Nutrition and Mortality Survey

NUTRITION AND MORTALITY SURVEY

Tharparkar, Sanghar and Kamber Shahdadkhot districts of

Sindh Province, Pakistan

18-25 March, 2014

TABLE OF CONTENT TABLE OF CONTENT ...... 2 ABBREVIATIONS ...... 3 EXECUTIVE SUMMARY ...... 4 1. Introduction ...... 6 2. Objective of the Study ...... 6 3. Methodology ...... 7 3.1 Study area ...... 7 3.2 Study population ...... 7 3.3 Study design ...... 8 3.3.1 Sample size determination: ...... 8 3.3.2 Cluster determination and selection ...... 8 3.4 Sampling Procedure...... 8 3.5 Data Collection ...... 9 3.5.1 Anthropometric measurements ...... 9 3.5.2 Mortality data ...... 9 3.5.3 Morbidity data ...... 9 3.5.4 Vaccination - Measles and BCG ...... 10 3.5.5 Vitamin A supplementations ...... 10 3.5.6 Contextual factors ...... 10 3.6 Survey management...... 10 3.6.1 Coordination of the survey...... 10 3.6.2 Recruitment and Training of Enumerators ...... 10 3.7 Data analysis and Reporting ...... 10 3.7.1 Data Analysis ...... 10 3.7.2 Preliminary result and final report ...... 10 4. RESULTS ...... 11 4.1 Sex and age distribution children 6 to 59 months ...... 11 4.2 Anthropometric results (WHO 2006) ...... 11 4.3 Mortality results (retrospective over x months/days prior to interview) ...... 16 4.4 Child morbidity ...... 16 4.5 Vitamin A Supplementation and Vaccination status ...... 17 4.6 Household (HH) Characteristics ...... 18 5. Discussion ...... 21 5.1 Nutritional status ...... 21 5.2 Mortality ...... 22 5.3 Morbidity and coverage public health intervention ...... 23 5.4 Water, sanitation and Hygiene (WASH) ...... 23 5.5 Household Food security ...... 24 6. Recommendations and priorities...... 25 7. APPENDICES ...... 26 7.1 Assignment of clusters ...... 26 7.2 Questionnaires...... 29

ABBREVIATIONS ARI Acute Respiratory infection

BCG Bacillus Calmette–Guérin

CMAM Community Management of Acute Malnutrition

CDC center for disease control

CI confidence Interval

CMR Crude Mortality rate

DHO District Health Office

DHS Demographic Health Survey

EBF Exclusive Breastfeeding

ENA Emergency Nutrition assessment (ENA/SMART)

GAM Global Acute malnutrition

HFA Height for Age

HH Household

IP Implementing partner

IYCF Infant and young child feeding

MUAC Mid-Upper Arm Circumference

NNS National Nutrition Survey

PPS Probability Proportional to Size

SMART Standardized Monitoring and Assessment of Relief and Transitions

UC Union Council

UNICEF United Nations Children’s Fund

WASH Water Sanitation and Hygiene

WFA Weight-for-Age

WFH Weight-for-Height

WHO World Health Organization

EXECUTIVE SUMMARY Through UNICEF technical and ECHO financial support, three SMART Nutrition and mortality surveys were conducted in Tharparkar, Sanghar and Kamber Shahdadkot districts of Sindh, Pakistan. The overall objective of the nutrition surveys were to measure the extent and severity of acute malnutrition in children aged 6-59 months in the above mentioned districts. The data collection was managed by implementing partners; HANDS, Shifa Foundation, and NDS through coordination from provincial nutrition cell. The survey for Tharparkar and Sanghar were conducted between 19th and 25th whereas for Kamber Shahdadkot between 18th and 24th March 2014. Provincial nutrition cell in coordination with District health office (DHO) and the implementing partners (IPs) in the respected district were responsible to manage the survey. UNICEF was responsible to provide technical support throughout the assessment including design the questionnaire, providing the training for enumerators, analyzing the data and supporting the report writing. The survey design was descriptive cross-sectional survey, two-stage cluster sampling. In stage one, in each district total of 35 clusters or villages were selected randomly from the list of all villages in the respected districts. In stage two, from each clusters, total of 15 houses were randomly selected using random table number. A total of 630 children in Tharparkar, 511 in Sanghar, and 693 children in Kamber Shahdadkot were assessed. The major findings are summarized below

FINDINGS The survey findings indicate that the prevalence of global acute malnutrition (GAM) of 22.7% in Tharparkar, 16.0% in Sanghar, and 13.8% in Kamber Shahdadkot. According to World Health Organization (WHO) classification of severity of acute malnutrition in a community, the rate in Tharparkar and Sanghar is classify as critical whereas for Kamber Shahdadkot it is under the classification of serious. According to WHO threshold for chronic malnutrition, the level of stunting all three surveys was found very high; 45.9% in Tharparkar, 53.4% in Sanghar and 48.4% in Kamber Shahdadkot.

The crude (CMR) and under-five mortality rates (U5MR) in Tharparkar and Sanghar were almost within the acceptable range for South Asia region. The CMR and U5MR for Tharparkar was 0.2 and 0.9 deaths/10,000 people/day respectively whereas in Sanghar CMR was 0.22 and U5MR 0.64 /10,000 people/day. However, the CMR and U5MR in Kamber was 0.45 and 2.45 deaths/10,000 people/day which was above emergency threshold levels of the region.

Two weeks period morbidity prevalence shows 43.5% of children in Tharparkar, 49.7% in Sanghar and 34.8% were sick. According to maternal report, the most common reported illness according to the rank were fever, cough, and diarrhea. Measles cases were reported in all three districts; Tharparkar 3.6%, Sanghar 24.6% and Kamber 4.1 percent.

The assessment revealed that 68.8% of children in Tharparkar, 85.3% in Sanghar and 64.5% percent in Kamber Shahdadkot were received Vitamin A supplementation. BCG vaccination coverage in Tharparkar, Sanghar and Kamber was 51.9%, 80.8%, and 73.5% respectively. The coverage for measles (9 to 59 months) confirmed by card was 35% in Tharparkar, 77.5% in Sanghar and 35.9 percent in Kamber.

Access to an improved source of drinking water in Sanghar and Kamber Shahdadkot is nearly universal whereas in Tharparkar it was low. Percentage of population with access to improved water sources in Tharparkar, Sanghar and Kamber Shahdadkot was 64, 90.6, and 89.8% respectively. The sanitation situation was found to be poor. Nearly 90 percent in Tharparkar and about half of the households in Sanghar and Kamber have no improve toilet facility. About 78 percent of the population in Tharparkar, 37% in Sanghar and 26 percent in Kamber were using open field for defecation. In all three survey districts, majority of the population dispose the garbage in the street (Tharparkar 56.3%, Sanghar 60.4% and Kamber 86.3%).

The main source of income for Tharparkar and Sanghar was unskilled wage labour, 41.3% and 43.6% respectively whereas for Kamber Shahdadkot the primary sources was from farming/agriculture (46.8%). The main sources of staple food in Tharparkar, Sanghar and Kamber was 99.5%, 96.1% and 78.4% respectively. About 34% of households in Tharparkar, 9% in Sanghar and 25% in Kamber own agricultural land. About 87% of households in Tharparkar, 44% in Sanghar and 56% in Kamber own farm animals; small animals (sheep, goat), large animals (cattle, buffalo, camel) and chickens.

Recommendations and priorities

1. Expansion and strengthen of CMAM services - As per the WHO cut-off points for acute malnutrition, the prevalence in all three districts are above the threshold for nutrition responses. So, given this fact, it is recommended that implementing partners (IP) to continue the exiting CMAM implementation in these districts. However, the current service coverage is low. By the time when this surveys were conducted; HANDS was implementing CMAM services in 20 UCs in Tharparkar, Shifa foundation in 9 UCs in Sanghar and NDS 9 in 11 UCs in Kamber Shahdadkot. So, it is recommended the IP to scale up the services through requesting financial support from Donors. 2. Blanket Supplementary feeding program in Tharparkar – as per the survey findings, close to quarter of children are suffering from acute malnutrition. Tharparkar district is severely drought affected and as a result the government of Sindh has declared emergency. So, until the humanitarian situation is improved and general food distribution is in place, it is recommended WFP to provide assistance to IP to start blanket supplementary program for all children 6-59 months. 3. Improve Measles vaccination coverage: As per the maternal confirmation, measles case are reported in all three districts. Moreover, 14% of under five deaths in Kamber Shahdadkot was due to measles. There is a close and important relationship between measles and malnutrition. Measles is far more severe in children who are malnourished. In addition, complications are more common and more serious in malnourished children. Measles is more severe in malnourished children and may make the existing malnutrition worse. Therefore, measles may result in, or aggravate, malnutrition. 4. Infant and young child feeding practices (IYCF):– as per the qualitative information from caregivers, there a gap both in knowledge and practices of recommended IYCF practices. According to 2013 lancet series, sub-optimum breast feeding is responsible for about 12% of under five death. In view of this fact, IPs should give more emphases on protection, promotion and Support of IYCF through integrating within the existing programs such CMAM and primary health care. 5. Water and sanitation - Efforts have to be made to improve the water and sanitation situation of the communities particularly in Tharparkar promotion of hygiene practices and provision of improved water supply.

