Professional Documents
Culture Documents
WAVE 1
TECHNICAL REPORT
2012
The International Tobacco Control Policy Evaluation Project (the ITC Project) is a
multi-country prospective cohort study designed to measure the psychosocial
and behavioural impact of key policies of the WHO Framework Convention on
Tobacco Control (FCTC).
Funding
The ITC Bhutan Project has received funding support from:
International Development Research Centre (IDRC) Research for international Tobacco Control (RITC)
Ontario Institute for Cancer Research (OICR)
Canadian Institutes of Health Research (CIHR) Knowledge Transfer and Utilization Grant (#104765)
Canadian Cancer Society Research Institute Prevention Scientist Award
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Contents
1. Introduction .............................................................................................................................................. 5
1.1 Background ......................................................................................................................................... 5
1.2 Survey Design ...................................................................................................................................... 6
1.3 The Research Team ............................................................................................................................. 6
1.4 Maps of Bhutan ................................................................................................................................... 6
2. Sampling Design ........................................................................................................................................ 8
2.1 Target Population................................................................................................................................ 8
2.2 Sampling Design .................................................................................................................................. 8
2.3 Sample Size ......................................................................................................................................... 8
3. Survey Development and Content ............................................................................................................ 9
3.1 Survey Development ........................................................................................................................... 9
3.2 Survey Content.................................................................................................................................... 9
4. Protocols and Quality Control ................................................................................................................. 11
4.1 ITC Bhutan Survey Protocol .............................................................................................................. 11
4.2 Respondents ..................................................................................................................................... 11
4.3 Components of the ITC Bhutan Survey Fieldwork ............................................................................ 11
4.4 Remuneration and Conclusion.......................................................................................................... 13
4.5 Monitoring & Quality Assurance....................................................................................................... 13
5. Disposition Codes and Cooperation Rate ............................................................................................... 14
5.1 Outcome codes: Household .............................................................................................................. 14
5.2 Outcome codes: Individual ............................................................................................................... 14
5.3 Respondent ID................................................................................................................................... 14
5.4 Cooperation Rate .............................................................................................................................. 15
6. Weights Construction ............................................................................................................................. 16
6.1 Wave 1 Sampling Plan ....................................................................................................................... 16
6.2 Weights Construction Overview ....................................................................................................... 17
6.3 Computation of Enumerated Household Weights (EHWT) .............................................................. 17
6.4 Prevalence Estimation ...................................................................................................................... 19
6.5 Computation of Individual Weights .................................................................................................. 19
1. Introduction
1.1 Background
The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever
international cohort study of tobacco use. The ITC Project is a collaborative effort with international
health organizations and policymakers in over 20 countries so far. The International Tobacco Control
Policy Evaluation Project in Bhutan (the ITC Bhutan Project) was created in 2009 to evaluate rigorously
the psychosocial and behavioural effects of Bhutanese tobacco control legislation. Wave 1 of the ITC
Bhutan Survey was conducted from September to November 2009, which is 5 years after Bhutan
became the only nation in the world with a comprehensive ban on all tobacco sales.
2. Sampling Design
2.1 Target Population
Eligible respondents included four categories of respondents: smoked tobacco users, smokeless tobacco
users, mixed tobacco users, never-monthly-users of tobacco and ex-users of tobacco who are
permanent residents and aged 18 and above in each household. Smoked tobacco users are adults (aged
18 years) who used smoked tobacco products including manufactured and hand-rolled cigarettes, bidis,
cigars & pipes at least once a month. Smokeless tobacco users are adults (aged 18 years) who used
smokeless tobacco products including khaini, zarda and snuff at least once a month. Mixed tobacco
users are adults (aged 18 years) who were both smoked tobacco users and smokeless tobacco users.
Ex-users/Never-monthly-users are adults (aged 18 years) who were neither smoked tobacco users nor
smokeless tobacco users.
