Nutrition and mortality SMART survey,
IYCF survey and household
dietary diversity score
Khargone
district,
Jhirniya
block
Madhya Pradesh, India
Dates of the survey :7th –
12th of September 2013
THANKS
Welhungerhilfe and Jansahas would like to thank
Madhya Pradesh health and nutrition authorities, and the head of villages
surveyed.
Welthungerhilfe and Jansahas would also like to
thank all the surveyors for their work, their enthusiasm, the quality of their
work and their flexibility, and also the drivers without whom this work could
not have been done.
Welthungerhilfe and Jansahas would like to thank
all the mothers, all the heads of household and all the children who have
participated to this survey.
Rakesh Shrivastava (MSW,MPH), Project Coordinator from Welthungerhilfe and Harshal Jariwala(MSW-TISS,PGDHRM-MSU), Project Coordinator from Jansahas Social Development Society have significantly contributed in conducting this research study and its presentation of findings in form of reports, posters, summaries, brief notes at further various platforms.
Mr. Vijay Rai, Program Manager, Welthungerhilfe and Ms. Heena Panday, Nutritionist, Welthungerhilfe had major support to conduct this research.
CONTENTS
ABBREVIATIONS
USED
LIST OF
THE TABLES
LIST OF
THE FIGURES
INTRODUCTION / CONTEXT
1.
OBJECTIVES
1.1 Main objectives
1.2 Specific objectives
2.
METHODOLOGY
2.1 Survey
2.2 Target population
2.3 Sampling
2.4 Children selection for the
anthropometry questionnaire
2.5 Data collected
2.5.1.
Mortality questionnaire
2.5.2.
Anthropometry questionnaire
2.5.3. IYCF questionnaire, children aged 0
to 23 months
2.5.4. Household dietary
diversity questionnaire
2.6 Indicators and cut off used
2.6.1 Weight for Height indicator
2.6.2 Mid Upper Arm
Circumference (MUAC)
2.6.3
Height for Age indicator
2.6.4
Weight for Age
2.6.5
Mortality rate
2.6.6 IYCF indicators
2.6.7Household Dietary Diversity Score
(HDDS)
2.7 Action taken in
case of a malnourished child (included or not in the selected household)
2.8 Training, Supervision and survey
2.8.1 Training
2.8.2 Supervision
2.8.3 Survey
2.9 Ethic
2.10 Data analysis
3
ANTHROPOMETRIC RESULTS
3.1 Sample characteristics
3.2 Prevalence of acute malnutrition
3.3 MUAC distribution
3.5 Prevalence of stunting
3.5 Prevalence of underweight
3.6 Retrospective mortality
4
IYCF RESULTS
5
HOUSEHOLD DIETARY DIVERSITY RESULTS
6
DISCUSSION
7
CONCLUSION & RECOMMENDATIONS
ANNEXES
ABBREVIATIONS USED
CTC: Community based Therapeutic Care
ENA:
Emergency Nutrition Assessment
FANTA: Food and Nutrition Technical Assistance Project
GAM:
Global Acute Malnutrition
HDDS:
Household Dietary Diversity Score
IDDS:
Individual Dietary Diversity Score
IYCF:
Infant and Young Child Feeding
MAM:
Moderate Acute Malnutrition
MUAC: Mid
Upper Arm Circumference
NFHS:
National Family Health Survey
NIN: National
Institute of Nutrition
NRC:
Nutrition Rehabilitation Centre
PPS:
Probability Proportional to Size
SAM:
Severe Acute Malnutrition
SMART:
Standardized Monitoring and Assessment of Relief and Transitions
UNICEF:
United Nation Childrens’ Fund
WHO:
World Health Organization
WWH: Welt
Hunger Hilfe
LIST OF THE TABLES
Table 1: Description of the method used to form the sample of the SMART
nutrition survey
Table 2: Weight for Height (W/H) values defining
global acute malnutrition (GAM), moderate acute malnutrition (MAM) and severe
acute malnutrition (SAM), with WHO 2006 standards
Table 3: Cut off values for MUAC measurement defining
moderate acute malnutrition and severe acute malnutrition with WHO 2006
standards
Table 4: Cut off values for Height for Age (H/A)
indicator, defining global chronic malnutrition, moderate chronic malnutrition
and severe chronic malnutrition, with WHO 2006 standards
Table 5: Cut off values for Weight for Age (W/A)
indicator, defining global, moderate and severe underweight, with WHO 2006
standards
Table 6: admission criteria for children in Madhya Pradesh
Table 7: Sampling characteristics
Table 8: Distribution of age and sex of sample
Table 9: Mean z-scores, Design Effects and excluded subjects
Table 10: Malnutrition rates, children aged
6-59 months and children aged 6-29 months, Weight for Height z-score, WHO 2006
reference population
Table 11: Prevalence of acute malnutrition by age, based on weight-for-height
z-scores and/or oedemas
Table 12: Prevalence of acute malnutrition based on MUAC cut off's (and/or
oedema) and by sex
Table 13: Prevalence of acute malnutrition by age, based on MUAC cut off's
and/or oedemas
Table 14: Prevalence of stunting based on height-for-age z-scores and by sex
Table 15: Prevalence of underweight based on weight-for-age z-scores by sex
LIST OF THE FIGURES
Figure 1: Population age and sex pyramid
Figure 2: Distribution of
Weight for Height (W/H) indicator, WHO 2006 standards
Figure 3: Food groups eaten by surveyed households
in the last 24 hours
Figure 4: Household Dietary Diversity Score (HDDS) in household surveyed
INTRODUCTION / CONTEXT
Madhya Pradesh is the state with the
highest level of child malnutrition rate in India.
