Module 11. Data collection tools, field manual, and database

Developing and testing the main survey questionnaire

Informed consent and assent

Age determination technique and tools

Field manual

Introduction

Data collection materials include the main survey questionnaire and other forms (or tools), such as the specimen collection control form, cluster control form, and anthropometry data form. These tools can be paper-based or electronic, or some of each. For example, where the main survey questionnaire is in electronic format, some of the control forms may be paper-based. See Module 4: Survey design for a more detailed comparison of the use of electronic- or paper-based data collection for the main survey questionnaire.

The Survey coordinator and the relevant technical subcommittee need to spend considerable time developing the questionnaire and related survey tools to ensure that they function as intended so that all collected data can be correctly processed and linked with parallel information, such as food samples or biological specimens. The data collection tools should be as concise as possible while ensuring that they measure indicators that meet the survey objectives. This may be a challenge in a situation where the Technical committee has representation from a wide range of disciplines.

The survey questionnaire and other data collection forms will be extensively reviewed, and interview techniques will be practiced during training. Pilot testing all aspects of the survey generally takes place at the end of the training. The questionnaire should be tested:

in one or more local languages, as appropriate
using the same data collection method (paper-based or electronic) that will be used during the survey
in conditions similar to the field to simulate the actual data collection
in a location that is not going to be visited as part of the survey.

Following the pilot testing, all survey teams should convene and discuss the experience and make any necessary modifications to the questionnaire and other data collection forms. More details can be found in Module 12: Training and pilot testing

Introduction

in one or more local languages, as appropriate
using the same data collection method (paper-based or electronic) that will be used during the survey
in conditions similar to the field to simulate the actual data collection
in a location that is not going to be visited as part of the survey.

Developing and testing the main survey questionnaire

The survey questionnaire should aim to gather information that will fulfil the survey objectives as well as provide data for monitoring current strategies and planning for the future. It needs to be clear how the results of the questionnaire will be used, how they will relate to other results, and whether the inclusion of a particular indicator can potentially affect overall programme management. In circumstances where the results of a specific part of the survey will be compared with the results from a previous survey, the wording of the questions and the population groups addressed should be as similar as possible across the two surveys.

It can be helpful at this stage to develop empty report tables (called “shells”) to show how final results could be presented. Each table can be accompanied by notes describing how the data will be collected and how they relate to the survey objectives.

The questionnaire is usually designed to collect certain types of information. This may include:

Information about the main micronutrient-related indicators stated in the survey objectives, for example:
- confirmation that the biological specimens or food samples were collected from respective individuals or households
- results of any field-based testing (for example, the haemoglobin concentration or the result of a rapid diagnostic test for malaria).
Information that can facilitate cross tabulations, such as:
- demographic information
- socioeconomic information
- information reflecting respondent knowledge, attitudes, and practices (KAP), usually in relation to micronutrient interventions
- participation in nutrition interventions.
Information that helps interpret measurements of micronutrient biomarkers Module 3: Biomarker selection and specimen handling tool for further information), such as
- pregnancy status
- lactation status
- use of supplements
- cooking practices that may affect the micronutrient content of food
- time of day that specimens were collected (if biomarkers are subject to diurnal variation)
- approximate time since last meal
- altitude of the cluster location
- whether the respondent is a smoker and, if so, the average number of cigarettes smoked per day.
Information to assess the impact of certain nationally-relevant practices on micronutrient status, for example:
- the frequency of using salt substitutes (such as bouillon), to estimate the potential contribution of this dietary habit to iodized salt intake
- behavior related to a culturally specific infant feeding practice, to assess the impact of a targeted behaviour change communication campaign
- the use of cooking ash, which affects food’s acidity and in turn affects the bioavailability of micronutrients in multiple micronutrient powders.

When questionnaire modules are similar to those included in the UNICEF Multiple Indicator Cluster Survey (MICS) and the Demographic and Health Survey (DHS), they should use similar design and wording. Using the same or similar wording of questions and similar tables for presenting results makes it easier to compare with other surveys conducted in the country as well as with surveys conducted in other countries. The UNICEF MICS questionnaires are available in English, Spanish, French, and Russian (http://mics.unicef.org/). The DHS model questionnaires are available in English and French (https://dhsprogram.com/What-We-Do/Survey-Types/DHS-Questionnaires.cfm). Standard methods for analysing the data to fill suggested table shells are provided in the MICS and DHS documentation, available on the respective websites. Suggested wording for questions used in micronutrient surveys among different population groups can be found online in the example questionnaires.

