Malaria Indicator Survey 2009-2010 - Uganda

Abstract
---------------------------

Since 1995, the NMCP and its partners have been scaling up malaria interventions in all parts of the country. To determine the progress made in malaria control and prevention in Uganda, the 2009 Uganda Malaria Indicator Survey (UMIS) was designed to provide data on key malaria indicators, including mosquito net ownership and use, as well as prompt treatment using ACT.

The key objectives of the 2009 UMIS were to:
• Measure the extent of ownership and use of mosquito bed nets
• Assess coverage of the intermittent preventive treatment programme for pregnant women
• Identify practices used to treat malaria among children under age 5 and the use of specific antimalarial medications
• Measure the prevalence of malaria and anaemia among children age 0-59 months
• Determine the species of plasmodium parasite most prevalent in Uganda
• Assess knowledge, attitudes, and practices regarding malaria in the general population

Methodology of The Uganda Lalaria Indicatior Survey
The 2009 UMIS was carried out during November and December 2009, using a nationally representative sample of 4,760 households in 170 census enumeration areas. All women age 15-49 years in these households were eligible for individual interviews, during which they were asked questions about malaria prevention during pregnancy and treatment of childhood fevers. In addition, the survey included testing for anaemia and malaria among children age 0-59 months using finger (or heel) prick blood samples. Test results for anaemia (using the HemoCue portable machine) and malaria (using malaria RDT) were available immediately and were provided to the children’s parents or guardians. Thick and thin blood smears were also made in the field and transported to the Uganda Malaria Surveillance Project Molecular Laboratory at the Mulago Hospital in Kampala where they were tested for the presence of malaria parasites and where the species of plasmodium parasite was determined.

Survey Organization
The 2009 UMIS was implemented by the Uganda Bureau of Statistics (UBOS) and the Uganda Malaria Surveillance Project (UMSP) on behalf of the National Malaria Control Program (NMCP). UBOS was responsible for general administrative management of the survey, including overseeing the day-to-day operations, designing the survey, and processing the data. UBOS assisted NMCP in the design of the UMIS, especially in the area of sample design and selection. In this regard, they provided the necessary maps and lists of households in the selected sample points. NMCP took primary responsibility for organizing the Technical Working Group, developing the survey protocol, and ensuring its approval by the Uganda National Council of Science and Technology prior to the data collection. Also, NMCP helped UBOS recruit, train, and monitor field staff and provided the medicines to treat children who tested positive for malaria during the survey.

The Uganda Malaria Surveillance Project (UMSP) Molecular Laboratory at the Mulago Hospital complex in Kampala trained field technicians and implemented the microscopic reading of the malaria slides to determine malaria parasite infection.

Technical assistance was provided by ICF Macro. ICF Macro staff assisted with overall survey design, sample design, questionnaire design, field staff training, field work monitoring, collection of biomarkers (anaemia testing, rapid diagnostic testing for malaria, and making and reading blood smears), data processing, data analysis, and report preparation.

Financial support for the survey was provided by the U.S. President’s Malaria Initiative (PMI) through the U.S. Agency for International Development (USAID).

Geographic coverage
---------------------------

National

Analysis unit
---------------------------

- Households
- Women age 15-49

Kind of data
---------------------------

Sample survey data [ssd]

Sampling procedure
---------------------------

Sample Design
The 2009 UMIS survey was designed to provide national, regional, urban, and rural estimates of key malaria indicators. The sample was stratified into 9 survey regions of the country, plus Kampala. Each of the nine regions consisted of 8 to 10 contiguous administrative districts of Uganda that share similar languages and cultural characteristics. Kampala district, because it had a unique character as an entirely urban district and also was the capital city of Uganda, comprised a separate region. The 10 regions contained the following districts:
1. North East region: Kotido, Abim, Kaabong, Moroto, Nakapiripirit, Katakwi, Amuria, Bukedea, Soroti, Kumi, and Kaberamaido
2. Mid Northern region: Gulu, Amuru, Kitgum, Pader, Apac, Oyam, Lira, Amolatar, and Dokolo
3. West Nile region: Moyo, Adjumani, Yumbe, Arua, Koboko, Nyadri, and Nebbi
4. Mid Western region: Masindi, Buliisa, Hoima, Kibaale, Bundibugyo, Kabarole, Kasese, Kyenjojo, and Kamwenge
5. South Western region: Bushenyi, Rukungiri, Kanungu, Kabale, Kisoro, Mbarara, Ibanda, Isingiro, Kiruhura, and Ntungamo
6. Mid- Eastern region: Kapchorwa, Bukwa, Mbale, Bududa, Manafwa, Tororo, Butaleja, Sironko, Pallisa, Budaka, and Busia
7. Central 1 region: Kalangala, Masaka, Mpigi, Rakai, Lyantonde, Sembabule, and Wakiso
8. Central 2 region: Kayunga, Kiboga, Luwero, Nakaseke, Mubende, Mityana, Mukono, and
Nakasongola
9. East Central region: Jinja, Iganga, Namutumba, Kamuli, Kaliro, Bugiri, and Mayuge
10. Kampala: Kampala