The results of the National Family
Health Survey NFHS-3 (2005-06) for Madhya Pradesh show that, among children
under 5 years old, 50% of them were suffering from chronic malnutrition
(stunting). Chronic malnutrition leads to growth, physical and
intellectual development retardation for children, with a strong impact on the
human capital. Moreover, 35% of the children were suffering
from acute malnutrition (stunting). Acute severe malnutrition has immediate
consequences on the child survival.
Madhya Pradesh is also the only
state in India that falls into the “extremely alarming” category of the India
State Hunger Index developed by Welthungerhilfe and IFPRI. The last few years
have seen an increased focus on malnutrition in Madhya Pradesh by both
government and non-governmental organizations.
Responding to the alarming situation
of malnutrition in Madhya Pradesh, Welthungerhilfe
in partnership with Jansahas have started the implementation of a pilot project
to address the issue of malnutrition in the Pawai and Jhirniya blocks of Panna
and Kargone districts.
The SMART nutrition and mortality
survey has been carried out at the beginning of this project, in order to have baseline
data.
The objectives were to evaluate:
-
the prevalence of acute and chronic
malnutrition among children 6-59 months,
-
the crude death rate and the 0-5
years death rate ;
-
Infant and Young Child Feeding
(IYCF) practices for children aged 0-23 months;
-
Household Dietary Diversity Intake
(HDDI) at household level.
The SMART survey has taken place at
the end of the rainy season, considered as the hunger peak season.
Data collection for Jhirniya block
took place from the 7th of September until the 12th of September.
The total population for the
surveyed area (Jhirniya block) was estimated 151824 (census data, 2011).
1.1 Mainobjective
To evaluate the nutritional status
of children 6-59 months and the death rates, in Jhirniya block (Khargone
district), in order to have a better understanding of the nutrition
problematic.
1.2 Specific objectives
In Jhirniya block :
1.
Determine the prevalence of Global
Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) for children aged
6 months to 59 months (WHO[1]
2006) ;
- Bring out, or not, vulnerable groups regarding
malnutrition (age, gender) ;
- Estimate the prevalence for chronic acute malnutrition
for children 6-59 months and 0-5 months ;
- Estimate the crude death rate and the 0-5 years
children’s death rate, for the retrospective period from the 15th of June
2013 until the 9th of September (87 days) ;
- Evaluate the IYCF practices among children 0-23
months ;
- Evaluate the Household Dietary Diversity Score.
1.
[1]World Health Organization
1.
METHODOLOGY
Added to mortality
and anthropometry questionnaires, two other questionnaires have been used
during this survey:
a)
IYCF questionnaire : to evaluate breastfeeding practices and
complementary feeding for children aged 0-23 months ;
b)
Household Dietary Diversity questionnaire: to evaluate the household’s
access to food diversity (24h recall period).
2.1. Survey
Because of thesparse populationand lackofhousehold
lists, cluster samplingwas conducted. It is a transversal nutrition cluster survey
(2 degrees), with a data collection done with anthropometric measurements and
questionnaires.
2.2. Target population
For the anthropometry, target population was
children aged 6-59 months because there are the most vulnerable population
regarding malnutrition.
For the mortality, target population was the
entire household.
For the IYCF, target population was the children
aged 0-23 months.
For Household Dietary Diversity Intake, target population
was the entire household.
2.3. Sampling
Population data from the 2011 census
have been used. Data were available at village level.
Sample size calculation has been
done with ENA software, with the hypothesis presented in table 1.
The survey has been conducted using
the SMART[1]
methodology, a quick, standardized and simplified survey method with daily data
entry, to improve the quality.
A total of 38 clusters, with 17
household each (including a non-responding rate of 7%) has been included in the
sample. This population’s sample is enough to represent statistically the whole
population in the area surveyed. Cluster selection has been done with the ENA[2]
for SMART software, to ensure that each household had the same chance to be
selected in all the different village of the area surveyed.
Some
villages had several hamlets (falyas)
sometimes quite far one from another. When these villages have been randomly
selected, selection of the hamlet to survey has been done using the PPS method
(Probability Proportional to Size).
When a big village had to be segmented, segmentation
and random selection has been done using the PPS method.
Knowing
that eight teams would be on the field, it has been calculated than 38/8=5 days
of data collection will be necessary to survey all the villages.
Table 1: Description of the method used to form
the sample of the SMART nutrition survey (SMART Nutrition and mortality
survey, Jhirniya block, WHH & Jansahas, September 2013)
Nutrition
survey
|
Parameters
|
Calculation
|
Justification
|
Total population
|
151824
|
Census 2011
|
|
Population children <5
|
22014
|
Considering 14,5% of total population (2011 census,
Madhya Pradesh)
|
|
GAM prevalence estimated
|
30,8%
|
National Institute of
Nutrition (NIN) 2011
|
|
Precision desired
|
5,0
|
Precision desired according to the prevalence rate
|
|
Design effect
|
1,5
|
NFHS
|
|
Average HH size
|
6,9
|
NIN 2011
|
|
Number of children less than 5 years per HH
|
1,0
|
6,9x0,145
|
|
Non response rate %
|
7
|
NFHS 2005-06
|
|
Sample size – number of children
|
535
|
Calculation done by ENA for SMART
|
|
Sample size – number of HH
|
639
|
Calculation done by ENA for SMART with the data
entered
|
|
Number of households per cluster
|
17
|
Estimation of the number of HH that could be
surveyed per day regarding the context
|
|
Number of clusters to include
|
38
|
639 (total number of HH for the survey) / 17 = 38
clusters
|
Household selection
The second sampling’s degree was the
selection of the households inside the clusters.
