CIET international Nepal Multiple Indicator Surveillance

THE NEPAL MULTIPLE INDICATOR SURVEY

Health and Nutrition

Phase I Jan to March 1995

Preliminary Report:
Table of Contents, Summary, Introduction
and Annex I: Sampling Considerations
(Final version of full report forthcoming)
CIET international Nepal Multiple Indicator Surveillance

A NOTE FOR USERS OF THIS REPORT

1. This is a preliminary report. Comments and questions are welcomed.

2. For non-technicians,

The summary and the introduction (for a flavour of the survey) is recommended.
It also might be useful to refer to key text and graphics in the results, such as for
Vaccinations Measles (page 3), DPT/OPV (page 8) - with graphs on opposite page
Salt Iodisation National distribution (page 11) with graphs Malnutrition Importance of age
(page 12) and scope (page 13) with graphs Feeding Practices Extent of exclusivity, added
foods and breastfeeding duration (page15/16)

District-level graphs give a good illustration of variation throughout rural areas and include:
Night blindness (Fig NB1 opp p18) Diarrhea prevalence and Jeevan Jal use (opp p 20 and 21)
Acute Respiratory Infection (ARI) prevalence (opp p 22) Women’s literacy (page 24)

3. The report is oriented to topics (key indicators) and location (e g. administrative areas).

For those mainly interested in topics, apart from summary and key indicators (p. 7)
a. A more detailed summary on Page 1 of the results
b.Refer to the Contents on page 1 under Results for the desired topic;
Technicians may wish to consult the more detailed tables in Annex 2
c. For district-level information, refer to Contents in Annex 4

For those also interested in Urban/Rural and Major regions (Developmental/Ecological):

a. The tables interspersed in the text (listed on page 2) provide this information in a
standardized format.
b.Annex 3 provides tabular and graphic presentations for each region

For those also interested in Sub-Regions:

Refer especially to the Tables in Annex 2

For those interested in Districts:

Refer especially to Annex 4 for district ranking of several indicators

4. A useful summary table for key indicators and regions heads Annex 3
CIET international Nepal Multiple Indicator Surveillance
CONTENTS

List of Tables and Figures

Summary
Key Indicators
Map
Introduction
Sentinel community studies
Site selection representation
Survey Process
The questionnaire
Quantifying qualitative data
Data management, cleaning and analysis
References

Results Result Section Page

"Progress to Goals" indicators from 144 sites, all regions
1: Measles Vaccination
2: BCG and DPT/OPV Vaccination
3: Universal Salt Iodisation
4: Malnutrition and Feeding Practices
5: Vitamin A Deficiency
6: Diarrhea
7: Acute Respiratory Infection (ARI)
8: Women's topics including Tetanus Toxoid Immunization
9: Water
10: Sanitation

Annexes

1. Sampling Considerations
Methods for sample design and sample size for rural and urban areas, expected precisions,
rationale for large cluster sizes and detailed account of numbers of subjects covered in the survey
2. Detailed Tables for Regions and Sub-Regions
Results for each key indicator with sample sizes for National, urban, rural,
developmental/ecological regions and their 15 sub-regions
3. Current Status for Major Indicators by Regions
Master table and Summary Result graph for all key indicators for each of National, urban, rural,
developmental/ecological regions
4. Graphs with District-level information
30 graphs which display rural districts according to ranking prevalence of key indicators
5. Questionnaires
Quantitative, Meso and Group discussions
CIET international Nepal Multiple Indicator Surveillance

TABLES

M1 % Vaccination Coverage - Measles Children 0-11 and 12-36m

M2 Measles even after Vaccination (% of vaccinated) 9-36m
M3 % Measles Prevalence (0-36m)
M4 Percent of Sites where death from measles reported by FVHV in past year
M5 Measles Vaccine Efficacy (I)
M6 Measles Vaccine Efficacy (II)
V1 % of Children aged 0-36 months with a Vaccination Card
V2 % of Children 0-36m vaccinated with BCG
V3 % of Children aged 12-36 months vaccinated with DPT/OPV3
V4 % of Children aged 12-36 months who completed BCG, Measles and DPT/OPV
V5 % of Children aged 12-36 m who had no vaccination whatsoever
Salt1 % of Local shops with salt iodised at 50 ppm or more
Salt2 % of Local shops with salt iodised at 30 ppm or more
Salt3 % of Local shops with salt not iodised at all
N1 % Chronic Malnutrition: 6-11 to 12-17m showing steep rise
N2 Prevalence of Chronic Malnutrition in children 6-36m
N3 Prevalence of General Malnutrition in children 6-36m
N4 Prevalence of Acute Malnutrition in children 6-36m
BF1 Mean duration of breast feeding in months (current status)
BF2 % of Eligible women still breast feeding from 24-36 m (current status)
BF3 % of children aged 0-3 months "exclusively" breast fed (recall)
BF4 % of children aged 6-8m who started added foods - recall
NB1 % of any prior night blindness in children aged 24-36 months
NB2 % of clusters where FVHV reported night blindness in any child during the past year
D1 % of children aged 0-36 m with diarrhea the past two weeks
D2 % of children with diarrhea which lasted 1 week or longer
D3 % where cost of treatment for Diarrhea Rs 100 or more
D4 % of children aged 0-36 m who received Jeeval Jal during Diarrhea episode
ARI1 % of children aged 0-36 m with ARI the past 2 weeks
ARI2 % of children aged 0-36 m with ARI lasting at least one week
ARI3 % of children aged 0-36 m with ARI with treatment costing Rs 100 or more
ARI4 % of children aged 0-36 m with ARI receiving less fluid than usual
ARI5 % of children aged 0-36 m with ARI receiving less food than usual
L1 % Literacy in Eligible Women by Region
Tet1 % of Eligible Women receiving Tetanus Toxoid in last Pregnancy
Tet2 % of Eligible Women receiving Tetanus Toxoid at least 3 times
Tet3 % of Clusters where a VHW reported local occurrence of Tetanus
Tet4 % of Clusters where FVHV reported a local child having Tetanus in past year
MO1 % of Clusters where FVHV stated a local woman had died in childbirth since 2046 (past 5 years)
MO1 % of Clusters where FVHV stated no trained attendant during delivery for all/almost all local women
MO2 % of Clusters where FVHV stated women in her area usually had harmful applications to cord at birth
W1 % Protected Water Supply
W2 % of Households needing to walk at least 1 hour for water
W3 % of Households which cover water vessel
S1 % of Households which have their own toilet
S2 % of Households with their own toilet appropriately modified pit or septic system
CIET international Nepal Multiple Indicator Surveillance
FIGURES Opposite Page

