Integrated SMART Survey Nutrition, WASH, Food Security and Livelihoods
DeSHARI Project Locations
Satkhira & Jessore Districts Bangladesh
August 2017
Acknowledgement Action Against Hunger would like to acknowledge and express great appreciation to the following organizations, communities and individuals for their contribution and support in carrying out this survey:
District and Upazila Authorities for their assistance to successful implementation of the survey in Satkhira and Jessore Districts.
Health and Family Planning staff at Upazila and community level for their active support during survey period
ECHO for funding to implement the Integrated SMART Survey in Satkhira and Jessore Districts.
Christian Aid, CCDB, Dan Church Aid, DSK, Muslim Aid and Shushilan for extending their support in recruitment of local enumerators and effective coordination with district authorities.
Md. Abdullah Al Mamun, Consortium Manager and DHoD-FSL & DRR, Tapan Chokrobarty, HoD- FSL & DRR, Leonie Toroitich-van Mil HoD-Nutrition and Health, Md. Amir Hossain, DHoD- Nutrition and Health, Mita Rani Ray Chowdhury, MHCP Coordinator, Md. Maksudul Amin, DHoD- WaSH, Md. Lalan Miah, Survey Manager for their valuable contributions to implement the survey successfully
Mothers, Fathers, Caregivers and children who took part in the assessment during data collection.
Action Against Hunger would like to acknowledge the community representatives and community people who have actively participated in the survey process for successful completion of the survey.
Finally, Action Against Hunger is thankful to all of the survey enumerators, team leaders and Survey Manager for their tremendous efforts to successfully complete the survey in the districts.
Acronyms ACF Action Contre La Faim ‖ Action Against Hunger ARI Acute Respiratory Infection BBS Bangladesh Bureau of Statistics BDHS Bangladesh Demographic and Health Survey CA Christian Aid CCDB Christian Commissions for Development in Bangladesh CI Confidence Interval CMAM Community Based Management of Acute Malnutrition DSK Dushtha Sasthya Kendra ENA Emergency Nutrition Assessment EPI Expanded Program on Immunization FAO Food and Agriculture Organization FCS Food Consumption Score FSL Food Security and Livelihoods GAM Global Acute Malnutrition HAZ Height-for-Age z-score HDDS Household Dietary Diversity Score HH Household IDDS Individual Dietary Diversity Score IPC Integrated Food Security Phase Classification IYCF Infant and Young Child Feeding MA Muslim Aid MAM Moderate acute malnutrition MEB Minimum Expenditure Basket MHCP Mental Health and Care Practice MoHFW Ministry of Health and Family Welfare MUAC Mid-Upper-Arm-Circumference. NGO Non-Governmental Organization OTP Outpatient Therapeutic Program PLW Pregnant and Lactating Women PPS Probability Proportion to Size rCSI Reduced Coping Strategy Index SAM Severe Acute Malnutrition SD Standard Deviation SFP Supplementary Feeding Program SMART Standardized Monitoring and Assessment of Relief and Transition U5 Under Five WaSH Water, Sanitation and Hygiene WAZ Weight-for-Age Z-score WFH Weight For Height WFP World Food Program WHO World Health Organization WHZ Weight-for-Height Z-score
Table of Contents Acknowledgement ...... 2 Acronyms ...... 3 1. Executive Summary ...... 8 Summery findings ...... 9 1. Introduction ...... 13 1.1Survey Objectives ...... 14 2. Methodology ...... 14 2.1 Survey Area ...... 14 2.2 Type of survey ...... 15 2.3 Sample size ...... 15 2.4 Survey Target Population ...... 16 2.5 Sampling procedure: selecting clusters ...... 16 2.6 Sampling procedure: selecting households and children ...... 16 Selection of number of household per cluster / per day ...... 17 2.7 Case definitions and inclusion criteria ...... 17 2.8 Questionnaire, training and supervision ...... 20 2.9 Data analysis and quality ...... 20 3. Results ...... 22 3.1 Household and Family composition ...... 22 3.2 Distribution Age and Sex ...... 22 3.3 Acute Malnutrition based on Weight for Height Z-score ...... 23 3.4 Acute Malnutrition based on Mid Upper Arm Circumference ...... 24 3.5 Underweight ...... 25 3.6 Chronic Malnutrition/ Stunting ...... 26 3.7 Childhood Morbidity ...... 28 3.8 Child Care practices including Infant Young Child Feeding (IYCF) ...... 29 3.8.1 Early Initiation of Breastfeeding ...... 29 3.8.2 Exclusive Breastfeeding ...... 29 3.8.3 Continued Breastfeeding (at 1 year and 2 years) ...... 29 3.8.4 Complementary feeding ...... 30 3.9 Knowledge of mothers on child care practices (0-23 months) ...... 31 3.10 Food Security and Livelihoods ...... 32 3.10.1 Household Source of Income ...... 32 3.10.2 Source of Food ...... 33 3.10.3 Household Dietary Diversity Score ...... 33 3.10.4 Reduced Coping Strategy Index (rCSI) ...... 34 3.11 Water and Sanitation ...... 35 3.11.1 Main sources of water by percentage of HH ...... 35
3.11.2 Distance to water source ...... 35 3.11.3 Water Transport and Storage ...... 36 3.11.4 Sanitation and Hygiene ...... 37 3.11.5 Hand washing Behaviour ...... 38 4 Discussion & Conclusion ...... 39 Nutrition ...... 39 Child Morbidity and Immunization ...... 39 Infant Young Child Feeding including Care Practices ...... 39 Food Security and Livelihood ...... 40 Water, Sanitation and Hygiene ...... 41 5 Causes of undernutrition ...... 41 6 Limitation and Bias ...... 41 7 Ethical Considerations ...... 42 8 Recommendations ...... 42 10. Appendices ...... 44 Appendix 1: Plausibility Report ...... 44 Appendix 2: Assignment of Clusters ...... 54 Appendix 3: Evaluation of enumerators ...... 55 Appendix 4: Questionnaire ...... 59 Appendix 5: Local Event Calendar ...... 67
List of Table Table 1: Summary findings of Nutrition and Health indicators 9 Table 2: Summary findings of IYCF practices 9 Table 3: Summary findings of Food Security and Livelihoods (FSL) 10 Table 4: Summary findings of Water Sanitation and Hygiene (WASH) 10 Table 5: Details of Administrative areas with population 14 Table 6: Sampling parameters for DeSHARI project locations in Satkhira and Jessore districts 15 Table 7: Details of Proposed and Actual Sample Size Achieved 17 Table 8: Calculation of households’ coverage/day/cluster 17 Table 9: Case definitions of Acute Malnutrition, Stunting and Underweight used for analysis 18 Table 10: Case definition for IYCF, morbidity, vitamin A and measles coverage 18 Table 11: Case definitions of public health significance level 19 Table 12: IPC classification Global Acute Malnutrition by MUAC 19 Table 13: Thresholds level for Household Dietary Diversity (HDD). 19 Table 14: Thresholds level for household Coping Strategy Index (CSI) 20 Table 15: Overall data quality from plausibility check 21 Table 16: Household and family composition-Satkhira and Jessore 22 Table 17: Distribution of age and sex of sample 22 Table 18: Prevalence of acute malnutrition based on Weight for Height z-scores (and or Oedema) and by sex 23 Table 19: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema 23 Table 20: Prevalence of Acute Malnutrition based on MUAC cut offs (and/or oedema) and by sex 24 Table 21: Prevalence of Acute Malnutrition by Age, based on MUAC cut offs (and/or oedema) and by sex 25 Table 22: Prevalence of Underweight, based on Weight for Age z-scores (WAZ) 26 Table 23: Prevalence of Underweight by Age, based on WAZ 26 Table 24: Prevalence of stunting based on Height for Age z-scores (HAZ) and by sex 27 Table 25: Prevalence of stunting by age based on height-for-age z-scores 27 Table 26: Mean z-scores, Design Effects and excluded subjects 28 Table 27: Prevalence of childhood (6-59 months) morbidities at 95% CI 28 Table 28: Summary Findings of IYCF Indicators 29 Table 30: Mean Income by category 33 Table 31: Main food source 33 Table 32: Food consumption in last 24 hours by household members 34 Table 33: Main source of drinking 35 Table 34: Distance of water source from home and latrine 36 Table 35: Washing behavior of storage container 36 Table 36: Category of sanitary latrines by % of households 37 Table 37: Disposal of Children’s faeces % of households 38
List of Figure Figure 1: Area of SMART Survey ...... 13 Figure 2: WHZ Gaussian Curve...... 24 Figure 3: MUAC by Age ...... 25 Figure 4: HAZ Gaussian Curve ...... 27 Figure 5: Treatment receive status ...... 28 Figure 6: Diet in the last 24 hours (6-23 months) ...... 30 Figure 7: Source of Indication of mother/caregiver to feed the child ...... 31 Figure 8: Perception of caregiver for child’s optimum growth and development ...... 31 Figure 9: Main source of income of Household in percentage ...... 32 Figure 10: Household dietary diversity status ...... 33 Figure 11: Status of reduced coping strategies ...... 34 Figure 12: Indicator wise status of reduced coping strategies index ...... 35 Figure 13: Covering of transport container Figure 14:Drinking water storage within the HH ...... 36 Figure 15: Percentage of handwashing behavior as per occasions ...... 38
1. Executive Summary Introduction In August 2017, Action Against Hunger Bangladesh conducted an integrated SMART Nutrition survey (including IYCF, Food Security, Livelihood and WaSH) in the project areas of DeSHARI Consortium working on the project “Enhance resilience of the most vulnerable community to cope with waterlogging in Satkhira and Jessore districts in Bangladesh’’. In Satkhira District, Dhulihar & Fingri unions of Satkhira Sadar Upazila; Kumira & Khalilnagar unions of Tala Upazila; Jogikhali & Joynagar union of Kolaroa Upazila were assessed. In Jessore District, Biddyanandakathi and Trimohini union of Keshubpur upazila were assessed. The survey was conducted during the mid of August which is counted as lean period when the economy of the households are still in the poorest of the year and people has very limited works access, less income when the loans and borrowings are taken by the farmers and food is at a minimal level in stock. The overall objectives of the integrated nutrition survey is to determine the nutritional status and morbidity patterns of children aged 6-59 months and care practices in children aged 0-23 months, households food security, water sanitation and hygiene situation of 8 unions in Satkhira and Jessore district.
Methodology A cross sectional household survey was designed to provide statistically representative nutrition, food security & livelihoods, and WASH indicators for 8 selected unions of Satkhira and Jessore District.
A two-stage cluster sampling method using SMART Methodology was used to achieve the desired outcomes of the survey. At the first stage, the required number of clusters were drawn randomly using the sampling with probability proportional to size (PPS). This PPS methods ensured that every clusters in the sample universe had an equal chance of being selected taking into account the population size of the village. The clusters were defined as villages for the most part and in some cases, a village may contain more than one cluster. At the second stage, simple random sampling method was applied to select the households within the cluster.
The sample size was calculated using ENA (Updated July 2015) software, which calculates the sample size; based on various parameters i.e. estimated prevalence, average household size, design effect, desired precision, percentage of children and non-response rate. The sample was then converted into number of households to be surveyed.
A total sample size of 1,284 households were estimated to provide a representative sample (411 children) for the selected indicators. A total of 72 clusters were randomly selected using the ENA-SMART Software. Each selected cluster included 18 households, regardless of the number of children interviewed. The study finally surveyed 1,288 households covering 518 children (6-59 months) for non-anthropometric based indicators and achieved to measure 384 children (6-59 months) for anthropometric indicators.
It should be noted that IYCF indicators require a larger sample size, and therefore the results of the IYCF indicators in the Kutubdia Upazila is only an indication and is NOT representative for the whole population.
Summery findings Table 1: Summary findings of Nutrition and Health indicators Satkhira & Jessore District 16th Sep - 30th Sep’17 INDICATOR N=380 Prevalence of Acute Malnutrition by WHZ Number Global Acute Malnutrition 11.6% WHZ- 44 scores W/H< -2 z and/or oedema (8.7-15.6 95% CI) (6-59 Severe Acute Malnutrition 1.1% 4 months) W/H < -3 z and/or oedema (0.4-2.8 95% CI) Prevalence of Acute Malnutrition by MUAC N=384 MUAC 1.3% Global Acute Malnutrition (<125mm) 5 (6-59 (0.5-3.1 95% CI) months) Severe Acute Malnutrition (<115mm) 0 0.0% Prevalence of Underweight N=380 WAZ- 27.1% Underweight (<-2 z-score) 103 scores (22.7-32.1 95% CI) (6-59 6.8 % Severe Underweight (<-3z-score) 26 months) (4.9 - 9.5 95% C.I.) Prevalence of Stunting N=381 HAZ- 27.6% Stunting (<-2 z-score) 105 scores (23.3-32.3 95% CI) (6-59 5.0% Severe Stunting (<-3z-score) 19 months) (3.2 - 7.7 95% C.I.) Morbidity status (6-59 months) in the last two weeks 393 54.5% (214) Diarrhoea 5.6% (22) Fever 41.0% (161) 393 Acute respiratory infections (ARI) 28.5% (112) Other diseases 12.5% (49) Measles immunization coverage (9-59 months) 372 94.1 % (350) By card 89.8% (350) 360 By recall 94.1 % (10) Vitamin A coverage (6-59 months) 393 94.1 % (353)
Table 2: Summary findings of IYCF practices IYCF Indicators Number Prevalence Early Initiation of Breastfeeding (0-23 months) 181 69.6% (126) Exclusive breastfeeding for children (0-5 months) 44 59.1% (26) Continuation of breastfeeding at 1 year (12-15 months) 27 100% (27) Continuation of breastfeeding at 2 year (20-23 months) 39 79.5% (31) Mean Dietary Diversity Score (IDDS) (6-23 months) 3.4 Minimum Dietary Diversity (6-23 months) (>=4 food groups) 137 47.5% (65)
Minimum meal frequency (6-23 months) 137 62.8% (86) Minimum acceptable diet (6-23 months) 137 33.6% (46)
Table 3: Summary findings of Food Security and Livelihoods (FSL) FSL Indicators Number Percentage Mean Household Income Category N=1288 BDT < 5000 334 25.9 BDT 5000 to ≤ 10000 638 49.5 BDT >10000 317 24.5 Main Source of Income N=1288 Unskilled wage labour (including agro) 560 43.5% Agriculture 127 9.9% Skilled labour 119 9.2% Main Source of Food N=1288 Purchasing 957 74.3% Own cultivation 318 24.7% Mean Household Dietary Diversity (HDDs) 1288 7.1 Poor (≤5) 202 15.7% Moderate (6 to 8) 857 66.5% Good (≥9) 166 18.9% Reduced Coping Strategy Index (rCSI) 1288 4.9 No or low rCSI (0 -3) 338 12.8% Medium rCSI (4–9) 106 66.4% High Coping (CSI ≥ 10 319 20.8%
Table 4: Summary findings of Water Sanitation and Hygiene (WASH) WASH Indicators Number Percentage Main Water Source of Drinking N=1288 Tubewell (shallow) 556 43.2% Tubewell (deep) 637 49.5% Distance from Drinking Water Source From Home N=1288 0 to 150 feet 804 62.4% More than 150 feet 488 37.6% Distance Between Water Source and Latrine Pit N=1288 0 to 30 feet 532 41.3% 30 to 100 feet 420 32.6% 100+feet 336 26.1% Main Water Collector N=1288
Adult women 1156 89.8% Girls 42 3.3% Washing Water Container Daily 972 75.5% Sanitation and Hygiene N=1288 Improved sanitary facility 737 57.2% Unimproved sanitary facility 551 42.8% Hand Washing Behaviour with Soap 1241 96.4% General Handwashing Material N=1288 Water only 231 17.9% Water and ash 153 11.9% Water and sand/mud 6 0.5% Water and soap 869 67.5% Soap available in Latrine/ besides Latrine 803 62.3%
Recommendations
Immediate Interventions Strengthening of inpatient treatment of severely acutely malnourished children U5 with medical complications in the Upazila Health Complexes. Reactivation and strengthening of CMAM services in outpatient facilities through GoB community clinics, low coverage areas and/or areas with high rates of acute malnutrition. Screening (MUAC), detection and referral should be strengthened for early detection and treatment Reactivation and strengthening the treatment of SAM and MAM as outpatients in the 122 villages preferably through the community clinics and effective coverage to areas with high rates of acute under nutrition. Implementation of an integrated multi-sectorial programme to address the high levels of acute and chronic malnutrition among U5 children and PLW at Upazila level taking into account Nutrition, Health, WASH, Maternal Child Care Practice and FSL. Implement Behaviour Change Communication at the health facilities: IYCF, child care, WASH Intensive social mobilization campaigns on improving maternal nutrition, IYCF and caring practices through behaviour change communication interventions. A nutritional causal analysis could be undertaken to identify causes of acute and chronic malnutrition. Support in village’s provision of safe drinking water, improved sanitation facilities; promote safe hygiene practices in the Upazilas.
Medium Term Interventions:
Establishing robust nutrition information monitoring system in Satkhira and Jessore districts and incorporating key health and food security indicators to closely monitor the situation and deliver timely response. Follow up SMART nutrition surveys next year at the same time to document progress of the response plan and lessons learnt. Market development of agriculture products, fish, livestock sale, traditional goods etc. Support for diversification of livelihoods option to ensure sustainable the food security.
Develop and introduce food-for-work interventions to support infrastructure development and provide alternative income generating activities during the lean periods, including social protection mechanisms like cash GoB health facility staff on Growth Monitoring & Promotion, detection & referral of Acute Malnutrition, CMAM and IYCF Others Recommendations: Plan for capacity building of community volunteers including local health care providers for delivering appropriate counselling regarding this on IYCF, Maternal & Child Care Practice and Hygiene promotion for the facilitation at community level.
1. Introduction
Satkhira and Jessore lie in the South-West corner of Bangladesh. Combined the 2 districts have an estimated population of 4,629,251 (Satkhira 1,864,704, Jessore 2,764,547). The total area of Satkhira is 3,817.29 km². (1,473.00 miles2) of which 1,632 km is forested. Jessore District encompasses 2,606.98 km². Satkhira consists of of 7 Upazilas, 2 municipalities, 79 unions and 1,436 villages. The main occupations of the population are agriculture (37%), agricultural labour (27%) and commerce (13%). The annual average temperature is 12.5°C - 35.5°C with an annual rainfall of 1,710mm. The main crops in Satkhira include rice, jute, sugarcane, mustard seed, potato, and onion 1. and betel leaf Figure 1: Area of SMART Survey Jessore consists of 8 Upazilas, 91 unions and 1419 villages. The main occupations are agriculture 39.8%, agricultural labourer 24.1%, wage labourer 2.7%, commerce 12%, service 8.7%, industry 1.4%, transport 3.1% and others 8.2%2. In 2011, Satkhira and Jessore districts experienced severe localized flooding. While floodwaters began to recede, some unions of Satkhira and Jessore Districts remained underwater, a situation referred to as ‘prolonged waterlogging’. This caused displacement of the population, disrupted livelihoods, and damaged agricultural crops, fisheries and housing.