This selection has been done using
the systematic random sampling with calculation of the sampling interval (most
of the villages) or using the simple random sampling (if small village/hamlet where
a Households’ list was available).
Definition for the household was
“all the persons who are eating from the pot and who have one household’s
chief”.
If several women were eating from
the same pot, all these women were considered as members of the household and
their children were included in the sample.
If households where parents and married children were living, each
married child with his wife and or children was considered as one household. If
one or both parents were depending on the married child he was part of the
household.
If one household or one child was
absent, he was not replaced by another household or child.
Segmentation :
If the cluster selected was with a spread population (falyas) or was a big village (important
number of households):
1. Population was
divided in segments with 100 households maximum.
2. One of these segments
was randomly selected using the PPS method and the village was reduced to an
area with no more than 100 household,easier to survey.
3. The 17 households
were then selected by the systematic random sampling or with the simple random
sampling in case a list of the households was available.
2.4 Children selection for the
anthropometry questionnaire
In the household, all the children from 0 to 59 months were surveyed for
the anthropometry. Analysis has been done for children 6-59 months; Stunting
has also been studied for children 0-5 months.
Each absent child who was filling the inclusion criteria was written on
the anthropometry questionnaire.
The team came back to the household at the end of the day to take the
measurements. If the child was still absent, this was notified and the child
was not replaced.
If households members were absent, surveyors had to come back to the
household at the end of the day. If the household was still absent, this was
notified on the household selection sheet and this household was not replaced
by another one.
If one child was hospitalized (hospital or NRC), he had to be measured at
the end of day by the team, and if not possible, the team had to contact the
centre to have the anthropometric data.
Disabled children were included in the survey, and disability was
written on the questionnaire. All the measurements which could be taken were
taken and written on the questionnaire. If the disability made not possible the
measurements, these data were considered as missing. For children with a
disability on the left arm, MUAC measurement was not taken and a note was
written on the anthropometrc questionnaire.
2.5.1. Mortality questionnaire(see annex)
Retrospective
mortality survey has been done on a 3 months recall period before the day of
the survey. The beginning of the recall period was the beginning of the
moonsoon (15th of june) and the end of the recall period was the middle of the
survey, the 9th of september, which was corresponding to a 87 days recall
period.
Questionnaire used was the simplified questionnaire at cluster level (one
line per household). It has been administrated in every
surveyed household, to the head of household, his representant or to the mother
of the children.
Following information was collected :
·
Total number of household’s members, present on the day of the survey
(total and children less than 5 years).
·
Number of people who came during the recall period (total and children
less than 5 years).
·
Number of people who left the household during the recall period (total
and children less than 5 years.
·
Number of births during the recall period.
·
Number of deaths during the recall period (total and children less than
5 years who have lived more than 24h in the household).
2.5.2. Anthropometry questionnaire (see annex)
It has been done
for all the children in the household from 0 to 59 months.
Sex:
It was coded « M » for male and « F » for female.
Age was written in
months, except if the exact birthdate was available on official documents (ID
card, birth certificate,…). When birthdate was not confirmed by official
document, local event calendar was used (see annex) to estimate the age (in
months). This calendar was made with seasonal events, as beginning or end of
the moonsoon, harvesting periods, religious events, national or local events.
All the children from
0 to 59 months were included, that is to say children who were born between
september 2008 and september 2009.
Age criteria was preferred to height criteria, as recommended by SMART
metodology.
Weight:
Weight measurement was done with Salter scales with a 100 g precision.
Children were weighted totally naked. Each day, before leaving for the field,
teams were checking the scale with a 2 kg standard weight.
Height:
Height was measured with a locally made measuring board, in centimeters,
at the nearest millimeter.
Children less than 87 cm were measured lying down and children more than
87 cm were measured standing up.
A wood stick of 110cm and marked at 87cm was used to see whether the
child had to be measured lying down or standing up.
Diagnosis
of oedemas:
Only bilateral oedemas were considered as nutritional oedemas.
A three seconds pressure was done on both feet with the thumbs. Oedemas
were present if there were thumb’s prints on both feet. They were coded Y for
yes, and N for no.
Mid Upper
Arm Circumference (MUAC) :
MUAC was measured on the left arm with the MUAC tape, in the middle of
the arm, according to the methodology. MUAC was measured in millimeters and at
the nearest millimeter.
2.5.3 IYCF
questionnaire, children aged 0 to 23 months (see annex)
IYCF questionnaire has been done only when there was a
child 0-23 months in the selected household. In every
household surveyed for anthropometry, one child 0-23 month was randomly
selected among all the children 0-23 months present in the household and IYCF
questionnaire was done for this child. If no child 0-23 month was present in
the household, no IYCF was done.
IYCF questionnaire was based on the WHO recommandations for the
breasfeeding part.
Data collected gave us information on :
-
Breastfeeding(introduction of breastfeeding, early initiation to breastfeeding, exclusive
breastfeeding, breastfeeding practices, breastfeeding duration…)
-
Introduction of other food after birth (if yes, which one)
-
Weaning (reasons, way of weaning the child)
-
Consumption of liquid in the last 24h
-
Individual dietary diversity in the last 24h (IDDS, for children
consuming complementary food)
IDDS questions were based on the FANTA[3]
method.