Meas1 Percent of Children Vaccinated for Measles by month - National

Meas2 Percent of Children aged 9-36 Vaccinated for Measles by month - by District
Meas3 Percent of Children aged 0-36 months who ever had Measles - by District
Vacc1 Percent of Children aged 0-36 months with a demonstrated Immunization card
Vacc2 Percent of Children Vaccinated for BCG by month - National
Vacc3 Percent of Children Vaccinated for DPT/OPV3 by month - National
Vacc5 Percent of Children 12-36 months who received at least 3 doses of DPT/OPV - by District
Vacc6 Pattern of DPT/OPV Vaccinations according to 0, 1, 2 or 3+ doses by Area
Salt1 Level of Iodine as ppm in Salt - tested in two shops in 144 clusters
Salt2 Number of shops where Iodine in salt was tested with levels
Nut1 Percent of children aged 6-36 months with Chronic Malnutrition - by Age
Nut2 Percent of children aged 6-36 months with Chronic Malnutrition (stunting) by District
Nut3 Percent of children aged 6-36 months with Malnutrition by Age
BF1 Percent of Children by Feeding patterns according to Age - National
BF2 Percent of Children by method of feeding cumulated by Month (current status) - National
NB1 Percent of Children aged 24-36 months whose mothers ever reported night blindness - by District
Dia1 Percent of Children aged 0-36 months with diarrhea in the last two weeks - by District
Dia2 Percent of Children with recent diarrhea episode who received Javeen Jal - by District
ARI1 Percent of Children 0-36 months with cough/difficult breathing (ARI) in last two weeks - by District
Moth1 Percent of Eligible Women who state can read and write

