METHODS

 

BACKGROUND: THE NMIS METHODOLOGY

The NMIS uses a methodology known as Sentinel Community Surveillance (SCS). This is described in detail elsewhere16,17,18. It has the underlying aim of 'building the community voice into planning'. SCS can be described as a multi sectoral community-based information management system. There are a number of particular features of the SCS methodology.

A key feature of SCS is the ability to do risk analysis to look at causes. In NMIS cycle five the focus is on reasons for not receiving antenatal care and for undersized babies or death of babies.

SCS is deliberately designed to concentrate data collection efforts: in time (a series of cycles in the sentinel sites, at approximately 6 monthly intervals); in space (representative communities are surveyed rather than collecting data from all communities); and in subject matter (each cycle focuses on one area at a time, rather than trying to collect all possible data on every occasion). SCS employs a type of cluster survey methodology, but the clusters are larger than in many cluster surveys: typically 100-120 households per site, rather than the 10-50 used in most cluster surveys. And in the SCS method, there is no sampling within each site; every household is included. This gives greater statistical power in the data analysis and also allows the linkage of data from the household questionnaires to other, mainly qualitative, data from the same sites. This data relating to the whole site is combined with the household data in a mesoanalysis18.

A key issue in the SCS methodology and in the NMIS is the selection of sites so as to be representative. In some countries, random sampling is not a possibility because no adequate sampling frame exists. In these situations, purposive selection is used, drawing on local knowledge of conditions to choose sites as representative as possible of the situation in a district, region or country. When possible, random sampling methods are used and this is the case in Nepal, where a reasonably good census sampling frame exists. In both cases, stratification is first used to ensure that certain types of sites are included in proportion to their occurrence in the population. For example, stratification can be by urban and rural sites, or by ecological zones. In the NMIS, the sample sites for the NMIS were drawn by the Central Bureau of Statistics (CBS), after stratification into development regions, ecological zones and urban/rural sites. The details of the sampling method and the selected sites are given in the report of the first NMIS cycle1 and the annexes to that report.

 

NMIS CYCLE 5: SAMPLE SITES

As mentioned above, these are the same sites as for the first four NMIS cycles, selected by a multistage random sampling method. As discussed in the report of the first NMIS cycle, the sites are representative of the country, of the five development regions, of the three ecological zones, of the 15 eco-development regions, and of urban and rural situations. The rural sites were selected primarily to give representation of the 15 eco-development regions but in 18 districts there are sufficient sites (four or more) to ensure reasonable district representativeness. In a further 19 districts, only 1-2 sites were selected so they cannot be relied upon to be representative of that district. Note that representation of the 15 eco-development regions is among the rural sites only; the urban sites are stratified separately and are not intended to be part of the representation of the different eco-development regions. This reflects the high proportion of the population living in rural communities (around 90%) and the difficulty of having a large enough urban samples to stratify separately among the 15 eco-development regions.

There are a total of 144 sites in the sample: 126 rural and 18 urban. The location of the sites is shown on the map in Annex 1. Annex 1 also gives the names of the Districts in the NMIS sample, with the number of sites in each. It also includes a list of all Districts in Nepal grouped into the 15 eco-development regions. This is intended for officials from non-NMIS Districts who read the report to find which results most nearly approximate to their situation (the results for the relevant eco-development region).

THE POPULATION IN NMIS CYCLE 5

A total of 18,996 households were visited in the 144 sites. Information was available for 18,653 households (99%). Only 1% households refused the interview. The total population in the households interviewed is 106,160 people. More detailed information was collected from ever-married women aged 15-49 years: a total of 19,557 women. They reported on their last pregnancy and data on a total of 17,609 pregnancies were collected.

Household information was collected from:
  • 18,653 households
  • 106,160 people
  • 19,557 ever--married women 15-49 years
  • 17,609 pregnancies

INSTRUMENTS

The instruments used in cycle 5 are reproduced in Annex 2. They include a household questionnaire, focus group guides, key informant and Traditional Birth Attendant (TBA) interviews, and a health facility review/interview. The instruments were designed with a Technical Group of the NMIS Steering Committee, including government, university and UNICEF experts in antenatal and obstetric care, and subsequently approved by the Steering Committee.

Instruments used in NMIS cycle 5:
  • Household questionnaire
  • Health facility interview schedule
  • Key informant and TBA interviews
  • Focus group guides

The household questionnaire includes questions about each ever-married woman aged 15-49: age, literacy, timing of last pregnancy, antenatal care, other practices during pregnancy (such as smoking), place of delivery and attendance at delivery, size of the baby and survival of the baby. The reference periods for the different questions on the household questionnaire are shown in the questionnaire itself (Annex 2).

