This post is part of a series commemorating 30 years of The DHS Program.
By Fred Arnold
Historically, India has suffered through devastating periods of famine, but due to the Green Revolution, improved food storage and distribution, and other factors, famine has been all but eradicated in the country. However, malnutrition continues to threaten the health of India’s population.
The National Family Health Surveys (as DHS surveys are known in India) have been documenting the nutrition situation in India since 1992 (by measuring the height, weight, and anemia status of children and adults, and by assessing infant and young child feeding practices). These surveys have brought to the nation’s consciousness the excessively high levels of stunting, wasting, underweight, and anemia that young children in India continue to suffer from. The most recent NFHS survey (NFHS-3) found that nearly half of children under five are stunted, 43% are underweight, 20% are wasted, and 7 out of every 10 children are anemic. Stunting among children was as high as 60% in the lowest wealth quintile, but was still considerable (25%) even in the highest wealth quintile. These findings were widely reported in the media, were agonized over by international organizations and NGOs, and were prominently discussed at the highest levels of government. In two national addresses, Prime Minister Manmohan Singh revealed that he had seen the results of the National Family Health Survey, and he declared the poor nutrition of India’s children to be “a national shame.” He immediately responded by writing a letter to the Chief Ministers of every state in the country, ordering them to take up the fight against malnutrition “on a war footing” and to report back to him every quarter on the progress that had been made.
Based on the NFHS-3 findings, that same year I wrote a paper on the nutrition landscape in India, which was published in Demography India and presented as the keynote speech at the Annual Meeting of the Indian Association for the Study of Population. That reached yet another important constituency that joined the national dialogue on nutrition.
Another aspect of nutrition that was documented in that paper was the emerging dual burden of simultaneous undernutrition and overnutrition among Indian adults. About one-third of women and men were abnormally thin and about 1 in 8 were overweight or obese, meaning that only about half of adults had a normal nutritional status. The figures are even more alarming in certain segments of the population. Thirty to forty percent of women were overweight or obese in some of India’s largest cities, and even in urban slums, 20-30% of women fell in that category.
Since NFHS-3, there have been encouraging signs of improvements in nutrition in some places, but discouraging signs of stagnation or deterioration in others. The results of the NFHS-4 survey, which is just about to go into the field, are eagerly awaited to provide more definitive information on the current nutrition situation. And when the next chapter in India’s nutrition history is written, NFHS will be there to monitor trends and provide vital information to guide informed policymaking and program planning.
Fred Arnold, Technical Deputy Director—Dr. Arnold is responsible for setting the overall technical direction for The DHS Program and coordinating the design of DHS questionnaires. He has coordinated technical assistance to four large-scale National Family Health Surveys in India, which have included interviews with more than one million women and men, working with more than 40 organizations (government ministries, funding agencies, international organizations, and implementing agencies) in the conduct of the surveys. He has been involved in the design and implementation of surveys in 15 additional countries. Dr. Arnold has a Ph.D. in economics/demography from the University of Michigan. He has authored more than 150 publications in areas such as malaria; HIV; maternal, newborn and child health; nutrition; son preference; international migration; and the value of children.
This post is part of a series commemorating 30 years of The DHS Program.
When I first started at The DHS Program in late 1993 as a Women-in-Development Specialist, the survey questionnaires contained few questions that could shed light on the impact of gender on demographic behavior and health. While the questionnaires were designed to collect all kinds of information on women’s and children’s health, women’s use of contraception, fertility, mortality and nutrition, there was virtually no information on the status of the women themselves other than information on their education and employment. In other words, there was little information that provided insights into the gendered context within which the health and demographic behavior of women and households was being determined.