5
CIET international Nepal Multiple Indicator Surveillance
THE NEPAL MULTIPLE INDICATOR SURVEY
Summary
The Nepal Multiple Indicator Surveillance
(NMIS) is a reiterative process designed to gather
data on key problems in the country, to provide this
information to planners in a timely manner and to
establish an operational framework for
decentralization. A feature of the approach is the
national representation of the data, while permitting
district level conclusions for around 20 districts.
The first phase of the survey was a national
baseline survey of many of the indicators
recommended for monitoring progress towards the
WSC goals. Under the aegis of the National
Planning Commission, this is intended as a step
towards the National Programme of Action for
Children and Development for the 1990s1.
A sample was developed by the Central Bureau
of Statistics. A total of 144 clusters were randomly
selected to represent the urban/rural balance in the
15 eco-development regions. Each cluster or site
was made up of approximately 120 contiguous
households.
Data were collected between January and March
1995 from 18,772 households, including 102,008
people, 9,537 of them children under the age of
three years. Some 3.6% of households could not be
contacted at the time of the survey. About two-
thirds (63%) of household heads were
predominantly farmers. Females head 9.9% of the
households.
The main indicators are listed in the Indicator
Summary table. From these, at least three
actionable points emerged: the measles vaccination
status, the extent of stunting and the lack of access
to iodised salt.
Measles vaccination coverage is low, with one
out of three children in the target age group
vaccinated (32% among 9-11 month olds, and 59%
among 12-36 month olds). There was no gender
disparity. Quite high coverage figures have been
obtained from some of the districts where reliable
district level data can be obtained; the sample
allows reliable estimates from some 20 districts.
Of the vaccinated children, not all will be
protected, because of low vaccine efficacy (the
ability of the vaccine to prevent the disease).
Furthermore, only about one in nine children under
the age of three years were reported to have
suffered measles. This implies a large number of
children are likely to be susceptible. Usually, when
vaccination levels are low, measles follows an
epidemic cycle of five years. Measles makes a
lethal combination with malnutrition due to
depression of the child's immunity. The main
causes of death are diarrhoea and pneumonia. In
Nepal, only one child in four (23%) receives ORT
when s/he suffers diarrhoea and very few (less than
5%) have added fluids or foods during acute
respiratory infections (ARI).
In many Nepali communities, iodised salt cannot
be purchased from the local shop. Tests on salt
from two shops in each of the 144 communities
revealed that 13% of shops sell salt that is not
iodised at all. One half of the shops (51%) sell salt
with less than 30 parts per million (ppm) of iodide.
Only a small fraction of salt samples (4%) was
found to have 50-60 ppm of iodide, the
recommended level at the point of sale. Since
virtually all table and cooking salt is imported into
Nepal, regulation of the amount of iodide to be
contained must be enforced.
"Stunting" -- or chronic malnutrition affecting the
height of the child -- affects two children in three in
Nepal (64%). Based on weight for height,
"accepting" that children are smaller than they
should be, a further 5-6% are underweight. This
probably reflects acute malnutrition. There is little
or no gender disparity. Thus none of the usual
discriminatory actions taken in favour of boys
comes out in nutritional status -- both boys and girls
suffer.
Examination of stunting by month of age reveals
a dramatic increase from 6 to 18 months of life.
After a peak, it drops off in the third year of life.
This indicates the problem is not one of food
security, but of feeding patterns compounded by
6
infection/ diarrhea and poor environmental
CIET international
conditions, including lack of clean water and
Breastfeeding is universal and prolonged;
however its quality is compromised by lack of
exclusivity in the first three months of life. Most
children received added foods by 6-8 months of
age; however the survey did not investigate food
quality (density) and frequency, both likely to be
inadequate.
The average duration of breastfeeding is about 30
months, both rural and urban, and across all
regions. This is a national resource.
It is necessary to move the national nutrition
focus to a younger age, emphasizing feeding
practices as breastfeeding is complemented and
replaced with solid food. Additional information is
required about the frequency of feeding of young
children. If this is the same as adults (twice or three
times per day) it is insufficient; young children have
small stomachs and cannot take in sufficient on
these occasions for their growing needs, given the
usually low energy density of most diets. Additional
information is required about what diet is
introduced, especially whether it is liquid or solid.
Liquid foods in general have low energy/nutrient
content than solid foods (the volume being taken up
with water).
Information about vaccinations for young
children was derived from all mothers - both with
(in 18%) and without card. Vaccination coverage
for BCG in Nepali children aged 0-36 months was
69%; only urban areas have reached the 80% goal.
Completion of three doses of DPT/OPV occurred in
54% of children with age of recall at 12-36 months.
The patterns vary throughout Nepal. For
example in the Tarai coverage for DPT/OPV3
would be greatly improved if those children with
already 1 or 2 doses were reached. In the
Mountains, there is a high lack of coverage for any
DPT/OPV. Hence a two-pronged strategy is
required: to reach children without any vaccinations
(BCG, Measles nor DPT/OPV) Nationally at 18%
and in certain Mountain and Hill sub-regions 37%;
and to ensure continued vaccinations to complete
DPT/OPV3.
Although the prevalence of night blindness seems
low (about 1% nationally, although in some areas
higher), many more children (and mothers) will
have sub-clinical Vitamin A deficiency, with its
effect on vision and increased mortality. The
Nepal Multiple Indicator Surveillance
sanitation.
continuation of the Vitamin A programme will
require regular monitoring, not only for night
blindness (in pregnant women as well as young
children) and receipt of capsules but also the other
programme components - seed distribution,
nutrition education and improved feeding, the latter
especially in view of the apparent poor feeding
habits (such as with ARI) found in the NMIS.
Recent diarrhea occurred in 15% of children,
suggesting it is common even outside the expected
summer peak. Mostly, no paid treatment was
sought; however in about one-fifth of urban and
one-eighth of rural episodes, treatment cost at least
Rs100. Jeevan Jal (ORT) was used in about one in
four attacks; in no rural region did this exceed 30%
and in 10 districts, its use was rare (less than 10%
of attacks)
Recent ARI occurred in 30% of Nepali children
aged 0-36 months and in one region (East) in 43%.
Almost half (40%) of the attacks lasting at least one
week. Mostly, no paid treatment was sought;
however in 28% of urban and 14% of rural children
payment was at least Rs100. Less than 5% of
children received more food or fluids during the
attack; more than half the children received less
fluids and more than three-quarters less food.
Included in the case management of ARI is the need
to continue fluids and foods at least in the same
amount as usual, ideally more. This clearly is not
being done in Nepal at present. As with diarrhea,
emphasis on early basic treatment would help
reduce the need for more expensive care, especially
with longer-duration ARI.
Literacy rates for Eligible Women (ever-married
aged 15-47 years) are low, but do vary throughout
Nepal by Region and District. About one-third of
women received tetanus toxoid during their last
pregnancy and about one-quarter received TT at
least 3 times. These rates are marginally higher in
urban areas and the Tarai compared with other
Regions; and lower than average in the Mountains,
Far- and Mid-West. According to statements by the
VHW’s and FVHV’s tetanus is not uncommon
throughout all areas of Nepal. Further, unsterile
applications to the umbilical cord stump is the usual
7practice in about one-half of the clusters surveyed.
CIET international Nepal Multiple Indicator Surveillance

Maternal Mortality also is prevalent throughout 81% gave less food,

Nepal, perhaps less in urban areas. 56% gave less liquids

Breastfeeding 50% exclusive 0-3 months

Neonatal tetanus seems not uncommon in Nepal; 85% start food 6-8 months
readily preventable with Tetanus Toxoid and Average stop at 29 months;
appropriate birth practices. This and prevention of 57% still breastfed 24-36m
maternal mortality would appear as very high
Growth Monitoring 21% have vaccination card,
priorities. Growth Monitoring is lower

