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REVIEW ARTICLE
Year : 2018  |  Volume : 148  |  Issue : 5  |  Page : 596-611

A review of selected nutrition & health surveys in India


1 Centre for Promotion of Nutrition Research and Training with Special Focus on North East, Tribal & Inaccessible Population, Division of Nutrition, Indian Council of Medical Research (Campus II), Tuberculosis Association of India Building, New Delhi, India
2 Centre for Promotion of Nutrition Research and Training with Special Focus on North East, Tribal & Inaccessible Population, Division of Nutrition, Indian Council of Medical Research (Campus II), Tuberculosis Association of India Building, New Delhi; ICMR-Desert Medicine Research Centre, Jodhpur, India

Date of Submission28-Sep-2018
Date of Web Publication21-Jan-2019

Correspondence Address:
Dr G S Toteja
Centre for Promotion of Nutrition Research & Training with Special Focus on North East, Tribal & Inaccessible Population, Division of Nutrition, Indian Council of Medical Research (Campus II), Tuberculosis Association of India Building, 3 Red Cross Road, New Delhi 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1808_18

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   Abstract 

Assessment of the status of health and nutrition of a population is imperative to design and implement sound public health policies and programmes. The various extensive national health and nutrition surveys provide national-level information on different domains of health. These provide vital information and statistics for the country, and the data generated are used to identify the prevalence and risk factors for the diseases and health challenges faced by a country. This review describes the various national health and nutrition surveys conducted in India and also compares the information generated by each of these surveys. These include the National Family Health Survey, District Level Household Survey, Annual Health Survey, National Nutrition Monitoring Bureau Survey, Rapid Survey on Children and Comprehensive National Nutrition Survey.

Keywords: Annual health survey - DLHS - health - NFHS - NNMB - nutrition - surveys


How to cite this article:
Rathi K, Kamboj P, Bansal PG, Toteja G S. A review of selected nutrition & health surveys in India. Indian J Med Res 2018;148:596-611

How to cite this URL:
Rathi K, Kamboj P, Bansal PG, Toteja G S. A review of selected nutrition & health surveys in India. Indian J Med Res [serial online] 2018 [cited 2019 Feb 20];148:596-611. Available from: http://www.ijmr.org.in/text.asp?2018/148/5/596/249985

Komal Rathi and Preeti Kamboj have contributed equally



   Significance of health & nutrition surveys Top


Large surveys are significant means to collect data related to health and aid to observe and check the progress on different indicators related to health measured in these surveys[1]. This review was aimed to assess the large-scale national-level community-based health- and nutrition-related surveys conducted in India since 1972 and also to compare the characteristics of these surveys such as survey period, nodal ministries, key themes and indicators covered by each survey.

Although the surveys put forward important and beneficial information on various health- and nutrition-related indicators at sub-national level, this review, in particular, focuses on the maternal and child health-related indicators. The community-based national-level surveys with large sample size were selected that provided data on various health and nutrition indicators. The major surveys discussed include the National Family Health Surveys (NFHS), District Level Household Survey (DLHS), Annual Health Survey (AHS), National Nutrition Monitoring Bureau (NNMB) Survey, Rapid Survey on Children (RSoC) and Comprehensive National Nutrition Survey (CNNS).


   Major surveys Top


National Family Health Survey (NFHS)

The NFHS is a large-scale survey, and multiple rounds of NFHS have been conducted since 1992 in representative sample households throughout India[2]. It is coordinated by the International Institute for Population Sciences (IIPS) as the nodal agency, Mumbai, under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India. Till now, four rounds of this survey have been conducted, NFHS-1 (1992-1993), NFHS-2 (1998-1999), NFHS-3 (2005-2006) and NFHS-4 (2015-2016). The most recent NFHS-4 provides estimates of most of the indicators at the district level for the first time for all the 640 districts[3].

District Level Household Survey (DLHS)

The DLHS is a household survey conducted at the district level. Like NFHS, the nodal agency for DLHS also is the IIPS, Mumbai. The survey was focussed on generating quality data on reproductive and child health in India at the district level[4]. Four rounds of the survey have been completed DLHS-1 (1998-1999), DLHS-2 (2002-2004), DLHS-3 (2007-2008) and DLHS-4 (2012-2013).

In DLHS-4, a population-linked facility survey was undertaken for the first time. Under the facility-based survey, the different levels of healthcare comprising the community health centres, district hospitals and sub-divisional hospitals were covered. Furthermore, all sub-health centres and primary health centres were included in this facility assessment under the survey[5].