1. Introduction

Tharparkar is one the 23 districts of Sindh province located on the south east end of the country. It is boarder district bounded by India. The district has a tropical desert climate. Administratively, it is divided into four Talukas and further subdivided into 44 union councils. The estimated population for 2012 is 1,428,610 (extrapolated from 1998 census). Following the failure of monsoon rains since Nov-2013, drought has occurred manifested by in severe shortage of food, fodder and water. As a result the government has declared an emergency in the entire district. According to 2009 food security assessment, Tharparkar is one of lowest in access to food index in the country. According to the same sources, 53.4% of the population is food insecure and was ranked as top in Sindh and 17th in the country.

Sanghar district is one of the boarder district bounded by Indian state on the east, district Khairpur and Shaheed Benazirabad on the north, district Matiari and Tando Allahyar on the west, and district Umerkot and Mirpur Khas on the south. Sanghar district has six talukas 55 union councils. The estimated population for 2012 is 1,834,212 (extrapolated from 1998 census). Sanghar is one of the district vulnerable to disaster. It was severely hit by rain/flood in 2010, 2011 and 2012.

Kamber-Shahdadkot district is situated in the north-west of Sindh. It is bounded by district Larkana in the east, Baluchistan province in the north-west, district Jacobabad in the north-east and district Dadu in the south. Kamber Shahdadkot consists of seven talukas and 40 union councils. The estimated population for 2012 is 1,300,649 (extrapolated from 1998 census). The district was consecutively hit by heavy floods and rains in 2010, 2011 and in 2012.

2. Objective of the Study

General Objective The overall objective of the nutrition survey was to measure the extent and severity of acute malnutrition in children aged 6-59 months in Tharparkar, Sanghar and Kamber Shahdadkot districts of Sindh province.

Specific OBJECTIVES  To estimate the prevalence of acute and chronic malnutrition among children 6-59 months of age;  To assess crude mortality rate (CMR) and under five mortality rates (U5MR);  To assess morbidity, immunization coverage (measles and BCG), and Vitamin A supplementation coverage among 6-59 months children;  To examine the population’s access to, and use of, improved water, sanitation and hygiene.

3. Methodology 3.1 Study area As it is shown in the map below, three independent SMART surveys were conducted in Tharparkar, Sanghar, and Kamber Shahdadkhot districts of Sindh province.

3.2 Study population The target population were children from 6 to 59 months of age and the household members.  Anthropometric and morbidity - children from 6 to 59 months  Retrospective mortality assessment – All household members  Household Food security, WASH, and other characteristics – the target was household with children 6-59 months.

3.3 Study design The survey design was cross-sectional study with two-stage cluster sampling using SMART methodology. Clusters are defined as Villages. Villages were considered as the smallest geographical unit (clusters). The sample size was determined using the Emergency Nutrition Assessment (ENA) for SMART software.

3.3.1 Sample size determination: As the survey was combination of Anthropometry and mortality assessment, the Sample sizes for anthropometric and mortality surveys were calculated separately. The sample size for both anthropometric and Mortality was calculated using ENA for SMART software (version November 16th, 2013). As shown in the following table, the minimum household to be visited for anthropometry survey was estimated at 518 households.

Table 1: Sample Size for Anthropometry Number of Estimated cluster

GAM Sample Number y Total require Prevalence size 6-59 Average number of of HH HH 15HH/cluster (NNS 2011) Precision DEFF children pop. HH size 6-59/HH required contingenc required 17.5% 4 1.3 491 14% 7 0.98 502 3% 518 35

Sample size for mortality was determined based on the following parameters; estimated Crude Mortality Rate (CMR), Level of the desired precision, Design effect, Recall period, Average household size, and Contingency

Table 2: Sample size for Mortality Number Number of Population of HH to cluster estimated Recall to be Average be require District CMR Precision DEFF period included HH size Contingency included 15HH/cluster 90 0.37 0.3 1.5 days 2865 7 3% 422 29

As per the above two tables, the sample size for nutrition was estimated at 518 households whereas for mortality it was 422 households. However, as both components were conducted concurrently by the same team, the larger sample size which, 518 households, was considered for both anthropometry and mortality.

3.3.2 Cluster determination and selection The total number of clusters were determined by dividing the total household sample size to the number of households that can be visited per a day per team. The number of households that can be visited per a day per team was determined as 15. Thereafter, the total number of clusters was calculated at 35 (518/15 = 34.5 rounded off to 35).

3.4 Sampling Procedure The sampling procedure was divided into two stages; stage-1 selection of villages from the total district villages and stage-2 selection of households from the village.

Stage-I Cluster Selection  Lists of all villages and their corresponding population estimates in each district were obtained from the implementing partners.

 Cluster election - total of 35 clusters in each district were selected using probability proportional to size (PPS) giving equal chance of selection for each village.  SMART software was applied in the selection of the clusters.

Stage-II Selection of the Household This was done by the teams in the field. After the teams arrived in the selected village, the following processes were carried out; 1. Listing of all households in the village. 2. Using random number table, 15 households were randomly selected 3. Then the selected households were visited by the team. Regardless of the presence of children under five, all household were interviewed for mortality questionnaire. If any child 6-59 months the anthropometric and household questionnaire were administered 4. When the villages were big with more than about 250 households, the team used segmentation approach.

3.5 Data Collection According to the assessment objectives the following data was collected.

3.5.1 Anthropometric measurements  Age: The mothers or care taker were asked to recall the date of birth of the child. When the mothers were failed to recall, then they were asked to show documents where birth date is written like a vaccination card. A local calendar by months was also prepared and provided to the team to assist age estimation.  Sex: (M/F)  Weight: All children were weighed using digital weighing scale.  Height/Length: Children under 87.0 cm or 24 months of age are measured lying down and children height greater or equal to 87.0 cm or 24 months are measured in the standing position.  MUAC: The eligible children for the survey aged between 6-59 months were measured in MUAC to the nearest 0.1 cm.  Oedema: The presence of nutritional Oedema was determined by pressing both feet for three seconds. Fortunately, no oedematous child was reported.

3.5.2 Mortality data The number of deaths during the three months prior to interview (90 days) was recorded retrospectively for all household. Regardless of the presence of children in the household, the mortality questionnaire was administered in all 15 household in each clustered. Causes of the death was also be recorded if known. December 5th 2013, “topi Ajkrak”, was selected as a reference/starting date and all the deaths, births, household members joined and household members left since the start of recall period was recorded. Then crude and under five mortality rates were calculated as the number of deaths occurring per 10,000 per day.

3.5.3 Morbidity data Two-week retrospective morbidity data of children 6-59 months was collected from mothers/caregivers. The mothers/caregivers were asked whether or not the child had diarrhea, fever and/or cough in the two weeks preceding the survey. Diarrhea was defined as three or more loose stools per day. Cough was considered any coughing or difficulty breathing. All morbidity reports were be based on mothers’/caregivers’ confirmation.

3.5.4 Vaccination - Measles and BCG Measles vaccination was collected from children 9-59 months. Caregivers were asked to show the vaccination cards of the child and then cards were observed and checked whether or not the child has had measles vaccination. If a child did not have a card, mothers were further sked whether or not they could recall child being vaccinated. BCG immunization coverage was assessed among all under-five children in the survey area by checking scar on the left arm.

3.5.5 Vitamin A supplementations Mothers were asked whether or not their children had received Vitamin A in the last 6 months. Mothers were shown Vitamin A capsule.

3.5.6 Contextual factors The contextual factors (Household characteristics, income, land ownership, livestock ownership, water, hygiene and sanitation) was collected through household interview.

3.6 Survey management

3.6.1 Coordination of the survey Provincial nutrition cell in coordination with District health office (DHO) and the implementing partners (IPs) in the respected district were responsible to manage the survey. They were The IPs were HANDS (Tharparkar), Shifa foundation (Sanghar) and NDS (Kamber). They were responsible in the selection of data collectors, managing the logistic and data collection. UNICEF was responsible to provide technical support throughout the assessment including design the questionnaire, providing the training for enumerators, analyzing the data and supporting the report writing.

