecological reasons (165) Reason for non-use: Not aware of methods (16b) Reason for non-use: Breastfeeding (16b) Husband (of non-user) approves of FP? (18b) Reason for non-use: Husband objects (16b) Difficulties in obtaining (contraceptive) supplies? (19) Husband knows / approves of use of FP? (19) and (20) Current FP user (15)

Current use of FP (15) Current use of FP (15) Live births, age of last-born child (7) and (9) FP knowledge (14a)

Age of last-born child (9)

Marital status (2) Husband (of non-user) approves of FP? Method(s) used (16a)

Marital status (2) Method(s) used (16a)

All of the checks given in Table 1 should have been made in the field at the time of interview. Not much can be done, at this stage, to edit the questionnaire, but the crosstabulations shown in the table will give a good idea on the quality of the fieldwork. Many of the most interesting and important cross-tabulations involve the use of five-year age groups, so the single years of age, calculated as above, should be regrouped into another variable, with values corresponding to seven five-year groups starting at age 1519 and ending at 44-49. Examination of the frequency distribution of the age group variable will also indicate whether or not it will be necessary to calculate adjustment factors for some of the indicators (see below). The variables normally generated from the basic data set, in the analysis of most of the GTZ Baseline Surveys, are summarised in Table 2 below. Many others are possible.

29

Data Management Table 2 Construction of transformed variables in survey data analysis Definition Single year ages of women Ages of women grouped in 5-year cohorts Type of marital union, monogamous = 1 polygamous = 2 AGELB BTH12M Age, in months of last-born child Gave birth in last 12 months? Yes =1 No =2 AGEDTH RISK SCORE Age of last-born child at death (in months) High-risk women, = 1 if para 1 or para 5, otherwise =0 Date of birth, date of death of last-born child No. of live births Date of birth of last-born child, date of interview Receding of AGELB, as above Data used to construct Month and year of birth, date of interview Receding of AGE Receding of MS

Variable Name AGE AGEGRP TYPE

Composite FP knowledge score Summation of codes for each method mentioned in knowledge question Classification of time since last live birth <12 months previously = 1 12-59 months previously = 2 60+ months previously = 3 Receding of AGELB, as above

WHNDEL

As mentioned above, AGEGRP is a key independent variable in many parts of the analysis, and age-specific fertility and contraceptive prevalence are important indicators. If a woman has not given her month of birth, an occasional problem of correct allocation of the case to an age group category can occur. A practical solution is to allocate a mid-year month of birth for women for whom this information is missing, or to allocate a random number between 1 and 12 to represent the month. AGELB is used with AGEDTH to estimate infant and child mortality rates, and is further recoded into BTH12M which, when cross-tabulated with AGEGRP, gives age-specific fertility rates. Calculation of total fertility rate (TFR) is then possible, as is shown in the next section. RISK is used to compare high and low-risk groups of women by the birth attendant and where the last-born child was delivered. A slight variation can be used to look at differences between groups of currently-pregnant women. SCORE is used as an aggregate indicator of FP knowledge, which can then be crosstabulated with possible explanatory variables, e.g., age, education, current or ever use of contraceptives. The prerequisite is to code the underlying variables in an ordinal manner.

30

Data Management Thus, in the most recent surveys, spontaneous mentioning of a method was coded 2, probed knowledge 1, and no knowledge, zero. SCORE is a simple summation over the codes of each method in the questionnaire. If there are nine separate methods on the list, SCORE would have a range of zero (no knowledge whatsoever) to 18 (all nine methods mentioned spontaneously). The range is sufficiently wide for significant differences to be investigated in sub-populations. WHNDEL is a simple re-categorisation of the age of the last-born child into three classes: those born within 12 months of the interview, those who were born between one and five years previously, and those who were born over five years from the date of interview. This variable has been used as a short-hand way of investigating any patterns of change in delivery procedures - for example, if there is a trend from medically unassisted to assisted (TBA or health professional deliveries). The interpretation should be cautious since there is some age bias of the mothers in these samples - older women tending to have longer birth intervals. The bias can be checked by looking at the mean ages of the mothers in each category11.

4.3

Data Analysis

A huge number of inter-relationships between the variables measured can be calculated, and statistical packages make available all manner of analytical techniques and test statistics. For baseline or follow-up analysis, however, it is best to keep it simple, unless there are specific hypotheses to be tested which require use of multivariate statistics. Module 4 gives detailed practical examples of how to obtain typical tables and figures from the data beyond the fertility calculation shown below. In the analysis of baseline surveys, four main types of operation are usually carried out: Basic frequencies Basic cross-tabulations Investigations of sub-populations Further calculations and adjustments

(Basic frequencies, in addition to being part of the data screening process, are used to describe the characteristics of the sampled women, and are often sufficient to generate important information on the main indicators sought. For example, the overall contraceptive prevalence rate (CPR) drops out of a frequency table of current users ("Yes" or "No"). The mix of contraceptive methods can be read straight from a frequency table of the method used. More thought is required in defining which variable to cross-tabulate with which other. Here, the interest is more on inter-relationships and explanation than description.

11

For example, in the Trans-Nzoia Baseline, the mean ages of mothers in the three WHNDEL categories were 25 years, for those giving birth within 12 months of the survey and 29 and 37 years, respectively, for those having their last-born children in the 12-59 month and 60 month and over categories.

31

Data Management Basic cross-tabulations involve two of the variables produced, without defining any particular sub-groups to include or exclude. One important cross-tab referred to above is the one used to estimate age-specific- fertility rates (ASFRs), from which total fertility rate (TFR), a major indicator, is calculated. Figure 1 shows the output of this tabulation for the Trans-Nzoia Baseline. Figure 1 Example of SPSS cross-tabulation AGE GROUP * BIRTH IN LAST 12 MONTHS? Crosstabulation
BIRTH IN LAST 12 MONTHS? YES NO 37 155 19,3% 80,7% 4,2% 87 40,3% 9,8% 52 34,0% 5,8% 38 29,0% 4,3% 13 13,4% 1,5% 4 6,3% 0,4% 2 5,1% 0,2% 658 73,8% 73,8% 17,4% 129 59,7% 14,5% 101 66,0% 11,3% 93 71,0% 10,4% 84 86,6% 9,4% 59 93,7% 6,6% 37 94,9% 4,2% 891 100% 100%

TOTAL 192 100% 21,5& 216 100% 24,2% 153 100% 17,2% 131 100% 14,7% 97 100% 10,9% 63 100% 7,1% 39 100% 4,4%

AGE GROUP

15-19

20-24

25-29

30-34

35-39

40-44

45-49

Total

Count % within AGE GROUP % of Total

Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total Count % within AGE GROUP % of Total 233 26,2% 26,2%

The proportions in the rightmost column give the proportions of women in each age group. Thus, in the Trans-Nzoia Baseline, 192 of the respondents were teenagers, representing 21.5% of the total sample of 891 women. The need for adjustment of certain indicators can be seen by examining the overall proportions of women in the different age groups. In 32

Data Management the example shown, there are lower proportions of teenagers than expected, so adjustment factors need to be calculated. How to do this is described below. The first column, consisting of those who had given birth in the 12 months prior to survey, shows the age-specific fertility rates. From the last row, it can be seen that 26.2% of sampled women gave birth in the year prior to the survey. By multiplying each of these proportions by five (to account for the five years women remain in each age-group) and summing, an estimate of the TFR will be obtained. This is a figure which represents the average number of children a woman will have given birth to by the end of her child-bearing years, if the pattern of births observed from the survey data is continued unchanged. More accurate estimates of TFR can be obtained by extending the "window" to measure recent births within two years, or more, of the survey date, and adjusting the calculations accordingly. Collection of full birth histories is timeconsuming, however, and would slow down the fieldwork significantly. Calculation and adjustment of TFR is shown below. Further refinement of cross-tabs are made when sub-populations of the data are investigated. Ever-married women is an example of a sub-population of all women, which is commonly used as a basis for investigations. Significance testing can be applied validly in cases where some underlying hypothesis exists. For example, comparison of the proportions of Catholics and Non-Catholics who use modern methods might be made, using a simple 2 test on the frequencies in the cells. A difference-of-means test might be used to show variations in duration of use of various methods or in the average age of the women using them. Various types of CPRs may be calculated, for example, for all women, ever-married women, using all methods or modern methods only. Each calculation will gave insight into the situation of the survey area and facilitate comparisons with other figures, e.g., from the DHS. Comparisons of the mean age of women using different types of methods, using a difference-of-means test to establish significance, is another possibility. Further calculations and refinements form the final stage of analysis. Depending on the needs of the survey, and the ability of the analysts, this may be or may not be a significant amount of work. One adjustment which often needs to be made is to re-calculate the TFR based on the difference in the numbers of women in the sampled age-groups from what would be expected. As described above, teenagers are usually poorly-represented in the sample, mainly because of absence at school during the home visit. The teenagers who are found at home are a biased sample: a higher than average proportion are married and/or have started child-bearing, so the ASFR for this group is over-estimated, and, probably, the overall CPR. Adjustment is usually made by calculating, from the most recent national

33

Data Management census, for the district in question, the ratio of females 15-19 years to those 20-24 years. If this ratio is then applied to the actual numbers of women aged 20-24 interviewed, then the expected number of teenage women in the sample can be estimated. If it is assumed that this "missing" proportion mainly represent girls at school who have never given birth, then the ASFR for teenagers can be adjusted by using the expected numbers rather than the actual numbers, as the denominator in the calculation. Let us use the data in Figure 1 to show an example of adjusted and unadjusted TFRs. Table 3 shows the calculation of the TFR from the unadjusted ASFRs in Figure 1. Table 3 Calculation of TFR Age Group 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Fertility Rate ASFR .193 .403 .340 .290 .134 .063 .051 x5 x5 x5 x5 x5 x5 x5 x5 = Result 0.965 2.015 1.700 1.450 0.670 0.315 0.255 7.37

Adjustment to the ASFR of females aged 15 to 19 uses the 1989 Kenya Census data for Trans-Nzoia district to calculate the expected numbers of teenage girls for a given number of women in the next (20-24) age cohort. From the Census, there were 21,837 females in Trans-Nzoia aged 15-19, and 17,195 aged 20-24. The ratio of younger to older females is therefore 1.27 to 1. From Figure 1, we see that 216 women aged 20 -24 were interviewed. The expected number of females aged 15-19 is therefore 274 (1.27 x 216). Since only 192 were actually interviewed, it is clear that adjustment is necessary. If, then, none of the "missing" teenagers had given birth in the year prior to survey, the ASFR for this group would be 0.135 (37 births divided by 274). The contribution of this ASFR to the TFR would be 0.135 x 5 = 0.675, instead of the unadjusted total of 0.965 shown in Table 3, and the TFR would be adjusted down to 7.08 from 7.37. The assumption underlying the adjustment, that none of the "missing" teenagers had given birth, may not be tenable - local knowledge will have to be deployed to decide on the best means. However, since fertility is so markedly different between the 15-19 and 20-24 age groups in nearly all African countries, adjustment to fertility estimates for biases in age is nearly always necessary. Again, there are other alternatives to using Census data to calculate the expected denominator, and the numbers in other cohorts can also be used in the weighting process.

34

Data Management Similar adjustments may have to be made to other indices, notably CPR for all women, and this is one advantage of working with sub-populations which exclude the biased group, for example, married women or women in older age-groups. Calculations of other indicators beyond the scope of the statistical package used may also be required. Most recent baseline surveys have calculated child survival probabilities using the so-called Brass-Trussell estimates, which requires average parity levels and proportions of surviving children by age group, and then applies a set of formulae to calculate the survival probabilities. Another example is calculation of the level of unmet need for contraception in the sample, where combination of the variables measuring demand for pregnancy, contraceptive use, biological status, and reasons given for non-use can be combined manually to give a proportion of non-pregnant, fecund women who are not protected from pregnancy, but who wish to delay their next birth. More advanced analysis of the data using multivariate techniques is also possible - for example, current use may be explained by a number of social and biological variables whose interactions and combined influence might be explored by use of logistic regression. If the main purpose is description, rather than explanation, it is probably not necessary to apply advanced techniques to produce a basic document, although it is good to be aware of the possibilities for more advanced analysis, and to make full use of the data collected. The reports generated from the last few baseline surveys carried out by the Project have a fairly standard format, consisting of six chapters, plus an appendix reproducing the questionnaire. These are: 1. 2. 3. 4. 5. 6. Introduction Sample Characteristics Fertility, Child Survival and Maternal Health Family Planning Prospects for Community-Based Distribution Conclusions and Recommendations

Chapters 2 to 5 correspond largely to the modules of the questionnaire and can be changed depending on the presence or absence of other modules, or on the emphasis given to particular aspects. Report length is usually 30 to 40 pages, including illustrations.

35

Costs

5.
5.1

Costs
Introduction

The final section of this handbook concerns the costs of carrying out a rapid assessment exercise like the one described above. Often, the anticipated costs of research are a deterrent, but, equally often, they may be more of a psychological barrier for the project leader inexperienced in field research. Apart from the obvious advantage of producing the needed information quickly, rapid assessment is usually a relatively cheap way of carrying out information, and costs are unlikely to be the main reason for not carrying out rapid evaluation. In this section, 1997 costs in Kenya are used to set out the expenses incurred in preparing, fielding, analysing and producing a report on a baseline study of reproductive health. Certain conventions and caveats need to be made clear at the outset. The type of research described in this handbook is most likely to apply to a donor-financed project working with a government or NGO counterpart. As such, certain overhead costs of running the project are not included. Major of these, is the cost of in-house expertise and time allocated to the entire exercise. Similarly, costs of counterpart time and indirect costs borne by the counterpart (e.g., vehicle depreciation costs) are excluded. All direct costs are included.

5.2

Example of Costs

Costs can be considered in three parts, preparation, fieldwork and analysis and completion of report, of which fieldwork bears by far the highest proportion of total costs. In the example given below, the following realistic assumptions are made: a) b) c) d) e) The distance between the project base and the field site is taken to be 400 km. A multi-cluster sample totalling 800 is to be collected, with simultaneous data collection for part of the time. Three members of the project staff and three counterpart staff are involved in training and field supervision for the whole field period. Two vehicles, one project and one counterpart, are used in the field. Project uses in-house computer hardware and software.

36

Costs Example of survey costs ($US at 1997 prices and exchange rates)
1. Preparation Sub-totals Questionnaires 1000 x 6 pages a 0.02 Other stationery and materials 2. Field Expenses Travel, project base to survey site and back 800 km a 0.33 Transport within field area (a) Project vehicle 300 km a' 0.33 (b) Fuel, counterpart vehicle 300 km a' 0.11 Travel allowances, field team 3 pax x 6 days a' 50.00 Field workers (a) Interviewer selection and training expenses (b) Interviewers 40 person-days a 50.00 Counterpart allowances and expenses Miscellaneous field costs 3. Data processing and reporting 30.00 50.00 200.00 280.00 2162.00 Data coding and entry 6 days a 5.00 Computer consumables Copy-printing and binding of report 40 copies x 40 pages a 0.125 4. Total 264.00 100.00 33.00 900.00 50.00 180.00 100.00 100.00 1727.00 120.00 35.00 155.00 Sub totals

Using in-house expertise during fieldwork and analysis, and with counterpart contributions costed as per the table entries, a typical baseline survey costs just over US $2,000. Having the project team in the field is the single major expense, accounting for about 40% of the total costs. Thus, the sooner the fieldwork is completed, the lower the overall costs. In the Trans-Nzoia and Uasin Gishu baseline surveys, both having three sample clusters, the GTZ and counterpart teams supervised together on the first two clusters. Thereafter, the GTZ team returned to Nairobi while the counterpart team alone completed the third clusters without any technical support from the Project. The transfer of fieldwork skills to the partner organisation should be one of the objectives of a project, with potential benefits beyond cost savings. Using a consultant as a principal investigator will cause the costs to rise greatly, depending on the local rates of suitably-qualified consultants. A consultant, responsible for fieldwork, data analysis and report-writing would need a minimum of 20 working days. It is noticeable that the interviewer expenses account for less than 5% of the total costs, even although they are a vital link in ensuring the quantitative and qualitative targets of the exercise are met. This demonstrates the value, in terms of cost-savings, of hiring local interviewers.

37

Limitations

6.

