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

18 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

19 Household size The average household size of the surveyed communities is approximately 7.7 members per household. The Population Census of 1998 reported an average of 7.6 people per household. Age and sex distribution The overall sex ratio was acceptable, at 0.9. However, the age distribution showed skewing towards older children, with 6-29: month ratio of 0.75, which is lower than the ideal of 1.0. It is not clear whether high infant mortality has affected this age distribution or highly erogenous age estimates by team leaders, despite training, supervision and the use of a local calendar of events. As the youngest are most vulnerable to malnutrition, under representation of this group implies that the overall prevalence may be slightly under estimated. Table 2: Distribution of age and sex of sample, Mirpur Bathoro Survey, December 2010 Age group Boys Girls Total Ratio no. % no. % no. % Boy:girl 6-17 months months months months months Total Figure 2: Distribution of age groups among the children of the sample (n=670) months months months girls boys months 6-17 months Malnutrition rates 19 The prevalence of acute malnutrition in the survey areas is presented in Table 3. In the total sample, the prevalence of global acute malnutrition (GAM, WHZ<-2 and/or oedema) was 19.6% and that of severe acute malnutrition (SAM, WHZ<-3 and/or oedema) was 2.4%. No case of oedema was found. Although, malnutrition was found to be more prevalent in boys, but the difference was not found to be significant. 19 Throughout the report global acute malnutrition (GAM) is defined as weight-for height <-2 Z scores and /or oedema. Severe global acute malnutrition is defined as weight-for-height <-3 Z scores and/or oedema. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

20 Table 3: Prevalence of acute malnutrition expressed in weight-for-height in z-scores and/or oedema, Mirpur Bathoro, December 2010 WHO NCHS Index Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H< -3 z and/or oedema Global Acute Malnutrition W/H< -2 z and/or oedema Severe Acute Malnutrition W/H< -3 z and/or oedema Total 19.6 % (15.9% %) 2.4 % (1.0% - 3.8%) 17.8 % (14.3% %.) 1.5 % (0.4% - 2.6%) From table 4, malnutrition appears to be fairly evenly distributed throughout the sample with a peak of 5 cases (WHZ<-3) found among the and month age group. This is unusual and it is not clear whether these children had suffered from previous illness that caused them to lose weight recently. Similarly, proportionately a high number of cases of moderate wasting were found in the year old group (28.9%). Slightly more representation of older age group children in the sample may explain why the older groups of sampled children were disproportionately wasted. Table 4: Prevalence of acute malnutrition by age based on weight-for-height z-scores and/or oedema, Mirpur Bathoro, December 2010 Age (mths) Total no. Severe wasting (<-3 z-score) Moderate wasting (>= -3 and <-2 z- score ) Normal (> = -2 z score) Oedema No. % No. % No. % No. % Total Distribution of anthropometry result compared to international reference Figure 3 shows the weight for height distribution curve of the survey sample in Z-scores compared to the WHO standard population. The entire weight for height distribution curve of the sample is skewed to the left with a fairly even distribution, which indicated that the sample population has a poorer nutritional status that the reference one. Figure 3: Weight-for-Height distribution in Z-scores, Mirpur Bathoro; December 2010 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

21 Prevalence of acute malnutrition based on mid-upper arm circumference scores (MUAC) 20 As can be seen in table 5, the prevalence of global acute malnutrition (GAM, MUAC< 125mm) was 17.2% and that of severe acute malnutrition (SAM, MUAC<115mm +/- oedema) was 3.9%. Table 5: Prevalence of acute malnutrition based on MUAC (n=670) MUAC scores (Children 65cm to 110 cm) Nutritional status Number % 95% CI <125mm Global Acute Malnutrition <115mm Severe Acute Malnutrition Mortality results (retrospective over 90 days prior to interview) Table 6: Mortality rates Mortality rates Total crude retrospective mortality /10,000/day 0.44 ( ) Under five crude retrospective mortality /10,000/day 0.80 ( ) Crude mortality rate (CMR) (total deaths/10,000 people / day) was estimated at 0.44 ( ) (95% CI). Under five mortality rate (U5MR) (deaths in children under five/10,000 children under five / day) was estimated at 0.80 ( ) (95% CI). Both the crude mortality and U5 mortality rates are well below emergency thresholds of 1.14 and 2.3 deaths/10,000 /day, respectively 21 Table 7: Reported cause of child mortality during 90 days recall period (n=6) Cause of death Number of Cases Percentage cases among reported deaths Diarrhoea ARI Other (Unknown) Total The majority of the mothers (66.6%) reported to not known the cause of their child deaths. Of the cases reported, ARI and diarrhea related disease were attributable for 33.4% of the U5 deaths in the last 3 months Children s morbidity The prevalence of reported illness in the 2 week period prior to the survey was high estimated at 53.2% (n=359). Table 7 presents the reported causes of illness. Table 8: Symptom breakdown in the children in the two weeks prior to interview (n=359) Cause of Illness Diarrhea Cough Fever Other (skin diseases +) % of children who reported illness 33.7 (n=121) 15.6 (n=56) 34.9 (n=125) 15.9 (n=57) 20 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 21 International emergency mortality thresholds by Sphere (2004) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

22 Fever and diarrhea related illnesses were the most prevalent contributing to almost 35% and 34% of illnesses respectively. It is recognized that suboptimal hygiene practice and low access to safe water, are the main factors contributing to diarrheal disease Vaccination Results Vitamin A supplementation coverage is very poor overall with only nearly a quarter (22.5%) of all children receiving a capsule within the six months prior to the survey. Less than half (43.6%) of all the children 9-59 months in the sample have received measles vaccination only 5.6% had documentation from the immunization card and 38% from the mother or caretaker s confirmation. The BCG coverage is relatively better with 59.9% of the sampled children received vaccination. It was reported that as a precautionary measure to control outbreak of diseases following the flood emergency, measles and other routine vaccination (BCG, Penta, TT) were given in all areas of Thatta between 26 th October to 6 th November while Vitamin A supplementation and polio vaccination was given 9-12 th November to prevent any outbreak following the flood emergency. However, the current survey findings for Measles, BCG and Vitamin A presented were surprisingly low. It was felt that while acknowledging factors such as missing children (vaccinated but not available during the survey), mother recall bias (very few MCH cards retained) and acknowledging the challenges faced by any outreach campaign in this vast area, the poor coverage estimate during the survey warranted further investigation. Table 9: Vaccination and Vitamin A supplementation coverage: BCG and vitamin A supplementation for 6-59 months and measles for 9-59 months Vaccination and Vitamin A supplementation Percent (95% C.I.) By card 5.6% ( ) Measles immunization coverage (children >=9 months old, n= 663) According to caretaker 38.0% ( ) Not immunized 56.4% ( ) BCG by scar (n=675) % ( ) Vitamin A (n=675) in the last 6 months 22.5% ( ) 11.6 Program Coverage Supplementary and Therapeutic Feeding Program There is no any operational supplementary or therapeutic feeding program in Mirpur Bathoro. None of the mothers and children in the sampled households received UNIMIX or PLUMPYNUT with in the six months prior to the survey Health care practice Reports of health seeking action taken was asked of mothers whose child had experienced one of the following 3 illnesses in the 2 weeks prior to the survey- serious diarrhea, persistent cough, or serious fever. 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; in addition (28.8%) received treatment from private physician and (2.6%) from pharmacy. Only 2% of the surveyed households reportedly sought treatment from other health care providers such as village health care worker. 22 BCG scar is observed in the right hand of the children ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

