Integrated KAP Survey Knowledge, Attitudes, and Practices Jamshoro District, Sindh Province, Pakistan December 2016
Table of Contents
Acknowledgments ...... 3 Acronyms and Abbreviations ...... 4 1. Executive Summary ...... 5 2. Introduction...... 7 3. Survey Objectives ...... 9 4. Methodology...... 9 4.1 Type of Survey and Survey Area ...... 9 4.2 Study Period ...... 10 4.3 Study Population ...... 10 4.4 Study Design and Sample Size ...... 10 4.6 Sample Size ...... 11 4.7 Data Collection Methods ...... 11 4.8 Training and Formation of Survey Teams ...... 12 4.9 Data Analysis ...... 12 5. Results ...... 12 5.1 Infant and Young Child Feeding ...... 12 5.2 Water and Sanitation ...... 19 5.3 MORBIDITY ...... 25 5.4 Food Security ...... 27 6. Conclusion ...... 30 7. Recommendations ...... 31 Annex I: Sampled clusters list for district Jamshoro ...... 32 Annex II. Key indicators used to measure IYCF practices for children aged 0-23 months ...... 33 Annex IV: Focus group discussion guide for IYCF ...... 36 Annex V: Focus group discussion guide for WASH and food security ...... 38
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List of figures Figure 1: MAP of Jamshoro district ...... 7 Figure 3: Distribution of number of children across age group and sex ...... 13 Figure 4: Liquids given in 1st three days after birth ...... 15 Figure 5 Knowledge of mother regarding infant and young child feeding ...... 18 Figure 6: Distance to main source of water/responsible family members for fetching water ...... 21 Figure 7: Water treatment methods locally used ...... 22 Figure 8: Stool disposal practices ...... 24 Figure 9: Handwashing timings ...... 24 Figure 10: Water borne diseases in households ...... 26 Figure 11: Figure illustrate categorized households HDDS ...... 28 Figure 12: Foods eaten by household members...... 28 Figure 13: Coping Strategy Score ...... 29 Figure 14: Type of coping strategy adapted by household ...... 30 Figure 15: proportion of household adapted one or more rCSI ...... 30
List of tables Table 1: Summery of all Indicators: ...... 6 Table 2 Indicators of interest ...... 9 Table 3 Summary of infant and young child feeding practices ...... 14 Table 4: Mothers’ knowledge about IYCF key messages ...... 18 Table 5: Knowledge about colostrum and pregnant/lactating women’s health care-seeking behavior ...... 19 Table 6: Main source of water and related information ...... 20 Table 7: Water quality and testing...... 21 Table 8: Protected toilet use ...... 22 Table 9: Stool disposal practices ...... 23 Table 10: Handwashing location and material ...... 24 Table 11: Wastewater drainage system ...... 25 Table 12: Morbidity and expenditures ...... 26 Table 13: Household Dietary Diversity ...... 27 Table 14: Reducing Coping Strategy Index ...... 29
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Acknowledgments
We are grateful to the Nutrition Support Program (NSP) – Sindh for their trust in Action Against Hunger, and for providing this opportunity to generate evidence about Jamshoro. Technical supervision and inputs from NSP have been instrumental in carrying out these activities. We would like to show our gratitude to Action Against Hunger’s technical advisors, national staff members, technical persons, and support team members for their contributions. We appreciate the hard work of staff members, especially Ms. Imelda Awino (Health and Nutrition Advisor) and Ms. Jennifer Majer (Monitoring and Evaluation Officer), Mr. Shahid Fazal (DCD Programs), and Mr. Muhammad Ali (Survey Manager) for their technical insights and leadership throughout the survey and for management of fieldwork, data quality, and reporting. We would like to extend our gratitude to the locally-hired enumerators and data analysts for their dedication and hard work at the field level. In addition, we owe our sincere gratitude to the participating community members for their valuable time and for providing the required information. We are thankful to UNICEF and the Nutrition Working Group Members for their consistent support and guidance throughout the activities. UNICEF, with the collaboration of ECHO, has financially supported these evidence generation activities, which can provide information to make concrete and relevant recommendations to interventions departments and organizations in Jamshoro.
This document was produced with the financial assistance of the Nutrition Support Program -
Sindh. The views expressed here should not be taken in any way to reflect the official opinion of
the Nutrition Support Program - Sindh.
Statement on Copyright
© Action Against Hunger, 2017
Unless otherwise indicated, reproduction is authorized on condition that the source is credited. If reproduction or use of texts and visual materials (sound, images, software, etc.) is subject to prior authorization, such authorization will render null and void the above- mentioned general authorization and will clearly indicate any restrictions on use.
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Acronyms and Abbreviations
ARI Acute Respiratory Infection CHW Community Health Worker CMAM Community-Managed Acute Malnutrition CSI Coping Strategy Index DCO District Coordination Officer ENA Emergency Nutrition Assessment FAO Food and Agriculture Organization FGD Focus Group Discussion FSL Food Security and Livelihoods HDDS Household Dietary Diversity Score HEA Household Economic Analysis HH Household IPC Integrated Food Security Phase Classification IYCF Infant and Young Child Feeding KAP Knowledge, Attitudes, and Practices KII Key Informant Interview LHV Lady Health Visitor LHW Lady Health Worker MICS Multiple Indicator Cluster Survey NSP Nutrition Support Program PKR Pakistan Rupees PLW Pregnant and Lactating Women PPS Probability Proportionate to Size RNT Random Number Table SDNA Sindh Drought Needs Assessment TBA Traditional Birth Attendant UC Union Council VIP Ventilated Improved Pit (latrine) WASH Water, Sanitation, and Hygiene WHO World Health Organization
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1. Executive Summary The Knowledge, Attitudes, and Practices (KAP) survey was carried out to assess infant and young child feeding practices (IYCF), water sanitation and health (WASH), and food security and livelihoods (FSL) among mothers and caregivers of children aged 0-23 months in Jamshoro district, Sindh. The KAP survey was conducted as a benchmark of the current situation in the district. There were no KAP surveys conducted previously in Jamshoro, which emphasizes the importance of the current survey to fill gaps in information with respect to knowledge, attitudes, and practices. Information gathered was useful in identifying barriers and facilitating factors to young child health, and in developing appropriate recommendations to inform programming in the district. The information was gathered from mothers, other community members, and selected key informants on IYCF practices, household-level WASH and personal hygiene, and household food security. Data collection involved mixed methods, employing both quantitative (household questionnaires) and qualitative (focus group discussions and key informant interviews) techniques. Out of 689 households, a total of 270 mothers were interviewed who had children aged 0-23 months. In Jamshoro, living in a joint family system is common, which leads to more than one mother with children aged 0-23 months per household. The standard definition of a householdi was followed throughout the assessment. Data collection was closely supervised by monitoring staff and survey manager throughout the survey. Each questionnaire and data sheet was checked on a daily basis for missing data prior to data entry. Based on the questionnaire reviews, supervisors provided feedback to enumerators every day before enumerators departed for data collection the next day. With regard to IYCF, the survey results indicated a lack of awareness among mothers about the importance of exclusive breastfeeding. In particular, during the first three days after birth it was common for infants to receive liquids such as gripe water, honey, sugar water, or green tea. Other challenges to appropriate IYCF practice was the perception of mothers that colostrum is “bad milk”, that it causes stomach pain due to its thickness. In addition, the colour of the first milk discouraged mothers to breastfed as well; only 53.7% of mothers surveyed described timely initiation of breastfeeding. Once complementary feeding began, difficulties persisted; the survey showed low dietary diversity and low meal frequency and indicated that majority of children aged 6-23 months received a diet that was not sufficiently diverse to supply their micro- and macronutrient requirements for adequate growth. With regard to cessation of breastfeeding, the main reasons of stopping breastfeeding were “mother or child became ill” (41.2%) and ”mother had become pregnant again” (35.3%). Traditional beliefs dictate that breastfeeding during illness or pregnancy may be harmful to the child. These traditional beliefs combined with short birth spacing may impact child health. Survey findings indicated that most community members felt that their water quality was not good, based on its color since its looked dirty or tasted different, with very few households who tested their water quality. Among families who treated their drinking water, the main method used was to filter water through a cloth. Adult women were primarily responsible for fetching water for their households; most households had a water source available nearby, but some had to fetch water from a distance. With regard to sanitation, over half of the participants lacked access to a protected latrine, and instead were practicing open defecation. Majority of participants disposed of their children’s stools by throwing them in the garbage, and of their solid waste by dumping it away from the house. In terms of personal hygiene, fewer than half of participating households had a designated location for handwashing, in which only 18% had soap in these designated locations. A low proportion of participants mentioned washing their hands before feeding children or after handling human or animal feces.
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The survey also assessed household dietary diversity; almost half of participating households had a medium or low household dietary diversity score. Among the participating households, 88% had adopted one or more food-based coping strategies; more than a quarter of these households had adopted all five food-based coping strategies.