2) Knowledge and Basic Beliefs About Smoking. Knowledge of the health effects of smoking and
important beliefs relevant to smoking and quitting, perceived risk and perceived severity of tobaccorelated diseases;
3) Tobacco Control Policies. Awareness of, impact of, and beliefs relevant for each of the FCTC demand
reduction policy domains (warning labels, taxation/price, sale-bans)
4) Other Important Psychosocial Predictors of smoking behaviour and potential moderator variables
(e.g., normative beliefs, self-efficacy, intentions to quit);
5) Individual Difference Variables Relevant to Smoking (e.g., depression, stress, time perspective);
6) Marijuana and Alcohol Use;
7) Demographics (e.g., age, marital status, income, education, occupation).
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4.2 Respondents
The sample consisted of 1806 respondents, of which 59 were smoked tobacco users, 181 were
smokeless tobacco users, 11 were both smoked and smokeless tobacco users, and 1555 were
non-users.
The eligible respondents for the cohort surveys were those who lived within the selected
households selected from 4 geographic districts in Bhutan.
The respondents were users and non-users of tobacco aged 18 years. The first part of the
cohort surveys contained the questions that were used to determine whether the individual met
the criteria for inclusion.
20 trained interviewers were assigned to an Enumeration Area (EA) from one of the four
districts that were being surveyed in Bhutan. Within each EA, households were chosen through
a random process.
If a member of the household agreed to participate in the enumeration of his/her household,
then information on all adults (aged 18 years or older) in the home was collected, including their
tobacco use status. 1604 households were enumerated from the 4 districts across Bhutan.
Only Bhutanese citizens were eligible for the interview.
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If the key informant refused to participate in enumeration, the interviewer would request the
following two pieces of information:
1) How many people aged 18 years and above live in the household? and
2) How many of them use tobacco regularly?
A maximum of 4 attempts in all urban areas and a minimum of 2 visits in rural areas were made
to enumerate each household.
Interviewers kept careful records of which households were visited, the outcome of each visit,
and whether or not a listing or an interview was obtained.
Respondents were selected based on their smoking status, were administered the screener, and
accordingly completed the appropriate survey.
Within each enumerated household, all adults who had ever been tobacco users were selected.
One adult from each household who had never used tobacco on a monthly basis was selected
randomly by a roll of a die. If the selected respondent had an individual outcome code that
required substitution, the die was rolled again to choose another respondent. If no eligible
person existed, then this spot would remain unfilled for the household.
A substitution from the same household was allowed only if a selected respondent from the
Never-monthly smoker category had outcome language barrier or health/mentally
incapable.
A verbal consent was obtained from each participant and each eligible, consenting participant
was interviewed independently, using a standardized consent form (either the user or non-user
version) that had been reviewed and cleared by ethics committees at the University of Waterloo
and Bhutan Ministry of Health. An interviewer was required to complete the Confirmation of
Verbal Consent Form to verify that consent had been given and that the information letter was
given to the respondent to keep.
Length of interviews
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The length of interviews was 35-40 minutes for the Smoked Tobacco User or Smokeless Tobacco User
Survey, 45 minutes for the Mixed User Survey and 25-30 minutes for Ex-user/Non-user Survey.
Languages of survey questionnaire
When possible, the survey was conducted in English. The interviewer would conduct surveys in
Dzongkha or other dialects as needed.
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5.3 Respondent ID
Each participant was assigned a 13-digit number, which was a combination of the 2-digit Dzongkhag
Number, 1-digit Urban/Rural Number, 2-digit Gewog Number, 2-digit EA Number, 4-digit Household
Number and 2-digit individual ID Number. This number was recorded to ensure that each participant
had a unique identification number, which could be referred to for recontact and also to indicate the
location of the respondent within the Dzongkhags of Bhutan.