23 Figure 4: Health seeking behavior related to child morbidity % of households seek treatment 100% 80% 60% 40% 20% 0% Hospital/health center/bhu Pharmacy Private physician Village health care provider 11.8 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. However, there was gradual decline in continuation of breastfeeding with age and only 59.5% children over 18 months were still continuing breastfeeding. 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. Mothers were asked at what age foods other than breast milk were fed to the child. Based on mothers response, (40%) of the children were introduced to complimentary foods at recommended age of 6 months. 30% of children as young as 4 months were introduced complementary food. Sixty percent of children 6 to 8 months of age and still breastfeeding received the minimum number of meals. Less than half (42.2%) of breastfeeding children 9 to 23 month of age, and only 17.6% of the 6 to 23 months old nonbreastfeeding children received the minimum number of meals. Table 10: Infant Feeding Practices, Mirpur Bathoro, December 2010 Indicators Percent Breastfeeding Child ever breastfed 85 Child still breastfeed 74 Reason for stopping breastfeeding Child grown-up 44.4 Milk not enough 40.7 Grief/disturbance 14.8 Age complementary food started <6 months months 40 >6 months 13.3 Minimum number of meals/child age (24 hours before survey) 23 6 to 8 months, breast feeding 60 9 to 23 months, breastfeeding to 23, non-breastfeeding Minimum defined as 2 times for breastfed infants 6-8 months, 3 times for breastfed infants 9-23 months, 4 times for nonbreastfed infants 6-23 months. PAHO ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

24 11.9 Maternal Knowledge Women were asked whether they know what balanced diet means. Approximately all (91.3%) of the women responded that they don t know what is meant by balanced diet. They were also asked to list the foods that are rich in Vitamin A. None of the surveyed women mentioned the foods that are rich in vitamin A. 22.9% of all women responded (Table 11) that the cause of diarrhea was from dirty contaminated liquid and spoiled food. The cause which received the third most responses was not washing hands before taking meals (4.1%). 14.3% of all women responded that the use of safe foods and fluids would prevent diarrhea. 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. Table 11: Maternal Knowledge of balanced diet, vitamin A, diarrhea causes and prevention Percent Do you know balanced diet? Yes No Food rich in vitamin A Don t know Causes of diarrhea Dirty/contaminated water/liquid Spoiled, stale food Not washing hands before taking meal Not using sanitary latrine Don t know Prevention of diarrhea Use of safe fluids Washing hands before taking foods Washing hands with soap after defecation Using sanitary latrine Don t know Household vulnerability 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. Labor was the most common form of occupation before the flood (20.4%) in the survey area and this occupation didn t decrease significantly after the flood (18.4%). Household assets The flood caused a significant but not extreme decrease in livestock size or other assets among the surveyed populations. Household possession of cow saw on an average the loss of nearly one (0.9) per household which is equivalent to a 30% loss on average. It should be noted that the number of households without livestock increased after the flood24. Chickens were the most depleted (57.7%) from a household s assets in the time since the flood. N 24 Households without livestock before the flood was 41.3%; while after the flood the number of HHs without livestock was found to be 48.5% ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

25 This suggests an increase in household level vulnerability due to increased exposure to shock and reduction in asset levels. 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 25 season crops. Figure 5: Average difference in livestock assets at households before and after flood, Mirpur Bathoro, December 2010 Difference in mean number of livestock Cow Sheep/Goats Chicken 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. Table 12: Household coping mechanisms, Mirpur Bathoro, December 2010 Percent N Sell of assets Livestock Jewelry +other valuable Land Loans Previous loan extended New loan Household food access The surveyed communities in Mirpur Bathoro were vulnerable as defined by access to food; 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. It is, however, possible that differences in food stock availability across the samples depend on the extent of the flood damage. 25 rabi season crops are short-cycled crops includes: vegetables and green fodder ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

26 Figure 6: Household Access to Food, measured by food stock, Mirpur Bathoro, December % of Households Less than a day Less than a week 1 week or more 10 0 Food Stock Availability 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 staplefood 26 every day. Almost two-third (61.7%) of the surveyed households consumes at least one source of protein 27 within the 24 hours recall period prior to the survey. However, consumption of animal protein source is relatively low with 51.5% of the surveyed households reported consumed within the 24 hours recall period. Milk and milk products consumption was reported as quite high (81.6%), but this result should be taken with caution as milk in tea was also considered dairy consumption and culturally tea is drunk frequently with milk product. The consumption of fruits is low with only 9.1% of the surveyed households consuming fruit at least once with in the 24 hours period prior to the survey. The results of the 24 hour recall data suggest that households in Mirpur Bathoro predominantly survive on daily cereal intake (wheat and rice). Table 13: Household food consumption (24 hour recall), Mirpur Bathoro, December 2010 Food groups % of Households Cereals (Wheat, Rice, Maize) 100 Legumes (Pulses, Ground nut) 38.3 Meat/Chicken/Fish 29.6 Egg 43.4 Cooking oil/fats 94.4 Vegetables 67.9 Fruits 9.1 Milk Products (Milk, Yoghurt, Cheese) 81.6 Sugar 91.8 Any other food (wild foods, etc) 6.6 The household food diversity of the population in Mirpur Bathoro was estimated using seven day food consumption recall data. The majority of households (55%) fell within the range of consuming 5-7 food items. Considering that commodities such as sugar and cooking oil were considered items, this dietary diversity could indicate a troublesome situation. Approximately 21% of the population surveyed consumed 1-4 food items over the past week with an additional 24% of the population consuming more than 7 food items. 26 Staple defined as rice or wheat 27 Protein source defined as legumes, meat/chicken/fish and eggs ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