Table 1: Summary of all Indicators:
1. Infant and young child feeding indicators (WHO standards 2010) IYCF indicators (WHO 2010) Age (Months) n Percentage CI (95%) 1. Child ever breastfed 0-23 Months 270 98.1% 96.5-99.7 2. Timely initiation of breastfeeding 0-23 Months 270 53.7% 47.7-59.6 3. Exclusive breastfeeding under 6 months 0-5 Months 74 52.7% 41.3-64.1 4. Predominant breastfeeding under 6 months 0-5 Months 74 24.7% 14.9-34.5 5. Continued breastfeeding at 1 year 12-15 Months 75 77.3% 67.8-86.8 6. Continued breastfeeding up to 2 years 20-23 Months 29 55.2% 37.1-73.3 7. Age-appropriate breastfeeding 0-23 Months 270 58.5% 52.6-64.4 8. Introduction of solid, semi-solid, or soft foods 6-8 Months 27 59.3% 40.8-77.8 9. Milk feeding frequency for non-breastfed infants 6-23 Months 37 56.8% 49.9-63.8 10. Minimum meal frequency for breastfed children 6-23 Months 159 78.4% 72.0-84.8 11. Minimum meal frequency for non-breastfed children 6-23 Months 37 68.6% 53.6-83.5 12. Minimum dietary diversity (four or more food groups) 6-23 Months 196 29.6% 23.2-35.9 13. Minimum acceptable diet (minimum meal and 6-23 Months 196 22.4% 16.6-28.3 minimum dietary diversity) 14. Bottle-feeding 0-23 Months 270 25.6% 20.4-30.8 15. Consumption of iron-rich or iron-fortified foods (At least 6-23 Months 196 15.2% 10.2-20.3 one iron-rich food) 2. WASH indicators 2.1. Main source of water in community is “Protected well” Household 248 27.4% 21.8-32.9 2.2. Distance to main source of water is 1-2 Hours Household 248 52.0% 45.8 - 58.2 2.3. Adult women and girls are responsible for fetching Household 248 76.2% 70.9-81.5 water 2.4. Water quality “not tested” Household 248 86.9% 82.7-91.1 2.5. Perception that water is safe for drinking Household 248 64.9% 58.9-70.8 2.6. Local water treatment Household 248 37.5% 31.5-43.5 2.7. Using protected toilet Household 248 46.3% 40.1-52.5 2.8. Open defecation Household 248 53.6% 47.4-59.8 2.9. Disposal of infant stool (Thrown into garbage + Thrown Household 248 56.0% 49.8-62.8 into toilet) (highest response) 2.10. Waste water drainage system (Just flow open in and Household 248 63.71% 57.7-69.7 outside home) (highest response) 2.11. Dump solid wastes close to their houses Household 248 67.7% 61.9-73.5 2.12. Identified handwashing location Household 248 46.3% 40.1-52.5 2.13. Hand washing with water only (highest response) Household 248 55.6% 49.4 - 61.8 2.14. Diarrhea (past two weeks’ recall) Household 248 80.2% 75.3-85.5 3. Food Security 3.1. Household dietary diversity score (HDDS) Household 248 5.26 Score 5.0-5.5 3.2. Household Reduced Coping Strategy Index (rCSI) Household 248 17.7 Score 16.1-19.3
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2. Introduction In 2004, the boundaries of district Dadu were redefined, leading to the creation of district Jamshoro1, and was named after the famous city of Jamshoro. The district is bordered on the north by Dadu and Naushehro Feroze districts; on the south by Thatta and Karachi districts; on the east by Nawab shah, Matiari, and Hyderabad districts; and on the west by Dadu and Karachi districts of Sindh and Lasbela district of Balochistan. The eastern part of the district consists of a range of limestone hills known as the Kirthar range. Figure 1 illustrates details of the district map.
Figure 1: Map of Jamshoro district
The total geographical area of the district is 11,5172 square kilometres. It is about 220 kilometers from north to south and about 100 kilometres wide from east to west. A two to six-kilometers-wide belt on the west bank of River Indus is cultivated and irrigated land, and the remaining area of the district is either hilly or cultivated. Agriculture is the main source of income.
1 https://en.wikipedia.org/wiki/Jamshoro_District#cite_note-2 2 https://en.wikipedia.org/wiki/Jamshoro_District Page 7 of 38
The district’s climate is intensively hot in summer and cold in winter. The northern part (Sehwan) is hotter than other parts of the district. The town of Sehwan is famous for the shrine of Hazrat Makhdoom Usman Marvindi, popularly known as Hazrat Lal Shahbaz Qalandar. Thousands of people from all over the country come to visit (Ziarat) and pay tribute to this great Saint during the 18th of Shaban every year. Administratively, the district is divided into five talukas – Jamshoro, Kotri, Sehwan Sharif, Thana Bulla Khan, and Manjhand. The district has a population of 450,000, according to the Pakistan census of 1998, and estimated 1,176,969 in 20113. While agriculture is the main source of employment for the rural population of the district, in the urban areas people are engaged in various activities like trade, services, personal business, government and private jobs. Noori abad and Kotri are two industrial zones, hosting almost 500 different industries.
The Sindh Multiple Indicator Cluster Survey (MICS4) 2014 found high rates of undernutrition across Sindh. Among children under five years of age; 42% were underweight, 48% were stunted, and 15.4% were wasted. The current survey showed even more severe level of malnutrition in the district, with 50.8% of underweight, 54.4% of stunting, and 23.8% of wasting among children under five. The critical malnutrition situation in the district was linked to poor IYCF practices, such as low timely initiation of breastfeeding (31.4%), inadequate exclusive breastfeeding (50.8%) and continued breastfeeding up to two years of age (48.9%), insufficient age appropriate complimentary feeding (63%), and limited minimum meal frequency (47.5%), minimum diet diversity (1.7%) and minimum acceptable diet (1.0%). Other contributing factors to malnutrition were lack of hygiene and sanitation and food insecurity. According to the MICS 2014, 41.8% of the community did not practice any water treatment to make drinking water safe. Furthermore, almost 77% of households practiced open defecation, and only 18.3% households used protected toilets. Mothers workload directly and indirectly affects the child’s access to water since 86% of adult women and girls were responsible for fetching water from distant places within the district.
According to the MQSUN report 2015, Sindh has the lowest rate of food security compared to the other provinces, with only 28% of the population considered as food secure. According to the Household Economic Analysis (HEA) 2015, Jamshoro is classified as an irrigated wheat zone. The main source of food and income is wheat; though other crops such as chili, onions, oil seed crops, and other vegetables are also important. Hence, the damages to the agricultural sector from floods and droughts have significantly impacted household livelihoods and food security. In 2010, the floods affected 49% of the population in 16 union councils of the district. In 2011, the floods affected 12% of the population in 25 union councils. Due to these floods, 70% of the cotton crop and 80% of other crops (including fodder and vegetables) were damaged. These losses, combined with the reduced functioning capacity of the markets, negatively impacted household incomes.
Current programs addressing malnutrition and related underlying causes in the district are supported by ECHO and implemented by UNICEF through the SHIFA Foundation (a national NGO), with the support and coordination of the Nutrition Support Program (NSP). This integrated package was targeted to 23 union councils (out of 28 union councils in the district), and ended in December 2016. Muslim-Aid has worked in some areas of the district to install hand-pumps, distribute seeds, and carry out kitchen gardening activities; however, these programs ended in August 2016.
The KAP survey was conducted in Jamshoro as a benchmark of the current situation in the district. There was no KAP survey conducted previously, which highlights the importance of the findings to fill previous information gaps with respect to knowledge, attitude and practices.
