Full ANC: At least three visits for antenatal check-up, one TT injection received and 100 IFA tablets or adequate amount of syrup consumed.
Full Immunization: BCG, three injection of DPT, three doses of Polio (excluding Polio 0) and Measles.
Unmet need for spacing includes the proportion of currently married women who are neither in menopause or had hysterectomy norare currently pregnant who want more children after two years or later and are currently not using any family planning method. The women whoare not sure about whether and when to have next child are also included.Unmet need for limiting includes the proportion of currently married women who are neither in menopause or had hysterectomy nor are currentlypregnant and do not want any more children but are currently not using any family planning method
1. District Level Household & Facility Survey III Dr. Suraj Chawla Department of Community Medicine, PGIMS, Rohtak
2. CONTENTSIntroductionObjectives of DLHS-3Agencies involved & fundingSurvey designSample instrumentsField work & sample coverageData processing & tabulationSample implementationFact sheet: India & HaryanaSalient points about DLHS- 4
3. INTRODUCTIONThe Reproductive and Child Health (RCH) programmethat has been launched by the Government of India(GoI) is expected to provide quality services and achievemultiple objectives.It ushered a positive paradigm shift from the method-oriented, target-based approach to providing client-centered and demand-driven quality services. Also,efforts are being made to reorient provider’s attitudeand to strengthen the services at outreach levels.The new approach requires decentralization of planning,monitoring and evaluation of the services.
4. CONT… The district being the basic nucleus of planning and implementation of the RCH programme, Government of India (GoI) has been interested in generating district level data on utilization of the services provided by government health facilities. It is also of interest to assess people’s perceptions on quality of services. Therefore, it was decided to undertake the District Level Household Survey (DLHS) under the RCH programme in the country. The recent District Level Household and Facility Survey (DLHS-3) 2007-08 is third in the series preceded by DLHS-1 in 1998-99 and DLHS-2 in 2002-04.
5. CONT… DLHS-3 is one of the largest ever demographic and health surveys carried out in India, with a sample size of about seven lakh households covering all districts of the country. DLHS-3, like other two earlier rounds, is designed to provide estimates on maternal and child health, family planning and other reproductive health indicators. In addition, DLHS-3 provides information related to the programmes under the National Rural Health Mission (NRHM). Unlike other two rounds in which currently married women aged 15-44 years were interviewed, DLHS-3 interviewed ever-married women (aged 15-49).
6. CONT… In DLHS-3, along with ever-married women, unmarried women (aged 15-24) are also included as respondents. In DLHS-3, facility survey is integrated with the household survey with a view to link the RCH care outcomes to health facility accessibility, availability of medical and paramedical manpower and other village infrastructure.
7. OBJECTIVESThe main objective of DLHS-3 is to provide RCH indicatorsat the district level covering the following aspects: Coverage of antenatal care and immunization services Proportion of institutional/safe deliveries JSY beneficiaries Contraceptive prevalence rates ASHA’s involvement Unmet need for family planning Awareness about RTI/STI and HIV/AIDS Family life education among unmarried adolescent girls Linkage between health facility and RCH indicators.
8. AGENCIES INVOLVED & FUNDING The Ministry of Health and Family Welfare (MoHFW), GoI designated the International Institute for Population Sciences (IIPS), Mumbai, as the Nodal Agency responsible for the development of survey design, instruments, data entry and tabulation software, training, supervision of field work, analysis and report writing. The sources of funds for DLHS-3 are the MoHFW, GoI and United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF). A Technical Advisory Committee (TAC) constituted by the MoHFW, GoI guided the designing, implementation, progress, tabulation, basis of selection of RCH indicators and consistency issues.