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1806
2031
88.92%
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6. Weights Construction
6.1 Wave 1 Sampling Plan
The research team was to conduct a survey of 1604 households, interviewing all adults in each
household who were thought by the original informant to be current tobacco or ever monthly tobacco
users, and a randomly selected one of those who are thought by the original informant to be nevermonthly tobacco users.
The households were recruited via a multistage sampling design in 4 of the 20 districts of the country.
The table of the 4 chosen districts and their populations is shown next. They were chosen purposively
for regional representation. The sample of households was allocated to districts approximately in
proportion to the square root of the population size, so as to allow for some regional comparisons, while
maintaining efficiency over the whole study population.
PHCB, 2005 and EC
District
Population
Bumthang
16,116
200
Chukha
74,387
500
Thimphu
98,676
500
Trashigang
51,134
400
Bhutan overall
634,982
1600
In the first stage, each of the 4 districts was stratified into an urban part and a rural part. Except in the
urban parts of Thimphu and Chukha, a selection of 2 gewog (towns) was made using probability
proportional to size in each urban stratum, and a selection of 3 gewog was made similarly in each rural
stratum. In the urban part of Chukha, Phuentsholing was selected, along with 2 other gewog with
probability proportional to size. The urban part of Thimphu consists of just one gewog, the city of
Thimphu.
From each selected gewog a selection of chiwog (blocks or villages) was made with probability
proportional to size, as detailed below and on the accompanying spreadsheet. The size measure at each
stage was the estimated number of households in the area unit. A certain number of households
(specified in the spreadsheet) were selected by systematic sampling with random start within each
selected chiwog. Within a district, the number of households in each urban/rural stratum was
approximately proportional to stratum size. The expected household weights were calculated, to check
that the final weights would be fairly uniform within each district.
16
~
N gew
N str
N cw
17
In the first (Geling), the 3 chiwogs were taken with certainty. The middle factor of the formula above
was replaced by 1.
In the second gewog (Bjachho), two very large chiwogs were selected with certainty, and one was
selected from the remaining three with probability proportional to size. In the first two chiwogs, the
middle factor of the formula above was replaced by 1.
In the third, in the middle factor was replaced by (Ngew minus the sum of the sizes of the first two
chiwogs), and nch set equal to 1.
In the third gewog (Sampheling), 1 very large chiwog was selected with certainty, and the other two
were selected from the remaining 16 with probability proportional to size. The number of households
per chiwog were varied to make the weights closer to uniform. In the first chiwog, the middle factor of
the formula above was replaced by 1. In the other two, Ngew in the middle factor was replaced by (Ngew
minus the size of the first chiwog), and nch set equal to 2.
Chukha urban: At the outset, Phuentsoling was selected with certainty, and two other gewogs were
selected with probability proportional to size. Within Phuentsoling, 6 blocks were chosen with
probability proportional to size, with roughly the same number of households in each. In Phuentsoling
the first factor in the above formula was replaced by 1.
In the first gewog (Chukha), two large blocks were chosen with certainty and a third from the remaining
2 by probability proportional to size. In the above formula, for the first two blocks the middle factor was
replaced by 1; for the third block, Ngew in the middle factor was replaced by ( Ngew minus the sum of the
sizes of the first two blocks), and nch set equal to 1. In these cases ng =2.
In the second gewog (Gedu), three blocks were chosen with probability proportional to size, and roughly
the same numbers of households were to be taken from each. Thus the normal formula above could be
used.
Thimphu rural: At the outset, 4 gewogs were removed from the sampling frame, and 3 were sampled
with probability proportional to size from the remaining 4. It was found not to be practical to select
more than 2 chiwogs per gewog.
In the first gewog (Geney), one large chiwog was chosen with certainty and the other chosen with
probability proportional to size from the remaining 2. Thus for the first chiwog, the middle term in the
above formula was replaced by 1; for the second chiwog,
Ngew in the middle factor was replaced by (Ngew minus the sum of the size of the first chiwog), and nch set
equal to 1.