Following an initial emergency response to the 2011 waterlogging, Action Against Hunger, has been implementing interventions in line with the urgent needs of Satkhira population through nutrition, health, and care practices, food security programmes, water, sanitation and hygiene activities, and disaster risk reduction and climate adaptation programmes. DeSHARI partners (Action Against Hunger, Christian Aid, Muslim Aid and Danish Church Aid) joined efforts in March 2016 to enhance he resilience of the most vulnerable communities to cope with waterlogging in Satkhira and Jessore Districts. Action Against Hunger in collaboration with Shushilan is implementing the project in 2 unions (Dhulihar and Fingri) in Satkhira Sadar Upazila. Muslim Aid in 2 unions (Kumira & Khalilnagar) of Tala Upazila, Danish Church Aid through local partner DSK in 2 unions (Jogikhali & Joynagar) of Kolaroa Upazila of Satkhira district and Christian Aid and local implementing partner CCDB is implementing activities in 2 unions (Biddyanandakathi and Trimohini) of Keshubpur Upazila of Jessore.
Action Against Hunger in collaboration with Muslim Aid, Danish Church Aid, Christian Aid, CCDB, DSK and Shushilan implemented this Integrated SMART survey in 8 selected unions of Satkhira and Jessore District from 12th -30th August 2017.
1Bangladesh Bureau of Statistics, Ministry of Planning (2011). Community Report Satkhira Zila June 2012: Population and Housing Census 2011 2 Bangladesh Bureau of Statistics, Ministry of Planning (2011). Community Report Jessore Zila June 2012: Population and Housing Census 2011 and Wiki
1.1Survey Objectives
The overall objectives of the integrated nutrition survey is to determine the nutritional status and morbidity patterns of children aged 6-59 months and care practices in children aged 0-23 months, households food security, water sanitation and hygiene situation of 8 unions (Dhulihar, Fingri, Kumira, Khalilnagar, Jogikhali, Joynagar, Biddyanandakathi and Trimohini) in Satkhira and Jessore district.
Specific Survey objective: 1. To determine the current global acute malnutrition prevalence among children aged 6-59 months. 2. To determine the prevalence of chronic malnutrition and underweight among children aged 6-59 months. 3. To estimate the prevalence of morbidity in children aged 6-59 months. 4. To determine the level of appropriate Infant and Young Child feeding practices. 5. To assess the current level of household dietary diversity (HDDS) and to explore the existing coping mechanism (rCSI). 6. To identify the current water access, sanitation facility access and hygiene practices at household level.
2. Methodology In August 2017, Action Against Hunger Bangladesh conducted an integrated SMART (Nutrition, IYCF, MHCP, Food Security, Livelihood and WaSH) survey Deshari Project Implementation areas (Dhulihar, Fingri, Kumira, Khalilnagar, Jogikhali, Joynagar, Biddyanandakathi and Trimohini) in Satkhira and Jessore district.
2.1 Survey Area The survey was conducted in Satkhira and Jessore District from 12th -30th August 2017, which is considered as late rainy season. All the villages from 8 Unions were included in the survey. Thus the total population figures for each union were defined as follows: Table 5: Details of Administrative areas with population Number of Total Projected Estimated Number Name of Union Households Population Population as of of under five (BBS-2011) (BBS-2011) 2016 Children 3 Dhulihar 3564 14144 14588 1255 Fingri 3663 14550 15007 1291 Kumira 7572 31406 32392 2786 Khalilnagar 5804 24644 25417 2186 Jogikhali 5754 23999 24752 2129 Joynagar 7087 28428 29320 2522 Biddyanandakathi 8572 34022 35935 3198 Trimohini 8279 33327 35201 3133 Total 42016 171193 212612 15365
3 Population is projected as of 2016 with annual growth rate of 0.62 and 1.11 and estimated number of U5 children is calculated as of 8.6 % and 8.9% for Satkhira and Jessore respectively (BBS 2011).
2.2 Type of survey This survey followed SMART (Standardised Monitoring and Assessment of Relief and Transition) updated version of July 2015 methodology. Two stage cluster sampling recommended by SMART methodology was used for sampling and data collection of the survey. The key objective of the survey was to assess the nutrition situation of 8 DeSHARI project areas in Satkhira and Jessore Districts through anthropometry while additional FSL, MHCP and WaSH indicators were incorporated for Integrated Food Security Phase Classification. Households were considered as the basic sampling unit in the second stage and village was selected as primary sampling unit (Cluster) at the first stage.
2.3 Sample size The following assumptions (based on the given context) were used to calculate the sample size in number of children, which was then converted into number of households to be surveyed. All calculations were made using ENA for SMART software (version 9th July 2015). The sample size calculation takes into consideration the proxy indicator: anthropometry. The parameters for the sample size calculation are as outlined in table below.
Table 6: Sampling parameters for DeSHARI project locations in Satkhira and Jessore districts Parameters for Satkhira and Value Remark/Source Jessore Estimated Prevalence of GAM (%) 11.9% SMART Survey 2016 ± Desired precision 4% Based on the prevalence and feasibility this precision rate. Design Effect (if applicable) 1.5 Correcting the effects of heterogeneity of the population under survey. The sample size inflates by this correction factor to have a representative sampling. Children to be included 411 Average HH Size 4.19 BBS 2011, Average of average HH size of Satkhira (4.21) and Jessore (4.17) district profile % Children under-5 8.75 % BBS 2011, Average of two percentage of children U5 Satkhira (8.60) and Jessore district profile (8.90) % Non-response Households 3% According to previous survey of the unions in Satkhira and Jessore district recommendations and accessibility, it is expected that maximum 3% of the households can be non-responder in the survey due to absenteeism and unwillingness to participate in the survey. Households to be included 1,284
Sample size for additional indicators: For the additional indicators: Infant Young Child Feeding (IYCF), care practices, food security and WASH, the same sample size as the anthropometric indicators (1,248 Households) was used. It is important to note when interpreting the IYCF indicators from this assessment, that the survey sample sizes were calculated based on anticipated prevalence of GAM for children 6-59 months. . It should be noted that IYCF indicators
require a larger sample size, and therefore the results of the IYCF indicators in the 8 selected unions is only an indication and is NOT representative for the whole population.
2.4 Survey Target Population The anthropometric results for children aged 6-59 months were based on the WHO 2006 standards. All the eligible children aged 6-59 months in the household were included for anthropometric measurements. Infant and Young Child Feeding (IYCF) and Care Practices were assessed by interviewing the mothers or primary care givers and was be applicable for children aged below 2 years (under 24 months). Morbidity for the preceding 14 days and was applicable for children 6-59 months. Vitamin A supplementation and measles vaccination coverage were applicable for 6-59 and 9-59 months respectively, for which the mother/primary caregivers recall and the child vaccination card was used. All eligible children within the same household were included for the survey. Food security and WASH information were collected for all targeted households. In case there are no children identified, other household information (food security and WASH) has been collected. For assessing household dietary diversity (HDDS) and Reduced Coping Strategy Index (rCSI), one adult women who is responsible for household cooking was.
2.5 Sampling procedure: selecting clusters Sampling procedure: definition of cluster The survey was using a 2-stage cluster sampling method where the primary sampling unit was the villages. The basic sampling unit for the survey was household because there were other indicators like IYCF and care practices, household food security and livelihoods, mental health, WASH and mortality, which were collected from household level. The SMART guideline for selection of clusters has been adapted to assign the required number of clusters for the survey to make it feasible for carrying out the survey with the concept of giving each household an equal opportunity to be selected.
Based on Probability to Population Size (PPS), 72 clusters were randomly selected using ENA for SMART (July 2015) software. PPS method ensured that every household in the Upazilas were an equal chance to be selected irrespective the size of the village. Reserved clusters planned to be included only when equal or more than 10% clusters could not be surveyed and if only less than 80% of the sampled households could be reached from separately two districts. Therefore, no reserved clusters were included in the survey since we could access all 35 clusters and reached minimum number of HHs expected (equal or more than 80% of the sampled HHs).
2.6 Sampling procedure: selecting households and children At second stage, households were selected using the simple random sampling within the cluster. In each area, the households list were updated before the day of data collection in collaboration with local health & family planning teams, consortium partner staff and local community representatives. If houses were in close proximity, and less than 250 HH in number, the survey team provided a number to each house. They used the random number table to select HHs. This number corresponded to estimated HHs need to cover for each cluster. If the houses were scattered throughout a large area, and/or they were more than 250 HH in number, the following method applied: The cluster divided into segments. As the numbers of household in each segment varied in size, PPS method was used with random selection of segment. Then the teams used a random number table to select a number between one and the total number of households. The segment contained this number selected to be the surveyed area. Consequently, Then the teams used a random number table to select a number between 1 and the total number of households. The segment contained this number selected to be the surveyed area. The survey targeted 1,284 households to be covered with a target of 411 children under five years. The targeted number of households in each cluster was 18, regardless of the number of children interviewed.
If individuals or children were absent, the team revisited the houses at the end of the day before they leave the village. A household with an absent family was not replaced as a non-response factored into the sample size calculations.
Table 7: Details of Proposed and Actual Sample Size Achieved Number of Number of Number of Number of children 6-59 households households % surveyed children 6-59 % surveyed months planned surveyed months surveyed planned 1,284 1,288 100.3% 411 384 93.4%
The minimum percentage of clusters surveyed (90%) and children measured (80%) stipulated by the SMART methodology to ensure representativeness was achieved for this survey.
Selection of number of household per cluster / per day Based on the following points, a calculation had been done for each team to estimate the number of household to be surveyed per cluster per day at each cluster.
Table 8: Calculation of households’ coverage/day/cluster Calculation of HH Satkhira Jessore coverage/day/cluster Total time Total time Event Time to dedicate Time to dedicate remaining remaining Time per day for field 7:00 until 18:00 = 6:00 until 18:30 = 660 min 750 min work 11 hours 12 hours Travel time to cluster 30 min X 2 ( go and 90 min X 2 ( go and 600 min 570 min location return)= 60 return)= 180 Two breaks of 10 min 10 min X 2 + 30 10 min X 2 + 30 550 min 520 min plus 30 min lunch break min = 50 min min = 50 min Presentation to village leader/volunteer of the 5 min 545 min 5 min 515 min area and selection of 1st HH 25 min for anthropometric measurements 25 min for anthropometric measurements Time to dedicate per HH and questionnaire + 5 min walk to next HH and questionnaire + 5 min walk to next and reach the next = 30 min HH = 30 min Total number of HH’s to be covered in one 18.16 HH = 18HH 17.16 H = 18HH day
2.7 Case definitions and inclusion criteria Household definition: In this survey, a household is defined as a group of people who normally live together and eat from the same pot. Polygamous Families counted as one household as long as they were living together and sharing a common cooking pot. Polygamous families or any other families living in the same house but not sharing a common cooking pot were counted as separate household. In such cases if the house was been selected for the survey, both households were included in the survey with a different household number.
Inclusion criteria of children: All children aged from 6-59 months were included for anthropometry, infants and children 0-23 months for IYCF and care practices, all houses for food security & livelihoods and WaSH related questions.
If age could not be defined by any means i.e. birth certificate, vaccination card, then a local calendars of events was used to estimate age.
For children with unknown age, thecut off point of height between 65 and 110cm was used as a secondary inclusion criteria for anthropometry.
The length of children less than 2 years old was measured lying down while the height of children more than 2 years was measured standing. In the absence of age, height 87cm was used to define whether to measure the child standing (≥87cm) or lying (<87cm).
The WHO growth reference 2006 was used to estimate the prevalence of under nutrition in the area. In addition, rate of acute malnutrition by MUAC criteria was analysed and reported.
Table 9: Case definitions of Acute Malnutrition, Stunting and Underweight used for analysis Nutritional Status Classification Nutritional Acute Malnutrition Chronic Malnutrition Underweight Weight/Age Status Weight/ Height (WHZ) MUAC Height/Age (HAZ) (WAZ) WHZ< -2 SD and/or MUAC< 125 mm Global HAZ< -2 SD WAZ< -2 SD Oedema and /or Oedema 115 mm≤ MUAC< WAZ <- 2SD to Moderate WHZ <- 2SD to ≥ -3 SD HAZ <- 2SD to ≥ -3 SD 125 mm ≥ -3 SD WHZ < -3 SD and/or MUAC< 115 mm Severe HAZ < -3 SD WAZ < -3 SD Oedema and /or Oedema
Table 10: Case definition for IYCF, morbidity, vitamin A and measles coverage Indicator Definitive criteria Early Initiation of Proportion of children aged 0-23 months who were put to the Breastfeeding breast within one hour of birth.
Exclusive Proportion of infants 0–5 months of age who are fed breastfeeding exclusively with breast milk Continued Proportion of children aged 12-15 months who are fed breast breastfeeding at 1 year milk and Proportion of children 20-23 months of age who are
and 2yr fed breast milk during the previous day.
Minimum dietary Proportion of children 6- 23 months of age who received foods diversity from 4 or more food groups during the previous day.
IYCF4 Proportion of breastfed and non-breastfed children 6–23 Minimum meal months of age, who receive solid, semi-solid, or soft foods (but frequency also including milk feeds for non-breastfed children) the at least 3 times (full meal) per day. Proportion of children 6–23 months of age who received a Minimum acceptable minimum acceptable diet (apart from breast milk). It is a diet composite indicator by combining minimum dietary diversity and meal frequency. Measles vaccination were assessed among children aged 9-59 months by checking for the measles vaccine on the EPI card if Measles vaccination available or by asking the caregiver to recall if no EPI card is available. Coverage Whether the child aged 6-59 months received a vitamin A capsule over the past six months was recorded from the EPI Vitamin A Coverage card or health card if available or by asking the caregiver to recall if no card is available. Morbidity for the preceding 14 days and applied for children 6- Morbidity patterns and Morbidity 59 months; for which the mother/primary care givers asked treatment status using recall response.
Table 11: Case definitions of public health significance level Global Acute Overall Overall Stunting Severity Malnutrition Underweight Interpretation (HAZ) (WHZ) (WAZ) Very High ≥ 15% ≥ 40% ≥ 30% Critical/ Emergency High ≥ 10% - <15% ≥ 30% - < 40% ≥ 20% - < 30% Serious Medium ≥ 5% - < 10% ≥ 20% - < 30% ≥ 10% - < 20% Poor Low < 5% < 20% < 10% Acceptable
Table 12: IPC classification5 Global Acute Malnutrition by MUAC Prevalence Global Acute Malnutrition MUAC Extreme Critical >17% Critical 11.0-16.9% Alert-Serious 6-11% Acceptable <6%
Table 13: Thresholds level for Household Dietary Diversity (HDD). Household Dietary Diversity Score (HDDS) Thresholds Low dietary diversity ≤ 5 food groups Medium dietary diversity Between 6 and 8 food groups High dietary diversity ≥ 9 food groups
4WHO 2010: Indicators for assessing infant and young child feeding practices: Part 3, Country profile. 5 IPC Acute Malnutrition Addendum 2016
Source: Dietary guideline for Bangladesh, BIRDEM, FAO
Table 14: Thresholds level for household Coping Strategy Index (CSI) Coping Strategy Index (CSI) Score Thresholds No or low coping 0 - 3 Medium coping 4 - 9 High coping ≥ 10 Source: Guidance note; WFP VAM unit, Afghanistan, December 2012
2.8 Questionnaire, training and supervision Questionnaire The questionnaire was developed to include indicators, IYCF, health and care practices, Food Security and Livelihoods, and WASH indicators. The questionnaire was translated in Bangla before the training. The questionnaire was pre-tested in the communities by the survey team.
Survey teams and supervision The integrated SMART survey implemented by six survey teams, each team consisting of a team leader cum measurer, one measurer, and two interviewers. The team leader cum measurer was responsible for day- to-day field supervision, household selection, and assist taking anthropometric measurements. To ensure the accuracy and consistency of data, joint monitoring and supervision were carried out through regular field visits, cross checking and plausibility checking through ENA software every day. Survey Manager, Survey and Reporting Manager, Nutrition and Health Head of Department and Deputy Head of Department oversaw the whole Integrated SMART survey and provided necessary support to the survey team.
Training The survey team received a 2-day refresher training on SMART methodology. The SMART training tools and presentation was adapted in line with the survey objective and used during the training. The training covered survey objectives, household selection techniques, demonstration on anthropometric measurements and standardization test, data collection and interview skills with group works, standardisation test & field-testing of questionnaire. During the field-testing, all the survey teams went to communities and each team conducted at least 4 household surveys.
2.9 Data analysis and quality Pre-defined excel database was used for data entry. During the data entry, random checks on sampled questionnaires were conducted to identify errors and minimizing data entry errors. The anthropometric data was imported into the ENA for SMART software (July 2015). Based on plausibility checks, the Survey Monitoring and Reporting Manager, with support from the nutrition technical team in Dhaka, provided daily feedback to the survey teams on the quality of the data and provided support on how to improve the quality of the measurements. Anthropometric data was analysed using ENA software & CDC calculator and additional indicators were analysed using excel and EPI info software. All flagged data using SMART flagging criteria (observed mean) was excluded from the analysis.
Table 15: Overall data quality from plausibility check CRITERIA Missing/ Overall Overall age Digit Digit Digit Standard Skewnes Kurtosis Poisson Overall flagged sex ratio distribution preferenc prefer preferenc deviation s WHZ WHZ distribution score WHZ data e score ence e score WHZ WHZ Weight score MUAC Height SCORE 0 (0.8%) 0 (p=1.0) 0 (p=0.793) 0 (5) 2 (9) 0 (4) 0 (0.97) 1 (0.35) 3 (0.40) 0 (p=0.513)) 6%
Interpretation Excellent Excellent Excellent Excellent Good Excellent Excellent Good Acceptable Excellent Excellent
3. Results
3.1 Household and Family composition Household data revealed that women led only 5.6% of the total households. The average household size was found to be 4.2 and percentage of U5 children was 8.2%. Male and female ratio was found almost equal.