New questions that have not been part of previous surveys need to be developed systematically, preferably following the cognitive interviewing process described in this module.

The overall format of the questionnaires will vary by survey, depending on the objectives, the number and types of micronutrients being assessed, population groups and interventions of interest. All formats must include standard identifying information for each household and participant so that information for each individual can be related to the respective household data and to samples and specimens collected. Sometimes it may also be useful to link the data for specific household members. Unique barcode labels, which are discussed in more detail in Module 9: Survey equipment and supplies, are the recommended method when collecting this information.

Designing an electronic data collection program, with all the required logic and error checks, can take many months. Developing the electronic data entry systems would ideally take place after the paper-based versions of these tools have been pretested with appropriate target populations (see the sequence of development in Fig. 11.1).

Interviewing should be done in the language most familiar to the participant. This may require translating the main survey questionnaire into several languages. Later sections in this module provide guidance on translating and pretesting questionnaires.

Fig. 11.1. Sample sequence for developing the main survey tool

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Cognitive interviewing

Cognitive interviewing is used to identify and resolve problems with the wording of survey questions and the flow of the questionnaire. This process should be conducted as part of questionnaire development, in parallel to or immediately after pretesting, as it will lead to greater reliability and better interpretation of the final survey questionnaire and outcomes. The process should be applied with each main language into which the tool has been translated.

Cognitive interviewing also helps to identify problems that are not always obvious when designing survey questions, such as:

differences between cultures or individuals in interpreting questions and the intention of answers provided;
participants not understanding, or being confused by, certain words;
participants not understanding, or not knowing, how to answer;
participants not being willing to respond truthfully to a question;
ambiguity or poor fit between a question and the options for response;
redundancy of questions that add no new useful information; and
problems with measuring the concept the question is trying to address, for example, questions that expect a knowledge of typical serving sizes or defining the intended period of time for a recall question.

Box 11.1 provides examples of how cognitive interviewing can improve micronutrient survey questions.

There are several approaches to conducting cognitive interviews. The approach described here is “concurrent cognitive interviewing”, which are one-on-one interviews where an interviewer asks the survey questions and the participant responds. After each question is asked and answered, the interviewer probes about that question and the participant’s response, seeking information to better understand the participant’s interpretation of the question and the basis for the response. Sample probing questions include “What did you think that question was trying to ask?”, “Can you repeat that question using your own words?” and “How did you come to that answer?” General probes often help identify problems that were not anticipated, and tailored probes can focus on areas that are anticipated to be problematic. Interviewers should write notes during the interview to document responses, problems, and potential solutions.

Initially, five to ten interviews are conducted with a range of people from the intended survey participant groups, then responses are analysed, and the questions are revised if needed. Additional interviews are carried out with new participants to test the revised questions. The process is repeated until the final questions are agreed.

Box 11.1 Examples of how cognitive interviewing can improve questions in the main survey tool

Time period recall errors: The common phrase “during the last week” may be interpreted in different ways, for example “from today through last week,” “the last 7 days,” “last Monday to Friday,” or “last Sunday to Saturday”. These interpretations can lead to recalls that cover a time period ranging from five to ten days. Pilot testing might not capture this error because respondents can provide an answer and usually appear to understand the question. Through cognitive interviewing, interviewers ask the participant specifically what they thought “the last week” meant and how many days they considered when responding. This will improve the validity and reliability of the question wording, and can improve interpretation of the data collected.

Development of appropriate language to reflect the intended meaning in the original language: In one example, short recall questions focused on the consumption of salt and sugar by women and, by parental recall, for young children. The questions were harder to phrase in the translated survey language compared to the original language. The intended meaning was extracted using the following clarifications: salt and sugar are ingredients added to foods and are not normally consumed alone, salt and sugar are added both during the cooking process and at the table, and women often prepare foods for others in the household that they do not necessarily consume themselves. Cognitive interviewing helped identify appropriate wording that was understood and that adequately and validly captured consumption by the populations of interest.