The sample was not spread geographically in proportion to the population, but rather equally across the regions, with 17 sample points or clusters per region. As a result, the UMIS sample is not selfweighting at the national level, and sample weighting factors have been applied to the survey records in order to bring them into proportion.

The survey utilized a two-stage sample design. The first stage involved selecting sample points or clusters from a list of enumeration areas (EAs) covered in the 2002 Population Census. A total of 170 clusters (26 urban and 144 rural) with probability proportional to size were selected. Several months prior to the main survey, a complete listing of all households in the 170 selected clusters was carried out. This provided a sampling frame from which households were then selected for the survey. The second stage of selection involved the systematic sampling of households from the list of households in each cluster. Twenty-eight households were selected in each cluster.

All women age 15-49 years who were either permanent residents of the households in the sample or visitors present in the household on the night before the survey were eligible to be interviewed in the survey. All children age 0-59 months who were listed in the household were eligible for the anaemia and malaria testing component of the survey.

Note: See detailed sampling information in APPENDEX A of the 2009 Uganda Malaria Indicator Survey (MIS).

Mode of data collection
---------------------------

Face-to-face [f2f]

Research instrument
---------------------------

Two questionnaires were used in the UMIS: a Household Questionnaire and a Woman’s Questionnaire for all women age 15-49 in the selected households. Both instruments were based on the standard Malaria Indicator Survey Questionnaires developed by the Roll Back Malaria and DHS programmes. In consultation with the Technical Working Group, NMCP and ICF Macro staff modified the model questionnaires to reflect issues relevant to malaria in Uganda. The questionnaires were translated into the 6 major local languages commonly spoken in Uganda (Ateso-Karamojong, Luganda, Lugbara, Luo, Runyankore-Rukiga, and Runyoro-Rutoro).

The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women who are eligible for the individual interview and children who are age 0-59 months for anaemia and malaria testing. The Household Questionnaire also collected information on characteristics of the household's dwelling unit, such as the source of water; type of toilet facilities; materials used for the floor, roof, and walls of the house; ownership of various durable goods; and ownership and use of mosquito nets. In addition, this questionnaire was used to record consent and results with regard to the anaemia and malaria testing of young children.

The Woman’s Questionnaire was used to collect information from all women age 15-49 years and covered the following topics:
• Background characteristics (age, residential history, education, literacy, and dialect)
• Full reproductive history and child mortality
• Antenatal care and preventive malaria treatment for most recent birth
• Prevalence and treatment of fever among children under age 5
• Knowledge about malaria (causes, ways to avoid, types of medicines, and so on).

The questionnaires and process of biomarker collection were pretested prior to the main data collection. The pretest involved 12 interviewers and 12 health technicians/nurses (2 for each of the 6 local languages into which the questionnaires were translated). The interviewers were trained for five days and collected data in the six languages for three days in areas close to Kampala. The purpose of the pretest was to assess the appropriateness of the wording of the questions as well as to verify the translations and skip patterns.

Cleaning operations
---------------------------

The processing of the UMIS questionnaire data began soon after the fieldwork commenced. Completed questionnaires were returned periodically from the field to the UBOS office in Kampala, where they were coded by data processing personnel recruited and trained for this task. The data processing staff consisted of a supervisor from UBOS, a questionnaire administrator, data entry operators, and data editors, all of whom were trained by a MEASURE DHS data processing specialist. Data were entered using the CSPro computer package. All data were entered twice (100 percent verification).