In the second gewog (Kawang), two large chiwogs were chosen with certainty. For both of these, the
middle term of the above formula was set equal to 1, and Ngew in the first factor was replaced by the
sum of the two chiwogs chosen with certainty.
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In the third gewog (Mewang), two chiwogs were selected with probability proportional to size. In these
chiwogs, the normal formula above could be used.
Thimphu urban: Ten blocks were chosen with probability proportional to size, with roughly equal
numbers of households to be sampled from each. The first factor in the formula above was replaced by
1.
Trashigang rural: At the outset, 6 gewogs were removed from the sampling frame, and 3 were selected
with probability proportional to size from the remaining 9.
The first gewog (Bidung) was composed of a large number of small chiwogs, and 6 of these were
selected with certainty. The case was similar for the other two gewogs (Radhi, Samkhar), in which 5 and
4 chiwogs were selected with certainty, respectively. Numbers of households to be taken from chiwogs
were varied accordingly. For each of these gewogs, the middle factor of the above formula was
replaced by 1, and Ngew in the denominator of the first factor was replaced by the sum of the sizes of the
chiwogs chosen in the gewog.
Trashigang urban: Here the design was implemented as expected. Two gewogs (Khaling, Trashigang)
were selected with probability proportional to size, and two chiwogs were selected with probability
proportional to size within each. The normal formula above could be used.
EHWT t
j j
EHWT m
j
where EHWTj is the weight for enumerated household j, mj is the number of adult males in household
j, and tj is the number of adult males who are reported in the enumeration to use tobacco in household
j. The sums are over all enumerated households.
If we sum the EHWT weight over all enumerated households with tobacco users, we obtain an estimate
of the number of households with tobacco users in the four districts, minus their inaccessible areas.
For an adult male tobacco ever-user, W1 is the number of adult male tobacco ever-users in the same
household, divided by the number of adult male tobacco ever-users interviewed in the household.
For an adult female tobacco user, W1 is the number of adult female tobacco ever-users in the same
household, divided by the number of adult female tobacco ever-users interviewed in the household.
For an adult never-user of tobacco, W1 is the number of adult never-users of tobacco in the same
household, capped at 3 to control the variability of the weights.
The interviewed individuals were classified according to their tobacco use status in the enumeration for
purposes of calculating W1. For those interviewed individuals with unknown tobacco use status at the
enumeration phase, W1 was set equal to 1.
Step I1a: Each interviewed individual has been given an adjusted household level weight W1a. This
adjustment guarantees that the prevalence estimates based on the EHWTs and on the individuals
would be the same, before calibration of the individual weights, if tobacco use status were the same as
at the enumeration phase.
Let ATcw and ANcw be respectively the numbers enumerated in the chiwog of adult tobacco ever-users
and adult never-users of tobacco, according to tobacco use status at the enumeration phase.
For an adult tobacco ever-user, W1a is given by
W1a AT cw W1/ W1
tcw
where the sum in the denominator is the sum of W1 over all interviewed adult tobacco ever-users in the
chiwog. A similar calculation applies for never-users of tobacco. For those interviewed individuals with
unknown tobacco use status at the enumeration stage, W1a was set equal to 1.
Step I2: Each interviewed individual was given a preliminary district-level weight W4 which is thought of
as the number of people in the district represented by that individual.
The weight W4 is given by
.
If we sum W4 over all tobacco ever-users interviewed, we should get an estimate of the number of
tobacco ever-users in the 4 districts, minus their inaccessible areas. Similarly if we sum W4 over all
never-user individuals interviewed, we should get an estimate of the number of never-users in the 4
districts, minus their inaccessible areas. (For these calculations we would likely want to use tobacco use
status as corrected from the interview data.)
We calibrated the weights to census-based estimates of the adult population numbers in the target
areas.