Development of the most relevant list of closed-end response options that might be used among different population groups: Conducting the cognitive interviewing process with a range of population groups leads to the inclusion of a comprehensive list of options for answers.

It is important to identify the most essential questions that require testing. These are most likely to be questions that have not been included in previous surveys or not in one or more of the languages of the planned survey, or questions that are challenging to phrase, or those intended to measure prioritized indicators. Box 11.2 provides more detail on the concurrent cognitive interview technique.

Box 11.2. Tips for the Concurrent Cognitive Interview Technique

Concurrent cognitive interviewing uses a structured interview guide with general and specific probes for each question. The interview guide helps ensure that all probes are asked.

Interviewers should be encouraged to help identify potential solutions to the problems that may arise by, for example, suggesting and testing revised wording during the test process.

At the beginning of the cognitive interview, it is important that participants understand that:

they are being interviewed to develop the survey questionnaires so that the interviewer can determine if there are any weaknesses or mistakes with the questions;

they are being asked to describe anything that is difficult to understand, or identify a question that is hard to answer;

the interviewer is interested in the ways that they decided on their answers, how sure they are about them, and any problems that they encountered;

the interviewer did not write the questions and they should not worry about criticizing or hurting anyone’s feelings by pointing out problems; and

there are no “wrong” statements and they should respond truthfully.

The sequence of processes required to finalize the data collection tool is shown in Fig. 11.1.

Translation and back-translation

The World Health Organization (WHO) has guidelines for the translation of survey tools ¹ that can be used for micronutrient status survey tools. The key steps described are:

Finalize the survey tools in English or another applicable language (such as Spanish, French or Portuguese).
Develop translated versions in each of the languages needed for the micronutrient survey. The translation should be conceptually equivalent (have the same meaning), culturally appropriate and easily understood.
Back-translate the questionnaires to the original language to ensure that the content and meaning of the questions have been maintained.

Translation and back-translation should be done by two different individuals who are fluent in the language of the original questionnaire, whose mother tongue is that of the translated questionnaire, and who have not been involved in the questionnaire development. Box 11.3 provides more detailed information on the process put forward in the WHO guidance.

Box 11.3 Main Steps in Translation and Back-Translation of Survey Questionnaires

Forward translation: Translators who are fluent in the language of the original questionnaire and whose mother tongue is the language that the questionnaire is being translated into translate the original version of each tool into their mother tongue. These translators should have a health/nutrition background, be familiar with nutrition terms, and have experience in interviewing. Instructions should emphasize the need for conceptual translations that provide the same meaning as the original and can be easily understood.

Group discussion to finalize translations: All those involved with the translations, the Survey Coordinator, and other health or nutrition experts with knowledge of at least one of the translation languages and expertise in developing and translating survey questionnaires should meet together to review the original and translated versions of the questionnaire to identify and resolve any discrepancies in the first translations.

Back-translation: Each questionnaire should then be back-translated into the original language using the same approach as the first step, but with a different independent translator. This version can then be compared with the original and, where needed, changes should be made to the translated questionnaires. It is useful to outline the main questions, terms used, and intended concept where discrepancies in meaning or translation were identified.

Pretesting and cognitive interviewing: The revised version of each translated questionnaire should then be pretested with a sample of individuals who are native speakers of that language and have similar demographic characteristics to the intended survey population group. This will assess the understanding and acceptability of the translated questionnaires. If necessary, cognitive interviewing should also be conducted.

Final translation: Based on the above steps, a final translated version should be produced for each of the languages that will be used for the micronutrient status survey. These versions should be used for the training and pilot testing.

Pretesting the survey questionnaire

The survey questionnaire must be pretested with a range of people from the intended different survey populations, including people of different educational and socioeconomic backgrounds. Testing each type of questionnaire tool with five to ten people should help identify any major concerns (such as erroneous skip patterns).

