Document(s) 34 of 38

Philomena Nyarko,¹ Peter Wontuo,¹ Alex Nazzar,¹ Jim Phillips,² Pierre Ngom,³ and Fred Binka¹

Site description

Physical geography of the Navrongo DSA

The Navrongo DSS site is in the Kassena-Nankana District of the Upper East region of Ghana (Figure 22.1). The district lies between latitudes 10°30' and 11°00'N and longitudes 1°00' and 1°30'W and covers an area of 1675 km² along the Ghana–Burkina Faso border. It measures roughly 55 km × 50 km and has an altitude of 200–400 m above sea level. The land is fairly flat, and passing through it from Burkina Faso is the White Volta River, which feeds Lake Volta (the world’s largest artificial lake) in the Volta region, south of Ghana.

¹ Navrongo Health Research Centre, Navrongo, Ghana.

² Policy Research Division, Population Council, New York, United States.

³ African Population and Health Research Centre, Nairobi, Kenya.

Located in the Guinea savannah belt, the district is typically Sahelian (hot and dry), with the vegetation consisting mostly of semi-arid grassland interspersed with short trees. The region has two main seasons, wet and dry. The wet season extends from April to October, with the heaviest rainfall mainly occurring between June and October. The mean annual rainfall is 1365 mm, but the highest level is recorded in August. Similarly, the dry season is subdivided into the harmattan (November–mid-February) and the dry hot season (mid-February–April). Monthly temperatures range from 20° to 40°C, with the mean minimum and maximum temperatures estimated at 22.8° and 34.4°C, respectively, for 1999.

Population characteristics of the Navrongo DSA

The population of Kassena-Nankana on 1 July 1999 was 140 881, which is slightly less than 1% of Ghana’s population and about 15% of the total population of the Upper East region. The population density is 84 individuals/km². The district is largely rural, with only 9.5% living in urban quarters. The population comprises two distinct ethnolinguistic groups: the Kassena (49%) and the Nankani (46%). The Builsa and migrants belonging to other ethnic groups constitute the remainder (5%). The main languages spoken are Kassim and Nankam, with Buili spoken by most of the minority tribe. Despite the linguistic distinction, the population is in many respects a homogeneous group, with a common culture. The district has 10 traditional paramount chiefdoms and has traditional forms of village organization, leadership, and governance. At both the village level and the family level, communities have a strong traditional social structure, which influences economic and social behaviour. Male dominance is strong, constraining the autonomy of women and limiting their health decisions. For example, curative and preventive health care may not be sought without the permission of the husband or, in his absence, the head of the compound (Binka et al. 1994).

The main religious faith is animism, but Christianity is gradually becoming more prominent, especially among women (Debpuur et al. 2000). Currently, about 33% of the people are Christian, 5% are Muslim, and the rest profess the indigenous religion. However, the dominant animist faith guides daily life, economic decisions, health beliefs, and practices. This reliance on indigenous medicine hampers the use of health services.

Lack of a communication system, a road network, and electricity in the district also impacts adversely on the health of the population. Subsistence agriculture is the mainstay of the district’s economy, complemented to some extent by retail trading. About 90% of the people are farmers. The major agricultural products are groundnuts, millet, guinea corn, rice, sorghum, sweet potatoes, beans, and tomatoes. Rearing of cattle, goats, sheep, pigs, and fowl, including guinea fowl, also forms part of the agricultural activities. Unfortunately, the rainfall pattern limits food cultivation to a single growing season; and even though the Tono irrigation dam and a few dugout wells supply water for dry-season farming, the major crop during this time is tomato. Weather conditions in the district can be very severe, with occasional floods or droughts and poor harvests as a result. This situation has given rise to a net annual out-migration for some time now. Nutritional problems are therefore common, aggravating the mortality impacts of infectious-disease morbidity, and poverty and economic isolation complicate efforts to improve health conditions in the district (Binka et al. 1999).

The district has 77 primary schools, 35 junior secondary schools, 5 senior secondary schools, 1 training college, and 2 vocational institutions. It also accommodates the Faculty for Integrated Development Studies of the University for Development Studies, which focuses on integrated science. Also, the Catholic mission manages an orphanage.

About 89% of the houses in the district are mud huts with thatched roofs. The rest, which are built with cement blocks, are mostly found in the urban area. Almost two-thirds (65%) of the roofs are constructed with straw. Zinc sheets are used for the remaining 35%. The main sources of water in Kassena-Nankana are streams, wells, and boreholes. In a few urban houses, however, pipelines have been installed to provide treated water. Similarly, only 7% of the compounds have access to properly constructed toilet facilities, suggesting that as many as 93% of households use the bushes in their immediate surroundings. For those compounds with toilet facilities, two-thirds use either Kumasi ventilated improved pit, pan, or pit latrines, and the rest use water closets.

