NUTRITION ANTHROPOMETRIC SURVEY Final report Battagram ... · PDF file1 NUTRITION ANTHROPOMETRIC SURVEY Final report Battagram, Balakot and Mansehra Districts Pakistan 10th April to

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NUTRITION ANTHROPOMETRIC SURVEY

Final report

Battagram, Balakot and Mansehra Districts Pakistan

10th April to 13th May 2006

Funded by: Action Contre la Faim

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Action Against Hunger, Nutrition Survey: North West Frontier Province, Pakistan, April/May 2006

ACKNOWLEDGMENTS

Action Against Hunger would like to thank UNICEF for providing equipment for the surveys and the MoH for the ongoing support of the nutrition program.

ACF-USA is also extremely grateful to the supervisors, measurers and Lady Health Workers (LHW’s)

from the supplementary feeding program for their assistance.

Final thanks go to the supervisors and measurers that participated in the surveys, and the community members for their cooperation and hospitality.

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LIST OF ABBREVIATIONS AAH Action Against Hunger AJK Azad Jammu and Kashmir Province ARI Acute respiratory infection BHU Basic health unit CI Confidence interval CMR Crude mortality rate DHQ District headquarter EPI Extended Programme of Immunization ERRA Earthquake Rehabilitation and Reconstruction Authority GAM Global acute malnutrition LHW Lady health worker MoH Ministry of Health MUAC Mid upper arm circumference NCHS National Centre of Health Statistics NWFP North West Frontier Province PKR Pakistani rupees RHC Regional health centre SAM Severe acute malnutrition SFC Supplementary feeding centre SFP Supplementary feeding programme TB Tuberculosis TFC Therapeutic feeding centre THQ Tertiary headquarter TMA Tehsil Municipal Authority U5MR Under-5 mortality rate WESNET Water, Environment and Sanitation Network WSB Wheat soya blend

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TABLE OF CONTENTS .I. INTRODUCTION.............................................................................................................................................................. 6

.I.1. CONTEXT ....................................................................................................................................................................... 6

.I.2. SECURITY AND POPULATION MOVEMENT ...................................................................................................................... 7

.I.3. ACCESS TO, AND AVAILABILITY OF FOOD...................................................................................................................... 8

.I.4. WATER AND SANITATION............................................................................................................................................... 9

.I.5. HEALTH AND CHILD CARE PRACTICES........................................................................................................................... 9 .I.5.1. The Health Care Systems ....................................................................................................................................... 9 .I.5.2. Morbidity and Mortality....................................................................................................................................... 10 .I.5.3. Childcare Practices.............................................................................................................................................. 11

.I.6. MALNUTRITION............................................................................................................................................................ 11

.I.7. THE SURVEY AREA ...................................................................................................................................................... 12 .I.7.1. Battagram............................................................................................................................................................. 12 .I.7.2. Balakot ................................................................................................................................................................. 12 .I.7.3. Mansehra.............................................................................................................................................................. 13

.II. OBJECTIVES................................................................................................................................................................. 14

.III. METHODOLOGY ....................................................................................................................................................... 14

.III.1. SAMPLING ................................................................................................................................................................. 14 .III.1.1. The Survey Area................................................................................................................................................. 14 .III.1.2. Population Data ................................................................................................................................................ 15 .III.1.3. Sample Size........................................................................................................................................................ 15 .III.1.4. Cluster Selection................................................................................................................................................ 15 .III.1.5. Household Selection .......................................................................................................................................... 16 .III.1.6. Selection of Subjects .......................................................................................................................................... 16

.III.2. DATA COLLECTION AND MEASUREMENT TECHNIQUES............................................................................................. 16 .III.2.1. The 6 to 59 months old Age Group .................................................................................................................... 16 .III.2.2. The Household................................................................................................................................................... 17 .III.2.3. The Survey Team ............................................................................................................................................... 18 .III.2.4. Data Collection and Entry................................................................................................................................. 18

.III.3. INDICATORS AND FORMULAE .................................................................................................................................... 18 .III.3.1. Acute Malnutrition............................................................................................................................................. 18 .III.3.2. Mid-Upper Arm Circumference (MUAC).......................................................................................................... 19 .III.3.3. Mortality ............................................................................................................................................................ 19 .III.3.4. Measles Vaccination Coverage ......................................................................................................................... 19

.IV. RESULTS ...................................................................................................................................................................... 20

.IV.1. NUTRITION ................................................................................................................................................................ 20 .IV.1.1. Battagram tehsil................................................................................................................................................. 20 .IV.1.2. Balakot tehsil ..................................................................................................................................................... 24 .IV.1.3. Mansehra tehsil.................................................................................................................................................. 27

.IV.2. MORTALITY .............................................................................................................................................................. 31 .IV.2.1. Battargam .......................................................................................................................................................... 31 .IV.2.2. Balakot............................................................................................................................................................... 31 .IV.2.3. Mansehra ........................................................................................................................................................... 31

.IV.3. MEASLES VACCINATION COVERAGE......................................................................................................................... 32

.IV.4. RESIDENTIAL STATUS AND HOUSEHOLD SIZE ........................................................................................................... 32

.V. DISCUSSION.................................................................................................................................................................. 32

.V.1. PREVALENCE OF MALNUTRITION ............................................................................................................................... 32

.V.2. AT RISK GROUPS ........................................................................................................................................................ 34

.V.3. MEASLES VACCINATION COVERAGE .......................................................................................................................... 35