Response rate
---------------------------

Of the 4,760 households selected in the sample, 4,536 were found to be occupied at the time of the fieldwork. The shortfall is due to dwellings that were found to be vacant or destroyed. Of the existing households, 4,421 were successfully interviewed, yielding a household response rate of 98 percent.

In the households interviewed in the survey, a total of 4,312 eligible women were identified, of whom 4,134 were successfully interviewed, yielding a response rate of 96 percent. The household and women’s response rates were slightly lower in the urban than in the rural sample. The principal reason for non-response among eligible women was the failure to find them at home despite repeated visits to the household.

Sampling error estimates
---------------------------

Estimates derived from a sample survey are affected by two types of errors: 1) non-sampling errors, and 2) sampling errors. Non-sampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2009 Uganda malaria indicator survey (2009 UMIS) to minimize this type of error, non-sampling errors are impossible to avoid and difficult to evaluate statistically.

Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2009 UMIS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results.

A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design.

If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2009 UMIS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use a more complex formula. The computer software used to calculate sampling errors for the 2009 UMIS is the sampling error module in ISSA (Integrated System for Survey Analysis). This module uses the Taylor linearization method of variance estimation for survey estimates that are means or proportions. Another approach, the Jackknife repeated replication method is used for variance estimation of more complex statistics such as fertility and mortality rates.

Note: See detailed estimate of sampling error calculation in APPENDIX B of the 2009 Uganda Malaria Indicator Survey (MIS) report.

Data appraisal
---------------------------

Data Quality Tables
- Household age distribution
- Age distribution of eligible and interviewed women
- Completeness of reporting

Note: Data quality tables are available in APPENDIX C of the 2009 Uganda Malaria Indicator Survey (MIS) report.

摘要
---------------------------
自1995年以来，国家疟疾控制计划（NMCP）及其合作伙伴已在全国范围内扩大疟疾干预措施。为评估乌干达疟疾控制与预防的进展情况，2009年乌干达疟疾指标调查（UMIS）被设计出来，旨在提供关键疟疾指标的数据，包括蚊帐拥有率和使用情况，以及使用抗疟疾药物（ACT）的及时治疗。
2009年UMIS的关键目标包括：
• 评估蚊帐拥有和使用程度
• 评估孕妇间歇性预防治疗计划的覆盖率
• 确定治疗5岁以下儿童疟疾的实践以及特定抗疟疾药物的使用
• 测量0-59个月大儿童中疟疾和贫血的患病率
• 确定乌干达最普遍的疟原虫种类
• 评估普通人群中关于疟疾的知识、态度和实践

乌干达疟疾指标调查的方法
2009年UMIS于2009年11月和12月进行，使用全国代表性的4,760户家庭样本，分布在170个普查登记地区。在这些家庭中，所有15-49岁的女性均有资格接受个人访谈，访谈内容包括孕期疟疾预防和儿童发热的治疗。此外，调查还包括对0-59个月大的儿童进行贫血和疟疾的指尖（或脚跟）血样检测。贫血（使用HemoCue便携式机器）和疟疾（使用疟疾快速诊断测试）的检测结果立即提供给孩子父母或监护人。厚薄血涂片也在现场制作，并运送至坎帕拉穆拉戈医院的乌干达疟疾监测项目分子实验室进行疟原虫存在性检测和疟原虫种类的确定。

调查组织
2009年UMIS由乌干达统计局（UBOS）和乌干达疟疾监测项目（UMSP）代表国家疟疾控制计划（NMCP）实施。UBOS负责调查的一般行政管理工作，包括监督日常运营、设计调查和处理数据。UBOS协助NMCP设计UMIS，特别是在样本设计和选择方面。在这方面，他们提供了必要的地图和选定样本点的家庭名单。NMCP负责组建技术工作组，制定调查方案，并确保在数据收集之前获得乌干达国家科学技术委员会的批准。此外，NMCP帮助UBOS招募、培训和监督现场工作人员，并为在调查期间检测出疟疾阳性的儿童提供药物。

乌干达疟疾监测项目（UMSP）分子实验室位于坎帕拉穆拉戈医院综合体内，负责培训现场技术人员，并实施疟疾涂片的显微镜阅读，以确定疟原虫感染。

技术援助由ICF Macro提供。ICF Macro工作人员协助整体调查设计、样本设计、问卷设计、现场工作人员培训、现场工作监督、生物标志物收集（贫血测试、疟疾快速诊断测试、制作和阅读血涂片）、数据处理、数据分析以及报告准备。

