Dr. Ok Amry, Dr. Lioba Weingärtner Nutrition Baseline Survey Cambodia For the Global Programme Food and Nutrition Security, Enhanced Resilience July 2016

Published by Global Programme Food and Nutrition Security, Enhanced Resilience

II Global Programme Food and Nutrition Security, Enhanced Resilience

Table of content

Annex...... IV Abbreviations...... V List of Tables...... VI Introduction...... VII Acknowledgements by the Authors...... VIII

1. EXECUTIVE SUMMARY...... 1

2. BACKGROUND AND OBJECTIVES...... 2 2.1. Country Context...... 2 2.2. Specific Project Information – the MUSEFO project...... 4 2.3. Objectives of the Nutrition Baseline Survey...... 6

3. METHODS...... 7 3.1. Project Area, Participants and Sample Size...... 7 3.2. Sampling procedure...... 8 3.3. Data collection ...... 10 3.4. Indicators...... 10 3.5. Data Analysis ...... 13

4. RESULTS...... 14 4.1. Socio demographic information ...... 15 4.2. Agriculture ...... 16 4.3. Household food insecurity ...... 21 4.4. Water, Sanitation and Hygiene ...... 22 4.5. Diarrhea...... 25 4.6. Knowledge, attitude and practice in regard to health aspects ...... 25 4.7. Knowledge, attitudes and practices regarding complementary feeding ...... 26 4.8. Nutrition Counselling ...... 30 4.9. Dietary diversity of women 15-49 years...... 31 4.10. Information on children aged 6-23 months ...... 33 4.11. Dietary diversity of children aged 6-23 months...... 33

5. CONCLUSIONS & RECOMMENDATIONS ...... 36

6. REFERENCES ...... 41

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Annex

A. List of selected villages...... 42 B. Selection of clusters proportional to population size...... 43 C. Overview of interventions in Kampot and Kampong Thom, Cambodia, under the Global Programme...... 44 D. Training Agenda of NBS Enumerator Training ...... 46 E. Nutrition Baseline Survey Interview Guide - Cambodia...... 48 F. Quality Control Protocol for Interviewer...... 51 G. Distribution of Household size...... 52 H. Individual Dietary Diversity Score – Women (IDDS-W)...... 52 I. Food Group Score – Women...... 52 J. Individual Dietary Diversity Score – all children 6-23 months...... 53 K. Individual Dietary Diversity Score – breastfed children 6-23 months...... 53 L. Individual Dietary Diversity Score – non-breastfed children 6-23 months...... 53 M. Feeding Frequency – children 6-23 months...... 54 N. Questionnaire...... 55 O. Results disaggregated by provinces...... 68 P. Number of Vegetable Grown ...... 96 Q. Number of Fruit Trees Grown ...... 96 R. Number of Farm Animals/livestock/other Aquatic Animals Reared...... 97 S. UNICEF Model ...... 98

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Abbreviations

BCC Behavioral Change Communication BMZ Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung Federal Ministry for Economic Cooperation and Development CDHS Cambodia Demographic and Health Survey FANTA Food and Nutrition Technical Assistance FAO Food and Agriculture Organization of the United Nations GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit IDDS-C Individual Dietary Diversity Score for Children IDDS-W Individual Dietary Diversity Score for Women IEC Information, Education, Communication IYCF Infant And Young Child Feeding KAP Knowledge, Attitudes, Practice MAD Minimum Acceptable Diet Md Median MMD Minimum Dietary Diversity MMF Minimum Meal Frequency MOH Ministry of Health MUSEFO Multisectoral Food and Nutrition Security NGO Non-Governmental Organization NIS National Institute of Statistics SD Standard Deviation SEWOH Sonderinitiative “Eine Welt ohne Hunger” Special Initiative “ONE WORLD – No Hunger” SPSS Statistical Package For Social Sciences UNICEF United Nations Children’s Fund WASH Water, Sanitation, and Hygiene WHO World Health Organization of the United Nations

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List of Tables

Table 1: Sample Size calculation for SEWOH NBS...... 8 Table 2: Estimations for NBS...... 8 Table 3: Excerpt of series of generated numbers (Completed list in Annex B)...... 9 Table 4: Overview of collected information and assessment instruments...... 10 Table 5: Food groups for 10 food group score with respective Cambodian food items ...... 11 Table 6: Food groups for 7 food group score with respective Cambodian food items...... 12 Table 7: Marital Status of respondents overall and by district...... 15 Table 8: Educational level of respondents...... 15 Table 9: Sources of income ...... 16 Table 10: Crop diversity...... 17 Table 11: Home garden and livestock ownership and main use of produces...... 20 Table 12: Households participating in social- / food-security programs...... 21 Table 13: Household Food Insecurity Experience Scale (HFIES)...... 21 Table 14: Categories of Household Food Insecurity Experience Scale (HFIES)...... 22 Table 15: Prevalence of experience of severe household food insecurity...... 22 Table 16: Storage of water...... 23 Table 17: Mentioned treatment of water for safe consumption ...... 23 Table 18: Use of soap for washing hands ...... 25 Table 19: Supporter in taking care of the child (6-23 months)...... 26 Table 20: Mentioned types of food making porridge more nutritious ...... 27 Table 21: Mentioned signs and reasons of malnutrition ...... 28 Table 22: Mentioned ways to prevent malnutrition in young children (6-23 months)...... 29 Table 23: Amount of fluids and food offered during illness...... 29 Table 24: Counselling structure for nutrition in the village...... 30 Table 25: Received nutrition counselling among respondents...... 31 Table 26: Children (6-23 months) achieving MMF, MDD, and MAD ...... 36

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Introduction

Over 800 million people worldwide suffer from hunger and two billion do not meet their micro nutrient requirements (Global Nutrition Report, 2016). While the global starving population has gone down in recent decades, the number of people suffering from hunger in sub-Saharan Africa today is higher than ever. Malnutrition is particularly prevalent in developing countries, where it has an impact not only upon the development prospects of an entire country, but also of each individual affected. If a child does not receive sufficient nutrients up to its second year, i.e. over its first 1,000 days beginning with the early embryonic phase, the impact on growth, mental faculties and therefore learning and work¬ing potential will endure a lifetime.

The German Ministry of Economic Co-operation and Development (BMZ) launched an Initiative “On World – No Hunger” to improve food and nutrition security (https://www.bmz.de/webapps/hunger/index.html#/de). Within this initiative GIZ implements the program “Food and nutrition security, enhanced resilience” in 11 countries in Africa and Asia. The project‘s main target group includes women of childbearing age, pregnant women, breastfeeding mothers and infants. The project‘s objective is to improve the nutritional situation of approximately 880000 women, 235000 young children and 4.000 households. Structural measures to combat hunger and malnutrition, particularly among mothers and young children, are one of the most effective ways of investing in the future of a society.

In order to measure our impact we used standard indica¬tors in line with internationally recognized methods in order to measure whether children (up to 23 months) receive a minimal acceptable diet and women eat more diversified. We conducted so far baselines in Benin, Burkina Faso, Cambodia, Ethiopia, India, Kenya, Mali, Malawi, Togo and Zambia in order to get an overview of the overall food and nutrition situation in the program areas of the respective countries. The baseline studies provided valuable data for intervention planning as well as our monitoring and evaluation system. All baseline studies were conducted in a standardized form and in line with a guideline especially developed for this purpose.

We want to thank all consultants and enumerators, all our partner organizations, FAO, University of Giessen, Bioversity International and last but not least more than 4.000 women who offered their time to answer our questions.

Bonn, September 2016 Michael Lossner

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Acknowledgements by the Authors

We would like to express our sincere gratitude to all people who were involved in this nutrition baseline survey (NBS) of the Multisectoral Food and Nutrition Security (MUSEFO) project. We are thankful for all the efforts and team work of so many people that enabled the accomplishment of this survey.

First and foremost, we would like to express our deepest gratitude to the people in the villages we visited for their hospitality and, in particular, to all the mothers who patiently answered the questionnaires despite having other pressing demands.

Our deepest gratitude goes to the GIZ Cambodia MUSEFO Team Leader, Evi-Kornelia Gruber for her direction and support rendered throughout the planning and execution of the Nutrition Baseline Survey and activities. Our thanks go to Ms. Kreal Dara, National Nutrition Coordinator of the MUSEFO project for her support. Our sincere thanks and appreciation goes to Dr. Ramji Dhakal, Deputy Director, Mr. Khnhel Bora, Executive Director from SBK Research and Development, Cambodia, the executing agency of the NBS, for their technical and logistical support which greatly contributed to the quality of outputs and timely and successful completion of the survey.

We extend our special thanks to Provincial Advisors for Agriculture and Food Security of MUSEFO project for their excellent coordination and support in identifying the sampled villages and households for the survey.

Special thanks go to the team of supervisors and enumerators, who were engaged in the data collection in Kampot and Kampong Thom provinces. Our special thanks go to Boran Altincicek for his technical support with electronic device-based data gathering and quality checks.

Again, thank you all for your support and assistance. We would not have been able to finalize the task without you all.

Dr. Ok Amry, Lead Consultant Dr. Lioba Weingärtner, Coordinator Diploma in Medical Doctor Consultant, Nutritionist [email protected] [email protected]

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1. EXECUTIVE SUMMARY

The MUSEFO project’s Nutrition Baseline Survey (NBS) was conducted among women of reproductive age (15-49 years) with young children between the age of 6-23 months, in Cambodia in March and April 2016. The main objective of this survey was to describe the nutrition situation among the project’s target groups in two selected provinces, namely Kampot and Kampong Thom. Of special interest were Minimum Acceptable Diet (MAD) of young children and Individual Dietary Diversity Score Women (IDDS-W). Further, it aimed to examine linkages between dietary diversity and complementary feeding practices with living conditions as well as with knowledge and practice in regard to nutrition and hygiene.

Figure 1: Summary of results of the NBS according to the UNICEF Mode

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2. BACKGROUND AND OBJECTIVES

2.1. Country Context Cambodia is an agricultural country located in Southeast Asia. It borders with Thailand to the west, Laos and Thailand to the north, the Gulf of Thailand to the southwest, and Vietnam to the east and the south. It has a total land area of 181,035 square kilometers. Cambodia has a tropical climate with two distinct seasons that set the rhythm of rural life. From November to February, the cool, dry northeastern monsoon brings little rain, whereas from May to October the southwestern monsoon carries strong winds, high humidity, and heavy rains. The mean annual temperature for Phnom Penh, the capital city, is 27°C.

Administratively, Cambodia is divided into 24 provinces and the special administrative unit Phnom Penh. Each of Cambodia‘s 24 provinces is divided into Districts. As of 2010, there are 159 districts and 12 districts in Phnom Penh. Districts of a province are divided into communes. Communes are further divided into villages.

The population census in 1998 recorded a population of 11.4 million with an annual growth rate of 2.5 percent (National Institute of Statistics, 1999). The 2004 Inter-Censual Population Survey showed that the annual growth rate had declined to 1.8 percent, with a total population of 13.1 million (National Institute of Statistics, 2004). In 2015, Cambodia had an estimated population of 15.67 million, up from the official 2008 General Population Census of 13.4 million (National Institute of Statistics, 2008).

The proportion of the population living in rural areas is 80.5 percent; only 19.5 percent of the country’s residents live in urban areas. The population density in the country as a whole is 75 per square kilometer. The largest city and capital is Phnom Penh, with a population of 1.4 million, or 2.2 million in the metropolitan area. The next largest city is Battambang, with a population not yet reaching 200,000.

The average size of the Cambodian household is 4.7. The total female to male sex ratio is 94.7. Cambodia has the highest female-biased sex ratio in the region. The literacy rate among adult males is 84 percent, considerably higher than the rate among females (76 percent). Currently, it is estimated that the percentage of the total population living below the poverty line fell to 21.1 percent in 2010 and decreased further to 19.8 percent in 2011 (Ministry of Planning, 2012). 90% of Cambodia‘s population is of Khmer origin, speaking the Khmer language. The population of Cambodia is fairly homogeneous with other ethnic groups being Vietnamese (5%) and Chinese (1%). The demographics of the country are very affected by the civil war and later genocide, and 50% of the population is under 22 years old.

Cambodia is one of the poorest and least developed countries in Asia, with the gross domestic product per capita estimated at approximately 4.4 million Riel or $1,088 in 2014 (US$1 = 4,087 Riel) (International Monetary Fund, 2011). Agriculture, mainly rice production, is still the main economic activity in Cambodia. Small-scale subsistence agriculture, such as fisheries, forestry, and livestock, is another important sector. Garment factories and tourism services are also important components of foreign direct investments.

Health outcomes have improved recently. The infant mortality rate has decreased from 45 per 1,000 live births in 2010 to 27 per 1,000 live births in 2014. The under-5 mortality rate decreased from 54 per 1,000

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live births to 35 per 1,000 live births in the same period. Life expectancy at birth is 67.1 years for males and 70.1 years for females (NIS, 2013). General government expenditures on health per capita increased from US$8 in 2008 to US$11 in 2010, US$13 in 2012, and US$16 in 2014 (MOH, 2015).

Child Nutritional Status

The 2014 Cambodia Demographic and Health Survey (CDHS) shows that overall, 32% of Cambodian children under age 5 are stunted, and 9% are severely stunted. Analysis by age group indicates that stunting is apparent even among children less than age 6 months (16%). In general, stunting increases with the age of the child, rising from 13% among children age 6-8 months to 40% among children age 36-47 months before declining to 36% among children age 48-59 months. There is very little difference in the level of stunting between boys and girls. Stunting is highest when the birth interval is less than 24 months (37%). Children whose mothers are underweight are more likely to be stunted (44%) than children of normal weight mothers (32%). The disparity in stunting prevalence between rural and urban children is substantial: 34% of rural children are stunted, as compared with 24 % of urban children. Variation in the nutritional status of children by province is quite evident, with stunting being highest in Preah Vihear/ Stung Treng (44%) and Kampong Chhnang (43%) and lowest in Phnom Penh (18%). Mother’s education and wealth quintile have an inverse relationship with stunting levels. For example, the prevalence of stunting is higher among children living in the poorest households (42%) than among children in the richest households (19 %).

Ten percent of children under age 5 are wasted, and 2%are severely wasted. There is a substantial correlation between wasting and size at birth. Babies who are very small and small at birth are more likely to be wasted (24 % and 17 %, respectively) than those of average or larger size at birth (9 %). The prevalence of wasting among children of thin mothers (BMI below 18.5) is more than twice that of children whose mothers are either normal weight or overweight/obese. Wasting is higher among rural children than urban children (10 % versus 8 %) and is highest in Takeo and Oddar Meanchey (15 % each). Wasting prevalence varies inconsistently by age of the child and does not differ substantially by sex. It is highest among children whose mothers have no education and those in the lowest two wealth quintiles (CDHS 2014).

Breastfeeding and Supplementation

Exclusive breastfeeding is recommended during the first 6 months of a child’s life. The 2014 CDHS shows that breastfeeding is nearly universal in Cambodia, as 93% of children age 0-5 months are breastfed. The results indicate that breastfeeding continues for the majority of Cambodian children well beyond the first year of life. At age 12-17 months, around 78% of children are still breastfed, and 40 percent of children 18- 23 months continue to be breastfed.

Exclusive breastfeeding is common but not universal in very early infancy in Cambodia. Among infants under age 2 months, 80% received only breast milk. But this proportion declines rapidly among older infants. By age 4-5 months, around two in five babies are receiving supplements, including one in five being given complementary foods. The majority of Cambodian children age 6 months and older are receiving other foods or milk in addition to breast milk (CDHS 2014).

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Children 6-23 who received minimum acceptable diet

A child who is considered to be receiving a minimum acceptable diet (MAD) needs to fulfill all of the following criteria:

• Breast milk; or if not breastfeeding must receive two or more feedings of commercial infant formula and/or fresh, tinned, or powdered animal milk and/or yogurt. • Food from four or more of the following groups: (1) infant formula, milk other than breast milk, cheese or yogurt, or other milk products; (2) foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; (3) vitamin A-rich fruits and vegetables (and red palm oil); (4) other fruits and vegetables; (5) eggs; (6)meat, poultry, fish, and shellfish (and organ meats); and (7) legumes and nuts. • The minimum number of recommended meals per day, according to age and breastfeeding status. For breastfed children, the minimum meal frequency is solid or semisolid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months. For non-breastfed children, the minimum meal frequency is solid or semisolid food or milk at least four times a day for children 6-23 months. • According to the 2014 CDHS, about one in three (30%) of Cambodian children age 6-23 months (breastfed and non-breastfed) receive this minimum acceptable diet.

2.2. Specific Project Information – the MUSEFO project

The Special Initiative ONE WORLD - No Hunger (SEWOH) addresses hunger and malnutrition, an issue that is of uppermost significance in the Post-2015 Development Agenda in the context of Germany’s G7 presidency (https://www.giz.de/en/mediacenter/30854.html). SEWOH is implemented through bilateral and multilateral development cooperation and through partnerships with enterprises, business associations, civil society, and academia. Further, this initiative includes the development of international goals, standards, and guidelines for global food security and nutrition under participation of the Bundesministerium für wirtschaftliche Zusammenarbeit und Entwicklung (BMZ). As part of the Global Programme Food and Nutrition Security and Enhanced Resilience of the SEWOH, implemented in Malawi, Ethiopia, Benin, Burkina Faso, Cambodia, India, Kenya, Mali, Togo, Yemen, and Zambia (Figure 2), nutrition baseline surveys were conducted in these countries using the same survey methodology and tools.

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Figure 2 Overview of countries of the Global Programme Food and Nutrition Security and Enhan- ced Resilience with nutrition baseline surveys

The Cambodia country package of this Global Programme – the Multisectoral Food and Nutrition Security (MUSEFO) project – aims at improving the food and nutrition security situation of women and their children who live in Kampot and Kampong Thom and are vulnerable to food insecurity.

The focus of the MUSEFO project is on three areas of intervention:

(1) Improving the quality of nutrition services by providing training for health workers.

(2) Diversifying nutrition and food production by providing trainings for farmers, building their capacity to grow a more diverse range of crops and improving their access to healthy foods.

(3) Embedding successful approaches on national and regional level. Successful interventions are assessed and documented. The information is then shared with other partners, particularly the Technical Working Group for Social Protection and Food Security and Nutrition which supports the National Strategy for Food Security and Nutrition and the Scaling Up Nutrition initiative for Cambodia, as well as with research institutes and the general public.

The above 3 interventions are further elaborated under 7 different working packages: i) capacity development of health personnel; ii) capacity development of farmers; iii) education at community level; iv) awareness raising campaign; v) strengthen farm production; vi) scaling up multipurpose farm; vii) institutionalization of successful measures (see more details in Annex C).

The political partner of the MUSEFO project is the Cambodia’s Council for Agricultural and Rural Development (CARD) which is responsible for implementing the National Food Security and Nutrition Strategy.

At national level, CARD and the Ministry of Health are partners. Responsibility for implementing the

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Ministry’s Nutrition Strategy lies with the National Maternal and Child Health Centre and its sub-unit, the National Nutrition Programme. Extensive consultation also takes place together with health authorities and the Technical Working Groups Food Security and Nutrition and for Social Protection. At provincial and district level, the project is implemented in cooperation with agricultural, health, rural development and women’s affairs authorities. At village level, it is implemented with the support of volunteers.

The project also cooperates with national and international non-governmental organizations (NGOs), such as the Cambodian Centre for Study and Development in Agriculture and the Reproductive and Child Health Alliance, as well as with other donors, including the United Nations Children’s Fund and the United States Agency for International Development. 2.3. Objectives of the Nutrition Baseline Survey The causes of malnutrition

In 1990, UNICEF developed a comprehensive model that describes the inter-linkages between the multi- dimensional causes of malnutrition that occur at various levels within societies. The model is still being widely used as well as amended in latest publications (i.e. LANCET 4/2013). It explains malnutrition both in rural and urban settings. All forms of malnutrition share a common cause: inappropriate diets that provide inadequate or excessive macronutrients and/or micronutrients. Yet, many other factors also play a role in malnutrition at different levels – as identified by the model:

• The immediate causes include inadequate dietary intake and disease, which directly impact on an individual’s nutritional status; • These primary causes are influenced by underlying causes such as food access and availability at household level, healthcare, water and sanitation, and care, particularly young children, but also women (breastfeeding practices, hygiene practices, women’s workload etc.) at the household or community level. Education levels – both formal and informal incl. life skills – play a determining major role; • The basic causes of malnutrition are wide-ranging, from structural and natural resources, to social, economic and legal environments, and political and cultural contexts across regional, national and international levels.

To identify the underlying causes of malnutrition in a target population, information is needed to design interventions that address the current situation of the potential beneficiaries. Therefore, the objective of this Nutrition Baseline Survey (NBS) is to provide reliable information on the food and nutrition situation of women of reproductive age, infants and young children in the project area. The target groups of women aged 15–49 years, infants and young children (6-23 months) were chosen, because they are particularly vulnerable to suffer from undernourishment and malnutrition. Especially households in fragile contexts, such as rural subsistence farming households, are often not in a position to independently strengthen their resilience to hunger crises. Furthermore, it is vital to focus on the ‘1,000 day window’ (from conception to the age of two years). In this window of opportunity, inadequate nutrition and diseases can lead to irreversible damage in regard to the development of mental and/or motor skills as well as immune system. Thus, a focus on these target groups is vital to guarantee a proper development of the individual and overall potential of the up-coming generations.

The main indicators of the NBS are:

• Household Food Insecurity Experience Scale (HFIES) for interviewed households • Individual Dietary Diversity Score Women (IDDS-W) for women 15-49 years of age • Minimum Acceptable Diet (MAD) for young children 6-23 months of age

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3. METHODS

3.1. Project Area, Participants and Sample Size

Kampot Kampot province, which is situated in the south-west part of Cambodia, borders the provinces of Koh Kong and Kampong Speu to the north, Takeo and Kep and Vietnam to the east and Sihanoukville to the west . Kampot province consists of eight districts and its total population is 585,110 (Census 2008). MUSEFO’s Project activities in Kampot will be carried out in three district, namely the Chhouk district, Dang Tong district and Angkor Chey district. In Kampot, the stunting (chronic malnutrition) rate of children under five years of age is high with 25.2%. Around 8% of the children in this age group are wasted (acute malnutrition) (CDHS 2014).

Kampong Thom

Kampong Thom province borders the provinces of Siem Reap to the northwest, Preah Vihear to the north, Stung Treng to the northeast, Kratie to the east, Kampong Cham, Kampong Chhnang to the south, and the Tonle Sap to the west. Kampong Thom has a total population of 630,803 people according to the 2008 National Population Census. Project activities in Kampong Thom will be carried out in the Santuk district, Kampong Svay district and Baray district. In Kampong Thom, stunting rates in children under five years is very high with 36.4%, indicating a severe public health problem. Wasting rates are at 13% (CDHS 2014).

Participants and Sample Size

The current NBS included participant pairs of the following two target groups:

Ÿ Women of reproductive age (15-49 years)

Ÿ Young children between 6-23 months

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The calculation of the sample size, i.e. households with eligible participants, was based on the program target impact of 0.5 food group increase in women1. The calculation of the necessary sample size was done with GPower. A sample size of 400, including some additions for drop-outs, was used for the NBS. The sample size will not change, no matter what mean food group score will be identified in the baseline (Table 1).

Table 1: Sample Size calculation for SEWOH NBS

Mean Base- Mean End- Power α error SD N Baseline N Endline Total line line 1-β error Increase by 0.5 food groups 4 4.5 0.05 0,95 2 396 396 792 3 3.5 0.05 0.95 2 396 396 792

3.2. Sampling procedure The sampling procedure was based on a two stage probability cluster sampling. The two provinces Kampot and Kampong Thom were the primary sampling unit. The secondary sampling unit were the 50 project villages in the two provinces where project interventions of both sectors (agriculture and health are to be implemented. Population information of all project villages was provided by the GIZ MUSEFO Team Leader. The calculated about 400 households to be selected for the baseline survey were distributed among the two provinces proportionally to size based on the provided population information. The 10 estimated survey days (based on conducting 40 questionnaires per day (4 per team, 10 teams in total), were proportionally allocated among provinces according to the targeted number of households (Table 2). At the first sampling stage, villages served as clusters and were randomly selected according to probability sampling proportional to size. The randomization process of selecting clusters followed the “Guidelines for nutrition baseline surveys in communities” (Gross et al. 1997). The proportion of young children between 6-23 months of age was estimated in order to calculate the least number of infants and children 6-23 months to be expected in the clusters.