Annual Health Survey (AHS)

The AHS is implemented by the Office of the Registrar General of India, Ministry of Home Affairs, Government of India, and sponsored by the MoHFW. The AHS is the largest sample survey in the world[6]. Three rounds of AHS have been completed which provide district- and State-level information. The first survey was commenced in 2010-2011 followed by two successive rounds in 2011-2012 and 2012-2013 covering the same households included during the baseline survey[7]. The DLHS and NFHS, on the contrary, had different cross-sectional sample for each round conducted. The nine empowered action group (EAG) States covered by AHS are the ones not incorporated in the DLHS-4[7].

Rapid Survey on Children (RSoC)

The RSoC is a country-wide household-cum facility-based survey focussed on maternal and child health. The survey covered 28 States and the Union Territory of Delhi with the purpose to generate more robust data on children and women. The survey comprehensively evaluates the Integrated Child Development Services programme with regard to its infrastructural facilities, awareness of the beneficiaries about the six services provided and the utilization of the same[8]. The survey was commissioned by the Ministry of Women and Child Development (WCD) with technical and financial assistance from the United Nations Children's Fund (UNICEF), India. Till date, only one round of the survey has been carried out in 2013-2014 and reports for all the States have been released[8].

Comprehensive National Nutrition Survey (CNNS)

The MoHFW along with UNICEF is conducting a comprehensive survey to assess the nutritional status of more than 115,000 children and adolescents (aged 0-19 yr) in all States of India. The main objective of this survey is to report the micronutrient deficiencies, overnutrition and nutritional risk factors for non-communicable diseases among the above-mentioned age group in India[9]. Reports on preliminary findings of only two States, Maharashtra (2012)[10] and Gujarat (2014)[11] have been released.

National Nutrition Monitoring Bureau (NNMB)

NNMB was established by the Indian Council of Medical Research (ICMR) in collaboration with respective state governments in 1972 in 10 States with ICMR-National Institute of Nutrition, Hyderabad, as the coordinating centre. The mandate of the survey was to collect and generate good-quality data on diet and nutritional status of the communities in the urban, rural and tribal areas. Another main objective was to assess the ongoing national nutrition programmes regularly[12]. NNMB has carried out repeat surveys in 1988-1990 and in 1996-1997 in the same villages in all the States that were surveyed during 1975-1979, to assess time trends in diet and nutritional situation. NNMB is the sole organization that gathers information on actual dietary intake of households altogether, along with individual members of the family belonging to different age and physiological groups[12].


   Key characteristics & themes of the surveys Top


[Table 1] provides the key characteristics of selected health and nutrition surveys in India.
Table 1: Key characteristics of selected health and nutrition surveys in India

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The first nutrition-related survey was conducted by NNMB in 1974-1979[13]. This was the baseline survey. Several subsequent rounds have been carried out in one to four year interval in the rural, urban and tribal communities. NNMB being a nutrition focussed survey has not covered the population health-related indicators pertaining to maternal and child health.

In 1992-1993, NFHS-1 was conducted[23]. The three subsequent rounds of NHFS were carried in five to nine years intervals. The period of NFHS-2 survey coincides with DLHS-1, both carried out during 1998-1999 and subsequent rounds of both conducted in propinquity with an interval of four-five years for DLHS. Three rounds of AHS survey were conducted at regular intervals (2010-2011, 2011-2012 and 2012-2013)[27],[28],[29] covering the nine empowered action group (EAG) States. The most recent was the RSoC survey conducted in 2013-2014[8]. The first CNNS was conducted in 2012 in Maharashtra[10].


   States & districts covered Top


The NNMB surveys have been carried out mainly in 10 representative States. The others surveys such as NFHS, DLHS and RSoC have been conducted in more number of States providing national-level data except for AHS that is implemented only in the nine EAG States and complements the DLHS data. CNNS has been carried out in two States till date, i.e. Maharashtra and Gujarat. Interim reports have been released and final reports are awaited. The number of households covered by AHS is much greater than that of DLHS surveys and it provides more robust estimates at the district level.