So I had a lot of work to do. My challenge was to develop a parsimonious module of questions that in the future could potentially be used by DHS surveys across the world to better understand the role that gender plays in demographic and health outcomes. To this end I put together a set of questions on women’s status based on a thorough literature review and an examination of several studies that used questionnaires to measure women’s status and gender relations in the household. Once ready we managed to include this module of questions in the 1995 Egypt DHS. Preparing the module was challenging since the literature provided mostly proxy indicators of women’s status at the household level, but few that could directly measure empowerment. Additionally, since one of the key features of The DHS Program is that it provides comparable data across countries, I needed questions that had similar meaning across cultures with widely varying perceptions of women’s roles. The pilot of the Women’s Status Module in the Egypt DHS yielded a lot of useful information and helped determine the key indicators that would be useful to have for most countries such as the questions on women’s role in household decision making, their attitudes towards spousal violence, and barriers to accessing health care for themselves.
Another gender-related topic that really increased in importance during my tenure as the Senior Gender Advisor to The DHS Program is domestic violence. The women’s status module implemented in Egypt contained only a couple of questions on women’s experience of domestic violence and the 1990 and the 1995 Colombia DHS surveys included country-specific questions on domestic violence. Then in 1998, a module of questions that utilized a modified conflict tactics scale approach (Strauss 1990) to the measurement of violence was implemented in the Nicaragua DHS. It was this module that became the foundation for the core DHS Domestic Violence Module which was finalized and piloted around 2000. Overtime we also developed a protocol for the ethical collection of data on violence, particularly for the protection of female respondents and field interviewers. However, having a standardized module and protocols for its implementation, did not mean that countries were immediately interested in collecting information on domestic violence. There was first a need to try and overcome commonly held beliefs that domestic violence was not a State concern and had no place in a demographic and health survey. Additionally few believed that women would be willing to talk about their experiences of violence.
The 1995 Egypt DHS marked a new chapter in the life of The DHS Program. Questions on women’s empowerment are now part of the core questionnaire and asked in most countries. The Domestic Violence Module has been included in more than 95 surveys in over 50 countries. Survey data have been used for major legislation, advocacy efforts, and national programs to protect women in their own homes in countries as diverse as Moldova, Uganda, Timor Leste, and Zimbabwe. Analysis of DHS data has convincingly linked violence with negative reproductive health outcomes and HIV, showing that violence is an important public health issue as well as a violation of individual rights.
In the coming years, The DHS Program will continue to collect more information on women’s empowerment. The 2014 revised survey instruments now include questions on women’s ownership of mobile phones, personal bank accounts, and ownership and co-ownership of property. We have come a long way since the first pilot module on women’s status, and we will continue to be on the forefront of research into women’s lives.
Straus, M.A. 1990. Measuring intrafamily conflict and violence: the conflict tactic (CT) scales. In M.A. Straus and R.J. Gelles (eds.) Physical Violence in American families: Risk Factors and Adaptations to Violence in 8,145 Families. 29-47. New Brunswick: Transaction Publishers.
What does 30 years look like? Here are some historical milestones of The DHS Program:
This post is part of a series commemorating 30 years of The DHS Program.
By Annie Cross
The fact that Liberia is currently battling the Ebola crisis makes it harder to appreciate the fact that the recently released report on the 2013 Liberia Demographic and Health Survey (LDHS) showed improvement in most of the health-related indicators since the 2007 LDHS was carried out. I prefer to remember Liberia the way it was during the first DHS, before Ebola and before the civil war.
The 1986 LDHS was the first DHS in Africa and only the second worldwide. I was the country manager assigned to cover the survey. However, because we recruited interviewers from the local areas in which they would work and it was deemed too expensive to bring them all to one central place, we decided to hold two simultaneous training courses. I travelled the 6 hours to the town of Zwedru, while my boss (then Regional Coordinator, later DHS Director) Ann Way, was in charge of the training in Monrovia. Zwedru was a small quiet city and I was lucky to be able to stay in a USAID guest house for the month-long training. We also had a pleasant, airy new building for the training. Ann, however, was training in an old school with broken windows in Monrovia.
