OF IODIZED SALT IN THE REPUBLIC OF KAZAKHSTAN

AN ASSESSMENT OF THE HOUSEHOLD USE AND ADEQUACY OF IODIZED SALT IN THE REPUBLIC OF KAZAKHSTAN

AN ASSESSMENT OF THE HOUSEHOLD USE AND ADEQUACY OF IODIZED SALT IN THE REPUBLIC OF KAZAKHSTAN Аlmaty, 5

Frits van der Haar, PhD Associate Professor Emory University Rollins School of Public Health Atlanta, Georgia USA May 5 We are grateful to the USAID for the financial support provided. We are grateful to the United States Agency for International Development (USAID) for the financial support provided for the assessment United Nations Children s Fund (UNICEF), 5 Photo Credit: UNICEF KAZA 4-8 Dmitrii Podlipaev Proof-reading: Walton Burns Design: Liliya Nenasheva UNICEF Astana office Kazakh Academy of Nutrition 38 Bukei Khan street 66 Klochkov str. Astana, Almaty, 58 Republic of Kazakhstan Republic of Kazakhstan Ph. (+7-37) 3 6 9, 3 83 7 Ph. (+7-37) 4 9 3 Fax: (+7-37) 3 8 3 Fax: (+7-37) 4 5 9 E-mail: tmukaeva@unicef.org

Contents Foreword........................................................................................ 4 Background note........................................................................................ 5 Acronyms........................................................................................ 6 SECTION SECTION An Assessment of the Household Use and Adequacy of Iodized Salt in Selected Regions of the Republic of Kazakhstan, 4................................................... 7 Executive Summary.................................................................................. 8 I. Introduction........................................................................................ 9 Short Overview of Progress toward IDD Elimination in Kazakhstan.............................. 9 Objectives of the Present Assessment......................................................... II. Methods....................................................................................... General Design Issues and Development of Survey Instruments................................ Household and Respondent Sampling and Identification...................................... Salt Testing Methods, Questionnaire Administration........................................... 3 Laboratory Method........................................................................... 3 Data Entry and Analysis....................................................................... 3 III. Results....................................................................................... 4 Household Use of Iodized Salt................................................................ 4 Quantitative Analysis of a Sub-sample of Household Salt...................................... 6 IV. Discussion....................................................................................... 8 General Considerations....................................................................... 8 Sources of Household Salt in Regions of Kazakhstan........................................... 9 Adequacy of Household Salt Iodization in Kazakhstan......................................... 9 Quantitative Iodine Analyses.................................................................. Recommendations........................................................................... IDD Rapid assessment Iodized Salt Consumption of Households, Level of knowledge and Adequacy of Salt Iodization in the Republic of Kazakhstan................................ Executive Summary................................................................................. I. Preamble....................................................................................... 3 Level of the population s knowledge and skills with regard to IDD............................. 3 Iodised salt (IS) production in Kazakhstan..................................................... 4 Media Campaign............................................................................. 5 II. Methods of survey................................................................................ 7 Selection of these geographical regions...................................................... 7 Survey sampling............................................................................. 7 Titration method. Backbone of the method.................................................... 8 Method of Questioning...................................................................... 9 III. Description of results............................................................................. 3 Rapid assessment of salt consumption at the local level - spot-testing.......................... 3 Results of the field survey Rapid Assessment of IDD campaign................................. 3 IV. Discussion....................................................................................... 47 Annexes....................................................................................... 68 Literature....................................................................................... 79

Foreword The UNICEF Representative in Kazakhstan Mr. Zouev Alexandre The President of the Kazakh Academy of Nutrition Mr. Sharmanov Toregeldy In September 5, in New York, the leaders of all countries will come together to review the progress made to achieve the Millennium Development Goals. Kazakhstan, together with the other countries, will report on achievements and progress made towards the elimination of iodine deficiency disorders, which play a significant role in overcoming the three issues of poverty alleviation, child mortality reduction and protection of maternal health. It is known, that health and intellectual capital are the major preconditions for progress both for individual nations and for the world as a whole. However, food deficiency problems which can be avoided continue to harm whole generations, reducing the intellectual quotient (IQ) of hundreds of millions of people. Now one of the most important and preventable causes of mental disorders is iodine deficiency. It poses a serious threat by decreasing the mental and physical abilities of people due to lack of iodine in food. It is established, that in Kazakhstan, in the greater part of its territory, there is a lack of iodine in soil, water and accordingly in local food products; Endemic Goiter Centers are registered in out of 4 oblasts. Kazakhstan is in the category of countries considered to be moderately endemic of iodine deficiency disorders. It is necessary to note, that even in the areas with light iodine deficiency, iodine deficiency disorders have an enormous impact on the intellectual and physical condition of the population. Research has shown that the IQ of each child living in such areas is lower by -5 points. Iodine is necessary during child bearing; newborns of mothers with iodine deficiency can have irreversible problems. The probability of abortion, infant mortality and premature birth sharply increase among women living in the areas with a lack of iodine. Those children who do survive can exhibit the characteristics of iodine deficiency disorders including, stunted growth and development, intellectual backwardness or mental retardation. It is possible to compensate a pre-existing deficiency by using a certain quantity of iodine or simply by consuming iodized salt. In the last few years, the Republic of Kazakhstan has achieved significant progress due to effective cooperation between the Government, producers of salt, and non-governmental and international organizations (UNICEF and АDB). The government has created the most suitable political conditions for producers of salt to develop and introduce a legal framework for obligatory fortification of salt in the country. In addition, international organizations have supported producers of salt to adjust production and carry out internal monitoring of iodized salts. The government of Kazakhstan and the nongovernmental sector provided support in raising public awareness about the necessity of consuming iodized salt to prevent iodine deficiency disorders. The report specifies that today children of Kazakhstan are protected from risk of the having mental development problems as in Kazakhstan access to iodized salts constantly increases. Kazakhstan is at the stage of joining the elite nations which have already reached universal salt iodization. However it is necessary to make one more step. Kazakhstan has made huge achievements: from 9 percent of the total number of households consuming iodized salt, up to 86 percent. Now it is necessary to ensure that more than 9 percent of the population has access to iodized salt. Mr. Alexandre Zouev Mr. Toregeldy Sharmanov 4 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Background note This document reports on the use and adequacy of iodized salt in households in Kazakhstan, based on data collected in a national survey carried out by the Kazakh Academy of Nutrition (KAN), with the financial support of UNICEF. The survey was conducted between August and December 4 and encompassed data collection among selected samples of households in urban and rural settlements of 5 regions of Kazakhstan (north, east, south, west and center) and in Almaty city. KAN was the lead responsible organization for all aspects of the survey including, overall design, development of the questionnaire and recording forms, the household sampling approach, field worker training and supervision, travel of field teams for data collection, salt sampling and laboratory analysis, and data entry, analysis and report writing. A draft report was made available to Emory University by UNICEF and KAN in April 5 with the request to verify the data analysis and provide an edit of the report with an executive summary. Emory received the SPSS database together with codes of responses and observations from KAN in May 5. Emory University then made a re-analysis and used the results obtained from the re-analysis in producing the present report. The entire report of Emory University is presented under SECTION and the draft report of KAN is provided integrally with the present report as SECTION to preserve the original meanings and nuances of reporting, which may have been unclear or seemingly irrelevant to the outside reviewers. The draft report by KAN also offered more details of the progress in Kazakhstan toward the national goal of IDD elimination, much of which falls outside the context of the present review and result verification. Inputs into the present report from the survey team in KAN are acknowledged, especially Mr. Toregeldy Sharmanov, President of the Kazakh Academy of Nutrition, member of the Russian Academy of Medical Science and the National Academy of Science of the Republic of Kazakhstan, Mr. Igor Tsoy, professor, doctor of medical science and the vicepresident of the Kazakh Academy of Nutrition, Ms. Lailya Kulmurzayeva, PhD, researcher and Ms. Feruza Ospanova, PhD, researcher. Mr. John Egbuta, Fortification Project Officer at UNICEF in Almaty was very helpful in further discussion and explanation of technical issues in the database and recording systems. Phuong Hong Nguyen, MPH assisted in the data analysis at Emory University. 5

Acronyms ADB CIS DHS KAN IDD JSC MOH NGO PHC QA RK UIC UNICEF USI Asian Development Bank Commonwealth of Independent States Demographic and Health Survey Kazakh Academy of Nutrition Iodine Deficiency Disorders Joint Stock Company Ministry of Health Non-governmental Organization Primary Health Care Quality Assurance Republic of Kazakhstan Urinary Iodine Concentration United Nations Children s Fund Universal Salt Iodization 6 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

SECTION An Assessment of the Household Use and Adequacy of Iodized Salt in Selected Regions of the Republic of Kazakhstan, 4 Frits van der Haar

EXECUTIVE SUMMARY IDD is a problem of public health concern in the Republic of Kazakhstan. In line with global policy, the Government has pledged to eliminate IDD through universal salt iodization. In recent years, Kazakhstan has enacted laws and regulations to ensure that all the salt supplied to households, the food processing industry and animal feeding is iodized with potassium iodate at a mandated level at production of 4±5ppm. The two domestic salt companies, AralTuz (Aralsk, Kyzlorda Oblast) and Pavlodarsol (Pavlodar, Pavlodar Oblast), have the full technical capacity established for supplying adequately iodized salt to the domestic markets. The responsibility for food inspection and control rests with the sanitary-epidemiological services in MOH. Because the latest national assessment dated from 999, the present assessment was undertaken with the aim to estimate the level and adequacy of iodized household salt use in Kazakhstan, and to validate the iodine adequacy in selected salt samples found iodized during the survey. The overall approach took advantage of prior experience by KAN in assessing iodine indicators in households in selected regions of Kazakhstan. The survey design was based on 3 clusters of 5 households each, canvassed in urban (6 of households) and rural (4) settlements in 6 regions (Almaty city, north, east, south, west and central region). KAN developed standardized methods and protocols, and trained field teams in administering a specially designed questionnaire. Household salt samples were tested for absence (ppm) and adequacy (<5ppm or 5ppm) of iodine by rapid test kits (MBI, Madras) and of each household where the salt was found adequately iodized, a salt sample was collected for shipment to the KAN laboratory. Among the salt samples collected, 5 were selected for analysis of iodine concentration by titration. Distinct patterns of household iodized salt adequacy and use existed in the different regions, related to the production sources and their proximity, and their wholesale/retail relations with markets in the regions. Salt purchased by weight and/or stored unpackaged in the household was most prevalent overall and it dominated the household salt shares in the east and north regions, and interestingly, Almaty city. The AralTuz Company was the major domestic source and its salt dominated the markets in the south and central regions and in Almaty city. Salt from Pavlodarsol Company was mainly present in the north and central regions, while in the west region Russian salt was the major source. Significant differences were observed in the adequacy of iodized household salt among regions, varying from 9 in Almaty city and the south and west regions, to approximately 8 in the center, 7 in the east and only 4 in the north. The share of household salt not iodized (ppm) varied conversely, from around -3% in Almaty city and south region, via 7% in the west, % in central and 3% in east, to a high of 43% in the north region. Differences in the adequacy of iodized household salt between urban and rural households were comparatively small, except in the north region. The production origin, and the habit of purchasing loose salt and/or storing it unpackaged in the household were the two major factors that explained the variations in adequacy of iodized salt in households. Branded salt (i.e. salt purchased and stored in its package) generally appeared to be better and more frequently well-iodized than unpackaged salt. Salt supplied from AralTuz Company and from Russia (Iletskaya) was mostly well iodized. Although branded salt supplied by Pavlodarsol Company was infrequent in the overall national scheme, it was a major source of inadequately and non-iodized salt in the north and, likely, central region. The range of iodine concentrations in the 5 salt samples analyzed by titration varied from 5 to 53ppm, thus confirming that salt iodized below 5ppm was not classified by the field teams as adequately iodized. Efforts to improve upon the use of adequately iodized salt in Kazakhstan should focus on ensuring that the Pavlodarsol Company improves its Quality Assurance (QA) during salt processing, and on inspections with follow-ups at the source in markets of the north, east and central regions where the survey showed that a large share of unpackaged salt that has not been iodized is being sold. From a consumer viewpoint, AralTuz and Iletsksol in Russia are the most reliable sources for iodized household salt, regardless of whether that salt has been packaged or is sold by weight. 8 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

I INTRODUCTION This document reports on the findings of a rapid household survey in Kazakhstan aimed at estimating the use and adequacy of iodized salt in households. The survey was carried out from August December 4 in five regions of the Republic and Almaty city by the Kazakh Academy of Nutrition (KAN), with the financial support of UNICEF. The present report is based on a draft text provided by KAN, combined with a re-analysis of the survey data by Emory University in Atlanta. The draft text produced by KAN is provided in SECTION as an integral part of the present report, so as to conserve its original text and meaning. The draft report by KAN also contains more specific and detailed data, which is not repeated in the present text. The reader is encouraged to consult the original report where indicated in the present text. Short Overview of Progress toward IDD Elimination in Kazakhstan Evidence of iodine deficiency As in many other countries of the world, IDD is a public health threat in the Republic of Kazakhstan (RK). The extent and severity of IDD, as documented on the basis of goiter prevalence, has been surveyed in the nation and found to be significant and somewhat variable among regions, but with a higher intensity in the south and east. Overall, the presence of IDD in RK is found in association with low iodine content in the water and the soil and thus is related to the consumption of locally grown food. A description of the national situation (see Section ) can be constructed from various information sources, including clinical records in Endemic Goiter Centers, neonatal TSH studies and small-scale goiter surveys. In association with the National Demographic and Health Survey (DHS) of 999, the Kazakh Academy of Nutrition (KAN) carried out a study of urinary iodine concentrations (UIC) among women of child-bearing age culled from various regions of RK. Table gives a summary of the results, along with the percent of household iodized salt use found in the DHS at that time. The median UIC among all the adult women was 95μg/L, with 53% of UIC values below μg/l (the cut-off point for school-aged children) and 4% below 5μg/L, indicating that iodine deficiency prevails nationally. Only 9% of households were found to use iodized salt in 999 (some of the salt at that time was iodized with iodide). Interestingly, the only region where the UIC among women of childbearing age was reaching the internationally minimum recommended level (5μg/L) was in the central region, where, notably, the highest household use of iodized salt (48%) was observed in the DHS. TABLE : Kazakhstan, DHS 999 and special KAN survey results Region % HH with iodized salt Women of child-bearing age Urinary iodine concentration (UIC) with iodate only all iodized salt median UIC % below 5 % below Almaty city 4. 4. 97 8.4 5. North 3.5 34. 77 34. 6.7 East.7.6 7 6.8 65.4 South.9 4.5 79 3.6 59. West.8 5.5 76 9.9 6. Central 43. 48. 57 4.7 5.7 Total 3.5 9. 95 4 53 9

Knowledge in the population and health service providers A national survey of Knowledge, Attitude and Practices concerning IDD elimination was conducted in - with UNICEF support. The study indicated that the level of knowledge and awareness among the general population about IDD and the strategy for its elimination was rather low. Of rural schoolchildren, 7 had no knowledge of IDD or its biological consequences. Only 33% of urban and 4% of rural children were aware that IDD could be prevented by the use of iodized salt, although almost 7 had heard of iodized salt. Only of adults knew that iodized salt is necessary to alleviate IDD, and among those who did use iodized salt in their households, as many as 44% did not know why iodized salt is a necessity. The survey identified health workers as an important traditional source of information. Among primary health care workers, however, only % were confident that IDD could be alleviated by the use of iodized salt, while onethird were convinced that the human body could produce iodine by itself. Significantly, 6% of Primary Health Care (PHC) workers recalled having been asked by their clients for advice on the need for using iodized salt. Salt production and supply situation Fig.. Iodized salt supply by national producers in Kazakhstan RK has an open market-based economy, which means that, just like other food, salt is a product of the market where local suppliers must compete against salt imported from foreign sources. The main national salt producers are located in the southwest of RK (Aralsk city in Kyzlorda Oblast) and the north (Pavlodar city in Pavlodar Oblast). With UNICEF support dating from before and with follow-up by the ADB, the two national salt companies (AralTuz and Pavlodarsol) have been assisted with iodization and packaging equipment, operational and laboratory training and input materials (mainly potassium iodate), for the production of iodized salt. Details of the capacity building efforts are found in Section. The total productive capacity in the companies is sufficient, in theory, to supply the total need for edible salt in RK. Both companies have sufficent technical QA capacity for ensuring dispatch of adequately iodized salt to their customers. As required by law, each delivery of iodized salt must be accompanied by a certificate that specifies adequate iodization according to mandated levels. The producing companies have been actively involved in the overall IDD elimination policy and more specifically, in attempts to promote the use of iodized salt by the population. Based on producer-provided supply data, the domestic market for iodized salt for the RK industry has been growing significantly during the past few years (Figure ). Based on estimates of national consumption and salt needs, it is estimated that the domestic supply constituted approximately 84% of the market in 4. The remainder of the market, supplied by companies outside RK, in particular the Russian Federation, is estimated at approximately 6, tons per year. Export of iodized salt from Kazakhstan is relatively small at 6, tons maximum. RK has passed a law on IDD prevention specifying that all dietary and fodder salt sold in markets of RK must be iodized. In line with agreements among CIS member states at Minsk in, the mandatory level of iodization at production has been set at 4±5ppm, with a shelf-life of year. The responsibility for inspection at supply and market outlets is invested in the sanitary-epidemiologic services of MOH. An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Recent media strategy Starting from, with the joint collaborative support of UNICEF, the Asian Development Bank (ADB), KAN, MOH and NGOs in RK, a major national, multi-level integrated media strategy was launched to ensure appropriate promotion and provision of information among consumers and service providers about the threat of IDD and the benefit of salt iodization. The campaign was backed by various Ministries, TV and radio stations, NGO activities and official channels for distribution of information, messages, and educational materials. Details of the media strategy and efforts can be found in Section. Important efforts are also being made to integrate information on IDD and universal salt iodization (USI) into the regular curriculums of primary schools. Objectives of the Present Assessment The previous sub-chapter illustrates the various efforts already made and those ongoing in RK as prerequisites for successful IDD elimination through USI. In summary: Enactment in RK of the necessary legal basis for the execution of a well-coordinated national plan for sustainable IDD elimination by ensuring the universal iodization of dietary salt through Presidential and Ministerial Decrees; Progressive capacity building in the domestic salt industry to facilitate the supply of adequately iodized salt only, in amounts sufficient to meet the total national market requirement in RK; Consolidated baseline data regarding the supply of iodized salt in households (9% in 999, DHS), the status of iodine nutrition among women of reproductive age (median 95μg/L in 999, KAN survey) and the level of knowledge among the population and health service staff (KAP survey, ); A multi-level integrated professional media strategy since aimed at mobilizing and informing many strands in society with the purpose of creating normative attitudes in society that can sustain universal salt iodization into the future. A previous national assessment of progress from 999 is available, using indicators of the use in households of iodized salt and its adequacy. Thus, the present survey had the following specific objectives: ) Estimate the level and adequacy of iodized salt use in households in RK ) Validate the iodine adequacy in salt samples found iodized during the survey 3) Assess the level of knowledge of the population about IDD prevention and salt iodization. The results of the assessment of population knowledge are reported in the KAN report and do not form part of the present report.

