It's been six months since the launch of field work on the 2018 National Nutrition Survey (NNS),
Pakistan's largest-ever survey into the health and nutrition status of its women and children. To date, research teams have gathered data at the doorsteps of over 28,000 homes across the country but they are facing an unusual challenge in the country's most populous city, Karachi.
An increasing number of homes in the city are turning away NNS teams with the refusal rate in some areas standing at more than double the figure in the previous survey in 2011.
Zainab Danish, a Karachi-based research supervisor on the NNS, is aware of the innate challenges of conducting door-to-door research in the busy metropolis. "Insecurity is one of the big issues," says Ms Danish. "Despite carrying cards [to identify ourselves], people fear that we are burglars at their door."
She and her field team sense that a different approach is needed in areas where there is suspicion of strangers. Until now, data collectors have been visiting homes at 9am – a time when male relatives are at work. This typically makes the family wary of outsiders and often results in them turning away research teams. Another challenge with morning visits is that female members of the home are often occupied with household tasks.
These on the ground insights mean that field visits have rescheduled visits to evenings when the men of the house are more likely to be at home. Their presence is significant as female members of the household feel safe in their relatives' presence making them more willing to partake in the research.
Back-up teams of data collectors have also been arranged to make a repeat visit in case a family is busy during the initial call. This make it easier for families to participate and reduces distrust as they recognise field staff on the second visit.
"Our field teams have been trained to reassure the public and to be mindful of each area's social dynamics," says Dr Sajid Soofi, an associate professor in paediatrics at AKU. "We make sure that all participants are aware of the importance of the contribution to the survey and are told that they can choose to withdraw at any time. Sharing this knowledge empowers communities and helps us build trust with them."
Aga Khan University is conducting the NNS on behalf of Pakistan's Ministry of National Health Services, Regulations and Coordination and UNICEF via the funding support of the UK's Department for International Development.
Dr Soofi notes that the government has played a crucial role in helping researchers gain access to neighbourhoods across the country. Other partners such as the Pakistan Bureau of Statistics and the Pakistan Council of Research in Water Resources have also provided valuable support by sharing access to detailed maps and data testing facilities, he adds.
Data collection under the NNS is expected to be completed by January 2019 and AKU's Professor Zulfiqar A. Bhutta is eager to assess whether the country is making progress in tackling the deep-rooted and widespread problem of malnutrition.
"We cannot find any reduction in levels of anaemia in our women for the last 50 years," said Professor Bhutta, founding director of AKU's Centre of Excellence in Women and Child Health. "We cannot understand why there is no reduction in this health issue despite so many health programmes.
"We have also had vitamin fortification programmes for the last 20 to 25 years. We want to check if these are effective or not. If Vitamin A and D is being added to oil and cooking fat, what is the reason behind such high deficiency levels among our people?"
The NNS will also see researchers analyse the country's progress in nutrition since 2011, the year of the previous survey, which found that more than half of all households in Pakistan suffer from food insecurity in other words are hungry or face the threat of hunger.
The NNS, which will survey 115,600 households, is unique in its breadth and depth as for the first time teams will collect data at the district rather than provincial level, providing targeted insights about the areas that face the greatest challenges.
Field teams will also collect information on household income, gender empowerment, education levels, and breastfeeding practices which are known to have an impact on nutrition indicators.