There is a major community felt need for
improved water and sanitation - evidenced by
responses of Community Leaders, Key Informants
and VHWs. About one-quarter of Nepali
households collect water from a protected supply,
one-half from partial protection and in one-quarter
the supply is not protected. One in eight
households need to walk at least 1 hour to fetch
water. And only one-quarter cover their water
vessel, although the range by district is wide (from
under 10% in some and over 50% in other districts).
Iodization 13% of salt purchased is not iodised
38% of salt purchased is 7-20 ppm
46% of salt purchased has 30+ ppm
4% of salt purchased has 50+ ppm
Water 30% walk 30+minutes to fetch water
27% cover household water recipient
Sanitation 18% have latrines; of these 60% are
pit with unsanitary modifications
Literacy 17% of mothers say they know how
to read or write

Only one in six households claim to own a toilet. IMR Declining IMR since 1980s, from 135-145
per 1000 to 80-90 per 1000 by 1994
(even less so in the Far- and Mid West, and Tarai
regions). Over two-thirds of toilets owned are ACKNOWLEDGEMENTS
simple pit with inadequate modifications for
appropriate sanitation. Fieldwork was conducted by New Era with CIET
international technical input. The study was
supported by UNICEF, which also coordinated
KEY INDICATORS logistical and personnel aspects of the study in each
regional office. This report prepared by CIET does
Male Female not necessarily represent the views of UNICEF.
Malnutrition acute 6.0% 5.0%
stunting 63% 65%

Night Blindness 0-3years 0.5%

under 3 yrs 0.9%

Received Vitamin-A 66% received once,

33% twice or more
Measles 12% of children 0-3 years

9-11m 12-36m
Vaccination Measles 32% 59%
BCG 67% 75%
DPT1 68% 78%
DPT2 55% 68%
DPT3 44% 54%

