Demographic and Health Survey 2011 - Nepal

Abstract
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The 2011 Nepal Demographic and Health Survey is the fourth nationally representative comprehensive survey conducted as part of the worldwide Demographic and Health Surveys (DHS) project in the country. The survey was implemented by New ERA under the aegis of the Population Division, Ministry of Health and Population. Technical support for this survey was provided by ICF International with financial support from the United States Agency for International Development (USAID) through its mission in Nepal.

The primary objective of the 2011 NDHS is to provide up-to-date and reliable data on different issues related to population and health, which provides guidance in planning, implementing, monitoring, and evaluating health programs in Nepal. The long term objective of the survey is to strengthen the technical capacity of the local institutions to plan, conduct, process and analyze data from complex national population and health surveys. The survey includes topics on fertility levels and determinants, family planning, fertility preferences, childhood mortality, children and women’s nutritional status, the utilization of maternal and child health services, knowledge of HIV/AIDS and STIs, women’s empowerment and for the first time, information on women facing different types of domestic violence. The survey also reports on the anemia status of women age 15-49 and children age 6-59 months.

In addition to providing national estimates, the survey report also provides disaggregated data at the level of various domains such as ecological region, development regions and for urban and rural areas. This being the fourth survey of its kind, there is considerable trend information on reproductive and health care over the past 15 years. Moreover, the 2011 NDHS is comparable to similar surveys conducted in other countries and therefore, affords an international comparison. The 2011 NDHS also adds to the vast and growing international database on demographic and health-related variables.

The 2011 NDHS collected demographic and health information from a nationally representative sample of 10,826 households, which yielded completed interviews with 12,674 women age 15-49 in all selected households and with 4, 121 men age 15-49 in every second household.

This survey is the concerted effort of various individuals and institutions.

Geographic coverage
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The primary focus of the 2011 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key variables for the 13 eco-development regions.

Analysis unit
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Household, adult woman, adult man

Kind of data
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Sample survey data

Sampling procedure
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The primary focus of the 2011 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key variables for the 13 eco-development regions.

Sampling Frame

Nepal is divided into 75 districts, which are further divided into smaller VDCs and municipalities. The VDCs and municipalities, in turn, are further divided into wards. The larger wards in the urban areas are divided into subwards. An enumeration area (EA) is defined as a ward in rural areas and a subward in urban areas. Each EA is classified as urban or rural. As the upcoming population census was scheduled for June 2011, the 2011 NDHS used the list of EAs with population and household information developed by the Central Bureau of Statistics for the 2001 Population Census. The long gap between the 2001 census and the fielding of the 2011 NDHS necessitated an updating of the 2001 sampling frame to take into account not only population growth but also mass internal and external migration due to the 10-year political conflict in the country. To obtain an updated list, a partial updating of the 2001 census frame was carried out by conducting a quick count of dwelling units in EAs five times more than the sample required for each of the 13 domains. The results of the quick count survey served as the actual frame for the 2011 NDHS sample design.

Domains

The country is broadly divided into three horizontal ecological zones, namely mountain, hill, and terai. Vertically, the country is divided into five development regions. The cross section of these zones and regions results in 15 eco-development regions, which are referred to in the 2011 NDHS as subregions or domains. Due to the small population size in the mountain regions, the Western, Mid-western, and Far-western mountain regions are combined into one domain, yielding a total of 13 domains. In order to provide an adequate sample to calculate most of the key indicators at an acceptable level of precision, each domain had a minimum of about 600 households.

Stratification was achieved by separating each of the 13 domains into urban and rural areas. The 2011 NDHS used the same urban-rural stratification as in the 2001 census frame. In total, 25 sampling strata were created. There are no urban areas in the Western, Mid-western, and Far-western mountain regions. The numbers of wards and subwards in each of the 13 domains are not allocated proportional to their population due to the need to provide estimates with acceptable levels of statistical precision for each domain and for urban and rural domains of the country as a whole. The vast majority of the population in Nepal resides in the rural areas. In order to provide national urban estimates, urban areas of the country were oversampled.