The district has a hospital, four health centres, and four clinics in selected communities. These static health-delivery points are complemented by community-based service delivery in all but the eastern part of the district, which serves as an experimental control cell. As part of the Ghana Ministry of Health policy, free health services are available for all children <5 years old and to all people =70 years old. In 1999, the district’s immunization coverage for children 12–23 months old was 80%; for BCG (bacillus Calmette-Guérin), 72%; for Polio3, 70%; for DPT3; and for measles, 63%. The major causes of morbidity in the district are malaria, gastroenteritis, and acute respiratory infections. The district also has a high prevalence of cerebrospinal meningitis, with the peak season being March to April. Although improved delivery of family-planning services is one of the objectives of the Navrongo community-health and family-planning (CHFP) project, only 10% of married women in the district use the service.

Navrongo DSS procedures

Introduction to the Navrongo DSS site

The Navrongo DSS uses a longitudinal household-registration system (HRS), set up in July 1993 by the Navrongo Health Research Centre (NHRC) to support research on the determinants of morbidity, mortality, and fertility in an area typical of Ghana’s rural savannah zone. The Navrongo DSS routinely updates vital events (births, deaths, migration, marriages, and pregnancies) in all of about 14 200 compounds within the study area. Where a death has occurred, the compound is revisited to obtain information on the circumstances leading to the death. These verbal postmortems are conducted using different schedules for children and adults. In addition to the vital events, educational attainment and vaccination coverage within the population are annually monitored.

The DSS started with a baseline census of the rural district in 1993, followed by compound visits at 90-day cycles to monitor demographic events. The baseline survey included a socioeconomic module, which lists compound possessions and the materials used in constructing the building. In the last quarter of 1995, DSS activities were extended to include Navrongo, the only urban area in the district. To qualify as a

member of a compound, a person should have been resident in the compound for at least 3 months, except for a newborn baby whose mother is already a compound member. The initial DSS covered about 125 000 people, but with the addition of the urban area the population has increased to almost 141 000. Detailed information on fertility and child health is obtained through the annual panel survey of a sample of DSS compounds. The HRS is the computing software used for processing and analyzing the Navrongo DSS database. The initial DOS software (HRS1) has been upgraded to a Windows version (HRS2). The HRS system allows for data entry, editing, validation, and calculation of age- and sex-specific demographic rates and life tables.

The field and data-processing operations of the Navrongo DSS are managed by a team comprising a demographer, two research assistants, two principal field supervisors, a data manager, and a data assistant. The team coordinates the activities of the 26 fieldworkers and 12 field supervisors, who are responsible for field data collection, as well as the 2 filing clerks and 3 data-entry clerks who receive and process the field instruments. The fieldworkers are expected to visit and interview all compounds within their work area. The 12 field supervisors, in contrast, are responsible for conducting verbal autopsies (VAs), carrying out quality checks, resolving queries, and pairing migrants. Training, planning, supervision, and coordination of field activities are undertaken by the two principal supervisors, the two research assistants, and the demographer.

The field data collection and processing are mainly supported by funds from the Rockefeller Foundation, with technical assistance from the Population Council. Data are used to compile reports for the Ghana Ministry of Health, which is the major consumer of the Navrongo DSS data. Lessons learned from the Navrongo CHFP project through the DSS and the panel surveys have, for example, activated a process of extending the new health-delivery approach implemented in this district to the country as a whole. Other institutions that have also benefited from the Navrongo DSS database are the universities and other educational and research institutions.

Navrongo DSS data collection and processing

The Navrongo DSS evolved from an earlier study of Kassena-Nankana in 1989 by the Department of Community Health of the Kwame Nkrumah University of Science and Technology and the London School of Hygiene and Tropical Medicine, with support from the Ghana Ministry of Health and the UK Overseas Development Administration (now the Department for International Development). This study, popularly called the Ghana vitamin-A supplementation trial (VAST), included continuous demographic and health surveys of resident members of the study compounds, with the aim of helping to evaluate the effect of vitamin-A supplementation to children <5 years old. When VAST came to an end in 1992, NHRC was established to shed more light on the health problems in northern Ghana and help find practical solutions to them. The NHRC thus used and built on existing VAST resources. In 1993, the DSS was reorganized, with respect to its coverage and content, and formally set up as the Navrongo DSS to serve as a basis for assessing the mortality effects of insecticide-treated bednets. The bednet study was concurrent with the factorial experiment on the fertility and mortality impacts of NHRC’s CHFP project, which has been in operation to date.