3.6.2 Recruitment and Training of Enumerators In each district, there were five teams each consists of three people composed of team leader and two enumerators. At district level, the teams were supervised by survey coordinator from implementing partners. Four days training was given to the enumerators. The first three days training was facilitated by Kiross Tefera (Nutrition specialist – UNICEF) and assisted by Dr Muhammad Mazhar Alam (Nutrition officer- UNICEF). In the first three days, they attend theoretical sessions and practical demonstration on body anthropometric measurement and how to collect other nutrition related information or data using SMART methodology. The field test was conducted in the fourth day and was managed by IPs. The fourth day was field testing. The following topics were covered during the training; objectives of the SMART survey; Basic concept of Sampling method; Anthropometrical measurements: height/length, weight, MUAC measurement techniques, and checking of bilateral oedema; Age assessments, preparation of local calendar and how to use local calendar to assist mothers to recall the age of their children; Assessment of health status of the child (illness), immunization and mortality data; Data collection and interview technique procedures; Question-by-question review of the questionnaire; Sampling procedure at village/cluster level; Practising interview/ role play; and Pilot testing in the field

3.7 Data analysis and Reporting

3.7.1 Data Analysis SMART (ENA) and EPI INFO version 3.5.4s was used to process and analyze the results of the survey. Data was cleaned and analyzed by Kiross Tefera (UNICEF).

3.7.2 Preliminary result and final report The preliminary summary result was shared two weeks after the data collection and this is the final report.

4. RESULTS

4.1 Sex and age distribution children 6 to 59 months The age distribution of the measured children is presented on the table 4.1 below. The overall sex ratio of each district indicates that boys and girls were equally represented and there was no bias in terms of sampling girls or boys.

Table 4.1.1: Distribution of age groups and sex of sample AGE Tharparkar Sanghar Kamber Shahdadkot (months) Total Ratio Total Ratio Total Ratio No % Boy: girl No % Boy: girl No % Boy: girl ( 338:292) ( 253:258) ( 358:335) 6-17 137 21.7 1.4 117 22.9 0.8 137 19.8 1.1 18-29 140 22.2 1.0 114 22.3 1.0 165 23.8 1.1 30-41 186 29.5 1.2 128 25.0 0.9 183 26.4 1.2 42-53 135 21.4 1.0 115 22.5 1.1 164 23.7 0.8 54-59 32 5.1 1.7 37 7.2 1.8 44 6.3 1.3 Total 630 100.0 1.2 511 100.0 1.0 693 100.0 1.1

The overall boys to girls ratio among all age groups of children was 1.16 in Tharparkar (p value 0.067), 1.0 in Sanghar (p value 0.825) and 1.1 in Kamber Shehdadkot (p value 0.382). A sex ratio of between 0.8 and 1.2 is believed to be acceptable.

4.2 Anthropometric results (WHO 2006) The prevalence of acute malnutrition in these surveys are presented using z-scores and MUAC. Global acute malnutrition (GAM) is defined as weight for height <-2 z-scores and or oedema whereas Severe acute malnutrition (SAM) is defined as weight for height <-3 z-scores and or oedema.

Table 4.2.1: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex

Tharparkar Sanghar Kamber Shehdadkot All Boys Girls All Boys Girls All Boys Girls n = 622 n = 333 n = 289 n = 511 n = 253 n = 258 n = 688 n = 353 n = 335 Prevalence of global (82) 16.0 % (41) 16.2 % (41) 15.9 % (141) 22.7 % (81) 24.3 % (60) 20.8 % (95) 13.8 % (47) 13.3 % (48) 14.3 % malnutrition (12.4 - 20.6) (11.6 - 22.2 ) (11.8 - 21.0) (18.3-27.8) (18.7-31.0 ) (15.8-26.7 ) (10.7 - 17.6 ) (10.2 - 17.2 ) (9.3 - 21.5 ) (<-2 z-score and/or oedema) Prevalence of moderate (57) 11.2 % (28) 11.1 % (29) 11.2 % malnutrition (101) 16.2 % (56) 16.8 % (45) 15.6 % (8.5 - 14.5 ) (7.7 - 15.6 ) (7.8 - 15.9) (65) 9.4 % (29) 8.2 % (36) 10.7 % (<-2 z-score and >=-3 z-score, (12.9-20.3 ) (12.4-22.3 ) (11.5-20.8 ) (7.1 - 12.5 ) (5.9 - 11.4 ) (7.0 - 16.1 ) no oedema) Prevalence of severe (25) 4.9 % (13) 5.1 % (12) 4.7 % (40) 6.4 % (25) 7.5 % (15) 5.2 % (30) 4.4 % (18) 5.1 % (12) 3.6 % malnutrition (3.2 - 7.4 ) (3.0 - 8.7 ) (2.8 - 7.7) (4.1-10.0 ) (4.5-12.3 ) (3.0-8.8 ) (3.1 - 6.0 ) (3.5 - 7.5 ) (1.7 - 7.4 ) (<-3 z-score and/or oedema)

Table 4.2.2: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Tharparkar Sanghar Kamber Shahdadkot Severe wasting Moderate wasting Severe wasting Moderate Severe Moderate (>= -3 and <-2 z-score ) wasting wasting (<-3 z-score) (<-3 z-score) wasting (>= -3 & <-2 z-score ) (>= -3 & <-2 z-score ) (<-3 z-score) Age Total Total Total (month) no. No. % No. % No. % No. % No. % No. % 6-17 134 16 11.9 23 17.2 117 9 7.7 23 19.7 137 11 8.0 14 10.2 18-29 139 4 2.9 26 18.7 114 9 7.9 13 11.4 163 6 3.7 17 10.4 30-41 183 9 4.9 20 10.9 128 4 3.1 10 7.8 181 7 3.9 11 6.1 42-53 134 7 5.2 23 17.2 115 2 1.7 10 8.7 163 5 3.1 20 12.3 54-59 32 4 12.5 9 28.1 37 1 2.7 1 2.7 44 1 2.3 3 6.8 Total 622 40 6.4 101 16.2 511 25 4.9 57 11.2 688 30 4.4 65 9.4

Table 4.2.3: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex

Tharparkar Sanghar Kamber Shahdadkot All Boys Girls All Boys Girls All Boys Girls n = 630 n = 338 n = 292 n = 511 n = 253 n = 258 n = 693 n = 358 n = 335 Prevalence of global malnutrition (103) 16.3 % (57) 16.9 % (46) 15.8 % (86) 16.8 % (40) 15.8 % (46) 17.8 % (107) 15.4 % (45) 12.6 % (62) 18.5 % (< 125 mm and/or (12.6 - 20.9) (11.9 - 23.3) (11.9 - 20.6) (12.6 - 22.2) (11.1 - 22.0) (12.7 - 24.5) (12.6 - 18.7) (9.5 - 16.5) (14.2 - 23.8) oedema) Prevalence of moderate malnutrition (75) 11.9 % (40) 11.8 % (35) 12.0 % (61) 11.9 % (28) 11.1 % (33) 12.8 % (80) 11.5 % (33) 9.2 % (47) 14.0 % (< 125 mm and >= 115 mm, (9.1 - 15.4) (7.7 - 17.7.) (9.2 - 15.4 ) (8.9 - 15.9 (7.4 - 16.2) (9.2 - 17.5) (9.0 - 14.7) (6.3 - 13.3) (10.1 - 19.2) no oedema) Prevalence of severe malnutrition (28) 4.4 % (17) 5.0 % (11) 3.8 % (25) 4.9 % (12) 4.7 % (13) 5.0 % (27) 3.9 % (12) 3.4 % (15) 4.5 % (< 115 mm and/or (2.9 - 6.7) (3.1 - 8.1 ) (2.0 - 7.1 ) (3.0 - 8.0) (2.3 - 9.7) (2.8 - 8.8 ) (2.5 - 6.1) (1.6 - 6.7) (2.7 - 7.4) oedema)

Table 4.2.4: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema Tharparkar Sanghar Kamber Shahdadkot Severe wasting Moderate wasting Severe wasting Moderate wasting Severe wasting Moderate wasting (>= 115 & < 125 mm) (>= 115&< 125 mm) (>= 115&< 125 mm) (< 115 mm) (< 115 mm) (< 115 mm) Age Total Total Total (month) no. No. % No. % No. % No. % No. % No. % 6-17 137 16 11.7 36 26.3 117 14 12.0 38 32.5 137 16 11.7 42 30.7 18-29 140 7 5.0 20 14.3 114 7 6.1 11 9.6 165 7 4.2 26 15.8 30-41 186 4 2.2 10 5.4 128 2 1.6 6 4.7 183 1 0.5 11 6.0 42-53 135 0 0.0 7 5.2 115 2 1.7 4 3.5 164 3 1.8 1 0.6 54-59 32 1 3.1 2 6.3 37 0 0.0 2 5.4 44 0 0.0 0 0.0 Total 630 28 4.4 75 11.9 511 25 4.9 61 11.9 693 27 3.9 80 11.5