Limitations

In the previous sections, we have tried to show how a baseline or follow-up survey can measure a number of reproductive health indicators in a rural community, covering a reasonably large sample quickly and accurately. To achieve this, several advance preparations will have to have been made, and some favourable pre-conditions met. All sample surveys are subject to sampling error and other possible biases, but there are some additional limitations when the evaluation is a rapid one, and it is worthwhile to review these. The major short-cut used to achieve speed rests with the sampling strategy. There is a possible bias from the cluster method used and from the selection or non-selection for interview of individual women. Selection of truly representative parts of the district, and, on the smaller scale, sampling typical population clusters, are essential when a sampling frame has not been used. This is one reason to involve those with good knowledge of the geography of the area, and for the outside team to familiarise themselves quickly with the characteristics of the district or area. One obvious bias which occurs from the sampling strategy used, and which has been referred to several times, is the common under-representation of teenagers in the sample. Coping with this requires some assumptions to be made and makes the estimates made less robust. The requirement for speed also reduces the detail which can be drawn from individuals. This particularly applies to teasing out knowledge and attitudes: details of knowledge of FP methods and the experience women have had with them are squeezed into rather terse categories, with limited opportunity for probing the responses or the underlying reasons for a particular attitude. The shortness of the interviews tend to make it difficult to build up sufficient rapport with some respondents for them to release some intimate information, even when a private location for the interview has been found. For example, the proportion of women stating they are currently pregnant is almost always an under-estimate. This can usually be seen when the reported pregnancies are divided by trimester, when the proportion of thirdtrimester women is nearly always far in excess of those in their first trimester. While a certain proportion of women will genuinely not know they are pregnant until after the first trimester, this type of result suggests concealment of early stages of pregnancy from the interviewer. Infant deaths also tend to be under-reported, a fact which can usually be suggested by looking at the distribution of reported ages at death of the child. Calculation of infant mortality rates from the sample data will usually show a rate that is much lower than expected.

38

Limitations Examples of consistency checking have been given above, but it is sometimes hard, in a 15-minute interview, to unearth genuine facts. No matter how persuasive an interviewer, young unmarried women will tend to cite abstention from sex as a reason for non-use of a family planning method in far higher numbers than the proportions of abstaining teenagers reported by most contemporary research on the topic. A large proportion of women cite breastfeeding as a reason for non-use of a method, the implication being that they are protected from pregnancy by post-partum amenorrhoea. However, if the cross-tabulation of the age of the child, suggested in Table 1, is run for those citing this reason, it will usually be found that over 50% of breastfeeding mothers have children over six months old, (53% in the Trans-Nzoia Baseline described above), and whose natural immunity to pregnancy is doubtful. An additional question on the return of menses would define this more clearly, but elicitation of a truthful response is still hard to guarantee! Interviewers, with only one day of training, tend not to have the skills to tease out responses which would be nearer the truth in these matters. In fairness, it is difficult to ensure truthful responses to some of these questions in any community survey. It is important to be aware of likely biases, such as the above, and to state the limitations during the report. It is a great advantage for the author(s) of the final report to have been involved directly in the fieldwork, for the knowledge and impressions gained during the course of accompanying and supervising the interviewers will give a strong impression on whether or not the survey is really working and what the limitations are. The true importance of the limitations described above can only be assessed by carrying out a more conventional sample survey in the same district, sampling through use of a conventional frame and targeting specific households. The estimations of the key indicators could then be compared to check for significant differences. There have been limited opportunities for checking limitations of the rapid assessment approach, since the KDHS surveys, utilising more formal sampling techniques, have not coincided spatially or temporally with most of the GTZ/MoH surveys, or have had district level samples which are too small for proper comparisons to be made. On the rare occasions in which comparisons have been possible, the major indicators have shown very good correspondence.

39

Appendix 1- Example of Sample Size Calculation

Appendix 1 - Example of Sample Size Calculation

Calculation of Acceptable Range for Estimates of CPR in Trans-Nzoia Data Set

The binomial formula for calculation of sample size is: n = {z SUP 2p(1-p)} OVER d SUP 2 (1)

Rearranging, the formula for d, the range of the variable to be estimated, corresponding to a given sample size, expected value of the variable p, and standard normal deviate, z, gives us: d = SQRT { {z SUP 2p(1-p) } OVER n } (2)

The overall sample size targeted in Trans-Nzoia was 750 women, a minimum of 250 in each of the three clusters. The expected CPR (p) was 25%, OR P=0.25. Corresponding to the 95% confidence level, the standard normal deviate, z, is 1.96. Substituting these values in equation 2 gives: d= SQRT { {(1.96)SUP 2 (0.25(1-0.25)) } OVER 750 } Thus, d=0.31, and, from a sample of 750, if the estimated CPR is 25%, there is a 95% probability that the actual CPR will lie between 21.9% and 28.1% (estimated CPR 3.1%). When the sample size is reduced to 250, the value of d increases to 5.37 - i.e., the true rate may be further away from the estimated one. If there is a strong reason to have a specific range that the estimate must fall within, then the sample size must be calculated from equation 1. For example, a range of 2% keeping the CPR and confidence interval the same, would necessitate a sample size of n=1801. Survey managers should experiment with the values in these equations to obtain optimal and realistic targets for sample size or accuracy of estimates.

40

Appendix 2 Aptitude Test

Appendix 2 - Aptitude Test

The following six questions have been used as a screening device for selecting interviewers in nearly all the surveys carried out by the GTZ/MoH Project. The test is administered to all prospective interviewers on entry. Its main purpose is to screen out people whose level of understanding of written English is weak, or whose attention to detail is poor. Even the way in which the personal details are completed at the head of the form gives a clue as to the suitability of candidates. While those who score poorly are unlikely to be able to manage the work, some of the high-scoring candidates may also be unsuitable. It is important to conduct a short interview with each candidate to assess whether she is suitable, in other respects, for the job of interviewer.

41

Appendix 2 Aptitude Test APTITUDE TEST NAME ................................................................ DATE OF BIRTH .............................................. EDUCATION: School......................................... Grade attained ................................................... MARRIED / SINGLE .......................................... 1. a Draw a circle round every 8 in the list below: 2158580865174 1. b 2. 4638303185632 7192469268471 Form ................................ Year left school................. NO. OF CHILDREN.......... DATE ...............................

How many sixes are there in the list? ..................... Cross all the even digits below directly followed by an odd digit: 271003824085207836523

3.

The following sentence is written backwards, but one word has a mistake. Draw a circle round the word with the mistake: Ekatsim eno thiw sdrawkcab nettirw si ecnetnes siht

4.

A woman tells you she has given birth four times, but has five surviving children of her own. Can she be telling the truth? If so, how can this be? .................................................................................................................................

5.

A man has three children by his first wife. Two of these are boys, of whom one died. By his second wife he has four children. One of these is a girl, and all are alive. He has no other children. How many living sons does he have? .............. sons

6.

A man said yesterday: "My wife had a baby girl two days ago". Tomorrow is October 2nd. On what date did the wife deliver the baby? Date:........................................

42

Appendix 2 Aptitude Test Answers to aptitude test: Q1 a Q1b Q2 Q3 Q4 Q5 Q6 There are six eights to be circled There are five sixes Seven even digits should be crossed. (A zero is an even digit) thiw This could be true if the woman has had a multiple birth, e.g., twins Four sons 28th September

43

Appendix 3 Fieldwork Checklist

Appendix 3 - Fieldwork Checklist

a) The Questionnaire Do you need to ask all the questions drafted? Are the questions worded to give the exact information required? Do you need to include additional modules / questions? Does the questionnaire need to be formally translated to, and back from, another language? Do you need to field-test the questionnaire? Have you produced enough questionnaires to cover the target sample size, interviewer training, wastage, etc.?

b) Sampling Have you a clear idea of where you want to field your survey? If not, have you discussed requirements with your associates in the district? Have you checked the proposed area(s) at first hand? Have you chosen the sample sites carefully? Is it possible to obtain good base-maps of the proposed sample sites? Have you calculated the sample size(s) to be targeted? Are these feasible given your financial and technical situation?

c)

Prior to fieldwork Have you identified and mobilised your key counterparts? Have you decided upon the best timing of the fieldwork? Has advance notice of the survey been passed to local leaders in the targeted sites? Have applications for interviewers positions been sought? Has existing background information on the area been assembled? Have you arranged deployment of your own and counterpart staff during the fieldwork? Have you secured a suitable place for training interviewers and other fieldwork preparation? Have you assembled all the required fieldwork materials: questionnaires, clipboards, storage cartons, pens, pencils, notebooks, pencil sharpeners, erasers, training aids? Are you going to computerise data in the field? If so, have you arranged all the essential computer hardware, software and consumables? Have you calculated all projected costs? Have you brought enough cash to cover field expenses? and have you a safe place to store it?

44

Appendix 3 Fieldwork Checklist d) Interviewer selection and training Has the appropriate information detailing who and what is required been passed? Have you decided on how many interviewers to employ, and where? Have you prepared the aptitude test, and brought enough copies to the field? Have you arranged a time and place to interview the candidates? Have you explained clearly the working conditions to the successful candidates? Have you introduced your team, and made the purpose of the survey clear? Have you agreed with the interviewers on the rendering of key terms and phrases of the questionnaire in the local vernacular language? Have you observed every interviewer during role-play, and given each remedial feedback? Have the interviewers completed sufficient trial interviews for them to begin fieldwork? Have you paired the interviewers in a balanced way for the first day of fieldwork? Have you given clear instructions for meeting interviewers at a given time and place to commence fieldwork?

e)

In the field Have you made a courtesy call to the local chief or other local leaders? Have you packed sufficient blank questionnaires for the day's work? Have you fuelled the vehicles? Have you carried enough drinking water in each vehicle? Have you given each interviewer team a clearly-designated area for the day's work and a time and place for them to be picked up by the vehicle at the end of the day? Are the interviewers being adequately supervised in the field? Are the interviewers targeting all potential women for interview? Are the interviewing procedures being followed correctly? Are completed questionnaires being adequately checked, in the field, by supervisors? Have all questionnaires been checked? Have you held a de-briefing on the day's work with the supervisors and noted issues to be taken up before the next day's work? Have errors been discussed with the individual interviewers, and, where possible, rectified prior to embarking on the next day's fieldwork? Have you given encouraging remarks to the interviewers before commencement of the day's fieldwork? Have you noted positive and negative aspects of the individual interviewers, together with contact addresses, in case of future need?

45

1. Module 1 Overview of Survey Implementation

Index to Section 1
A alphanumeric codes aptitude test 27 iv, 20, 21, 43, 45 L lead-in sentence log-frame M marital status N numeric codes P physical design planning document pre-test R religion 7, 15, 23, 25, 26, 35 11 3

C cluster sampling 16 coding 12, 27, 37, 11, 18 community-based distribution 2, 7 confidentiality 6, 13, 22 contraceptive prevalence rate 12, 16, 31, 5, 39 cross-tabulations 14, 28, 29, 31, 32, 15, 38 D data cleaning data entry Demographic and Health Surveys E Epi-lnfo ethnic group ethnic groups F field supervisors frequency tables G geographical identification H household

27

23 23, 27 2, 8, 21

5 3, 4 14, 15

7, 14, 15

27, 38 7, 8, 62 8, 19, 62, 80

25 27, 28

S sample sites 11, 15, 44 sample size iv, 16, 20, 40, 44, 14 sequence 5, 6, 11, 7 shyness 21, 25 software 36, 44, 22, 23 SPSS 27, 32, 14, 15, 18, 19, 22, 23, 24, 28, 32, 33, 34, 38, 41, 44 sublocation 6 T total fertility rate

6 30, 32, 5, 39

6, 13, 14, 15, 16, 17, 19, 24, 25, 8, 62

V vernacular language

5, 12, 14, 22, 45, 12

46

Section 2
Baseline Surveys Working Examples from Kenya

Table of Contents Section 2

Table of Contents Section 2

What to find in Section 2 1. 2. 3. Module 1 - Overview of Survey Implementation Module 2 - Amalgamating and Standardising the Data Set Module 3: Navigating the Data Set - Practical Examples 3.1 Examples from Single Surveys using SPSS 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 3.2 Example 1: Frequency Distribution Example 2: Cross-Tabulation Example 3: Graph Example 4: Data Transformation Example 5: Importing and Using SPSS Output in Other Applications 4 5 14 22 23 23 25 27 28 32 34 35 36 36 37 38

Examples from Single Surveys using Epi Info 3.2.1 3.2.2 3.2.3 3.2.4 Example 1: Frequency Distribution Example 2: Cross-Tabulation Example 3: Graph Example 4: Data Transformation

3.3

Examples of Meta Analysis of the Data Set 3.3.1 Example 1: Fertility Transition: Trends in Total Fertility and Contraceptive Prevalence Rates among Ever-Married Women Example 2: Effects of Education on Contraceptive Prevalence Rates among Ever-Married Women Example 3: The Role of Female Education in the Choice of Birth Attendant Example 4: Differentials in Contraceptive Method Mix between Eastern and Western Kenya Example 5: Paired comparisons of two survey results

38 40 41 42 44

3.3.2 3.3.3 3.3.4 3.3.5

Table of Contents Section 2 4. Module 4: Forms and Tables 4.1 4.2 Trans Nzoia Fertility Survey Table 1: Template for Fertility, Mortality and MCH/FP Variables in GTZ Family Planning Project Baseline Surveys, 1989 1997 Table 2: List of Variables in GTZ Family Planning Baseline Survey Data Set Table 3: List of Variables by GZT Family Planning Project Baseline Surveys (1989 - 1997) 46 47

52 54 58 63 63 64 66 66 67 68 69 70 71 72 73 74 75 76 77 77 78 78 79 80 81

4.3 4.4 5.

Module 5: Baseline Summaries 5.1 5.2 5.3 Introduction Baseline Surveys Factsheet (summarising Module 5 data) Fact Sheets Fertility and Baseline 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.6 5.3.7 5.3.8 5.3.9 5.3.10 5.3.11 5.4 Fact Sheet Kinango Contraceptive Prevalence Survey March 1989 Fact Sheet Etono Fertility Survey August 1990 Fact Sheet Lake Kenyatta Fertility Survey March 1990 Fact Sheet Bukwala Baseline Survey April 1990 Fact Sheet Lwanda Baseline survey May 1990 Fact Sheet Nyamira Baseline Survey September 1990 Fact Sheet Bungoma Baseline Survey December 1994 Fact Sheet Siaya Baseline Survey April 1995 Fact Sheet Makueni Baseline Survey April 1996 Fact Sheet Meru Baseline Survey May 1997 Fact Sheet Uasin Gishu Baseline Survey December 1997

Trans Nzoia Baseline Survey - Summary Report July 1996 5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.4.6 Fact Sheet Background Fertility Family Planning Knowledge and Use of Contraception Maternal and Child Health Conclusions

Table of Contents Section 2 5.5 Nyamira Follow-Up Survey - Summary Report June 1996 5.5.1 5.5.2 5.5.3 5.5.4 5.5.5 5.5.6 Fact Sheet Background Fertility Family Planning Maternal and Child Health Conclusions 82 82 83 83 84 85 86

What to find in Section 2

What to find in Section 2

Module 1 (pp. 6) can be read as an introduction to much of this section, for it gives you a chronology and brief explanatory background to the Kenyan survey work as a whole. It sketches out how field surveys evolved in practice, from the Kinango Survey early in 1989, where questionnaires were not yet being field-tested, through to the more sophisticated and standardised techniques employed in Rift Valley Province in 1997. Module 2 (pp. 13) sets out the procedures that were followed to collate the data sets from the Kenyan surveys. Once compiled, the baseline survey data files have to be amalgamated and standardised to make them accessible and informative for other users. The module can serve as a useful model for project staff wishing to perform this task. Please note: Module 2 has to read in conjunction with the three tables presented in Module 4 to which it refers. Module 3 (pp. 20) is intended to guide the reader through a series of working examples of data analysis using the baseline surveys. This data navigation module is divided into two parts: the first part deals with single surveys, and takes the reader through the windows and commands required to produce the most common types of analysis: the second part uses the merged data files to explore some of the possible applications for generating interrelationships between the results of several surveys. Module 4 (pp. 41) is a forms and tables annex containing a sample questionnaire and three comprehensive tables. They are referred to in other parts of this manual: the questionnaire (used for the Trans-Nzoia survey) should be referred to whilst reading the rapid assessment guide in Section 1; tables 1 to 3 are referred to extensively in Module 2 in connection with amalgamation and standardisation techniques. Module 5 (pp. 58) contains factsheets of all summary reports of all the 1 3 Kenyan surveys introduced in Module 1 and examples of a full summary report of a baseline and a follow up survey. They present the substantive findings in a concise format, setting out the results as a set of "executive summaries". This module is introduced by a brief explanation of the uniform format for summarising the findings, followed by a comprehensive two-page table collating all the data, i.e. the baseline surveys factsheet to facilitate comparison and cross-district analysis. On the floppy disk you will find the full text version of all the remaining summaries in RFT format for perusal on screen or printing.