3 http://www.thenews.com.pk/Todays-News-13-13637-Sindh-population-surges-by-81.5-pc,-households-by-83.9-pc 4 http://sindhbos.gov.pk/mics-report/ Page 8 of 38
3. Survey Objectives The main objectives of the KAP survey were: • To assess the current knowledge, attitudes, and practices (KAP) among the community’s mothers regarding infant and young child feeding (IYCF); • To assess the food security and livelihoods (FSL) situation among the communities; • To examine the population’s access to and use of water, sanitation, and hygiene (WASH); • To provide recommendations for designing appropriate interventions by stakeholders in the district to address community needs
4. Methodology 4.1 Type of Survey and Survey Area A cross-sectional population survey was conducted in all union councils of Jamshoro district. The survey used quantitative and qualitative methods to collect relevant information. The data was collected through household questionnaires, Focus Group Discussions (FDGs) and Key Informant Interviews (KIIs) within the community. TO determine the survey area, a list of union councils, villages and all other necessary information (average household size, population, etc.) was taken from the 1998 Census of Pakistan and MICS Survey Sindh 2014, and validated by the concerned district authorities. The following IYCF, FSL, WASH indicators were used for data collection:
Table 2 Indicators of interest IYCF Indicators (WHO Guidelines 2010) 1 Timely initiation of breastfeeding 2 Exclusive breastfeeding under 6 months 3 Continued breastfeeding at 1 year 4 Age appropriate complementary feeding 5 Minimum dietary diversity 6 Minimum meal frequency (breastfed children) 7 Minimum meal frequency (non-breastfed children) 8 Minimum acceptable diet 9 Consumption of iron-rich or iron-fortified foods 10 Children ever breastfed 11 Continued breastfeeding at 2 years 12 Age-appropriate breastfeeding 13 Predominant breastfeeding under 6 months 14 Milk feeding frequency for non-breastfed children 15 Bottle feeding WASH Indicators 16 Diarrhea prevalence 17 Designated handwashing location with soap/ash and water available 18 Critical handwashing times 19 Access to improved water source 20 Use of latrine / latrine characteristics 21 Disposal of child stools FSL Indicators 22 Household Dietary Diversity Score (HDDS) 23 Reduced Coping Strategy Index (rCSI)
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4.2 Study Period The study period was from November to December 2016, whereas field data collection was conducted between the second and third week of November 2016. 4.3 Study Population a) Mothers of children under two years of age: To assess IYCF practices, relevant information was gathered from the primary caregiver of children who were under two years of age via household questionnaires in all selected villages. For the purpose of this survey, the primary caregiver refers to the person or persons who feed and care for the infant or young child most of the time and/or make decisions about how and what the child should be fed. In most cases the caregiver was the mother, however for some children the primary caregiver was the child’s grandmother. Depending on the primary caregiver, specific questions related to complimentary feeding were asked to either the mother or grandmother. b) Pregnant and breastfeeding women: To gauge the level of knowledge among women on IYCF, relevant information was gathered from pregnant and breastfeeding mothers via focus group discussions in all selected villages; c) Households: To gauge the FSL and WASH situation, relevant information was gathered via household questionnaires in the intervention areas. 4.4 Study Design and Sample Size Villages were considered as the smallest geographical unit (when required, groups of small villages were merged into clusters). The primary sampling unit was the village and the basic sampling unit was the household, considering households that had a child aged 0-23 months of age. The sampling was completed using the following two-stage process: Stage 1: Random selection of clusters The survey area was divided into small distinct villages. An approximate size of the population for each village was estimated. Clusters were assigned randomly using the Emergency Nutrition Assessment (ENA) software, which assigns clusters based on the proportion of the village population to the total population. This method is known as probability proportional to population size (PPS). Stage 2: Selection of households At cluster locations, data collection teams confirmed the location of the village and number of households in the area. After confirming the village and number of households, one of the following methods was used household selection:
I. Simple random sampling: When an updated list of all households in the village was available or it was possible to make a list for all the households, households were randomly selected by using a random number table (RNT). II. Systematic random selection of households: In cases where it was not possible to list all households in the village, the households were selected based on systematic random sampling. When the team arrived at the location identified for the cluster, they confirmed the number of households in the area, and listed all these households. Systematic sampling was employed, using an appropriate sampling interval to move from one household to another. When the assessment team reached the first selected household, they were asked whether there was at least one child aged 0-23 months. If there was a child aged 0-23 months, the team collected data and then moved to the next household based on the sampling interval. III. Segmentation: In some high-density population clusters (having more than 100 households), SMART survey standard procedure was applied before using simple random sampling or systematic sampling; for this purpose, the whole cluster was divided in almost equal parts (subunits) according to the geographical conditions of the area. One subunit was randomly selected for data collection.
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For IYCF assessment, a questionnaire was administered for each child aged 0-23 months living in the selected household. The child’s primary caregiver filled the study questionnaire. If the child and/or the caregiver were temporarily out of the house, the assessment team revisited the house to collect the information at a later date and time. This process was repeated until the required number of households in a cluster was achieved, and sufficient children aged 0-23 months were who assessed for IYCF practices.
4.6 Sample Size The sample size derived using the formula: 2 푝×푞 푁=2푡 )] 2 푑 Parameters defined below. N= Sample size (number of children) t= test statistics (error risk: 1.96 at 95% confidence interval) p= Estimated prevalence (calculated for all indicators) q= 1-p (for estimated prevalence 50%: 0.5)* d= Desired Precision (7%) and design effect for cluster survey 1.5 Non-response rate: 3%
Note: *Estimated prevalence was calculated for all indicators and the highest sample size was selected for assessment; 262 children. Conversion of sample size to the number of households to be visited: Based on MICS Sindh5, an average household size of 7.2 members and a proportion of children under five of 13.6% were used to determine the number of children aged 0-23 months and total number of households (689 households) to be visited to reach the sample size.
Out of a total sample of 689 households, 270 mothers or primary caregivers were interviewed in 248 households with children aged 0-23 months. Since living in a joint family system was common in the community, there was often more than one mother with a child aged 0-23 months per household. A standard definition of a householdii followed throughout the assessment. 4.7 Data Collection Methods a) Household questionnaires: Information was collected on IYCF, FSL, and WASH from participating households using a quantitative questionnaire. The questionnaire respondents were women with children aged 0-23 months, however questions related to WASH and food security were completed by the head of household or any person in the household. b) FGDs: The village residents participated in FGDs to share their opinions on the WASH and FSL situation. Each FGD had 8-12 members who participated in the discussion. The data collection techniques used were listening, note taking and observing participants. To complement information collected quantitatively in the KAP survey and to draw more in-depth meanings, focus group discussions (FGDs) conducted. Participants were purposively identified to take into account homoogeneity across and within union councils in terms of culture, livelihood activities, and ecological factors. The target groups for FGDs were breastfeeding mothers, PLWs, grandmothers and community health workers.
5 http://sindhbos.gov.pk/wp-content/uploads/2014/09/01-Sindh-MICS-2014-Final-Report.pdf Page 11 of 38
c) KIIs: Key informants were Lady Health Workers (LHWs), Lady Health Visitors (LHVs) and Traditional Birth Attendants (TBAs); who discussed IYCF practices and barriers to IYCF and other health practices for PLW. 4.8 Training and Formation of Survey Teams Survey team members received four days of comprehensive training on overall processes and scope of the study including sessions to introducing questionnaires, interview guides, sampling process, and household selection (Annex. III). Training included role-play between team members to facilitate their understanding of the tools and of interviewing techniques. The training consisted of three-day in-house sessions, and testing of the tools done on the fourth day. At this point, amendments to the tools made as appropriate. 4.9 Data Analysis Data verified on a daily basis in order to correct anomalies quickly and findings were shared with the team on the following day. Data was re-coded into the relevant indices as per IYCF indicators. Data on IYCF, WASH and food security was analyzed using EPI Info Software and Microsoft Excel 2016. Simple descriptive statistics to obtain frequencies and proportions were derived and interpreted accordingly for each indicator. Qualitative data was organized into themes within the scope of the KAP objectives.
5. Results All mothers or primary caregiver with children aged 0-23 months were interviewed; with 133 boys and 137 girls. In households where more than one child under two years of age was a present, with the same mother or different mother information was gathered for each child on separate questionnaires. Information on WASH and food security was gathered at the household level only. Table 3: Detailed information of data collected in the survey Qualitative method used Section Method/ No Method/ No Method/ respondents No respondents respondents Mother interviewed 270 FGDs 30 KII 15 IYCF (Mothers having children (0- (PLWs, CBA, (LHW:4, TBA:3, private 23 months) Grandmothers, mother in practitioners:5, Doctors:3 law) HH participant 248 FGDs 25 KII 12 WASH (Social worker:5, local (Mother, HoH, HH member) (Community men, leaders) committee members:4, teachers:1), village chief:2 Food HH participant 248 FGDs 25 KII 14 security (Social worker:5, local (Mother, HoH, HH member) (Community men, committee members:4, community leaders) teachers:1), village chief:2
5.1 Infant and Young Child Feeding Proper IYCF can increase their chances of child survival; it can also promote optimal growth and development, especially during the critical window of birth to 2 years of age. Breastfeeding helps protect children from diseases, provides an ideal source of nutrients, and is economical and safe. However, many mothers do not start to breastfeed early or exclusively for the recommended 6 months Page 12 of 38
or stop breastfeeding before the 6 months are completed. Mothers are often pressured to switch to infant formula, which can contribute to growth faltering, micronutrient deficiency, and can be unsafe if hygienic conditions, including safe drinking water are not readily available.
UNICEF and WHO 6 recommend that infants be breastfed within one hour of birth, exclusively breastfed for the first six months of life and continue to be breastfed up to 2 years of age and beyond. Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.
In Jamshoro, according to the MICS 2014; 45.9% of children who were ever breastfed received their first feed within one hour of birth, and the median duration of exclusive breastfeeding was only 0.4 months. Only 18.6% of children aged 6-23 months in the district received the minimum acceptable diet.
The IYCF indicators were analyzed based on data collected from 270 children. A total of 248 households with children aged 0-23 months participated in the survey. There were no aberrant data, so all child information collected was included in the analysis. Figure 2 shows the breakdown of the sample size by age and gender, while Table 3 provides a summary of findings regarding IYCF.