Table 4.2.5: Prevalence of underweight based on weight-for-age z-scores by sex Tharparkar Sanghar Kamber Shahdadkot All Boys Girls All Boys Girls All Boys Girls n = 627 n = 336 n = 291 n = 511 n = 253 n = 258 n = 693 n = 358 n = 335 Prevalence of (269) 42.9 % (149) 44.3 % (120) 41.2 % (216) 42.3 % (105) 41.5 % (111) 43.0 % (201) 29.0 % (113) 31.6 % (88) 26.3 % underweight (36.8 - 49.2) (36.9 - 52.1) (34.6 - 48.2) (36.0 - 48.8) (34.2 - 49.2) (34.8 - 51.7) (23.8 - 34.8) (26.1 - 37.6) (20.1 - 33.6) (<-2 z-score) Prevalence of (146) 23.3 % (75) 22.3 % (71) 24.4 % (133) 26.0 % (64) 25.3 % (69) 26.7 % (152) 21.9 % (82) 22.9 % (70) 20.9 % moderate (19.3 - 27.8) (18.0 - 27.4) (18.8 - 31.0) (21.9 - 30.6) (19.4 - 32.3) (21.5 - 32.7) (18.3 - 26.0) (18.3 - 28.2) (15.9 - 26.9) underweight (<-2 z-score and >=-3 z-score) Prevalence of severe (123) 19.6 % (74) 22.0 % (49) 16.8 % (83) 16.2 % (41) 16.2 % (42) 16.3 % (49) 7.1 % (31) 8.7 % (18) 5.4 % underweight (15.7 - 24.2) (16.9 - 28.2) (12.5 - 22.3) (12.1 - 21.5) (11.5 - 22.3) (11.3 - 23.0) (4.7 - 10.5) (5.4 - 13.6) (3.3 - 8.7) (<-3 z-score)

Table 4.2.6: Prevalence of underweight by age, based on weight-for-age z-scores Tharparkar Sanghar Kamber Shahdadkot Severe Moderate Severe Moderate Severe Moderate underweight underweight underweight underweight underweight underweight (>= -3 and <-2 z- (>= -3 and <-2 z- (>= -3 and <-2 z- (<-3 z-score) score ) (<-3 z-score) score ) (<-3 z-score) score ) Age Total Total Total (month) no. No. % No. % No. % No. % No. % No. % 6-17 135 30 22.2 33 24.4 117 22 18.8 36 30.8 137 12 8.8 36 26.3 18-29 139 31 22.3 28 20.1 114 24 21.1 29 25.4 165 17 10.3 42 25.5 30-41 186 35 18.8 36 19.4 128 24 18.8 28 21.9 183 7 3.8 38 20.8 42-53 135 19 14.1 38 28.1 115 9 7.8 35 30.4 164 9 5.5 29 17.7 54-59 32 8 25.0 11 34.4 37 4 10.8 5 13.5 44 4 9.1 7 15.9 Total 627 123 19.6 146 23.3 511 83 16.2 133 26.0 693 49 7.1 152 21.9

Table 4.2.7: Prevalence of stunting based on height-for-age z-scores and by sex

Tharparkar Sanghar Kamber Shahdadkot All Boys Girls All Boys Girls All Boys Girls n = 617 n = 329 n = 288 n = 511 n = 253 n = 258 n = 690 n = 355 n = 335 Prevalence of stunting (273) 53.4 % (146) 57.7 % (127) 49.2 % (334) 48.4 % (185) 52.1 % (149) 44.5 (283) 45.9 % (154) 46.8 % (129) 44.8 % (<-2 z-score) (48.0 - 58.8) (50.4 - 64.7) (41.3 - 57.2) (44.3 - 52.6) (46.9 - 57.3) % (40.1 - 51.7) (39.2 - 54.6) (38.3 - 51.5) (38.4 - 50.7) Prevalence of moderate (123) 24.1 % (65) 25.7 % (58) 22.5 % (171) 24.8 % (95) 26.8 % (76) 22.7 % stunting (157) 25.4 % (88) 26.7 % (69) 24.0 % (19.7 - 29.1) (20.5 - 31.6) (16.5 - 29.8) (20.6 - 29.5) (22.4 - 31.6) (16.7 - 30.0) (<-2 z-score and >=-3 z- (21.2 - 30.3) (21.1 - 33.3) (19.1 - 29.6) score) Prevalence of severe (150) 29.4 % (81) 32.0 % (69) 26.7 % (163) 23.6 % (90) 25.4 % (73) 21.8 % (126) 20.4 % (66) 20.1 % (60) 20.8 % stunting (24.6 - 34.7) (25.7 - 39.0) (20.9 - 33.5) (19.3 - 28.6) (20.3 - 31.1) (16.9 - 27.6) (16.7 - 24.7) (15.4 - 25.7) (16.5 - 26.0) (<-3 z-score)

Table 4.2.8: Prevalence of stunting by age based on height-for-age z-scores

Tharparkar Sanghar Kamber Shahdadkot Severe Moderate stunting Severe Moderate stunting Severe stunting Moderate stunting (>= -3 & <-2 z-score ) (>= -3 & <-2 z- (>= -3 & <-2 z- stunting stunting (<-3 z-score) score ) score ) (<-3 z-score) (<-3 z-score) Age Total Total Total (mo) no. No. % No. % No. % No. % No. % No. % 6-17 134 25 18.7 34 25.4 117 22 18.8 24 20.5 135 37 27.4 29 21.5 18-29 135 40 29.6 36 26.7 114 40 35.1 30 26.3 165 52 31.5 49 29.7 30-41 182 34 18.7 47 25.8 128 48 37.5 29 22.7 183 40 21.9 55 30.1 42-53 134 22 16.4 32 23.9 115 34 29.6 32 27.8 163 26 16.0 32 19.6 54-59 32 5 15.6 8 25.0 37 6 16.2 8 21.6 44 8 18.2 6 13.6 Total 617 126 20.4 157 25.4 511 150 29.4 123 24.1 690 163 23.6 171 24.8

4.3 Mortality results (retrospective over x months/days prior to interview) A three months retrospective mortality data was collected from each household. December 5, 2013 was taken as a reference/starting date. In each survey district, the mortality data was collected from 3911 household residents in Tharparkar, 3479 in Sanghar and 4051 in Kamber Shahdadkot. Of the total residents, the population under five months (0-59) in Tharparkar, Sanghar, and Kamber was 709,510, and 622 respectively. A total deaths reported in Tharparkar, Sanghar and Kamber were 9, 7 and 17 respectively. Of the total deaths, the under five (0-59 months) were 6, 3, and 14 respectively.

Table 4.3.1: Mortality rates Indicators Tharparkar Sanghar Kamber Shahdadkot Crude mortality rate – CMR 0.24 0.22 0.45 Total deaths/10,000 people / day): (0.12-0.48 95% CI) (0.11-0.4495% CI) (0.22-0.94 95% CI) Mortality Rate Under five mortality rate – U5MR 0.91 0.64 2.45 Number of Under five deaths/10,000 under five/day (0.44-1.88 95% CI) (0.21-1.97) (95% CI) (1.2-4.93 95% CI)

According to the respondent’s confirmation, the main causes of under five deaths in Kamber Shahdadkot were fever (21%), measles (14%), malaria (7%), diarrhea (7%), unknown (29%), and others (21%).

4.4 Child morbidity Table 4.4.1: Prevalence of reported illness in children 6-59 months in the last two weeks Indicators Tharparkar Sanghar Kamber Shahdadkot 43.5 % (n=628) 48.7% (n=511) 34.8% (n=693) Prevalence of all reported Illnesses in the last two weeks prior to survey (39.6 – 47.5 95% C.I.) (44.3 – 53.2 95% C.I.) (31.3 – 38.5 95% C.I.) 60.6% (n=274) 74.6% (n=248) 65.1% (n=241) Of those who were sick, who visited health facilities for treatment (54.5 – 66.4 95% C.I.) (68.7 – 79.9 95% C.I.) (58.8 – 71.1 95% C.I.) Symptom breakdown based on maternal confirmation1 n=274 N=248 N=241 Diarrhea 26.3% 41% 39.4% Fever 71.9% 57% 61.4% Cough 28.8% 45.8% 53.9% Measles 3.6% 24.6% 4.1%

1 Some children were with more than one symptom. 16

4.5 Vitamin A Supplementation and Vaccination status Table 4.5.1: BCG and measles vaccination and Vitamin A supplementation coverage Indicators Tharparkar Sanghar Kamber Shahdadkot 68.8% (N=624) 85.3% (n=509) 64.5% (n=654) Vitamin A supplementation 6-59 months - By Maternal recall (64.9 – 72.3 95% C.I.) (81.8 – 88.2 95% C.I.) (60.7 – 68.2 95% C.I.) 35.0 % (N=604) 77.5 % (n=475) 35.9 % (n=560) 9-59 months - Confirmed with card (31.1 – 39.1 95% C.I.) (73.4 – 81.1 95% C.I.) (31.9 – 40.0 95% C.I.) Measles Vaccination 63.4 % (N=604) 84.2 % (n=475) 67.7 % (n=560) 9-59 months -With card or confirmation from mother (59.3 – 67.3 95% C.I.) (80.5 – 87.3 95% C.I.) (63.6 – 71.5 95% C.I.) 51.9 % (N=628) 80.8 % (n=510) 73.5 % (n=510) BCG Vaccination 6-59 months - scar (47.9 – 55.9 95% C.I.) (77.0 – 84.1 95% C.I.) (70.0 – 76.7 95% C.I.)