According to the latest data from Cambodia (CDHS 2014), about 11.2% of the population is under five years of age and about 3.5% of the population is aged between 6 to 23 months. The village with the least number of inhabitants was identified. Then, the expected number of young children aged from 6 to 23 months was calculated (3.5% of the respective population).

Table 2: Estimations for NBS

Expected least Number of number of Number of HH Planned Provinces children Actual survey days Villages to be se- Survey days 6-23 months lected per village Kampot 18 216 5.4 12 5.4 Kampong Thom 15 180 4.5 12 4.5 Total 33 396 10 Ø 12 10

1 An increase of 0.5 food groups is equal to 5% increase since dietary diversity of women is measured based on 10 food groups.

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With the existing survey team, it was possible to reach up to four villages per day. Consideration of logistics and survey days, the number of clusters per provinces had to be limited. In case there were not enough children found in a cluster, additional children were sampled from the neighboring village. In total, 33 villages were sampled for the survey (see Annex A). Villages (clusters) were randomly selected proportional to population size. The total number of inhabitants was divided by the selected number of clusters, which then served as the mean number of inhabitants. Afterwards, a number below this mean was generated using a random number generator. With this random number, a series of numbers (equivalent to the number of clusters to be selected) was constructed by addition of the mean number of inhabitants to this randomly selected number and subsequently to each sum (Table 3).

Table 3: Excerpt of series of generated numbers

Villages Total Population Accumulated Population Population 119142 Mean 3610 Random number 1596 1 1,368 1,368 2 1,511 5,020 3 1,106 8,058 4 … … ------

(Completed list in Annex B) Using cumulative population information for each province, this series of numbers was used to select the villages. Villages that had the lowest difference between the cumulative number of inhabitants and the numbers in the series were selected.

At the third sampling stage, 12 households were randomly selected per village. The selection criterion for households was one woman in reproductive age (15-49 years) with at least one child in the age group 6-23 months of age.

Respondents were mothers aged from 15 to 49 years old who have children from 6 to 23 months old. Prior to data collection in the villages, village chiefs were informed about the survey. After arriving in the village, the team members introduced themselves to the village chief, explained the random selection of households, and asked for permission to collect data in the village. The team asked the village chief for the list of HHs with women aged from 15 to 49 years old with children from 6 to 23 months old. Then the team gave a number to each HH on the list, starting at #1. Households were selected by using a random number table, by dropping a pencil or stone on it. The first HH started at the number where the pencil or stone lands on (X). The enumerators had to select the next HH by adding the Xth. If there was no female with the target children, then the next number in the HH list was taken. The team continued selecting the names on the list with the next numbers in the table by adding the Xth until the 12 HHs were reached. If the targeted number of mothers and children was not found in the sampled village, the next closest village was chosen to include the missing mother-child pair. In case there was more than one child in the respective age group of 6-23 months, always the youngest child was enrolled. The same approach was used for twins.

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3.3. Data collection The data collection took place between 22th March and 1st April 2016. Prior to data collection, 20 enumerators (10 females, 10 males), and 3 supervisors (1 female, 2 males), were trained for 5 days (Annex D). During the data collection, enumerators worked in pairs: enumerator 1 interviewed the respondents and recorded the paper based 24h-recalls, while enumerator 2 recorded answers with the tablet. Each pair had at least one female enumerator. The overall survey team was divided into 3 groups (three to four pairs in each) and guided by one supervisor each. Every survey day, two to three villages were scheduled per group (four to six in total) and each enumerator pair conducted three to five interviews per day. Data were collected with a standardized questionnaire to capture relevant food and nutrition security related themes (see Table 4). The questionnaire is presented in Annex N.

All interviews were conducted in the local language Khmer. The location of the interview was around the homestead of the selected respondent. During the interview, privacy was assured by keeping an adequate distance between the interviewee and other household members. After the interview, enumerators 1 and 2 compared the paper based and tablet version of the 24h dietary recalls in order to minimize recording biases. Furthermore, general household and participant observations were discussed and the GPS coordinates of the household recorded.

Interviews were conducted according to the Nutrition Baseline Survey Interview Guide (Annex E) to ensure standardization of interviews. In case the respondent was not the caretaker of the child of the day before the interview, the actual caretaker of that day was interviewed for the child’s 24h-recall. Quality control of data collection was done every day by the assigned supervisors using the Quality Control Protocol for Interviewer (Annex F).

Table 4: Overview of collected information and assessment instruments

Collected data Assessment instrument 1 Socio-demographic information Structured questions 2 Agriculture Structured questions 3 Sanitation and hygiene situation Structured questions 4 Food security status Household food insecurity experience scale 5 Childcare and feeding practices Structured questions 6 Dietary intakes of children 6-23 months 24h dietary recall (qualitative) 7 Nutritional knowledge of women KAP (knowledge, attitude, practice) questions 8 Hygiene behavior KAP questions 9 Dietary intake of women 24h dietary recall (qualitative)

3.4. Indicators

Household Food Insecurity Experience Scale (HFIES)

The pattern of responses to the ten standard HFIES questions was used to classify the severity of food insecurity of households. The number of affirmative responses to the HFIES questions is called the raw score, which was used to produce food insecurity prevalence estimates within the total survey population. The HFIES is composed of eight questions with dichotomous yes/no responses and two extended follow- up questions. Each question contributes one point to the raw score if the response is “yes” and each follow-up question contributes one point if the response is “almost every week”. Therefore, the raw score has a minimum of 0 and a maximum of 10. Households with a raw score of 0 are classified as food secure.

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A raw score of 1-3 indicates mild food insecurity. Moderate food insecure households have a raw sore of 4-6, and severe food insecure households have a raw score of 7-10. This simple method of food insecurity classification does not allow for the comparison of estimates among different countries or sub-populations within a country. Intra-country comparisons require further analysis by adjusting each country’s scale to a global standard (Cafier, Nord, Viviani et al, 2015).

Dietary diversity

Dietary diversity was assessed and categorized with the indicators “Individual Dietary Diversity Score” (IDDS) and “Minimum Dietary Diversity” (MDD). Both indicators are used as a proxy measure of the nutritional quality of an individual’s diet. In the current survey, dietary diversity information of women and children 6-23 months was collected by conducting free 24h-recalls, whereby respondents are asked about the different types of food they (or their children respectively) had eaten during the day prior to the interview. The different consumed food items are assigned to predefined food groups and used to calculate IDDS and MDD.

Individual Dietary Diversity Score and Minimum Dietary Diversity - Women

The Individual Dietary Diversity Score of women (IDDS-W) was assessed based on a total of nine food groups (FAO 2013). To calculate the prevalence of Minimum Dietary Diversity of women (MDD-W), FAO and others recommend a cut-off point of 5 out of 10 food groups (Table 5). A high prevalence of MDD-W is a proxy for better micronutrient adequacy among women aged 15-49 years in the respective population (FAO/FANTA 2014).

Table 5: Food groups for 10 food group score with respective Cambodian food items

Foods made from rice, corn, cassava, white (sweet) potatoes, white yams, green unripe Starchy staple foods banana, bread, noodles, spaghetti or other any food made from grains/cereals Beans and peas Any foods made from mature beans or peas (fresh or dried), soya, beans Any foods made from groundnuts, peanut-butter, tree-nuts, pumpkin seeds, sesame Nuts and seeds seeds, sunflower seeds, cashew nuts or seeds including nut/seed butters Dairy products Milk (fresh or powder), cheese, yoghurt or other milk products (ice cream) Any meat, such as beef, pork, lamb, goat, chicken, mice, rats, dog, snake, turtle, rabbits, Flesh foods ducks, fowls, geese Eggs Eggs from any kind of birds Any dark green leafy vegetables including wild green vegetables like cassava leaves, Dark green leafy vege- pumpkin leaves, mustard, spinach, morning glory, garlic chives and other local varieties tables (slek prech, slek bas, slek m’rom, slek ngob, p’ty) Vitamin A-rich fruit/ Ripe mangoes, ripe Paw paws, ripe passion fruit, pumpkin, carrots, squash, or sweet vegetables potatoes that are yellow or orange inside Any other vegetables likecabbage, mushrooms, bamboo shoot, sprouts, eggplants, tomatoes, onions, green pepper, green beans, reddish, yam bean, young jackfruit, nnong Other vegetables (sponge gourd), trolach (bottle gourd), winter melon (young), long beans, cauliflower, cucumber, green papaya (not ripe papaya) Any other fruit like oranges, lemons, tangerines, bananas, avocado, coconut flesh, green/ Other fruits unripe mangoes, watermelon, jackfruit, winter melon

Minimum Acceptable Diet (MAD) of children 6-23 months of age

The WHO indicator Minimum Acceptable Diet and its required indicators Minimum Dietary Diversity (MDD) and Minimum Meal Frequency (MMF) were assessed and analyzed according to the description in the WHO Indicators for assessing infant and young child feeding practices part 2: measurement (WHO 2010).

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Minimum dietary diversity for children is defined as receiving foods from ≥4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables (Table 6).

Definition:Proportion of children 6–23 months of age who receive foods from 4 or more food groups. children 6–23 months of age who received foods from ≥4 food groups during the previous day

children 6–23 months of age

Table 6: Food groups for 7 food group score with respective Cambodian food items

Grains, roots and Foods made from rice, corn, cassava, white (sweet) potatoes, white yams, green unripe tubers banana, bread, noodles, spaghetti or other any food made from grains/cereals

Any foods made from mature beans or peas (fresh or dried), soya, beans Legumes and nuts Any foods made from groundnuts, peanut-butter, tree-nuts, pumpkin seeds, sesame seeds, sunflower seeds, cashew nuts or seeds including nut/seed butters

Dairy products Milk (fresh or powder), cheese, yoghurt or other milk products (ice cream) Any meat, such as beef, pork, lamb, goat, chicken, mice, rats, dog, snake, turtle, rabbits, Flesh foods ducks, fowls, geese Eggs Eggs from any kind of birds Any dark green leafy vegetables including wild green vegetables like cassava leaves, pump- kin leaves, mustard, spinach, morning glory, garlic chives and other local varieties (slek prech, Vitamin-A rich fruit/ slek bas, slek m’rom, slek ngob, p’ty) vegetables Ripe mangoes, ripe Paw paws, ripe passion fruit, pumpkin, carrots, squash, or sweet pota- toes that are yellow or orange inside Any other fruit like oranges, lemons, tangerines, bananas, avocado, coconut flesh, green/ unripe mangoes, watermelon, jackfruit, winter melon Other fruits/ vege- Any other vegetables like cabbage, mushrooms, bamboo shoot, sprouts, eggplants, toma- tables toes, onions, green pepper, green beans, reddish, yam bean, young jackfruit, nnong (sponge gourd), trolach (bottle gourd), winter melon (young), long beans, cauliflower, cucumber, green papaya (not ripe papaya)

Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times.

Definition:Proportion of breastfed and non-breastfed children 6–23 months of age, who receive solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum number of times or more.

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Breastfed children 6–23 months of age who received solid, semi-solid or soft foods the minimum number of times or more during the previous day

Breastfed children 6–23 months of age and

non-breastfed children 6–23 months of age who received solid, semi-solid or soft foods or milk feeds the minimum number of times or more during the previous day

non-breastfed children 6–23 months of age

The minimum acceptable diet (MAD) for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while – for non-breastfed children – it further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds.

Definition:Proportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breast milk).

Breastfed children 6–23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day

Breastfed children 6–23 months of age and

non-breastfed children 6–23 months of age who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day

non-breastfed children 6–23 months of age

Measuring Knowledge, Attitudes and Practices

Nutrition-related KAP questions are a useful method for gaining an insight into peoples’ personal determinants of their dietary habits and closely related hygiene and health issues. They can thus provide valuable inputs for effective program and project planning. Nutrition-related KAP questions assess and explore peoples’ KAP relating to nutrition, diet, foods and closely related hygiene and health issues. KAP studies have been used for two main purposes: 1) to collect key information during a situation analysis, which can then feed into the design of nutrition interventions and 2) to evaluate nutrition education interventions (FAO 2014). Several KAP questions were included in the NBS questionnaire.

3.5. Data Analysis Data were entered into tablets during the process of the interview. Every evening, collected data were transferred to IBM SPSS Statistics Version 23 (IBM Corp 2015) (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). After completion of data collection, data were cleaned and analyzed with IBM SPSS Statistics Version 23. Data were analyzed applying descriptive analysis, including frequency, percentage, mean, median (Md), standard deviation (SD), minimum (Min) and maximum (Max).

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4. RESULTS

In total, 396 households were visited for collecting nutrition data, in which 216 households were in Kampot province and 180 household were in Kampong Thom province. In Kampot, the baseline survey was conducted in three districts, namely Chhouk, Dang Tong and Angkor Chey. Likewise, the survey was conducted in three different districts in Kampong Thom. These included Santuk, Kampong Svay and Baray (Figure 3). The survey results disaggregated by provinces are presented in Annex 0. Respondents were mothers of reproductive age (15-49 years of age) with a child in the age range 6-23 months. All interviewed mothers were aged from 19 to 49 years old with a median of 29.

Map prepared by Dr. Boran Altincicek

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Figure 3: Map of survey area (Kampot and Kampong Thom province)2 4.1. Socio demographic information The great majority of interviewed mothers were married (96.7%) while only a small percentage of them were widowed and divorced or separated (1.5% and 1.8%), respectively (Table 7). There were no significant differences between the two provinces. Female-headed households were found less than ten percent (9.3%), while male-headed household represented up to 90.7%. The figures of female-headed households in both provinces were not significantly different, but the percentage of female-headed households in Kampot was slightly higher than ten per cent (or 10.6%). The figure of female-headed household is lower than the one identified in the CDHS 2014 (27%).

Table 7: Marital Status of respondents overall and by district

Kampot Marital Status Total (N=396) (%) Kampong Thom (n=180) (%) (n=216) (%) Married 96.7 97.7 95.6 Widowed 1.5 1.4 1.7 Divorced or Separated 1.8 0.9 2.8

The average household size was 5 (±1.6) (Md=5, (N=396)) with a minimum of 3 and a maximum of 15 members living permanently (reference time six months) in the respondent’s household. Annex G shows the distribution of household sizes. The mean number of household members in Kampot was 4.8 (±1.3) (Md=5, min=3, max=10 (N=216)). In Kampong Thom, on average 5.3 (±1.8) (Md=5, min=3, max=15 (N=180)) people lived permanently in a household. In Cambodia, it is common that children, parents, and grandparents live in one household.

The majority of interviewed mothers (90.4%) had some kind of education, while only less than one tenth or 9.6% had no schooling at all. Almost half of respondents (48.5%) attended any grade in primary education, but only 22.9% of those who attended primary education completed five classes and more than one fifth (26.6%) completed 6 classes in primary education. Only 40.4% of respondents had attended some grades in secondary education and only a small percentage of them had some form of higher education (only 1.5%). Among those who had attended secondary education, only 5.6% completed 5 classes and 12.5% completed 6 classes. Moreover, there were no significant differences between the two provinces in terms of level of education.

Table 8: Educational level of respondents

Total (N=396) Kampot Kampong Thom Level of Education (%) (n=216) (%) (n=180) (%) No schooling 9.6 7.9 11.7 Primary 48.5 44.4 53.3 Secondary 40.4 46.3 33.3 More than Secondary 1.5 1.4 1.7

Likewise, many household heads had some forms of education, while 14.6% had no education at all. Almost one third or 32.8% had attended any grades in primary education, while 37.6% completed some

2 Prepared with google maps: https://www.google.com/maps/d/edit?mid=z6_PvGRNP3do.k4wNbemVxbLk

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grades in secondary education. Household heads who continued their education further after completion of secondary school was only 3.8% (Annex O).

Respondents were asked for income sources of their household throughout the year. The main income sources for the household were sale of crops, vegetables or fruits that accounted for 37.1%, followed by casual labor with 29.8% and petty trade/small business with 16.2% (Table 9). Only 3.3% of household income was from the sale of animals or animal products. This is partly due to the fact that some animals reared in rural areas were mainly used for labor. Salary from being employed accounted for 11.1%, while sale of own produced goods/crafts, sale of fish/seafood and remittances from relatives/husband took only small percentage (one percent or even less than that for each category). There were no remarkable differences of the income sources between the two provinces, except that none of the respondents in Kampong Thom reported the sale of own produced goods/crafts and remittances from relatives/husband as sources of income, while none of respondents in Kampot reported the sale of fish and seafood as a source of income for the household.

Table 9: Sources of income

Total Kampot Source of income (N=396) Kampong Thom (n=180) (%) (n=216) (%) (%) Sale of crops, vegetables or fruit 37.1 34.3 40.6 Sale of animals or animal products 3.3 5.1 1.1 Sale of fish and seafood 0.3 0.0 0.6 Sale of own produced goods/crafts 1.0 1.9 0.0 Casual labor 29.8 28.2 31.7 Petty trade / small business 16.2 14.4 18.3 Employment/salary 11.1 13.9 7.8 Remittances from relatives/husband 0.3 0.5 0.0

4.2. Agriculture Respondents were asked if their household had access to any land that could be used for agriculture, besides home garden. In total, 84.6% of the households had access to land, while 15.4% of the households reported not having land that could be used for agriculture. There were remarkable differences in accessing land between Kampot and Kampong Thom. In Kampot, the majority of households or up to 90.7% had access to land, while in Kampong Thom, only 77.2% of the interviewed households could access to land for agriculture.

Among households who could access land for agriculture, the majority (95.2%) grew rice in their accessed land with no significant difference between the two provinces, while cassava was the second largest crop grown in the land (15.2%), followed by beans with 7.5%, maize (5.7%), peanuts (4.5%), yam with all colors (2.4%) and soya with 0.9%. More cassava was grown in Kampong Thom than in Kampot (32.4% versus 3.1%). While beans were grown by 12.8% of households in Kampot, none of the households was found growing any kinds of beans in Kampong Thom.

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Table 10: Crop diversity

Kampot Crop Total (N=335) (%) Kampong Thom (n=139) (%) (n=196) (%) Rice 95.2 98.0 91.4 Maize 5.7 8.2 2.2 Cassava 15.2 3.1 32.4 Peanuts 4.5 6.6 1.4 Beans 7.5 12.8 0.0 Soya 0.9 1.5 0.0 Yam (all colours) 2.4 4.1 0.0

Respondents were also asked if they had home garden. In both provinces, 41.2% of households had home garden, while the percentage of households having home garden in Kampong Thom is slightly higher compared to its counterpart province, Kampot (45.6% versus 37.5%). Among the households who had home garden, almost all of them (99.4%) were growing some kinds of vegetables, while all households with home garden in Kampong Thom were growing vegetables. Vegetable production varies according to season. Wet-season was the season in which most households grew vegetables, while only around one fifth (or 21%) grew vegetables during the dry-season. More than one fifth (or 22.2%) of home garden vegetables were grown all year-round. More households in Kampot preferred growing vegetables in wet-season than those in Kampong Thom (70% versus 43.9%), but more households in Kampong Thom were able to grow vegetables in dry-season than those in Kampot (24.4% versus 17.5%). Likewise, the percentage of year-round vegetable production was seen higher in Kampong Thom than in Kampot (31.7% versus 12.5%) (Table 11).

Households grew different types of vegetables in their home gardens. On average, 2.6 different kinds of vegetables were grown in each household with a minimum of 1 and a maximum of 9 different types (see Annex P). The mean of vegetable diversity grown in Kampong Thom was found higher than in Kampot – meaning households in Kampong Thom were growing more different types of vegetables than in Kampot (3.1 versus 2.6). Sponge gourd was grown by 61.7% of the households in both provinces, followed by morning glory with 54.9% and squash/pumpkin with 37%. Eggplants and bottle gourd were found growing much more in Kampong Thom than Kampot (eggplants: 41.5% in Kampong Thom and 5% in Kampot and bottle gourd: 29.3% in Kampong Thom and 5% in Kampot), while cucumbers were grown much more in Kampot than in Kampong Thom (32.5% versus 11%). None of the households grew green beans in their home garden in Kampong Thom, but 8.8% in Kampot grew them. The main use of vegetable was for own consumption, while only 11.7% of the vegetable production was for sale. This tendency was found similar in both provinces.

The majority of the vegetable growing households grew two, three, one or four different types of vegetables at the time of the survey – with similar numbers in Kampot and Kampong Thom (see Figure 4 and Annex P).

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Figure 4: Number of different types of vegetables grown

Respondents were also asked if they had any fruits or fruit trees at their homestead. Table 12 shows that 86.4% of household could access to fruit or fruit trees with no significant differences between the two provinces. On average, 3.2 different kinds of fruit trees were grown in each household. Means of fruit trees diversity grown in both provinces were the same (3.2) (see Annex Q). Mango, coconut and banana were the main fruit trees grown by household in both provinces, with 80.4%, 74.9% and 69.9%, respectively. The main use of produced fruits was for own consumption, while only 7.7% of the production was for sale.

The majority of the fruit tree growing households grew three, two, four, one or five different types of fruits at the time of the survey (see Figure 5 and Annex Q).

Figure 5: Number of different types of fruit trees grown

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To explore further on household production, respondents were also asked if their household owned any livestock herds or farm animals or poultry, fish or other aquatic animals. According to Table 12, many households (up to 88.9%) raised any kinds of animals, with no significant differences between the two provinces. On average, 1.8 different kinds of farm animals or livestock or other aquatic animals were reared in each household with a minimum of 1 and a max. of 4 different types (see Annex R). The mean of animal reared in Kampot was found higher than in Kampong Thom – meaning households in Kampot were raising more types of farm animals/livestock/other aquatic animals than households in Kampong Thom (2.0 versus 1.6). Poultry, including duck, chicken, geese and fowl was owned by majority of households (97.2%), with similar figure in both provinces, while cow was raised by more than half of the households (55.7%). Households in Kampot were more likely to raise cows than those in Kampong Thom (64.8% versus 43.8%). None of the households was found raising goat or sheep, while only few households in Kampot raised fish (3 households) and other aquatic animals, such as frogs, eels (2 households). Only a bit more than one third or 37.8% of livestock production was for own consumption, while 39.8% of them were for sale. This is because the main use of cow and buffalo traditionally is for labor (ploughing), rather than for sale or consumption purposes.

The majority of the animal rearing households reared two or one different types of animals at the time of the survey (see Figure 6 and Annex R).

Figure 6: Number of different types of animals reared

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The following Table 11 presents the summary of the vegetable, fruit and livestock production pattern and use in Kampot and Kampong Thom at the time of the survey.

Table 11: Home garden and livestock ownership and main use of produces

Kampong Total (%) Kampot (%) Thom (%) Households without home garden (N=233) 58.8 62.5 54.4 Households with home garden (N=163) 41.2 37.5 45.6 Households growing vegetables (N=162) 99.4 98.8 100.0 Season of vegetable production (N=162) - during wet-season 56.8 70.0 43.9 - during dry-season 21.0 17.5 24.4 - year-round 22.2 12.5 31.7 Main use of vegetables (N=162) - own consumption 77.8 76.3 79.3 - sale 11.7 12.5 11.0 - both (in approx. equal amounts) 10.5 11.3 9.8 Households with no access to fruits (n=54) 13.6 9.3 18.9 Households with access to fruits (n=342) 86.4 90.7 81.1 Main use of fruits (N=342) - own consumption 84.7 93.2 88.3 - sale 7.7 4.1 6.1 - both (in approx. equal amounts) 7.7 2.7 5.6 Households not keeping livestock (n=44) 11.1 7.9 15.0 Households with access to livestock (n=352) 88.9 92.1 85.0 Main use of livestock (N=352) - own consumption 37.8 28.1 50.3 - sale 39.8 48.7 28.1 - both (in approx. equal amounts) 21.9 22.6 20.9

Respondents were asked if they participated in any social- and/or food-security program. Access to agricultural development programs was mentioned in most cases compared to other programs, but not many households actually participated (only 26%), followed by food security and nutrition programs, which was mentioned by 18.4% of the interviewed households. Only 16.2% of the households reported having access to cash transfer, while school feeding was mentioned by only 15.2%. Only around 7% of the households benefited from food assistance, while around 6% benefited from a food-for-work program. Households in Kampong Thom seem to have better access to social and/or food security programs, including school feeding, food security and nutrition and cash transfer (Table 12).

