Food Security Survey in Supplementary Feeding Center Caretakers –

Kurgan Teppe and Kulyab zones, of

August/September 2005

Acknowledgements

Action Against Hunger (AAH) would like to thank all the people who helped make this survey possible. In particular, we would like to extend our gratitude to the caregivers who participated actively in this survey.

1. Executive summary

1.1. AAH background

Action Against Hunger has been implementing integrated programs in Tajikistan since 1998. The targeted region is Khatlon Oblast, which has the highest rates of poverty, food insecurity, migration and female- headed households in the country.

With very limited food supplies and low incomes, all segments of Tajikistan’s population were estimated to consume nutritionally inadequate diets in 2001. This situation is expected to persist over the next decade1. As a consequence, Action Against Hunger has been working to improve the food security of the most vulnerable households through the implementation of various programs: health and nutrition programs focus on the immediate causes of malnutrition in children between 6 and 59 months through detection and treatment activities, whereas food security and irrigation / water sanitation programs were focus on the prevention of malnutrition by targeting the underlying causes.

According to the National Nutrition Survey 2003 (NNS 03), conducted by a consortium of NGOs with the lead of Action Against Hunger, the Global Acute Malnutrition (GAM) rate in Kulyab zones was 7.1% and the Severe Acute Malnutrition (SAM) rate was 1.4%. In 2004 the NNS showed an increase in the number of malnourished children, with a 9.9% GAM rate and a 1.6% SAM rate in Kulyab area2. In the Kurgan Teppe zone the NNS 03 showed a GAM rate of 5.4% and a SAM of 0.9%. The following year, the NNS indicated a GAM of 11.1% and a SAM of 3.1%.

The goal of this survey, conducted among Supplementary Feeding Centers (SFC) caregivers, is two- fold: on the one hand to better understand the underlying causes for the persisting high rates of malnutrition with a view to adapt AAH programs accordingly, and on the other hand to establish a base-line profile of SFC caretakers for future food security activities.

Supplementary feeding centers are designed to provide moderately malnourished patients with a food supplementation corresponding to their physiological needs3 This supplementation is given either as wet rations (ready-to-eat) or dry rations (take home). In the case of dry rations, nutritional values are doubled to allow for the fact that they will probably be shared with the family.

In Tajikistan AAH distributes dry rations in SFCs spread over 14 districts within Khatlon Oblast. The dry ration consists of porridge (wheat flour, oil, and sugar) which the beneficiaries cook at home. Caregivers come with their malnourished child once a week to the SFC, at which point the children have their anthropometrical measurements taken and receive vitamin A, folic acid, iron supplementation, as well as their porridge ration. Such visits ensure that a clear picture of their evolution within the program is available. Health education is also a very important part of each SFC visit.

The admission into the SFC program is based on the following criteria:

Children from 6 to 59 months W-H index between 70 % and 79 % of the median and/or MUAC between 110 and 119 mm Table 1: Criteria of Admission to SFC Program

1.2. Main findings

Family information

¾ The survey revealed that 89% and 90% (Kurgan Teppe zone and Kulyab zone respectively) of primary caregivers at the SFC are mothers. Their ages varied from 19-46 years old, with the average for both Kurgan Teppe and Kulyab zones being 29.

1 US Department of Agriculture, Economic Research Service Food Security Assessment/GFA-13/March 2002 2 National Nutrition Survey 2003 and 2004 3 Golden MHN, Briend A, Grellety Y. (1995). Report of meeting in supplementary feeding programmes with particular reference to refugee populations. Eur. J. Clin. Nutr.; 49, 137-45.

Malnourished child profile

¾ The average age of the children assessed was 16 months. ¾ 69% of caretakers in Kurgan Teppe and 79% in Kulyab declared that their child was being admitted for the first time. Surprisingly, in Kurgan Teppe 19.5% of mothers claimed it was their third time in the SFC. This means that 20-30% of the children in the SFC program relapsed at least once, thus demonstrating that malnutrition is a chronic problem in Khatlon Oblast. ¾ Amongst caregivers, 74% in Kurgan Teppe and 61% in Kulyab claimed that malnutrition was caused by health problems. In Kulyab another 31% of caregivers thought that malnutrition was the result of food problems (access and use). However, less than 2% declared that malnutrition was linked to poor hygiene practices. This indicates a poor level of understanding regarding the causes of malnutrition.

Motivation to come to SFC

¾ 47% of surveyed caregivers in Kurgan Teppe zone claimed that they were referred to the SFC by the doctors and nurses of the village, and only 5% by the ACF screening teams. Although this may indicate a poor level of performance in the screening teams (which in turn would warrant a refresher course for the teams), this may also be due to a more efficient and implanted system of health structures in Kurgan Teppe. Comparatively, in Kulyab doctors and nurses sent only 30% of the surveyed caregivers, whereas screening teams sent 34%. In both regions a sizeable proportion of caretakers were motivated by friends and neighbors to come to the program. This indicates that both information regarding the program and positive word-of-mouth are wide-spread and facilitating the program.

Health

¾ 59.5% of children admitted to SFC in Kurgan Teppe zone stated they had had diarrhea during the past month. In Kulyab, 53% made the same claim. ¾ For the children who were ill, 91% sought treatment and 9% did not in Kurgan Teppe. In Kulyab 70% of ill children were treated and 30% were not. ¾ For those who did not seek treatment, the primary reason given was that treatment was not available or that it was too expensive.

All these results point towards the prevalence of water-born diseases and problems of availability and accessibility to medical care in Kulyab.

Water

¾ According to the caretakers interviewed, the main sources of water for villages in Kurgan Teppe zone are irrigation channels (21%) and river/stream (41%). For Kulyab zone, water piped outside the house (29%) and piped directly into the house (25%) were the most common sources. ¾ More than 90% of caregivers interviewed during the survey said they were boiling water for drinking purposes. However only 77% of mothers in Kurgan Teppe zone and 31% in Kulyab zone used boiled water in food preparation.

Once again, results point towards high risks of water-born diseases and poor hygiene practices, which may represent a danger to health and facilitate the incidence of malnutrition.

Land and livestock access

¾ About 91% of caregivers interviewed claimed to have access to agricultural land in Kurgan Teppe, compared to only 48% in Kulyab zone. The majority of caregivers have private kitchen gardens with an average size of 0.12 hectare of land per household. They use these gardens mainly to grow staple foods and vegetables. ¾ 76% of families in Kurgan Teppe reported owning livestock while only 41% did in Kulyab. ¾ In both areas the most commonly kept livestock in the households were chickens (47% Kurgan Teppe; 17% Kulyab) and cattle (58% Kurgan Teppe; 31% Kulyab).

Household food consumption

¾ 87% of surveyed caregivers in Kurgan Teppe zone and 75% in Kulyab zone responded that they prepared enough food to feed the entire family.