Only pertinent questions were asked to the person in charge of the
child : if the child has been breasfed, no question was ask about
breasfeeding practices.
2.5.4. Household dietary diversity questionnaire(see annex)
Household Dietary Diversity
questionnaire has been done in one household upon two (9 first households). If
one household selected was absent, the next one was surveyed, in order to have
9 questionnaires per cluster.
Dietary diversity gives qualitative
information on food consumption.
Questions were based on the FANTA
method, but at household level. This allowed to measure the household access to
the different food groups.
Twelve food groups were defined in
the questionnaire:
1.
Cereals
2.
Roots and tubers
3.
Vegetables
4.
Fruits
5.
Meats, poultry and offals
6.
Eggs
7.
Fish and seafood
8.
Pulses, legumes, seeds and nuts
9.
Milks and milk products
10.
Oils and greases
11.
Sweets and honey
12.
Misceallenous
The methodology uses these 12 groups for the analysis.
A score
at household level has been calculated :Household Dietary Diversity Score
(HDDS).
HDDS can facilitate the dietary changes measurement before and after
anintervention (improvement) or after a disaster (worsening situation).
2.6 Indicators and cut off used
2.6.1 Weight for Height indicator
For children, acute malnutrition rates are estimated from the Weight for
Height values combined with presence of oedemas. Weight for Height indicator
compares the weight of the measured child to a reference population for the
same size. References values used are those from WHO 2006. Weight for Height
indicator is expressed in z-score.
Table2 :Weight
for Height (W/H) values defining global acute malnutrition (GAM), moderate
acute malnutrition (MAM) and severe acute malnutrition (SAM), with WHO 2006
standards(Nutrition and mortality SMART survey, Khargone district, Jhirniya
block, WHH, Jansahas, September 2013)
Acute
malnutrition
|
Weight for Height indicator
|
Global
|
W/H<-2
z-score
and/or
bilateral
oedemas
|
Moderate
|
-2≤W/H <-2
z-score
|
Severe
|
W/H<-3
z-score
And/ or
Bilateral
oedemas
|
2.6.2 Mid Upper Arm Circumference (MUAC)
MUAC is used for a
rapid screening and measures the mortality risk. This is also a secondary
malnutrition indicator, because of the link between MUAC and muscular mass.
MUAC measurement shows few variations for children aged 6-59 months and was
analysed as a malnutrition indicator for children more than 6 months.
Table3 :Cut
off values for MUAC measurement defining moderate acute malnutrition and severe
acute malnutrition with WHO 2006 standards (Nutrition and
mortality SMART survey, Khargone district, Jhirniya block, WHH, Jansahas,
September 2013)
Severity
levels
|
MUAC
(mm)
|
Mortality risk
|
MUAC<115
|
Moderate acute malnutrition
|
115 ≤ MUAC< 125
|
At risk of malnutrition
|
125 ≤ MUAC< 135
|
Normal
|
135 ≤ MUAC
|
2.6.3 Height for Age
indicator
[1] Standardized Monitoring and
Assessment of Relief and Transition
[2] Emergency Nutrition Assessment
[3]
Food and Nutrition Technical Assistance Project
Table 4 : Cut off values for Height
for Age (H/A) indicator, defining global chronic malnutrition, moderate chronic
malnutrition and severe chronic malnutrition, with WHO 2006 standards (Nutrition
and mortality SMART survey, Khargone district, Jhirniya block, WHH, Jansahas,
September 2013)
Chronic malnutrition
|
Height / Age indicator
|
Global
|
H/A< -2 z-score
|
Moderate
|
-3 z-score <H/A≤ -2 z-score
|
Severe
|
H/A< -3 z-score
|
2.6.4 Weight for Age
This indicator compare the weight of the child
to the median weight of a reference population for the age. It allows to
determine underweight for a given age. It informs us at the same time on chronic
malnutrition and acute malnutrition.
Table 5 : Cut off values for Weight
for Age (W/A) indicator, defining global, moderate and severe underweight, with
WHO 2006 standards (Nutrition and mortality SMART survey, Khargone district, Jhirniya
block, WHH, Jansahas, September 2013)
Underweight
|
Weight for Age indicator
|
Global
|
< -2 z-score
|
Moderate
|
<-2 z-score and ≥ -3 z-score
|
Severe
|
< -3 z-score
|
2.6.5 Mortality
rate
Crude Mortality Rate (CMR) 10000/d = n / [(N / 10 000) x
d]
n = total number of deaths in the
surveyed households
N = total number of persons
living in the surveyed households at the time of the survey
d = number of days of the
considered recall period
Mortality
rate 0-5 years10000/d= n / [(N / 10 000) x d]
n = total number of deaths for
children 0-5 years in the surveyed households
N = total number of children
living in the surveyed household at the time of the survey
d = number of days or the considered recall period
2.6.6 IYCF indicators
Basic indicators, WHO
2011
Early
initiation of breastfeeding: Proportion of children born in the last 24 months, who were
put to the breast within one hour of birth
Exclusive
breastfeeding under 6 months: Proportion of infants 0-5.9 months of age who are
fed
exclusively with breastmilk
Breastfeeding
at the age of 1 year: Proportion of children 12 – 15.9 months of age who are fed
breastmilk
Introduction
of solid, semi solid or soft food (complementary feeding) :Proportion
of infants 6-8.9 months of age who receive solid, semi-solid or soft foods.
Minimum
dietary diversity:Proportion of children 6-23.9 months of age who receive foods
from 4 or
more food groups.