4.6 Household (HH) Characteristics Table 4.6.1 Household Characteristics and food security No. Characteristics/Variables Tharparkar Sanghar 1 Sex of Household head N=387 N=510 N=361 Male 100% - 97.5% 2 Marital Status N=387 N=509 N=361 Married 99.2% 99.0% 98.6% Divorced 0.3% 0.6% 0.0% Widowed 0 0.4% 1.1% other 0 0 0.3% 3 Number of Household members N=382 N=507 N=360 3 3.1% 5.1% 2.8% 4 7.9% 10.2% 6.7% 5 11.8% 15.7% 9.4% 6 15.4% 15.4% 14.4% 7 15.4% 13.2% 9.7% 8 10.5% 7.3% 12.5% 9 8.6% 10.0% 10.6% 10+ 27.3% 23.0% 34.0% Average HH size 7.8 7.8 8.8 4 Household head education N=387 N=509 N=361 No education 47% 44.0% 59.8% Primary (Class 1-5) 11.90% 16.1% 15.0% Middle (Class 6-8) 7.20% 11.4% 3.3% Secondary (Class 9-10) 15% 13.4% 9.4% Intermediate (Class 11-12) 13.40% 10.8% 7.2% Tertiary education 5.20% 4.3% 3.6% Other 0.30% 0 1.7% 5 Primary income of the household N=387 N=507 N=361 Agriculture (Fishing, Livestock, crop) 30.0% 28.6% 46.8% Trading/Business 2.6% 6.7% 6.6% Salaried (private/government/ 19.6% 15.6% 8.6% Unskilled Wage labour (Agriculture/non-Agri) 41.3% 43.6% 11.1% Handicraft 0.5% 1.2% 7.8% Remittance – family support from outside Pakistan) 0.0% 2.4% 2.8% Support (zakat, family, social welfare) 0.0% 1.8% 1.1% Others 5.9% 0.2% 15.2% 6 The major source of main staple food for the HH N=385 N=508 N=361 Purchase 99.5% 96.1% 78.4% Own production 0.3% 3.0% 4.4% Relief food 0.3% 0.2% 0% Food loans 0 0.4% 15.8% Food gift from family or neighbors 0 0.4% 1.1% Others 0 9.6% 0.3% 7 Household owned livestock/other farm animals, or poultry N=383 N=509 N=360 Yes 87.2% 43.8% 56.4% Household own any land that can be used for agriculture N=384 N=510 N=361 Yes 34.1% 9.6% 35.2% 8 If owned livestock, which type of animals do have? N=334 N=223 N=203 Small animal – Sheep or goat 95.7% 71.8% 77.5% Large Animals - cattle , Buffalo, camel 67.8% 55.6% 91.0% Poultry/chicken- 13.3% 14.3% 68.3%

Table 4.6.2: Maternal questionnaire on IYCF No Question Answer Tharparkar Sanghar Kamber 1 Maternal education N=382 N=508 N=361 No education 91.6% 68.3% 82.5% Primary (Class 1-5) 3.4% 15.7% 10.8% Middle (Class 6-8) 1.6% 5.3% 2.2% Secondary (Class 9-10) 2.4% 6.1% 2.8% Intermediate (Class 11-12) 0.3% 3.5% 1.4% Tertiary education 0.3% 1.0% 0.3% Other 0.5% 0 0% N=373 N=501 N=361 Do you know how long after delivery Within one hour 29.8% 33.7% 36.3% 2 should a mother initiate Between 1 and 23 hours 47.7% 44.9% 36.6% breastfeeding for the new-born? After 24 hours 20.9% 21.2% 23.5% Don’t know 1.6% 0.2% 3.6% N=376 N=503 N=361 What did you do with the first milk 3 Discard /remove / 64.9% 23.9% 23.3% yellowish colour of breast milk 75.5% 75.6% (colostrum) Given to the child 32.2% Don’t know 2.9% 0.4% 1.1% N=237 N=130 N=84 It is dirty 84.0% 65.4% 61.9% If the colostrum was throw away or Harmful to the baby 8.4% 20.0% 20.2% 4 discard, what was the reason? Advice from elders/in-law 4.6% 11.5% 15.5% It is tradition 2.5% 2.3% 1.2% Other 0.4% 0.8% 1.2% N=376 N=510 N=358 For how long (up to what age) do Before 4 months 33.2% 20.8% 46.0% 5 you think a child should feed only 4 to 5 months 22.6% 24.9% 20.4% breast milk (even no water)? 6 months 27.1% 44.7% 31.0% After six months 17.0% 9.6% 2.5% N=375 N=510 N=361 Besides breast milk, at what age do Before 4 months 6.7% 14.9% 8.4% 6 you think, it is best to start giving Between 4 to 5 months 27.5% 22.2% 20.2% soft, semi-solid or foods in addition Between 6 to 8 months 49.6% 57.1% 59.6% breast milk to children? After 9 months 16.3% 5.9% 11.9% Have you ever received any counselling or advice regarding BF? N=377 N=489 N=350 7 Yes 28.4% 57.3% 66.0% N=107 N=280 N=231 Health facility staff 0 15.4% 75.0% If you received counselling or advice Leady health workers 28.1% 47.9% 35.4% on breastfeeding, from whom do 8 CMAM staff (NGO staff) 25.5% 5.7% 6.1% you get the information about TTBA 61.3% 1.1% 2.1% breastfeeding? Media (radio, TV, newspaper, ) 2.4% 5.7% 45.3% Family (husband/ in-low) 0 22.9% 72.4% Friends/neighbors 0 0.7% 23,7%

Table 4.6.3: Hygiene and Sanitation No Characteristics/Variable Tharparkar Sanghar Kamber Main source of drinking water for household? N=385 N=509 N=361 Piped water into dwelling/yard/plot 1.3% 11.2% 18.6% Public tap/standpipe (piped) 4.7% 2.0% 12.7% Tubewell/borehole/hand pump 12.5% 69.9% 54.6% Protected dug well with hand pump 45.5% 7.3% 3.3% Protected spring/karez 0% 0.2% 0.6% Rainwater collection from roof 1.8% 0.0% 0.0% Open, Uncover well 31.7% 0.4% 0.0% Surface water (river/dam/ pond/stream/irrigation channels). 0.5% 9.0% 5.3% Other sources 2.1% 0.0% 5.0% What do you usually do to the water to make it safer to drink? N=385 N=504 N=361 Drink without any treatment 55.6% 82.9% 98.1% Boil 0% 4.8% 0.3% Add Bleach/chlorine 1.0% 2.4% 0.0% Strained through cloth 43.4% 9.3% 1.7% Other 0% 0.6% 0.0% Type of toilet used by the HH N=384 N=506 N=353 Connected flush toilet 6.3% 36.0% 26.6% Toilet – simple dry covered pit. 3.4% 18.4% 24.6% Toilet – uncovered pit 11.5% 8.7% 22.4% Outdoors in the open air 78.4% 37% 26.3% How do you dispose the garbage Disposal N=382 N=503 N=285 Collector 3.4% 11.5% 1.4% Dumping in rubbish pit 2.1% 13.5% 1.4% Burning 38.2% 13.5% 10.9% Throws in the street 56.3% 60.4% 86.3% When do you usually wash your hands with soap? N=306 N=510 After using toilet 47.1% 62.4% 95.3% Before eating. 39.1% 53.7% 84.4% Before food preparation 33.3% 50.5% 79.7% After changing diapers or cleaning up a child who has defecated 11.3% 52.7% 63.4% Before feeding the child 12.9% 40.8% 38.9% After touching an animal, animal feed, or animal waste 14.7% 34.5% 51.7% Households with any soap (confirmed)? N=374 N=510 N=361 Yes 48.7% 76.1% 80.6% What do you think is the possible cause of diarrhea N=227 N=510 Unclean Water 96.9% 24.1% 53.8% Unclean Food 89.4% 74.5% 86.3% Unclean house/environment 20.3% 30.0% 70.9% Teething 40.9% 21.8% 19.6% spiritual/evil eye 2.9% 1.4% 6.1%

5. Discussion

5.1 Nutritional status Children whose weight-for-height is below minus two standard deviation (-2SD) from the median of the reference population are considered wasted while those who measure below minus three standard deviation (-3SD) from the median of the reference population are considered severely wasted. Global acute malnutrition (GAM) is defined as weight for height < -2 Z-scores and or Oedema. Severe acute malnutrition (SAM) is defined as weight for height < -3 Z-scores and or Oedema. The nutritional status was calculated based on the WHO 2006 reference population. Results based on the NCHS 1977 reference are attached in appendix).