调查的资金支持由美国总统疟疾倡议（PMI）通过美国国际开发署（USAID）提供。

地理覆盖范围
---------------------------
全国

分析单元
---------------------------
- 家庭
- 15-49岁女性

数据类型
---------------------------
样本调查数据 [ssd]

抽样程序
---------------------------
样本设计
2009年UMIS调查旨在提供全国、地区、城市和农村的关键疟疾指标估计。样本被分层为9个调查区域，加上坎帕拉。每个区域由8至10个相邻的行政管辖区组成，这些管辖区具有相似的语言和文化特征。坎帕拉区由于其作为一个完全的城市区以及乌干达首都的独特特征，构成了一个单独的区域。10个区域包含以下地区：
1. 东北部地区：科蒂多、阿比姆、卡邦贡、莫罗托、纳卡皮里皮里特、卡塔基、阿穆里亚、布凯代亚、索托蒂、库米和卡贝拉马伊多
2. 中北部地区：古卢、阿穆鲁、基图姆、帕德、阿帕克、奥亚姆、利拉、阿莫拉塔拉和多科洛
3. 西尼罗河地区：莫约、阿杜马尼、尤梅贝、阿鲁阿、科博科、尼亚德里和内贝比
4. 中西部地区：马辛迪、布利伊萨、胡伊马、基巴莱、邦迪布吉奥、卡巴罗勒、卡塞塞、基延朱乔和卡姆韦恩加
5. 西南部地区：布申尼、鲁昆吉里、卡努古、卡巴莱、基索罗、基索罗、姆巴腊、伊班达、伊辛吉罗、基鲁胡拉和恩图加莫
6. 中东部地区：卡波查瓦、布夸、姆巴莱、布杜达、马纳法瓦、托罗罗、巴塔莱贾、西罗科、帕利萨、布达卡和布斯亚
7. 中1区：卡拉加拉、马萨卡、姆皮吉、拉卡伊、利亚ントondo、塞姆巴布勒和瓦基索
8. 中2区：卡尤加、基博加、卢韦罗、纳卡谢克、穆本德、米泰亚纳、穆科诺和纳卡斯贡加
9. 东中部地区：金贾、伊加纳、纳木图马、卡穆利、卡利罗、布吉里和马尤加
10. 坎帕拉：坎帕拉
样本不是按人口比例地理分布的，而是在各个地区均匀分布，每个地区有17个样本点或聚类。因此，UMIS样本在国家层面上不是自我加权，并且已对调查记录应用样本加权因子，以使其成比例。
调查采用了两阶段样本设计。第一阶段涉及从2002年人口普查中涵盖的普查区域名单中选择样本点或聚类。总共选择了170个聚类（26个城市和144个农村），采用大小成比例的概率进行选择。在主要调查几个月前，对170个选定聚居区中的所有家庭进行了完整列表。这为从其中选择家庭提供了抽样框架。选择过程的第二阶段涉及对每个聚居区中家庭名单的系统抽样。每个聚居区选择了28个家庭。
所有15-49岁的女性，无论是样本家庭中的永久居民还是调查前夜在家庭中出现的访客，均有资格接受调查访谈。所有0-59个月大的儿童，只要他们在家庭中列出，均有资格接受调查的贫血和疟疾检测部分。

注意：有关2009年乌干达疟疾指标调查（MIS）的详细抽样信息，请参阅附录A。

数据收集方式
---------------------------
面对面 [f2f]