Sample Selection

Samples were selected independently in each stratum through a two-stage selection process. In the first stage, EAs were selected using a probability-proportional-to-size strategy. In order to achieve the target sample size in each domain, the ratio of urban EAs to rural EAs in each domain was roughly 1 to 2, resulting in 95 urban and 194 rural EAs (a total of 289 EAs).

Complete household listing and mapping was carried out in all selected EAs (clusters). In the second stage, 35 households in each urban EA and 40 households in each rural EA were randomly selected. Due to the nonproportional allocation of the sample to the different domains and to oversampling of urban areas in each domain, sampling weights are required for any analysis using the 2011 NDHS data to ensure the actual representativeness of the sample at the national level as well as at the domain levels. Since the 2011 NDHS sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities separately for each sampling stage, taking into account nonproportionality in the allocation process for domains and urban-rural strata.

Mode of data collection
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Face-to-face

Research instrument
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Three questionnaires were administered in the 2011 NDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were adapted from the standard DHS6 core questionnaires to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, nongovernmental organizations, EDPs, and international donors. The final draft of each questionnaire was discussed at a questionnaire design workshop organized by the MOHP, Population Division on 22 April 2010 in Kathmandu. These questionnaires were then translated from English into the three main local languages—Nepali, Maithali, and Bhojpuri—and back translated into English. Questionnaires were finalized after the pretest, which was held from 30 September to 4 November 2010, with a one-week break in October for the Dasain holiday.

The Household Questionnaire was used to list all of the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, the survival status of the parents was determined. The Household Questionnaire was used to identify women and men who were eligible for the individual interview and women who were eligible for the interview focusing on domestic violence. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, ownership of mosquito nets, and household food security. The results of salt testing for iodine content, height and weight measurements, and anemia testing were also recorded in the Household Questionnaire.

The Woman’s Questionnaire was used to collect information from women age 15-49. Women were asked questions on the following topics:
- background characteristics (education, residential history, media exposure, etc.)
- pregnancy history and childhood mortality
- knowledge and use of family planning methods
- fertility preferences
- antenatal, delivery, and postnatal care
- breastfeeding and infant feeding practices
- vaccinations and childhood illnesses
- marriage and sexual activity
- work characteristics and husband’s background characteristics
- awareness and behavior regarding AIDS and other sexually transmitted infections
- domestic violence

The Man’s Questionnaire was administered to all men age 15-49 living in every second household in the 2011 NDHS. The Man’s Questionnaire collected much of the same information as the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health, nutrition, or domestic violence.

HEMOGLOBIN TESTING

In the 2011 NDHS, anemia testing was conducted in every second household (i.e., in households where male interviews were conducted). In such households, all women age 15-49 and children age 6-59 months were tested for anemia. The protocol for hemoglobin testing was approved by the Nepal Health Research Council and the ICF Macro Institutional Review Board in Calverton, Maryland, USA.

Selected interviewers were trained to conduct this procedure. Respondents (and their parent or guardian in the case of unmarried minors) were asked for their consent to participate in the anemia testing. The interviewers explained the purpose of the test, informed prospective subjects and/or their caretakers that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Levels of anemia were classified as severe, moderate, or mild according to criteria developed by the World Health Organization (DeMaeyer et al., 1989).

To measure the level of hemoglobin, capillary blood was taken in the field from a finger using sterile, one-time-use lancets that allowed for a relatively painless puncture. The concentration of hemoglobin in the blood was measured using the HemoCue system. Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of the finger was punctured with a sterile, non-reusable, self-retractable lancet. A drop of blood was collected with a HemoCue microcuvette and placed in a HemoCue photometer, where the results were displayed. For children age 6 to 11 months who were particularly undernourished and bony, a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure given to each woman, parent, or responsible adult explaining what the results meant. Women or children whose results indicated severe anemia were provided with a card referring them to the nearest health facility.

