Nutrition Causal Analysis in 4 Upazila Satkhira District March 2014 ACF-International would like to thank the Satkhira District, Upazila and Union Authorities for their support and collaborations during the planning and implementation of the Nutrition Causal Analysis. ACF-International would also like to all the stakeholders who participated in the technical workshop to detail the hypotheses to be tested as well as the validation workshop for the rating of risk factors. The background information they provided was invaluable. The European Commission’s Humanitarian Aid department provided funds for the Nutrition Causal Analysis in the ACF-INT working areas of Satkhira district, alongside the other surveys that were conducted. Finally, ACF-International would especially like to thank all ACF staff that participated in the NCA – from providing input and advice on the issues facing Satkhira district, logistical arrangement to move around the field as well as assistance in the organisation, coordination and translation of all the fieldwork. Nutrition Causal Analysis - Satkhira i March 2014 Table of Contents Abbreviations ................................................................................................................................... 1 Executive Summary ........................................................................................................................ 2 1. Introduction .............................................................................................................................. 6 ACF-International in Bangladesh ..................................................................................................................... 7 ACF-International in Satkhira District ........................................................................................................... 8 Nutrition Causal Analysis Objectives .............................................................................................................. 8 2. Methodology ............................................................................................................................. 9 Background to the NCA methodology development ................................................................................ 9 The NCA Approach ................................................................................................................................................. 9 Location and Population of Study Area ............................................................................................ 14 3. Results ....................................................................................................................................... 15 3.1 Nutrition Situation in Satkhira ...................................................................................... 17 Prevalence of Undernutrition by Age and Gender ................................................................................. 18 Community Perceptions of Malnutrition ................................................................................................... 18 3.2 Immediate causes ............................................................................................................... 21 I. Acute Childhood Illness ............................................................................................................................. 21 II. Inadequate Dietary Intake ...................................................................................................................... 22 3.3 Underlying and Basic causes .......................................................................................... 23 A. Inadequate maternal and child care and feeding practices ............................................. 23 I. Inadequate Breastfeeding Practices ..................................................................................................... 23 II. Inappropriate Complementary Feeding Practices ........................................................................ 26 III. Low Birth Weight, Adolescent Pregnancies and Inadequate care for PLW ...................... 33 IV. Poor Female Psychosocial Care, Practices and Cultural Restriction .................................... 37 V. Unequal Intra-Household Food Distribution .................................................................................. 43 B. Poor Household Access to Sufficient, Safe and Nutritious Foods ................................... 44 I. Changing agricultural patterns and resulting consequences .................................................... 44 II. Limited Land Access and poor household Food Production .................................................... 47 C. Poor household access to quality health services and unhealthy environments ..... 51 I. Poor appropriate Health Seeking Behaviour .................................................................................... 51 II. Poor Water and Sanitation Quality ..................................................................................................... 53 III. Poor Hygiene Practices ........................................................................................................................... 56 3.4 Seasonality ............................................................................................................................ 58 Waterlogging ......................................................................................................................................................... 58 4. Discussion ................................................................................................................................ 62 5. Conclusion ............................................................................................................................... 66 Limitations of the NCA ....................................................................................................................................... 67 6. Recommendations ................................................................................................................ 70 7. Bibliography ........................................................................................................................... 71 8. Appendices .............................................................................................................................. 75 Nutrition Causal Analysis - Satkhira ii March 2014 List of Figures Figure 1: Nutritional Trends in Bangladesh [2,5,22] ......................................................................................... 6 Figure 2: CMAM Admissions in ACF/WFP nutritional centres ................................................................... 18 Figure 3: Hypothesised Pathways to Inadequate Breastfeeding Practices ........................................... 24 Figure 4: Hypothesised pathways for inappropriate complementary feeding practices ................ 27 Figure 5: Female Activity Clock ............................................................................................................................... 31 Figure 6: Nutrition in the Life Cycle[19] .............................................................................................................. 33 Figure 7: Hypothesised pathways for Low Birth Weight .............................................................................. 34 Figure 8: Hypothesised pathways for female psychosocial care ............Erreur ! Signet non défini. Figure 9: Decision making distribution ................................................................................................................ 40 Figure 10: Hypothesised Pathway for unequal intra-household food distributionErreur ! Signet non défini. Figure 11: Hypothesised pathways for changing agricultural practices ................................................ 45 Figure 12: Hypothesised pathway for household food production .......................................................... 47 Figure 13: Land Ownership and Land Cultivation Patterns ........................................................................ 48 Figure 14: Hypothesised pathways for health-Seeking behaviour ........................................................... 52 Figure 15: Hypothesised pathways on the impact of waterlogging ......................................................... 59 Figure 16: Local conceptual model of undernutrition ................................................................................... 69 List of Tables Table 1: Quantitative data collection plan........................................................................................................... 10 Table 2: Qualitative data collection plan.............................................................................................................. 11 Table 3: Rating matrix for different data sources ............................................................................................ 12 Table 4: Categorisation matrix ................................................................................................................................. 13 Table 5: Characteristics of selected villages ....................................................................................................... 14 Table 6: Anthropometric Indicators ...................................................................................................................... 17 Table 7: Community perception of causes, characteristics and