A Nutrition and Food Security Assessment of the Dry Zone of Myanmar, June 24 th - July 18 th January 16th 2014

Transcription

1 A Nutrition and Food Security Assessment of the Dry Zone of Myanmar, June 24 th - July 18 th 2013 January 16th 2014

2 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

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4 Agroeco logical zone number Agroecological zone name 1 Dry land farming Characteristics 1. Low land, not flood prone, no irrigation 2. Suitable soil for cultivation 2 3 High land with sloping agriculture Flood plains and irrigated areas 3. Only single or double cropping possibilities 1. High land (greater than 300 meters) 2. Soil suitable for orchards, plantations, forest 3. Sloping/ shifting cultivation agriculture practiced 1. Flood plain with good soil fertility 2. Irrigated land 3. Multi-cropping possibilities year round

5 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

6 METHODS (2/5) SAMPLE SIZE Nutrition: 1,800 children 0-59 months Infant and Young Child Feeding: 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

7 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

8 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

9 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

10 NUTRITION RESULTS

11 SAMPLE SIZE ACHIEVED: Maximum achieved sample sizes Dry land farming zone (1) Highland farming zone (2) Flood plains/ irrigated zone (3) Dry Zone total Planned sample size Villages Households with children U ND Households with OR without children U Children U5 Children U2 Mothers (children U5) ND

12 P r e v a le n c e o f G lo b a l A c u te M a ln u tr itio n % P r e v a le n c e o f G lo b a l A c u te M a ln u tr itio n % % Wasted / acutely malnourished (0-59 month olds) Z o n e 1 P u b lic H e a lth S ig n ific a n c e S e v e re Z o n e C ritic a l M o d e ra te 2 0 Z o n e H ig h P o o r A c c e p ta b le Zo n e 1 Zo n e 2 Zo n e 3 Ag g r e g a te d A groecological Zones A g e (m o n th s )

13 P r e v a le n c e o f S tu n tin g % P r e v a le n c e o f S tu n tin g % % Stunted/chronically malnourished (0-59 month olds) 5 0 P u b lic H e a lth S ig n ific a n c e S e v e re 5 0 Z o n e V e ry h ig h M o d e ra te 4 0 Z o n e 2 Z o n e 3 H ig h M e d iu m L o w 0 Zo n e 1 Zo n e 2 Zo n e 3 Ag g r e g a te d A groecological Zones A g e (m o n th s )

14 Proportion Weight for Height Z-score (WHZ) and Height for Age Z-score (HAZ) distributions <-2 = wasted <-2 = stunted Weight-for-length z-score Height-for-age z-score

15 P r e v a le n c e o f L o w B ir th w e ig h t % % Babies born Low Birth Weight (<2500g) Zo n e 1 Zo n e 2 Zo n e 3 Ag g r e g a t e d A g ro e c o lo g ic a l Z o n e s

16 P re v a le n c e o f m o th e rs ' u n d e rn u tritio n % % Undernutrition in mothers Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 1 5 Mean MUAC pregnant/lactating mothers: 26.0cm Mean MUAC nonpregnant/lactating mothers: 26.8cm M U A C < c m B M I < k g /m 2 In d ic a to r

17 DISEASE AND PUBLIC HEALTH

18 P r e v a le n c e o f M o r b id ity % % Child sickness (previous two weeks) 2 0 Dry Zone sickness prevalence: 28.0% Z o n e 1 Z o n e 2 Z o n e F e v e r C o u g h D ia r r h o e a M e a s le s O th e r F e v e r C o u g h D ia r r h o e a M e a s le s O th e r F e v e r C o u g h D ia r r h o e a M e a s le s O th e r

19 P r o p o r tio n % Health caring practices: Care of children with diarrhoea m o r e f lu id s m o r e f o o d O R S H o m e O R S Zin c t a b le t Zin c s yr u p D ia r r h o e a c a r e

20 P r o p o r tio n % Health caring practices: Hygiene practices Z o n e 1 Z o n e 2 Z o n e H a n d w a s h in g a f t e r c h ild d e f a e c a t e d H a n d w a s h in g a f t e r c h ild d e f a e c a t e d ( w it h s o a p ) H a n d w a s h in g p r io r t o f o o d p r e p a r a t io n f o r c h ild r e n H a n d w a s h in g p r io r t o f o o d p r e p a r a t io n f o r c h ild r e n ( w it h s o a p ) D is p o s a l o f f a e c e s in t o ile t H y g ie n e p r a c tic e s