Cleaning operations
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The 2011 NDHS used ASUS Eee T101MT tablet PCs with data entry programs developed in CSPro. Code division multiple access (CDMA) wireless technology via Internet File Streaming System (IFSS) was used to transfer data from the field to the central office in Kathmandu. The IFSS package was developed by MEASURE DHS and tested for the first time in Nepal.

The data were sent to the central office at New ERA by the teams once they had checked and closed each EA file. This was mostly done before the team left the EA. In the central office, the data were edited by a senior data supervisor who had been specially trained for this task. The concurrent processing of the data was an advantage because field check tables to monitor various data quality parameters could be generated almost instantly and sent to the teams through the field coordinators, the quality control teams, and the core study team members. This allowed the field teams to receive immediate feedback and improve their performance. The data entry and editing phase of the survey was complete by the end of June 2011.

Response rate
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A total of 11,353 households were selected, out of which 10,888 were found to be occupied during data collection. Interviews were completed for 10,826 of these existing households, yielding a response rate of 99 percent. In the selected households, 12,918 women were identified as eligible for the individual interview.

Interviews were completed for 12,674 women, resulting in a response rate of 98 percent. Of the 4,323 eligible men identified in the selected subsample of households, 4,121 were successfully interviewed, yielding a 95 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men.

Sampling error estimates
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Sampling errors for the 2011 NDHS were calculated for selected variables considered to be of primary interest. The results are presented in an appendix to the Final report for the country as a whole, for urban and rural areas, three ecological zones, and for five development regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1 of the Final Report. Tables B.2 through B.12 present the value of the statistic (R), its standard error (SE), the number of un-weighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE), for each variable. The sampling errors for mortality rates are presented for the five year period preceding the survey for the whole country and for the ten year period preceding the survey by residence, ecological zones, and development regions. The DEFT is considered undefined when the standard error considering a simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing.

The confidence interval (e.g., as calculated for children ever born to women age 40-49) can be interpreted as follows: the estimated proportion from the national sample is 4.250 and its standard error is 0.083. Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, i.e., 4.250±2×0.083. There is a high probability (95 percent) that the true average number of children ever born to all women aged 40 to 49 is between 4.083 and 4.417.

In general, the relative standard error for most estimates for the country as a whole is small, except for estimates of very small proportions values. The relative error for the total fertility rate is 3.8 percent. However for the mortality rates, the average relative standard error for the five-year period mortality rates is much higher, about 10 percent.

There are differentials in the relative standard error for estimates of sub-populations of women, for example for the variable children ever born to women 40-49, the relative standard error as percent of the estimated value for the whole country, for the urban area, and for the rural area are 2 percent, 2.8 percent, and 2.2 percent, respectively.

摘要
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2011年尼泊尔人口与健康调查作为全球人口与健康调查（DHS）项目在尼泊尔进行的第四次全国代表性综合调查，旨在为该国提供最新、可靠的人口与健康相关数据，以指导尼泊尔健康计划的规划、实施、监测和评估。该调查的长期目标是加强当地机构在规划、执行、处理和分析复杂国家人口与健康调查数据方面的技术能力。调查内容包括生育水平及其决定因素、家庭规划、生育偏好、儿童死亡率、儿童和妇女的营养状况、母亲和儿童健康服务的利用、对艾滋病/获得性免疫缺陷综合征（AIDS）和性传播感染（STIs）的认识、妇女赋权，以及首次关于面临不同类型家庭暴力的妇女的信息。调查还报告了15-49岁妇女和6-59个月大儿童的营养不良状况。