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W 4
W 6 N str,dem W 4 /
str , dem
where Nstr,dem is the number of adults in the stratum (district crossed with urban/rural) and demographic
group (gender crossed with age group), and the sum in the denominator is taken over interviewed
individuals in the same stratum and demographic group. The age groups were taken to be under 35
years of age, and 35 years of age or older. W6 is variable aDE64915v in the data set.
6.6 Rescaling
Finally, the weights were rescaled to sum to country sample size within each of the following categories,
for use in regression analyses: district crossed with tobacco use status (ever-user vs. never-user,
according to tobacco use status as corrected from the interview data). The rescaled weight is
aDE64919v in the data set.
W 8 W 7*
W 6
al l
W 7
al l
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22
23
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Read out the information sheet and obtain verbal consent before proceeding with the survey.
CONSENT:
1. Obtained
2. Not Obtained
Terminate interview
SALES BAN
1
In this survey, we are going to be asking you about tobacco use. As far as you know, are people in
Bhutan allowed to use tobacco products?
1
Yes If YES: Thats correct; there is no law against using or possessing tobacco products.
2
No
If NO: Provide explanation. Actually, there is no law against using or possessing
tobacco products.
Are you aware that there is a ban on the sale of tobacco product in Bhutan?
1
2
88
99
Yes
No
Refused
(Dont read out)
Dont Know (Dont read out)
In your opinion, how well is the ban on sale of tobacco products in Bhutan enforced?
1
Well enforced,
2
Somewhat enforced, or
Poorly enforced.
88
99
Refused
Dont Know
Generally easy,
3
4
Somewhat difficult
Very difficult.
Cant say.
Based on your observation, do you think less people are using tobacco products because of the
ban, or has it made no difference?
1
Less,
2
No difference, or
3
More.
5
Cant say
Refused
Dont Know
Yes
No
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Do you use smokeless tobacco at lease once a month? (Including: khaini, zarda and snuff.)
1
Yes
2
No
Routing:
If use both forms of tobacco (Yes to both Q7 and Q8) Go to Mixed User Survey
If only smoked (Yes to Q7 and No to Q8)
If only smokeless (No to Q7 and Yes to Q8)
If uses neither (No to both Q7 and Q8)
Go to Smoker survey
Go to Smokeless survey
Go to Non-User/Ex-User survey
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We are going to read out a list of tobacco products and would like to know how often you use each of
these products.
Do you smoke/use <manufactured cigarettes> daily, at least weekly, less than weekly or not at all? Circle
appropriate number in USAGE Column 3 (0 = Not used, 1 = Less than Weekly, 2 = Weekly, 3 = Daily)
For smoked: How many do you smoke per day/week/month? (use appropriate interval)
For smokeless: How long a pack or tin lasts and record in appropriate column.
Smoked
Usage
a.
Manufactured cigarettes
0 1 2 3
b.
Hand-rolled cigarettes
0 1 2 3
c.
Bidis
0 1 2 3
d.
0 1 2 3
Smokeless
e.
Khaini/surti
0 1 2 3
f.
Zarda
0 1 2 3
g.
Snuff
0 1 2 3
h.
0 1 2 3
Routing:
Usage
Number per
day
Number per
week
Number per
month
Days per
packet/tin
Weeks per
packet/tin
Months per
packet/tin
Continue
Go to Q3
Go to Q7
Is the main reason you use a variety of products because you like the variety or
because you use what is available, or is it or for some other reason?
1
2
3
4
Variety
Availability
Both, or
Some other reason (specify)____________________________________
88
Refused
(Don't read out)
99
Don't Know
(Don't read out)
If any daily use in Q1 Go to Q5, else continue
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*NOTE: This form should be completed by the interviewer if the participant agrees to
participate in the study.
I,
following
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7. References
1. Map of Bhutan. http://www.infoplease.com/atlas/country/bhutan.html
2. Administrative map of Bhutan. http://swedish-bhutan-society.org/en/fakta/
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