27 Figure 7: Household food diversity, measured by frequency of food consumed, Mirpur Bathoro, December % 21% 1-4 food items 5-7 food items 8+ food items 55% The lack of dietary diversity as measured by food consumption score (FCS) indicated that more than two-third of the population having acceptable consumption intake. Overall, 10.2% of the households have poor consumption, 13.3% have borderline consumption and 76.5% had adequate consumption. Households with poor consumption eat the equivalent of only cereals on a daily basis. This is considered a bare minimum and is a sign of extreme household food insecurity. Table 13 shows the FCS in Mirpur Bathoro using standard global threshold values 28. These results are indicative only and should be calibrated against FCS thresholds developed in the national context. Table 14: Food Consumption Score (FCS), Mirpur Bathoro, December 2010 Mirpur Bathoro Water, sanitation and hygiene Acceptable Borderline Poor Table 14 shows that among all households, 93.4% were using improved sources of drinking water 29. Over 89% of the households in the surveyed areas indicated that they have access to drinking water from hand pump, 2.6% had water from tanker/truck, while 1.5% had it from spring; on the other hand, 2.6% were using a river and 4.1% were using other unprotected water source such as pooled flood water and exposed springs. Regarding water collection times 30, 57.7% of households were using a water source located on the premises and a further 26% less than onehour round trip. Overall, 29.6% of the sampled households reportedly boiling water (28.1% always and 1.5% sometimes). The only form of water treatment used is boiling. Of those households that do treat, most boil the water always (28.1%) and fewer households boiling the water sometimes (1.5%). 28 The food consumption score (FCS) was calculated based on the number of days particular food groups were consumed as follows: FCS = 2(cereal) +3(pulses) +4(poultry/meat/eggs) +0.5(oil) +4(milk products) +1(vegetables) +1(fruit) +0.5(sugar/sweets). Cut-offs were applied as follows: - Poor food consumption is score between Moderately food consumption is score between Adequate food consumption is score of more than Improved drinking water source is defined as being one of the following: hand pump, tap stand, tap in house, supplied by govt. /NGO, water point. In the surveyed context, spring water is also considered to be a safe water source. 30 Including the distance to the water point and queuing times ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

28 As indicated by the findings on table 14, access to safe sanitation is very low in Mirpur Bathoro. Among all households, only 10.2% were using improved toilet facilities % of households were not using any facility; they reported using the bush/open-field 32. A small number of households were using an open pit or latrine without slab (3.6%). Among the surveyed households, only 32.7% had their waste disposed either buried or dump in the toilet. The majority of households were either disposing of the waste on the open space (40.8%). The other common practice of the surveyed households was to dump it in their own compounds (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, 46.4% bathe twice a week and 26.5% bathe every week. Table 15: Water, sanitation and hygiene practices, Mirpur Bathoro, December 2010 Percent N Sources of drinking water Hand pump Tanker/truck Spring River Pooled flood water/exposed springs Time taken to fetch drinking water (round trip and queuing time) Water on premises Less than 1 hour hour or more Treatment of water at home Yes, always Yes, sometimes No treatment Toilet facilities Pour Flush Pit Latrine without slab Open field/bush Method of waste disposal Buried Pit-latrine Dumped in the street/open space Disposed in the compound Hand wash with soap Yes, always Yes, sometimes Never Bath Daily Twice a week Every week Once in fifteen days Once a month Improved toilet is defined as being one of the following: flush to piped sewer system, flush to septic tank, flush to pit latrine, ventilated pit latrine, pit latrine with slab or composting toilet. 32 In Pakistan culture, women often use to defecate in corner around the house where there is no toilet facility ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

29 12. DISCUSSION Anthropometry Anthropometric indicators used to measure child malnutrition include wasting, stunting, and underweight. These indicators compare the growth of the child being measured with the growth of a well-nourished and healthy, reference population of children of the same age (WHO/NCHS). Nutritional status can be negatively impacted by illness/infection and dietary intake. Within the household, conditions such as food security, clean water, safe sanitation facilities, hygiene practices, maternal care practices and access to health services can have an impact overall on the nutrition situation. Wasting, or thinness, is an indicator of acute (short-term) malnutrition. It is calculated by comparing the weight for height of a child with a reference population; a child is considered wasted if her/his weight-for-height z-score is below -2SD of the reference population. Wasting is usually the result of recent food insecurity or infection/illness, such as diarrhea. It is often used to assess the severity of an emergency situation, with severe wasting being highly correlated with mortality. Since wasting is a nutritional deficiency of recent incidence, that prevail usually due to emergencies, at 19.6% ( % C.I), the prevalence of acute nutrition in Mirpur Bathoro is classified as critical. However, the prevalence of acute malnutrition in Sindh Province is estimated to be 18.1% (NNS ), and it is appropriate to conclude that the above results didn t deviate much from the usual prevalence of acute malnutrition and wasting in these populations and only slightly increase since the flood and therefore, the high prevalence of GAM is unlikely due, to any great extent, to the flood disaster. Still, it should not be overlooked that the flood exasperated the situation. The age distribution of the sample population showed shift towards older children, which may suggest that the overall prevalence may be slightly under estimated as the underrepresented young age children are most vulnerable to malnutrition. The prevalence of severe acute malnutrition found in the survey (2.4%) in lower than the value reported for Sindh Province (5%) in NNS , but this finding should be viewed with caution since there are high number of moderately malnourished cases near to the severe cutoff and that can easily fall into the severe category and push the prevalence of SAM to a higher level. Programmatic responses to acute malnutrition as classified by -3 z-scores need to consider this. From the finding of this assessment, 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 this assessment indicate a prevalence rate of 19.6%. This has several implications especially with regards to addressing nutritional problems and there is an urgent need for treatment and prevention of acute malnutrition to improve the overall situation of children. Mortality Both crude and under five mortality rates were well below emergency thresholds of 1.14/10,000/day and 2.33/10,000/day respectively. While the child mortality rate was relatively low, it is difficult to comment on the cause of mortality given that for the majority of cases, cause of death was unknown. Of the reported cases of U5 death, diarrheal and ARI related disease was attributable for one-third of the deaths in the last 3 months. These causes are preventable and efforts should continue to be made to address the causes of U5 death. Morbidity and Health Care Practices The prevalence of morbidity in the survey samples was high (53.2%). This clearly indicated that the situation in Mirpur Bathoro is precarious. Fever and diarrhea are attributable for more than two-third (68.5%) of the reported illnesses. The finding of this survey is consistent with the NNS finding 33. The U5 children in Mirpur Bathoro had a very high prevalence of diarrhea with almost one-third (33.7%) experiencing diarrhea in the previous two weeks. The diarrhea morbidity found in this assessment is higher than the national prevalence of 25% (NNS, ). 33 According to the NNS , fever and watery diarrhea are common with higher occurrence in the rural areas of Pakistan. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