除了提供全国估计值外，调查报告还提供了按生态区域、发展区域以及城市和农村地区等不同领域的分层数据。作为此类调查的第四次，过去15年在生殖和医疗保健方面积累了大量趋势信息。此外，2011年尼泊尔人口与健康调查与其他国家进行的类似调查具有可比性，因此提供了国际比较。2011年尼泊尔人口与健康调查还丰富了关于人口与健康相关变量的庞大且不断增长的国际数据库。

2011年尼泊尔人口与健康调查从10,826个家庭的全国代表性样本中收集了人口与健康信息，其中对所有选定家庭中的12,674名15-49岁妇女进行了完整访谈，并在每两个家庭中每个家庭中的4,121名15-49岁男性进行了访谈。

本次调查是众多个人和机构的共同努力成果。

地理覆盖范围
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2011年尼泊尔人口与健康调查的主要重点是提供全国整体以及城市和农村地区分别的关键人口与健康指标估计值，包括生育率和死亡率。此外，样本设计旨在为13个生态发展区域的大多数关键变量提供估计值。

分析单元
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家庭、成年妇女、成年男子

数据类型
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样本调查数据

抽样程序
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2011年尼泊尔人口与健康调查的主要重点是提供全国整体以及城市和农村地区分别的关键人口与健康指标估计值，包括生育率和死亡率。此外，样本设计旨在为13个生态发展区域的大多数关键变量提供估计值。

抽样框架
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尼泊尔分为75个区，这些区进一步分为更小的VDC和市镇。VDC和市镇反过来又进一步分为街区。城市地区的较大街区分为次街区。人口普查区域（EA）在乡村地区定义为街区，在城市地区定义为次街区。每个EA都被归类为城市或乡村。由于即将到来的人口普查计划于2011年6月进行，2011年尼泊尔人口与健康调查使用了中央统计局为2001年人口普查开发的EA人口和 household信息清单。2001年人口普查与2011年尼泊尔人口与健康调查实地调查之间的大间隔迫使更新2001年抽样框架，不仅要考虑人口增长，还要考虑由于国家10年政治冲突而导致的内部和外部大量迁移。为了获得更新的列表，对2001年人口普查框架进行了五次快速计数调查，每次调查的样本量是每个13个领域的所需样本量的五倍。快速计数调查的结果成为2011年尼泊尔人口与健康调查样本设计的实际框架。

领域
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国家大致分为三个水平生态区，即山地、丘陵和特莱。垂直方向上，国家分为五个发展区域。这些区域和区域的交叉形成了15个生态发展区域，在2011年尼泊尔人口与健康调查中被称为子区域或领域。由于山地地区人口规模较小，西部、中部和远西部山地地区合并为一个领域，总共形成13个领域。为了在可接受的精度水平上计算大多数关键指标，每个领域至少有约600户家庭。

通过将每个13个领域分别划分为城市和乡村地区来实现分层。2011年尼泊尔人口与健康调查使用了与2001年人口普查框架相同的城乡分层。总共有25个抽样层。西部、中部和远西部山地地区没有城市地区。由于需要为每个领域以及整个国家的城乡领域提供具有可接受统计精度的估计值，因此每个领域街区和次街区的数量并不是按其人口比例分配的。尼泊尔的大多数人口居住在乡村地区。为了提供国家城市估计值，对国家的城市地区进行了过抽样。

样本选择
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在每个层中使用两阶段选择过程独立选择样本。在第一阶段，使用概率比例大小策略选择EA。为了在各个领域实现目标样本量，每个领域城市EA与乡村EA的比例大致为1比2，结果产生95个城市EA和194个乡村EA（总共289个EA）。

在所有选定的EA（簇）中进行了完整的家庭清单和制图。在第二阶段，每个城市EA随机选择35户家庭，每个乡村EA随机选择40户家庭。由于样本在不同领域和城乡层中的分配不是成比例的，并且每个领域对城市地区进行了过抽样，因此在分析2011年尼泊尔人口与健康调查数据时需要使用抽样权重，以确保样本在国家级以及领域级上的实际代表性。由于2011年尼泊尔人口与健康调查样本是两阶段分层簇样本，因此根据每个抽样阶段的抽样概率分别计算抽样权重，考虑到分配过程中的领域和城乡层的非成比例分配。