II METHODS General Design Issues and Development of Survey Instruments The overall approach in the present survey took advantage of the prior experience of KAN in conducting the survey of iodine nutrition in 999. Previous and recent data collected by Endemic Goiter Centers in (out of the 4) Oblasts of RK had provided confirmation that goiter rates persist in each region of the country. Furthermore, region-wide sampling is justified by the great variety among regions of socio-economic, ethnic, climatic and geographical conditions, all of which are associated with nutritional practices. By sampling in each of the regions, it was hoped that the data would contribute to further fine-tuning of the IDD elimination policy. Household and Respondent Sampling and Identification Primary sampling units consisted of households in RK, selected by the following method: Division of the 4 Oblasts in RK into the following 6 Regions: Almaty City (5 clusters; 5 households in each cluster) North: (Akmola, Kostanay, Pavlodar, North-Kazakhstan Oblasts) East: (East-Kazakhstan Oblast) South: (Almaty, Djambyl, South-Kazakhstan, Kzylorda Oblasts) West: (Aktobe, Atyrau, Mangistau, West-Kazakhstan Oblasts), and Central: (Karaganda Oblast). Identification of city and rural area in each of the geographic regions, followed by the random selection of.5 clusters (selection points) in each city or area Random selection of 5 households in each cluster (selection point). Thus, the total number of clusters contained in the survey was 3 (7.5 urban and.5 rural), while the total number of households included in the survey was,5. In the areas selected, the field teams coordinated closely with district nurses of out-patient health care facilities to identify and invite household members to the assessments. As a general rule, household recruitment was continued until the required number of responsive households was obtained. The location of household clusters is shown in Table. In every household where the spot test indicated that the salt was adequately iodized (i.e. the spot-test yielded an intense color), a sample of iodized salt was collected for transfer to the laboratory of KAN. TABLE : Locations of household clusters in the survey Region Oblast Urban clusters Rural clusters Almaty town Almaty 6 districts in Almaty None North Pavlodar Pavlodar Sharbakty village East East-Kazakhstan Ust-Kamenogorsk Shemonaikha village South South-Kazakhstan Shymkent Sairam village West Aktyubinsk Aktobe Alga village Central Karaganda Karaganda Osakarovka village An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

As shown in ANNEX, KAN developed a special questionnaire for recording responses on the knowledge questionnaire. To record the salt iodine spot-test results, KAN developed a second special recording form (ANNEX ) to allow more specific characterization of the household s salt brand and origin. Salt Testing Methods, Questionnaire Administration KAN assigned 6 field teams of persons each one team per region to collect data and make observations. Each team was given a standard scope of work, encompassing data collection (rapid salt testing; salt sampling when rapid testing showed an adequate iodate level; and interview of the primary respondent, recorded in a standard questionnaire) for 5 households. Prior to field work, each team was trained in interviewing techniques, standardized coding and completion of forms, spot-testing of household salt, and sampling and marking of household salt for transport and laboratory analysis by KAN staff. Details of rapid spot-testing of salt for the presence of iodine are described in the manual on Monitoring of Universal Salt Iodization Programs. Test kits were obtained through UNICEF and, according to manufacturer s specification the kits were accurate for visual detection of the potassium iodate concentration at a threshold of 5ppm. Laboratory Method The KAN laboratory performed the analyses of iodine content in salt samples using the standard titration technique for potassium iodate (KIO3) described in the Manual on Monitoring of Universal Salt Iodization Programs. A detailed description of the technique is given in Section. The method is based on the fact that iodine liberated from iodate upon addition of sodium thiosulphate in a slightly acid solution develops a distinct blue color with a stable starch solution. All salt determinations were carried out in duplicate, and the mean of the tests was recorded. The laboratory of KAN participated in the CDC-supported IRLI network of iodine laboratories and provides QA services to national laboratories in neighboring countries. Data Entry and Analysis The questionnaire data was coded before entry into a PC. SPSS software was used for entering the data consolidated by household. Double entry of data was used to ensure data accuracy in the database. Upon a first attempt at re-analysis, the total cell numbers for urban/rural areas and for Kazakhstan did not add up accurately. Upon inspection of the raw database, it appeared that the urban/rural codes for a number of households were missing while for one household, the code for the region was missing. For the present re-analysis, code corrections were made on the following data records: Household number Correction made for the present analysis 97 For city code, entered code = urban 366 For city code, entered code = urban 4 For city code, entered code = rural 64 For city code, entered code = urban 964 For city code, entered code = rural,36 For region code, entered code 6 = Almaty City Descriptive variables were calculated with routine SPSS commands. Standard 95% confidence intervals for proportions 3 were calculated and are shown in the text between square brackets. The Chi-square test (with continuity correction) was used for comparing proportions between two independent samples. A Russian Edition has been published in 997, edited by G.Gerasimov. See www.webiodine.com (Manuals) MBI Chemicals, Madras, India 3 Altman DG, Machin D, Bryant TN & Gardner MJ: Statistics with Confidence. nd Edition. Bristol, BMJ Books, 3

III RESULTS Household Use of Iodized Salt Tables showing the results of rapid salt testing in households broken down by urban/rural and by region, and consolidated for RK are in ANNEX 3. Regional patterns Fig.. % adequately iodized household salt by region and urban/rural location of the households Almaty city The majority of salt (54.7%) in Almaty city s households [48.4% - 6.8%] was purchased or stored in the household without packaging. Nearly 9 of the household salt in Almaty city [83.% - 9.3%] was found to be adequately iodized (>5ppm). Of the household salt stored in packages (45.3%), the majority (93 out of = 76.9%) was produced by the AralTuz Company and 96.8% of these samples were adequately iodized. North region As in Almaty city, the majority (58.9%) of salt found in households in the north [5.7% - 64.9%] was purchased or stored without packaging, and the majority of this unbranded salt (8 out of 45 = 55.9%) was found to be not iodized (ppm). Most of the branded household salt in the north (83 out of = 8.%) was of domestic origin, mostly from Pavlodarsol. The imported brands were from Russia and Belarus. Overall in the north, only 37.8% [3. - 44.] of the household salt was adequately iodized; 47.6% in urban and 9.7% in rural households (Χ =., p<.). More than a quarter (7.4%) of the Pavlodarsol salt was not iodized, but an even greater share of the unbranded salt (55.9%) was also not iodized. East region In the east, 68.7% of households [6.7% - 74.%] had unbranded and/or unpackaged salt, a significant part (6.4%) of which was not iodized. The majority of branded salt (57 out of 78 = 73.%) was domestic, mainly from the AralTuz Company. Foreign salt sources were mainly from Russia. Overall, 69.% of the household salt samples in the east were adequately iodized [63.%-74.5%], with little difference between urban (7.%) and rural (68.) households (Χ not significant). South region The large majority (7.4%) of household salt in the south was branded and from the AralTuz Company. Almost all household salt (96.) was adequately iodized [9.7% - 97.8%] with no difference between urban (96.8%) and rural (95.%) households. West region A high share of household salt (4.%) in the south was of Russian (Iletskaya) origin and an almost equal share (39.) was unpackaged. The large majority of Russian salt (93.3%) was adequately iodized. Overall, 9.% of the household salt in west region [87. - 94.%] was adequately iodized slightly more in rural (95.) than in urban (87.6%) households (Χ not significant). Central region The majority share of household salt (6.8%) in the central region was domestically produced, mainly by the AralTuz Company (53.6%) and only a small part (9.%) by Pavlodarsol. Overall, 8.6% of all household salt in the central region was adequately iodized [76.3% - 85.9%], with no substantial difference between urban (8.8%) and rural (8.8%) households. Compared to other regions, the Belarusian salt share was high (9.%) and virtually all these were found in the households of Karaganda. 4 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

The percentages of household salt found adequately iodized in the regions of RK, broken down by urban/rural location of the households and by branded or unpackaged storage in households are shown in Figures and 3. The percentage of adequately iodized household salt was highest in Almaty city, followed by the south and west regions, while in the north region it was lowest (p<.). Differences between urban and rural households in adequately iodized salt were generally small, except in the north where the difference between urban and rural households was substantial and statistically significant. As can be seen in Figure 3, the household salt that was either bought or stored without packaging (unpackaged) was generally less adequately iodized than salt stored in the original package (branded). This difference was statistically significant in all regions, except the west. Only a few salt samples found in households in any region were noted as adulterated ; the majority of these were in Almaty city. Fig. 3. % adequately iodized household salt by region and branded and unpackaged character of the salt National pattern For the entire dataset, 77.3% [75.%-79.3%] of household salt was found upon rapid field testing to be adequately iodized ( 5ppm), with a significant difference of 6.5% between urban (79.8%) and rural (73.3%) households (Χ = 8.3, p<.). In contrast, 3.% [.4% - 4.9%] of all household salt tested in the survey had not been iodized (ppm). In urban households this percentage was 9.9% while in rural households it was almost twice as big (7.8%, Χ = 8.88, p<.). Almost half of the households (45.; [4.5% - 47.6%]) in Kazakhstan were found to either purchase or store their salt without packaging. This custom prevailed more often in rural (5.%) than in urban (4.4%) areas (Χ = 9.4, p<.). A significant part (9.7%) of this salt was found not iodized, again with a preponderance in rural (6.6%) compared to urban (3.6%) areas (Χ = 8.3, p<.). About 4% of the salt in this survey was noted as domestically produced, mainly by AralTuz Company (34.9%), with Pavlodarsol (6.%) only a distant second. Among foreign salt suppliers, producers from the Russian Federation (Iletskaya) are the main source (.4% nationwide for all Russian salt), with Belarusia (Mozyrsol) following. As noted before, the market share of Russian origin is especially large in the west of RK. Other imported salt sources (from Ukraine, Turkey, etc) appear to have an insignificant share of the national household salt market. Of the salt from AralTuz Company stored with branding, virtually all samples (97.%) were adequately iodized, while only just half (53.8%) of the salt samples of Pavlodarsol were adequately iodized. Among the salt of Russian sources, 8.6% was adequately iodized. Of the household salt stored without package, only 64.9% was adequately iodized. In summary, strong differences were observed in adequately iodized salt levels between regions and rural and urban households in RK. Upon further analysis, the purchase and/or storage of unpackaged salt was a significant reason for the lower adequacy. The habit of obtaining and storing loose salt was significantly more prevalent in the rural areas of the north and east, although it prevailed also in Almaty city. The Pavlodarsol Company was a major source of the non-iodized salt samples, followed by unbranded/ unpackaged salt. Household salt of the AralTuz Company was virtually always adequately iodized. 5

Quantitative Analysis of a Sub-sample of Household Salt For quantitative laboratory analysis of the iodine concentrations in household salt, 5 salt samples were drawn from the,58 salt samples collected in households in which spot testing indicated that the salt was adequately iodized (>5ppm). The purpose of selection was to reduce costs, while at the same time, to ensure an approximately even distribution according to the geographical regions used in the survey design. Given the prevailing salt iodization prevalence found in RK overall, the 5 salt samples analyzed represent approximately 4-45% of all salt samples tested by rapid test kits in each region (Table 3) and, logically, they therefore also represent 4-45% of each of the salt producer/supply sources in the country. Thus, the results of quantitative analysis reflect the typical national household supply of iodine from salt that had been adequately iodized at source as provided from the market. The distribution of salt iodine concentrations of the 5 household salt samples is shown in Figure 4. Fig. 4. Salt iodine concentrations in adequately iodized household salt TABLE 3: Number of household salt samples collected and analyzed by region and supply source Number of household salt samples tested Number of household salt samples testing adequate Number of household salt samples collected Salt samples analyzed Number % of collected Region Almaty 44 4 94 4.5 North 46 93 93 4 45. East 49 7 73 75 43.4 South 47 37 4 4 43. West 49 7 6 97 4.9 Center 5 4 4 89 43.6 Total,486,48,58 5 43.3 Supply source AralTuz 59 54 55 43.6 Pavlodar 9 49 45 44.4 Russian salt 55 8 6 55 43.7 Unpackaged 669 434 448 9 4.9 Belarusian 5 33 3 4 43.8 Total,486,48,56 5 43.3 6 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

The iodine contents (Figure 4) in the household samples selected for laboratory analyses follow an essentially normal distribution. The proportions of samples with iodine content below ppm or in excess of 5ppm were small. Overall, 6% of the samples fall between 3 and 5ppm, the range of iodization levels mandated by law at the point of production. The average iodine concentration in adequately iodized household salt was 3.7ppm. The distribution parameters for salt iodine contents by region and salt supply sources are shown in Figures 5 and 6. Among the adequately iodized household salt samples selected for laboratory analysis, differences in salt iodine concentrations between regions (Figure 5) and supply sources (Figure 6) are generally rather small, although they reach statistical significance. The variability in iodine concentration of the salt was smallest from AralTuz Company among the supply sources, and the iodine concentrations in salt sampled in Almaty city were higher than in the other regions. The overall lowest salt iodine concentrations were in samples selected from the north and the east regions, and that supplied by the Pavlodarsol Company. Fig. 5. Household salt iodine concentrations by region Fig. 6. Household salt iodine concentrations by supply source 7

IV DISCUSSION General Considerations As in most other countries where IDD is a significant public health threat, Kazakhstan has embarked on universal salt iodization as the principal strategy to reach the national IDD elimination goal. A nationwide survey by KAN in 999, carried out parallel to the DHS, demonstrated that at that time household salt iodization rates were low, and that the iodine nutrition status among women of childbearing age was significantly lower than the internationally recommended range. During the past few years, Kazakhstan has made a major effort to stimulate and improve efforts under the national salt iodization strategy. The domestic salt production and supply systems have been improved tremendously and by 3-4, the two major salt companies AralTuz and Pavlodarsol had established technical capacity trained and human resources sufficient to be able to serve the major share of the national demand for iodized edible salt. Led by a dedicated group in MOH and with the support of UNICEF and ADB, consistent progress has also been made in establishing the required legal basis to mandate the supply and market sale of only iodized salt to consumers, the food industry and the animal husbandry industry, and to build the attendant systems for salt inspection and monitoring throughout RK. Finally, a strong, multi-level, collaborative media strategy has been addressing the need to improve the understanding and acceptance of the dangers of IDD and the benefits of USI among decision-makers, a broad range of professionals and the population at-large. The present survey was therefore important as a means of taking stock of the progress made in universal salt iodization since 999 and to explore areas and possibilities for further steps and improvements. The design of the present survey was similar to that in 999, with a fixed number of households in urban and rural areas of 5 geographically distinct areas of the country, plus Almaty city (the largest national urban area). Within each region, one urban and one rural settlement was to be identified and within the settlements, 3 clusters were to be selected in a 6/4 ratio of urban to rural. Households were canvassed until the required number of 5 households in each cluster was reached. It would seem from the numbers of tests reported and included in the tables, that this general design pattern was not adhered to consistently in each region, however. The particular design of this survey is efficient for comparisons of cohorts by region and urban and rural contrasts, but it is not optimal for calculating an overall national estimate of the percentage of adequately iodized household salt. Therefore, the estimate in this report (77.3%) is not unbiased. The survey method included the rapid test kit for an assessment of the iodate level in the salt that households use. Spot test methods basically use the same reaction mechanism: a stabilized starch-based solution produces a blue color when the molecular iodine is detached from a salt sample. Because spot-tests are simple, rapid and easily employed in the field, this spot-testing is most dependably used for verifying that a salt sample has no iodine in it. The sensitivity of the kits for determing a specific salt iodine concentration (such as 5ppm) has been less firmly established however. Thus, the second objective of the present survey was to verify that the spot-tests carried out by the field teams in households accurately identified the salt samples that turned dark blue as being adequately iodized. Rapid spot-testing of salt in households has become a key process indicator for the assessment of progress toward the national goal of IDD elimination worldwide. The salt used in households, however, is only one fraction of the overall use and consumption of manufactured salt by the population. Fortunately in Kazakhstan, the mandate to iodize edible salt also applies to the salt used in food processing industries and to the salt used in animal husbandry. Nevertheless, despite the fact that the salt for food industry and animal fodder constitute a relatively small fraction of the total salt supplies, the results of salt testing in households do not paint the entire picture of salt iodization adequacy in RK. 8 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Sources of Household Salt in Regions of Kazakhstan Distinct patterns of iodized salt use exist in the households of different regions of RK (Figure 7), which most likely are related to the proximity of the production sources and type of salt purchased. In the present survey, unpackaged salt was the most prevalent recorded type of salt, dominating the share in the east and north regions, and in Almaty city. Salt produced by the AralTuz Company was the major domestic source and found throughout the territory of RK but predominantly in the south, central and Almaty regions. Russian salt was found mainly in the west region with a small share in east and central regions, while salt from Pavlodarsol is mainly supplied in the north and central regions. As further analysis by region, urban/rural location and branded/unbranded and packaged/unpackaged salt showed, these distinct supply patterns underlie to a large extent the variations observed in the adequacy levels of iodized household salt in RK. Fig. 7. Sources of household salt and their importance by region Adequacy of Household Salt Iodization in Kazakhstan Significant differences were observed in the adequacy of iodized salt in households between the regions in RK, varying from nearly 9 in Almaty city and the south and west regions, to approximately 8 in the center, 7 in the east and only 4 in the north. Conversely, the percentage of household salt not iodized (ppm) also varied, from around -3% in the south region and Almaty city, via 7% in the west, % in central and 3% in east, to as high as 43% in north region. Although there were some differences in adequacy between rural and urban settlements (Figure ), the manufacturer s sources and the purchase of salt by weight and/or storing it unpackaged in the household were the major factors that explained these variations. Therefore, two factors would appear to be important in addressing the presence of non-iodized and insufficiently-iodized salt in the households of RK:. Purchasing salt by weight and/or storing it unpackaged is an important factor in RK overall. This practice appears to be widespread in the households of RK. In Almaty city and the south region, however, this did not mean a noticeably smaller share of households having adequately iodized salt. However, this was a major reason for the low adequacy of iodized salt in households in the east region overall, and to a lesser extent in the rural as well as urban households of the north. Thus, addressing this factor would require an approach that identifies the supply source(s) of loose or bulk salt and addressing the failures in not producing adequately iodized edible salt at the source.. The second most important cause is its manufacture by Pavlodarsol Company, and most likely this also explains in part the difference in adequacy of unpackaged salt described above between regions. In the north, salt from Pavlodarsol in the household taken in combination with salt purchased and/or stored unpackaged in the households led to the lowest iodine adequacy in rural as well as urban households in that region. 9

Branded salt (i.e. household salt purchased and stored in its original package) generally appeared to be better and more frequently well iodized, particularly salt from the AralTuz Company and from Russia (Iletskaya). This probably plays a major role in explaining why, compared to other regions, the adequacy of salt in Almaty city and in the south and west regions was higher despite the fact that unpackaged salt still constituted a major share of the overall household salt in these regions. Quantitative Iodine Analyses Laboratory analyses were performed on a selection of those household salt samples found adequately iodized upon testing in households with the rapid testing kit. The laboratory analysis essentially served to verify whether the test kit performed well in the hands of the field teams, thus answering the question: Is the rapid test kit only accurate in identifying only salt with an iodine content 5ppm? The range of iodine concentrations upon titration varied from 5 to 53ppm, thus confirming that no household salt iodized below 5ppm had been classified by the teams as being adequately iodized. Therefore, the reported estimates of adequacy are considered reliable. Recommendations. Efforts to improve upon the use of adequately iodized salt in the households of RK should first focus on ensuring that the Pavlodarsol Company improves upon the quality assurance of the product during salt processing, and second on more effective inspections in the markets of regions (north, east and centre) where a large share of unpackaged salt is being sold that has not been iodized or has been inadequately iodized.. From the consumer s perspective, the main message from this survey appears to be that salt produced by AralTuz and salt in Russia are the most reliable products for purchasing iodized household salt, regardless of whether that salt has been packaged or is sold by weight. 3. Although the present design of canvassing a fixed number of salt samples by region and urban/rural areas is effective for analyzing differences between regions and locations, such a design is not optimal for obtaining a nationally representative estimate of the adequacy of iodized household salt. To derive the latter estimate, the average adequacies of urban and rural areas should be weighted by the respective population sizes to obtain an overall average for RK. 4. Future household salt surveys should consider taking a systematic sub-sample of all household salt to analyze whether the rapid test kit performed well (and thus, for confirming the accuracy of the field tests). This approach will also permit estimation of the sensitivity and specificity of the test kit in the hands of the field teams, which will also indicate whether the test kit was reliable in estimating the adequacy of salt iodization. 5. As regards the timing of a future survey, it would seem to be important for surveys to be carried out during the fall to also investigate whether any unpackaged salt found in the household was purchased for habitual or for occasional use (such as pickling). 6. It will be important in a future survey to complement the data collected in households with information from producers and their associated sales channels about the share(s) and/or amount(s) of edible salt supplied to food processing industries (bread bakeries in particular) and to animal husbandry industries. An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

SECTION IDD Rapid assessment Iodized Salt Consumption of Households, Level of knowledge and Adequacy of Salt Iodization in the Republic of Kazakhstan T. Sh. Sharmanov E.G. Tsoy L.R. Kulmurzayeva F.E. Ospanova

EXECUTIVE SUMMARY Purpose of survey To assess the adequacy of iodized dietary salt consumption level of the population at the national level through households for the purpose of assessing the Iodine Deficiency Control Program and monitoring its progress. Strategy Assessment activities to measure the standard and quality of iodized salt in households and also the level of knowledge of the population about iodized salt. Based on the results of the assessment analysis, to elaborate on recommendations for improving the Iodine Deficiency Control Program and monitoring its progress. Objectives of the project. To monitor the iodized dietary salt consumption in representative sample households using a cluster method in 6 regions of RK.. To assess the adequacy of table salt iodization using a quantitative iodine variable in samples selected in households. 3. To define the level of knowledge and changes in the population behavior with respect to iodized salt consumption based on the results of a household questionnaire. 4. To fill in a pre-existing database, starting with data from background surveys (including information about monitoring of iodized salt (IS) production, QA at all levels, consumption at the level of households, biological monitoring regarding adequate provision of iodine). 5. To give recommendations for improving the media strategy and plan of action and also evaluation and monitoring of its effectiveness. 6. To discuss the surveys data among concerned ministries, authorities, institutions and enterprises with the purpose of providing the entire population with quality iodised salt (IS), as well as making the resuts of the survey open to thethe general public using the support of the mass media. An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

I PREAMBLE Summary of the situation with regard to the prevalence of Iodine Deficiency Disorders (IDD) in Kazakhstan The medical, social and economic importance of the IDD problem first of all lies in the reduction of the intellectual, educational and professional potential of the nation; this highlights the necessity of the development and realization of a national strategy for elimination of IDD and its consequences. Practically the entire territory of Kazakhstan is classified as moderately endemic of IDD zone; The low content of iodine in the soil, water and locally produced foodstuffs is noted in the half of the country, and Endemic Goiter Centers are registered in of 4 oblasts (regions). The most pronounced situation is in the south and east regions. As a whole from to 7 of the republic s population is affected by endemic goiters (М.Е. Zeltser, ). Based on data from the latest large-scale survey, conducted in 99-993, the rate of congenital thyroid deficiency (hypothyroidism) in the southern oblasts (regions) of RK is 6-7% and among children who were born by women with goiters, it runs up to 4%. In obstetrical institutions in Almaty, neonatal hypothyroidism is found in 7.% of all cases (М.Е. Zeltser, R.B. Bazarbekova, 996). Prevalence of goiters among school-aged children in the Markakol and Katon- Karagay areas in the East-Kazakhstan oblast (region) varies from % up to 35%, and the general prevalence of goiters among schoolchildren in Kentau city in the South-Kazakhstan oblast (region) is equal to 6%. In these regions, up to 5-6 of the adult population has clinical signs of the goiter. The Kazakhstan Academy of Nutrition (KAN) for the first time, within the framework of the National Demographic and Health Survey of Kazakhstan (NDHS, 999), carried out a study of the median level of UIC in women of childbearing age, and surveyed 5844 households for a background survey of iodised salt (IS) consumption. Only 9% of these households consumed iodised salt (IS). Among 979 households surveyed in the south and east regions of Kazakhstan, where the situation with the endemic goiter is the most severe, the consumption of iodised salt (IS) was.6% and 4.5% respectively. Among women of childbearing age in the south and east regions of Kazakhstan the percentage of women with a low level of UIC was 5% and 67% respectively. In the north region of the republic this parameter was 6.7% and in the west region, which was considered as not being severely affected by IDD, it was 6.. Only in the Central region it was at the lower level of 5%. According to this survey among 48 respondents only 58.6% were aware of the necessity of regular consumption of iodized table salt and 4% deliberately bought this salt (F.E. Ospanova, ). Level of the population s knowledge and skills with regard to IDD In -, with the technical support of UNICEF in Kazakhstan the national survey Study of the level of knowledge and practices with regard to IDD problem among the general population and health workers of RK was implemented with the purpose of studying the level of knowledge and practices of the general population by various groups with regard to IDD (Т.А. Germanyuk, ). The principal findings of the project indicated that schoolchildren and adults were not fully aware of problem of IDD, diseases caused by iodine deficiency in the human body, the advantages of iodised salt (IS), methods of IDD prevention. Therefore development of target informational and educational programs for various target groups of the general population as a whole was required. In particular about 7 of questioned rural schoolchildren no knowledge of IDD or its biological consequences s. Of those who were aware of IDD, 3.% of schoolchildren got this information from television broadcasts and.7% from their teachers. 33.% of urban schoolchildren and 4.% of rural schoolchildren knew that IDD could be prevented with iodised salt (IS) consumption, although more than 7 of them had heard of IS. The survey of PHC workers found that in fact only % of them were confident that the consumption of iodised salt (IS) could alleivate IDD and 36.5% were convinced that the human body could produce iodine. At the same time 6.3% of the questioned PHC health workers had been asked by clients for suggestions concerning necessity of iodised salt (IS) consumption. 3