0-5 months 39 35
6-11 months 33 34
12-17 months 35 52
18-23 months 26 16
0 10 20 30 40 50 60 70 80 90 100
Boys Girls
Figure 2: Distribution of number of children across age group and sex
6 WHO (2003); Global Strategy for Infant and Young Child Feeding Page 13 of 38
Table 3 Summary of infant and young child feeding practices
Infant and young child feeding indicators (WHO standards 2010) IYCF indicators (WHO 2010) Age (Months) n Percentage CI (95%) 1. Child ever breastfed 0-23 Months 270 98.1% 96.5-99.7 2. Timely initiation of breastfeeding 0-23 Months 270 53.7% 47.7-59.6 3. Exclusive breastfeeding under 6 months 0-5 Months 74 52.7% 41.3-64.1 4. Predominant breastfeeding under 6 months 0-5 Months 74 24.7% 14.9-34.5 5. Continued breastfeeding at 1 year 12-15 Months 75 77.3% 67.8-86.8 6. Continued breastfeeding up to 2 years 20-23 Months 29 55.2% 37.1-73.3 7. Age-appropriate breastfeeding 0-23 Months 270 58.5% 52.6-64.4 8. Introduction of solid, semi-solid, or soft foods 6-8 Months 27 59.3% 40.8-77.8 9. Milk feeding frequency for non-breastfed infants 6-23 Months 37 56.8% 49.9-63.8 10. Minimum meal frequency for breastfed children 6-23 Months 159 78.4% 72.0-84.8 11. Minimum meal frequency for non-breastfed children 6-23 Months 37 68.6% 53.6-83.5 12. Minimum dietary diversity (four or more food groups) 6-23 Months 196 29.6% 23.2-35.9 13. Minimum acceptable diet (minimum meal and 6-23 Months 196 22.4% 16.6-28.3 minimum dietary diversity) 14. Bottle-feeding 0-23 Months 270 25.6% 20.4-30.8 15. Consumption of iron-rich or iron-fortified foods (At least 6-23 Months 196 15.2% 10.2-20.3 one iron-rich food)
I. Timely initiation of breastfeeding: Early initiation of breastfeeding refers to the percentage of newborns who received breastmilk within one hour of birth; which protects the newborn from infection and reduces newborn mortality. It facilitates emotional bonding between the mother and the baby, and also has a positive impact on duration of exclusive breastfeeding. When a mother initiate’s breastfeeding within one hour after birth, production of breast milk is stimulated. According to our findings, timely initiation of breastfeeding was reported as 53.7% (53.8% in boys and 46.2% in girls), which is slightly higher than the MICS Sindh 2014 (45.9%). Nevertheless, there must be more focus on early initiation of breastfeeding to avoid health complications among infants.
Mothers initiated breastfeeding after 2 to 3 hours; some mothers even initiated breastfeeding after 2 to 3 days. Mothers were most influenced by family elders, who decided when to initiate breastfeeding after birth. In some cases, mothers who delivered in health centers or with trained medical staff initiated breastfeeding immediately while mothers who delivered at home initiated breastfeeding from 1 hour to several days. Some mothers felt that feeding colostrum was prohibited and some are preferred providing goat milk instead of breast milk.
A total of 39.7% of mothers provided other milk (animal or powdered) during the first three days of life (48.2% in boys while 51.8% girls); whereas 26.5% of children were provided with glucose water (Ghutee). These liquids are commonly provided to newborns in the community for different reasons. The community perceived these liquids as having a positive impact on child health.
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Liquids and foods given in 1st 3 days after birth
39.7% 26.5% 25.7% 40.0% 12.5% 14.7% 30.0%
20.0%
10.0% Series1 0.0% Plain water Sugar water or Powdered milk or Infant formula Others (green tea, glucose water fresh animal milk gripe water, (Ghutee) honey)
Figure 3: Liquids given in 1st three days after birth
II. Exclusive breastfeeding Exclusive breastfeeding for six months has many benefits for the infant and mother due to its protective effect against gastrointestinal infections. Survey analysis showed that 52.7% of mothers had exclusively breastfed their children (51.3% boys and 49.8% girls) who were under 6 months of age. This is substantially higher than the MICS Sindh, which indicated that 28.7% of mothers had exclusively breastfed their children under 6 months. The main challenge associated with exclusive breastfeeding was that decision-making powers were provided to the mother in law and family relatives. These relatives decided the weaning age of the child and influenced the additional foods provided before five months of age. During discussions, some mothers stated that they felt were unable to produce enough milk to feed her child three months after delivery
III. Continued breastfeeding Continued breastfeeding for one year and two years was 77.3% and 55.2%, respectively. Our findings indicated that grandmothers stressed some aspects of breastfeeding, such as continued breastfeeding up to two years. LHWs and CHWs incorporated IYCF messages in their campaigns that focused on appropriate child feeding practices.
IV. Minimum meal frequency among breastfed and non-breastfed children Minimum meal frequency was calculated for all children aged 6-23 months, disaggregated by breastfeeding status, based on the WHO standards. The standards are 2 meals per day for breastfed infants aged 6–8 months, 3 meals for breastfed children 9–23 months and 4 meals for non-breastfed children 6–23 months. Minimum meal frequency among breastfed and non-breastfed children was 78.4% and 68.6%, respectively.
V. Predominant breastfeeding under 6 months Majority of caregivers did not practice predominant breastfeeding (24.7%). Predominant breastfeeding consists of providing liquids such as Ghutee (an herbal concoction) and goat milk to infants after birth. The MICS Sindh identified that 56% of infants were predominantly breastfed; which
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is higher than the KAP findings. The low prevalence of predominant breastfeeding and exclusive breastfeeding may be a result of mothers’ limited knowledge of appropriate IYCF practices. During discussions, some mothers believed that when a baby cried it meant that he or she was thirsty and therefore should be provided with water or milk.
VI. Bottle-feeding Bottle-feeding provided in unhygienic conditions or with poor preparation of infant formula can put the infant at an increased risk for illness. Feeding an infant from a bottle with an artificial teat may also make it more difficult for the baby to learn to attach well at the breast, and has been associated with earlier cessation of breastfeeding. In Jamshoro, the proportion of children 0-23 months who were bottle-fed during the previous day was 25.3% based on MICS Sindh; while in the current survey identified 26.3% of children 0-23 months were bottle-fed.
In general, traditional practices support breastfeeding a few practices of mothers contradict it; they stop breast-feeding if they get ill or pregnant, according to a traditional understanding that continuing to breast feed in these situations may harm the infant. Due to these reasons mother adapts the bottle- feeding practices. In discussions with mothers during the survey, it was noticed that there is no privacy in hospitals, schools and public places, that is why mothers pre planned milk in bottle/ feeder during visits to those areas and until returning to home, the children are 100% relying on this technique instead of mother milk.
VII. Complementary feeding: initiation of solid, semi–solid, or soft foods Around 6 months of age, an infant’s energy needs start to exceed that which is provided by breast milk and complementary foods are necessary to meet energy and nutrient requirements. Complementary feeding is calculated as the proportion of infants aged 6–8 months who received solid, semi-solid, or soft foods. The KAP survey found 59.3% (31.3% boys and 68.7% girls) of children to have received complementary feeding. In comparison with the prevalence of complementary feeding (67.7%) in MICS Sindh, a slight decrease was identified among children from the district.
Lack of awareness about IYCF practices and poverty are the main challenges, which prevent mothers from starting complementary feeding after the child reaches 6 months of age. Due to these challenges, mothers are unable to buy appropriate additional food for their children. Most mothers start complimentary feeding around 4 months of age.
VIII. Dietary diversity Dietary diversity indicates the proportion of children who have had a minimum of 04 food groups out of the 07 food groups. Among children aged 6-59 months, only 29.6% were able to access 04 or more food groups, which was similar to the MICS results of 30.8%. The most common food items provided children were potatoes, milk, rice pudding (kheer), rice (khichri), eggs, bananas, Cerelac, tapioca (sabudana), biscuits, tea, yogurt, chapattis, and infant formula milk. Some parents fed their children the food cooked for the entire household. Due to poverty, the household meals consisted of less expensive seasonal foods. Caretaker provide sugary foods such as toffees and sweets, which decrease hunger and reduce the interest of child towards available food in the household. Diet diversity among age group (6-7 months’ children) is low as compared to other groups.
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IX. Consumption of iron-rich or iron-fortified foods: Consumption of iron-rich or iron-fortified foods was low (15.2%) among children. Lack of knowledge on the importance of iron-rich foods among mothers is the main reason for low consumption of iron-rich foods. Foods mainly consumed by children are same ones consumed by the rest of the household. Families are able to lower the amount of income spend of food by providing similar foods to children as the households,
X. Minimum acceptable diet: A minimum acceptable diet is a composite indicator reflecting the adequacy of complementary feeding practices (the proportion of children 6–23 months of age who received a minimum acceptable diet apart from breast milk during the previous day). The KAP results revealed that 22.4% of children 6-23 months of age received minimum acceptable diet. Undernutrition is common in the survey areas due to food insecurity. Widespread poverty was identified as a major cause of food insecurity; whereas some mothers reported that the recurrent droughts were the main cause of undernutrition over the last 2-3 years. Secondary causes of undernutrition identified were knowledge gaps on IYCF practices and the high prevalence of diseases in children under five. Key individuals who influenced mothers’ feeding practices were elderly family members and traditional healers. In several cases, community health workers from various organizations informed mothers on appropriate IYCF practices.
The major challenges to access information on IYCF practices were: Lack of awareness about services provided at health centers Travel costs to health centers located at large distances Limited timings of available health services Lack of family support for mothers to access ANC and PNC Family preference of least expensive treatment options
Figure 4a: Results comparison with MICS survey Sindh results
100.00% 90.00%
80.00% 99.2% 86% 70.00% 93.90%
60.00% 76%
50.00% 74.80% 64.0%
40.00% 63.30%
56.8%
59.80%
54.8% 53.9%
30.00% 49.6%
50.80%
46.7%
48.90%
44.2% 47.50% 20.00% 43.5%
10.00% 33.5%
31.40%
25.7% 1.70% 17.9% 10.7% 3.40% 1% 0.00%
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XI. Knowledge about IYCF key messages Mothers had various levels of knowledge regarding breastfeeding and complementary feeding. The key messages consisted of early initiation of breastfeeding, exclusive breastfeeding, age appropriate complementary feeding, and continued breastfeeding up to 2 years of age. These messages were provided to mothers through CHWs, family members, friends, media (radio or television), medical staff and other women in the community. Mothers recalled these IYCF messages during discussions. The frequency was calculated based on the number of messages recalled by the mothers. Overall, 53.7% of mothers were aware of any key messages 7 regarding IYCF. Table 4 illustrates the percentage of key messages recalled by mothers and the source of the key messages.