数据收集方式
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面对面

研究工具
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2011年尼泊尔人口与健康调查中使用了三种问卷：家庭问卷、妇女问卷和男子问卷。这些问卷是根据与政府各部门和机构、非政府组织、EDPs和国际捐助者的利益相关者的一系列会议中与尼泊尔相关的人口与健康问题改编自标准DHS6核心问卷的。每个问卷的最终草案都是在尼泊尔卫生与人口部人口司于2010年4月22日在加德满都组织的一次问卷设计研讨会上讨论的。然后，这些问卷从英语翻译成三种主要地方语言——尼泊尔语、迈蒂利语和博杰普里语，然后翻译回英语。在2010年9月30日至11月4日进行的预测试后，最终确定了问卷。这些问卷在以下主题上收集了信息：
- 背景（教育、居住史、媒体接触等）
- 怀孕史和儿童死亡率
- 家庭规划方法的知识和使用
- 生育偏好
- 产前、分娩和产后护理
- 哺乳和婴儿喂养实践
- 疫苗接种和儿童疾病
- 婚姻和性行为
- 工作特征和丈夫的背景特征
- 关于艾滋病和其他性传播感染的认识和行为
- 家庭暴力

家庭问卷用于列出选定家庭中的所有常住人口和访客。收集了有关列出的每个人特征的基本信息，包括年龄、性别、教育和与家庭户主的关系。对于18岁以下的儿童，确定了父母的存活状况。家庭问卷用于确定符合个人访谈资格的妇女和符合关注家庭暴力的妇女访谈资格的妇女。家庭问卷还收集了有关家庭住房单位特征的信息，例如水源、卫生设施类型、房屋地板的材料、耐用商品的拥有权、蚊帐的拥有权以及家庭食物安全。家庭问卷还记录了食盐碘含量测试、身高和体重测量以及贫血测试的结果。

妇女问卷用于收集15-49岁妇女的信息。向妇女提出了以下主题的问题：
- 背景（教育、居住史、媒体接触等）
- 怀孕史和儿童死亡率
- 家庭规划方法的知识和使用
- 生育偏好
- 产前、分娩和产后护理
- 哺乳和婴儿喂养实践
- 疫苗接种和儿童疾病
- 婚姻和性行为
- 工作特征和丈夫的背景特征
- 关于艾滋病和其他性传播感染的认识和行为
- 家庭暴力

男子问卷用于2011年尼泊尔人口与健康调查中每两个家庭中每个家庭中的所有15-49岁男性。男子问卷收集了与妇女问卷类似的大量信息，但由于不包含详细的生育史或有关母亲和儿童健康、营养或家庭暴力的提问，因此较短。

血红蛋白测试
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在2011年尼泊尔人口与健康调查中，每两个家庭（即男性访谈的家庭）进行了贫血测试。在这样家庭中，对所有15-49岁妇女和6-59个月大儿童进行了贫血测试。血红蛋白测试方案已由尼泊尔健康研究委员会和位于美国马里兰州卡莱顿的ICF Macro机构审查委员会批准。

经过专门培训的访谈员被培训执行此程序。受访者（以及在未婚未成年人的情况下，他们的父母或监护人）被要求同意参与贫血测试。访谈员解释了测试的目的，并向潜在的受试者及其照顾者告知测试结果将在测试完成后立即提供，并请求许可进行测试。根据世界卫生组织（DeMaeyer等，1989年）制定的标准，根据贫血程度将贫血程度分为严重、中度或轻度。

