THE PHC MAP SERIES OF MODULES, GUIDES AND REFERENCE MATERIALS Each module includes: a User's guide a Facilitator's guide computer programs Module 1 Assessing information needs Module 2 Assessing community health needs and coverage Module 3 Planning and assessing health worker activities Module 4 Surveillance of morbidity and mortality Module 5 Monitoring and evaluating programmes Module 6 Assessing the quality of service Module 7 Assessing the quality of management Module 8 Cost analysis Module 9 Sustainability analysis Manager's guides and references Better management: 100 tips Problem-solving Computers The computerised PRICOR thesaurus Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva and Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok, Thailand Co-Editors: Jennifer Sharples, Colin De'Ath, Bangkok, Thailand Design & Layout: Helene Sackstein, France Desktop Publishing: Marilyn J. Murphy, Suracha Suntarasut, Somboon Vacharotai Foundation, Bangkok, Thailand Printing: Thai Wattana Panich, Bangkok, Thailand Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W., Washington DC and the Aga Khan Foundation, P.O. Box 6179, 1211 Geneva 6, Switzerland. Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan Foundation (United Kingdom) in London; and AKF offices in Dhaka, Bangladesh; Delhi, India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal; and Dar-es-Salaam, Tanzania; the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand ASSESSING COMMUNITY HEALTH NEEDS AND COVERAGE MODULE 2 FACILITATOR'S GUIDE Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B. Steeler (1948-1992) and all other health leaders, managers and workers who follow their example in the effort to bring quality health care to all in need. The Primary Health Care Management Advancement Programme has been funded by the Aga Khan Foundation Canada, the Commission of the European Communities, the Aga Khan Foundation U.S.A., the Aga Khan Foundation's head office in Geneva, the Rockefeller Foundation, the Canadian International Development Agency, Alberta Aid, and the United States Agency for International Development under two matching grants to AKF USA. The first of these grants was "Strengthening the Management, Monitoring and Evaluation of PHC Programs in Selected Countries of Asia and Africa" (cooperative agreement no. OTR-0158-A-00-8161-00, 1988-1991); and the second was "Strengthening the Effectiveness, Management and Sustainability of PHC/Mother and Child Survival Programs in Asia and Africa" (cooperative agreement no. PCD-0158-A-00-1102-00, 1991-1994). The development of Modules 6 and 7 was partially funded through in-kind contributions from the Primary Health Care Operations Research project (PRICOR) of the Center for Human Services under its cooperative agreement with USAID (DSPE-6920-A-00-1048-00). This support is gratefully acknowledged. The views and opinions expressed in the PHC MAP materials are those of the authors and do not necessarily reflect those of the donors. All PHC MAP material (written and computer files) is in the public domain and may be freely copied and distributed to others. Contents FOREWORD 1 SESSION 1: INTRODUCTION AND OVERVIEW 7 Transparencies 2-1: Workshop objectives 12 2-2: Purposes of Module 2 13 SESSION 2: SPECIFY THE OBJECTIVES AND INDICATORS (STEPS 1, 2 AND 3) 15 Transparencies 2-3: Session 2: Objectives 20 2-4: Information needed to state the survey objectives 22 2-5: Keep It Straightforward and Simple 24 SESSION 3: DESIGN THE DATA COLLECTION INSTRUMENTS (STEP 4) 25 Transparencies 2-6: Session 3: Objective 29 2-7: Pre-test the instrument 31 SESSION 4: DEVELOP THE SAMPLING PROCEDURES (STEP 5) 33 Transparencies 2-8: Session 4: Objective <|>37 SESSION 5: SCHEDULE THE SURVEY AND COLLECT THE DATA (STEPS 6 AND 7) 39 Transparencies 2-9: Session 5: Objective 42 2-10: Activities in scheduling the survey 43 2-11: Events to be scheduled 44 2-12: Written instructions 45 SESSION 6: ENTER, VERIFY, AND TABULATE THE DATA (STEP 8) 47 Transparency 2-13: Session 6: Objectives 51 SESSION 7: REPORT FINDINGS AND DEVELOP AN ACTION PLAN (STEPS 9 AND 10) 53 Transparencies 2-14: Session 7: Objectives 57 2-15: Types of interpretation 58 Foreword What is the purpose of the Facilitator's guide? The Facilitator's guide contains a suggested workshop design for use by individuals who will help PHC managers and staff learn how to use the Primary Health Care Management Advancement Programme (PHC MAP) series. There is a Facilitator's guide for each module in the PHC MAP series. What information does it contain? Each Facilitator's guide contains instructions for conducting a workshop on one of the modules in the PHC MAP series using the information contained in the User's guide. The instructions are arranged in one to two hour sessions. The number of sessions depends on the amount of information and/or the number of steps contained in the User's guide. The first page of each session lists session objectives, major topic headings, time required, and materials and equipment. The following pages describe the instructional activities in outline form. The outline is divided into two columns. The right-hand column indicates what the facilitator says or does to conduct the session. The left-hand column lists the handouts, overhead transparencies, or other materials needed to support the activity. Copies of these materials, suitable for duplication, appear at the end of the session in which they are first used. Some transparencies are used in more than one session. How are the workshops