Multi Country Study Survey 2000-2001 - Lebanon

Abstract
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In order to develop various methods of comparable data collection on health and health system responsiveness WHO started a scientific survey study in 2000-2001. This study has used a common survey instrument in nationally representative populations with modular structure for assessing health of indviduals in various domains, health system responsiveness, household health care expenditures, and additional modules in other areas such as adult mortality and health state valuations.

The health module of the survey instrument was based on selected domains of the International Classification of Functioning, Disability and Health (ICF) and was developed after a rigorous scientific review of various existing assessment instruments. The responsiveness module has been the result of ongoing work over the last 2 years that has involved international consultations with experts and key informants and has been informed by the scientific literature and pilot studies.

Questions on household expenditure and proportionate expenditure on health have been borrowed from existing surveys. The survey instrument has been developed in multiple languages using cognitive interviews and cultural applicability tests, stringent psychometric tests for reliability (i.e. test-retest reliability to demonstrate the stability of application) and most importantly, utilizing novel psychometric techniques for cross-population comparability.

The study was carried out in 61 countries completing 71 surveys because two different modes were intentionally used for comparison purposes in 10 countries. Surveys were conducted in different modes of in- person household 90 minute interviews in 14 countries; brief face-to-face interviews in 27 countries and computerized telephone interviews in 2 countries; and postal surveys in 28 countries. All samples were selected from nationally representative sampling frames with a known probability so as to make estimates based on general population parameters.

The survey study tested novel techniques to control the reporting bias between different groups of people in different cultures or demographic groups ( i.e. differential item functioning) so as to produce comparable estimates across cultures and groups. To achieve comparability, the selfreports of individuals of their own health were calibrated against well-known performance tests (i.e. self-report vision was measured against standard Snellen's visual acuity test) or against short descriptions in vignettes that marked known anchor points of difficulty (e.g. people with different levels of mobility such as a paraplegic person or an athlete who runs 4 km each day) so as to adjust the responses for comparability . The same method was also used for self-reports of individuals assessing responsiveness of their health systems where vignettes on different responsiveness domains describing different levels of responsiveness were used to calibrate the individual responses.

This data are useful in their own right to standardize indicators for different domains of health (such as cognition, mobility, self care, affect, usual activities, pain, social participation, etc.) but also provide a better measurement basis for assessing health of the populations in a comparable manner. The data from the surveys can be fed into composite measures such as "Healthy Life Expectancy" and improve the empirical data input for health information systems in different regions of the world. Data from the surveys were also useful to improve the measurement of the responsiveness of different health systems to the legitimate expectations of the population.

Kind of data
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Sample survey data [ssd]

Sampling procedure
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As there has been no census since 1930 and due to ongoing unrest, there are no available national sampling frames in Lebanon except a geographical frame by administrative districts and based on urban data such as blocks, buildings and apartments. Postal addresses remain incomplete with respect to both coverage and validity particularly for rural areas.

The sample selection was therefore based on local standards for nationwide samples which consist in a cluster sampling of district areas from which housing blocks were randomly selected. Households were then selected randomly from the blocks.

The individual selected from the household was 18+ years in age and the closest birthday method was used to select the respondent.

2,500 households were visited and from each one of them, two individuals were selected.

Mode of data collection
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Mail Questionnaire [mail]

Cleaning operations
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Data Coding
At each site the data was coded by investigators to indicate the respondent status and the selection of the modules for each respondent within the survey design. After the interview was edited by the supervisor and considered adequate it was entered locally.

Data Entry Program
A data entry program was developed in WHO specifically for the survey study and provided to the sites. It was developed using a database program called the I-Shell (short for Interview Shell), a tool designed for easy development of computerized questionnaires and data entry (34). This program allows for easy data cleaning and processing.

The data entry program checked for inconsistencies and validated the entries in each field by checking for valid response categories and range checks. For example, the program didn’t accept an age greater than 120. For almost all of the variables there existed a range or a list of possible values that the program checked for.

In addition, the data was entered twice to capture other data entry errors. The data entry program was able to warn the user whenever a value that did not match the first entry was entered at the second data entry. In this case the program asked the user to resolve the conflict by choosing either the 1st or the 2nd data entry value to be able to continue. After the second data entry was completed successfully, the data entry program placed a mark in the database in order to enable the checking of whether this process had been completed for each and every case.

Data Transfer
The data entry program was capable of exporting the data that was entered into one compressed database file which could be easily sent to WHO using email attachments or a file transfer program onto a secure server no matter how many cases were in the file.
The sites were allowed the use of as many computers and as many data entry personnel as they wanted. Each computer used for this purpose produced one file and they were merged once they were delivered to WHO with the help of other programs that were built for automating the process. The sites sent the data periodically as they collected it enabling the checking procedures and preliminary analyses in the early stages of the data collection.

Data quality checks
Once the data was received it was analyzed for missing information, invalid responses and representativeness. Inconsistencies were also noted and reported back to sites.

Data Cleaning and Feedback
After receipt of cleaned data from sites, another program was run to check for missing information, incorrect information (e.g. wrong use of center codes), duplicated data, etc. The output of this program was fed back to sites regularly. Mainly, this consisted of cases with duplicate IDs, duplicate cases (where the data for two respondents with different IDs were identical), wrong country codes, missing age, sex, education and some other important variables.