Pretests should be conducted by one or more trained interviewers. Ideally, these interviewers would be those who are likely to serve as supervisors or Team leaders for survey implementation. Interviewers should note where the participant hesitates or gives incorrect answers, to indicate where the tool could be made clearer. The pretest experience should be discussed with the Survey coordinator and relevant Technical committee members to suggest improvements when revising each tool. Whenever a significant change is made, such as the structure of a form, a second round of pretesting should be conducted.

Other data collection tools

A number of additional tools are needed to support survey implementation and to monitor the progress of the fieldwork. These are described in the following sections. Not all surveys will use all tools.

Anthropometry data collection tool

Anthropometry is usually conducted after having completed the interviews, therefore the anthropometry form often comes at the end of the questionnaire. It is essential to confirm that anthropometry measurements are taken from and recorded for the correct individual. This means that the anthropometry form may include questions about date of birth and about sex even when these were collected at the beginning of the interview. Repeating the questions helps the field team verify that the correct individual is being measured. Any errors would also be picked up during programmed data cross-checks, which may happen in the field with electronic data collection, or at a later stage of data management with paper-based forms. The main data collected on the form should include:

date of birth and date of assessment to determine age
sex
height/length (with indication of which was collected) and unit of measurement
weight and unit of measurement
response: successful, refused, did not come for measurement
codes to identify the stadiometer, scale and measurer.

Additional anthropometric data may include:

a note of bilateral pitting oedema
mid-upper arm circumference (MUAC)

The format of the tool needs to be pilot tested. The form used for training should be the same as that used in the field.

Specimen collection and tracking tools

Biological specimen collection is also usually conducted after the main interview, so the tool to document this process may be located at the end of paper questionnaires or in another format that can be linked to the main paper or electronic questionnaire. Similar to anthropometry, it is essential to check that the specimen ID matches the respective individual ID number.

The specimen collection tool notes:

the code of the person collecting the specimens
the codes for the equipment used (to check for systematic errors)
the time of data collection, and fasting status if applicable
whether each of the intended specimens was collected for each individual
the value of results (if applicable)
referrals to health facilities (if applicable)

A yes/no question for all intended specimen collection should be included at the end of each questionnaire and should also be included in the summary cluster control form (described later in this module).

Specimen tracking forms should be developed to allow the field phlebotomists and laboratory technicians to match the specimens collected at the household and analysed in the field with the specimens transported to the laboratory. The forms can be modified according to the survey. If necessary, an additional form should be developed, depending on what laboratory processing is done in the field. The specimen tracking forms should accompany biological specimens or food samples collected (and processed, where applicable) from the field to the laboratory where they will be further processed, analysed or stored. Tracking forms include a summary of the total number of each type of specimen processed and transported, the time and temperature at each transfer from field collection to arrival at the final analysis laboratory, and the signature of the person responsible at each stage.

In addition, a “laboratory specimen log” should be created to record each specimen that arrives, is stored, and is analysed at that laboratory. To reduce errors in data entry, this would ideally be an electronic spreadsheet with barcode scanning of sample IDs.

Sample ”Specimen Tracking Form for Phlebotomist” and ”Specimen Tracking Form for Laboratory Technician” are found in the online tools.

Temperature monitoring

A section to record temperature is included in the “Specimen tracking form for phlebotomist” online tool. Additional forms need to be developed for each level of the cold chain. Thermometers or temperature monitors must be used to check the temperature of each cool box. It is important to set up a system that allows the temperature to be determined in a way that does not cause repetitive opening of the cool box. The ”Specimen tracking form for phlebotomist” is best placed inside a plastic covering to prevent moisture damage to the paper forms and secured with tape on the outside of each specimen storage container (cool box, refrigerator or freezer).

Referral forms

Some indicators, such as the prevalence of anaemia, can be tested in the field. The Steering committee should agree with the ministry of health on the appropriate action to take if results indicate that a participant has a health condition or nutritional deficiency that needs attention. These conditions are most frequently severe anaemia, malaria or oedema.

In some cases, survey participants may be referred to local health facilities according to criteria determined by the ministry of health. These criteria usually include the availability of clinical guidelines and treatment, the capacity of staff to handle an increased volume of patients, and costs. If survey staff are instructed to refer participants, the ministry of health will need to advise staff in nearby public health facilities about the possibility of participants arriving with survey referrals for specific conditions or illnesses. See the ”Referral Form” online tool for an example of a referral form.

