A Nutrition and Food Security Assessment of the Dry Zone ... zone survey - Nutrition... · A...

A Nutrition and Food Security Assessment of the Dry Zone of Myanmar,

June 24th - July 18th 2013

January 16th 2014

OBJECTIVES

1. Estimate the prevalence of indicators

of undernutrition in the Dry Zone, and

three different agroecological zones

within

2. Estimate infant and young child

feeding practice rates

3. Assess the differences in the nutrition

situation by agroecological zone and

the likely reasons, examining the

associations between nutrition and

other indicators

4. Make recommendations for

programming, policy and advocacy

Agroecological zone

number

Agroecological zone name

Characteristics

1 Dry land farming

1. Low land, not flood prone, no

irrigation

2. Suitable soil for cultivation

3. Only single or double cropping possibilities

High land with sloping agriculture

1. High land (greater than 300

meters)

2. Soil suitable for orchards,

plantations, forest

3. Sloping/ shifting cultivation

agriculture practiced

3 Flood plains and irrigated areas

1. Flood plain with good soil fertility 2. Irrigated land 3. Multi-cropping possibilities year round

METHODS (1/5): DESIGN

A cross sectional, two stage, random,

cluster survey of rural villages, with 3

strata (agroecological zones)

Stage 1: Random selection of 50 village

clusters per zone

Stage 2: Random selection of 40

households per village (12 households with

children under 5 for nutrition/IYCF data and

13 (minimum 10) households with/without

children under 5 for food security/HH data)

A household: “ a person or group of people eating and sleeping in the same compound four nights weekly and sharing resources, not including those who may have migrated”

METHODS (2/5) SAMPLE SIZE

Nutrition: • 1,800 children 0-59 months Infant and Young Child Feeding: • 522 0-24 month olds Mothers: • All of the children 0-59 months Food security, wealth/poverty and Water Sanitation and Hygiene (WASH): • 1,500 households (with/without U5s) • Including 560 households with child

nutrition and household food security data

METHODS (3/5): QUESTIONNAIRES

• Village profile: Population (for weighting);

crop production; market, clinic and water

source access and distance by season;

and common diseases affecting children

• Household: Written consent and

household demography

• Mother: Anthropometry; ANC/PNC; 24

hour diet recall

• Household Food Security,

wealth/poverty, WASH

• Child under 5: Anthropometry; recent

sickness; supplementation and

vaccination status and hygiene practices

• Child under 2: Infant and Young Child

Feeding practices

METHODS (4/5): MEASUREMENTS

• Children: weight, height/length, Mid Upper Arm

Circumference (MUAC) and check for oedema.

Date of birth

• Mothers: weight, height and MUAC. Age

• Salt iodisation test at household level

METHODS (5/5):

FIELD LOGISTICS

• 64 staff (10 from DRD), 9

teams, 8 supervisors

• 2 weeks training, including

practice anthropometry &

village pilot

• 3.5 weeks field work

NUTRITION RESULTS

Maximum achieved

sample sizes Dry land

farming zone (1)

Highland farming zone

Flood plains/

irrigated zone (3)

Dry Zone total

Planned sample size

Villages 51 50 51 152 150

Households with children U5 601 607 600 1808 ND

Households with OR without children U5 617 574 612 1803 1500

Children U5 687 689 600 2037 1800

Children U2 290 289 243 822 522

Mothers (children U5) 591 598 599 1789 ND

SAMPLE SIZE ACHIEVED:

% Wasted / acutely malnourished (0-59 month olds)

A g e (m o n th s )

utritio

Z o n e 1

Z o n e 2

Z o n e 3

Zo n e 1 Zo n e 2 Zo n e 3 Ag g r e g a te d

A g ro e c o lo g ic a l Z o n e s

utritio

n % M o d e ra te

S e v e re

A c c e p ta b le

P o o r

H ig h

C rit ic a l

P u b lic H e a lth S ig n ific a n c e

% Stunted/chronically malnourished (0-59 month olds)

A g e (m o n th s )

Z o n e 1

Z o n e 2

Z o n e 3

M o d e ra te

S e v e re

M e d iu m

H ig h

V e ry h ig h

P u b lic H e a lth S ig n ific a n c e

Weight for Height Z-score (WHZ) and Height for Age Z-score (HAZ) distributions

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Weight-for-length z-score

-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6

Height-for-age z-score

<-2 = wasted <-2 = stunted

% Babies born Low Birth Weight (<2500g)