Optional indicators,
WHO 2011
Children
ever breastfed: Proportion of children born in the last 23.9 months who were
ever breastfed
Continued
breastfeeding at 2 years: Proportion of children 20 – 23.9 months of age who are
fed
breastmilk
Other IYCF
information collected:
Other data collected will give information about the introduction of
other food given just after birth and which one, the way the child is breastfed
and the duration of breastfeeding, the weaning (reason, way of weaning the
child).
2.6.7 Household Dietary Diversity
Score (HDDS)
HDDS gives the information on household economic access to food.
Twelve food groups are used in the HDDS:1 - Cereals ; 2 – Roots and
tubers ; 3 Vegetables ; 4-Fruits ; 5-Meat, poultry and offals ; 6- Eggs ; 7- Fish
nad seafood ; 8- Pulses, legumes, seeds and nuts ; 9-Milk and milk products ;
10-Oils and greases ; 11– Sweets and honey; 12- Misceallaneous.
HDDS includes food
groups that need ressources at household level, like spices, sugar and sweets,
oil and greases, and drinks.
HDDS per household is
obtained counting the number of food groups eaten in the last 24 hours (24h
recall).
HDDS evaluate the average number of food groups eaten by households.
Calculation of the HDDS = Sum, for all the households surveyed, of the number of food groups
per household/ Total number of households
HDDS also allowsto evaluate the percentage of households who are eating
a specific food group.
2.7Action taken in case of a malnourished child (included
or not in the selected household)
Children with admission criteria for Nutrition
Rehabilitation Centre (NRC) have been referred to NRC with a double referral
form (in order to keep their data and to check their admission).
Table 6: Admission criteria for children in Madhya Pradesh(Nutrition
and mortality SMART survey, Khargone district, Jhirniya block, WHH, Jansahas,
September 2013)
Children aged 6-59
months
|
|
SAM
children :Admission in NRC
|
|
MAM children: No nutrition structure for MAM children in Madhya Pradesh
|
|
2.8Training, Supervision and survey
2.8.1 Training
Practical sessionincluded:
- field test for one day (in a village who will not be surveyed during
the survey) where the surveyors have practiced household selection, filling up
of the questionnaires, anthropometric measurements.
Results
for standardization test and field test have been used to make the final teams.
Each person trained has received the surveyor’s guideline summarizing the
survey methodology and procedures on the field.
2.8.2
Supervision
During the survey, teams have been surveyed by
the nutrition consultant, Welhungerhilfe and Jansahas managers.
Anthropometric and mortality data have been entered by the nutrition
consultant day after day on the ENA software, in order to have a daily
evaluation of the data quality for each team (with the flagged data on ENA
screen and the plausibility check report about digit preferences) and to give
them recommendations for the next day.
2.8.3 Survey
Survey has taken place from the 7th of September until the 12th
of September in Jhirniya block, Khargone district.
Three vehicules have been used. Communication with the teams has been
done by mobile phone, when network was available.
Team were composed as follow:
- One team leader who was in charge of the
methodology, the presentation of the objectives to the chief of the
village and the heads of household, and who was in charge of checking the
measurements and filling up the questionnaires. In case the team leader
was a male, questionnaire for IYCF was done by the female of the team.
- Two measurers in charge of anthropometric
measurements and responsible for the anthropometric equipment.
When necessary, in the villages surveyed, one local guide was helping
the team to define the borders of the village and to indicate the households
who were part or not of the village/segment selected.
2.9Ethic
Villages authorities have been contacted before the survey and they were
asked the authorization to do the survey.
Free and informed consent for the participation to the survey has been
asked to the head of household or his representant in case he was absent.
Same procedure has been followed with the mothers, before anthropometric
measurements and for the questionnaires.
2.10Data analysis
Anthropometric
and mortality data have been entered in ENA software, version june 2013.
Epi Info
have been used for the Chi² tests.
Individual
measurements have been compared to the OMS 2006 international reference
standards. Household dietary diversity and IYCF data have been entered and analysed
with Excel.
1. ANTHROPOMETRIC
RESULTS
3.1 Sample characteristics
A total of 478 children aged 6-59
months have been surveyed for the anthropometry.
One child was disabled and only weight has been
measured, thus, this child has not been included in the Weight/Height and
Height/Age analysis.
Data analysis has been done
excluding the FLAG SMART, in order to exclude extreme data which are more
likely to be mistakes.
Finally, a total of 468 children’s
data have been used for the Weight/Height analysis, 468 for the Weight/Age
analysis, 452 for the Height/Age analysis and 468 for the MUAC analysis.
Table
7: Sampling characteristics (SMART Nutrition and mortality survey, Jhirniya block,
WHH & Jansahas, September 2013)
n
|
Percentage (%)
|
|
Total number of children 6-59
months surveyed
|
478
|
|
Children aged 6 - 29 months
|
232
|
48,5
|
Children aged 30 - 59 months
|
246
|
51,5
|
Gender
|
||
Girls
|
247
|
51,7
|
Boys
|
231
|
48,3
|
Ratio (m/f)
|
0,9
|
Sex ratio is 0,9: it is between 0,8
and 1,2, meaning that both genders are equally represented, which validate the
representativeness of the sample.