¾ Bread, tea, cooking oil, and potatoes were the most commonly consumed foods and are accessible to most people in the surveyed districts. ¾ 83% of families surveyed in Kurgan Teppe zone and 81% in Kulyab found it necessary to reduce their food intake at some point during the year. The most commonly reported periods of food reduction were the winter months, from February to May. The main reason evoked for food reduction was financial constraints (58.5% Kurgan Teppe; 82% Kulyab).

Although food consumption seems to be satisfying in terms of quantity, food quality and variety may be insufficient. Furthermore, the seasonality of food scarcity must be with compared the seasonal fluctuations of SFC/TFC admission figures in order to establish whether there is a correlation (see recommendations).

Child food consumption

¾ 99% of the surveyed children were breastfed from birth. ¾ From the interviewed caregivers, 41% in Kurgan Teppe zone and 65% in Kulyab zone introduced other liquid/foods at the age of 4-6 months. ¾ The most commonly given liquid/foods are tea/water with sugar (27% Kurgan Teppe; 32% Kulyab). ¾ 32% of the interviewed caregivers in Kurgan Teppe zone and 35% in Kulyab zone stopped breastfeeding when their child was less than 6 months old. ¾ Apart from sweetened tea/water, for the last three days children had reportedly consumed mostly staple foods (56% Kurgan Teppe; 40% Kulyab).

1.3. Main recommendations

From the survey, the following recommendations can be made regarding nutrition:

1. Improved availability and access to adequate health structures must be ensured in remote areas, especially in Kulyab.

2. Health and nutrition education focusing on personal and general hygienic practices should be reinforced. Development and supply of training materials such as brochures, flip charts, exercise books by Ministry of Health, Ministry of Education and Republican Healthy life Center is highly recommended.

3. The identification and prevention of acute malnutrition must be reinforced, ideally by public structures and communities. Specifically, screening activities must be strengthened, especially in Kurgan Teppe,

4. Breastfeeding support groups focusing on appropriate weaning and complementary feeding practices should be increased.

5. A 24h food recall survey should be administered during the lean period (February to May) to monitor food consumption and diversity.

6. The use of SFC rations must be monitored via home visits, in order to determine who consumes the ration and how it is perceived by the family

The following recommendations can also be made regarding Food Security

1. Gardening seeds such as potatoes, cucumbers, onions, tomatoes, in addition to wheat and fertilizers distribution (Agricultural inputs) should be considered. A focus should also be placed on advocacy and improving knowledge of agricultural sectors, such as agriculture extension, information on crops prices and demand & supply of different agricultural products, agricultural policies of Tajikistan country as well as what is happening outside the country. Assistance should be given in the forming of dekan farmers’ organizations, which will help them to monitor and evaluate their objectives and program evolution. It will be easy for these organizations to secure funds from various micro credit financial sources, banks, government and non government organizations.

2. Exploring land inaccessibility in Kulyab zone and giving people more access to land and the freedom of what to cultivate. In Kulyab zone the government should help people affected by floods to find new fertile lands; this will help them to produce cash crops for income and food crops for personal use.

2. Introduction

In most instances nutrition surveys are conducted independently from food security assessments. However, in this particular case it was important to try to integrate both activities in order to understand the relationship between household food security and malnutrition, and adapt interventions accordingly. As a result several complementary themes were covered, including, but not limited to food insecurity, water and sanitation, as well as health coverage.

2.1. Objective of the survey

The goal of this survey, conducted among Supplementary Feeding Center (SFC) caregivers, is two- fold: on the one hand to better understand the underlying causes for persisting high rates of malnutrition with a view to adapt AAH programs accordingly; and on the other hand to establish a base-line profile of SFC caretakers for future food security activities.

3. Presentation of the area surveyed

3.1. Population number & repartition

This survey was conducted in 9 districts of Kurgan Teppe and 7 districts of Kulyab, both being located within the Khatlon Oblast province (see Annex 1). A total of 80 villages in Kurgan Teppe and 79 in Kulyab were covered.

Oblast Total # of districts # of villages # of SFC points # of interviews population assessed covered assessed conducted Kurgan Teppe 759,639 9 81 81 627 Kulyab 596,242 7 79 79 803 TOTAL 1,355,881 16 160 160 1,430 Table 2: Summary of Survey Coverage

Among the population sampled in Kurgan Teppe, 85% were Tajik and 15% Uzbek, whereas in Kulyab 96% were Tajik and only 4% were Uzbek. No difference in vulnerability was immediately apparent between the two ethnicities.

3.2. Geography & accessibility

All surveyed districts, with the exception of Shurobod, Muminobod and some part of Temurmalik, are located in lowland grounds. The main crops for these lowland areas are cotton, cereals and vegetables. However, as most of the population participates in dehkan farms, the majority of land and labour are used for cotton production. The government has often given farm-owners private land plots, but these are typically small in size and entail a higher rate of taxation.4 Similarly, most families have private land plots for vegetable and cereal production, but these are usually small.

The districts of Shurobod, Muminobod and some parts of Temurmalik are located in highland grounds. The population of these districts use rain-fed land for agricultural production. Some people keep livestock for both breeding domestic/commercial purposes, such as the production of manure and milk products.

Shurobod, Hamadoni (Moskovsky), Farhor, Pyanj and Kumsangir districts share a border with Afghanistan. Bishkent district borders .

Some areas covered by the survey are not accessible year round, due to impassable roads during the winter and rainy seasons.

Food and non-food markets exist in all surveyed districts; usually within a central location. Surveyors also report the presence of retail shops in each village. However, most people typically prefer to buy food in the markets. People living near the centre of the district often go to the food market every day. Those in villages further from the centre may have access to a food market only once per week.

3.3. Main humanitarian problematic

4 Field observations

Khatlon Oblast, as the poorest region in the poorest country in Central Asia, has a complex humanitarian problematic. Poverty is widespread in Tajikistan, with unemployment rates estimated at over 30%, and the average monthly salary at $7 USD5. Due to the lack of employment opportunities many men migrate to Russia looking for work. Many of these labor migrants take second wives in Russia, abandoning their families in Tajikistan. Others return, bringing with them HIV, AIDS and other diseases.

Designated as a cotton growing region when part of the USSR, Tajikistan has remained dependent on this crop ever since. Cotton provides a major source of revenue for the government and a select number of individuals, but it is grown at the disadvantage of the general population. As is often the case in Tajik government and society, the cotton industry is rife with corruption. Most of those who pick cotton are indentured laborers, students or employees of state-run institutions who are subjected to forced labor6. The dependency of Tajikistan on the cotton industry makes it not only extremely vulnerable to price fluctuations on the international market, but it also limits the land left over for cultivation and the diversification of the agricultural sector. The agricultural industry, like many others, also suffers from a lack of modernization which limits production and efficiency.

