SAVING LIVES CHANGING INTEGRATED “SMART” STUDY LIVES District Umerkot Sindh, Pakistan November-2018 TABLE OF CONTENT Contents Acronyms .................................................................................................................................... 3 List of Tables ............................................................................................................................... 4 List of Figures .............................................................................................................................. 5 Acknowledgements .................................................................................................................... 6 Executive Summary .................................................................................................................... 7 Introduction .............................................................................................................................. 10 District Profile ........................................................................................................................... 10 Figure 2: District Map ................................................................................................................ 12 Survey Objectives ..................................................................................................................... 12 Specific objectives ..................................................................................................................... 12 Methodology ............................................................................................................................ 13 Meetings conducted with provincial and district authorities .................................................... 16 Training and Organization of Survey Team ............................................................................... 16 Ethical Consideration ................................................................................................................ 17 Data Quality Assurance Process ................................................................................................ 18 Data collection .......................................................................................................................... 18 Household questionnaires: ....................................................................................................... 19 Data entry and analysis: ............................................................................................................ 19 Results and Findings: ................................................................................................................ 20 Anthropometric Measurements (Based on WHO Standards 2006) ........................................... 20 Historical Trend of Malnutrition ............................................................................................... 28 Maternal Nutritional Status ...................................................................................................... 29 Nutrition Programme Coverage ................................................................................................ 29 Infant and Young Child Feeding Practices (IYCF) Children 0-23 months ..................................... 30 Page 1 of 43 Minimum Dietary Diversity (MDD) ........................................................................................... 31 Household Food Security Circumstance .................................................................................... 31 Household Coping Strategy ....................................................................................................... 32 Household Dietary Diversity (HDDS) ......................................................................................... 33 Child Morbidity ......................................................................................................................... 33 Mortality ................................................................................................................................... 34 Vaccination and Vitamin-A Coverage ........................................................................................ 35 Water, Sanitation and Hygiene (WASH) .................................................................................... 35 Conclusion ................................................................................................................................ 37 Recommendations: ................................................................................................................... 38 Annexure: I Plausibility Check ..................................................................................................... 0 Annexure: II List of Surved Clusters ............................................................................................. 0 Page 2 of 43 Acronyms ARI Acute Respiratory Infection BCG Bacillus Calmette Guerin CI Confidence Interval CMAM Community Based Management of Acute Malnutrition CMR Crude Mortality Rate DOH Department of Health ECHO European Civil Protection and Humanitarian Aid Operations ENA Emergency Nutrition Assessment EPI Expended Programme for Immunization FSL Food Security and Livelihood GAM Global Acute Malnutrition HH Household HDDS Household Dietary Diversity IYCF Infant and Young Child Nutrition HAZ Height-for-Age z-score LHW Lady Health Worker MAM Moderate Acute Malnutrition MDD Minimum Dietary Diversity MICS Multiple Indicator Cluster Survey MUAC Mid Upper Arm Circumference NGO Non-Government Organization NOC No Objection Certificate NSP Nutrition Support Program OTP Outpatient Therapeutic Programme PPS Probability Proportion to Size PLW Pregnant and Lactating Women RC Reserved Cluster RNT Random Number Table RTK Rapid Test Kit SAM Severe Acute Malnutrition SI Sampling Interval SMART Standardized Monitoring and Assessment of Relief and Transition TSFP Targeted Supplementary Feeding Programme UC Union Council U5MR Under Five Mortality Rate WASH Water, Sanitation and Hygiene WAZ Weight-for-Age z-score WFP World Food Programme WHZ Weight-for-Height z-score WHO World Health Organization Page 3 of 43 List of Tables Table: 1 Summary of Acute & Chronic Malnutrition Trends …………………………………………………..…… 7 Table: 2 History of WFP Programmes in Umerkot ………………………………………………………….………….10 Table 3 Sample Size for Anthropometry …………………………………………………………….…………….….. 14 Table: 4 Sample Size for Retrospective Mortality ……………………………………………….…………..………… 14 Table: 5 Distribution of Age and Sex of Sample ……………………………………………………………………… 19 Table: 6 Prevalance of Acute Malnutrition based on Weight-for-Height Z-Score and Sex …....20 Table: 7 Prevalence of GAM based on MUAC and Gender …………………..…………………………..……22 Table: 8 Prevalence of Acute Malnutrition by Age based on MUAC ……………………………….………23 Table: 9 Prevalence of stunting based on height-for-age z-scores and by Gender ……..…………24 Table: 10 Prevalence of stunting by age based on height-for-age z-scores ………………..……………24 Table: 11 Prevalence of Underweight based on Weight-for-Age Z-Score and by Gender …….……25 Table: 12 Prevalence of Underweight by Age based on Weight-for-Age Z-Score ……………………26 Table: 13 Prevalence of Acute Malnutrition in PLW ………………………………………………………..…….…27 Table: 14 CMR &U5MR …………………………………………………………………………………………………………..…33 Table: 15 Vaccination (BCG, Measles) and Vitamin-A coverage ……………………………………....…..…33 Page 4 of 43 List of Figures Figure: 1 District Facts ……………………………………………………………………………………………………………9 Figure: 2 District Map …………………………………………………………………………………………………………… 11 Figure: 3 Survey Teams Composition ……………………………………………………………….…………………….16 Figure: 4 Distribution of Sex by age group …………………………………….………………………………………. 20 Figure: 5 Prevalence of Acute Malnutrition by Age based on WHZ-Score ………….…………………… 21 Figure: 6 WHZ-Score Distribution ………………………………………………………………….……………….……. 21 Figure: 7 Cumulative Distribution of WHZ (Overall and gender) …………………………………..…………22 Figure: 8 Cumulative distribution of stunting (Overall and Gender) based on MUAC …………...…23 Figure: 9 HAZ-Score Distribution ……………………………………………………………………………...………….. 24 Figure: 10 Cumulative Distribution HAZ (Overall and gender) ……………….………………………………… 25 Figure: 11 WAZ-Score Distribution ……………………………………………………….………….……………………. 26 Figure: 12 Cumulative Distribution of WAZ (Overall and Gender) …………………………………………….26 Figure: 13 Historical Trend of Malnutrition in District Umerkot ………………………..………………………27 Figure: 14 Programme Covarage (Children OTP& TSFP and TSFP PLW) ……………………….…………..28 Figure: 15 IYCF Pratices …………………………………………………………………………………………..………………29 Figure: 16 Minimum Dietary Diversity for children age 06-23 months ……………………..………………29 Figure: 17 Source of income/livelihood …………………………………………………………….…………………… 30 Figure: 18 Household Dietary Diversity Score (HDDS) ………………………………………..………………….. 31 Figure: 19 Trends of Child morbidity and Health Services Seeking Behaviours …………………..…….32 Figure: 20 Health Services Seeking Behaviours …………………………………………………..…………………..32 Figure: 21 Water sources for drinking and personal hygiene …………………………..………………………34 Page 5 of 43 Acknowledgements World Food Programme (WFP), Pakistan hereby acknowledges the lead role of Provincial and District health authorities for timely conduct of the “Integrated SMART” Study in District Umerkot- Sindh. WFP in particular appreciates the timely approval initiatives of the “Director General Health Services-Sindh” for facilitating the smooth access to district