Abstract

The 2022 Nepal Demographic and Health Survey (NDHS) is the sixth survey of its kind implemented in the country as part of the worldwide Demographic and Health Surveys (DHS) Program. It was implemented by New ERA under the aegis of the Ministry of Health and Population (MoHP) of the Government of Nepal with the objective of providing reliable, accurate, and up-to-date data for the country.

The primary objective of the 2022 NDHS is to provide up-to-date estimates of basic demographic and health indicators. Specifically, the 2022 NDHS collected information on fertility, marriage, family planning, breastfeeding practices, nutrition, food insecurity, maternal and child health, childhood mortality, awareness and behavior regarding HIV/AIDS and other sexually transmitted infections (STIs), women’s empowerment, domestic violence, fistula, mental health, accident and injury, disability, and other healthrelated issues such as smoking, knowledge of tuberculosis, and prevalence of hypertension.

The information collected through the 2022 NDHS is intended to assist policymakers and program managers in evaluating and designing programs and strategies for improving the health of Nepal’s population. The survey also provides indicators relevant to the Sustainable Development Goals (SDGs) for Nepal.

Geographic coverage

National coverage

Analysis unit

• Household
• Individual
• Children age 0-5
• Woman age 15-49
• Man age 15-49

Universe

The survey covered all de jure household members (usual residents), all women aged 15-49, men ageed 15-49, and all children aged 0-4 resident in the household.

Kind of data

Sample survey data [ssd]

Sampling procedure

The sampling frame used for the 2022 NDHS is an updated version of the frame from the 2011 Nepal Population and Housing Census (NPHC) provided by the National Statistical Office. The 2022 NDHS considered wards from the 2011 census as sub-wards, the smallest administrative unit for the survey. The census frame includes a complete list of Nepal’s 36,020 sub-wards. Each sub-ward has a residence type (urban or rural), and the measure of size is the number of households.

In September 2015, Nepal’s Constituent Assembly declared changes in the administrative units and reclassified urban and rural areas in the country. Nepal is divided into seven provinces: Koshi Province, Madhesh Province, Bagmati Province, Gandaki Province, Lumbini Province, Karnali Province, and Sudurpashchim Province. Provinces are divided into districts, districts into municipalities, and municipalities into wards. Nepal has 77 districts comprising a total of 753 (local-level) municipalities. Of the municipalities, 293 are urban and 460 are rural.

Originally, the 2011 NPHC included 58 urban municipalities. This number increased to 217 as of 2015. On March 10, 2017, structural changes were made in the classification system for urban (Nagarpalika) and rural (Gaonpalika) locations. Nepal currently has 293 Nagarpalika, with 65% of the population living in these urban areas. The 2022 NDHS used this updated urban-rural classification system. The survey sample is a stratified sample selected in two stages. Stratification was achieved by dividing each of the seven provinces into urban and rural areas that together formed the sampling stratum for that province. A total of 14 sampling strata were created in this way. Implicit stratification with proportional allocation was achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection, according to administrative units at the different levels, and by using a probability-proportional-to-size selection at the first stage of sampling. In the first stage of sampling, 476 primary sampling units (PSUs) were selected with probability proportional to PSU size and with independent selection in each sampling stratum within the sample allocation. Among the 476 PSUs, 248 were from urban areas and 228 from rural areas. A household listing operation was carried out in all of the selected PSUs before the main survey. The resulting list of households served as the sampling frame for the selection of sample households in the second stage. Thirty households were selected from each cluster, for a total sample size of 14,280 households. Of these households, 7,440 were in urban areas and 6,840 were in rural areas. Some of the selected sub-wards were found to be overly large during the household listing operation. Selected sub-wards with an estimated number of households greater than 300 were segmented. Only one segment was selected for the survey with probability proportional to segment size.

For further details on sample design, see APPENDIX A of the final report.

Mode of data collection

Computer Assisted Personal Interview [capi]

Research instrument

Four questionnaires were used in the 2022 NDHS: the Household Questionnaire, the Woman’s Questionnaire, the Man’s Questionnaire, and the Biomarker Questionnaire. The questionnaires, based on The DHS Program’s model questionnaires, were adapted to reflect the population and health issues relevant to Nepal. In addition, a self-administered Fieldworker Questionnaire collected information about the survey’s fieldworkers.

Input was solicited from various stakeholders representing government ministries and agencies, nongovernmental organizations, and international donors. After all questionnaires were finalized in English, they were translated into Nepali, Maithili, and Bhojpuri. The Household, Woman’s, and Man’s Questionnaires were programmed into tablet computers to facilitate computer-assisted personal interviewing (CAPI) for data collection purposes, with the capability to choose any of the three languages for each questionnaire. The Biomarker Questionnaire was completed on paper during data collection and then entered in the CAPI system.

