Abstract

The 2011 Bangladesh Demographic and Health Survey (BDHS) is the sixth DHS undertaken in Bangladesh, following those implemented in 1993-94, 1996-97, 1999-2000, 2004, and 2007. The main objectives of the 2011 BDHS are to: • Provide information to meet the monitoring and evaluation needs of health and family planning programs, and • Provide program managers and policy makers involved in these programs with the information they need to plan and implement future interventions.

The specific objectives of the 2011 BDHS were as follows: • To provide up-to-date data on demographic rates, particularly fertility and infant mortality rates, at the national and subnational level; • To analyze the direct and indirect factors that determine the level of and trends in fertility and mortality; • To measure the level of contraceptive use of currently married women; • To provide data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS; • To assess the nutritional status of children (under age 5), women, and men by means of anthropometric measurements (weight and height), and to assess infant and child feeding practices; • To provide data on maternal and child health, including antenatal care, assistance at delivery, breastfeeding, immunizations, and prevalence and treatment of diarrhea and other diseases among children under age 5; • To measure biomarkers, such as hemoglobin level for women and children, and blood pressure, and blood glucose for women and men 35 years and older; • To measure key education indicators, including school attendance ratios and primary school grade repetition and dropout rates; • To provide information on the causes of death among children under age 5; • To provide community-level data on accessibility and availability of health and family planning services; • To measure food security.

The 2011 BDHS was conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. ICF International of Calverton, Maryland, USA, provided technical assistance to the project as part of its international Demographic and Health Surveys program (MEASURE DHS). Financial support was provided by the U.S. Agency for International Development (USAID).

Geographic coverage

National

Analysis unit

• Household
• Children under five years
• Women age 15-49
• Men age 15-54

Universe

The 2011 BDHS covers the entire population residing in noninstitutional dwelling units in the country.

Kind of data

Sample survey data

Sampling procedure

Sample Design The sample for the 2011 BDHS is nationally representative and covers the entire population residing in noninstitutional dwelling units in the country. The survey used as a sampling frame the list of enumeration areas (EAs) prepared for the 2011 Population and Housing Census, provided by the Bangladesh Bureau of Statistics (BBS). The primary sampling unit (PSU) for the survey is an EA that was created to have an average of about 120 households.

Bangladesh has seven administrative divisions: Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet. Each division is subdivided into zilas, and each zila into upazilas. Each urban area in an upazila is divided into wards, and into mohallas within a ward. A rural area in the upazila is divided into union parishads (UP) and mouzas within a UP. These divisions allow the country as a whole to be easily separated into rural and urban areas.

The survey is based on a two-stage stratified sample of households. In the first stage, 600 EAs were selected with probability proportional to the EA size, with 207 clusters in urban areas and 393 in rural areas. 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. In the second stage of sampling, a systematic sample of 30 households on average was selected per EA to provide statistically reliable estimates of key demographic and health variables for the country as a whole, for urban and rural areas separately, and for each of the seven divisions. With this design, the survey selected 18,000 residential households, which were expected to result in completed interviews with about 18,000 ever-married women. In addition, in a subsample of one-third of the households, all evermarried men age 15-54 were selected and interviewed for the male survey. In this subsample, a group of eligible members were selected to participate in testing of the biomarker component, including blood pressure measurements, anemia, blood glucose testing, and height and weight measurements.

Note: See Appendix A (in final survey report) for the details of the sample design.

Sampling deviation

The 2007 BDHS sampled all ever-married women age 10-49. The number of eligible women age 10-49 was 11,234, of whom 11,051 were interviewed for a response rate of 98.4 percent. However, there were very few ever-married women age 10-14 (55 unweighted cases or less than one percent). These women have been removed from the data set and weights recalculated for the 15-49 age group. The tables in the survey report discuss only women age 15-49.

Mode of data collection

Face-to-face

Research instrument

The 2011 BDHS used five types of questionnaires: a Household Questionnaire, a Woman’s Questionnaire, a Man’s Questionnaire, a Community Questionnaire, and two Verbal Autopsy Questionnaires to collect data on causes of death among children under age 5. The contents of the household and individual questionnaires were based on the MEASURE DHS model questionnaires. These model questionnaires were adapted for use in Bangladesh during a series of meetings with a Technical Working Group (TWG) that consisted of representatives from NIPORT, Mitra and Associates, International Centre for Diarrheal Diseases and Control, Bangladesh (ICDDR,B), USAID/Bangladesh, and MEASURE DHS. Draft questionnaires were then circulated to other interested groups and were reviewed by the 2011 BDHS Technical Review Committee. The questionnaires were developed in English and then translated and printed into Bangla.