Table 8: Distribution of age and sex of
sample(SMART Nutrition and mortality survey, Jhirniya block,
WHH & Jansahas, September 2013)
Boys
|
Girls
|
Total
|
Ratio
|
||||
AGE (months)
|
n
|
%
|
n
|
%
|
n
|
%
|
boy/girl
|
6-17
|
60
|
50,4
|
59
|
49,6
|
119
|
24,9
|
1,0
|
18-29
|
51
|
45,1
|
62
|
54,9
|
113
|
23,6
|
0,8
|
30-41
|
65
|
45,5
|
78
|
54,5
|
143
|
29,9
|
0,8
|
42-53
|
38
|
53,5
|
33
|
46,5
|
71
|
14,9
|
1,2
|
54-59
|
17
|
53,1
|
15
|
46,9
|
32
|
6,7
|
1,1
|
Total
|
231
|
48,3
|
247
|
51,7
|
478
|
100,0
|
0,9
|
Age interval 6-29 is under represented for both sex.
Exact
birthday has been found for only 44% of the children.
Table 9:
Mean z-scores, Design Effects and excluded subjects(SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
Indicator
|
n
|
Mean z-scores ±
SD
|
Design Effect
(z-score < -2)
|
z-scores not
available*
|
z-scores out of
range
|
Weight-for-Height
|
466
|
-1,52±0,95
|
1,06
|
6
|
6
|
Weight-for-Age
|
468
|
-2,29±1,04
|
1,36
|
6
|
4
|
Height-for-Age
|
452
|
-2,21±1,23
|
1,09
|
4
|
22
|
* contains for WHZ
and WAZ the children with edema.
Design effect (WHO standards) was equal to 1,06.
Figure 2: Distribution of Weight for Height (W/H) indicator, WHO 2006 standards(SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
The red curve (children from the
sample) has shifted on the left comparing to the reference population curve
(green curve), indicating that the population surveyed has more malnourished
children than the reference population.
Kurtosis test for Weight for Height (0,06) is less
than the absolute value of 0,2, then the distribution can be considered as
normal.
Table
10: Malnutrition rates, children aged 6-59 months (n=468) and children aged
6-29 months (n=228), Weight for Height z-score, WHO 2006 reference population (SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
Weight
for Height in z-score or bilateral oedemas
|
WHO
2006
|
Global Acute Malnutrition
6-59
months
|
31,0 %
(26,8
- 35,5 95% C.I.)
|
Severe Acute Malnutrition
6-59
months
|
6,6 %
(4,6
- 9,5 95% C.I.)
|
Global Acute Malnutrition
6-29
months
|
36,8 %
(30,4
- 43,8 95% C.I.)
|
Severe Acute Malnutrition
6-29
months
|
10,5 %
(7,3
- 15,0 95% C.I.)
|
Oedemas’ prevalence is equal to 0,4%
(n=2). These two cases have been confirmed by the supervisors.
GAM prevalence (31,0%, WHO 2006)
show a critical situation in the Jhirniya block, according to the WHO
classification cut-off[1].
Table 11: Prevalence of acute
malnutrition by age, based on weight-for-height z-scores and/or oedemas(SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
Severe wasting
(<-3
z-score)
|
Moderate
wasting
(>=
-3 and <-2 z-score )
|
Normal
(>
= -2 z score)
|
Oedema
|
||||||
Age
(months)
|
Total N
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
6-17
|
117
|
15
|
12,8
|
36
|
30,8
|
66
|
56,4
|
0
|
0,0
|
18-29
|
111
|
7
|
6,3
|
24
|
21,6
|
78
|
70,3
|
2
|
1,8
|
30-41
|
142
|
4
|
2,8
|
28
|
19,7
|
110
|
77,5
|
0
|
0,0
|
42-53
|
70
|
2
|
2,9
|
18
|
25,7
|
50
|
71,4
|
0
|
0,0
|
54-59
|
28
|
1
|
3,6
|
8
|
28,6
|
19
|
67,9
|
0
|
0,0
|
Total
|
468
|
29
|
6,2
|
114
|
24,4
|
323
|
69,0
|
2
|
0,4
|
§ Acceptable situation : <5%
§ Precarious
situation : 5 to 9%
§ Sérieuse situation : 9 to 14%
§ Critical situation :
≥ 15 %
3.3 MUAC distribution
MUAC is a good indicator for the
mortality risk linked with malnutrition.
Table 12: Prevalence of acute malnutrition based on MUAC cut off's
(and/or oedemas) and by sex(SMARTNutrition
and mortality survey, Jhirniya block, WHH & Jansahas, September 2013)
All
n =
468
|
Boys
n
= 223
|
Girls
n
= 245
|
|
Prevalence of global malnutrition
(< 125 mm and/or oedema)
|
(58)
12,4 %
(9,4
- 16,2 95% C.I.)
|
(23) 10,3 %
(6,6 - 15,7 95% C.I.)
|
(35) 14,3 %
(9,9 - 20,2 95% C.I.)
|
Prevalence of moderate malnutrition
(< 125 mm and >= 115 mm, no oedema)
|
(39)
8,3 %
(5,8
- 11,7 95% C.I.)
|
(16)
7,2 %
(4,2
- 11,9 95% C.I.)
|
(23)
9,4 %
(6,0
- 14,4 95% C.I.)
|
Prevalence of severe malnutrition
(< 115 mm and/or oedema)
|
(19)
4,1 %
(2,5
- 6,4 95% C.I.)
|
(7) 3,1 %
(1,4 - 7,0 95% C.I.)
|
(12) 4,9 %
(2,6 - 9,0 95% C.I.)