为了测量血红蛋白水平，在野外从手指指尖使用无菌的一次性使用刺针抽取毛细血管血，以实现相对无痛的穿刺。使用HemoCue系统测量血液中的血红蛋白浓度。在取血之前，用酒精预消毒纱布擦拭手指，并允许其自然晾干。然后，使用无菌的非一次性自退式刺针在手指末端的掌侧刺穿。使用HemoCue微量杯收集一滴血，并将其放入HemoCue光度计中，结果在光度计上显示。对于特别营养不良和瘦弱的6-11个月大的儿童，进行脚跟穿刺以抽取一滴血。结果记录在家庭问卷中，以及发给每位妇女、父母或负责成人的小册子中，解释了结果的意义。对于血红蛋白测试结果表明严重贫血的妇女或儿童，提供了卡片，将其引荐到最近的医疗机构。

数据清理操作
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2011年尼泊尔人口与健康调查使用ASUS Eee T101MT平板电脑，并使用在CSPro中开发的程序进行数据录入。通过互联网文件流系统（IFSS）使用码分多址（CDMA）无线技术将数据从现场传输到加德满都的中央办公室。IFSS包由MEASURE DHS开发，并在尼泊尔进行了首次测试。

一旦检查和关闭每个EA文件，团队将数据发送到New ERA的中央办公室。这主要是在团队离开EA之前完成的。在中央办公室，由专门接受过此任务培训的高级数据监督员编辑了数据。数据的同时处理是一个优势，因为可以几乎立即生成用于监控各种数据质量参数的现场检查表，并通过现场协调员、质量控制团队和核心研究团队成员发送给团队。这使得现场团队能够立即收到反馈并提高其表现。调查的数据录入和编辑阶段于2011年6月底完成。

响应率
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总共选择了11,353个家庭，其中10,888个在数据收集期间被发现有人居住。对10,826个现有家庭进行了访谈，响应率为99％。在选定的家庭中，确定了12,918名符合个人访谈资格的妇女。

对12,674名妇女进行了访谈，响应率为98％。在选定的子样本家庭中确定的4,323名符合条件的男子中，4,121人接受了访谈，响应率为95％。乡村地区的响应率高于城市地区，尤其是符合条件的男子。

抽样误差估计
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对2011年尼泊尔人口与健康调查中考虑为首要兴趣的选定变量计算了抽样误差。结果呈现在国家整体、城市和农村地区、三个生态区域和五个发展区域的国家最终报告中。在最终报告的表B.1中，为每个变量给出了统计量类型（平均值、比例或率）和基人口。表B.2至B.12展示了统计量的值（R）、标准误差（SE）、未加权（N）和加权（WN）案例数、设计效应（DEFT）、相对标准误差（SE/R）和95％置信区间（R±2SE），对于每个变量。死亡率率的抽样误差为调查前五年整个国家以及按居住地、生态区域和发展区域的前十年死亡率率。

设计效应（DEFT）在考虑简单随机样本的标准误差为零时被视为未定义（当估计值接近0或1时）。在总生育率的情况下，未加权案例数不相关，因为没有已知的未加权妇女年生育率值。

置信区间（例如，为40-49岁妇女所生的儿童数量计算）可以这样解释：来自国家样本的估计比例为4.250，其标准误差为0.083。因此，为了获得95％置信区间，将标准误差的两倍加到样本估计值和从中减去，即4.250±2×0.083。有很高的概率（95％）表明，所有40至49岁妇女所生的儿童的真实平均数量在4.083和4.417之间。

一般来说，对于整个国家的估计值，相对标准误差很小，除了非常小的比例值估计外。总生育率的相对误差为3.8％。然而，对于死亡率，五年期死亡率率的平均相对标准误差要高得多，约为10％。

对于妇女子群体的估计值，相对标准误差存在差异，例如，对于妇女40-49岁所生的儿童数量这一变量，对于整个国家、城市地区和农村地区的估计值的相对标准误差分别是2％、2.8％和2.2％。”
}