The Demographic and Health Surveys (DHS) are a vital source of nutrition data for governments and development partners. In an online survey conducted by DataDENT in 2018, nutrition professionals were asked how they access and use nutrition data. Among the 191 survey respondents working at global and country levels, 74% reported accessing DHS data in the last year. It was by far the most commonly used data source across all respondents.
About every five years, the DHS Program reviews and updates the core questionnaires that are used across more than 90 countries. Planning for the new DHS Round 9 questionnaires (DHS-9) is well underway. On January 13th the DHS Program began accepting recommendations for questionnaire modifications through the DHS-9 Revision Portal. According to DHS guidance, recommendations must follow a structured format and include detailed justifications, including clear evidence of demand from national stakeholders.
Back in 2018, the global nutrition community submitted and advocated for a set of 11 recommendations for the DHS Round 8 that resulted in more than 30 new nutrition questions in the current DHS-8 woman’s questionnaire. This round, a coalition of nutrition partners is recommending questions be added or modified in the DHS-9 around four topic areas.
What changes are we recommending to the DHS-9?
1. Household Staple Food Fortification Coverage
According to the Global Fortification Data Exchange there are currently mandatory or voluntary staple food fortification programs in 147 countries for salt, 105 countries for wheat flour, 43 countries for edible oil; many countries have programs for other staple foods such as maize flour, rice, and sugar. However, information on the household-level coverage of large-scale staple food fortification programs is limited and where available, indicator definitions and measurement methods can be inconsistent. Key indicators needed by countries to design and monitor food fortification programs include household coverage of target food vehicles that are – 1) in any form, 2) in a fortifiable form (i.e. industrially processed, not home-produced), and 3) confirmed to be fortified. The DHS-8 household questionnaire includes one indicator and question about coverage of salt fortified with iodine (Q.145).
In 2018, the nutrition community submitted a recommendation for the DHS-8 to add six additional household fortification coverage indicators to the household questionnaire. The recommended indicators measured household-level coverage of three staple foods (i.e., edible oil, wheat flour, and salt) in – 1) any form and 2) a fortifiable form. We also recommended that countries modify these questions for other staple foods in their national policies as needed. Unfortunately, this recommendation was not accepted for DHS-8 (except for a modification of the pre-existing question for salt iodization).
For DHS-9, we are expanding the 2018 recommendation to include the third category of household staple food fortification coverage indicators, i.e., coverage of fortified edible oil and fortified wheat flour, in addition to the existing coverage of fortified salt indicator (Q.145). Large, multicounty periodic survey programs, such as the DHS, are the only way to obtain comparable representative information on the potential reach and actual performance of food fortification programs at national and global levels. Expanding the indicators in the DHS core household questionnaire will provide actionable data to monitor, evaluate and improve existing fortification programs and to design new or expanded programs.
2. Iron-containing supplements during Pregnancy (MMS/IFA)
DHS-8 includes questions about iron-containing supplements during pregnancy; however, they do not meet the needs of nutrition data users. Changes to WHO guidance on micronutrient supplementation during pregnancy in 2020 have led more than 30 countries to pursue the introduction of the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) Maternal Micronutrient Supplementation (MMS) in place of iron folic acid (IFA) during antenatal care. UNIMMAP MMS is an internationally accepted and standardized formulation that contains 15 essential vitamins and minerals, including iron and folic acid in recommended doses.
Countries introducing MMS need to monitor the percentage of pregnant women who received UNIMMAP MMS compared to those who received IFA/iron. However, the current DHS-8 asks about and reports on any iron-containing supplement; it does not distinguish between IFA and MMS. Another problem is that validation studies have shown that women cannot respond accurately to Q428 in the DHS-8 woman’s questionnaire about how many days she consumed iron-containing supplements across her most recent pregnancy in the last 2-3 years.