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. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. In addition, information was collected about the dwelling unit, such as the source of water, type of toilet facilities, materials used to construct the floors and walls, and ownership of various consumer goods. The Household Questionnaire was also used to record for eligible individuals: • Height and weight measurements • Anemia test results • Measurements of blood pressure and blood glucose

The Woman’s Questionnaire was used to collect information from ever-married women age 12-49. Women were asked questions on the following topics: • Background characteristics (e.g., age, education, religion, and media exposure) • Reproductive history • Use and source of family planning methods • Antenatal, delivery, postnatal, and newborn care • Breastfeeding and infant feeding practices • Child immunizations and childhood illnesses • Marriage • Fertility preferences • Husband’s background and respondent’s work • Awareness of AIDS and other sexually transmitted infections • Food security

The Man’s Questionnaire was used to collect information from ever-married men age 15-54. Men were asked questions on the following topics: • Background characteristics (including respondent’s work) • Marriage • Fertility preferences • Participation in reproductive health care • Awareness of AIDS and other sexually transmitted infections

The Community Questionnaire was administered in each selected cluster during the household listing operation. Data were collected by administering the Community Questionnaire to a group of four to six community leaders who were knowledgeable about socioeconomic conditions and the availability of health and family planning services/facilities, in or near the sample area (cluster). Community leaders included such persons as government officials, social workers, teachers, religious leaders, traditional healers, and health care providers.

The Community Questionnaire collected information about the existence of development organizations in the community and the availability and accessibility of health services and other facilities. During the household listing operation, the geographic coordinates and altitude of each cluster were also recorded. The information obtained in these questionnaires was also used to verify information gathered in the Woman’s and Man’s Questionnaires on the types of facilities accessed and health services personnel seen.

The Verbal Autopsy Questionnaires were developed based on the work done by an expert group led by the WHO, consisting of researchers, data users, and other stakeholders under the sponsorship of the Health Metrics Network (HMN). The verbal autopsy tools are intended to serve the various needs of the users of mortality information. Two questionnaires were used to collect information related to the causes of death among young children; the first questionnaire collected data on neonatal deaths (deaths at 0-28 days), and the

Abstract

The 2017-18 Bangladesh Demographic and Health Survey (2017-18 BDHS) is a nationwide survey with a nationally representative sample of approximately 20,250 selected households. All ever-married women age 15-49 who are usual members of the selected households or who spent the night before the survey in the selected households were eligible for individual interviews. The survey was designed to produce reliable estimates for key indicators at the national level as well as for urban and rural areas and each of the country’s eight divisions: Barishal, Chattogram, Dhaka, Khulna, Mymensingh, Rajshahi, Rangpur, and Sylhet.

The main objective of the 2017-18 BDHS is to provide up-to-date information on fertility and fertility preferences; childhood mortality levels and causes of death; awareness, approval, and use of family planning methods; maternal and child health, including breastfeeding practices and nutritional status; newborn care; women’s empowerment; selected noncommunicable diseases (NCDS); and availability and accessibility of health and family planning services at the community level.

This information is intended to assist policymakers and program managers in monitoring and evaluating the 4th Health, Population and Nutrition Sector Program (4th HPNSP) 2017-2022 of the Ministry of Health and Family Welfare (MOHFW) and to provide estimates for 14 major indicators of the HPNSP Results Framework (MOHFW 2017).

Geographic coverage

National coverage

Analysis unit

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

Universe

The survey covered all de jure household members (usual residents), all women aged 15-49 and all children aged 0-5 resident in the household.

Kind of data

Sample survey data [ssd]

Sampling procedure

The sample for the 2017-18 BDHS is nationally representative and covers the entire population residing in non-institutional dwelling units in the country. The survey used a list of enumeration areas (EAs) from the 2011 Population and Housing Census of the People’s Republic of Bangladesh, provided by the Bangladesh Bureau of Statistics (BBS), as a sampling frame (BBS 2011). The primary sampling unit (PSU) of the survey is an EA with an average of about 120 households.

