December Integrated Survey Mirpur Bathoro Thaluka. Thatta District, Sindh Province Pakistan

Transcription

1 December 2010 Integrated Survey Mirpur Bathoro Thaluka Thatta District, Sindh Province Pakistan

2 Acknowledgements First and for most, it is a duty to thank the district authorities (EDO-H and FCM) for their immense support in the survey undertakings. We would also like to thank all the survey teams comprising of Coordinator, Team Leaders, Enumerators and Drivers for their energy and commitment shown throughout the fieldwork and it would not be possible if they had not dedicated their time efforts to doing this tedious job non-stop (even on weekends). Full names and offices of the team members appear in appendix XI. Last but not least, we appreciate the time and paramount hospitality of the community and the households who allowed us to conduct interviews and take anthropometric measurements of the children. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

3 Table of Contents EXECUTIVE SUMMARY INTRODUCTION RATIONALE FOR THE SURVEY SURVEY OBJECTIVES METHODOLOGY Survey timing Survey design Survey area Sample size a) Sample size for Anthropometry b) Sample size for Mortality Sampling methodology a) Sampling universe b) Cluster selection c) Household selection Villages with less than 1000 people Villages with more than 1000 people Training and survey team composition Field supervision and quality assurance Data collection methods Anthropometric measurements Household Mortality Data Household Data Ethical considerations Data Analysis Survey limitation RESULTS Demographic characteristics Household size Age and sex distribution Malnutrition rates Mortality results (retrospective over 90 days prior to interview) Children s morbidity Vaccination Results Program Coverage Health care practice Infant feeding practice Maternal Knowledge Household vulnerability Water, sanitation and hygiene DISCUSSION RECOMMENDATIONS Appendix I - Map of the Surveyed District Appendix II - Clusters selected, Mirpur Bathoro Thaluka, Thatta district, December Appendix III Appendix IV Appendix V ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

4 Acronyms ACF ARI BCG CI CMR/CDR CMAM DCO EDO ENA EPI FCM FCS GAM HFA HH ITN KG MAM MUAC NCHS NDMA NGO OTP PPS SAM SC SMART TB TFP TSFP U5 UC UNICEF WFH WFP WHO ACF International Acute Respiratory Infection Bacillus Calmette-Guérin Confidence Interval Crude Mortality Rate/Crude Death Rate Community Management of Acute Malnutrition District Coordination Officer Executive District Officer Emergency Nutrition Assessment Extended Program of Immunization First Class Magistrate Food Consumption Score Global Acute Malnutrition Height-for-Age Household Insecticide Treated Net Kilogram Moderate Acute Malnutrition Middle Upper Arm Circumference National Center for Health Statistics National Disaster Management Agency Non Governmental Organizations Outpatient Therapeutic Programme Population Proportional Sampling Severe Acute Malnutrition Stabilization Centre Standardized Monitoring & Assessment of Relief and Transition Tuberculosis Therapeutic Feeding Programme Targeted Supplementary Feeding Programme Under-five Union Council United Nations Children s Fund Weight-for-Height World Food Programme World Health Organization ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

5 EXECUTIVE SUMMARY RATIONALE: The 2010 monsoon flood disaster in Pakistan has been massive and unprecedented, affecting vast areas in the country, causing damages to infrastructure, housing, agriculture and livestock, and other family assets. In a country that already had high rates of malnutrition, the floods have made the situation worse. Thatta district is one of the most affected areas of the country. Mirpur Bathoro is one of the 9 Thalukas in Thatta district that was highly affected by the flood. Previous nutrition assessment findings indicated that even before the floods, the rate of malnutrition in Lower Sindh was alarmingly high. It is, therefore, imperative to assess the post flood nutrition situation to understand the extent and severity of the nutrition situation and subsequent planning of an appropriate response. METHODOLOGY: The survey was done using the Standardized Monitoring & Assessment of Relief & Transition (SMART) methodology to assess the nutrition, mortality and food security situation in Mirpur Bathoro Thaluka. The collection of data exercise was carried out from 20 th to 26 th December, 2010 in 4 Union Councils of Mirpur Bathoro Thaluka. Anthropometric measurements (weight, height, MUAC) from 670 children 6-59 months were collected. A retrospective mortality data over the past 90 days was also collected from 595 households. In addition, information on infant feeding practices, maternal knowledge, household vulnerability, food security, water sanitation and hygiene and selected health practices were collected from 196 households. RESULTS: Malnutrition rates: Table 1: Prevalence of Acute Malnutrition based on weight-for-height z-scores and/or oedema Index Indicator Results WHO 2006 (n =670) NCHS 1977 (n=670) Z-scores Z-scores % Median MUAC 1 (n=670) Children 65cm to 110 cm Global Acute Malnutrition W/H< -2 z and/or edema Severe Acute Malnutrition W/H < -3 z and/or edema Global Acute Malnutrition W/H< -2 z and/or edema Severe Acute Malnutrition W/H < -3 z and/or edema Global Acute Malnutrition W/H < 80% and/or edema Severe Acute Malnutrition W/H < 70% and/or edema Global acute malnutrition MUAC < 125 mm Severe acute malnutrition MUAC < 115 mm 19.6% [16.4% %] 2.4% [1.3% - 4.3%] 17.8% [14.9% %] 1.5% [0.7% - 3.0%] 9.9% [7.7% %] 0.0% [0.0% - 0.2%] 17.2% [14.3% %] 3.9% [2.4% - 5.3%] 1 According to the national guidelines for the management of acute malnutrition for Pakistan, the entry criteria for therapeutic feeding programs for severe acute malnutrition and supplementary feeding programs for moderate acute malnutrition, is based on MUAC score and the presence of oedema ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

