On November 5, 2007, the Wilson Center hosted the U.S. launch of India's much-anticipated third National Family Household Survey (NFHS-3). The household survey contains data collected from 200,000 individuals, across population groups throughout India, and provides information about vital health and welfare indicators. Five years after the release of the last survey, NFHS-3 shows important improvements in child survival, use of contraception, and fertility levels; and presents more accurate information on HIV/AIDS rates in India than had previously been available. Notwithstanding these improvements, the data indicates much greater attention must be given to issues of nutrition, child health, and the barriers to quality healthcare that persist for many in the population. Kamla Gupta, Fred Arnold, and Sunita Kishor focused on three significant health challenges identified by the 2005-2006 NFHS: domestic violence, nutrition, and HIV/AIDS.
"Very often when we are talking to audiences in India, the question perpetually comes up: Why address domestic violence in a National Health Survey?" said Sunita Kishor, the senior gender specialist at Macro International and a co-manager of technical assistance for NFHS-3. This was the first time questions concerning domestic violence were included in the NFHS, indicating the interest in increased policy action to address this continuing threat to women's health. Kishor explained that understanding the prevalence and characteristics of domestic violence is important, not only because it is a human rights issue, but also due to the associated public health concerns and significant economic costs. "[Domestic violence] has significant, documented public health consequences," she continued, which include increased rates of unplanned pregnancies; HIV/AIDS and other STIs; infant and child mortality; and decreased rates of immunization and healthcare access for children. Economic impacts include underutilization of women in the workforce and increased health-care expenditures.
The results of NFHS-3 indicate that physical spousal abuse is the most common form of violence against women, said Kishor, with 40 percent of respondents acknowledging having ever been physically abused by a spouse. Only 1 percent of women admitted having initiated violence against their husband. Of particular importance is that the majority of spousal abuse begins in the first 5 years of marriage. Kishor emphasized that this finding countered a predominant conception in India that domestic violence is circumstantial and based on the victim's faults, rather than a crime committed by the perpetrator. "This is not something that happens later on. If violence occurs it tends to begin early in the marriage. And this is a result we find in other countries as well," she said. In fact, said Kishor, the NFHS data indicates there are certain indicators that strongly correlate to the likelihood of abuse. Education level is highly correlated to spousal abuse and has important policy implications, particularly for improving female education, she explained. Additionally, a man's alcohol consumption and a woman's family history of abuse were highly correlated to spousal abuse. "The two most important factors with the strongest correlation are husband's alcohol consumption, and whether the respondent's father beat her mother," said Kishor. However, for husbands who never drink the rate of spousal abuse is still 30%. "This is extremely revealing because it does suggest that those who blame alcohol consumption alone for spousal violence are only partially correct," she emphasized.
Unlike the spousal abuse and education level correlation, help-seeking behavior varies little by background characteristics, including education and wealth, said Kishor. Only 1 in 4 women surveyed have sought help from abuse and it was usually from a family member rather than a government institution; only 2 percent of respondents sought help from the police, even though the local police are charged with the duty of maintaining services specifically for women.
Kishor stressed the need to enact policies that work against domestic violence, such as improving female education and enabling help seeking behavior. "Most women suffer violence in silence. If we knew that more than a third of women had a debilitating disease that is wearing them down mentally and physically would we continue to ignore it?" Kishor asked. "The results of the NFHS point to the importance of the intergenerational effect of violence. Even if they do not care what happens to women today, we should at least care [about] what happens to the children tomorrow," she concluded.
Nutrition in India
Undernutrition and micronutrient deficiency anemia remain as major burdens of disease across the population. Nutritional status of Indian children and adults has been slow to improve and the issue is now receiving much more attention from the highest levels, said Fred Arnold, vice president at Macro International. "Children in India suffer from some of the highest levels of stunting, wasting, and underweight in the world, and the situation has not improved markedly in recent years," he reported. "The Indian economy is booming but the children are getting left behind, at least in terms of nutrition," he said. It is important to do away with the unfounded conclusion that Indian children are "naturally small," said Arnold, as Indian children will grow at the same rate as children elsewhere in the world if they receive adequate nutrition to achieve their full genetic potential.
Undernutrition among children under 5 years of age remains widespread in India and NFHS-3 shows only minimal improvement since NFHS-2. Rates of wasting in children less than 3 years of age have increased from 20 percent to 23 percent, most likely due to children growing taller without putting on sufficient weight, he argued. Undernutrition is higher in rural areas and among children in larger families with shorter birth intervals. Arnold also strengthened Kishor's arguement for improving education rates among girls and young women by highlighting the fact that underweight decreases sharply with improvements in mother's education level and household wealth.