Table 16: Household and family composition-Satkhira and Jessore Category/Indicator Sample HH Value Proportion/Mean % of Women Headed Household 1288 72 5.6% % of Men Headed Household 1288 1216 94.4% Average age of HH Head 1288 - 45yrs Mean Family Size 1288 5346 4.2 % of Male members 1288 2698 50.5% % of Female members 1288 2648 49.5% % of Children 0 to 5 months 1288 44 0.8% % of children 6 to 23 months 1288 138 2.6% % of children 24 to 59 months 1288 259 4.8% % of Children aged 5-17 years 1288 1269 23.7% % Adult members (18-50y) 1288 2846 53.2% % Elderly members (50 years and above) 1288 790 14.8%
3.2 Distribution Age and Sex The overall age and sex distribution (1.0) of the sampled children has shown equal representation of boys and girls. The overall age distribution was observed as expected (P=0.163) both in of boys (P=0.140) and girls (P=0.535).The overall age ratio of 6-29 months and 30-59 months was also found to be expected (P=0.793). However, the age ratio across the age groups (42-53) months and (54-59) months were outside the normal range of 0.8-1.2. This could be due to recall bias as some of the children in these age groups did not have documents to determine the exact age and a calendar of events was used to determine the age of the child. Table 17: Distribution of age and sex of sample Boys Girls Total Ratio AGE (mo.) no. % no. % no. % Boy: girl 6-17 37 45.7 44 54.3 81 21.1 0.8 18-29 50 51.0 48 49.0 98 25.5 1.0 30-41 48 50.0 48 50.0 96 25.0 1.0 42-53 45 57.7 33 42.3 78 20.3 1.4 54-59 12 38.7 19 61.3 31 8.1 0.6 Total 192 50.0 192 50.0 384 100.0 1.0
Anthropometric results (based on WHO standards 2006) Anthropometric data from a representative sample of 384 children was collected. The anthropometric data was analysed excluding z-scores from observed mean (SMART flags): WHZ-3 to 3; HAZ -3 to 3; WAZ -3 to 3. Therefore, a total of four, four and three children were excluded from the analysis to estimate prevalence of GAM (WHZ), Underweight (WAZ) and stunting (HAZ) respectively with SMART flag criteria.
3.3 Acute Malnutrition based on Weight for Height Z-score Acute malnutrition or wasting occurs when an individual suffers from current, severe nutritional restrictions, a recent bout of illness, inappropriate childcare practices or a combination of various factors (flooding, cyclones, limited income opportunities etc.) in any context as weight changes rapidly compared to height. It is characterised by extreme weight loss, resulting in low weight-for-height. Wasting is a reflection of present malnutrition.
Table 18: Prevalence of acute malnutrition based on Weight for Height z-scores (and or Oedema) and by sex All Boys Girls P-value n = 380 n = 190 n = 190 (44) 11.6 % (25) 13.2 % (19) 10.0 % Prevalence of global malnutrition (8.7 - 15.3 (9.2 - 18.5 (6.2 - 15.7 0.335 (<-2 z-score and/or oedema) 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate (40) 10.5 % (24) 12.6 % (16) 8.4 % malnutrition (7.8 - 14.1 (8.7 - 17.9 (5.3 - 13.2 0.160 (<-2 z-score and >=-3 z-score, no 95% C.I.) 95% C.I.) 95% C.I.) oedema) (4) 1.1 % (1) 0.5 % (3) 1.6 % Prevalence of severe malnutrition (0.4 - 2.8 95% (0.1 - 3.9 95% (0.5 - 4.9 95% 0.278 (<-3 z-score and/or oedema) C.I.) C.I.) C.I.)
Anthropometrics of 380 children were considered (flags excluded). The assessment found 44 children 6-59 months to be acutely malnourished. The overall Global Acute Malnutrition (GAM) prevalence by Weight for Height Z score and/or oedema was found to be 11.6% (8.7 - 15.3 95% C.I.) with MAM rate of 10.5 % (7.8 - 14.1 95% C.I.) which is considered serious according to WHO thresholds. This is an indication for further reinforcement of community-based management of acute malnutrition to prevent towards severe acute malnutrition (SAM) and returns to normal growth and development.
The Severe Acute Malnutrition (SAM) rate by Weight for Height Z score and/or oedema was 1.1% (0.4 - 2.8 95% C.I.). This indicates that children in the surveyed areas are in need of immediate life-saving treatment for their recovery and prevention of sudden risk of death.
Further analysis revealed found no statistically significant difference in the prevalence of GAM (P=0.335), MAM (P=0.160) and SAM (P=0.278) rates between boys and girls. No oedema cases were found during the assessment. Table 19: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Severe wasting Moderate wasting Normal Oedema (<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) Age Total No. % No. % No. % No. % (mo.) no. 6-17 80 1 1.3 3 3.8 76 95.0 0 0.0 18-29 97 0 0.0 8 8.2 89 91.8 0 0.0 30-41 95 3 3.2 14 14.7 78 82.1 0 0.0 42-53 78 0 0.0 9 11.5 69 88.5 0 0.0 54-59 30 0 0.0 6 20.0 24 80.0 0 0.0 Total 380 4 1.1 40 10.5 336 88.4 0 0.0
The assessment findings revealed that the prevalence of acute malnutrition considering WHZ found to be higher among younger children for SAM and MAM. About 66% (29 out of 44) of those identified as acutely malnourished were below 42 months and more than 85% (38 out of 44) aged less than 54 months. Z scores were found to be the lowest (14%; 6 out of 44) in the 54-59 age group.
Figure 2: WHZ Gaussian Curve. The sampled population curve (red curve) shows a displacement to the left of the reference curve (green curve) representing the WHO standards. This is an indication of poor nutritional status. The overall mean standard deviation (SD) is 0.97 and falls within the acceptable range of 0.8-1.2.
3.4 Acute Malnutrition based on Mid Upper Arm Circumference
A child is identified as malnourished if the circumference is less than 125 millimetres and severely malnourished if it is less than 115 millimetres. In Bangladesh as in other countries, MUAC is the primary admission criteria for nutrition treatment for children who are less than 59 months old. The Global Acute Malnutrition prevalence by MUAC is found to be “acceptable” according to IPC Acute Malnutrition classification.
Table 20: Prevalence of Acute Malnutrition based on MUAC cut offs (and/or oedema) and by sex All Boys Girls P-value n = 384 n = 192 n = 192 Prevalence of global (5) 1.3 % (1) 0.5 % (4) 2.1 % malnutrition (0.5 - 3.1 95% (0.1 - 3.7 95% (0.8 - 5.5 95% 0.143 (< 125 mm and/or oedema) C.I.) C.I.) C.I.) Prevalence of moderate (5) 1.3 % (1) 0.5 % (4) 2.1 % malnutrition (0.5 - 3.1 95% (0.1 - 3.7 95% (0.8 - 5.5 95% 0.143 (< 125 mm and >= 115 mm, no C.I.) C.I.) C.I.) oedema) Prevalence of severe (0) 0.0 % (0) 0.0 % (0) 0.0 % malnutrition (0.0 - 0.0 95% (0.0 - 0.0 95% (0.0 - 0.0 95% -- (< 115 mm and/or oedema) C.I.) C.I.) C.I.)
The prevalence of Global Acute Malnutrition by MUAC was found to be 1.3 % (0.5 - 3.1 95% C.I.) in the selected unions of Satkhira and Jessore Districts. According to GAM prevalence based on MUAC, there was no statistical difference between boys and girls (p= 0.143).
Figure 3: MUAC by Age The assessment findings revealed that the prevalence of acute malnutrition considering MUAC found to be lower than the WHZ scores. Based on MUAC, the prevalence of GAM was found 1.3 % (0.5 - 3.1 95% C.I.) and SAM 0.0 %. MUAC also identified younger children for both SAM and MAM. About 60% (3 out of 5) of those identified as malnourished within the age group of 6-17 months and 100% (5 out of 5) of malnourished children were aged less than 29 months. No MAM children aged 30 to 59 months were detected using MUAC. Being an absolute measure, MUAC mostly detects younger children.
However, this discrepancy has been reported as a general phenomenon by Grellety and M. H Golden6 based on survey data from 47 countries. The discrepancy of rates of GAM across age groups and sex supports the conclusion that MUAC is dependent on age and sex. MUAC overestimates acute malnutrition among younger children and underestimates among older children7. Low MUAC for girls compared to boys was observed and reported by LT Hop, R Gross, S Sastroamidjojo, T GiaY and W Schultink8, which is similar to this survey finding.
Table 21: Prevalence of Acute Malnutrition by Age, based on MUAC cut offs (and/or oedema) and by sex Moderate wasting Severe wasting Normal (>= 115 mm and < Oedema (< 115 mm) (> = 125 mm ) 125 mm) Age Total No. % No. % No. % No. % (mo.) no. 6-17 81 0 0.0 3 3.7 78 96.3 0 0.0 18-29 98 0 0.0 2 2.0 96 98.0 0 0.0 30-41 96 0 0.0 0 0.0 96 100.0 0 0.0 42-53 78 0 0.0 0 0.0 78 100.0 0 0.0 54-59 31 0 0.0 0 0.0 31 100.0 0 0.0 Total 384 0 0.0 5 1.3 379 98.7 0 0.0
3.5 Underweight Underweight is an effect of both wasting and stunting, and is therefore a composite indicator of general malnutrition. It is measured by low weight-for-age in children, and is an outcome of either past or present undernutrition. The index does not indicate whether the child has a low weight-for-age because of inadequate weight or because of a small stature for his or her age, and therefore cannot distinguish between chronic and acute malnutrition.
6 Emmanuel Grellety and M H Golden: Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications 7 de Onis M., Yip R., and Mei Z., "The development of MUAC-for-age reference data recommended by a WHO Expert Committee," Bull World Health Organization, vol. 75, pp. 11–8, 1997. PMID: 9141745 8 Hop le T., Gross R., Sastroamidjojo S., Giay T., and Schultink W., "Mid-upper-arm circumference development and its validity in assessment of undernutrition
Table 22: Prevalence of Underweight, based on Weight for Age z-scores (WAZ) All Boys Girls P-value n = 380 n = 188 n = 192
(103) 27.1 % (52) 27.7 % (51) 26.6 % Prevalence of underweight (22.7 - 32.1 (21.3 - 35.1 95% (21.0 - 33.0 0.812 (<-2 z-score) 95% C.I.) C.I.) 95% C.I.) Prevalence of moderate (77) 20.3 % (40) 21.3 % (37) 19.3 % underweight(<-2 z-score (16.1 - 25.1 (15.2 - 28.9 95% (14.5 - 25.2 0.649 and >=-3 z-score) 95% C.I.) C.I.) 95% C.I.) Prevalence of sever (26) 6.8 % (12) 6.4 % (14) 7.3 % underweight (4.9 - 9.5 95% (3.6 - 11.1 95% (4.4 - 11.7 95% 0.727 (<-3 z-score) C.I.) C.I.) C.I.)
The overall prevalence of underweight, based on WAZ was found to be 27.1 % (22.7 - 32.1 95% C.I.) with 6.8 % (4.9 - 9.5 95% C.I.) of the children being assessed as severely underweight which is considered high according to WHO thresholds. There was no significant difference (p=0.812) in prevalence of underweight found between boys and girls. This indicates chronic episodes of hunger, insufficient food intake, access, and could point towards a historically bad state of household food security. Moreover, with such high numbers, where more than one in every four children is underweight, requires immediate intervention and assessment on food security and nutrition intake within the households.
Table 23: Prevalence of Underweight by Age, based on WAZ Severe underweight Moderate underweight Normal Oedema (<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) Age Total No. % No. % No. % No. % (mo.) no. 6-17 79 3 3.8 8 10.1 68 86.1 0 0.0 18-29 98 2 2.0 17 17.3 79 80.6 0 0.0 30-41 95 12 12.6 23 24.2 60 63.2 0 0.0 42-53 78 7 9.0 19 24.4 52 66.7 0 0.0 54-59 30 2 6.7 10 33.3 18 60.0 0 0.0 Total 380 26 6.8 77 20.3 277 72.9 0 0.0
3.6 Chronic Malnutrition/ Stunting Stunting is an adaptation to chronic malnutrition and reflects the negative effects of nutritional deprivation on a child’s potential growth, over time. Stunting can occur when a child suffers from long-term nutrient deficiencies and/or chronic illness, so that not only weight gain but also height is affected. It can also be an outcome of repeated episodes of acute infections, or acute malnutrition.
Table 24: Prevalence of stunting based on Height for Age z-scores (HAZ) and by sex All Boys Girls P-value n = 381 n = 190 n = 191 (105) 27.6 % (51) 26.8 % (54) 28.3 % Prevalence of stunting (23.3 - 32.3 95% (21.3 - 33.2 95% (22.0 - 35.5 0.741 (<-2 z-score) C.I.) C.I.) 95% C.I.) Prevalence of moderate (86) 22.6 % (43) 22.6 % (43) 22.5 % stunting (18.3 - 27.5 95% (17.4 - 28.9 95% (16.8 - 29.4 0.981 (<-2 z-score and >=-3 z- C.I.) C.I.) 95% C.I.) score) Prevalence of severe (19) 5.0 % (8) 4.2 % (11) 5.8 % stunting (3.2 - 7.7 95% (2.1 - 8.1 95% (3.0 - 10.7 95% 0.502 (<-3 z-score) C.I.) C.I.) C.I.)
The prevalence of stunting, based on HAZ was found to be 27.6 % (23.3 - 32.3 95% C.I.) with severely stunting prevalence of 5.0 % (3.2 - 7.7 95% C.I.) which is considered medium according to WHO thresholds with many of them are probably at risk of permanently damaging their mental, physical health, growth, undermining their future productivity and therefore income. There was no major significant difference in prevalence of stunting found between boys and girls (P=0.741). Figure 4: HAZ Gaussian Curve The sampled population curve (red curve) shows a displacement to the left of the reference curve (green curve). This is an indication of poor nutritional status. The mean standard deviation (SD) is 0.95 in Satkhira and Jessore and falls within the acceptable range of 0.8-1.2.
Table 25: Prevalence of stunting by age based on height-for-age z-scores Severe stunting Moderate stunting Normal
(<-3 z-score) (>= -3 and <-2 z-score ) (> = -2 z score) Age (mo.) Total no. No. % No. % No. % 6-17 79 4 5.1 15 19.0 60 75.9 18-29 97 2 2.1 16 16.5 79 81.4 30-41 96 6 6.3 30 31.3 60 62.5 42-53 78 6 7.7 19 24.4 53 67.9 54-59 31 1 3.2 6 19.4 24 77.4 Total 381 19 5.0 86 22.6 276 72.4
It is alarming to find that the prevalence of stunting does not reduce as the children ages suggesting hampered growth during pregnancy and before the infant reaches 6 months. If not addressed before the child is 40 months the situation is irreversible. Later these children will grow up as stunted and will not have linear growth as adults.
Table 26: Mean z-scores, Design Effects and excluded subjects Mean z-scores Design Effect (z- z-scores not z-scores out of Indicator n ± SD score < -2) available* range Weight-for-Height 380 -0.92±0.97 1.01 1 3 Weight-for-Age 380 -1.44±0.97 1.07 0 4 Height-for-Age 381 -1.43±0.95 1.00 1 2
3.7 Childhood Morbidity A total of 393 children’s were assessed to determine the morbidity status of children aged 6-59 months in the last 2 weeks . Almost 55% of the children (214 households) reported an illness in the two weeks prior to the assessment. Overall 41.0% suffered from fever, 5.6% of the children had diarrhoea and 28.5% had an Acute Respiratory Infection (ARI) and 12.2 % of the children suffered from other diseases.
Table 27: Prevalence of childhood (6-59 months) morbidities at 95% CI Type of Total Satkhira Sadar Tala Kolaroa Kashabpur Morbidity (N=393) (N=127) (N=136) (N=55) (N=75) Diarrhoea 5.6% 6.3% 8.1% 3.6% 1.3% Fever 41.0% 35.4% 38.2% 50.9% 48.0% ARI 28.5% 30.7% 24.3% 30.9% 30.7% Other diseases 12.2% 15.0% 9.6% 16.4% 9.3%
The assessment revealed that an estimated overall Figure 5: Treatment receive status 86.4% parents/ caregivers reported that they took their children for treatment from different sources and 13.6% received treatment from different health facilities whereas overall 713.6 % of the children did not receive 50.0% 23.4% any kind of treatment. However, 13.1% of the children received treatment from Government Hospital, 23.4% from Private Clinic and a high rate of 50.0% children 13.1% were managed by traditional treatment or others like from village (untrained) doctors Did not receive treatment Private clinic Govt. Clinic Other villages/Village doctors On the other hand, the coverage of vitamin A and measles vaccination was found to be remarkably lower than the Sphere Standard’s recommendation of 95 % coverage. Overall, 89.8 % (86.4-92.4 CI 95%) of the assessed children aged 6-59 months received Vitamin A in the last six months. Besides, an estimated 94.1% (91.2%-96.1% CI 95%) of children who were 9 months old received a good coverage of measles immunisation.
3.8 Child Care practices including Infant Young Child Feeding (IYCF) Optimal infant and young child feeding entails the initiation of breastfeeding within one hour of birth; exclusive breastfeeding for the first six months; and continued breastfeeding for two years or more, together with safe, age-appropriate feeding of solid, semi-solid and soft foods starting at 6 months of age following recommended dietary diversity and meal frequency. During the survey period, it was challenging to get adequate sample for IYCF indicators within the framework of SMART methodology. However, these results can provide an overview of the situation especially on IYCF practices in lieu of generalizing the whole population.
Table 28: Summary Findings of IYCF Indicators IYCF Indicators Number Prevalence Early Initiation of Breastfeeding (0-23 months) 181 69.6% (126) Exclusive breastfeeding for children (0-5 months) 44 59.1% (26) Continuation of breastfeeding at 1 year (12-15 months) 27 100% (27) Continuation of breastfeeding at 2 year (20-23 months) 39 79.5% (31) Mean Dietary Diversity Score (IDDS) (6-23 months) 3.4 Minimum Dietary Diversity (6-23 months) (>=4 food groups) 137 47.5% (65) Minimum meal frequency (6-23 months) 137 62.8% (86) Minimum acceptable diet (6-23 months) 137 33.6% (46)
3.8.1 Early Initiation of Breastfeeding A total of 181 children aged 0-23 months from the 8 selected unions in Satkhira and Jessore Districts were identified and their mothers were asked about their initiation of breastfeeding after birth. An estimated 69.6% mothers initiated breast-feeding within one hour after birth. This result indicates that a significant number of mothers initiate breast feeding within 1 hour after giving birth which is highly positive nutritious practice. The practice helps to increase immunity of child as well as prevent post-partum haemorrhage, maternal morbidity and so on. It also works to increase emotional bonding very quickly between mother and child. Moreover, it could be improved as it is one of the recommended practices of IYCF and contributes to decrease neo-natal mortality by up to 22%9.