Module 1: Overview of Survey Implementation

1.

Module 1 - Overview of Survey Implementation

Twelve of the thirteen surveys comprising this series had the objective of measuring baseline conditions in aspects of reproductive health of interest to the Project. The thirteenth was a follow-up study aimed at measuring the impact of the Project implementation five years on. For simplicity, however, we will refer to all as "Baseline Surveys". Table 1 shows the location of the surveys carried out, the dates of the fieldwork, sample sizes, and two of the key indicators used by the GTZ Project, the total fertility rate (TFR), adjusted, where necessary, for age structure, and the contraceptive prevalence rate (CPR) for ever-married women. Table 1 Summary of Baseline Surveys SURVEY Kinango Etono Lake Kenyatta Bukwala Lwanda Gwassi Nyamira Bungoma Siaya DISTRICT Kwale Nyamira Lamu Kakamega S. Nyanza Nyamira Bungoma Siaya DATES OF FIELDWORK Feb/March 1989 July 1989 November 1989 April 1990 May 1990 August 1990 November 1994 February 1995 November 1995, April 1996 March 1996 April 1996 August 1996 September 1997 SAMPLE SIZE 581 635 518 574 530 947 678 904 620 707 891 718 798 TFR 10.8 5.7 6.3 6.7 8.7 6.5 5.9 6.6 4.8 5.0 7.1 3.7 6.9 CPR (%) 3.9 30.4 35.6 17.3 5.3 38.3 25.4 17.6 54.0 46.8 28.3 80.7 22.4

Nyamira (follow-up) Nyamira Makueni Trans-Nzoia Meru Uasin Gishu Makueni Trans-Nzoia Meru Uasin Gishu

There is an obvious chronological division amongst the surveys between those up to 1990 and those from 1994 on. The four year gap reflects the initial implementation phase of the Project's CBD programme which developed in Kakamega, Nyamira and South Nyanza districts at this time. The latter surveys were also much more standardised in terms of sampling strategy (all multi-clustered, seeking representative samples of whole districts) and in terms of the questions included in the questionnaire, and the wording used.

Module 1: Overview of Survey Implementation The group of surveys up to 1990, with the exception of the first Nyamira survey, were smaller-scale, carried out in the catchment areas of individual health facilities, and with differing types of intended end-use. The Nyamira survey of August 1990 marks the watershed between the two groups. Intended as a means of obtaining data representative of an entire district, six months before the commencement of CBD activities, it was fielded in three widely-separated clusters with a total sample of 947 women. The questionnaire used, however, was identical to the one used in the two previous surveys carried out in 1990 in Bukwala and Lwanda Gwassi; several changes were made for the next survey in Bungoma in 1994, mainly reflecting the wordings of questions used in the 1993 Kenya Demographic and Health Survey. Bearing this general classification in mind, the individual surveys are now briefly described in their chronological order. The earlier surveys are given slightly more attention to show how the questionnaire and fieldwork practices developed with continuing replication of the rapid assessment technique. The exact nature of differences in the questions used in each survey, and how these differences were accommodated when producing a single data file containing all 13 surveys, are set out later. The lists of variables used, and their definition, appear as forms in Module 4. The Kinango Survey explicitly concentrated on measuring contraceptive prevalence and fertility rates in the community. Sited in a semi-arid area of Coast Province with low population densities and poor communications, it was not the easiest place for an experimental survey. The GTZ team drafted the questionnaire and some modifications were made in collaboration with the sub-DHMT who also located 10 interviewers, a mixture of nurses and school-leavers. Constraints of time and cost dictated that this would be a rapid monitoring exercise, and no field-testing of the questionnaire was done, everyone agreeing that the questions were straightforward, and that there should be few problems with the fieldwork. A set of 20 population clusters was defined, using 1:50,000 maps, and the experience of the hospital's public health officer, and a target of 25 interviews with women aged 15-49 per cluster set. Interviewer training and "dry runs" - interviewing clients at the hospital's MCH/FP unit were completed in one day and, on the last day of February 1989, the team took to the field. After four days, a total of 581 usable questionnaires had been collected, despite the difficult working conditions. The GTZ team, well pleased with the outcome, slaughtered a goat, held a party for the field team, and returned to Nairobi with the data. Six weeks later, the findings were disseminated to the Kinango sub-DHMT at a one-day seminar in a Coast hotel: the pre-fertility transition character of Kinango was heavily emphasised. With fertility rates of almost eleven and a single-figure contraceptive prevalence, the Kinango team were facing a major uphill task in spreading the gospel of family planning. No written report, other than a two-page data summary passed round at the dissemination meeting, was ever produced from the Kinango baseline. The experience of being able to design and field a community-based survey involving a relatively large number of respondents in a difficult environment and of producing and

Module 1: Overview of Survey Implementation disseminating results, all within a two-month period, was, however, perceived afterwards to have been a valuable one. During the first half of 1989, the Project began activities in the three "new" districts of Kakamega, South Nyanza and Nyamira. One of these activities was the construction of a Family Planning room at a busy health centre, Etono, in Nyamira District. No baseline indicators of fertility, maternal and child health or contraceptive prevalence were available, and the survey was designed, as in the case of Kinango, to provide the district counterpart with information upon which an implementation strategy could be assessed. Etono was a very different area from Kinango, with an average population density of around 500 persons per km2 and occupying very hilly terrain, at around 1800 metres above sea-level. A few additional questions appeared in the Etono questionnaire. Mothers were asked for the month and year of birth of their last-born children, and, if the child had not survived, for the month and year of death. Pregnant women were asked about the stage of their pregnancy. Otherwise, the questions, and their sequence, did not change from the Kinango survey. Ten nurses from Nyamira Hospital were recruited by the DHMT and trained. Two were dropped after the first day, most of the others complained about the physical difficulty of the work, and a few were not very sympathetic interviewers. (This was the last survey in which nurses were used as interviewers). However, data collection was rapid, and 635 usable questionnaires were collected during four days of fieldwork. By August 1989, the data had been analysed, and a printed and bound report produced and multiple copies delivered to the DHMT in Nyamira. The conclusions were that contraceptive use was already common in Etono, and that the new facility would attract a larger number of users than had been imagined by the DHMT. CBD also seemed to be an acceptable concept, a conclusion which was subsequently verified. By this time, the GTZ FP Project had a new Team Leader, a gynaecologist with strong ideas about old-fashioned regulations pertaining to hormonal contraceptives, and a great deal of enthusiasm about community-based distribution. Within eighteen months, the Project had adopted CBD as the principal medium of achieving its higher-level objectives. While Western Kenya was the target area of the Project, the first opportunity to try out the intensive CBD model being proposed arrived from the other end of the country. The German-assisted settlement programme (GASP) had been working in the Lake Kenyatta area of Lamu District for several years. At its inception, a survey carried out by AMREF had indicated high fertility and low contraceptive prevalence, and several improvements had been implemented. The need for re-assessment of the fertility change, and, also having an interest in developing CBD, the GASP Project invited the FP Project to conduct a baseline survey in the settlement scheme.

Module 1: Overview of Survey Implementation Although a remote area, the main scheme at Lake Kenyatta was very conducive to survey organisation. Being a settlement scheme, plots were of a standard size, and were properly mapped and numbered, making systematic sampling possible for the only occasion in the series. On the other hand, educational levels were low, especially for females, and recruitment and training of interviewers took longer and was more difficult than usual. The entire team had to be mobilised on bicycles, as the distances between holdings were substantial. Twelve interviewers were deployed - the largest number working simultaneously of any of the series of surveys - and the quality of recording was sometimes below requirements. Although sampling had been done systematically, less than half of the sampled plots were found to be occupied, resulting in delays while a substitute household was located. A module on maternal mortality was introduced in the Lake Kenyatta questionnaire for the first time. The self-contained nature of the scheme made it relatively easy to trace and interview relatives of women suspected to have died as a result of pregnancy. The local public health nurse performed follow-ups after the fieldwork and established that all cited women were, indeed, likely to have died from a pregnancy-related cause. Several other changes were made to the Etono questionnaire. Marital status included the useful sub-category "married - husband away" and the "separated" category disappeared. Ethnic group of the respondent was recorded for the first time. Further questions were added on the birth attendant of the last-born child, with an explicit question on the reasons for choosing particular TBAs. Information on where the last-born child was delivered was another innovation in the questionnaire. Other minor changes were also made. Five days of fieldwork yielded 518 usable questionnaires, representing around 10% of women of fertile age at Lake Kenyatta. The results showed declining fertility and unexpectedly high contraceptive prevalence, with the CPR for married women at almost 40%, but a substantial unmet need for FP. While child survival was very good, maternal mortality was identified as a rather serious problem. The results were reported back to the GASP and counterpart teams at a seminar within two months of the fieldwork, and a full written report was delivered in March 1990. Plans for introducing a large-scale CBD programme into Western Kenya were well under way by this time, and the three surveys fielded during 1990 were explicitly planned to provide baseline indicators upon which to measure the impact of the upcoming programme. Collaboration was initiated with the Seventh-Day Adventist (SDA) Church, a pro-family planning NGO having a network of rural health facilities, particularly oriented to parts of Nyanza Province. The SDA church identified two small dispensaries, one in Western Province, the other in Nyanza, which they thought would be able to benefit from physical upgrading and, thus, be able to initiate and properly support CBD. The GTZ FP Project then carried out baseline surveys in the catchment areas of Bukwala (Kakamega) and Lwanda Gwassi (South Nyanza, now Suba) in rapid succession in April and May of 1990.

Module 1: Overview of Survey Implementation Both the Bukwala and the Lwanda Gwassi Baselines used the questionnaire developed for Lake Kenyatta in a practically unaltered form, with the maternal mortality module intact, but with no subsequent follow-up to verify the citations (Lake Kenyatta was the only survey in which this proved possible). In Bukwala, a high-quality set of ten local interviewers, working in fairly easy conditions, (high population densities, receptive respondents, flat terrain) produced 574 questionnaires in five days. With the next survey already planned, the Bukwala report was brief and to the point: Bukwala had low CPRs and a high degree of unmet need for family planning. CBD was thought to have a good chance of success, so long as the other reproductive health needs were also attended to. Possible problems of the narrow base of SDA adherents and the charging policies of the church were also noted. In May 1990, the survey team then repeated the fieldwork in Lwanda Gwassi, in a remote part of the then South Nyanza district. The community had half-built a dispensary under the church auspices, and the GTZ Project agreed to provide funds for its completion and to finance the CBD training. Once again, ten interviewers were selected and, working in pairs, covered 530 women in four days. The level of community support for the survey was remarkably good, presumably because of the anticipated support for completion of the dispensary. Lwanda and Kinango were the only surveys which identified truly pre-fertility transition conditions. In Lwanda, the calculated TFR of 8.7 was two above the national level. Half of the married women (two-thirds of the over-forties) were in polygynous unions, and over half had not completed primary school, and the CPR was only 5%. With isolation from any service delivery, there was clearly a fine opportunity for CBD to make an impact. Unfortunately, the completion of the dispensary was fraught with problems. It eventually opened in 1995, with CBDs trained and deployed during 1997, seven years after the survey! In August 1990, attention returned to Nyamira District, where the earlier Etono survey had been fielded. By now, the potential scale of the upcoming CBD programme was unfolding, and it was thought better to increase the scale of the baseline surveys so that one single survey would represent an entire district. Thus, the Nyamira baseline targeted three separate clusters. The catchment areas of the Government health centres were selected by the District Public Health Nurse, with the view of getting a balanced geographical sample, although the settlement schemes around Kijauri and Chepng'ombe were not represented. Three sets of interviewers - six for each cluster - were selected and trained in the usual way. This meant that the field time was long - almost two weeks continuously - but a total sample of 947 women was generated using exactly the same set of questions as in the two previous surveys.

Module 1: Overview of Survey Implementation The Nyamira baseline was a snapshot of a dramatic fertility transition in progress. Knowledge levels were high and CPRs for married women were in the upper thirties. Fertility was still high, suggesting very recent adoption of methods, and the injectable showed itself to be the dominant method, a pattern repeated in all subsequent surveys in western Kenya. Unfortunately, for the goal of attributing programme impact, two clusters already had active CBD agents from an NGO. By the end of 1990, therefore, baseline surveys had been completed in the three districts in which the new CBD programme was to be launched. Unfortunately, the two smaller surveys, based on the SDA church facilities, could not be used for later follow-up, as the proposed interventions either did not materialise or occurred a long time after. The main expansion period of the CBD intervention then ensued. By the end of 1991, 2222 CBDs had been trained and deployed and 3251 by the end of 1993. The technical aspects of the programme were then approved by the Ministry of Health, so that the "pilot" rubric could be removed and geographical expansion undertaken. The Project was then extended to cover two more districts in western Kenya - Bungoma and Siaya - both rather traditional areas where family planning had not made much impact. A baseline was carried out in Bungoma in November 1994, followed by Siaya in February 1995, prior to the training and deployment of CBD agents. The questionnaire for the Nyamira baseline was dusted off and revised. The main change was to bring the wording of the FP knowledge questions into line with the corresponding KDHS questions, and to train the interviewers accordingly to distinguish spontaneous and probed responses. Norplant and vasectomy were added to the list of methods on the knowledge questions. A question of ever-use of contraceptives was added and, with CBD now a growing force in service delivery, three questions were asked to assess knowledge of any pre-existing CBD activities in the sampled area. Two questions were dropped from the questionnaire, concerning whether the respondent would be afraid to visit a health facility to seek family planning, and, if so, why she would be afraid. Responses to these questions in the three previous surveys had not yielded much significant information. More data from the questionnaire were entered as separate variables. For example, months and years of child births and deaths had been dropped from the data sets once the calculations of age and age at death had been made. From the Bungoma survey, all of these were retained in the whole set. Details of maternal deaths were also entered as variables, having previously been used by hand to corroborate the citations. A new variable, classifying the time which had elapsed since the birth of the last child into three periods, was generated to examine any changes in the pattern of birth attendants over time. This proved useful for identifying the growing impact of the policy of training traditional birth attendants. The Bungoma baseline was fielded in two clusters - Kimaeti, a traditional area, and Tongaren, a settlement scheme of recent immigrants, more developed and dynamic than

10

Module 1: Overview of Survey Implementation Kimaeti. A group of interviews were trained for each cluster, and a map had to be constructed for the Tongaren sample as the 1:50,000 series had pre-settlement scheme information. Six days were spent in the field and 677 women were interviewed. Bungoma was found to have started fertility transition, but with Tongaren well ahead of Kimaeti in the fertility measures and social background. Traditional anti-FP attitudes were identified, but a large unmet need was calculated also. The Siaya baseline, fielded in February 1995, used an identical questionnaire. However, instead of direct coding into five-year cohorts, individual months and years of birth of the women interviewed were retained as individual variables, as there was some interest in using single years of birth as a variable in some tabulations. The Siaya DPHN picked out three areas all in the northern part of the district, as his plans were to train and deploy CBDs only in this northern area during the first year. One cluster, Yala, was clearly more developed than the other two, but, in all, not a great deal of impact had been made in reproductive health despite the notorious problems of HIV/AIDS, child mortality and maternal morbidity in Siaya. Again, three groups of interviewers were trained and deployed and a large total sample (904) produced after 11 days in the field. Results were rather similar to those of Bungoma: high fertility and traditional attitudes were still pervasive, but the beginnings of change were apparent, with a CPR of 18% for ever-married women, and much potential for a good CBD programme. At the end of 1995, it was timely to measure the impact of the CBD programme. Nyamira seemed ideal: around 1000 CBD agents had been trained and deployed since the 1990 baseline, and the fact that one of the three sampled clusters (Esani) had not developed a CBD initiative under the GTZ Project gave the follow-up a possible "control" aspect. Some fieldwork problems developed, however, which made the follow-up survey less than ideal, and illustrates well that, despite experience, mistakes can easily be made if control in the field is not well established. To save time, it was originally intended to use one set of interviewers throughout, but this proved difficult when the local leaders at Ekerenyo objected. Thus, three groups of interviewers had to be trained. The next problem arose when one set of interviewers strayed outside the Ekerenyo catchment, but this only came to light during data analysis and subsequent inquiries. The Ekerenyo cluster had then to be revisited some five months later, in April 1996, and a second sample interviewed. The Nyamira terrain and weather also complicated fieldwork, and the final sample of 620 was rather lower than desirable. Despite these field problems, the data showed that much progress had been made since 1990, and the role of CBD was clearly discernible. The TFR had dropped from 6.4 to 4.8, and CPRs for ever-married women exceeded 50%. It was more difficult, however, to make direct linkage between the CBD initiatives of the GTZ Project and the outcome measures.