organised? The first session of each workshop contains activities designed to introduce the PHC MAP series and explain its importance to PHC programmes, present an overview of the workshop, explain the purpose of the module, review specific terms or concepts used in the module, and acquaint the participants with the organisation and content of the User's guide. The final session of each workshop contains activities designed to review key points of the User's guide, if appropriate, help participants prepare an action plan, and brings the workshop to a formal conclusion. The sessions in between present the steps required to accomplish the purpose of the module and provide an opportunity for participants to apply those steps to their own programmes. Each workshop is designed to be given on consecutive days, uninterrupted except for breaks, meals, and rest, if the workshop is longer than one day. It is recognised, however, that situations vary and the PHC MAP modules will be used singly or in combination by individuals and organisations in the field and on university campuses. Therefore, it is expected that the workshops described in the Facilitator's guides will be adapted to fit a range of circumstances. Indeed, those who facilitate PHC MAP workshops are encouraged to make adaptations to meet the needs of participants and/or specific PHC programmes. Who can be a facilitator? Ideally, the person who serves as facilitator has training and experience in the fields of public health, management, planning, and evaluation, as well as sampling and survey design. It is recommended that this person also be skilful in working with small groups. The facilitator should be someone from outside the PHC programme, perhaps from another agency or a university. As a person with no direct interest in the programme, the facilitator can be neutral in disagreements that may arise and help the group members resolve an issue objectively. Having an outside person as facilitator also allows the programme director, who usually has a leadership role, to contribute his or her knowledge and experience as a full participant in the work of the group. It is also recommended that a facilitator have a full set of PHC MAP User's guides and Facilitator's guides. It is sometimes necessary, in the course of completing one module, to refer to information in another module. Who should participate in the workshop? The primary audience for the PHC MAP series is the team that manages PHC programmes or other population-based health programmes in either the public or private sector. An example of a PHC management team in the public sector is the core staff of a district ranging from 100,000 to 300,000 in size of population served. An example of a PHC management team in the private sector is the core staff of an NGO that provides PHC services to a specific population in a given geographic area. The average size of the service population may range from 40,000 to 60,000, but may be as small as 10,000 or more than 100,000. In either case, the management team should have: the knowledge and skills needed to complete the steps in the module the time and resources required to collect and analyse the required data the authority to plan and implement improvements in management systems and procedures based on this analysis. If feasible, teams from several districts or from several PHC programmes within a given NGO, may work simultaneously with one facilitator to complete a module. It is recommended that one facilitator work with no more than four teams or 20 people at one time. What does the facilitator do? Understands the needs of participants. If the facilitator is working with one PHC programme, the most efficient way to gather information about participants and the programme in which they work is to meet with the PHC director to determine: the nature of the PHC programme (services provided, size and description of area served, number and type of facilities, number and qualifications of staff, community involvement, computer capability, strengths, major problems, etc.) if information needs have been clearly identified previous staff training in management information systems or related topics resources available for training (time, space, equipment) possibility for subsequent technical assistance to workshop participants. Understands the content of Module 1. Read the User's guide and Facilitator's guide for Module 1 and consider options for workshop delivery. The purpose of Module 1 is to help participants select priority information needs and to review some basic concepts underlying management information systems. Depending on participant background, the amount of time available, and the need to establish priorities among management information needs, Module 1 can be presented in its entirety, limited to Level 1: Quick start, limited to the PHC MAP systems framework, or in summary form as contained in the first session of the Facilitator's guides for Modules 2 through 9. If information needs have not been clearly identified and participants have no background in systems, then Module 1 should be presented in full. The selection of the next module will depend upon priorities set by the participants as they complete the steps in Module 1. If information needs have been clearly identified and participants have no background in systems, then that portion of Module 1 can be added to the first session of the selected module. If information needs have been clearly identified and participants have a background in