3.8.2 Exclusive Breastfeeding The sample size for exclusively breast-feeding aged 0-5 months was too small to statistically validate these results. The findings can be used as an indicative estimation for exclusive breastfeeding among infants. An estimated overall 59.1% of infants were exclusively breastfed during last 24 hours. Therefore, focused behaviour change activities should be continued to encourage the practices of exclusive breastfeeding, which is requisite for optimal growth and development, as well as to protect the child from various forms of disease.
3.8.3 Continued Breastfeeding (at 1 year and 2 years) The findings analysed provide a picture of the situation of continued breast-feeding of these 8 unions in Satkhira and Jessore Districts although the sample size for this indicator was too small to validate the findings. An estimated overall 100.0% of children continued breastfeeding at 1 year and 79.5% of children continued
9World Health Organisation. Infant and young child feeding. [press release] July 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385257/#CR3
breastfeeding at 2 years reflects to the approximate rate of continued Breast-feeding among children aged 20-23 months.
3.8.4 Complementary feeding Minimum Dietary Diversity was overall 47.5%, which indicate that almost half of children aged 6-59 months received, recommended at least four category of food groups. Mean dietary diversity score of Children- IDDS was 3.4 whereas overall only 33.6 % children had an acceptable diet in the 8 selected unions in Satkhira and Jessore districts. This means children did not consume the recommended minimum four food groups following minimum meal frequency that are essential for proper growth and development.
Figure 6: Diet in the last 24 hours (6-23 months) % 100.0% 89.1% 90.0% 80.0% 71.5% 70.0% 52.6% 54.7% 60.0% 47.4% 46.0% 50.0% 41.6% 40.1% 40.0% 30.0% 24.1% 20.0% 10.0% 0.0% Grains, Legumes or Dairy Flesh foods Vitamin A Eggs Other fruits Any oil, fats Any Sugary Roots, Nuts Products rich fruits & and foods Tubers vegetables Vegetables
Complementary foods are essential once the child has reached six months and lack of it can cause serious deficiencies and puts the child at risk of malnutrition and infections by weakening the child’s immune system. Figure 6 indicates that grains, roots and tubers are mostly consumed (89.1%). It was reported that about half of the children consumed meat and other fruits and vegetables. The consumption of legumes or nuts, were consumed by less than 30% of the children. This indicates that behaviour change communication on nutritious balanced diet should be enhanced.
Minimum Dietary Diversity The survey findings indicated that overall, minimum meal frequency rate for children aged 6-23 months was 47.5% and the dietary diversity score was found to be 3.4. This indicates a not even half of the children received complementary from 6 months as per the recommended optimal feeding and feeding practices (4 food groups) in 8 selected unions in Satkhira and Jessore Districts.
Minimum Meal Frequency The survey findings indicated that overall minimum meal frequency rate for children aged 6-23 months was 62.8%. This indicates about 2 in 3 of children received complementary food from 6 months as per the recommendation for optimal feeding and feeding practice (at least 3 full meals per day).
Minimum Acceptable Diet The overall minimum acceptable diet was assessed by 33.6% meaning only about 1 in 3 children within age group of 6-23 months consumed at least minimum four food groups following minimum meal frequency that are essential for proper growth and development.
3.9 Knowledge of mothers on child care practices (0-23 months) Figure 7: Source of Indication of mother/caregiver to feed the child
Caregiver’s were asked to share their difficulties Do not Know 0.2% or challenges in terms of childcare practices that is linked to health and nutrition. The survey found Others 41.7% that caregivers fed their child based on more than one characteristic. An estimated 55.2% of the Every 3-4 hrs 13.1% mothers said that they feed the child when the child cries. This situation refers to the extreme Some one told me 1.2% hungry condition and child needs to feed before s/he cries due to hunger. Besides, an overall Pre-Determine schedule 3.6% 41.9% of the mothers looked for clues from the child in form of fussiness, putting hands in mouth Crying 55.2% etc. A few mothers (3.6%) have a predetermined Looking for cues from schedule, which is necessary for good feeding 41.9% child(fussiness,putting hand in… practices. Another interesting point is that only 41.7% mother have learned from others when about feeding timing, which might have a big impact on their knowledge about child feeding practices. Thus, awareness and practices regarding frequency of meal including other feeding related knowledge are very pertinent for the surveyed area. As can be seen in the figure below, in most of households sampled, the caregivers (0-59) were found to believe that health (64.6%) and positive environment (56.9%) are most important for their young child’s optimum growth and development. All other perceptions like importance of play, interaction with child and giving opportunity to learn all were less prioritized (less than 40% of caregivers) by the respondents. This could be attributed due to low level of exposure to information about interaction and limited knowledge about the need of child stimulation required for age appropriate child development including cognitive, motor, language and emotional development. (0-59 months).
Figure 8: Perception of caregiver for child’s optimum growth and development Donot Know, 0.5% Having good Others, 40.4% health(free from disease), 64.6%
Safty security & love, 35.1%
Being happy(Cheerful Oppurtunity to learn, not fusy,playful), 14.3% 24.7%
Oppurtunity to play, 25.7% Interaction with the Positive environment, 56.9% child, 22.3%
3.10 Food Security and Livelihoods
3.10.1 Household Source of Income Head of the households or whosoever was the head of the house at the time of the interview were asked about the household’s main income source and monthly income. Given the complexity of calculating the average monthly income of household, the total monthly income from all sources for the previous 12 months was asked and then the main source of income was identified. It was believed that there could be more than one source of income and therefore the question was specifically asked in a way that the respondent would understand that they need to give the total income from all sources of income for the month.
Overall 95.3 % HH found only one income source and 4.7 % had second option of income. The main source of income overall was unskilled wage labour 43.5%, Agriculture and sales of crops 9.9%, Skilled labour was 9.2%, trading-less than 10,000 monthly income 7.7% and Salaries, wages-employees was 9.2%. Figure-9 shows income sources of the surveyed households:
Figure 9: Main source of income of Household in percentage % Agriculture and sales of crops Livestock and sales of animals 0.3% Fishing (open /common water) 0.1% 0.7% 0.7% Aquaculture((in a pond) 4.3% 0.7% 0.3% 7.6% 9.9% Unskilled wage labour (including agro 4.1% Skilled labour Handicrafts/cottage industry 9.2% Collection of natural resources Petty trading-less than 10,000 monthly income 1.5% Seller, commercial activity 7.7% Salaries, wages-employees Begging 0.2% Gift 0.2% 9.2% 43.5% Remittance Government allowance Land renting Others
The monthly average income of surveyed households is BDT 9,513 in the 8 selected unions in Satkhira and Jessore district. To better understanding of the income level, surveyed households are categorized in three income groups – monthly income
Table 29: Mean Income by category Poor Moderate Good Mean Income Normal HH MAM HH SAM HH HDDS HDDS (6- HDDS (9- HH INCOME (BDT) (BDT) (BDT) (BDT) (below 6) 8) HH 12) HH HH (BDT) (BDT) (BDT) (Overall) 9,513 9,982 7,346 8,500 6,639 9,086 13,385
3.10.2 Source of Food There were only two main sources of foods – purchase and own production as mentioned by the survey respondents in 8 selected unions in Satkhira and Jessore Districts. Out of the total surveyed households 74.3% mentioned that purchase was their main food source. About a quarter of the household’s food source was their own production. As most of the household’s food source was purchase, meaning that market access is very crucial for food security in the surveyed areas. Food price hike or drop of income due to any man made or natural disasters have big negative impact on the food security of the low-income groups in the survey area. Table 31 shows the status of food source of the surveyed area.
Table 30: Main food source Main Source of Food Number Overall % Own cultivation 318 24.7% Cash loan 4 0.3% Borrowing 6 0.5% Purchasing 957 74.3% Begging 2 0.2% Others 1 0.1%
3.10.3 Household Dietary Diversity Score Households were asked to identify the foods that were consumed in the previous 24 hours by the family members. Due to the shorter recall period, the data can provide a clearer picture of the variety of foods consumed at the household level. In measuring the household dietary diversity, food items were grouped into 12 food groups. Figure 10: Household dietary diversity status Mean Household dietary diversity Score (HDDS) of the surveyed households was 7.1 that indicates overall good dietary diversity status among the 100.00% 66.5% surveyed households. Out of total surveyed 80.00% households, about 18.9% had good dietary diversity 60.00% 18.9% and 82.2% households had medium to low dietary 40.00% 15.7% diversity. Percentage 20.00% 0.00% Overall Category of household
Poor (≤5) Moderate (6 to 8) Good (≥9)
Dietary consumption in the selected 8 unions in Satkhira and Jessore Districts was dominated by cereals (rice, roti etc.) while consumption of pulses, legumes; meat & fish, milk were less than one-third of the total households surveyed. Consumption of fish that was quite similar in the unions and is a very low consumption of animal protein.
Table 31: Food consumption in last 24 hours by household members % of Food groups consumption Number households Starchy foods –(Rice, wheat, muri, maize ) 1,287 99.9% Tubers - (Potatoes, Sweet potatoes, 1,025 79.6% Vegetables 1,054 81.8% Meat - (Beef , Goat and Chicken) 243 18.9% Fish/Dry fish 806 62.6% Eggs 348 27.0% Fruits 552 42.9% Pulses & Legumes (any type of dal) 534 41.5% Milk - yogurt and other dairy 338 26.2% Oil, fat, butter 1,254 97.4% Sugar, Honey 450 34.9% Condiments/other (Tea, Coffee, spices, 1,286 99.8% etc.)
3.10.4 Reduced Coping Strategy Index (rCSI) Figure 11: Status of reduced coping strategies
Reduced Coping Strategy Index (rCSI) was employed to understand the different behaviours No or low coping related to food consumption as a coping strategy with (CSI score 0 -3) food shortage induced from inadequate income of 20.8% access related problems. It provides information on the way households respond when they face limited Medium coping (CSI score 4 – 9) access to sufficient food. The analysis of these 12.8% behaviours helps understanding the food insecurity 66.4% situation. The r-CSI helps identifying areas and High Coping (CSI population groups at risk or suffering from food score ≥ 10) insecurity. It also allows estimating the impact of an intervention. In addition, the r-CSI can be used as an early warning indicator. It also helps to understand the level of food insecurity among the targeted beneficiaries’ households. Higher the Coping Strategy Index (CSI) score indicates higher level of food insecurity and vice versa.
The average rCSI (reduced Coping Strategy Index) score of the sample households was 4.9 among the surveyed households in the 8 selected unions in Satkhira and Jessore Districts. About 66.4% of the surveyed households had high rCSI score, which indicated higher food insecurity among the groups. In contrast, 14% of the survey respondents said that they have to rely on no or low coping. Figure 16 shows level of coping strategies by the surveyed households:
Figure 12: Indicator wise status of reduced coping strategies index
50.0% 44.3% Rely on less preferred & less expensive 40.0% foods 28.5% Borrow food or rely on help from 30.0% 25.8% neighbour/relatives 20.7% Reduce meal size at meal times 20.0% 16.2%
10.0% Restrict consumption by adults so that small children can eat 0.0% Reduce the number of meal eaten per day % of households
Out of total sampled households 20.7% mentioned that they restrict consumption by adults so that small children can eat. On the other hand, 16.2% of the households mentioned about reducing the number of meals.
3.11 Water and Sanitation
3.11.1 Main sources of water by percentage of HH The main source of drinking water was deep tube-well as reported by the respondents (49.5%). On the other hand, 43.2% of total demand of drinking water was met by shallow tube-well. There is no other dominant of source of drinking water in the area. It is also important to check the water quality of shallow tube-well, because it has a potential threat to be contaminated. Table 32: Main source of drinking Water source for drinking N= 1288 % in surveyed HH Tube well (shallow) 556 43.2% Tube well (deep) 637 49.5% Protected well 1 0.1% Unprotected well 0 0.0% Rainwater harvesting 4 0.3% Surface water (river, stream, pond) 0 0.0% Pond Sand Water 5 0.4% Piped network 30 2.3% Arsenic, Iron removal plant (AIRP) 1 0.1% Others 54 4.2%
3.11.2 Distance to water source Just over 62% of the houses were close to the water source i.e. within 150 feet, which is a very good indicator. On the other hand, almost 37.6% of the households had to collect drinking water from the source that is more than 150 feet away. Therefore, there is a necessity to install more water points to meet the national standard (DPHE/HYSAWA). On the other hand, the Bangladesh standard of safe distance between water source and nearest latrine is at least 30 feet. Survey findings revealed that 41.3% of the latrines did not follow the standard, which means potential risk for faecal contamination of water source. In addition, it is interesting to note that in 93.1% of the households’ women including girls and adult women were solely responsible to collect water from source of drinking. This particular task is very gender biased which need special attention to reduce the burden of women.
Table 33: Distance of water source from home and latrine Distance of water source from home and latrine Upazila-wise Upazila Distance Satkhira Sadar Tala Kolaroa Keshabpur Total
Water source 0-150ft 48.6% 65.9% 69.7% 74.9% 62.4% from your home > 150ft 51.4% 34.1% 30.3% 25.1% 37.6% Water source 0-30ft 29.4% 42.3% 49.5% 53.8% 41.3% from the 30-100ft 33.6% 31.6% 36.9% 29.1% 32.6% nearest latrine >100ft 37.0% 26.0% 13.6% 17.0% 26.1%
3.11.3 Water Transport and Storage For the most part water is stored and transported properly. Most people are washing their water storage containers daily and at least two times per week.
Table 34: Washing behaviour of storage container Frequency N= 1288 Overall % of HH Daily 972 75.5% Twice per week 255 19.8% Once per week 52 4.0% Less than once per week 9 0.7%
Water containers are either always (89.4%) or sometimes (9.2%) covered during transport, Work is needed to improve this so that everyone always covers their containers while transporting water in order to prevent contamination. The majority of households (67.2%) use the same container for both transport and storage of water.
Figure 13: Covering of transport container Figure 14: Drinking water storage within the HH
Bucket/pitcher/container 1.3% 100.00% covered and tap 89.4% 90.00% 80.00% Bucket/pitcher/container 28.2% 70.00% covered 60.00% 50.00% Bucket/pitcher/container 40.00% uncovered 3.3% 30.00% 20.00% 9.2% Same container used for 10.00% 1.3% 67.2% collection/transport 0.00% Yes Sometimes No
3.11.4 Sanitation and Hygiene Over a third (42.8%) of households use unhygienic/unimproved sanitary latrine facilities and thus have a high risk of recurrent illness and deterioration of nutritional status.
Table 35: Category of sanitary latrines by % of households Upazila - improved/unimproved Type of % Satkhira latrine Overall Overall Kolaroa Tala Keshubpur Sadar Piped with (42) Sewerage 3.3% system Latrine Improved (235) with Septic 57.2% 50.0% 62.0 % 60.6% 49.0% Sanitary 18.3% Tank Facilities Latrine (460) with water 35.7% sealed Latrine without (392) water 30.4% sealed Open pit (87) latrine 6.8% Hanging (11) latrine 0.9% Unimproved No latrine sanitary 42.8 % 50.0 % 38.0 % 39.4 % 51.0 % (defecate facilities openly nearby (29) roads, 2.3% river, field, jungle etc.) (32) Others 2.5%
About one third (36.3%) of children used latrines. This may negatively influence the usage of hygienic latrine, as children under 5 may not use latrine properly. A bigger issue is that 36.6 % HH who had under-5 children were not properly managed child faeces regularly contributing to the increased risk of faecal-oral transmission of disease and ultimately worsening the nutritional status.
Table 36: Disposal of Children’s faeces % of households
Child under 5 defecation and disposal N=413 % HH
Child used latrine 150 36.3% Picked up and threw in latrine 109 26.4% Left in the open where child defecated 23 5.6% Buried or covered with soil/ash 3 0.7% Picked up and thrown in solid waste pile 68 16.5% Picked up and thrown out of compound (in open) 60 14.5%
3.11.5 Hand washing Behaviour The interviewees were asked about the hand washing practices. Nine different occasions were already prepared on the questionnaire but the respondents were not prompted on these occasions. These occasions are such that people in general would wash their hands. The respondents were allowed to mention more than one occasion.
Figure 15: Percentage of handwashing behaviour as per occasions Percentage of handwashing behavior as per occasions
After handing money 0.5% After sneezing 4.9% Before breast-feeding to child 3.6% Before feeding child 11.0% After working with animals, crops etc 56.7% After disposing child's feces/cleaning child 28.8% Before eating food 56.8% After defecation 91.0% Before cooking 36.1%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
Hand washing after defecation was prevalent almost universally and one third of households indicated to wash their hands before cooking. It is matter of concern that only 56.7% of households washed their hands before eating, 28.8% caregivers washed their hand after cleaning the child faeces and only 11.0% caregivers washed their hand before child feeding and only 3.6% before breastfeeding. People very rarely wash their hands after sneezing and handling money. Hygiene practice regarding childcare is very poor that may aggravate the nutritional. Improved sensitization is needed on this.
Figure 18: Hand-washing material It is good that majority (67.5%) of households used water and soap or ash to wash their hand. Using 2.3% Water only soap, or even ash, along with water to wash hands 17.9% is a very effective way to stop the transmission of Water and ash 11.9% many diseases. More research needs to be done Water and to find out the way to increase the number of 0.5% sand/mud people for using soap or ash while handwashing 67.5% Water and soap following appropriate steps.
4 Discussion & Conclusion
Nutrition The GAM prevalence by WHZ and/or oedema was found to be 11.6 % (8.7% - 15.6% 95% CI) in the 8 selected unions of Satkhira and Jessore district. The SAM prevalence by WHZ was found to be 1.1% (0.4-2.8 95% CI). No cases of oedema were found during the assessment. The GAM prevalence was found to be high according to the WHO thresholds. There is a large discrepancy between GAM prevalence by WHZ and MUAC. The GAM prevalence by MUAC was found to be 1.3% (0.5-3.1 95% CI). However, there is no significant difference found in GAM prevalence among boys and girls by both WHZ (P=0.335) and MUAC (P=0.143).
Almost one third of the children U5 were found to be underweight (27.1%) and stunted (27.6 %). According to the WHO classification, the prevalence of underweight was found to be high and stunting could be interpreted as medium. There was no significant difference in prevalence of underweight (p=0.812) and stunting (p=0.741) found between boys and girls.
Child Morbidity and Immunization Presence of disease results in lowered immunity, mucosal damage, and exacerbates the loss of nutrients. This in turn worsens the nutritional status of an individual. There was a high incidence of illness reported in this survey (54.5%). Overall 5.6% of the children had diarrhoea, 41.0% had fever and 28.5% had Acute Respiratory Infection (ARI) and 12.2 % of the children suffered from other diseases.