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Table 12: Households participating in social- / food-security programs

Kampot Kampong Total Social / Food-security program (n=216) Thom (n=180) (N=396) (%) (%) (%) School feeding 15.2 5.1 27.2 Agricultural development 26.0 25.5 26.7 Food security and nutrition 18.4 10.2 28.3 Cash transfer 16.2 12.5 20.6 Food assistance 6.6 3.2 10.6 Food for work 5.6 4.6 6.7

4.3. Household food insecurity In order to assess food security of the households the standardized HFIES was used (FAO 2015). Respondents were asked if they or anyone else in their household (1) were worried about not having enough food, (2) were unable to eat healthy and nutritious food, (3) ate only a few kinds of foods, (4) had to skip a meal, (5) ate less than she thought she should, (6) ran out of food, (7) were hungry but did not eat (if yes, how often), (8) went without eating for a whole day (if yes, how often). The reference period was the previous 30 days (one month). As presented in Table 13, only 17.2% of households were categorized as food secure, while most respondents (up to almost two thirds or 65.4%) were suffering from mild food insecurity and 16.9% suffering from moderate food insecurity. However, only few households (0.5%) were suffering from severe food insecurity. Households in Kampot seem to have better food security, compared to households in Kampong Thom, but the figures were not significantly different.

Table 13: Household Food Insecurity Experience Scale (HFIES)

Kampong Total (N=396) Classification of food security Kampot (n=216) (%) Thom (n=180) (%) (%) Food secure 17.2 19.9 13.9 Mild food insecure 65.4 60.6 71.1 Moderate food insecure 16.9 19.0 14.4 Severe food insecure 0.5 0.5 0.6

Looking at individual categories of household food insecurity during the last 30 days, the majority of respondents were worried that they would not have enough food to eat because of a lack of money or other sources (79.5%), with no significant differences between the two provinces. Being unable to eat healthy and nutritious food was mentioned by around half of the respondents (45.8% in Kampot and 53.3% in Kampong Thom). Around one third of respondents (36.6%) were able to eat only a few kinds of food, while almost one fourth (24.5%) of HHs were likely to eat less food than they thought they should. However, only 10 households reported that they had experienced skipping a meal (7 household in Kampot and 3 household in Kampong Thom), while another ten households had experienced running out of food (5 household in Kampot and another 5 households in Kampong Thom). Only 12 households reported being hungry but did not had food to eat (10 household in Kampot and 2 in Kampong Thom), while three households mentioned that they went without eating a whole day during the last 30 days (2 households in Kampot and 1 household in Kampong Thom) (Table 14).

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Table 14: Categories of Household Food Insecurity Experience Scale (HFIES)

Total Kampot Kampong Thom Categories of the household food insecurity (N=396) (n=216) (n=180) (%) (%) (%) Worried not have enough food to eat 79.5% 75.0% 85.0% Unable to eat healthy and nutritious food 49.2% 45.8% 53.3% Ate only a few kinds of food 36.6% 34.3% 39.4% Skipped a meal 2.5% 3.2% 1.7% Ate less than should eat 24.5% 29.2% 18.9% Ran out of food 2.5% 2.3% 2.8% Were hungry but did not eat 3.0% 4.6% 1.1% Went without eating for a whole day 0.8% 0.9% 0.6%

Among the 12 respondents who reported being hungry but did not eat because there was not enough money or other resources, half of them experienced this phenomenon only once or twice, and 5 households faced this situation in some weeks but not every week, while only 1 household reported happening this almost every week. Among the three respondents who reported going without eating for a whole day because of a lack of money or other resources, two households reported happening this only once or twice while 1 household faced this situation in some weeks but not every week (Table 15).

Table 15: Prevalence of experience of severe household food insecurity

Frequency of being hungry but Frequency of going without eat- did not eat because there was not ing for a whole day because of a Provenance of household food enough money or other resources lack of money or other resources insecurity for food (n=12) (n=3)

Only once or twice 50.0% 66.7% In some weeks but not every week 41.7% 33.3% Almost every week 8.3% 0

4.4. Water, Sanitation and Hygiene

Drinking water from an improved source was defined as water coming from piped water into dwelling, yard or plot, public tab or standpipe, tube well or borehole, protected dug well or protected spring and rainwater collection. The majority of the interviewed households (89.4%) had access to improved drinking water during the wet-season, while only more than three fourths (or 75.5%) of households could access the same during the dry-season. The figures are slightly higher compared with the CDHS 2014, where only 84% of households used an improved source of drinking water during the rainy season and 65% during the dry season. Comparing between the two provinces, access to improved drinking water by households in Kampong Thom was found much higher in both wet and dry seasons than those in Kampot. In the wet season, up to 95% of households in Kampong Thom had access to improved drinking water, while only 84.7% of households could access the same in Kampot. Access to improved drinking water in Kampot was even worse in the dry season (only 60.2% of the survey population had access to it).

Respondents were asked to recall how they store water. The answers were assigned to three predefined categories presented in Table 16. The category “clean and covered container/jar” is the most improved way to store water. Not cleaning containers/jars before usage increases the risk for pathogens to multiply easily and contaminate the stored water. Not covering containers increases the risk for pathogens to enter the

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water for example through contact with dirt/dust (carried though the wind) or animals drinking the water. According to Table 16, 40.2% of households normally practiced covering water container or jar, while only around one fourth (24.2%) cleaned and covered their container or jar before using. These practices were found more prevalent in Kampot than in Kampong Thom, with more than half of the survey population (56%) covered their container and jar, while this practice was seen only around one fifth or 21.1% among the survey population in Kampong Thom. Likewise, 32.4% of households in Kampot cleaned as well as covered their container or jar, while only 14.4% practiced the same in Kampong Thom.

Table 16: Storage of water

Kampong Total (N=396) Water to store water Kampot (n=216) (%) Thom (n=180) (%) (%) Clean container or jar 3.0 2.3 3.9 Covered container or jar 40.2 56.0 21.1 Clean and covered container or jar 24.2 32.4 14.4 Unclean container or jar 1.3 1.9 0.6 Uncovered container or jar 8.8 5.1 13.3 Unclean and uncovered container or jar 0.3 0.5 No container or jar 19.4 1.4 41.1 Other 2.8 0.5 5.6

Respondents were further asked, if they were treating their water to make it safer to drink. More than one fourth or 25.8% of respondents said that they did nothing to their water before drinking, but drank it raw, while 74.2% mentioned some ways of treating their drinking water. There were significant differences of households drinking raw water between the two provinces. Higher percentage of households (32.9%) drank raw water in Kampot, while only 17.2% of households in Kampong Thom did the same. Among those who mentioned some ways of treating water before drinking, boiling was the most common way mentioned by almost two thirds or 65.3% of respondents, with significant difference between the two provinces (93.8% in Kampot and 37.6% in Kampong Thom). One third of the households used water filters, with significant differences between the two provinces (59.1% in Kampong Thom and only 6.2% in Kampot). ‘Let it stand and settle’ was the method that was mentioned by only few households (1.4%) (Table 17).

Table 17: Mentioned treatment of water for safe consumption

Kampong Total (N=396) Treatment of drinking water Kampot (n=216) (%) Thom (n=180) (%) (%) Not treating drinking water 25.8 32.9 17.2 Treating drinking water 74.2 67.1 82.8 Boil it 65.3 93.8 37.6

Use a water filter (ceramic, sand, composite, etc.) 33.0 6.2 59.1

Let it stand and settle 1.4 2.7 Other 0.3 0.7

To explore further on sanitation and hygiene information of the household, respondents were asked to describe the type of toilet facility members of the household usually use, and then enumerators observed the toilet facility to verify exact type of the facility. Many households (55.6%) were using an improved

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sanitation facility, which was defined as a flush toilet, piped sewer system, septic tank, flush/pour flush to pit latrine, pit latrine with slab, composting toilet, while a small percentage of households (7.8%) were using an unimproved sanitation facility, which was defined as the absence of a flush or pour-flush toilet piped sewer system, septic tank, flush. On the other hand, more than one third of the interviewed households (35.6%) did not have access to sanitation facility. Therefore they were practicing open defecation. The figures of households using an improved sanitation facility and an unimproved sanitation facility were quite similar between the two provinces. However, the percentage of households practicing open defecation was found higher in Kampot than in Kampong Thom (38% versus 32.8%) (Figure 7)

Figure 7: Access to improved/unimproved sanitation facility

All interviewed households in both provinces had soap of any kinds, including washing powder and liquid at the time of the interview. All respondents used soap mainly for personal hygiene (washing body, hair, clothes, dishes and pots, cleaning the house). If respondents mentioned to use soap for washing hands, the enumerators had to probe to find out on what occasion the soap was used for. Table 18 below shows that soap was used for hand washing in different occasions, including washing children’s hands, washing hands after defecation, washing hands after cleaning the child, washing hands before feeding the child, washing hands before preparing food and before eating. Using soap for washing children’s hands was a common practice by respondents in both locations, but the figure was relatively low – only 42.2% (41.2% in Kampot and 43.3% in Kampong Thom). Only less than one fourth (23.5%) mentioned using soap for hand washing after defecation (20.4% in Kampot and 27.2% in Kampong Thom), while less than one fifth (19.2%) reported using soap for washing hand after cleaning children (20.4% in Kampot and 17.8% in Kampong Thom).

Percentages of respondents using soap for washing hands before preparing food and before feeding child were even lower with 14.6% and 13.9%, respectively (with similar figures in both provinces). Around one third or 33.6% of households reported using soap for hand washing before eating (30.1% in Kampot and 37.8% in Kampong Thom).

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Table 18: Use of soap for washing hands

Kampong Total (N=396) Kampot Hand washing occasion Thom (n=180) (%) (n=216) (%) (%) Washing my children’s hands 42.2 41.2 43.3 Washing hands after defecation 23.5 20.4 27.2 Washing hands after cleaning child 19.2 20.4 17.8 Washing hands before feeding child 13.9 13.0 15.0 Washing hands before preparing food 14.6 15.7 13.3 Washing hands before eating 33.6 30.1 37.8 Washing body 100.0 100.0 100.0 Respondents were asked if they had received any hygiene counselling at their villages. According to the survey result, availability of hygiene counselling/training at village level was very low, with only around one fourth of the respondents (25.5%) reported having received hygiene counselling (23.1% in Kampot and 28.3% in Kampong Thom).

4.5. Diarrhea High prevalence of diarrhea as well as frequent diarrhea episodes can be an indicator for poor sanitation and hygiene environment. Information on child health included the occurrence of diarrhea in the past two weeks prior to the survey and the frequency of periods of diarrhea of the child in the last six months. Diarrhea was determined as perceived by the respondent. The prevalence of diarrhea within the two weeks prior to the survey was 38.6% (35.6% in Kampot, and 42.2% in Kampong Thom). This survey result shows that diarrhea is still a constant problem among this population, and only 28.3% of the children have never had diarrhea in the last six months (31.5% in Kampot and 24.4% in Kampong Thom).

On average, children had 2.3 (± 2.9) times diarrhea (Md=2, Min=0, Max=25) in the last six month prior to the interview.

4.6. Knowledge, attitude and practice in regard to health aspects Antenatal care from a trained service provider is vital for the health of both mother and the child. Interviewed mothers were asked how many times they sought for antenatal care during the last pregnancy. According to the survey, the mean number of antenatal care visits of interviewed mothers was 6.7 (±2.4) (N=396, Md=7, min=1, max=13) during their last pregnancy. The majority of women (87.1%) received antenatal care four times or more during the pregnancy, with no significant differences between the two provinces (88.4% in Kampot and 85.6% in Kampong Thom). The finding is a bit higher compared to CDHS 2014, in which the percentage of women, aged from 15 to 49 years old, who received antenatal care visits at least four times was 75.6%. Some women (10.6%) made 2 to 3 antenatal care visits (9.3% in Kampot and 12.2% in Kampong Thom), while only a small number of women (8 in total, 5 in Kampot and 3 in Kampong Thom) received only 1 antenatal care, and only one mother in Kampong Thom said that she had never received antenatal care during her last pregnancy.

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Respondents were further asked for the number of times the child brought to the health center, clinic or hospital since the child was born. Children are supposed to visit health center or clinic or hospital every month and participate in regular growth promotion and monitoring. The mean number of the visits to the health center/clinic/hospital with the enrolled child was 8.2 (±5.1) times (N= 396, Md=7, Min=0, Max=36). Considering the mean age of the children (13.3 months), the average number of the visits is insufficient and needs to be emphasized in future projects.

According to respondents, taking care of the child is a joint responsibility. Mothers or mothers-in-law, spouse or male relatives and older children most often supported women in taking care of the child. However, around 41% of respondents reported that they themselves were taking care of their child aged 6-23 months without support of others, with the same rates in both provinces (Table 19). Other than that, when asked who was taking care of the child yesterday, the majority of women (up to 89.9%) said that she was the one who was taking care of the child alone. Around one third of the respondents reported that mothers or mothers-in-law supported in care taking of the child, while around 14% of respondents mentioned the husband or other male relatives as the one supporting child care. Other helpers mentioned were: female relatives (6.8%), older siblings of the child (4.5%) and housemaid (0.5%).

Table 19: Supporter in taking care of the child (6-23 months)

Kampong Total (N=396) Kampot (n=216) Care taker of the child Thom (n=180) (%) (%) (%) Respondent alone 41.2 41.2 41.1 Mother/mother-in-law 33.1 34.7 31.1 Older siblings of child 4.5 3.7 5.6 Spouse/ other male relative 13.9 13.0 15.0 Other female relative 6.8 6.9 6.7 Other 0.5 0.5 0.6

4.7. Knowledge, attitudes and practices regarding complementary feeding During the interview, the respondents were presented three pictures showing Borbor Khab Krop Kroeung (homemade, nutrient-rich, mixed thick porridge), Borbor Kroeung (porridge bought from market) and Borbor Sor (watery porridge) (Figure 8). Then they were asked to choose which porridge they would give to a young child aged between 6 and 23 months. Watery porridge usually contains fewer nutrients compared to mixed thick porridge, and watery, nutrient-lacking porridge is one common reason for malnutrition in young children. Therefore, the correct consistency of porridge should be thick and should not be dripping from a spoon. According to the survey results, thick and nutrient-rich porridge was preferred by most women (72.2%); only 16.2% of mothers chose the porridge bought from market, while 11.6% of the mothers were likely to give watery porridge for their young child. There were no significant differences between the two provinces in terms of mother’s preference of the type of porridge for their young child.

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Borbor Khab Krop Kroeung Borbor Kroeung Borbor Sar

Figure 8: Examples of three different types of porridges

In addition to the consistency, respondents were asked about ways to enrich the porridge (increase dietary quality). Women were encouraged to recall ways to make porridge more nutritious that is better for their baby’s health. Almost all women (96.2%) knew that adding animal-source foods, such as meat, poultry, fish, liver/organ meat, eggs, milk etc. will make porridge more nutritious, while more than three fourths (77.8%) of mothers were likely to put orange flesh fruits or vegetables, like carrot, orange-fleshed sweet potato, yellow pumpkin, mango, papaya, etc. in the porridge for their young child. There were no significant differences between the two provinces. The benefits of green leafy vegetables, like spinach as well as energy-rich foods, such as oil/fat/butter were known by 78% and 33.1% respectively. Most women were unaware of the nutritional value of pulses and nuts, such as flours of groundnut and other legumes (peas, soya, etc.), sunflower seed in this context (table 20).

Table 20: Mentioned types of food making porridge more nutritious

Total Kampot Kampong Thom Additions to porridge (n=396) (n=216) (n=180) (%) (%) (%) Animal-source foods 96.2 94.9 97.8 Pulses and nuts 5.8 6.5 5.0 Orange (vitamin A rich) fruits and vege- 77.8 73.6 82.8 tables Green leafy vegetables 78.0 71.8 85.6 Energy-rich foods 33.1 28.2 38.9

In order to figure out the knowledge score of enriching porridge, the prevalence of women who knew any way was calculated. Most respondents only knew three (44.7%) types of food that would make porridge more nutritious, while some were aware of four (26%). Only 3.1% could mention up to five types, and 6.7% were aware of only 1 types of food to make the porridge more nutritious for their baby. The mean number of mentioned types of foods was 3 (±0.9) (Md=3, Min=0, Max=5).

When asked how could they recognize that someone is not eating enough food (asked them to recall signs of malnutrition), more than three fourths (76.8%) mentioned a lack of energy/weakness as a sign of malnutrition, while around three fourths of the respondents (74.7%) mentioned weight loss/thinness as sign of malnutrition, with no major differences between the two provinces. Weakness of the immune system was mentioned by 30.3% as other sign of malnutrition by one third of respondents in Kampot, while only a bit more than one fourth (26.7%) mentioned it in Kampong Thom (Table 21). Growth faltering (being slow in child growth) was recognized as sign of malnutrition by only 14.1% of the women, with 10.2% in

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Kampot, while up to 18.9% mentioned it in Kampong Thom. In order to figure out the knowledge score of recognizing malnutrition signs, the prevalence of women who knew any sign was calculated. Most of the respondents only mentioned one (22%) or two (54.9%) signs of malnutrition. Some respondents (20.5%) could mention three, while only a small number of women mentioned four types of signs of malnutrition (2.6%). The mean number of mentioned signs of malnutrition was 2.1 (±0.7) (Md=2, Min=0, Max=4).

Most commonly known reason for malnutrition was not getting enough food (89.4%), while watery food with lack of nutrients was mentioned by only 21% and disease as reason for malnutrition was mentioned by 16.7% of the respondents, with no significant differences between the two provinces (Table 21). In order to figure out the knowledge score of knowing reason for malnutrition, the prevalence of women who knew any reason was calculated. Almost all respondents (94.7%) were able to mention at least one reason of malnutrition. Only 1.8% of respondents were able to mention all three predefined reasons for malnutrition (2.5% in Kampot and 1.1% in Kampong Thom). The mean number of mentioned reasons for malnutrition was 1.3 (±0.5) (Md=1, Min=1, Max=3).

Table 21: Mentioned signs and reasons of malnutrition

Total Kampot Signs of malnutrition (N=396) Kampong Thom (n=180) (%) (n=216) (%) (%) Lack of energy/weakness 76.8 78.7 74.4 Weakness of the immune system 30.3 33.3 26.7 Loss of weight/thinness 74.7 75.9 73.3 Children do not grow as they should 14.1 10.2 18.9

Reasons of malnutrition Not getting enough food 89.4 87.5 91.7 Food is watery, does not contain enough 21.0 20.4 21.7 nutrients Disease/ill and not eating food 16.7 17.6 15.6

Furthermore, respondents were asked to recall ways to prevent malnutrition among young children (6- 23 months). More than two thirds of respondents (68.9%) mentioned that malnutrition could be prevented through giving more food, with no significant differences between the two provinces. Giving diverse types of food each day was mentioned by more than half of the respondents (55.8%) as way to prevent malnutrition, with 52.3% in Kampot and 60% in Kampong Thom, followed by feeding more frequently (21.2%), giving attention during meals (15.9%), and attending growth monitoring (13.1%) (Table 22). In order to figure out the knowledge score of prevention of malnutrition, the prevalence of women who knew any prevention methods was calculated. The mean number of mentioned ways to prevent malnutrition was 1.8 (±0.8) (Md=2, Min=0, Max=5). Most of the respondents only mentioned one (37%) or two (45.9%) ways to prevent malnutrition in young children. Some respondents (15.5%) were aware of three ways, while only few women knew four or five ways of prevention of malnutrition.

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Table 22: Mentioned ways to prevent malnutrition in young children (6-23 months)

Kampong Total (N=396) Kampot Prevention of malnutrition Thom (n=180) (%) (n=216) (%) (%) Give more food 68.9 67.6 70.6 Give different types of food each day 55.8 52.3 60.0 Feed frequently 21.2 29.2 11.7 Give attention during meals 15.9 14.4 17.8 Attend growth monitoring 13.1 13.4 12.8

Respondents were further asked about their feeding practice regarding amounts of fluids (including breast milk) and food offered during episodes of illness if the child already takes food (Table 23). Around 63% of respondents knew the importance of fluids given to their sick child, by mentioning that they would give their sick child at least about the same or more fluids to drink (about the same is 26% and more is 37.1%). However, food was not considered as important as fluids for the sick child, with only less than half of respondents mentioned that they would give at least about the same or a higher amount of food for their sick child to eat during episodes of sickness (about the same is 18.4% and more is 20.7%). More than half of respondents opined that they would give less foods for their sick child, in which more than one fifth (21.5%) would give much less food and 6.1% would stop food when the child is sick, while around 36% of respondents would give less fluids to the sick child, with 10.1% would give much less and 0.5% would give nothing to drink during episodes of illness.

Table 23: Amount of fluids and food offered during illness

Total (N=396) Kampong Thom Amount of fluids offered during illness Kampot (n=216) (%) (%) (n=180) (%)

Much less 10.1 11.6 8.3 Somewhat less 25.8 23.6 28.3 About the same 26.0 26.4 25.6 More 37.1 37.0 37.2 Nothing 0.5 0.5 0.6 Child never been sick 0.5 0.9 Amount of food offered during illness Much less 21.5 25.0 17.2 Somewhat less 30.8 25.5 37.2 About the same 18.4 21.3 15.0 More 20.7 20.4 21.1 Nothing, stopped food 6.1 5.1 7.2 Child never been sick 0.8 0.9 0.6 Does not yet take food 1.8 1.9 1.7

When asked what should they do to ensure proper nutrition of pregnant woman, more than one fifth (22.5%) of the respondents said that the woman should eat as usual – meaning nothing specific for the pregnant woman. However, more than half of respondents stated that women should be given not only different types of food each day (mentioned by 59.8% of respondents), but also give more food each day (mentioned by 56.8% by respondents) during pregnancy. More than one fifth (21.5%) of respondents said that woman should go to the health center/hospital to check whether they are gaining weight properly,

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while around one fifth (19.9%) of respondents believed that the woman should eat food more frequently. There were no significant differences between the two provinces (see Annex O).

The same question was asked for lactating mother. The pattern of responses was quite similar to the responses on pregnant woman. More than one fifth (21.5%) would prefer to continue eating as usual, while more than half of them (59.6%) were likely to give different types of food each day, while another more than half of respondents (58.3%) preferred to give more food during lactating. Only less than one fifth (17.9%) would choose to feed more frequently, while only around ten percent of respondent would go to health center/hospital to check their health (see Annex O).

Further questions were asked to figure out respondents’ knowledge of the causes of diarrhea. According to the survey result, the majority of respondents (89.9%) knew at least one factor that would cause diarrhea, with a major difference between the two provinces (only 84.7% were able to mention those causes in Kampot, while 96.1% could do the same in Kampong Thom). The most common factor mentioned by the majority of respondents was contaminated food (84.6%, with the same rates in both locations). Contaminated water was mentioned by more than half of the respondent (56.7%), followed by contaminated hands (21.6%), with no significant differences between the two provinces. Flies were mentioned by only a small percentage of respondents (2%), with 3.3% in Kampot and 0.6% in Kampong Thom.

The majority of respondents (91.2%) knew at least one way to prevent their child from getting diarrhea (88% in Kampot and 95% in Kampong Thom). Boiling or filtering drinking water was mentioned by more than three fourths of respondents, followed by protecting food and water supplies with cover, mentioned by 59.3% with similar rates in both provinces. Other ways to prevent diarrhea were mentioned by respondents, including washing hands (40.7%), exclusive breastfeeding (5.3%), and using latrines or burying feces (4.4%), with similar rates in both provinces (see Annex O). 4.8. Nutrition Counselling With the purpose of identifying the availability of nutrition counselling structures at village level, respondents were asked to name any counselling structures for nutrition in their villages. Around half of the respondents (49.7%) mentioned that there was no nutrition counselling structure in their village, while 42.4% of respondents mentioned that health center was a place where people seek for counselling on nutrition. Health center as nutrition counselling structure was mentioned more often in Kampong Thom than in Kampot. Volunteer group and agricultural extension service were also mentioned as places they would go to seek counselling service on nutrition, however, only one respondent in Kampot mentioned agricultural extension service. Around 8% of respondents did not know if a counselling structure for nutrition is available in their villages (Table 24).