systems, then the overview of PHC MAP in the selected module will be sufficient. Understands the content of the selected module. Read the User's guide and Facilitator's guide for the selected module and consider options for workshop delivery. Depending upon the length of the module and the availability of staff for training, the workshop sessions may be presented as described in the Facilitator's guide, or workshop sessions may be delivered at intervals (for example, every morning for a certain number of days, one session per week, or one day per week for three or four weeks). If follow-on technical assistance is available, the content of the module could be presented in the workshop and the application of the procedure to the PHC programme could be conducted on the job. Participants could plan steps in the workshop, complete them on the job, and bring the results to the next workshop session. This approach is particularly applicable to Module 2 which requires development of a questionnaire, selection of a survey sample, training of data collectors, and data collection. These steps cannot actually be carried out within the time limits of the workshop as contained in the Module 2 Facilitator's guide. Other options are possible depending upon the circumstances of each situation. Determines what programme information, if any, is needed for completion of the module. For example, census data and lists of households are required to complete some of the steps in Module 3. Determines the most appropriate people to attend the workshop. For example, Module 7 is best completed by those responsible for planning, training, supervision, logistics, and other management services. Discusses the delivery options and participants with the PHC manager and make decisions regarding the most appropriate option and participant selection. Also determines if the needed information is available and if it is not, the alternatives for obtaining the information. Notifies participants of the date, time, and purpose of the workshop and confirms attendance. Initial notice of the meeting may come from the PHC manager, with follow-up by the facilitator. Prepares the agenda, using as a model the sample in Session 1 of the Facilitator's guide for the selected module. Inspects the room where the workshop will be held and answers these questions: Is the room large enough to seat all the participants? Can chairs and tables be arranged in a variety of ways; all participants around one table; participants in groups of three or four at smaller tables? Is the lighting adequate? Can temperature and humidity be controlled? Is there an electrical outlet for an overhead projector? Is a microphone necessary for everyone to hear and to be heard? Are toilets conveniently located? Is the site convenient to parking, restaurants and public transportation? Are supporting facilities available and convenient: duplication, word processing, computers? Prepares notes to conduct the workshop using the session outlines in the Facilitator's guide for the selected module, and makes the necessary adaptations. Refer to the appropriate User's guide for content. Duplicates the worksheets and other handouts as indicated in the Facilitator's guide and obtains the necessary equipment. Conducts the workshop as planned. Provides follow-on assistance, if appropriate. Session 1: Introduction and overview Objectives: Participants will be able to: Explain at least one purpose of Module 2. Discuss the purposes and benefits of rapid community surveys. Explain the major steps involved in conducting a rapid community survey. Discuss some limitations of rapid community surveys. Session outline: I. Introduction (30 minutes) II. Overview of workshop (10 minutes) III. Purpose of Module 2 (20 minutes) IV. Module 2 User's guide (10 minutes) V. Rapid community surveys (20 minutes) Materials: Module 2 User's guide Handout 2-1: Agenda Transparency 2-1: Workshop objectives Transparency 2-2: Purposes of Module 2 Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (30 minutes) Note: Omit Section I if you have presented Module 1, or some other module, immediately prior to the presentation of Module 2. A. OPENING REMARKS Introduce self and other staff, as necessary. Explain your role in the workshop. If you do not know the participants, ask each one to state his or her name, position title, and job location. Note: If the group is larger than 6 or 8, you may wish to have them wear name tags or place cards with their names at the places where they are sitting. Ask each participant to complete this sentence: "As a result of attending this workshop, I expect . . . " and write their responses on the flip chart. When all responses have been recorded, say that you will return to this list after giving an overview of the workshop. B. OVERVIEW OF PHC MAP Explain why information is important for PHC programmes. Summarise PHC MAP, including: Purpose of PHC MAP Title and purpose of each module and other materials Make the following points about PHC MAP: Has been field-tested and revised to ensure usefulness to PHC programme staff. Modules can be used in any sequence. Surveys and other materials can be adapted to fit a particular situation. The procedures outlined in the modules can be adopted as routine monitoring activities in a PHC programme. Explain why MAP is being introduced in this PHC programme. Note: The remarks here should be tailored to the specific programme and should provide answers to these questions: Why are we doing this workshop? What do we expect