The survey findings also revealed that a high rate of 50.0% (43.1-56.9 CI 95%) children were managed by traditional treatment or others like from untrained village doctors whereas 13.1% ( 8.8- 18.4 CI 95%) of children were brought to the Government Hospital, 23.3 % (17.8-29.6 CI 95%) to the Private Clinic.
Moreover, an estimated 89.8% (86.4-92.4 CI 95%) of children aged 6-59 months received Vitamin A in the last six months; In addition, an estimated 94.1% (91.2%-96.1% CI 95%) of the children who were 9 months old received a good coverage of measles immunization. The immunisation coverage is slightly below the SPHERE recommendation of 95% measles immunisation coverage.
Infant Young Child Feeding including Care Practices An estimated 69.6% (62.4%-76.2% CI 95%) mothers of 0-23 month’s children initiated breast-feeding within one hour after birth. This result indicates that a significant number of mothers initiate breast- feeding within the first 1 hour after giving birth, which is highly positive IYCF practice. However, this
percentage was high but it could be improved much more as this practice is very critical to child’s nutrition and health and contributes to a decrease neo-natal mortality by up to 22%.10
Overall 59.1% of infants’ months were exclusively breastfed up to six months. This indicates more sensitization is needed to encourage exclusive breastfeeding up to six months to ensure optimal growth and development of infants. Though the sample size for exclusively breast-feeding aged 0-5 months was too small to statistically validate these results, these findings can be used as an indicative estimation for exclusive breastfeeding among infants.
The approximate rate of continued breast-feeding at 1 year found 100% and continued breastfeeding at 2 year 79.5 %. The survey findings indicated that Minimum Dietary Diversity was 47.5% (38.9-56.2, CI 95%) and minimum acceptable diet was 33.6% (25.1-41.4, CI 95%) that indicate few children received recommended at least four category of food groups and age appropriate feeding. The findings also revealed that overall minimum meal frequency rate for children aged 6-23 months was 62.8%; infant 6-8 months was 52.4%, Infants aged 9-11 months was 47.4 %, and children aged 12-23 months 68.0%. These indicates an improved percentage of children received complementary food from 6 months as per the recommendation for optimal feeding and feeding practice among the Upazila is most probably responsible for under nutrition.
Food Security and Livelihood The mean income during this survey was overall BDT 9513 BDT (Satkhira Sadar 9116 BDT, Tala 9423 BDT, Keshabpur 9638 BDT and Kolaroa 10410 BDT). A stark difference was seen in between those households that are in good household dietary diversity: mean income BDT 13385 and those that are classified as Poor: mean income BDT 6639. Overall 95.3 % HH found only one income source and 4.7 % had second option of income. The main source of income overall was unskilled wage labour 43.5% (42.0%-47.5% CI 95%), Agriculture and sales of crops 9.9% (9.5%-12.9% CI 95%), Skilled labour was 9.2% (8%-11.2% CI 95%), trading- less than 10,000 monthly income 7.7% (6.5%-9.4% CI 95%) and Salaries, wages-employees was 9.2% (7.8%-11% CI 95%). As every two in five households main income source was unskilled day labour and many of households depending on agro based income sources in this disaster prone areas probably triggers their vulnerability and malnutrition of their children and all. More than seven in ten households purchased their food 74.3% while small proportion grew their own food, suggesting that the food security in the four Upazilas are directly related to the availability of food markets and prices value thus making the Upazilas more vulnerable. Any increase in price of the food products would also bear adversely on the nutritional state, expenditure on food and food security situation in the household level consumption. The Mean Household Dietary Diversity Score (HDDS) was 7.1 and overall 18.9% of the households have good dietary diversity (equal to or above 9 food groups), 65.5% households have medium (between 6 to 8 food groups) and 15.7% household have low (less than or equal to 5 food groups) dietary diversity. Overall, reduced Coping Strategy Index score was 4.9, in Satkhira and Jessore that indicates medium level of coping strategies exist in the household’s level. Higher-level negative coping strategies such
10World Health Organisation. Infant and young child feeding. [press release] July 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385257/#CR3
as “restrict consumption by adult so that children can eat” and “reduce the number of meal eaten per day” were undertaken by 20.7% and 16.2% of the households respectively.
Water, Sanitation and Hygiene Major sources of drinking water were shallow tube well 43.2 % and deep tube well 49.5%. In addition, 98.2% of surveyed households said their water source was available year round. Overall 42.8% households had unimproved latrine facilities. This is a strong indicator of high risk for recurrent diarrheal disease and deterioration of nutritional status. Around 38% of households in Satkhira Sadar, 50% in Kolaroa 39.4% in Tala and 51.0% in Keshabpur Upazilas have unimproved latrine and/or water points close to latrines indicating a high potential threat of water contamination and frequent cases of water borne diseases. Worrying is that despite repeated messaging, 36.6% of households with under 5 children were not properly managing their children’s faeces this contributes to an increased risk of faecal-oral disease and the worsening nutritional status. Overall 37.6 % water source were more than 150 feet from the households. Adult women (89.8%) are the primary regular collector of water with 3.3% girls collecting the water regularly. Men and boys rarely collected water. Most households have the good practices of covering their water transport containers during transport (89.4%) and wash their water storage container daily (75.5%). It is good that majority of households used water and soap (67.5%) or ash (11.9%) to wash their hand. More research needs to be done to find out the way to increase the number of people for using soap or ash while handwashing following appropriate steps.
5 Causes of undernutrition Identifying the direct causal relationship is out of the scope of the cross sectional survey conducted in these areas. However, the basis of finding high prevalence of fever 86.2% (68.3-92.1 CI 95%), ARI 55.2% (35.7-73.6 CI 95%) and diarrhoea 3.5% (0.1-17 .8% CI 95%) among the acute malnourished children. Children with poor complementary feeding practices with minimal acceptable diet and a low level of knowledge about childcare and feeding practices in the areas were directly correlated with acute malnutrition. Family’s high dependency on daily work, unstable income sources, and high purchasing of food source could be key underlying factors affecting child nutritional health negatively in the Upazilas. Additionally, poverty11, less income source, low level of improved sanitation, high level of food insecurity might have played a key role in dietary consumption of children particularly in a large segment of population who have lower rate of income, vulnerable income sources and highly dependent on purchasing of staple foods.
6 Limitation and Bias Following SMART methodology and tools, it was ensured to overcome all biases. Some selected clusters, especially in Jessore District, were scattered, some clusters required long travelling time by walking, and therefore in some cases the survey teams had limited time to finish the questionnaires. In addition, sudden
11 Households with SAM children earned as much 85% of the income as those households with normal nutrition children indicating that the poorer the household, the higher the under nutrition prevalence
rain, waterlogging and fear of snake affected the survey team to gather data. However, due to strong supervision and the support from partner agencies CCDB, DSK, Muslim Aid and Shushilan helped the survey teams to complete the assessment. It is also mentionable that SMART methodology only allows the sample size for anthropometric indicators and therefore, no separate sample size was calculated for IYCF indicators. It should be noted that IYCF indicators require a larger sample size, and therefore the results of the IYCF indicators in the Satkhira and Jessore District Integrated SMART survey is only an indication for future planning and direction and NOT a representative for the whole population.
7 Ethical Considerations During the survey, wasted children MUAC < 125 mm and/or presence of bilateral oedema) were referred to community clinic or Upazila Health Complex for correct management and follow up. Referral forms were completed: one copy was given to caregiver and the other was used for follow-up. Any refusal household was substituted but not replace by another.
8 Recommendations Immediate Interventions Strengthening of inpatient treatment of severely acutely malnourished children U5 with medical complications in the Upazila Health Complexes. Reactivation and strengthening of CMAM services in outpatient facilities through GoB community clinics, low coverage areas and/or areas with high rates of acute malnutrition. Screening (MUAC), detection and referral should be strengthened for early detection and treatment Reactivation and strengthening the treatment of SAM and MAM as outpatients in the 122 villages preferably through the community clinics and effective coverage to areas with high rates of acute under nutrition. Implementation of an integrated multi-sectorial programme to address the high levels of acute and chronic malnutrition among U5 children and PLW at Upazila level taking into account Nutrition, Health, WASH, Maternal Child Care Practice and FSL. Implement Behaviour Change Communication at the health facilities: IYCF, child care, WASH Intensive social mobilization campaigns on improving maternal nutrition, IYCF and caring practices through behaviour change communication interventions. A nutritional causal analysis could be undertaken to identify causes of acute and chronic malnutrition. Support in village’s provision of safe drinking water, improved sanitation facilities; promote safe hygiene practices in the Upazilas.
Medium Term Interventions: Establishing robust nutrition information monitoring system in Satkhira and Jessore districts and incorporating key health and food security indicators to closely monitor the situation and deliver timely response. Follow up SMART nutrition surveys next year at the same time to document progress of the response plan and lessons learnt. Market development of agriculture products, fish, livestock sale, traditional goods etc. Support for diversification of livelihoods option to ensure sustainable the food security. Develop and introduce food-for-work interventions to support infrastructure development and provide alternative income generating activities during the lean periods, including social protection mechanisms like cash GoB health facility staff on Growth Monitoring & Promotion, detection & referral of Acute Malnutrition, CMAM and IYCF
Others Recommendations: Plan for capacity building of community volunteers including local health care providers for delivering appropriate counselling regarding this on IYCF, Maternal & Child Care Practice and Hygiene promotion for the facilitation at community level.
10. Appendices
Appendix 1: Plausibility Report
Overall data quality
Criteria Flags* Unit Excel. Good Accept Problematic Score
Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (0.8 %)
Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=1.000)
Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.793)
Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (5)
Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (9)
Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (4)
Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 0 (0.97)
Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (0.35)
Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 3 (0.40)
Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.513)
OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 6 %
The overall score of this survey is 6 %, this is excellent.
There were no duplicate entries detected.
Missing or wrong data:
HEIGHT: Line=57/ID=151
Percentage of children with no exact birthday: 0 %
Anthropometric Indices likely to be in error (-3 to 3 for WHZ, -3 to 3 for HAZ, -3 to 3 for WAZ, from observed mean - chosen in Options panel - these values will be flagged and should be excluded from analysis for a nutrition survey in emergencies. For other surveys this might not be the best procedure e.g. when the percentage of overweight children has to be calculated):
Line=27/ID=464: WHZ (2.230), Weight may be incorrect Line=132/ID=93: WHZ (3.301), WAZ (2.218), Weight may be incorrect
Line=149/ID=887: WAZ (1.614), Age may be incorrect Line=225/ID=33: WHZ (3.484), WAZ (2.829), Weight may be incorrect Line=356/ID=348: HAZ (3.425), WAZ (2.079), Age may be incorrect Line=379/ID=83: HAZ (-4.758), Age may be incorrect
Percentage of values flagged with SMART flags:WHZ: 0.8 %, HAZ: 0.5 %, WAZ: 1.0 %
Age distribution:
Month 6 : ###### Month 7 : ####### Month 8 : #### Month 9 : ####### Month 10 : ######### Month 11 : #### Month 12 : ############ Month 13 : #### Month 14 : ##### Month 15 : ###### Month 16 : ####### Month 17 : ######## Month 18 : ######## Month 19 : ##### Month 20 : ##### Month 21 : ############# Month 22 : ########## Month 23 : ######### Month 24 : ##### Month 25 : ######### Month 26 : ####### Month 27 : ######## Month 28 : ########## Month 29 : ###### Month 30 : ######## Month 31 : ####### Month 32 : ########## Month 33 : ########## Month 34 : ############# Month 35 : ########### Month 36 : ######## Month 37 : ### Month 38 : ##### Month 39 : ####### Month 40 : ####### Month 41 : ##### Month 42 : ########## Month 43 : ####### Month 44 : ######## Month 45 : ###### Month 46 : #########
Month 47 : ########### Month 48 : ### Month 49 : ######### Month 50 : ##### Month 51 : ## Month 52 : ##### Month 53 : ######## Month 54 : #### Month 55 : ### Month 56 : ###### Month 57 : ####### Month 58 : #### Month 59 : ####### Month 60 : ##
Age ratio of 6-29 months to 30-59 months: 0.87 (The value should be around 0.85).: p-value = 0.793 (as expected)
Statistical evaluation of sex and age ratios (using Chi squared statistic):
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 37/44.5 (0.8) 44/44.5 (1.0) 81/89.1 (0.9) 0.84 18 to 29 12 50/43.4 (1.2) 48/43.4 (1.1) 98/86.9 (1.1) 1.04 30 to 41 12 48/42.1 (1.1) 48/42.1 (1.1) 96/84.2 (1.1) 1.00 42 to 53 12 45/41.4 (1.1) 33/41.4 (0.8) 78/82.9 (0.9) 1.36 54 to 59 6 12/20.5 (0.6) 19/20.5 (0.9) 31/41.0 (0.8) 0.63 ------6 to 59 54 192/192.0 (1.0) 192/192.0 (1.0) 1.00
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 1.000 (boys and girls equally represented) Overall age distribution: p-value = 0.163 (as expected) Overall age distribution for boys: p-value = 0.140 (as expected) Overall age distribution for girls: p-value = 0.535 (as expected) Overall sex/age distribution: p-value = 0.039 (significant difference)
Digit preference Weight:
Digit .0 : #################################################### Digit .1 : ####################################### Digit .2 : ################################# Digit .3 : ##################################### Digit .4 : ####################################### Digit .5 : ################################### Digit .6 : ############################################### Digit .7 : #################################### Digit .8 : ############################# Digit .9 : #####################################
Digit preference score: 5 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.321
Digit preference Height:
Digit .0 : ############################# Digit .1 : ############################################### Digit .2 : ############################################################ Digit .3 : ################################################# Digit .4 : ######################################### Digit .5 : ############################# Digit .6 : ################################### Digit .7 : ############################# Digit .8 : ################################### Digit .9 : #############################
Digit preference score: 9 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.001 (significant difference)
Digit preference MUAC:
Digit .0 : ######################################## Digit .1 : ######################################## Digit .2 : ################################### Digit .3 : ######################################## Digit .4 : ################################### Digit .5 : ################################ Digit .6 : ################################ Digit .7 : ####################################### Digit .8 : ######################################### Digit .9 : ##################################################
Digit preference score: 4 (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) p-value for chi2: 0.676
Evaluation of Standard deviation, Normal distribution, Skewness and Kurtosis using the 3 exclusion (Flag) procedures
. no exclusion exclusion from exclusion from . reference mean observed mean . (WHO flags) (SMART flags) WHZ Standard Deviation SD: 1.02 1.02 0.97 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 11.5% 11.5% calculated with current SD: 14.0% 14.0% calculated with a SD of 1: 13.4% 13.4%
HAZ Standard Deviation SD: 0.99 0.99 0.95 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: calculated with current SD: calculated with a SD of 1:
WAZ Standard Deviation SD: 1.03 1.03 0.97 (The SD should be between 0.8 and 1.2) Prevalence (< -2) observed: 26.8% 26.8% calculated with current SD: 28.3% 28.3% calculated with a SD of 1: 27.6% 27.6%
Results for Shapiro-Wilk test for normally (Gaussian) distributed data: WHZ p= 0.000 p= 0.000 p= 0.006 HAZ p= 0.002 p= 0.002 p= 0.458 WAZ p= 0.000 p= 0.000 p= 0.108 (If p < 0.05 then the data are not normally distributed. If p > 0.05 you can consider the data normally distributed)
Skewness WHZ 0.67 0.67 0.35 HAZ 0.32 0.32 0.14 WAZ 0.46 0.46 0.11 If the value is: -below minus 0.4 there is a relative excess of wasted/stunted/underweight subjects in the sample -between minus 0.4 and minus 0.2, there may be a relative excess of wasted/stunted/underweight subjects in the sample. -between minus 0.2 and plus 0.2, the distribution can be considered as symmetrical. -between 0.2 and 0.4, there may be an excess of obese/tall/overweight subjects in the sample. -above 0.4, there is an excess of obese/tall/overweight subjects in the sample
Kurtosis WHZ 1.51 1.51 0.40 HAZ 1.42 1.42 0.09 WAZ 1.23 1.23 0.35 Kurtosis characterizes the relative size of the body versus the tails of the distribution. Positive kurtosis indicates relatively large tails and small body. Negative kurtosis indicates relatively large body and small tails. If the absolute value is: -above 0.4 it indicates a problem. There might have been a problem with data collection or sampling. -between 0.2 and 0.4, the data may be affected with a problem. -less than an absolute value of 0.2 the distribution can be considered as normal.
Test if cases are randomly distributed or aggregated over the clusters by calculation of the Index of Dispersion (ID) and comparison with the Poisson distribution for:
WHZ < -2: ID=0.99 (p=0.513) WHZ < -3: ID=0.96 (p=0.580) GAM: ID=0.99 (p=0.513) SAM: ID=0.96 (p=0.580) HAZ < -2: ID=0.79 (p=0.901) HAZ < -3: ID=0.96 (p=0.581) WAZ < -2: ID=0.88 (p=0.749) WAZ < -3: ID=0.80 (p=0.889)
Subjects with SMART flags are excluded from this analysis.
The Index of Dispersion (ID) indicates the degree to which the cases are aggregated into certain clusters (the degree to which there are "pockets"). If the ID is less than 1 and p > 0.95 it indicates that the cases are UNIFORMLY distributed among the clusters. If the p value is between 0.05 and 0.95 the cases appear to be randomly distributed among the clusters, if ID is higher than 1 and p is less than 0.05 the cases are aggregated into certain cluster (there appear to be pockets of cases). If this is the case for Oedema but not for WHZ then aggregation of GAM and SAM cases is likely due to inclusion of oedematous cases in GAM and SAM estimates.
Are the data of the same quality at the beginning and the end of the clusters? Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one
cluster per day is measured then this will be related to the time of the day the measurement is made).