30 Diarrhea has a major impact on the nutritional status of the patient. Frequent bouts of diarrhea for example can quickly result in loss of weight and deterioration of the nutrition status of the young child. When a child has diarrhea, absorption and intake of food are reduced while there is a higher need of energy. Besides this, malnourished children are more vulnerable towards diarrhea resulting in a vicious circle (diarrhea leads to malnutrition and malnutrition worsen diarrhea) that needs to be broken. The impact of a poor WASH situation is reflected in the high incidence of diarrheal disease in the Thaluka, contributing to unnecessary morbidity and mortality in children, as treatment for diarrhea is simple, easy to prepare, readily available and highly effective. Young children are especially vulnerable to losing excessive weight very quickly due to successive bouts of diarrheal disease and subsequently becoming malnourished. Diarrhea is a symptom of many illnesses. There is a clear need for an immediate improvement of the health situation of the target population. Much can be done to turn this situation around by improving access to safe water, promotion of water treatment options, improving sanitation access and hygiene promotion as well as focusing on the home management of childhood illness. It is recommended that continued joint efforts with WASH experts is needed to address the lack of safe water resources and the lack of sufficient sanitation facilities in the Thaluka and to continue working to mobilize the community to improve hygiene practices and promote best practice for the home management of diarrhea treatment. Likewise, the prevalence of fever was high at 34.9% among the sample U5 children. This is approximately similar to the national prevalence of 36% (NNS ). Fever illness, which is commonly a symptom of malaria, is important to identify early and treat due to the morbidity and mortality associated with it. Targeting nutrition alone without making an effort on the general health situation might be insufficient as diseases and nutrition are so clearly linked. Besides this, sick children need more energy and thus more food to recover. It is suggested that to mitigate serious illness and deterioration of the child s nutrition status, home based care of sick child should be a strong component of any health education and counseling package especially in remote areas where access to health services may be low. Health seeking practices as reported by mothers with sick children was encouraging, with a high proportion of mothers visiting health facilities. However, the limitation of some centres is their accessibility: as transportation costs are high, visiting a health care provider is time consuming and expensive as well; so some mothers practice treatment at home and resorting to local health care provider such as village health care workers for curative services. At the health facilities level, the nutritional status of children is not often evaluated, and when it is, it rarely induces a referral to the existing nutritional program. The health facilities are understaffed and lack of drugs and basic equipments to measure the nutritional status of children and monitor the growth. There is a general lack of understanding toward acute malnutrition, its potential impact and causes. However, the health professionals in the health facilities at Mirpur Bathoro acknowledged that there is high influx of clinically visible malnourished cases admitted to their facility, but there is no any service provided to treat them and stressed the need of the nutrition program in their area. Infant Feeding Practices and Maternal Nutrition Knowledge Breast milk is the only food or drink that a newborn child needs in the first 6 months of his life. 34 Adhering to the recommendation of exclusive breastfeeding during this period is important to help protect babies from dangerous illnesses. Giving other foods or liquids increases the risk of morbidity as a baby s exposure to pathogens and contaminants is increased. After 6 months, the child can be introduced to appropriate complementary foods, but it is recommended that they be breastfed until 24 months of age. In this survey, breastfeeding practices are high with over 85% of children breastfed at some point before 24 months of age. Continuation of the breastfeeding gradually declined with age. Child grown-up and insufficient milk were the main reasons for stopping breastfeeding in the survey populations. Although the breastfeeding practice is 34 Breastfeeding Key Messages: What Every Family and Community has a Right to Know January 20, 2011 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

31 encouraging, the reasons given for stopping breastfeeding is a concern and conspicuous threats to the nutritional status of children in the area. A mother who has the appropriate knowledge about nutrition and the cause of childhood illnesses and infections is better able to provide appropriate care to the child and seek treatment of her children. If her knowledge is inadequate or wrong, it can lead to inappropriate child caring practices and incorrect treatment and prevent recovery from illness. The finding of this assessment led to the realization that low maternal knowledge on the causes of common childhood illness and poor nutritional knowledge are some of the areas of concern that needs appropriate intervention as these factors have direct and indirect effect on the health and nutrition status of children and mothers. However, in reference with the scale and severity of the nutritional problem in the surveyed area, the health and nutrition education activity alone is inadequate to address the issue of malnutrition in the area. Household Vulnerability Assessment Almost (40%) of the surveyed households experienced flood related damage to their houses. The flood had a minimal impact on employment of the household heads. Only 2% more residents in the surveyed households reported unemployment after the flood. Labor was the most common form of occupation before the flood (20.4%) in the survey area and this occupation didn t decrease significantly after the flood (18.4%). Loss of livestock was not considerable in mean numbers; however the loss in terms of economic and nutrient value of even a small number of livestock holdings could have an impact on the future food security status of the households and expose them to minor vulnerability and nutritional deprivation of the surveyed population. On the other hand, losses of poultry were substantial with households reporting that more half (57.7%) of their chicken/ducks drowned by the flood water; and this could limits households from accessing a diversified diet, which in turn increases the risk of malnutrition especially among vulnerable groups % of the populations in Mirpur Bathoro have reported some losses of their major crops, such as rice, vegetables, cotton, sugar and fodder; which in turn affect the income and the purchasing power of the community and indirectly affect the nutrition situation. Only less than half (45%) of the surveyed households reported planting of the rabi season crops, and in areas where flood waters do not recede yet and due to the salinity after the flood, farmers were prohibited from planting. This could also have a long-term implication on the nutritional condition of the population. Distress sales of assets and loan taking was not as high as might be expected with 39.3% of the populations selling assets and a minor portion of the surveyed populations (23%) taking loans after the flood disaster. Still, the finding of this assessment gives a reflection of the shock felt among the populations of Mirpur Bathoro Thaluka. Household Food Access, Consumption and Dietary Diversity The surveyed communities in Mirpur Bathoro were vulnerable as defined by access to food; with only 48.5% enjoying access to more than one week of food. Food stocks are limited and this leads to high vulnerability of the population towards food shortage. Household food diversity (as defined by seven day food recall) is an attractive proxy indicator of a more diversified diet with a number of improved outcomes in areas such as birth weight, child anthropometric status, and improved calorie and protein adequacy. Knowing that households consume, for example, an average of four different food groups implies that their diets offer some diversity in both macro- and micronutrients. The survey finding indicated that the household food diversity is limited. The majority of the population consumes 5-7 food items, but interpretation of the result should be taken with caution as this analysis contains items such as sugar, oil and milk with tea. Almost one-quarter of the population (21% in all sample areas) consumes only 1-4 food items in their diet. The lack of dietary diversity as measured by food consumption score (FCS) is indicated that (10.2%) of the population having a poor consumption intake suggesting the vulnerability of the households to food shortage and nutritional deprivation. Water, Sanitation and Hygiene ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