to achieve? It may be appropriate for the PHC manager to make these remarks. II. Overview of workshop (10 minutes) Review the workshop objectives. Distribute and review the workshop agenda, describing the activities that will take place to accomplish the workshop objectives. Review the expectations contributed by participants at the beginning of the session. Indicate which ones will be met and which ones will not and why. Suggest, if possible, alternatives for meeting the expectations that will not be met in this workshop. Explain the process to be followed in completing Module 2. Questions will be addressed in sequence. Facilitator will provide guidance and explanations as needed. Participants will complete the forms provided, drawing on their experience with their programme. Ask for questions or comments. III. Purpose of Module 2 (20 minutes) Explain that the purposes of Module 2 are to help managers: Collect and analyse population-based information on health status, behaviour, and knowledge. Assess PHC programme impact on health knowledge, behaviour, and status of target groups. Review the information that is helpful to have for this module and provide it, as appropriate. An estimate of the total population to be surveyed. An estimate of the size of the subunits of the sample. A map of the survey area. An up-to-date household listing of the community. Ask for questions and comments. IV. Module 2 User's guide (10 minutes) Distribute a User's guide to each participant. Highlight key sections of the User's guide: Overview of PHC MAP has more details on its purpose and the materials included; information that has already been presented in summary form. Quick start provides a procedure for conducting a survey using the Epi Info computer program and can be used if the questionnaires do not need to be modified. 10-step procedure for carrying out rapid community surveys. Appendices (refer participants to the table of contents as you describe the purpose and contents of each appendix.) Explain that Session 2 will be devoted to Steps 1 and 2. V. Rapid community surveys (20 minutes) Explain what are rapid community surveys. Review example discussed in User's guide. Discuss some limitations of rapid surveys: Does not provide for detailed findings or analysis Not designed to identify the determinants or causes of health problems Often conducted by nonprofessional interviewers Should be scheduled when respondents are likely to be home, to minimise bias Does not provide exact estimates of values Can be completed most rapidly if computers are used Ask for questions and comments. WORKSHOP OBJECTIVES: Participants will be able to: 1. Explain at least one purpose of Module 2 2. Explain the purposes and benefits of rapid community surveys 3. Explain the major steps involved in conducting a rapid community survey 4. Discuss some limitations of rapid community surveys PURPOSES OF MODULE 2: Module 2 will help PHC programme managers to: 1. Collect and analyse population-based information on health status, behaviour, and knowledge 2. Assess PHC programme impact on health knowledge, behaviour, and status of target groups SAMPLE AGENDA MODULE 2* Session 1(1 hr,, 30 mins), Introduction and overview Session 2(2 hrs,, 30 mins), Specify the objectives and indicators (Steps 1,, 2,, and 3) Session 3(2 hrs,, 20 mins), Design the data collection instruments (Step 4) Session 4(2 hrs), Develop the sampling procedures (Step 5) Session 5(1 hr), Schedule the survey and collect the data (Steps 6 & 7) Session 6:(1 hr,, 25 mins), Enter,, verify,, and tabulate the data (Step 8) Session 7:(1 hr,, 10 mins), Report findings and develop an action plan (Steps 9 and 10) *For an actual presentation, substitute the appropriate clock hours in the first column. Session 2: Specify the objectives and indicators (Steps 1, 2 and 3) Objectives: Participants will be able to follow the directions in the Module 2 User's guide to: Specify the objectives of the rapid survey. Decide what indicators to use. Develop an outline for the survey report. Plan what information will be produced as a result of the outline. Session outline: I. Introduction (10 minutes) II. Specify the objectives of the rapid survey (60 minutes) III. Decide what indicators to use (40 minutes) IV. Develop an outline (40 minutes) Materials: Module 2 User's guide Transparency 2-3: Session 2: Objectives Transparency 2-4: Information needed to state the objectives Transparency 2-5: KISS Handout 2-2: Worksheet for target groups, health services, and coverage indicators Handout 2-3: Worksheet for specifying rapid survey objectives Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (10 minutes) Review the session objectives. Explain the two reasons for knowing about the health status of target groups: Setting goals. Assessing programme impact on health. II. Specify the objectives of the rapid survey (60 minutes) If participants have completed Module 1, review with them the information needs they have identified. If participants have not completed Module 1, assist them to fill in the worksheet for target groups, health services offered, and coverage indicators. Assist participants to determine the information needed to state the objectives of the rapid survey, and then to draw conclusions: Who are the users of the information? Why is this information needed? Which target population and PHC components does the user want to study? What will be the geographic scope of the survey? What are the scheduling requirements? Direct participants to complete the Worksheet