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.89 (n=71, f=0) #### 02: 0.94 (n=69, f=0) ###### 03: 1.05 (n=64, f=0) ########## 04: 1.24 (n=58, f=1) ################### 05: 1.06 (n=48, f=1) ########### 06: 1.02 (n=32, f=1) ######### 07: 1.01 (n=21, f=0) OOOOOOOOO 08: 0.87 (n=11, f=0) ~~~ 09: 1.68 (n=05, f=0) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 10: 0.16 (n=02, f=0)
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Analysis by Team
Team 1 2 3 4 5 6 n = 66 61 58 78 61 60 Percentage of values flagged with SMART flags: WHZ: 1.5 0.0 1.7 0.0 3.3 0.0 HAZ: 0.0 0.0 0.0 0.0 5.0 0.0 WAZ: 1.5 0.0 3.4 0.0 1.6 0.0 Age ratio of 6-29 months to 30-59 months: 0.65 0.69 1.23 0.73 0.91 1.31 Sex ratio (male/female): 0.94 1.65 1.23 0.73 0.85 0.94 Digit preference Weight (%): .0 : 11 11 12 14 10 23 .1 : 14 7 12 9 15 5 .2 : 9 15 3 10 8 5 .3 : 14 7 14 8 10 7 .4 : 3 13 19 8 15 5 .5 : 12 7 7 10 10 8 .6 : 14 15 10 13 8 13 .7 : 11 10 7 12 8 8 .8 : 5 8 5 8 10 10 .9 : 9 8 10 9 7 15 DPS: 12 10 14 7 9 18 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference Height (%): .0 : 6 10 5 10 3 10 .1 : 8 11 9 18 18 8 .2 : 14 20 14 14 17 17 .3 : 15 8 21 9 10 15 .4 : 15 8 9 6 10 17 .5 : 8 8 3 4 15 8 .6 : 5 13 2 15 8 10 .7 : 15 7 14 6 2 2 .8 : 8 11 7 12 10 7 .9 : 8 3 17 5 7 7 DPS: 13 14 20 15 17 15
Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Digit preference MUAC (%): .0 : 14 10 7 15 7 8 .1 : 9 13 14 12 8 7 .2 : 6 5 9 10 13 12 .3 : 6 10 14 8 13 13 .4 : 6 13 7 8 10 12 .5 : 9 8 9 5 5 15 .6 : 12 7 10 4 15 3 .7 : 9 11 12 8 13 8 .8 : 11 13 9 14 7 10 .9 : 18 10 10 17 10 12 DPS: 12 9 8 14 11 11 Digit preference score (0-7 excellent, 8-12 good, 13-20 acceptable and > 20 problematic) Standard deviation of WHZ: SD 1.07 0.84 1.13 0.98 1.21 0.88 Prevalence (< -2) observed: % 7.6 10.3 23.3 Prevalence (< -2) calculated with current SD: % 12.0 13.1 22.9 Prevalence (< -2) calculated with a SD of 1: % 10.6 10.4 18.4 Standard deviation of HAZ: SD 0.96 1.07 1.00 0.88 1.17 0.91 observed: % 36.1 20.7 28.3 calculated with current SD: % 31.2 26.7 30.2 calculated with a SD of 1: % 30.0 26.7 27.3
Statistical evaluation of sex and age ratios (using Chi squared statistic) for:
Team 1:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 9/7.4 (1.2) 7/7.9 (0.9) 16/15.3 (1.0) 1.29 18 to 29 12 2/7.2 (0.3) 8/7.7 (1.0) 10/14.9 (0.7) 0.25 30 to 41 12 11/7.0 (1.6) 9/7.5 (1.2) 20/14.5 (1.4) 1.22 42 to 53 12 10/6.9 (1.4) 8/7.3 (1.1) 18/14.2 (1.3) 1.25 54 to 59 6 0/3.4 (0.0) 2/3.6 (0.6) 2/7.0 (0.3) 0.00 ------6 to 59 54 32/33.0 (1.0) 34/33.0 (1.0) 0.94
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.806 (boys and girls equally represented) Overall age distribution: p-value = 0.079 (as expected) Overall age distribution for boys: p-value = 0.025 (significant difference) Overall age distribution for girls: p-value = 0.874 (as expected) Overall sex/age distribution: p-value = 0.016 (significant difference)
Team 2:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 3/8.8 (0.3) 7/5.3 (1.3) 10/14.2 (0.7) 0.43 18 to 29 12 11/8.6 (1.3) 4/5.2 (0.8) 15/13.8 (1.1) 2.75 30 to 41 12 10/8.3 (1.2) 5/5.0 (1.0) 15/13.4 (1.1) 2.00 42 to 53 12 8/8.2 (1.0) 5/5.0 (1.0) 13/13.2 (1.0) 1.60 54 to 59 6 6/4.1 (1.5) 2/2.5 (0.8) 8/6.5 (1.2) 3.00 ------6 to 59 54 38/30.5 (1.2) 23/30.5 (0.8) 1.65
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.055 (boys and girls equally represented) Overall age distribution: p-value = 0.761 (as expected) Overall age distribution for boys: p-value = 0.216 (as expected) Overall age distribution for girls: p-value = 0.927 (as expected) Overall sex/age distribution: p-value = 0.021 (significant difference)
Team 3:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 8/7.4 (1.1) 3/6.0 (0.5) 11/13.5 (0.8) 2.67 18 to 29 12 10/7.2 (1.4) 11/5.9 (1.9) 21/13.1 (1.6) 0.91 30 to 41 12 5/7.0 (0.7) 5/5.7 (0.9) 10/12.7 (0.8) 1.00 42 to 53 12 7/6.9 (1.0) 5/5.6 (0.9) 12/12.5 (1.0) 1.40 54 to 59 6 2/3.4 (0.6) 2/2.8 (0.7) 4/6.2 (0.6) 1.00 ------6 to 59 54 32/29.0 (1.1) 26/29.0 (0.9) 1.23
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.431 (boys and girls equally represented) Overall age distribution: p-value = 0.161 (as expected) Overall age distribution for boys: p-value = 0.687 (as expected) Overall age distribution for girls: p-value = 0.175 (as expected) Overall sex/age distribution: p-value = 0.066 (as expected)
Team 4:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 10/7.7 (1.3) 6/10.4 (0.6) 16/18.1 (0.9) 1.67 18 to 29 12 9/7.5 (1.2) 8/10.2 (0.8) 17/17.6 (1.0) 1.13 30 to 41 12 6/7.2 (0.8) 15/9.9 (1.5) 21/17.1 (1.2) 0.40 42 to 53 12 6/7.1 (0.8) 10/9.7 (1.0) 16/16.8 (1.0) 0.60 54 to 59 6 2/3.5 (0.6) 6/4.8 (1.2) 8/8.3 (1.0) 0.33 ------6 to 59 54 33/39.0 (0.8) 45/39.0 (1.2) 0.73
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.174 (boys and girls equally represented) Overall age distribution: p-value = 0.877 (as expected) Overall age distribution for boys: p-value = 0.721 (as expected) Overall age distribution for girls: p-value = 0.255 (as expected) Overall sex/age distribution: p-value = 0.045 (significant difference)
Team 5:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 4/6.5 (0.6) 10/7.7 (1.3) 14/14.2 (1.0) 0.40 18 to 29 12 4/6.3 (0.6) 11/7.5 (1.5) 15/13.8 (1.1) 0.36 30 to 41 12 12/6.1 (2.0) 8/7.2 (1.1) 20/13.4 (1.5) 1.50 42 to 53 12 7/6.0 (1.2) 3/7.1 (0.4) 10/13.2 (0.8) 2.33 54 to 59 6 1/3.0 (0.3) 1/3.5 (0.3) 2/6.5 (0.3) 1.00 ------6 to 59 54 28/30.5 (0.9) 33/30.5 (1.1) 0.85
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.522 (boys and girls equally represented) Overall age distribution: p-value = 0.122 (as expected) Overall age distribution for boys: p-value = 0.064 (as expected) Overall age distribution for girls: p-value = 0.155 (as expected) Overall sex/age distribution: p-value = 0.003 (significant difference)
Team 6:
Age cat. mo. boys girls total ratio boys/girls ------6 to 17 12 3/6.7 (0.4) 11/7.2 (1.5) 14/13.9 (1.0) 0.27 18 to 29 12 14/6.6 (2.1) 6/7.0 (0.9) 20/13.6 (1.5) 2.33 30 to 41 12 4/6.4 (0.6) 6/6.8 (0.9) 10/13.2 (0.8) 0.67 42 to 53 12 7/6.3 (1.1) 2/6.7 (0.3) 9/12.9 (0.7) 3.50 54 to 59 6 1/3.1 (0.3) 6/3.3 (1.8) 7/6.4 (1.1) 0.17 ------6 to 59 54 29/30.0 (1.0) 31/30.0 (1.0) 0.94
The data are expressed as observed number/expected number (ratio of obs/expect)
Overall sex ratio: p-value = 0.796 (boys and girls equally represented) Overall age distribution: p-value = 0.281 (as expected) Overall age distribution for boys: p-value = 0.012 (significant difference) Overall age distribution for girls: p-value = 0.102 (as expected) Overall sex/age distribution: p-value = 0.000 (significant difference)
Evaluation of the SD for WHZ depending upon the order the cases are measured within each cluster (if one cluster per day is measured then this will be related to the time of the day the measurement is made).
Team: 1
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.82 (n=12, f=0) # 02: 0.81 (n=12, f=0) 03: 1.22 (n=12, f=0) ################## 04: 1.72 (n=11, f=1) ####################################### 05: 0.62 (n=10, f=0) 06: 0.60 (n=04, f=0) 07: 0.96 (n=03, f=0) OOOOOOO
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Team: 2
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.68 (n=12, f=0)
02: 0.87 (n=12, f=0) ### 03: 0.56 (n=11, f=0) 04: 1.17 (n=10, f=0) ################ 05: 0.72 (n=08, f=0) 06: 1.12 (n=04, f=0) OOOOOOOOOOOOO 07: 0.88 (n=03, f=0) ~~~
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Team: 3
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 1.39 (n=12, f=0) ######################### 02: 0.97 (n=12, f=0) ####### 03: 0.90 (n=11, f=0) #### 04: 1.03 (n=10, f=0) ########## 05: 1.57 (n=07, f=1) ################################ 06: 0.70 (n=04, f=0) 07: 0.40 (n=02, f=0)
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Team: 4
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.70 (n=12, f=0) 02: 1.24 (n=12, f=0) ################## 03: 0.53 (n=11, f=0) 04: 1.44 (n=11, f=1) ########################### 05: 1.04 (n=11, f=0) ########## 06: 0.85 (n=10, f=0) ## 07: 0.81 (n=07, f=0) 08: 0.99 (n=04, f=0) OOOOOOOO
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Team: 5
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.69 (n=12, f=0) 02: 1.12 (n=11, f=0) ############# 03: 1.62 (n=09, f=0) ################################## 04: 0.56 (n=08, f=0) 05: 1.19 (n=06, f=0) ################ 06: 1.84 (n=05, f=1) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 07: 1.74 (n=04, f=0) OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 08: 0.96 (n=03, f=0) OOOOOOO 09: 1.16 (n=02, f=0) ~~~~~~~~~~~~~~~
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
Team: 6
Time SD for WHZ point 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 01: 0.83 (n=12, f=0) # 02: 0.77 (n=11, f=0) 03: 0.91 (n=11, f=0) ##### 04: 1.27 (n=09, f=0) #################### 05: 0.93 (n=07, f=0) ##### 06: 0.44 (n=05, f=0) 07: 0.35 (n=02, f=0)
(when n is much less than the average number of subjects per cluster different symbols are used: 0 for n < 80% and ~ for n < 40%; The numbers marked "f" are the numbers of SMART flags found in the different time points)
(for better comparison it can be helpful to copy/paste part of this report into Excel)
Appendix 2: Assignment of Clusters Population Geographical unit Population size Cluster Geographical unit size Cluster Joynagar Union Kumira Union Dhandia 1958 RC Amanullapur 620 36 Joynagar 1885 1 Dadpur 2571 37 Gazna 2060 2 Gauripur 887 38 Chak Joynagar 332 3 Kesa 1034 39 Khetra Para 2209 4 Kumira 6275 40,41 Khurda Bantra 1071 5 Bhagbah 1114 42 Bamankhali 627 6 Manoharpur 942 43 Jugikhali Union Union Union Noakati 1704 44 Ophapur 2698 RC Pari para 2329 RC Paikpara 1190 7 Abhaytala 1781 45 Panchnal 2105 8 Senpur 1211 46 Rajnagar 998 9 Khalilnagar Union Union Union Rambhadrapur 2459 10 Gangarampur 1642 47 Kamar Ali 1986 11 Gonali 1884 48 Fingri Union Union Union Harischandra kati 1578 49 Balitha 3630 12,13 Hajrakati 3061 50 Ellar Chak 1719 14 Khalilnagar 2082 51 Faizullapur 2380 15 Uttar Machhiara 1438 52 Dakshin Uttar Fingri 3416 16,17 Machhiara 3590 53 Dakshin Fingri 2469 18 Mahandi 3090 54,55 Gabha 3496 19 Uttar Nalta 2512 56 Gobardari 2169 20 Dokshin Nalta 2551 57 Gobindapur 533 21 Prasadpur 2122 RC Jordia 5041 22,23 Roypur 1466 58 Bidyanandokati Kultia 1247 24 uni Union Union Sarba kashimpur 923 25 Bidyananadakati 2023 59 Shimulbaria 2163 26 Teghori 1739 60 Dhulihar Union Union Union Bausala 3981 61 Chandpur 4108 27,RC Bhabanipur 356 62 Dhulihar 4235 28,29 Kaliarai 1270 63 Jahanabaj 1163 30 Fatehpur 987 64
Gobindapur 1419 31 Hizaldanga 800 65 Damarporta 1162 32 Parchakra 3133 RC,66 Matiadanga 1631 33 Trimohoni Union Union Union Taltala 227 34 Barandali 4601 67,68 Shukdeppur 584 RC Chandra 3997 69,70 Kumarpur 2167 35 Mirzanagar 4449 71,RC Saraskati 494 72
Appendix 3: Evaluation of enumerators
Standardisat Pre ion test cisi Accura OUTC results on cy OME sub m Techni TEM Coef of Bias Bias ject ea S cal /mea reliabilit from from s n D max error n y superv median result k TEM TEM Bias Bias # kg g kg (kg) (%) R (%) (kg) (kg) Bias Supervis 13 3. TEM R value goo or 10 .8 4 0.8 0.22 1.6 99.6 - -0.25 reject good d Bias Enumer 13 3. TEM R value goo ator 1 10 .8 4 0.3 0.12 0.9 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 2 10 .8 4 0.3 0.1 0.7 99.9 0.01 -0.24 poor good d TEM Bias Enumer 13 3. accept R value goo ator 3 10 .8 4 0.3 0.1 0.7 99.9 0 -0.25 able good d Bias Enumer 13 3. TEM R value goo ator 4 10 .9 5 4.1 0.93 6.7 93.1 0.2 -0.05 reject poor d Bias Enumer 13 3. TEM R value goo Weight ator 5 10 .8 4 0.4 0.14 1 99.8 0.01 -0.24 poor good d R value Bias Enumer 13 3. TEM accepta goo ator 6 10 .9 4 2.8 0.64 4.6 96.4 0.13 -0.12 reject ble d Bias Enumer 13 3. TEM R value goo ator 7 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 8 10 .8 4 0.3 0.12 0.9 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 9 10 .8 4 0.3 0.1 0.7 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 10 10 .8 4 0.5 0.15 1.1 99.8 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 11 10 .8 4 0.4 0.13 0.9 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 12 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d
Bias Enumer 13 3. TEM R value goo ator 13 10 .8 4 0.3 0.1 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 14 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 15 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 3. TEM R value goo ator 16 10 14 5 4.1 0.92 6.6 93.2 0.21 -0.04 reject poor d Bias Enumer 13 3. TEM R value goo ator 17 10 .7 4 0.4 0.14 1 99.8 -0.01 -0.26 poor good d Bias Enumer 13 3. TEM R value goo ator 18 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 19 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d Bias Enumer 13 3. TEM R value goo ator 20 10 .8 4 0.3 0.11 0.8 99.9 0.01 -0.24 poor good d R value enum 20x 13 3. TEM accepta inter 1st 10 .8 4 - 0.4 2.9 98.6 - - reject ble enum TEM inter 20x 13 3. accept R value 2nd 10 .8 3 - 0.2 1.4 99.7 - - able good inter enum + 21x 13 3. TEM R value sup 10 .8 4 - 0.3 2.1 99.1 - - reject good TOTAL R value Bias intra+in 20x TEM accepta goo ter 10 - - - 0.47 3.4 98.1 0.03 -0.22 reject ble d R value TOTAL 21x TEM accepta + sup 10 - - - 0.46 3.3 98.1 - - reject ble
sub m Techni TEM Coef of Bias Bias ject ea S cal /mea reliabilit from from s n D max error n y superv median result c c TEM TEM Bias Bias # m m cm (cm) (%) R (%) (cm) (cm) 1 TEM Bias Supervis 95 4. accept R value goo or 10 .2 4 2 0.54 0.6 99.9 - 0.2 able good d 1 R value Bias Enumer 95 3. 10. TEM accepta goo ator 1 10 .4 9 1 2.31 2.4 97.3 0.16 0.36 reject ble d Height 1 TEM Bias Enumer 94 4. accept R value goo ator 2 10 .8 2 1.4 0.46 0.5 99.9 -0.35 -0.15 able good d 1 TEM Bias Enumer 4. accept R value goo ator 3 10 95 2 1.3 0.51 0.5 99.9 -0.24 -0.04 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 4 10 .8 2 1.2 0.47 0.5 99.9 -0.36 -0.16 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 5 10 .8 1 1.4 0.47 0.5 99.9 -0.38 -0.18 able good d