9. SURVEY DESIGNA multi-stage stratified systematic sampling design wasadopted for DLHS-3.In each district, 50 Primary Sampling Units (PSUs) whichwere census villages for rural areas and wards for urbanareas were selected in the first stage by systematicProbability Proportional to Size (PPS) sampling.The Census of India 2001 was the sampling frame . Allvillages and urban wards in a district were stratified in todifferent strata based on household size ( < 50, 51-300and 300+ ); percentage of ST/SC population (below orabove 20%), female literacy ( in 7+ age), etc.
10. CONT… The sample size among the districts in the country varies according to their performance in terms of ante-natal care (ANC), institutional delivery, immunization, etc. and it was fixed based on information related to such indicators from DLHS-2. For low performing districts, 1500 Households (HHs), for medium performing districts, 1200 HHs and for good performing districts, 1000 HHs were fixed as sample size. In addition 10 percent over-sampling of households was made to cushion for non-response.
11. CONT… The PSUs are allocated to rural and urban areas of each district proportionally to the actual rural-urban population ratio. Within the rural-urban domains, the PSUs are further distributed proportionately to the different sub-strata of combinations of household size, percentage of SC/ST population and levels of female literacy. In rural areas in the second stage of sampling households were drawn from the selected villages (PSUs) after house listing.
12. CONT… For larger villages (more than 300 HHs) segmentation was carried out. In case of 300 to 600 HHs, two segments of equal size were made and one was selected using PPS. For PSUs having more than 600 HHs, segments of 150 HHs were created depending on the size and then two segments were selected using PPS. No segmentation was necessitated for sampled villages with less than 300 households. Small villages with less than 50 households were linked with other nearby villages to form a PSU appropriate for mapping and listing.
13. CONT… In case of urban areas, number of wards were selected using PPS at first stage. In a selected ward, one census enumeration block (CEB) from 2001 census was selected again using PPS. No CEB was segmented as the CEBs had less than 300 households. Mapping and listing of selected CEBs in urban areas were carried out under systematic monitoring and supervision. The numbers of households selected from the sampled PSUs of districts represented by 1,000, 1,200 and 1,500 households were 22, 27 and 33 respectively. Circular systematic sampling was adopted for the selection of households.
14. SURVEY INSTRUMENTSThe uniform bilingual questionnaires, both in English andin local language, were used in DLHS-3 viz., Household,Ever Married Women (age 15-49), Unmarried Women(age 15-24), Village and Health facility questionnaires.In the household questionnaire, information on allmembers of the household and the socio-economiccharacteristics of the household, assets possessed, numberof marriages and deaths in the household since January2004 etc. was collected.In case of female deaths, attempts were made to assessmaternal death.
15. CONT… The household questionnaire also collected information on respondent’s knowledge (seen/read/heard) about messages related to various government health programmes being spread through media and other sources. The ever married womens questionnaire consisted of sections on womens characteristics, maternal care, immunization and child care, contraception and fertility preferences, reproductive health including knowledge about HIV/AIDS.
16. CONT… The unmarried womens questionnaire contained information on her characteristics, family life education and age at marriage, reproductive health-knowledge and awareness about contraception, HIV / AIDS, etc. The village questionnaire contained information on availability of health, education and other facilities in the village and whether the health facilities are accessible throughout the year. The respondent for the village questionnaire is either ‘Sarpanch’ or ‘Pradhan’, or any other knowledgeable person in the village including ‘teacher’.
17. CONT… For the first time, population-linked facility survey has been conducted in DLHS-3. In a district, all Community Health Centres (CHCs) and District Hospital (DH) were covered. Further, all Sub-centres (SC) and Primary Health Centres (PHC) which were expected to serve the population of the selected PSU were also covered. There were separate questionnaires for SC, PHC, CHC and DH. They broadly include questions on infrastructure, human resources, supply of drugs & instruments, and performance.