In total, about of the adult population believed that it is necessary to consume iodised salt (IS) for IDD prevention. Among respondents buying iodised salt (IS), 43.7% did not know why it was necessesary. The results of the implemented survey show clearly that a complex and longterm media strategy for education of the general population is necessary for IDD elimination at the national level in Kazakhstan. First of all, the strategy should target the most vulnerable groups of the population as well as health workers, and develop new practices of deliberate IS consumption, and provide production of high-quality IS. The survey findings have provided the basis for a national media strategy for IDD prevention. Iodised salt (IS) production in Kazakhstan The main salt producers are located in the southwest of the republic (Aralsk city in the Kyzylorda oblast) and in the north (Pavlodar oblast). At the present time in Kazakhstan there are two main active enterprises (Araltuz JSC and Pavlodarsol OJSC) producing an iodized dietary table salt. With UNICEF support these companies were provided with iodinated plants and potassium iodate in the amounts of 4 tons in 999 and.5 tons in. Also since, financial and technical support for iodized dietary salt production at these companies has been provided by a project of the Asian Development Bank (ADB). This project stipulated a usage of a special logo for fortified foodstuffs, in particular iodised salt (IS) and wheat flour of the first- and high-classes. A corresponding logo, healthy food, was developed by the Kazakhstan Academy of Nutrition (KAN) together with UNICEF and it is used to mark iodized dietary salt produced in RK. Also this logo was incorporated into all media including TV spots. It is used in all 6 countries-participants of the Asian Development Bank s project with theinscription translated into appropriate national languages. An analysis of dietary salt quality conducted in July with the technical assistance of UNICEF together with Mr. Frits Van der Haar, the UNICEF consultant, showed that in - iodized salt production increased.5 times; thus it covered only 46% of the population s requirements. KAN s long-term work with the salt producers and the effective technical support of UNICEF and the Asian Development Bank project have resulted in a much needed increase in iodized salt production. Based on the latest monitoring data for 3 and February 4, iodized salt production at Araltuz JSC was 6 89 metric tons, and at Pavlodarsol OJSC, it was 3 metric tons. Thus total iodized salt production in RK amounted to 78 53 metric tons and at the present time it covers 4.3% of the population requirements. However it is necessary to take into account that these calculations are based only on data submitted by salt producers and do not indicate whether iodized salt is being sold uniformly in the various regions of RK. The quality of iodized salt sold in the market is still too low. Periodic inspections by the Sanitary and Epidemiological Service (SES) in Almaty city found that 43.5% of the examined samples contained low levels of iodine, in most cases due to poor storage and selling salt past its expiration date. An objective appraisal of this situation can be assembled from information gathered from various sources and by conducting biological monitoring. GOST (State Standards) of RK 5574-3 Iodized dietary table salt and Technical Specifications set a new standard of dietary salt iodization of 4+5 mkg/kg. Iodine consisting of potassium iodate is retained well in iodized salt, allowing producers to increase its expiration date to months. Ideally all salt in the consumer market and the food industry should be iodized. With the direct assistance of the Ministry of Health (MoH) of РК, the Kazakhstan Academy of Nutrition (KAN), UNICEF and the regional project office of the Asian Development Bank s project, the Law of the Republic of Kazakhstan On IDD Prevention (No 489-II LRК) was approved on the 4th of October, 3. Clause of this law reads in part: Dietary and fodder salt produced in the territory of the Republic of Kazakhstan is subject to mandatory iodization (Item ); Production, import and selling of salt in the territory of the Republic of Kazakhstan is prohibited without compliance with the iodization requirements stipulated by this clause (Item 4); and Production, import, export and selling of adulterated dietary salt is prohibited. According to clause 4 of the same law of RK: On packaging of iodized salt and other fortified foodstuff, enriched with iodine compounds, the following items of information should be specified in the State and Russian languages: nutritional value and caloric content; contents of iodine compounds; conditions of use; instructions regarding storage. The present normative legal base should ensure total fulfillment of the demand for high-quality iodized salt in the domestic consumer market. For the present time by-laws for promotion of this legislative act (orders of the MoH of РК) have been developed, approved and executed. 4 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Media Campaign One of the keystones in realization of the national strategy for prevention of micronutrient deficiencies is raising the awareness of various segments of the population about the importance of IDD, available techniques for prevention of disorders caused by an insufficient intake of micronutrients and creation of consumer demand for iodized salt. In the beginning of 3, the UNICEF representative office together with partners (KAN, MoH of RK, the regional project office of the JFPR95 program and the Confederation of Non-Governmental Organizations (NGO)) started an active multilevel media campaign accompanied by distribution of various informational and educational materials for target public groups, involving all forms of mass media. This media program was integrated completely with the regional media strategy of the ADB s international project JFPR Improvement of nutrition for women and children from poor families in the Asian Countries in the transition period, whose basic purpose was the industrial production of high-quality iodized dietary table salt and regular consumption of such salt by 66.6% of the republic s population (in the middle of 4). The IDD prevention campaign was officially launched on February 8, 3. The press conference was broadcasted on 6 television channels in RK. Then the presentation Millenium Goals was organized with financial support from UNICEF in the Parliament of RK on February, 3 with distribution to the higher legislative and executive authorities of the republic, of the project s informational and educational materials. Since the th of March until the 3st of December 3 with the support of the Ministry of Culture, Information and Public Consensus of RK, publicservice announcements about IDD prevention through consumption of high-quality iodized salt were aired on 3 national TV channels: Khabar, El- Arna and TRC Kazakhstan (in the State and Russian languages) within the framework of State Orders. Packets of informational and educational materials for schoolchildren and teachers have been developed and distributed among all 8 public general schools in RK through regional and city education authorities. With regard to IDD prevention problems in -3, the following informational and educational materials were developed, issued and distributed among target groups in RK: leaflets for policy makers (75 copies), media for salt producers and retailers (55 copies), mass media ( copies), general population (3 copies); brochures (8 copies), booklets (8 copies), booklets for schoolchildren (9 copies), booklets for pregnant women (85 copies); posters and calendars (5 copies), instruction manuals for teachers of general schools (9 copies), instruction manuals for health workers (5 copies), recommendations for the Sanitary and Epidemiological Service (SES) of RK, on methodologies for QA of iodized salt ( copies). In total with regard to IDD problems and prevention techniques, 3 types of printed materials were published with a total run of 4 3 copies. The importance of the introduction of IDD prevention issues to school curricula was raised with and agreed to by the Ministry of Education and Science. It was approved to integrate IDD issues into school subjects such as healthy lifestyle (valeology), biology and chemistry with the purpose of forming a deliberate habit of consuming iodized salt regularly for IDD prevention from a young age and to involve schoolchildren in IDD prevention activities. Under the joint initiative of the MoH of RK, KAN, the UNICEF representative office in RK and the ADB regional project office, a special item (Item 4.4 of the Section 4: To ensure IDD prevention among the population of Kazakhstan ) has been included in the Decree of the Government of РК No 89 dated.3.3, On the statement of Plan of Activities for realizing the national program Health of the People for 3-5. The previous sub-chapter illustrates the important and strategic media projects by partners aimed at changing of public practice with regard to regular consumption of high-quality iodized salt. In summary, the following necessary prerequisites for successful IDD prevention at the national level were created: An appropriate normative legal basis has been created including a special law of RK, by-laws for its realization and a special statement on the Plan of Activities for the realization of the national program Health of the People authorized by the Decree of the President of RK and the Government of RK; The volume of high-quality iodized salt production has been increased taking into account the existing fundamental and market demand by consumers in 999 (only 9% of households consumed iodized salt); Information from the background surveys, a study of iodine excretion in urine, iodized salt consumption (999) and, an assessment of the level of knowledge regarding IDD and its prevention () guided development of the national strategy of IDD prevention in Kazakhstan; An active multilevel media campaign involving all forms of media was carried out, accompanied by distribution of informational and educational materials for target public groups; All public groups from policy makers to NGOs, schoolchildren, interested state institutions and the private sector (on behalf of producers and distributors) have been involved in IDD prevention activities. 5

Of course, the great scope of media activities implemented at the national level requires an evaluation of their effectiveness at raising the level of knowledge about IDD, its consequences and effective prevention by regular consumption of high-quality iodized salt at the household level through representative sampling. This is the basic purpose of the present project. Such a survey is urgently needed in order to develop the media strategy, update its implementation, and methods of monitoring its efficency. In view of this situation the present project offer has been proposed, including the following issues: ) Single-step and short-term evaluation of consumption of highquality iodized salt in households at the national level; ) Study of the adequacy of iodination of dietary salt consumed in households using quantitative definition of iodine in the salt; 3) Assessment of the level of knowledge of the population by conducting a questionnaire survey of selected groups through the selected groups on the subject of IDD prevention through steady consumption of iodized salt. Period of implementation: August - December, 4. Location of the project implementation: six regions of RK (the south, north, east, west and center of RK) and Almaty city, coverage is determined according to the sampling method described below. Target group - urban and rural population Survey sampling was based on the random representative method. The sampling was carried out using a cluster method; 3 clusters (points) were identified including 7.5 urban clusters and.5 rural clusters. In total there were six regions and 5 clusters in each region (.5 clusters in each urban and rural areas of each region). There were 5 households in each cluster, or 5 per each region. The total number of households covered by the survey was 5 including 75 urban and 75 rural households. In 45% of the households, i.e. in more than a thid, samples of dietary salt were taken to the laboratory to determine the exact content of iodine, and in all sampled households, i.e. in 5 households, respondents were questioned about their knowledge of IDD and its prevention by regular consumption of high-qualitity iodized salt, their attitude to iodized salt and the practice of consuming it. For the purpose of carrying out the project tasks, the following activities were arranged: A field survey team was formed consisting of persons ( persons per region); Each survey worker covered.5 clusters or 5 households on average. Field survey workers were selected taking into account their experience in implementing similar questionnaire surveys in households. A one-day training course has was arranged for the survey teams. During the training course, survey workers were made familiar with the purposes and tasks of the project and informed in detail about the upcoming work. They were trained to analyze salt samples using a method of spot-testing. Also survey teams were trained on methods of interviewing respondents. A form to record information from the spot-test was developed for all survey workers and they filled it in based on the data of the implemented surveys. At the seminar there was a practical demonstration of techniques of determining iodine contents in salt and a test regarding the questionnaire. A packet of documents was prepared for this seminar. Sampling of the settlements Region City Area/village Total number of households Almaty city Almaty 5 Southern Shymkent Sairam area 5+5 Northern Pavlodar Sharbakty area Sharbakty village Eastern Ust-Kamenogorsk Shemonaikha area Shemonaikha village Western Aktobe Alga area Alga village Central Karaganda Osakarov area Osakarovka village 5+5 5+5 5+5 5+5 6 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

II METHODS OF SURVEY Selection of these geographical regions Selection of these geographical regions was decided by the fact that KAN has carried out previous surveys on IDD prevalence among women of childbearing age in these regions and also that these regions have high rates of endemic goiter prevalence. Based on the data of repeated but sporadic examinations of the endemic regions, which were implemented in -, the percentage of children with goiters noticeably increased, to 3.8% 46.9% for children from the ages of 9-5 years old. The goiter rate of pregnant women was 35.3% - 59.3%. A sample survey of schoolchildren in east Kazakhstan showed higher parameters: up to 78.6%. In Taldykorgan and Petropavlovsk the prevalence rate was 46. and 46.9% respectively. At the present time, endemic goiters are found even in regions considered safe with regard to iodine provision. In the entire territory of Karaganda oblast (region) the goiter rate of children comes to 4.5% - 8.7% for children from the age of 9-5 years old, whereas before endemic goiter was found only in the Osakarov area. Endemic goiters has even been discovered in the western oblasts (regions) of the republic: 46.% of children had endemic goiter, though before this disease had only sporadic prevalence in these regions. The project has provided, where possible, the most complete coverage of all administrative-geographical regions of Kazakhstan taking into account their significant socio-economic and ethnic differences, differences in lifestyle, diverse nutritional traditions, and climatic and geographical conditions. This is an attempt to get a realistic model, which can be applied to the population of the whole republic, and thus take further measures to improve IDD prevention activities. This project survey planned to collect some salt consumed in households and to select approximately 4-45% of all salt samples for further laboratory detection of iodine contents to assess the adequacy of iodination of consumed dietary salt. Assessment of the efficacy of the media campaign and the level of public knowledge with regard to IDD prevention was determined by questioning the population in 6 regions of Kazakhstan: the north Region (Pavlodar city, Scharbaktin area of the Pavlodar oblast (region)); the south Region (Shymkent city, Sairam area of the South-Kazakhstan oblast (region)); the central Region (Karaganda city, Osakarov area of the Karaganda oblast (region)); the west Region (Aktyubinsk city, Alga area of the Aktyubinsk oblast (region)); the east Region (Ust-Kamenogorsk city, Shemonaikha area of the East Kazakhstan oblast (region)) and Almaty city. Survey sampling Survey sampling was based on the random representative method. The sampling was carried out using a cluster method; 3 clusters (points) were identified including 7.5 urban clusters and.5 rural clusters. In total there were six regions and 5 clusters in each region (.5 clusters in each urban and rural areas of each region). There were 5 households in each cluster, or 5 per each region. The total number of households covered by the survey was 5 including 75 urban and 75 rural households. In 45% of the households, i.e. in more than a third, samples of dietary salt were taken to the laboratory to determine the exact content of iodine, and in all sampled households, i.e. in 5 households, respondents were questioned about their knowledge of IDD and its prevention by regular consumption of high-quality iodized salt, their attitude to iodized salt and the practice of consuming it. 7

Titration method. Backbone of the method. All measuring instruments, auxiliaries, materials and reagents, used for the exact determination of the iodine contents in dietary iodized salt complied with GOST requirements of RK and the recommendations of the manual Monitoring of Universal Salt Iodization Programs edited by Mr. Kevin M. Sallivan, Program of Micronutrients deficiency elimination, Mr. Robin Haustan (РАММ) and Rollins Public Health Institute of Emory University, Mr. Jonathan Gorstein (РАММ), Center for Elimination and Prevention of Diseases, Ms. Jenny Chervinkas, Initiative in the Area of Micronutrients as well as the 997 Russian edition, edited by Mr. G.A. Gerasimov., and also recommendations from the manual Micronutrient Laboratory Equipment Manual, (UNICEF, PAMM, 996). Iodine contents in salt samples were determined using a method of iodometric titration as described in 979 by De Maeyer, Lowenstein and Thilly. The method is based on the determination of iodine educed by the interaction of potassium iodate and potassium iodide in an acid medium (solution of sodium sulphate) in the presence of an indicator. The indicator is a starch. The two-stage reaction mechanism can be shown as follows: KJO 3 + 5KJ + 3H SO 4 = 3J + 3K SO 4 + 3H O () (from salt) potassium iodide Na S O 3 + J = NaJ + Na S 4 O 6 () Stage. Release of free iodine (I ) from iodized salt. Addition of sulfuric acid (H SO 4 ) generates the release of iodine from potassium iodate (KIO 3 ) present in salt samples. Stage. Titration of free iodine (I ) by sodium thiosulfate (Na S O 3 ). At the stage of titration, the free iodine is absorbed, at the amount of input sodium thiosulfate proportionate to the amount of iodine released from the salt. Addition of starch as a external (indirect) indicator of this reaction interacts with the iodine and as a consequence a blue color appears. The starch is added at the end when only trace amounts of free iodine remain. The disappearance of the blue color under further addition of sodium thiosulfate is the end point of analysis. At that point, the volume of input sodium thiosulfate is stated and recorded. Reagents. Deionized water.. Sulfuric acid 4 (pure), produced in Germany, index number is 986.5. 3. Potassium iodide (pure), produced in Germany, index number is 544.5. 4. Sodium chloride (pure), produced in Germany, index number is 644.5. 5. Sodium thiosulfate (pure), produced in France, index number is А 4384. 6. Soluble refined starch, produced in France, index number is А 47538. Preparation of reagents.5 М solution of sodium thiosulfate (Na S O 3 5H O). They dissolve.4 g of Na S O 3 5H O in l of deionized water. This solution is kept in a cool dark place and it is sufficient for - salt samples depending on iodine contents. If storage conditions are met the solution is stable during one month. 6 ml of concentrated Н SO 4 is slowly poured into 9 ml of distilled water, bringing the solution to the final volume of ml with the addition of water. This volume is sufficient for analysis of salt samples and it is can be kept for an indefinite period of time. Determination of iodine contents in iodized salt Determination scheme a) Weighted examined sample (iodized salt) in a mass of. g is dissolved in cm 3 of distilled water in a conical flask with a volume of 5 cm 3. If the solution is turbid it is necessary to filter it out. b) cm 3 of Н Sulfuric acid solution is added by a graduated pipette to the above mentioned solution. 5 cm 3 of solution of potassium iodide is added with a mass portion of using a pipette. The solutions intermix, and the flask is closed with a plug and put in a dark place for minutes. c) The examined solution, which turns a dark-yellow color, is titrated from a burette by a.5 М solution of NaSO3 with continuous shaking until the color turns light-yellow. d) Approximately ml of starch indicated solution is added into the examined solution. The mixture should acquire a dark-blue colouring and titration is continued until the solution becomes colorless. The volume of NaSO3 solution used for titration is registered. Two parallel determinations of the same salt sample are carried out. 8 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Check experiment To account for sample matrix and purity of used reagents they carry out a check experiment. For that reagents are added to. g of dietary salt which is not processed by additives of potassium iodate or to chemically pure sodium chloride and then they carry out determination as described in the subparagraph above. Data handling The quantity of iodine contained in the salt in mg per kg of examined salt are calculated according to the following formula: X = V x.57 x / = V x.57 (mg/kg), V volume.5 М NaSO3 used for titration, cm 3 ; - weighted salt for analyze, g; - recalculation per kg of salt;.57 amount of iodine in potassium iodate contained in examined salt sample, which corresponds to cm3 titrated.5 М solution of NaSO3 used for titration of this sample. Notes: According to reaction equations () and () underlined of this determination method of iodine contents in iodized salt it is evident that /6 portion of the total amount of iodine, which is titrated by sodium hyposulfite in examined sample, falls to the share of iodine educed from KJO 3, in other words not.6345 mg, but.57 mg. The final result is determined by taking the arithmetic average of the two parallel measurements. Method of Questioning For the purpose of assessment of the population s knowledge and practices with regard to IDD prevention and the public s attitude toward iodized salt, the questionnaire was developed, containing 3 questions (This questionnaire is in Appendix ). 5 people from 5 households in 6 regions of Kazakhstan were questioned using this questionnaire. A computer version for inputting questionnaire data was developed in the SPSS application. The outcomes are submitted in percentages with the error in mean (m) and the validity coefficient (t) 9