Cleaning operations

Data capture for the 2022 NDHS was carried out with Microsoft Surface Go 2 tablets running Windows 10.1. Software was prepared for the survey using CSPro. The processing of the 2022 NDHS data began shortly after the fieldwork started. When data collection was completed in each cluster, the electronic data files were transferred via the Internet File Streaming System (IFSS) to the New ERA central office in Kathmandu. The data files were registered and checked for inconsistencies, incompleteness, and outliers. Errors and inconsistencies were immediately communicated to the field teams for review so that problems would be mitigated going forward. Secondary editing, carried out in the central office at New ERA, involved resolving inconsistencies and coding the open-ended questions. The New ERA senior data processor coordinated the exercise at the central office. The NDHS core team members assisted with the secondary editing. The paper Biomarker Questionnaires were compared with the electronic data file to check for any inconsistencies in data entry. The pictures of vaccination cards that were captured during data collection were verified with the data entered. Data processing and editing were carried out using the CSPro software package. The concurrent data collection and processing offered a distinct advantage because it maximized the likelihood of the data being error-free and accurate. Timely generation of field check tables allowed for effective monitoring. The secondary editing of the data was completed by July 2022, and the final cleaning of the data set was completed by the end of August.

Response rate

A total of 14,243 households were selected for the sample, of which 13,833 were found to be occupied. Of the occupied households, 13,786 were successfully interviewed, yielding a response rate of more than 99%. In the interviewed households, 15,238 women age 15-49 were identified as eligible for individual interviews. Interviews were completed with 14,845 women, yielding a response rate of 97%. In the subsample of households selected for the men’s survey, 5,185 men age 15-49 were identified as eligible for individual interviews and 4,913 were successfully interviewed, yielding a response rate of 95%.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling errors result from mistakes made in implementing data collection and in data processing, such as failing to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and entering the data incorrectly. Although numerous efforts were made during the implementation of the 2022 Nepal Demographic and Health Survey (2022 NDHS) 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 2022 NDHS is only one of many samples that could have been selected from the same population, using the same design and expected sample size. Each of these samples would yield results that differ somewhat from the results of the selected sample. Sampling errors are a measure of the variability among all possible samples. Although the exact degree of variability is unknown, it can be estimated from the survey results.

Sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, and so on), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the

The 2022 Nepal Demographic and Health Survey (NDHS) is the sixth survey of its kind implemented in the country as part of the worldwide Demographic and Health Surveys (DHS) Program. It was implemented by New ERA under the aegis of the Ministry of Health and Population (MoHP) of the Government of Nepal with the objective of providing reliable, accurate, and up-to-date data for the country.

The primary objective of the 2022 NDHS is to provide up-to-date estimates of basic demographic and health indicators. Specifically, the 2022 NDHS collected information on fertility, marriage, family planning, breastfeeding practices, nutrition, food insecurity, maternal and child health, childhood mortality, awareness and behavior regarding HIV/AIDS and other sexually transmitted infections (STIs), women’s empowerment, domestic violence, fistula, mental health, accident and injury, disability, and other healthrelated issues such as smoking, knowledge of tuberculosis, and prevalence of hypertension.

The information collected through the 2022 NDHS is intended to assist policymakers and program managers in evaluating and designing programs and strategies for improving the health of Nepal’s population. The survey also provides indicators relevant to the Sustainable Development Goals (SDGs) for Nepal.

Abstract

The principal objective of the 2006 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. For the first time, the 2006 NDHS conducted anemia testing at the household level for the country as a whole to provide information on the prevalence of anemia at the population level. The specific objectives of the survey are to:

• collect data at the national level which will allow the calculation of key demographic rates;
• analyze the direct and indirect factors which determine the level and trends of fertility;
• measure the level of contraceptive knowledge and practice among women and men by method, urban-rural residence and region,
• collect high-quality data on family health including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators including antenatal visits, assistance at delivery, and postnatal care;
• collect data on infant and child mortality, and 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 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;
• conduct hemoglobin testing on women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women in the reproductive ages and young children.

This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional 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 2006 NDHS provides national, regional and subregional 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 Nepal was the 1996 Nepal Family Health Survey (NFHS) conducted as part of the worldwide DHS program, and was followed five years later by the 2001 Nepal Demographic and Health Survey (NDHS). Data from the 2006 NDHS survey, the third such survey, 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.

Wherever possible, the 2006 NDHS data are compared with data from the two earlier DHS surveys—the 2001 NDHS and the 1996 NFHS—which also sampled women age 15-49. Additionally, men age 15-59 were interviewed in the 2001 NDHS and the 2006 NDHS to provide comparable data for men over the last five years.

Geographic coverage

National

Analysis unit

• Household
• Children under five years
• Women age 15-49
• Men age 15-59

Kind of data

Sample survey data

Sampling procedure

The primary focus of the 2006 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 indicators for the 13 domains obtained by cross-classifying the three ecological zones (mountain, hill and terai) with the five development regions (East, Central, West, Mid-west, and Far-west).

The 2006 NDHS used the sampling frame provided by the list of census enumeration areas with population and household information from the 2001 Population Census. Each of the 75 districts in Nepal is subdivided into Village Development Committees (VDCs), and each VDC into wards. The primary sampling unit (PSU) for the 2006 NDHS is a ward, subward, or group of wards in rural areas, and subwards in urban areas. In rural areas, the ward is small enough in size for a complete household listing, but in urban areas the ward is large. It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivision of the urban wards was obtained from the updated Living Standards Measurement Survey. The sampling frame is representative of 96 percent of the noninstitutional population.