|
Table 13: Prevalence of acute malnutrition by age, based on MUAC cut
off's and/or oedemas(SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
Severe wasting
(<
115 mm)
|
Moderate
wasting
(>=
115 mm and < 125 mm)
|
Normal
(>
= 125 mm )
|
Oedema
|
||||||
Age
(months)
|
Total N
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
6-17
|
113
|
8
|
7,1
|
20
|
17,7
|
85
|
75,2
|
0
|
0,0
|
18-29
|
112
|
6
|
5,4
|
13
|
11,6
|
93
|
83,0
|
2
|
1,8
|
30-41
|
143
|
5
|
3,5
|
4
|
2,8
|
134
|
93,7
|
0
|
0,0
|
42-53
|
71
|
0
|
0,0
|
2
|
2,8
|
69
|
97,2
|
0
|
0,0
|
54-59
|
29
|
0
|
0,0
|
0
|
0,0
|
29
|
100,0
|
0
|
0,0
|
Total
|
468
|
19
|
4,1
|
39
|
8,3
|
410
|
87,6
|
2
|
0,4
|
3.4 Prevalence of
stunting
Exact
birthday has been found for only 44% of the children. Despite the systematic use of the
local calendar of events, age has to be used with caution, especially regarding
estimating of chronic malnutrition.
Table 14:
Prevalence of stunting based on height-for-age z-scores and by sex(SMART Nutrition and
mortality survey, Jhirniya block, WHH & Jansahas, September 2013)
All
n =
452
|
Boys
n
= 215
|
Girls
n
= 237
|
|
Prevalence of stunting
(<-2 z-score)
|
(259)
57,3 %
(52,3
- 62,1 95% C.I.)
|
(124) 57,7 %
(50,8 - 64,2 95% C.I.)
|
(135) 57,0 %
(51,0 - 62,8 95% C.I.)
|
Prevalence of moderate stunting
(<-2 z-score and >=-3 z-score)
|
(143)
31,6 %
(27,5
- 36,1 95% C.I.)
|
(68)
31,6 %
(25,8
- 38,1 95% C.I.)
|
(75)
31,6 %
(26,4
- 37,4 95% C.I.)
|
Prevalence of severe stunting
(<-3 z-score)
|
(116)
25,7 %
(20,9
- 31,1 95% C.I.)
|
(56) 26,0 %
(20,1 - 33,0 95% C.I.)
|
(60) 25,3 %
(19,5 - 32,2 95% C.I.)
|
3.5Prevalence of underweight
Table 15: Prevalence
of underweight based on weight-for-age z-scores by sex(SMART
Nutrition and mortality survey, Jhirniya block, WHH & Jansahas, September
2013)
|
|
All
n = 468
|
Boys
n = 223
|
Girls
n = 245
|
Prevalence
of underweight
(<-2
z-score)
|
(285) 60,9 %
(55,5 - 66,1 95% C.I.)
|
(140) 62,8 %
(56,4 - 68,8 95%
C.I.)
|
(145) 59,2 %
(50,6 - 67,2 95%
C.I.)
|
Prevalence
of moderate underweight
(<-2
z-score and >=-3 z-score)
|
(176) 37,6 %
(32,4 - 43,2 95% C.I.)
|
(86) 38,6 %
(32,6 - 44,9 95% C.I.)
|
(90) 36,7 %
(29,1 - 45,1 95% C.I.)
|
Prevalence
of severe underweight
(<-3
z-score)
|
(109) 23,3 %
(19,4 - 27,7 95% C.I.)
|
(54) 24,2 %
(18,7 - 30,8 95%
C.I.)
|
(55) 22,4 %
(17,5 - 28,3 95%
C.I.)
|
3.6Retrospective
mortality (87 days
recall period)
§ Crude mortality rate (87 days recall period) : 0,35/10 000/day (IC 0,19-0,65)
§ Mortality rate children under 5 years old (87 days recall period):1,06/10 000/day (IC : 0,45-2,47)
Both rates are above the alert
cut-off[1].
1.
IYCF RESULTS
Table 16 : IYCF results(SMART Nutrition and
mortality survey, Jhirniya block, WHH & Jansahas, September 2013)
|
|
|||
|
|||
Jaggery
water
|
|||
Ghutti
|
|||
Animal
milk powder or fresh animal milk
|
|||
Infant
formula
|
|||
Do not
know
|
|||
Other
|
|||
Progressively
|
|||
Abruptely
|
|||
DNK
|
|||
Most frequent reasons for weaning, n=19 children not breastfed on the day of the survey, 6 missing data
|
New
pregnancy
|
||
Child
too old
|
|||
It has not been possible to have the
average breastfeeding duration as questionnaires were not filled in the
rightway for this question.
96,0% of surveyed
households are eating at leat 4 food groups (equal or greater that 4 groups).
1.
DISCUSSION/CONCLUSION
The main objective
of the SMART survey had to evaluate the nutritional status of children 6-59
months in Jhirnya block, Khargone district.
Data
quality
Sex ratio, SD and design effect
§
Collected data show a balanced
gender repartition as sex ratio is equal to 0,9, which is in the norm (between
0,8 and 1,2).
§
Only 44% of the children had an
official document proving their birthdate (day/month/year). Thus, age may be
interpreted with caution, especially regarding the chronic malnutrition.
§
SD for Weight for Height (0,95) is
less than 1,2 according to WHO 2006 reference, which indicate a normal
distribution for the sample.
§
SD for Height for Age are is 1,23,
which is on the limit according to WHO 2006 reference, which may indicate a
slight problem for height data.
§
Skewness tests for Weight for Height
(-0,10) and Height for Age (0,06) give results between -0,2 and 0,2, then the
distributions for these indicators can be considered as symmetrical.