In all cases, the referral policy should be clear and set by the ministry of health. This policy needs to include a management plan for test results and referral logs that are in accordance with the agreed confidentiality of personal data. Participants need to be clearly informed about how data will be used and by whom. The referral protocols should be tested and practiced in the field. A log of all referrals to health facilities should be maintained by each team. Examples of these can be found in the ”Referral Log for Anemia”) and a ”Referral Log for Malaria” online tools. Additional logs can be developed depending on the specific referral criteria in country.

Cluster control form

The cluster control form provides a list of all households that are to be interviewed in the cluster, and is useful to the interviewers, laboratory personnel and supervisors. The main information usually includes the items in the list below. In cases with prior selection of households based on an earlier census, other details might be included.

household and cluster number
name of the head of household
status of interview/sample collection (not present, refused, complete, incomplete)
number of attempts to contact household members
call-back information if an interview was not completed
referrals made
reasons for any non-response.

The information on the cluster control form must be concise and at the same time must include all important information needed to summarize the main data collected. See the generic cluster control form online tool and an example from Malawi “Malawi cluster control form”.

At the end of each day, the supervisor(s) should check all cluster control forms filled out by the survey team members and produce a “Cluster summary sheet” for each cluster. This form can be either paper-based or electronic. If in paper format, it can be photographed when complete and uploaded along with electronic data collection forms, or it can be transported or emailed to the central data location. The information contained in the form should be entered into a database of monitoring information so it can be cross checked with the laboratories that are monitoring data collection within clusters to ensure consistency.

Process of translation and adaptation of instruments. Geneva: World Health Organization; 2010 http://www.who.int/substance_abuse/research_tools/translation/en, accessed 18 July 2019. ↩

Most countries require an ethical or scientific review of the survey, and guidelines concerning the rights of each potential respondent, both adults and children, should be followed. This is detailed in Module 1: Planning and designing a micronutrient survey.

Ethical considerations protect the dignity and rights of survey participants. Written or verbal informed consent from participants is conventional. For a young child, the caregiver may give this consent. Separate consent should be requested for the questionnaire, for specimen collection and for anthropometry, and the response to each consent process should be indicated on the questionnaire. Children over a certain age (the specific age varies by country) may be requested to provide assent in addition to the consent from their caregiver. It is important to consult with country-specific ethical review boards before starting any data collection. The informed consent form template can be found in the online tools, and must be adapted using specific guidance available in the country. Additional templates for consent and assent forms can be found at https://www.who.int/ethics/review-committee/informed_consent/en/.

During the consent process, the interviewer explains to the participant (or caregiver of the child) the purpose of the survey, the type of questions that will be asked, and the biological specimens and measurements that are to be taken. Each type of specimen (such as blood, urine or stool) and the procedure for collecting it should be carefully explained during the consent process so that the participant understands the benefits and risks of what they are agreeing to. The consent process should also explain the various tests that will be conducted and what, if any, results the participant will receive. If the participant refuses the entire survey or part of the survey (for example, the collection of biological specimens), his or her choice must be respected.

Age determination technique and tools

Most surveys ask for the age and date of birth of each participant. For participants up to 59 months of age, the date of birth and date of visit should be recorded.¹ For individuals 6 years of age and above, age can be estimated in completed years, that is, the age at the time of the person’s last birthday. If the respondent (ideally the main caregiver of the child) knows a child’s age in months or years this should be entered in the appropriate section on the form. If data are being collected electronically, the electronic device should be programmed to calculate the number of years and months from the reported date of birth to the date of the interview. If paper-based forms are used, the interviewer should record the date of birth and the date of the visit on the questionnaire for later use in a tool developed for determining age in months or years. These calculated ages should be cross-checked with the age provided by the caregiver.

The age of a child is crucial for making and interpreting appropriate anthropometric measurements. This underscores the importance of probing for an accurate date of birth. Even where the date of birth is included on a child health card or similar document, it is possible that it was incorrectly recorded or that the writing may make it difficult to determine, therefore the date of birth should always be confirmed with the caregiver. If the primary respondent does not have the necessary information, the interviewer should ask other household members.