21 P ro p o rtio n (% ) Household latrine access 6 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 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

22 % o f v illa g e s Village main water source Z o n e 1 Z o n e 2 Z o n e 3 Households with access to protected water year round: 64.5% T u b e w e ll/b o r e h o le H a n d d u g w e ll P o n d T u b e w e ll/b o r e h o le H a n d d u g w e ll P o n d T u b e w e ll/b o r e h o le H a n d d u g w e ll P o n d W a te r s o u r c e s

23 DIET

24 Infant and Young Child Feeding practices C o n s u m p t io n o f M N P C o n s u m p t io n o f f o r t if ie d f o o d s C o n s u m p t io n o f ir o n - r ic h o r ir o n - f o r t if ie d f o o d s M in im u m a c c e p t a b le d ie t ( b r e a s t f e d c h ild r e n ) M in im u m m e a l f r e q u e n c y ( b r e a s t f e d c h ild r e n ) C o m p le m e n ta r y fe e d in g M in im u m d ie t a r y d iv e r s it y 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 f o o d s T im e ly c o m p le m e n t a r y f e e d in g B o t t le f e e d in g E v e r b r e a s t f e d C o n t in u e d b r e a s t f e e d in g a t 2 ye a r s B re a s tfe e d in g C o n t in u e d b r e a s t f e e d in g a t 1 ye a r T im le y in it ia t io n o f b r e a s t f e e d in g E x c lu s iv e b r e a s t f e e d in g P r o p o r tio n (% )

25 D ie ta ry d iv e rs ity s c o re (ID D S & H D D S ) Mean dietary diversity scores (child, mother, household) 1 2 Z o n e 1 12 Z o n e 2 Z o n e 3 A g g re g a te d M o th e rs 4 * 4 * Individual Dietary Diversity Score non-pregnant/ lactating mothers: C h ild re n m o n th s A ll N o -p re g n a n t n o -la c ta tin g P re g n a n t o r la c ta tin g H o u s e h o ld s Individual Dietary Diversity Score pregnant/ lactating mothers: 4.2

26 QUESTIONS / COMMENTS?

27 HOUSEHOLD FOOD SECURITY, WEALTH AND POVERTY

28 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

29 P r o p o r tio n (% ) Season 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)? 5 0 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

30 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)

31 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

32 P r e v a le n c e o f M o r b id ity % P r e v a le n c e o f G lo b a l A c u te M a ln u tr itio n % Disease and poor public health environment, including WASH 1. Sickness similar trends as wasting and stunting Recent sickness/age Wasting/age 6 0 Z o n e Z o n e 1 Z o n e 2 Z o n e 2 Z o n e Z o n e A g e (m o n th s ) A g e (m o n th s )

33 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

34 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 food insecurity

35 F o o d e x p e n d itu re (% o f to ta l e x p e n d itu re ) Household incomes/expenditure 1. Low incomes from limited sources, agriculturefocused 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) Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d * * 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

36 T r a v e l tim e fo r a ro u n d trip to m a rk e t (h r s ) 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. 4 0 Z o n e 1 Z o n e 2 Z o n e R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n R a in y s e a s o n S u m m e r s e a s o n W in te r s e a s o n S e a s o n

37 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

38 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

39 QUESTIONS / COMMENTS?

40 Spare slides in case of questions about some specifics

41 P r o p o r tio n % Key preventative health interventions (children) * Z o n e 1 Z o n e 2 Z o n e B e d n e t u s e ( m o n t h s ) M e a s le s v a c c in a t io n ( m o n t h s ) An t ih e lm in t h c o v e r a g e ( m o n t h s ) V it a m in A s u p p le m e n t a t io n ( m o n t h s ) T B v a c c in a t io n b y B C G s c a r ( m o n t h s ) P r e v e n ta tiv e H e a lth C a r e

42 Ante-natal Care provision O th e r Z o n e 1 Z o n e 2 Z o n e 3 T r a d itio n a l b ir th a tte n d a n t A u x ilia r y m id w ife M id w ife N u r s e D o c to r P r o p o r tio n (% )

43 Mother s micronutrient supplementation 5 days a week 5 d a y s a w e e k Ir o n d u r in g p r e g n a n c y 3-4 tim e s a w e e k 1-2 tim e s a w e e k V ita m in B tim e s a m o n th A g g re g a te d Z o n e 3 Z o n e 2 Z o n e P r o p o r tio n (% ) A g g re g a te d P o s tp a r tu m V it A Z o n e 3 Z o n e 2 Z o n e P r o p o r tio n (% )