6 Total crude retrospective mortality /10,000/day 0.44 ( ) Under five crude retrospective mortality /10,000/day 0.80 ( ) By card 43.6% [29.9%-57.2%] Measles immunization coverage (children >=9 months old, n= 663) According to caretaker 38.0% [25.6%-50.4%] Not immunized 5.6% [2.5%-8.7%] BCG by scar (n=675) % [48.2%-71.6%] Vitamin A (n=675) in the last 6 months 22.5% [11.5%-33.5%] The prevalence of global acute malnutrition (GAM) (<-2 z-score/or oedema), based on weight-for-height z-scores, and using WHO 2006 standards was at 19.6% (95% C.I. 16.4% %), while the prevalence of severe acute malnutrition (SAM) (<-3 z-score and/ or oedema) was 2.4% (95% C.I. 1.3% - 4.3%) 2.0%. By gender, prevalence of wasting was higher in boys than in girls (18.5% and 15.9% respectively), although the difference was not statistically significant. The high proportion of malnourished children was found in the youngest age group of 6-17 and months old. This is not surprising since young children are vulnerable to childhood illness and subsequent weight loss due to mixed feeding. For the entire sample the prevalence of acute malnutrition based on MUAC, and using a cut-off point of <12.5cm, was at 17.2% (95% C.I. 14.3% %); while the prevalence of severely wasted children (MUAC<11.5cm) is estimated at 3.9% (95% C.I. 2.4% - 5.3%). Mortality Rate: The Crude Mortality Rate (CMR) was 0.44 (95% C.I ) and Under 5 Mortality Rate (U5MR) was 0.80 (95% C.I ). Both the crude mortality and U5 mortality rates are well below emergency thresholds of 1.14 and 2.3 deaths/10,000 /day respectively. Immunization coverage: About 60% of children in the sample had BCG vaccination. Only 22.5% of the children have received Vitamin A supplementation in the last 6 months prior to the survey. The immunization coverage reported for measles is 43.6 (card and mother recall). However, the measles coverage by EPI card is very low, only 5.6%. The results of the immunization coverage clearly indicate that the routine EPI program is performing poorly, requiring strengthening to increase the coverage. Health care practice: Approximately (82.5%) of the community populations surveyed seek treatment for children s illness outside of the home. The majority (62.5%) of them sought treatment for children in a hospital/health center/bhu. Infant feeding practice: Over 85% of children in the surveyed households were breastfeed at some point between 0-24 months and around 74% children under 2 year were still breastfeeding on the day of interview. Among the mothers who stopped breastfeeding, child grown-up (44.4%) and lack of enough breast milk (40.7%) were the main causes of ceasing breastfeeding. Among children who started complementary foods, 40% of them were introduced to complimentary foods at recommended age of 6 months. Sixty percent of children 6 to 8 months of age and still breastfeeding received the minimum number of meals. Maternal Knowledge: Approximately all (91.3%) of the women reported that they don t know what is meant by balanced diet. None of the surveyed women mentioned the foods that are rich in vitamin A. Only less than a quarter (22.9%) of all women responded that the cause of diarrhea was from dirty contaminated liquid and spoiled food. 2 BCG scar is observed in the right hand of the children. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

