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					IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary



                            IHFAN Online Forum 12 – 23 January 2009
                                          Discussion Summary


The IHFAN online forum on the use of technology in conducting Health Facility Assessment
(HFA) and household surveys and censuses was held from 12 to 23 January, 2009.
The objectives of the forum were the followings:
            To share field experience and lessons-learned in using PDAs and GPS units within the
             context of HFA, and household surveys and censuses including advantages and
             disadvantages of these technologies;
            To serve as a forum for persons who have not used these technologies to pose
             questions related to their use to experienced participants;
            To discuss challenges and propose solutions for overcoming these in the field; and
            To explore the potential for future use of these technologies in HFA and household
             surveys


 Theme A: Lessons learned from the field.
 Under this theme, the participants shared lessons learned from field experience in using
 PDAs and GPS in developing countries.


The following is a brief summary of the discussion.
1.     PDA experiences and lessons learned
1.1.       Advantages
           One of the key advantages of using PDA is its completion and accuracy of data, when
            the PDA is properly programmed. Data collection using PDAs can reduce errors with
            previously programmed skip patterns, standardized responses and mandatory question
            responses. It is recommended that the surveys be well developed and field tested prior
            to beginning any programming onto PDAs. Data validation procedures can also be
            included in the PDA program to maintain accuracy of the response (e.g. range controls,
            internal consistency and other value checks). Furthermore, data transcription errors can
            also be minimized when using PDA.
           The speed of data transmission to the main computer is much faster by PDA compared
            with the paper-based approach as double data entry is not required. The faster
            transmission of data by PDA tends to result in prompt analysis and presentation of the
            key findings to decision-makers such as donors, policy makers and practitioners, and
            heightened data transparency between sectors.




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IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary



1.2.       Disadvantages
Despite the apparent advantages of the use of electric devices such as PDAs, a number of
disadvantages and challenges were pointed out by the participants.
           Depending on the software being used, programming PDAs may require involving
            persons with the required technical skills. There are, however a growing number of free
            software programs available that can be used by lay persons.
           If using PDAs in the field, appropriate on-going supervision and technical assistance
            needs to be planned in order to resolve any issues that arise. In addition, the PDAs
            require back-up system cards and additional memory cards in order to assure data and
            required programs are not lost.      Both of these incur a higher up-front cost compared
            with the paper-based approach.
           The small screen size and small keyboard of PDA is also a challenge in the field. The
            data collectors sometimes find it tedious to fill in qualitative, open-ended responses
            with small keyboards of PDAs (although for close-ended questions, they found using
            PDAs was faster and easier). The screen size is also too small to put long questions
            (especially once translated in another language) and list of responses in one page.
            Therefore, the data collectors needed to scroll multiple screens to ask a question, and
            this disrupts the flow of the interview. However, the more familiar interviewers become
            with the questionnaires, the easier it is to overcome this challenge.
           Maintaining battery life and power is often hard in the field. The PDAs can be charged
            by the vehicle battery, but these are often not available for field work.
           The cost of procuring the PDAs is a major concern. Other costs, including the costs of
            the software, field laptop computers (in some cases), back-up memory cards (e.g.
            Secure Digital (SD)-card) to avoid loss, and training of interviewers, increase the total
            cost of the using the system. Added to this is the need to configure the questionnaires
            with special language characters, which requires the services of special programmer and
            time for programming.
           Transmission of data from PDA to the main computer can be problematic. For example,
            the DHS in Albania originally planned to use internet café to transfer data, but many SD
            cards ended up being infected with virus from the infected computers in the internet
            cafes. The free wireless connection option was not very feasible as it was not widely
            available. Alternative methods, such as manual (person-to-person) transfer or setting up
            of mini field offices where data can be uploaded to the HQ are even more expensive as
            this may require additional computers and traveling cost.


1.3.       Other lessons learned for addressing some of the disadvantages of the use of PDA



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IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary



     -       A data management plan for receiving, uploading and checking incoming cases or cluster
             data is important.
     -       A person located in the central office must be familiar with the program and the process for
             receiving and synching collected records
     -       Separate sessions for interviewer training on the paper questionnaire (in order for them to
             understand the content), followed by PDA training, including filed practice should be
             considered.


2.        GPS experiences and lessons learned
The following are the lessons learned in the use of GPS units with surveys.
              Similar to PDA training, data collectors should be provided with hands-on experiences
               in order to gain confidence in using the units. The key notes for the data collectors are
               (1) how to read the coordinates, and (2) the importance of including all the digits on the
               survey.
              Before the training, all GPS receivers should be formatted to follow the standard for
               collecting geographic coordinates.
              To minimize data entry errors of coordinates, the use of a linked GPS/PDA
               /Smartphone units is recommended. GPStrackmaker < www.gpstm.com > is one
               freeware software available that can also be considered.
              As a follow-up procedure after data collection, it was suggested to have the GPS
               locations reviewed in-country by the cartography or mapping department, since “they
               know the country as good as anyone else and they may be able to resolve issue of
               misplaced locations”.