The sample for the survey is based on a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 260 PSUs (82 in urban areas and 178 in rural areas) were selected using systematic sampling with probability proportional to size. A complete household listing operation was then carried out in all the selected PSUs to provide a sampling frame for the second stage selection of households. At the second stage of sampling, systematic samples of about 30 households per PSU on average in urban areas and about 36 households per PSU on average in rural areas were selected in all the regions, in order to provide statistically reliable estimates of key demographic and health variables. However, since Nepal is predominantly rural, in order to obtain statistically reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total sample is weighted and a final weighting procedure was applied to provide estimates for the different domains, and for the urban and rural areas of the country as a whole.

The survey was designed to obtain completed interviews of 8,600 women age 15-49. In addition, males age 15-59 in every second household were interviewed. To take nonresponse into account, a total of 9,036 households nationwide were selected.

Mode of data collection

Face-to-face

Research instrument

Three questionnaires were administered for the 2006 NDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, NGOs and international donors. The final draft of the questionnaires was discussed at a questionnaire design workshop organized by MOHP in September 2005 in Kathmandu. The survey questionnaires were then translated into the three main local languages—Nepali, Bhojpuri and Maithili and pretested from November 16 to December 13, 2005.

The Household Questionnaire was used to list all the usual members and visitors in the selected households and to identify women and men who were eligible for the individual interview. 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 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, weight, and hemoglobin measurements of women age 15-49 and children age 6-59 months. The Women’s Questionnaire was used to collect information from all women age 15-49.

These women were asked questions on the following topics: - respondent’s characteristics such as education, residential history, media exposure, - pregnancy history, childhood mortality, - knowledge and use of family planning methods, - fertility preferences, - antenatal, delivery, and postnatal care, - breastfeeding and infant feeding practices, - immunization 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), and - maternal mortality.

The Men’s Questionnaire was administered to all men age 15-59 living in every second household in the 2006 NDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition.

In addition, the Verbal Autopsy Module into the causes of under-five mortality was administered to all women age 15-49 (and anyone else who remembered the circumstances surrounding the reported death) who reported a death or stillbirth in the five years preceding the survey to children under five years of age.

Response rate

A total of 9,036 households were selected, of which 8,742 were found to be occupied during data collection. Of these existing households, 8,707 were successfully interviewed, giving a household response rate of nearly 100 percent.

In the selected households, 10,973 women were identified as eligible for the individual interview. Interviews were completed for 10,793 women, yielding a response rate of 98 percent. Of the 4,582 eligible men identified in the selected subsample of households, 4,397 were successfully interviewed, giving a 96 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: (1) nonsampling errors, and (2)

Different countries have different health outcomes that are in part due to the way respective health systems perform. Regardless of the type of health system, individuals will have health and non-health expectations in terms of how the institution responds to their needs. In many countries, however, health systems do not perform effectively and this is in part due to lack of information on health system performance, and on the different service providers. The aim of the WHO World Health Survey is to provide empirical data to the national health information systems so that there is a better monitoring of health of the people, responsiveness of health systems and measurement of health-related parameters. The overall aims of the survey is to examine the way populations report their health, understand how people value health states, measure the performance of health systems in relation to responsiveness and gather information on modes and extents of payment for health encounters through a nationally representative population based community survey. In addition, it addresses various areas such as health care expenditures, adult mortality, birth history, various risk factors, assessment of main chronic health conditions and the coverage of health interventions, in specific additional modules. The objectives of the survey programme are to: 1. develop a means of providing valid, reliable and comparable information, at low cost, to supplement the information provided by routine health information systems. 2. build the evidence base necessary for policy-makers to monitor if health systems are achieving the desired goals, and to assess if additional investment in health is achieving the desired outcomes. 3. provide policy-makers with the evidence they need to adjust their policies, strategies and programmes as necessary.

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.