7 9.7% of women responded that washing hands before eating would prevent diarrhea while only 5.6% responded that washing hands with soap after using the toilet would prevent diarrhea. All of the study women reported that they never receive nutrition information before. Level of damage to housing: Among the populations surveyed in Mirpur Bathoro, 39.8% of the residents reported some damages to their houses that included 19.9% with complete destruction. Occupation of the head of the household: The finding of this assessment revealed that the flood had minimal impact on the occupations of the head of the household. There was no significant increase in unemployment in the time period after the flood among populations in the survey areas (only 2% more residents in the surveyed households reported unemployment after the flood). Household assets: The flood did not cause a considerable decrease in livestock size or other assets among the surveyed populations. Chickens were the most depleted (57.7%) from a household s assets in the time since the flood. 35.2% of the surveyed households reported some damages to their crop that included 25.5% who suffered complete damage by the monsoon flood. Almost, 45% of the households reported replanting the rabi season crops. Household stress and coping strategies: Household stress or coping mechanism was measured through the burden of loans and sale of household assets. The pattern of selling valuable assets (distress sales) after the flood was not extreme and 39.3% of the households in the survey area reported selling assets after the flood disaster. 20.4% of the surveyed population had a loan before the flood and, only 23.0% reported receiving new loan after the flood. Household food access: Less than a quarter (21.9%) of the survey sample having access to less than one day food stock, 29.6% had access to less than one week of food stock, and 48.5% had access to more than one week of food. Household food consumption and dietary diversity: The results of the 24-hour recall food frequency data show that households in all the survey areas eat a staple-food every day. Almost two-third (61.7%) of the surveyed households consumes at least one source of protein3 with in the 24 hours recall period prior to the survey. However, consumption of animal protein source is relatively lower with 51.5% of the surveyed households reported consumed with in the 24 hours recall period. The consumption of fruits is less with only 9.1% of the surveyed households eat at least once with in the 24 hours period prior to the survey. The lack of dietary diversity as measured by food consumption score (FCS) indicated that 10.2% of the households have poor consumption, 13.3% have borderline consumption and 76.5% had adequate consumption. Water, sanitation and hygiene: Among all households, 93.4% were using improved sources of drinking water. Over 89% of the households in the surveyed areas indicated that they have access to drinking water from hand pump. 57.7% of households were using a water source located on the premises and few households treat water for drinking purposes (29.6%). Among all households, only 10.2% were using improved toilet facilities. The majority of households were dumping their waste either in the open space (40.8%) or in their compound (26.5%). Most households reported that they wash their hands after toilet use (61.7%). Less than half (43.4%) of households reported that they sometimes use soap to wash their hands, and 30.1% of the surveyed households always washed their hands with soap. Among all households, only 19.9% reported that they bathe daily. CONCLUSION By WHO standards, the nutritional situation is classified as critical considering the presence of aggravating factors such as absence of nutrition program to address the high case load, high disease burden, poor immunization coverage, poor maternal knowledge, poor household food access, consumption and poor sanitation practice. 3 Protein source defined as legumes, meat/chicken/fish and eggs ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

8 RECOMMENDATIONS CMAM Program: A full-fledged CMAC program has to start immediately to provide SC/OTP/SFP service to treat children who are already malnourished and to prevent those that are at risk of becoming malnourished. The operation should be intensified in terms of appropriate targeting, number of beneficiaries and frequency of distribution. Static Nutrition and Health Service: Establish the delivery of static nutrition and health services by ensuring adequate staff and supplies are available. Mobile Service Delivery: Establish a mobile service delivery to support static services targeting remote villages with little access to road side facilities, to provide an integrated health and nutrition package. Linkage between Mobile and Static: Ensure effective linkage between mobile and static operations. Food Assistance: Based on the findings on household food access and consumption, there is a need to provide food and/or income support to vulnerable groups in the population. ITN Distribution: Given high fever morbidity, it is recommended ITN to be distributed through the mobile teams to reach remote communities in the area. Health and Nutrition Education: Given the high diarrhea morbidity, poor nutritional knowledge; health and nutrition education related to the signs and causes, and prevention of diarrhea, IYCF, use of soap, water disposal, bathing, and sanitation practice is the area of concern that needs appropriate intervention to safe guard against spread of disease. Optimal Infant and Young Child Feeding: Opportunities should be sought to intensify the promotion of optimal infant and young child feeding practices through other program. Surveillance System: Develop a district specific surveillance system to monitor the trends on key indicators related to health and nutritional status and plan timely response. Immunization: Immunization campaign targeting Mirpur Bathoro. Restocking: Consider re-stocking packages for poor families that lost their livestock and crop after the flood. Innovative alternatives: Consider piloting innovative alternatives to support these communities during times of economic shock caused by disaster. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

9 1. INTRODUCTION Background The Islamic Republic of Pakistan is a South Asian Country, bordering the Arabian Sea, between India on the east and Iran and Afghanistan on the west and China in the north. Islamabad is the capital city of Pakistan. Urdu is the official language and Muslims form majority of the local population of Pakistan. Pakistan has five provinces, which are Sindh, Punjab, KPK, Baluchistan and Gilgil Baltistan. Figure 1: Map of Pakistan and main statistical characteristics (Map: Google and statistics: UNICEF) Statistics Population, ,952 Population annual growth 2.2 rate, Crude death rate, Crude birth rate, Life expectancy, U5 mortality rate, Infant mortality (U1), Percentage of infant with 32 LBW, Percentage of people 23 below $1.25/day, GNI per capita (US$), Total adult literacy rate, Area: total 803, 940 km² Adult HIV Prevalence rate 0.1 (aged 15-49), 2007 GDP per capita average 3 annual growth rate, Percent U5 stunted (WHO), Percent U5 underweight 31 (WHO), Percent U5 wasting (WHO), Although some progress has been made towards meeting the UN Millennium Development Goals (MDGs), the country is still confronted with worryingly poor human development indicators. An estimated 23 percent of the population continues to live below the poverty line and almost 55 percent are illiterate. Infant mortality rates are as high as 72 per 1,000 live births, and under-five mortality stands at about 89 deaths per 1,000. Sindh is one of the five provinces of Pakistan. It is also locally known as the "Mehran" (Mehran River). Sindh is located on the western corner of South Asia, bordering the Iranian plateau in the west. Geographically it is the third largest province of Pakistan, stretching about 579 km from north to south and 442 km (extreme) or 281 km (average) from east to west, with an area of 140,915 square kilometers of Pakistani territory. Sindh is bounded by the Thar Desert to the east, the Kirthar Mountains to the west, and the Arabian Sea in the south. In the centre is a fertile plain around the Indus River. The 1998 Census of Pakistan indicated a population of 35 million; the current population in 2010 is 51,337,129 using a compound growth in the range of 2% to 2.8%. Just under half of the population are urban dwellers. Sindh's population is mainly Muslim (91.32%). Sindh is divided into three climatic ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