Table 24: Counselling structure for nutrition in the village

Total Kampot Kampong Nutrition counseling structure (N=396) (n=216) Thom (%) (%) (n=180) No counseling structure 49.7% 54.6% 43.9% Health center 42.4% 37.5% 48.3% Volunteer group (mother to mother support groups) 15.4% 6.9% 25.6% Agricultural extension service (development agents) 0.3% 0.5% Don‘t know 8.1% 8.3% 7.8%

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In both locations, more than half of the respondents (52.5%) did not receive any nutrition counselling, with 57.4% in Kampot and 46.7% in Kampong Thom (Table 25). However, around one third of the respondents (33.1%) received nutrition counselling at the health center (36.6% in Kampot and 28.9% in Kampong Thom). Other nutrition counselling services included volunteer group, such as mother to mother support group (12.6%) and agricultural extension service (0.8%). Overall, nutrition counselling was rare. Future projects should ensure or create availability of nutrition counselling and control for compliance among communities.

Table 25: Received nutrition counselling among respondents

Kampong Thom Source of nutrition counseling Total (N=396) (%) Kampot (n=180) (n=216) (%) (%) No 52.5 57.4 46.7 Health center 33.1 36.6 28.9 Volunteer group 12.6 5.1 21.7 Agricultural extension service 0.8 0.5 1.1 Other 1.0 0.5 1.7

According to the survey result, a very small proportion of respondents (8.8%) reported having participated in cooking demonstration, with only 3.7% in Kampot and 15% in Kampong Thom. A follow-up question was asked among those who have participated in cooking demonstration in order to find out whether the cooking demonstration they received helped them to improve both knowledge and feeding practices. More than half of them said that the demonstration was very useful for improving both their knowledge and feeding practices. There was a significant difference between the two provinces, in which only 37.5% of respondents in Kampot said that the cooking demonstration helped them improve both, knowledge and feeding practices, while 55.6% mentioned the same in Kampong Thom.

When asked whom they could ask for advice when they have a question about feeding their child, more than half of respondents (52.3%) mentioned that they would go to health professional, including health center, health post or hospital staff), with the same rates in both provinces, while almost half of them (46.5%) mentioned that they would not go anywhere, but just consult with their own mothers. More than one third (36.1%) of respondents referred to friend/neighbor as source for advice, with similar rates in both provinces. Grandmother, mother-in-law and villages chief were also mentioned, but only by small percentages of respondents (6.8%, 4.3% and 2.3%, respectively). 4.9. Dietary diversity of women 15-49 years

The mean IDDS of women was 4.6 (±1.4) (Md=5, Min=1, Max=9), meaning that on average, 4.6 different food groups were consumed by women the day before the interview during the day or night, including at home or outside the home. In Kampot, the mean of dietary diversity was a bit lower than in Kampong Thom (Kampot 4.6 (±1.3) versus Kampong Thom 4.7 (±1.5)) (Annex H). Detailed information about the food group scores in each province is provided in Annex I).

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Most women consumed 5, 4, 3 or 6 food groups the day before the survey (Figure 6).

Figure 9: Number of food groups consumed by women 15-49 years

Figure 10 shows that all women consumed starchy staple foods in both provinces and the majority of them consumed flesh foods (98%), followed by other vegetables (73.7%). Dark green leafy vegetables were consumed by more than half of women (55.1%), with 49.5% in Kampot and 61.7% in Kampong Thom. Only around one third of women consumed vitamin A-rich fruits and vegetables (36.1%), other fruits (34.6%), and eggs (28.8%), nuts and seeds (14.4%), dairy products (12.1%) and beans and peas (10.6%). Overall, there were no significant differences between the two provinces in terms of prevalence of consumed food groups by women aged 15 to 49 years old.

Figure 10: Prevalence of consumed food groups by women aged 15-49 years

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In regard to MDD-W, only 53% of the women achieved a minimum dietary diversity of ≥ 5 different food groups, with 50.5% achieving MDD-W in Kampot, while 56.1% achieving MDD-W in Kampong Thom. This shows that nutrient adequacy is not achieved among almost half of the women of reproductive age in the survey area and needs to be addressed in up-coming projects. Consumption of vitamin A-rich fruits and vegetables, other fruits, eggs, nuts and seeds, dairy products and beans and peas was especially low in the survey areas. 4.10. Information on children aged 6-23 months The mean age of children between 6 and 23 months included in the survey was 13.2 (±4.7) months (Md=13, Min=6, Max=23). Half of these children were girls (50.5%) with a slightly higher percentage of girls in Kampong Thom (51.7% girls, 48.3% boys) and almost equal distribution in Kampot. 4.11. Dietary diversity of children aged 6-23 months Respondents were asked if the child was ever breastfed, how long after birth was the child first put to the breast, when mothers introduced other foods apart from breast milk, and if the child consumed breast milk the day or night prior to the interview. According to the result of the survey, breastfeeding is nearly universal (around 97%), with equal distribution in both provinces, and similar to national data of 96% (CDHS 2014). Among those who have been breastfed, more than half of them (59%) were firstly put to the breast in less than one hour after birth, with no significant differences between the two provinces, while around 41% of them were put to the breast in some hours later (with an average of 2.7 (± 3.2) hours) and even some days (with an average of 2.6 (± 1.8) days). On average, children stopped breastfeeding at the age of 13 months (12 months in Kampot and 13 months in Kampong Thom). The majority of children (89.6%) were not given anything to drink or eat after they were born and before they were put to the breast the first time, with the equal distribution in both provinces. Similarly, the majority of the children (86.5%) were not given anything apart from breastmilk within the first three days, with similar rates in both locations. More than three fourths or 76.3% of children reported having breastfed during day or at night prior to the interview, with 7.1% consumed breast milk in anyway, rather than receiving it directly from the breast (see Annex O).

Individual Dietary Diversity Score (IDDS) The mean IDDS of children 6-23 months was 3.3 (±1.2) (Md=3, Min=0, Max=6) (see Annex J). In Kampot, the IDDS was a bit lower than in Kampong Thom (Kampot 3.2 (± 1.2) versus Kampong Thom 3.4 (±1.2)). Figure 11 presents the number of food groups consumed by children (6-23 months) the day before the interview. Disaggregated according to the breastfeeding status, the mean IDDS was lower among breastfed compared with non-breastfed children (breastfed 3.4 (±1.3), non-breastfed 4.1 (±1.2)). (see Annexes K and L).

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Figure 11: Number of Food Groups consumed by children (6-23 months)

Figure 12 shows the distribution of consumed food groups among children 6-23 months. Almost all children consumed grains, roots and tubers (98%) and the majority of them consumed flesh foods (87.4%). More than half of children consumed other fruits and vegetables (53.5%), and Vitamin A-rich fruits and vegetables (50.8%). Only 13.1% of children consumed pulses and nuts and more than one fourth of children consumed eggs (26.3%). In Kampong Thom, the consumption of other fruits and vegetables and Vitamin A-rich fruit and vegetables is higher than in Kampot (55% and 55% versus 52.3% and 47.2% respectively). Likewise, the consumption of pulses and nuts in Kampong Thom is higher than in Kampot (15% versus 11.6%). However, the consumption of flesh foods in Kampot is higher than in Kampong Thom (88.9% versus 85.6%). The distribution of consumption of grains, roots and tubers, and eggs is almost equal in both provinces.

Figure 12: Prevalence of consumed food groups all children 6-23 months

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Minimum Dietary Diversity (MDD)

Less than half (46.7%) of all children (6-23 months) achieved a minimum dietary diversity equal to or above 4 different food groups consumed the day before the interview. The minimum dietary diversity achieved in Kampong Thom is slightly higher than in Kampot (49.4% versus 44.4%).

Minimum Meal Frequency (MMF)

Respondents reported that 95.2% of the children received any kind of food apart from breast milk the 24 hours before the survey, with no significant difference between the two provinces. Mean feeding frequency for children (6-23 months) was 4.5 (±1.7) times within the last day (Md=4.0, Min=1, Max=12) (see Annex M). Disaggregated according to breastfeeding status, the same distribution of breastfed and non-breastfed children (93.5% of breastfed children and 93% of non-breastfed children) achieved MMF with no significant differences between the two provinces.

Apart from food, around 79% of children were given some kinds of snack. The common snack given to the children were sweet biscuits/cookies with around one third or 34% (33.3% in Kampot and 35% in Kampong Thom), followed by fruits (17.4%), with 19.4% in Kampot and 15% in Kampong Thom and crisps/chips/ popcorn (13%), and candies/sweets (10%).

When asked whether any special meals were prepared for the children the day before the survey, only around one fourth (25.5%) of respondents reported that they did it, while up to around three fourths (74.5%) did not do it, with similar rates in both provinces. For those who did not prepare a special meal for the children, more than half of them (53.2%) reported that the children ate the food as other family members did. Moreover, the most common reason preventing them to prepare special meals for their children was lack of time, which was mentioned by 19.3%, with no difference between the two provinces, followed by no food available/no money to buy food (12.5%), with 14.7% in Kampot and 9.8% in Kampong Thom. Some 4.7% of respondents said that they did not know how to make meal specifically for children (6.1% in Kampot and 3% in Kampong Thom).

Minimum Acceptable Diet (MAD)

The WHO indicator MAD includes all children aged 6 to 23 months of age who at least received the MDD of 4 different food groups and the minimum age appropriate meal frequency apart from breast milk during the previous day. Overall, only 41.4% of all children in this age group achieved a MAD and less than half of breastfed children (48.5%). The percentage of breastfed children achieving a MAD is slightly higher in Kampong Thom than in Kampot (50.4% versus 46.8%). However, among non-breastfed children, only 17.4% of children achieved MAD, with higher percentage in Kampot than in Kampong Thom (19.5% versus 15.6%). Table 26 presents the percentage of children achieving the MMF, the MDD and the MAD.

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Table 26: Children (6-23 months) achieving MMF, MDD, and MAD

Total Kampot Kampong Thom Infant and young child feeding (IYCF) indicators (%) (%) (%) Minimum meal frequency (MMF) 93.4 94.5 92.1 breastfed 93.5 94.3 92.5 non-breastfed 93 95.1 91.1 Minimum dietary diversity (MDD) 46.7 44.4 49.4 breastfed 44.2 41.6 47.4 non-breastfed 55.7 55.8 55.6 Minimum acceptable diet (MAD) 41.4 41.2 41.6 breastfed 48.5 46.8 50.4 non-breastfed 17.4 19.5 15.6

Respondents were also asked if the child’s reported food intake the day prior to the interview was different from usual. The majority of respondents (80.3%) said that the food consumed by the child the day prior to the interview was the same as usual. In Kampot, the percentage of respondents describing unusual food consumption the day before the interview was significantly higher than in Kampong Thom (27.8% in Kampot and only 9.4% in Kampong Thom).

Respondents were further asked about some liquids that their children might have had the day prior to the survey during the day or night. According to the results, only a small percentage of children (less than ten percent) took any kinds of commercial infant formula, with similar rates in both provinces. Among those who took infant formula, an average frequency was 4.3 (± 1.9) times (Kampot = 4 (± 1.9) times and Kampong Thom = 4.7 (± 1.9) times). Similarly, only 16.7% of children took some kinds of milk products, such as tinned, powered, fresh or packed milk, with similar rates in both provinces. For those who received milk, an average frequency given the day prior to the survey was 1.9 (± 1.2) times, with 2.1 (± 1.3) times in Kampot and 1.6 (± 0.9) times in Kampong Thom. Sour milk and yoghurt were also given to the children, but only around 1 percent.

The overall low consumption of vitamin-rich foods and iron-rich foods and the low rate of children achieving a MAD show that nutrient adequacy is insufficient among the majority of that target group. Also the limited knowledge among mothers on how to nutritionally enrich porridge need to be addressed in future nutrition counselling programs. Such programs should not only provide mothers with theoretical knowledge, but also include active cooking demonstrations with locally available and diversified food that is accessible and affordable for the households.

5. CONCLUSIONS & RECOMMENDATIONS

The current nutrition baseline survey, which was conducted in March and April 2016, describes the nutrition and food security situation of households in MUSEFO project villages in the two target provinces, namely Kampot and Kampong Thom. Conclusions and related recommendations are presented in accordance to the causal model of malnutrition (UNICEF 1990) (Annex S) and its underlying as well as immediate causes of malnutrition.

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Main conclusion Recommendation

Food and nutrition security situation • It should be promoted that people participate in social and/or cash transfers programs, especially during the lean season to balance food shortages at household level. 65.4% of households were suffering from mild food insecurity, 16.9% suffering from moderate food insecurity and 0.5% were • The project should investigate in the specific causes of this suffering from severe food insecurity (HFIES- applied in the post- mild food insecurity situation (rice dependence, low income for harvest season, 4 months after harvest). The high prevalence of women, crop diversity, availability of quality food in the market, mild food insecurity is probably caused by the dependence on knowledge to buy and prepare adequate food etc.) rice as the main crop grown and the general low crop diversity. Concerning the immediate causes of malnutrition:

Food intake (food use)

Dietary diversity of children 6-23 months of age was low • Improve dietary diversity through nutrition information, (53.3% <4 food groups). On average, children in this age group education, communication (IEC)/behavioral change consumed 3.6 food groups (mainly “grains, roots and tubers”, communication (BCC): inform and communication with women “flesh foods”, “other fruits and vegetables”, and “vitamin A-rich about benefits of diversified and healthy diets empowers them fruits and vegetables”). Main sources for protein were pulses, to make healthier choices and can increase dietary diversity consumed by only 13.1% of the children, while eggs were consumed by only 26.3%. The prevalence of minimum dietary • Increase consumption of pulses and eggs: Improve the diet diversity (MDD) is 46.7%. A minimum acceptable diet (MAD) of children under two and women by providing information was achieved by 41.4% of the children under two years of age. regarding the nutritional benefits and value of pulses and eggs However, it is still too low and needs to be addressed in order

to improve nutrient adequacy and proper development of the Monitoring children. • Since levels of food insecurity are high (dietary diversity depends on the food security situation and seasonality) Dietary diversity of women is 47% (≥ 5 food groups). On regular assessment of HFIES and dietary diversity of women average, women consumed 4.6 different food groups (mainly and children (6-23 months) is recommended (sub-sample of “starchy staple foods”, “flesh foods”, and “other vegetables”. 2 villages randomly selected per province) especially since The lowest consumed food groups in the two target groups were national data for both target populations are not available. “vitamin A-rich fruits and vegetables”, “other fruits”, “eggs”, “nuts and seeds”, “dairy products” and “beans and peas”. While dairy products are expensive and require refrigeration, eggs might be easier accessible for rural households.

Health status (food utilization) • Identification and elimination of main contamination ways that might influence diarrheal infection (hygiene, water-borne The severity of shortcomings regarding the WASH sector is diseases, food safety). Ensure recognizing diarrhea as a reflected in the high prevalence and frequency of diarrhea in serious health-threat for young children (hygiene counselling, children. More than one third of the children (>38%) under two implication of health promoters at village level). Ensure that years of age were suffering from diarrhea within two weeks prior adequate treatment is available as well as ask mothers to the survey. This figure is more than twice as high as the national regularly follow their children’s growth (growth monitoring and average of 19.5% (CDHS 2014, table 14.6, page 159). On promotion). The care givers should assure that breastfeeding average, children suffered from at least 2.3 episodes of diarrhea. and food intake continues during diarrhea. Frequent episodes of diarrhea can easily lead to malnutrition and therefore have a negative impact on the development of • Nutritional and hygiene messages should be harmonized with children. the local health structures and practiced.

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Main conclusion Recommendation

Concerning the underlying causes

Availability of food through own agricultural production

Land availability was high (84.6%) in both provinces, but average landholding size is generally very low in Cambodia. • Increasing food availability at household level by identification Crop diversity was low (mean=1.3) with a high dependence and promotion of crops adapted to local conditions, especially on rice as the main crop grown (95.2%). Households in pulses, beans, peanuts, soya to encourage crop diversity for Kampong Thom seem to be less dependent on rice as staple own consumption as well as income generation. food. Cassava (15.2%) and maize (5.7%) were grown as complementary staples, while cultivation of protein-rich pulses • Measures to increase crop diversity need to consider reaching like peanuts, bean, yams with all colors and soya is also possible out to main decision makers (Who is making decisions of in the area. It seems that the condition in Kampong Thom is what to grow on the arable land?). Information on benefits of better for cassava than in Kampot. In contrast, the condition divers diets should be provided to all household member in seems better for beans in Kampot, than in Kampong Thom. order to avoid conflicts between income generation and own Home gardens and homestead are a possibility to grow consumption. vegetables and fruit for home consumption as well as for • Increasing food availability at household level by encouraging income generation, diversification of the daily diet and probably households to establish a home garden. Barriers that prevent increasing food security. Ownership of home gardens was low households from establishing home gardens and growing (41.2%) and most households with a home garden were found vegetables need to be assessed. Distribution of seed starter- in Kampong Thom (45.6%). This might also be related to the kits could encourage more households to establish a home access of irrigation (close to Tonle Sap lake) in Kampong Thom, garden with diversified production. Availability of vegetables while households in the target districts in Kampot depend mostly year-around could be increased by teaching food processing on rainwater for growing vegetables. Production of vegetables and preservation techniques. among households with home gardens was common (99.4%) and most households used the vegetables for own consumption. • Identifying and strengthening model/demonstration farmers Only small numbers of households sold them. Production of and local women’s groups around kitchen gardens could be vegetables depends on the season, but some households an entry point for introducing nutrition aspects in agriculture managed to grow vegetables year around. (nutrition-sensitive agriculture). Keeping livestock was high in the survey area (88.9%). However, only more than one third or 37.8% of livestock production was for own consumption, while 39.8% of them was for sale. This is because the main use of cow and buffalo were traditionally for labor, rather than sale or consumption purposes. • Improve the access to more income (market access, cash Access to food (income, Infrastructure and access to markets) transfer) to buy more and diverse food. Improve access to food assistance programs in the region. Food assistance in Main sources of income throughout the last year were sale of terms of distributing dry rations to households should only be crops, vegetables and fruits (37.1%), casual labor (29.8%) and discussed in case of emergencies. Avoid a conflict between petty trade/small business (16.2%), while only around 11% of generating income by selling versus consumption for nutritional the surveyed households had a regular salary. The percentage benefits especially for pulses, beans, soya and animal source of households generating income by selling agricultural products foods through increased production of these foods. Elaborate a was higher in Kampong Thom than Kampot. The close proximity strategy with local agricultural extension staff. of Kampong Thom to Tonle Sap Lake might be a reason why that is the case. • If fruit consumption is low despite availability, it would be worth to find out with the households whether conservation such The fact that there is a high level of (mild) food insecurity (65.4% as drying mangos for cash income might be a more efficient of mild food insecure and 16.9% of moderate food insecure and solution then promoting consumption. With the additional cash 0.5 of severe food insecure) indicates a strong access and/ income, high quality food could also be purchased. or availability problem of food at household level. Access to food assistance as well as social cash transfer is limited. Only • Nevertheless, high quality food items should be also promoted 6.6% of households received food assistance, and 16.2% of for usage in meals by transferring the benefits and additional households were benefitting from social cash transfer, while 5.6 nutritional value to specific household members. of households were benefiting from food for work. • Local fares to demonstrate the best nutritious and economic and the Fruit were accessible to 86.4% of the households food preparation organized by young farmers or women’s majority of households used fruit for their own consumption group at village level could have a positive effect on (84.7%). However, consumption of fruit especially among women consumption of quality food. was very low (only around one third of women consumed vitamin A-rich fruits (36.1%) and other fruits (34.6%). Between the two • Best results to promote the consumption of specific food items provinces, a difference in dietary diversity could be observed are observed when existing traditional meals and compositions in the food group “other fruits” which was higher in Kampot for of food are enriched with new items. During the community women, but higher in Kampong Thom for children. communication on nutrition, enriched meals could be given a 38 specific name as local marketing. Global Programme Food and Nutrition Security, Enhanced Resilience

Main conclusion Recommendation

Care behavior • IEC/BCC on nutrition and hygiene needs to be strengthened in The educational status of the survey participants was high the communities: compared to national data (CDHS 2014: 87.2%). However, 9.6% o nutritional and health value of diverse diets, esp. never attended school. Formal education as well as informal for children of different age groups, pregnant and education, such as nutrition and hygiene counselling, are key lactating women, needs to be communicated elements on the pathway of malnutrition. Dietary diversity is usually lower and malnutrition rates are higher if women are less o grandmothers, older female household member educated. Thus, education on nutrition and hygiene needs to be as well as fathers need to be included in the strengthened in the communities. Nutrition counselling is very counselling in order to avoid conflicts at household limited in the project area (49.7% of surveyed villages do not level have a nutrition counselling structure). Only around one fourth of the respondents had received hygiene counselling. • Invite women and men to cooking demonstrations to inform, Main care taker of children< 2 are mothers. More than 33% educate and communicate about of respondents were supported in child care by their mother o the appropriate porridge consistency or mother-in-law. Traditionally, grandmothers can have a big influence on decisions related to child feeding and general care. o maximizing dietary diversity with local resources is nearly universal in Cambodia. The assessed Breastfeeding o nutritional value and benefit of available foods (e.g. breastfeeding rates were high (>97%) and similar to national green leafy vegetables, pulses, ripe mangoes, data of 96% (CDHS 2014, table 16.2, page 179). Continued orange flesh sweet potatoes) breastfeeding after the child reaches six months of age is recommended in addition to complementary feeding. o barriers for improved food and feeding habits and how to overcome them Knowledge of appropriate complementary feeding in terms of dietary quality and consistency is a challenge. Some mothers considered watery porridge (11.6%) and Monitoring at individual level porridge bought from market (16.2%), which is low in nutrient content, as adequate for young children 6-23 months of age. Qualitative interviews may be a useful tool to get insights into Knowledge about enriching porridge was generally limited. Most the gap between knowledge and practice for project design and respondents knew only three (44.7%) types of food that would monitoring purposes. It is recommended to apply the following make porridge more nutritious, while only around one fourth tools for assessment: were aware of four (26%). Only 3.1% could mention up to five predefined types of food. Amongst different foods that were • KAP survey with subsample (2 villages randomly selected per stated to enrich porridge, animal-source foods were known by province) of actual program participants to measure direct almost all mothers, while vitamin A-rich orange flesh fruits and program impact. Knowledge levels and behavior of direct vegetables known by more than three fourths (77.8%) of the beneficiaries of the project should be assessed before they mothers and green leafy vegetable by 78%. Alarming was the enroll in the program and after they have attended the program lack of knowledge regarding energy-rich foods and pulses and (sub-sample pre- and post-knowledge quiz) nuts. Only around 6% of mothers mentioned pulses and nuts as one way to enrich porridge, while only around 33% of the • Key-informant interviews to assess barriers of behavior change respondents considered energy-rich foods as a way to enrich (sub sample) porridge. The low consumption rates of these food groups might • Attendance of program should carefully be recorded for each therefore not only be caused by low access and availability but participant including information of location (village, provinces) as well by not knowing about the nutritional value of this food and sessions attended (information can be linked with group. knowledge test) Especially during episodes of illness, appropriate child feeding is essential for convalescence and prevention of malnutrition. However, feeding behavior during episodes of illness was Monitoring at institutional level inappropriate with many respondents offering less fluids (36%) and more than half of them offering less foods (>52%) to their • Knowledge levels of direct beneficiaries of the project should children. be assessed before they enroll in the program and after they have attended the program (sub-sample pre- and post- Knowledge about causes, signs and prevention of knowledge quiz) malnutrition was very limited. The most common reason for malnutrition mentioned was lacking food in terms of quantity • Monitoring training of multipliers: (>89%). Around 17% knew that insufficient amounts of food o assess knowledge of multipliers before and after during episodes of illness can cause malnutrition (which training explains the high prevalence of inappropriate feeding practice during illness). Only 21% of the respondents mentioned that o establish feed-back and support structure for malnutrition can be caused by watery nutrient-lacking food multipliers during implementation encourage regular (which explains the preference of watery porridge). Most refresher trainings for multipliers mothers were aware that weakness and lacking energy as well as weight loss or thinness are sings of malnutrition in young children. Growth faltering which is common in this age group in Cambodia and related to low dietary diversity was only recognized as a sign of malnutrition by 14% of the respondents. Diversifying the diet of their children to prevent malnutrition was mentioned by around 55% of the mothers.