5.1.1 Acute malnutrition (6 to 59 months) The surveys found GAM prevalence of 22.7% in Tharparkar, 16.0% in Sanghar, and 13.8% in Kamber Shahdadkot. According to World Health Organization (WHO) classification of severity of acute malnutrition in a community, the rate for Tharparkar and Sanghar is classify as critical whereas for Kamber Shehdadkot it is under the classification of serious2. Even though there is no agreed threshold for severe acute malnutrition, the rate of SAM in all the three districts was very high; Tharparkar 6.4%, Sanghar 4.3% and Kamber Shahdadkot 4.4 percent. There were no children with oedema. The statistical test showed that in all three surveys there was no significant statistical difference between boys and girls. However, in all three districts the level of acute malnutrition was disproportionately higher among the younger age groups (6-23 months) compared to those above 24 months (p value Tharparkar 0.044, Sanghar 0.001 and Kamber 0.007).

The strength of association between potential risk factors and nutritional status was estimated using odds ratio, and 95% confidence intervals (CI) were used to judge the statistical significant for associations. In Tharparkar and Sanghar, wasting was positively associated with morbidity. In Tharparkar, Children who had diarrhea and fever two weeks prior to survey had a greater risk of being malnourished than those who were not sick (Odds ratio (OR) 2.35 (1.39-3.96 95% CI), and 1.58 (1.074 – 2.35% CI) respectively. In Sanghar wasting was associated with only Diarrhea (OR 2.43 95% CI 1.43 – 4.13). Malnutrition starts either with the failure of an individual to acquire enough food to eat, or with ill health. Illness and malnutrition are closely linked.

The statistical test also revealed that in Tharparkar low maternal MUAC were positively associated with acute malnutrition (OR 2.15 95% C.I 1.36 – 3.39). Mothers who were malnourished (MUAC <21cm), were more likely to have acutely malnourished children, and there are many potential reasons for this association. On the other hand, in Sanghar maternal education was negatively associated with wasting (OR 0.52 95% C.I 0.28 – 0.99).

Findings Relative to previous Nutrition surveys In order to further understand the situation in regards to the current prevalence of acute malnutrition in the three districts, it is important to compare these results with the previous surveys conducted in the same area. However, there have not been anthropometric surveys done in the three districts. As a result it was difficult to make trend analysis. However, comparisons was made with surveys conducted in the Sindh in 2013. During this period total of six SMART nutrition surveys were conducted in the following districts; Thatta, Badin, TMK, Dadu, Shikarpur and Kashmore. These surveys were conducted at different tome; one in July, three in November and the two in December).

2 WHO (2000). The Management of Nutrition in Major Emergencies. The classification is as follow; <5% acceptable, 5-9% poor, 10-14% serious, and >=15% critical. 21

The current three surveys were conducted in March 2014. So, given the seasonal variation, comparison of these survey results is not technically feasible. However, it might give rough insight. As it is shown below, the situation of acute malnutrition in the whole province is very widespread.

50.0% 45.0% 40.0% SMART Nutrition Surveys in Sindh (July 2013 - March 2014)

35.0% SAM GAM 30.0% 25.0% 20.0% 22.1% 22.7% 15.0% 19.4% 18.5% 16.0% 13.8% 10.0% 12.20% 12.6% 13.5% 5.0% 5.8% 5.6% 5.1% 1.8% 7.2% 3.0% 6.4% 4.3% 4.4% 0.0%

5.1.2 Chronic Malnutrition (6 to 59 months) Sindh province has the highest stunting rate in the country. Over half (56.7%)3 of children are stunted and according to WHO classification, the prevalence of stunting is “very high”4. Stunting is attributable to many factors. Stunting is a good indicator of a nation’s level of socioeconomic development. This is why stunting is used as an outcome indicator in poverty reduction strategy papers. The level of stunting found in the current surveys; Tharparkar, Sanghar and Kamber Shehdadkot is 45.9, 53.4 and 48.4 percent respectively which is categorized under the WHO classification of “very high”. Statistical analysis found that there was no a significant difference between boys and girls and across all age groups.

5.2 Mortality In Tharparkar and Sanghar, both the Crude (CMR) and Under-five Mortality Rates (U5MR) were almost within the acceptable range for South Asia region5. The CMR and U5MR for Tharparkar was 0.2 and 0.9 respectively whereas in Sanghar CMR was 0.22 and U5MR 0.64 /10,000 people/day. However, the CMR and U5MR in Kamber was 0.45 and 2.45 deaths/10,000 people/day which was above emergency threshold levels of the region. According to the respondent’s confirmation, the main causes of under five deaths in Kamber Shehdadkot were fever (21%), measles (14%), malaria (7%), diarrhea (7%), unknown (29%), and others (21%).

3 Pakistan DHS 2012-13 4 WHO. Physical Status: The use and interpretation of anthropometry, WHO Technical Report Series. 1995. According to the technical report; <20% low, 20-29% medium, 30-39% high, >=40 very high. 5 SPHERE 2011. The emergency baseline reference mortality for South Asia; CMR 0.4 and U5MR 0.9 22

5.3 Morbidity and coverage public health intervention 5.3.1 Morbidity Two weeks period morbidity prevalence shows 43.5 percent of children in Tharparkar, 49.7% in Sanghar and 34.8% were reported to be recently sick. As it is shown in section 5.4, the most common reported illness according to the rank were fever, cough, and diarrhea. Measles cases were reported in all three districts; Tharparkar 3.6%, Sanghar 24.6% and Kamber 4.1 percent. All the reported cases were based on maternal perception of the illness. The reported illness were not validated by medical personnel. So, it is likely that there was over reporting of illness. As a result it was difficult to interpret morbidity results confidently. As it is stated in the previous section of 6.1, there was association between morbidity (diarrhea and fever) with wasting. The prevalence of illness was not uniform across all age groups being higher with 6-23 months age groups than the older 24-59 months. The statistical analysis showed that significant difference among the age groups in the prevalence of diarrhea (Tharparkar X2=14.0, p-value=0.000; Sanghar X2=11.4, p- value=0.000; Kamber X2=53.3, p-value =0.000), Fever (Tharparkar X2= 5.27, p-value=0.02; Kamber X2=22.26, p-value =0.000), and cough (Kamber X2=14.2, p-value =0.000). The younger age groups are more vulnerable as they are mobile and pick up dirty objects exposing themselves to disease.

5.3.2 Vitamin A supplementation As per the WHO recommendation, children under 5 years of age should be supplemented twice a year with vitamin A. Vitamin A is an essential micronutrient for proper functioning of the immune system and also for eyesight. Supplementation of vitamin A capsule is one of the main strategies that have been adapted globally. The national Vitamin A supplementation coverage (2012) is 99%6. However, the current assessment found 68.8 percent of children in Tharparkar, 85.3 in Sanghar and 64.5 percent in Kamber Shehdadkot were received Vitamin A supplementation.

5.3.3 Measles and BCG Vaccination In order to determine vaccination coverage, information on BCG and measles vaccinations was collected via vaccination card, maternal recall (if the card was lost), and scar (BCG). The assessment found that BCG vaccination coverage in Tharparkar at 51.9%, Sanghar 80.8% and Kamber 73.5 percent. The coverage for measles (9 to 59 months) confirmed by card was 35% in Tharparkar, 77.5% in Sanghar and 35.9 percent in Kamber. The national coverage for Measles and BCG is 83 and 87 percent respectively7.

5.4 Water, sanitation and Hygiene (WASH) Access to improved water supply and sanitation facilities is the one of the powerful public health interventions in preventing morbidity particularly diarrhea. Research has shown that Improved water sources reduce diarrhea morbidity by 21%; improved sanitation reduces diarrhea morbidity by 37.5%; and the simple act of washing hands at critical times can reduce the number of diarrhea cases by as much as 35%8. According WHO and UNICEF joint monitoring for water and sanitation, an improved water source is defined as water that is supplied through a household connection, public standpipe, borehole well, protected dug well, protected spring, or rainwater collection.

