Surveys in Low- and Middle-Income Countries

Abstract Sexual and reproductive health (SRH) surveys around the world, especially in low- and middle-income countries, have been and continue to be the primary sources of data about individual-, community-, and population-level sexual and reproductive health. Beginning with the Knowledge, Attitudes, and Practices surveys of the late 1950s, SRH surveys have been crucial tools for informing public health programming, healthcare delivery, public policy, and more. Additionally, major demographic and health modeling and estimation efforts rely on SRH survey data, as have thousands of research studies. For more than half a century, surveys have met major SRH information needs, especially in low- and middle-income countries. And even as the world has achieved impressive information technology advances, increasing by orders of magnitude the depth and breadth of data collected and analyzed, the necessity and importance of surveys have not waned. As of 2021, four major internationally comparable SRH survey platforms are operating in low- and middle-income countries—the Demographic and Health Surveys Program (DHS), Multiple-Indicator Cluster Survey (MICS), Population-Based HIV Impact Assessment (PHIA), and Performance Monitoring for Action (PMA). Among these platforms, DHS collects the widest range of data on population, health, and nutrition, followed by MICS. PHIA collects the most HIV-related data. And PMA’s family planning data are collected with the most frequency. These population-based household surveys are rich data sources, collecting data to measure a wide range of SRH indicators—from contraceptive prevalence to HIV prevalence, from cervical cancer screening rates to skilled birth delivery rates, from age at menarche to age at first sex, and more. As with other surveys, SRH surveys are imperfect; selection bias, recall bias, social desirability bias, interviewer bias, and misclassification bias and error can represent major concerns. Furthermore, thorny issues persist across the decades, including perpetual historic, measurement, and methodological concerns. To provide a few examples with regard to history, because the major survey programs have historically been led by donors and multilateral organizations based in the Global North, survey content and implementation have been closely connected with donor priorities, which may not align with local priorities. Regarding measurement, maternal mortality data are highly valued and best collected through complete vital registration systems, but many low- and middle-income countries do not have complete systems and therefore rely on estimates collected through household surveys and censuses. And regarding methods, because most surveys offer only a snapshot in time, with the primary purpose of monitoring key indicators using a representative sample, most analyses of survey data can only show correlation and association rather than causation. Opportunities abound for ongoing innovation to address potential biases and persistent thorny issues. Finally, the SHR field has been and continues to be a global leader for survey development and implementation. If past is prelude, SRH surveys will be invaluable sources of knowledge for decades to come.