32 The quality of the household drinking water source and the type of toilet facility the household uses is commonly used as a socio-economic status proxy. In addition, they are both useful for their relationship to health outcomes (diarrheal illness, etc). The time taken to collect drinking water is important in assessing the general welfare of the household. What a household does to treat drinking water, the method of waste disposal and hygiene practices are indicators of a household s knowledge and practices about appropriate and safe health behaviors. Among the surveyed households, high proportions (93.4%) were using improved sources of drinking water, from which over 89% uses hand-pump. In addition, 57.7% of households were using a water source located on the premises. In some of the surveyed villages, the residents reported that the use of hand pump has decreased as most of them have been submerged under flood water for a certain period. Some households (4.1%) in the visited villages are using unclean water source from the pooled water in the canal formed by the flood, which is open for microbial contamination and animal interference. In some villages (7.5%), heavy rains caused animal carcasses to be washed into water pans, leading to contaminated water sources. It should also be noted that only few households treat water for drinking purposes (29.6%). Access to safe sanitation is of concern in Mirpur Bathoro. Majority of households reported mostly that they do not use soap to wash their hands (56.4%) and 38.3% of individuals questioned did not wash their hands after defecating. Among all households, only 19.9% reported that they bathe daily. Among all households, only 10.2% were using improved toilet facilities. 86.2% of households were not using any facility; they reported using the bush/field. The majority of households were either disposing of the waste on the open space (40.8%). Worryingly, in some villages, the distance between the main house and the open defecation field is barely distant. It is to be noted as well that in some of the villages visited, it was common to see the defecation areas very close to the water points. Access to clean water and sanitation are detrimental factors to the nutritional well-being of children. The fact that the communities reported high incidence of diarrhea illness (33.7% of children suffering bouts in preceding last 2 weeks) gives some explanation to the observed high rate of children malnutrition. Therefore, poor access to safe water for human consumption, poor hygienic practice and a lack of defecation control are important factors contributing to morbidity (in particular diarrheal diseases), and increases the risk of nutritional deprivation of children. Program Coverage There is no any operational supplementary or therapeutic feeding program in Mirpur Bathoro. None of the mothers and children in the sampled households received UNIMIX or PLUMPYNUT with in the six months prior to the survey. Vitamin A supplementation coverage is very poor overall with only nearly a quarter (22.5%) of all children receiving a capsule within the six months prior to the survey. Less than half (43.6%) of all the children 9-59 months in the sample have received measles vaccination - only 5.6% had documentation from the immunization card and 38% from the mother or caretaker s confirmation. The BCG coverage is relatively better with 59.9% of the sampled children received vaccination. It was felt that while acknowledging factors such as missing children (vaccinated but not available during the survey), mother recall bias (very few MCH cards retained) and acknowledging the challenges faced by any outreach campaign in this vast area, the coverage estimate during the survey were surprisingly low. The results of this assessment clearly suggest that achieving acceptable levels of immunization coverage, remains a huge challenge in Mirpur Bathoro. The result also indicates that the routine immunization program is performing poorly and attention should be placed on strengthening to achieve a very high level of immunization coverage. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

33 13. RECOMMENDATIONS CMAM Program: A full-fledged CMAC program has to start immediately to provide SC/OTP service to treat children who are already severely malnourished and to prevent those that are at risk of becoming severely malnourished. The operation should be intensified in terms of appropriate targeting, number of beneficiaries and frequency of distribution. The SC/OTP should be linked with strong SFP component. Supplementary Feeding Program: Provide supplementary food under a SFP targeting the most vulnerable in the community, pregnant and lactating women (PLW) and children U5; providing 2 months blanket SF distribution to prevent further malnutrition among the community, followed by 4 months targeted supplementary feeding for moderately malnourished PLW and U5 to cap a rise in moderate malnutrition and prevent an increase in severe acute malnutrition in children in the months ahead. Static Nutrition and Health Service: Establish the delivery of static nutrition and health services by ensuring adequate staff and supplies are available. As the existing local health institutions are constrained by poor resources to manage cases of severe malnutrition and staff have not been trained on protocols for the management of acute malnutrition, it is recommended that health staffs at local health centres should be trained in the Management of Acute Malnutrition and treatment using the national protocol and materials should be provided. 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, to promote early case detection of malnutrition cases and disease and treatment and management of severe acute malnutrition. Seek the support of local health authorities to expedite the process. Linkage between Mobile and Static: Ensure effective linkage between mobile and static operations to deliver an integrated package for the treatment and management of malnourished cases. 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 and promote correct utilization by all family members in this malaria prevailing area. Health and Nutrition Education: Given the high diarrhea morbidity and 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. This is likely to include SMART nutrition and mortality surveys and involving key partners from EDO, DCO, DDMA, UN agencies and partner NGOs. Immunization: Immunization campaign targeting Mirpur Bathoro for an enhanced EPI campaign throughout the entire Union Councils. 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. This may be in the form of food for work and infrastructure development initiatives. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

34 Appendix I - Map of the Surveyed District Thatta District/Pakistan Mirpur Bathoro Thaluka covered by nutrition survey December 2010 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

35 Appendix II - Clusters selected, Mirpur Bathoro Thaluka, Thatta district, December 2010 Union Council Bachal Gugo Banno Mahar Shah Laik Pur Geographic unit Population size Assigned cluster Village Deh Atelsha QM Shah 2 AB Sumr Shapur Saindino Gugo Gulmammad M Uris Dachri Mamoom Soomru Gahki Sidiqi Dars MengiiLedo Nuur Bux Khoso BeloKedi Ayoub Shoro Banno Unit Ali Bahar RelMolchand Lemo Jamari Tiko Arab Lashari Baadh Soof Palijo Rahoth Fazel Palijo KheerDehi HUB Poto HusseinPur Roil Lashari Kotadya Aban Lashan KarimPur Abdurahim Tetri LaroCharo 3000 Layari Kauro Kharik Peryarki Sikdo Pakadi Kandor 3800 Railo 3500 Munjiri Hafiz Shah Kamaro Anb Mallah DaryaKhansoho 4300 Oberado Laikpur 4000 Alondo Laikpur Saleh Soomro KhanPur Natho Khaskeli 36 Qasim Su Abral Umaid Ali LaikPur Cenetr Bhambro 41 Haji Budoo Sumroo Hashim Prehar Ali Mohd Khaskele Ibrahim Mallah Ghulam Kehar Yousif Mallah Ali Bhambhro Arab Bhumbro Mommed Udejo Isaq Khas Achar Mallah Golo Khan Khakhi Dars Allah Rakhyo Shoro MK Sumroo ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

