In 2010, the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) was established in Nepal with its main office in the NMC community hospital in Jhaukhel (Figure ).
Photos (from top left to lower right): HDSS office (Nepal Medical College, Jhaukhel) and the office room; training session; enumerators during training; the making of social maps; enumerator during an interview (baseline survey training and action).
Findings of the baseline census 2010
Figure and Tables , , present the findings, separately and combined, of the 2010 baseline census. JD-HDSS includes 2,712 households containing a total of 13,669 individuals (Table ). The study population covers nearly 5% of the total population of Bhaktapur district [14
]. The total population of the study area has increased nearly by 3% (annual growth rate
0.26%) and total household number has increased by 15% after the national census 2001 [15
]. The average household size of JD-HDSS is similar to the data reported by the Nepal Health Demographic Survey 2006 [16
]. Households in both villages showed a 96% response rate during data collection. With few exceptions, all forms were filled in completely.
Population pyramid of the Duwakot (A) and Jhaukhel (B) development committees, Baseline Survey 2010.
Household size, population size and sex ratio of JD-HDSS, Bhaktapur, 2010
Vital statistics, JD-HDSS, Bhaktapur, 2010
Common causes of mortality, JD-HDSS, Bhaktapur, 2010
According to the age-sex pyramids of the two villages, a majority of the population was between 10 and 30
years of age, and the birth rate was low (Figure A and B). The proportion of population is decreasing with age group after 20–24
years. It indicates that the proportion of deaths may rise in the future as a consequence of low birth rate. The median age of the population is 27
years for both males and females.
The predominant castes were Newars (36.5%), Chhetris (30.4%) and Brahmins (23.4%); and nearly 97% of the population was Hindu. Among employable individuals, 25% were students aged between 10 and 30
years, fewer than 11% worked in agriculture, nearly 20% were service holders, and 2% were unemployed. Almost one fifth (18.2%) of the individuals
years of age were illiterate. More than two thirds of the population was economically active and based on education, occupation and income levels attained by heads of the households, about 60% belonged to the upper-lower class (Figure ); 93% owned their own home. Around 50% of households used piped drinking water, almost all (99.5%) had electricity, and 3% lacked indoor toilet facilities.
Figure 4 Socio-economic classification of the households in the Health Demographic Surveillance site at Jhaukhel and Duwakot (JD-HDSS). The socioeconomic class was defined by Kuppuswamy’s socioeconomic status scale modified to the Nepalese context [13 (more ...)
Fertility–related indicators for JD-HDSS offered a good picture of overall fertility rate, with a crude birth rate of 9.7/1,000 total population and a home delivery rate of 11% (Table ). Mean age at marriage (± standard deviation) was 22.2 (±4.6) and 18.4 (±3.6) years for boys and girls respectively with difference in mean age at marriage of 3.4 which is similar to the national figures for rural areas [17
]. Females produced offspring within 2
years of marriage (20.4
Migration data shows that about 2% of the population had migrated to the area (Table ), mostly as family units, and the majority migrated from adjacent districts, including Dolakha (14.8%), Sindhupalchock (14.5%), Ramechap (12.5%), Kavrepalanchok (6.6%) and Kathmandu (4.9%). On the other hand, out-migration (i.e., predominantly one member per house, who moved for work or study) was 1.36% (Table ). Among the out-migrant population, about one fifth migrated internationally.
Our survey recorded no deaths among infants or children younger than 5
years of age. One third of all deaths occurred below the average life expectancy (i.e., 64
]. The crude death rate was 3.9 per 1,000 population per year. Non-communicable diseases (NCDs), including hypertension, diabetes mellitus and cancer, were major causes of death (Tables ). Based on 2001 census, among total deaths, 2.6%, 1%, 0.6% and 3.6% of deaths were accountable to heart diseases, hypertension, diabetes, and cancer respectively [15
Health and health behavior
Nearly 15% of individuals in the study area smoked cigarettes (1 in 5 among the males and 1 in 10 among the females), and about 67% of smokers belonged to an upper-lower class family (data not shown). One in 10 people reported being ill during the four weeks immediately preceding the survey (Table ). Table shows the top 10 causes of morbidity. The most common cause of illness was respiratory problems, followed by heart disease, hypertension and gastric ailments. Age-adjusted multivariate analysis of the composite prevalence of the main four NCDs (i.e., heart disease, hypertension, cancer and diabetes) shows that NCDs occur more frequently in females, Tibeto-Burman ethnic groups, agricultural workers or laborers, the illiterate and smokers (Table ) [19
]. Nearly 25% of ill individuals visited traditional healers. For modern medicine, they visited the district hospital or bought medicine directly from a medicine shop; they visited local governmental outlets (e.g., health posts and the private hospitals/clinics) less frequently (Figure ).