10 regions: Siro (the upper region, centered on Jacobabad), Wicholo (the middle region, centered on Hyderabad), and Lar (the lower region, centered on Karachi) Monsoon Flooding Over the course of the 2010 monsoon season, Pakistan experienced the worst floods in its history. At the end of July, heavy rains triggered both flash floods and riverine floods in several parts of Pakistan, resulting in loss of life, widespread displacement and damage. The floods have affected 84 districts out of a total of 121 districts in Pakistan, and more than 20 million people - one-tenth of Pakistan's population. Devastating communities throughout the country, in an area of at least 160,000 square kilometers - the floods killed more than 1,700 men, women and children, and nearly 1.9 million homes have been damaged or destroyed. 4 The degree of severity to which people have been affected by the floods varies depending on their particular losses and damages. The UN have identified 2.7 million people in Khyber Pakhtunkhwa, 5.3 million in Punjab and over 6 million in Sindh that are affected. 5 Women and children are likely to be disproportionately affected by the flood disaster. Women have limited access to income-generating opportunities even at the best of times and are at greater risk of being dispossessed of property and assets. Children are more vulnerable to infectious diseases and malnutrition, the effects of which are life-long. A McRAM assessment was conducted after the flood emergency to assess the impact of the flood on livelihoods, 6 food security and nutrition in four provinces and 27 districts. Based on WFP s analysis of the McRAM data, around 55% of households surveyed at the household level said that they had no food stock or would run out within one week. 8.4% of women and 9.1% of men reported going without food the day before they were interviewed, with much higher levels reported in Sindh (17.6% and 19.3% for women and men, respectively). Households were reported resorting to a range of coping strategies that are known to have negative effects. These included debts, borrowing, reducing meal size, skipping meals and women eating less than men. A few weeks in to the disaster a small number of households already reported they will spend less on health care in order to purchase food and others reported they will withdraw children from school. Almost half of nursing mothers report at the household level that they have reduced breastfeeding and around 15% have stopped breastfeeding since the floods. The McRAM finding suggests that areas affected by the disaster have already experienced high levels of poverty, food insecurity and it is expected that many households will remain highly or moderately food-insecure until their homes, agricultural lands and jobs have been restored. Compounding the problem is that Pakistan suffered from widespread hunger even before the monsoon floods, with an estimated 82.6 million people - a little less than half 7 the population - estimated to be food insecure. Nutrition Situation The nutrition situation in Pakistan is not well documented. The latest national survey is the National Nutrition Survey (NNS), where the prevalence of Global Acute Malnutrition rate is measured at 13.1 percent, close to the WHO emergency threshold of 15 percent, while the national prevalence of severe acute malnutrition was 3.1 percent. According to NNS, the prevalence of wasting was found to be highest in the Sindh Province (18.2%) but lowest in KPK (10.9%). Similarly, the proportion of wasting in NNS ranged from 5% in Sindh to 3.1% in KPK. On the other hand, the national prevalence of underweight and stunting in the NNS was 38% and 36.8%, respectively. According to McRAM assessment in flood affected areas (August 25-29, 2010) the average MUAC measurement for children 6-59 months was 13.9 cm and global acute malnutrition was measured at 26 percent and severe acute malnutrition (SAM) among children 6-59 months was at 9% using globally defined threshold values for MUAC. Despite the global debate concerning MUAC result interpretation, the figure gives as an indication that acute malnutrition has likely increased among the flood affected population and the impact of the floods on the 4 January 12, January 13, Pakistan flood impact assessment. September WFP 7 WFP Fact Sheet - Pakistan Hunger Facts. January 12, 2011 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