The 1996 Nepal Family Health Survey (NFHS) is a nationally representative survey of 8,429 ever- married women age 15-49. The survey is the fifth in a series of demographic and health surveys conducted in Nepal since 1976. The main purpose of the NFHS was to provide detailed information on fertility, family planning, infant and child mortality, and matemal and child health and nutrition. In addition, the NFHS included a series of questions on knowledge of AIDS. The primary objective of the Nepal Family Health Survey (NFHS) is to provide national level estimates of fertility and child mortality. The survey also provides information on nuptiality, contraceptive knowledge and behaviour, the potential demand for contraception, other proximate determinants of fertility, family size preferences, utilization of antenatal services, breastfeeding and food supplementation practices, child nutrition and health, immunizations, and knowledge about Acquired Immune Deficiency Syndrome (AIDS). This information will assist policy-makers, administrators and researchers to assess and evaluate population and health programmes and strategies. The NFHS is comparable to Demographic and Health Surveys (DHS) conducted in other developing countries. MAIN RESULTS FERTILITY Survey results indicate that fertility in Nepal has declined steadily from over 6 births per woman in the mid-1970s to 4.6 births per woman during the period of 1994-1996. Differentials in fertility by place of residence are marked, with the total fertility rate (TFR) for urban Nepal (2.9 births per woman) about two children less than for rural Nepal (4.8 births per woman). The TFR in the Mountains (5.6 births per woman) is about one child higher than the TFR in the Hills and Terai (4.5 and 4.6 births per woman, respectively). By development region, the highest TFR is observed in the Mid-western region (5.5 births per woman) and the lowest TFR in the Eastern region (4.1 births per woman). Fertility decline in Nepal has been influenced in part by a steady increase in age at marriage over the past 25 years. The median age at first marriage has risen from 15.5 years among women age 45-49 to 17.1 years among women age 20-24. This trend towards later marriage is supported by the fact that the proportion of women married by age 15 has declined from 41 percent among women age 45-49 to 14 percent among women age 15-19. There is a strong relationship between female education and age at marriage. The median age at first marriage for women with no formal education is 16 years, compared with 19.8 years for women with some secondary education. Despite the trend towards later age at marriage, childbearing begins early for many Nepalese women. One in four women age 15-19 is already a mother or pregnant with her first child, with teenage childbearing more common among rural women (24 percent) than urban women (20 percent). Nearly one in three adolescent women residing in the Terai has begun childbearing, compared with one in five living in the Mountains and 17 percent living in the Hills. Regionally, the highest level of adolescent childbearing is observed in the Central development region while the lowest is found in the Western region. Short birth intervals are also common in Nepal, with one in four births occurring within 24 months of a previous birth. This is partly due to the relatively short period of insusceptibility, which averages 14 months, during which women are not exposed to the risk of pregnancy either because they are amenorrhoeic or abstaining. By 12-13 months after a birth, mothers of the majority of births (57 percent) are susceptible to the risk of pregnancy. Early childbearing and short birth intervals remain a challenge to policy-makers. NFHS data show that children born to young mothers and those born after short birth intervals suffer higher rates of morbidity and mortality. Despite the decline in fertility, Nepalese women continue to have more children than they consider ideal. At current fertility levels, the average woman in Nepal is having almost 60 percent more births than she wantsthe total wanted fertility rate is 2.9 births per woman, compared with the actual total fertility rate of 4.6 births per woman. Unplanned and unwanted births are often associated with increased mortality risks. More than half(56 percent) of all births in the five-year period before the survey had an increased risk of dying because the mother was too young (under 18 years) or too old (more than 34 years), or the birth was of order 3 or higher, or the birth occurred within 24 months of a previous birth. Nevertheless, the percentage of women who want to stop childbearing in Nepal has increased substantially, from 40 percent in 1981 to 52 percent in 1991 and to 59 percent in 1996. According to the NFHS, 41 percent of currently married women age 15-49 say they do not want any more children, and an additional 18 percent have been sterilized. Furthermore, 21 percent of married women want to wait at least two years for their next child and only 13 percent want to have a child soon, that is, within two years. FAMILY PLANNING Knowledge of family planning is virtually universal in Nepal, with 98 percent of currently married women having heard of at least one method of family planning. This is a five-fold increase over the last two decades (1976-1996). Much of this knowledge comes from media exposure. Fifty-three percent of ever-married women had been exposed to family planning messages on the radio and/or the television and 23 percent have been exposed to messages through the print media. In addition, about one in four women has heard at least one of three specific family planning programmes on the radio. There has been a steady increase in the level of ever use of modern contraceptive method over the past 20 years, from 4 percent of currently married women in 1976, to 27 percent in 1991 and 35 percent in 1996. Among ever-users, female sterilization and male sterilization are the most popular methods (37 percent), indicating that contraceptive methods have been used more for limiting than for spacing births. The contraceptive prevalence rate among currently married women is 29 percent, with the majority of women using modern methods (26 percent). Again, the most widely used method is sterilization (18 percent, male and female combined), followed by injectables (5 percent). Although current use of modern contraceptive methods has risen steadily over the last two decades, the pace of change has been slowest in the most recent years (1991-1996). Current use among currently married non-pregnant women increased from 3 percent in 1976 to 15 percent in 1986 to 24 percent in 1991 and to 29 percent in 1996. While female sterilization increased by only 3 percent from 45 percent of modern methods in 1986 to 46 percent in 1996, male sterilization declined by almost 50 percent from 41 percent to 21 percent over the same period. The level of current use is nearly twice as high in the urban areas (50 percent) as in rural areas (27 percent). Only 18 percent of currently married women residing in the Mountains are currently using contraception, compared with 30 percent and 29 percent living in the Hills and Terai regions, respectively. There is a notable difference in current contraceptive use between the Far-western region (21 percent) and all the other regions, especially the Central and Eastern regions (31 percent each). Educational differences in current use are large, with 26 percent of women with no education currently using contraception, compared with 52 percent of women who have completed their School Leaving Certificate (SLC). In general, as women's level of education rises, they are more likely to use modem spacing methods. The public sector figures prominently as a source of modem contraceptives. Seventy-nine percent of modem method users obtained their methods from a public source, especially hospitals and district clinics (32 percent) and mobile camps (28 percent). The public sector is the predominant source of sterilizations, 1UDs, injectables, and Norplant, and both the public and private sectors are equally important sources of the pill and condoms. Nevertheless, the public sector's share of the market has fallen over the last five years from 93 percent of current users in 1991 to 79 percent in 1996. There is considerable potential for increased family planning use in Nepal. Overall, one in three women has an unmet need for family planning14 percent for spacing and 17 percent for limiting. The total demand for family planning, including those women who are currently using contraception, is 60 percent. Currently, the family planning needs of only one in two women is being met. While the increase in unmet need between 1991 (28 percent) and 1996 (31 percent) was small, there was a 14 percent increase in the percentage of women using any method of family planning and, over the same period, a corresponding increase of 18 percent in the demand for family planning. MATERNAL AND CHILD HEALTH At current mortality levels, one of every 8 children born in Nepal will die before the fifth birthday, with two of three deaths occurring during the first year of life. Nevertheless, NFHS data show that mortality levels have been declining rapidly in Nepal since the eighties. Under-five mortality in the period 0-4 years before the survey is 40 percent lower than it was 10-14 years before the survey, with child mortality declining faster (45 percent) than infant mortality (38 percent). Mortality is consistently lower in urban than in rural areas, with children in the Mountains faring much worse than children living in the Hills and Terai. Mortality is also far worse in the Far-western and Mid-western development regions than in the other regions. Maternal education is strongly related to mortality, and children of highly educated mothers are least likely to die young. For example, infant mortality is nearly