% Undernutrition in mothers

M U A C < 2 1 0 c m B M I < 1 8 .5 k g /m 2

In d ic a to r

n % Z o n e 2

Z o n e 3

Z o n e 1

A g g re g a te d

• Mean MUAC pregnant/lactating mothers: 26.0cm

• Mean MUAC non-pregnant/lactating mothers: 26.8cm

DISEASE AND PUBLIC HEALTH

% Child sickness (previous two weeks)

Measle

Z o n e 1

Z o n e 2

Z o n e 3

Dry Zone sickness prevalence: 28.0%

Health caring practices: Care of children with diarrhoea

m o r e f lu id s m o r e fo o d O R S H o m e O R S Zin c ta b le t Z in c s yr u p

D ia r r h o e a c a r e

Health caring practices: Hygiene practices

H a n d w a s h in g

a f te r c h ild

d e fa e c a te d

a f te r c h ild

d e fa e c a te d

(w ith s o a p )

p r io r to

fo o d p r e p a r a t io n

fo r c h ild r e n

p r io r to

fo o d p r e p a r a t io n

fo r c h ild r e n

(w ith s o a p )

D is p o s a l

o f fa e c e s

in to ile t

H y g ie n e p ra c tic e s

Z o n e 1

Z o n e 2

Z o n e 3

Household latrine access

F lu s h la tr in e P it la tr in e

V e n tila te d

im p r o v e d

P it la tr in e

w ith s la b

P it la tr in e

w ith o u t s la b

N o la tr in e

o p e n d e fe c a tio n

Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

W a te r s o u rc e s

Z o n e 1 Z o n e 2 Z o n e 3

Village main water source

Households with access to protected water year round: 64.5%

0 5 0 1 0 0

E x c lu s iv e b r e a s t fe e d in g

T im le y in it ia t io n o f b r e a s t fe e d in g

C o n t in u e d b r e a s t fe e d in g a t 1 ye a r

C o n t in u e d b r e a s t fe e d in g a t 2 ye a r s

E v e r b r e a s t fe d

B o t t le fe e d in g

T im e ly c o m p le m e n ta r y fe e d in g

T im e ly in t r o d u c t io n o f s o lid , s e m is o lid , o r s o f t fo o d s

M in im u m d ie ta r y d iv e r s ity

M in im u m m e a l f r e q u e n c y (b r e a s t fe d c h ild r e n )

M in im u m a c c e p ta b le d ie t (b r e a s t fe d c h ild r e n )

C o n s u m p t io n o f ir o n - r ic h o r ir o n - fo r t if ie d fo o d s

C o n s u m p t io n o f fo r t if ie d fo o d s

C o n s u m p t io n o f M N P

P ro p o r t io n (% )

C o m p le m e n ta ry

fe e d in g

B re a s t fe e d in g

Infant and Young Child Feeding practices

Mean dietary diversity scores (child, mother, household)

C h ild re n

6 - 2 3 m o n th s

A ll N o -p re g n a n t

n o -la c ta t in g

P re g n a n t

o r la c ta t in g

H o u s e h o ld s

Z o n e 2

Z o n e 3

Z o n e 1

A g g re g a te d

M o th e rs

* • Individual Dietary Diversity Score non-pregnant/ lactating mothers: 4.4

• Individual Dietary Diversity Score pregnant/ lactating mothers: 4.2

QUESTIONS / COMMENTS?

HOUSEHOLD FOOD SECURITY, WEALTH AND POVERTY

POTENTIAL CAUSES OF UNDERNUTRITION:

Using: Descriptive analysis • Q1: What indicators are

inadequate? • Q2: What patterns exist

between agroecological zones?

And Exploration of associations and risk factors NOTWITHSTANDING THE LIMITATIONS OF THE CROSS SECTIONAL DATA…

Season

Months of food gap

J u n J u l A u g S e p O c t N o v D e c J a n F e b M a r A p r M a y

M o n th

Seasonal timing places the survey in the hunger gap, impacting on the ‘high’ rates of acute malnutrition, and other indicators (e.g. diet diversity, sickness) – worst case scenario (acute malnutrition)?