for specifying rapid survey objectives. Ask participants how satisfied they are with their answers to these questions. If they are not satisfied, direct participants to review and restate their information needs. Say that they may also check an information need for services they do not provide, but think they should. Direct participants to select one target group from Handout 2-2 and one corresponding service. Direct participants to write a specific rapid survey objective for this target group. Review Appendix G.2. Explain the steps required to determine the sample sizes needed for a "before-and-after" comparison. Explain the study design used to conduct impact evaluations. Ask for questions and comments. III. Decide what indicators to use (40 minutes) Ask participants to make a list of the key outcome (coverage) indicators for those services identified above, starting with the desired outcome. Review "if..., then..." statements from Module 1, p. 6. If participants require further assistance for this step, refer them to Module 5, which lists recommended indicators for each PHC service. Review the purpose of other types of data which are needed in a rapid survey: Descriptors Characteristics Survey management data IV. Develop an outline (40 minutes) Review the purpose of developing a survey report outline. Discuss the general outline format to be used. Refer participants to the generic outline in Step 9. Explain the purpose and content of each section. Work with participants to adapt the outline, as necessary, to fit the objectives they have specified. Direct participants to construct a list of "dummy tables." Identify the kinds of frequency distributions and cross-tabulations the user(s) will want (see Appendix I for an illustrative list). Review the typical questions that should be addressed in the report and list other questions and issues. Emphasise the use of visual presentations. Remind participants of "KISS." SESSION 2: OBJECTIVES Participants will follow the directions in the Module 2 User's guide to: 1. Specify the objectives of the rapid survey 2. Decide what indicators to use 3. Develop an outline for the survey report 4. Plan what information will be produced as a result of the survey Coverage indicators Health services offered Target group WORKSHEET FOR TARGET GROUPS,, HEALTH SERVICES AND COVERAGE INDICATORS, , INFORMATION NEEDED TO STATE THE SURVEY OBJECTIVES: 1. Who are the users of the information? 2. Why is this information needed? 3. Which target population and PHC components does the user want to study? 4. What will be the geographic scope of the survey? 5. What are the scheduling requirements? WORKSHEET FOR SPECIFYING RAPID SURVEY OBJECTIVES User ____Manager ____Board ____Donor ____Community ____Other: ________________ Purpose ____Planning ____Health status/needs ____Service status/needs ____Evaluation ____Service coverage/effects ____Health status/impact Target groups ____Children ____Women: ________________ ____Other: ________________ ________________ PHC service(s) _______________________________________ _______________________________________ _______________________________________ _______________________________________ Geographic area:_____________ Start date:____________________ End date:_____________________ K EEP IT S TRAIGHTFORWARDAND S IMPLE Session 3: Design the data collection instruments (Step 4) Objectives: Participants will select and design the data collection instruments to be used. Session outline: I. Introduction (5 minutes) II. Review main options (30 minutes) III. Design or adapt data collection instrument(s) (50 minutes) IV. Pretest the data collection instruments (20 minutes) V. Estimate the data collection requirements (25 minutes) VI. Develop a code book (10 minutes) Materials: Module 2 User's guide Transparency 2-6: Session 3: Objective Handout 2-5: Checklist for designing questionnaires Transparency 2-7: Pre-test the instrument Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review the session objective. Give an overview of session activities. II. Review main options (30 minutes) Discuss main differences and limitations of questionnaires and cluster registers. Questionnaires: provide more information, use exact phrasing, and have pre-coded responses, but researcher must use one questionnaire for each respondent. Cluster registers: Record all respondents from one cluster on the same page, but the number of questions is limited to size of the paper. Direct participants to select the type of survey instrument they will use. Discuss the option of selecting one target group or several: Single target group Several target groups Need to draw separate samples for each target group. Use of modular format for questionnaire. Explain the three options for including several topics and target groups in the same survey. Use the sample Multiple PHC service questionnaire in Appendix C. Combine several questionnaires from Appendix C into a single instrument. Construct a new instrument. Instruct participants to select one or more target <+>groups and, if appropriate, one of the three options for a multi-target group questionnaire. III. Design or adapt data collection instruments (50 minutes) Remind participants that questions should be designed to collect information on the indicators they identified in Step 2. Explain the difference in statistical analysis between multiple choice and dichotomous questions. Demonstrate how a multiple choice question can be reworded into a dichotomous question. Refer participants to Appendix