11

Module 1: Overview of Survey Implementation Partly, this was because of the activities of CBD agents of other organisations, and partly, it must be suspected, of deficiencies in the data collection. The next survey to be undertaken, in April 1996, was in Makueni District of Eastern Province. Marking the expansion of the Project into a completely different part of Kenya, this survey was of particular interest, as the population densities, culture and history of FP uptake were in contrast to most areas of the west. Two clusters, representing relatively rich highland and poor semi-arid parts of Makueni were selected. Two groups of interviewers were trained, and the by-now standard questionnaire was used. Some interviewing was done at market centres, a departure from normal field practice, but more reflective of the settlement patterns of the area. A variable distinguishing market and village residence was used to reflect this feature. One week of fieldwork was enough to produce 707 completed questionnaires. As expected, the fertility transition in Makueni, despite its semi-arid nature, was welladvanced, with a TFR of 5 and almost half of ever-married women using a method of contraception. Later in 1996, another two-cluster baseline was fielded in Meru District, by far the most advanced, economically and socially, of the districts supported by the GTZ Project. This time, the DHMT selected two high-potential areas for survey, although it was apparent that these were not totally representative of the district as a whole. Two excellent groups of interviewers completed 718 questionnaires working simultaneously during four fieldwork days. Results from the Meru survey may be regarded as some sort of benchmark of what is possible to achieve in reproductive health in rural Kenya. All health indicators were extremely good, and fertility rate of 3.7 was estimated, with 80% of evermarried women being current users. The final two surveys in the series were carried out in two districts of Rift Valley Province where the Project had expanded at the request of the DHMTs in Trans Nzoia and Uasin Gishu. Both were three-cluster surveys using the standard questionnaire, although the Uasin Gishu survey added a few more questions to establish ideal family size and to specify more clearly the desire for future pregnancies. The Trans Nzoia survey, fielded in April 1996, was placed in a multi-cultural district and interviews were carried out mainly in Kiswahili, instead of the usual dominant vernacular language. The counterparts from the District, having been "apprenticed" to the survey team for the first two clusters, undertook to survey the Cherangani cluster independently, returning the data to Nairobi for analysis after reaching the targeted numbers. A total of 891 respondents were interviewed. In Uasin Gishu, a similar process took place in the baseline survey fielded in September 1997, as the District team surveyed the Moiben cluster without GTZ field assistance, after

12

Module 1: Overview of Survey Implementation participating in the fieldwork of the first two clusters, a total of 798 interviews being completed. Results from these two districts were remarkably similar, with an early stage in the fertility. transition being identified, a high level of unmet demand for FP services, and rather poor utilisation of professional assistance during deliveries. In 1998, the GTZ Family Planning Project entered its fifth phase and changed its name into MOH/GTZ Reproductive Health project, with a subsequent broadening of the scope. Geographical expansion was curtailed putting an emphasis on quality assurance of CBD services, sustainability, study of the feasibility to expand the pallet of services offered by CBD agents and implementation of a pilot "fee for service" scheme. Follow-up surveys are due in Bungoma and Siaya in April 1999, and the rapid assessment methodology will be followed. Each survey undertaken has been analysed independently of the others. Most have made comparisons of key indicators with earlier surveys, and, especially to KDHS tabulations, but the data sets have, up till now, been regarded as separate entities. In the next module, a technical description of how the data sets have been amalgamated is given, a code book is attached, and some examples of how the amalgamated data set can be used are shown.

13

Module 2: Amalgamating and Standardising the Data Set

2.

Module 2 - Amalgamating and Standardising the Data Set

The purpose of amalgamating the GTZ Family Planning Project baseline survey data files is to standardise and integrate the data so that it is available to other users, singly as baseline survey data files, or collectively as a set. Three tables, which are found in the "Forms and Tables" of Module 4, are referred to extensively during the description of how the survey data were amalgamated and standardised, and are essential to have at hand while reading through this module. They are also useful for reference during any practical work with the data. The task of amalgamating the data files was painstaking and time consuming. It involved assembling reports of all baseline surveys carried out by the Project, then reviewing the reports to identify common features regarding the demographic and socio-economic profiles of the sample populations and identifying measures of their fertility, mortality, maternal and child health and family planning experiences. While some parameters for estimating these measures were not in place in the earlier versions of the baseline questionnaire reviewed in Section 1 (e.g., crude survival rates), others had changed over time (e.g., knowledge of FP). However, most of the parameters in the baseline questionnaire remained the same and have withstood the test of time over the years, which makes the amalgamation of the measures of reproductive health between the GTZ FP baseline surveys possible. Table 1 in section 4.2 of Module 4, summarises these measures by baseline surveys. A shaded box denotes unavailability of the measure in the survey data file. This table was used primarily for guiding the process of standardising and integrating the data. Table 1 also shows each baseline survey's sample size and, more important, the dates when the Project carried out the baseline survey data collection. The latter information is necessary for the computation of age in single years (AGE) from which age groups (AGEGRP) are re-coded, and age of the last-born child (AGELB) from which the variables WHNDEL (when was the last delivery) and BTH12M (gave birth in the last 12 months) are receded. After reviewing the baseline reports and identifying the measures of reproductive health common to all the surveys, the next step was to obtain the data used for generating the measures and preparing the reports. With all the data files in place, new data files were created from the original ones using SPSS for Windows data analysis package. The original data files were left intact. Standardisation of the data followed. Standardisation involved modifying or redefining the variables in the data files by giving them identical names, labels, value numbers and value labels without which amalgamation would not be possible. For ease of identification, most variable names in the set attempt to describe the variables as closely as possible. For instance, while some variable names describe the variables verbatim (e.g., SURVEY,

14

Module 2: Amalgamating and Standardising the Data Set AGE, COWIFE, ETHNIC), others have shortened descriptive names (e.g., AGEGRP for age group, EDUC for level of education, RELIG for religion, CLUST for sample cluster). The set also has variables with abbreviated names (e.g., MOB for month of birth, YOB for year of birth, MS for marital status, CEB for children ever borne, SC for surviving children), and variables with a combination of a descriptive and an abbreviated names (e.g., AGELB for age of the last-born child, AGEDTH for age of the last-born child at death, and LBALIVE for the last-born alive). Standardisation also involved running basic frequencies and cross-tabulations to confirm that the distributions obtained from modified or redefined variables were consistent with the distributions presented in the original reports. Thus, substantial time was spent reading the baseline reports before and after modifying or redefining the variables. Having standardised the variables, integration simply involved merging the data files by adding cases from 13 GTZ FP baseline surveys. Three amalgamated files are available in SPSS format. The first is an amalgamation of data files from earlier surveys carried out before 1994 (Mergedl.sav), the second, an amalgamation of data files from later surveys carried out after 1994 (Merged2.sav) and the third, an amalgamation of Mergedl and Merged2 data files comprising the 13 GTZ baseline surveys (Baseline.sav). The composition of these data files in provided in the table below. SPSS Data File Mergedl.sav Merged2.sav Baseline.sav Number of Baseline Surveys 6 7 13 Number of Cases 3,787 5,315 9,102

Although these SPSS data files can be saved in other formats (e.g., Excel, Lotus, dBase, etc.), variable and value labels and missing-value specifications are lost in the process. However, the variable and value labels and missing-values can be restored in the new formats using the specifications listed in Table 2 of Module 4 "Forms and Tables", should need arise. Table 2 of the "Forms and Tables" module presents a complete list of variable names, their labels, values and value labels in the amalgamated data file for a total of 101 variables. The variables on this list are arranged to correspond with the sections or modules of the baseline questionnaire, with a few exceptions. For example, the first variable on the list, SURVEY (baseline survey), was created as an identifier of the various baseline surveys. Its value label represents the 13 baseline surveys carried out by the Project starting with the earliest survey conducted in Kinango in 1989 and ending with the latest survey conducted in Uasin Gishu in 1997. The creation of the variable was necessary for purposes of data amalgamation and can only be used to select subsets of cases, e.g. a baseline survey or a group of baseline surveys, from the amalgamated data files. Table 2 has two sets of variables; those defined and coded directly from the baseline questionnaire, which are largely self-explanatory from the pre-coded answers, and those constructed through data transformation. The data file has nine constructed variables. 15

Module 2: Amalgamating and Standardising the Data Set These are AGE (age in single years), AGEGRP (age group), TYPE (type of marriage), AGELB (age of the last-born child [in months]), AGEDTH (age of the last-born child at death [in months]), WHNDEL (time elapsed since last delivery), RISK (risk status at last delivery), BTH12M (gave birth in the last 12 months), and SCORE (FP knowledge score). The procedures used to construct these variables are as follows: 1. AGE is constructed by computing the difference between the year of survey and the year of birth (YOB) using the expression: AGE = Year of Survey YOB However, if the month of birth (MOB) is also coded and the MOB is greater than the month of survey, then a year is subtracted from the computed value of AGE above using the conditional expression: If (MOB > Month of Survey) AGE = AGE 1 2. AGEGRP is constructed by receding the values of AGE above as shown in the table below: 15 through 19 = 1 for 15-19 age group, 20 through 24 = 2 for 20-24 age group, 25 through 29 = 3 for 25-29 age group up to 45 through 49 = 7 for 45-49 age group. Receded Value Number 1 2 3 4 5 6 7 Age Group Value Label 15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age Range 15 through 19 20 through 24 25 through 29 30 through 34 35 through 39 40 through 44 45 through 49 3.

TYPE is constructed by receding the values of cowife (COWIFE) as 0 = 1 for monogamy, and 1 through highest = 2 for polygamy. AGELB is constructed by computing the difference between the month of survey and the last-born child's month of birth (LBMOB), and the difference between the year of the survey and the last-born child's year of birth (LBYOB) multiplied by 12 to convert into months using the expression: AGELB = (Month of Survey - LBMOB) + ((Year of Survey - LBYOB) * 12)

4.

5.

AGEDTH is constructed by computing the difference between the last born child's month of death (LBMOD) and month of birth (LBMOB), and the difference between the last born child's year of death (LBYOD) and year of birth (LBYOB) multiplied by 12 to convert into months using the expression: AGEDTH = (LBMOD - LBMOB) + ((LBYOD - LBYOB) * 12)

16

Module 2: Amalgamating and Standardising the Data Set 6. WHNDEL is constructed by receding the values of AGELB above as lowest through 11 = 1 for <12 months previously, 12 through 59 = 2 for 12-59 months previously, and 60 through highest = 3 for 60+ months previously. RISK is constructed by receding the values of number of children ever born (CEB) as para 2 through 4 = 1 for low risk at last delivery, para 1 and para 5 through highest = 2 for high risk at last delivery, and all other values = system-missing. It should be noted that the risk category refers to the pregnancy resulting in the last-born child, not the current pregnancy. BTH12M is constructed by receding the values of AGELB above as zero through 11 = 1 for Yes, and all other values = 2 for No. SCORE is constructed by summing the values of each variable of knowledge of family planning method (KNOPIL, KNOINJ, KNOIUD, etc.) mentioned in the questionnaire using the expression: SCORE = SUM (KNOPIL + KNOINJ + KNOIUD + ..... + KNOOTH). Note that in the list of variables, the variable CLUST (sample cluster) has no value labels. This is because the labels denote localised sample cluster names specific to individual surveys. However, the earlier surveys (Kinango and Etono) did not record cluster names. The sample cluster value numbers and labels are available only in individual baseline survey data files as follows: Baseline Survey Nyamirat and Nyamira2 Sample Cluster Value Number & Label 1 2 3 1 2 1 2 3 1 2 1 2 3 1 2 1 2 3 Ekerenyo Manga Esani Kimaeti Tongaren Yala Wagai Boro Kalawa Mbooni Waitaluk Endebess Cherangani Kibirichia Kyonyo Ainabkoi Soy Moiben

7.

8.

9.

Bungoma Siaya

Makueni Trans Nzoia

Meru Uasin Gishu

17

Module 2: Amalgamating and Standardising the Data Set The list of variables in Table 2 also includes variables unique to specific surveys only. For example, the variable RESID (place of residence) is only available in the Makueni data because the settlement pattern in the area consists of two specific types, namely, market centres and dispersed households. In addition, the last baseline survey carried out in Uasin Gishu, in the Rift Valley Province, in 1997, included three questions not asked in the previous surveys. The variables created from these questions are WANTEDPR (wanted current pregnancy), WANTKIDS (want another child in future) and HOWMANY (number of children wanted in future). A few variables defined from questions in an earlier version of the questionnaire, which have since been discontinued, are also listed in Table 2. These variables are WHYTBA1 and WHYTBA2 (if delivered by TBA, why this TBA [1] and [2]), FEARSDP (afraid of attending clinic for FP), and FEARWHY (reason for fearing clinic for FP). Lastly, Table 2 captures the evolution in measuring and coding basic knowledge of family planning methods. The coding has evolved from "not known" and "known" levels of knowledge (e.g., FFPP, FFPU, FFPU, FFPC, etc.), to "not known", "heard of, "knows something", and "knows a lot" levels of knowledge (e.g., FPP, FPU, FPU, FPC, etc.), and lately to "not known", "probed" and "spontaneous" levels of knowledge (e.g., KNOPIL, KNOINJ, KNOIUD, KNOCON, etc.). Besides SPSS, other data analysis packages, data bases and spread sheets (e.g., Epi Info, dBase, Paradox, Fox Pro, Excel, Lotus, Quattro Pro, etc.) can also be used to transform and manipulate data and files in the manner described above. The next table which has been produced from the process of amalgamating the data sets is Table 3 of the "Forms and Tables" module. Table 3 lists the same variables by baseline surveys carried out between 1989 and 1997. The table, presented for purposes of navigating the data set, shows the baseline survey names, the dates (years) the Project published the baseline reports, and the number of variables available in each baseline survey data file. A shaded box denotes unavailability of the variable in the baseline survey data file and is therefore assigned a system-missing value marked by a dot in the amalgamated data files. In addition, the table below lists SPSS baseline survey data files by name and total number of variables per data file.

18

Module 2: Amalgamating and Standardising the Data Set

SPSS Data File Kinango.sav Etono.sav Kenyatta.sav Bukwala.sav Gwassi.sav Nyamira l.sav Bungoma.sav Siaya.sav Nyamira2.sav Makueni.sav Transnzo.sav Meru.sav Uasingis.sav

Name of Baseline Survey Kinango Etono Lake Kenyatta Bukwala Lwanda Gwassi Nyamira Bungoma Siaya Nyamira Follow-up Makueni Trans Nzoia Meru Uasin Gishu

Number of Variables 35 43 47 49 49 49 63 66 65 67 67 66 71

The salient features of Table 3 are, as follows: 1. The Project introduced interviewers' number (INTNO) as a variable only recently and is limited to four baseline surveys carried out from the Makueni survey of 1996. The variable is neither mentioned nor appears in any baseline report. Nonetheless, the variable is useful for measuring variations in the quality and quantity of information collected by interviewers within and between sample clusters. In the earlier surveys, age was pre-coded in seven five-year age groups presented as boxes in the questionnaire. Once a respondent gave age information, the interviewer simply checked the relevant box. Thus, the Project defined five-year age groups (AGEGRP) from the pre-coded responses. As shown in the first variable construction procedure above, the introduction of the month (MOB) and the year of birth (YOB) in the questionnaire in 1995 in the Siaya and subsequent surveys, has made it possible to compute a new variable, age in single years (AGE) from which the variable AGEGRP is now receded. Sample clusters (CLUST) became important as a selection criterion for fielding baseline surveys from the Nyamiral survey of 1989. The Project centred each cluster on a health facility where a GTZ CBD programme was to be initiated. The clusters represent either administrative divisions (Nyamira, Siaya and Uasin Gishu), high potential areas (Meru), dominant topographies (Makueni) or types of settlement patterns (Bungoma) or cultural and socio-economic diversity (Trans Nzoia) in the district. As mentioned earlier, some baseline surveys had particular questions or transformed variables that do not appear in other surveys. For example, only the Makueni data file has place of residence variable (RESID) while the Trans Nzoia and Uasin Gishu data files are the only ones that have expanded some ethnic groups into subgroups in the variables ETHNIC1 and ETHNIC2 respectively. The Trans Nzoia data file 19

2.

