FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING Final Report AND MATERNAL NUTRITION 2016 IN TAJIKISTAN Conducted by Dornsife School of Public Health & College of Nursing and Health Professions, Drexel University, Philadelphia, PA USA For UNICEF Tajikistan Under Drexel’s Long Term Agreement for Services In Communication for Development (C4D) with UNICEF And Contract # 43192550 January 11 through November 30, 2016 Principal Investigator Ann C Klassen, PhD , Professor, Department of Community Health and Prevention Co-Investigators Brandy Joe Milliron PhD, Assistant Professor, Department of Nutrition Sciences Beth Leonberg, MA, MS, RD – Assistant Clinical Professor, Department of Nutrition Sciences Graduate Research Staff Lisa Bossert, MPH, Margaret Chenault, MS, Suzanne Grossman, MSc, Jalal Maqsood, MD Professional Translation Staff Rauf Abduzhalilov, Shokhin Asadov, Malika Iskandari, Muhiddin Tojiev This research is conducted with the financial support of the Government of the Russian Federation Appendices : (Available Separately) Additional Bibliography Data Collector Training, Dushanbe, March, 2016 Data Collection Instruments Drexel Presentations at National Nutrition Forum, Dushanbe, July, 2016 cover page photo © mromanyuk/2014 FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING AND MATERNAL NUTRITION IN TAJIKISTAN TABLE OF CONTENTS Section 1: Executive Summary 5 Section 2: Overview of Project 12 Section 3: Review of the Literature 65 Section 4: Field Work Report 75 Section 4a: Methods 86 Section 4b: Results 101 Section 5: Conclusions and Recommendations 120 Section 6: Literature Cited 138 FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING 3 AND MATERNAL NUTRITION IN TAJIKISTAN AND MATERNAL NUTRITION IN TAJIKISTAN SECTION 1: EXECUTIVE SUMMARY Introduction Tajikistan is a mountainous, primarily rural country of approximately 8 million residents in Central Asia. Despite economic growth since achieving independence twenty five years ago, Tajikistan continues to be the poorest nation in the CIS region. Malnutrition in Tajikistan remains a significant public health problem. The first Demographic Health Survey in Tajikistan, conducted in 2012, found that 26% of children under 5 years old are stunted, due to chronic malnutrition, 10% are wasted, a sign of acute malnutrition, and 12% are underweight. Micronutrient deficiency is widespread, with the prevalence of anaemia and iodine deficiency among children 6-59 months being 28.8% and 55% respectively, and anaemia prevalence among women of reproductive age being 24.2%. Although the vast majority of children are offered breast feeding at birth, only 34 percent of infants below 6 months old receive exclusive breastfeeding, only 49% of the children are introduced to complementary foods at an appropriate age, and only 20% of children 6-23 months receive the optimal infant and young child feeding (IYCF) in terms of food diversity and meal frequency. As nutrition at the population level is a complex phenomenon impacted by many factors, the government of Tajikistan is working across all sectors, in concert with development partners involved in child health and nutrition programs, to plan strategic interventions at multiple levels. In order to intervene effectively across the diverse geographic settings, ethnic and cultural groups, and unique contexts in the country, formative research was essential, to understand the drivers behind the concerning nutrition statistics. UNICEF Tajikistan, in partnership with the Ministry of Health and Social Protection, engaged Drexel University as a consultant, to design and conduct formative research on IYCF practices in Tajikistan. Research Design and Methods The research process included an initial phase to explore the relevant existing knowledge and evidence, in order to best focus the project. A desk review of both peer-reviewed literature and reports was conducted, followed by a series of expert interviews. A series of seven interviews, conducted by Drexel Project Leads with translation support as needed, collected data from regional and national health leaders in Tajikistan, as well as nutrition-focused experts from three development partners. These initial activities informed the design and methods used for the second project phase. A purposive sample of 13 districts and villages, across all five regions of 4 FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING AND MATERNAL NUTRITION IN TAJIKISTAN SECTION 1: EXECUTIVE SUMMARY Tajikistan, were selected for village- level in-depth data collection. In each village, data collection at the village level included transect walks, participatory mapping, and market and store assessments of food availability and pricing. Data collection at the community