11 nutritional situation of children and pregnant women could be significant, and this will lead to increased morbidity and mortality among infants and young children Even before the monsoon flood, child malnutrition rates in Sindh Province remain persistently high. An ACF survey conducted in Kamber-Shahdadkot and Dadu districts in November 2007 indicated that the level of acute malnutrition to be very high among children 6-59 months 8. In this survey, the overall prevalence of GAM was 18.7% and 17.8% in Kamber-Shahdadkot and Dadu districts, respectively. Similarly, high SAM rates were found; 4.1% in Kamber-Shahdadkot and 3.2% in Dadu districts. These findings have several implications especially with regards to addressing nutrition problems. A follow-up survey done in June 2008 in Kamber-Shahdadkot and Dadu districts 9 on 617 under-five children revealed that about a quarter were found to be acutely malnourished. In this survey, the prevalence of GAM was 25.4% in Dadu and 22.0% in Kamber-Shahdadko), respectively. The rate of wasting in this study is higher than the provincial average and may suggest that that the nutrition situation is continue deteriorating. A recent study conducted in flood affected districts of Southern Sindh gives a similar high picture of the state of acute malnutrition. The findings of this study indicated 21.2% of the children to be acutely malnourished and 2.9% severely wasted. 10 From analyses of the different surveys conducted in Sindh Province, we can conclude that no progress has been made in the last 10 years in reducing the prevalence of wasting in Sindh Province, may be it has worsened as the findings of surveys indicate a prevalence rate higher than the provisional average. In a Province that already had alarmingly high rates of malnutrition, the floods have made the situation worse. Considering the extent of the flood damage in Sindh and Thatta district in particular, the on-going emergency situations, have had a serious impact on the nutritional status of children under-five, and pregnant and lactating women. Currently, a large number of displaced families have limited access to food and the loss of household properties, food stocks and damage to standing crops will further increase food insecurity at the household level and subsequent deterioration of the nutritional status among vulnerable groups. Given the current hygiene and sanitation situation, the risk of water-borne diseases has increased, with serious implications on the already compromised nutritional status of children, and PLW. 2. RATIONALE FOR THE SURVEY Mirpur Bathoro is one of the 9 Thaluka's in Thatta that is highly affected by the flood. The post flood nutrition situation analysis conducted by ACF and UNICEF in November in Mirpur Bithoro indicates that the nutritional status of children is deteriorating considering the observed aggravating factors, such as the absence of feeding program to address acute malnutrition cases in the community, the scarcity of safe water for human consumption, extremely poor sanitation condition, emerging diseases such as malaria and diarrhea and low access to outreach health services and the food insecurity due to the heavy flood causing crop destruction and reduced livestock size (death). The situation analysis signal an acute deterioration of the current nutrition situation and the children in this community are highly vulnerable to acute malnutrition. Despite concerns of nutritional deterioration, very little baseline nutrition information is available in Thatta district in general and at Thaluka level in particular. Therefore, it is imperative to conduct standard nutrition assessment to further understand the scale and severity of the nutrition situation and verify the necessarily for an immediate response. Documenting the essential baseline data on the magnitude of the problem in the target area would help to establish plan of actions and environmentally sound strategies to proceed and guide suitable interventions in alleviating the nutrition problem. The information will also serve as benchmark for operational plan design and eventually measuring the achievements and success/ impact of the proposed interventions. 8 ACF FINAL REPORT. Nutritional Assessment on Flood-Affected Populations, Kamber-Shahdadkot and Dadu Districts, Sindh Province, Pakistan. November ACF Nutritional Anthropometric and Retrospective Mortality Survey Children aged 6 to 59 months Kamber-Shahdadkot and Dadu Districts, Sindh Province, Pakistan. May June Preliminary Results - Anthropometry. FANS - Southern Sindh. October 29 th - November 4 th Post Flood Nutrition Situation Analysis in Thatta District, Lower Sindh Province, Pakistan. ACF, November 2010 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

12 3. SURVEY OBJECTIVES General Objective The general objective of the survey is to assess the nutrition situation in Mirpur Bathoro Thaluka for the purposes of guiding the design and implementation of an appropriate response. Specific Objectives To estimate the prevalence of acute malnutrition among children aged 6-59 months ( cm height/length) To estimate retrospective morbidity and mortality (CMR & U5MR) rates among people residing in the survey Thaluka. To assess the Measles coverage among children 9-59 months, BCG vaccination and vitamin A supplementation coverage among children 6-59 months in the survey area. To assess key food security indicators and other contextual factors affecting the nutrition situation in the Thaluka. To understand the causes of malnutrition in the survey area. To draw appropriate recommendations for the improvement of the nutritional status of the population in the area. 4. METHODOLOGY 4.1 Survey timing Data collection was executed between 20 th and 26 th December 2010, four months after the monsoon flood Survey design Standard two-stage 41 x 15 cluster sampling based on probability proportion to size (PPS) and SMART methodology was used for the survey Survey area The survey was conducted in 4 Union Councils of Mirpur Bathoro Thaluka in Thatta district. For a non-biased selection of the Union Councils to be surveyed (four out of the eight), the following criteria were considered: a) extent of flood damage; b) proportion of the population; c) NGO program implementation; d) vulnerability. Consequently, Banno, MaharShah, LaikPur and Bachal Gugo were selected. The selected Union Councils were considered as geographically dispersed Sample size Sample size for malnutrition and mortality is calculated separately as described below. a) Sample size for Anthropometry The anthropometric sample size calculation is performed with the assumption that the maximum prevalence of acute malnutrition would be 20%, with 5% precision and a design effect of 2 and the under-five populations from Mirpur Bathoro, following the results of the latest available nutrition surveys implemented in the Province 12. An assumption is made that within the geographic units selected, the population are expected not to be equally affected and differences to be seen between clusters (design effect 2 used). 12 Kamer-Shahdadkot and Dadu districts, Sindh Province, ACF surveys, June ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