§
Kurtosis test for Weight for Height
(0,06) is less than the absolute value of 0,2, then the distribution can be
considered as normal.
§
Kurtosis test for Height for Age
(-0,38) is between 0,2 and 0,4 thus some height data may be affected with a
slight problem.
§
Design effect is 1,06, less than the
planned design effect (1,5) which indicate an homogenous population.
Absent households & reserve cluster
Data collection had been done in
September, when households have started harvesting. It often happened that
households were absents, working in their fields and coming back at the end of
the day, when the teams have left.
Thus, the four reserve clusters has
been surveyed, in order to reach the number of children required in the ENA
planning phase.
Nutrition
situation
Acute malnutrition
This
survey has been done at the end of the hunger peak.
With a
GAM rate of 31,0% (26,8 - 35,5 95% C.I.) with WHO standard
reference, the situation in the surveyed area is critical, according to the WHO
cut-off.
Moreover, it has to be underlined that prevalence represent an instant
picture of the nutrition situation at the time of the survey. This indicator
can not explain or predict the evolution of the situation.
Thus, it would be possible than in some areas surveyed, the nutrition
situation become worth : because of important flooding during the rainy season,
some crops (soja beans) have been spoiled.
Chronic malnutrition
Chronic
malnutrition affects 53,7% of the children aged 6-59 months (52,3
- 62,1 95% C.I.), 25,7% of severe forms (20,9 - 31,1 95% C.I.)(WHO 2006).The global
chronic malnutrition rate is above than the WHO alert cut off of 40%.
Results
for children 0-5 months show that stunting probably starts during the
pregnancy, as 26,2% (17,1-38,1 95% CI)of children 0-5 months are stunted with 3,3%
(0,7-13,6 95% CI)of severe stunting.
Malnutrition and risk
factors
·
6-29 months vs 30-59 months
X² testshowsfor
global acute malnutrition (GAM) that significative difference exists between
6-29 months and 30-59 months children, with WHO 2006 standards : children aged 6-29
months have 1,5 more risks to be malnourished than children 30-59 months.[1]
(p<0,05).
For
severe acute malnutrition (SAM), children 6-29 months have 3,6 more risks to be
severely malnourished tan children 30-59 months (p<0,05)[2].
·
Girls vs Boys
There is
no significative difference between girls and boys regarding GAM or SAM
(p>0,05 in both cases).
There is no significative diffenrence between girls and boys regarding
stunting (global or severe) (p>0,05).
Infant and Young Child Feeding (IYCF)
According toWHO recommendations, the
type of diet to ensureoptimalhealth andproper growthof the
child isexclusive breastfeedingfor the first 6months of life, then a
sufficient and safecomplementary foodsaccompanying
thebreastfeeding up to24 months or more.
In fact, breast milk no longer meets60 to80%
ofneedsbetween6 and 11months and only35 to 40%ofneedsbetween12 and23 months.The
transition frombreastfeeding(exclusive)to the consumption offamily foodsis a
verydelicate phasefor the infant.During thisperiod, manychildren suffer
frommalnutritionmore or lessassociated withinfectious episodeswhich
contributesignificantly tomorbidityand mortalityin childrenunder 5years.
Among children aged 0 to 23 months surveyed, 27.4% of them
were early breastfed, in the first hour of life. Regarding the colostrum , 37.9
% of mothers reported that the child has received. However, mothers
traditionally give fluids other than breast milk very early in the life of the
child and 47.2% of children received another liquid within three days of birth.
This, coupled with the fact that complementary feeding is
often introduced before the age of six months, gives a rate of 5,6% of the
children who are exclusively breastfed up to 6 months. It is even possible that
the exclusive breastfeeding rate is lower, because question regarding exclusive
breastfeeding was asked in a way to avoid stereotypical responses, with other
questions like introduction of other fluids in the days following birth, consumption
of other foods or liquids within 24 hours preceding the survey. This does not
give us information on the period from 3 days after birth child before and 24
hours before the survey day.
Breasfeeding
is on demand for 2,9% of the children, and 56,3% of the children are breastfed
until the age of two years.
Breastfeeding
is generaly stopped abruptely (28,6% of the children), because of a new
pregnancy of when the child is considered too old (respectively 21,1% and
15,8%).
Note: for
some indicators, data were very few (n<30).
Household
dietary diversityscore (HDDS) and Individual Dietary
Diversity Score 6-23 months (IDDS)
Most of the vegetable eaten (60,4%) at this season were cucumbers.
Regarding the HDDS,
96,0% of surveyed households are eating at leat 4 food groups (equal or greater
that 4 groups).
For children 6-23
months, 35,8% of them are eating at least 4 food groups.
Althoughhouseholds
surveyedforIYCFand those surveyed for dietary
diversity/foodsecurity are notnecessarilythe same,it appears that the
HDDS is significatively higher than IDDS (ԑ>1,96).
Dietary
diversitythat householdscan access may not befully
exploitedto providea more diverse diet to children 6to
23 months. The problem of food diversification
for children 6-23 months may not lie necessarily on household's
accessto foodbut also on infant feedingpractices.
1. RECOMMENDATIONS
·
To do a nutrition surveillance on a
regular basis;
·
To implement nutrition education
sessions in the community, on a regular basis, in order to sensitize the
community on undernutrition, the causes and the treatment;
·
To cure the moderate acute
malnourished (MAM) children in order to prevent these children from severe
acute malnutrition;
·
To
implement IYCF sensitization sessions in the community;
·
To implement dietary
diversity education sessions for the households to improve dietary diversity of
their children.
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