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Main conclusion Recommendation

Health services and WASH (water, sanitation, hygiene)

Throughout the survey locations, access to improved sanitation facilities was still low (55.6%). Access to improved drinking water was high year-round; however less than one fourth (24%) of the households cleaned and covered their water container or jar before using. Cleaning and covering container/ • It is highly recommended to increase the access to improved jar is the most improved way to store. Water stores under sanitation facilities. unhygienic conditions increases the risk of contamination. • IEC/BCC on basic hygiene should complement IEC/BCC for Even though all households had soap during the visits, hand improved nutrition washing with soap was not common. Hand-washing practice was generally poor. Using soap for washing children’s hands • At community level, reaching pregnant women via health was the most common practice, but the figure was relatively services seems feasible

low (42.2%). The low usage of soap for hand-washing puts the • Identification of barriers that prevent mothers and pregnant population at high risk of contracting food- and water-borne women to attend basic health service regularly diseases (see high prevalence of diarrhea).

Most children attended basic health service (health center/ clinic/hospital).

The majority of the women (87%) attended antenatal care ≥4 times during their last pregnancy.

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6. REFERENCES

FAO (2013): Guidelines for measuring household and individual dietary diversity. Rome

FAO (2014) Guidelines for assessing nutrition-related Knowledge, Attitudes and Practices available at http://www.fao.org/3/a-i3545e.pdf (accessed 28.04.2016)

FAO/FANTA (2014) Introducing the Minimum Dietary Diversity – Women (MDD-W) Global Dietary Diversity Indicator for Women. Available at: http://www.fantaproject.org/sites/default/files/resources/Introduce-MDD- W-indicator-brief-Sep2014.pdf (accessed 28.04.2016)

GIZ (2015): Guideline for Nutrition Baseline Surveys for the Global Programme Food and Nutrition Security and Enhanced Resilience. Bonn

Gross, R. et al. (1997): Guidelines for nutrition baseline surveys in communities. Version 1.2. Jakarta

National Institute of Statistics, Directorate General for Health, and ICF International (2015): Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF International.

National Institute of Statistics, Ministry of Planning (1999): General Population Census of Cambodia 2008. Phnom Penh, Cambodia.

National Institute of Statistics, Ministry of Planning (2004): General Population Census of Cambodia 2008. Phnom Penh, Cambodia.

National Institute of Statistics, Ministry of Planning (2008): General Population Census of Cambodia 2008. Phnom Penh, Cambodia.

WHO (1997): Global Database on Child Growth and Malnutrition. Available at: http://apps.who.int/iris/ bitstream/10665/63750/1/WHO_NUT_97.4.pdf (accessed 28.04.2016)

WHO (2010): Indicators for assessing infant and young child feeding practices part 2: indicators. Available at: http://www.who.int/child_adolescent_health/documents/9789241599290/en/index.html (accessed 28.04.2016)

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Annex

A. List of selected villages

Province District Commune Village Srangae Boeng Nimol Pou Dos Trapeang Chrey Chhouk Chhuok Krahung Sat Porng Sat Porng Trapeang Andong Thum Thmei Dang Tong Khcheay Cheung Prey Pork Kampot Tuol Kpos Dang Tong District Totong Trapeang Niel Damnak Sokram Ang Ropeak Prey Krang Khang Cheung Mean Rith Trapaing Chhuk Skor Tung Phnom Kong Pou Angkor Chey Prey Phdau Tani Russei Sam Roung Typo Kbal Bei O Thom Santuk Pram Pi Makara Taing Krasang Taing Krasang Vang Cheung Sang Klaing Kampong Kampong Svay Trapaing Russey Sam Raung Thom Ponarey Prey Dom Chhoeung Doeung Boeung Baray Pro Neak Tross Balaing Balaing Dong

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B. Selection of clusters proportional to population size

Accumulated Villages Total Population Population Population 119142 Mean 3610 Number of Villages 33 Random number 1596 Srangae 1,368 1,368 Pou Dos 1,511 5,020 Prey Krang Khang Cheung 1,106 8,058 Trapaing Chhuk 1,912 12,386 Trapeang Chrey 1,933 16,817 Krahung 1,089 17,906 Sat Porng 5,380 23,286 Trapeang Andong 2,670 27,313 Thum Thmei 2,189 30,855 Khcheay Cheung 743 33,715 Prey Pork 688 37,698 Tuol Kpos 714 41,162 Trapeang Niel 1,184 45,187 Ang Ropeak 1,065 48,289 Skor Tung 646 52,214 Pou 2,328 56,365 Prey Phdau 1,597 59,288 Russei 1,092 63,075 Sam Roung 243 66,532 Kbal Bei 348 70,127 O Thom 1,187 73,672 Sam Raung 506 76,977 Pram Pi Makara 1,268 82,147 Taing Krasang 1,497 85,047 Vang Cheung 1,225 88,367 Sang Klaing 1,841 92,479 Ponarey 1,576 95,250 Prey Dom 962 99,006 Boeung 848 102,296 Pro Neak 2,002 105,164 Tross 5,079 110,243 Balaing 1,186 113,652 Dong 1,439 117,421

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C. Overview of interventions in Kampot and Kampong Thom, Cambodia, under the Global Programme

Name of the Capacity Development for health Interpersonal Communication and Capacity Development for Farmers intervention personnel Community involvement Household members especially 200 advisory actors (midwives, nurses, WRA (20.000) and caregivers, Target Group 200 key farmers carers etc.) farmers (13.000), community multipliers (vhsg, CCWC, etc.) Increased awareness of Awareness and knowledge of balanced The competence of key farmers to households of the importance of a Main Objective diet and importance of hygiene by health diversify agricultural cultivation has diversified production and balanced services has increased increased diet • increased capacity of community multipliers to pass on their knowledge on nutrition, • increased capacity of 200 • Improved capacities of health agriculture and hygiene key farmers to diversify their advisory actors to provide advisory agricultural production • improved knowledge of service on nutrition and hygiene especially WRA and caregivers Expected • revised and adapted training • Revised and adapted training to provide a balanced diet for outcomes material on MPF that include handbook and courses themselves, their children under nutrition 2 and their families • group of trainers established and • exchanging best practices updated on new training program • increased capacity of farmers through exchange visits to diversify their (homestead) food production and to pass this on Analyzing the current situation as well as multiplier performance Assessing the training needs and and capacity through a community revising and adapting existing training Selection of key farmers with the help quick assessment. Establish material. A group of trainers will be of village general meetings. Existing training modules on agriculture, Intervention established and trained according to the training material is adapted and key nutrition and hygiene for community updated training program. This group farmers are trained in learning groups multipliers and train these. of trainers will train health advisory with the use of the training material. Partners for community activities providers (nurses, midwives, carers) In this scope, exchange visits are are identified and capacitated. on diversified diet, hygiene and growth organised to show best practices. Community activities are monitoring. implemented with the support of these partners and sub-contracted NGOs. • Supervision and monitoring of • Coaching and follow-up visits community activities • training participation • Coaching and mentoring • training participation • questionnaires for self- • training participation • Assessment (KAP Survey) Monitoring and evaluation Evaluation • questionnaires for self-evaluation • Survey of the advisory actors on the application and expansion of • possibly interviews • possibly interviews their services • spot survey on nutrition • possibly interviews knowledge

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Name of the Mass Communication on agriculture, Improvement of farm production Scaling Up Multi-Purpose Farms intervention nutrition and hygiene Household members especially WRA 200 key farmers, 2000 cooperating Target Group (20.000) and caregivers, farmers 200 key farmers farmers (13.000) Diversity of food production on Diversity of food production in the Increase awareness of household the farms of key farmers has target region has improved, so that members of the importance of a Main Objective improved so that sufficient, nutritious sufficient, nutritious and diversified diversified diet, basic hygiene and and diversified food is available food is available in the 2 provinces organic agriculture throughout the year. throughout the year.

• Increased awareness and improved • MPF is disseminated to knowledge at community level of cooperating farmers, increasing a balanced and adequate diet, • Increased capacity to incorporate their competence to diversify diversified food production and different elements into the farm their food production hygiene such as vegetable and food • inclusion of success stories production, animal husbandry, fish • participation in 4 national into adapted demonstration Expected growing etc. campaigns for the events: World material outcomes Breastfeeding Week, National • sharing good practices within • set-up of demonstration farms Nutrition Day, Pesticide Impact learning groups Campaign, Global Handwashing Day • knowledge sharing through • documentation of successful learning groups, Field Days, • Effective cooperation with stories farmer competitions and use of stakeholders for contributing in existing structures at community campaigns level Adapt existing demonstration The situation of the selected key material on MPF, include success farmers is assessed and their For each campaign approx. the stories and disseminate. For contribution is defined in a farmer same procedure is used. MUSEFO knowledge dissemination and contract. Agricultural input is provided will only contribute with its input and experience sharing, demonstration to the farmer according to the farmer experiences to existing campaigns. For farms are set-up and inter- Intervention contract. Capacity of the farmers are this, contributions are identified during provincial exchange visits are further increased in learning groups meetings with responsible stakeholders organized. Further events to share where best practices are shared and which are further planned in technical knowledge are learning groups, farm plans including a farm business meetings at provincial meetings and training, Field Days, etc. On the plan are set up. Putting the farm internally. For the events, IEC material other hand, existing structures on planning into practice is accompanied and activities are developed. community level for experience by advisory service, coaching and sharing are used and cooperation follow-up. with other projects supported. • coaching and follow-up • Spot survey (baseline, endline) on • project documentation • project documentation Monitoring and nutrition knowledge • event/training participation • workshop participation Evaluation • observation/participation during • spot survey (baseline, endline) event • spot survey (baseline, endline) on agricultural production on agricultural production

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D. Training Agenda of NBS Enumerator Training

Enumerator and Supervisor Training Phnom Penh, Cambodia 14/03/2016 – 18/03/2016 Agenda

Monday Topic 14/032016 Opening remarks 08:30 SBK GIZ Introduction Introduction of survey team and enumerators (incl. the role assigned) Icebreaker Overview of Training Objective, Workshop Agenda How do we work for the next five days? Overview of MUSEFO (as part of SEWOH) 10:30 – 10:45 Coffee/Tea break 10:45 Overview of the questionnaire Review questionnaire (English and Khmer) Questions and answers to the questionnaire 12:30 - 13:30 Lunch break Review questionnaire (English and Khmer) 13:30 Questions and answers to the questionnaire 15:00 Coffee/Tea break Review questionnaire (English and Khmer) 15:15 Questions and answers to the questionnaire 16:45 Wrap up of day, feedback 17:00 End of the workshop day

Tuesday Topic 15/03.2016 08:30 Briefing of day’s agenda, group warm up, Review questionnaire (English and Khmer) 08:45 Questions and answers to the questionnaire 10:45 – 11:00 Coffee/Tea break How to conduct an interview (rapport building, how to approach people, how to obtain consent) Completing a questionnaire: what is important Practice questionnaire in pairs (excluding 24h-recalls) 12:30 Lunch break Practice questionnaire in pairs (excluding 24h-recalls), cont.

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Experience exchange on practice of questionnaire 15:00 – 15:15 Coffee/Tea break Child Dietary diversity and Women Dietary diversity – introduction to relevant food groups, 15:15 identification of common local foods from each group 16:45 Wrap up of day – what did we learn? Feedback 17:00 End of the workshop day

Wednesday Topic 16/03/2016 08:30 – 08:45 Briefing of day’s agenda, group warm up, clarifying questions How to conduct 24h dietary recall: What is important? 08:45 – 10:45 Presentation of some examples Women dietary diversity and Child Dietary diversity practice in small groups 10:45 – 11:00 Coffee/Tea break 11:00 Introduction to tablets 11:30 Practice of questionnaire in pairs groups using the tablets 12:30 – 13:30 Lunch break Group discussion: Clarifying questions on questionnaire and other questions 13:30 Finalizing the questionnaire guide for the field 15:30 – 15:45 Coffee/Tea break 15:45 Practice questionnaire in pairs groups using the tablets 16:15 Preparation for field testing, incl. Selection of household and respondent Roles/responsibilities of team members (team leader, Supervisors and data collectors Logistics 17:15 Wrap up, feedback 17:30 End of the workshop day

Thursday Topic 17/03/2016 Departure for pre-test in Sre Ampil and Preak Svay II in Cheu Teal Commune, Kean Svay 08:00 District, Kandal Province à 3 interview per team of enumerators 13:30 Coming back from the field (lunch package in the car), coffee break in Phnom Penh Completing the task: What to do at the end of the data 15:00 Review in pairs, supported by supervisor Data transfer 17:00 End of the field work day

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Friday 18/03/2016 Topic Lessons Learned Review in pairs, supported by supervisor: Discussion of experience during the pre-test, fol- 08:30 low-up on challenges Data transfer 12:30 – 13:30 Lunch break Presentation of adjusted questionnaire 13:30 If necessary adjustment of questionnaire guide 15:30 Coffee/Tea break 15:45 Overview of logistics for data collection period 16:45 – 17:00 Wrap-up of the training 17:00 End of the workshop training and closing

Next steps

Saturday Topic 19/03/2016

Sunday Topic 20/03/2016 Travel to the field for data collection (detailed program in separate sheet)

E. Nutrition Baseline Survey Interview Guide - Cambodia

The role of an enumerator:

You are responsible for interviewing mothers in the villages selected for the NBS. You have to collect and record data as accurately as possible. You should always follow the NBS Enumerator Guideline and NBS Questionnaire Guide. All problems have to be reported to the supervisor (Ms. Dany, Mr. Makara, Mr. Tekngun) or team leader (Mr. Amry)

Why an enumerator pair?

All interviews for the NBS will be conducted by an enumerator pair. Interviewer 1 will interview the mothers while Interviewer 2 will record the answers with the tablet/questionnaire.

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How to handle the tablet?

Every day during the period of data collection, a tablet will be handed out to Interviewer 2. At the end of each day, the tablet has to be given back to the supervisors. Interviewer 2 will always get the same tablet and it is her/his duty to handle the tablet responsibly and carefully. The tablet should only be switched on shortly before the interview and has to be put on plane mode after the interview. Turn on GPS at least 5mn before the interview. Turn off Wi-Fi and turn off the sound of the tablet to save battery. The tablet is only to be used for data collection. It is strictly forbidden to use it for any private purposes, to connect it to other electronic devices or to connect it to the internet.

How to prepare for the interview?

Carefully review the questionnaire and be absolutely clear about what you are going to ask during the interview. Make sure you know the reason behind every question. If you are unsure, check the Questionnaire Guide or consult with your supervisor.

Think about what sort of answers you might expect to the questions you will be asking.

Prepare your survey bag with the following supplies:

• 2 pens (blue colour) • picture of the three types of porridge • Excel sheets on age of children from 6 to 23 months, and age of women from 15 to 49 years old • Consent form • Shorthand notebook • NBS Enumerator Guideline and NBS Questionnaire Guide • Tablet • Paper questionnaires in Khmer and English • Your mobile phone and airtime (airtime will be provided)

How to approach the household?

Always begin the interview by introducing yourself, your partner and the NBS to the family: who are you, your names, from where, which project do you work for? Use the first minutes with the family to build rapport. It is important that the family feels comfortable with you and trusts you.

Please clarify:

Whether this family has a mother (15-49 years of age) with a child aged 6 to 23 months.

• Inform the family about the duration: - 1 hour interview • Inform the family that no direct benefits will be given. • Tell the respondent that she has the right of anonymity and that her responses are treated confidentially. Ask politely for cooperation. Use the “Consent Form” as a guideline for this conversation.

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How to conduct the interview:

Maintain the confidentiality and privacy of the mother/participant. Try to find somewhere where the mother/ caregiver and child can sit comfortably. If there are onlookers around, politely ask them to leave.

Be neutral throughout the interview: never laugh about, compliment or correct an answer. Do not imply that some answers are better than others. Never lead a respondent to a specific answer or assume or anticipate a response.

Speak loudly, clearly and in a respectful manner. Be patient and let the respondent finish.

Do not change the wording or sequence of questions. Ask each question exactly as it is written since even slight variations in wording may affect responses. Don’t use English words in the questions, except when necessary such as program/NGO names.

If the respondent remains silent after a particularly question is asked, repeat the question exactly as it is written. Always handle hesitant respondents tactfully. If the respondent is refusing to give an answer to a specific question continue with the next question.

How to use the tablet:

Carefully type identity number of Interviewer 1 and identity number (Interviewer 2) at the beginning of the interview. Once you have confirmed the presence of a mother and a child in the right age group in the household, fill in the required information about the location. Communicate to Interviewer 1 as soon as you are ready. The tablet will guide you from question to question following the questions that Interviewer 1 is asking the mother. Carefully listen to the answers and tick them accordingly.

How to fill in the questionnaire:

If the tablet is not working and you are too far away from your supervisor (back-up tablet) you have to record the responses using the printed questionnaire.

The questionnaire will be filled in line by line by Interviewer 2 while Interviewer 1 conducts the interview. None of the lines is optional!

Write clearly and not too small, use a blue pen. Remember that all numbers should be recorded using the following system:

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If you made a mistake, correct it clearly!

The questions in the columns have a logical connection with each other. Pay attention while filling them in. Follow the “Skip”. F. Quality Control Protocol for Interviewer

Interviewer 1: ______Date: ______

Interviewer 2: ______Supervisor: ______

DID INTERVIEWER 1. . . YES NO Introduce himself/herself and interviewer 2 correctly? Informed the respondent about purpose, duration etc. at the beginning of the interview and get permission without coercion? Put the cell phone on silent and did not interrupt the interview to take calls? Speak clearly during the interview? Have neutral facial expressions/body language (did not react positively or negatively to the respondent’s answers)? Does not start giving instructions to apparently wrong answers or behavior? Refrain from asking leading questions that might have influenced the respondent’s answers? Read the questions exactly as they were written? Repeat the questions exactly as worded when the respondent gave a response that was not very clear? Use probes when the response still was not very clear? Write legibly on the questionnaire (24h-recalls!!!)? Follow the skip patterns correctly? Read responses aloud when he/she was supposed to? Prompt the mother for all answers (say “Anything else?”) for questions that allow multiple responses especially the 24h-recalls? Thank the respondent for the time spent and involvement in the survey? Discuss with interviewer 2 the household observations

DID INTERVIEWER 2… YES NO Put the cell phone on silent and did not interrupt the interview to take calls? Communicate that he/she is ready to record the answers at the beginning of the interview Thank the respondent for the time spent and involvement in the survey? Copy the information from both 24h recalls after the interview Discuss with interviewer 1 the household observations

On a scale of 1 (needs more training) to 10 (excellent), I rate the interviewer’s performance during this interview as follows (circle one):

1 2 3 4 5 6 7 8 9 10

Other Comments/Plan of Action for Making Improvements: 51 Global Programme Food and Nutrition Security, Enhanced Resilience

G. Distribution of Household size

Total Kampot Kampong Thom (N=396) Mean 5.0 4.8 5.3 Md 5.0 5.0 5.0 SD 1.6 1.3 1.8 Min 3.0 3.0 3.0 Max 15.0 10.0 15.0

H. Individual Dietary Diversity Score – Women (IDDS-W)

Total Kampot Kampong Thom (N=396) Mean 4.6 4.6 4.7 Md 5.0 5.0 5.0 SD 1.4 1.3 1.5 Min 1.0 2.0 1.0 Max 9.0 9.0 9.0

I. Food Group Score – Women

Total Kampot Kampong Thom

(N=396) (%) (%) 1 0.3 0.0 0.6 2 4.3 3.7 5.0 3 18.9 19.9 17.8 4 23.5 25.9 20.6 5 25.5 26.4 24.4 6 19.2 17.1 21.7 7 6.1 5.1 7.2 8 1.8 1.4 2.2 9 0.5 0.5 0.6

52 Global Programme Food and Nutrition Security, Enhanced Resilience

J. Individual Dietary Diversity Score – all children 6-23 months

Total Kampot Kampong Thom (N=396) Mean 3.3 3.2 3.4 SD 1.2 1.2 1.2 Md 3.0 3.0 3.0 Min 0.0 0.0 0.0 Max 6.0 6.0 6.0

K. Individual Dietary Diversity Score – breastfed children 6-23 months

Total Kampot Kampong Thom (N=396) Mean 3.4 3.4 3.5 Md 3.0 3.0 4.0 SD 1.3 1.3 1.4 Min 0.0 0.0 0.0 Max 7.0 6.0 7.0

L. Individual Dietary Diversity Score – non- breastfed children 6-23 months

Total Kampot Kampong Thom (N=396) Mean 4.1 4.1 4.1 Md 4.0 4.0 4.0 SD 1.2 1.1 1.2 Min 1.0 1.0 2.0 Max 7.0 6.0 7.0

53 Global Programme Food and Nutrition Security, Enhanced Resilience

M. Feeding Frequency – children 6-23 months

Total Kampot Kampong Thom (N=396) Mean 4.5 4.7 4.4 Md 4.0 4.0 4.0 SD 1.7 1.8 1.7 Min 1.0 2.0 1.0 Max 12.0 12.0 10.0

54 Global Programme Food and Nutrition Security, Enhanced Resilience

N. Questionnaire

Date: Name of Mother/ Caregiver: Name of Child: ID Interviewer 1 |_|_|, ID Interviewer 2 |_|_|, Date: ______

Name of Mother: ______

Name of Child: ______

ID Interviewer 1 |_|_|, ID Interviewer 2 |_|_|

Identity Number of the household |_| |_| |_|_| |_|_| |_|_| |_|

Province District Commune Village Household Child

I. Demographic and socio-economic information 1 Please note the birth date of the child (as per as birth certificate, family book or BIRTHDAT vaccination card) |_|_| |_|_| |_|_|_|_| Day Month Year 2 What is your year of birth or age in years? A Record year of birth BDATEMO 88= don’t know |_|_|_|_| Year B Record age in years AGEMO 88= don’t know |_|_| 3 What is your marital status? 1= married HEADMAR 2= widowed |_|_| 3= divorced or separated 4= single 99= other (specify): 4 What is the sex of the household head? 1= male HEADHH 2= female |_| 5 How many people live permanently in your household? HHMEMNO Record total number of household members |_|_| 6 What is the highest level of school you attended: 0= no schooling à Q7 EDUCLEV primary, secondary, or higher? 1= primary |_| 2= secondary 3= more than secondary 6a How many years did you completed at that level? EDUCYEAR Record number of years completed at that |_|_| level of schooling 7 What is the highest level of school the head of the 0= no schooling àQ8 EDUCHH household attended: primary, secondary, or higher? 1= primary |_|_| 2= secondary 3= more than secondary 4= respondent is head of household àQ8 88= don’t know àQ8 7a How many years did the household head completed at EDUCHHY that level? Record number of years completed at that |_|_| level of schooling 88 = don’t know 8 What are the main sources of 1= sale of own produced crops, vegetables, fruits income of your household 2= sale of own produced animals and animal products INCYEARA |_|_| throughout the year? 3= sale of fish and seafood 4= sale of own produced goods/crafts (Do not read out the options! Record 5= casual labor INCYEARB up to 3 with priority) 6= petty trade / small business |_|_| 7= employment/salary 8= remittances from relatives/husband 9= none INCYEARC |_|_| 88= don’t know 99= other (specify): ______

55 Global Programme Food and Nutrition Security, Enhanced Resilience

9 Does any member of this household have access to any land that 0= no à Q11 HHLAND can be used for agriculture? 1= yes |_| 10 Which crops (apart from fruit trees) did your household grow on the land? 0= no, 1= yes List as many as relevant to the household. 88= don’t know a Rice RICE |_|_| b Maize MAIZE |_|_| c Cassava CASS |_|_| d Peanuts GNUT |_|_| e Beans BEAN |_|_| f Soya SOYA |_|_| g Yam (all colours) YAM |_|_| h CSPEC Other (Specify):______|_|_| 0= no àIf no, go to Q 14 HOMEGAR 11 Do you have a home garden? 1= yes |_| 0= no à Q 14 GROVEG Do you grow vegetables in your home garden? 1= yes, but only during the wet season 12o 2= yes, but only during the dry season |_| 3= yes, year-round 13 What kind of vegetables do you grow? 0= no, 1= yes, List as many as relevant to the household. 88= don’t know a Cucumber VCUCUMB |_|_| b Tomato VTOMATO |_|_| c Morning glory VMORNIN |_|_| d Mustard VMUSTAR |_|_| e Cabbage VCABBAG |_|_| f Cauliflower VCAULIF |_|_| g Egg plants VEGGPL |_|_| h Gourd VGOURD |_|_| i Squash/pumpkin VPUMPK |_|_| j Radish VRADISH |_|_| k Green beans VGRBEAN |_|_| l Carrot VCARROT |_|_| m NNong |_|_| n Herb (all kinds) VHERB |_|_| o VSPEC Other (Specify):______|_|_| 13a What is the main use of the vegetables produced? 1= mainly own consumption USEVEG 2= mainly for sale |_|_| 3= both (in approx. equal amounts) 99= other (specify):

