Demographic and Health Survey 2009-2010 - Timor-Leste

Abstract
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The principal objective of the 2009-10 Timor-Leste Demographic and Health Survey (TLDHS) was to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, child nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS.

The specific objectives of the survey were to:
- collect data at the national level that will allow the calculation of key demographic rates;
- analyze the direct and indirect factors that determine the levels and trends in fertility;
- measure the level of contraceptive knowledge among women and men, and measure the level of practice among women by method, according to urban or rural residence;
- collect quality data on family health, including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under age 5, and maternity care indicators, including antenatal visits, assistance at delivery, and postnatal care;
- collect data on infant and child mortality and on maternal and adult mortality;
- obtain data on child feeding practices, including breastfeeding, and collect anthropometric measures to use in assessing the nutritional status of women and children;
- collect information on knowledge of tuberculosis (TB), knowledge of the spread of TB, and attitudes towards people infected with TB among women and men;
- collect data on use of treated and untreated mosquito nets, persons who sleep under the nets, use of drugs for malaria during pregnancy, and use of antimalarial drugs fortreatment of fever among children under age 5;
- collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS, and evaluate patterns of recent behavior regarding condom use;
- collect information on the sexual practices of women and men; their number of sexual partners in the past 12 months, and over their lifetime; risky sexual behavior, including condom use at last sexual intercourse; and payment for sex;
- conduct hemoglobin testing on women age 15-49 and children age 6-59 months in a subsample of households selected for the survey to provide information on the prevalence of anemia among women of reproductive age and young children;
- collect information on domestic violence

This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general, and on reproductive health in particular, at both the national and district levels. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2009-10 TLDHS provides national and district-level estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first Demographic and Health Survey (DHS) in Timor-Leste was done in 2003. Unlike the 2003 DHS, however, the 2009-10 TLDHS was conducted under the worldwide MEASURE DHS program, funded by the United States Agency for International Development (USAID) and with technical assistance provided by ICF Macro. Data from the 2009-10 TLDHS allow for comparison of information gathered over a longer period of time and add to the vast and growing international database on demographic and health variables.

The 2009-10 TLDHS supplements and complements the information collected through the censuses, updates the available information on population and health issues, and provides guidance in planning, implementing, monitoring and evaluating Timor-Leste's health programs. Further, the results of the survey assist in monitoring the progress made towards meeting the Millennium Development Goals (MDGs) and other international initiatives.

The 2009-10 TLDHS includes topics related to fertility levels and determinants; family planning; fertility preferences; infant, child, adult and maternal mortality; maternal and child health; nutrition; malaria; domestic violence; knowledge of HIV/AIDS and women's empowerment. The 2009-10 TLDHS for the first time also includes anemia testing among women age 15-49 and children age 6-59 months. As well as providing national estimates, the survey also provides disaggregated data at the level of various domains such as administrative district, as well as for urban and rural areas. This being the third survey of its kind in the country (after the 2002 MICS and the 2003 DHS), there is considerable trend information on demographic and reproductive health indicators.

Geographic coverage
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National

Analysis unit
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- Household
- Children under five years
- Women age 15-49
- Men age 15-49

Kind of data
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Sample survey data [ssd]

Sampling procedure
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The primary focus of the 2009-10 TLDHS 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 districts.

Sampling Frame

The TLDHS used the sampling frame provided by the list of census enumeration areas (EAs) with population and household information from the 2004 Population and Housing Census (PHC). Administratively, Timor-Leste is divided into 13 districts. Stratification is achieved by separating each of the 13 districts into urban and rural areas. In total, 26 sampling strata were created. Samples were selected independently in every stratum, through a two-stage selection process. Implicit stratification was achieved at each of the lower administrative levels by sorting the sampling frame before sample selection, both according to administrative units and also by using a probability proportional-to-size selection at the first stage of sampling. The implicit stratification also allowed for the proportional allocation of sample points at each of the lower administrative levels.

Sample Selection

At the first stage of sampling, 455 enumeration areas (116 urban areas and 339 rural areas) were selected with probability proportional to the EA size, which is the number of households residing in the EA at the time of the census. A complete household listing operation in all of the selected EAs is the usual procedure to provide a sampling frame for the second-stage selection of households. However, a complete household listing was only carried out in select clusters in Dili, Ermera, and Viqueque, where more than 20 percent of the households had been destroyed. In all other clusters, a complete household listing was not possible because the country does not have written boundary maps for clusters. Instead, using the GPS coordinate locations for structures in each selected cluster as provided for by the 2004 PHC, households were randomly selected using their Geographic Information System (GIS) location identification in the central office. A map for each cluster was then generated, marking the households to be surveyed with their location identification. The maps also contained all the other households, roads, rivers, and major landmarks for easier location of selected households in the field. To provide statistically reliable estimates of key demographic and health variables and to cater for nonresponse, 27 households each were selected.

The survey was designed to cover a nationally representative sample of 12,285 residential households, taking into account nonresponse; to obtain completed interviews of 11,800 women age 15-49 in every selected household; and to obtain completed interviews of 3,800 men age 15-49 in every third selected household.