摘要
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为开发可比的健康和卫生系统响应的各种数据收集方法，世界卫生组织于2000-2001年启动了一项科学调查研究。该研究采用了适用于全国代表性人群的通用调查工具，并具有模块化结构，用于评估个体在不同领域的健康状况、卫生系统响应、家庭卫生保健支出，以及其他领域的附加模块，如成人死亡率和健康状况评估。
调查工具的健康模块基于国际功能、残疾和健康分类（ICF）选定的领域，并在对各种现有评估工具进行严格科学审查后开发而成。响应模块则是过去两年持续工作的成果，涉及与专家和关键信息提供者的国际磋商，并受到科学文献和试点研究的指导。
家庭支出和卫生相关支出比例的问题借鉴了现有调查。调查工具使用认知访谈和文化适用性测试在多种语言中进行开发，并进行了严格的心理学测试以确保可靠性（即重测信度以证明应用的稳定性），最重要的是，利用新颖的心理学技术以实现跨人群的可比性。
该研究在61个国家进行了71项调查，因为10个国家有意使用了两种不同的模式进行对比。在14个国家，调查采用面对面家庭90分钟访谈的方式进行；在27个国家进行简短面对面访谈；在2个国家进行计算机电话访谈；在28个国家进行邮寄调查。所有样本均从全国代表性的抽样框架中选取，具有已知的概率，以便基于总体人口参数进行估计。
该调查研究测试了新颖的技术来控制不同文化或人口群体中的不同群体之间的报告偏差（即项目功能差异），以便产生跨文化和群体的可比估计。为了实现可比性，将个体对自身健康状况的自我报告与已知的性能测试（即自我报告视力与标准斯内伦视力测试）或与标记已知难度锚点的简短描述（例如，不同活动能力水平的人，如截瘫患者或每天跑4公里的运动员）进行校准，以调整响应以提高可比性。同样，该方法也用于评估个体对其卫生系统响应的自我报告，使用描述不同响应领域不同响应水平的案例来校准个体响应。
这些数据本身具有价值，可用于标准化不同健康领域（如认知、活动能力、自我护理、情感、日常活动、疼痛、社会参与等）的指标，并为以可比方式评估人群健康状况提供更好的测量基础。调查数据可以输入到复合指标中，如“健康预期寿命”，并改善世界各地卫生信息系统中的经验数据输入。调查数据还有助于改进不同卫生系统对人群合法期望的响应的测量。
数据类型
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样本调查数据 [ssd]
抽样程序
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由于自1930年以来没有进行人口普查，以及由于持续的动荡，黎巴嫩没有可用的国家抽样框架，除了基于行政区的地理框架和基于城市数据的框架（如街区、建筑和公寓）。邮政地址在覆盖范围和有效性方面均不完整，尤其是在农村地区。
因此，样本选择基于全国样本的当地标准，包括对地区行政区域的聚类抽样，从中随机选择住宅街区。然后从街区中随机选择家庭。
从家庭中选出的个体年龄为18岁以上，使用最近的生日方法选择受访者。
访问了2,500个家庭，并从每个家庭中选出两个人。
数据收集方式
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邮寄问卷 [mail]
数据清理操作
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数据编码
在每个地点，调查员对数据进行编码，以指示受访者的状态和每个受访者调查设计内选择的模块。在主管编辑并认为访谈合格后，数据在本地输入。
数据输入程序
世界卫生组织开发了专门用于调查研究的数据库程序——I-Shell（Interview Shell的缩写），该程序是一个用于轻松开发计算机化问卷和数据输入的工具，并将其提供给各地点。该程序允许轻松地进行数据清理和处理。
数据输入程序检查数据中的不一致性，并通过检查有效响应类别和范围检查来验证每个字段的输入。例如，程序不接受大于120岁的年龄。对于几乎所有变量，都存在一个范围或可能的值列表，程序会进行检查。
此外，数据输入了两次以捕捉其他数据输入错误。数据输入程序能够在第二次数据输入时警告用户，如果输入的值与第一次输入不匹配。在这种情况下，程序要求用户通过选择第一个或第二个数据输入值来解决冲突，以便继续。在第二次数据输入成功完成后，数据输入程序在数据库中放置一个标记，以便检查每个案例是否已完成此过程。
数据传输
数据输入程序能够将输入的数据导出为一个压缩的数据库文件，可以轻松地通过电子邮件附件或文件传输程序发送到世界卫生组织的安全服务器，无论文件中有多少案例。
各地点被允许使用尽可能多的计算机和尽可能多的数据输入人员。用于此目的的每台计算机都产生一个文件，它们在交付世界卫生组织时与其他用于自动化流程的程序一起合并。各地点在收集数据时定期发送数据，以便在数据收集的早期阶段进行检查程序和初步分析。
数据质量检查
一旦收到数据，就会分析缺失信息、无效响应和代表性。同时还会记录不一致性，并将其反馈给各地点。
数据清理和反馈
在收到来自各地点的清理数据后，运行另一个程序来检查缺失信息、错误信息（例如，错误使用中心代码）、重复数据等。该程序输出的结果定期反馈给各地点。主要涉及具有重复ID的案例、重复案例（其中两个具有不同ID的受访者的数据相同）、错误的国籍代码、缺失的年龄、性别、教育和其他一些重要变量。