THE MCH SURVEY
4.3 Data collection
required to revisit the homestead to conduct the interview with the mother/caregiver at a time when she was expected to be present. Other reasons for revisits were the absence of the index child or a RTHC at the time of the visit. If the child was unlikely to be available within one week of the first visit, another mother-child pair was selected from a nearby homestead. If the mother was unlikely to be available, the interview was conducted with the primary caregiver such as the granny, the stepmother or aunt. Only one mother-child pair was included from each selected homestead. If there were more than one child in the household, the names of the children were written on pieces of paper and put in a plastic bag and then selected one name randomly.
Availability of other services and facilities such as hospitals and mobile points, shops and schools and community health workers (CHWs) was also determined. The last part of section three required respondents to comment on the clinic services so as to determine the quality of the clinic services. Part four of the questionnaire sought data on maternal health service utilization patterns. Section five posed questions about child health service utilization patterns and child health status.
The concluding section aimed to determine the socio-economic status of the homestead members. Socio-economic status indicators measured from this study were percentage of school-age children who were attending school; presence of a pensioner and migrant worker as a source of income; house type; wealth indicators such as ownership of a television set, radio, car, furniture and fridge. None of the data collected permitted an evaluation of the quality of services at each PHC clinic. Data on the convenience of travel were limited to identifying the mode of transportation, amount paid and an estimation of the time taken to reach the clinic.
4.3.2 Fieldworker selection, training and pilot study
Before the household survey was undertaken, five fieldworkers were recruited from the Durban region during February 1998. Together with the researcher, these fieldworkers underwent one-week training in March 1998 with a professional trainer from the Department of Nutrition, University of Natal, Pietermaritzburg. The training sessions involved interviewing skills using the questionnaire, understanding the questionnaire content, weighing babies using hanging scales, measuring babies' length using measuring boards. The training included practical sessions at the Outpatient Paediatric Ward of the nearby King Edward VIII Hospital in Durban. During this period a GIS specialist also trained the fieldworkers on how to take the position of each homestead using a handheld battery-operated Global Positioning System (GPS).
Prior to commencing fieldwork, ethical approval to carry out the study was obtained from the University of Natal, Medical School Ethics Review Committee. After development of the questionnaire and training of the fieldworkers, a pilot study was undertaken in the field during April 1998 on a small sample of 75 homesteads. The pilot phase was undertaken to determine any methodological and logistical requirements of the fieldwork. Following the pilot study the questionnaire was revised accordingly to include changes determined during this phase of the study.
4.3.3 Administration of the questionnaire
Quantitative data was collected directly with a personally administered questionnaire (see Appendix 3 for the sample) in face-to-face interviews with mothers/caregivers of children aged 12-23 months within each homestead. The field data collection took place from 01 June 1998 to 15 August 1998. There were three field teams each comprising two fieldworkers, one driver of the four wheel drive vehicle and a surveillance agent from the Malaria Control Programme. The surveillance agent assisted the field team to identify the sampled homesteads within the catchment area for each clinic and introduced the field team to the homestead head according to the local custom.
In the case where a child of the required age was not found within the selected homestead, the nearest homestead in any direction from the randomly selected homestead was visited. During each homestead visit, the two trained fieldworkers interviewed the mother, weighed the child, recorded information from the RTHC and took co-ordinate points of the geographical position of each homestead using a GPS instrument. Each homestead interview took about 20 minutes to complete. This time included five minutes of taking anthropometric measurements and gathering data from the RTHC.
The homestead was re-visited if the mother, the child or both were not present on the day of the first visit, except where the mother was away for more than two weeks. In the case where the mother had died, or the child was abandoned and left to be raised by other family members, the primary caregiver of the child was interviewed on sections one to two and five to six of the questionnaire which were specifically created to cater for these circumstances.
All questionnaire forms were checked daily for accuracy, completeness and consistency by the researcher. Out of the 685 homesteads identified in the sampling frame, 652 were completed. Thirty-three homestead members refused to be interviewed. Out of these 33 homesteads, 29 belonged to section four of Mphakathini and section five of Mbazwana areas in the catchment area for Mbazwana Clinic. The remaining four belonged to the catchment area for Ntshongwe Clinic. Out of the 652 completed questionnaire forms, six were excluded as non-respondents because they had incomplete data. The total number of completed questionnaires that were used in the analysis was 646 and each questionnaire represented one mother-child pair from one homestead.
4.3.4 Transcription of data from RTHC
While one field worker interviewed the mother of the child, the other recorded data relevant to the study from the RTHC (see Appendix 4 for a sample of RTHC). The RTHC is the only on-going and consistent link between different health workers and those caring for the child. Therefore, RTHC is the easiest and quickest tool available for routine and regular growth monitoring for early detection of disease and nutritional problems in children (Department of Health, 1995b). Information collected that was relevant for this study was the date of birth of child, the place of birth, birthweight, date of each
vaccination, the type of vaccines given, clinic attendance for growth monitoring and treatment of minor ailments, and the types of minor ailments the child had suffered in the first year of life. Although fever and cough may be symptoms of the same illness, these symptoms were recorded separately to analyse symptoms that would make the child seek curative care. Since this approach was consistently applied for all minor ailments it is not expected to bias the relationship between individual minor ailments and distance of between homesteads and clinics. All these data were recorded on section five of the questionnaire and a prepared copy of the RTHC.
4.3.5 Anthropometric measurements
In order to collect data to evaluate the health status of children, anthropometric measurements were taken. The current nutritional status of the child was determined by physical measurements of length and weight. These data were recorded on section five of the questionnaire.
4.3.5.1 Measurement of the child's weight
The body weight of each child was measured using Salter hanging scales (maximum capacity 25 kg). The scales were standardized with objects of known weight at the start of each day in the field and during fieldwork. The children were weighed without any clothes on. Weights were measured to the nearest 0.1 kg.
4.3.5.2 Measurement of child's length
The child's length was measured using portable plywood measuring board, mounted on a right-angled base and fitted to measure recumbent length in children aged less than two years. These measuring boards were specifically designed for this survey and were not commercially manufactured measuring boards.
The child's length was measured with the child lying down. The measurement procedure involved two people. The head of the child in the Frankfurt plane was placed against the fixed headboard. The child was gently stretched in a straight line and contact of shoulders, buttock, calves and heels with the board ensured. Care was taken to keep the knees straight. In this position the footboard was slid along the board until it made contact with the soles of the feet at right angles to the lower leg. The length was read off the scale on the measuring board in centimetres to the nearest 0.1 cm.
4.3.6 Homestead mapping using GPS
This exercise was necessary to include the geographical positions of those homesteads of people who have settled in the study area after the initial mapping of the homesteads was done in 1996 and were therefore not in the MI5 database. The homesteads were mapped during the fieldwork with a battery-operated hand-held standard GP5. A GP5 is an electronic device that makes use of satellite technology to geo-reference (allocate a geographical position) a specific location on earth (Hurn, 1989; Trimble Navigation, 1993).
Trimble Navigation Ensign® GP5's were used to record the geographical position (latitude and longitude coordinates) for each homestead. The GP5 was calibrated using trigonometric beacons. The accuracy of the Ensign® GPS is 25 to 100 m root mean square on the ground (Trimble Navigation, 1993). The geographical position data thus captured were imported into MapInfo® GI5 software and a map of the homesteads was created using Table and Create points functions.