6 Accessed from UNICEF website on May 11/2014 http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html 7 Ibid 8 CDC- http://www.cdc.gov/healthywater/global/wash_statistics.html access on 15th of May 2014 23

The most common source of drinking water in urban areas is a tube well/borehole/hand pump (Sanghar 69.9% and Kamber 54.6%) followed by piped water into dwelling/yard/plot (Sanghar 11.2% and Kamber 18.6%).. The sanitation situation was found to be poor. Nearly 90 percent in Tharparkar and about half of the households in Sanghar and Kamber have no improve toilet facility. About 78 percent of the population in Tharparkar, 37% in Sanghar and 26 percent in Kamber were using open field for defecation. In all three survey districts, majority of the population dispose the garbage in the street (Tharparkar 56.3%, Sanghar 60.4% and Kamber 86.3%). Hand washing practices with soap is not common particularly in Tharparkar district. About 47 percent of respondents in Tharparkar, 62% in Sanghar and 95% in Kamber wash their hands after using a toilet. About 39 percent in Tharparkar, 54% in Sanghar, and 85% in Kamber use soap before eating. About 33 percent in Tharparkar, 51 percent in Sanghar, and 80 percent in Kamber use soap before food preparation.

5.5 Household Food security Information regarding household income, sources of staple food, livestock and land ownership was collected. The survey finding indicated that the main source of income for Tharparkar and Sanghar was unskilled wage labour, 41.3% and 43.6% respectively whereas for Kamber Shahdadkot the primary sources was from farming/agriculture (46.8%). The main sources of staple food in Tharparkar, Sanghar and Kamber was 99.5%, 96.1% and 78.4% respectively. This assessment was conducted about three month after rice harvest and one months before wheat harvest. The hunger season usually starts around August and goes up to mid-October. Thirty-four percent of households in Tharparkar, nine percent in Sanghar and thirty-five percent in Kamber own agricultural land. About 87% of households in Tharparkar, 44% in Sanghar and 56% in Kamber own farm animals; small animals (sheep, goat), large animals (cattle, buffalo, camel) and chickens.

6. Recommendations and priorities

7. APPENDICES 7.1 Assignment of clusters

Table 7.1.1 Sanghar District Clusters Cluster Place of catchment area Union Council Taluka Number 1 B-14 Housing Society Sanghar Sanghar-II 2 Vill.Darya Khan Chandio Kandiari 3 Vill.Chak-1 Khadwari 4 Vill.Chak-9-B Gujri 5 Vill. Mazhar Mari Sethar Pir 6 Vill.Rakhyal Rajar Chotiaryoon Sanghar 7 Vill.Jaffar Khan Lighari Jaffar Khan Lighari 8 Ward-1 Khadro Khadro 9 Vill.Sahib Khan Rind Khadro 10 Vill.Suleman Chang Shah Mardanabad 11 Vill.Allah Dad Palh Pritamabad 12 Chakki Para Shahdadpur Shahdadpur-I 13 Mohammad Bux Colony Shahdadpur-II 14 Mustafa Colony Shahdadpur Shahdadpur-III 15 Bismillah Town Shahdadpur-IV 16 Vill.Bachal Bodani Jatia 17 Vill.Jan Mohammad Birohi Shahpurchakar Shahdadpur 18 Jamali Muhalla Sarhari Sarhari 19 Vill.Maqsoodo Rind Lundo 20 Vill.Maroof Dahri S.F.Hingoro 21 Vill.Nachayo Bhanojo Asgharabad 22 Vill.Chanessar Bagrani Maldasi 23 Khatti Para Tando Adam Tando Adam-I 24 Juman Shah Road Tando Adam Tando Adam-II 25 Joharabad Tadno Adam Tando Adam-IV Tando Adam 26 Vill.Haji Pir Bux Hingoro Mir Hassan Mari 27 Vill.Kumb Darhoon Kumb Darhoon 28 Bhittai Colony Khipro Khipro 29 Vill.Qazi Mubeen Dars Roonjho 30 Vill.Majeed Khaskheli Roonjho 31 Vill.M.Sharif Samejo Khahi Khipro 32 Vill.Haji Ali Samoon Khori 33 Vill.Lakhoo Tajiyo Bilawal Hingorjo 34 Vill.Naley Chango Hingoro Qazi Faiz M.Rajar 35 Vill.Haji Jian Faqir Hingorjo Dhilyar

Table 7.1.2 Tharparkar District Name of Cluster Village Name of UC 1 Sahiyaro Chelhar 2 Mevo rind Kantio 3 Jhanjhi Rajoro 4 Bhunio Ssaranghiar 5 Tar Dos Tar Dos 6 Jatrar Tar Ahmed 7 Jumoon Dhani Mithrio Charan 8 Kamanhar Kheensar 9 Ramlani Lapolo 10 Pirbhe Jo Par Pirane Jo Par 11 Sakree Dahli 12 Shabik Jee Veri Gadhro 13 Sanurani Jase Jo Par 14 Gadhro Pethapur 15 Ghartiyari Nagarparkar 16 Pano Jee Veri Harho 17 Ramsar Veerwah 18 Piaro Dal Sati Dera Matheno 19 Bajeer Peeloo Malanhore 20 Veena Malanhor Vina Janjhno 21 Menghwar Mohrano 22 Leyari Joruo 23 Chownhar Bhakuo 24 Noora Tal Mainthee Khankhaniyar 25 Raham Islamkot 26 Joglar Sonal Bah Meenhoon 27 lanjo Seengaro 28 Mole Jo Tar Khario G.Shah 29 Khorooro Aarokhee 30 Konral Jhimiryo 31 Dago Seengalo 32 Kaloi Kaloi 33 Otaq Memon Kaloi 34 Hajamro Khetlari 35 U.C Mihi Town

Table 7.1.3 Kamber Shahdadkhot clusters

NAME OF VILLEGES Name of Union Councils Name of Taluka Cluster number 1 JAKHAR KHANDU Warah 2 MUHAMMAD HASHIM CHHUTTO ABAD Warah 3 QAIM KHAN MUGHERI LALU RAUNK Warah 4 KHATAN KHAN MUGHERI WAGAN Warah 5 GAZI MURKHAND GAJI KHUHAWAR=16 Warah 6 RAISE JAHAN KHAN CHANDIO MIR PUR Warah 7 ARZI DEPAR MIANDAD CHINJI Nasirabad 8 WAZIR MALANO LAKHA Nasirabad 9 MIANI RAWAL (MIANI MUGHERI) KHAIR PUR JUSO Nasirabad 10 BHAWANDO LAKHO KAMBAR 1-2 Kambar 11 BER BER Kambar 12 CHUNDIA KALHORA BER Kambar 13 KHAMISO KHAN BROHI KALAR Kambar 14 HJI GHULAM HUSSAIN BOOHAR Kambar 15 CHHATANIN JO GOTH RANWATI Kambar 16 ESSO JIAN ABRO Kambar 17 MUJAWARAN JO GOTH JIAN ABRO Kambar 18 SHAKAL JI WAHI GAIBI DERO Kambar 19 NAO GOTH SIJAWAL Sijawal 20 MOHD HASSAN MASTOI MASTOI Sijawal 21 ARZ MOHD GADRO`S HOUSED MASTOI Sijawal 22 BAHADUR BHAND DHIGANO MAHESSAR Sijawal 23 TILLAN JATOI DHIGANO MAHESSAR Sijawal 24 LASHAKAR KHAN CHANDIO THUF CHOSOOL Sijawal 25 QADIR BUX CHANDIO THUF CHOSOOL Sijawal 26 QAMARUDDIN GOPANG MIROKHAN Miro Khan 27 MIRAN MUGHERI BAHRAM HATHION Miro Khan 28 ALI MOHMAD AHIR BAHRAM HATHION Miro Khan 29 DALIL BURIRO KARIRA Miro Khan 30 KHIRO GADAHI KALHORA Miro Khan 31 CHAJRI KALHORA Miro Khan 32 MIR JE NARI SILRA Shahdad Kot 33 MOLVI SHAKARUDIN (ARAKN) AITBAR KHAN CHANDIO Shahdad Kot 34 MOHD ALAM BHURGERI JAMALI Shahdad Kot 35 PATHAN BURIRO BAGO DARO Qubo Saeed Khan

7.2 Questionnaires

SMART NUTRITION SURVEY, SINDH March 2014 HOUSEHOLD QUESTIONAIRE

Section 1: Identification s

1 District ______4 Village: ______7 Date of Survey: ______2 Taluka: ______5 Cluster Number: ______8 Household Number: ______3 UC: ______6 Team Number: ______m Section 1: Household Characteristics 1 Male 9 What sex is the head of the household? 2 Female 1 Married 2 Divorced Marital status of household head 10 3 Widow

4 Separated 5 others 11 Number of household members (HH size including head) /______/ 1 No formal schooling پرایمری ,(Education level of the head of the 2 Primary level (Grade 1 to 5 مڈل ,(household 3 Middle Level (Grad 5-8 grade ہائی (secondary ( Grade 9-10, SSC 4 گھر کے سربراہ کی تعلیمی معیار کیا ہے؟ 12 5 Intermediate (grade 11-12, HSSC) 6 Higher education and above 7 Other (specify) ______O