Field procedures

INITIAL CENSUS — The baseline census provided basic demographic data on all residents as of 1 July 1993. Other information gathered includes that on family relationships, compound possessions, and characteristics of the residential structure. For DSS purposes, Kassena-Nankana is divided into five zones. These are further subdivided into 21 subzones and 244 clusters. On average, 9 contiguous clusters are assigned to each of the 26 fieldworkers to enhance fieldwork and reduce costs. To track the population, each fieldworker is expected to visit, and update demographic information on, 15 compounds every day. The main data-collection instruments used for the routine recording and updating of vital events are compound-registration books (CRBs) and event forms. CRBs are field registers containing basic demographic information on all compounds in a cluster. Where a cluster has more than 99 compounds, an additional CRB is used. An event form is also filled out for each recorded event.

REGULAR UPDATE ROUNDS — All vital demographic events occurring within the district are updated through regular visits to each compound every 90 days. During these compound visits, new events are registered. Pregnancies recorded earlier are also monitored during these quarterly visits, until the pregnancies are terminated. This is to help improve on birth and death reporting, in particular by capturing neonatal deaths. For every vital event that is recorded, detailed information is collected using the appropriate event-registration form. VAs on deaths of any of those registered with the Navrongo DSS are also conducted to obtain information on the circumstances leading to the death. Trained field supervisors visit each of the compounds where a death has been reported and administer the appropriate VA questionnaire to the closest relative of the deceased. Three medical doctors independently code these questionnaires to determine the probable cause of death. Where at least two of the doctors agree on one diagnosis, it is accepted as the cause of death. When they disagree, the case is coded as “undetermined” and is set aside for further discussion.

Apart from the event updates, the first quarter of each year is devoted to updating information on the educational attainment of those aged 6 years or more and the last quarter of the year is used to collect data on the vaccination status of children younger than 2 years.

CONTINUOUS SURVEILLANCE — Vital demographic events, including in- and out-migrations, marriages, pregnancies, births, and deaths, are continuously monitored through quarterly updates. In addition to the routine collection of data by fieldworkers, the Navrongo DSS has recruited a number of voluntary community key informants (CKIs) to record all pregnancies, births, and child deaths that occur in their localities during the intervals between interviewer visits to compounds. Currently, 170 CKIs work within the district. Two field supervisors are assigned to visit the CKIs in their homes every 2 weeks to collect the information they have gathered over the period. These data supplement what the Navrongo DSS fieldworkers collect during their regular visits to the compounds every 90 days.

FIELD SUPERVISION AND QUALITY CONTROL — For each round of data collection, quality assurance is achieved through reinterviewing a 3% random sample of compounds, conducted by a quality control supervisor. Other field checks include the reinterviewing of some of the compounds already covered by the fieldworker, random reviews of CRBs and event forms for inconsistencies and omissions, and observation of field

interviews. Procedures employed at the office level include the assessment of the work progress of field staff at weekly meetings and a week’s retraining of interviewers at the end of each round of data collection.

The Navrongo DSS also has a mechanism for pairing internal migrants, to avoid double counting and to minimize loss to follow up on. This process of pairing migrants is aided by issuing identity cards to all compound members. The identity cards are meant to improve the reporting of event dates and facilitate the linking of migrants to their previous records. To avoid familiarity with the respondents and forestall any attempts to manipulate data, the field staff do not work in the same clusters for more than two consecutive rounds. Improvement in event capture is also achieved through the voluntary activities of CKIs, who for a token fee record births, deaths, and pregnancies in their communities during the interval between interviewer visits.

Data management

Every fortnight, each fieldworker submits all completed CRBs and event forms to the filing clerks. These records are then carefully documented and sent to the data-entry clerks, who upddate the database, using the HRS data-entry system.

A data manager, a data assistant, and three data-entry clerks carry out the data-processing operations of the Navrongo DSS. Each of these personnel has a different level of access to operate the database. A successful entry into the system allows for data to be added, edited, or deleted. Other forms of data manipulation, such as validation and report generation, can also be carried out, depending on the level of access. Until July 2000, the DOS-based HRS1 software was used to process and analyze the Navrongo DSS data. Currently, data-processing is done using HRS2, an upgrade of HRS1. This software operates in Windows (using Visual FoxPro) and has a number of improved features, including its flexibility in specifying constraints on the legal values for a data-entry field, database triggers to help make the appropriate changes in other related tables to maintain consistency, and use of one ID specification for referencing all data-entry forms, thus making data management easier (Ngom et al. 1999).

The functional components of the HRS2 software comprise data entry, validation, reports and output, visit register, and utilities. The data-entry option permits the entry, deleting, and editing of both baseline compound information and longitudinal data, and the validation procedure allows for logical-consistency checks on subsets of compounds and their members. The reports-and-output option is used to generate key demographic rates, population distribution, and life tables. The visit-register procedure is used to print the CRBs, which are used to record information during field visits. Finally, the utilities function is used by the data manager to add new user IDs, set interview-round information, and generate reconciliation reports to help follow up on unreported pregnancy outcomes and unmatched internal migrants, among others.