3.

4.

Module 2: Amalgamating and Standardising the Data Set amalgamates the Kalenjin and the Luhya ethnic subgroups into broader ethnic groups in the variable ETHNIC1 and the Uasin Gishu data file amalgamates the Kalenjin ethnic subgroup into broader ethnic groups in the variable ETHNIC2. In addition, the Uasin Gishu data file is the only one with the variables: wanted current pregnancy (WANTEDPR), want another child in the future (WANTKIDS), and number of children wanted in future (HOWMANY). 5. Earlier surveys collected and coded data for defining the last-born child's month (LBMOB) and the year of birth (LBYOB) and the month (LBMOD) and the year of death (LBYOD). The Project then transformed these data to compute the age of the last-born child (AGELB) and the age of the last-born child at death (AGEDTH). After the transformations were completed, they dropped the variables LBMOB, LBYOB, LBMOD, and LBYOD from the data files to compress the data. This explains why the Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral data files have AGELB and AGEDTH, but not LBMOB, LBYOB, LBMOD and LBYOD. The Project has, from the Bungoma survey, retained these variables in the baseline survey data files. During the same period, data for defining knowledge of a maternal death (MDKNO), the month (MDMOD) and the year of maternal death (MDYOD), and circumstances of maternal death (MDCIRC), was collected, coded and dropped from the data files (except MDKNO) for similar reasons. Likewise, the Project has, from the Bungoma survey, retained these variables in the baseline survey data files. In the earlier surveys, besides home deliveries, the Project coded the place of delivery of the last-born child (WHRDEL) as a specific facility, e.g., Mpeketoni Health Centre, Yamira Hospital, etc. Such localised names, specific to heath facilities in specific (geographical locations, do not lend themselves to standardisation and data amalgamation. To preserve these data, we have created the variables WHNDEL1, WHNDEL2, WHNDEL3, and WHNDEL4, which are available only in the Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral data files respectively. The Project has, from the Bungoma survey, adopted generic value labels for defining place of delivery of the last-born child: at home, a hospital, other health facilities, and elsewhere. Similarly, during the same period, the Project coded the source of supplies or information on FP (SOURCE) as a specific facility. Again, to preserve these data, we have created the variables SOURCE1, SOURCE2, SOURCES, SOURCE4, and SOURCES, which are available only in the Etono, Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral data files respectively. The Project has, from the Bungoma survey, adopted generic value labels for defining the source of supplies or information on FP: CBD, SDP and others. We mentioned above that the Project introduced briefly some questions in an earlier version of the questionnaire asked only in the Lake Kenyatta, Bukwala, Lwanda Gwassiand Nyamiral surveys, but later discarded them. For example, if a TBA delivered a respondent's last-born child (WHODEL), the respondent was asked an

6.

7.

8.

9.

20

Module 2: Amalgamating and Standardising the Data Set additional question to provide reasons why that particular TBA was chosen to deliver the child. Responses to this question created the variables WHYTAB1 and WHYTBA2. Other variables like, fear of attending a clinic for FP (FEARSDP) and the reasons for being afraid (FEARWHY), were also introduced briefly and later discarded. As a possible reason for non-use of FP, the question "If you wanted to use FP, would you be afraid to go to the clinic?" proved difficult to render correctly. We did not observe any variations from the responses to this question as only a few women admitted to being afraid of going to a clinic for FP. Thus, the question was discarded from the questionnaire. The only surveys in which the Project asked this question are Bukwala, Lwanda Gwassi and Nyamira1. 10. The parameters for measuring basic knowledge of family planning methods have changed over time. At the beginning, the Project simply coded in the Kinango and Etono data files responses for measuring knowledge levels as "not known" and "known". To preserve and distinguish these variables from other FP knowledge variables in the amalgamated data files, we assign the first two letters of the variable names as FF, e.g., FFPP, FFPI, FFPU, FFPC, etc. for knowledge of the pill, injectables, IUCD and condom respectively. 11 At the time the Project was conducting the baseline surveys for Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral, the responses for measuring knowledge levels had changed to "not known", "heard of, "knows something" and "knows a lot". In the amalgamated data files, the first letter of the knowledge variable names with these responses, is F, e.g., FPP, FPI, FPU, FPC, etc. for knowledge of the pill, injectables, IUCD and condom respectively. 12. The parameters for measuring FP knowledge levels from the Bungoma survey were changed yet again in line with the knowledge question asked in the Demographic and Health Surveys. The Project now measures FP knowledge as "not known", "probed" and "spontaneous" levels of knowledge. In the amalgamated data files, the first three letters of the knowledge variable names with these responses, are assigned KNO, e.g., KNOPIL, KNOINJ, KNOIUD, KNOCON, etc. for knowledge of the pill, injectables, IUCD and condom respectively. 13. The last additions to the list of variables in the data files from the Bungoma survey of 1994, are ever use of FP (EVUSE), methods used (EVUSE1, EVUSE2 and EVUSE3) and knowledge of CBD workers: heard of (CBDHAD) knows of (CBDKNO), and talked to (CBDTAK) a CBD.

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Module 3: Navigating the Data Set Practical Examples

3.

Module 3: Navigating the Data Set - Practical Examples

This module is intended to guide the reader through a series of working examples of data analysis using the baseline surveys. The module is divided into two parts. The first part deals with worked examples from single surveys, and takes the reader through the windows and commands required to produce the most common types of analysis. This part, again, is divided into two, giving similar examples using SPSS and Epi Info, respectively, for analysing the data. The second part uses the merged SPSS data files to explore some of the possible applications to which these data can be put. More emphasis is put, in the second part, on the possible relationships and explanations which might be generated from looking at the results of several surveys simultaneously. Though other data analysis packages can also be used to navigate the data set and produce similar outputs, the emphasis here is on understanding the basics of data navigation and obtaining results you can trust, not on how to use a particular analytical package (A dBase-3 version of the amalgamated data set is available on the floppy disk for this purpose). The examples presented here merely serve to illustrate how data navigation can help summarise data and draw conclusions from them and are neither lessons in statistics nor data interpretation. While Epi Info is more widely used and, with free distribution, more accessible than SPSS, it is not such a powerful package as SPSS, and does not give such sophisticated and flexible output. Program managers must decide, given the capacity of their staff, their main objectives of data analysis, and their hardware and financial status, which of these or any other software - to use. Before the user can start the practical examples the necessary files have to be downloaded from the supplied diskette . This diskette contains various zipped files named e.g. SPSSBASE.ZIP, SPSSBSEP.ZIP, please type here the names of the files that contain the data in epi info and or dbf format. If you are to practice using SPSS, type at the DOS prompt: A:\PKUNZIP A:\SPSSBASE.ZIP C:\SPSS (if this is the subdirectory where you have installed SPSS). A:\PKUNZIP A:\SPSSBSEP.ZIP C:\SPSS (if this is the subdirectory where you have installed SPSS). Now you are ready to open any of the *. SAV files written in the SPSS directory.

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Module 3: Navigating the Data Set Practical Examples Sometimes it is useful to make a separate subdirectory in the SPSS folder which will contain only the baseline files, e.g. C:\SPSS\GTZ. For that you have to extend the path in the commands above. When working with another software package adapt the command above by replacing the file names accordingly.

3.1

Examples from Single Surveys using SPSS

In this section, we will take the user through a few basic examples on how to navigate the data set, using individual baseline survey data files. We will use the SPSS for Windows data analysis package to illustrate how to navigate the data set and produce the outputs presented as examples. In all examples, the syntax and dialogue from SPSS for Windows version 8.0 is followed. It is recommended that the examples are followed interactively on the computer. 3.1.1 Example 1: Frequency Distribution

The first example (Figure 1) shows the distribution of marital status in the Siaya Baseline. The output is generated from the variable marital status (MS) in the Siaya baseline survey data file (Siaya.sav). To open this file, from the menu choose: File Open... In this >Open< dialog box, select the Siaya.sav data file and click Open to get the file or simply double-click the file to open it. If the data file is not in the default directory, you may need to browse through the directories to locate the file. Frequency MARRIED: WITH HUSBAND MARRIED: HUSBAND AWAY HUSBAND DIED SEPARATED / DIVORCED NEVER MARRIED TOTAL Figure 1: Marital status To produce the output in Figure 1, from the menus choose: Statistics Summarise Frequencies... 23 411 224 62 17 190 904 Percent 45.5 24.8 6.9 1.9 21.0 100.0 Valid Percent 45.5 24.8 6.9 1.9 21.0 100.0 Cumulative Percent 45.5 70.2 77.1 79.0 100.0

Module 3: Navigating the Data Set Practical Examples In this >Frequencies< dialog box, click Reset to restore the dialog box defaults. The variables in the data file are displayed on the source variable list to the left of the dialog box. From this dialog box select MS by clicking to highlight it on the source variable list and then clicking the right arrow button or double-clicking the variable to move it to the target variable(s) list on the right of the dialog box. Next, click OK to run the frequencies. To produce the same output from any merged data file (Merge2.sav or Baseline.sav), first, open the file as shown above. To select the Siaya baseline survey from the merged files, from the menus choose: Data Select Cases... In this >Select Cases< dialog box, click Reset to restore the dialog box defaults, and then select: If condition is satisfied and click If... The symbol at the start of this sentence shows funny in my print out!!! Please check It should look like as much as possible the tick box as shown in SPSS In the "Select Cases: If" dialog box, the variables in the data file are displayed on the source variable list to the left of the dialog box. From this dialog box select: SURVEY by double-clicking it or click to print the variable in the Expression field and then enter the following conditional expression: SURVEY = 8 (meaning select cases if baseline survey equals 8 for "Siaya Baseline Survey")

To enter this expression, you can either paste it into the Expression field by clicking on its components from the calculator pad or type it directly in the Expression field. If unsure of the value label for Siaya Baseline, right-click SURVEY on the source variable list and click Variable Information in the pop-up context menu. The pop-up menu will display the variable name, label, and value labels. Click the down arrow button on the right of the value labels window to display SURVEY value labels. The value label for Siaya Baseline appears as 8 SIAYA. Next, click Continue and OK to select the Siaya Baseline cases only. If the result of the conditional expression is true, the cases are selected and the unselected cases are marked in the SPSS Data Editor with a diagonal line through the row number. You can then run the frequency distribution as shown above.

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Module 3: Navigating the Data Set Practical Examples 3.1.2 Example 2: Cross-Tabulation

Figure 2 is an example of a cross-tabulation to show age-specific contraceptive prevalence rates among ever-married women in the Makueni Baseline. The output is generated from the Makueni baseline survey data file (Makueni.sav). To produce this output, open the Makueni baseline data file and select cases of women who have ever been married. To select these women from the Makueni data file, follow the steps of Selecting Cases above and in the >Select Cases: lf< dialog box, select: MS and specify the criteria for selecting cases of ever-married women by entering the following conditional expression: MS ~= 5 (meaning select cases if marital status is not equal to 5 for >never married<) If unsure of MS value labels, follow the steps in the example above by right-click MS on the source variable list to get information about the variable. Please try to let fig 2 follow the text without a big gap CURRENT USER OF FP YES NO 1 6 14.3% 85.7% 23 28.4% 75 49.3% 56 59.6% 39 57.4% 17 40.5% 12 36.4% 58 71.6% 77 50.7% 38 40.4% 29 42.6% 25 59.5% 21 63.6% Total 7 100.0% 81 100.0% 152 100.0% 94 100.0% 68 100.0% 42 100.0% 33 100.0% 477 100.0%

15-19

20-24

25-29

ARGE GROUP

30-34

35-39

40-44 45-49

Total

Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP Count % within AGE GROUP

223 46.8%

254 53.2%

Figure 2: Example of cross-tabulation

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Module 3: Navigating the Data Set Practical Examples You can also use the following expression to select ever-married women from the Makueni data file: MS <= 4 (meaning select cases if marital status is less than or equals 4, i.e., MS = 1 for" married: with husband" or MS = 2 for "married: husband away" or MS = 3 for "husband died" or MS = 4 for "separated/divorced"). If the result of the conditional expression is true, the case is selected. Click Continue and OK to select the cases of ever-married women only. After selecting ever-married women from the data file, the next step is to cross-tabulate age group (AGEGRP) by current use of FP (USER) to generate contraceptive prevalence rates (CPR) by age among ever-married women in the Makueni Baseline. The CPR drops out of the frequency distribution of current users of FP (" ("Yes" or "No") in the crosstabulation. To do this, from the menus choose: Statistics Summarise Crosstabs... In the "Crosstabs" dialog box, click Reset to restore the dialog box defaults. The variables in the data file are displayed on the source variable list to the left of the dialog box. From this dialog box select AGEGRP as a row variable and USER as a column variable. To do this, highlight AGEGRP on the source variable list and clicking to move it to the target Row(s) variables list on the right of the dialog box. Next, highlight USER and clicking to move it to the target Column(s) variables list also on the right of the dialog box. Click cells and in the dialog box, select "row percentages". Then click Continue and OK to run the crosstab.

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Module 3: Navigating the Data Set Practical Examples 3.1.3 Example 3: Graph

Tubal Ligation 9% Natural 8% Foam Tablets 0% Condom 2% IUCD 11%

Norplant 1%

Pill 35%

Injectables 34%

Figure 3: Contraceptive method mix in Meru

Figure 3 is an example of a contraceptive method mix pie chart obtained from the Meru baseline data file (Meru.sav). To obtain this pie chart, from the menus choose: Graphs Pie... In the >Pie Charts< dialog box, select: Data in Chart Are: Summaries for groups of cases (the default) and click Define. In the >Define Pie: Summaries for Groups of Cases< dialog box, the variables in the data file are displayed on the source variable list to the left of the dialog box. From the right side of this dialog box select: Slices Represent: % of cases. Next, highlight METHOD on the source variable list and click to move it into the Define Slices by box. One slice is generated for each category of the variable. To add the title, click Titles... and in the >Titles< dialog box, type the title >Contraceptive Method Mix in the Meru Baseline< in Title Line 1: and click Continue. Pie chart titles, by default, are centre justified and, if too long, are cropped at both ends. Next, click Options... and deselect Display groups defined by missing values in the >Options< dialog box. (This option is selected by default and should be deselected each 27

Module 3: Navigating the Data Set Practical Examples time you want to exclude cases with system-missing or user-missing values for the grouping variable from appearing as a separate slice in the chart.) Click Continue and OK to obtain the chart. You can also modify the existing chart by labelling the pie slices with text and percentages as in Figure 3. To do this, or to change other characteristics of the pie chart, you select the chart in the SPSS Output Navigator window and double-click it, or from the SPSS Output Navigator menus, choose: Edit SPSS Chart Object Open SPSS chart editor appears. From the chart editor menus choose: Chart Options... In the >Pie Options< dialog box, check Labels Percents box with a 9 and click OK. To exit SPSS chart editor, from the menus choose: File Close

3.1.4

Example 4: Data Transformation

In the next two examples, we show how new variables are constructed through data transformation. The first example of data transformation shows how to compute a new variable, FP knowledge score (SCORE), based on the values of knowledge of family planning method variables (KNOPIL, KNOINJ, KNOIUD, etc.), which we have coded in an ordinal manner. Thus, in the most recent surveys (from the Bungoma survey), we coded no knowledge as zero, probed knowledge as 1, and spontaneous mentioning of a method as 2. SCORE is a summation over the codes of the knowledge of each FP method in the questionnaire. If there are nine separate methods on the list, SCORE would have a range of zero (no knowledge at all) to 18 (all nine methods mentioned spontaneously). However, if we include KNOOTH (Knowledge of Other Methods) on the list, SCORE would have a range of zero (no knowledge at all) to 20 (all ten methods mentioned spontaneously). The range is sufficiently wide for significant differences to be investigated in sub-populations. Since the new variable SCORE already exists in the data file, you may want to construct your own new variable by following the steps below. For purposes of gaining first hand experience in navigating the data set, you may want to name your new variable NEWSCORE or a name of your choice. If you follow the steps below correctly,

28

Module 3: Navigating the Data Set Practical Examples the new variable NEWSCORE should be identical in content to SCORE . To compute this variable, from the menus choose: Transform Compute... In the >Compute Variable< dialog box, type the name of the target variable >NEWSCORE< in the Target Variable window. To specify the variable >type< and >label< click Type&Label and the >Compute Variable: Type and Labek dialog box appears. Type >FP Knowledge Score< in the Label window and click Continue to bring you back to the >Compute Variable< dialog box. In the Numeric Expression field, you can build the summation expression >SUM()< by either typing it directly in the Expression field or pasting it from the built-in function list. To do this, scroll through the Functions window, locate and highlight the function, SUM(numexpr, numexpr...), and click the up arrow button to drop the function SUM(?,?) in the Expression field. Note that the first question mark in the parentheses is highlighted (?,?), the reason being that as you enter a knowledge variable, one at a time, the highlighted question mark is replaced. Highlight the next question mark and enter the next knowledge variable, which replaces it. Continue entering the knowledge variables by either typing them directly, clicking or double-clicking the variables until all the nine or ten knowledge variables (displayed on the source variable list to the left of the >Compute Variable< dialog box), are included in the summation expression. Remember to separate each knowledge variable in the expression with a comma. The expression built to compute the new variable NEWSCORE is as follows: NEWSCORE = SUM (KNOPIL, KNOINJ, KNOIUD, KNOCON, KNOFTB, KNONAT, KNOTL, KNOVAS, KNONOR, KNOOTH) In the above expression, we have entered the knowledge variables in file order, which is the order in which they actually occur in the data file. Although you may want to enter the knowledge variables in alphabetical order, the outcome of the computation will be the same. On completing building the above expression, click OK to compute the new variable NEWSCORE.