4. Main constraints faced during the survey

The main constraints faced during this survey were the time limitations during interviews and the difficulty in finding a suitable place in which to conduct them. Indeed, since the target population of the survey was caregivers coming to the Supplementary Feeding Centers (SFC), it was necessary to conduct the interviews at the SFC points, during the distributions. The surveyors therefore had to wait until the children and mothers were done with the SFC monitors. Keeping the mothers’ attention during the interviews also proved difficult, especially if when the accompanying child was sick or restless. Occasionally the interviews had to be conducted outside or in a populated place, and some mothers felt shy and uncomfortable.

Sometimes the children were not accompanied by the primary caregiver, but by another member of the family (often an older sibling). If this was the case, the surveyors still tried to get qualitative information from them about the family’s living conditions.

Another constraint faced during this survey came during the phases of data entry and analysis. Data was often entered incorrectly or mistakenly omitted, which in turn hampered the data analysis process. The database therefore had to be verified and compared to each original questionnaire before the analysis could start.

Please note that a bias is possible in this survey due to the nature of the interview conditions: as the interviews were conducted in the SFCs, and consequently among beneficiaries already receiving humanitarian aid, it is possible that the beneficiaries endeavored to appear needier than they truly are in the hopes of receiving more aid. It almost certainly prompted them to propose an increase in food aid distributions.

5. Methodology

5.1. Village selection

All SFC points were selected for the Food Security and Nutrition survey. In total, 80 SFC points in Kurgan Teppe zone and 79 in Kulyab zone were surveyed (refer to Annex 2 for the list of villages).

5.2. Mother selection

All primary caregivers of newly admitted children were selected for the interviews. Individual interviews with mothers at the SFC points were the primary tool used to conduct the Food Security and Nutrition survey.

5.3. Questionnaire

The questionnaire for the survey was prepared by Action Against Hunger’s Food Security department, in conjunction with the Nutrition team. The questionnaire was field-tested first in order to better adapt the

5 Tajikistan: A roadmap to development. (2003). ICG Asia Report; 51. 6 Ibid

questionnaire to the situation. It was also translated into Russian to make it easier for the surveyors to use in the field. (Refer to Annex 3 for the questionnaire).

5.4. Staff selection and training

Eleven surveyors were selected via job announcements and a thorough interview process. Five surveyors were selected for Kulyab zone and six for Kurgan Teppe zone. During the survey, a health educator in Kurgan Teppe also worked as a surveyor due to the technical constraints, making for a total of twelve surveyors, five males and seven females. For the twelve surveyors, one day of training (refer to Annex 4) was conducted. The training module covered the objectives of the survey, an explanation of the questionnaire, group discussions and role-playing games enacting different survey situations. The training was conducted by the Food Security program officer.

5.5. Time line: field work, data entry and analysis.

The data collection took place simultaneously in both zones between 09/08/05 and 08/09/05. As the surveyors were to travel to various SFC locations and act as a team with the SFC monitors, the survey required a strong level of coordination between the Food Security and Nutrition offices. Over the course of the survey month, new beneficiaries were often identified via SFC screenings and then referred to the surveyors for interview. All caretakers of newly admitted children were surveyed. The Food Security officer in Kurgan Teppe zone and the Nutrition program manager in Kulyab zone supervised fieldwork. Two volunteers per base were hired for data entry. EPI INFO 2002 was used for the data entry and analysis. The survey analysis was done jointly by the Food Security program officer, the Food Security Intern and the Nutrition program managers.

6. Nutritional Results

In total 1,430 primary caregivers were interviewed during the survey. Of these, 803 (56%) were from Kulyab zone and 627 (44%) were from Kurgan Teppe.

6.1. Family information

Most of the surveyed families had two adults capable of taking care of children. However, the survey shows that it is the mother who is the primary responsible for the child (89% KT; 90% Kulyab), and not the father. Also, though many families claim to have two adults, many of the fathers are often migrant workers living in Russia7.

Analysis:

According to the findings of the survey, most of the mothers of admitted children were within the 25-35 years age range. Except in the mountainous districts of Muminobod and Shurobod, these women spend much of their time in the fields for picking cotton. This leads in turn to improper child care and neglect. Children whose mothers are forced to work are often looked after by grandmothers or older siblings. These population groups are usually either too old or too young to properly look after a child under 5 years old, and has a negative effect on breastfeeding as it forces premature weaning.

6.2. Malnourished child profile

Data:

As observed in the figure 1, during the survey month, Kulyab zone had more new admissions than Kurgan Teppe zone. This is because during the time of the survey the nutrition program in Kulyab zone had started to work in a new district (Hamadoni) affected by floods. As mentioned, in Kurgan Teppe zone there is a high percent of children who were readmitted for the third time to the SFC. There is even a report of a mother claiming it was her sixth time in SFC, but with multiple children.

80

70

60 Kulyab 50 Kurgan Teppe

40 Percent

30

20

10

0 1 2 3 4 5 6 Number of admissions

Figure 1: Admissions into Supplementary Feeding Centers

As observed in Figure 2 below, the primary cause of malnutrition mentioned by the mothers is by far ‘health problems’ (74% KT; 61% Kulyab). Another significant amount of responses in Kulyab (31%) pointed to ‘food problems’ being the cause of malnutrition. Interestingly only 11% of caregivers from Kurgan Teppe zone associated their child’s malnutrition with ‘food problems’. Virtually no respondents in either zone mentioned hygiene as a factor in malnutrition.

7 Field observations

Analysis:

Malnutrition can result from various factors such as insufficient food supply, poor health status, inadequate feeding practices, diseases, inaccessibility of land for food production, lack of safe drinking water and sanitation, poverty and poor health education. Although providing solutions to all of these factors is the optimum way of eliminating malnutrition, the pattern of responses in the respondents shows a poor level of education concerning malnutrition issues, especially as regards hygiene. As a result, it is recommended to reinforce health and nutrition education in both zones, focusing especially on personal and general hygienic practices. The development and supply of training materials such as brochures, flip charts, exercise books by Ministry of Health and Ministry of Education is highly recommended.

80

70

60

50 Percent 40 Kulyab 30 Kurgan Teppe

20

10

0 Care problem Don't Know Food Problem Health Problem Hygiene Problems Causes of malnutrition

Figure 2: Reasons evoked by caregivers for child’s malnutrition

6.3. Referral method to SFC

Data:

Referring to figure 3, one can see that mothers from both zones claimed to have been referred to the SFC by the screening team of nutrition program and by the doctors/nurses from the village medical houses. However, the low number of beneficiaries referred by ACF’s screening teams in Kurgan Teppe may be cause for concern: either this indicates a poor level of performance in the screening teams (which in turn would warrant a refresher course for the teams), or it may be due to a more efficient and implanted system of health structures in Kurgan Teppe. Further investigation will be required to confirm either hypothesis, but as a precautionary measure it is recommended that the survey teams have their performance reviewed.

Please not that a large number of beneficiaries were advised to come to the SFCs by neighbours who had previously attended a nutrition program or at least knew of their existence. This shows that word-of-mouth is present and working in favour of the program.