18. Team Composition of Field StaffMapping & Listing Team No. Educational QualificationMapper 1 Graduate in any discipline (Preferably Social Sciences)Lister 1 Graduate in any discipline (Preferably Social Sciences)Facility Survey TeamHealth Investigator (Facility Survey) 2 The minimum qualification for health investigator should be Diploma or degree in Para medical coursesHousehold Survey TeamSupervisor 1 Graduate in any Social Science (Prefer knowledge of Biology) having experience of large scale surveyInvestigator 4 Graduate in any discipline(3 Females and 1 Male) (Preferably Social Sciences)
19. State Level Staffs with Regional AgenciesSl. No. Name of Position No. Educational Qualification Experience State Level Staff 1 Project 1 Ph D./Masters Degree in 1. Experience in large scale surveys Coordinator Mathematics/ • At least 5 years experience of (Full time) Statistics/Social Science / handling large scale One x per State x Demography demographic/health surveys as a per RA team leader 2 I.T. Consultant 1 Post Graduate 5 years of experience in handling (Full time) degree/Diploma in any 1. Large Scale Demographic Survey One x per State x Computer Science data per RA Application 3 Health Coordinator 1 MBBS/BAMS or any other At least two years experience in Bio- (Full time) medical degree marker in Health surveys One x per State x per RA 4 Statistician/ 1 Ph D./M.Phil/ Masters 3 years of experience for Ph.D./M. Demographer Degree in the relevant field Phil holders (Consultant) 5 years of experience for Master Degree holder in handling Large Scale Demographic Survey data
20. FIELD WORK AND SAMPLE COVERAGE The field work of DLHS-3 was carried out during December 2007-December 2008 in 34 states and union territories covering 601 districts in the country. The present report excludes the state of Nagaland. DLHS-3 questionnaires were canvassed from 7,20,320 households, 6,43,944 ever married women aged 15-49 years and 1,66,260 unmarried women aged 15-24 years. However, for the purpose of comparison with DLHS-2 indicators based on currently married women aged 15-44 years in the selected tables. The Facility Survey covered 18,068 Sub-Centres, 8,619 Primary Health Centres, 4,162 Community Health Centres and 596 District Hospitals.
21. DATA PROCESSING AND TABULATION CSPro (Census and Survey Processing System) based data entry software was developed in-house and IT-in- Charge personnel of all Regional Agencies (RAs) were given one weeks’ training on the use of the software. DLHS-3 data for all types of questionnaires were entered by the collaborating Regional Agencies and validated centrally at IIPS. CSPro software has a module for generation of district socio-demographic and RCH indicators and RAs used this module to run district level indicators and brought out district fact sheets. For state and national tabulation STATA and SPSS syntaxes were written and executed.
22. SAMPLE IMPLEMENTATIONThe overall household response rate − the number ofhouseholds interviewed per targeted 100 households −was 94 percent.For the ever-married women, the overall response rateat the national level was 89 percent.However, the overall response rate for unmarriedwomen was only 85 percent.Regional Agency for Haryana : ORG Centre of SocialResearch, New DelhiMonitoring Agency for Haryana : NIHFW, New Delhi