III DESCRIPTION OF RESULTS Rapid assessment of salt consumption at the local level - spot-testing At the initial stage of the survey Rapid assessment of the IDD campaign KAN, in the person of UNICEF, the coordinator of the project, the assistant to the coordinator, assisting UNICEF projects, and the field survey workers, performed the following duties and functions:. KAN developed a methodology and project design for rapid assessment of access to iodized salt for households in RK and for gathering data with regard to adequate iodine consumption by the population of Kazakhstan on the basis of questionnaires, spot-testing of salt samples, and quantitative determination of micronutrient contents in the laboratory using the titration method.. KAN developed Questionnaires for questioning the population while visiting households. 3. KAN developed Forms for information gathering based on the results of analyses of iodine contents in salt with the application of a qualitative method of spot-testing, including recording the name of the producer of salt. 4. KAN arranged a field trip and performed a rapid assessment of access to iodized salt in 6 regions of Kazakhstan (availability of iodized salt in households using a spottesting, questioning the population and salt sampling for quantitative determination of salt iodization levels using the titration method at the laboratory of IDD control of KAN. 5. KAN conducted a preliminary training seminar for 6 field teams consisting of persons. They were trained in interviewing skills of interviewing, rules of questionnaire completing, spot-analyzing iodine contents in salt, filling out the forms, methods of selecting and marking salt samples for further transportation to the laboratory of KAN. 6. KAN provided the field teams with the necessary number of questionnaires, forms for information gathering, spot-test systems, and marking materials. For the purpose of prompt rapid assessment of access to iodized salt in households using spot-tests, and collection of salt samples and questionnaire data, 6 regions of RK were selected in a method similar to the sampling performed by the program of the Demographic and Health Survey (DHS) in 995 and 999 and the National survey of nutritional status of the population of Kazakhstan (the UNDP project, 966). Settlements for the survey in 5 regions were selected using a method of random sampling; in each region there was a defined scope of work the number of surveyed households in each region was 5 (5 urban households and 5 rural households),for a total of 5 households in the territory of RK. Teams of survey workers were given the task of implementing rapid assessments of the quality of dietary salt iodization in all selected households (5 units of spot-tests), questioning with regard to awareness about IDD prevention in all selected households (5 questionnaires), sampling of dietary salt for further laboratory analysis with regard to determining the quantity of salt iodization in every second household (75 samples). An example of the public questionnaire is shown in Appendix, an example of the form for information gathering for assessment of the quality of iodization of dietary salt in households using spot-tests is shown in Appendix. From October 6 until November 9, 4, 5 field teams consisting of people from KAN worked in 5 regions of RK and one team worked in 6 districts of Almaty city. The teams executed the scheduled work including questioning, spot-testing, selection and transportation of salt samples to the laboratory of KAN. 3 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table 5. Regions allocation for Rapid assessment of IDD campaign: Region Oblast (region) of RK Urban conditions Rural conditions East East-Kazakhstan Oblast Ust-Kamenogorsk Shemonaikha village (Shemonaikha area) North Pavlodar Oblast Pavlodar Sharbakty village (Sharbakty area) West Aktyubinsk Oblast Aktobe Alga village (Alga area) Center Karaganda Oblast Karaganda Osakarovka village (Osakarovsk area) South South-Kazakhstan Oblast Shymkent Sairam village (Sairam area) Almaty Almaty Oblast 6 districts of Almaty - Results of the field survey Rapid Assessment of IDD campaign. Region the North of the Republic of Kazakhstan In Pavlodar city and Sharbakty village (Sharbakty area) of Pavlodar oblast (region) field survey workers assessed the quality of iodized salt consumed in households, gave the questionnaire, performed spot-tests, and monitored producers of salt and informational activities among the population. In Pavlodar city they visited 5 households in the field with the assistance and close cooperation of district nurses of district out-patient institutions. In a similar manner they visited 5 households in Sharbakty village of Sharbakty area. The results of the quality of dietary salt consumed in Pavlodar city and in Sharbakty village of the North-Kazakhstan oblast (region) are indicated below in the Table 6. The scheduled work and explanatory activities in households was completed in full. It is necessary to note that in this region, the salt of domestic producers (Pavlodarsol and Araltuz) was consumed in only /3 cases (33.7%) and about 6. of surveyed households (59.4%) used salt sold by weight or not stored in the original packaging; the proportion of such households was particularly high in rural areas (66.7%) as compared with urban areas (5.). It is reasonable to assume that among such households there was very low recognition of fortified iodized salt logotype. This fact indicates that consumers pay little attention to branding and marking of salt and its iodization. In the markets of the north Region, besides salt produced in Kazakhstan, Russian salt (Iletskaya, Rossol, Ural), Byelorussian salt (Polesye, Mozyr) and even one sample of Turkish salt was available. Thus it is necessary to note that based on the results of spot-tests among total salt samples of non-domestic production (8) sufficient iodine contents were found in only 3 cases (6.7 + 8.8%), iodine was not found in 8 cases (44.4 +.7%), and in 3 cases (6.7 + 8.8%) the iodine contents were low. The salt was recognized as adulterated in 4 cases (. + 9.8%). 3

A very high percentage of salt samples were found which contained no iodine at all (33.6 + 4.% in Pavlodar city and 54.8 + 4.4% in Sharbakty village). Moreover based on the data of the spot-test, almost /5 of selected samples (9. + 3.5% in urban areas and 8. + 3.4% in rural areas) had iodine contents lower than 5 ppm. Adulterated dietary salt was used in 4.8% of households in urban areas and.6% in rural areas. Among 36 salt samples selected in households of Pavlodar city the iodine contents of the locally produced salt (Pavlodarsol) exceeded 5 ppm only in half of the samples (8), in rural areas this value was even lower (4.7 + 9.4%); This is probably related to poor storage conditions or selling past the expiration date.as proved by the data of spot-testing of Araltuz salt which found that in urban areas quality iodization was present in. of the samples and in rural areas in 77.8 + 3.8% of cases. As a whole, for the north region high-quality iodized salt was used in only 37. + 3. of households. This value was a little bit lower in rural areas (3. + 4.%) than in urban areas (47. + 4.5%). The proportion of adulterated samples of iodized salt was 3 times higher in urban areas than in rural areas (4.8 +.9% and.6 +.% accordingly). Based on this data it is evident that the highest proportion of qualitative iodized salt was found in Araltuz salt (9.5%), second for Pavlodarsol (63,) and the lowest proportion was found in Byelorussian salt (Polesye, Mozyrsol 37.5%). The rate of high-quality salt among non-packed samples amounted to only 5.. Table 6. Quality of consumed dietary salt for the North Region. Producer Kazakhstan salt Iodine contents in salt <5 ppm >5 ppm Pavlodar city No iodine Adulterated Total Pavlodarsol 9 (5.+7.%) 8 (5.+8.3%) 9 (5.+7.%) 3 (8.3+4.6%) 36 (8.8+4.) Araltuz - (.+.9%) - - (9.6+.6%) Russian salt Iletskaya (4.3+4.) 4 (57.+8.7%) (8.6+6.9%) (4.3+4.) 7 (5.6+.%) Rossiyskaya - - (.8+.8%) Byelorussian salt Polesye Mozyrsol (33.3+7.%) (33.3+7.%) (33.3+7.%) (33.3+7.%) 3 (.4+.4%) Turkish salt Turkish - - - (.8+.8%) Salt sold by weight / without packing 3 (.+5.) 4 (36.9+6.) 8 (43.+6.%) - 65 (5.+4.5%) Total: 5 4 (9.+3.5%) 59 (47.+4.5%) 4 (33.6+4.%) 6 (4.8+.9%) 5 3 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Producer Iodine contents in salt <5 ppm >5 ppm No iodine Adulterated Total Sharbakty village (North-Kazakhstan oblast (region)) Kazakhstan salt Pavlodarsol 8 (9.6+8.8%) (4.7+ 9.4%) 8 (9.6+8.8%) (3.7+3.6%) 7 (.4+3.6%) Araltuz (.+.4%) 7 (77.8+3.8%) (.+.4%) (.+.4%) 9 (7.+.3%) Russian salt Uralskaya - - - (.8+.8%) Byelorussian salt Polesye Mozyrsol (.+7.9%) (4.+.9%) (.+.4%) - 5 (6.3+.%) Salt sold by weight / without packing 3 (5.5+3.9%) 4 (6.7+4.%) 57 (67.8+5.%) - 84 (66.7+4.%) Total: 6 3 (8.+3.4%) 34 (3.+4.%) 69 (54.8+4.4%) (.6+.%) 6 For the North Region (Total) Kazakhstan salt Pavlodarsol 7 (34.6+7.) 9 (63.+7.%) 7 (34.6+7.) 4 (8.7+4.%) 46 (8.3+.4%) Araltuz (4.8+4.6%) 9 (9.5+6.4%) (4.8+4.6%) (4.8+4.6%) (8.4+.7%) Russian salt Iletskaya (4.3+4.) 4 (57.+8.7%) (8.6+6.9%) (4.3+4.) 7 (.8+.) Rossiyskaya - - (.4+.4%) Uralskaya - - - (.4+.4%) Byelorussian salt Polesye Mozyrsol (5.+5.3%) 3 (37.5+7.% 3 (37.5+7.% (.5+.7%) 8 (3.+.%) Turkish salt Turkish - - - (.4+.4%) Salt sold by weight / without packing 6 (7.4+3.%) 38 (5.5+3.6%) 85 (57.+4.) - 49 (59.4+3.%) Total: 5 47 (8.7+.5%) 93 (37.+3.) (44.4+3.%) 8 (3.+.%) 5 33

. Region the South of the Republic of Kazakhstan As in the North Region the field team assessed the quality of iodized salt consumed in households, gave the questionnaire, performed spot-tests, and monitored producers of salt and informational activities among the population in Shymkent city and Aksu village (Sairam area of the South-Kazakhstan oblast (region)). In Shymkent city they visited 5 households with the assistance and close cooperation of district nurses and in a similar manner they visited 5 households in Aksu village (Sairam area of the South- Kazakhstan oblast (region)). The results of the quality of consumed dietary salt in Shymkent city and Aksu village are indicated below in Table 7. In contrast to the North Region, in surveyed households Kazakhstan salt prevailed, mainly Araltuz, packaged in kg packages in kg sacks without a logo but marked as being iodized salt (such salt is convenient for purchase by families having many children). Respondents mentioned the availability of Russian salt in the market and salt sold by weight from unknown producers, which are more expensive. Respondants mainly bought iodized dietary salt, but they mentioned the higher price of such salt as affecting purchasing power. The scheduled work and informational activities in households of the South Region have been completed in full. The public questioning revealed that the population recognizes the fortified iodized salt logo. In most cases, respondents mentioned that product packaging should inform the buyer about the product s characteristics and ingredients; however further questions showed that buyers do not pay attention to such information. In the markets of this oblast (region) there is basically Kazakhstan salt produced by Araltuz, the biggest salt producer. Among a total of 49 salt samples 79 samples (7.9 +.8%) were produced by this company. Based on the data of spot-testing, its iodization level (> 5 ppm) has amounted was 99.4 +.7% as a whole for the oblast (region), i.e. practically all selected salt of this producer was high-quality with regard to iodine contents. Only in one case (.8 +.8%) was the contents of this microelement below the normative level,and this was obviously related to poor storage conditions or selling past the expiration date. The majority of salt sold by weight or unbranded salt (9. + 3.6%) also met national GOST and technical requirements of iodine contents, and only in. of samples was this microelement was not found. Most likely this result indicates the presence of Araltuz brand salt in this category of salt due to the proximity of the producer and the success of the company s distributors. No essential difference between iodized dietary salt in urban and rural areas was found. It is necessary to note that among selected branded samples there were no cases of falsification. 34 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table 7. Quality of consumed dietary salt for the South Region. Producer Kazakhstan salt Iodine contents in salt <5 ppm >5 ppm Shymkent city Araltuz - (.+.) Salt sold by weight / without packing No salt in household (sample) - (86.9+7.) Total: 4 - (97.6+.4%) Kazakhstan salt Araltuz (.3+.3%) Russian salt Aksu village 76 (98.7+.3%) No iodine Adulterated Total - - (8.4+3.5%) 3 (3.+7.) 3 (.4+.4%) - 3 (8.5+3.5%) - 4 - - 77 (6.6+4.3%) Iletskaya - - - (.8+.8%) Salt sold by weight / without packing - 43 (9.5+4.%) 4 (8.5+4.%) No salt in household (sample) - - - - Total: 5 (.8+.8%) Kazakhstan salt Araltuz (.6+.6%) Salt sold by weight / without packing (96.+.7%) For the South Region 78 (99.4+.6%) - 63 (9.+3.6%) 4 (3.+.6%) - 47 (37.6+4.3%) - 5 - - 79 (7.9+.8%) 7 (.+3.6%) No salt in household (sample) - - - - Total: 49 (.4+.4%) 4 (96.8+.%) 7 (.8+.) - 7 (.+.%) - 49 35

3. Region the West of the Republic of Kazakhstan. Surveys were carried out in Aktobe city and Alga village (central area) of Aktyubinsk oblast (region) from October 6 until November, 4. 5 households were surveyed and 47 dietary salt samples were examined using spot-tests. Based on the data from Table 8, it is evident that the total percentage of consumed salt for the region that was produced in Kazakhstan, mainly salt from Araltuz, to only 8.% and it was slightly higher in urban areas than in rural areas (.% and 5. accordingly). It is necessary to note that Araltuz is located in the adjoining Kyzylorda oblast (region). There was practically no salt from other Kazakhstan producers (according to available branding on samples in households). At the same time, in the region Table 8. Quality of consumed dietary salt for the West Region. Producer Kazakhstan salt Araltuz 3 (.+6.) Russian salt Iodine contents in salt <5 ppm >5 ppm Aktobe city 4 (88.9+6.) Iletskaya - 5 (93.6+3.3%) No iodine Adulterated Total - - 7 (.+3.6%) 4 (6.4+3.3%) 3 (5.5+3.%) 54 (4.5+4.4%) Vyvarochnaya, Moscow - - - (.8+.8%) Byelorussian salt Polesye Mozyrsol - - - (.8+.8%) Ukrainian salt Donetskaya - - - (.8+.8%) Salt sold by weight / without packing No salt in household (sample) Total: 7 3 (.4+.3%) Iletskaya salt (from the Russian Federation) held a big proportion of consumed salt, at 4.5 + 4.4% in Aktobe households and 4.8 + 4.5% in Alga village. In a few isolated instances salt produced in Byelorussia (Polesye, Mozyrsol), Ukraine (Donetsk) and Moscow (Vyvarochnaya) was also found. As with the above mentioned regions samples of weight or unpackaged salt have taken a relatively big portion of consumed salt (33.8% in the regional centre and 44.% in the countryside). With regard to the quality of dietary salt in total for the region 9.5 +.8% of samples met the GOST requirements, and this value was even slightly higher in rural areas than in urban areas (94.% and 89. respectively). Thus the percentage of samples with insufficient iodine content was.% in urban areas and.% in rural areas. Adulterated salt samples were found 3 times more often in urban areas (.4% and.8% accordingly). Comparison of the iodization level of selected salt samples shows that the domestically produced salt is of high-quality (93.4 + 3.7%) and practically Iletskaya salt (9. +.6%) is essentially similar. Iodine contents of >5 ррm were found even in samples of salt sold by weight and unpackaged salt (89.6 + 3.%). - 36 (83.7+5.6%) 3 (89.+.8%) 7 (6.3+5.6%) (8.7+.5%) - 43 (33.8+4.%) 3 (.4+.3%) 7 36 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Alga village Kazakhstan salt Araltuz - 8 (.+.3%) Russian salt Iletskaya - 45 (9.8+3.9%) Salt sold by weight / without packing - 5 (94.3+3.%) Total: - 3 (94.+.%) Kazakhstan salt Araltuz 3 (6.6+3.7%) Russian salt For the West Region 4 (93.4+3.7%) Iletskaya - 95 (9.+.6%) - - 8 (5.+3.%) 4 (8.+3.9%) 3 (5.7+3.3%) 7 (5.8+.%) (.+.) 49 (4.8+4.5%) - 53 (44.+4.5%) (.8+.8%) - - 45 (8.+.4%) 8 (7.8+.6%) 4 (3.9+.7%) 3 (4.7+3.%) Vyvarochnaya, Moscow - - - (.4+.4%) Byelorussian salt Polesye Mozyrsol - - - (.4+.4%) Ukrainian salt Donetskaya - - - (.4+.4%) Salt sold by weight / without packing No salt in household (sample) Total: 47 3 (.+.7%) - 86 (89.6+3.%) 6 (9.5+.8%) (.4+3.%) 8 (7.3+.6%) - 96 (38.9+3.%) 4 (.6+.8%) 47 The proportion of salt with insufficient iodine contents was minimal (.%) and in all 3 cases it was a product of the Araltuz company. The scheduled work and informational activities in households of the West Region have been completed in full. 37

4. Region the East of the Republic of Kazakhstan. Surveys were carried out in Ust- Kamenogorsk city and Shemonaikha village (regional center of the Shemonaikha area) of the East-Kazakhstan oblast (region) from October 6 until November 9, 4. Results of the survey are found in Table 9. According the survey program, 5 households were surveyed and 48 salt samples were taken. In households there was no salt. Based on the data of all samples for the east region, consumption of domestically produced salt was.6% only (.4% - Araltuz and only.% - Pavlodarsol). The proportion of Araltuz salt used in Ust- Kamengorsk was slightly higher than that in the regional center (5.6% and 7.% accordingly). With regard to salt of Pavlodorasol there was an inverse ratio between urban and rural areas (.8% and.6% accordingly). Russian salt was the seond most frequently available salt in surveyed households (6.8% and 8.8% in Ust-Kamenogorsk). 3.% of rural families had the Byelorussian salt. In this region, samples of salt sold by weight or unpackaged salt made up a relatively large proportion of consumed salt (68.9 +.9%). It was found more often in rural households (73. + 4.9% and 64.8 + 4.3%). Based on the results of the rapid assessment it was determined that in all 53 samples taken from packages of Araltuz, iodine contents were >5 ррm. The dietary salt of the Pavlodarsol company was much less frequent in the region s - only 3 samples (one of these samples had an iodization level below the standard). Among 7 samples of the Russian salt only 6 samples (35.3 +.6%) had iodine contents >5 ррm. The other 6 samples were <5 ррm and 5 samples had no detected iodine at all. Among these cases, 3 samples (7.6 + 9.%) were adulterated iodized salt samples. High-quality iodized dietary salt was found in 63.% ofselected samples of salt sold by weight or salt without branded packing. In. of the samples the level of this microelement was below required standard and in 5.8% of samples it was not found at all in the spot-test. On the whole, qualitative iodized salt (regardless of producer) was more often consumed by urban families (7.4 + 4.%) than rural ones (64.4 + 5.) and adulterated samples were found only among samples from urban households (.4%). Questioning revealed that the population had basically the correct approach to iodized salt use and storage, but respondents prefered to use non-iodized salt for pickling purposes as they believe that iodized salt is unusable for preserving. The population did not know about the iodized salt logo at all. 38 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table 9. Quality of consumed dietary salt for the East Region. Producer Kazakhstan salt Iodine contents in salt <5 ppm >5 ppm Ust-Kamenogorsk city Araltuz - 3 (.+.8%) No iodine Adulterated Total - - 3 (5.6+3.9%) Pavlodarsol - - - (.8+.8%) Russian salt 3 (7.3+3.4%) Salt sold by weight / without packing 3 (8.4+5.) Total: 5 6 (.8+3.6%) Kazakhstan salt 5 (45.4+5.) 5 (6.7+5.4%) 88 (7.4+4.%) Shemonaikha village Araltuz - (.+.%) 3 (7.3+3.4%) 8 (9.9+3.3%) (8.8+.3%) 3 (7.3+3.4%) (8.8+.5%) - 8 (8.8+.5%) 3 (.4+.4%) 5 - - (7.+3.4%) Pavlodarsol - - (.6+.%) Russian salt 3 (5.+.4%) (6.7+5.%) Byelorussian salt - 4 (.+5.) Salt sold by weight / without packing No salt in household ( samples) 3 (4.4+3.7%) Total: 3 7 (3.8+3.%) Kazakhstan salt 58 (64.4+5.) 85 (69.+4.%) For the East Region Araltuz - 53 (.+.9%) Pavlodarsol (33.3+7.%) Russian salt 6 (35.3+.6%) (66.6+7.%) 6 (35.3+.6%) Byelorussian salt - 4 (.+5.) Salt sold by weight / without packing 36 (.+3.%) Total: 48 43 (7.3+.4%) 8 (63.+3.7%) 73 (69.7+.9%) (33.3+9.%) - 6 (4.9+.9%) - - 4 (3.+.6%) 9 (.+4.3%) (7.+3.4%) - 9 (73.+4.) - 3 - - 53 (.4+.6%) - - 3 (.+.7%) 5 (9.4+.) 3 (7.6+9.%) 7 (6.8+.6%) - - 4 (.6+.8%) 7 (5.8+.8%) 3 (.9+.) - 7 (68.9+.9%) 3 (.+.7%) 48 39

5. Region the Center of the Republic of Kazakhstan. Surveys were carried out in Karaganda city and Osakarovka village (regional center of the Osakarovsk center) of the Karaganda oblast (region) from October 6 until November 9, 4. Results of survey are indicated in the Table. Table. Quality of consumed dietary salt for the Central Region. Producer Kazakhstan salt Araltuz (.+.6%) Pavlodarsol (8.6+7.%) Iodine contents in salt <5 ppm >5 ppm Karaganda city 83 (93.+.7%) 5 (7.4+7.%) No iodine Adulterated Total 4 (4.5+.%) - 89 (59.3+4.) - - 7 (4.7+.7%) Promcomplekt, Almaty - - - (.7+.7%) Extra-sol - - - (.7+.7%) Russian salt Rossiyskaya - - - (.7+.7%) Uralskaya - - - (.3+.9%) Iletskaya - 7 (77.8+3.8%) Byelorussian salt Polesye Mozyrsol - 3 (56.5+.3%) Salt sold by weight / without packing No salt in household ( sample) 4 (3.5+.3%) Total: 5 9 (6.+.9%) Kazakhstan salt Araltuz (.4+.3%) (64.7+.6%) (8.3+3.) Osakarovka village 4 (97.6+.3%) Pavlodarsol - 9 (75.+.5%) Russian salt (.+3.8%) (43.5+.3%) (.8+7.8%) 9 (.7+.7%) (.+3.8%) 9 (6.+.9%) - 3 (5.3+.9%) - 7 (.3+.6%) (.3+.9%) 5 - - 4 (4.8+4.) 3 (5.+.5%) - (.+3.3%) Iletskaya - - - (.+.4%) Uralskaya - 4 (.+5.) - - 4 (4.+.) Sib-sol - - - (.+.) 4 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Ukrainian salt Producer Iodine contents in salt <5 ppm >5 ppm No iodine Adulterated Total Artem-sol, extra - - - (.+.4%) Byelorussian salt Polesye Mozyrsol - - - (.+.) Salt sold by weight / without packing No salt in household (3 sample) 3 (8.8+4.9%) Total: 98 4 (4.+.) Kazakhstan salt Araltuz 3 (.3+.3%) Pavlodarsol (.5+7.) 6 (76.5+7.3%) 8 (83.7+3.7%) For the Central Region 4 (94.7+.9%) 4 (73.7+.%) 5 (4.7+6.%) (.+3.3%) 4 (3.+.5%) 3 (5.3+8.4%) - 34 (34.7+4.8%) - 98-3 (5.8+3.%) - 9 (7.7+.7%) Promcomplekt, Almaty - - - (.4+.4%) Extra-sol - - - (.4+.4%) Russian salt Iletskaya - 9 (8.8+.6%) Uralskaya - 6 (.+4.%) (8.+.6%) (8.+.6%) (4.4+.3%) - - 6 (.4+.) Sib-sol - - - (.4+.4%) Rossiyskaya - - - (.4+.4%) Byelorussian salt Polesye Mozyrsol - 3 (54.+.%) Ukrainian salt (45.8+.%) - 4 (9.7+.9%) Artem-sol, extra - - - (.8+.6%) Salt sold by weight / without packing 7 (3.7+4.8%) 37 (7.5+6.%) 7 (3.7+4.8) - 5 (.6+.6%) No salt in household (4 sample) - - - - - Total: 48 3 (5.+.4%) 4 (8.+.4%) 3 (.5+.%) (.8+.8%) 48 4