56 Global Programme Food and Nutrition Security, Enhanced Resilience

14 Do you have any fruit or fruit trees at your homestead? 0= no à Q16 GARFRUIT 1= yes |_| What kind of fruits or fruit trees do you grow? 0= no, 1= yes, 14a List as many as relevant to the household. 88= don’t know Banana FBANANA |_|_| Jackfruit FJACKFR |_|_| Pineapple FPINAPP |_|_| Coconut FCOCON |_|_| Papaya FPAPAYA |_|_| Guava FGUAVE |_|_| Mango FMANGO |_|_| Longan FLONGAN |_|_| Milk fruit FMILKFRUIT |_|_| FSPEC Other (Specify):______|_|_| 15 What is the main use of the fruits produced? 1= mainly own consumption USEFRUIT 2= mainly for sale |_|_| 3= both (in approx. equal amounts) 99= other (specify): ______16 Does this household own any livestock herds, or farm animals, 0= no à Q18 ANIMALS or poultry, fish or other aquatic animals? 1= yes |_| What type of farm animals/ livestock/ other aquatic animals is reared in this household? 0= no, 1= yes 16a List as many as relevant to the household. 88= don’t know Buffalo BUFFALO |_|_| Cow COW |_|_| Pig PIG |_|_| Goat, sheep GOASHEE |_|_| Dog DOG |_|_| Poultry (duck, chicken, geese, fowl) POULTRY |_|_| Fish FISH |_|_| Other aquatic animals (frogs, eels) AQUATIC |_|_| ANSPEC Other (Specify):______|_|_| 17 What is the main use of the animals reared? 1= mainly own consumption USEANIM 2= mainly for sale |_|_| 3= both (in approx. equal amounts) 99= other (specify): Do you or any other family member of your household participate in any of the following programs: 0= no, 1= yes 18 (Read) 88= don’t know

School feeding SCHOOLF |_|_| Agricultural development support program AGRDEV |_|_| Information, education, communication about food security and nutrition IECFNS |_|_|

57 Global Programme Food and Nutrition Security, Enhanced Resilience

Cash transfer (incl. cash for work, health equity fund for P1 and P2) CASHTRA |_|_| Food assistance FOODAID |_|_| Food for work FOODAS |_|_| SUPPSPEC Other (specify):______: |_|_|

II. Sanitation and Hygiene Information 19 What is the main source of drinking 1= piped water into dwelling, to yard or plot, public DRINKWAW water for members of your tap/standpipe, tubewell / borehole, protected dug well, |_|_| household during the wet season? protected spring, rainwater collection 2= unprotected spring, unprotected dug well, cart with small tank/drum, surface water (river, stream, dam, lake, pond, canal, irrigation channel) 3= tanker truck, bottled water

99= other (specify):

20 What is the main source of drinking 1= piped water into dwelling, to yard or plot, public DRINKWAD water for members of your tap/standpipe, tubewell / borehole, protected dug well, |_|_| household during the dry season? protected spring, rainwater collection 2= unprotected spring, unprotected dug well, cart with small tank/drum, surface water (river, stream, dam, lake, pond, canal, irrigation channel) 3= tanker truck, bottled water

99= other (specify):

21 How do you store drinking water in your 1= clean container or jar WSTORE household? 2= covered container or jar |_|_| 3= clean and covered container or jar 4= unclean container or jar 5= uncovered container or jar 6= unclean and uncovered container or jar 7= no container or jar 88= don’t know 99= other (specify):______22 Do you do anything to your water before drinking? 0= no If no, go to à Q23 TREATWA1 1= yes |_|_| 88= don’t know 22a What do you usually do to the drinking water? 0= nothing TREATWA2 (Only one option is possible) 1= boil it |_|_| 2= add bleach/chlorine 3= strain it through a cloth 4= use a water filter (ceramic, sand, composite, etc.) 5= use solar disinfection 6= let it stand and settle 7= Add traditional medicine 88= don’t know 99= other (specify): ______23 What kind of toilet facility do members of your 1= Flush toilet, piped sewer system, septic LATRINE household usually use? tank, flush/pour flush to pit latrine, pit |_|_| latrine with slab, composting toilet Observe if there is any toilet facility in the (improved toilet facility) homestead 2= Flush/ pour flush to elsewhere, pit latrine without slab/open pit, bucket, hanging toilet/hanging latrine, (unimproved toilet facility)

58 Global Programme Food and Nutrition Security, Enhanced Resilience

3= No facilities or bush or field (open defecation)

99= other (specify):

III. Household Food Insecurity Experience Scale 24 Now I would like to ask you some questions about food. a During the last MONTH/30 days, was there a time when you were 0= no HFIESA worried that you would not have enough food to eat because of 1= yes |_|_| a lack of money or other resources? 88 = don’t know 98= refused/no answer b Still thinking about the last MONTH/30 days, was there a time 0= no HFIESB when you were unable to eat healthy and nutritious food 1= yes |_|_| because of a lack of money or other resources 88 = don’t know 98= refused/no answer c You ate only a few kinds of foods (low variety) because of a lack 0= no HFIESC of money or other resources 1= yes |_|_| 88 = don’t know 98= refused/no answer

d You had to skip a meal because there was not enough money or 0= no HFIESD other resources to get food 1= yes |_|_| 88 = don’t know 98= refused/no answer e Still thinking about the last MONTH/30 days, was there a time 0= no HFIESE when you ate less than you thought you should because of a 1= yes |_|_| lack of money or other resources 88 = don’t know 98= refused/no answer f Your household ran out of food because of a lack of money or 0= no HFIESF other resources 1= yes |_|_| 88 = don’t know 98= refused/no answer g You or others in your household were hungry but did not eat 0= no à If no, go to Qi HFIESG because there was not enough money or other resources for food 1= yes |_|_| 88 = don’t know If no, go to à Qi 98= refused/no answer h In the last MONTH/30 days, how often did it happen that you or 1= Only once or twice HFIESH others in your household were hungry but did not eat because 2= In some weeks but not every |_|_| there was not enough money or other resources for food? Did this week 3= Almost every week happen only once or twice, in some weeks but not every week, or 88= Don’t Know almost every week? 98= refused/no answer

Note: If respondent says this did not happen in the last MONTH, go back to Qg and code as "No" [code 0]. 0= did not happen

i In the last MONTH/30 days, was there a time when you or others 0= no à If no, go to Q25 HFIESI in your household went without eating for a whole day because 1= yes |_|_| of a lack of money or other resources? 88 = don’t know If no, go to à Q25 98= refused/no answer j In the last MONTH/30 days, how often did it happen that you or 1= Only once or twice HFIESJ others in your household went without eating for a whole day 2= In some weeks but not every |_|_| because of a lack of money or other resources? Did this happen week 3= Almost every week only once or twice, in some weeks but not every week, or almost 88= Don’t Know every week? 98= refused/no answer

Note: If respondent says this did not happen in the last MONTH, go back to Qi and code as "No" [code 0]. 0= did not happen

IV. Child Information

59 3= No facilities or bush or field (open defecation)

99= other (specify):

III. Household Food Insecurity Experience Scale 24 Now I would like to ask you some questions about food. a During the last MONTH/30 days, was there a time when you were 0= no HFIESA worried that you would not have enough food to eat because of 1= yes |_|_| a lack of money or other resources? 88 = don’t know 98= refused/no answer b Still thinking about the last MONTH/30 days, was there a time 0= no HFIESB when you were unable to eat healthy and nutritious food 1= yes |_|_| because of a lack of money or other resources 88 = don’t know 98= refused/no answer c You ate only a few kinds of foods (low variety) because of a lack 0= no HFIESC of money or other resources 1= yes |_|_| 88 = don’t know 98= refused/no answer

d You had to skip a meal because there was not enough money or 0= no HFIESD other resources to get food 1= yes |_|_| 88 = don’t know 98= refused/no answer e Still thinking about the last MONTH/30 days, was there a time 0= no HFIESE when you ate less than you thought you should because of a 1= yes |_|_| lack of money or other resources 88 = don’t know 98= refused/no answer f Your household ran out of food because of a lack of money or 0= no HFIESF other resources 1= yes |_|_| 88 = don’t know 98= refused/no answer g You or others in your household were hungry but did not eat 0= no à If no, go to Qi HFIESG because there was not enough money or other resources for food 1= yes |_|_| 88 = don’t know If no, go to à Qi 98= refused/no answer h In the last MONTH/30 days, how often did it happen that you or 1= Only once or twice HFIESH others in your household were hungry but did not eat because 2= In some weeks but not every |_|_| there was not enough money or other resources for food? Did this week 3= Almost every week happen only once or twice, in some weeks but not every week, or 88= Don’t Know almost every week? 98= refused/no answer

Note: If respondent says this did not happen in the last MONTH, go back to Qg and code as "No" [code 0]. 0= did not happen

i In the last MONTH/30 days, was there a time when you or others 0= no à If no, go to Q25 HFIESI in your household went without eating for a whole day because 1= yes |_|_| of a lack of money or other resources? 88 = don’t know If no, go to à Q25 98= refused/no answer j In the last MONTH/30 days, how often did it happen that you or 1= Only once or twice HFIESJ others in your household went without eating for a whole day 2= In some weeks but not every |_|_| because of a lack of money or other resources? Did this happen week 3= Almost every week only once or twice, in some weeks but not every week, or almost Global Programme Food and Nutrition Security, Enhanced88= Resilience Don’t Know every week? 98= refused/no answer

Note: If respondent says this did not happen in the last MONTH, go back to Qi and code as "No" [code 0]. 0= did not happen

IV. Child Information

Is your child a boy or a girl? 1 = male SEXCHILD 25 2 = female |_| Information on breastfeeding, child care and liquids consumed 26 Has (name of child) ever been breastfed? 0= no à Q27 IBFQ10 1= yes |_|_| 88= don’t know a How long after birth was (name of child) first put <1 hour = 00 à Q26b RECCOL1 to the breast? <1 hour|_|_| Only one option is possible! Hours (01- below 24 hours after birth) à RECCOL2 Q26b Hours|_|_| Days (record number of days) RECCOL3 Days|_|_| 88= don’t know RECCOL4 |_|_| b At what age did you stop breastfeeding (name of child) Record age in months AGEBFST 77= not yet stop |_|_| c After (name of child) was born and before he/she was put to the breast 0= no PLF the first time, was he/she given anything to drink or eat? 1= yes |_|_| 88= don’t know d Was (name of child) given anything apart from breast milk within the first 0= no ESPF 3 days? 1= yes |_|_| 88= don’t know 27 Was (name of the child) breastfed yesterday during day or at night? 0= no IYCFQ7 1= yes |_|_| 88= don’t know 27a Did (name of child) consume breast milk in any other way yesterday 0= no IYCFQ7A during the day or at night? e. g. by spoon, cup or bottle; by his/her 1= yes |_|_| mother or another woman? 88= don’t know 28 Who is supporting you in taking care of (name of child)? 0= respondent alone CARESUP 1= mother/mother-in-law |_|_| 2= older siblings of child 3= Spouse/ other male relative 4= other female relative 99=Other (specify):______28a Who was taking care of (name of child) yesterday? 0= respondent alone CAREYES 1= mother/mother-in-law |_| 2= older siblings of child 3= Spouse or other male relative 4= other female relative 99=Other (specify):______29a Now I would like to ask you about some liquids that (name of child) may have had yesterday during the day or night. RECORD: Did (name of child) have any….. 0= no, 1= yes, Read each item aloud and record response before proceeding to the next item. 88= don’t know A Infant formula such as Dutch Baby Grow, Physiolac, Similac for children, …? IYCFQ10B (Ask the mother to show you the product and take note) |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11B child) consume infant formula? |_|_| IYCFQ10C B Tinned, powdered, fresh or packed milk? |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11C child) consume milk tinned, powdered, fresh or packed milk? |_|_| IYCFQ10F C Sour milk, yoghurt? |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11F child) consume milk or yoghurt? |_|_|

V. Minimum Dietary Diversity Children

29b Please describe everything that (name of child) ate yesterday during the day or night, whether at home or outside the home. (a) Think about when (name of child) first woke up yesterday. Did (name of child) eat anything at that time? If Yes, please tell me

60 Is your child a boy or a girl? 1 = male SEXCHILD 25 2 = female |_| Information on breastfeeding, child care and liquids consumed 26 Has (name of child) ever been breastfed? 0= no à Q27 IBFQ10 1= yes |_|_| 88= don’t know a How long after birth was (name of child) first put <1 hour = 00 à Q26b RECCOL1 to the breast? <1 hour|_|_| Only one option is possible! Hours (01- below 24 hours after birth) à RECCOL2 Q26b Hours|_|_| Days (record number of days) RECCOL3 Days|_|_| 88= don’t know RECCOL4 |_|_| b At what age did you stop breastfeeding (name of child) Record age in months AGEBFST 77= not yet stop |_|_| c After (name of child) was born and before he/she was put to the breast 0= no PLF the first time, was he/she given anything to drink or eat? 1= yes |_|_| 88= don’t know d Was (name of child) given anything apart from breast milk within the first 0= no ESPF 3 days? 1= yes |_|_| 88= don’t know 27 Was (name of the child) breastfed yesterday during day or at night? 0= no IYCFQ7 1= yes |_|_| 88= don’t know 27a Did (name of child) consume breast milk in any other way yesterday 0= no IYCFQ7A during the day or at night? e. g. by spoon, cup or bottle; by his/her 1= yes |_|_| mother or another woman? 88= don’t know 28 Who is supporting you in taking care of (name of child)? 0= respondent alone CARESUP 1= mother/mother-in-law |_|_| 2= older siblings of child 3= Spouse/ other male relative 4= other female relative 99=Other (specify):______28a Who was taking care of (name of child) yesterday? 0= respondent alone CAREYES 1= mother/mother-in-law |_| 2= older siblings of child 3= Spouse or other male relative 4= other female relative 99=Other (specify):______29a Now I would like to ask you about some liquids that (name of child) may have had yesterday during the day or night. RECORD: Did (name of child) have any….. 0= no, 1= yes, Read each item aloud and record response before proceeding to the next item. 88= don’t know A Infant formula such as Dutch Baby Grow, Physiolac, Similac for children, …? IYCFQ10B (Ask the mother to show you the product and take note) |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11B child) consume infant formula? |_|_| IYCFQ10C B Tinned, powdered, fresh or packed milk? |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11C child) consume milk tinned, powdered, fresh or packed milk? |_|_| Global Programme Food and Nutrition Security, Enhanced Resilience IYCFQ10F C Sour milk, yoghurt? |_|_| If yes, how many times yesterday during the day or at night did (name of IYCFQ11F child) consume milk or yoghurt? |_|_|

V. Minimum Dietary Diversity Children

29b Please describe everything that (name of child) ate yesterday during the day or night, whether at home or outside the home. (a) Think about when (name of child) first woke up yesterday. Did (name of child) eat anything at that time? If Yes, please tell me

everything (name of child) ate at that time. Probe Anything else? Then continue to question b b) What else did (name of child) eat after that? Did (name of child) eat anything at that time? If yes, please tell me everything that (name of child) ate at that time. Probe: Anything else? First food after waking up?

Anything else?

Anything else?

Anything else?

Anything else?

If food was consumed =1, If food was not consumed=0 a) Cereals: Porridge, rice, corn, bread, noodles, spaghetti, or other any food made from IYCFQ12A |_| grains/cereals b) Orange fleshed roots/tubers or vegetables Pumpkin, carrots, yellow sweet potatoes or sweet IYCFQ12B |_| potatoes that are yellow or orange inside c) White roots and tubers: White potatoes, white yams, cassava, lotus root or any other foods made IYCFQ12C |_| from roots d) Dark green leafy vegetables: Any dark green leafy vegetables including wild green vegetables IYCFQ12D like cassava leaves, pumpkin leaves, mustard, spinach, morning glory, garlic chives, incl. wild green |_| leafy vegetables (slek prech, slek bas, slek m’rom, slek ngob, p’ty), and other local varieties e) Orange fleshed fruits: Ripe mangoes, ripe paw paw and other local vitamin A-rich fruits IYCFQ12E |_| f) Other vegetables and fruits: Any other fruits or vegetables including wild fruits and vegetables like IYCFQ12F cabbage, mushrooms, eggplants, tomatoes, onions, green pepper, green beans, oranges, lemons, |_| tangerines, bananas, coconut flesh, watermelon, reddish, yam, bamboo shoot, sprouts, jackfruit, nnong, trolach, winter melon, long beans, cauliflower, cucumber, green papaya (not ripe papaya) g) Organ meat: Organ meats including liver, kidney, heart, stomach, lung, gizzard, pancreas, IYCFQ12G |_| intestine, blood, blood-based foods or other organ meats h) Flesh meat: Any meat, such as beef, pork, lamb, goat, chicken, mice, rats, dog, snake, turtle, IYCFQ12H |_| rabbits, ducks, fowls, geese i) Eggs: Eggs from any kind of birds IYCFQ12I |_| j) Fish: Fresh or dried fish, shellfish, or sea foods, pa’ork, fish paste (prohok) IYCFQ12J |_| k) Pulses, nuts and seeds: Any foods made from beans, peas, soya, peanuts (peanuts groundnut IYCFQ12K |_| flower), tree-nuts, or seeds including sunflower seeds, sesame seeds, pumpkin seeds, cashew nuts, Lactasoy l) Milk and milk-products: Milk, cheese, yoghurt or other dairy products IYCFQ12L |_| m) Oils/Fats: Oil, fats or butter added to food or used for cooking, including extracted oils from nuts, IYCFQ12M |_| fruits and seeds, and all animal fat (incl. fat from pigs) n) Sugar and sweets: Any sugary foods such as chocolates, sugar, honey, sweets, candies, cakes, IYCFQ12N |_| or biscuits, sugarcane juice, sugar palm juice, sugar palm, ice-cream o) Condiments: Condiments/ Ingredients used in small amounts for flavor, such as chilies, pepper, IYCFQ12O |_| ginger, spices, herbs, lemongrass, fish sauce or fish powder, soya sauce, salt, lime/lemon, MSG, preserved reddish, soybean paste, fish paste (prohok), vinegar, garlic, galanga

VI. Minimum Meal Frequency

30c Did (name of child) receive anything to eat/any kind of food 0= no If no, go to à Q 32 IYCFQ13 1= yes yesterday? |_|_| 88= don’t know If no, go to à Q 32

61 Global Programme Food and Nutrition Security, Enhanced Resilience

31 How many times did (name of child) receive food including Record number of times IYCFQ14 88= don’t know meals and snacks yesterday? |_|_|

VII. Feeding Habits 32 Was (name of child)’s feeding yesterday different from usual? 0= no CFUSUAL 1= yes |_|_ 88= don’t know | 33 How old was (name of child) when you first gave other food Record age in months CFAGE apart from breast milk? |_|_ 88= don’t know 77= does not yet take food | a What is the most common snack you give to your child? 0= no snacks SNACKS 1= fruits |_|_ 2= sweet biscuits / cookies 3= crisps / chips / popcorn | 4= candies/ sweets 88= don’t know 99= other (specify): b Did you prepare any meals especially for (name of child) yesterday? 0= no SPMEAL For interviewer: special meal is a meal (any type of food, not only Bobor 1= yes à Q 34 |_| Khab Krop Kroeung) which was not consumed among other family members and was cooked to feed the child only. c What prevented you to prepare special 1= don’t know how to do àQ 34 SPMPREV 2= lack of time à meals for (name of child) yesterday? Q 34 |_|_ 3= no food available/ no money to buy food à Q 33d | 4= family food àQ 34 5= child not yet eating 99= other (specify): ______àQ 34 d If 3 = no food available/no money to buy food: What kind of food was not available?

34 Please look at this picture of porridges: 1= Borbor Khab Krop Kroeung CONSIST Which one would you give to a young child? 2= Borbor Kroeung |_|_ 3= Borbor Sor 88= don’t know | 34a Please tell me some ways to make porridge more nutritious or better for your baby’s health. 0= no, 1= yes, Probe if necessary: Which foods or types of food can be added to rice porridge to make it more 88= don’t know nutritious? Do not read the answers, Check all that applies Animal-source foods (meat, poultry, fish, liver/organ meat, eggs, milk etc.) ADANIM |_|_ | Pulses and nuts: flours of groundnut and other legumes (peas, soya, etc.), sunflower seed ADPULS |_|_ | Orange (vitamin A rich) fruits and vegetables (carrot, orange-fleshed sweet potato, yellow ADVITA pumpkin, mango, papaya, etc.) |_|_ | Green leafy vegetables (e.g. spinach) ADLVEG |_|_ | Energy-rich foods (e.g. oil, butter) ADFAT |_|_ |

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GROSPEC Other (specify):______|_|_ | 35 When (name of child) is sick, is he/she given less than usual, 1= much less ILLDRINK about the same amount, more than usual or nothing to drink 2= somewhat less |_|_ (including breast milk)? 3= about the same 4= more | If less, PROBE: Was he/she given much less than usual to 5= nothing drink or somewhat less? 6= child never been sick 88= don’t know 36 When (name of child) is sick, is he/she given less food than 1= much less ILLEAT usual, about the same amount, more than usual or nothing to 2= somewhat less |_|_ eat? 3= about the same 4= more | If less, PROBE: Was he/she given much less than usual to 5= nothing, stopped food eat or somewhat less? 6= child never been sick 7= does not yet take food 88 = don’t know 37 Has (name of child) had diarrhea in the past two weeks? 0= no CHDIAR 1= yes |_|_ 88= don’t know | 38 In the last six month, how many times has (name of child) Record number of diarrhea FREQDIA suffered from diarrhea episodes? episodes |_|_ 88= don’t know | a Can you tell me what causes diarrhea? 0= no àQ38b CAUSDIA 1= yes |_| Do not read aloud the list, probe for further responses. More than one answer possible. RECORD: 0= no, 1= yes Contaminated food CAUSDIA1 |_| Contaminated water CAUSDIA2 |_| Contaminated hands CAUSDIA3 |_| Flies CAUSDIA4 |_| CAUSDIA5 Other (specify):______|_| b Can you name anything you can do to help prevent you child 0= no àQ38c PREVDIA from getting diarrhea? 1= yes |_| Do not read aloud the list, probe for further responses. More than one answer possible. RECORD: 0= no, 1= yes Washing hands PREVDIA1 |_| Use latrine or bury feces PREVDIA2 |_| Boil or filter drinking water PREVDIA3 |_| Exclusive breast feeding PREVDIA4 |_| Protect food and water supplies with cover PREVDIA5 |_| PREVDIA6 Other (specify):______|_| c Whom do you ask for advice when you have a question about feeding your child? RECORD: Do not read out the list, probe for further responses. More than one answer possible. 0= no, 1= yes Health professional (Health worker, NRU/Health poste, hospital) IFSUPP1 |_| Own mother IFSUPP2 |_|

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Own mother in law IFSUPP3 |_| Own grandmother IFSUPP4 |_| Village chief IFSUPP5 |_| Friend/neighbor IFSUPP6 |_| IFSUPP7 Other (specify):______|_| 39 How can you recognize that someone is not eating enough food? 0= no, 1= yes, Probe if necessary: What are the signs of undernutrition? 88=don’t know Do not read the answers, Check all that applies. Lack of energy/weakness: cannot work, study or play as normal (disability) RECMAL1 |_|_ | Weakness of the immune system (becomes ill easily or becomes seriously ill) RECMAL2 |_|_ | Loss of weight/thinness RECMAL3 |_|_ | Children do not grow as they should (growth faltering) RECMAL4 |_|_ |