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Module 3: Navigating the Data Set Practical Examples

FP KNOWLEDGE SCORE N Mean Median Std. Deviation Range Minimum Maximum Sum Valid Missing 677 0 10,30 11,00 3,25 20 0 20 6970 Figure 4 shows the Bungoma Baseline FP knowledge score summary statistics generated from a frequency distribution of the new variable.

Figure 4: FP knowledge score

The second example of data transformation shows how to construct a new variable, risk status at last delivery (RISK), based on the values of the number of children ever born (CEB). RISK is used to compare low and high-risk groups of women by birth attendant and where they delivered the last-born child. A slight variation can be used to look at differences between groups of currently-pregnant women. Again, the new variable RISK already exists in the data file. For purposes of gaining first hand experience in navigating the data set, you may want to name your new variable NEWRISK or a name of your choice. If you follow the steps below correctly, the new variable NEWRISK should be identical in content to RISK . To construct this variable, from the menus choose: Transform Recode Into Different Variables... In the >Recode Into Different Variable< dialog box, click Reset to restore the dialog box defaults. The variables in the data file are displayed on the source variable list to the left of the dialog box. From this dialog box select CEB by highlighting it on the source variable list and clicking or double-click the variable to move it into the target Numeric Variables list on the right of the dialog box. Note that the Numeric Variable -> Output Variable list shows CEB --> ? in the >Recode Into Different Variable< dialog box. Next, enter the (new) Output Variable Name: >NEWRISK< and Label: >Risk Status at Last Delivery< and click Change. The Numeric Variable -> Output Variable list will now show CEB --> NEWRISK

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Module 3: Navigating the Data Set Practical Examples Click Old and New Values and >Recode Into Different Variable: the Old and New Values< dialog box appears. You define values to recode in this dialog box, which has two sections, Old Value and New Value. Old Value is the single value out of which each new value or range of values is to be receded. New Value is the single value into which each old value or range of values is re-coded. The window has several boxes into which old values are entered, depending on how you wish to recode them. This example uses four of them. CEB is receded into a new variable NEWRISK as follows: Old Value(s) Value: 1 Range: 2 through 4 Range: 5 through highest All other values New Value(s) Value: 2 Value: 1 Value: 2 System-missing Old -->New: 1 2 thru 4 5 thru Highest ELSE --> 2 --> 1 --> 2 --> SYSMIS

In the table above, Old --> New column lists the specifications that are used to recode the new variable NEWRISK. As a reminder, Table 2 in module 4, section 2 shows the new variable NEWRISK coded as 1 for low-risk (para 2-4) at the last delivery and 2 as high-risk (para 1, 5+) at the last delivery. Frequency Valid 1 LOW (PARA 2-4) 2 HIGH (PARA 1,5+) Total Missing System Missing Total Total 148 620 23,9 100,0 472 148 76,1 23,9 100,0 240 38,7 50,8 100,0 232 Percent 37,4 Valid Percent Cumulative Percent 49,2 49,2

Figure 5: Risk status at last delivery To complete, click Continue and OK to construct the new variable NEWRISK. Figure 5 shows the resulting table of distribution of risk status at delivery among women in the Nyamira Follow-up Baseline, or Nyamira2.

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Module 3: Navigating the Data Set Practical Examples 3.1.5 Example 5: Importing and Using SPSS Output in Other Applications

SPSS pivot tables and charts can be copied and pasted or dragged and dropped into other Windows applications, such as word processors or spreadsheets. If you have SPSS 7.0 or higher, you can paste or drop the pivot tables or charts in various format, including the following: An embedded object (SPSS Pivot Table Object). After pasting or dropping the object into other Windows applications, you can activate the object in place by double-clicking and then editing it as if in SPSS. A picture (enhanced metafile). The picture format can be resized in other Windows applications and sometimes a limited amount of editing can be done with the facilities of the other applications. NB - At the time of writing, it was considerably easier to reproduce SPSS output in WordPerfect than in MS-Word. However, with a little perseverance satisfactory results can be obtained from the latter. To copy an SPSS Pivot Table Object, select the pivot table to be copied from SPSS Output Navigator window by clicking it. Then, click the right mouse button and choose copy, or from the SPSS Output Navigator menus choose: Edit Copy To paste an SPSS Pivot Table Object into a target Windows application (e.g., word processor or spreadsheet), from the applications menus choose: Edit Paste Special... In Corel WordPerfect or MS Word, a >Paste Speciak dialog box appears. From this dialog box window, choose SPSS Pivot Table or Picture for a graph and click OK. The pivot table is pasted into the active window in a target application. Alternatively, you can drag and drop an SPSS Pivot Table Object into a target Windows application. To do this, follow these steps exactly. 1. 2. Start the target Windows application. From the target Windows application, switch to SPSS Output Navigator window by clicking its button on the Taskbar on Windows 95 or 98 desktop1.

The Taskbar is the bar on your desktop that has the Start button on it. Buttons representing running applications appear on this bar.

32

Module 3: Navigating the Data Set Practical Examples 3. 4. Select the pivot table to be copied from the SPSS Output Navigator window. Click onto the pivot table once and hold down the left button of the mouse. You will notice that the pivot table image moves as you move your mouse while holding down your mouse button. While keeping your mouse button held down, drag the pivot table image toward the target Windows application's button on the Taskbar until the image disappears. When the pivot table image disappears, several things happen: - you will notice a circular object like this 4 appearing briefly; - immediately after that, your mouse cursor will reappear; - the target application will open. Do not release your mouse button yet. 7. While still holding your mouse button down, move the mouse cursor upward away from the Taskbar. You will immediately see the pivot table image reappear on your screen. Move the pivot table image to a location of your choice in the active window, then release the mouse button to drop SPSS Pivot Table Object into your document. You can now move the pivot table anywhere in your document, resize it, activate it in place by double-clicking and then editing it as if in SPSS.

5.

6.

8.

To export an SPSS chart into a word processor, select the chart to be copied from SPSS Output Navigator window. Double-click the chart and SPSS Chart Editor appears. From the SPSS Chart Editor menus choose: File Export Chart In the >Export Chart< dialog box, select an export format by specifying a file type. In the >Save File as Type< window, you can choose one of the following file types: Windows Metafile (*.wmf). This is the default format. CGM Metafile (*.cgm) PostScript (*.eps) Windows Bitmap (*.bmp) Tagged Image File (*.tif) Macintosh PICT (*.pct) Choose the format you want, (most word processors can handle Windows Metafile) then type a name for the chart and click Save and exit SPSS Chart Editor. SPSS Chart Editor

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Module 3: Navigating the Data Set Practical Examples saves the file in Windows temporary directory C:\WINDOWS\TEMP by default, but you can change the directory in which to save the file. To retrieve the chart into an active window in a word processor, from the applications menus choose: Insert File...

3.2

Examples from Single Surveys using Epi Info

In this section, we will use Epi Info data analysis package to illustrate how to navigate the data set and produce the output presented as examples. We assume some experience with using the package. The real novice should go through tutorials 2 and 3 which form part of the Epi Info package. The examples presented here are drawn from individual baseline surveys data files which were constructed from the amalgamated data set. Trends, effects, differentials and comparative examples will not be shown, as we believe that experienced Epi Info users will know how to perform these tasks by reading the corresponding section on SPSS for Windows. Epi-Info commands are in italics. It is recommended that the examples are followed interactively on the computer. Before one can start the analysis, the database in Epi Info format has to be decompressed and moved from the floppy disk to the subdirectory where Epi Info is situated. This is done as follows: At the DOS prompt (or in a DOS window) type: A:\PKUNZIP A:\BASELREC.ZIP C:\EPI6 Open Epi Info, start Analysis, READ BASELINE.REC and look at the variables with F3 and F4. All variables are numeric. What they represent is tabulated in the variables list in Module 4, Table 2. If you want to see these values on the screen, or in the printed output, a receding process has to be done. The floppy disk contains a RECODE.CMD file. This ASCI-file contains a set of receding commands to show the process. Look at the file first using EPED and it will be self-explanatory. In ANALYSIS you can apply this set of commands with the command: RUN A:\RECODE.CMD. Look once more at the variables using F3. You will see that a whole set of new variables has been created. You can practice creating additional variables using the format of the RECODE.CMD file.

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Module 3: Navigating the Data Set Practical Examples The present examples are of analysis within individual baseline surveys. It is more practical to create separate REC files for the surveys to be analysed, than to use the large merged file. Use the select command: SELECT SURVEY = n, where n is the number corresponding to the baseline study you want to capture in a separate file. Refer to Module 4, Table 2. In the first example we use the Siaya Baseline Survey. Therefore type: SELECT SURVEY=8 ROUTE SIAYA.REC WRITE RECFILE This will create a new rec-file which we will load with the READ command. 3.2.1 Example 1: Frequency Distribution

The first example shows the distribution of marital status in the Siaya Baseline. The output is generated from the marital status variable (MS) in the Siaya.rec baseline survey data file. Use FREQ MS to see a frequency distribution with the frequencies only, and compare the output with FREQ MARITAL-STAT which will give you the same distribution with full labels. To switch to printer output, press F5 and then repeat the command. To capture the output for use in a word processor follow these commands: ROUTE MARSTAT. TXT FREQ MARITAL-STAT The text file can be found in the Epi Info subdirectory and imported for further layout, as per the example below. MARITAL STATUS Husband died Married, with husband Married, husband away Never married Separated / divorced TOTAL Freq Percent Cum. Percent 62 411 224 190 17 904 6.9 45.5 24.8 21.0 1.9 100.0 6.9 52.3 77.1 98.1 100

To produce the same output for all the surveys READ the original baseline.rec, repeat the recoding, and run the FREQ command. To prevent having to repeat the receding each time you read the BASELINE.REC afresh, it is advisable to write a new rec-file as described above.

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Module 3: Navigating the Data Set Practical Examples 3.2.2 Example 2: Cross-Tabulation

Open the baseline.rec as usual, select the Makueni baseline data and write a new rec-file as described above. Open this new file and select cases of women who have ever been married with the command: SELECT MS<5. This will exclude the women who answered: >never married<. If unsure of MS value labels, refer to Table 2 in Module 4 in the folder. An example of a cross-tabulation to show age-specific contraceptive prevalence rates among ever-married women in the Makueni Baseline can be generated with the tables command: TABLES AGEGRP USER. The CPR drops out of the frequency distribution of current users of FP where 1=user and 2=non-user. Do not forget to give the command SET PERCENTS=ON before the tables command otherwise only the frequencies will be reflected in your table. As in Example 1 above, the Epi Info output can be routed to a text file and incorporated in a word processor. The later versions of, e.g., Word and Word Perfect will enable you to convert the naked text into a table (See your word processor manual for more details). As Epi Info produces both row and column percentages when the command "percents=on" is given you will need to take the column percentages out manually, they may be confusing. AGE-GROUP 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Yes 1 14,3% 23 28,4% 75 49,3% 56 59,6% 39 57,4% 17 40,5% 12 36,4 223 No 6 85,7% 58 71,6% 77 50,7% 38 40,4% 29 42,6% 25 59,5% 21 63,6% 254 Total 7 1,5% 81 17,0% 152 31,9% 94 19,7% 68 14,3% 42 8,8% 33 6,9% 477

3.2.3

Example 3: Graph

The contraceptive method mix can be represented by a pie chart. As an example we will use the Meru baseline data file. Open the baseline.rec with the READ command, SELECT SURVEY=12. The command Pie METHOD will produce the pie. If you want the value labels instead of the frequencies, you need to recede the variable using the value labels table (the syntax can be studied in the help file) and the RECODE.CMD file. Alternatively , a frequency distribution FREQ METHOD can be IMPORTED in later versions of 36

Module 3: Navigating the Data Set Practical Examples WordPerfect or Word and shown as a pie chart. Also Harvard Graphics produces highquality charts which can be imported into the document. The capacity of Epi Info to output graphs has remained very limited up to version 6.04. Below, an example is shown of a pie chart made directly in Word Perfect, importing the frequency data of the variable >Method< in the Meru survey. Contraceptive Method Mix

1,4% 7,9% 7,5% 0,2% 3,0%

35,2%

10,7%

34,2%

Pill Foam Tab

Injectables natural

iucd Tubaligation

condom Norplant

1 = Pill 74 2 = lnjectables 168 3 = iucd 53 4 = condom 15 5 = Foam Tab 1 6= natural 37 7 = Tubaligation 39 9 = Norplant 7

35.2% 34.0% 10.7% 3.0% 0.2% 7.5% 7.9% 1.4%

3.2.4

Example 4: Data Transformation

In this example, we show how a new variable is constructed by receding. The variable risk status at last delivery (RISK) is based on the values of the number of children ever born (CEB). RISK is used to compare low and high-risk groups of women by birth attendant and where they delivered the last-born child. A slight variation can be used to look at differences between groups of currently-pregnant women. This variable, RISK, already exists as a >computed< variable in the amalgamated data file. For purposes of gaining first hand experience in navigating the data set, we will name a new variable NEWRISK. If

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Module 3: Navigating the Data Set Practical Examples you follow the steps below correctly, the new variable NEWRISK and RISK should be identical, except for the names. Define NEWRISK # RECODE CEB TO NEWRISK 1=2 2-4=1 ELSE=2 Old Value(s) Value: 1 Range: 2 through 4 Else (all other values) New Value(s) Value: 2 Value: 1 Value: 2 Old -> New: 1 2-4 else =2 =1 =2

The table below shows the distribution of risk status at delivery among women in the Nyamira Follow-up Survey (Nyamira2). NEWRISK 1 = low (para 2-4) 2 = high (para 1 and 5+) 0 = missing value Frequency 242 320 115 Percent 35.7 47.3 17.0

Distribution of risk status at delivery. This new variable can now be used to crosstabulate with other variables. If you find such a newly-constructed variable useful, and want to use it each time the rec-file is read, then you have to write the rec-file under a new name as shown before with the ROUTE and the WRITE RECFILE command. Unfortunately Epi-lnfo does not save a newly created variable in the existing rec-file when exiting ANALYSIS.