   Comparison of nutrition & health-related themes & indicators in the recent national nutrition surveys of India Top


The key themes and indicators related to nutrition and health from fact sheets of the most recent national nutrition surveys (i.e. NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5], RSoC 2013-2014[8], AHS 2012-2013[28] and AHS CAB 2014[33]) in India have been summerized in [Table 2].
Table 2: Comparison of key themes and indicators pertaining to nutrition and health listed under the national nutrition surveys

Click here to view


Households using iodized salt

While NFHS-4 (2015-2016)[32] and RSoC 2013-2014[8] listed the indicator households using iodized salt and adequately iodized salt under the heading 'Population and household profile' and 'Household characteristics (%)', respectively, DLHS-4 (2012-2013)[5] provided a separate heading for iodized salt use in households (%). AHS gave this information in its CAB factsheets without any specific heading[33].

Infant & child mortality rates

The indicators infant mortality rate (IMR) and under-five mortality rate (U5MR) have been mentioned under the heading 'Infant and child mortality rates' (per 1000 live births) by NFHS-4 (2015-2016)[32]. DLHS-4 (2012-2013)[5] used the heading mortality for listing IMR, neonatal mortality rate and U5MR. RSoC (2013-2014)[8] and DLHS-4 (2012-2013)[5] did not capture this information.

Maternity care/antenatal care (ANC)

In NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5], RSoC 2013-2014[8] and AHS 2012-2013[28] the headings 'Maternity care (for last birth in the five years before the survey)', 'Antenatal care (ANC, women who had last live/stillbirth during reference period) (%)', 'Women who had live-birth in 35 months before survey by specific maternal health care (%)' and 'ANC', respectively, have been used for listing indicators related to antenatal check-up in the first trimester, number of ANC visits, consumption of ≥100 iron and folic acid (IFA) tablets/syrup during pregnancy and full ANC. RSoC 2013-2014[8] used three sub-headings pre-natal care, natal care and post-natal check-up (PNC) under this main heading. In addition, DLHS-4 (2012-2013)[5] and AHS 2012-2013[28] used the indicator for collecting information on receipt of any antenatal check-up by pregnant women. RSoC 2013-20148 has used two separate indicators for collecting information on “Registered pregnancies and mothers receiving mother and child protection (MCP) at the time of pregnancy registration”, while NFHS-4 (2015-2016)[32] has used only one indicator i.e. registered pregnancies for which MCP card received.

Information related to protection against neonatal tetanus has been asked in different ways in all these surveys. In NFHS-4 (2015-2016)[32] this information was collected under 'Protection of last birth against neonatal tetanus'. DLHS-4 (2012-2013)[5] provided this information under 'Pregnant women who had at least one tetanus toxoid (TT) injection', RSoC 2013-2014[8] under 'Received two or more TT injections' and AHS 2012-2013[28] used 'Mothers who received at least one TT injection'. DLHS-4 (2012-2013)[5] and AHS 2012-2013[28] also included information on blood pressure (BP) measurement and blood test for haemoglobin (Hb). RSoC 2013-2014[8] has included information on institutional delivery and delivery by skilled health provider under the sub-heading natal care.

Delivery care: NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and AHS 2012-2013[28] used the headings 'Delivery care (for births in the five years before the survey)', 'Delivery care (women who had live/still-birth during reference period) (%)' and 'Delivery care', respectively, for collecting information pertaining to institutional births, delivery in public facility and government health institutions and private institutions. In addition, NFHS-4 (2015-2016)[32] and DLHS-4 (2012-2013)[5] mentioned about births attended by skilled health personnel. Only AHS 2012-2013[28] mentioned about the indicator 'Safe delivery'. Information on caesarean deliveries was collected only by NFHS-4 (2015-2016)[32] and AHS 2012-2013[28]. The indicator 'Out-of-pocket expenditure per delivery in public health facility (₹ in 000+)' has been mentioned under this heading by DLHS-4 (2012-2013)[5], whereas NFHS-4 (2015-2016)[32] mentioned this indicator under the heading maternity care.

Post-natal care (PNC): This heading has only been used by AHS 2012-2013[28] unlike other surveys which have included this information mostly in the heading maternity care/ANC. AHS 2012-2013[28] has listed indicators related to mothers receiving PNC within 48 h of delivery, mothers who did not receive any PNC and new-borns who were checked up within 24 h of birth.

Janani Suraksha Yojana (JSY) benefits: DLHS-4 (2012-2013)[5] and AHS 2012-2013[28] have listed indicators related to JSY under a separate heading, whereas NFHS-4 (2015-2016)[32] and RSoC 2013-2014[8] have collected this information under the heading maternity care/ANC. The indicators used in DLHS-4 (2012-2013)[5] intended to collect information on percentage of women who used JSY benefits for home and institutional delivery. AHS 2012-2013[28] provided information related to mothers availing financial assistance for delivery, institutional delivery and government institutional delivery under JSY.