level included focus group discussions with expectant women, mothers of young children, fathers of young children, and mothers-in-law in homes with young children, as well as individual in-depth interviews with key informants within the village, including health care workers, religious leaders, heads of women’s councils, and local political leaders. Data collection at the household level, in four diverse homes in each village, included structured observations of sanitation, meal preparation, and (as permitted) mealtime behaviors, 24 hour and 7 day food recalls for mothers, an index child age 0-24 months, and the household, and an in-depth semi-structured interview with mothers. All data collected, including audio-recordings, written notes and questionnaires, maps and photographs, were transmitted to Drexel for translation when necessary, data entry, and analysis. Results were shared in a two day National Nutrition Forum in Dushanbe in July, 2016, and are being disseminated though reports and manuscripts for both scholarly and policy-oriented use. Results Findings confirm that although most Tajik mothers and families are committed in principle to breast feeding through age 24 months, exclusive breast feeding until six months is not always maintained. Although some mothers introduce formula because they are not able to breast feed, or believe their supply is not adequate, other mothers introduce formula as a complementary diet or first food while breast feeding, and others introduce a range of liquids and solids before six months, with or without continued breast feeding. Black tea, which inhibits the uptake of iron, as well as cow’s milk before nine months, are common feeding behaviors. As well, the introduction of sweetened liquids and foods adds “empty” calories, decreasing demand for, and thus supply of, breast milk. Dietary diversity among infants and young children in this study was also sub-optimal, even in homes where adult diversity was adequate. Compared to age-specific dietary recommendations, mothers often believed certain foods, including meat, vegetables and some fruits, were harmful to young children. Foods were seldom prepared separately, and planning for child diets was rare, with most foods introduced from the family diet. Although some foods were mashed or pureed for young children (most often porridge, pureed potatoes or bread soaked in milk or tea), foods such as meats were withheld until the child could eat them in whole form. When comparing their infant’s diet to recommended foods, mothers uniformly felt it was unrealistic FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING FORMATIVE RESEARCH ON INFANT AND YOUNG CHILD FEEDING 5 AND MATERNAL NUTRITION IN TAJIKISTAN AND MATERNAL NUTRITION IN TAJIKISTAN to provide food to an infant that was different, or potentially superior, to the usual household diet for older children or adults, and did not believe they could realistically improve their child’s diet within their current economic and household constraints. Households were often multi-generational and hierarchical in terms of dietary decision-making, with multiple actors involved in planning, purchasing and preparing foods. Little overt disagreement over children’s diets was acknowledged, however, and most mothers felt they were the final decision maker regarding their infant’s diet. Young women reported receiving advice on child nutrition from their own mothers and doctors, as well as the most immediate influence, their mothers-in-law. Communication channels for women were typically limited to these interpersonal sources, as well as television, which was reported to be a fairly strong source of child nutrition information. Village-level influences on food accessibility were apparent, and shaped by geography, climate and village-level economic conditions. In some villages, only a single small shop was available for families who lacked transportation to larger markets, while in others, multiple market vendors and shops offered diverse foods and, generally speaking, lower prices. Although 90% of households grew some food or had some livestock, there were still seasonal scarcity issues. For example, despite growing a range of fruits and vegetables rich in Vitamin A, many families had eaten little or none of these foods recently, and spoke of food scarcity during late winter and spring. Thus, the selection of the month of April for data collection provided insight into the types of families who experience seasonal hardship, as well as identifying some families who reported no food-related hardship. In regard to health care, both during pregnancy and during infancy, there were strong disparities by village and region in both access and utilization. Although some women had good