TT last pregnancy 36% of mothers received

never received TTo 47% TT1 14%
TT2 14% TT3+ 25%

Diarrhoea 15% 0-3year olds suffered in 2

weeks;27% used Jeevan Jal
8
ARI 30% had in last 2 weeks;
CIET international
INTRODUCTION
Sentinel community studies (SCS)
A scheme of community-based measurement
was conceived in Central America in 1984 as a
capacity building development process while
producing accurate, detailed and actionable data
rapidly and at low cost1 2. It focuses on the use of
those data in local and national planning, by
stimulating informed dialogue3 4. This dialogue
occurs not only in the sites but, via a well-informed
communication strategy, throughout the
empowerment area represented by the sites. This
may be a municipality5, a city6, a state7, a number of
provinces8 or an entire country9.
Cyclical contact with the sentinel communities
is effectively a concentration of measurement
resources in time and place, a series of calculated
snapshots of a panel of meso-universes.
The ability to repeat measurement in the same
place makes impact estimation straightforward10. -
Abundant household occurrence data (typically on
3-5,000 children) are compared between sites, and
over time. SCS is a flexible multisectoral data
source concerned with different dimensions of life;
the household is the unit of measurement and it is a
truly multisectoral institution.
Site selection and representation
SCS is often implemented in "data poor"
countries or emergency situations, without reliable
sampling frames. It has been used, for example, in
civil wars in Nicaragua, El Salvador, Angola,
Mozambique, Liberia, Somalia, Rwanda, and
Serbia and Montenegro, where non-parametric
sampling was the only recourse.
In order to generate a summary indicator for the
whole of Nepal, sizes of the study population was
balanced from each of the 15 eco-development
regions.
The objective was to permit national estimates,
disaggregated by the three ecological zones (Tarai,
mid-hills and mountains), by urban and rural and, in
most cases, by district. The basic sample unit was
the ward, with smaller wards combined and larger
ward divided to make up a logistically appropriate
site of approximately 120 households. In urban
areas, municipalities were selected in 15 districts.
Nepal Multiple Indicator Surveillance
In the rural areas, one district in three found its way
into the sample (26 of the 75 in the country). There
were thus a total of 126 rural and 18 urban sites
(total 144), each with 80-160 households. The full
sampling process is described in Annex 1. The
statistical handling and inferential implications of
this method are discussed in detail in other
documents11 12.
Survey Process
Since late in November 1994, the content and
procedures for this first phase of the NMIS became
established. The National Planning Commission
formed a Steering Committee consisting of all
concerned Ministries, the Social Welfare Council,
Central Bureau of Statistics, New Era, UNICEF and
other relevant agencies.
Training of 14 supervisors and initially for three
UNICEF Field Officers lasted from December 6 to
22. This was attended by a representative of the
DOH and included a full-scale rehearsal in Sita
Palia on December 15-16. Initial analysis of this
trial site helped finalize the instruments. Training
of 24 interviewers (five teams) at New Era,
Kathmandu went from December 28 to January 9.
The training cycle continued at Birgunj (three
teams) and Nepalgunj centres (two teams) from
January 12 to 20. Each team consisted of one
supervisor and four or five interviewers.
The field phase started on January 12 (for
Kathmandu trained teams and 10 days after that for
the other teams), upon authorization from the
National Planning Commission. A critical
component of fieldwork was briefing by teams
(often with UNICEF Regional Office coordination)
on the NMIS to senior government officials at the
selected District HQs. The whole concept of the
NMIS including the cluster and district-level
analysis/feedback was generally greeted with
favour and anticipation. In some Districts, HQ
personnel visited the sites with teams for a first-
hand understanding. Also, teams presented the
National Planning Commission letters to the
District CDO and DPHO, who transferred the
9information to the Ward Chairmen and Village
Health Post Officer. Further, letters with more
CIET international
detailed information about NMIS were presented at
District HQ to the CDO, DPHO, LDO, ADO, DEO,
DDO and DWSO; and to the VDC and Ward
Chairmen for each selected site.
The field phase lasted until March/April and
included mountain sites, visited when accessible.
New Era completed data entry and editing shortly
after fieldwork completion.
Preliminary analysis for the whole survey
(guided by CIET International) was presented at a
half-day Steering Committee and Stakeholders
Seminar at NPC on April 20. A member from each
of NPC and UNICEF acted as resource people. The
seminar was attended by 13 committee members,
senior representatives from 6 key Ministries, senior
representatives from 8 selected agencies and 7 from
UNICEF. The focus was on interpretation and a
short list of actionable indicators; defining special
sub-groups and the need to establish a
communication strategy. This was followed by a
Technicians Workshop from April 25-27, attended
by 28 Government and NGO Officers (both
National and District) responsible for planning,
monitoring/ evaluation and communication. This
workshop embraced the concept and technical
aspects of the topics in the April 20 seminar, as well
as computer hands-on analysis; relevance of focus
group discussions and communication strategy
formulation.
The second phase of the NMIS primarily for
education is expected to last from May to July for
training and fieldwork, where the same sites and
officials (and in general the same households) are
being re-visited. This will reinforce and extend the
surveillance cycle of assessment, analysis/feedback/
dialogue to support relevant action at the central
and local levels.
The questionnaire
The questionnaire had three components:
household: dealing primarily with water,
sanitation, sex, ethnicity and occupation of the
household head, household size and number of
rooms for sleeping
eligible woman (ever-married and aged 15-45+
years): age, literacy, having tetanus toxoid during
last pregnancy and total number of times ever
received, births and deaths of children
Nepal Multiple Indicator Surveillance
Child aged 0-36 months: date of birth, sex,
breastfeeding (exclusivity, duration and onset of
added foods - all by recall), ever had night
blindness, receipt of Vitamin A capsules, diarrhea
and cough/difficult breathing in past 2 weeks -
duration and treatment cost for each; use of Jeevan
Jal for diarrhea and change in fluid, liquid intake for
ARI, availability of immunization card, ever
vaccinated for measles, BCG and DPT (number of
times), whether measles occurred after the
vaccination; in addition weight using a hanging
scale, length with a locally-made board and arm
circumference using an insertion tape.
Quantifying qualitative data
The SCS framework established in Nepal invol-
ves 70-180 contiguous households in each com-
munity -- not just seven households per cluster, as
in the EPI cluster method13 -- to permit the in-site
analysis of local "environmental" factors in the
context of household level occurrence data.
As many as possible of the qualitative
appreciations were channeled through the
meso-analysis schedule (the format for interviews
with key informants) in order to optimize the
quantitative aspect of the household questionnaire
(see Annex 5). In each community, for example,
salt was sampled from the local shop and tested for
iodide.
Community leaders were also asked what their
main problems were and what had been done about
them, when and how successful it had been. This
provided for a first classification of development
activity across the 144 sites, to help understand
differences in key status indicators. The
development "players" were identified in each site,
including any government or non-government
agencies, the ward chairman and committee, the
Village Health Worker and the Female Village
Health Volunteer.
Key informants from the VDC were asked about
the occurrence of health-related problem in the
ward, and the availability of information on each
(Polio, Measles, Neonatal Tetanus). They were also
asked about the major health problems of
mothers/young children in the area.
There were thus two main forms of data capture,
10(i) the household questionnaire, administered by
CIET international
interviewers to all contiguous households in the 144
sites and (ii) the key informants, who were asked a
set of less structured questions covering a number
of general or "environmental" issues. A further
component was group discussions with mothers
about vaccinations, diarrhea, ARI and Vitamin A
deficiency.
Nepal Multiple Indicator Surveillance
Data management, cleaning and
analysis
The Bhopal book14 was used for data capture at
the household interview (exercise book with cut
pages and the questionnaire pasted on the inside
cover). Data entry relied on Epi-Info, the public
domain data entry and analysis package. The
analysis started with a seminar with the counterpart
group, using Nanostat15, following the analysis -
schedule established at the design stage. A 650-line
macro was developed that did the analysis for each
region (frequencies, sequential stratification) on
site. Preliminary data were discussed with
programme staff in a regional feedback meeting
before going on to survey the next region. After
completion of all regions, a consolidated analysis
for the entire study area was developed, using
EpiInfo Version 6.1.
Risk analysis was based on sequential -
stratification using the Mantel-Haenszel16 and the
Mantel-Extension17 tests (for trend). Contrasts are
expressed as the odds ratio (OR) or risk difference
(RD)18. Confidence intervals (CI) are those of
Miettinen19. Heterogeneity between strata was
tested using the procedure proposed by Zelen20
11
CIET international Nepal Multiple Indicator Surveillance

ANNEX 1

SAMPLE DESCRIPTION

The NMIS has a random statistically valid sample with adequate size for sufficiently precise
descriptions of indicator prevalence for rural and urban national; regional (East, Central, Mid-
West, West, Far-West); and ecological (Mountain, Foothill and Tarai). The sample was taken
from the total population of Nepal based on results of the 1991 Census, using the services of two
consultants from the Central Bureau of Statistics, one of whom had a lead role in the 1991
Population Census and the 1986/7 Demographic Sample Survey. For rural and urban areas,
clusters were selected systematically on the basis of probability proportion to size (PPS) with a
random start and sampling interval according to the total household size.