B, which includes some other suggestions for designing questionnaires, and give these directions: Read the section on physical layout on page 81. Select one of the questionnaires in Appendix C and look for examples of the recommendations for physical layout. Repeat this process for question construction, sequence of questions, precoding, and identification items. As participants work, circulate among them and answer questions individually. When all participants are done, ask for individual questions or comments. Ask participants to return to Handout 2-5: Checklist for designing questionnaires and indicate the type(s) of questions appropriate to their survey objectives. IV. Pretest the data collection instrument(s) (20 minutes) Review the steps involved in pre-testing the instrument, and the purpose of doing so. Ask for questions or comments. V. Estimate the data collection requirements (25 minutes) Review requirements of a two-person team. Explain how to estimate the number of interviewers and days it will take to complete the data collection, based on the pre-test. Review the formula for estimating the minimum number of "team days". Instruct participants to estimate the requirements for this survey, considering the number of teams available, the length of the questionnaire, the nature of the sample and the time available to complete the survey. VI. Develop a code book (10 minutes) Explain the purpose of code books and when a code book is recommended. Review the components of a code book. Variable number Name Label Value codes Value labels Review example of a code book included in Appendix B. Ask for questions and comments on the design of data collection instruments. SESSION 3: OBJECTIVE Participants will select and design the data collection instruments to be used CHECKLIST FOR DESIGNING QUESTIONNAIRES Type of survey instrument: ____Questionnaire ____Register ____Other: _________________ _________________ Target group(s): ____Children ____Women ____Other: _________________ _________________ Types of questions/fields: ____Yes/no ____Multiple choice ____Open-ended ____Dates ____Ranges (e.g., 1-4 years) Coding: ____Uncoded ____Pre-coded ____Numerical ____Alphabetical ____NA: Not applicable ____DK: Don't know ____NR: No response PRE-TEST THE INSTRUMENT: Translation Administer to small sample of intended target group Use actual survey interviewers, if possible Value of pre-testing Understandable questions Realistic responses Logical sequence Revise Session 4: Develop the sampling procedures (Step 5) Objectives: Participants will review the procedures for developing the sample. Note: This session is optional if participants have a complete household listing of the survey and/or if they plan to use a computer to draw the sample. Session outline: I. Introduction (10 minutes) II. Determine the size of the clusters (50 minutes) III. Variations (60 minutes) Materials: Module 2 User's guide Transparency 2-8: Session 4: Objective Handout 2-5: Cluster identification form Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (10 minutes) Review the session objective. Explain that computer programs can also be used to draw cluster samples. II. Determine the size of the cluster (50 minutes) Explain the basic procedures for manually drawing a sample of 30 clusters. Discuss the definition of a population-based cluster. Explain that identification of the respondents in each cluster will be covered in Step 7. Review the importance of selecting a representative sample. Explain the random sampling procedure for cluster samples. Instruct the participants to use the cluster identification form from Exhibit 3 to list the subunits of the sample and their estimated population sizes. Instruct the participants to complete the cluster identification form up to Step D and then to calculate the sampling interval. Review each step of the example in the User's guide. If actual survey information is available, instruct participants to identify the 30 clusters from their sampling list, using the steps explained, and then make any necessary revisions to the estimates they made at the end of Step 3. Ask for questions and comments. III. Variations (60 minutes) Explain that very large populations (300,000 or more) require that the procedure be done twice. List large subunits (i.e., districts), and follow the procedure to identify where the 30 clusters are located. List the smaller subunits in each of those districts, and make computations again to find the village where each start number occurs. Explain what to do if the population is 15,000 or less using the WHO example for an EPI survey on page 34. Note: If the participants have fewer than 30 "natural clusters," demonstrate the sampling procedure described on page 35. Explain that surveys of rare events require larger clusters, and review the information needed to estimate cluster size for rare events. Percentage of the target group in the sample population. Percentage of that target group that has the attribute you are looking for (identified in Step 2). Review the antenatal care survey, as an example of a rare event survey. Explain that more accurate results can be achieved by increasing the number of clusters and the number of respondents per cluster. Review the rule-of-thumb for sampling of homogeneous and heterogeneous groups. Explain that there must be a minimum of 30 clusters. Refer participants to Appendix G for a computer programme that can help estimate the required sizes. Refer participants to the worksheet for identifying attributes