Fig. 8. Rate of salt consumption of domestic producers for regions of the Republic of Kazakhstan Fig. 9. Rate of the Russian and Byelorussian salt for regions of Kazakhstan Fig.. Share of sold by weight/ unpackaged salt consumption for regions of Kazakhstan As was scheduled for the Central Region, 5 households were surveyed, qualitative analysis of iodine contents in salt was carried out for 48 samples of dietary salt. In the regional market, there was both Kazakhstan salt and salt from other CIS countries. The proportion of Kazakhstan salt was more than 6.: Araltuz in 5.8% of cases and Pavlodarsol in 7.7% of cases. In urban areas the percentage of households consuming Araltuz salt consumption exceeded that of rural families (59.3% and 4.8% respectively) whereas regarding Pavlodar salt there was an inverse ratio (4.7% and.3% respectively). The second most frequently used salt was filled by Byelorussian salt (Polesye, Mozyrsol) in the Central Region (9.7 +.9%) and for Karaganda city frequency of use of this salt was even higher (5.3 +.9%),but for the Osakarovka regional center it was only.. In contrast to other regions the samples of salt sold by weight or unpackaged salt in the Central Region made up a relatively small proportion of consumed salt (.6 +.6%). It was approximately times less in selected samples at the regional center than in the countryside (.3% and.6% accordingly). The total share of Russian dietary salt in the region amounted to 8.8% including 8. of urban and 7.% of rural samples. Data from spot-testing also specified an adequate iodization level: among 3 samples, only 4 samples did not shown a coloring reaction during spottesting which amounted to only 3% of the of all tested samples. Araltuz held the largest proportion of high-quality iodized salt (94.7 +.9%). Iletskaya salt held second place (8.8 +.6%), and then Pavlodarsol salt (73.7 +.%) and Byelorussian salt (54. +.%). In spite of the fact that among 6 examined samples of Uralskaya salt a sufficient level of KJO3 contents was detected in all samples, i.e. the total number of samples taken, it is necessary to take into account its rather small share of the total. In the Central Region there was a relatively large portion of qualitative iodized salt (8. +.4%). During the survey, questioning showed that the population had basically the correct approach to iodized salt use and storage. We may note that for pickling purposes a share of the respondents could purchase some salt with an inscription for pickling/preserving. Salt produced by Araltuz and Pavlodarsol was found in the region with such inscriptions; on packages there was no mark saying iodized salt, however spot-testing of a sample of this salt showed a positive colouring reaction indicating that producers, taking into account the interests of this group of consumers, put iodized salt on sale in this way. 7. Region Almaty city 5 households were surveyed in the following 6 districts of Almaty: Turksibskiy, Auezovskiy, Medeuskiy, Bostandykskiy, Almalinskiy andzhetysuskiy. 5 respondents were questioned and 5 salt samples were collected. In households spot-testing of 3 consumed dietary salt samples was carried out using the rapid testing method. Samples of table salt from households of Almaty city is notable for its poor variety in comparison with other regions of the republic (Table ). There was an absence of salt produced in Pavlodar. The proportion of Araltuz salt was less than 4 (39.6%) and the majority of samples were sold by weight or unpackaged (53.4 + 3.3%). Three types of the Russian salt made up.76% of the total number of selected samples, whereas the Byelorussian salt (Polesye, Mozyrsol) came to 5.%. 4 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table. Quality of consumed dietary salt for Almaty city. Producer Kazakhstan salt Araltuz (.+.5%) Russian salt Iodine contents in salt <5 ppm >5 ppm 9 (97.8+.5%) No iodine Adulterated Total - - 9 (39.6+3.%) Iletskaya - - - (.9+.6) Rossiyskaya - - - (.43+.43) Slavyanskaya - - - (.43+.43) Byelorussian salt Polesye Mozyrsol - (9.7+8.) Salt sold by weight / without packing No salt in household ( samples) 5 (4.+.8%) Total: 3 7 (3.+.%) 6 (93.5+.) (95.+.4%) (8.3+8.) 3 (.4+.4%) 4 (.7+.8%) (8.3+8.) (5.+.4%) - 4 (53.4+3.3%) (.43+.43%) 3 The rate of high-qualiy iodized salt was 95.%, salt with insufficient contents of potassium iodate made up 3.9% and non-iodized salt made up.7%, including one sample (.43%) of the Byelorussian dietary salt which was adulterated. The highest percent of sufficient iodization was determined in samples of Araltuz dietary table salt (97.8 +.5%); only out of 9 samples (. +.5%) had insufficient iodine contents, according to spot-testing. The proportion of high-quality salt from Byelorussia was 9.7 + 8.. It is necessary to note a rather high level of high-quality iodized salt among salt sold by weight and unpackaged salt samples (93.5 +.%); 4. of samples had insufficient iodine presence and only.4% did not have this a microelement. A comparative analysis of dietary table salt from different producers indicates the essential interregional distinctions (Fig.8). In particular the greatest consumption of domestic products was recorded in the south region (7.9% was fromaraltuz). However in the north region this type of salt was present in only 8.4% of all samples, i.e. 8.5 times less. Products of Araltuz accounted for most of the analyzed salt samples in the south and central regions and also in Almaty city (7.9%, 5.8% and 39.6% respectively). Dietary salt from the Pavlodar company was available only in three regions (north, east and central) and its share did not exceed. of the total samples. This is certainly related to the locationof salt producers and also to the existing production delivery scheme. This was also demonstrated by the relatively large share of Russian salt in the west region (4.7%), its availability in the central (7.6%), east (6.8%) and north Regions (3.6%) and almost complete absence in the south region and Almaty (Fig. 9). Byelorussian salt was also present in households in the central (9.7%) and north regions (3.6%) and also in the southern city of Almaty (5.%). It is necessary to note that in surveyed households in practically all regions a large proportion of samples of salt sold by weight or not stored in its original packaging was recorded (Fig. ). Particularly high percentages of such salt were found in the east (68.9%) and north regions (59.4%), and the lowest percentages were in the central (.6%) and south regions (.%). At the same time, within this category of salt, as specified above, in some regions there was a share of samples with sufficient iodine contents. Results of the qualitative analysis of dietary salt consumed in selected regions of Kazakhstan broken down by urban/rural, country of production, and the overall contents of salt consumed are shown in Table and Fig.. 43

In total for RK, comsumption of dietary salt produced domestically came to slightly more than 4. (4.9%)., The proportion of consumption of Russian salt as.8%, whereas more than half of all samples were from salt sold by weight or unpackaged dietary salt (44.7 +.3%). The share of Kazakhstan salt consumption in urban areas was a little bit greater than in rural areas: 44.8% and 35.% respectively. An especially large difference was observed regarding salt produced by Araltuz (in cities the share was 39.8 +.6% and in rural areas, 8. +., р <.5). However, the proportion of salt sold by weight found in rural households was greater than that in urban samples: 5. +. and 39.8 +.6% respectively, р <.5). In general for the republic, regardless of which company produced it, the total proportion of dietary salt with adequate iodine contents was only 78.3%. 3.9% of the time, iodine was not detected by spot-testing at all, and 7.7% of the time, the level of iodine contents was inadequate. The share of adulterated dietary salt was slightly more than. percent (.3 +.3%). With regard to the iodization level high-quality salt was most frequently detected in samples of Araltuz salt (97. +.7%) and least frequently in Pavlodarsol production (5.9 + 5.4%) (data regarding Ukrainian salt was not taken into account because of the small number of samples). Absence of iodine was Table. Quality of consumed dietary salt in Kazakhstan. Producer Kazakhstan salt Araltuz 7 (.+.7%) Pavlodarsol (5.+6.5%) Iodine contents in salt <5 ppm >5 ppm Urban area 34 (96.9+.9%) 4 (54.5+7.5%) No iodine Adulterated Total 4 (.+.5%) 9 (.4+6.%) - 353 (39.8+.6%) 3 (6.8+3.8%) 44 (5.+.7%) Promcomplekt, Almaty - - - (.+.%) Extra-sol - - - (.+.%) Russian salt 4 (4.3+.%) Byelorussian salt (.6+.5%) 73 (78.5+4.%) 6 (66.7+7.5%) 6 (7.+3.9%) (3.8+7.4%) (.7+3.%) (5.+3.5%) 93 (.5+.) 39 (4.4+3.3%) Ukrainian salt - - - (.+.%) Turkish salt - - - (.+.%) Salt sold by weight / without packing 45 (.7+.8%) Total: 886 69 (7.8+.9%) Kazakhstan salt Araltuz 3 (.8+.) Pavlodarsol 9 (.9+6.5%) Russian salt 3 (4.7+.6%) 57 (7.8+.4%) 74 (8.7+.3%) Rural area 63 (97.6+.%) (5.+7.8%) 53 (8.8+4.7%) 5 (4.4+.9%) 93 (.5+.) (.6+.6%) (6.8+6.9%) 8 (.5+ 4.%) - 353 (39.8+.6%) 5 (.7+.4%) (.6+.6%) (.4+.4%) (3.+.8%) 886 67 (8.+.) 4 (6.9+.) 64 (.8+.3%) 44 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Producer Byelorussian salt (.+9.5%) Iodine contents in salt <5 ppm >5 ppm 6 (6.+5.4%) No iodine Adulterated Total 3 (3.+4.5%) - (.7+.5%) Ukrainian salt - - - (.3+.%) Salt sold by weight / without packing 9 (9.4+.7%) 9 (6.+.8%) 88 (8.6+.6%) - 38 (5.+.) Total: 59 45 434 3 4 59 Kazakhstan salt Araltuz (.9+.6%) Pavlodarsol (3.5+4.6%) Overall picture for RK 55 (97.+.7%) 45 (5.9+5.4%) 5 (.+.4%) (3.5+4.6%) (.+.%) 4 (4.7+.3%) 5 (35.+.%) 85 (5.7+.6%) Promcomplekt, Almaty - - (.7+.7%) Extra-sol - - - (.7+.7%) Russian salt 7 (4.5+.6%) Byelorussian salt (4.+.8%) 6 (8.+3.%) 3 (65.3+6.8%) Ukrainian salt - (33.3+7.%) 4 (5.3+.9%) 5 (3.6+6.6%) (66.6+7.%) (7.6+.%) (4.+.8%) 57 (.6+.8%) 49 (3.3+.5%) - 3 (.+.%) Turkish salt - - - (.7+.7%) Salt sold by weight / without packing 74 (.+.%) Total: 478 4 (7.7+.7%) 448 (67.8+.8%) 58 (78.3+.%) 39 (.+.6%) 6 (3.9+.9%) - 66 (44.7+.3%) 9 (.3+.3%) 478 detected most frequently in Byelorussian salt samples (3.6 + 6.6%) and in Pavlodar salt samples (3.5 + 4.6%), and also in samples of salt sold by weight or unpackaged salt (. +.6%). Russian salt also had a high proportion of non-iodized salt (5.3 +.9%). No statistically important differences were found in the quality of dietary table salt regarding samples from urban versus rural households, except for salt sold by weight, in which sufficient iodine contents were found more frequently in urban samples than in rural ones (8.7 +.3% and 6. +.8% accordingly, р <,5). As is shown in Figure the proportion of high-quality iodized salt in Kazakhstan regions is essentially varied. The highest shares were detected in salt samples from the south region (96.8%), approximately the same level was found in Almaty and in the west region (96.8% and 9.5% accordingly). Fig.. Iodized salt quality in Kazakhstan regions 45

Fig.. Share of high-quality iodized salt produced by various companies Fig. 3. Rate of non-iodized and adulterated salt of different producers The lowest share of qualitative iodized salt was in the north region (47.%) as well as the highest share of salt with insufficient iodine contents (9.%) and that not containing iodine at all (33.6%). The east region also had a low share of high-quality iodized salt (69.7%). In 7.3% of the samples there were insufficient iodine contents and in.9% of the samples there were no iodine contents at all. These variations are, in many respects,related to differences in quality of dietary salt produced by various manufacturers (Fig. ). Specifically, the highest percentage of salt with sufficent contents of iodine was produced by Araltuz (97.%) and in Russia (8.%); the lowest percentage of highquality salt was that produced by Pavlodarsol (5.9%). Allowing for the relatively low share of quality salt detected from that produced in Russian, Belarus or the Ukraine because they fortify their salt with potassium iodide, which is not detected using our spot-tests, the results indicate that the Pavlodarsol company, as a participant in the project, should implement wide-spread iodization of dietary salt using potassium iodate. Figure 6 shows that practically one-quarter (3.5%) of Pavlodar salt was not iodized including the 4.5% of Pavlodarsol products found to be adulterated. We should also note that salt produced by Araltuz was found to be non-iodized salt in very few samples (.), and this is most likely due to improper storage, transportation, or selling the product after its expiration date. 46 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

IV DISCUSSION. The KAN survey team interviewed 5 respondents in 6 regions of RK with regard to their awareness of IDD their attitude toward IDD, the logo Healthy food. This corresponded to the scheduled scope of work.. The KAN survey team implemented a rapid analysis of 478 salt samples in households, which corresponded to the scheduled scope of work. 3. According to visual analysis using spot-tests, 7 salt samples (86% of all samples examined) were iodized; 58 salt samples were classified as samples with parameters > 5 ppm and 4 samples were classified as samples with parameters < 5 ppm).. If we set a standard of > 5 ppm (clear coloring), then adequate iodized salt was found in 78% of households of RK, based on the results of spot-testing. Non-iodized salt was found 4% of the time ( of 85 samples collected in different regions of RK) all of which was salt produced by Pavlodarsol; 4% of salt samples from this company were classified as having a low level of iodization. 5.3% of the samples of Russian salt were also non-iodized (Iletskaya, Sib-sol salt), and half of these salt samples were adulterated (the package was marked iodized ). The Byelorussian salt Polesye from Mozyr city was also non-iodized in 3.6 of the samples, but the share of adulterated, non-iodized salt from Polesye was much lower (only 4.%) because their salt is sold in packages of extra-salt with different markings of iodized, iodized-fluorinated and also non-iodized extra-salt. 4. The high level of iodized salt consumed in households was due to the high production level of this kind of salt by the Kazakhstan company Araltuz. The company produces not only standard salt packages of kg, but also sacks of kg, 5 kg and 5 kg, which are marked iodized and accordingly the salt is iodized. That is a high probability that people purchase such salt by weight in markets and stores. 5. Salt marked for pickling/preserving produced by Araltuz and Pavlodarsol was found in the central, north and south regions. On these packages there was no marking iodized, however, spot-testing of samples from this salt produced a positive coloring reaction, indicating that this salt was iodized. Producers put this type of marking on packages, taking into account the interests of a particular group of consumers. 6. The KAN survey team selected 378 salt samples for quantitative analysis of the iodization level in the laboratory using a titration method. This goes beyond the scheduled scope of works. 47

Quantitative analysis of iodine contents in iodized dietary salt selected in different regions of RK using a method of titration Salt sampling for quantitative analysis of iodine contents. Among 58 dietary iodized salt samples containing > 5 ppm of iodine (by preliminary detection by the coloring reaction of the spot-tests), which were collected in different regions of RK, 5 samples were selected for laboratory analysis of the iodine contents, or 43.5% of the total amount. Sampling of salt for quantitative analysis was conducted in such a way so as to ensure that all regions were covered equally in order to give a complete picture of the adequacy of the iodization the salt consumed in the regions of RK. The data are shown in the Table 3. The majority of salt samples collected in the RK regions were produced by Araltuz (55 samples); among them samples, of 4, were analyzed in the laboratory. Further, a number of dietary salt samples, 448, contained salt sold by weight or kept unpackaged in the households, of which samples were analyzed in the laboratory or 44.6% of all such samples. Of the 45 samples of Pavlodarsol salt with iodine contents of >5 ppm according to the spot-test, samples were selected for laboratory analysis, or 44.4% of all such samples. In addition 43.7% of the samples of imported salt from Russian and Byelorussian were also analyzed in the laboratory. Titration data of 5 iodized salt samples from different regions of RK are shown in Table 3. Quantitative iodine contents were detected using a titration method conforming to the results of the requirements of GOST Р 5575 3 (State Standards of the Republic of Kazakhstan): Table dietary iodized salt, Methods of iodine and sodium hyposulfite detection. All measuring instruments, auxiliaries, materials and reagents, used for the exact determination of the iodine contents in dietary iodized salt complied with GOST requirements of RK and the recommendations of the manual Monitoring of Table 3. Percentage of salt samples collected in households in different regions of Kazakhstan to analyze iodine contents. Regions Total collected samples of iodized dietary salt Number of analyzed samples (abs.) East 73 75 43.4 North 93 4 45. West 6 97 43 South 4 4 43. Center 4 89 43.6 Almaty 94 4.5 Total: 58 5 43.5 Table 4. Percentage of salt samples of different producers collected in different regions of Kazakhstan to analyze iodine contents Producers Kazakhstan salt Total collected samples of iodized dietary salt Number of analyzed samples (abs.) Araltuz 55 43.5 Pavlodarsol 45 44.4 Russian salt 6 55 43.7 Byelorussian salt 3 4 43.7 Salt sold by weight / without packing 448 9 4.9 Total:,56 5 43.6 Universal Salt Iodization Programs edited by Mr. Kevin M. Sallivan, Program of Micronutrients deficiency elimination, Mr. Robin Haustan (РАММ) and Rollins Public Health Institute of Emory University, Mr. Jonathan Gorstein (РАММ), Center for Elimination and Prevention of Diseases, Ms. Jenny Chervinkas, Initiative in the Area of Micronutrients as well as the 997 Russian edition, edited by Mr. G.A. Gerasimov., and also recommendations from the manual Micronutrient Laboratory Equipment Manual, (UNICEF, PAMM, 996). % % 48 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Results and considerations of laboratory examination for Rapid Assessment of IDD campaign Results of the quantitative analysis of the iodine contents in dietary iodized salt samples by producer (collected throughout the entire territory of RK) are shown in Table 5. Table 5. Quantitative iodine contents in dietary salt of different producers Producers Kazakhstan salt Number of analyzed samples Average iodine contents in samples (ppm) Standard deviation Araltuz 3.7 ±.6 Pavlodarsol 9. ±.7 Russian salt 55 3. ± 8.7 Byelorussian salt 4 4.8 ±.7 Salt sold by weight / without packing 9 3.5 ±7.9 Total: 5 33.6 ±9.6 The average iodine contents of samples from Araltuz came to 3.7 ±.6 ppm. This complies with the GOST requirements Р 5574 3: Table dietary iodized salt, Specifications; according to which the level of iodization should be equal to 4 ± 5 ppm. The average iodine contents in the salt samples from Pavlodarsol company came to 9. ±.7 ppm. The lowest level of iodine by mass found in salt samples from this producer was 8.4 ppm which does not correspond to the lowest level permitted by GOST requirements Р 5574 3: Table dietary iodized salt, Methods of iodine and sodium thiosulfate determination. All other salt samples, which include salt sold by weight or unpackaged salt and salt imported from Russia and Byelorussia, complied with GOST requirements Р 5574 3: Table dietary iodized salt, Methods of iodine and sodium thiosulfate determination. Data is shown in the Figure 7. Table 6. Quantitative iodine contents in dietary salt samples by region of Kazakhstan Regions Number of analyzed samples Average iodine contents in samples Standard deviation East 75 9.6 ±6.7 North 4 7.3 ±9. West 97 3. ± 6.9 South 4 37.6 ±3.75 Center 89 35. ± 9.8 Almaty 94 4. ±7.47 Total: 5 33.5 7.7 Table 6 and Figure 5 summarize data of the quantitative iodine contents in dietary salt considered by region of RK. The average iodine contents of salt Fig. 4. Average quantitative iodine contents in dietary salt by producer in the consumer market of Kazakhstan Fig. 5. Average quantitative iodine contents in dietary salt samples by region of Kazakhstan samples collected in Pavlodar city and the Scherbakty area of the Pavlodar oblast (region), in the north region, was 7.3 ± 9. ppm. The lowest level of iodine by mass found in salt samples collected from this region was 8.3 ppm which does not correspond to the lowest level permitted by GOST requirements Р 5574 3: Table dietary iodized salt, Methods of iodine and sodium thiosulfate determination. This is likely because a number of samples collected in the north region were Pavlodarsol salt samples and the lowest level of iodine by mass detected in salt samples of this producer does not correspond to the lowest permissible level permitted by GOST requirements Р 5574 3. On average, iodine contents in salt samples collected in all other regions of RK corresponded to the legally permissible level of iodine by mass. 49