When CRBs and event forms are returned to the computer centre at the weekly zonal meetings for fieldworkers, it takes 1 or 2 days to have them sorted and distributed to the data-entry clerks. Data entry and validation take about 1 week.

The HRS system has built-in validation programs, which help to maintain consistency in the database. Computer operations are organized to correspond to the interviewing cycle so that information that fails the HRS logical checks is printed with the relevant error message for field reconciliation. On the other hand, records that pass the logical tests are archived into the database. Thus, each round generates fully edited and cleaned data before a new cycle begins. The updated information is used

to generate new CRBs for the next round’s compound visits, and the old ones are archived by the filing clerks for future reference.

Analysis of the data is achieved using FoxPro and STATA software. Most of the output from the Navrongo DSS is compiled as reports and circulated to the Ghana Ministry of Health, the sponsors, and other interested bodies. Regular dissemination seminars are also organized for visitors to NHRC and institutions making specific requests. Occasionally, durbars (traditional gatherings organized by community leaders to build consensus on community issues) are convened to share the findings with the chiefs and subjects of the various paramouncies within the district.

Navrongo DSS basic outputs

Demographic indicators

In 1999, Kassena-Nankana registered a population of 140 881. The population is quite young, with about 41% <15 years old (Figure 22.2). The broad age distribution is as follows: 0–4 years old, 13.1%; 5–14 years old, 28.0%; 15–64 years old, 54.2%; and =65 years old, 4.7%. These figures imply an age-dependency ratio of 84%. Females constitute 53% of the population, giving a sex ratio of 89 males per 100 females. Educational attainment in the district is quite low. In general, about two-thirds (65.5%) of the population =15 years old have received no formal education, and only 8.2% have attained senior secondary or higher levels of schooling. The distribution by sex indicates that more females (74.6%) tend to be uneducated than males (54.4%). Similarly, current school attendance among those 6–25 years old is lower for females (48%) than males (54%). Overall, about 55% of all the population =6 years old has never been to school.

In the Navrongo DSS, the compound is the unit of observation, and the compound has an average of 10 members. A compound is defined as a traditional multi-roomed house, which is usually walled together and stands alone from other housing structures. It houses one family unit, which could include several generations, and is recognized by the name of its head. Males dominate the headships of these compounds, with females heading only 10.2%. In 1999, the population recorded a crude death rate of 14.1 per 1000 and a crude birth rate of 28.0 per 1000 person–years, suggesting a crude rate of natural increase of 13.9%. The total fertility rate for the same year was 4.1 for each woman.

Mortality in Kassena-Nankana is very high. The infant and under-five mortality rates for 1999 are estimated at 90 per 1000 live births and 150 per 1000 children <5 years old, respectively. Life expectancy at birth is 52.6 years. Generally, males in the district have a shorter life span (49.9 years) than females (54.8 years). For the period 1995–99, the crude death rate was 17.7 per 1000 person–years for males and 15.1 per 1000 person–years for females (Table 22.1). The age pattern of mortality for each sex is, as expected, curvilinear, with children and adults being the most vulnerable. At all ages, males generally have higher mortality rates than females, but the differentials are much larger for those =35 years old.

A trend assessment indicates that between 1994–96 and 1997–99, the age-standardized death rate declined from 20.8 per 1000 to 19.6 per 1000 for males and from 19.7 per 1000 to 16.5 per 1000 for females. Infant mortality rate for the period of 1997–99 is estimated at 106.1 per 1000 live births for males and 99.7 per 1000 live births for females, a decline from a level of 124.5 per 1000 live births for male infants

and 125.7 per 1000 live births for female infants within the period 1994–96. Although these figures are far above those recorded at the national level, the registered improvements in survival may have resulted from the participatory approach to health-service delivery launched within the district by NHRC, as well as the various health interventions put in place as part of the research activities of NHRC. Obviously, females recorded the highest decline in mortality of the period under consideration.

Similarly, the fertility rate has declined from 4.7 births per woman to 4.2 births per woman between 1994–96 and 1997–99 (Table 22.2).

Migration figures for the district show that the population is highly mobile. For the period 1997–99, the district had a net out-migration of 12.0 per 1000 person–years. Migration is concentrated among young adults 15–29 years old (Tables 22.3 and 22.4).

Acknowledgments

NHRC acknowledges, with sincere gratitude, the financial support of the Rockefeller Foundation for the overall running of the Navrongo DSS. The DSS was developed in collaboration with Bruce MacLeod of the University of Southern Maine. Development work was funded by the Mellon Foundation, the Population Council, the Thrasher Foundation, and the Finnish International Development Assistance. Finally, we are most grateful to our mother institution, the Ministry of Health, and the people of the Kassena-Nankana District for their immense assistance and cooperation in the implementation of the DSS.

Document(s) 34 of 38