Bias Enumer 94 1 TEM R value goo ator 6 10 .9 4 1.3 0.35 0.4 99.9 -0.27 -0.07 good good d 1 TEM Bias Enumer 94 4. accept R value goo ator 7 10 .9 2 1.3 0.44 0.5 99.9 -0.26 -0.06 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 8 10 .9 2 1.3 0.46 0.5 99.9 -0.32 -0.13 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 9 10 .9 1 1.3 0.46 0.5 99.9 -0.25 -0.05 able good d 1 Bias Enumer 94 4. TEM R value goo ator 10 10 .8 3 1.1 0.36 0.4 99.9 -0.38 -0.18 good good d 1 TEM Bias Enumer 94 4. accept R value goo ator 11 10 .9 2 1.1 0.45 0.5 99.9 -0.32 -0.13 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 12 10 .9 2 1.3 0.42 0.4 99.9 -0.25 -0.06 able good d 2 Bias Enumer 10 5. 98. TEM R value reje ator 13 10 0 8 4 22.01 22 27.4 4.78 4.97 reject reject ct 1 Bias Enumer 94 4. TEM R value goo ator 14 10 .9 2 1.2 0.28 0.3 100 -0.28 -0.08 good good d 1 TEM Bias Enumer 94 4. accept R value goo ator 15 10 .9 1 1.2 0.47 0.5 99.9 -0.25 -0.05 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 16 10 .9 2 1.3 0.51 0.5 99.9 -0.27 -0.07 able good d 1 Bias Enumer 95 4. TEM R value goo ator 17 10 .1 1 2.1 0.65 0.7 99.8 -0.12 0.08 poor good d Bias Enumer 95 1 TEM R value goo ator 18 10 .1 4 0.8 0.27 0.3 100 -0.08 0.12 good good d 1 TEM Bias Enumer 94 4. accept R value goo ator 19 10 .8 2 1.5 0.52 0.6 99.9 -0.38 -0.18 able good d 1 TEM Bias Enumer 94 4. accept R value goo ator 20 10 .9 1 1.4 0.45 0.5 99.9 -0.33 -0.13 able good d 1 enum 20x 95 5. TEM R value inter 1st 10 .6 3 - 7.1 7.4 78.4 - - reject reject enum inter 20x 94 1 TEM R value 2nd 10 .8 4 - 0.33 0.3 99.9 - - good good inter 1 enum + 21x 95 4. TEM R value sup 10 .2 6 - 3.65 3.8 89.7 - - reject reject TOTAL Bias intra+in 20x TEM R value goo ter 10 - - - 7.07 7.4 76.7 -0.01 0.19 reject reject d TOTAL 21x TEM R value + sup 10 - - - 6.9 7.2 77.7 - - reject reject
sub m Techni TEM Coef of Bias Bias MUAC ject ea S cal /mea reliabilit from from s n D max error n y superv median result
m m TEM TEM Bias Bias # m m mm (mm) (%) R (%) (mm) (mm) 15 1 Supervis 5. 2. TEM R value or 10 1 7 2 0.74 0.5 99.7 - 0.05 good good 15 1 Bias Enumer 5. 2. TEM R value goo ator 1 10 8 7 16 3.69 2.4 91.5 0.7 0.75 reject poor d 15 1 Bias Enumer 5. 2. TEM R value goo ator 2 10 1 9 4 1.24 0.8 99.1 0.1 0.15 good good d 15 1 Bias Enumer 3. 2. TEM R value goo ator 3 10 8 7 2 0.81 0.5 99.6 -1.3 -1.25 good good d 15 1 Bias Enumer 4. 2. TEM R value goo ator 4 10 4 5 13 4.1 2.7 89.3 -0.7 -0.65 reject reject d 15 1 R value Bias Enumer 4. 2. TEM accepta goo ator 5 10 9 7 6 1.66 1.1 98.3 -0.2 -0.15 good ble d 15 1 Bias Enumer 4. 2. TEM R value goo ator 6 10 3 9 2 0.89 0.6 99.5 -0.75 -0.7 good good d 15 1 R value Bias Enumer 4. 3. TEM accepta goo ator 7 10 1 1 4 1.4 0.9 98.9 -1 -0.95 good ble d 15 1 TEM R value Bias Enumer 3. 2. accept accepta goo ator 8 10 3 7 9 2.46 1.6 96.2 -1.8 -1.75 able ble d 15 Bias Enumer 4. 1 TEM R value goo ator 9 10 2 3 3 0.84 0.5 99.6 -0.85 -0.8 good good d 15 1 TEM R value Bias Enumer 4. 2. accept accepta goo ator 10 10 3 8 6 2.46 1.6 96.3 -0.8 -0.75 able ble d 15 1 TEM R value Bias Enumer 4. 2. accept accepta goo ator 11 10 1 7 8 2.12 1.4 97.2 -0.95 -0.9 able ble d 15 1 Bias Enumer 3. 2. TEM R value goo ator 12 10 9 7 3 1.14 0.7 99.2 -1.15 -1.1 good good d 15 1 R value Bias Enumer 4. 2. TEM accepta goo ator 13 10 9 9 5 1.61 1 98.4 -0.15 -0.1 good ble d 15 1 Bias Enumer 4. 2. TEM R value goo ator 14 10 9 9 1 0.39 0.2 99.9 -0.1 -0.05 good good d 15 1 Bias Enumer 3. 2. TEM R value goo ator 15 10 9 8 3 1.05 0.7 99.3 -1.15 -1.1 good good d 15 1 Bias Enumer 4. 2. TEM R value goo ator 16 10 9 5 15 4.38 2.8 87.7 -0.2 -0.15 reject reject d 15 1 Bias Enumer 2. 3. TEM R value goo ator 17 10 6 6 28 6.3 4.1 78.6 -2.45 -2.4 reject reject d 15 1 Bias Enumer 4. 2. TEM R value goo ator 18 10 2 7 2 1 0.6 99.4 -0.85 -0.8 good good d 15 1 Bias Enumer 5. 2. TEM R value goo ator 19 10 9 6 19 4.57 2.9 86.9 0.8 0.85 reject reject d 15 1 Bias Enumer 5. 3. TEM R value goo ator 20 10 4 4 14 3.41 2.2 93.5 0.3 0.35 reject poor d
15 1 enum 20x 4. 2. TEM R value inter 1st 10 8 4 - 3.06 2 93.9 - - poor poor enum 1 TEM R value inter 20x 15 2. accept accepta 2nd 10 4 7 - 2.41 1.6 96.4 - - able ble inter 15 1 R value enum + 21x 4. 2. TEM accepta sup 10 5 6 - 2.7 1.8 95.3 - - poor ble TOTAL Bias intra+in 20x TEM R value goo ter 10 - - - 3.91 2.5 90.3 -0.63 -0.55 reject poor d TOTAL 21x TEM R value + sup 10 - - - 3.84 2.5 90.7 - - reject poor
Appendix 4: Questionnaire INTEGRATED SMART SURVEY – SATKHIRA & JESSORE (August-2017)
UPAZILA (Dc‡Rjv): ______UNION (BDwbqb): ______WARD (Iqv©W): ______VILLAGE (MÖvg): ______PARA (cvov):______
DATE (ZvwiL): TEAM (wUg): CLUSTER (K¬v÷vi): HOUSEHOLD (Lvbv): HOUSE ID (Lvbv bs):
The team should note the answers in PEN not in pencil (`j‡K Aek¨B DËi¸‡jv Kjg w`‡q †jL‡Z n‡e, †cbwmj w`‡q bq) 1.cwimsL¨vb / HH Demography cwiev‡i ‡gvU ‡g‡q ev gwnjv / Number of cwiev‡i ‡gvU cyil ev ‡Q‡j / Number of Male: Female: cwievi cÖav‡bi wj½ / Male= 1 ; Female= 2 cwievi cÖav‡bi eqm (eQi) / Age of HH Head
Gender of HH Head: (yrs):
2.cwiev‡ii MVb / Family composition cwiev‡ii m`‡m¨i †kÖbx ev aib / Age Categories †gvU m`m¨ msL¨v / Total Number of members bvevjK (0-<6 gvm) / Infants (0-<6 months): শি� (৬-২৩ মাস)Children (6-23 months): wkï (24 gvm - <5 eQi) / Young Children (24 m – <5yrs): wkï (5-<18 eQi) / Children (5 - <18yrs): cÖvßeq¯‹ (18-50 eQi) / Adults (18-50yrs): e„× (>50 eQi) / Elderly (> 50yrs):
3.kixi e„Ëxq cwigvc (6-59 gvm) / Anthropometry (6-59 months)
Child SEX (wj½) Date of birth (জন্ম AGE(Months)/ Weight (Kg) Height or Length12(cm) Oedema MUAC 0 ) N M/F(†Q‡j/†g‡q) তারিখ eqm (gvm) ±0.1kg 0.1 cm/D”PZv ev (Y/N) (mm) DD/MM/YYYY
12 Height measurement standing when child is ≥24 months (height proxy ≥87 cm) and lying down when child is < 24 months (< 87
(wkï IRb (†KwR) ˆ`N©¨ (‡mwg) BwWgv/ gyqvK b¤^i) ±0.1†KwR ±0.1‡mwg cv‡q cvwb (wg: Avmv wg:) (nvu/bv) 1 2 3
3.1 hw` †Kvb wkï Zxeª Acywó‡Z (BwWgv/gyqvK <125 wg.wg) AvµvšÍ _v‡K Zvn‡j wb‡Pi cÖkœwU Ki”b / If any child is acutely malnourished then ask caregiver, if she/he is enrolled into nutrition program and receiving treatment ? wkï b¤^i /Child N0 1 2 3 Avcbvi wkïwU ‡Kvb cywó wPwKrmv †mevq fwZ© Av‡Q wK? wkïi KvW© †`‡L wbwðZ †nvb (0=bv, 1= nvmcvZvj/Gm.wm, 2= IwUwc, 3=GmGdwc, 4= †Kvb †cÖvMÖvg †bB, 88 =Rvwb bv) / Is your child admitted into Nutrition feeding program? (0=No, 1=SC/Hospital, 2=OTP, 3=SFP, 4= No program, 88=Don’t know)
4. Amy¯’Zvi Z_¨ (6-59 gvm) / Morbidity (6-59 MONTHS) MZ 2 mßv‡ni g‡a¨ Avcbvi wkïwUi wK †Kvb ai‡bi AmyL n‡qwQj? wUK wPý () emvb (n¨vu/ bv)| hw` DËi Õn¨vuÕ nq Amy¯’Zvi Z_¨ m¤úwK©Z cÖkœ Kiæb, DËi ÕbvÕ n‡j wb‡b¥v³ Amy¯’Zvi cÖkœ, cÖkœ bs 4.1 ev` w`‡q cieZ©x cÖkœ Kiæb) / In the past 2 WEEKS has your child had the following illnesses? Put tick sign () if yes, if not then do not ask the following questions and go to next questions. MZ 14 w`‡bi g‡a¨, Avcbvi wkïi wK k¦vmZ‡š¿i cÖ`vn (†hgbt Kvwk, k¦vmKó, ey‡Ki LvuPv wfZ‡ii Ab¨vb¨ (ïaygvÎ MZ 14 w`‡bi g‡a¨, MZ 14 w`‡bi g‡a¨, Avcbvi wkïi wK w`‡K †`‡e hvIqv, Nb Nb k¦vm †bIqv) n‡qwQj? nu¨v/bv) wkï Avcbvi wkïi wK Wvqwiqv n‡qwQj? জ্বর (nu¨v/bv) b¤^i n‡qwQj? Other disease (nu¨v/bv) মা এর তথ্য /Child অনুযায়ী জ্বর (হযাাঁ/না) Acute Respiratory Infections (Cough, breathing (Only 0 N Diarrhoea Fever (Y/N) difficulties, Chest in-drawing, Rapid Yes=Y/No=N) (Y/N) breathing) (Y/N) 1 2 3
wkï b¤^i /Child 0 1 2 3 N 4.1 Avcbvi wkï wK Amy¯’Zvi Rb¨ †Kvb wPwKrmv MÖnY K‡i‡Q? †Kvb RvqMv †_‡K wPwKrmv MÖnb K‡i‡Q? (0= cÖ‡hvR¨ bq,[1 = †Kvb wPwKrmv MÖnb K‡i bvB, 2= ‡emiKvwi wK¬wbK, 3 = miKvwi wK¬wbK, 4=Ab¨vb¨ wPwKrmv (wbw`wó K‡i bvg wjLyb) / Have your child received treatment for illnesses? [0= Not applicable, 1= did not receive treatment, 2= private clinic, 3= Govt. Clinic, 4= Other source/ Village doctor (specify)] 4.2 wkïwU wK nvg Gi wUKv wb‡q‡Q? ( 1=KvW© Abyhvqx, 2= AbymiY Kiv Z_¨, 3 =bv, 4= Rvwb bv) /
Has the child received measles immunization? (1=by card; 2=by recall; 3=No, 4=Don’t Know) 4.3 MZ Qq gv‡m wkïwU wK wfUvwgb G ‡L‡qwQj? (1=nu¨v, 0=bv) /
Did the child receive Vitamin A in last six months? (1=yes, 0=No)
5.wkïi Lv`¨vf¨vm (0-23 gvm)/ Infant and Young Child Feeding-IYCF Practices (Only for Children between 0 – 23 Months)
cm)
wkï b¤^i /Child N0 1 2 3 AGE বয়স (মাসস) 5.1 Has (NAME) ever been breastfed? (bvg) Zv‡K wK KLbI ey‡Ki `ya LvB‡q‡Qb? (1=yes, 0=No, 88=Don’t Know) 5.2 If Yes, how long after delivery was [NAME] put to the breast/nipple? হযাাঁ হলে, R‡b¥i KZ¶Y c‡i (bvg) Zv‡K ey‡Ki `ya †`qv n‡qwQj? (1=Less than 1 hour, 2=1-24 hours, 3=More than 24 hours, 88=Don’t Know) 5.3 Was [NAME] breastfed yesterday during the day or at night? MZKvj w`‡b A_ev iv‡Z (bvg) Zv‡K wK ey‡Ki `ya LvIqv‡bv n‡qwQj? (0=No, 1=yes, 2=Stop feeding) 5.4 Was [NAME] bottle fed with nipple yesterday during the day or at night? (bvg) MZKvj mvivw`b A_ev mvivivZ wbcjmn †evZ‡j (wdWvi) K‡i †Kv‡bv wKQy cvb K‡iwQj? (1=yes, 0=No, 88=Don’t Know) 5.5 Was any liquid/water/food given to child before 6 month of birth? Avcwb (bvg) ‡K R‡b¥i cieZ©x 6 gv‡mi g‡a¨ Zvi gy‡L †Kv‡bv Zij/cvbxq/Lvevi w`‡qwQ‡jb? (1=yes, 0=No, 88=Don’t Know) 5.6 At what age after birth did you start giving foods and liquids other than breast milk? (Including pre-lacteal) wkï‡K †Kvb eqm †_‡K ey‡Ki `ya Qvov Ab¨ †Kvb Lvevi Ges Zij †`qv ïi“K‡iwQ‡jb? (wcÖ- j¨vK‡Uj mn) 5.7 Was [NAME] drink liquid/water yesterday during the day or at night? Chi Chil Chi (bvg) wK MZKvj mvivw`b A_ev mvivivZ wbgœwjwLZ Lvevi/ Zij/cvbxq cvb †L‡qwQj? (1=Yes, ld 1 d 2 ld 3 0=No) Water- cvwb Sugar water-wPwbi cvwb Fruit Juice/ juice drinks/Coconut water-d‡ji im/ Rym wWªsKm/Wv‡ei cvwb Container milk, milk powder- wUbRvZ `ya, ¸ov `ya, cÖvYxR `ya Curd- `B Infant Formula- wkï (Baby) dg©~jv Juice/foods from outside shop (juice, candy, biscuits etc.)-evRv‡ii †evZ‡ji Rym, K¨vwÛ, we®‹zU
&&&&&&&BZ¨vw`
5.8 Did [NAME] receive any soft/ semi-solid/ solid food yesterday during the day or at night? MZKvj w`‡b ev iv‡Z (bvg) †m wK ey‡Ki `ya Qvov Ab¨ †Kvb Zij / Aa© k³/ k³ Lvevi †L‡qwQj? (1=Yes, 0=No, 88=Don’t Know) 5.9 If Yes, How many times did (NAME) eat solid, semi-solid, or soft foods other than liquids yesterday during the day or at night?
হ্যাঁ হলে , MZKvj w`‡b Ges iv‡Z (MZ 24 N›Uvi g‡a¨) me©‡gvU KZevi (wkïi bvg) k³, Avav-k³ A_ev big evowZ cvwievwiK Lvevi †L‡q‡Q? wb‡b¥v³ cÖkœwU ïaygvÎ 6-23 gvm eqmx wkïi Rb¨ cÖ‡hvR¨ Chi Chi 5.10 MZ 24 N›Uvi g‡a¨ Avcbvi wkïwU wb‡b¥ ewY©Z wK ai‡bi Lvevi †L‡q‡Q? / Did your child eat Chil ld ld any of the following food groups in the PAST 24-HOURS (1=yes, 0=No) d 2 1 3 AGE বয়স (মাসস) 1. Grains, roots, tubers (nan, chapatti, parata, bread, rice, potato শস্্,শশকড় এবং কন্দ ( নযন, চযপযশি, পল যটয, 쇁綿, ভযি/চযে, আেু) 2. Legumes or nuts (lentils) শশম জযিীয় বয বযদযম Beans, peas, other lentils, nuts (peanuts) or seeds (pumpkin seed, spinach seed, jackfruit seed) or any foods made from these (chanachur) মট �綿, ডযে বয যেলকযন ডযে, বযদযম বয শবশচ যেমন শমশি-嗁মড়য শবশচ, শযলক শবশচ, কযাঁঠযলে শবশচ বয এ巁লেয যেলক ি ী যেলকযন খযবয (চযনযচু )
3. Dairy products (milk, yoghurt, cheese) 駁দ্ধজযিীয় পণ্্ (駁ধ, ইলয়যগযটট , পশন ) 4. Flesh foods (meat, fish, poultry, liver/organ meat) মযংস্জযিীয় খযবয (মযছ, মযংস্, মু শগ মযংস্ এবং শেভয / অন্যন্ অঙ্গ যেমন- দশপণ্ড, শকডশন, শজহবয, অগ্ন্্যশয়, মগজ ইি্যশদ) 5. Vitamin A rich fruits and vegetables (carrot, pumpkin, orange, sweet potato, mango, papaya, dark green leafy vegetables, long beans) শভটযশমন এ স্মৃদ্ধ ফেমূে ও শযকস্বশজ (গযাঁজ, শমশি 嗁মড়য, কমেয, শমশি আেু, আম, যপাঁলপ, গযঢ় স্বুজ শযক স্বশজ, শশম)
6. Egg শডম 7. Other fruit and vegetables (banana, apples, pineapple, watermelon , eggplant, onion, cucumbers, tomatoes) অন্যন্ ফেমূে ও শযকস্বশজ (কেয, আলপে, আনয স্, ি মুজ, যব巁ন, যপাঁয়যজ, শস্য, টলমলটয) 8. Any oil, fats, butter, ghee or foods made with any of these যেলকযন তিে, চশবট, মযখন, শি বয এ巁লেয শদলয় তিশ খযবয 9. Any sugary foods such as chocolates, sweets, candies, pastries, cakes, biscuits or just sugar যেলকযন শচশন জযশিয় খযবয যেমন চকলেট, শমশি, ক্যশি, যপশি, যকক, শবস্কু ট বয �ধু শচশন
6. CHILD CARE PRACTICE KNOWLEDGE AND PRACTICES (Only for Children between 0 – 59 Months) 6.1 What is the source of indication for the mother/caregiver to feed the child? Put a Tick sign (√) on the correct Avcwb wKfv‡e eyS‡Z cv‡ib ‡h Avcbvi wkï‡K LvIqv‡bv `iKvi? responses/mwVK Dˇi wUK wPý (√) w`b 1 = Looking for cues from child (fussiness, putting hands in mouth, rooting etc.)/ wkïi AvKvi Bw½Z †`‡L(N¨vb N¨vb Ki‡j ev wei³ †`Lv‡j, nvZ gy‡L ‡`Iqv, Gw`K Iw`K ZvKvZvwK Kiv BZ¨vw`) 2 = Crying / wkï KvbœvKvwU Ki‡j 3 = Pre-determined schedule/ c~‡e©B wb‡Ri †_‡K wmwWDj wVK K‡i wb‡q 4 = Someone told me/ ‡KD e‡jwQj KZ mgq cici ev”Pv‡K LvIqv‡Z nq 5 = Every three to four hours/ cÖwZ wZb Pvi NÈv cici 6 = Others / Ab¨vb¨.... 7 = Do not know/ Rvwbbv 6.2 What are the factors you think important for your young child’s optimum Put a Tick sign (√) on the correct growth and development? Tick on the correct responses/ responses/mwVK Dˇi wUK Avcbvi wkïi mwVKfv‡e †e‡o DVvi Rb¨ †Kvb †Kvb welq¸‡jv ¸iæZ¡c~Y©/`iKvi wPý (√) w`b e‡j g‡b nq? (mwVK Dˇi wUK wPý w`b) 1 = Having good health (free from disease)/ ¯^v¯’¨ fv‡jv _vKv (†ivM gy³ _vKv) 2 = Being happy (cheerful, not fussy, playful)/ nvwmLykx _vKv (Drdzjø _vKv wei³ bq, †Ljvi ga¨ _vKv) 3 = Positive environment/ fv‡jv cwi‡ek _vKv 4 = Interaction with the child/ ev”Pvi mv‡_ mgq w`‡q gRv K‡i K_v ejv 5 = Opportunity to play/ ‡Ljva~jvi my‡hvM ‡`Iqv 6 = Opportunity to learn/ ‡kLvi my‡hvM †`Iqv 7 = Safety, security and love/ wbivcËv, Avk¦vm Ges Av`i-fv‡jvevmv 8 = Others…. /Ab¨vb¨... 9 = Do not know/ Rvwbbv
HOUSEHOLDS FOOD SECURITY & LIVELIHOODS 7. Monthly Household Income (cvwievwiK gvwmK Avq) BDT. 8. Main Source of Income for the household /Avcbvi cwiev‡ii g~j Av‡qi Drm wK?