Rural Areas
For rural areas, a two-stage cluster design selected 14934 households from 126 clusters in 26
districts. The design stratified all 15 eco-developmental sub-regions to improve efficiency and to
ensure each sub-region would contribute at least one district. The choice of 26 Districts for the
rural sample would be consistent with survey resources, allow more time for quality of data
collection and result in more sites by district. Hence District-level personnel would derive a better
understanding of the results and their use.

The first rural stage randomly selected one-third of the total districts for each sub-region (Table
Sam1). The second rural stage randomly selected clusters from a frame within each of the chosen
districts. This frame consisted of wards or their grouping so that the total number of households
ranged from 80-160 (average 120) and that all nine wards within a village were included. Thus
small rural wards were combined to reach the required number of households.

Table Sam1: Number of Rural Districts Selected by Sub_region (Eco-

developmental)
TOTALS F-West. M-West. West Central East
AREAS
26 (75) 3 (9) 5 (15) 6 (16) 6 (19) 6 (16)

Mountain 6 (16) 1 (3) 2 (5) 1 (2) 1 (3) 1 (3)

Hill 13 (39) 1 (4) 2 (7) 4 (11) 3 (9) 3 (8)

Tarai 7 (20) 1 (2) 1 (3) 1 (3) 2 (7) 2 (5)

Note: Figures in brackets represent the total number of districts.

The probability of choosing any district in a sub-region and the number of clusters within that
district was proportional to its total number of rural households. The more highly populated
districts, particularly in the West, Central and 12
East Tarai each comprise 8 or more clusters
CIET international Nepal Multiple Indicator Surveillance

and should provide adequate sample sizes for appropriate descriptions (Table Sam2). Those
districts with 4-6 clusters will probably provide adequate descriptions. Districts with 2 to 3
clusters, such as those in the mountain and east-hill areas will have less precise descriptions.

Table Sam2: Number of clusters in sample by area and District

Nation 144 Rural 126 U 18
al rban
--- Areas --- Far West 12 Mid West 18 West 29 Central 36 East 31

Mountains 16 Darchula 3 2 Sindhupalch 4 Mustang 2 Sankhuwasa 3

Jumla k b
Kalikote 2

Hills 54 Achham 5 Dailekh 4 Gorkha 5 Ramechhap 4 Ilam 3

Rolpa 4 Syangja 5 Kathmandu 5 Bhojpur 3

Myagdi 2 Dhading 5 Udayapur 4

Gulmi 5

Tarai 56 Kailali 4 Bardiya 6 Rupandehi 8 Dhanusha 11 Morang 10

Rautahat 9 Siraha 8

Precision is a function of prevalence, sample size and design effect (DEFF). The design effect
takes into account that the sample is derived from clusters or groups of subjects rather than separate subjects
as occurs in simple random sampling. The precision describes the range of the result. By convention, this
range indicates that the census result (if there were no sample) would be within the range 95% of the time.
If the prevalence of Measles coverage in children aged 12-36 months was .50 or 50% and the precision 0.1
or 10%, then the revised prevalence estimate for the sample would be 50% +/- 10% or 40 to 60%.

Table Sam3 provides more details. The first column gives the estimated populations of various
groups, so that their numbers can be derived from that of households. The lower part of the table calculates
the precisions based on the target populations, prevalence for indicators (from National results of the survey)
and number of clusters and households. Such precisions vary by indicator. Thus a district with 4 clusters
would provide reasonable estimates for most of the indicators. The use of ORT in diarrhea is a special case
as the derived prevalence (diarrhea*ORT use or 0.10*.25= 0.025) is quite low. Results for child vaccination
would effectively double the sample size (and decrease the precision by a factor of 1.4) for children 12-24
months, by using recall for children aged 12-36 months. Results for 12-24 months and 24-36 months are
very similar, hence we used the wider age range to increase the target sample size.

On the other hand precisions would be wider if the design effect (estimated at 2) was greater. It
should be realized that this effect and resulting precisions can be estimated from the survey results (analysis
has not yet reached that stage).

Cluster numbers for each of the developmental (12, 38, 18, 29, 38 and 31 from
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CIET international Nepal Multiple Indicator Surveillance

Far-West to East) and ecological regions (16, 54 and 58 for Mountain, Hills and Tarai) would appear more
than adequate for reliable precisions (Table Sam4). Within the 15 eco-developmental sub-regions all Hill
and Tarai cells apart from the Far-West seem satisfactory. Those in the Mountain Region are on the light
side.

Table Sam4: Number of Rural Clusters Selected by Sub-region (Eco-

developmental)
TOTALS Far-west. Mid-west. Western Central Eastern
AREAS
126 12 18 29 38 31

Mountain 16 3 4 4 2 3

Hill 54 5 8 17 14 10

Tarai 58 4 6 8 20 18

Urban Areas

For urban areas, a two stage cluster design selected 18 municipalities and 2336 households. The
urban frame was divided into three strata on the basis of female literacy rates based on the 1991 Population
Census results: Over 54.8% (urban average), 39% (national average) to 54.8%, and below 39%. It was
expected that indicator results relating to child health/nutrition and education within each stratum would be
more homogeneous than between strata, ensuring a more efficient sample.