Others (Specify): ______|_|_| 40 0= no, 1= yes, What are some of the reasons why people are malnourished? 88=don’t know Do not read the answers, Check all that applies Not getting enough food REAMAL1 |_|_| Food is watery, does not contain enough nutrients REAMAL2 |_|_| Disease/ill and not eating food REAMAL3 |_|_| REAMALSP Other ( Specify)______|_|_| 41 What should we do to prevent malnutrition among young children (6–23 months) 0= no, 1= yes, Do not read the answers, Check all that applies 88=don’t know Give more food PRVMAL1 |_|_| Give different types of food each day PRVMAL2 |_|_| Feed frequently PRVMAL3 |_|_| Give attention during meals PRVMAL4 |_|_| Go to the health center/hospital and check that the child is growing (growth monitoring services) PRVMAL5 |_|_|

Others (Specify)______|_|_|

42 Do you have a counseling structure for nutrition in your 0= no NUSTRUC1 1= Health center village? |_|_| 2= volunteer group (mother to mother NUSTRUC2 If yes, which one? support groups) |_|_| (All options are possible) 3= agricultural extension service (development agents) NUSTRUC3 |_|_|

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88= don’t know NUSTRUCS 99= Others, (specify):______P |_|_| 43 Do you receive any nutrition counseling? 0= no NUCOUN 1= Health center |_|_ If yes, from where/ from whom? 2= volunteer group (mother to mother support groups) (Name the most important one) 3= agricultural extension service | (development agents) 99= Others, specify:______44 Have you participated in any cooking demonstration in 0= no, If no, go to à Q 45 CODEMON 1= yes the past six months? |_|

44a Do you think it helped you to improve both your 0= No IKDEMON 1= Yes, just the knowledge |_| knowledge and feeding practices? 2= Yes, just the practice 3= Yes, both

VIII. Women (Mother) Information 45 How many times did you receive antenatal care during the Record number of times ANTECAR pregnancy with (name of child)? 88= don’t know |_|_|

a What should we do to ensure proper nutrition of pregnant women? 0= no, 1= yes, Do not read the answers, Check all that applies 88=don’t know Nothing specific (eating as usual) NUTPREG1 |_|_| Give more food NUTPREG2 |_|_| Give different types of food each day NUTPREG3 |_|_| Feed frequently NUTPREG4 |_|_| Go to the health center/hospital and check that the mother is gaining weight properly NUTPREG5 |_|_| NUTPREG Others (Specify)______SP |_|_| b What should we do to ensure proper nutrition of lactating women? 0= no, 1= yes, Do not read the answers, Check all that applies 88=don’t know Nothing specific (eating as usual) NUTLACT1 |_|_| Give more food NUTLACT2 |_|_| Give different types of food each day NUTLACT3 |_|_| Feed frequently NUTLACT4 |_|_| Go to the health center/hospital and check that the child of the lactating mother is gaining weight NUTLACT5 properly |_|_| NUTLACTS Others (Specify)______P |_|_| 46 How many times did you go to the health center/clinic/hospital Record number of times UNDER5 with (name of child) since the child was born? 88= don’t know |_|_| Does your household have soap (or washing powder/ liquid) at 47 present? 0= no, 1=yes, 88= don’t HHSOAP |_|_| Ask her to show you the soap. know 47a When you used soap today or yesterday, what did you use it for? If “for washing my hands” is mentioned, probe what was the occasion, but do not read the answers! (Do not read the answers, ask to be specific, encourage “what else” until nothing further is mentioned and check all that applies) RECORD: 0= no, 1= yes Washing my children’s hands WCHILDH 1= yes |_|

88= don’t know

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Washing hands after visiting the toilet (defecation) WCHILDD |_| Washing hands after cleaning child (after child defecation) WAFTERC |_| Washing hands before feeding child WBEFFED |_| Washing hands before preparing food WBEFFOO D |_| Washing hands before eating WBEFEAT |_| Washing body, hair, clothes, dishes and pots, cleaning the house WBODY |_|

Others (Specify)______

48 Did you ever receive any hygiene counseling? 0= no HWCOUN 1= yes |_|_| 88= don’t know

IX. MDD-W (Minimum Dietary Diversity – Women)

49 Please describe everything that you ate yesterday during the day or night, whether at home or outside the home. (a) Think about when you first woke up yesterday. Did you eat anything at that time? If Yes, please tell me everything Then continue to question b b) What else did you eat after that? Go from possible meal/snack to meal/snack and complete the list Anything else? First food after waking up?

Anything else?

Anything else?

Anything else?

Anything else?

Anything else?

Anything else?

If food was consumed =1, If food was not consumed=0 a) Cereals: Rice, corn, bread, noodles, spaghetti or other any food made from grains/cereals? IWDDS |_| A b) White roots and tubers: White potatoes, white yams, cassava, lotus root or any other IWDDS |_| foods made from roots B c)Pulses: Any foods made from beans, peas, lentils, soya, Lactasoy IWDDS |_|

mum 15g = 1 C i

d) Nuts and seeds: Any foods made from peanuts (peanuts groundnut flower), tree-nuts, or IWDDS |_| seeds including sunflower seeds, sesame seeds, pumpkin seeds, cashew nuts D spoon e e) Milk and milk-products: Milk, cheese, yoghurt or other dairy products IWDDS |_| ties!!!!! Minties!!!!! i E Tabl f) Organ meat: Organ meets including liver, kidney, heart, stomach, lung, gizzard, pancreas, IWDDS uant |_| intestine, blood, blood-based foods or other organ meats F g) Flesh meat: Any meat, such as beef, pork, lamb, goat, chicken, mice, rats, dog, snake, IWDDS |_| turtle, rabbits, ducks, fowls, geese G Consider q Consider h) Fish: Fresh or dried fish, shellfish, or sea foods, pa’ork, fish paste (prohok) IWDDS |_| H

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i) Eggs: Eggs from any kind of birds IWDDSI |_| j) Dark green leafy vegetables: Any dark green leafy vegetables including wild green IWDDS |_| vegetables like cassava leaves, pumpkin leaves, mustard, spinach, morning glory, garlic J chives and other local varieties (slek prech, slek bas, slek m’rom, slek ngob, p’ty) k) Orange roots/tubers or vegetables: Pumpkin, carrots, yellow sweet potatoes or sweet IWDDS |_| potatoes that are yellow or orange inside K l) Orange fleshed fruits: Ripe mangoes, ripe paw paw and other local vitamin A-rich fruits IWDDS |_| L m) Other vegetables: like cabbage, mushrooms, bamboo shoot, sprouts, eggplants, IWDDS |_| tomatoes, onions, green pepper, green beans, reddish, yam bean, young jackfruit, nnong, M trolach, winter melon (young), long beans, cauliflower, cucumber, green papaya (not ripe papaya) n) Other fruits: oranges, lemons, tangerines, bananas, coconut flesh, watermelon, jackfruit, IWDDS |_| winter melon N o) Insects: Any edible insects such as termites, grasshoppers, crickets IWDDS |_| O p) Oils/ fats: Oil, fats or butter added to food or used for cooking, including extracted oils from nuts, IWDDS |_| fruits and seeds, and all animal fat P q) Fried snacks: Crisps and chips, fried potatoes, fried dough, other fried snacks IWDDS |_| Q r) Sugar and sugary foods: Any sugary foods such as chocolates, sugar, honey, sweets, candies, IWDDS |_| cakes, or biscuits, sugarcane juice, sugar palm juice, sugar palm, ice-cream R s) Sweet drinks or alcoholic beverages Sweetened fruit juice or juice-drinks, soft drinks/fizzy drinks IWDDS |_| like, fanta, coca cola, sprite, chocolate drinks, tea or coffee with sugar etc. S t) Condiments: Condiments/ Ingredients used in small amounts for flavor, such as chilies, pepper, IWDDS |_| ginger, spices, herbs, lemongrass, fish sauce or fish powder, soya sauce salt, lime/lemon, MSG, T preserved reddish, soybean paste, fish paste (prohok), vinegar, garlic, galanga

Thank the mother for her time and cooperation.

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O. Results disaggregated by provinces

The following table presents the answers to the questions following the questionnaire. The answers are disaggregated by the two provinces.

Total Kampot Kampong Thom N=396 N=216 N=180 Demographic data 1 Age of child Mean 13.2 13.0 13.4 SD 4.7 4.7 4.7 Md 13.0 13.0 13.0 Min 6.0 6.0 6.0 Max 23.0 23.0 23.0

2 What is your age in years? Mean 28.8 28.3 29.3 SD 5.8 5.4 6.2 Md 29.0 28.0 29.0 Min 19.0 19.0 19.0 Max 49.0 44.0 49.0

3 What is your marital status? Married 96.7 97.7 95.6 Widowed 1.5 1.4 1.7 Divorced or Separated 1.8 0.9 2.8

4 What is the sex of the household head? Male 90.7 89.4 92.2 Female 9.3 10.6 7.8

5 How many people live permanently in your household? Mean 5.0 4.8 5.3 SD 1.6 1.3 1.8 Md 5.0 5.0 5.0 Min 3.0 3.0 3.0 Max 15.0 10.0 15.0

6 What is the highest level of school you attended? No schooling 9.6 7.9 11.7 Primary 48.5 44.4 53.3 Secondary 40.4 46.3 33.3 More than Secondary 1.5 1.4 1.7

6a How many years did you completed at that level?

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Mean 3.6 3.6 3.7 SD 1.8 1.8 1.8 Md 4.0 4.0 4.0 Min 1.0 1.0 1.0 Max 10.0 6.0 10.0

What is the highest level of school the head of the household attended: primary, secondary or 7 higher? No schooling 8.3 22.2 14.6 Primary 32.4 33.3 32.8 Secondary 45.4 28.3 37.6 More than secondary 3.7 3.9 3.8 Respondent is head of

household 3.2 0.6 2.0 Don’t know 6.9 11.7 9.1

7a How many years did the household head completed at that level? Mean 3.7 3.5 4.0 SD 2.0 1.8 2.2 Md 4.0 3.0 4.0 Min 1.0 1.0 1.0 Max 16.0 6.0 16.0

What the main sources of income of your household throughout the year? (3 answers possible 8 with answers in order of priority) Sale of own produced crops, vegetables, fruits No priority 40.2 36.6 44.4 1st priority 37.1 34.3 40.6 2nd priority 18.9 24.5 12.2 3rd priority 3.8 4.6 2.8 Sale of own produced animals and animal products No priority 73.0 63.9 83.9 1st priority 3.3 5.1 1.1 2nd priority 10.9 13.9 7.2 3rd priority 12.9 17.1 7.8 Sale of fish and

seafood No priority 97.2 99.1 95.0 1st priority 0.3 0.0 0.6 2nd priority 1.8 0.9 2.8 3rd priority 0.8 0.0 1.7 Sale of own produced

goods/crafts

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No priority 97.7 96.8 0.0 1st priority 1.0 1.9 0.0 2nd priority 0.8 0.9 0.6 3rd priority 0.5 0.5 0.6 Casual labor No priority 42.2 45.8 37.8 1st priority 29.8 28.2 31.7 2nd priority 25.3 22.7 28.3 3rd priority 2.8 3.2 2.2 Petty trade / small

business No priority 69.9 74.1 65.0 1st priority 16.2 14.4 18.3 2nd priority 10.4 8.3 12.8 3rd priority 3.5 3.2 3.9 Employment/salary No priority 83.8 81.5 86.7 1st priority 11.1 13.9 7.8 2nd priority 3.8 3.7 3.9 3rd priority 1.3 0.9 1.7 Remittances from

relatives/husband No priority 98.0 98.1 97.8 1st priority 0.3 0.5 0.0 2nd priority 0.5 0.5 0.6 3rd priority 1.3 0.9 1.7

9 Does any member of this household have access to any land that can be used for agriculture? No 15.4 9.3 22.8 Yes 84.6 90.7 77.2

10 Which crops (apart from fruit trees) did your household grow on the land? Rice No 4.8 2.0 8.6 Yes 95.2 98.0 91.4 Maize No 93.1 91.3 95.7 Yes 5.7 8.2 2.2 Don‘t know 1.2 0.5 2.2 Cassava No 83.9 96.4 66.2 Yes 15.2 3.1 32.4 Don‘t know 0.9 0.5 1.4 Peanuts No 94.3 92.9 96.4 Yes 4.5 6.6 1.4

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Don‘t know 1.2 0.5 2.2 Beans No 91.3 86.7 97.8 Yes 7.5 12.8 0.0 Don‘t know 1.2 0.5 2.2 Soya No 97.9 98.0 97.8 Yes 0.9 1.5 0.0 Don‘t know 1.2 0.5 2.2 Yam (all colours) No 96.4 95.4 97.8 Yes 2.4 4.1 0.0 Don‘t know 1.2 0.5 2.2

11 Do you have a home garden? No 58.8 62.5 54.4 Yes 41.2 37.5 45.6

12 Do you grow vegetables in your home garden? No 0.6 1.2 0.0 Yes 99.4 98.8 100.0

13 What kind of vegetables do you grow? Cucumber No 76.5 66.3 86.6 Yes 21.6 32.5 11.0 Don‘t know 1.9 1.3 2.4 Tomato No 96.9 98.8 95.1 Yes 1.2 0.0 2.4 Don‘t know 1.9 1.3 2.4 Morning glory No 45.1 53.8 36.6 Yes 54.9 46.3 63.4 Mustard No 71.0 73.8 68.3 Yes 27.2 25.0 29.3 Don‘t know 1.9 1.3 2.4 Cabbage No 96.9 96.3 97.6 Yes 0.6 1.3 0.0 Don‘t know 2.5 2.5 2.4 Cauliflower No 96.9 98.8 95.1 Yes 0.6 0.0 1.2 Don‘t know 2.5 1.3 3.7

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Egg plants No 74.7 93.8 56.1 Yes 23.5 5.0 41.5 Don‘t know 1.9 1.3 2.4 Gourd No 81.5 93.8 69.5 Yes 17.3 5.0 29.3 Don‘t know 1.2 1.3 1.2 Squash/pumpkin No 60.5 51.3 69.5 Yes 37.0 47.5 26.8 Don‘t know 2.5 1.3 3.7 Radish No 96.9 98.8 95.1 Yes 0.6 0.0 1.2 Don‘t know 2.5 1.3 3.7 Green beans No 93.2 90.0 96.3 Yes 4.3 8.8 0.0 Don‘t know 2.5 1.3 3.7 Carrot No 97.5 98.8 96.3 Don‘t know 2.5 1.3 3.7 NNong No 37.7 46.3 29.3 Yes 61.7 53.8 69.5 Don‘t know 0.6 0.0 1.2 Herb (all kinds) No 74.7 81.3 68.3 Yes 24.1 17.5 30.5 Don‘t know 1.2 1.3 1.2

13a What is the main use of the vegetables produced? Mainly own

consumption 77.8 76.3 79.3 Mainly for sale 11.7 12.5 11.0 Both (in approx. equal

amounts) 10.5 11.3 9.8

14 Do you have any fruit or fruit trees at your homestead? No 13.6 9.3 18.9 Yes 86.4 90.7 81.1

14a What kind of fruits or fruit trees do you grow? Banana No 30.1 27.6 33.6

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Yes 69.9 72.4 66.4 Jackfruit No 78.7 82.1 74.0 Yes 21.3 17.9 26.0 Pineapple No 93.3 97.4 87.7 Yes 6.4 2.6 11.6 Don‘t know 0.3 0.0 0.7 Coconut No 25.1 16.3 37.0 Yes 74.9 83.7 63.0 Papaya No 67.5 74.5 58.2 Yes 32.5 25.5 41.8 Guava No 79.8 77.6 82.9 Yes 19.6 22.4 15.8 Don‘t know 0.6 0.0 1.4 Mango No 19.6 17.3 22.6 Yes 80.4 82.7 77.4 Longan No 96.5 96.4 96.6 Yes 2.6 3.1 2.1 Don‘t know 0.9 0.5 1.4 Milk fruit No 84.8 88.8 79.5 Yes 14.9 11.2 19.9 Don‘t know 0.3 0.0 0.7

15 What is the main use of the fruits produced? Mainly own

consumption 88.3 84.7 93.2 Mainly for sale 6.1 7.7 4.1 Both (in approx. equal

amounts) 5.6 7.7 2.7 Does this household own any livestock herds or farm animals or poultryor fish or other aquatic 16 animals? No 11.1 7.9 15.0 Yes 88.9 92.1 85.0

16a What type of farm animals/livestock/other aquatic animals is reared in this household? Buffalo No 97.4 100.0 94.1 Yes 2.6 0.0 5.9 Cow

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No 44.3 35.2 56.2 Yes 55.7 64.8 43.8 Pig No 82.7 77.4 89.5 Yes 17.3 22.6 10.5 Goat, sheep No 100.0 100.0 100.0 Dog No 90.9 87.9 94.8 Yes 9.1 12.1 5.2 Poultry (duck,

chicken, geese, fowl) No 2.8 0.5 5.9 Yes 97.2 99.5 94.1 Fish No 99.1 98.5 100.0 Yes 0.9 1.5 0.0 Other aquatic animals

(frogs, eels) No 99.4 99.0 100.0 Yes 0.6 1.0 0.0

17 What is the main use of the animals reared? Mainly own

consumption 37.8 28.1 50.3 Mainly for sale 39.8 48.7 28.1 Both (in approx. equal

amounts) 21.9 22.6 20.9 Other 0.6 0.5 0.7

Do you or any other family member of your household participate in any of the following 18 programs? School feeding No 80.1 89.8 68.3 Yes 15.2 5.1 27.2 Don‘t know 4.8 5.1 4.4 Agricultural development support program No 69.2 69.4 68.9 Yes 26.0 25.5 26.7 Don‘t know 4.8 5.1 4.4 Information, education, communication about food security and nutrition

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No 76.8 84.7 67.2 Yes 18.4 10.2 28.3 Don‘t know 4.8 5.1 4.4 Cash transfer (incl. cash for work, health

equity fund for P1 and P2) No 79.0 82.4 75.0 Yes 16.2 12.5 20.6 Don‘t know 4.8 5.1 4.4 Food assistance No 88.6 91.7 85.0 Yes 6.6 3.2 10.6 Don‘t know 4.8 5.1 4.4 Food for work No 89.6 90.3 88.9 Yes 5.6 4.6 6.7 Don‘t know 4.8 5.1 4.4

19 What is the main source of drinking water for members of your household during the wet season? Piped water into … 89.4 84.7 95.0 Unprotected spring, … 9.1 14.4 2.8 Tanker truck, … 1.5 0.9 2.2

20 What is the main source of drinking water for members of your household during the dry season? Piped water into … 75.5 60.2 93.9 Unprotected spring, … 21.2 36.6 2.8 Tanker truck .… 3.3 3.2 3.3

21 How do you store drinking water in your household? Clean container or jar 3.0 2.3 3.9 Covered container or jar 40.2 56.0 21.1 Clean and covered

container or jar 24.2 32.4 14.4 Unclean container or jar 1.3 1.9 0.6 Uncovered container

or jar 8.8 5.1 13.3 Unclean and uncovered

container or jar 0.3 0.5 0.0 No container or jar 19.4 1.4 41.1 Other 2.8 0.5 5.6

22 Do you do anything to your water before drinking? No 25.8 32.9 17.2 Yes 74.2 67.1 82.8

22a What do you usually do to the drinking water?

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Boil it 65.3 93.8 37.6 Use a water filter 33.0 6.2 59.1 Let it stand an settle 1.4 0.0 2.7 Other 0.3 0.0 0.7

23 What kind of toilet facility do members of your household usually use? Flush toilet, … 55.6 55.1 56.1 Flush/pour flush, … 7.8 6.9 8.9 No facilities or … 35.6 38.0 32.8 Other 1.0 0.0 2.2

24 Now I would like to ask you some questions about food: During the last MONTH/30 days, was there a time when you were worried a that you would not have enough food to eat because of a lack of money or other resources? No 20.5 25.0 15.0 Yes 79.5 75.0 85.0 Still thinking about the last MONTH/30 days, was there a time when you were unable to eat b healthy and nutritious food because of a lack of money or other resources No 50.8 54.2 46.7 Yes 49.2 45.8 53.3 You ate only a few kinds of foods (low c variety) because of a lack of money or other resources No 63.4 65.7 60.6 Yes 36.6 34.3 39.4 You had to skip a meal because there was d not enough money or other resources to get food No 97.5 96.8 98.3 Yes 2.5 3.2 1.7

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Still thinking about the last MONTH/30 days, was there a time when you ate less e than you thought you should because of a lack of money or other resources No 75.5 70.8 81.1 Yes 24.5 29.2 18.9 Your household ran out of food because f of a lack of money or other resources No 97.5 97.7 97.2 Yes 2.5 2.3 2.8 You or others in your household were hungry but did not eat g because there was not enough money or other resources for food No 97.0 95.4 98.9 Yes 3.0 4.6 1.1 In the last MONTH/30 days, how often did it happen that you or others in your household were hungry but did not eat because there was h not enough money or other resources for food? Did this happen only once or twice, in some weeks but not every week, or almost every week? Only once or twice 50.0 50.0 50.0 In some weeks but not

every week 41.7 40.0 50.0 Almost every week 8.3 10.0 0.0

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In the last MONTH/30 days, was there a time when you or others in your household went i without eating for a whole day because of a lack of money or other resources? No 99.2 99.1 99.4 Yes 0.8 0.9 0.6 In the last MONTH/30 days, how often did it happen that you or others in your household went without eating for a whole day because j of a lack of money or other resources? Did this happen only once or twice, in some weeks but not every week, or almost every week? Only once or twice 66.7 100.0 0.0 In some weeks but not

every week 33.3 0.0 100.0

25 Is your child a boy or a girl? Male 49.5 50.5 48.3 Female 50.5 49.5 51.7

26 Has (name of child) ever been breastfed? No 2.5 2.3 2.8 Yes 97.5 97.7 97.2

26a How Long after birth was (name of children) first put to the breast? <1 hour no 40.93 43.60 37.71 yes 59.07 56.40 62.29 Hours 1 41.67 47.76 33.96 2 30.00 26.87 33.96 3 11.67 13.43 9.43 4 5.00 5.97 3.77 6 4.17 2.99 5.66 7 0.83 0.00 1.89

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8 0.83 1.49 0.00 9 0.83 1.49 0.00 10 0.83 0.00 1.89 12 1.67 0.00 3.77 16 0.83 0.00 1.89 18 1.67 0.00 3.77

Mean 2.7 2.1 3.5 SD 3.2 1.6 4.3 Md 2.0 2.0 2.0 Min 1.0 1.0 1.0 Max 18.0 9.0 18.0

Days 1 31.58 30.77 33.33 2 26.32 23.08 33.33 3 28.95 34.62 16.67 5 2.63 3.85 0.00 7 10.53 7.69 16.67

Mean 2.6 2.5 2.7 SD 1.8 1.7 2.1 Md 2.0 2.0 2.0 Min 1.0 1.0 1.0 Max 7.0 7.0 7.0

26b At what age did you stop breastfeeding (name of child) 0 0.52 0.95 0.00 1 0.78 0.47 1.14 2 0.52 0.47 0.57 3 0.52 0.47 0.57 4 0.78 0.95 0.57 5 0.26 0.00 0.57 6 0.26 0.00 0.57 7 0.26 0.47 0.00 8 0.52 0.95 0.00 9 0.26 0.47 0.00 10 0.52 0.00 1.14 11 1.30 0.47 2.29 12 1.81 1.90 1.71 13 1.30 1.90 0.57 14 0.78 0.95 0.57 15 0.52 0.00 1.14 16 1.81 1.42 2.29 17 2.07 0.47 4.00 18 2.33 2.84 1.71

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19 0.52 0.00 1.14 20 1.81 1.90 1.71 Not yet stop 80.57 82.94 77.71

Mean 12.7 12.2 13.2 SD 5.9 6.2 5.6 Md 14.0 13.0 15.0 Min 0.0 0.0 1.0 Max 20.0 20.0 20.0

After (name of child) was born and before he/she was put to the breast the first time, was he/she 26c given anything to drink or eat? No 89.64 89.57 89.71 Yes 10.36 10.43 10.29

26d Was (name of child) given anything apart from breast milk within the first 3 days? No 86.53 86.73 86.29 Yes 13.47 13.27 13.71

27 Was (name of the child) breastfed yesterday during day or at night? No 23.7 21.3 26.7 Yes 76.3 78.7 73.3

Did (name of child) consume breast milk in any other way yesterday during the day or at night? e. 27a g. by spoon, cup or bottle; by his/her mother or another woman? No 92.9 88.9 97.8 Yes 7.1 11.1 2.2