50

45

40

35

30 Percent 25 Kulyab 20 Kurgan Teppe 15 10

5

0 Doctor / nurse Multiple Neighbors Other Screening Team from village admissions Home visit

Referral to SFC point

Figure 3: Referral method to Supplementary Feeding Centres

Most people come to the SFC points on foot, walking an average of 2.4 kilometres. Some beneficiaries use other types of transport, such as bicycles (average 0.25 km travelled), family cars (average 2.4 km travelled), and public transport (average 4 km travelled), but only rarely. The farthest distance travelled was 20km in Kulyab zone and 8 km in Kurgan Teppe zone. These distances are acceptable, and indicate good program coverage.

This survey was not designed to elucidate reasons for defaulting or for treatment refusal. However according to Action Against Hunger’s experience beneficiaries will eschew treatment for inclement weather, family reasons, or because they have too much work at home.

6.4. Health

Data:

From figure 4 it can be seen that the most prevalent symptom reported during the survey period was diarrhoea, with 53 % in Kulyab zone and 60 % in Kurgan Teppe zone.

Analysis:

This could be due to infection of the children from water-borne diseases, which are highly prevalent during summer time. Another possible source of infection is from food contamination and poor hygiene during preparation and storage.

60

50

Kulyab 40 Kurgan Teppe 30 Percent

20

10

0 Cough Diarrhea Fever Nothing Other Vomiting Illness Figure 4: Health history of a child

It is advised to improve the availability and access to adequate health structures, especially in Kulyab.

6.5. Water

Data:

Due to an inadequate water supply and a poor system infrastructure, the most commonly accessed water source for Kurgan Teppe zone is irrigation channels (21%) and water from rivers/streams (41%) For Kulyab zone the situation is different, with water being piped outside (29%) or inside (25%) the house as the most commonly used sources. The fact that irrigation channels and river water are the main sources in Kurgan Teppe zone means that access to safe drinking water remains a significant problem.

It can be observed from the figure 6, that 95.5 % of respondents in Kulyab and 99 % in Kurgan Teppe claim to boil their water for drinking purposes. However, fewer caregivers take the precaution to boil their water before using it in food preparation, especially in Kulyab zone (31%; KT 77%).

Water availability to caregivers 45

40

35

30

25 Percent Kulyab 20 Kurgan Teppe 15

10

5

0 Hand Irrigation Piped Spring Piped to Rain- River / Shared Well Water Other pump Channel Outside House water Stream Hand- Spring Tank House pump Water source

Figure 5: Water sources accessed by caregivers

Analysis

The water sources accessed by the caregivers differ greatly between the two zones. However the questionnaire was not designed with the purpose to elucidate the reason for this difference. Action Against Hunger knows from experience that a family’s water source is usually seasonal: irrigation channels are drained in the fall, and in Kulyab zone the piped water supply is severely disrupted during the winter.

Even though a high number of caregivers reported boiling their drinking water, it can be assumed from the high frequency of diarrhea that the admitted children drank contaminated water outside of the household or that the boiled water was re-contaminated after boiling and food preparation.

100 90 80 70 60 Percent50 Kulyab 40 Kurgan Teppe 30 20 10 0 Before drinking Before food preparation Boiling water

Figure 6: Water treatment before use

Consequently, it is once again recommended that health and nutrition education focusing on personal and general hygienic practices should be reinforced. Development and supply of training materials such as brochures, flip charts, exercise books by Ministry of Health and Ministry of Education is highly recommended.

Conclusions and Recommendations Concerning Nutrition:

The primary goal of this survey was to better understand the underlying causes for persisting high rates of malnutrition with a view to adapt AAH programs accordingly. The survey was a success in this respect, as several important points have been identified, namely:

• Health problems

As suggested by the caregivers, much of the malnutrition seen during this survey can be linked with health problems. Diarrheic diseases are the most common, due to the summer water problems in Khatlon region and to the “acute watery diarrhea” crisis. Accessibility of health care to treat any problems that do occur is also clearly an issue, especially in Kulyab zone.

• Bad feeding practices

It can be concluded that more work is needed to encourage women not just to breastfeed their infants, but also to practice exclusive breastfeeding until 6 months. From the survey, several factors influence the practice of exclusive breastfeeding were highlighted, these include: the beliefs surrounding regarding the use of tea (and water) and it’s benefits for the child, the misconception that babies need to drink additional fluids (especially in the hot weather), mothers being forced to work in the cotton fields, and the knowledge gap of the older generation surrounding breastfeeding practices which is passed down to new mothers who are unable to access relevant and up-to-date information on breastfeeding. Unfortunately even when nutritious foods are available they are not properly employed. The importance and value of breastfeeding continues to be underestimated. Weaning is started too early and the appropriate foods are not used, leading too much of the malnutrition Action Against Hunger see year-round.

It is worth making a special note of the traditional role of women and its impact on the causes of child malnutrition. Indeed, in the remote areas surveyed the role women bore the main workload, and in addition to stereotypical tasks such as domestic work or child education, women also care for the livestock and work in the fields. Lack of education, especially on nutrition and health, results in the women themselves being disadvantaged. One outcome is that the main caregivers then fail to feed and educate their children appropriately.

• Bad drinking water

Nearly half of the population of Tajikistan lacks access to potable water8, and this problem is especially significant in Khatlon Oblast. The lack of safe drinking water has had a damaging effect on the health of the general population and especially that of children. This is compounded by a general lack of access to adequate and affordable health care.

Diarrhea is often caused by drinking unhygienic water and despite some doubts it is a large cause of malnutrition. The provision of potable water should be an objective in any activities addressing the healthy development of children.

The high prevalence of boiling drinking water does not necessarily ensure that once children are away from home they are consuming clean water. Also, neglecting the importance of fly-prevention and using un- boiled water in food preparation will increase the likelihood of infection. The reported water sources were more worrying for Kurgan Teppe zone than for Kulyab.

As a result of these findings, the following courses of action are recommended:

1 Improved availability and access to adequate health structures must be ensured in remote areas, especially in Kulyab.

2 Health and nutrition education focusing on personal and general hygienic practices should be introduced / reinforced. Development and supply of training materials such as brochures, flip charts, exercise books by Ministry of Health and Ministry of Education, Republican Healthy life Center is highly recommended.

7. The identification and prevention of acute malnutrition must be reinforced, ideally by public structures and communities. Specifically, screening activities must be strengthened, especially in Kurgan Teppe,

3 Breastfeeding support groups focusing on appropriate weaning and complementary feeding practices should be increased.

4 A 24h food recall survey should be administered during the lean period (February to May) to monitor food consumption and diversity (see Household Food Consumption, in Food Security below).

5 The use of SFC rations must be monitored via home visits, in order to determine who consumes the ration and how it is perceived by the family.

8 Conference Report: The situation of mother and child health in Tajikistan. (2004). UNICEF.

7. Food Security

7.1. Land

Data

The ability of caregivers to access land differed greatly between the two zones. In Kurgan Teppe zone 91% have land access, but this number drops to 48% in Kulyab zone.