36 Appendix III Report for Evaluation of Enumerators Weight: NB. This is only single measurement analysis (round 1). Each child was supposed to be measured by 10 measurers two times, total of 24 times. However, some mothers refuse after only 12 measurements as children were children crying. So the analysis is only to show accuracy. Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [W2-W1] [Superv.(W1+W2)- Enum.(W1+W2] Supervisor Error Enumerator 1 Error 0.04 OK 10/0 3/1 Enumerator 2 Error 0.07 OK 10/0 4/3 Enumerator 3 Error 0.05 OK 10/0 2/3 Enumerator 4 Error 0.07 OK 10/0 2/2 Enumerator 5 Error 0.06 OK 10/0 0/3 Enumerator 6 Error 0.04 OK 10/0 2/2 Enumerator 7 Error 0.03 OK 10/0 2/1 Enumerator 8 Error 0.04 OK 10/0 2/2 Enumerator 9 Error 0.03 OK 10/0 2/1 Enumerator 10 Error 0.04 OK 10/0 1/3 Enumerator 11 Error 0.01 OK 10/0 1/0 Enumerator 12 Error 0.02 OK 10/0 1/1 Height: Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [H2-H1] [Superv.(H1+H2)- Enum.(H1+H2] Supervisor Error Enumerator 1 Error 1.29 OK 10/0 2/7 Enumerator 2 Error 0.10 OK 10/0 3/4 Enumerator 3 Error 0.04 OK 10/0 1/3 Enumerator 4 Error 0.08 OK 10/0 4/1 Enumerator 5 Error OK 10/0 0/3 Enumerator 6 Error 0.01 OK 10/0 0/1 Enumerator 7 Error 0.02 OK 10/0 0/2 Enumerator 8 Error 0.02 OK 10/0 1/1 Enumerator 9 Error 0.03 OK 10/0 0/3 Enumerator 10 Error 0.01 OK 10/0 0/1 Enumerator 11 Error 0.03 OK 10/0 1/2 Enumerator 12 Error 0.03 OK 10/0 2/1 For evaluating the enumerators the precision and the accuracy of their measurements is calculated. For precision the sum of the square of the differences for the double measurements is calculated. This value should be less than two times the value of the supervisor. For the accuracy the sum of the square of the differences between the enumerator values (weight1+weight2) and the supervisor values (weight1+weight2) is calculated. This value should be less than three times the accuracy value of the supervisor. To check for systematic errors of the enumerators the number of positive and negative deviations can be used. ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

37 Appendix IV ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE ANTHROPOMETRY FORM, DECEMBER 2010 Survey Date: / /2010 UC; Name Deh Name ; Village Name: Cluster Number: ; Team Number: ; T. Leader: Child No. HH No. Name Sex (F/ M) Date of Birth (DD/MM /YY) Age Wt. (kg) 100g Ht (cm) 0.1 cm Oedema (Y/N) MUAC in cm WH% Vitamin A in the last six months 0= no 1=yes =Diarrhea, more than three loose stools/day; 2= cough or difficulty breathing; 3= Fever or high temperature; 4= other illness in the two weeks before the survey. Vaccination in the last 6 months BCG Measles Mark yes card= 1 0= no yes no 1=yes card=2 no= 0 Illness in the last 2 weeks No= 0 Diarrhea=1 Cough=3 Fever=3 Other=4 Did child receive unimix in last 6 months Did child receive plumpyn ut in last 6 months

38 Appendix V ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE RETROSPECTIVE MORTALITY FORM, DECEMBER 2010 Survey Date: / /2010 UC; Name Deh Name ; Village Name: Cluster Number: ; Team Number: ; T. Leader: HH HH Members Join HH since Start date Leave HH since Start date No. births Since start date Deaths since Start date Remark Total < 5 Total < 5 Total < 5 Total < Key for cause of death: 1 = Diarrhea, 2=ARI, 3= fever, 4= measles, 5 = accident, 6 =unknown, 7= other (specify) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

39 Appendix VI ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE, PAKISTAN DECEMBER 2010 HOUSEHOLD QUESTIONNAIRE INSTRUCTION TO ENUMERATORS Greet the household first and then introduce yourself as follows: We are from ACF. We are conducting nutrition survey for a project concerned with improving the nutritional status of the population. We would like to talk to you about this and we will also weigh and measure children who are younger than 5 years of age. The interview will take about 45 minutes. All the information we obtain will remain strictly confidential and your answers will never be disclosed to any one else. This is voluntary and you can choose not to answer any or all of the questions. How ever your participation is important to the success of this survey. During this time I would like to speak with the household head and all mothers or others who take care of children in the household. May I start now? Yes No If permission is granted, begin the interview if not, thank him/her and complete SECTION I. Inform your team leader and supervisor about the situation. SECTION I: IDENTIFICATION Date / /2010 Name of Respondent: Day Month Name of Interviewer: Name of Team Leader: Area/Location: I) Province: II) District: III) Thaluka: IV) Union Council: V) Unit/ Deh : VI) Village: Interviewer/team leaders note: Use this space to record notes about the interview with this household, such as call-back times, incomplete individual interview forms, number of attempts to re-visit, etc. Interviewers visit: Date of the final visit: 1st visit ; 2nd visit ; 3rd visit / /2010 Day Month Interview with HH 1= Complete 2= Partially complete 3= Refused 4= Not available 5= Other (Specify) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

40 SECTION II: HOUSEHOLD INFORMATION 2) Please list members of the HH who are currently present and those who were living during the flood (recall period) and not present in the HH now. Line no. Name Start by the household head What is the relation-ship of (name) to the head of the household? 01 husband 02 wife 03 son 04 daughter 05 brother 06 sister 07 father 08 mother 09 cousin 10 mother-in-law 11 father-in-law 12 other Is (name) male or female? (1= male, 2= female) How old is (name)? Age in (yrs) for adults and in month/days for children/ newborns Present Now (1=Yes, 2=No) Present at the beginning of the recall period (1=Yes, 2=No) Current status (1=alive, 2=dead, 3=unknown) If dead Record cause of death, date of death Occupation 01 Agriculture (Only own land) 02 Farmer (Only sharecropping) 03 Farmer (Own & sharecropping) 04 tenant farmers 05 small farm ownrs 06 Agri-labour /Daily labor/unskilled labor 07 Horse/Donkey/Cow cart driver Mechanical transport driver 08 Potter/Blacksmith/Cobbler/ Tailor/ Construction worker/fisher etc. 09 Petty or middle class business 10 Big business man (Whole seller) 11 Govt. or non-govt. official 12 Professional (Teacher/Lawyer/Doctor) 13 Beggar 14 House work/ House wife 15 Retired officer / staff 16 Unemployed LINE NAME REL. M F AGE YES NO YES NO Alive Dead UK Cause 1. Measles 2. Diarrhoea 3. Malnutrition 4. Injury 5. Injury due to flood 6. Not known 7. Other specify Exact date/m onth Past Present Education 0=No education If educated write exact years of education 1= can sign only 2=non-formal education 3=other (specify) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