Table 4: Mothers’ knowledge about IYCF key messages Mother can recall any key messages regarding IYCF n=270 53.7% 1. Mother can recall any key messages regarding IYCF 53.7% 1.1. One key message 27.6% 1.2. Two key messages 29.7% 1.3. Three key messages 37.2% 1.4. Four key messages 2.8% 1.5. Five key messages 2.8% 2. Source of key messages (By whom these messages were delivered) n=145 2.1. CHWs 15.2% 2.2. Family members or friends 66.9% 2.3. Radio/Television 1.4% 2.4. Medical staff 12.4% 2.5. Other (community women) 4.1%
The percentage of mothers who remembered and recalled at least one key message was 53.7%. A decreasing trend was observed between maternal recall and the number of key messages, which indicates that more messages were difficult to remember. The most common source of key messages was family members or friends, while the media (radio/television) was the least common source. Figure 4: Knowledge of mothers regarding infant and young child feeding Knowledge of IYCF Key messages
5 Message 2.8
4 Message 2.8
3 Message 37.2
2 Message 29.7
1 Message 27.6
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0
7 Key messages were (1)Early initiation of BF, (2) Exclusive Breast Feeding, (3) Age appropriate CF, (4) Continuous BF up to 2 years (5) If any key message from IYCF core indicators Page 18 of 38
XII.Knowledge about colostrum and pregnant/lactating women’s health care-seeking behavior There were varying community perceptions toward colostrum, which is considered as an important source of nutrition and immune protection for the newborn. Table 5 describes community perceptions and practices regarding colostrum, and care-seeking behaviors. Table 5: Knowledge about colostrum and pregnant/lactating women’s health care-seeking behavior Community perceptions and practices regarding colostrum, liquids introduction in the first three days after birth, and health care-seeking behavior 1. Colostrum (mother’s first milk) n=270 1.1. Colostrum given to child 76.7% 1.2. Colostrum not given to child 23.3 % 2. Reasons for not giving colostrum n=63 2.1. Considered “bad milk” 55.6% 2.2. Mother or child was ill 14.3% 2.3. Family traditions 14.3% 2.4. No breast milk 12.7% 3. Percentage of mothers who stopped breast feeding and reasons n=34 12.8% 3.1. Became pregnant 35.3% 3.2. Mother or child was ill 41.2% 3.3. Child reached the weaning age 8.8% 3.4. Child refused to feed 17.6% 4. Care-seeking behavior of pregnant and lactating mothers n=270 4.1. CHWs/LHWs 2.8% 4.2. Traditional treatment 48.9% 4.3. Doctors in hospitals (government or private) 36.7% 4.4. Other (family members, grandparents) 5.6% 4.5. No idea to consult anyone 6.3%
Based on information collected on the introduction of liquids in the first three days of life and care- seeking behaviors, 76.7% of mothers fed colostrum to their infants and 23.3% mothers did not feed colostrum to their infants. Of the women who chose not to provide colostrum, 55.6% stated that colostrum is “bad milk”, which will cause stomach infection due to the thickness. Mothers also indicated that bottle-feeding was the most convenient way to feed their child. The most common reason for stopping breastfeeding was the mother or child was ill (41.2%), followed by the mother becoming pregnant again (35.3%) and the child refusing to feed (17.6%). When seeking care, 48.9% of mothers sought traditional treatment, which may indicate limited access to medical facilities because of financial, social, and/or traditional constraints.
5.2 Water and Sanitation Access to improved water supply and sanitation facilities is a major public health intervention, which prevents morbidity, particularly diarrhea. Research has shown that improved water sources reduced diarrhea morbidity by 21%; improved sanitation reduced diarrhea morbidity by 37.5%; and the act of handwashing at critical times reduced the number of diarrhea cases by as much as 35%8. According to MICS 2014, 90.5% of households in Sindh have access to an improved source of drinking water, while 38.8% of households consumed drinking water contaminated with E. coli. Moreover, 53.6% of households drank water from sources contaminated with total coliforms
8 http://www.cdc.gov/healthywater/global/wash_statistics.html Page 19 of 38
(including E. coli as well as other coliforms). In Sindh, 72.9% of the population lives in households with improved sanitation facilities; however, this percentage reduced to 47.7% when only the rural population was considered. MICS Sindh also showed that 28.4% of children under five years had had an episode of diarrhea in the preceding two weeks.
I.Main Source of Water The main source of water for 27.4% of the population was the government water supply. Most participants’ (52%) main source of water was available inside their home, whereas 21.3% fetched their water from sources available under 15 minutes. Often, households living as a joint family relied on one water source accessible within 15 minutes. Some households (11.6%) relied on a water source located within 30 to 45 minutes and 11.2% relied on a source located at an hour or more and 3.6% relied on a source within two or more hours. Based on the MICS Sindh, a higher proportion of families living in Jamshoro (73.7%) reported that their water source was located on their premises. Table 6: Main source of water and related information 1. Main sources of water n=248 1.1. Public borehole with hand pump 17.3% 1.2. Private borehole with hand pump 24.1% 1.3 Water supply scheme 27.4% 1.4. Surface water source 8.8% 1.5. Open well 6.0% 1.6. Tanker 12.9% 1.7. Motor pump 1.6% 1.8. Tube well 1.2% 1.9. Other (water tank) 0.4% 2. Distance to main source of water n=248 2.1. Inside house 52.0% 2.2. <15 min 21.3% 2.3. 30-45 min 11.6% 2.4. >1 hour 11.2% 2.5. >2 hours 3.6% 3. People responsible for fetching water n=248 3.1. Adult women 76.2% 3.2. Adult men 12.5% 3.3. Girls 0.8% 3.4. Boys 3.6% 3.5. Adults (both men and women) 6.4% 3.6. Children (both girls and boys) 0.4%
Water supply schemes and private boreholes with hand pumps were the main source of drinking water, but people felt that the water was contaminated and caused various diseases. Other sources of water included hand pumps (boreholes), water tankers, wells, rivers, and water filtration plants. A major challenge for households was the distance to the main water source. Adult women (76.2%) within the community had the main responsibility of fetching water for the household. Often, women continued to fetch water even during their third trimester of pregnancy. Due to lack of resources and poverty, community members faced barriers such as transportation of water and inability to pay for water tankers.
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Distance to main source of water Responsible family members for fetching water 52.00% 76.2%
21.30% 12.5% 0.8% 3.6% 6.4% 0.4%
11.60% 11.20% Adult Adult Child GirlsChild Boys Adults Children 3.60% women men (both (both girls men and and boys) Inside house <15 min 30-45 min >1 hour >2 hours women) Figure 5: Distance to main source of water/responsible family members for fetching water
II.Water Quality and Treatment The majority of participants (86.9%) had not conducted a water quality test (Table 7). A total of 64.9% of participants felt that their water was safe for drinking and 32.2% thought that their water was not safe. Among the participants who deemed their water unsafe, 83.7% gave the reason that the water seemed dirty. Most community members did not treat their water, even though they knew that the water quality was not good due to the smell or bad taste. Overall, 37.5% of participants stated that they treated their drinking water; the main water treatment method used was filtration at the household level with a cloth (56.9%) because it is inexpensive. In some households, however, the cloth used for filtration was observed to be unhygienic. Although filtrating by cloth and waiting for water to settle down is principally not considered a water treatment method. However, this method did remove physical contaminants from water. Moreover, some households boiled their water (12%) and others used alum (11%) to treat their drinking water (Figure 7). Table 7: Water quality and testing 1. Water quality testing n=248 1.1. Tested 8.6% 1.2. Not tested 86.9% 1.3. No idea 2.4% 2. Community awareness about water quality n=248 2.1. Perception that water is safe for drinking 64.9% 2.2. Perception that water is not safe for drinking 32.2% How participant knows that water is not safe*9 n=80 a. Seems dirty 83.7% b. Smells bad 3.5% c. Tastes bad 40.% d. Cause of sickness 12.5% e. Salty water 1.2% f. No idea 2.8%
9 Multi-answers were received from some households Page 21 of 38
Fitki (Alum) n: 248 11% Water treatment
Arsenic water filters Boiling 12% 18%
Use chlorination tablets for water treatment… Filtration at HH level with cloth Wait for the dirt to 57% settle 1%
Figure 6: Water treatment methods locally used
III.Protected Latrine Use An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. Improved sanitation facilities for excreta disposal include flush or pour flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrine, pit latrine with slab, and use of a composting toilet. More than half of the participating households (53.6%) did not use protected latrines. Among households where a protected latrine was available by not used, the main reasons given for open defecation were overload in households and insufficient water availability. Table 8: Protected toilet use 1. Use of protected latrine n=248 1.1. Using protected latrine 46.3% 1.2. Not using protected latrine 53.6% 2. Practice if protected latrine is not available n=133 2.1. Open defecation 95.1% 2.2. Using the compound 4.3% 2.3. Pit latrine 0.6% 3. Latrine type (among participants using a protected latrine)10 n=133 3.1. Household 80.3% 3.2. Shared 19.7%
10 They include flush/pour flush (to piped sewer system, septic tank, pit latrine), ventilated improved pit (VIP) latrine, pit latrine with slab, and composting toilet. Page 22 of 38
4. Benefits of using a latrine n=248 4.1. Privacy of family members 73.3% 4.2. Disease prevention 27.8% 4.3. Protection from insects 8.8% 4.4. Close to home 28.6% 4.5. Clean (hygienic) 24.1% 4.6. Don’t know 4.4% *Some participants mentioned two or more benefits
Among 46% of households who used protected toilets, 19.7% of them used a shared or communal toilet. In shared toilets, there may be a lack of water and the presence of unhygienic conditions, which may lead to waterborne diseases. When discussing the benefits of using a protected toilet, the participants identified improved privacy (73.3) and lower risk of waterborne diseases (27.8%).