Abstract

Different countries have different health outcomes that are in part due to the way respective health systems perform. Regardless of the type of health system, individuals will have health and non-health expectations in terms of how the institution responds to their needs. In many countries, however, health systems do not perform effectively and this is in part due to lack of information on health system performance, and on the different service providers.

The aim of the WHO World Health Survey is to provide empirical data to the national health information systems so that there is a better monitoring of health of the people, responsiveness of health systems and measurement of health-related parameters.

The overall aims of the survey is to examine the way populations report their health, understand how people value health states, measure the performance of health systems in relation to responsiveness and gather information on modes and extents of payment for health encounters through a nationally representative population based community survey. In addition, it addresses various areas such as health care expenditures, adult mortality, birth history, various risk factors, assessment of main chronic health conditions and the coverage of health interventions, in specific additional modules.

The objectives of the survey programme are to: 1. develop a means of providing valid, reliable and comparable information, at low cost, to supplement the information provided by routine health information systems. 2. build the evidence base necessary for policy-makers to monitor if health systems are achieving the desired goals, and to assess if additional investment in health is achieving the desired outcomes. 3. provide policy-makers with the evidence they need to adjust their policies, strategies and programmes as necessary.

Geographic coverage

The survey sampling frame must cover 100% of the country's eligible population, meaning that the entire national territory must be included. This does not mean that every province or territory need be represented in the survey sample but, rather, that all must have a chance (known probability) of being included in the survey sample.

There may be exceptional circumstances that preclude 100% national coverage. Certain areas in certain countries may be impossible to include due to reasons such as accessibility or conflict. All such exceptions must be discussed with WHO sampling experts. If any region must be excluded, it must constitute a coherent area, such as a particular province or region. For example if ¾ of region D in country X is not accessible due to war, the entire region D will be excluded from analysis.

Analysis unit

Households and individuals

Universe

The WHS will include all male and female adults (18 years of age and older) who are not out of the country during the survey period. It should be noted that this includes the population who may be institutionalized for health reasons at the time of the survey: all persons who would have fit the definition of household member at the time of their institutionalisation are included in the eligible population.

If the randomly selected individual is institutionalized short-term (e.g. a 3-day stay at a hospital) the interviewer must return to the household when the individual will have come back to interview him/her. If the randomly selected individual is institutionalized long term (e.g. has been in a nursing home the last 8 years), the interviewer must travel to that institution to interview him/her.

The target population includes any adult, male or female age 18 or over living in private households. Populations in group quarters, on military reservations, or in other non-household living arrangements will not be eligible for the study. People who are in an institution due to a health condition (such as a hospital, hospice, nursing home, home for the aged, etc.) at the time of the visit to the household are interviewed either in the institution or upon their return to their household if this is within a period of two weeks from the first visit to the household.

Kind of data

Sample survey data [ssd]

Sampling procedure

SAMPLING GUIDELINES FOR WHS

Surveys in the WHS program must employ a probability sampling design. This means that every single individual in the sampling frame has a known and non-zero chance of being selected into the survey sample. While a Single Stage Random Sample is ideal if feasible, it is recognized that most sites will carry out Multi-stage Cluster Sampling.

The WHS sampling frame should cover 100% of the eligible population in the surveyed country. This means that every eligible person in the country has a chance of being included in the survey sample. It also means that particular ethnic groups or geographical areas may not be excluded from the sampling frame.

The sample size of the WHS in each country is 5000 persons (exceptions considered on a by-country basis). An adequate number of persons must be drawn from the sampling frame to account for an estimated amount of non-response (refusal to participate, empty houses etc.). The highest estimate of potential non-response and empty households should be used to ensure that the desired sample size is reached at the end of the survey period. This is very important because if, at the end of data collection, the required sample size of 5000 has not been reached additional persons must be selected randomly into the survey sample from the sampling frame. This is both costly and technically complicated (if this situation is to occur, consult WHO sampling experts for assistance), and best avoided by proper planning before data collection begins.