Bangladesh consists of eight administrative divisions: Barishal, Chattogram, Dhaka, Khulna, Mymensingh, Rajshahi, Rangpur, and Sylhet. Each division is divided into zilas and each zila into upazilas. Each urban area in an upazila is divided into wards, which are further subdivided into mohallas. A rural area in an upazila is divided into union parishads (UPs) and, within UPs, into mouzas. These divisions allow the country as a whole to be separated into rural and urban areas.

The survey is based on a two-stage stratified sample of households. In the first stage, 675 EAs (250 in urban areas and 425 in rural areas) were selected with probability proportional to EA size. The sample in that stage was drawn by BBS, following the specifications provided by ICF that include cluster allocation and instructions on sample selection. A complete household listing operation was then carried out in all selected EAs to provide a sampling frame for the second-stage selection of households. In the second stage of sampling, a systematic sample of an average of 30 households per EA was selected to provide

statistically reliable estimates of key demographic and health variables for the country as a whole, for urban and rural areas separately, and for each of the eight divisions. Based on this design, 20,250 residential households were selected. Completed interviews were expected from about 20,100 ever-married women age 15-49. In addition, in a subsample of one-fourth of the households (about 7-8 households per EA), all ever-married women age 50 and older, never-married women age 18 and older, and men age 18 and older were weighed and had their height measured. In the same households, blood pressure and blood glucose testing were conducted for all adult men and women age 18 and older.

The survey was successfully carried out in 672 clusters after elimination of three clusters (one urban and two rural) that were completely eroded by floodwater. These clusters were in Dhaka (one urban cluster), Rajshahi (one rural cluster), and Rangpur (one rural cluster). A total of 20,160 households were selected for the survey.

For further details on sample selection, see Appendix A of the final report.

Mode of data collection

Computer Assisted Personal Interview [capi]

Research instrument

The 2017-18 BDHS used six types of questionnaires: (1) the Household Questionnaire, (2) the Woman’s Questionnaire (completed by ever-married women age 15-49), (3) the Biomarker Questionnaire, (4) two verbal autopsy questionnaires to collect data on causes of death among children under age 5, (5) the Community Questionnaire, and the Fieldworker Questionnaire. The first three questionnaires were based on the model questionnaires developed for the DHS-7 Program, adapted to the situation and needs in Bangladesh and taking into account the content of the instruments employed in prior BDHS surveys. The verbal autopsy module was replicated from the questionnaires used in the 2011 BDHS, as the objectives of the 2011 BDHS and the 2017-18 BDHS were the same. The module was adapted from the standardized WHO 2016 verbal autopsy module. The Community Questionnaire was adapted from the version used in the 2014 BDHS. The adaptation process for the 2017-18 BDHS involved a series of meetings with a technical working group. Additionally, draft questionnaires were circulated to other interested groups and were reviewed by the TWG and SAC. The questionnaires were developed in English and then translated into and printed in Bangla. Back translations were conducted by people not involved with the Bangla translations.

Cleaning operations

Completed BDHS questionnaires were returned to Dhaka every 2 weeks for data processing at Mitra and Associates offices. Data processing began shortly after fieldwork commenced and consisted of office editing, coding of open-ended questions, data entry, and editing of inconsistencies found by the computer program. The field teams were alerted regarding any inconsistencies or errors found during data processing. Eight data entry operators and two data entry supervisors performed the work, which commenced on November 17, 2017, and ended on March 27, 2018. Data processing was accomplished using Census and Survey Processing System (CSPro) software, jointly developed by the United States Census Bureau, ICF, and Serpro S.A.

Response rate

Among the 20,160 households selected, 19,584 were occupied. Interviews were successfully completed in 19,457 (99%) of the occupied households. Among the 20,376 ever-married women age 15-49 eligible for interviews, 20,127 were interviewed, yielding a response rate of 99%. The principal reason for non-response among women was their absence from home despite repeated visits. Response rates did not vary notably by urbanrural residence.