41 SECTION II: HOUSEHOLD INFORMATION 2) Please list members of the HH who are currently present and those who were living during the flood (recall period) and not present in the HH now. Line no. Name Start by the household head What is the relation-ship of (name) to the head of the household? 01 husband 02 wife 03 son 04 daughter 05 brother 06 sister 07 father 08 mother 09 cousin 10 mother-in-law 11 father-in-law 12 other Is (name) male or female? (1= male, 2= female) How old is (name)? Age in (yrs) for adults and in month/days for children/ newborns Present Now (1=Yes, 2=No) Present at the beginning of the recall period (1=Yes, 2=No) Current status (1=alive, 2=dead, 3=unknown) If dead Record cause of death, date of death Occupation 01 Agriculture (Only own land) 02 Farmer (Only sharecropping) 03 Farmer (Own & sharecropping) 04 tenant farmers 05 small farm ownrs 06 Agri-labour /Daily labor/unskilled labor 07 Horse/Donkey/Cow cart driver Mechanical transport driver 08 Potter/Blacksmith/Cobbler/ Tailor/ Construction worker/fisher etc. 09 Petty or middle class business 10 Big business man (Whole seller) 11 Govt. or non-govt. official 12 Professional (Teacher/Lawyer/Doctor) 13 Beggar 14 House work/ House wife 15 Retired officer / staff 16 Unemployed LINE NAME REL. M F AGE YES NO YES NO Alive Dead UK Cause 1. Measles 2. Diarrhoea 3. Malnutrition 4. Injury 5. Injury due to flood 6. Not known 7. Other specify Exact date/m onth Past Present Education 0=No education If educated write exact years of education 1= can sign only 2=non-formal education 3=other (specify) ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

42 SECTION III - HOUSEHOLD CHARACTERISTIC 3.1. Is this your usual place of residence? 1=Yes 2=No 3.2. Has your house been damaged by the flood? 1=Yes If no, skip to 3.4 2=No 3.3. The level of house destruction (observe) 1=Partial destruction 2=Complete destruction 1=Mud/mud brick 2=Stone/concrete/brink 3.4. What type of housing are they living in? 3=Thatch 4=Plastic Shelter 5=Other (specify) 3.5. Has there been any added member (s) to 1=Yes If no, skip to 3.7 your family after the flood? 2=No 3.6. How many added members? members 3.7. Does the added members arranging food for themselves or dependent on your family? 1=Totally dependent 2=Partially dependent 3=Totally independent SECTION IV - HOUSEHOLD ASSESTS 4.1. How many of the following animals do your family own before and after If None, write 0 the flood? Cow Sheep/goats Chicken Before After Before After Before After 4.2. Has your crop been damaged by the flood? (observe) 4.3. Did you replant the rabi season crops (wheat, vegetables, green fodder, etc.) 4.4. Have your family sold any valuable assets after the flood? 4.5. What valuable assets have you sold? 1=Livestock 2=Land 0=No damage If not applicable, 1=Partial damage write NA 2=Complete damage 1=Yes 2=Land preparation 3=No 1=Yes If no, skip to 4.5 2=No 3=Other (specify) 4.6. Did you family receive any financial 1=Yes If no, skip to 4.7 assistance after the flood? 2=No 4.7. Who gave you the financial assistance? 1=Government 2=NGO 3=Private Loan 4=Other (Specify) 4.8. How much cash did you receive? ruppees 2=Don t know 4.9. Has your household taken any loan or extended a previous loan due to the flood? 1=Yes, new loan 2=Previous loan extended 3=No 4=Don t know 5=Other specify

43 4.10. What is the current level of loan? ruppees 2=Don t know SECTION V - WATER, SANITATION AND HYGEINE 5.1. What is the main source of drinking water for members of your household? 5.2. How long does it take to fetch water? get water and come back 5.3. Do you treat your water in any way to make it safer to drink? 5.4. What kind of toilet facility do members of your household usually use? If flush or pour flush, probe: Where does it flush to? If necessary, ask permission to observe the facility 5.5. How does your household primarily dispose off household waste? 5.6. When do you wash your hands? Circle all mentioned, but do not prompt respondent 5.7. Do you use soap while washing your hands? 01 Hand pump 02 Tap stand 03 Protected well 04 Unprotected well 05 River 06 Spring 07 Vendor/Buy water 08 Tanker/Truck 09 Pooled flood water/exposed springs 10 Other (Specify) In Hours In minutes Water in premises 1 DK 2 Yes, always 1 Yes, sometimes 2 No 3 DK 4 Pour flush toilet 1 Pit latrine 2 Open field 3 Other (Specify) 4 Dumped in the street/open space 1 Disposed in the compound 2 Buried 3 Pit latrine 4 Sewer connected 5 Other (Specify) 6 Before eating 1 Before preparation of food 2 After defecation 3 Before feeding children 4 After disposing of children faeces 5 Other (Specify) 6 Yes, always 1 Yes, sometimes 2 Never How often do you bath your body? Every day 1 Twice a week 2 Every week 3 Once in fifteen days 4 Once a month 5 Other (Specify) 6 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

44 SECTION VI - FOOD CONSUMPTION AND DIETARY DIVERSITY 6) Could you tell me how many days in the PAST ONE WEEK and LAST 24 HOURS your household has eaten the following foods either separately or combined with other foods or liquids Write 0 for food items not eaten over the last 7 days and tick food items eaten during the last 24 hours Food Item Past 7 days Last 24 hours 6.1 Cereals (Wheat, Rice, Maize) 6.2 Legumes (Beans, Ground nut) 6.3 Meat/Chicken/Fish 6.4 Egg 6.5 Cooking oil/fats 6.6 Vegetables 6.7 Fruits 6.8 Milk Products (Milk, Yoghurt, Cheese) 6.9 Sugar 6.10 Any other food (wild foods, etc) <1 day For your family, how long the current stock of food will last? <1 week 2 1 week or more 3 SECTION VII - WOMEN NUTRITION Yes Do you know what is meant by balanced diet? No Can you list foods that are rich in vitamin A? Fruits 1 circle all mentioned, but do not prompt respondent Egg 2 Liver 3 Vegetables 4 Breast milk 5 Others (specify) What are the major causes of diarrhoea? Dirty/contaminated water/liquid 1 Spoiled, stale food 2 Not washing hands before taking meal 3 Not washing hands with soap after defecating 4 Not using sanitary latrine 5 Not giving immunization properly 6 Other (specify) 7 DK How can diarrhoea be prevented? Use of safe fluids 1 Washing hands before taking foods 2 Washing hands with soap after Defecation 3 Using sanitary latrine 4 Proper immunization 5 Other (specify) 6 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