28 Who is supporting you in taking care of (name of child)? Respondent alone 41.2 41.2 41.1 Mother/mother-in-law 33.1 34.7 31.1 Older siblings of child 4.5 3.7 5.6 Spouse/ other male

relative 13.9 13.0 15.0 Other female relative 6.8 6.9 6.7 Other 0.5 0.5 0.6

28a Who was taking care of (name of child) yesterday? Respondent alone 89.9 88.0 92.2 Mother/mother-in-law 7.6 8.8 6.1 Older siblings of child 0.3 0.5 0.0 Spouse/ other male

relative 1.0 1.4 0.6 Other female relative 1.3 1.4 1.1

29a Now I would like to ask you about some liquids that (name of children) may have had yesterday…

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A Infant formula such as…? No 90.66 89.81 91.67 Yes 9.34 10.19 8.33 If yes, how many times yesterday… 1 5.41 4.55 6.67 2 5.41 9.09 0.00 3 35.14 40.91 26.67 4 16.22 18.18 13.33 5 10.81 9.09 13.33 6 10.81 4.55 20.00 7 10.81 9.09 13.33 8 2.70 0.00 6.67 9 2.70 4.55 0.00

Mean 4.3 4.0 4.7 SD 1.9 1.9 1.9 Md 4.0 3.0 5.0 Min 1.0 1.0 1.0 Max 9.0 9.0 8.0

Tinned, powdered, fresh or … No 83.33 82.41 84.44 Yes 16.67 17.59 15.56 If yes, how many times yesterday… 1 50.00 44.74 57.14 2 27.27 23.68 32.14 3 13.64 21.05 3.57 4 6.06 5.26 7.14 6 3.03 5.26 0.00

Mean 1.9 2.1 1.6 SD 1.2 1.3 0.9 Md 1.5 2.0 1.0 Min 1.0 1.0 1.0 Max 6.0 6.0 4.0

Sour milk, yoghurt? No 98.99 99.07 98.89 Yes 1.01 0.93 1.11

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If yes, how many times yesterday during the day or at night did (name of child) consume milk or yoghurt? 1 50.00 50.00 50.00 2 25.00 50.00 0.00 3 25.00 0.00 50.00

–29b Please describe everything that (name of child) ate yesterday… Cereals No 2.0 2.8 1.1 Yes 98.0 97.2 98.9 Orange fleshed roots/

tubers or vegetables No 78.8 79.2 78.3 Yes 21.2 20.8 21.7 White roots and

tubers No 94.4 94.0 95.0 Yes 5.6 6.0 5.0 Dark green leafy

vegetables No 63.1 71.8 52.8 Yes 36.9 28.2 47.2 Orange fleshed fruits No 87.9 88.4 87.2 Yes 12.1 11.6 12.8 Other vegetables and

fruits No 46.5 47.7 45.0 Yes 53.5 52.3 55.0 Organ meat No 85.4 87.5 82.8 Yes 14.6 12.5 17.2 Flesh meat No 33.8 31.5 36.7 Yes 66.2 68.5 63.3 Eggs No 73.7 73.1 74.4 Yes 26.3 26.9 25.6 Fish No 33.3 34.7 31.7 Yes 66.7 65.3 68.3 Pulses, nuts and

seeds

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No 86.9 88.4 85.0 Yes 13.1 11.6 15.0 Milk and milk-products No 78.0 77.8 78.3 Yes 22.0 22.2 21.7 Oils/Fats No 46.5 47.7 45.0 Yes 53.5 52.3 55.0 Sugar and sweets No 28.5 26.4 31.1 Yes 71.5 73.6 68.9 Condiments No 4.3 5.1 3.3 Yes 95.7 94.9 96.7

Individual Dietary Diversity Score (IDDS) - non-breastfed child Mean 3.6 3.5 3.6 SD 1.2 1.1 1.3 Md 4.0 4.0 4.0 Min 0.0 0.0 1.0 Max 6.0 6.0 6.0

Individual Dietary Diversity Score (IDDS) – breastfed child Mean 3.2 3.2 3.3 SD 1.2 1.2 1.3 Md 3.0 3.0 3.0 Min 0.0 0.0 0.0 Max 6.0 6.0 6.0

Individual Dietary Diversity Score (IDDS) – non-breastfed and breastfed child Mean 3.3 3.2 3.4 SD 1.2 1.2 1.3 Md 3.0 3.0 3.0 Min 0.0 0.0 0.0 Max 6.0 6.0 6.0

Minimum Dietary Diversity - MDD – breastfed child No 55.8 58.4 52.6 Yes 44.2 41.6 47.4

Minimum Dietary Diversity - MDD – non-breastfed child No 44.3 44.2 44.4 Yes 55.7 55.8 55.6

Minimum Dietary Diversity - MDD - breastfed and non-breastfed child No 53.3 55.6 50.6

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Yes 46.7 44.4 49.4

Minimum Meal Frequency – MMF - breastfed children No 6.5 5.7 7.5 Yes 93.5 94.3 92.5

Minimum Meal Frequency - MMF non - breastfed children No 7.0 4.9 8.9 Yes 93.0 95.1 91.1

Minimum Meal Frequency - MMF breastfed and non - breastfed children No 6.6 5.5 7.9 Yes 93.4 94.5 92.1

Minimum Acceptable Diet - MAD - breastfed Children No 51.5 53.2 49.6 Yes 48.5 46.8 50.4

Minimum Acceptable Diet - MAD - non-breastfed Children No 82.6 80.5 84.4 Yes 17.4 19.5 15.6

Minimum Acceptable Diet - MAD – breastfed and non-breastfed Children No 58.6 58.8 58.4 Yes 41.4 41.2 41.6

30c Did (name of child) receive anything to eat/any kind of food yesterday? No 4.80 7.87 1.11 Yes 95.20 92.13 98.89

How many times did (name of child) receive food including meals and snacks 31 yesterday? 1 1.1 0.0 2.2 2 6.6 6.5 6.7 3 22.5 21.1 24.2 4 25.5 26.1 24.7 5 17.8 17.1 18.5 6 14.1 16.1 11.8 7 7.2 7.0 7.3 8 2.9 2.5 3.4 9 0.5 0.5 0.6 10 1.6 2.5 0.6 12 0.3 0.5 0.0

Mean 4.5 4.7 4.4 SD 1.7 1.8 1.7

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Md 4.0 4.0 4.0 Min 1.0 2.0 1.0 Max 12.0 12.0 10.0

32 Was (name of child)‘s feeding yesterday different from usual? No 80.3 71.8 90.6 Yes 19.4 27.8 9.4 Don‘t know 0.3 0.5 0.0

33 How old was (name of child) when you first gave other food apart from breast milk? 0 5.1 3.7 6.7 1 0.5 0.5 0.6 2 1.3 0.9 1.7 3 1.8 0.5 3.3 4 3.8 2.3 5.6 5 3.8 4.6 2.8 6 72.5 77.3 66.7 7 4.0 3.7 4.4 8 2.8 1.4 4.4 9 1.5 1.9 1.1 10 0.5 0.5 0.6 12 1.0 0.5 1.7 Does not yet take food 1.5 2.3 0.6

33a What is the most common snack you give to your child? No snacks 20.7 19.9 21.7 Fruits 17.4 19.4 15.0 Sweet biscuits / cookies 34.1 33.3 35.0 Crisps / chips / popcorn 12.9 14.4 11.1 Candies/ sweets 9.8 10.2 9.4 Other 5.1 2.8 7.8

33b Did you prepare any meals especially for (name of child) yesterday? No 74.5 75.5 73.3 Yes 25.5 24.5 26.7

33c What prevented you to prepare special meals for (name of child) yesterday? Don’t know how to do 4.7 6.1 3.0 Lack of time 19.3 19.6 18.9 No food available/ no money to buy food 12.5 14.7 9.8 Family food 53.2 49.7 57.6 Child not yet eating 6.8 7.4 6.1 Other 3.4 2.5 4.5

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Mean age (in months) 5.8 5.6 5.7 SD 1.5 2.1 1.8 Md 6.0 6.0 6.0 Min 0.0 0.0 0.0 Max 12.0 12.0 12.0

34 Please look at this picture of porridges: Which one would you give to a young child? Borbor Khab Krop

Kroeung 72.2 71.3 73.3 Borbor Kroeung 16.2 19.0 12.8 Borbor Sor 11.6 9.7 13.9

34a Please tell me some ways to make porridge more nutritious or better for your baby‘s health Animal-source foods No 1.5 1.4 1.7 Yes 96.2 94.9 97.8 Don‘t know 2.3 3.7 0.6 Pulses and nuts No 91.9 89.8 94.4 Yes 5.8 6.5 5.0 Don‘t know 2.3 3.7 0.6 Orange (vitamin A rich) fruits and vegetables No 19.9 22.7 16.7 Yes 77.8 73.6 82.8 Don‘t know 2.3 3.7 0.6 Green leafy vegetables No 19.7 24.5 13.9 Yes 78.0 71.8 85.6 Don‘t know 2.3 3.7 0.6 Energy rich foods No 64.6 68.1 60.6 Yes 33.1 28.2 38.9 Don‘t know 2.3 3.7 0.6

Knowledge Score -

Enriching porridge Mean 3.0 2.9 3.1 SD 0.9 0.9 0.9 Md 3.0 3.0 3.0 Min 0.0 0.0 0.0 Max 5.0 5.0 5.0

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When (name of child) is sick, is he/she given less than usual, about the same amount, more than 35 usual or nothing to drink (including breast milk)? Much less 10.1 11.6 8.3 Somewhat less 25.8 23.6 28.3 About the same 26.0 26.4 25.6 More 37.1 37.0 37.2 Nothing 0.5 0.5 0.6 Child never been sick 0.5 0.9 0.0

When (name of child) is sick, is he/she given less food than usual, about the same amount, more 36 than usual or nothing to eat? Much less 21.5 25.0 17.2 Somewhat less 30.8 25.5 37.2 About the same 18.4 21.3 15.0 More 20.7 20.4 21.1 Nothing, stopped food 6.1 5.1 7.2 Child never been sick 0.8 0.9 0.6 does not yet take food 1.8 1.9 1.7

37 Has (name of child) had diarrhea in the past two weeks? No 61.4 64.4 57.8 Yes 38.6 35.6 42.2

38 In the last six month, how many times has (name of child) suffered from diarrhea episodes? Mean 2.3 2.2 2.5 SD 2.9 2.9 2.9 Md 2.0 1.0 2.0 Min 0.0 0.0 0.0 Max 25.0 25.0 20.0

38a Can you tell me what causes diarrhea? No 10.1 15.3 3.9 Yes 89.9 84.7 96.1 Contaminated food No 15.4 16.4 14.5 Yes 84.6 83.6 85.5 Contaminated water No 43.3 45.9 40.5 Yes 56.7 54.1 59.5 Contaminated hands No 78.4 82.0 74.6 Yes 21.6 18.0 25.4 Flies No 98.0 96.7 99.4

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Yes 2.0 3.3 0.6

38b Can you name anything you can do to help prevent you child from getting diarrhea? No 8.8 12.0 5.0 Yes 91.2 88.0 95.0 Washing hands No 59.3 65.3 52.6 Yes 40.7 34.7 47.4 Use latrine or bury feces No 95.6 94.7 96.5 Yes 4.4 5.3 3.5 Boil or filter drinking water No 22.7 20.5 25.1 Yes 77.3 79.5 74.9 Exclusive breast feeding No 94.7 92.1 97.7 Yes 5.3 7.9 2.3 Protect food and water supplies with cover No 40.7 41.6 39.8 Yes 59.3 58.4 60.2

38c Whom do you ask for advice when you have a question about feeding your child? Health professional (Health worker, NRU/Health poste, hospital) No 47.7 47.7 47.8 Yes 52.3 52.3 52.2 Own mother No 53.5 50.9 56.7 Yes 46.5 49.1 43.3 Own mother in law No 95.7 93.5 98.3 Yes 4.3 6.5 1.7 Own grandmother No 93.2 92.1 94.4 Yes 6.8 7.9 5.6 Village chief No 97.7 97.2 98.3 Yes 2.3 2.8 1.7

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Friend/neighbor No 63.9 62.0 66.1 Yes 36.1 38.0 33.9

39 How can you recognize that someone is not eating enough food? Lack of energy/

weakness No 19.9 15.7 25.0 Yes 76.8 78.7 74.4 Don‘t know 3.3 5.6 0.6 Weakness of the

immune system No 65.9 61.1 71.7 Yes 30.3 33.3 26.7 Don‘t know 3.8 5.6 1.7 Loss of weight/

thinness No 21.7 18.5 25.6 Yes 74.7 75.9 73.3 Don‘t know 3.5 5.6 1.1 Children do not grow

as they should No 82.1 83.8 80.0 Yes 14.1 10.2 18.9 Don‘t know 3.8 6.0 1.1

Knowledge Score

- Recognizing Malnutrition Mean 2.1 2.1 2.0 SD 0.7 0.7 0.7 Md 2.0 2.0 2.0 Min 0.0 1.0 0.0 Max 4.0 4.0 4.0 40 What are the reasons why people are malnourished? Not getting enough

food No 6.6 6.0 7.2 Yes 89.4 87.5 91.7 Don‘t know 4.0 6.5 1.1 Food is watery, does not contain enough nutrients No 75.0 73.1 77.2 Yes 21.0 20.4 21.7 Don‘t know 4.0 6.5 1.1

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Disease/ill and not

eating food No 79.3 75.9 83.3 Yes 16.7 17.6 15.6 Don‘t know 4.0 6.5 1.1

Knowledge Score - Reasons for Malnutrition Mean 1.3 1.4 1.3 SD 0.5 0.5 0.5 Md 1.0 1.0 1.0 Min 1.0 1.0 1.0 Max 3.0 3.0 3.0

41 What should we do to prevent malnutrition among young children (6 - 23months)? Give more food No 27.8 27.3 28.3 Yes 68.9 67.6 70.6 Don‘t know 3.3 5.1 1.1 Give different types of

food each day No 40.9 42.6 38.9 Yes 55.8 52.3 60.0 Don‘t know 3.3 5.1 1.1 Feed frequently No 75.5 65.7 87.2 Yes 21.2 29.2 11.7 Don‘t know 3.3 5.1 1.1 Give attention during

meals No 80.8 80.6 81.1 Yes 15.9 14.4 17.8 Don‘t know 3.3 5.1 1.1 Go to the health center/hospital and check if the child is growing (growth monitoring services) No 83.6 81.5 86.1 Yes 13.1 13.4 12.8 Don‘t know 3.3 5.1 1.1

Knowledge Score

- Prevention of Malnutrition Mean 1.8 1.9 1.8 SD 0.8 0.8 0.7 Md 2.0 2.0 2.0 Min 0.0 0.0 0.0 Max 5.0 5.0 4.0

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42 Do you have a counseling structure for nutrition in your village? No 49.7 54.6 43.9 Health center 42.4 37.5 48.3 Volunteer group (mother to mother support groups) 15.4 6.9 25.6 Agricultural extension service (development agents) 0.3 0.5 0.0 Don‘t know 8.1 8.3 7.8

43 Do you receive any nutrition counseling? No 52.5 57.4 46.7 Health center 33.1 36.6 28.9 Volunteer group (mother to mother support groups) 12.6 5.1 21.7 Agricultural extension service (development agents) 0.8 0.5 1.1 Other 1.0 0.5 1.7

44 Have you participated in any cooking demonstration in the past six months? No 91.2 96.3 85.0 Yes 8.8 3.7 15.0

44a Do you think it helped you to improve both your knowledge and feeding practices? Yes, just the knowledge 34.3 12.5 40.7 Yes, just the practice 14.3 50.0 3.7 Yes, both 51.4 37.5 55.6

45 How many times did you receive antenatal care during the pregnancy with (name of child)? Mean 6.7 6.1 6.4 SD 2.4 2.4 2.4 Md 7.0 6.0 7.0 Min 1.0 0.0 0.0 Max 13.0 13.0 13.0

45a What should we do to ensure proper nutrition of pregnant woman? Nothing specific (eating as usual) No 76.5 77.8 75.0 Yes 22.5 20.4 25.0 Don‘t know 1.0 1.9 0.0 Give more food No 42.2 42.1 42.2

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Yes 56.8 56.0 57.8 Don‘t know 1.0 1.9 0.0 Give different types of food each day No 39.1 41.2 36.7 Yes 59.8 56.9 63.3 Don‘t know 1.0 1.9 0.0 Feed frequently No 79.0 78.2 80.0 Yes 19.9 19.9 20.0 Don‘t know 1.0 1.9 0.0 Go to the health center/hospital and check that the mother is gaining weight properly No 77.5 76.4 78.9 Yes 21.5 21.8 21.1 Don‘t know 1.0 1.9 0.0

45b What should we do to ensure proper nutrition of lactating women? Nothing specific (eating as usual) No 78.0 76.9 79.4 Yes 21.5 22.2 20.6 Don‘t know 0.5 0.9 0.0 Give more food No 41.2 41.2 41.1 Yes 58.3 57.9 58.9 Don‘t know 0.5 0.9 0.0 Give different types of food each day No 39.9 43.5 35.6 Yes 59.6 55.6 64.4 Don‘t know 0.5 0.9 0.0 Feed frequently No 81.6 79.2 84.4 Yes 17.9 19.9 15.6 Don‘t know 0.5 0.9 0.0 Go to the health center/hospital and check that the mother is gaining weight properly No 89.1 85.6 93.3 Yes 10.4 13.4 6.7

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Don‘t know 0.5 0.9 0.0

How many times did you go to the health center/clinic/hospital with (name of child) since the child 46 was born? Mean 8.2 8.1 8.2 SD 5.1 5.5 5.3 Md 7.0 7.0 7.0 Min 0.0 0.0 0.0 Max 36.0 30.0 36.0

47 Does your household have soap (or washing powder / liquid) at present? Yes 100.0 100.0 100.0

47a When you used soap today or yesterday, what did you use it for? Washing my children’s

hands No 57.8 58.8 56.7 Yes 42.2 41.2 43.3 Washing hands after

visiting the toilet … No 76.5 79.6 72.8 Yes 23.5 20.4 27.2 Washing hands after

cleaning child … No 80.8 79.6 82.2 Yes 19.2 20.4 17.8 Washing hands before

feeding child No 86.1 87.0 85.0 Yes 13.9 13.0 15.0 Washing hands before

preparing food No 85.4 84.3 86.7 Yes 14.6 15.7 13.3 Washing hands before

eating No 66.4 69.9 62.2 Yes 33.6 30.1 37.8 Washing body, hair … Yes 100.0 100.0 100.0

48 Did you ever receive any hygiene counseling? No 74.2 76.4 71.7 Yes 25.5 23.1 28.3 Don‘t know 0.3 0.5 #VALUE!

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Please describe everything that you ate yesterday during the day or night, whether at home or 49 outside the home. Cereals… Yes 100.0 100.0 100.0 White roots and

tubers No 89.4 89.4 89.4 Yes 10.6 10.6 10.6 Pulses No 89.4 91.2 87.2 Yes 10.6 8.8 12.8 Nuts and seeds No 85.6 85.2 86.1 Yes 14.4 14.8 13.9 Milk and milk-products No 87.9 86.6 89.4 Yes 12.1 13.4 10.6 Organ meat No 81.8 78.2 86.1 Yes 18.2 21.8 13.9 Flesh meat No 24.2 23.1 25.6 Yes 75.8 76.9 74.4 Fish No 19.7 22.7 16.1 Yes 80.3 77.3 83.9 Eggs No 71.2 72.7 69.4 Yes 28.8 27.3 30.6 Dark green leafy

vegetables No 44.9 50.5 38.3 Yes 55.1 49.5 61.7 Orange roots/tubers

or vegetables No 72.5 74.5 70.0 Yes 27.5 25.5 30.0 Orange fleshed fruits No 86.1 83.3 89.4 Yes 13.9 16.7 10.6 Other vegetables No 26.3 30.1 21.7 Yes 73.7 69.9 78.3 Other fruits No 65.4 62.0 69.4 Yes 34.6 38.0 30.6 Insects

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No 98.7 99.5 97.8 Yes 1.3 0.5 2.2 Oils/ fats No 24.5 23.6 25.6 Yes 75.5 76.4 74.4 Fried snacks No 83.8 82.4 85.6 Yes 16.2 17.6 14.4 Sugar and sugary

foods No 30.1 27.3 33.3 Yes 69.9 72.7 66.7 Sweet drinks or

alcoholic beverages No 67.4 67.6 67.2 Yes 32.6 32.4 32.8 Condiments No 0.3 0.5 0.0 Yes 99.7 99.5 100.0

IDDS – W (prevalence) 1 0.3 0.0 0.6 2 4.3 3.7 5.0 3 18.9 19.9 17.8 4 23.5 25.9 20.6 5 25.5 26.4 24.4 6 19.2 17.1 21.7 7 6.1 5.1 7.2 8 1.8 1.4 2.2 9 0.5 0.5 0.6 IDDS – W (mean) Mean 4.6 4.6 4.7 SD 5.0 5.0 5.0 Md 1.4 1.3 1.5 Min 1 2 1 Max 9.0 9.0 9.0 MDD – W (Women who received 5 or more food groups) No 47.0 49.5 43.9 Yes 53.0 50.5 56.1 Total Kampot Kampong Thom N=396 N=216 N=180

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P. Number of Vegetable Grown

Total Kampot Kampong Thom

(N=396) (N=216) (N=180)

Mean 2.8 2.6 3.1 SD 1.5 1.3 1.6 Md 3.0 2.0 3.0 Min 1.0 1.0 1.0 Max 7.0 7.0 7.0

Number of Total Kampot Kampong Thom different (N=396) (N=216) (N=180) types of vegetables Number Percentage of Number of Percentage Number of Percentage of HH grown of HH HH (%) HH of HH (%) HH (%) 0 239 60,4 140 64,8 99 55,0 1 30 7,6 18 8,3 12 6,7 2 46 11,6 23 10,6 23 12,8 3 36 9,1 18 8,3 18 10,0 4 26 6,6 12 5,6 14 7,8 5 8 2,0 3 1,4 5 2,8 6 6 1,5 1 0,5 5 2,8 7 5 1,3 1 0,5 4 2,2

Q. Number of Fruit Trees Grown

Total Kampot Kampong Thom

(N=396) (N=216) (N=180) Mean 3.2 3.2 3.2 SD 1.5 1.4 1.7 Md 3.0 3.0 3.0 Min 1.0 1.0 1.0 Max 9.0 8.0 9.0

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Total Kampot Kampong Thom Number of (N=396) (N=216) (N=180) different types of Number Percentage Number Percentage of Number Percentage of HH (%) fruits of HH of HH (%) of HH HH (%) of HH

0 54 13,6 20 9,3 34 18,9 1 43 10,9 21 9,7 22 12,2 2 74 18,7 42 19,4 32 17,8 3 96 24,2 62 28,7 34 18,9 4 64 16,2 36 16,7 28 15,6 5 35 8,8 18 8,3 17 9,4 6 22 5,6 15 6,9 7 3,9 7 4 1,0 1 0,5 3 1,7 8 3 0,8 1 0,5 2 1,1 9 1 0,3 0 0 1 0,6

R. Number of Farm Animals/livestock/other Aquatic Animals Reared

Total Kampot Kampong Thom

(N=396) (N=216) (N=180) Mean 1.8 2.0 1.6 SD 0.8 0.8 0.7 Md 2.0 2.0 2.0 Min 1.0 1.0 1.0 Max 4.0 4.0 4.0

Total Kampot Kampong Thom No. of (N=396) (N=216) (N=180) different Percent- types of Number Number Number Percentage of age of HH Percentage of HH (%) animals of HH of HH of HH HH (%) (%) 0 44 11,1 17,0 7,9 27,0 15,0 1 126 31,8 51,0 23,6 75,0 41,7 2 170 42,9 103,0 47,7 67,0 37,2 3 45 11,4 36,0 16,7 9,0 5,0 4 11 2,8 9,0 4,2 2,0 1,1

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S. UNICEF Model

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Global Programme Food and Nutrition Security, Enhanced Resilience Friedrich-Ebert-Allee 36+40 53113 Bonn

T +49 (0) 228 44 60 - 3824 F +49 (0) 228 44 60 - 1766 [email protected] www.giz.de

Autors Dr. Ok Amry, Dr. Lioba Weingärtner

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As at August, 2016

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