Top ten morbidity reported in JD-HDSS, Bhaktapur, 2010
Age-adjusted multivariate analysis for non-communicable diseases
Health service utilization by people during illness, Baseline Survey 2010 (multiple answers).
Challenges at JD-HDSS
HDSS provide methods for collecting unique and continuous demographic data that describes an entire population; hence, producing reliable data is both imperative and a major challenge. Our team faced many administrative, political, geographical and social challenges during establishment of the JD-HDSS.
Before performing the baseline survey, our team conducted several rounds of discussion with concerned authorities (i.e., medical schools, governmental bodies, local authorities and political leaders) about the importance of JD-HDSS. One challenge involved justifying the need for the study and then obtaining the commitment of the authorities, which was crucial to the long-term continuation of the project.
Another critical element in establishing a well-defined surveillance site involves hiring appropriate human resources from within the study locality. The norm developed in JD-HDSS involves hiring local data enumerators and supervisors, thus establishing an easy rapport between the study population and the researchers, enhancing convenient data collection and benefiting economic activities. Although the minimum qualification was grade 10 for data enumerators and an Intermediate passed for field supervisors, bachelor or master-level candidates applied for both posts. Thus, high competition and overqualified candidates increased the challenge of selecting suitable manpower. Moreover, political leaders and bureaucrats exerted additional pressure during the recruitment process.
As JD-HDSS is located in mid-hills, participant households were scattered even within wards and they are not easily accessible from the single concrete road of the village. Indeed, access to the entire area is limited by the road facility and the poor availability of public transportation. It requires more than an hour to travel from one location to another. Moreover, Nepal lacks a systematic numbering system for its households, making it very difficult for enumerators and field supervisors to identify the exact location of some houses and, thus, hampering fieldwork.
Household members were not always available during the survey visits, necessitating a second visit. In addition, even when respondents were at home, they were often busy and unable to devote the time required to complete the lengthy questionnaire (9 different parts in 16 pages). Similarly, the questionnaire included the collection of very difficult information regarding migration. Despite these difficulties, our supervisors and enumerators were able to collect information from 96% households.
Data management is a crucial component of reliability and validation. At JD-HDSS, the preparation of data for analysis included several stages. First, completed forms were kept in the JD-HDSS office, where staff members checked that they were filled out completely. Next, the completed forms were sent to the data entry operators. If they found an error, the data entry operators sent the forms back to the field for correction. For example, some forms were completed in mixed language (i.e., both English and Nepali). Frequent cross-checking between computer entries and filled forms ensured accuracy and completeness. This type of scrutiny increased the focus and awareness of the data entry operators.
Similarly, all concerned staff members received guidance on the ethical issues regarding the storage and use of data. All clean data sets were shared among the concerned authorities of JD-HDSS in a format that was user-friendly for scientific publication. Because keeping completed forms and other necessary documents in safe, long-term storage posed another challenge, it was necessary to develop a code of conduct that governed access and sharing of the data.
We encountered many ethical issues during the baseline survey. Although such issues did not reach the sensitivity level of clinical or drug trials, respecting the dignity, feelings, freedom and confidentiality of all respondents was essential. While establishing an HDSS in a selected area, one hurdle involves the fact that many other groups may already have visited the households to collect data for different purposes. Consequently, study participants may become irritated by the attention they receive for monitoring purposes and they may demand immediate direct benefits. Because team members were unable to provide medication to ill participants, such individuals wanted assurance about the long- term benefits of participating in the survey. Team members explained the plan to develop their village as a health model village in Nepal, and households received 25%–50% discounts on hospital services at Kathmandu Medical College and Nepal Medical College.
We also encountered many issues regarding migration. Some participants did not wish to disclose the reasons for their migration (e.g., political pressure, family issues). Similarly, they did not want to share information about monthly income, some diseases (e.g., uterine prolapse), sexually transmitted infections and HIV/AIDS.
Although respondents received no in-hand benefits for participating in the baseline survey, the HDSS team is now considering awarding each household with in-hand benefits (e.g., soap, toothpaste, toothbrushes) during data collection by enumerators and posters, pamphlets and health education when they complete the baseline study. In the long-term, it simplifies the collection of data and also ensures that the project will remain sustainable.