As seen in figure 7 the majority of caregivers who reported having land have access to private land (61 % KT; Kulyab 52%).

70

60

50

40

Percent 30 Kulyab

Kurgan Teppe 20

10

0 Dekham Farm Other Presidential Private Land Rented Land Shared Land Land Type of land

Figure 7: Percent of caregivers having access to land

Analysis

Both the private lands and government-given lands are mainly used for cereal and staple food production. The most commonly produced vegetables are tomatoes, onions, carrots, cucumbers and leafy green vegetable such as cabbages. Potatoes are also occasionally produced as staple foods.

The poor land access in Kulyab zone could be due to recent and extensive flooding in the region at the time of the survey. Many families were displaced or were cut of from the cultivating land during this period. Therefore these results could be significantly different at another time.

It is general knowledge in the region that irrigated lands are usually kept for cotton production while the rain fed lands are left for the production of food. This means that the harvest of food crops depends on good rains. For the last two years crops have been consistently destroyed by heavy rains.

7.2. Livestock access

Data

In Kurgan Teppe zone 76% of caregivers reported owning livestock, in Kulyab the number is 41%.

The number of animals that these families reported having is presented the table below:

Livestock % of families Average number of % of families Average number of type owning in animal in the family in owning in Kulyab animal Kurgan Teppe Kurgan Teppe in the family Kulayb chicken 46.9% 5 17.2% 6 cow 58.4% 2 30.8% 4 sheep 4.8% 4 3.9% 4 duck 4.6% 5 1.5% 4 turkey 3.0% 3 0.5% 3 goat 7.2% 3 8.6% 4 Table 3: The percentage of families owning livestock from each zone, and the average possessed per family

From table 3 it can be seen that the most commonly owned livestock are cows (58% KT; 31% Kulyab), followed by chickens (47% KT; 17% Kulyab), and then by goats (7% KT; 9% Kulayb).

Analysis:

There is difference between the reported livestock owned in Kurgan Teppe and in Kulyab, especially regarding chickens and cows. The statistics for Kulyab zone are a concern, as livestock can be a large source of income and family security.

Typically, these livestock either have access to a communal grazing land or they are fed by fodder grown by the family. Cows are a popular livestock due to their multiple uses. Families often use their dung for heating or cooking; their milk and meat for drinking and eating; and they are very often used as dowry. This survey did not determine if the rearing of livestock is for domestic (family use) or commercial purpose (for selling/business).

7.3 Household food consumption

Data

Globally for both zones 93% of families eat 3 meals per day (89% KT; 97% Kulyab). Only 3 families in Kurgan Teppe reported consuming 1 meal per day which makes 0.5% for the zone and 0.25% globally. No one reported only consuming 1 meal per day in Kulyab zone.

Figure 8 also shows that few people reported only consuming 2 meals per day, for a global of 2.5% (4.5% KT; 0.5% Kulyab).

Globally 2% of respondents reported eating 4 meals per day (5% KT; 3% Kulyab), and one caregiver in Kurgan Teppe claimed her family consumes 5 meals per day (0.2%).

100

90

80

70 60 Kulyab Percent50 Kurgan Teppe 40

30

20

10

0 1 2 3 45 Usual number of meals per day

Figure 8: Number of meals consumed per family per day

Most families surveyed claimed that the day before the survey enough food had been prepared for their needs (87% KT; 75% Kulyab).

Kulyab Very Food Item Everyday 3x/week 1x/week Monthly Never TOTAL Rare Beans 27.23 23.76 24.56 9.21 9.61 5.6 100 Bread, Wheat, 96.36 0.88 0.13 0.5 1.38 0.75 100 Maize Chicken 0.77 0.77 2.9 10.87 42.71 41.94 100 Cooking Oil 73.57 21.95 4.11 0.37 0 0 100 Egg 1.52 10.76 22.28 15.06 24.05 26.33 100 Fruit 32.21 20.44 24.84 15.65 6.6 0.26 100 Meat 0.87 1.62 7.2 18.03 48.26 24 100 Milk products 18.71 17.19 30.47 14.41 14.92 4.3 100 Potatoes 64.54 25.47 8 1.37 0.37 0.25 100 Rice 4.52 14.6 32.56 30.88 13.95 3.49 100 Sugar 50.56 31.26 10.59 6.6 1 0 100 Tea 96.29 3.07 0.64 0 0 0 100 Vegetables 44.16 26.83 21.18 5.65 1.93 0.26 100 Table 4: Food item consumed in Kulyab in percent

Kurgan Teppe Very Food Item Everyday 3x/week 1x/week Monthly Never TOTAL Rare Beans 31.69 13.96 14.12 8.87 11.82 19.54 100 Bread, Wheat, 99.21 0.16 0.16 0 0.32 0 100 Maize Chicken 0.48 2.55 6.86 21.69 27.59 40.83 100 Cooking Oil 97.59 2.11 0.3 0 0 0 100 Egg 15.78 17.23 23.67 11.92 19.16 12.24 100 Fruit 78.45 9.67 10.3 1.11 0.48 0 100 Meat 6.74 14.93 22.15 24.4 22.63 9.15 100 Milk products 50.89 18.84 12.56 6.44 8.05 3.22 100 Potatoes 93.78 3.35 1.91 0.16 0.32 0.48 100 Rice 19.43 30.56 29.57 11.96 7.48 1 100 Sugar 82.17 6.36 9.08 0.8 1.27 0.32 100 Tea 99.68 0.32 0 0 0 0 100 Vegetables 77.46 11.11 8.37 2.09 0.64 0.32 100 Table 5: Food item consumed in Kurgan Teppe in percent

Bread, tea, cooking oil, and potatoes are the most commonly consumed (daily basis usually) and accessible foods in the surveyed districts. We observe as well that milk products, fruits, sugar and vegetables are consumed quite regularly at least on weekly basis.

From table 4 it is shown that approximately 96.36 % caregivers eat bread, wheat and maize every day in Kulyab zone and about 99.21 % in Kurgan Teppe.

In Kulyab zone at least 41.94 % caregivers reported never eat chicken and about 48.26 % eat meat very rarely. At least approximately 22.56 % of caregivers eat eggs once per week.

In Kurgan Teppe zone table 5 shows that about 27.59 % and 22.63 % of caregivers eat chicken and meat very rarely respectively. Approximately 40.83 % of caregivers never eat chicken.