13 Based on the demographic information obtained from the district 13, the total population of Mirpur Bathoro is estimated at 197,398 with an average household size of 6.3. The proportion of under-five children is 17% of the total population. This will give an average of 33,558 under-five children in Mirpur Bathoro. The above data are entered to SMART ENA software and generated 488 children. Thus, the sample size for anthropometry is 488 under-five children. In order to estimate the number of households available for the entire survey, the total population is divided by the average household size. Accordingly, the number of households available for anthropometric measurement is 31,333. The average number of children per household is, therefore, estimated to be 1.07 (33,558/31,333 HHs). The number of children calculated for the anthropometry sample size needs to be converted in terms of households, and based on the above demographic data, 1.07 children can be found from one household and thus 488 children will be found from 456 households. Considering possible non response, a contingency of 10% of sample HHs is added resulting in the sample size HHs of 502. Therefore, a total of 488 under-five children are expected to be sampled from the final corresponding sample HHs of 502. Considering the time needed to travel daily to the sites, 15 households per day set as achievable. The total number of clusters to be surveyed is estimated by dividing the total number of households to be visited by each team per day, which gives a cluster of 34. b) Sample size for Mortality The mortality sample size is estimated based on the expected mortality rate of 0.5 death/10 000/day with a precision of 0.3 and a design effect of 1.5; 90-day recall period and the total populations of Mirpur Bathoro. Design effect for CMR was estimated to be 1.5 because all the residents evacuated the areas following the district government warning and the impact of the flood is, most likely, uniform. The sample sizes of the individuals needed to estimate the CMR is, therefore, 3,499. Dividing the total sample size for mortality by 6.3 (average household size) gives the number of households to be surveyed at 555 HHs. Taking into account the possible non response, a contingency of 10% of sample HHs is added resulting in the sample size HHs of 611. Considering that 15 households can be surveyed per day per team, the number of clusters to be surveyed is 41. Conclusion about sample size: As shown above, the total number of clusters to be visited in order to estimate the under-five nutritional status and CMR differ. As per the SMART guideline, it is recommended to use the higher number of households when the anthropometric and mortality sample sizes vary. In this case, the mortality sample size was used for the survey. Although only 502 households are needed for anthropometric data collection, the actual number of households to be surveyed followed the mortality calculations, i.e., 611 households. Therefore, anthropometric data was collected in all households visited for mortality data Sampling methodology a) Sampling universe In Pakistan, districts are subdivided in to Thalukas; subdivided in numerous Union Councils, which are further divided into Deh or Unit. A Deh consists of several villages or goth. The universe that the samples were drawn was based on the complete list of goth and the number of population from the selected Deh was obtained from the local government. b) Cluster selection Since it is difficult to obtain an updated sampling frame of under-five children or households at village level, deh 14 level population data was used for cluster assignment. A total of 41 clusters were randomly selected by assigning probability proportional to population size (PPS) using ENA software (appendix II) 13 U/C Wise Population 2010 Of District Thatta based on 1998 Census. 14 deh is a geographic unit consisting of a number of villages ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

14 c) Household selection The survey teams visited the selected cluster location and met village leaders. The team leader explained the purpose of the survey and survey procedures. After obtaining the initial permission of village leaders, two methodologies or selecting the households surveyed were used depending on the sample size of the selected village. Villages with less than 1000 people In small villages, a systematic sampling is used. The nutrition survey teams first counts all houses in the village. Thereafter the first house is chosen using the interval (amount of houses present in the village/15 houses needed) and the random table was drawn between one and the sampling interval for the assignment of the first house, and using the sampling interval for assignment of all other houses, finally 15 houses were drawn. If there are insufficient houses present in the village, all houses in this village are surveyed where after the team moves to the nearest village. The nutrition survey team counts the houses again, and calculates another interval to complete the cluster. If this village has more than 1000 citizens, the EPI method is used. Villages with more than 1000 people In large villages, the nutrition survey teams use the EPI method. In the centre of each cluster 15, the survey team chooses a direction by using the spinning pencil method, whereby a pen is thrown into the air to decide the way of direction. All the team members walked to the edge of the village following the direction of the pen. When the border was reached, a new direction was randomly selected by spinning pen again until it pointed into the body of the village. Then, the whole team walked to the end of the selected direction counting all the available households (HHs ). The first house was selected by using a random table. The second house was taken by proximity, always choosing the houses on the right hand side when leaving the houses and continues until the required data was collected. All eligible children aged 6 to 59 months were measured (between the length/height of 65 and 110 cm) were measured regardless of the desired quota of children already being measured in the cluster. If a child s age was unknown, it was estimated using a seasonal/local calendar. Absent children were followed up during the survey day. Children present the day of the survey, but who are not living in the household are not included in the survey. In all households selected the retrospective mortality questionnaire was filled, even if there were no children present in the requested age group. For HH questionnaires, every third HH was selected, starting from the first selected HH. 5. Training and survey team composition Six survey teams each consists of team leaders and two enumerators were recruited, trained and subsequently participated in the data collection and conduct of the survey. Candidates with prior experience in nutrition assessments were given preference. Enumerators final selection was based on merit, commitment and performance shown during training. Prior to the survey, three days of training was provided to the survey team by nutrition technical staff/survey coordinator from ACF in Thatta. For the first two days, the group was trained on the theory sessions such as definition of malnutrition, causes, classification and UNICEF framework, and basic concepts of sampling and the survey methodology; that was followed by a practical exercise on the important nutrition data collection procedures, anthropometric measurement techniques, recognition of the signs and symptoms of malnutrition including nutritional oedema, how to identify selected households and interview techniques, how to fill questionnaire, complete interviewing households, edit questionnaires, avoid/minimize errors and how to compile the data files. More than half of the training sessions focused on anthropometric measurement including The centre of the cluster was determined with the assistance of a village chief /leader 16 A household was considered all people eating from the some cooking pot as this is considered one household in the Pakistani culture. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