All steps of sampling, including justification for stratification, cluster sizes, probabilities of selection, weights at each stage of selection, and the computer program used for randomization must be communicated to WHO

STRATIFICATION

Stratification is the process by which the population is divided into subgroups. Sampling will then be conducted separately in each subgroup. Strata or subgroups are chosen because evidence is available that they are related to the outcome (e.g. health, responsiveness, mortality, coverage etc.). The strata chosen will vary by country and reflect local conditions. Some examples of factors that can be stratified on are geography (e.g. North, Central, South), level of urbanization (e.g. urban, rural), socio-economic zones, provinces (especially if health administration is primarily under the jurisdiction of provincial authorities), or presence of health facility in area. Strata to be used must be identified by each country and the reasons for selection explicitly justified.

Stratification is strongly recommended at the first stage of sampling. Once the strata have been chosen and justified, all stages of selection will be conducted separately in each stratum. We recommend stratifying on 3-5 factors. It is optimum to have half as many strata (note the difference between stratifying variables, which may be such variables as gender, socio-economic status, province/region etc. and strata, which are the combination of variable categories, for example Male, High socio-economic status, Xingtao Province would be a stratum).

Strata should be as homogenous as possible within and as heterogeneous as possible between. This means that strata should be formulated in such a way that individuals belonging to a stratum should be as similar to each other with respect to key variables as possible and as different as possible from individuals belonging to a different stratum. This maximises the efficiency of stratification in reducing sampling variance.

MULTI-STAGE CLUSTER SELECTION

A cluster is a naturally occurring unit or grouping within the population (e.g. enumeration areas, cities, universities, provinces, hospitals etc.); it is a unit for which the administrative level has clear, nonoverlapping boundaries. Cluster sampling is useful because it avoids having to compile exhaustive lists of every single person in the population. Clusters should be as heterogeneous as possible within and as homogenous as possible between (note that this is the opposite criterion as that for strata). Clusters should be as small as possible (i.e. large administrative units such as Provinces or States are not good clusters) but not so small as to be homogenous.

In cluster sampling, a number of clusters are randomly selected from a list of clusters. Then, either all members of the chosen cluster or a random selection from among them are included in the sample. Multistage sampling is an extension of cluster sampling where a hierarchy of clusters are chosen going from larger to smaller.

In order to carry out multi-stage sampling, one needs to know only the population sizes of the sampling units. For the smallest sampling unit above the elementary unit however, a complete list of all elementary units (households) is needed; in order to be able to randomly select among all households in the TSU, a list of all those households is required. This information may be available from the most recent population census. If the last census was >3 years ago or the information furnished by it was of poor quality or unreliable, the survey staff will have the task of enumerating all households in the smallest randomly selected sampling unit. It is very important to budget for this step if it is necessary and ensure that all households are properly enumerated in order that a representative sample is obtained.

It is always best to have as many clusters in the PSU as possible. The reason for this is that the fewer the number of respondents in each PSU, the lower will be the clustering effect which

Abstract

The 2001 Nepal Demographic and Health Survey (NDHS) is a nationally representative survey of 8,726 women age 15-49 and 2,261 men age 15-59. This Survey is the sixth in a series of national-level population and health surveys conducted in Nepal. It is the second nationally representative comprehensive survey conducted as part of the global Demographic and Health Survey (DHS) program, the first being the 1996 Nepal Family Health Survey (NFHS). The 2001 NDHS is the first in the history of demographic and health surveys conducted in Nepal that included a male sample. The 2001 NDHS was carried out under the aegis of the Family Health Division of the Department of Health Services, Ministry of Health, and was implemented by New ERA, a local research organization, which also conducted the 1996 NFHS. ORC Macro provided technical support through its MEASURE DHS+ project. The survey was funded by the United States Agency for International Development (USAID) through its mission in Nepal.

The principal objective of the 2001 NDHS is to provide current and reliable data on fertility and family planning, infant and child mortality, children's and women's nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels.

A long-term objective of the survey is to strengthen the technical capacity of the Family Health Division of the Ministry of Health to plan, conduct, process, and analyze data from complex national population and health surveys. The 2001 NDHS data is comparable to data collected in the 1996 NFHS and similar to survey data conducted in other developing countries. This allows for temporal and spatial comparisons of demographic health information. The 2001 NDHS also adds to the vast and growing international database on demographic and health variables. The inclusion of data on men adds to the richness of this data.

Geographic coverage

The 2001 NDHS collected demographic and health information from a nationally representative sample of ever-married women and men in the reproductive age groups of 15-49 and 15-59, respectively. The primary focus of the 2001 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.

Analysis unit

• Household
• Women age 15-49
• Men age 15-59

Universe

The population covered by the 2008 DHS is defined as the universe of all women ever-married women and men in the reproductive age groups of 15-49 and 15-59

Kind of data

Sample survey data

Sampling procedure

The survey was designed to obtain completed interviews of 8,400 ever-married women age 15-49. In addition, all ever-married males age 15-59 in every third household were interviewed. To take nonresponse into account, a total of 8,700 households nationwide were selected. The sample size was allocated to each district by urban and rural areas and the numbers of PSUs were calculated based on an average sample "take" (the number of ultimate sampled units in a cluster) of 34 completed interviews per PSU.