For the urban sample, the probability of choosing any municipality and the number of clusters
within that municipality was proportional to its total number of households. In urban, unlike rural areas
large wards needed dividing so that each cluster or site had approximately 120 households. Copies of
municipal maps which included each of the 18 sites selected were obtained from the Household Survey
Division, Central Bureau of Statistics. These were used to facilitate the random selection of the designated
cluster boundaries.

Of the 18 municipal clusters selected, four were from Kathmandu and the remainder from separate
districts (Table Sam4a). Kathmandu, Biratnagar (Morang District), Lahan (Siraha) and Dhangadhi (Kailali)
also have sampled rural clusters in the same district. Municipal clusters are not included in the eco-
developmental nor regular district descriptions. This is to maintain the integrity of the basic sample
stratification dividing rural and urban.

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CIET international Nepal Multiple Indicator Surveillance

Table Sam4: Number of Urban area clusters

Name of Municipality District No. Clusters

Kathmandu Kathmandu 4
Lalitpur Lalitpur 1
Dhulikhel Kavrepalamchok 1
Hetauda Makwanpur 1
Rajbiraj Saptari 1
Birgunj Parsa 1
Pokhara Kaski 1
Tansen Palpa 1
Taulihawa Kapilvastu 1
Nepalgunj Banke 1
Dhanagadhi Kailali 1
Damak Jhapa 1
Biratnagar Morang 1
Dharan Sunsari 1
Lahan Siraha 1

National Descriptions

The national descriptions combine both rural and urban areas. National results are very similar to
rural. This is because the rural population comprises about 90% of Nepal. Further, urban areas were “over-
sampled”; that is an added 50% of urban households above what was need according to population were
selected, done to increase the precision for urban estimates. Hence the urban contribution to the National
result would be of the order of 7%, compared with rural of about 93%.

Rationale for large cluster sizes

The large ward-based size (average 120 households) amounts to a census in almost all rural wards.
This allows a more complete description locally, especially for the repeated cycles in the same wards. The
result is better comprehension by the concerned communities during feedback, reinforced by the meso-
analysis results. District authorities can focus not only on the totals for all clusters, but also on each entity.
This cannot occur on smaller cluster sizes of 10 to 30 households.

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CIET international Nepal Multiple Indicator Surveillance

Raising Factors (“weights”)

Raising factors (akin to weights, but not termed as such as their sum does not equal 1) represent the
adjustment required for the results because although the selection of districts was proportional to their size,
the sample sizes for these districts were not. The range of these factors is wide. For example, Mustang has
a low value. This is due to the need to include one district in the Western Mountain region which has a
small population. Hence a fixed sample size is much larger than that district’s population. Myagdi has a
high raising factor as only two clusters were selected from this relatively large district. The raising factors
for all districts in the urban sample are low, because as already indicated the sample was 50% higher than
the equivalent proportion in the rural frame.

Preliminary analysis indicates that weighting changes the results for national estimates mainly due
to the different weights between urban and rural areas. The urban contribution to national is generally small
because of this and because it comprises about 10% of the total population. Total rural is less likely to be
affected by weighting. In general within sub-regions changes are not likely to be more than 2-3%, because
the districts within a specific sub-region usually have similar raising factors.

Sample Coverage

All 144 selected clusters were covered. The estimated number of households to be surveyed was
17270, with 2336 urban and 14934 rural. The actual households reached was almost 10% greater than these
numbers, most likely due to population increase since the 1991 census (estimated at 11.6%). This increase
was particularly marked in the West Hill, East Hill and Central Tarai rural sub-regions. (see Table Sam5 for
details).

Almost all (96.5%) of the households registered were visited and interviewed - a coverage rate
consistent throughout all districts. Key survey subjects were eligible women (ever-married aged 15-47) and
children aged 0-36 months; with 20034 and 9537 documented (Table Sam 6). Of the women, 85.7% were
covered (14.3% absent) and of the children 89.9% covered (10.1% absent). For the women, the usual reason
was absence from the household during the period of the site visit (usually 2-3 days). For the children the
same would apply. In addition, some children not covered were actually present but their mother not
available to provide the key information.

For different areas of Nepal, absent eligible women and their children varied from 4 to 20%.

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Table Sam5: Numbers of Households in NMIS

Sample Households No. of Households

Areas No. of Estimate Inter-viewed % Absent

Clusters number Registered
Urban 18 2336 2621 2461 6.1
Rural 128 14934 16151 15646 3.1
National 144 17270 18772 18107 3.5

Development (rural)
Far-western 12 1428 1457 1391 4.5
Mid-western 18 1934 2097 2003 4.5
Western 27 3124 3557 3424 3.7
Central 38 4618 5084 4957 2.5
Eastern 31 3634 3956 3871 2.1

Eco-areas (rural)
Mountain 16 1703 1714 1657 3.3
Hill 56 6752 6966 6760 3.0
Tarai 54 6283 7471 7229 3.2