These are the steps for estimating the age of a child under 6 years, using a recorded birthdate:¹

Ask the respondent for documentary evidence of the child’s date of birth (such as a birth certificate, child health card or holy book).
Record the day, month and year of birth as noted on the documentary evidence, and indicate the type of documentary evidence that was provided. Even if the respondent recalls the child’s date of birth, politely ask to see a copy of the documentary evidence and record the information directly from it.
If no document is available, ask the respondent for the date of birth as they recall it and indicate the source on the questionnaire as “respondent’s report”.
If the respondent does not know the child’s exact date of birth, then at minimum the month and year of birth should be obtained using a local events calendar. The local events calendar will have been prepared and tested previously, and all anthropometrists should have been trained its use. See the Age determination for children under 6 years of age online tool for more guidance on estimating the month and year of birth using the calendar of events and indexing techniques.

Whether using documentary evidence or the respondent’s report, the anthropometric team should record the actual date of birth, if specified. If using the local events calendar, it is probable that it will be impossible to identify the exact date of birth. In this case, anthropometrists should enter “00 00 00” (unknown) for the date of birth and enter the birth month and year as determined by the local events calendar. The source of the information should always be recorded in the questionnaire.

For children aged 6 to 18 years, follow the same steps as for children under 6 years to get the best estimate of the date of birth. If it is not possible to get the exact date, the month and year of birth are adequate. For adults over 18 years of age, the year of birth is adequate.

Recommendations for data collection, analysis and reporting on anthropometric indicators in children under 5 years old. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF); 2019. Licence: CC BY-NC-SA 3.0 IGO, https://apps.who.int/iris/bitstream/handle/10665/324791/9789241515559-eng.pdf, accessed 15 July 2019). ↩ ↩²

Field manual

A comprehensive field manual for the survey provides detailed guidelines for every component, including:

An overview of the survey objectives, sampling and household selection, population groups assessed, team composition, and indicators to be collected.
Data collection processes, data collection forms, consent processes, and interview techniques.
Labeling.
Anthropometry techniques.
Collection methods for biological specimens and food samples.
Specimen and sample processing, referrals (for malaria, severe acute malnutrition or severe anaemia), and cold chain.
Quality control procedures.
Care of equipment and supplies.

The field manual should be developed by the Survey coordinator with input from the Technical committee as soon as the survey protocol is completed and approved. Each member of the field team should have a copy of the manual, which will be used in all stages of training, pilot fieldwork, and data collection. Thorough familiarity with the manual will help ensure a high degree of standardization and consistency across multiple survey teams. Separate manuals for enumerators and phlebotomists/ laboratory technicians might be developed depending on separate roles and responsibilities. Box 11.3 contains a typical table of contents for a manual. See the different survey manuals for examples of field manuals developed for previous national micronutrient surveys.

Box 11.3. Typical table of contents for a micronutrient survey field manual

Module 1: General Information

Introduction and background

Aims and objectives of the survey

Population groups

Household enumeration

Selection of households

Fieldwork logistics

Team composition and training

Roles and responsibilities of staff for the survey

Protocol for data collection in the household

Informed consent process

Data entry and analysis

Supervision

Module 2: Interviewing

Consent process, interview techniques

Completion of the questionnaire

Recording responses, writing numbers

Correcting mistakes

Detailed instructions for questionnaire modules

Visit schedules

Editing and checking

Referral procedures

Module 3: Biological specimen collection

Consent process

Universal precautions

Cold chain logistics

Laboratory personnel

Labeling

Preparing for fieldwork and specimen collection procedures in the household

Transportation of specimens from the field to district or central laboratories

Specimen processing and storage

Quality control

Packaging and shipping

Module 4: Food specimen collection

Consent process

Collection and labeling

Specimen processing and storage

Quality control

Replacement

Module 5: Anthropometry

Consent process

Measuring children under 24 months of age

Measuring children 24 months of age or older

Measuring adults

Calibrating equipment

Anthropometry standardization

Tips for successful measurements