SAMPLE DESIGN

The 2001 NDHS collected demographic and health information from a nationally representative sample of ever-married women and men in the reproductive age groups of 15-49 and 15-59, respectively. The primary focus of the 2001 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 domains obtained by cross-classifying the three ecological zones (mountains, hills, and terai) with the five development regions (Eastern, Central, Western, Mid-western, and Far-western). Due to their small size, the mountain areas of the Western, Mid-western, and Far-western regions were combined.

SAMPLING FRAME

The 2001 NDHS used the sampling frame provided by the list of census enumeration areas (EAs) with population and household information from the 1991 Population Census. Administratively, Nepal is divided into 75 districts. Each district is subdivided into village development committees (VDCs), and each VDC is divided into wards. The primary sampling unit (PSU) for the 2001 NDHS is a ward or group of wards in rural areas and subwards in urban areas. In rural areas, the ward is small enough for a complete household listing, but in urban areas, the ward size is large. It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivision of the urban wards was obtained from the Living Standards Measurement Survey, a project funded by the World Bank.

SAMPLE SELECTION

The sample for the survey is based on a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 257 PSUs - 42 in urban areas and 215 in rural areas were selected using systematic sampling with probability proportional to size. During fieldwork, six PSUs in the Mid-western region were dropped from the sample due to security issues, reducing the total number of PSUs covered to 251 and reducing the number of rural PSUs to 209. This also reduced the expected number of completed interviews to 8,170 from 8,400.

A complete household listing operation was then carried out in all the selected EAs to provide a sampling frame for the second-stage selection of households. Sketch maps were constructed to identify the relative position of housing units in an EA to help interviewers locate selected households during fieldwork. Table A.1 shows the sample distribution of PSUs.

Global positioning system (GPS) units were used to calculate latitude and longitude coordinates for each selected ward (or subward) during the household listing stage. One latitude/longitude coordinate was taken for the center of each settlement or community within the ward. The altitude reading was also taken with the GPS units. The positional accuracy of the GPS readings is approximately 5 to 10 meters for latitude/longitude and approximately 30 meters for altitude. This geographic information allows the 2001 NDHS data to be integrated into a geographic information system (GIS) along with other spatial data collected in the same localities and adds to the depth of information available from the 2001 NDHS.

At the second stage of sampling, systematic samples of 34 households per PSU on average were selected in all the regions in order to provide statistically reliable estimates of key demographic and health variables. However, since Nepal is predominantly rural, in order to obtain statistically reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total sample is weighted and a final weighting procedure was applied to provide estimates for the different domains and for the urban and rural areas of the country as a whole.

Mode of data collection

Face-to-face

Research instrument

The 2001 NDHS used three questionnaires: the Household Questionnaire, the Women's Questionnaire, and the Men's Questionnaire. The content and design of the questionnaires were based on the MEASURE DHS+ Model 'B' Questionnaire. The questionnaires were specifically geared toward obtaining the kind of information needed by health and family planning program managers and policymakers. The model questionnaires were then adapted to local conditions and a number of additional questions specific to ongoing health and family planning programs in Nepal were added. These questionnaires were developed in English and translated into the three principal languages in use in the country: Nepali (the national language), Bhojpuri, and Maithili. They were then independently translated back to English and appropriate changes were made in the translation of questions in which the back-translated version did not compare well with the original English version. A pretest of all three questionnaires was conducted in the three local languages in September 2000.

a) All usual members in a selected household and visitors who stayed there the previous night were enumerated using the Household Questionnaire. Specifically, the Household Questionnaire obtained information on the relationship to the head of the household, residence, sex, age, marital status, and education of each usual resident or visitor. This information was used to identify eligible women and men for the individual interview. Ever-married women age 15-49 in all selected households and ever-married men age 15-59 in every third selected household, whether usual residents or visitors, were deemed eligible and were interviewed. The Household Questionnaire also obtained information on some basic socioeconomic indicators such as the source of drinking water, the type of toilet facilities, the ownership of a variety of consumer durable items, and the flooring material. All eligible women and all children born since Baisakh 2052 in the Nepali calendar (which roughly corresponds to April 1995 in the Gregorian calendar) were weighed and measured.

b) The Women's Questionnaire collected information on female respondent's background characteristics; reproductive history; contraceptive knowledge and use; antenatal, delivery, and postnatal care; infant feeding practices; child immunization and health; marriage; fertility preferences; attitudes about family planning;

The principal objective of the 2006 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. For the first time, the 2006 NDHS conducted anemia testing at the household level for the country as a whole to provide information on the prevalence of anemia at the population level. The specific objectives of the survey are to: collect data at the national level which will allow the calculation of key demographic rates; analyze the direct and indirect factors which determine the level and trends of fertility; measure the level of contraceptive knowledge and practice among women and men by method, urban-rural residence and region, collect high-quality data on family health including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators including antenatal visits, assistance at delivery, and postnatal care; collect data on infant and child mortality, and 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 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; conduct hemoglobin testing on women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women in the reproductive ages and young children. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional 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 2006 NDHS provides national, regional and subregional 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 Nepal was the 1996 Nepal Family Health Survey (NFHS) conducted as part of the worldwide DHS program, and was followed five years later by the 2001 Nepal Demographic and Health Survey (NDHS). Data from the 2006 NDHS survey, the third such survey, 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. Wherever possible, the 2006 NDHS data are compared with data from the two earlier DHS surveys—the 2001 NDHS and the 1996 NFHS—which also sampled women age 15-49. Additionally, men age 15-59 were interviewed in the 2001 NDHS and the 2006 NDHS to provide comparable data for men over the last five years.