23. Antenatal care India- Total India- Rural India- Urban (Haryana) (Haryana) (Haryana) Indicators (%) DLHS DLHS DLHS DLHS DLHS DLHS III II III II III IIMothers who received any 75.2 73.6 70.6 67.5 87.1 89.3antenatal check-up (87.3) (86.4) (85.2) (85.6) (93.8) (93.1)Mothers who had antenatal 45.0 40.4 38.5 33.3 61.8 58.7check-up in first trimester (55.1) (13.7) (52.0) (14.4) (64.4) (6.9)Mothers who had three or 49.8 50.4 44.1 41.9 69.1 72.1more ANC (51.9) (43.1) (47.2) (40.8) (66.1) (63.9)Mothers who had at least 73.4 80.2 68.7 76.6 85.6 89.6one TT injection (86.1) (83.5) (84.1) (82.7) (92.1) (90.9) 45.7 57.7 38.0 50.2 65.8 77.1Mothers whose BP taken (42.8) (38.0) (36.9) (34.9) (60.6) (65.7)Mothers who consumed 100 46.6 20.5 47.3 16.9 45.0 29.6IFA Tablet (29.0) (16.5) (28.1) (15.9) (31.7) (21.6) 18.8 16.5 14.7 12.8 29.4 25.9Mothers who had full ANC (13.3) (10.3) (10.2) (9.5) (22.6) (17.9)
24. DLHS-3 India & State factsheet Percentage of women who received full ANC
25. Delivery care India- Total India- Rural India- Urban (Haryana) (Haryana) (Haryana) Indicators (%) DLHS DLHS DLHS DLHS DLHS DLHS III II III II III II 47.0 40.9 37.9 29.8 70.5 69.4Institutional delivery (46.9) (35.7) (42.2) (27.3) (61.4) (56.4) 52.3 58.6 61.3 69.8 29.0 29.8Delivery at home (52.6) (64.3) (57.4) (72.7) (38.0) (43.6)Delivery at home 5.7 13.5 5.7 10.5 5.4 21.3conducted by SBA (6.5) (14.0) (5.8) (10.0) (8.2) (23.7) 52.7 48.0 43.6 37.2 75.9 75.8Safe Delivery (53.4) (43.9) (48.0) (34.6) (69.6) (66.7)Mothers who received 49.7 41.7 69.7PNC within 2 Weeks of (49.5) NA (46.5) NA (58.7) NAdeliveryMothers who received FA 13.3 NA 13.6 NA 12.5 NAfor delivery under JSY (4.7) (4.5) (5.7)
33. Child feeding practices (based on last-born children) India- Total India- Rural India- Urban (Haryana) (Haryana) (Haryana)Indicators (%) DLHS DLHS DLHS DLHS DLHS DLHS III II III II III IIChildren under 3 years 40.5 27.8 39.8 25.1 42.5 34.7breastfed within one hour (17.4) (17.4) (16.8) (16.0) (18.7) (20.8)of birthChildren age 0-5 months 46.8 48.1 43.2 NA NA NAexclusively breastfed (9.4) (9.3) (9.7)Children age 6-35 months 25.5 22.7 26.2 23.7exclusively breastfed for NA NA (5.7) (33.0) (5.4) (6.5)at least 6 monthsChildren age 6-9 months 57.1 56.5 58.8receiving solid/semi-solid NA NA NA (74.1) (72.7) (78.9)food and breast milk
34. DLHS-3 Facility Facts INDIA HARYANA
35. DLHS - 4The data from previous three rounds of DLHS have beenuseful in setting the benchmarks and examining theprogress of the country after the implementation ofRCH programme.These surveys were useful for the central and stategovernments in evaluation, monitoring and planningstrategies.In view of the completion of six years of National RuralHealth Mission (2005-12), there is a felt need to focus onthe achievements and improvements so far.It is, therefore, proposed to conduct DLHS-4 during 2011-2012.
36. Objectives of DLHS-4The overall objective is to assess the performance of variousprogrammes under NRHM at district level. The specificobjectives are same as DLHS – 3 but additional objectivesare: To Know the level of anaemia, blood sugar, BP and anthropometric parameters through the Clinical, Anthropometric and Bio-Chemical (CAB) test and measurements. To know the contribution of public-private sectors to RCH services
37. Proposed ActivitiesIn DLHS-4, it is proposed to complete the field survey inall the districts within a period of 6 months.In EAG states including Assam (9 states), IIPS willundertake only the facility survey. In all other states, IIPSwill carry out both household and facility surveytogether.The NIHFW will be the nodal agency for the CABcomponent of DLHS-4, under the overall coordination ofIIPS.