Difficult Easy % of answers % of answers District Frequency from that Frequency from that district district Farhor 101 13,40 9 18,40 Kulyab 150 20,00 16 32,70 Moscovsky 150 20,00 4 8,20 Muminobod 98 13,00 9 18,40 Shurobod 16 2,10 1 2,00 Sovietsky 39 5,20 2 4,10 Vose 197 26,20 8 16,30 Total 751 93.875 49 6.125 Table 6: Easy of obtaining food items in Kulyab zone:

% of answers % of answers District Difficult from that Easy from that district district Bishkent 31 60.8 20 39.2 Bokhtar 93 66.4 47 33.6 36 66.7 18 33.3 Khojamaston 50 48.0 54 51.9 Kolkhozabod 40 57.1 30 42.9 Kumsangir 60 68.2 28 31.8 Kurgan Teppe 8 80.0 2 20.0 Sarband 11 52.4 10 47.6 Vakhsh 46 52.9 41 47.1 Total 375 60 250 40.0 Table 7: Easy of obtaining food items in Kurgan Teppe zone

From table 6 and table 7 it can be revealed that in both bases, it was difficult to access foods from markets although it was reported that foods are available in shops and markets. Approximately 93.87% of caregivers in Kulyab had difficult in obtaining foods while in Kurgan Teppe, it counted approximately 60 %.

Analysis:

The most commonly eaten foods (bread, wheat, maize tea, potatoes, and cooking oil) and the low consumption of chicken and meat shown in table 4 and table 5, point to an unbalanced diet deficient in quality proteins and micronutrients sure but you have to mention the milk products consumption to balance the argument. This is not at all surprising considering what known of the high prevalence of chronic malnutrition (stunting), anemia, folic acid deficiency, and vitamin A and iodine deficiencies in the region. For example, the prevalence of iron deficiency anemia among women and children aged 6-59 months in Tajikistan is high, 41% and 38%9 with big disparities within region.1011

The fact that a large majority of families consume 3 meals per day and that they claim to have been able to prepare enough for their needs, confirms the supposition that there is not a lack of food in the region, although table 4 and table 5 show that a poor variety of foods are consumed. It’s not so poor but limited it seems.

It should be noted that the survey was not conducted during the proclaimed “lean period” (February to May) and there could be seasonal variation in these responses. The simple fact that a lean period

9 National Nutrition Survey, 2003 10 UNICEF brochure, 2005 11 Nutrition status of mothers and children in Tajikistan, 2004

exists between the harvests, reveals that household food security is not reached due to a lack of purchasing power. About 82.2 % of caregivers in Kurgan Teppe said that they had a period of reduced food intake because of financial and seasonal reasons in order to meet their demand during winter. In winter the diversity of the food supply is limited and prices of available items are higher when compared to summer prices.

It is surprising to see that even those districts which are small distance from the centers of trade had problems in obtaining foods, despite the ready availability of the food products in the markets and shops. It can be assumed that caregivers suffered from a lack of purchasing power caused by a lack of financial means, unemployment etc.

In order to verify whether there is any correlation between the so-called ‘lean period’ and an increase in food insecurity, we have reproduced below the chart detailing the number of admissions in ACF’s SFCs:

Admission SFC 2004-2005

1400 1200 1000 800 2005 600 2004 400 200 0

y r r r ril er rch p July be rua a A May June mb m M e Januaryeb August te October c F Novembe Sep De

Chart 1: ACF SFC Admission 2004-2005

It is hard to draw any definite conclusions from this chart. For instance, the drops observed in February may be due to a drop in attendance caused by poor accessibility during winter (roads blocked by snow, etc) rather than because of a genuine drop in malnutrition. However, it is interesting to note that in both 2004 and 2005, attendance rates shot up immediately after the lean period. It is all-together possible that pro-longed absence of certain food-stuffs during the prolonged lean period may be the cause of certain types of nutritional insufficiencies in breast-feeding mothers, which would in turn lead to malnutrition in their young children. Since heavy rains destroyed many complementary crops in 2004 and then again in 2005, intake would be even more limited, hence the increase between the two years. This explanation remains for the time being only a hypothesis requiring confirmation. Consequently, it is recommended that a 24h food recall survey should be administered during the lean period (February to May) to monitor food consumption and diversity. This recommendation has been included in the nutrition section of this report.

7.2. Child food consumption

Even though there is a high percentage of mothers still breastfeeding their children (99% KT; 99.5% Kulyab); the reported age of introduction of complimentary foods is not consistent with several former surveys or with Action Against Hunger’s practical field experience. For Kurgan Teppe and Kulyab, referring to figure 9, 41% and 62% of caregivers respectively introduced their child to weaning foods at the age range of 4 to 6 months.

In 2000 UNICEF found that more than 95% of women in Tajikistan were breastfeeding their infants for at least 6 months and in some cases for even longer. However, it was acknowledged in the findings that the breastfeeding was not exclusive and that even at an early age children were receiving other liquids or foods. In addition, approximately 19% of infants under the age of 4 months were exclusively breastfed12.

12 UNICEF 2000

From figure 9 it can be seen that the foods other than breast milk being consumed by the beneficiaries differed between the two bases. However the most commonly given food was sweetened tea/water (23% KT; 30% Kulyab).

70

60

50

Kulyab 40 Percent Kurgan Teppe 30

20

10

0 4-6 Months 7-12 Months Less than 3 Month More than 12 Months Age of a child

Figure 9: Introduction of complementary foods

Analysis:

The reported weaning practices are inappropriate and are most likely causing much of the malnutrition in this age group. The high prevalence of sweeten tea consumption in children under 5 years is extremely worrying. Tea is a “dangerous” liquid to give a child as it causes and aggravates anemia, which encourages the development of malnutrition. The reported foods given during the weaning period are also deficient in several essential nutrients. Children are being feed too much with bread and biscuits. Their diet needs to be diversified to include more nutritious porridges, protein-rich eggs and yogurts, as well as fruit and vegetable purees.

30

25

20

Kulyab Percent15 Kurgan Teppe

10

5

0 Boiled Non Bought Home Made Other Same as Same as Tea/Water Unboiled Breast Milk Porridge Porridge Family Family (non Non Breast (cow, goat) (liquidized) liquidized) with Sugar Milk (cow, goat) Food item

Figure 10: Food consumed during weaning

7.3. Solutions to avoid malnutrition proposed by the caregivers

According to the interviews conducted, the most commonly proposed solutions to malnutrition in both zones were: 1- Food aid distributions (44% KT; 42% Kulyab). However this favored recommendation might be due to the caregivers’ ideas that since they are given dry rations they are automatically eligible for food aid distributions. Interestingly, this recommendation does not concur with the main cause of malnutrition evoked, namely health problems. Food problems were the second reported cause of malnutrition; however food aid distributions are not a sustainable venture. 2- Livestock distributions (23% KT; 16% Kulyab). 3- Land distributions (19% KT; 17% Kulyab) 4- Seed distributions (10% KT; 24.5% Kulyab)

Conclusions and Recommendations Concerning Food Security

This survey has served to better understand the situation of the caregivers. In terms of food security, the main problems identified are as follows:

• Food accessibility

Food accessibility during winter is a problem in both zones, evidenced by the general need to reduce food consumption during the winter months. This problem becomes alarming in Kulyab zone where over 90% of respondents claim having trouble procuring items not locally produced. The problem is not essentially that foods are not available but that they are not necessarily at a price that makes them accessible to everyone. Exploitation of kitchen gardens and what to grow is something that could be emphasized in both areas. However land accessibility in Kulyab is poor and should be further investigated and if possible the arable land redistributed again for the families hit by flooding.