Undernutrition in children and mothers

1. Wasting more likely in stunted children (a risk factor), and vice versa

2. Birth weight determines later nutrition status (and LBW is a risk factor for stunting)

3. Mother’s nutrition status (BMI) determines child’s nutrition status (WHZ) (and low BMI is a risk factor for wasting)

Inadequate diets

1. Late and non-exclusive breastfeeding

2. Poor dietary diversity and meal frequency for children during the complementary feeding period

3. Low diet diversity diets for mothers, particularly pregnant/breastfeeding – affects their nutrition and the nutrition of their baby

4. Diet diversity of mother a determinant of child’s diet, regardless of HH economic status, suggesting need to tackle poverty and/or increase knowledge and change attitudes around IYCF/diets

Recent sickness/age Wasting/age

A g e (m o n th s )

Z o n e 1

Z o n e 2

Z o n e 3

A g e (m o n th s )

Z o n e 1

Z o n e 2

Z o n e 3

Disease and poor public health environment, including WASH

1. Sickness – similar trends as wasting and stunting

Disease and poor public health environment, including WASH

2. Inappropriate care of sick children

3. Poor hygiene practices, particularly hand washing

4. Poor latrine access

5. Use of unprotected water sources

6. Poor drinking water treatment practices

Household food insecurity

1. Low contribution of household subsistence production to household food needs (livestock ownership and land access determinants of mothers BMI)

2. Reliance on market purchase for food access

(due to small landholdings/high landlessness; limited irrigation/low yields; small stocks) (poor economic access to food)

3. Challenges in accessing market may impede food access

4. Potentially, poor intrahousehold food allocation

Household incomes/expenditure

1. Low incomes from limited sources, agriculture-focused so vulnerable to climatic and economic shocks

2. Typicality of loan taking / credit purchase, for many, on unfavourable terms; i.e entrenched indebtedness

3. Poor economic access to food: high proportionate spends on food needs, much on rice (driving poor diversity of diets)

A ll fo o d R ic e P a d d y p u r c h a s e

o n c r e d it

) Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

Challenges of physical access – affecting causes of undernutrition through different pathways?

• As the highest rates of sickness are in zone 2 it could be that factors associated with the zones could be ‘causing’ malnutrition, particularly poor infrastructure/ service access.

y se a s o n

me r s

e a s o n

y se a s o n

me r s

e a s o n

y se a s o n

me r s

e a s o n

S e a s o n

Z o n e 1 Z o n e 2 Z o n e 3

CONCLUSIONS

1. The nutrition situation in the Dry Zone is more concerning than expected. Both acute and chronic malnutrition require attention, as well as the nutrition status of mothers, particularly pregnant and lactating mothers

2. Zone 3 (irrigated/flood plains) is generally better off, but the situation in the whole Dry Zone warrants attention. The population of Zone 2 (highland farming) may be particularly vulnerable due to access issues as well as poorer food security

3. Children’s nutrition status is associated with mother’s nutrition status and may be poor from birth, so a life cycle approach is vital

4. Individual explanatory variables explain only a small proportion of variance of nutrition indicators. This highlights that a multisector approach is needed

5. Sickness is a key driver of undernutrition, particularly in older children and in zone 2

6. Deficiencies in the water, sanitation and hygiene environment are implicated

7. Poor diets are an important driver of undernutrition, in children and mothers

8. The relationship of nutrition with household economy / poverty is not clear, but widespread low incomes, high debts and insecure livelihood need to be tackled to improve diets and nutrition

QUESTIONS / COMMENTS?

Spare slides in case of questions about some specifics

Key preventative health interventions (children)

B e d n e t u s e

(6 - 5 0 m o n th s )

M e a s le s

v a c c in a t io n

(1 2 - 2 3 m o n th s )

An t ih e lm in th

c o v e r a g e

(1 2 - 5 9 m o n th s )

V ita m in A

s u p p le m e n ta t io n

(6 - 5 9 m o n th s )

T B v a c c in a t io n

b y B C G s c a r

(0 - 5 9 m o n th s )