Micronutrient deficiencies are also a significant issue for children in India, particularly micronutrient-related anemia. Anemia can result in cognitive disabilities and reduction in fine motor skills, explained Arnold. For children 6-35 months, rates of anemia have increased from 74 percent in NFHS-2 to 79 percent in NFHS-3. While disaggregated rates do vary dramatically by region, wealth, and education, they never drop below 55 percent for any given socioeconomic indicator. The lack of improvement and persistently high rates of anemia are startling and require immediate action.
Not only does India continue to face significant issues in childhood malnutrition, but 50 percent of the adult population is malnourished as well, said Arnold. This has not improved over the years, because "the gains that have been made in underweight over the last seven years have been exactly off set by increases in overweight." Importantly, obesity is not a disease of only the wealthy, as 1/3 of women in the slums of Chennai and Hyderbad are overweight or obese. India is suffering from a debilitating double burden of disease as they proceed through the nutrition transition, said Arnold. "Many health officials now seem energized to take on the challenge and to develop innovative programs to get results, but their chances of success remain to be seen. We hope the NFHS-4 and other data collection efforts in the coming years will be able to document the fruits of their efforts."
HIV/AIDS in India
One of the most notable results of the NFHS-3 is the revision of the HIV prevalence rate. The survey provided more in-depth information on HIV/AIDS prevalence in India, leading to a dramatic reduction in official prevalence estimates. "Based on the NFHS-3 estimate of HIV prevalence and other data, the Government of India revised its official HIV estimate from .92 percent to .36 percent," said Kamla Gupta, professor and head of the Department of Migration and Urban Studies at the International Institute for Population Sciences in Mumbai, India, and the chief coordinator of the NFHS-3. This estimate is slightly higher than the NFHS-3 estimate of .28 percent in the 15-49 age group, explained Gupta, however, the government estimate took into account additional information collected on other population groups, which would not have been captured in the NFHS sample, including the homeless. While this is excellent news, Gupta emphasized the need to focus now more than ever on stopping the spread of HIV in India before it can take hold. "Strong programs are still required to prevent the further spread of HIV".
NFHS-3 collected over 100,000 blood samples in order to establish the HIV prevalence rate. The samples were collected from women ages 15-49 and men ages 15-54. While test results were anonymous, married couples in which both people were tested were identified. The data on these couples provides a unique opportunity to study HIV discordance and could contribute to designing more effective HIV/AIDS interventions, continued Gupta.
Clear HIV trends have emerged through the prevalence indicators, providing concrete evidence upon which to build successful programs, she noted. Men are predominantly affected, with HIV prevalence rates 61 percent higher among males. HIV transmission is also still concentrated in urban areas, where prevalence is 40 percent higher than in rural areas. Gupta did note, however, that the scope of the NFHS-3 is not broad enough to capture all groups affected by HIV, some of which may be most at risk of contracting the disease, including populations involved in sex work, injection drug users, and men who have sex with men.
While awareness of HIV/AIDS has increased significantly in India, the depth of knowledge, particularly concerning preventive measures and condom use, varies significantly across the nation and by population groups, said Gupta. Overall, 70 percent of men but only 36 percent of women are aware that condoms can stop the transmission of HIV. Urban residents are more likely than rural residents to have comprehensive knowledge of HIV/AIDS, and there remains a significant gap in the prevalence of education concerning sexually transmitted diseases. Importantly, there is strong support among respondents to the NFHS-3 for increased education in schools concerning HIV/AIDS, for both boys and girls, said Gupta.
Data contained in NFHS-3 will help policy-makers in crafting both national and regional evidence-based policies. Kishor, Arnold, and Gupta stressed the importance of improving access to education, particularly in rural areas as policies that increase education, particularly for women, have the potential to positively impact a variety of health indicators, including nutrition, domestic violence, and the spread of HIV/AIDS. The NFHS remains a vital tool for policy makers to monitor the impact of current programs and adapt to the rapidly changing population and health indicators in India.
Kamla Gupta is a professor and head of the Department of Migration and Urban Studies at the International Institute for Population Sciences in Mumbai, India. She is also the chief coordinator of the NFHS-3 survey, as well as the principal investigator of a project on alcohol use, sexual behaviour and HIV risk in Mumbai. Her research has focused on a variety of topics including migration, urbanization, gender and health.
Fred Arnold is a vice president at Macro International. Previously, he was deputy director of the East-West Population Institute, Honolulu, and research director of the Select Committee on Population, U.S. House of Representatives. His primary fields of interest are survey research, gender preference for children, and nutrition. He has provided technical assistance to demographic and health surveys in India and 12 other countries.
Sunita Kishor is the senior gender specialist at Macro International and a co-manager of technical assistance for NFHS-3. She has 15 years of experience in conducting research on the interface between gender and health in developing countries. She has been instrumental in developing, refining and promoting gender indicators, including indicators of gender-based violence that are widely used in survey research. Previously, she lectured in Economics at Delhi University.
Drafted by Michaela Hoffman.