IV.Stool Disposal The main practice used for stool disposal was to throw it into the garbage (56%). The main practice used to dispose of solid waste was to throw it far from the house (67.7%). Some mothers stated that they left the infant on the ground in order to practice open defecation after which the stool was disposed. Table 9 shows the different stool disposal practices in Jamshoro. Table 9: Stool disposal practices
1. Disposal of stools (What was done with the stool of the youngest child) n=248 1.1. Child used toilet/latrine 6.4% 1.2. Put/rinsed stool into toilet or latrine 20.5% 1.3. Put/rinsed stool into drain or ditch 5.2% 1.4. Threw stool into garbage 56.0% 1.5. Left stool in an open space 9.6% 1.6. Buried stool 0.8% 1.7. Others 1.2% 2. Disposal of solid waste n=248 2.1. Dump wastes close to house 28.2% 2.2. Dump wastes far from house 67.7% 2.3. Bury wastes 2.0% 2.4. Nothing 2.0%
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STOOL DISPOSAL PRACTICES
1.2% 0.8% 9.6% 56.0% 5.2% 20.5% 6.4%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Others Buried stool Left stool in an open space Threw stool into garbage Put/rinsed stool into drain or ditch Put/rinsed stool into toilet or latrine Child used toilet/latrine
Figure 7: Stool disposal practices
V.Handwashing Majority of participating households (83.6%) had a designated handwashing location, with 73.9% of these households using water and soap or ash. Only 16.4% of households did not have a designated handwashing location. In addition, the hygienic conditions of these designated areas were often poor. Table 10: Handwashing location and material 1. Designated handwashing location n=248 1.1. Handwashing space designated 83.6% 1.2. No handwashing space designated 16.4% 2. Availability of water and soap/ash in designated location n=115 2.1. Available 73.9% 2.2. Not available 26.1% 3. Handwashing with n=115 3.1. Water only 55.6% 3.2. Water and soap 40.7% 3.3. Water and ash/soil 2.4% 3.4. Washing powder 1.2%
Households mentioned washing their hands before and after eating (70.1%), before making food (55.2%), after domestic work (55.2%), after handling human or animal feces (13.7%), before feeding their child (18.9%), and after using the latrine (56.8%). The most important timings after which handwashing should be practiced are handling human or animal feces and before feeding a child; however within the community handwashing after these timings were very low (Figure 9). Figure 8: Handwashing timings
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Hand Washing timings
After using the latrine 56.8%
Before child feeding 18.9%
After handling human/ animal feces 13.7%
After domestic work 55.2%
Before making food 55.2%
Before eating 70.1%
VI.Waste Water Drainage System Sanitation systems were observed to be in worse conditions in the district. In some households, there was standing water because of no proper drainage system. More than half (63.7%) of the community drained wastewater into the open or outside the home. This is a poor method for water drainage, which can lead to an increase in disease prevalence.
Table 11: Wastewater drainage system 5.2 Waste water drainage system n=248 1. Just flow open in and outside home 63.7% 2. Drained outside home through culvert in open 10.5% 3. Drained outside home through culvert into bigger culvert 10.9% 4. Drained outside home through drain pipe into open 7.3% 5. Drained outside home through drain pipe into bigger culvert or drain pipe 3.6% 6. Drain outside home through drain pipe into ground septic tank 1.6% 7. Other 2.4%
5.3 MORBIDITY
Waterborne diseases are caused by pathogenic microbes, which can directly spread through contaminated water. Most waterborne diseases cause diarrheal illnesses. In general, 88% of diarrhea cases worldwide are linked to unsafe water, inadequate sanitation or insufficient hygiene11. These cases result in a high volume of deaths each year, mostly in young children. The usual cause of death is dehydration. Most cases of diarrheal illness and death occur in vulnerable or poor communities because of unsafe water, poor sanitation, and insufficient hygiene.
Information was collected about morbidity prevalence in the past two-week period from households, and data for diarrhea was collected from children under five years. The most commonly reported illnesses were fever, ARI, cough, and diarrhea. The high prevalence of ARI, cough and fever may be due to the prolonged cold dry weather in the region. In the region of Jamshoro, there has been no rain since September 2016.
11 World Health Organization; Safer Water, Better Health: by Annette Prüss-Üstün, Robert Bos, Fiona Gore, Jamie Bartram Page 25 of 38
Table 12: Morbidity and expenditures 1. Diseases in HH members (last two weeks’ recall) n=248 1.1. ARI, cough, fever 80.2% 1.2. Diarrhea** 45.1% 1.3. Malaria 4.0% 1.4. Skin diseases 2.8% 1.5. Others* 3.6% 2. Number of children under five in one household who had had diarrhea 41.5% 2.1. One child with diarrhea 63.1% 2.2. Two children with diarrhea 28.1% 2.3. Three children with diarrhea 7.8% 2.4. More than three children with diarrhea 0.9% 3. Expenses on treatment of waterborne disease (PKR) 3.1. < 1000 38.7% 3.2. 1000 – 2000 12.0% 3.3. 2000 – 3000 10.8% 3.4. More than 3000 3.2% 3.5. Nothing 35.0% * TB, abdominal pain, diabetes, asthma, vomiting, hepatitis C ** 3 or more watery stools passed in 24 hours
Poor water treatment practices were observed in 63.5% of households, which may lead to high prevalence of diarrhea in the community. Although there was awareness about waterborne diseases caused by contaminated water in the community, only a small number of households treated their drinking water. If family migrates from their native place for more than a month, water treatment is rarely practiced by them. Water was only boiled for child who suffered with diarrhea as per the medical practitioner’s recommendations.
Waterborne diseases in Household
Others 3.6%
Skin diseases 2.8%
Malaria 4.0%
Diarrhea** 45.1%
ARI, cough, fever 80.2%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%
Figure 9: Waterborne diseases in households
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5.4 Food Security Jamshoro is considered a “high drought area” (SDNA 2016) and is subject to increasingly prolonged and frequent droughts. The current drought began in 2013, with leaner monsoons; it has caused significant reductions in the yield and cultivation in the district. Due to the drought, farmers reported a 29% reduction in wheat production and a loss of 44% of buffalos and 52% of small ruminants. According to the Sindh Drought Needs Assessment (SDNA) 2016, 90% of households in the western zone, which includes Jamshoro, experienced the highest severity of drought. In December 2014, the district was classified as “highly food insecure (crisis)” according to FAO’s Integrated Food Security Phase Classification (IPC). The IPC also designated district outlook as “likely to deteriorate” with regard to its food security status.
I.Household dietary diversity score (HDDS) The HDDS is based on the number of different food groups consumed by the head of household or any household members in the past 24 hours. The set of 12 food groups are derived from the U.N. Food & Agriculture Organization (FAO). The HDDS ranges from 0 to 12, with lower numbers indicating less dietary diversity. Although the HDDS gives an indication of food groups consumed in the household in the last 24 hours, it serves as a proxy for socioeconomic status. The following set of 12 food groups were used to calculate the HDDS.
I. Cereals (Porridge bread, rice noodles/, or other foods made from grains) II. Roots and tubers (White potatoes, yams, radish, or any other foods made from roots) III. Pulses/legumes/nuts (Any foods made from beans, peas, lentils, nuts, or seeds) IV. Vegetables and leaves (Any dark green leafy vegetables) V. Fruits (Ripe mangoes, ripe papayas lemons) VI. Meat, poultry (Any meat such as beef, lamb, goat, chicken, or duck) VII. Fish and seafood (Fresh or dried fish, shellfish, or seafood) VIII. Milk/Dairy products (Cheese, yogurt, Milk or other milk products) IX. Eggs X. Sugar, sugar products, honey XI. Oil/fats (Foods made with red palm oil, red palm nut, or red palm nut pulp sauce) XII. Condiments (spices, tea, coffee) or other miscellaneous food
The overall HDDS score recorded for the HHs was 5.26, which indicated that, on average, each household consumed 5 of the 12 food groups. This indicated that households had moderate access to diverse foods. Moreover, 44% of the HHs fell in the high dietary diversity scale, meaning these HHs consumed 6 or more different food groups in last 24 hours. Another 38% HHs fell under the medium diversity scale, indicating that these HHs consumed between 4 to 5 different food groups. Only 19% of HHs fell under the low dietary diversity scale, meaning that they consumed in between 0 and 3 different food groups. Table 13: Household Dietary Diversity 9.1. Household diet diversity score n=248 Overall HDDS 5.26 (CI 5.0-5.5) Criteria Categories 1. ( 0-3) Low dietary diversity 19% 2. ( 4-5) Medium dietary diversity 38% 3. ( 6 or above) High dietary diversity 44%
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Figure 10: HDDS
Low dietary diversity …
19% Medium dietary diversity (From 4-5), 38%
High dietary diversity (From 6 and above) , 44%
As reported by the respondents, cereals (90%), roots and tubers (81%), oil/fats (54%), milk and milk products (45%), and pulses/legumes/nuts (44%) were the most commonly consumed foods, along with those in the miscellaneous category, such as coffee, tea, bouillon and spices (75%). Fruits (14%), fish and seafood (13%), meat and poultry (16%), and eggs (32%) were consumed least frequently.