15 classroom practice. Adequate attention was given in training on standardizing the instrument and keep record of the procedure and variation or error (if any). As a means to verify anthropometric skills of enumerators, to detect differences among measurers and identify their possible causes anthropometric standardization test was carried out in a village that is not part of the survey sample, during the third day of the training as the main purpose is qualifying measurers and each participants had to practice in the community before qualifying to join the team. Ten children were measured once by the survey coordinator/ supervisor and each of the 12 enumerators. Normally, each enumerator is supposed to measure 10 different children twice with a time interval between individual measures that means one child to be measured 24 times. However, after the children were measured 12 times (end of round one), the children were crying and some mothers were complaining. Each enumerator had managed only a single measurement of each child. As a result it was not possible to calculate both precision and accuracy of each enumerator using ENA/SMART standardization exercise. However, the accuracy was analyzed based on single measurement. Extra training and support was given based on the scores attained by each enumerator during the standardization test. A piloting survey was also conducted at the end of the training day. This was done in order to provide practical training for the enumerators including demonstration of children with oedema, and to test the suitability of the questionnaires. The questionnaires were commented and revised after the pilot test. 6. Field supervision and quality assurance The survey coordinator was responsible for the supervision of the assessment teams and for the overall coordination of the nutrition survey activities. Constant supervision and monitoring of all field activities, editing, was emphasized. Concurrent crosscheck of the data collected by interviewers was performed by the survey coordinator in a random sample of households. Team leaders were consulted for any erogenous or irregular data on a daily basis. Discussions were conducted in each day after the teams returned from field data collection. The team leaders were responsible for strictly following the day-to-day activities of enumerators. Team leaders were reviewed all questionnaires everyday so that any mistakes could be checked on the spot and necessary correction be made. Team leaders were responsible for the overall compilation of cleaned data Female enumerators collected information from the mothers and porters from the village carried the instruments, arranged and helped in anthropometric measurements. The nutrition advisor in Head Quarter ran independent quality checks and validated data, including re-entry and systematic data checking. Each weight scale was numbered and calibrated daily prior to data collection using a standard weight of 10 Kg to ensure the scale is sturdy, reliable and accurate. All the scales were accurate and no adjustment factors were required. 7. Data collection methods17 Anthropometric measurements The following data was collected to all children aged between 6 and 59 months (children between 65 and 110 cm were included in the survey, typically because of age inaccuracies) Age (in months) of the children is, in the first instance, established by an official document stating his data of birth (birth certificate, immunization card, etc). In this case, the surveyors verify that the child is above 6 months and below 60 months and record the exact date of birth. If the child does not have an official document mentioning his date of birth, the age of the child estimated in months with the help of a local calendar of events using religious, agricultural and seasonal events. 17 In the absence of emergency nutrition assessment guideline for Pakistan, anthropometric measurement techniques followed those outlined in the SMART methodology. Measuring Mortality, Nutritional Status, and Food Security in Crisis Situations. Version 1. April ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