Assessment of the level of knowledge and practices of the population regarding IDD prevention questioning. Fig. 6. Age distribution of respondents Fig. 7. Distribution of respondents with regard to standard of education Fig. 8. Distribution of respondents with regard to the income level In order to assess the level of the population s knowledge and practices regarding IDD prevention and public attitude toward iodized salt, a questionnaire containing 3 questions was developed (the form of this questionnaire is in the Appendix ). 5 people (of the age of 4 years old and older) from 5 households throughout the entire territory of RK were questioned using this questionnaire. Respondents of 5 regions (North, South, West, East, Central) were divided into two groups: urban and rural; respondents from Almaty city formed a separate group. For the purpose of processing the results of the questionnaire, respondents were divided into three groups by age (Fig. 6): youth (up to years old), adults aged -4 years old, and adults older than 4 years old. 87.6% of respondents were adults. Respondents were divided into 4 groups by level of education (Fig. 7): primary education, secondary education, specialized secondary education and higher education. 5.3% of respondants had higher education and/or specialized secondary. The level of respondents education was related to the number of correct answers during questioning. Respondents were also divided into 4 groups by the monthly income of one member of the family (Fig. 8): income up to Tenge; from up to Tenge; from up to 5 Tenge; more than 5 Tenge. It is necessary to note that a media strategy for IDD prevention and availability of the fortified product (iodized salt) was performed in 3-4 throughout RK and especially in the South Pilot Region South-Kazakhstan oblast (region) of RK because preliminary surveys by NHLSC in revealed a low competence (%) of health workers with regard to mass prevention of IDD. Informational and educational materials about the benefits of iodized salt consumption for IDD prevention (instruction manuals, posters) were distributed to PHC institutions of the republic through regional health authorities of MoH (Ministry of Health) of RK for and through personnel training for PHC workers by the NHLSC (National Healthy Life Style Center). Materials for teachers and schoolchildren were distributed through regional departments of education of the Ministry of Education and Science (MoES) of RK. For the general population, the information campaign involved the national and local TV and radio network with the support of the Ministry of Information (MoI) of RK, and through public events with the participation of the non governmental sector (NGOs). 5 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Results of the survey Rapid Assessment of IDD campaign. The results of questioning after being processed by the SPSS application are given in percentage in Tables 3-. For all digital percentage parameters, the error in mean (m) and standard deviation (t) is calculated. The percentage parameters are represented as M ± m. Table 7 shows that 88% ±.89 of respondents had heard something about problem of iodine deficiency in the environment of RK..7% ±.43 of respondents had not heard anything about such a problem;.93% ±.56 of respondents had difficulty answering this question. A high percentage of affirmative answers to this question were recorded in Almaty (94.4% ±.49), the south region (94% ±.54) and the east region (94% ±.54). The problem of iodine deficiency in the environment was less well-known in the north region (87.6% ±.) and in the west region (83.% ±.59). In the central region of the country there was a low rate of awareness of this problem (74.8% ± 3.7), which was statistically lower than the average for the republic (p<.5). Differences in answers corresponded to the level of education of respondents: the more educated the respondent, the more familiar with the problem of iodine deficiency in the environment. The percentage of affirmative answers by level of education was: 77.44% ± 3.7 for respondents with primary education; 84.76% ±.68 for respondents with secondary education; 9.63% ±.48 for respondents with specialized secondary education and 95.63% ±. for respondents with higher education. Respondents with higher education were more familiar with the problem of iodine deficiency in the environment than respondents with primary education, respondents with secondary education (p<.5) and respondents with specialized secondary education (p<.5) were. This indicates that the more educated a person is, the broader his or her outlook regarding the problem of iodine deficiency in the environment (Fig. 9). In total for the country, 84.87% ±. of respondents have heard about the consequences of IDD for the human body. Respondents in the east region (9.% ±.87), the south Region (87.6% ±.), and the north region (87.% ±.6) were more informed about this problem. It was less well-known in the west region (8% ±.68) and in the central region there was a low rate of awareness with regard to this problem (76.4% ± 3.97), which was lower than the average for RK with a statistical significance of (p<.5). Results of this question also indicate education plays a role in awareness regarding the consequences of IDD for the human body (from 76.83% ± 3.75 among respondents with primary education up to 9.7% ±.45 among respondents with higher education (p<.5)) (Fig. 9). 74.87% ±.9 of respondents believed that there was an IDD problem in RK, 4.67% ±.5 of respondents believed that in Kazakhstan there was no such a problem and.46% ±.6 of respondents were not aware of it or had difficulty answering. The highest number of affirmative answers to this question were found in the east region (85.6%), Almaty (8.4%) and the south region (78.8%); respondents in the west region (64.8%) and the central region (63.6%) had the lowest awareness of the problem. The more educated respondents, the broader their outlook regarding the IDD problem in Kazakhstan (from 53.66% ± 5.3 among the respondents with primary education up to 87.46% ±.9 among the respondents with higher education). This distinction is statistically significant (p<.5) (Fig. 9). Regarding sources of information about IDD prevention for the period of 3-4 the respondents mentioned most TV/Radio (59.47% ±.64), Fig.9. Population knowledge depending on the standard of education Fig.. Sources of IDD information gaining health workers (3.93% ±.3) and printed materials in newspapers/magazines (6.53% ±.) (Fig.. ). The influence of health workers was uneven by region. Health workers had the most effect with regard to IDD in the pilot south region (5. ± 4.38%), where PHC workers were more intensively trained; health workers were less influential in the East Region (4. ± 4.84%), where it was shown that urban health workers had twice as much effect as rural workers (56. ± 5.93% and 6.4 ± 7.67% respectively); In other regions the least effective health services were in the north region (.6% ± 5.94), which is 3 times less than on average for the republic (p<.5) and 5 times less (p<.5) than in the pilot region (Fig. 4). This numerical data clearly shows the powerful potential of health 5

Table 7. Have they ever heard anything about a problem of iodine deficiency? (% ) Total, absolute numbers Characteristics Have they ever heard anything about the problem of iodine deficiency in the environment? Have they ever heard anything about the consequences of IDD for the human body? Are there IDD problems in Kazakhstan? Yes No Yes No Yes No From what sources have they received information regarding IDD and its prevention? Printed materials TV, Radio Health workers Family Members School Other North - Region 87.6. 87..4 74. 7. 8.8 76..6.8 4.4 9.6 5 City 87.. 85.6. 73.6 8. 4. 75..8 4.8.4. 5 Village 88..4 88.8 8.8 74.4 6.4 3.6 76.8.4.8 6.4 7. 5 South- Region 94. 4.4 87.6 4. 78.8 3.6. 58.4 5. 7. 3..8 5 City 96.3.79 86.5.38 83.33.38.3 64.9 54.76.38 4.76.79 6 Village 9.94 8.6 88.7 5.65 74.9 4.84 3.6 5.4 49.9..6 4.84 4 West - Region 83. 4.8 8. 3.6 64.8 6.8 34.4 65. 6.4 8.4.6 8.8 5 City 87.6 8.53 89.5 7.75 7.87 5.43 4.3 68.99 6.36 9.3.33 7.75 9 Village 78.5.49 74.38 9.83 56. 8.6 8. 6.6 6.45 7.44.83 9.9 East - Region 94. 5.6 9. 5. 85.6.8 3. 6. 4. 7.6 8.8.6 5 City 96. 4. 9.8 4. 9..6 4. 39. 56....4 5 Village 9. 7. 89.6 6.4 8...4 84.8 6.4 4. 6.4.8 5 Center - Region 74.8 4.8 76.4. 63.6 3.6 5.6 47.6 3.4 8.4 3..4 5 City 79.9.3 8.88 5.44 69.8 4.7 8.79 6.4 33.56 38.93 9.46.67 49 Village 68.3 3.68 68.3 3.68 54.46.98.89 8.7 5.74.87 3.96. Almaty 94.4 5.6 84.8 3. 8.4 6. 38. 47.6 3. 4.8 8.4. 5 KAZAKHSTAN 88..7 84.87.4 74.87 4.67 6.53 59.47 3.93 9.87 6.6 3.87 5 Age Up to 8.8 6.67 8. 6.67 65.59 6.99 5.59 6..5 3.65 3..6 86 Up to -4 89.5 9.97 85.46.9 76.96 3.76 5.8 55.88 38.4 7.5 4.9 3.43 6 Older than 4 88.46.54 85.6.97 75.5 4.84 3.6 6.39 9.6 6.4.85 4.84 7 Education Primary 77.44.95 76.83 9.5 53.66 8.54. 64.63.34 3.78 4.63 4.7 64 Secondary 84.76 4.3 8.3 5.99 69.33 5.39 8. 55.39 5.65 7.5 6.5 4.8 538 Spec.secondary 9.63 7.96 87.35 9.3 8.56 3.8 9.98 63.3 35.6 7.73 4.68 3.98 47 Higher 95.63 3.79 9.7 3. 87.46 3.5 95.63 58. 4.4 9.6 4.96 3. 343 Spec.secondary Up to KT 93.75 5. 86.5 3.75 77.5 7.5.5 68.75 3.5 7.5.5.5 8 KT 88.33.83 83.33. 73.33 4.7 5.83 6.5 37.5.67 5.83.67 5 KT 8.37 6.4 8.46 6.4 65.65 6.8 3. 5.8 3. 3.37 8.5 3.95 39 Over 5 KT 89.7 9.43 86.67.8 78.66 4. 3.77 6. 3.64 8.78 6.8 4. 93 Total 88..7 84.87.4 74.87 4.67 6.53 59.47 3.93 9.87 6.6 3.87 5 5 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

services, which it is possible and necessary to use in further projects for decreasing IDD prevalence. School as a source of information was given much less on average for RK (in total 6.6%) (Fig. ). However among youth up to years old this source of information filled an adequate place (3.%) equal to the family as a source of information (3.65%) (Fig. ). TV programming was the leading source of information, and watched basically equally by youth (6.% ± 4.6) and mature respondents (6.39% ± 5.35). This source was equally accessible to all respondents, and did not depend on level of education or income (Fig. ). Health workers as a source of information were also accessible to all groups of respondents, not depending on the level of income, but it was indicated as a source of information more often, with a statistical significance of (p<.5), depending on the educational standard (from.34% ± 6.9 among the respondents with primary education up to 4.4% ± 4.3 among the respondents with higher education). By age group the importance of the health worker at first increased (from.5% ± 6.49 among youth up to 38.4 ± 3.7 among group of the population at the age of -4 years old), a statistically significant correlation (p<.5), and then went down to 9.6% among mature respondents. This correlates with data from the NHLSC survey in. The increase in the role of printed materials as a source of information was shown to be proportional to age (from 5.59% ± 6.73 among youth up to years old to 3.6% ± 3.8 among the mature respondents) which was statistically significant (p<.5)- as well as to level of education (from.% ± 7.3 in the group with primary education up to 95.63% ±. in the group with higher education) and also to the income level of the population (from.5% ±.45 in the group with a low income up to 3.77% ±.7 in the group with the income >5 Tenge per person) (Fig. ). Table 8, shows that in total for RK, the respondents could list IDD in 79.47% ±.6 of cases, they could not list it in 5.47% ±.37 of cases and they were not aware of IDD in 5.6% ±.5 of cases. Again respondents of the east region were most informed and could list IDD (89.% ±.7) of the time, next was the south region (86.8% ±.9) and Almaty (8.8% ±.6). Respondents of the north region were less knowledgeable about IDD (76.4% ± 3.7), then the central region (7.4% ± 3.3) and respondents of the West Region were less well-informed in comparison to the average for the republic (69.% ± 3.5) with a statistical significance of (p<.5). Correalted with level of education, a statistically significant increase in (t=5.3, p<.5) positive answers about IDD was also observed (from 66.46% ± 4.5 among the respondents with primary education up to 9.84% ±.5 among the respondents with higher education). In total for the republic, respondents named goiter most often among IDDs (75.73% ±.7), and fourth one named memory impairment (5.3% ±.4) and mental deficiency in children (3.8% ±.5). Goiter was the most frequent IDD named among respondents in the east region (9.4% ±.6); most likely endocrinological institutions of MoH of RK work intensively there. This type of IDD was also frequentlynamed by respondents in the south region (84.4% ±.49) and the north region (79.% ±.88). However such IDDs as memory impairment was given most often by respondents of the central region (36.4% ± 5.4) and the south region (35.6% ± 5.7). These respondants also listed IDDs such as mental deficiency in children rather frequently (33.% ± 5.6 and 5.6% ± 5.45 respectively). It is interesting to note that IDDs such as memory impairment and mental deficiency of children was a Fig.. Health Services as sources of information Fig.. Sources of information regarding IDD by age of respondents 53

Table 8. Assessment of the population s knowledge about IDD (%) Characteristics They can list IDDs What kind of Iodine Deficiency Disorders do they know? Yes No Miscarriage / premature birth Mental deficiency in children Memory Impairment Goiter Osteochondrosis Parodontosis Colitis Heart pain North - Region 76.4 6.8. 8. 6.8 79..8.4..8 5 City 73.6 9..6 7.6.4 77.6.6.8..6 5 Village 79. 4.4.8 8.4 3. 8.8.... 5 South- Region 86.8 7.6 9.6 5.6 35.6 84.4 8. 8.8.6 6.4 5 City 89.68 4.76 4.9 6.9 5. 87.3.7 5.8.59 3.95 6 Village 83.87.48 4.84 5..97 8.45 3.3.4.6.6 4 West - Region 69. 8. 4. 9.6 9. 74.4...4 9. 5 City 7.9 3.8 7.75 4.73 3.95 79.7.78.. 3.95 9 Village 66. 3.4. 4.3 4.3 69.4 3.3..83 4.3 East - Region 89. 7.. 4. 8.4 9.4.4..8.8 5 City 87. 6.4 3. 7.. 9.4 4.8.4.6 5.6 5 Village 9. 8..8.8 6.8 9.4.... 5 Center - Region 7.4 6.8.4 33. 36.4 5.4 3. 3.6. 8.4 5 City 76.5.5.8 48.3 49.66 46.3 5.37 4.7.68.7 49 Village 66.34 33.66 7.9.89 6.83 6.39..98.99 5.94 Almaty 8.8 6.4 6.8 3.4 4.4 73.6 4. 4.8. 9.6 5 KAZAKHSTAN 79.47 5.47 5.67 3.8 5.3 75.73 3.4 3.3.3 7.87 5 Age Up to 73. 4.73 7.53 38.7 4.3 49.46 3.76 3.76.5 5.9 86 Up to -4 8.5 4.5 6.7 4.84 5.49 78.76.94 3.59.65 8. 6 Older than 4 79.77 4.5 4.7 9.9.8 8.6 3.7.56.8 8.6 7 Education Primary 66.46 9.7 3.66 6.83 8.5 5.6 3.5 3.66.83 4.7 64 Secondary 7..9 3.7 4.3 7. 7.45 3.9.79.93 6.3 538 Spec.secondary 83.6.7 5.5 5.6 9.4 8.97 3.8.58.7 9.6 47 Higher 9.84 4.66.5 34.69 3.3 88.5 9.84 4.8.46.5 343 Spec.secondary Up to KT 87.5..5.5 3.5 8.5.5.5.5.5 8 KT 8.67 6.67 5.83.83 33.33 74.7 6.67 8.33.67 5. 5 KT 7. 4. 5.78.67 4.9 65.96.5.3.5 6.99 39 Over 5 KT 8.58.89 5.4 5.89 4.38 79.9.93.7.87 6.5 93 Total 79.47 5.47 5.67 3.8 5.3 75.73 3.4 3.3.3 7.87 5 Total, absolute numbers 54 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table 9. Assessment of the population knowledge about IDD prevention (%). Characteristics Possibility of IDD prevention What to do for IDD prevention? Yes No Seafood consumption IS consumption Vitamin consumption Iodine preparation Dairy products consumption To play sports Improving the environment To take a good vacation North - Region 78.4. 7.6 7.4 3.6 8.4.8.4.8.4 5 City 75..4 9. 7.4 9.6 8.8.8.8.6.8 5 Village 8.6 7.6 6. 7.4 33.6 8..8... 5 South- Region 93.6.8 5.6 8.8 6.8.4 4.8 3..4 4.4 5 City 93.65.59 58.73 83.33 3.49. 4.6 34.3 8.57 3.7 6 Village 93.55 4.3 44.35 8.6.6.8 4.84. 6.3 5.65 4 West - Region 65.6 9..4 6. 9.6.4 3..4 3.6.4 5 City 74.4 7.83 7.9 74.4 3.8 4.65 5.43.78 6.98.78 9 Village 56. 4.3 6.53 48.76 5.79 6.53.83... East - Region 86.4 9.6 35.6 8. 33..8...8.4 5 City 84.8 9.6 44. 8.6 48. 4..8. 3.6.8 5 Village 88. 9.6 7. 78.4 8.4.6.6. 8.. 5 Center - Region 88.. 56.4 75. 38.4 8.8 6.4.8 9..4 5 City 9.95 6.4 68.46 75.84 49.66 5.44 8.7 6. 3. 3.4 49 Village 8.8 5.84 38.6 74.6.78 3.76.97.97 4.75 5.94 Almaty 86. 3.6 5.6 67.6.6 5.6 4.8.8 8.4. 5 KAZAKHSTAN 83. 4. 39. 73. 5..7 5. 6.7 4. 3. 5 Age Up to 87.. 55.9 69.89 5.54 5.38 7.53 3.44 4.73 8.6 86 Up to -4 86.44.44 4.6 77..7.58 5.56 5.39.78.78 6 Older than 4 78.9 7.66 3.9 7.3.66.5 4.7 5.3 4.39.85 7 Education Primary 7.34 5.6 37. 56.7 37. 3.5 6. 9.5.34 7.93 64 Secondary 78.7 9.4 9. 67.9.8 8.8 4.65 7.6.64.86 538 Spec.secondary 87.35 9.6 4.45 79.6 5.9.7 5.39 4.9 4.99.8 47 Higher 9.96 6.4 53.64 8. 5.66 9.4 9.96 4.37.95.6 343 Spec.secondary Up to KT 86.5.5 36.5 76.5.5.5. 3.75 5..5 8 KT 85.83 3.33 47.5 75.. 3.33.83 9.7 9.7 5. 5 KT 8.4 6. 39.5 69. 3.83 3.7 5.7 6.38 6.7 6.69 39 Over 5 KT 83.53 3.54 39. 74. 5.3.46 3.9 3.4.3.5 93 Total 83. 4. 39. 73. 5..7 5. 6.7 4. 3. 5 Total, absolute numbers 55

Fig. 3. IDD distribution depending on the age Fig. 4. Assessment of the population knowledge regarding IDD prevention. Fig. 5. Public knowledge of Iodized salt more common answer, with statistical significance, amongyouth (4.3% ± 5.66 (t=.97) and 38.7% ± 5.76 (p<.5)) among the mature respondents (.8 ± 3.35 and 9.9% ± 3.39 respectively) (Fig. 7). At the same time, there was a statistically significant correlation (t=5.49, p<.5) between frequency of naminggoiters as an IDD, and age of respondents (from 49.46% ± 5. among young people up to 8.6% ±.68 among mature people (Fig. 7)). We can explain the increase of associations between consequences of IDD and mental development by the effects of media campaign in - 4, because according to the NHLSC survey (), in the beginning of only.% of schoolchildren named IDDs such as stupidity and laziness, not looking at the adult population of the republic. ИAccording to Table 9, 83% ±.6 of RK respondents believe it is possible to prevent IDD. As preventive measures they have selected the following options: IS (Iodized Salt) consumption (73% ±.34 of respondents), Seafood consumption (39.% ±.), Vitamins consumption (5.% ±.3) and Iodine preparations (.7% ±.7). High frequencies of positive answers regarding the possibility of IDD prevention were recorded in the south region (93.6% ±.6), in the central region (88% ±.9), in the east region (86.4% ±.33), in Almaty city (86% ±.36) and in the north region (78.4% ±.93). The least frequent positive answers were given in the west region (65.6% ± 3.7), lower than theaverage index for the country with a statistical significance of (p<.5). This was probably related to the effectiveness of the media campaign in -4 (TV-broadcasting, film preview trailers, activities of departments of MoH and MoSE of RK and thengos confederation), which was slightly more poorly arranged in the West Region of the country, without NGOs participation. Fig. 4 shows the average index of the population s knowledge about IDD prevention. (values are specified) broken down by age. As shown intable 93.7% ±.6 of all respondents in RK have heard something about IS (Iodized Salt) and according to respondents 89.67% ±.8 of households have been purchasing IS. Though 39.% of the respondents named seafood consumption as one of measure to prevent IDD, in fact seafood consumption in households as a food habit wasabsolutely insignificant sh(only 8.53% ±.46 of respondents consumed seafood each week and.7% ±.44 - every day). Among the tiny share of people consuming seafood,only respondents with higher education consumed it frequently (95.63% ±.), which was or more times more than other groups. But 38.7% ±. of all respondents do not consume seafood at all, 4.53% ±.38 of all respondents consume it very seldom, and 9.3% ±.33 of all respondents consume it from time to time. This indicates that this food habit as an IDD preventive measure is not effective in RK. Tables, and Fig. 5 show the public attitude toward iodized salt. The index of public knowledge regarding IDD elimination through frequent IS consumption comes to 56.4 for RK. Among youth, it was 5.6% which was almost.5 times more than that recorded in the NHLSC survey index in, or 39.84% among schoolchildren. In general people store IS correctly by covering it (68.47% ±.44). Table shows the main reasons why people purchased iodized salt included: they knew that IS was good for health (68.4% ±.45); according to them there was no other salt (.% ±.43); a doctor advised them to buy IS (4.8% ±.5); they wanted to have IS in families (.87% ±.54). People from different age groups were aware that IS was good for health and frequency 56 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table. Assessment of the population knowledge of IDD prevention (%). Characteristics They ve heard of IS They ve been purchasing IS They ve been consuming the sea food Total, absolute Yes No Yes No No Every day Every week Once a month From time to time Very seldom North - Region 93.6 4.8 83.6 4.8 69.6.4.8 3.. 8.8 5 City 93.6 4.8 85.6.8 64..8 4. 4.8 4.4 8. 5 Village 93.6 4.8 8.6 6.8 75...6.6 9.6 9.6 5 South- Region 94.4.4 9.. 4.4. 5. 4.8 6.8 5. 5 City 9.7. 9.48.79.38.38 6.35 5.4 5.4 3. 6 Village 97.58.8 93.55 3.3 6.6. 4.3 4.3 8.3 7.4 4 West - Region 9.4 3.6 9.8 3.6 3.6.4.4. 8..4 5 City 94.57.55 93..33 7.5..63 8.6 3.6 5.5 9 Village 9.8 5.79 88.43 4.96 3.58.83 3. 3.97.4 4.96 East - Region 94.8. 97.6.4 74.8.4 4.8 6.8 8..4 5 City 96.8. 96..8 6.8.8 7. 3.6. 4.8 5 Village 9.8. 99.. 88.8..4. 4.. 5 Center - Region 89.6 9. 84.4 5. 6.4.8.8 5.6 3..6 5 City 9.6 6.7 8.88 7.45 6.7 4.3 4.77.75 4.7.3 49 Village 85.5.87 88..88 3.69.99 4.95 9.8 7.8 3.76 Almaty 94.8 3.6 89.6 9. 3.8. 5. 3. 8.8 8.8 5 KAZAKHSTAN 93.7 3.6 89.67 7.53 38.7.7 8.53.47 9.3 4.53 5 Age Up to 89.78 7.53 8.6 5.59.97.69.9.75 35.48 3.44 86 Up to -4 94.77.45 9.99 4.58 3.37.65.6 4.38 8.79 7.48 6 Older than 4 9.88 3.56 89.6 7.98 48.86. 5.56.5 5..5 7 Education Primary 86.59.37 76..95 4.4.44 9.76 6. 6.. 64 Secondary 9.94 3.9 88.66 8.55 47..93 5..7 5.6 3. 538 Spec.secondary 94.38.58 93.9 3.75 36.77.7 8. 5. 8.3 4.75 47 Higher 95.63.87 93. 3. 4.78.7 95.63 3.7 3.3 7.78 343 Spec.secondary Up to KT 9.5.5 86.5 6.5 3.5.5 3.75..5.5 8 KT 9.5 5. 9.83 7.5 5.83.83 6.67.67 7.5. 5 KT 93.3 6.8 87.84 9. 34.65. 8.5.64.67 8.4 39 Over 5 KT 93.7.8 9.5 7.37 4.4.98 9.43.78 8.3.9 93 Total 93.7 3.6 89.67 7.53 38.7.7 8.53.47 9.3 4.53 5 numbers 57