38. Proposed ActivitiesIn DLHS-3, the district-wise sample size vary (1000, 1200,1500 households) across districts. In DLHS-4, it varies from1000 to 1750 householdsThe number of households per PSU is 25, however thisshall vary for North-Eastern states and hilly districts.Number PSU per district: - 40X25 = 1000 for 1100 HH district - 50X25 = 1250 for 1370 HH district - 60X25 = 1500 for 1650 HH district - 70X25 = 1750 for 1925 HH district
39. Proposed ActivitiesOne of the main factors that influence the quality ofdata is the length of training period and monitoring offield work. In DLHS-4, the length of training of trainers(TOT) will be of at-least 14 days including 2 days of fieldpractice.Later, the field agencies would be asked to provide thetraining to their investigators for a minimum of threeweeks which includes the field practice
40. Proposed ActivitiesAnother factor that influences the quality of data is themonitoring mechanism at the nodal agency. It isproposed to strengthen the monitoring by involvingmore coordinators and project personnel at IIPS.In addition to this, the Principal Investigator/ProjectCoordinators will be regularly visiting and supervisingeach state during the field work. Along with the IIPSofficials, MoHFW officials would also be involved in themonitoring of the survey.
41. SAMPLING DESIGNSample Survey- Collection of information fromrepresentative sample of villages, HH, individuals andfacilitiesDLHS-4 coverage- 20 states and 6 union territoriesFacility survey will be conducted in all states/UTs.Independent sampling for each district in the 26 states/union territories. Within each district urban and ruralareas shall form non-overlapping strata
42. SAMPLING DESIGNDLHS-4 sampling design is multi-stage stratified PPSsystematic sampling. Each selected rural/urban PSU isrepresented by 25 HH.Multistage sampling- selection of representativevillages/urban primary sampling units (PSU) by PPSsampling first followed by selection of representativehouseholdsRural PSUs are villages and sampling frame in theCensus 2001. Urban PSUs are NSSO UFS(Urban framesurvey block).
43. SAMPLING DESIGNSub-strata within urban strata-million class towns andother towns/cities and allocation is proportional topopulation of sub-strataSub-strata with rural strata-less than 50, 51-300 and300+ households and allocation is proportional to size ofeach sub-strataThe selected village (PSU) will be under the jurisdictionof one Sub Centre and that Sub Centre will be coveredfor the survey. The PHC to which this Sub Centre isattached, will also be covered in the survey.All CHCs, Sub Divisional Hospitals and District Hospitalswill be covered in facility survey.
44. DATA COLLECTIONHousehold Survey In DLHS-4, it is proposed to use Computer Assisted Personal Interview (CAPI) for data collection. Therefore, each investigator will be provided a mini laptop that will have bilingual questionnaire. This will save a lot of time usually taken for transferring the filled- in questionnaires from field to office, data editing, data entry, etc.Facility Survey It would be conducted using the paper-pencil format as the information has to be collected from different officials/departments in each facility and more than one visit is required to gather all the required information.
45. DATA COLLECTIONCAB Component Field Agencies will record the test results for the CAB tests as well as other relevant information on CAPI. Field Agency would also need to take the consent on the ‘consent form’, from the eligible individuals/ households (as required) before conducting the tests in each household.
46. Team Composition of Field StaffMapping & Listing Team No. Educational QualificationMapper 1 Graduate in any discipline (Preferably Social Sciences)Lister 1 Graduate in any discipline (Preferably Social Sciences)Facility Survey TeamHealth Investigator (Facility Survey) 2 The minimum qualification for health investigator should be Diploma or degree in Para medical coursesHousehold Survey TeamSupervisor 1 Graduate in any Social Science (Prefer knowledge of Biology) having experience of large scale surveyInvestigator 4 Graduate in any discipline(3 Females and 1 Male) (Preferably Social Sciences)Health Investigator (CAB) 2 The minimum qualification for health investigator in CAB should be Diploma in Nursing/ANM/B.Sc. Nursing/Diploma in Medical lab technology/ Bachelor in Medical lab technology/ B.Sc. Nutrition/DDPHN/ Diploma in