Our recommendations around MMS/IFA for DHS-9 include three changes to the current questionnaires: 1) modify the current woman’s questionnaire Q.426 to ask separately about iron, MMS and, when applicable, iron-containing multiple micronutrient powders (MNP) using context-specific images of the products as visual aids, 2) replace the current Q. 428 with up to 3 questions also related to adherence across pregnancy, and 3) consider also posing questions about iron-containing supplement receipt and adherence in the last month to currently pregnant women. To replace Q. 428 we are recommending a question about how many months total the women received iron-containing supplements during her most recent pregnancy, as formative research across multiple contexts suggests this is feasible. We are also recommending two new questions about the timing of the start of iron-containing supplement and usual adherence during her most recent pregnancy; although we consider these lower priority given space limitations in DHS. There is precedent for posing questions to currently pregnant women in the DHS-8 section on family planning. With the DHS limitations, it is unlikely that they will adopt our recommendation to measure coverage in currently pregnant women, but we encourage countries to consider using the approach in other national surveys.
3. Biomarkers & Anemia
Alongside the Sustainable Development Goal (SDG) to reduce anemia among women 15-49 years (SDG 2.2 target) and growing investment in micronutrient interventions like MMS and Household Staple Food Fortification Coverage, there have been persistent calls for more national and subnational data on anemia and micronutrient status of key populations including women of reproductive age and young children. Recent estimates suggest that 372 million children 6-59 months and 1.2 billion non-pregnant women 15-49 years have one or more micronutrient deficiencies. Across two recommendations, we have prioritized collection of biomarkers that are of public health importance and feasible to collect in the DHS context. The DHS includes a rich set of household- and individual-level data that can be used to model context-specific factors associated with anemia and micronutrient deficiencies.
Our first recommendation for DHS-9 reflects new WHO guidance to only measure hemoglobin concentration in venous blood samples when measuring anemia prevalence in a population-based survey. Historically, the DHS core questionnaire includes hemoglobin assessment using predominantly capillary blood samples rather than venous. Hemoglobin assessment in venous blood can be measured at the household with a portable hemoglobinometer; in malaria endemic environments, malaria rapid testing can be measured to identify recent malaria infection. The collection of venous blood is an opportunity to assess several other recommended biomarkers related to anemia if a cold chain can be established, in particular, serum ferritin to determine iron deficiency and C-reactive protein (CRP) and α1-acid glycoprotein (AGP) to determine inflammation status and adjust serum ferritin concentration for inflammation.
Our second biomarker-related recommendation is to include median urinary iodine concentration in pregnant and non-pregnant women in the DHS-9 core questionnaire. Adequate maternal iodine status is important for fetal and early child development; deficiency can lead to cretinism, loss of learning ability, stillbirth and miscarriage. Iodine deficiency disorders cannot be eliminated and so it is essential for countries to continuously monitor whether the population has adequate and safe iodine concentrations as well as the reach and impact of national salt iodization programs. Collection of data on population-level urinary iodine concentration and household-level salt iodine coverage is recommended every 5 years. Spot urine specimen collection is easy. No cold chain is required for transport and storage, and analysis using spectrophotometric detection is feasible across survey contexts. Adding urinary iodine in women to DHS-9 will complement testing of salt which is already in the DHS household questionnaire and provide countries with data on the sustained impact of their longstanding programs.
4. Household Food Insecurity Experience Scale (FIES)
Prevalence of moderate or severe food insecurity in the population is an SDG indicator (2.1.2); it specifies the Food Insecurity Experience Scale (FIES), a series of 8 questions, as the measurement method. In 2018, the nutrition community successfully advocated for the FIES to be added as an optional module in DHS-8. However, uptake of any optional DHS modules in country-specific surveys is limited; and relatively few countries collected this important data in the last DHS cycle. Therefore, for DHS-9 we recommend moving the FIES questions from the optional module to the core household questionnaire. In addition to facilitating SDG reporting, inclusion of the FIES in the core household questionnaire will allow stratification of other key nutrition indicators by household food insecurity status and produce comparable data across time and context.
How can you contribute to improving the nutrition content of the DHS-9?
The DHS-9 Revision Portal will remain open until March 3rd 2025. During that period we encourage institutions and individuals interested in improving the availability of nutrition data to do the following:
Comment on nutrition recommendations posted. We will submit the final recommendations for the four topic areas above by early February. We encourage you to log in and comment on the recommendations, ideally expressing your support for them! Follow the Data for Nutrition Community of Practice (CoP) on LinkedIn or X for updates about when the recommendations have been posted.
Submit a new recommendation. Is there something else you and your colleagues want to add or change in the DHS core questionnaires or reports? You can submit your own recommendations by following this guidance.