P r e v e n ta t iv e H e a lth C a r e

Z o n e 1

Z o n e 2

Z o n e 3

0 5 0 1 0 0

D o c to r

N u r s e

M id w ife

A u x ilia r y m id w ife

T r a d itio n a l b ir th a tte n d a n t

O th e r

Z o n e 2

Z o n e 3

Z o n e 1

Ante-natal Care provision

0 5 0 1 0 0

P o s tp a r tu m V it A

V ita m in B 1

Ir o n d u r in g p r e g n a n c y

Z o n e 2

Z o n e 3

A g g re g a te d

Z o n e 1

Mother’s micronutrient supplementation

0 5 0 1 0 0

1 - 2 t im e s a m o n th

1 - 2 t im e s a w e e k

3 - 4 t im e s a w e e k

5 d a y s a w e e k

Z o n e 2

Z o n e 3

A g g re g a te d

Z o n e 1

5 days a week

Drinking water treatment

B o ilin g C lo th f iltr a tio n L e a v in g it

to s e ttle

N o filtr a tio n O th e r

0 5 0 1 0 0

S ta r c h y s ta p le s

F a ts /o ils

L e g u m e s

O th e r V ita m in A r ic h fr u its a n d v e g s

O th e r fr u its a n d v e g e ta b le s

F is h a n d m e a t

D a r k g r e e n le a fy v e g e ta b le s

E g g s

M ilk a n d d a ir y p r o d u c ts

O r g a n m e a t

Z o n e 2

Z o n e 3

Z o n e 1

Food group consumption (mothers, 24 hour recall)

Zo n e 1 Zo n e 2 Z o n e 3 A g g re g a te d

A d e q u a te (H D D S > 4 )M o d e ra te (H D D S 3 -4 )S e v e re (H D D S < 3 )

Zo n e 1 Zo n e 2 Zo n e 3 A g g re g a te d

A d e q u a te (F C S > 3 8 .5 )B o rd e rlin e (F C S 2 4 .6 -3 8 .5 )P o o r (F C S < 2 4 .6 )

L a n d le s s < 2 2 - 4 5 - 1 0 > 1 0

A c re s o f la n d a c c e s s ib le to th e h o u s e h o ld

Z o n e 2

Z o n e 3Z o n e 1

A g g re g a te d

H o u s e h o ld s e n g a g e d in a g r ic u ltu re0

L a n d le s s < 2 2 - 4 5 - 1 0 > 1 0

A c re s o w n e d b y th e h o u s e h o ld

Z o n e 2

Z o n e 3Z o n e 1

A g g re g a te d

ld Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

< 1 1 - < 2 2 - < 3 3

M o n th s w o rth o f s to c k

R e p o rte d p ro b le m s

to m e e t fo o d n e e d s

in th e la s t 1 2 m o n th s

R e p o rte d p ro b le m s

to m e e t fo o d n e e d s

in th e la s t 7 d a ys

D a ily c o p in g

N o h u n g e r

H H S < 1

M o d e ra te h u n g e r

H H S 2 -3

S e v e re h u n g e r

H H S 4 -6

)Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

A d e q u a te

C S I < 3

M o d e ra te

C S I 3 -3 .4

S e v e re

C S I > 3 .4

1 0 0P

N o in c o m e 1 in c o m e 2 in c o m e s 3 + in c o m e s

N o in c o m e < 2 5 U S D 2 5 -5 9 U S D 5 0 -7 5 U S D 7 5 -9 9 U S D > 1 0 0 U S D

W a g e la b o u r

a g r ic u ltu r a l

W a g e la b o u r

n o n -a g r ic u ltu r a l

S e llin g

p a d d y

S e llin g

p u ls e s /b e a n s

A ll fo o d R ic e P a d d y p u r c h a s e

o n c r e d it

) Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

T o ta l F o o d N o n -fo o d E d u c a tio n A d u lt

h e a lth

C h ild

h e a lth

T r a n s p o r t

5 0 ,0 0 0

1 0 0 ,0 0 0

1 5 0 ,0 0 0

2 0 0 ,0 0 0

2 5 0 ,0 0 0E

t)Z o n e 2 Z o n e 3Z o n e 1 A g g re g a te d

L a s t m o n th e x p e n d itu re L a s t 6 m o n th s e x p e n d itu re

< 1 0 0

1 0 0 -2 0 0

2 0 0 -3 0 0

B e lo w n a tio n a l

p o v e r ty lin e

B e lo w fo o d

p o v e r ty lin e

METHODS (2/5) MORE ON SAMPLE SIZE Nutrition and IYCF: 1,800 children 0-59 months, including 522 0-24 month olds: • For anthropometric indices: using stunting 39% in 0-59 month olds, precision 5%, power