(wb‡b¥v³ Drm Abyhvqx †KvWwU wjLyb †hgbt hw` K…wlev Lv`¨km¨ weµq nq Z‡e 1; Dcnvi n‡j 13)
1 = Agriculture and sales of crops 6 = Skilled labour 11= Salaries, wages-employees (K…wl ev Lv`¨km¨ weµq); (`ÿ kÖwgK); (PvKix); 2= Livestock and sales of animals 7 = Handicrafts/cottage industry (n¯Í 12= Begging (wfÿv); (M„ncvwjZ Mevw`cï weµq); wkí); 13= Gift (Dcnvi); 3= Fishing (open /common water) 8= Collection of natural resources 14= Remittance (ˆe‡`wkK Avq); gvQ aiv (D¤§y³ Rjvkq); (firewood, charcoal, bricks, grass, wild 15= Government allowance foods, honey) (Rv¡jvbx KvV, Kqjv, Nvm, 4 = aquaculture (in a pond) Mevw` ckyi Lvevi, gay msMÖn); (miKvwi fvZv ); (†Ni ev cyKz‡i grm Pvl); 9 = Petty trading-less than 10,000 16= Land renting 5= Unskilled wage labour (including monthly income (Rwg eM©v/fvov †`Iqv); agro) (A`ÿ w`b gyRyi K…wl (ÿz`ª e¨vemv- 10,000 nvRv‡ii wb‡P gvwmK 17= Money lender (UvKv avi) gRywimn); Avq ); ১৮= Others (অনযানয) 10= Seller, commercial activity (we‡µZv) ; 9. Identify Main Food Source(How do you obtain your food) -Multiple answer may come (Avcbvi cwiev‡ii Lv‡`¨i cÖavb Drm )(wb‡b¥v³ Drm Abyhvwq †KvWwU wjLyb †hgbt hw` wbR¯^ Pvlvev`/Drcv`b nq Z‡e 1; avi Kiv n‡j 3 BZ¨vw`) 1 = Own Cultivation/production (wbR¯^ Pvl Avev` / 5 = Purchasing (†Kbv ) Drcv`b ) 6 = Begging (wfÿv) 2 = Cash Loan (bM` FY ev KR©) 7 = Barter/Exchange (wewbgq) 3 = Borrowing (avi Kiv) 8 = Other (Ab¨vb¨) 4 = Food Aid (Lv`¨ mnvqZv)
Did you consume it yesterday? Food Source 10. Household Dietary Diversity(HDDS) : পশ বযল (MZKvj wbb¥ ewY©Z Purchase =1, Produced খযদ্ তবশচত্র্্ †Kvb Lvevi †L‡q‡Qb =2, Other =3 [Lv‡`¨i Drm wKbv?) (µq=1, Drcv`b=2, Ab¨vb¨=3)] 1= Yes, O= No
1. Starchy foods – kK©iv RvZxq Lv`¨ (Rice (fvZ), wheat (iæwU), muri (gywo), maize (f’Æv), 2. Tubers (K›`) - (Potatoes (Avjy), Sweet potatoes (wgwó Avjy), 3. Vegetables (kvK mâx) 4. Meat - gvsm [Beef (Miæi gvsm), Goat (Lvmxi gvsm) and Chicken (gyiMx)] 5. Fish/Dry fish (gvQ/ïUKx gvQ) 6. Eggs (wWg)
7. Fruits (dj)
8. Pulses & Legumes (Wvj/ mxg RvZxq Lvevi) (any type of dal - (‡h †Kvb cÖKv‡ii Wvj/mxg) 9. Milk - `ya ev `„»RvZxq Lv`¨, yogurt (`wa) and other dairy (Ab¨vb¨ `y»RvZ Lv`¨) 10. Oil, fat, butter (‡Zj, Pwe©, gvLb) 11. Sugar, Honey (wPwb/¸uo, gay) 12. Condiments/other (gmjv/Ab¨vb¨) (Tea - Pv, Coffee - Kwd, spices (gwiP I gmjv), etc.
Key (DËi) Never (KLbB bv n‡j) = 0 11. Reduced Coping Strategy Less than 1 day (GK w`‡bi Kg n‡j) = 0.5 Index (Consumption based 1 – 2 days (GK †_‡K `yB w`b n‡j) = 1.5 coping)/গি স্যি শদলন পশরবালরর খাদ্য 3 – 6 days (wZb †_‡K Qq w`b n‡j) = 4.5 ঘাটশত মমাকালবোর মকৌিে In the past 7 days, did you or any 7 days (mvZ w`b n‡j) = 7 household member: (MZ 7 w`‡b Avcbvi cwievi) A. Number B. Points C. Universal Score- †¯‹vi of days according to severity (BxC) the key weight 1. Rely on less preferred & less expensive foods? 1 (Kg cQ‡›`i Lvevi ev Kg `vgx Lvev‡ii Dci wbf©i K‡i wQ‡jb?) 2. Borrow food or rely on help from neighbor/relatives? (Lvevi avi K‡i ev 2 cÖwZ‡ekx/AvZ¥x‡qi KvQ †_‡K wb‡q †L‡qwQ‡jb?) 3. Reduce meal size at meal 1 times?
(Lvev‡ii Afv‡e cÖ‡qvR‡bi Zzjbvq Kg cwigv‡Y Lvevi MªnY K‡i‡Qb?) 4. Restrict consumption by adults so that small children can eat? 3 (Lvev‡ii Afv‡e eq¯‹iv Kg †L‡q‡Qb, hv‡Z wkïiv †L‡Z cv‡i?) 5. Reduce the number of meal eaten per day? (Lvev‡ii Afv‡e w`‡b 3 †ejvi Zzjbvq 1 Kg‡ejv (2/1 †ejv) Lvevi MªnY K‡i‡Qb?)
12. Water, Sanitation and Hygiene (cvwb cqwb®‹vmb e¨e¯’v I cwiQbœZv) 12.1 MAIN WATER SOURCE FOR DRINKING/ Lvevi cvwbi cÖavb Drm wK ? (GKwU DËi) 6 = Surface water (river, stream pond) SY©v, b`x cyKzi 1 = Tubewell (shallow) bjKzc (AMfxi) 7 = Pond Sand Filter cÛ-m¨vÛ wdëvi 2 = Tubewell (deep) bjKzc (Mfxi) 8 = Piped network mieivnK…Z cvwb 3 = Protected well msiwÿZ Kzc 9 =Arsenic, Iron Removal Plant (AIRP) Av‡m©wbK, Avqib 4 = Unprotected well D¤§y³ Kzc wi‡gvfvj cø¨v›U 5 = Rainwater harvesting e„wói cvwb (msiÿb) 10. Others……………….. 12.2 Is this source available round the year cvwbi GB Drm ‡_‡K wK mviv eQi cvwb cvIqv hvq? (1=Yes, 2=No) 12.3 How far is the drinking water source from your home? evwo ‡_‡K LvIqvi cvwbi Dr‡mi `yiZ¡ KZ ? 1= 0-150 ft (1=0-150 dzU) 2= >150 ft (2= 150 dz‡Ui ‡P‡q †ekx) 12.4 How far is the water source from the nearest latrine pit? খাওয়ার পাশনর উৎস মথ্লক শনকটবতী েযাশিলনর 嗁লপর মধ্যবতী দ্ুরত্ব কত? 1= 0-30 ft 2= 30 to 100 ft, 3= 100 ft + 12.5 Who usually collects the water from 1= Adult Women (1=cÖvßeq¯‹ gwnjv); 2=Girls (2 = evwjKv); the water source?/ 3= Adult Men (3 = cÖvßeq¯‹ cyiæl); 4= Boys (4 = evjK) মক সাধ্ারনত পাশন সংগ্রহ কলর? 12.6 Do you cover containers when 1 = Yes, all of them are covered every time (1 = n¨uv, memgq) Transporting drinking water / খাওয়ার 2 = Some are covered some are not (2 = wKQy XvKbv †`qv wKQy XvKbv Qvov) পানি বহসেি সময় পাসে ঢাকো দেে রকো? 3 = No, do not cover (3 = bv, XvKbv Qvov) 1 = Same container used for collection/transport (1= msMÖn/enb GKB cvÎ) 12.7 How is drinking water stored 2 = Bucket/ pitcher (Kalash)/ container uncovered (2=
within the HH? রকভাসব বাড়ীসত খাবাি evjwZ/Kjmx XvKbv Qvov) 3 = Bucket/ pitcher (Kalash) /container covered (3 = পারে সংিক্ষে কসি হয়? (Observe also) evjwZ/Kjmx XvKbv ‡`qv) 4 = Bucket/pitcher (Kalash) /container with cover and tap (4 = evjwZ/ Kjmx XvKbvmn †gvov‡bv) 12.8 How often do you wash the container for storing water? 1= every day (1=cÖwZ w`b) 2= twice per week(2=mßv‡n 2 evi) 3= once per week (3= mßv‡n GKevi) 4= less than once per week পারে সংিক্ষসেি জেয বযবত পাে কত বাি (4=m߇n GKw`bI bv) দ ায়া হয়?
13. HOUSEHOLD SANITATION AND HYGIENE (cvwievwiK cqwb®‹vmb e¨e¯’v I cwiQbœZv)
1 = Piped with Sewerage system/m¨yqv‡iR jvB‡bi mv‡_ hy³ cvqLvbv 2 = Latrine with Septic Tank/ m¨vwÞK U¨vsKmn cvqLvbv Where do the members of your HH defecate? 3 =Latrine withwater seal/IqvUvi wmj mn cvqLvbv (Observe latrines 4 = Latrine without water seal/IqvUvi wmj Qvov cvqLvbv 13.1 mentioned to confirm) / 5= Latrine which pit is broken/unmanaged/mixed wiht nearby water body পরিবাসিি দ াকজে 6 = Hanging latrine/SzjšÍ cvqLvbv সা ািেত দকাথায় পায়খাো কসি থাসকে? 7 = No latrine (defecate openly nearby roads, river, field, jungle etc.) /cvqLvbv bvB (iv¯Ív/b`xi av‡i/‡Lvjv gv‡V/ ‡hLv‡b-†mLv‡b/‡Svc-R½j) 8 = Others (specify)/ Ab¨vb¨ (wbw`©ó Kiæb) 1 = Child used latrine Last time your young (1 = ev”PvwU cvqLvbv e¨envi K‡i‡Q) 2 = Picked up and threw in latrine child defecated, what (2 = gj wb‡q cvqLvbvq †djv n‡q‡Q) was done with the 3 = Left in the open where child defecated feces? (Only one (3 = †hLv‡b gj Z¨vM K‡i‡Q †m_v‡bB Db¥y³fv‡e †djv Av‡Q) 13.2 answer) 4 = Buried or covered with soil/ash আপনার ম াট বাচ্চা綿 গতবার (4 = gvwU/QvuB w`‡q XvKv‡bv) মকাথ্ায় মে তযাগ কলরল এবং 5 = Picked up and thrown in solid waste pile মসটা শক কলরল ন? (�ধ্ুমাত্র (5 = gj wb‡q gqjv ¯‘‡c †djv n‡q‡Q) এক綿 উত্তর) 6 = Picked up and thrown out of compound (in open) (6 = gj wb‡q Qz‡o †djv n‡q‡Q)
14. Hand-washing Behaviour (হাত মধ্ায়ার Af¨vm) 0 = No, I don’t specifically 14.1 On a normal day, do you wash your hands with soap? If yes then ask wash my hands (1 = bv, nvZ the following questions/ ¯^vfvweK fve Avcwb wK স্যবযন শদলয় nvZ cwi¯‹vi/ মধ্ৌত cwi¯‹vi Kwi bv) 1 = Yes, I do কলরন? হাাঁ হলে শনলমাক্ত প্রশ্ন巁লো ক쇁ন,hw` bv nq ZLb 14.2 bs cÖkœwU ev` w`b| wash my hands (n¨uv, Avwg nvZ ay‡q _vwK) Put a Tick sign (√) on the correct 14.2 If yes, what times do you wash your hand with soap? যশদ্ হযাাঁ হয়, কখন responses/ mwVK Dˇi wUK wPý (√) আপশন আপনার হাত স্যবযন শদলয় ধ্ুলয় থ্ালকন? (multiple answers possible/ উত্তর অলনক w`b
হলত পালর। DO NOT PROMPT/ উত্তরসমূহ আলগ মথ্লক বলে শদ্লবন না। �ধ্ুমাত্র ময উত্তর巁লো বেলব তার ডানপালিে 綿ক শিহ্ন শদ্লবন।
1 = Before cooking food (1 = n¨uv, ivbœvi Av‡M) 2 = After defecation (2 = n¨uv, gj Z¨v‡Mi c‡i) 3 = Before eating food (3 = n¨uv, Lvev‡ii Av‡M) 4 = After disposing of child’s feces/cleaning child (4= n¨uv, ev”Pvi ‡kŠP
KvR Kiv‡bv c‡i) 5 = After working with animals, crops, etc. (5 = n¨uv, Mfvw`cï, km¨ wb‡q
KvR Kivi c‡i) 6 = Before feeding child (6 = n¨uv, ev”Pv‡K Lvevi) 7= Before breastfeeding (7 = n¨uv, ev”Pv‡K ey‡Ki `ya †`Iqvi Av‡M ) 8= After sneezing (8 = n¨uv, nvuwP †`Iqvi ci) 9= After handling money (9 = n¨uv, UvKv-cqmv bvovPvov Kivi ci) 14.3 MOST OFTEN, what do you use to 1 = Water only (1= ïay cvwb) wash your hands? / আপশন সাধ্ারনত শক শদ্লয় 2 = Water and ash (2 = cvwb Ges QvuB ) হাত পশরস্কার কলরন? Ask open ended. Only 3 = Water and sand/mud (3 = cvwb Ges evwj ) one answer representing most frequent 4 = Water and soap (4 = cvwb Ges mvevb) behaviour 5 = Other: (specify) ______(5 = Ab¨vb¨, wbw`ó K‡i ejyb)
14.4 হাত মধ্ায়া জনয পায়খানার মলধ্য বা তার পালি সাবান আল শকনা তা পযেলবক্ষণ ক쇁ন। (1=yes; 0= no) Observ that Soap is available in Latrine or besides?
Appendix 5: Local Event Calendar
2012 2013 2014 2015 2016 2017
Jan New Year’s day 67 New Year’s day 55 New Year’s day 43 New Year’s day 31 New Year’s day 19 New Year’s day 7
Pohela Pohela Pohela Pohela Pohela Pohela Feb 66 54 42 30 18 6 Falgun/Int. MLD Falgun/Int. MLD Falgun/Int. MLD Falgun/Int. MLD Falgun/Int. MLD Falgun/Int. MLD
Independence Independence Independence Independence Independence Independence Mar 65 53 41 29 17 5 day day day day day day
Phohela Phohela Phohela Phohela Phohela Phohela Baishak Baishak Baishak Baishak April Baishak (Bangla 64 52 Baishak (Bangla 40 28 16 4 (Bangla new (Bangla new (Bangla new (Bangla new new year) new year) year) year) year) year) Labour day, Labour day, Labour day, Labour day, Labour day, Labour day, Boddhu May Boddhu 63 Boddhu 51 Boddhu 39 Boddhu 27 Boddhu 15 3 pornima, pornima, pornima, pornima, pornima, pornima, Ramadan Start of the long Start of the long Start of the long Start of the long Start of the long Before Eidul June rainy season 62 50 38 26 14 2 rainy season rainy season rainy season rainy season Fitar
Ramadan, Eid Eid Ul Fitar, After Eid Ul July Shab-e-borat 61 Heavy rainfall 49 Ramadan 37 25 13 1 Ul Fitar, Flood Fitar
Eidul Fitar, National National National National Aug 60 National 48 36 24 12 0 Mourning Day Mourning Day Mourning Day Mourning Day Mourning Day
End of the long End of the long End of the long End of the long Sept 59 47 rainy season 35 rainy season, 23 Eid Ul Adha 11 rainy season rainy season Eid Ul Adha
Waterlogging, Holy Dorga Holy Dorga Holy Dorga Holy Dorga Ashura, Holy Oct Puga , Eid Ul 58 46 Puga , Eid Ul 34 Puga, Eid Ul 22 10 Puga , Eid Ul Dorga Puga Adha Adha Adha Adha
Laxmi Puja, Sri Shayama Nov Ashura 57 45 Ashura 33 21 PSC Exam 9 Ashura Puja
Christmas, Christmas, Christmas, Christmas, Christmas, Dec 56 44 32 20 8 Victory Day Victory Day Victory Day Victory Day Victory Day