16 Gender: Male children are recorded as M and female as F. Height/Length: Height and length of children was measured using height boards and recorded to the nearest 0.1cm. Children less than 85cm are measured lying down and those more than 85cm standing up. Before taking the height/length, caretakers were requested to take off shoes (if any). For children measured standing up, the measurers are trained to ensure that the child s head, shoulder blades, buttocks, calves and heels are touching the board and that they are looking straight ahead. Children measured lying down are placed in the middle of the board with the head touching the fixed end, the knees pressed down and the heels touching the movable base of the board Weight was measured by using Salter hanging scales and recorded to the nearest 0.1kg. The scale is hung from a stick held by two measurers, and recalibrated to zero before the child is put into the weighing pants. All children were measured without or with light clothing. Oedema is diagnosed by applying normal thumb pressure to the anterior surface of both feet for three seconds. If an indentation remains after the pressure is removed, presence of edema is considered positive and a Y is entered on the data collection form. If the thumb imprint does not persist, or if the edema is not bilateral, the child is recorded as not having edema and an N is entered on the data collection form. The survey coordinator has to check and verify all positive or questionable cases of edema. Mid Upper Arm Circumference (MUAC) was measured on the left arm of all sampled under-five children following all the 10 steps for measuring MUAC as recommended in the Anthropometric Indicators Measurement Guide18. MUAC was recorded to the nearest 0.1cm. Vaccination and Vitamin A supplementation coverage: Measles coverage was assessed among children 9-59 months by firstly checking the vaccination /MCH card. Where cards were not available, a verbal recall (yes, No or do not know) from the mother or caretaker was recorded. BCG immunization coverage was assessed among all among under-five children in the survey households by observing a scar on the left arm (and MCH/card where possible). Vitamin A supplementation coverage was asked by demonstrating the blue capsule and asking mothers whether their child had received this capsule in the six month period prior to the survey. Morbidity: Retrospective morbidity information was collected on selected illness (diarrhea, fever, measles, cough or other) within a 14 day recall period. Morbidity information relies on the mothers perception and memory of the child/children s illness and is therefore considered to be very subjective. UNIMIX distribution: All mothers were asked if their children received and ate UNIMIX in the last six months prior to the survey. Treatment status: All mothers were asked if their children were treated in a nutrition program, and received PlumpyNut (therapeutic product used for the treatment of Severe Acute Malnutrition) in the last six months prior to the survey. Household Mortality Data Crude death rate was assessed in the entire population of the selected HHs. Mortality data was collected regardless of whether or not there were any children under five years in a household. The numbers of deaths during the 3 months prior to the survey were retrospectively recorded, noting that if the death was in an underfive child or an individual over five years of age. Household size and the number of under-fives in each household were also recorded. So that the crude and under-five mortality rates could be calculated. The cause of U5 death was also noted. Apart from considering the number of people currently in the households, those who were present at the beginning recall period, birth and deaths the methods takes into account the number of people who joined or left the households during the recall period.. 18 Anthropometric Indicators Measurement Guide Revision. Bruce Cogill. Food and Nutrition Technical Assistance Project (FANTA). Academy for Educational Development ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

17 Household Data Information on food diversity, water and health, livestock, loan, financial assistance, and distress asset sales and involvement on food relief programs were collected in every third household in each cluster based on the tool developed by ACF. Physical observations and secondary data of all available reference were used whenever possible to complement the information collected through household interview. 8. Ethical considerations All children that were diagnosed as severely or moderately malnourished based on Weight / Height, MUAC or with oedema were referred to Civil Hospital for medical attention (referral slips were provided to each team leaders to facilitate the process). 9. Data Analysis Anthropometric and mortality data were analyzed using ENA software for SMART (version October 2007). Information on vaccination coverage, morbidity and MUAC were analyzed in EpiInfo version A p-value <0.05 was considered to be statistically significant at 95% CI. All data was entered on a daily basis. Checks were made using the plausibility function of the ENA software to ensure data collection quality daily. Team leaders were consulted for any erogenous or irregular data on a daily basis. Data cleaning and editing of the completed household questionnaires was done by trained data operator before the data entry. Random check of the data entry of questionnaire (10%) was done by the survey coordinator, and consistency checks were run to detect and correct data entry errors. 10. Survey limitation - The nutritional findings from Mirpur Bathoro Thaluka cannot be extrapolated to represent the nutritional situation Thatta or other Thalukas. However, it is suggested that they are indicative of the situation faced in other adjacent Thalukas and Thatta district in general. - Because of the lack of comparable data (nutrition assessments using similar methodology, conducted in the same season and in the same Thaluka), it is difficult to assess the relative gravity of the current situation. It is hoped that in future, by repeating surveys in the same and other Thalukas, comparative baselines will be developed for trend analysis. - Not all team leaders had prior experience in survey execution. While efforts were made to ensure they had anthropometric measurement experience and where possible prior experience in nutrition surveys, this was not always possible. - Anthropometric data was not collected among other vulnerable groups such as pregnant and lactating women or the elderly. In light of the severity of the situation, the nutritional situation of other vulnerable groups should also have been captured for emergency response planning. - One cluster (Cluster 12) was not surveyed because of a car accident on the team on the last survey day. Therefore, the survey was completed in 40 clusters. Cluster 28, had only 10 households 11. RESULTS 11.1 Demographic characteristics Education Generally, education level is low. Among all fathers and mothers, 83.7% had no schooling. This was, however, different between fathers and mothers ; with 73.7% of fathers with no schooling while for mothers 93.4% had no schooling. Among fathers, 8.4% had reached secondary school, which is significantly higher than for mothers (1%) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December