Need to involve relevant stakeholders –lessons from NFHS data

Abstract

Contextualizing data to their settings is perhaps the most important step in deriving a meaning from them. This is no less true for health data. The National Health Survey data are an excellent source of information; however, its strength may not be its contextualization. Our habit of, for example, doing primary care without family physicians or doing public health without understanding the complete domain and involvement of its proponent seems to have extended to this exercise (collection of National Health Survey data) as well. Relegating health data to statistics and calculus alone should be a pitfall all of us must avoid. Identifying the right stakeholders to understand the complexity of health data is the key.

Context

The National Health Survey and its synonyms are considered a standard source of information on the health of the civilian noninstitutionalized population across the world. Whether it is the National Health Interview Survey of the United States, the major data collection programs of the National Center for Health Statistics which is part of the Centers for Disease Control and Prevention or the National Family Health Survey (NFHS) conducted in India, the big data thus generated have always proved useful.^[1,2] Perhaps the idea to secure accurate and current statistical information on the amount, distribution, and effects of illness and disability may have been the governing principle of this information gathering process across the nations. The information thus captured has not only been used by the healthcare professionals to analyze and interpret the trends and pattern of the health conditions but has also served as a ready reference for development and implementation of various national and local healthcare initiatives or programs. Therefore, accuracy in the collection of the data and the methodology involved to collect the same requires following a standardized and updated protocol/s.

National Family Health Survey

NFHS surveys are being conducted under the stewardship of the Ministry of Health and Family Welfare, Government of India, with the International Institute for Population Sciences, Mumbai, functioning as the nodal agency. The first NFHS was conducted in 1992-1993 and covered all states except the state of Sikkim while NFHS-2 was conducted in 1998-1999 in all states of the country with similar content and methods to those in NFHS-1.

In addition, NFHS-2 also gathered information on reproductive health, women’s autonomy and domestic violence, women’s and children’s nutrition, anemia, and salt iodization. NFHS-3 followed and built on the data collection process NFHS-1 and NFHS-2 by maintaining continuity in content and methods with an additional component of community-based Human Immunodeficiency Virus testing. With additional components of clinical, anthropometric, and biochemical testing (CAB), NFHS-4 (2015-16) provided information at the district level through increasing the sample size by nearly fivefold as compared with NFHS-3.^[3]

Objective of the NFHS

Like other National Health Survey, the main objective of the NFHS in India has been to provide high-quality data on health and family welfare and emerging issues.^[3] In fulfilling this objective of the survey, NFHS-5 data are expected to be useful in setting benchmarks and examining the progress that health sector has made over a period of time. Besides providing evidence for the effectiveness of ongoing programs, the data from NFHS-5 are expected to help in identifying the need for new programs with an area-specific focus and identifying groups that are most in need of essential services related to health and family welfare for example.

National Family Health Survey-5

The fieldwork for NFHS-5 was conducted in two phases: Phase-I from June 17, 2019 to January 30, 2020 covering 17 states and 5 union territories and Phase-II from January 2, 2020 to April 30, 2021 covering 11 states and 3 union territories, by 17 field agencies.^[3] Information was gathered from 6,36,699 households, 7,24,115 women, and 1,01,839 men.

However, NFHS-5 includes some new topics, such as preschool education, disability, access to a toilet facility, death registration, bathing practices during menstruation, and methods and reasons for abortion. The scope of CAB testing has also been expanded to include measurement of waist and hip circumferences and the age range for the measurement of blood pressure and blood glucose has been expanded.

Key stakeholders for NFHS

The funding for execution of the activity comes from the Ministry of Health and Family Welfare, Government of India with International Classification of Functioning, Disability and Health through the Demographic and Health Surveys Program, funded by United States Agency for International Development providing the technical assistance.

The assistance for the collection of Dried Blood Sample, a component of the survey was provided by the Indian Council of Medical Research and the National AIDS Research Institute, Pune.

Questionnaires and measurements

Four survey schedules/questionnaires—Household, Woman, Man, and Biomarker—were used. The questionnaires/schedules were canvassed in 18 local languages using computer-assisted personal interviewing technique.^[3] Information was collected on all members of the household as also the visitors who stayed in the household the night before the interview. The schedule also covered measurements of height, weight, and hemoglobin levels for children; measurements of height, weight, waist and hip circumference, and hemoglobin levels for women aged 15-49 years and men aged 15-54 years; and blood pressure and random blood glucose levels for women and men aged 15 years and more.

Concerns

Identifying the right stakeholders to understand and implement the complexity of health data is important and like all big data, the diversity in health data is more than enough to escape attention if due caution is not exercised. Delving into each of these aspects and identifying the right kind of research system/structure along with the right kind of data interpreting and implementing system to guide through this diversity is needed. This massive exercise (NFHS) seems to have erred on this aspect as some vital information gathering techniques and the interpretation likely to come out from such information seems to have suffered from the lack of using valid tools. For example, if one looks us at the available data, the classification of groups has generally been based as following:

1. Children aged 0-59 months.
2. Women aged 15-49 years.
3. Men aged 15-54 years.

Basing CAB parameters using such age groups (as for example taking age (15-49) years as adults) do not appear to be in accordance with standard definitions used for classification or definition of obesity, diabetes, or hypertension, for example. Furthermore, the criteria used for the defining of diabetes and hypertension have not been detailed and the cutoffs used appear arbitrary. But the overlook is not restricted to these aspects only but to some other aspects as well.

The missing link

The contextualization of the data with respect to its end users is the key. For the NFHS and surveys of similar nature, the end users are not just a researcher (analyzing and interpreting the data) or a healthcare practitioner basing his empirical judgment of treatment on these data but also the policy makers, who view these data with not just curiosity but also with valuation. Therefore, inclusion of these as part of the key stakeholder’s team on formulation of design, tools, and protocols is not just imperative but mandatory. The presence on- board of all of these stakeholders will only strengthen the outcomes of the exercise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.