Figure 11: Foods eaten by household members
Fruits 5% Fish and seafood 13% Meat, poultry, offal 16% Eggs 32% Sugar/honey 35% Vegetables 37% Pulses/legumes/nuts 44% Milk and milk products 45% Oil/fats 54% Condiments 75% Root and tubers 81% Cereals 90% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
XIII.Household Reduced Coping Strategy Index (rCSI) The reduced CSI was developed to compare food security across different contexts. It is a sub-set of the context-specific CSI, but is calculated using a specific set of behaviors with a universal set of severity weightings for each behavior. Thus, the reduced CSI uses a standard set of five individual coping behaviors that employed by any household, anywhere. The five standard coping strategies and their severity weightings are:
I.Eating less-preferred foods (1.0), II.Borrowing food/money from friends and relatives (2.0), III.Limiting portions at mealtime (1.0), IV.Limiting adult intake (3.0), and Page 28 of 38
V.Reducing the number of meals per day (1.0).
Overall, 88% of the respondents reported that they chose one or more coping strategies in last seven days. The most commonly used coping strategies were “rely on less preferred and less expensive food” followed by “borrow food or rely on helps from friends or relatives”.
Table 14: Reduced Coping Strategy Index 10. Overall Reduced Copying Strategy score n=248 17.75 (CI 16.1-19.4) (rSCI) 10.1. Rely on less preferred and less expensive foods 75% 10.2. Borrow food or rely on help from friends or relatives 72% 10.3. Limit portion size at mealtime 46% 10.4. Restrict consumption by adults in order for small children to eat 42% 10.5. Reduce number of meals eaten in a day 38% 10-a. Number coping strategies adopted by each household n=187 88% HH adopted one strategy 19% HH adopted two strategies 20% HH adopted three strategies 10% HH adopted four strategies 13% HH adopted five strategies 27%
Figure 12: Coping Strategy Score The most used coping strategy was “less-preferred and less expensive foods” (75%). Furthermore, 72% relied on “borrowing food/money from friends and relatives”, 46% “limited portion sizes at mealtime”, 38% relied on “reduced number of meals eaten in a day” and 42% “restricted consumption by adults in order for small children to eat”.
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Reduce number of meals eaten in a day 38%
Restrict consumption by adults in order for small 42% children to eat
Limit portion size at mealtime 46%
Borrow food or rely on help from friends or relatives 72%
Rely on less preferred and less expensive foods 75%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Figure 13: Type of coping strategy adapted by households From the households that adopted coping strategies, 19% adopted one strategy (any one from the stated five), 20% adopted two strategies (any two from the stated five), 10% adopted three strategies, 13% adopted four strategies and 27% adopted five strategies.
5 CSs adopted 27%
4 CSs adopted 13%
3 CSs adopted 10%
2 CSs adopted 20%
1 CS adopted 19%
No CS adopted 12%
0% 5% 10% 15% 20% 25% 30%
Figure 14: Proportion of households that adopted one or more rCSI
6. Conclusion
The KAP survey revealed that practices related to IYCF, WASH, and FSL are not satisfactory and the community in the targeted district is lacking awareness about the best practices. There was a common myth in the community that mothers do not have enough breast milk to feed their children without knowing any reasons. There were a certain number of mothers who believed that the colostrum was not good for newborns and therefore they discarded their colostrum before starting breastfeeding. The traditional way of giving liquids (green tea, gripe water, honey and “ghuti”) immediately after the birth was also common in the community. In addition, the use of formula milk was common due to the encouragement of general practitioners. All the common myths and practices contributed towards the low practices of breastfeeding. Decision-making was another cause of the low prevalence of breastfeeding since the main decision makers in the family are mostly grandmothers and elders. Other significant observations revealed during the survey were the low dietary diversity of food intake, and food provided to children 6-23 months was not rich in
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micronutrients. During pregnancy, women in the district did not seek antenatal care or received improper antenatal care. PLWs were also unable to seek care or consult relevant health care providers as they were engaged with domestic responsibilities, including fetching water for the family, taking care of the other family members and other domestic work.
In Jamshoro, lack of family planning and birth spacing awareness among women and adolescents, and decision-making by the husband and grandmother results in multiple pregnancies within a short span of time. The multiple pregnancies ultimately affect the IYCF practices of children.
Availability of safe drinking water was another problem faced by the community. Although, they have water sources available, purification methods were lacking due to limited knowledge and available resources. Poor sanitation practices like open defecation was very common and handwashing awareness was almost absent in the community, contributing to the increase in malnutrition and disease prevalence. The overall household dietary diversity score was between low and medium, which could further deteriorate due to prevailing drought situation in the district.
7. Recommendations
Nutrition sensitive programming needs to be ensure in the district. The dietary diversity and minimum acceptable diet is very low. Further effort should be made in the new projects to improve the dietary diversity and minimum acceptable diet by considering livelihood diversification strategies. IYCF knowledge and practices improvement programs, practical exercises need to be initiated for nutrition education. It is vital that the staff animating the session fully master the package and behavior change in community techniques (interactive session) Attention should be given to reducing bottle feeding by incorporating and focusing on the disadvantages of bottle feeding as part of the behavioral change communication (BCC) strategy. It is essential to do a further barrier analysis to identify the reasons for the poor practices (like bottle feeding, inappropriate feeding during pregnancy etc.). Support the scaling up of maternal and child health services at health centers to increase utilization by mothers and children. It is recommended to engage all the household members in IYCF and Hygiene practices promoting activities to ensure the effectiveness Supplementation of PLW and children aged 6-23 months with MM tablets and sachets, making these products available at health centers to encourage utilization. Water, Sanitation and Hygiene programs should be implemented in the district To establish and rigors surveillance system need to be ensured for early disease trends and outbreaks Improve coordination among different health and social safety net programs
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Annex I: Sampled clusters list for district Jamshoro Number UC Village Name Cluster 1 Petaro Wawan Bada 4 2 A. B. Shoro Dhani Bux Khoso 5 3 A. B. Shoro Labour Colony A 6 4 Sonwalhar-2 Khuda Ji Basti 8 5 Sonwalhar-1 Bhittai Collony 10 6 Sonwalhar-1 Essa Dal 11 7 Sonwalhar-2 Sikander Abad Colony 7 8 Amri Faqeero Khaskheli 37 9 Moro Jabal Detharo Burfat 30 10 Moro Jabal Abdullah Chawera 31 11 Sari Ali Murad Barijo 29 12 Sehwan-1 Ghul Mohammad Shah 41 13 Sehwan-1 Pir Pota Mohalla 42 14 Sonwalhar-1 Mohammad Khan Shoro 9 15 Sonwalhar-3 Shoro Village 12 16 Sonwalhar Khurshed Colony One 13 17 Sonwalhar-3 SUECH Society Jamshoro 14 18 Petaro Manjho 25 19 Manzoor Abad Khanot 1 20 Manzoor Abad Indus Wapda Collony 2 21 Manzoor Abad Sukhioyo Khoso 3 22 Manjhand Budha Pur 15 23 Manjhand Maiyan Dad 1+2 Rajri 16 24 Mole Motan Khan Hamlani 40 25 Lakha Hazar Khan 17 26 Sann Qubbi 18 27 Lakha Ghulam Hajano 19 28 Sann Jumo Khoso 20 29 Channa Baghrani Panhwar 21 30 Channa Karam Pur 22 31 T. Bula Khan Abdullah Khan 34 32 T. Arab Khan Ghul Bahar Khoso 43 33 T. Arab Khan Umaid Ali Shahani 44 34 Toung Ayoub Barecho 45 35 T. Bula Khan Thano Bula Khan City 32,33 36 Bhan Mohammad Ashraf Rodhrani 2 23 37 Bhan Bhan Ward No. 3 24 38 Dall Rabdino Gambhir 27 39 Bubak Moula Bux Mallah 35 40 Talti Bhoral Jatoi 38 41 Talti Daryai 39 42 Jhanghara Kai 26 Page 32 of 38
43 Jhanghara Bhandhni 28 44 Amri Kalri 36
Annex II. Key indicators used to measure IYCF practices for children aged 0-23 months12
IYCF Indicators (WHO Guidelines 2010) 1 Timely initiation of breastfeeding 2 Exclusive breastfeeding under 6 months 3 Continued breastfeeding at 1 year 4 Age appropriate complimentary feeding 5 Minimum dietary diversity 6 Minimum meal frequency (breastfed children) 7 Minimum meal frequency (non-breastfed children) 8 Minimum acceptable diet 9 Consumption of iron-rich or iron-fortified foods 10 Children ever breastfed 11 Continued breastfeeding at 2 years 12 Age-appropriate breastfeeding 13 Predominant breastfeeding under 6 months 14 Milk feeding frequency for non-breastfed children 15 Bottle feeding