45 DK Did you receive nutrition information from anyone? Yes 1 No When was the most recent visit? days/months SECTION VIII - CHILD NUTRITION (for children 0-24 months of age) Yes Has this child ever been breastfed at any time in his/her life? No 2 If no, skip to 8.5 Yes Is this child still breastfeeding now? No 2 If yes, skip to 8.5 Months 8.3. In which month did you stopped breastfeeding the child? DK 2 Milk not enough 1 Grief/Disturbance 2 Child refused 3 Child away 4 Child grown-up Why did stop breastfeeding? Other (Specify) At what age did you start giving complementary foods to your child? Months DK Since this time yesterday, how many times did your child eat semisolid/solid or liquid foods other than breast milk? 8.7. What did the child eat yesterday? record all answers 8.8. Has this child received a vitamin A capsule after the flood? (for children 6-59 months of age) 8.9. Has this child received a measles vaccination after the flood? Has (name) had diarrhoea in the last two weeks? Diarrhoea is three or more loose or watery stools per day, or blood in stool During this last episode of diarrhoea, did he/she drink any of the following: Read each item aloud and record response before proceeding to the next item Did not eat 1 Once 2 Twice 3 Thrice 4 Four and above 5 As demanded 6 Water/tea 1 Fresh milk/formula milk 2 Semi-solid/mashed food 3 Family food 4 Other (Specify) 5 Yes 1 No 2 Yes 1 No 2 Yes 1 No, if no, skip to DK 3 Breast milk 1 Gruel from cereal or soup 2 Salt solution or yoghurt drink 3 ORS packet solution 4 Other milk/ infant formula 5 Water or other liquid 6 ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

46 8.12. During your child illness, did he/she drink much less, about the same, or more than usual? In the last 2 weeks, has your child had a cough illness with short, difficult, faster breathing than usual? Has your child had an illness with a fever any time in the last two weeks? Did you seek advice or treatment for illness outside the home? From where did you seek treatment? Don t probe Nothing 7 Much less or none 1 About the same 2 More 3 DK 4 Yes 1 No 2 DK 3 Yes 1 No 2 DK 3 Yes 1 No, if no, skip to XI 2 Hospital/BHU 1 Private physician 2 Village health worker 3 Pharmacy 4 Other (Specify) 5 SECTION IX - PROGRAM COVERAGE 9.1. Did you receive any relief food/food aid in the past six Yes 1 months? No 2 If no, skip to 9.2 If Yes, tick the months you received it Food Commodity June 2010 July 2010 Aug 2010 Sept 2010 Oct 2010 Nov 2010 Wheat Rice Pulses Oil Sugar Milk Other (Specify) 9.2. Did you receive supplementary food while you were pregnant with your child? Yes 1 No Did you receive supplementary food while you were lactating your child? Yes 1 No Is any member of your family currently enrolled in supplementary feeding program? Yes 1 No If Yes, who is enrolled in the TSFP? U5 1 Pregnant 2 Lactating 3 Other (Specify) 4 THANK YOU FOR YOUR COLLABORATION Signature of Interviewer: Signature of Team Leader: Date: Date: ACF Integrated assessment Survey / Mirpur Bathoro Thaluka / Pakistan, December

47 Appendix VII ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE, DECEMBER 2010 DAILY MOVEMENTS OF TEAMS FOR DATA COLLECTION AND MONITORING REPORT FORM Date Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Team No UC Deh Village (s) CL no HH Children F M Age =< 29 Age >=30 WHZ <-2 WHZ <-3 Oedema MUAC <11.5cm Death >5 Death <5 Birth BCG, Yes Measles Yes Vit A, Yes Illness Yes SFP Yes TFP Yes

48 Appendix VIII ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE CLUSTER CONTROL SHEET, DECEMBER 2010 Survey Date: / /2010; UC Name Deh Name ; Village Name: Cluster Number: ; Team Number: ; T. Leader: ; Signature ; Arrival Time: ; Departure Time: Weighing Scale Calibration: Standardization with 5kg weight (before departing to and leaving the cluster) Scale No Reading 1 Reading 2 Reading 3 Mean Salter scale 1 2 HH No Questionnaire completeness check-up form (before leaving the cluster) Outcome No of U5-2 SD -3 SD Scale children No. Complete Incomplete Refusal/not present Comments Total

49 Appendix IX LOCAL EVENT CALENDER MONTH January Eid ul Adha 59 Ashura 47 Ashura 35 Ashura February Ashura Kashmir day 22 Kashmir day 10 March 57 Eid Milad u Nabi 45 Eid Milad u Nabi Eid Milad u Nabi Eid Milad u Nabi & end Harvest & Pakistan day Pakistan day wheat 9 April Start Harvest Wheat 56 Start Harvest Start Harvest Start Harvest Start Harvest Wheat Wheat Wheat Wheat 8 May Eid Milad u Nabi end Labor day & end Labor day & end 55 End harvest wheat 43 End harvest wheat harvest wheat harvest wheat harvest wheat 7 June July Start rainy season 53 Start rainy season 41 Start rainy season 29 Start rainy season 17 Start rainy season 5 August End rainy season End rainy season End rainy season End rainy season End rainy season Independence day Independence day Independence day Independence day Independence day 4 September 51 Ramadan 39 Ramadan 27 Eid-ul-Fitr 15 Eid-ul-Fitr 3 October 50 Eid-ul-Fitr 38 Eid-ul-Fitr November Start Harvest Rice Iqbal day Eid-ul- Iqbal day Eid-ul- 49 Start Harvest Rice 37 Iqbal day Ramadan Eid ulfitr Adha Adha 1 December End Harvest Rice 48 Eid-ul-Adha Eid-ul-Adha Quidi-Azam day Ashura Ashura Quid-i-Azam day Quid-i-Azam day End Harvest Rice 0

50 Appendix X ACF NUTRITION SURVEY IN MIRPUR BATHORO, THATTA DISTRICT, SINDH PROVINCE, PAKISTAN DECEMBER 2010 SURVEY TEAM MEMBERS NAME SEX LEVEL OF RESIDENCE RESPONSIBILITY EDUCATION/FIELD OF STUDY Beka Teshome M MSc/Nutrition ACF-Pakistan Coordinator and Survey Manager Anees Bibi F BA/Art Mirpur Bathoro Team leader Sobia Arain F BA/Art Thatta Team leader Farooq Ali M MA/Sociology Mirpur Bathoro Team leader Riaz Ahmed M BA/Art Thatta Team leader Mumtaz Shaikh M BA/Art Thatta Team leader Mohammed Ashraf M BSc/Science Thatta Team leader Abdul Rehman M BA/Art Mirpur Bathoro Enumerator Shahid Ali M BA/General Mirpur Bathoro Enumerator Ayaz Ali Soomro M BA/General Mirpur Bathoro Enumerator Mohammed Anwer M BA/General Mirpur Bathoro Enumerator Mohammed Iqbal M BA/Art, MA-continue Thatta Enumerator Irfan Gul M BA/Art-continue Mirpur Bathoro Enumerator Shaista Soomro F BSc/Science Thatta Enumerator Shagufta Soomro F BSc/Science Thatta Enumerator Sarwat Qureshi F BA/Art Mirpur Bathoro Enumerator Ruqsana Imrani F BSc/Science Mirpur Bathoro Enumerator Sana Marvi F BA/Art-continue Thatta Enumerator Mirzadi Halo F BA/Art-continue Thatta Enumerator Jawad Akhtar M DVM and IT Thatta Data encoder Wazir Qureshi M MA/Sociology Thatta Assistant