Section 2: Household Food security 1 Agriculture/farming (Fishing, Livestock, crop) 2 Trading/Business 3 Salaried employee What is the primary source of income of the 4 Unskilled Wage labour (Agriculture/non-Agri) 13 household? (Only one Major economic activity)? 5 Handicraft 6 Remittance – family support from outside Pakistan 7 Support (zakat, family, social welfare) 8 Other -Specify Yes 14 Does this household own any livestock, herds, other farm animals, or poultry? If no go to Q16 No Q15A Small animal – Sheep or goat Yes No If Q14 yes, which of the following animals 15 does this household own? Q15B Large Animals - cattle , Buffalo, camel Yes No Q15C Poultry/chicken- Yes No Does this household own any land that can be used for agriculture? 1 Yes 16 0 No 1 Purchase 2 Own production At this time, What is the major source of your main staple food for 3 Relief food 17 the household? 4 Food loans

5 Food gift from family or neighbors 6 Others

Section 3: Hygiene and Sanitation پانی کی پائپ الئن Piped water into dwelling/yard/plot 1 سرکاری نلکا (Public tap/standpipe (piped 2 ہینڈ پمپ, ٹیوب ویل , ڈھکا ہوا کنواں , چشمہTubewell/borehole/hand pump 3 کھال ہوا کنواں, کھال چشمہ What is the main source of 4 Protected dug well with hand pump drinking water for members of 5 Protected spring/karez 18 your household? Rainwater collection from roof 6 آپ کے گھرانے میں پینے کے پانی کا Open, Uncover well 7 ذریعہ کیا ہے؟ دریا ، نہر .(Surface water (river/dam/ pond/stream/irrigation channels 8 ، تاالب ،آبی ذرائع دیگر )وضاحت کریں.……… Other – specify 9 1 Drink without any treatment 2 Boil What do you usually do to the water to 3 Add Bleach/chlorine 19 make it safer to drink? 4 Strained through cloth

5 Use water filter (Ceramic, sand or other filter) 6 Other (specify) ------فلش Connected flush toilet 1 گڑھا لٹرین .Type of toilet used by the HH 2 Toilet – simple dry covered pit Toilet – uncovered pit 3 آپ کے گھرانے میں کس قسم کی بیت الخال ئ کی سہولت 20 کوئی سہولت نہیں ، جھاڑی دار کھیت Outdoors in the open air 4 موجود ہے؟ 5 Others - Specify 1 Collector 2 Dumping in rubbish pit

21 3 Burning How do you dispose the garbage Disposal 4 Throws in the street

5 Others – specify 22a After using toilet Yes No When do you 22b Before eating. Yes No usually wash your hands with soap? 22c Before food preparation Yes No 22 22d After changing diapers or cleaning up a child who has defecated Yes No (More than one 22e Before feeding the child Yes No answer possible) 22f After touching an animal, animal feed, or animal waste Yes No

22g Any other - specify 1 Yes 23 Is there any soap in the household for hand washing? (Ask to see it) 0 No 24a Unclean Water Yes No What do you think is the possible cause of diarrhoea? 24b Unclean Food Yes No , 24c Unclean house/environment Yes No 24 (More than one answer possible) 24d Teething Yes No

24e spiritual/evil eye Yes No 24f Others:______

N 30

Section 4: IYCF – Maternal Knowledge and Practice 1 No formal schooling 2 Primary level (Grade 1 to 5), Education level of mother of the 3 Middle Level (Grad 5-8 grade), 25 child or primary care giver 4 secondary ( Grade 9-10, SSC) 5 Intermediate (grade 11-12, HSSC) 6 Higher education and above 7 Other (specify) ______Do you know how long after delivery 1 Within one hour should a mother initiate breastfeeding 2 Between 1 and 23 hours 26 for the newborn? 3 More than 24 hours 4 Don’t know 1 Discard /remove /throw away If given to the child What did you do with the first milk yellowish 27 2 Given to the child go to 29 color of breast milk (colostrum 3 Don’t know 1 It is dirty If the colostrum was throw away or discard, what was 2 Harmful to the baby, cause sick 28 the reason? 3 Advice from elders/in-law/peer 4 It is tradition 5 Other specify ______

For how long (up to what age) do you think a mother should breastfed 29 ------months her child only breast milk (even no water)? (if less than one months, write 0) In addition to breast milk, at what age do you think, it is best to start 30 giving soft, semi-solid or foods? ------Month (if less than I month, write “0”. 1 Yes 31 Have you ever received any information or advice about breastfeeding? 2 No 1 Health facility staff (BHU, RHC, MCHC, Hospital) Yes No 2 Leady health workers Yes No If you received counseling or advice on 3 Nutrition CMAM staff (NGO staff) Yes No breastfeeding, from whom do you get the 4 Trained Traditional birth attendants Yes No 32 information about breastfeeding? (multiple 5 Media (radio, TV, newspaper, ) Yes No option) 6 Family (husband/ parent/in-low) Yes No 7 Friends/neighbours Yes No 8 Other (specify): ______

MORTALITY DATA QUESTIONNAIRE March 2014 District: ______Taluka: ______, UC Name: ______Village: ______Cluster number:_____ Team No: ____

Total Family Family New household member member births

Members joined who left between Death Causes of deaths HH between between December between December 5 Remark December 5 December 5 5 2013 to 2013 to March موت کے وجوھات to 2013 to March 5/2014 (between 2013 March March 5/2014 2013 Topi Ajkrak to 5/2014 5/2014 (between 5th 00 دن میں کوئی فوتگی ہو between (between 2013 Topi) 2013 Topi 2013 Topi Ajkrak to ئی ہے Ajkrak to 5th Ajkrak to 00 دن 5th March 5th میں کوئی 00 دن March 00 دن میں پیدائش ہوئی میں کسی نے کوئی شامل ہوا ہے چھوڑا ہے ہے

Causes Cause of Total < 5 Total < 5 Total < 5 Total U5 Deaths of U5 death >5 death Code 1-10 Code 1-10 1

2 3 4 5 6 7 8 7  10 11 12 13 14 15

Tota l

Note: If there is more than one death, please detail the cause of each death under “Cause”. 1. Diarrhea 6. Malnutrition 2. Measles 7. Accident 3. Malaria 8. Conflict 4. Fever 9. Unknown 5. ARI – coughing/breathing difficulty 10. Others (specify)

ANTHROPOMETRIC, MORBIDITY, VACCINATION and IYCF District: ___ Taluka: ______UC: ______Village Name:___ Cluster Number __

Survey Date :_____ Team Number: __ Team Leader Name: ______

IYCF Vaccinati was the child ill since children 6-23 Maternal Nutrition and

on last two weeks months Education

5 = 1, 5

o =0, Yes = 1 o = Yes =0,

59 months)**

Mother MUAC Mother

12 =4 higher, =5) higher, =4 12

Q22

o =0, Yes = 1, DK=8) 1, =0, = o Yes

(No =0, Yes = 1, = (NoYes DK=8) =0,

Q18

not vaccinated, 8= don't know 8=not don't vaccinated,

Fever (No =0, Yes = 1, = Yes DK=8) =0, Fever (No Other

Measles (N0=0, Measles DK=*) Yes=1,

Cough Cough (N

Diarrea illnes

Q15

BCG mark (No =0, Yes = 1, DK=8) 1, =0, = BCG mark (No Yes

Q17

Q16 s

10 =3, Class 11 =3, 10

Q14

(Never attended =0, class1 (Never =0, attended (writ -

Q13

Measles vaccination (age 9 vaccination (age Measles

(No DK=8) 1, =0, = Yes down No=0, Yes=1 Q12 )

(N0=0, DK=8) Yes=1,

8 =2, 9 8Class

is the child currently still on breastfed? onN breastfed? still child currently is the

Q8 Q21

if the child was sick, did he/she visit Health facility Health visit facility he/she sick, did was if child the

Class 6

What is the highest level of school the mother attended? attended? of mother school the highest level theWhatis

Q Q3 Q5 Q6 Q7 Heig

Vitamin A supplementation in the last six months (Show mother capsule) months in (Show last six mother the Vitamin A supplementation

Q1 2 Chil Q4 Date of Age Weig ht Q9

Q19

Q23

Has this child ever been breast fed at any time in his/her life? his/her timebreast at in fed ever beenany child Has this

Chil H d Sex birth in ht (cm) Oedem Q10

(1= Yes confirmed from card, 2= yes mother confirmation/no card, 3 yes mother = confirmedcard, card, (1=2= Yes confirmation/no from d H Nam (F/M (dd/mm/y month (kg) ±0.1 a MUA Q11

No. No e ) y) s ±100g cm (Y/N) C Q20



Diarrhea - is defined any episode of more than 3 stools in 24 hours (it can be bloody or not). Measles - is can be manifested as fever, rash or red eyes Cough - includes difficulty breathing; Fever - is elevated body temperature;