Some differences between Kurgan Teppe and Kulyab zones became obvious during the survey. While caregivers in both zones claimed that the number one reason for malnutrition was a health problem, another significant percent of caregivers in Kulyab but not in Kurgan Teppe claimed that the malnutrition was caused by a food accessibility problem. Health accessibility was also an issue in Kulyab zone but not Kurgan Teppe, evidenced by a large difference in the number of people seeking health care when a child fell sick. Water sources varied between the two zones. In the past three months caregivers in Kurgan Teppe zone had relied on irrigation canals and rivers/streams where as those in Kulyab zone used mainly water piped into and outside of their houses. A final difference seen was with respect to land access and livestock ownership. A large majority of caregivers in Kurgan Teppe zone had land access and owned livestock while few did in Kulyab.

As a result of these findings, the following recommendations can be made regarding Food Security:

1 Gardening seeds such as potatoes, cucumbers, onions, tomatoes, in addition to wheat and fertilizers distribution (Agricultural inputs) should be considered. A focus should also be placed on advocacy and improving knowledge of agricultural sectors, such as agriculture extension, information on crops prices and demand & supply of different agricultural products, agricultural policies of Tajikistan country as well as what is happening outside the country. Assistance should be given in the forming of farmers’ organizations, which will help them to monitor and evaluate their objectives and program evolution. It will be easy for these organizations to secure funds from various micro credit financial sources, banks, government and non government organizations.

2 Exploring land inaccessibility in Kulyab zone and giving people more access to land and the freedom of what to cultivate. In Kulyab zone the government should help people affected by floods to find new fertile lands; this will help them to produce cash crops for income and food crops for personal use.

Annexes

Annex 1: Maps

Annex 2: List of villages

List of villages for KT zone

# District Jamoat SFC point 1. Bishkent Istiklol Arabhona Firuza Bishkent Istiklol Chiluchor Chashma Komsomol Komsomol Istiklol Oltinsoy Istiklol Shark Istiklol Voroshilov 7 2. Bokhtar Bohtarion 1 Otdelenie Sarvati Istiklol 18-Godovshina Zargar 23 Brigade Zargar Baroi Hosilot Orion Budeni Bohtarion Bohtarion F.Saidov 4 Zargar Gairat Orion Haetinav Navbahor Komsomol Navbahor Kuibishev Navbahor Lenin Zargar Maxim Gorky Mehnatobod Mehnatobod Orion Politotdel Sarvati Istiklol Rohi Lenin Buston Kala Sabzavod 1 Buston Kala Sabzavod 2 Bohtarion Saripul Zargar Stahanov Voroshilov 21 3. Jilikul Jilikul Agronom Jilikul Center Jilikul Engels Garauti Garauti Jilikul Komsomol Jilikul Mirovoi Navzamin Umed 7 4. Khojamaston 50 solagi Tojikiston 1 May 50 solagi Tojikiston 01-May Dusti Dusti Gulobod Dusti Ittifok Yakatut Khojamaston Yakatut Komsomol Yakatut Krasnaya zvezda

Kalinin Kulsang Kalinin Kutuzov Aral Iftihor Navobod Yakatut Policlinic Kalinin Tut Yakatut Yakatut 14 5. Kolkhozabod Tugalang Aini Navobod Kalinin Navobod Komsomol Guliston Orzu Tugalang Policlinic Uzun Telman Uzun Uzun 7 6. Kumsangir Bolshevik Krupskaya Emahmadov Telman Lohuti Kumsangir Ok-Oltin Dusti Ozodi 3 Kumsangir Poselok 1 Kumsangir Poselok 2 Kumsangir Poselok 3 Pyanj Poselok 4 Pyanj Poselok 6 Telman Socializm Telman Vahsh 12 7. Kurgan Teppe KT central policlinic Total 1 8. Sarband Guliston Ogkaza Sarband 2 9. Vakhsh Tojikobod Andrey Rohi Lenin Center Rohi Lenin Dusti Tojikobod Havaskor Tojikobod Proletar Okgaza Rohi Lenin Okgaza Sovetobod Yangiobod Vahsh Yangiobod Yakadin 9

List of villages for Kulyab zone

# District Jamoat SFC point 1. Farhor Gulshan Bahoriston Gulshan Davlatobod Gairat Dehkonarik Gulshan Gulshan Komsomol Komsomol Vatan Lolazor Vatan Orjinikidze Farhor Shahrak Policlinic Gairat Sebi surkh Zafar Somonchi Total 10 2. Kulyab Zarbdor Beshtigirmon Kulyab Chorbog Dahana Dahana Zarbdor Guliston Ziraki Hokimobod Dahana Honobod Ziraki Jerkala Zarbdor Khatlon Kulyab Lagmon Dahana Mirapok Kulyab Policlinic 1 Kulyab Policlinic 2 Kulyab Policlinic 2/5 Kulyab Policlinic 3 Kulyab Pos.Sino Dahana Yoksuchiyon Ziraki Ziraki Dahana Sh.Faizaliev Total 18 3. Hamadoni Chubek Hamadoni CRB Moskovsky Dashti-gulo Dashti-gulo Kalenin Davlatobod Mehnatobod Drujba Dashti-gulo Faizobod Chubek Khojamumin Hamadoni Kirov Chubek Komsomol Mehnatobod Navobod O.Hoshim Chubek Okmazor Kahramon Pushkin Hamadoni Rudaki Kalenin Safedobod Chubek Yangiyul Total 16

4. Muminobod Muminobod CRB Muminobod Kulchashma Delolo Kulchashma Ghesh Kulchashma Gofilobod Tu-tu Kipchok Kulchashma Kulchashma Boghgai Langar Kulchashma Momandion Dehbaland Sarmaidon Boghgai Sarsibulok Dehbaland Tu-tu Tu-tu Total 12 5. Shurobod Dagistan Darai ob Shurobod Khojaghalton Sarchashma Sarchashma Total 3 6. Temurmalik Vatan Jorubkul Center Policlinic Tanobchi Tanobchi Total 3 7. Vose Michurin Angurbog Mehnatobod Arpatuguldi Besharik Pakhtaobod Chorbog Shahraki Vose CRB Vose Pakhtaobod Dashtidili Guliston Guliston Mehnatobod Gulobod Aral Pakhtaobod Kaduchi Pakhtaobod Kainar Guliston Kurbonshahid Tugarak Navbahor Aral Okjar Mehnatobod Voseobod Aral Zarcamar Mehnatobod Navobod Total 17

Annex 3: Questionnaire

MISSION TAJIKISTAN Questionnaire for Women attending the SFC (having a moderate malnourished child) in South Khatlon (July-September 2005)