44 P ro p o rtio n (% ) Drinking water treatment Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d B o ilin g C lo th filtr a tio n L e a v in g it to s e ttle N o filtr a tio n O th e r

45 Food group consumption (mothers, 24 hour Z o n e 1 recall) O r g a n m e a t Z o n e 2 Z o n e 3 M ilk a n d d a ir y p r o d u c ts E g g s D a r k g r e e n le a fy v e g e ta b le s F is h a n d m e a t O th e r fr u its a n d v e g e ta b le s O th e r V ita m in A r ic h fr u its a n d v e g s L e g u m e s F a ts /o ils S ta r c h y s ta p le s P r o p o r tio n (% )

46 P ro p o rtio n % S e v e re (H D D S < 3 ) M o d e ra te (H D D S 3-4 ) A d e q u a te (H D D S > 4 ) Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d A g ro e c o lo g ic a l Z o n e s

47 P ro p o rtio n % P o o r (F C S < ) B o rd e rlin e (F C S ) A d e q u a te (F C S > ) * Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d A g ro e c o lo g ic a l Z o n e s

48 P ro p o rtio n o f h o u s e h o ld s (% ) 5 0 Z o n e 1 Z o n e Z o n e 2 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 r e L a n d le s s < > 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

49 P ro p o rtio n o f h o u s e h o ld s (% ) P r o p o r tio n o f a c c e s s e d la n d ir r ig a te d (% ) 5 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 6 0 * L a n d le s s < > 1 0 A c re s o w n e d b y th e h o u s e h o ld

50 % H o u s e h o ld s w ith s ta p le s to c k s Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d

51 M e d ia n d a y s o f s to c k a v a ila b le p e r h o u s e h o ld 2 5 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d

52 P ro p o rtio n o f h o u s e h o ld s (% ) 8 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d * 0 < < < 3 3 M o n th s w o rth o f s to c k

53 % H o u s e h o ld s w ith io d is e d s a lt Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d

54 P ro p o rtio n (% ) 5 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 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 y s D a ily c o p in g

55 P ro p o rtio n (% ) Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 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

56 P ro p o rtio n (% ) Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 5 0 A d e q u a te C S I < 3 M o d e ra te C S I S e v e re C S I > 3.4

57 P ro p o rtio n (% ) 5 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 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

58 P ro p o rtio n (% ) 4 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d N o in c o m e < 2 5 U S D U S D U S D U S D > U S D

59 P ro p o rtio n (% ) 2 5 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te 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

60 F o o d e x p e n d itu re (% o f to ta l e x p e n d itu re ) 8 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 6 0 * 4 0 * 2 0 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

61 E x p e n d itu re (k y a t) 2 5 0,0 0 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 2 0 0,0 0 0 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 5 0,0 0 0 * 1 0 0, ,0 0 0 * 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

62 P ro p o rtio n (% ) 6 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d < U S D U S D U S D

63 P ro p o rtio n (% ) 4 0 Z o n e 1 Z o n e 2 Z o n e 3 A g g re g a te d 3 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

64 METHODS (2/5) MORE ON SAMPLE SIZE Nutrition and IYCF: 1,800 children 0-59 months, including month olds: For anthropometric indices: using stunting 39% in 0-59 month olds, precision 5%, power 90%, design effect 1.5, 10% refusal = 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 = 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

65 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

66 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)** 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)** 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)

67 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

68 Significant associations Nutrition indicators as explanatory variables Outcome HAZ, explanatory variable birthweight, R 2 = 13.1% (0.1, 0.4) Outcome WHZ, explanatory variable birthweight, R 2 = 7.8% (0.1, 0.3) Outcome WHZ, explanatory variable mother s BMI, R 2 = 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 (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, R 2 = 2.2 (0.1, 1.3) Outcome HAZ, explanatory variable adequate FCS, R 2 = 1.8 (0.1, 0.7) Outcome BMI, explanatory variable mother s IDDS, R 2 = 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, R 2 = 3.4 (-0.7, 0.0)

69 More regression results Household food security indicators as explanatory variables Outcome BMI, explanatory variable HH livestock ownership, R 2 = 2.3 (- 0.0, 0.0) Outcome BMI, explanatory variable HH subsistence production, R 2 = 1.9 (1.8, 0.0) Outcome stunting, explanatory variable adequate HDDS, OR 0.43 (0.18, 0.99)