3.3

Examples of Meta Analysis of the Data Set

The examples presented here are based on the analysis of the amalgamated data set, and can be regarded as a form of >meta-analysis<. They are produced in much the same way as the examples given earlier, using cross-tabulations and the various chart options in SPSS, or else by exporting the relevant data and making more sophisticated graphs using a spreadsheet (in the examples shown, this is MS-Excel). The emphasis in this section is on demonstrating possible ways in which to use all the data sets simultaneously to answer the types of questions demographers and reproductive health analysts may be interested in. 3.3.1 Example 1: Fertility Transition: Trends in Total Fertility and Contraceptive Prevalence Rates among Ever-Married Women

The GTZ FP Project began at a time when Kenya was embarking on a rapid transition to lower fertility, one of the most dramatic changes seen in history. The transition did not take place evenly in time and space, with leading and lagging areas. Demographers have ascertained that changes in contraceptive prevalence are the most potent predictors of

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Module 3: Navigating the Data Set Practical Examples fertility decline over the short term. The baseline surveys have been carried out in a variety of conditions of fertility change, and over a period of nine years. The relationship between contraceptive prevalence rate (CPR) and total fertility rate (TFR), both of which have been calculated in every survey, can be shown diagrammatically to give specific insights into the fertility change in Kenya. This graph is shown as Figure 6.

Figure 6: Total Fertility and Contraceptive Prevalence Rates among Ever-Married Women, Baseline Surveys 1989-1997 Figure 6 shows that there is a very close relationship between the hypothesised dependent variable (TFR) and the independent variable (CPR). Over the 13 surveys, almost three-quarters of the variance in total fertility is accounted for by variations in contraceptive prevalence. In other words, the meta-analysis confirms that contraceptive prevalence is a good predictor of fertility rates within relatively constrained time and space regimes. The graph shows the wide ranges in the values of the two variables between the different survey sites and times. At the extreme, Kinango, in 1989, with a CPR of 4% and a TFR of almost 11 children per woman, contrasts remarkably with Meru in 1997 (CPR=81%, TFR=3.8). Even without these extremes, however, it can be seen that fertility and contraceptive prevalence are closely related. The equation associated with the regression line can be used to predict a TFR from a given level of CPR, with relatively narrow confidence intervals. For example, applying the formula, a CPR of 30% for ever-married women will predict a TFR of 6.6 children per woman, and one of 50% would give an estimate of 5.1.

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Module 3: Navigating the Data Set Practical Examples Further hypotheses may be generated on the basis of this result. For example, the regression equation may be compared with others built up from, for example, the DHS series. The slope of the line in the present example, is not as steep as would be anticipated from the international comparisons, and it may be hypothesised that the rapid uptake of contraceptive use in Kenya has not had sufficient time for the full response in reduced fertility to be felt, or it may mean that there is a larger than average overlap between contraceptive use and other proximate determinants of fertility, such as duration of breastfeeding, or spousal separation. 3.3.2 Example 2: Effects of Education on Contraceptive Prevalence Rates among Ever-Married Women

Contraceptive prevalence, itself, depends on several social factors. One of the most important predictors of contraceptive use is the prevalence of female education. In most of the survey reports, differences in CPR by four levels of educational achievement are tabulated, with strong evidence that women with more education have higher use rates of contraceptives. This can be illustrated by a graph using CPR for ever-married women, this time as a dependent variable, with a variable measuring inter-survey differentials in the proportions of women having secondary education, as the predictor. This relationship is shown on Figure 7.

Figure 7: Contraceptive prevalence rate by percentage of ever-married women having secondary education Figure 7 confirms the strong predictive effect of female education on contraceptive prevalence, with a high positive correlation and most surveys following a consistent trend.

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Module 3: Navigating the Data Set Practical Examples Kinango and Meru, again, occupy opposite ends of the spectrum, with most of the other surveys clustered near the regression line. Lwanda Gwassi and Lake Kenyatta, however, show diverging results. Both had around 13% of married women having secondary education, but the contrast in CPR is noticeable. To explain this, further refinement of the data (e.g. standardisation for age and/or parity) might be tried, before suggesting a cultural hypothesis (nearly all women in Lwanda Gwassi are Luo, those in Lake Kenyatta, Kikuyu).Another possible interpretation from examination of the scatter of points, is that the relationship between education level and contraceptive use is strongest at the highest and lowest levels of secondary education. Several hypotheses might be developed to explain why this should be. 3.3.3 Example 3: The Role of Female Education in the Choice of Birth Attendant

Many of the surveys have noted that high proportions of women interviewed, often over 50%, give birth at home, without any trained assistance (see the Factsheet or the individual summaries of Module 5 for details). Education level attained might also be hypothesised as an explanatory factor for the place of delivery of the woman's last-born child. Figure 8 shows the SPSS output from a cross-tabulation of education level with place of delivery using the data from all 13 surveys. LEVEL OF EDUCATION * PLACE OF DELIVERY Crosstabulation
PLACE OF DELIVERY HOME HOSPITAL OTHER HEALTH FACILITY 449 89 78 72.9% 14.4% 12.7% Total

LEVEL OF NONE EDUCATION

Total

Count % within LEVEL OF EDUCATION STD1 - STD6 Count % within LEVEL OF EDUCATION STD7 - STD8 Count % within LEVEL OF EDUCATION SECONDARY Count + % within LEVEL OF EDUCATION Count % within LEVEL OF EDUCATION

616 100.0%

820 66.2%

254 20.5%

164 13.2%

1238 100.0%

862 58.9%

342 23.4%

260 17.8%

1464 100.0%

375 33.9%

462 41.8%

269 24.3%

1106 100.0%

2506 56.6%

1147 25.9%

771 17.4%

4424 100.0%

Figure 8: Education level of mother and place of delivery of last-born child

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Module 3: Navigating the Data Set Practical Examples Figure 8 shows a strong and consistent tendency for increasing proportions of women to deliver at a health facility with increasing education levels. At the extreme, 73% of women with no education gave birth to their last-born child at home, compared to 34% of women who had been to secondary school, while only 14% of the illiterate women compared to 42% of secondary-educated ones gave birth in a hospital. Chi-Square Tests Asymp. Sig. Value Pearson Chi-Square Likelihood Ratio Linear-by-Linear Association N of Valid Cases
a

df 6 6 1

(2-tailed) .000 .000 .000

357.849a 360.494 222.523 4424

0 cells (.0%) have expected count less than 5. The minimum expected count is 107.35.

The 2 value corresponding to the proportions in the table is practically off the scale, as the association is very strong. 3.3.4 Example 4: Differentials in Contraceptive Method Mix between Eastern and Western Kenya

It is often of interest to investigate variations in the contraceptive methods used over time and from country to country, or region to region, as these can reflect particular supply and demand conditions. It has been observed in Kenya, that the regions in which adoption of contraception came earliest, tend to have a wider range of methods in use, compared with areas of later adoption. In particular, it has been noted in several of the Surveys, that the injectable is often the first contraceptive used by the late adopters, and that this is a clear contraceptive of choice in Western Kenya. Figure 9 shows the different contraceptive method mix in current users in two broad Kenyan regions - "east" and "west". These two regions have been produced using a simple receding of the SURVEY variable: Kinango, Lake Kenyatta, Makueni and Meru have been amalgamated as "East Kenya", while the rest, (with the exception of the Nyamira follow-up survey, excluded since it would weight the data too heavily towards this district) are receded into a new group called "West Kenya".

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Module 3: Navigating the Data Set Practical Examples WEST KENYA

TRADITIONAL 1% PILL 27% NATURAL 13% FOAM TABS 1% CONDOM 2% UCD 4%

TL 14%

INJECTABLE 38%

EAST KENYA
NORPLANT 1%

TL 13%

PILL 30%

NATURAL 21%

CONDOM 4% IUCD 8% INJECTABLE 23%

Figure 9: Contraceptive method mix in West and East Kenya Figure 9 shows that the method mix in both regions is dominated by the two hormonal methods, pill and injectable. However, the proportions using the injectable are significantly higher in the West.

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Module 3: Navigating the Data Set Practical Examples It is also seen from Figure 9, that proportions of women currently using IUCD, condoms and natural methods are around double the proportions in the East, with equal proportions of women using tubal ligation (TL) in both regions. 3.3.5 Example 5: Paired comparisons of two survey results

One follow-up study, following a baseline, was carried out in Nyamira, specifically to assess the changes which had occurred since the installation of a CBD programme in this district. The Nyamira 2 report obviously concentrated on the analysis of the changes observed. This final example of meta-analysis demonstrates one possible mode of analysis for this type of comparison. Nyamira District had already entered the fertility transition in 1990 when the baseline survey was carried out, and this proceeded apace, helped, it was believed, by the GTZ/MoH CBD initiative there. Several outcome measures of the effect of FP uptake are available for comparison. One of these is the duration of use of individual methods: in the early stages of adoption of FP, mean duration of use could be hypothesised to be shorter than at a period when FP is more firmly established. Figure 10 shows a comparison of mean duration of use (in months) for the three main methods of contraception used in Nyamira in 1990 (Nyamira 1) and 1996 (Nyamira 2). The figure shows the direct output from the SPSS MEANS routine2.

A rather lengthy case-selection command on the merged data file is needed to obtain the relevant data. This includes selection of the correct surveys (Nyamiral and Nyamira2) and the relevant contraceptive methods (pill, injectable and TL). The MEANS command has two layers SURVEY and METHOD and the dependent variable, DUR.

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Module 3: Navigating the Data Set Practical Examples Report FP METHOD IN USE PILL Mean BASELINE SURVEY NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total NYAMIRA1 NYAMIRA2 Total DURATION OF USE 13.83 13.85 13.83 103 71 174 22.15 38.84 30.07 114 103 217 69.39 75.96 72.53 59 54 113 29.14 39.85 33.99 276 228 504

INJECTABLES Mean

TL

Mean

Total

Mean

Figure 10: Example of comparison of duration of method use Figure 10 shows that the overall duration of use of the three main methods, taken together, has increased by 10 months. There has been little change in the average duration of use of pills since uptake was initiated. The length of time since initiation has increased among injectable users (the major method) from a mean of 22.15 months to 38.84. For women undergoing TL, the average elapsed time has also risen slightly to an average of 72.53 months. Significance testing and hypothesising reasons for the differences observed would then form the next stage of analysis.

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Module 4: Forms and Tables

4.

Module 4: Forms and Tables

This module contains a sample questionnaire and three large tables. The questionnaire is taken from the Trans-Nzoia Baseline Survey, and is typical of those used in the later surveys. It should be referred to whilst using the rapid assessment guide in Section 1. Tables 1 to 3 are referred to extensively in Module 2, which describes how the data from the individual surveys were amalgamated and standardised. Table 1 is a template showing which data was collected where, so that analysts can check on the which data is available for given surveys. The table is broken into sections which correspond with those of the Questionnaire. Table 2 lists all the variable names, variable labels and value labels for every variable in the data set, and is essential to have as a reference while planning any data analysis using the individual or merged data sets. Table 3 is similar to Table 1, showing the availability of particular variables for any given survey. However, Table 3 is more specific, listing each variable name and label and noting its availability in each of the 13 surveys. Variations in variable definition and notes on other features of the data set particular to individual surveys are noted in the table.

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Module 4: Forms and Tables

4.1

Trans Nzoia Fertility Survey

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4.2

Table 1: Template for Fertility, Mortality and MCH/FP Variables in GTZ Family Planning Project Baseline Surveys, 1989 1997

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Module 4: Forms and Tables

4.3

Table 2: List of Variables in GTZ Family Planning Baseline Survey Data Set

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Module 4: Forms and Tables

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Module 4: Forms and Tables

4.4

Table 3: List of Variables by GZT Family Planning Project Baseline Surveys (1989 - 1997)

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Module 4: Forms and Tables NOTES 1. Lake Kenyatta data file has no household numbers (HSENO) but plot numbers (PLOTNO). Two categories of marital Status (MS) in the Lake Kenyatta data file, >Married: Husband Away< and >Husband Died<, are combined. The variable cowife (COWIFE) in Kinango data file has only two categories, >Only Wife< and >Other Wife<. Trans Nzoia and Uasin Gishu data files have additional ethnic group variables, ETHNIC1 and ETHNIC2 respectively, which amalgamates some subgroups into broader ethnic groups. In the earlier surveys, place of delivery (WHRDEL) was coded as a specific facility, which does not make standardisation and data amalgamation possible. To preserve these data, the variables WHNDEL1, WHNDEL2, WHNDEL3, and WHNDEL4 are created for Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral data files respectively. Source of supplies or information on FP (SOURCE) was also coded as a specific facility. To preserve these data, SOURCE1, SOURCE2, SOURCE3, SOURCE4, and SOURCE5 are created for Etono, Lake Kenyatta, Bukwala, Lwanda Gwassi and Nyamiral respectively.

2.

3.

4.

5.

6.

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Module 5: Baseline Summaries

5.
5.1

Module 5: Baseline Summaries

Introduction

This module is intended for those who need the essential findings of the 13 surveys described in Module 1, but who do not require the full survey reports. It is concluded with a Factsheet presenting the figures for all indicators in all surveys. The contents of this module may be regarded as a set of "executive summaries" of each survey. If further details are still needed, the original reports of each survey (excepting the Kinango Contraceptive Prevalence Survey) may be obtained directly from the GTZ Reproductive Health Project, Kenya. The summaries have uniform structure: Each survey in this module is presented chronologically. A title page showing the dates and a map?? indicating the location of the region covered. The key data is listed in an individual fact sheet for the survey. The figures are repeated at the end of this module in a comprehensive table, which offers you a basis for comparison and an overview of findings for the whole project. The next section gives a brief background about the environmental and socioeconomic characteristics of the area in which the survey was carried out, plus some information about the health service provision and, finally, the rationale of the survey and some details of its operationalisation. These introductory sections are followed by brief descriptions of the main results falling under three headings: Fertility, Family Planning and Maternal and Child Health, which are the main areas of interest. The final section summarises the main conclusions of the survey report, and adds a few lines on what the eventual outcome of the actions of the GTZ Project was on the area under survey.

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5.2

Baseline Surveys Factsheet (summarising Module 5 data)

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5.3
5.3.1

Fact Sheets Fertility and Baseline

Fact Sheet Kinango Contraceptive Prevalence Survey March 1989

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Module 5: Baseline Summaries 5.3.2 Fact Sheet Etono Fertility Survey August 1990

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Module 5: Baseline Summaries 5.3.3 Fact Sheet Lake Kenyatta Fertility Survey March 1990

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Module 5: Baseline Summaries 5.3.4 Fact Sheet Bukwala Baseline Survey April 1990

Maternal and child health and family planning in the catchment area of Bukwala SOA Church dispensary, Kakamega District

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Module 5: Baseline Summaries 5.3.5 Fact Sheet Lwanda Baseline survey May 1990

Maternal and child health and family planning in the potential catchment area of Lwanda SDA Church dispensary, South Nyanza District

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Module 5: Baseline Summaries 5.3.6 Fact Sheet Nyamira Baseline Survey September 1990

Fertility, maternal and child health and family planning in Nyamara District

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Module 5: Baseline Summaries 5.3.7 Fact Sheet Bungoma Baseline Survey December 1994

Fertility, mortality and child health and family planning in Bungoma District

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Module 5: Baseline Summaries 5.3.8 Fact Sheet Siaya Baseline Survey April 1995

Fertility, mortality and child health and family planning in Siyaya DistrictI

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Module 5: Baseline Summaries 5.3.9 Fact Sheet Makueni Baseline Survey April 1996

Fertility, mortality, maternal and child health and family planning in Makueni District

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Module 5: Baseline Summaries 5.3.10 Fact Sheet Meru Baseline Survey May 1997I

Fertility, mortality, maternal and child health and family planning in Meru District

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Module 5: Baseline Summaries 5.3.11 Fact Sheet Uasin Gishu Baseline Survey December 1997

Fertility, mortality, maternal and child health and family planning in Uasin Gishu District

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5.4

Trans Nzoia Baseline Survey - Summary Report July 1996

Fertility, mortality, maternal and child health and family planning in Trans Nzoia District 5.4.1 Fact Sheet

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Module 5: Baseline Summaries 5.4.2 Background

Trans Nzoia District, located in Rift Valley Province, has an area of 2,467 km2 and a population at the 1989 census of 393,682 with a sex ratio of 101 males per 100 females. The district is situated in a rich agricultural area of Kenya, with several large private and Government-run farms producing maize, coffee, sunflowers and a range of other cash crops. Maize and sweet potatoes are also grown on smallholdings, and dairy farming is an activity also found on large and small farms. The district has 61 static health facilities, including a District Hospital at Kitale, three health centres and 16 dispensaries operated by the Ministry of Health. Several NGOs currently operate mobile outreach clinics and CBD programmes in the district. The district, however, is poorly covered by CBD services. Most CBDs operate in the peri-urban slum areas of Kitale Town, leaving the rural areas thinly covered. Trans Nzoia has one of the most diverse cultural and socio-economic environments of any rural part of Kenya. The district was an area of European mixed farming during colonial times, and the post-colonial era saw in-migration from many cultural groups, those nearby (Nandi, Luhya), and those from further away (Kikuyu, Luo, Teso, Kisii, Giriama). More recently, Turkana and Pokot fleeing the insecurity of their homelands, have joined these groups. Three sample clusters representing the cultural and socio-economic diversity in the district, were selected for fielding the baseline survey each cluster centred on a health facility where a GTZ/DPHC CBD programme was to be initiated. Waitaluk, some 15 km south of Kitale, consists mainly of smallholder farms. Endebess, about 20 km west of Kitale close to Mount Elgon consists of large-scale farms and squatter smallholdings. Cherangani, some 50 km east of Kitale bordering Elgeyo District, has a mixture of these types. Fieldwork took place between 16-19 and 23-25 April 1996, yielding a total sample of 891 women age 15-49. 5.4.3 Fertility

Levels and Differentials At current fertility levels, a woman in Trans Nzoia will give birth to an average of 7.1 children during her reproductive years compared with the national average of 5.4 children reported in the 1993 KDHS. This high rate of fertility suggests that the demographic transition has hardly began in the district, although the average parity levels for women over 40 years, at 8.2, suggests that some decline in fertility has already occurred. Women in the main childbearing ages 20-34 account for most of the high fertility, suggesting low contraceptive prevalence in this group.