Interview details 1. Surveyor: ______2. Date: ______3. SFC point: ______

4. District: ______5. Jamoat: ______

Family information 6. Family size Quantity Adults Children above 5 years old Children under 5 years old

7. Age of mother______

8. Primary caregiver of the assessed child? Mother 1 Father 2 Grandparent 3 Specify if Mother in Law 4 Sibling 5 Uncle/Aunt 6 Outside Family ______7

Malnourished child Profile 9. How old is the child? ______(put the month of child

10. Is it your first treatment in the SFC? 1. Yes 2. No. If, no: how many admissions/default:

11. According to you, what is your understanding of the reason for your child to be like that? (Possibility of several answers). Health problem 1 Hygiene problem 2 Food problem 3 other: ______4 Doesn’t know 5

Motivations to come to the SFC 12. How far is the centre from your living place? ______(Km) and in minutes to come:

13. How do you know about the SFC point? 1. Screening team came to visit you to measure and weight your child 2. The doctor/nurse suggest after the consultation that you may get some porridge here 3. You’ve heard from neighbours about the distribution centre and you’ve wanted to checked 4. It’s not the first time you come, you’ve been there already for a older/same child 5. Other (specify) 14. How did do you come here? And how much did you pay (return ticket)?

Walking 1 Using personal car 2 Using car from friend / neighbour/relative 3 Using public transportation 4 Bicycle 5 Cart 6

Health 15. Has the child had any of the following symptoms during the last month? circle one main problem

No 1 Yes, diarrhoea 2 Yes, cough 3 Yes, fever 4 Yes, vomiting 5 Yes, other 6

16. If the child was ill during the last month was any treatment given? Yes 1/ No 2

17. If no, why not? (Circle one or more numbers) Travel too expensive 1 treatment too expensive 2 Treatment not available 3 did not have time to seek treatment 4 Other 5

Water 18. During the last 3 months where has the family acquired its water from? (Circle one or more numbers)

Piped in house 1 Piped outside house 2 Hand pump 3 Rainwater 4 Well 5 Spring 6 River/stream 7 Irrigation channel 8 Other 9

19. Do you use to boil the water before? - Drinking it? 1Yes / 2 No - Using it for the preparation of the meals? 3Yes /4 No

Lands access 20. Do you have an access to land? Yes 1 No 2

21. If yes, what type of land? Type of land Size (Sot) * sotok = 100 m2 Private land (cereal, staple food) Presidential land (cereal, staple food) Land given by Dekhan farm instead of the salary Rental land (cereal, staple food) Other (specify)

22. List the items which have been harvested during the last cycles

Gardening items (i.e. onion, tomato, eggplant, carrot…): ______

Food producing item (i.e. Maize, wheat, potato…): ______

Livestock 23. How many of the following types of livestock does the family own?

Put quantity in each box

Type of livestock Quantity owned (put quantity in each box) Cows Goats

Sheep Chickens Ducks Turkeys Other (specify) ______

Household food consumption 24. Usually, how many meals per day do you take (breakfast, lunch and dinner): ____

25. What did you eat yesterday (24h food recall)? ORIGIN: (market, village shop, own ITEMS production-hunting, wild product, exchange). Breakfast

Lunch

Dinner

26. If snack (between meals) yesterday, what:______

27. According to you, did you prepare enough food for your family yesterday: Yes No If no what was missing:______

28. General frequency of food items consumption (validate for each item with a cross) Everyday 3- 1 Monthly Very Never If Very rare and never, why 4/Week /Week rare (cost, not available…) Bread, wheat, maize Meat Chicken Milk products Egg Rice Potatoes Beans Vegetable Fruit Sugar Cooking oil Tea

29. To obtain items none produced in the village (sugar, soap…), is it: Easy Difficult

30. During the year is there a long period of time where you have to reduce your food intake? Yes No If yes, when (from-to):______Why:______

31. Do you receive food from relatives or other? Yes No If yes, which items: ______is it regular: Daily Weekly Monthly

Child food consumption 32. What types of food does the child consume?

Circle one number only Breast milk and other foods 1 (go to Section 1 only) Other foods only (no breast milk) 2 (go to Section 2 only)

Section 1: Breast milk and other foods 33. Was the child breast fed from birth? Yes 1 No 2

34. Is the child breast-fed every time demanded including at night? Yes 1 No 2

35. Age other foods/liquids first introduced? (circle one number only) < 3 months 1 4-6 months 2 7-12 months 3 12 + months 4

36. What other foods is the child consuming? circle one or more numbers

Home-made porridge 1 Bought porridge 2 Non-breast milk (i.e. cow, goat etc) 3 specify if boiled before 4.yes 5.no Tea/water with sugar 6 Same as family (liquidised) 7 Same as family (not liquidised) 8 Other ______9

Section 2: Other foods only (no breast milk) 37. What other foods did the child consume during 2nd 6 months of weaning? Idem than above circle one or more numbers

Home made porridge 1 Bought porridge 2 Non-breast milk (e.g. cow) 3 specify, was it boiled? 4. Yes 5. No Tea/water with sugar 6 Same as family (liquidized) 7 Same as family (not liquidized) 8 Other ______9

38. At which age breast-feeding stopped completely? circle one number only < 6 months 1 7-12 months 2 13-18 months 3 10-24 months 4 25+ months 5

39. What types of food has the child consumed (In the last 3 days)* circle one or more numbers Staples 1 Meat/fish/animal products 2 Pulses/nuts 3 Oils/fats 4 Fruit/vegetables 5 Other foods ______7

40. What will be the solutions to avoid malnutrition in your family? (To be prepared) Food aid 1 Land 2 Seeds 3 Livestock 4 Food for cattle 5 other (specify) ______6

Annex 4: Plan of daily seminar for FS surveyors

PLAN OF DAILY SEMINAR FOR FS SURVEYORS

Time in Topics Methods Written Trainers Time minutes materials 09.00 – 10.10 1:10 1. AAH charter. Malika Cession 1 Interview Presentation 1. Main part (acquaintance, determination of expectations, agreement) 2. AAH activities and charter of organization 3. The objectives of the study

10.10-10.30 20 Presentation 2. Copy of the Malika Cession 2 Group discussion questionnaire 1. Questionnaire for the FS survey. 10.30-11.00 30 Coffee break 11.00-12.30 1:30 Presentation Malika Cession 2 (continue) Group discussion 1. Questionnaire for the FS survey. 12.30- 13.30 1:00 Lunch, game 13.30-14.30 1:00 Group discussion Malika Cession 3 Group work 1. Practicing of the questionnaire. 2. Discussion of the different situation during the survey 14.30-15.30 1:00 3. Role scenes Malika Work in groups 15.30-15.45 15 Coffee break 15.45- 16.15 30 1. Question and answers Discussion 3 Dividing of scenes Malika 16.15-16.40 20 Achievements of seminar, distribution of the Joint determination Questionnaires, Malika questionnaires, stationeries and