Eco-Developmental (rural)
Far-west Mountain 3 344 333 324 2.7
Mid-west Mountain 4 371 391 369 5.6
West Mountain 2 179 165 158 4.2
Central Mountain 4 479 500 496 0.8
East Mountain 3 330 325 310 4.6
Far-west Hill 5 616 616 579 6.0
Mid-west Hill 8 848 876 858 2.1
West Hill 17 1976 2389 2311 3.3
Central Hill 14 1692 1741 1718 1.3
East Hill 10 1114 1344 1294 3.7
Far-west Tarai 4 468 508 488 3.9
Mid-west Tarai 6 765 830 776 6.5
West Tarai 8 932 1003 955 4.8
Central Tarai 20 2534 2843 2743 3.5
East Tarai 18 2286 2287 2267 0.9

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CIET international Nepal Multiple Indicator Surveillance

Sample Households No. of Households

Areas No. of Estimate Inter- % Absent

Clusters number Registered viewed
Districts (rural)
Darchula 3 344 333 324 2.7
Jumla 2 176 180 173 3.9
Kalikot 2 195 211 196 7.1
Sindhupalchowk 4 479 500 496 0.8
Mustang 2 179 165 158 4.2
Sankhuwasabha 3 330 325 310 4.6
Accham 5 616 616 579 6.0
Ramechhap 4 498 481 480 0.2
Dailekh 4 441 460 451 2.0
Kathmandu 5 620 665 628 2.3
Rolpa 4 407 416 407 2.2
Dhading 5 574 595 577 3.0
Gorkha 5 515 530 514 3.0
Gulmi 5 616 939 919 2.1
Myagdi 2 222 225 207 8.0
Syangja 5 660 695 671 3.5
Ilam 3 308 328 325 0.9
Bhojpur 3 406 421 414 1.7
Udayapur 4 400 595 555 6.7
Kailali 4 468 508 488 4.0
Bardiya 6 715 830 776 6.5
Rupandehi 8 932 1003 955 4.8
Dhanusha 11 1400 1608 1528 5.0
Rautahat 9 1047 1235 1215 1.6
Morang 10 1246 1262 1255 0.5
Siraha 8 944 1025 1012 1.4

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Table Sam6: Numbers of Eligible women and children aged 0-36 months in survey

Eligible Women Children aged 0-36 months

Areas Docum- Present % Absent Docum-ented Present % Absent

ented
Urban 2708 2315 14.5 1123 1005 10.5
Rural 17326 14859 14.2 8414 7563 10.1
National 20034 17174 14.3 9537 8568 10.2

Development (rural)
Far-western 1676 1470 12.3 867 806 7.0
Mid-western 2366 2032 14.1 1296 1189 8.3
Western 3763 3148 16.3 1719 1507 12.3
Central 5491 4669 15.0 2532 2260 10.7
Eastern 4030 3540 12.2 2000 1801 10.0

Eco-areas (rural)
Mountain 1734 1573 9.3 862 790 8.4
Hill 7105 6097 14.2 3534 3252 8.0
Tarai 8487 7189 15.3 4018 3521 12.4

Eco-Developmental
Far-west Mountain 415 398 4.1 164 156 4.9
Mid-west Mountain 431 389 9.7 252 226 10.3
West Mountain 106 99 6.6 43 35 18.6
Central Mountain 527 470 10.8 266 242 9.0
East Mountain 255 217 14.9 137 131 4.4
Far-west Hill 619 518 16.3 318 302 5.0
Mid-west Hill 928 770 17.0 513 477 7.0
West Hill 2519 2145 14.8 1155 1029 10.9
Central Hill 1775 1537 13.4 879 810 7.9
East Hill 1264 1127 10.8 669 634 5.2
Far-west Tarai 642 554 13.7 385 348 9.6
Mid-west Tarai 1007 873 13.3 531 486 8.5
West Tarai 1138 904 20.6 521 443 15.0
Central Tarai 3189 2662 16.5 1387 1208 12.9
East Tarai 2511 2196 12.5 1194 1036 13.2

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Eligible Women Children aged 0-36 months

Areas Docum- Present % Absent Docum-ented Present % Absent

ented
Districts (rural)
Ilam 324 280 13.6 170 155 8.8
Myagdi 213 177 16.9 96 87 9.4
Rautahat 1438 1245 13.4 606 531 12.4
Rupandehi 1138 904 20.6 521 443 15.0
Bardiya 1007 873 13.3 531 486 8.5
Kailali 683 602 13.2 385 348 9.5
Sankhuwasabha 255 217 14.9 137 131 4.4
Mustang 106 99 6.6 43 35 18.6
Sindhupalchowk 527 470 10.8 266 242 9.0
Jumla 186 171 8.1 113 107 5.3
Kalikot 245 218 11.0 139 119 14.4
Darchula 415 398 4.1 164 156 4.9
Bhojpur 371 339 8.6 197 189 4.1
Kathmandu 691 611 11.6 270 238 11.6
Ramechhap 492 410 16.7 267 243 9.0
Udayapur 569 508 10.7 302 290 4.0
Dhading 592 516 12.8 343 330 3.8
Gorkha 551 453 17.8 259 235 9.3
Syangja 713 604 15.3 319 284 11.0
Gulmi 1042 911 12.6 481 423 12.1
Dailekh 477 405 15.1 238 230 3.4
Rolpa 451 365 19.1 275 247 10.2
Accham 619 518 16.3 318 302 5.0
Morang 1253 1137 9.2 654 573 12.3
Siraha 1238 1059 12.5 550 461 16.3
Dhanusha 1751 1417 19.1 781 677 13.3

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