Immunization & supplementation

NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5], RSoC 2013-2014[8] and AHS 2012-2013[28] have all collected this information under headings 'Child immunizations and vitamin A supplementation', 'Child immunization (%) (children aged 12-23 months),' 'Immunization (percentage of children aged 12-23 months)' and 'Immunization, vitamin A and iron supplementation, and birth weight', respectively. RSoC 2013-2014[8] is the only survey which has listed 'Having Mother and Child Protection (MCP) card /immunization card' under this heading. NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and AHS 2012-2013[28] have also included indicators on receipt of BCG vaccine and three doses of polio (AHS has asked about polio dose at birth also). NFHS-4 (2015-2016)[32] has also listed the percentage of children who received three doses of hepatitis B vaccine, and AHS 2012-2013[28] has listed the percentage of children who received no immunization. All three surveys provided information about vitamin A supplementation, but the age groups covered by all three differ. The indicators use the age group 9-59 months (NFHS-4 (2015-2016)[32]), 9-35 months (DLHS-4 (2012-2013)[5]) and 6-35 months (AHS 2012-2013[28]) to find out receipt of vitamin A dose in the last six months. NFHS-4 (2015-2016)[32] has also provided information about children age 12-23 months who received most of the vaccinations in public and private health facility. AHS has included indicators pertaining to children (aged 6-35 months) receiving IFA tablets/syrup during the last three months, children whose birth weight was taken and those who weighed <2.5 kg.


   Childhood diseases/morbidity Top


Diarrhoea

The headings used to collect information on diarrhoea by NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5], RSoC 2013-2014[8] and AHS 2012-2013[28] were 'Treatment of childhood diseases (children under age five years)', 'Treatment of childhood diseases (based on last two surviving children born during the reference period) (%)', 'Morbidity-percentage of children aged 0-59 months (%)' and 'Childhood diseases', respectively. Information related to the prevalence of diarrhoea in the last two weeks and about children with diarrhoea in the last two weeks who received oral rehydration salts (ORS) was collected by all these surveys.

Acute respiratory infection (ARI)

NFHS-4 (2015-2016)[32] and DLHS-4 (2012-2013)[5] have listed indicators which give information about prevalence of symptoms of ARI[32] and prevalence of ARI[5] in the last two weeks preceding the survey and children with fever or symptoms of ARI in the last two weeks preceding the survey taken to a health facility[32] and children with ARI or fever in last two weeks who sought advice/treatment[5]. AHS 2012-2013[28] mentioned about children suffering from ARI and those suffering with ARI who sought treatment.

Nutritional status of children

The height and weight of children of the following age groups have been measured: less than five years (NFHS-4 (2015-2016)[32]), more than or equal to one month (DLHS-4 (2012-2013))[5] and AHS (2012-2013)[28]); 5-59 months (AHS CAB 2014[33]) and 0-4 yr (RSoC 2013-2014[8]). All three cover wasting, stunting and underweight below −2 standard deviation (−2SD) and −3SD, respectively. In addition, AHS CAB[33] provided information on body mass index (BMI) for age: undernourished (below −2SD and −3SD, respectively) and overnourished (above −2SD and −3SD, respectively).

Infant feeding practices

The DLHS-4 (2012-2013)[5] and RSoC 2013-2014[8] provided information on infant feeding practices under 'Child feeding practices (based on last-born child in the reference period) (%)' and 'Infant and young child feeding practices (%)'. As mentioned above, NFHS-4 (2015-2016)[27] used one heading to give details about infant feeding practices and their nutritional status. NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and RSoC 2013-2014[8] used different age groups when asking information about breastfeeding immediately/within an hour of birth: children under three years[5],[32] and children aged 0-23 months[8]. Information on exclusive breastfeeding in children under age six months[32] and children aged 0-5 months[5],[8] has been collected by all three surveys. Details asked about complementary feeding include children age 6-8 months[32] and 6-9 months[5] receiving solid or semi-solid food and breast milk and children aged 6-8 months who were fed complementary foods[8]. NFHS-4 (2015-2016)[32] has also listed breastfed, non-breastfed and total children age 6-23 months receiving an adequate diet. DLHS-4 (2012-2013)[5] has used the indicator children aged 12-23 months receiving breastfeeding along with complementary feeding (includes infant food, tinned powdered or fresh animal milk, fruit juice, tea/coffee or other liquid). RSoC 2013-2014[8] has included information on breastfed children (6-23 months) who are fed a minimum number of times and have a minimum dietary diversity (and included their specifications in the footnotes in the State Report). NFHS-4 (2015-2016)[32] has also listed indicators related to stunting, wasting, severe wasting and underweight in children less than five years.