         Theme B: Overcoming issues and challenges
         The focus of this theme was around issues and challenges that are faced when adapting the
         PDA and GPS to assessments and surveys and how to address such issues and challenges.


3.        Other recommendations/suggestions to cope with challenges
The participants shared many tips and ideas on how to cope with the challenges of using
technologies in resource-poor settings:
        Training, training, training! : Most people emphasized the importance of training. It is
         necessary to make sure that data collectors not only understand the content of the
         questionnaires, but also feel comfortable in using PDAs and GPS to collect data. Field
         practice should be incorporated to give interviewers “real life” experience. Training from
         one week (focused on PDA use only) to 4 weeks for more complex surveys is needed.



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IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary




   IT support: When using PDAs in a survey, good training for the data processing (IT) staff
    supporting the survey is necessary. The areas of IT support include: correcting user,
    programs not functioning properly, lost data problems, PDA viruses and PC viruses on SD
    cards, frozen PDAs, problems transferring data, problems related to data inconsistencies
    that cannot be resolved by the team, and upgrading programs.


   Alternative to PDA: Mini laptops (with sizes that can fit in a coat pocket) with fully loaded
    windows XP are available for as low as $300. The advantages of the mini laptops include 1)
    larger screen and key board, reducing the pain and error in data entry , 2) lower training cost
    since many people are familiar with the windows platform, 3) data synching is made easy
    by the availability of industry standard software, and 4) better compatibility. Cell phones (or
    smart phones) are another alternative.


   Battery charging: Solar backpack is one solution, although it adds to the cost of PDA use.
    One example is < http://www.voltaicsystems.com/>, although this option may not be
    efficient during raining season


   Cost: To reduce cost of PDA, consider working directly with PDA dealers, such as Palm,
    since they might provide PDAs at a lower cost for development projects. It's always
    worthwhile to contact a dealer and explore this.


   Software: There is a wide variety of software available to assist in transforming a paper
    questionnaire into a PDA. It is important to make the selection based on need, the level of
    IT support available and cost. The list of software information shared by the participants is
    presented below.


Table 1. List of Software Information Shared by the Participants
Software for PDA        Comments
programming
Pocket PC Creations + Low cost
                        + User friendly (a non-computer programmer can easily learn to make
                        questionnaires)
                        - Not possible to print the questionnaire (need to create parallel version
                        of the quest. in MS Word)
                        - Programming for complicated skip patterns or filling in a table of
                        information is convoluted
                        - Data can not be manipulated in PPCC but have to be exported
                        - Require manual programming



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IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary



                           < http://www.pocketpccreations.com/ >
CSPro 4.0                  A few of the features:
                           - Dynamically customized questions and response categories
                           - Radio buttons, check boxes, drop down list, combo box, text field,
                                dates
                           - Multiple languages on the fly
                           - Roster manipulation
                           - Saving an interview in the middle and returning later to the same
                                point
                           - Powerful programming language
                           - Able to handle complex consistency checks and skips
                           - Ability to run the same application in PDAs or PCs
                           - Able to handle long/complex questionnaires (such as the DHS)
                           < www.census.gov/ipc/www/cspro/index.html >
EpiHandy                   Designed to develop questionnaires quickly and easily and record the
                           results. Free open source software. It runs on Windows
                           PocketPC/Mobile and also J2ME phones.
                           < http://www.epihandy.com/>
EpiSurveyor                This is also free open source software that runs on the PalmOS.
                           < http://www.datadyne.org/?q=episurveyor/home >
Microsoft Visual           + Using the .NET development platform allows the user to migrate from
Studio.NET 2005            PDA's to tablet computers without re-writing the whole program.
and 2007                   + Finding developers, even on a temporary basis, is easier with .NET
                           (there seem to be plenty of people with the skills to jump in on a project
                           if necessary).


    Theme C: Future use of technologies in surveys and censuses
    Based on the discussions related to the 2 themes above, this final theme will focus
    on taking these technologies further.


On the future of the use of technologies in surveys and censuses in the resource poor countries,
the participants presented the following views:
   PDAs are indeed valuable technologies that can be used in the near and far future,
    especially in developing countries. However, one should always investigate new technology
    options as this is a rapidly evolving area.
   For implementation, it is suggested that PDAs are better applied for non-routine data
    collection, especially within public health systems since a lot more support could be availed
    in such a setting rather in routine settings where infrequent breakdowns, high staff turnover
    and the continued use of paper based systems for most of the data collection can be
    challenging for sustainability.
   Overall, participants felt that the future looks better for larger screen mini-laptop,
    Ultra-mobile PC's and touch-screen laptops than PDA. Other cellular technologies, such as
    cell phones combined with Interactive Voice Response Systems (IVRS), also appear


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IHFAN Online forum 12-23 January 2009-01-26
Use of Technology in Conducting Health Facility Assessment and household surveys and censuses
Discussion Summary



    promising.




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