Note: See detailed description of the sample design in Appendix A of the report presented in this documentation.

Mode of data collection
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Face-to-face

Research instrument
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Three questionnaires were administered in the TLDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires were adapted from the standard MEASURE DHS core questionnaires to reflect the population and health issues relevant to Timor-Leste based on a series of meetings with various stakeholders from government ministries and agencies, NGOs, and international donors. The final draft of each questionnaire was discussed at a questionnaire design workshop organized by NSD on March 10, 2009, in Dili. These questionnaires were then translated and back translated from English into the two main local languages-Tetum and Bahasa—and pretested prior to the main fieldwork to ensure that the original meanings of the questions were not lost in translation.

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, education, and relationship to the head of the household. For children under age 18, survival status of the parents was determined. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. 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 of the house, ownership of various durable goods, and ownership of mosquito nets. Additionally, the Household Questionnaire was used to record height and weight measurements for women age 15-49 and children under age 5, and to list hemoglobin measurements for women age 15-49 and children age 6-59 months.

The Woman’s Questionnaire was used to collect information from women age 15-49. These
women were asked questions on the following topics:
- Background characteristics (education, residential history, media exposure, etc.)
- Birth 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
- Woman’s work and husband’s background characteristics
- Awareness and behavior regarding AIDS and other sexually transmitted infections (STIs)
- Maternal mortality
- Domestic violence

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

Response rate
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A total of 12,128 households were selected for the sample, of which 11,671 were found to be occupied during data collection. Of these existing households, 11,463 were successfully interviewed, giving a household response rate of 98 percent.

In these households, 13,796 women were identified as eligible for the individual interview. Interviews were completed with 13,137 women, yielding a response rate of 95 percent. Of the 4,421 eligible men identified in the selected sub-sample of households, 4,076 or 92 percent were successfully interviewed. Response rates were higher in rural than urban areas, with the rural-urban difference in response rates more marked among eligible men than among eligible women.

Sampling error estimates
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The estimates from a sample survey are affected by two types of errors: non-sampling errors and 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 Timor-Leste Demographic and Health Survey 2009-10 (TLDHS 2009-10) to minimize this type of error, nonsampling 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 TLDHS 2009-10 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 TLDHS 2009-10 sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. The computer software used to calculate sampling errors for the TLDHS 2009-10 is a Macro SAS procedure. This procedure used the Taylor linearization method of variance estimation for survey estimates that are means, proportions or ratios. 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 report which is presented in this documentation.

Data appraisal
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Data Quality Tables
- Household age distribution
- Age distribution of eligible and interviewed women
- Age distribution of eligible and interviewed men
- Completeness of reporting
- Births by calendar years
- Reporting of age at death in days
- Reporting of age at death in months
- Nutritional status of children
- Completeness of information on siblings
- Indicators on data quality
- Sibship size and sex ratio of siblings

Note: See these tables in APPENDIX C of the report which is presented in this documentation.

摘要
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2009-10东帝汶人口与健康调查（TLDHS）的主要目标是提供关于生育和计划生育行为、儿童死亡率、成人和孕产妇死亡率、儿童营养状况、孕产妇健康服务的利用情况以及HIV/AIDS知识的当前和可靠数据。

调查的具体目标包括：
- 收集国家级数据，以计算关键的人口统计指标；
- 分析决定生育水平及其趋势的直接和间接因素；
- 测量男女对避孕知识的掌握程度，并根据居住地（城市或农村）测量女性采用各种避孕方法的比例；
- 收集关于家庭健康的高质量数据，包括儿童免疫接种覆盖率、5岁以下儿童腹泻和其他疾病的流行和治疗方法，以及孕产妇保健指标，包括产前检查、分娩协助和产后护理；
- 收集关于婴儿和儿童死亡率以及孕产妇和成人死亡率的数据；
- 获取关于儿童喂养实践的数据，包括母乳喂养，并收集用于评估妇女和儿童营养状况的体格测量数据；
- 收集关于男女对结核病（TB）的认识、对TB传播的认识以及男女对感染TB的人的态度；
- 收集关于使用处理过的和未处理过的蚊帐、睡在蚊帐下的人、孕期使用抗疟疾药物以及5岁以下儿童治疗发热使用抗疟疾药物的数据；
- 收集关于男女对性传播感染和HIV/AIDS的认识和态度，并评估近期关于避孕套使用的行为模式；
- 收集关于男女的性行为信息；他们在过去12个月和一生中的性伴侣数量；风险性行为，包括最后一次性交时的避孕套使用；以及性交易支付；
- 对15-49岁妇女和6-59个月儿童在调查中选定的家庭子样本进行血红蛋白测试，以提供关于生育年龄妇女和幼儿贫血普遍率的信息；
- 收集关于家庭暴力的信息。

这些信息对于制定、规划和评估国家及地区层面的公共卫生政策、特别是生殖健康政策至关重要。调查的长期目标是加强政府机构规划、执行、处理和分析复杂国家人口与健康调查数据的技