Although we had conducted a pretest several months before, this was the first DHS main interviewer training for both of us. Consequently, we had a number of questions that came up. How do you estimate a person’s age when they don’t have any documents and can’t remember who was president when they were born? Do you list someone in the household schedule who works away from home but comes home every weekend? Although we had a detailed interviewers’ manual, some of these questions had not been fleshed out. And of course, there were a slew of administrative issues too, like locating enough vehicles, getting payments wired from the U.S., etc.
Ann and I set up a plan to call each other every few days. Since this was before cell phones and even land lines were pretty scarce in Liberia, I would walk to a pay phone in Zwedru, put in several of the heavy Liberian coins (nicknamed “Doe Dollars” after the Liberian President) and call her in Monrovia. We would review various issues and catch up on news. It sounds so quaint now, but it was like a lifeline for me and I remember saving up the coins so that when the phone indicated the time was running out, I could drop another dollar in and talk a bit longer. We always had to remember to set up the time for the next call so that we would be sure to be at our respective phones. We don’t realize how much cell phones have changed the survey landscape.
Anne Cross, former Deputy Director – Survey Operations: A demographer and survey specialist, she has extensive experience in survey research, including nearly 40 years of experience in population- and facility-based data collection, analysis, capacity building, dissemination and use of data in developing countries. Ms. Cross received her M.A. degree in Demography from Georgetown University in 1973. Prior to joining Macro in 1982 as a Demographer on various USAID-funded projects, she spent several years as a Demographer at the University of North Carolina, where she implemented a demographic survey in Somalia and assisted in the design of various survey questionnaires. Earlier in her career, Ms. Cross was a Demographic Advisor to Kenya’s Central Bureau of Statistics with responsibility for analyzing survey data.
2014 marks the 30th anniversary for the USAID-funded Demographic and Health Surveys Program and my eleventh anniversary as Senior Advisor for Communication with the project. Much has changed over the past three decades: we’ve done many more surveys and much more complex surveys, added biomarkers, conducted more formal capacity building, and varied the kind of dissemination products and activities. What hasn’t changed is how much people all over the world value the DHS.
When I joined The DHS Program—then MEASURE DHS—in 2003, I was a devoted DHS user, relying on surveys for background information to inform behavior change communication programs. But I knew very little about how national governments and development partners used the surveys. It was my first trip for the project that gave me a whole new perspective on the impact of DHS findings.
I went to Abuja, Nigeria for the launch of the 2003 Nigeria DHS Final Report. More than 500 people crammed into the Sheraton Hotel Conference Centre designed to hold only about 350. The morning session included opening prayers, introductory speeches by four government ministers, the USAID Mission Director, the head of the National Population Commission, the Chief Economic Advisor to the President, and more. Finally, we got to the data—a short key findings presentation of the survey results highlighting childhood vaccination rates from Nigeria and from DHS surveys in other African countries (see chart below).
At the time, only 13% of Nigerian children had been fully vaccinated, putting Nigeria dead last in Africa. When this statistic was presented, all 500 participants in the audience sat in shocked silence. The data told the story, and the Nigerians were not happy to be so far behind their smaller and much poorer neighbors. The DHS results were a critical factor prompting Nigerian leaders to focus on improving national immunization programs. While still not impressive, vaccination coverage for Nigerian children has doubled since 2003, reaching 25% in the 2013 DHS.
I heard another example of the impact of the 2003 Nigeria DHS during my trip. The survey found that only 12% of households owned mosquito nets. As a result, a DFID-funded Society of Family Health project decided to increase malaria prevention activities and add insecticide treated nets to its roster of social marketing products. For both the national government, private sector, and development partners, the DHS made the difference.
I’m immensely proud to introduce this blog series, which will highlight many different stories of DHS over the years. In the coming weeks, you will hear from DHS leaders over the years, including Sunita Kishor, Martin Vaessen, Trevor Croft, Guillermo Rojas, Fred Arnold, and Annie Cross, on topics ranging from gender & women’s issues in the DHS to nutrition in India, Data Processing and collection methods to experiences from the first DHS in Liberia. I hope this series unlocks some of DHS history for you, our users. Here’s to 30 years of DHS!