90%, design effect 1.5, 10% refusal = 426 0-59 month olds per zone (9 per village cluster) • For IYCF: exclusive breastfeeding 8% in 0-5 month olds, precision 5%, power 90% = 80

infants per zone, * 4 and design effect of 1.5 = 480 0-24 month olds • Estimate 8.8% U5s (2.6% U2s) in Dry Zone, and 31% HH with a child U5 = 12 children U5

in 39 households, of which 3 U2 And their mothers Food security, wealth/poverty and WASH: 1,500 households (with/without U5s), including 560 HH with child nutrition and household food sec data • Prevalence 50%, precision 10%, power 90%, design effect 5 = 340 HH per zone (7 per

village cluster), BUT 7HH=2U5. Increase pragmatically to 13 (10 minimum) households

METHODS: DATA MANAGEMENT AND PROCESSING

• Anthropometry data double entered & processed in ENA for SMART (2011)

• Other data entered in Excel / SPSS

• Data entry complete September

• Datasets merged & analysed in ‘svy’ in STATA (12.0)

• Data weighted at cluster & strata level for child/mother/household level estimates, & strata level for analysis of village data

Undernutrition Child stunting (HAZ score / <-2 HAZ (y/n)), wasting (WHZ score / <-2

WHZ (y/n)) Maternal undernutrition (BMI score / < 18.5 (y/n))

Inadequate diet

IYCF practices: exclusively breastfed (y/n), meal frequency / min meal freq (y/n), dietary diversity score** / min diet

diversity (y/n), min adequate diet (y/n) Mother’s dietary diversity score**

Disease Recent morbidity (y/n)

Household food insecurity

Travel time to market Household Dietary Diversity Score**

Food Consumption Score, including adequacy (y/n)** Income amount

Food expenditure and food expenditure amounts HH subsistence production (y/n)**

Livestock ownership (y/n)**

Household poverty and demography Probability of falling below national poverty line

Sex of household head (m/f) Number of people in the household

Dependency ratio Labour migration (y/n)

Inadequate care environment

Poor public health environment Antihelminth (y/n);

Vitamin A supplementation (y/n) Hand washing wiih soap

Child’s faeces disposal in latrine (y/n) Drinking water on the premise (y/n)

Clinic in village (y/n) and time to travel to the clinic Latrine access (y/n)**

Detecting significant associations

Requires variability in the population, as well as a sufficiently powered sample. No evidence of association or risk does not mean no association or risk exists….

e.g. poverty

Significant associations

Nutrition indicators as explanatory variables

• Outcome HAZ, explanatory variable birthweight, R2 = 13.1% (0.1, 0.4)

• Outcome WHZ, explanatory variable birthweight, R2 = 7.8% (0.1, 0.3)

• Outcome WHZ, explanatory variable mother’s BMI, R2 = 1.4% (0.0, 0.1)

• Outcome stunting, explanatory variable wasting, OR 1.68 (1.16, 2.42)

• Outcome stunting, explanatory variable low birth weight, OR 10.66 (2.47, 45.98)

• Outcome wasting, explanatory variable mother’s BMI, OR 0.93 (0.87, 0.98)

Diet indicators as explanatory variables

• Outcome HAZ, explanatory variable adequate HDDS, R2 = 2.2 (0.1, 1.3)

• Outcome HAZ, explanatory variable adequate FCS, R2 = 1.8 (0.1, 0.7)

• Outcome BMI, explanatory variable mother’s IDDS, R2 = 1.3 (0.5, 0.0)

• Outcome stunting, explanatory variable Minimum Meal Frequency, OR 1.73 (1.07, 2.8)

• Outcome wasting, explanatory variable Minimum Adequate Diet, OR 3.24 (1.06, 9.9)

Public Health environment as explan

• Outcome BMI, explanatory variable latrine access, R2 = 3.4 (-0.7, 0.0)

More regression results

Household food security indicators as explanatory variables • Outcome BMI, explanatory variable

HH livestock ownership, R2 = 2.3 (-0.0, 0.0)

• Outcome BMI, explanatory variable HH subsistence production, R2 = 1.9 (1.8, 0.0)

• Outcome stunting, explanatory variable adequate HDDS, OR 0.43 (0.18, 0.99)

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