研究工具
---------------------------
UMIS中使用了两个问卷：家庭问卷和针对所有15-49岁女性的女性问卷。这两个工具都是基于疟疾指标调查问卷的标准问卷，由疟疾控制计划和DHS项目开发。在技术工作组的咨询下，NMCP和ICF Macro工作人员修改了模型问卷，以反映与乌干达疟疾相关的问题。问卷被翻译成乌干达6种主要地方语言（阿特索-卡拉莫琼、卢干达、卢加巴、鲁奥、鲁尼亚科罗-鲁基加和鲁尼奥罗-鲁托罗）。
家庭问卷用于列出选定家庭中的所有常住成员和访客。收集了有关列出每个人的基本信息的某些信息，包括年龄、性别和与户主的关系。家庭问卷的主要目的是确定有资格接受个人访谈的女性和0-59个月大的儿童进行贫血和疟疾测试。家庭问卷还收集了有关家庭居住单元特征的信息，例如水源；厕所设施类型；房屋地板、屋顶和墙壁的材料；耐用商品的拥有情况；以及蚊帐的拥有和使用情况。此外，此问卷还用于记录有关年轻儿童贫血和疟疾检测的同意和结果。
女性问卷用于收集所有15-49岁女性的信息，并涵盖以下主题：
• 背景（年龄、居住史、教育、识字和方言）
• 全部生殖史和儿童死亡率
• 最近出生的产前护理和预防疟疾治疗
• 5岁以下儿童发热的患病率和治疗
• 疟疾知识（原因、避免方式、药物类型等）。
问卷和生物标志物收集过程在主要数据收集之前进行了预测试。预测试涉及12名访谈员和12名健康技术人员/护士（每种翻译成6种地方语言的各有2名）。访谈员接受了五天的培训，并在靠近坎帕拉的地区用六种语言收集了三天数据。预测试的目的是评估问题的措辞的适当性以及验证翻译和跳转模式。

数据清理操作
---------------------------
UMIS问卷数据的处理在实地工作开始后不久就开始了。完成后的问卷定期从现场返回到坎帕拉的UBOS办公室，由为这项任务招募和培训的数据处理人员进行编码。数据处理人员包括来自UBOS的监督员、问卷管理员、数据录入操作员和数据编辑人员，他们都由MEASURE DHS数据处理专家培训。使用CSPro计算机包输入数据。所有数据都输入了两次（100%验证）。

响应率
---------------------------
在样本中选定的4,760户家庭中，发现4,536户在实地工作期间有人居住。短缺是由于发现住宅空置或被破坏。在现有家庭中，4,421户成功接受了访谈，家庭响应率为98%。
在调查中访谈的家庭中，共确定了4,312名有资格的女性，其中4,134名成功接受了访谈，响应率为96%。城市样本中的家庭和女性的响应率略低于农村样本。合格女性非响应的主要原因是在反复访问家庭后未能找到她们。

抽样误差估计
---------------------------
从样本调查中得出的估计值受两种类型的误差的影响：1）非抽样误差，2）抽样误差。非抽样误差是实施数据收集和数据处理中出现的错误的结果，例如未能找到和访谈正确的家庭，访谈员或受访者对问题理解错误，以及数据输入错误。尽管在实施2009年乌干达疟疾指标调查（2009年UMIS）期间做出了许多努力以最大限度地减少此类错误，但非抽样误差是无法避免且难以进行统计评估的。
另一方面，抽样误差可以统计评估。2009年UMIS中选定的受访者样本只是从同一人口中可以选出的许多样本之一，使用相同的设计和预期规模。这些样本中的每一个都会产生与实际选定样本的结果略有不同的结果。抽样误差是衡量所有可能样本之间差异的指标。虽然差异的程度无法确切知道，但可以从调查结果中估计出来。
抽样误差通常用特定统计量（均值、百分比等）的标准误差来衡量，这是方差的平方根。标准误差可用于计算置信区间，在这个区间内，可以合理地假设总体中的真实值。
例如，对于从样本调查中计算出的任何给定统计量，该统计量的值将在95%的所有可能样本（大小和设计相同）的标准误差的两倍范围内。
如果受访者样本被选为简单随机样本，则可以使用简单的公式来计算抽样误差。然而，2009年UMIS样本是分层多阶段设计的产物，因此有必要使用更复杂的公式。用于计算2009年UMIS抽样误差的计算机软件是ISSA（综合调查分析系统）中的抽样误差模块。该模块使用泰勒线性化方法进行方差估计，用于调查估计的均值或比例。另一种方法，Jackknife重复复制法用于更复杂统计量（如生育率和死亡率）的方差估计。

注意：有关2009年乌干达疟疾指标调查（MIS）报告中抽样误差计算详细估计的信息，请参阅附录B。

数据评估
---------------------------
数据质量表
- 家庭年龄分布
- 合格和接受访谈的女性的年龄分布
- 报告的完整性

注意：数据质量表可在2009年乌干达疟疾指标调查（MIS）报告的附录C中找到。