Table. Public attitude to Iodized Salt (%). Total, absolute numbers Age Characteristics Where have they been purchasing IS? Market Store How have they been storing IS? Open package Without cover With cover Why have they been purchasing IS? Why have they not been purchasing IS? IS was good for health No other salt Advice Theydid not Doctor Family known its purpose More expensive North - Region 96..4.8 3.4 56. 68.8 6.8.8.4 8.4.6.8. 5 City 95..8 5. 9.6 54.4 64.8..6.8 7...6. 5 Village 96.8..4 3. 57.6 7.8.6.. 9.6 3... 5 South- Region 68.4 3. 3.6 5.6 8. 56.8 7. 3.6 3..4 4.8..4 5 City 69.5 3.6.59.63 77.78 6.3 4.76 4.6 4.76.79...79 6 Village 67.74 9.84 5.65.48 8.6 53.3 9.68.58.6. 9.68.. 4 West - Region 9.8 3..6 6.8 7. 74.8 6..8. 3..4.. 5 City 94.57 3. 6. 9.38 73.64 8.95 8.53.78..33... 9 Village 9.9 3.3 7.36 4.5 66. 66. 3.97.83. 4.3.83.. East - Region 97.6. 8.4. 68.8 93.6.8.4.4.8...4 5 City 98.4. 9.6 9. 68.8 89.6 4.8.8.8.8...8 5 Village 96.8. 7. 3. 68.8 97.6.8...8... 5 Center - Region 8. 7..4 8.8 6. 49. 3..8. 8..4..8 5 City 86.58.8.8.3 67. 56.38 4.7.34 8. 9.4.67.67.34 49 Village 75.5 4.75 3.67 6.83 49.5 38.6 5.74 4.95.97 5.94..98. Almaty 76..8 3.6.4 76. 67...4. 7..4.6. 5 KAZAKHSTAN 85.47.7.73 8.87 68.47 68.4. 4.8.87 4.67.7.6.7 5 Education Up to 87.63.9 9.68 3. 66.67 56.45..8 5.5.83.54.8.8 86 Up to -4 8.3 5.3.7 6.8 7.8 68.63.6 7.84.96.9.3.8.6 6 Older than 4 87.89..68.9 66.67 7.37.97 3.3.43 4.84.4.8.4 7 Primary 84.76.8 8.9.95 58.54 48.7 9.5 3.66.8 3.4.83.. 64 Secondary 84.57.7.59.93 66.7 65.4.7 5..3 5..67.74.37 538 Spec.secondary 85.5 3. 3.8 6.63 69.9 7.43 3.35 5.5.94 3.4.7.47. 47 Higher 87.46.79 7.87 4.9 76.68 8.7 87.46 4.66.87.7.87.87. 343 Spec.secondary Up to KT 8.5 6.5 5..5 7.5 55..5 6.5 3.75 5..5.. 8 KT 7.83 7.5 5.83.83 7.67 55.83..5 9.7.5.67.67. 5 KT 8.7 5. 6.7 8.84 64.3 56.53 7. 5.7 3.95 6.38.43.6. 39 Over 5 KT 89.8 8.3.38 8.53 68.9 75.84 9.43.6.5 4.55.76.54.43 93 Total 85.47.7.73 8.87 68.47 68.4. 4.8.87 4.67.7.6.7 5 They did not want to No one advised them to 58 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table. Assessment of public knowledge of iodized salt (%). Characteristics They knewis advantages Advantages of IS Yes No Better gustatory characteristics Better digested Compensation for iodine deficiency Has the salt iodization affected its taste? Total, absolute numbers Yes No North - Region 79.6 7.6.4. 8.. 86. 5 City 78.4..8. 77.6 6. 8. 5 Village 8.8 5... 8.4 8. 9. 5 South- Region 8.. 6.4.4 68. 69. 7. 5 City 8.6.7.59 8.73 7. 64.9 33.33 6 Village 83.87.9.9. 63.7 74.9.97 4 West - Region 76.8...8 75.6.4 74. 5 City 85.7.63..55 84.5.93 75.97 9 Village 67.77 8.93.48. 66. 9.83 7.9 East - Region 93. 6...4 9.4 4.4 9.4 5 City 87...8. 85.6 8.8 85.6 5 Village 99..8 3..8 95.. 95. 5 Center - Region 63.6 35.6 3.6 3. 55. 34.4 63.6 5 City 74.5 5.5 3.36 5.37 65. 37.58 59.73 49 Village 47.5 5.5 3.96. 4.59 9.7 69.3 Almaty 8.4 7.6..4 77. 34.8 63.6 5 KAZAKHSTAN 79.7 8.3.6.53 74.4 9. 67.47 5 Age Up to 74.73 5.7 3.3 5.38 65.5 3.65 66.3 86 Up to -4 79.9 6.99.94.78 75. 36. 6.44 6 Older than 4 79.9 7.4.4.57 76.35.79 73.8 7 Education Primary 68.9 3. 4.88 4.7 57.3 5.6 7.34 64 Secondary 75.46.93.97 3.6 69.7 9.8 66.36 538 Spec.secondary 8.44 4.75.64.34 78.9 8.57 68.6 47 Higher 86.59..4.7 84.6 3.9 86.59 343 Spec.secondary Up to KT 76.5 7.5 3.75 5. 7.5 53.75 4.5 8 KT 73.33 3.33 5.83 6.67 6.67 46.67 5.67 5 KT 73.5 4.3.8.74 67.7 3.6 65.96 39 Over 5 KT 83. 5.7.73.5 8.7.97 73.46 93 Total 79.7 8.3.6.53 74.4 9. 67.47 5 59

of affirmative answers increased with statistical significance (p<.5) by age, from 56.45% ± 4.8 among young people to 7.37% ±. among mature respondents. on the level of educationalso was correlated with more positive answers, with statistical significance of (p<.5) from 48.7% ± 5.6 among respondents with only primary education, to 8.7% ±.4 among the respondents with higher education. In the same table, there were analyzed reasons why the population did not buy IS. In our opinion the most notable response was that people did not know the purpose of IS consumption; the share of such answers was 4.67% ±.5 in RK (8.4% ± 6.5 in the north region, 8. ± 6.6 in the central region and 7.% ± 6.9 in Almaty). This is necessary to take into account for further plans more media/educational projects, and to consider that in the south pilot region after a successful media campaign there were no such answers (.4% ± 4.3). 79.7% ±.7 of respondents in RK knew of the advantages of IS (Tab. 8) and responded that IS compensates for iodine deficiency (74.4% ±.3). The more educated the respondent, the more affirmative the answers (from 57.3% ± 5. for those with only primary education to 84.6% ±.4 for those with higher education) (p<.5). 9.% ±.7 of respondents for RK believed that the salt iodization process affected its taste, but overwhelming majority disagreed (67.47% ±.47), as was evident from the frequency with which people buy this product. Table 3 provides information regarding public attitude toward IS packaging as a source of information. 9.3% ±.76 of respondents were unambiguously believed that the package should give information about a product s properties, but in fact only 68.67% ±.44 of respondents read the information on the package. 8.7% ±.33 of respondents would like to have the following information on salt package: salt fortification with iodine (47.8% ±.86), healthy- characteristics of salt (4.73% ±.97), contents of salt (3.6% ±.), terms of storage (3.7% ±.5), producer of salt (7.8% ±.9) and weight (8.7% ±.33). We tried to estimate the rate of recognition of our project s logo, Healthy food, for iodized salt. Among the total respondents at the end of 4, 5.4%±.8 of them had not seen such a logo, 3.% ±.6 of them did not know about it or, did not pay attention to it; but we should note that one-fourth of the respondents (3.7% ±.6) have seen such a brand on IS package. The meaning of this logologo was not known by 7.67%±.38 of respondents; 3.33%±.5 of them haddifficulty answering and one-fifth gave the correct answer that this logo indicated a high quality product, good for health (.53%±.8). Youth up to years old and the age group of - 4 years old had seen this logo more often (8.49%±6.9 and 8.7%±3.4, respectively) and the same groups was aware of its meaning (6.34%±6.9 and 7.79%±3.46 respectively). With regard to income level there was revealed correlation that people with a low income (< Tenge) have seen it more often (4±8.6) and knew the meaning of this logo more frequently (4.5%±8.56) than people with a high level of income (8.3%±.97 and 7.33%±.99 ) (t=.38; t=.64). Most likely it is possible to explain this with the effectiveness of media materials, television broadcasts and information provided about iodized salt as a high-quality and healthy product and its accessibility to all categories of population of RK. However, for further media campaigns it is necessary to take these results into account and to make the logo of IS more recognizable for mass consumers. Table 4 provides data regarding the effect of the media campaign of - 4 on the population, and also reasons for not taking the opportunity to eliminate IDDs with frequent IS consumption. For the last year, information about IS and IDD prevention was seen by 55.4%±.7 of respondents in total for RK. The most effective information source was TV broadcasts and film preview trailers regarding IDD problems (45.7%±.9). Posters in health institutions were less effective (3%±.4 of respondents for RK), but also important for the purpose of the media campaign and for assessment of cooperation with MoH of RK. Third place among information sources for the last year (3-4), in total for the republic, was filled by newspaper articles (9.67%±.45) in published mass media. These information sources are necessary to use in media activities in the future, together with efforts by health institutions (training of health workers) and educational institutions (schools). 6 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Table 3. Public attitude to IS package (%) Total, absolute numbers Characteristics They ve read information on package Yes No Yes No Yes No They ve seen logo Meaning of the logo They would like to have information on the IS package No info Package should inform about product s properties Qualitative product No info Other weight contents healthy characteristics terms of storage producer fortification with iodine North - Region 6. 36.4 98..6 8.4 4. 46.8 7. 75.6..4 7.6 3. 4. 6. 48.4 6. 5 City 59. 37.6 98.4.6 8. 6. 8.8 6. 78.4..8.6 8. 3.. 5.4 9. 5 Village 63. 35. 97.6.6 8.8.4 64.8 8.4 7.8.. 33.6 3. 4.8.8 46.4.8 5 South- Region 85.6.8 9.4.8 58.4.6 5.6 54.4 4.8. 44. 4.8 6.4 5.4 8.4.8. 5 City 85.7 7.4 88.89.79 63.49 5.56 6.9 6.9 3.54. 6.3 46.3 5.59 64.9 3..3.59 6 Village 85.48 4.5 9.94 4.84 53.3 7.74 5. 46.77 49.9. 7.4 35.48 73.39 36.9 3.7 35.48.4 4 West - Region 66.4 8.4 75. 6.4 9.6 66.8.4 4.4 93.6..8.8 3. 5..8 6. 46. 5 City 73.64.7 76.74.4 9.3 5.94 37.98 7.75 9.47..55 4.65.48 9.3.33 6.36 4.3 9 Village 58.68 35.54 73.55.66 9.9 8.64 5.79.83 95.87...83 3.3.83 3.3 5.6 5.7 East - Region 79. 8. 95.. 7. 76.8 3.6. 94.8.4 7. 55.6 4.6.4 48.8 7.4.4 5 City 7. 4.8 96.8.6 3.6 6.4.6 4. 89.6.8 4.4 63. 66.4 36.8 48. 68.8 4. 5 Village 86.4. 93.6.4.8 9. 5.6.... 48. 6.8 8. 49.6 7..8 5 Center - Region 5.6 46.8 95. 3.6 8.4 54.4 5.6.4 73.6. 3.6 34. 45. 46.4 4.8 77.6.4 5 City 54.36 44.3 97.3. 38.6 39.6.8 3.87 63.76. 3.87 46.98 63.9 6.4 46.98 7.8. 49 Village 47.5 5.5 9.8 5.94 3.86 76.4 7.9 9.9 88.. 3.67 4.85 8.8.77 3.68 86.4.99 Almaty 68. 8.4 9.8 3. 6.4 57.6 5. 8.8 5.6 8.4 4.4 34.8 58. 5. 4. 4.6. 5 KAZAKHSTAN 68.67 8.3 9.3 4.93 3.7 5.4 3..53 7.67 3.33 8.7 3.6 4.73 3.7 7.8 47.8.3 5 Age Up to 53.76 4.47 96.4.69 8.49 45.7 4.9 6.34 67.74 4.3 8.49 48.9 67.74.37 9.68 8.6.69 86 Up to -4 73. 3.86 89.7 4.9 8.7 47.88.4 7.9 65.36.94 9.6 3.5 44.77 6.54 6. 6.37 6.7 6 Older than 4 68.66 8.6 9.3 5.56 7.9 55.98 4.5 5.4 78. 3.4 3.96 9.63 3.9 5.7 6.3 6.55 7.69 7 Education Primary 47.56 5.6 9.85 8.54. 4.85 35.37.56 74.39. 3.78 4.46 5. 9.5 7.93 6.7 4.88 64 Secondary 65.6 3.86 88.66 6.88.68 54.65.8 8.59 75.65.3 5.6 9.74 35.87 5.58 4.83 5.95 7.99 538 Spec.secondary 7.6 4. 93.9.34.48 54.57.84.84 7.37.8 6.86 8.57 37.7 5.85 6.79 7.3 6.56 47 Higher 78.3 8.66 9.84 3. 5.36 48.98 78.3 5.66 64.4 7.. 38.9 5.9 7.87 8.75 7.58 5.83 343 Spec.secondary Up to KT 77.5 6.5 9..5 4. 7.5 7.5 4.5 53.75.5 38.75 3. 33.75 8.75 3.75.5 5. 8 KT 7.5 3.33 88.33.67 43.33 9.7 4.7 39.7 55.83.83 44.7 39.7 47.5.67 5. 4.7 3.33 5 KT 6. 35.87 9.79 6.69 4. 5.46 3.4.9 7.8.74.58 8.7 45.59 6.69 6.8 6.99 6.99 39 Over 5 KT 7. 6.87 9.77 4.77 8.3 57..64 7.33 75.5 4.3.7 33.69 4.9 5.85 7.48 7.37 7.6 93 Total 68.67 8.3 9.3 4.93 3.7 5.4 3..53 7.67 3.33 8.7 3.6 4.73 3.7 7.8 47.8.3 5 Other 6

Table 4. Assessment of informational effect with regard to IS (%) Total, absolute numbers Characteristics Frequent IS consumption eliminates IDD Yes No No info It is not enough Reasons if No Not allowed much salt IS cons. under med. supervision Have they seen information for the last year? Yes No Where have they seen information for the last year? Newspaper articles ТV Radio North - Region 59.6.6 6.8 9.6.8.4 64.4 3.4.8 6.4 5. 6..8. 5 City 56. 6.8 6.4..6.8 63. 3.8 3.6 56. 8. 8.8 4.. 5 Village 63. 6.4 7. 8... 65.6 3.. 64.8.4 3..6. 5 South- Region 63.6 4.4 8.8. 9.6.8 76.8. 8.8 55.6 5.6 37.6. 5. 5 City 7.63 3.49 3.49 8.73 4.76. 87.3 8.73 7.4 67.46 6.35 4.7 3.7 7.94 6 Village 56.45 5.3 4.9 5.3 4.5.6 66.3 33.87.48 43.55 4.84 33.87.8.4 4 West - Region 5.8. 38.4 9. 8.4 5. 49. 48. 8.8 43.6. 7..8.4 5 City 63.57 8.53 7.9 9.3 7.83 6.98 5.39 47.9.85 43.4. 7.75.55.78 9 Village 37.9.57 49.59 9.75 9. 3.3 47.93 48.76 6.6 43.8. 6.6.. East - Region 65.6 6. 5. 6.4.. 4.4 56.. 38..8 5.6.8. 5 City 66.4.4 8.4.8.. 4.8 57.6.4 35..8 6.4.6. 5 Village 64.8.6 3.... 44. 54.4.6 4.8.8 4.8.. 5 Center - Region 44.4 8.8 5. 6.4..8 44.4 55. 9. 3. 3.6 5.6.. 5 City 44.3 8.86 4.83.8 6.78.67 48.99 5..4 3.87 6.4 9.46 3.36 3.36 49 Village 44.55 8.7 5.74.77 4.95.99 37.6 6.39 5.94 8.7. 9.9.. Almaty 54.4 9. 5.6. 6.8. 55. 44.8 6.4 4.8. 6..4.4 5 KAZAKHSTAN 56.4 6.67 5. 4.7 7.93. 55.4 4.93 9.67 45.7.87 3..47.33 5 Age Up to 5.6.43 6.34 8.6 3.98.6 43.55 55.38 8.6 3.6 3.76 7. 3.3.5 86 Up to -4 58.66 6.99.9 5.69 7.35.63 6.58 36.76.3 47.7.94 8.95.63.63 6 Older than 4 55.7 5.38 7.35 4.67 6.84.7 5.8 45. 9.69 46.5.56 6.7.85.85 7 Education Primary 4.4 5.85 4.46 5.49 5.85. 4.46 57.3 7.3 35.37 5.49.8 3.66. 64 Secondary 56.3.4 3.6.97 7.8.3 48.7 49.8 5.39 39.3.6.5.74.49 538 Spec.secondary 59.48.78 7.8.4 5.5.7 6.6 36.7.8 54..64 3..7.4 47 Higher 6.5.7 4.87 6.6 7.9.7 6.5 34.4 4.9 48.69 3. 5.6.75.7 343 Spec.secondary Up to KT 66.5.5. 8.75 8.75. 7.5 3.75 7.5 63.75 3.75 8.75. 3.75 8 KT 65. 3.33 8.33.67 6.67. 6.67 35.83 8.33 5.5 4.7 5..83 5.83 5 KT 45.9.8 3.7 7..85.5 5.46 47.4.33 39.8 3.34 4.9 3.4.3 39 Over 5 KT Total 56.4 6.67 5. 4.7 7.93. 55.4 4.93 9.67 45.7.87 3..47.33 5 Posters in health inst-s Posters in stores Info on package 6 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