For 132 of the 144 communities, the health facility that most served the community was visited and the most senior worker was interviewed. The visit and interview focused on aspects of antenatal and delivery care.

TBAs working in the communities were interviewed about their practices for care and advice during pregnancy and delivery. In total, 177 TBAs were interviewed. Up to 4 were interviewed in a single community, but no TBA was interviewed in 23 of the 144 communities (16%).

In 142 of the 144 communities, a focus group of ever-married women of child bearing age (15-49 years) was held to discuss practices and care during pregnancy and delivery and the best ways to give messages about antenatal and delivery care to communities. A second focus group of mothers of young children was held in each community to discuss the findings of NMIS cycle 4 (on early childhood feeding, nutrition and development) and the best way to pass on the important messages about this to communities.

The focus group guide for cycle 5 covers reasons for not having antenatal care and suggestions for improving antenatal services, arrangements for emergencies during pregnancy and delivery and suggestions about improving matters. The cycle 4 focus group guide covers ways in which mothers could be helped to feed their young children more often and the importance of feeding food of high nutritional value to children. The results of the cycle 4 feedback are not given in this report.

Coding sheets and data entry formats were created for each instrument. Data entry was programmed using Epi Info (version 6)19. The data were entered twice and validated using Epi Info. Epi Info was also used for the analysis of the data. The data collection instruments were piloted several times to ensure that they were appropriate to the households, health facility workers and focus groups concerned and that the coding and data entry arrangements were satisfactory.

Training and field work

Field staff were recruited in March 1997. They were recruited from and trained in five regional centres: Kathmandu, Janakpur, Nepalgunj, Pokhara and Sunsari. Twenty-six teams, each containing four or five members, were recruited. The thirty field supervisors were trained in Kathmandu. The field survey was carried out between March and April 1997.

When communities were visited, the opportunity was taken to give them a summary of the results of cycle 4 and conduct focus groups to discuss the implications of the key findings and the ways in which important messages might best be disseminated.

Data coding and entry began during fieldwork, with messengers bringing back as much data as possible to Kathmandu from each of the field teams. Data entry began in July 1997 and data entry and cleaning of quantitative data was completed by mid September 1997. Data entry of qualitative data from focus groups was completed by the end of October 1997.

Analysis

The analysis aimed to produce national indicators on antenatal and delivery care in Nepal; to examine variables that might be related to this antenatal and delivery care and birth weight and survival of the baby; and, importantly, to look for contrasts so as to discover actionable factors that might help to improve the situation. This required an analysis of the risk of not having adequate care or of an adverse outcome for the baby in relation to possible explanatory variables (for example, literacy, access to facilities, advice from health workers, antenatal and delivery practices - for the baby outcomes). The effects of variables in combination were examined using multiple stratification and logistic regression. The logistic regression was a step down from a saturated model to find the best fitting, most parsimonious model.

For most of the analyses, all reported last pregnancies are included. Analyses including only pregnancies within the last 5 years were also undertaken. In most cases the results for all pregnancies are very similar to those when only more recent pregnancies are included, suggesting little recent change in practices. Any differences are highlighted in the report.

The analysis used the EpiInfo package (version 6)19. This public domain package assists with questionnaire creation, data entry and data analysis. The strength and statistical significance of associations were tested using the Mantel-Haenszel X2 test20 and the Mantel Extension of this test21. Logistic regression used SPSS22.

Quantitative analysis was supplemented by qualitative data from focus groups, key informants and observation. The records of all focus groups were reviewed for an overview of the ideas expressed. Each record was then coded the issues raised by the participants. These codes were then related to information from the household questionnaires from the same community. The focus group themes and data from other qualitative instruments are shown in Annex 3, with the frequencies of each theme and response.

Weighting of results to give national indicators.

As explained previously1, the sample sizes of Districts were not proportional to the populations of the Districts and weights were calculated to take this into account for national indicators. The weights give the correct balance of individual areas in national figures, for example taking into account relative over sampling of mountain eco development regions and urban sites. These weights were used in this cycle of the NMIS for national indicators. The weighted and unweighted national values for key indicators are shown in annex 4. The Epi Info programme CSAMPLE was used to calculate weighted values of key indicators. In practice, the weighted values are close to the unweighted values. Unless stated otherwise, values of indicators quoted in the Results section for the whole of Nepal are weighted. Values of indicators at subnational levels (such as eco development regions and in urban and rural sites separately) given in Annex 5 are deliberately not shown weighted.

 


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