The primary objective of the 2016 Nepal Demographic and Health Survey (NDHS) is to provide up-to-date estimates of basic demographic and health indicators. The NDHS provides a comprehensive overview of population, maternal, and child health issues in Nepal. Specifically, the 2016 NDHS: Collected data that allowed calculation of key demographic indicators, particularly fertility and under-5 mortality rates, at the national level, for urban and rural areas, and for the country’s seven provinces Collected data that allowed for calculation of adult and maternal mortality rates at the national level Explored the direct and indirect factors that determine levels and trends of fertility and child mortality Measured levels of contraceptive knowledge and practice Collected data on key aspects of family health, including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under age 5, maternity care indicators such as antenatal visits and assistance at delivery, and newborn care Obtained data on child feeding practices, including breastfeeding Collected anthropometric measures to assess the nutritional status of children under age 5 and women and men age 15-49 Conducted hemoglobin testing on eligible children age 6-59 months and women age 15-49 to provide information on the prevalence of anemia in these groups Collected data on knowledge and attitudes of women and men about sexually transmitted diseases and HIV/AIDS and evaluated potential exposure to the risk of HIV infection by exploring high-risk behaviors and condom use Measured blood pressure among women and men age 15 and above Obtained data on women’s experience of emotional, physical, and sexual violence The information collected through the 2016 NDHS is intended to assist policymakers and program managers in the Ministry of Health and other organizations in designing and evaluating programs and strategies for improving the health of the country’s population. The 2016 NDHS also provides data on indicators relevant to the Nepal Health Sector Strategy (NHSS) 2016-2021 and the Sustainable Development Goals (SDGs).

Abstract

The GSHS is a school-based survey which uses a self-administered questionnaire to obtain data on young people's health behaviour and protective factors related to the leading causes of morbidity and mortality among children and adults worldwide.

Geographic coverage

National

Analysis unit

Individuals

Universe

School-going adolescents aged 13-17 years.

Kind of data

Sample survey data [ssd]

Sampling procedure

A two-stage cluster sample design was used to produce data representative of all students in Class 7-11 in Nepal. At the first stage, schools were selected with probability proportional to enrollment size. At the second stage, classes were randomly selected and all students in selected classes were eligible to participate.

Mode of data collection

self-administered

Research instrument

The following core modules were included in the survey: alcohol use dietary behaviours drug use hygiene mental health physical activity protective factors sexual behaviors tobacco use violence and unintentional injury

Cleaning operations

All data processing (scanning, cleaning, editing, and weighting) was conducted at the US Centers for Disease Control.

Response rate

The school response rate was 92%, the student response rate was 75%, and the overall response rate was 69%.

Analysis unit

Woman, Birth, Child, Birth, Man, Household Member

Universe

Women age 15-49, Births, Children age 0-4, Men age 15-59, All persons

Kind of data

Demographic and Household Survey [hh/dhs]

Sampling procedure

MICRODATA SOURCE: Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc.

SAMPLE UNIT: Woman SAMPLE SIZE: 10793

SAMPLE UNIT: Birth SAMPLE SIZE: 26394

SAMPLE UNIT: Child SAMPLE SIZE: 5783

SAMPLE UNIT: Man SAMPLE SIZE: 4397

SAMPLE UNIT: Member SAMPLE SIZE: 44057

Mode of data collection

Face-to-face [f2f]

Counts and proportions of study variables – Nepal Demographic and Health Survey 2022.

Characteristics of 15-49-year-old women participating in the 2016 Nepal Demographic and Health Survey.

Detail results of the hierarchical modeling using logistic regression. (XLSX 35 kb)

Crude odds ratios and adjusted odds ratios for all statistically significant associations between intimate partner violence and the selected variables – Nepal Demographic and Health Survey 2022.

Logistic regression analysis of determinants of hypertension among adults in Nepal stratified by sex, Nepal Demographic and Health Survey (NDHS), 2016 (N = 13,304).

Data source: Nepal demographic and health surveys 1996 and 2006.amaternal mortality rate from the later survey was used as the reference, so the incidence rate ratio in the earlier survey was 2.69 times greater.**denotes statistical significance at p

Characteristic of the study participants by hypertension status (weighted) and prevalence of hypertension, Nepal Demographic and Health Survey (NDHS), 2016 (N = 13,304).

The Chlorhexidine Coverage and Compliance Survey, 2017 was implemented by USAID’s Monitoring, Evaluation and Learning Activity and NEW ERA under the leadership of the Government of Nepal’s Ministry of Health and Population, Department of Health Services, Child Health Division. Technical assistance was provided by JSI Research and Training Institute, Inc., implementer of the USAID-funded Chlorhexidine Navi Care Program. The purpose of the survey was to determine the level of receipt, application, and compliance with application guidelines of chlorhexidine at the community level in a nationally representative sample of recently delivered women (RDWs). RDWs were defined as women aged 15-49 years living in the selected districts during pregnancy, who had been or were currently married, and who had given birth to a live baby or had had a stillbirth since Baishakh 2073 (April 2016).