V CONCLUSION, SUMMARY AND RECOMMENDATIONS The necessity of appropriate surveying of households in all the main regions of RK was based on the need to assess the Iodine Deficiency Control Program and monitor its progress, and also caused by the following activities: 4..3 the Law of the Republic of Kazakhstan On IDD Prevention was approved. It regulated mandatory iodization of all dietary and fodder salt produced, imported, exported and sold in the domestic consumer market; Plan of Activities for the national program Health of the People for 3-5 authorized by the Decree of the Government of RK dated.3.3 No 89 was also stipulated for IDD prevention; The regional media strategy and plan of activities for IDD elimination within the Program of Cooperation between the Government of RK and UNICEF, the regional media plan of the international project of the Asian Development Bank (ADB) stipulated for -3, a multilevel media campaign accompanyed by distribution of a variety of informational and educational materials for target public groups involving of all forms of mass media (3 types of materials with a total run of more than 4 3 copies); In 4 sets of informational and educational materials were distributed among all 8. thousand secondary general schools through regional educational departments andamong PHC workers through regional health authorities and offices of the National Healthy Lifestyle Center; In the period of -4, training seminars about IDD problems were conducted for representatives of the mass media, NGOs, Sanitary and Epidemiological Services (SES), customs authorities and others; In 3, an assessment of the level of the knowledge of target groups of the population were arranged twice in a short period (March-April and October-November) in the pilot region (Shymkent and Sayram area of the south-kazakhstan oblast (region)); With the financial and technical support of UNICEF, the National Healthy Lifestyle Center in implemented a survey to assess the level of knowledge of the population with regard to IDD prevention problem by various age- and professional groupings The above list of activities with regard to realization of the media strategy has demonstrated the advisability of this national survey to assess its effectiveness and to develop recommendations for improving the Iodine Deficiency Control Program. The goal and objectives of this survey: Assess the quality of adequate potassium iodate contents in consumed dietary table salt using a method of spot-testing in urban and rural households of five regions of the republic and in Almaty; Assesthe level of iodization of dietary table salt samples from various producers with adequate iodine contents (> 5 ppm) using a method of iodometric titration based on the data of spot-tests; Study the level of knowledge of members of households, using the developed questionnaires,with regard to the main aspects of IDD and its prevention; Develop recommendations for improving the plan of activity, including media activities with regard to IDD prevention in the RK based on the results of data analysis. Based on the results of examination of 478 dietary table salt samples with spot-tests of potassium iodate, selected in 5 surveyed households in 5 regions of Kazakhstan and in Almaty, laboratory titration data of 5 samples with iodine contents of >5 ppm, analysis of the questionnaire from 5 respondents with regard to their awareness of IDD and its prevention using high-quality iodized dietary salt it is possible to draw the following conclusions. Conclusion : Regions of the republic vary greatly in salt consumption by different producer which is related to their territorial closeness to contiguous countries and to current marketing outlets. These variations also determined the quality of dietary table salt used in households. 63

Conclusion : In total for the RK, the rate of dietary salt consumption of domestic production was 4.9%, although the total amount of iodized salt produced by the two main salt producing companies Araltuz and OJSC Pavlodarsol meets total demand in the RK. The frequency of use of Kazakhstan dietary salt is higher, with stastical significance, in urban households than in rural ones: 44.8+.7% and 35.+. respectively Conclusion 3: A high share of consumption of dietary salt sold by weight or without the package was recorded, more frequently in rural households (5.+.) than in urban ones (39.8+.6%), with this correlation having statistical significance. This situation indicates that consumers do not deliberately select salt from wellknown producers.. Conclusion 4: In total for the RK, regardless of salt producers, the proportion of dietary salt with adequate iodine contents was 78.3%, in 7.7% of cases the iodine content was insufficient, and in 3.9% of cases iodine was not detected at all in spot-tests on potassium iodate; the percentage of adulterated salt was.3%. Conclusion 5: With regard to iodization level, high-quality dietary table salt was detected most among salt samples of Araltuz company (97.+.7%) and least of all among salt samples of Pavlodarsol company (5.9+5.4%). Lack of iodine was recorded most of all in Byelorussian salt (3.6+6.6%) and Pavlodarsol (3.5+4.6%); this statistic for Russian salt was 5.3+.9%. Conclusion 6: Use of high-quality iodized salt varies by region. Use was most frequent in the south region (96.8+.%), and approximately the same data was found in households in Almaty (95.+.4%) and the west region (9.5+.5%) and the lowest rate was recorded in the north region (37.+3.) and the east region (69.7+.9%). Conclusion 7: Based on the results of iodometric titration all examined samples of high-quality salt (based on the data of spot-tests) of Araltuz, Russian and Byelorussian production and also salt sold by weight or unpackaged salt complied with requirements of GOST Р 5574-3 Dietary table iodized salt. Byelorussian salt hadthe greatest iodine contents. Conclusion 8: surveyed dietary salt samples of Pavlodarsol with adequate iodine contents (based on the data of spot-tests) (on average 9.+.7 ppm) did not comply with the lowest permissible requirements of GOST Р 5574-3 Dietary table iodized salt with regard to the proportion of iodine by mass. Conclusion 9: The average proportion of iodine contents in dietary salt samples from households of the north region of RK did not comply with the lowest permissible requirements of GOST Р 5574-3 Dietary table iodized salt with regard to the proportion of iodine by mass.he lower permissible range of iodine mass portion. Conclusion : The population of the republic considers IDD prevention as necessary and realizable. Iodized dietary salt was indicated as the most effective measure and food habit for decreasing iodine deficiency in 73.±.34% of cases. Food habits as consuming seafood in view of traditions of nutrition and socioeconomic situation is not effective in Kazakhstan. Conclusion : The practice of purchase of iodized salt as a foodstuff in all regions of Kazakhstan is sufficent;. 93.7±.6% of the population have heard of iodized salt and 89.67±.8% of the population buy iodized salt. Conclusion : The media campaign had a positive effect on increasing the level of the population s knowledge about IDD. In comparison with, now the level of knowledge regarding consequences of IDD is not limited only to goiter. One-fourth of the citizens of the RK understand the negative consequences of IDD on mental development such as deterioration of memory (5.3±.4%) and mental deficiency of children (3.8±.5%). Conclusion 3: PHC workers were specified as the basic information source of IDD information about preventing IDD by consuming high-quality iodized salt (3.9% of the respondents). This source of information was given most frequently in the pilot south region (5.%) and least frequently in the north region (.6%). Conclusion 4: In practically all regions, except for the south Region and Almaty, a low level of recognition of logo Healthy food used to mark dietary table iodized salt was recorded. Thisproves the necessity of improving appropriate media activities, especially in the eest, east and north regions of the RK. Conclusion 5: These data indicate the necessity of more active continuation of large-scale media activities for social mobilization and education of the population, monitoring the quality of iodized salt, social and biological testing for adequate iodine intake in the human body with the necessary participation of all sectors of the national economy, legal and physical persons, and also non governmental organizations. 64 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Recommendations. With the support of the government of the RK or the coordinating council for fortification of foodstuffs at the MoH of RK, to carry out a revision of the existing regional programs on IDD prevention approved to execute the Law of the RK and the State Program for Health of the People; based on the results to implement their coordination with regard to uniform approaches and plans of activities.. Under the development of by-laws to execute the Law of the RK On IDD Prevention, to stipulate development and introduction of economic incentives for producers of high-quality iodized dietary salt. 3. In view of existing opportunities in the industry and its reputation as a high-quality salt producer, to recommend for the Araltuz company to expand its marketing outlets, especially in the north, east and west regions of the RK. 4. To strengthen the internal QA of iodized salt at OJSC Pavlodarsol and to recommend it increase volume of sales in the central, north and east regions of Kazakhstan. 5. To recommend that the salt producers to place additional brief information on salt packages regarding the nutritional and social importance of IDD and its effective prevention with the help of iodized salt. 6. For customs authorities and sanitary and epidemiological services in regions bordering on the Russian Federation to strengthen the control of dietary table salt imported and sold in the internal consumer market. 7. To continue the large-scale media campaign according to the developed national strategy and recommendations of international organizations, by involving NGOs, PHC workers and dealers of salt producers. 8. To promote preparation of PHC workers to educate the general population about IDD prevention by frequent high-quality iodized salt consumption. 9. To conduct special lessons on IDD with a demonstration of spot-tests to detect the quality of dietary salt from households of the pupils in secondary schools, with the support of the MoES of the RK and regional (urban) educational authorities, the Kazakhstan Academy of Nutrition and Non Governmental Organizations. 65

66 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

ANNEXES 67

Appendix Kind respondent, this research is being conducted for the goal of protecting the health of all of us, most importantly the health of our children, and if you agree to participate, please answer the questions on this survey, on the topic of problems related to protection of health and nutrition. Regional Code, Survey Number. Have you heard about the problem of a deficiency of iodine in the environment and insufficient intake of iodine in the human body? Yes No. Have you ever heard of the effects of iodine deficiency on the human body? Yes No 3. Can you list some problems (disorders) as a result of iodine deficiency? Yes No 4. Which problems (disorders)? Miscarriage/Stillbirth Heart Pain Parodontosis Retarded development of children Reduced immunity Osteochondritis Memory Loss Colitis Goiters Other 5. Where do you receive information about iodine deficiency disorders and preventing them? Printed material Television, radio Medical worker Member of your family School Other 6. In your opinion, is it possible to develop problems related to iodine deficiency through a chronic lack of iodine in your body? Yes No 7. What do you need to do about this? Play sport Improve the environment Consume seafood More and more complete rest Consume iodized salt Consume vitamins Consume dairy products Other 8. In your opinion, is there a problem regarding iodine deficiency in Kazakhstan? Yes No I don t know 9. Do you or your children consume seafood? No Every day Every week Once a month From time to time Very rarely Do not consume (eat). Have you ever heard of iodized salt? Yes No. Do you buy iodized salt? Yes No. (If you answered no to question ) Why don t you buy iodized salt? I don t know why it is necessary It is usually more expensive Members of my family don t advise me to (or don t want it) Friends do not advise me to Other 3. (If you answered Yes to question ) Why do you but iodized salt? I know that it is healthy Because other kinds of salt are not available Because of advice from: a doctor The salesperson Members of my family Friends Colleagues Neighbors Other 4. Do you know the advantages of iodized salt over regular salt? Yes No 5. (If you answered yes to question 4) What advantages are there? Better taste Better digestion Makes up for iodine deficiency in the human body Other 68 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

6. Where do you usually purchase salt? At the store At the bazaar Other 7. How do you usually store your salt? In an open package (sack) I pour it into a jar (or other container) and store it without a lid I pour it into a jar (or other container) and store it with a closed lid Other 8. In your opinion, does iodine in the salt affect its taste? Yes No 9. Do you usually read the salt packaging? Yes No. Should salt packaging have information for the buyer about the contents of the product? Yes No. Did you see this logo on your salt (We show the LOGO)? Yes No I don t know. In your opinion, what does this logo tell you? The quality of the product I don t know Other 3. Please bring the packaging from your salt (if you have it). Look for whether it has this logo. Logo present Logo absent Name of producer Word iodized present Word iodized absent 4. We would like to verify whether the salt you use in your home is iodized or not. Can you please bring a sample of the salt that you use for food (testing)? Not iodized ppm (no colouring) Less than 5 ppm (weak coloring) 5 ppm or more (definite colouring) Not salt in the home 5. What information would you like to see on the packaging for iodized salt? Weight Contents Health values Period of storage Producer Enrichment (iodine, fluorine, etc.) Other 6. Do you think that regular consumption of iodized salt can remove iodine deficiency in the body? Yes No I don t know 7. (If No ) Why do you think not? It isn t enough We shouldn t eat too much salt Have you ever seen any kind of information about prevention of iodine deficiency? Use of salt should be under monitoring by a doctor 8. Other disorders in the last year? Yes No 9. (If yes to question 8) Where did you see this information? Newspaper article Television Radio Posters in medical institutions Posters in a store Trademarks and information on outside of the salt packaging Other I have a few questions about your personal character, if you are willing to discuss them with us. 3. Tell us please how old you are: Gender: 3. Your education: Higher education Secondary-professional Secondary Primary 3. What level of income does one member of your family receive per month? tenge or less from to tenge from to 5 tenge More than 5 tenge Thank you for your time. Interviewer (Last Name, First Name, Patronymic) Date Location of Interview Answer form Region Town 69

Appendix Форма отчета Регион Населенный пункт No Producer of Salt Contents of iodine in salt < 5 ppm >5 ppm No iodine, i.e. no colouring when testing Falsification i.e. salt marked iodized, but testing showed no iodine.. 3. 4. 5. 6. 7. 8. 9.... 3. 4. 5. 6. 7. 8. 9.... 3. 4. 5. 6. 7. Etc Total 7 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Appendix 3 Results of Household Salt Testing, ALMATY city Origin of salt Reading by rapid test kit ppm < 5ppm 5ppm Adulterated* Total Pavlodarsol Kazakhstan salt..8% Araltuz 3 9 93 3.% 96.8% 38. Russian salt 4 4.6% Byelorussian salt 8.3% 9.7% 4.9% Salt sold by weight/ without packaging.5% 5 3.7% 8 8.6% 9 4.% 3 54.7% Total 3 8 5 9 45.% 3.3% 87.8% 7.8% The category adulterated indicates the household salt definition used in the codebook. 7

Results of Household Salt Testing, NORTH Region Kazakhstan salt Location/ Origin of salt Pavlodarsol 9 5. Araltuz Russian salt 3 37.5% Byelorussian salt 33.3% Turkish salt Salt sold by weight/ without packaging Kazakhstan salt Reading by rapid test kit ppm < 5ppm 5ppm 7 4.% Total 4 33.% Pavlodarsol 8 3.8% Araltuz.% Pavlodar city 9 5..5% 33.3% 3.3% 4 9.4% Sharbakty village 8 3.8%.% Russian salt Byelorussian salt Salt sold by weight/ without packaging Kazakhstan salt 54 66.7% Total 65 53.3% Pavlodarsol 7 7.4% Araltuz 4.8% 3 6. 3 8.9% North region 7 7.4% 4.8% Russian salt.% Byelorussian salt 5% Turkish salt Salt sold by weight/ without packaging 6 7.9% Total 47 9.% 8 5. 4 5. 33.3% 4 37.5% 59 47.6% 38.5% 7 77.8% 3 6 4 7.3% 34 9.7% 8 45.% 9 9.5% 4 44.4% 4 5 38 6.% 93 37.8% Adulterated - - - - - - - - - - - - - - - - - - - - Total 36 9. 9.7% 8 6.5% 3.4%.8% 64 5.6% 4 6.3% 9 7.4%.8% 5 4.% 8 66.4% 6 5.% 8.5% 9 3.7% 8 3.3%.4% 45 58.9% 46 7 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Results of Household Salt Testing, EAST Region Kazakhstan salt Location/ Origin of salt Pavlodarsol Araltuz Reading by rapid test kit ppm < 5ppm 5ppm Ust-Kamenogorsk city Russian salt 3 Salt sold by weight/ without packaging Kazakhstan salt 9.3% Total 9.7% Pavlodarsol Araltuz 7.3% 7.5% 5.% Shemonaikha village 5 Russian salt 3 4.9% Byelorussian salt Salt sold by weight/ without packaging Kazakhstan salt 3 4.3% Total 7 Pavlodarsol Araltuz 3.6% East region 5% Russian salt 6 33.3% Byelorussian salt Salt sold by weight/ without packaging 35.5% Total 4 6.9% 3 5 45.5% 49 6.3% 87 7.% 5 95.5% 8.6% 3 58 63.7% 85 68. 3 75% 5 98.% 7 38.9% 3 7 6.6% 7 69.% Adulterated - - - - - 4.5%.%.6%.9%.6%.8% Total.6% 3 5. 8.9% 8 64.5% 4.6% 7.6% 7 5.6% 3.4% 9 7.8% 5 4.6% 53.3% 8 7.% 3.% 7 68.7% 49 73

Results of Household Salt Testing, SOUTH Region Location/ Origin of salt Reading by rapid test kit ppm < 5ppm 5ppm Adulterated Total Shymkent city Kazakhstan salt Araltuz 83.3% 8.6% Salt sold by weight/ without packaging 3.5% 83.3% 4.% 4 9.4% Total 3 4.4% 96.8%.8% Aksu village Kazakhstan salt Araltuz 73 73 59.3% Russian salt.8% Salt sold by weight/ without packaging 3 6.% 4.% 43 87.8%. 49 38.9% Total 3 6 3.4%.6% 95.%.8% South region Kazakhstan salt Araltuz 73 73 7 Russian salt.4% Salt sold by weight/ without packaging.7% 63 86.3%.7% 73 9.6% Total 37 47.8% 96%.8% 74 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Results of Household Salt Testing, WEST Region Location/ Origin of salt Reading by rapid test kit ppm < 5ppm 5ppm Adulterated Total Aktobe city Kazakhstan salt Araltuz 3.% 4 88.9% 7.9% Russian salt 5 55 9.9% 43.4% Byelorussian salt.8% Unidentified.8% Salt sold by weight/ without packaging 7 5.9% 35 79.5% 4.5% 44 34.% Total 3 3 9 8.5%.3% 87.6%.6% Alga village Kazakhstan salt Araltuz 8-8 5% Russian salt 46 93.9% - 49 4.8% Salt sold by weight/ without packaging 5 94.3% - 53 44.% Total 4 95. - West region Kazakhstan salt Araltuz 3 6.7% 4 93.3% 45 8.% Russian salt 98 5 93.3% 4.% Byelorussian salt.4% Unidentified.4% Salt sold by weight/ without packaging 85 87.6%.% 97 39. Total 3 7 49.% 9.%.8% 75

Results of Household Salt Testing, CENTRAL Region Kazakhstan salt Location/ Origin of salt Pavlodarsol. Araltuz 3 3.3% Reading by rapid test kit ppm < 5ppm 5ppm Karaganda city 3 3..% Russian salt Byelorussian salt Unidentified Salt sold by weight/ without packaging Kazakhstan salt.5% Total 9.6% Pavlodarsol 3.3% Araltuz 4 5. 9 6. Osakarovka village.3% Russian salt Byelorussian salt Unidentified Salt sold by weight/ without packaging Kazakhstan salt 3 9.% Total 4 4. Pavlodarsol 4 7.4% Araltuz 3.% Central region 3 3. 3.% Russian salt Byelorussian salt Unidentified Salt sold by weight/ without packaging 7 4.3% Total 3 5.% 6 6. 86 94.5% 8 7.7% 54.5% 9 56.3% 8.8% 76.9% 4 97.7% 6 85.7% 4 7.7% 8 8.8% 6 69.6% 8 95.5% 4 77.8% 5.% 33.3% 33 67.3% 4 8.6% Adulterated 6.3%.7% 3 9.% 3 3. 4 8.% 4.6% Total 6.6% 9 6.3% 7.3% 4.6%.7% 6.6% 5 3 3.% 43 43.4% 7 7.%. % 33 33.3% 99 3 9.% 34 53.6% 8 7.% 3.% 3.% 49 9.6% 5 76 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Results of Household Salt Testing, KAZAKHSTAN Location/ Origin of salt Reading by rapid test kit ppm < 5ppm 5ppm Adulterated Total Urban areas Pavlodarsol 8 5 Kazakhstan salt 4% 56. 5.6% Araltuz 3 8 343 354.8%.3% 96.9% 39.6% Russian salt 4 7 89 4.5% 8.9%. Byelorussian salt 5 38.6% 65.8% 4.3% Turkish salt.% Unidentified.% Salt sold by weight/ without packaging 49 3.6% 44.% 44 67.8% 3 6.4% 36 4.3% Total 88 69 74 3 894 9.8% 7.7% 79.9%.6% Rural areas Pavlodarsol 9 4 Kazakhstan salt 6.8%. 5.% 7. Araltuz 6 65.6%.% 97.6%.6% 8.% Russian salt 3 55 65 4.6% 84.6%.% Byelorussian salt 6 9.% 66.7%.5% Unidentified.3% Salt sold by weight/ without packaging 3.% 88 6.6% 5.6% 35 5. Total 46 43 6 587 7.8% 73.4%. Overall Republic of Kazakhstan Pavlodarsol 49 9 Kazakhstan salt 3.% 3.% 53.8% 6.% Araltuz 4 54 59.8%.9% 97.%.% 34.9% 77

Russian salt 7 8 55 4.5% 8.6%.4% Byelorussian salt 3 47 4.3% 66. 3.% Turkish salt.% Unidentified 4 5.3% Salt sold by weight/ without packaging 75.% 434 64.9% 8 4.% 669 45. Total 5 48 9 486 7.7% 77.3%. 78 An Assessment of the Household Use and Adequacy of Iodized Salt in the Republic of Kazakhstan

Literature. М.Е. Zeltser, R.B. Bazarbekova. Mother and child in the IDD center. Almaty, 99, 84 p.. М.Е. Zeltser and others. Epidemiology and endemic goiter prevention in Kazakhstan. Alma-Ata, Science, 979. 3. R.B. Bazarbekova. Health characteristics of pregnant women and children of an early age in the center of goitrous endemia.// Abstract of thesis for a Doctor of Medicine s degree. Almaty, 996, 6 p. 4. F.E. Ospanova. With regard to IDD prevention problem. // Materials of the National research and practical conference. Almaty,, p. 64. 5. Methods of iodized salt quality assurance. Methodical recommendations. Institute of Nutrition of MoES of RK, Almaty,. 6. F.E. Ospanova. Iodized salt consumption in assessment of iodine status of the population.// Health and Disease, Almaty,, No(9), p.3-4. 7. Control of IDD prevention by universal salt iodization. Methodical guideline. МU.3.7. 64-., MoH of RF. Moscow,, р. 33. 8. Study of knowledge and skills standard with regard to IDD problem among the general population and health workers of the Republic of Kazakhstan.// Report of NHLSC and UNICEF, Almaty,, 89 p. 9. I.G. Tsoy, N.M. Karsybekova, L.R. Kulmurzayeva. National program for foodstuff fortification in Kazakhstan.// Health and Disease, Almaty, 4, No5(35), р.7-.. L.R. Kulmurzayeva, I.G. Tsoy, Zh.T. Tolysbayeva. Short-term monitoring of communication activities with regard to iron-deficient anemia and IDD in pilot regions. // Health and Disease, Almaty, 4, No5(35), р.75-79.. Zh.T. Tolysbayeva., F.E. Ospanova. Awareness of people from the South-Kazakhstan oblast (region) about IDD consequences and IDD prevention by iodized salt consumption. // Health and Disease, Almaty, 4, No5(35), р.79-8. 79