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Module 5: Baseline Summaries Though fertility is high in all three clusters, the rates are much higher in Cherangani (7.85 children per woman) than Waitaluk (7.12) and Endebess (6.96). Childbearing begins early in Trans Nzoia. Over one in four teenage women (age 1519) has begun childbearing compared with the national figure of one in five in the 1993 KDHS. Twenty-three percent of teenage women in Trans Nzoia are already mothers and another 5 percent are pregnant with their first child. Marriage and Exposure to Risk of Pregnancy The levels of desire for more children are remarkably low in Trans Nzoia, given the very high rates of fertility. Only 16 percent of all non-pregnant ever-married women want to give birth soon. The desire for more children among the youngest women age 15-19 and 20-24 (30 and 23 percent respectively) compare with 34 and 17 percent in the 1993 KDHS, where overall fertility was much lower than in Trans Nzoia. Polygamy is not very common in Trans Nzoia. Just over one in five currently married women is in a polygamous union. Polygamy varies by age and education. It is most common among women age 35-39 (39.5 percent) and uneducated women (30 percent). 5.4.4 Family Planning Knowledge and Use of Contraception

Knowledge of family planning methods is virtually universal. Among ever-married women, 99 percent know at least one modern method. This figure compares with the 1993 KDHS figure of 97 percent. The injectables, pill, condom, IUCD and TL are the most widely known methods. Trans Nzoia rates for ever-use and current use of contraception are all below comparable national rates. Almost half of ever-married women have ever-used a contraceptive method while 28 percent are currently using a contraceptive method. The national figures for ever-use and current use are 55 and 33 percent respectively. The Trans Nzoia baseline survey CPRs are identical to the 1993 KDHS estimates for Rift Valley Province for currently married women using any method (28 percent) and those using any modern method (21 percent). Just over two in three women who are using contraception employ modern methods, principally the injectables (13 percent of ever-married women), pill (4 percent) and tubal ligation (2 percent each). Contraceptive use varies by age, sample cluster, education, ethnicity and desire for children. Contraceptive prevalence is highest among women in the main childbearing ages 25-39 (between 33 and 34 percent) than any other age group; in Waitaluk (28 percent) compared with Endebess (22 percent) and Cherangani (24 percent); among women with secondary education (31 percent) than those with lower or no education;

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Module 5: Baseline Summaries among Kikuyu women (31 percent) than women in other ethnic groups; and among women who want to delay the birth of their next child (13 percent). The government is the most important provider of family planning services. Ninetyfour percent of women who use modern methods obtain their supplies from a conventional health facility, with 6 percent from other sources. Despite the existence of NGO CBD programmes in the district, no single user obtaining their method from a CBD was interviewed. Nonuse of Contraception The main reasons given for non-use of methods were breastfeeding (30%), abstaining from sex (19%), afraid of contraceptive side effects or infertility (16%), want a pregnancy soon or already pregnant (14%each), or gynaecological problems (10%). Lack of awareness of methods was cited by 7.5%of non-users, and religious reasons by 5%. Demand for Family Planning Services More than one third of all women in Trans Nzoia have an unmet need for family planning. This group comprises women who are not using any family planning methods and gave non-biological reasons for non-use (22 percent) and those breastfeeding and/or amenorrheic (14 percent). Combined with the 24.5 percent of all women who are currently using a contraceptive method, the total potential demand for family planning services comprises 60.5 percent of all women in Trans Nzoia. 5.4.5 Maternal and Child Health

Infant and Child Mortality The data for the most recent two-year period (1994-95) before the survey are too scanty to estimate a reliable infant mortality rate. However, the District data base estimates an infant mortality rate for Trans Nzoia District of 48 per 1,000 live births, a rate well below the national average of 62 but almost identical to the 1993 KDHS rate for Rift Valley Province of 45 per 1,000. Estimates of child survival using the Brass-Trussed method, also confirm the high survival probabilities for recently-born children in the district. For example, while a child born 1.5 years ago to a teenage mother age 15-19 has a 96 percent chance of being alive at the time of the survey, a child born 2.8 years before the survey, to a mother age 20-24 has a survival probability of 92 percent.

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Module 5: Baseline Summaries Antenatal Care and Assistance at Delivery Utilisation of antenatal services is lower than it should be, given the reasonable coverage of the district by Government and private or NGO health facilities. However, 30 out of 33 women in their third trimester had attended an ANC clinic at least once. None of the 17 women in their first trimester had attended by the time of interview. The median number of antenatal care visits is 3. The rate of delivery at home is extremely high. Over three-quarters of women delivered their last-born children at home. Almost one in four of last-born children were delivered by medically trained personnel, 26.5 percent of births were assisted by traditional birth attendants, while almost one in three was assisted by relatives. Almost 18 percent of women delivered their last child without assistance. Given the high rate of home deliveries, the role of the TBA is important in the safe motherhood of the district. A much higher proportion of recent births, compared to births from five years or more before the survey, have been attended by TBAs, illustrating the growth of this programme. 5.4.6 Conclusions

Fertility levels in Trans Nzoia are well above the Kenyan average, but there are many signs from the survey data that rapid fertility decline may be imminent in the district. The remarkably low rates of polygamy and desire for more children, favourable male attitudes towards family planning and the relatively high contraceptive prevalence, given the very high rates of fertility, reflect this view. The high fertility in Trans Nzoia may be symptomatic of supply-side deficiencies, which a CBD programme could help alleviate. Thus, Trans Nzoia presents a great opportunity for CBD services because the objective demographic, social and geographical conditions in the district are most conducive to the CBD model supported by the GTZ FP Project. The same conclusion can be reached regarding safe motherhood. Although it does not appear that maternal mortality is a serious problem, extremely high proportions of women give birth at home, many of them attended by untrained personnel. Trans Nzoia District also has a significant unmet demand for family planning, with more than one third of all non-pregnant, fecund women at risk of an unwanted pregnancy. To cater for unmet needs, the CPR in the district would have to exceed 60%. (The CBD programme in Trans Nzoia District has taken off well, with a total of some 500 CBD agents operating in the catchment areas of 17 health facilities, including the three areas sampled in the survey by the end of 1997. Waitaluk Dispensary won the "Best District Project" prize for the 1996/97 period.)

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5.5

Nyamira Follow-Up Survey - Summary Report June 1996

Fertility change, family planning and the impact of Community-Based Distribution of contraceptives in Nyamira District, 1990 1995 5.5.1 Fact Sheet

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Module 5: Baseline Summaries 5.5.2 Background

The follow-up survey in Nyamira District is the first of its kind in the series of baseline surveys carried out by the GTZ/MoH Project. Revisiting the same sample clusters as the 1990 survey, its purpose was to monitor change in behaviour and fertility outcomes in the district, and to assess the impact of the CBD programme in contributing to this change. Nyamira District is situated in Nyanza Province and has an area of 1,105 km2 divided into five administrative divisions. The district, created in 1989 from a subdivision of Kisii District, has an average population density of 475 persons per km2, including some of the highest densities in rural Africa. Population at the 1989 census was 525,096, with a sex ratio of 93 males per 100 females. Most of Nyamira District lies above 2,000 metres in the Western Highlands, forming part of the eastern rim of the Lake Basin. The combination of climatic, pedologic and topographical conditions favour commercial agriculture. The district supports a significantly-developed cash economy. Tea is the leading cash crop followed by coffee, pyrethrum and banana grown mainly on smallholder farms. Dairy farming is an activity also found on smallholder farms. Subsistence crops include maize, beans, bananas, sweet potatoes, millet and fruit crops. The district has 36 static health facilities operated by Government, NGO and private concerns, including a District Hospital in Nyamira Town. Of these, 19 are health centres and 16 dispensaries. Several agencies currently operate CBD programmes in the district, i.e. GTZ FP Project with 40 active CBDs in Ekerenyo and 47 in Manga, and Family Planning Association of Kenya with 38 CBDs covering both Esani and Manga. Ekerenyo, Manga and Esani, the three clusters used in the 1990 Baseline Survey were revisited. Ekerenyo lies in the north-east corner of Nyamira, Manga in the north-west and Esani in the south. Fieldwork took place between 19-22 November 1995. A flaw in the siting of one set of interviews necessitated the repeat of one cluster taken between 9-13 April 1996, yielding a total sample of 620 women age 15-49. 5.5.3 Fertility

Levels and Differentials At current fertility levels, a woman in Nyamira will give birth to an average of 4.8 children during her reproductive years compared with the national figure of 5.4 children reported in the1993 KDHS. Women in the main childbearing ages (except age 30-34) account for most of the low fertility, suggesting a strong limiting strategy following a child-spacing one, an ideal combination for good family planning.

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Module 5: Baseline Summaries Fertility rates are almost twice as high in Ekerenyo (6.54 children per woman) compared with either Manga (3.89) or Esani (3.97), the wide differences being attributable to differing levels of female education between the clusters. Childbearing begins late in Nyamira. Only 8.5 percent of teenage women (age 15-19) have begun childbearing, a figure almost three times lower than the national figure of 21 percent in the 1993 KDHS. Seven percent of teenage women in Nyamira are already mothers and another 1 percent are pregnant with their first child. Marriage and Exposure to Risk of Pregnancy Nyamira is vastly a pro-family planning district with only 12 percent of all nonpregnant ever-married women wanting to give birth soon. However, the desire for children is slightly high among the youngest women (40 and 19 percent for age groups 15-19 and 20-24 respectively). The KDHS figures for 1993 are 34 and 17 percent respectively. Polygamy is uncommon in Nyamira. One in five currently married women is in a polygamous union. Polygamy varies by sample cluster and education. It is highest in Manga (31 percent) and most common among women who have not completed a full primary education (30 percent). 5.5.4 Family Planning

Knowledge and Use of Contraception Knowledge of family planning methods is universal. All ever-married women interviewed in this survey, know at least one modern method. This figure compares favourably with the 1993 KDHS figure of 97 percent. The pill, injectables, condom and TL are the most widely known methods. Nyamira rates for ever-use and current use of contraception are all below comparable national rates. Almost three in four ever-married women have ever-used a contraceptive method while more than half (54 percent) are currently using a contraceptive method. The national figures for ever-use and current use are 55 and 33 percent respectively. The Nyamira baseline survey CPRs are much higher than the 1993 KDHS estimates for Kisii District for currently married women using any method (40 percent) by 14 percentage points and those using any modern method (38 percent) by 12 percentage points. The use of modern methods of family planning is the norm among contracepting women. More than 90 percent of women who are using contraception employ modern methods, principally injectables (22 percent of ever-married women), the pill (15 percent) and tubal ligation (12 percent).

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Module 5: Baseline Summaries Contraceptive use varies by age and sample cluster. Among ever-married women, contraceptive prevalence is higher among women age 35-39 and 40-44 (79 and 69 percent respectively) than any other age group and in Esani (60 percent) than in Ekerenyo (52 percent) and Manga (51 percent). Around one-quarter of all pill-users in the sample were supplied by CBD agents.=> 78% of respondents had heard of CBD and 28% said they had talked to a CBD. 40% of users had talked to a CBD. Most Ekerenyo respondents had heard of the programme, but comparatively few had ever talked to a CBD agent compared with the other clusters. Non-use of Contraception Close to three in five women in Nyamira who are currently not using a contraceptive method are either abstaining from sex (40 percent), breastfeeding/amenorrheic (20 percent), already pregnant (14 each), want a pregnancy soon (13 percent), or experiencing a gynaecological problem (11 percent). Nonusers also cited fear of contraceptive side effects or infertility (6 percent), husband objection (3 percent) and lack of awareness of methods (1 percent). Demand for Family Planning Services Excluding women claiming to be abstaining from sex, only 3.5% of all non-pregnant, fecund women have an unmet need for contraception. However, a large proportion of the breastfeeding group is also most likely to be at risk. The proportions of women desiring a pregnancy soon declined from 19% to 11% between the surveys. 5.5.5 Maternal and Child Health

Infant and Child Mortality The data for the most recent two-year period (1993-94 and 1994-95) before the survey is too scanty to estimate a reliable infant mortality rate. Both the 1990 and the present survey record very few children born recently who failed to survive. Antenatal Care and Assistance at Delivery Utilisation of antenatal services is relatively high, with over 60% of currently pregnant women, including all women in the third trimester, having made at least one clinic visit. Although ANC attendance is good, over half (55 percent) of the births take place at home, probably a reflection of the poor communications in the district. 45% of

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Module 5: Baseline Summaries deliveries are assisted by medically trained personnel, 26.5 percent assisted by traditional birth attendants, while slightly more than one in ten is assisted by relatives. Seventeen percent of women delivered their last-born child without assistance. The proportion of babies delivered by TBAs in Nyamira over time has risen greatly, from 6% of all deliveries and 11% of all home deliveries, to 27% and 49% respectively. Ekerenyo has a particularly high proportion of births attended by TBAs. Knowledge of a local maternal death was almost double in 1995/6 compared with 1990, suggesting that there are still significant problems with safe motherhood to be solved. 5.5.6 Conclusions

Nyamira District is undergoing a rapid demographic transition, which probably began before the GTZ FP Project activities began. This is reflected in the low rates of polygamy (by Western Kenya standards) and fertility, smaller proportions of women desiring a pregnancy soon, positive male attitudes towards family planning and very high levels of female education and contraceptive prevalence. Because of the very high levels of female education in Nyamira, knowledge of family planning methods is universal and the role of the CBDs in dispelling rumours and reassuring clients is an important one. Consequently, the pattern of non-use of contraception shows a dominance of biological rather than "involuntary" reasons usually targeted particularly for attack by CBDs during counselling. However, overstatement of the contraceptive effect of breastfeeding and exaggeration of the extent of sexual abstinence among teenage women as "biological" reasons for nonuse, possibly underestimate the true extent of unmet need for family planning. Because of the significant activity of FPAK CBD workers in the area, it is difficult to attribute these changes to the Project's CBD activities. There is a high level of awareness amongst the population of the existence of CBD. The results for Ekerenyo, however, suggest that the programme there is rather weak. The health of mothers and children in Nyamira is generally good, with an absence of the major infectious and parasitic diseases, high rates of child survival and little apparent problems of maternal mortality. Antenatal clinic attendance is at a reasonable level. Home deliveries, are, however, the norm, and the importance of TBAs in ensuring safe deliveries is clearly growing. (By 1996, most of the health facilities in Nyamira had a CBD programme supported by the GTZ/MoH Project. Further expansion took place, mainly amongst company clinics in the tea estates during 1996. By the end of 1997, just under 1000 CBD agents were active in 31 sites. Drop-out of CBD agents has been a greater problem in Nyamira, compared with other districts, probably due mainly to the importance of the local cash economy, but the Nyamira DHMT have been training replacements in the worst-hit areas. The CBD programme at Manga has won the "best district project" award for two consecutive years.)

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