and estimates on page 32 in the User's guide, and direct them to estimate the number of households needed to find the quotas for each part of the survey. Review the general rule-of-thumb for estimating minimal cluster sizes for multiple target groups, using the example for multiple target groups on page 26. Explain the modifications which must be made in order to measure mortality rates or ratios. Refer participants to the SIZE.WK1 worksheet in Appendix G.2 to estimate the size of the sample they will need. Review the vital events and health status questionnaire in Appendix C, used to collect mortality data. Review the sisterhood method of measuring maternal mortality. Ask for questions or comments. SESSION 4: OBJECTIVE Participants will review the procedures for developing the sample Number of clusters:________________ Sample population size:_____________ Cluster size:_____________________ Random start number:_____________ Total (A)Communityname Input data Enter Preset (B)Communitynumber Output dataPreset (E)Selectedcluster (G)Communityname Sample Sites Computer (D)Cumulativepopulation (F)Startnumber Computer Enter (C)Estimated population CLUSTER IDENTIFICATION FORM, , , , Session 5: Schedule the survey and collect the data (Steps 6 and 7) Objectives: Participants will review steps and forms needed to schedule and conduct the survey. Session outline: I. Introduction (5 minutes) II. Schedule the survey (20 minutes) III. Collect data (35 minutes) Materials: Module 2 User's guide Transparency 2-9: Session 5: Objective Transparency 2-10: Activities in scheduling the survey Transparency 2-11: Events to be scheduled Transparency 2-12: Written instructions Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review the session objective. II. Schedule the survey (20 minutes) Explain the major activities in scheduling the survey. Review the events that need to be scheduled based on estimates made in Step 5. Prepare the management forms. Explain the purposes of the management forms. Refer participants to Appendix H for examples of survey management forms for single and multiple target groups. Recruit and train the interviewers. Refer participants to Appendix E for training and supervision guidelines. Review the points to be included in written instructions. III. Collect data (35 minutes) Remind participants that in Step 5 they identified clusters in the population, and explain that in this step, they will select households from within those clusters. Explain the random sampling procedures for selecting households. Use an up-to-date household listing. Do a quick enumeration of households if the community is small and there is no listing. Explain the EPI method as a third alternative. Explain that oversampling (10 households, instead of 7) will compensate for refusals, etc. Remind participants that a separate random sample must be drawn for each target group selected and for multiple target groups. Explain that if a respondent is not at home, at least two revisits should be attempted before replacing them with the next available respondent. SESSION 5: OBJECTIVE Participants will review steps and forms needed to schedule and conduct the survey ACTIVITIES IN SCHEDULING THE SURVEY Finalise data collection schedule Prepare survey management forms Recruit and train interviewers EVENTS TO BE SCHEDULED Recruitment and training Questionnaire production Logistical arrangements Checking and verifying procedures Data entry Analysis Report preparation WRITTEN INSTRUCTIONS Household selection Call back visits: when, how often Checking completed forms What to do about a mistake Session 6: Enter, verify, and tabulate the data (Step 8) Objectives: Participants will be able to follow the procedures in the User's guide to manually: Summarise the data that have been collected. Produce some simple tables. Note: This session is optional if participants plan to use Epi Info or some other computer programme for this step. Session outline: I. Introduction (5 minutes) II. Manual data entry (20 minutes) III. Verifying and cleaning the data (20 minutes) IV. Tabulation (40 minutes) Materials: Module 2 User's guide Transparency 2-13: Session 6: Objectives Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review the session objectives. Explain that this step may be skipped if the participants will use Epi Info, or some other computer program for data entry, verification, and tabulation. II. Manual data entry (20 minutes) Review and explain the important steps in manual data entry. Summarise the data that have been collected. If cluster registers were used, compile the summary tabulations from each of the 30 registers on a summary form. Review the example in the User's guide. If questionnaires were used, summarise and tabulate the data from a cluster on a form similar to the cluster register, or develop a summary form with a column for each interview. Refer participants to Appendix I, which includes two computerised forms for this purpose. Produce some simple tables. III. Verifying and cleaning the data (20 minutes) Explain that verification of data ensures that no mistakes were made in summarising and transferring the original data. Explain a simple verification procedure. Two separate teams independently summarise and transfer the data. Results are compared and discrepancies checked. Explain that cleaning the data involves correcting mistakes in the original interview forms and summary sheets. Review each step of the data entry process to find the source of the mistake. Review the mistakes