Sampling error estimates

The estimates from a sample survey are affected by two types of errors: nonsampling errors and sampling errors. Nonsampling 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 2017-18 Bangladesh Demographic and Health Survey (BDHS) 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 2017-18 BDHS 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 among all possible samples. Although the degree of variability is not known exactly, 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, 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% 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 2017-18 BDHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulas. Sampling errors are computed in SAS, using programs developed by ICF. These programs use the Taylor linearization method to estimate variances 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: A more detailed description of estimates of sampling errors are presented in APPENDIX B of the survey report.

Data

First and second most probable cause of neonatal death assigned using InterVA probabilistic model (n = 1433).

The Government of Bangladesh has invested in a maternal health program with support from a number of development partners. Committed to achieving the Millennium Development Goal (MDG) 5, Bangladesh’s targets are to reduce the maternal mortality ratio (MMR) to 143 per 100,000 live births by 2015, and to increase skilled attendance at birth to 50 percent by 2016. In the last decade, the health, nutrition, and population sector program of Bangladesh has adopted a national strategy for maternal health focusing on Emergency Obstetric Care (EmOC) for reducing maternal mortality, focusing especially on early detection and appropriate referral of complications, and improvement of quality of care. Since 2001, the government embarked on program to retrain existing government community health care workers as Community Skilled Birth Attendants (CSBA) as the primary operational strategy for achieving the 2015 target of 50 percent skilled attendance at birth. The second Bangladesh Maternal Mortality and Health Care Survey was conducted in 2010 (BMMS 2010) with the major objectives being to provide a maternal mortality estimate for the period 2008-2010, to determine whether MMR has significantly declined from 1998-2001, and to ascertain the causes of maternal death. The first such national level survey was conducted in 2001 (BMMS 2001). The survey was carried out in a national sample of 175,000 households, interviewing ever-married women 13 to 49, as well as investigating any deaths to women of reproductive ages, especially maternal and pregnancy-related deaths. Data collection for the survey was conducted from 18 January to 6 August, 2010. For Verbal Autopsy data coding information for causes of deaths, see the International Classification of Diseases (ICD-10). [RESTRICTED DATA] MEASURE Evaluation Restricted Data Request Process The Verbal Autopsy data within this study are restricted due to the sensitive nature of the data and the potential for deductive disclosure. The documentation is publicly accessible, but the data files are available only upon request. If you would like to gain access to the Verbal Autopsy data in this study, please submit a request by clicking on the “Request Access” link to the right of the dataset in the Files section. Requests can only be made by registered Dataverse users. If you do not have a Dataverse account, please create one and log-in before making your request. Once your request has been submitted, MEASURE Evaluation will review it and follow-up with you by email. Please note that requests for restricted data files frequently require review and approval from international partners and can take several weeks to process. If you have any questions or concerns, please e-mail MEASURE Evaluation at measure_data@unc.edu. Thank you, MEASURE Evaluation Dataverse.

This project aims to map and analyse global and national governance of childhood pneumonia (CP) control through examination of existing health policies, financing mechanisms and health system analysis. Lois will investigate the extent of neglect at the international level and look at the extent of neglect at the domestic level, uncovering if and why there are differences when comparing global to national prioritisation, what the local effects of this are and how Bangladesh’s policies have adapted to tackle CP.

Globally, childhood pneumonia (CP) remains the leading infectious cause of death among children under five. However, the disease receives less prioritisation and funding in global health when compared to other infectious diseases such as tuberculosis, malaria and polio. Thus, CP can be described as a neglected health issue at the global level due to lack of synergy among key stakeholders and current agenda-setting practices between influential global health actors.

Bangladesh is typically seen as a success story due to huge reductions in CP in the last few decades. Nevertheless, it remains the 13th highest burden country globally for CP. As such, Bangladesh offers a unique example of what governments are doing to address CP, despite the lack of global prioritisation. Due to the complex wider determinants of health that need to be considered when tackling CP, this disease is a useful litmus test of how well a health system is functioning.

This project aims to map and analyse global and national governance of CP control through examination of existing health policies, financing mechanisms and health system analysis. Lois will investigate the extent of neglect at the international level and look at the extent of neglect at the domestic level, uncovering if and why there are differences when comparing global to national prioritisation, what the local effects of this are and how Bangladesh’s policies have adapted to tackle CP.

For further information, see: "https://www.ed.ac.uk/usher/respire/phd-studentships/lois-king"

Years-wise distribution of most prevalent climate-sensitive diseases in Bangladesh, year 2017-2022.