Micronutrient & deworming

RSoC 2013-2014[8] has used a separate heading to list percentage of children aged 6-59 months who received in six months before the survey: vitamin A dose, IFA supplement and deworming medication.

Birth weight

DLHS-4 (2012-2013)[5] and RSoC 2013-2014[8] have used the headings 'Birth weight (%) (age below 36 months)' and 'Birth weight (percentage of children aged 0-35 months)' to give details about: percentage of children weighed at birth[5] and within 24 h of birth[8] and percentage of children with low birth weight (out of those who weighed below 2.5 kg).

Nutritional status of children above five years & adolescents

RSoC 2013-2014[8] provided information if the BMI of adolescent girls (15-18 yr) was below or above 18.5 kg/m2 (although measurement of height and weight was done for adolescent girls 10-18 yr), whereas AHS CAB[33] gave details for BMI for age for all children aged 5-18 yr (whether BMI below −2SD or −3SD or above +2SD or +3SD).

Nutritional status of adults

NFHS-4 (2015-2016)[32] has covered the age group 15-49 yr, and AHS CAB 2014[33] has covered the age group 18 yr and above. NFHS-4 (2015-2016)[32] provided information about women and men whose BMI was below normal (BMI <18.5 kg/m2) or those who were overweight or obese (BMI ≥25.0 kg/m2). AHS CAB 2014[33] gave information for age groups 18-59 yr and age 60 and above whose BMI was <18.5, ≥25 and ≥30.

Anaemia among children & adults

NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and AHS CAB 2014[33] have used the headings 'Anaemia among children and adults', 'Anaemia status by Hb level (%) (based on CAB tests)' and 'Anaemia status by Hb level' respectively. NFHS-4 (2015-2016)[32] has given information about anaemic children aged 6-59 months (<11.0 g/dl Hb), non-pregnant women aged 15-49 yr (<12.0 g/dl Hb), pregnant women aged 15-49 yr (<11.0 g/dl Hb) and all women and men (<13.0 g/dl) aged 15-49 yr. DLHS-4 (2012-2013)[5] listed children (6-59 months), children aged 6-14 yr (both males and females), children aged 10-19 yr (both males and females), adolescents (15-19 yr), pregnant women (15-49 yr), women aged 15-49 yr and persons (20 yr and above) having anaemia and severe anaemia. AHS CAB 2014[33] has given information about age groups 6-59 months, 5-9, 10-17, 18-59, 60 yr and above having anaemia and severe anaemia.

Blood sugar level in adults

NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and AHS CAB 2014[33] provided information under the headings 'Blood sugar level among adults (age 15-49 yr)', 'Blood sugar level (age 18 yr and above) (%) (based on CAB tests)' and 'Blood sugar level (18 yr and above)'. NFHS-4 (2015-2016)[32] and DLHS-4 (2012-2013)[5] used different age groups: 15-49 yr[32] (NFHS) and 18 yr and above[5] but the same cut-offs (high: >140 mg/dl and very high: >160 mg/dl) for blood sugar. AHS CAB 2014[33] used the cut-off ≥110, ≥130 and ≥150 mg/dl to calculate blood sugar for people 18 yr and above.

Hypertension in adults

The headings used by NFHS-4 (2015-2016)[32], DLHS-4 (2012-2013)[5] and AHS CAB 2014[33] were 'Hypertension among adults (women and men) (age 15-49 yr)', 'Hypertension (%) (based on CAB tests)' and 'Hypertension (18 yr and above)', respectively, with different cut-offs [Table 2].

The Biomarker Schedule in NFHS included measurements such as height, weight and estimation of Hb levels of children; whereas for adults [women (15-49 yr), men (15-54 yr)], measurements included height, weight, BP, estimation of Hb and random blood glucose levels[32].


   Way forward Top


These national surveys are a great reservoir of information and some of these surveys generate information on the same indicators. As a great deal of resources are involved in conducting these surveys, designing and implementing one comprehensive survey that provides information on all the important and relevant indicators and generate large data can be considered with timely provision of the findings so that it can be used to improve the health and nutritional status of the population.

Financial support & sponsorship: None.

Conflicts of Interest: None.



 
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