typically found: using the wrong code leaving a question mark misinterpreting a written code skipping to the wrong question entering an answer in the wrong space IV. Tabulation (40 minutes) Review the steps for manual tabulation. Summarise counts. Based on totals in the Summary Form and report outline prepared in Step 3, decide what information to prepare. Fill in data for the "dummy tables". Review Appendix I, which includes an illustrative list of frequency distributions and cross-tabulations. Compute averages. Perform the division of the data of the continuous variables entered in the summary table. Make sure that the correct denominator is used. Compute coverage percentages. Divide the number of people covered by the number of eligible respondents. Multiply that amount by 100 to convert into a percentage. Prepare frequency distributions. Explain that frequency distributions are used to determine the numbers and percentages of people who use different services, use different providers, have different reasons for accepting a service, etc. Divide the number of people who use a specific source, provider, etc., by the total number who received that general category of service. Multiply that amount by 100 to convert into a percentage. Demonstrate each of these calculations using the examples in the User's guide on page 46. Explain that more detailed tabulations (and statistical analysis) can be done with the use of a computer program. Refer participants to Appendix I for examples of simple computerised tabulation procedures. Refer participants to Appendix I.3 for examples of a program for computing confidence intervals. SESSION 6: OBJECTIVES Participants will be able to follow the procedures in the User's guide to manually: 1. Summarise the data that have been collected 2. Produce some simple tables Session 7: Report findings and develop an action plan (Steps 9 and 10) Objectives: Participants will: Review main issues for analysis and interpretation of the data collected. Develop an action plan. Session outline: I. Introduction (5 minutes) II. Analysis and interpretation (15 minutes) III. Reporting (20 minutes) IV. Action plan (20 minutes) V. Conclusion (10 minutes) Materials: Module 2 User's guide Transparency 2-14: Session 7: Objectives Transparency 2-15: Types of interpretation Handout 2-6: Worksheet for developing action plans Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review the session objectives. Explain that this step should be based on the most important indicators, questions, and issues which were identified in the report outline constructed in Step 3. II. Analysis and interpretation (25 minutes) Review and explain the types of interpretation that should be applied to the completed tables. Descriptions present the facts, without the interpretation of the writer. Performance appraisals compare the descriptive data with performance expectations or standards. Explanations about the frequency distributions can stimulate staff discussion on the observed behaviour of the target population. The procedures in Modules 6 and 7 (Assessing the quality of services and Assessing the quality of management) can help gather some explanatory data. Implications address what future actions can or should be taken by the programme, given the findings of the survey. Issues pending further study identify questions which cannot be answered with the available data, and that might be investigated with a second survey or one of the other modules. Remind participants that analysis must be done on the entire sample, and that analysis of subsamples to compare groups requires separate rapid surveys for each group. Ask for questions and comments on interpretation of findings. III. Reporting (20 minutes) Ask participants to review the outline they prepared in Session 2 and decide if they wish to make any modifications. Discuss report format options. Present findings from each question in the sequence followed in the questionnaire. This is the easiest way to prepare a report. Present major findings first. An oral report, if given, should include a few key tables and graphs. Keep the audience in mind when preparing the report. IV. Action plan (20 minutes) Explain that the development of an action plan should be a separate step and that it should be introduced as part of the study objectives. Review and explain the main questions answered in an action plan. What are the specific actions to be taken as a result of the study? Which specific people will be responsible for each action? When will these actions start and/or be completed? Where will the actions take place? How will the procedures be followed? What resources will be made available to carry out the actions? Explain that specific details of these questions can be worked out after the formal report is ready. Ask for final questions or comments on this session or the workshop as a whole. V. Conclusion (10 minutes) Review the workshop objectives. Review the list of participant expectations you recorded on a flip chart in Session 1 and ask participants to indicate the extent to which they were met. Thank participants for their attention and hard work. SESSION 7: OBJECTIVES Participants will: 1. Review main issues for analysis and interpretation of the data collected 2. Develop details of their action plan TYPES OF INTERPRETATION Descriptions Performance Explanations Implications Issues needing further study Action to take (What) Dates (When) Other (Where, how, resources) Responsible (Who) WORKSHEET FOR DEVELOPING ACTION PLANS, ,