I.Timely initiation of breastfeeding: Proportion of children born in the last 24 months and still alive who were put to the breast within one hour of birth out of all children born in the last 24 months and still alive II.Exclusive breastfeeding under six months: Proportion of infants aged 0-5 months who are fed exclusively with breast milk; infants aged 0-5 months of age who received only breast milk during the previous 24 hours / infants aged 0-5 months III.Continued breastfeeding at one year: Proportion of children aged 12-15 months who are fed breast milk; children aged 12-15 months who received breast milk during the previous 24 hours / children aged 12-15 months IV.Introduction of solid, semi-solid, or soft foods: Proportion of infants aged 6-8 months who received solid, semi-solid, or soft foods; infants aged 6-8 months who received solid, semi- solid, or soft foods during the previous 24 hours / infants aged 6-8 months. Timely complementary feeding measures the proportion of children aged 6-9 months who received breast milk and consumed solid, semi-solid, or soft foods at least once in the past 24 hours. V.Minimum dietary diversity: Individual dietary diversity scores (IDDS) are derived from information on foods consumed by children aged 6-24 months in the past 24 hours. This score is based on the 17 food groups shown in the table below. These food groups are amalgamated to form 7 food groups for measuring individual dietary diversity score (IDDS). The IDDS is used as a proxy measure of the nutritional quality of an individual’s diet. It is considered that minimum dietary diversity is reached when the individual has consumed food from four or more of the seven food groups. Minimum dietary diversity measures the proportion of children aged 6-23 months who consumed foods from four or more of the food groups; children aged 6-23 months who received foods from four or more of the seven food groups during the previous 24 hours / children aged 6-23 months. The seven food groups are:
12 WHO 2010 guidelines Page 33 of 38
a. Grains, roots, and tubers b. Legumes and nuts c. Dairy products (milk, yogurt, cheese) d. Flesh foods (meat, fish, poultry, liver/organ meats) e. Eggs f. Vitamin A-rich fruits and vegetables g. Other fruits and vegetables
Number Food group 1 Bread, rice, noodles, or other foods made from grains, including thick grain-based porridge. 2 White potatoes, white yams, manioc, cassava, or any other foods made from roots 3 Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside 4 Any food made from beans, peas, lentils or nuts, including PlumpyNut 5 Any dark green leafy vegetables 6 Ripe mangoes, ripe papayas, or (insert other local vitamin A-rich fruits) 7 Any other fruits or vegetables 8 Liver, kidney, heart, or other organ meats 9 Any meat such as beef, pork, lamb, goat, chicken, or duck 10 Fresh or dried fish, shellfish, or seafood 11 Grubs, snails, or insects 12 Eggs 13 Cheese, yogurt, or other milk products 14 Any oil, fats, or butter; or foods made with any of these 15 Foods made with red palm oil, red palm nut, and red palm nut pulp sauce 16 Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits 17 Condiments for flavor such as chilies, spices, herbs, or fish powder
VI. Minimum meal frequency 1. Breastfed children: Proportion of breastfed children aged 6-23 months who receive solid, semi-solid, or soft foods the minimum number of times or more; breastfed children aged 6- 23 months who received solid, semi-solid, or soft foods the minimum number of times or more during the previous 24 hours / breastfed children aged 6-23 months 2. Non-breastfed children: proportion of non-breastfed children aged 6-23 months who received solid, semi-solid, or soft foods (also including milk feeds) the minimum number of times or more; non-breastfed children aged 6-23 months who received solid, semi-solid, or soft foods or milk feeds the minimum number of times or more during the previous 24 hours / non-breastfed children aged 6-23 months Minimum is defined as: 1. 2 times for breastfed infants aged 6-8 months 2. 3 times for breastfed children aged 9-23 months 3. 4 times for non-breastfed children aged 6-23 months 4. A “meal” includes both meals and snacks (other than trivial amounts), and frequency is based on caregiver report VII.Minimum acceptable diet: Proportion of children aged 6-23 months who receive a minimum acceptable diet (apart from breast milk). This indicator is composite and is calculated from the following two fractions: Breastfed children aged 6-23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day / breastfed children aged 6-23 months And Non-breastfed children aged 6-23 months who received at least two milk feedings and had at least the minimum dietary diversity (not including milk feeds) and the minimum meal frequency during the previous day / non-breastfed children aged 6-23 months
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VIII.Consumption of iron-rich or iron-fortified foods: Proportion of children aged 6-23 months who received an iron-rich or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home IX.Child ever breastfed: Proportion of children born in the last 24 months who were ever breastfed; children born in the last 24 months who were ever breastfed / children born in the last 24 months X.Continued breastfeeding at two years: Proportion of children aged 20-23 months who are fed breast milk; children 20-23 months of age who received breast milk during the previous 24 hours / children 20-23 months of age XI.Age-appropriate breastfeeding: Proportion of children aged 0-23 months who are appropriately breastfed; this indicator is calculated using the following two fractions: Infants aged 0-5 months who received only breast milk during the previous 24 hours / infants aged 0-5 months And Children aged 6-23 months who received breast milk as well as solid, semi-solid, or soft foods during the previous 24 hours / children aged 6-23 months XII.Predominant breastfeeding under six months: Proportion of children aged 0-5 months who were predominantly breastfed in the previous 24 hours. Predominant breastfeeding allows ORS, vitamin and/or mineral supplements, ritual fluids, water and water-based drinks, and fruit juice. Other liquids, including non-human milks and food-based fluids, are not allowed, and no semi-solid or solid foods are allowed XIII.Milk feeding frequency for non-breastfed children: Proportion of non-breastfed children aged 6-23 months who received at least two milk feedings in the previous 24 hours XIV.Bottle-feeding: Proportion of children aged 0-23 months who were fed from a bottle in the previous 24 hours
Annex III: Survey team structure
Survey manager M&E Coordinator,Data Analyst
Team Leader Team Leader Enumerator-1 Enumerator-1 Enumerator-2 Enumerator-2
Team Leader Team Leader Enumerator-1 Enumerator-1 Enumerator-2 Enumerator-2
Team Leader Team Leader Enumerator-1 Enumerator-1 Enumerator-2 Enumerator-2
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Annex IV: Focus group discussion guide for IYCF
UC ______Village Name ______Cluster No _____ Team No ___ Date: __ /_11_ / 2016
(Kindly Use these questions as a guideline in focus group discussion, probe the community group for more and more information)
a) Include minimum 8 persons or more b) Don’t ask questions from only one persons
I.What are the traditional beliefs that prevent mothers to exclusively breastfeed their baby for the first 6 months? وه کون سے عالقائى رسم و رواج ہىں جو بچے کو مسلسل 6 ماه تک صرف ماں کا دودھ پالنے سے روکتے ہىں؟
II.What is the traditional belief concerning initiation, frequency and duration of breastfeeding (Initiation –traditionally when do they start, Frequency – how many times per day is recommended, Duration – when should the child stop breast milk)
III.What are the major problems that prevent you from starting complementary/additional food for your baby after 6 months of age?
IV.For how long do mothers continue to breastfeed their babies in your community?
V.In this community, what types of foods do you give to children 6 months to 2 years in addition to breast milk?
.Do the complementary foods vary every day/every other day/every week or do not vary at all
VI.How often do mothers cook/prepare food for babies’ age 6-23 months? How do mothers know how much food to give a baby? How often are young infants fed in a day?
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VII.What are the foods that are prohibited for children of age 0-6 months; age 6-12 months; age 12- 24 months? and what happens if child consumes these food? 0-6 ماه: 6-12ماه 12-24 ماه:
VIII.Is malnutrition common in this district? If yes, what is the cause (probe for food insecurity, knowledge gap, diseases, etc)
IX.Who are the key persons and institutions who influenced your infant and child feeding practices? (probe for: father of the baby, biological mother, mother–in-law, grandmother, health workers, LHW, religious leader) and why
X.What are the main problems you face in getting information about child care and feeding practices?
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Annex V: Focus group discussion guide for WASH and food security
UC ______Village Name ______Cluster No ______Team No ______Date: ___/___/______
(Kindly Use these questions as a guideline in focal group discussion, and probe the community group for more and more information)
a) Include minimum 8 persons or more b) Don’t ask questions from only one persons
I.What are the main sources of drinking and domestic water in your community?
II.What are the main challenges community are facing for collecting water, mainly who is responsible for collecting water?
III.What are the common practices in community to treat water for drinking?
IV.Please specify main defecation practices in community, and what are the common reasons that people are doing open defecation?
V.What are the main income sources of the community?
VI.Did the community aware about Water related diseases? What are these? Who are the key persons for dissemination of its awareness?
VII.What are the main occupations, the village residents are involved in?
VIII.What are the main crops cultivated?
IX.What percent of the land in this village is cultivated during the last year? (Estimation)
HH survey not attached due to length of the questionnaire i Members of households eating from one pot ii Members of households eating from one pot
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