.V.4. LIMITATIONS TO THE STUDY ...................................................................................................................................... 35

.V.5. CONCLUSION .............................................................................................................................................................. 36

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.VI. RECOMMENDATIONS.............................................................................................................................................. 37

.VII. REFERENCES ............................................................................................................................................................ 38

.VIII. APPENDICES............................................................................................................................................................ 39

.VIII.1. POPULATION DATA AND CLUSTER SELECTION ....................................................................................................... 39

.VIII.2. ANTHROPOMETRICS AND RETROSPECTIVE MORTALITY SURVEY QUESTIONNAIRES (THE SAME BASIC QUESTIONNAIRES WERE USED FOR EACH SURVEY) .............................................................................................................. 43 .VIII.3. ED FOR EACH SURVEY)............................................................................................................................................ 43

LIST OF TABLES TABLE 1 GAM AND SAM USING Z-SCORE AND PERCENTAGE OF THE MEDIAN ...................................................................... 18 TABLE 2 CLASSIFICATION OF THE NUTRITIONAL STATUS USING MUAC ................................................................................ 19 TABLE 3 AGE AND SEX DISTRIBUTION OF THE SAMPLE POPULATION– BATTAGRAM, NWFP, PAKISTAN (APRIL/MAY 2006).. 20 TABLE 4 PERCENTAGE SEVERE AND GLOBAL ACUTE MALNUTRITION– BATTAGRAM, NWFP, PAKISTAN (APRIL 2006).......... 21 TABLE 5 PREVALENCE OF THE TYPES OF MALNUTRITION– BATTAGRAM, NWFP, PAKISTAN (APRIL 2006) ............................ 21 TABLE 6 SEVERE AND MODERATE ACUTE MALNUTRITION BY SEX – BATTAGRAM, NWFP, PAKISTAN (APRIL 2006).............. 22 TABLE 7 SEVERE AND MODERATE ACUTE MALNUTRITION BY AG – BATTAGRAM, NWFP, PAKISTAN (APRIL 2006) ............... 22 TABLE 8 MID-UPPER ARM CIRCUMFERENCE – BATTAGRAM, NWFP, PAKISTAN (APRIL 2006) ............................................... 23 TABLE 9 AGE AND GENDER DISTRIBUTION OF THE SAMPLE POPULATION – BALAKOT, NWFP, PAKISTAN (APRIL 2006) ........ 24 TABLE 10 PERCENTAGE SEVERE AND GLOBAL ACUTE MALNUTRITION – BALAKOT, NWFP, PAKISTAN (APRIL 2006)............ 25 TABLE 11 PREVALENCE OF THE TYPES OF MALNUTRITION – BALAKOT, NWFP, PAKISTAN (APRIL 2006) .............................. 25 TABLE 12 SEVERE AND MODERATE ACUTE MALNUTRITION BY SEX – BALAKOT, NWFP, PAKISTAN (APRIL 2006)................. 25 TABLE 13 SEVERE AND MODERATE ACUTE MALNUTRITION BY AGE– BALAKOT, NWFP, PAKISTAN (APRIL 2006)................. 26 TABLE 14 MID-UPPER ARM CIRCUMFERENCE – BALAKOT, NWFP, PAKISTAN (APRIL 2006) .................................................. 27 TABLE 15 AGE AND SEX DISTRIBUTION OF THE SAMPLE POPULATION – MANSEHRA, NWFP, PAKISTAN (MAY 2006) ............ 27 TABLE 16 PERCENTAGE SEVERE AND GLOBAL ACUTE MALNUTRITION – MANSEHRA, NWFP, PAKISTAN (MAY 2006)........... 28 TABLE 17 PREVALENCE OF THE TYPES OF MALNUTRITION – MANSEHRA, NWFP, PAKISTAN (MAY 2006) ............................. 28 TABLE 18 SEVERE AND MODERATE ACUTE MALNUTRITION BY SEX – MANSEHRA, NWFP, PAKISTAN (MAY 2006) ............... 29 TABLE 19 SEVERE AND MODERATE ACUTE MALNUTRITION BY AGE – MANSEHRA, NWFP, PAKISTAN (MAY 2006)............... 29 TABLE 20 MID-UPPER ARM CIRCUMFERENCE – MANSEHRA, NWFP, PAKISTAN (MAY 2006)................................................. 30 TABLE 21 MEASLES VACCINATION COVERAGE FOR CHILDREN ≥9 MONTHS – NWFP, PAKISTAN (APRIL/MAY 2006)............. 32 TABLE 22 HOUSEHOLD INFORMATION – NWFP, PAKISTAN (APRIL/MAY2006)...................................................................... 32

LIST OF FIGURES FIGURE 1 THE AFFECTED AREA ................................................................................................................................................ 6 FIGURE 2 ADMISSIONS OF MODERATE ACUTE MALNUTRITION TO THE AAH SFCS (THE X-AXIS SHOWS EACH MONTH

DIVIDED INTO REPORTING WEEK). .................................................................................................................................. 12 FIGURE 3 THE AREAS COVERED BY THE SURVEYS (NB, NOT ALL AREAS SHOWN ON THIS MAP WERE INCLUDED IN THE SURVEY,

REFER TO APPENDIX 1 FOR DETAILS)............................................................................................................................... 13 FIGURE 4 AGE AND GENDER DISTRIBUTION OF THE SAMPLE POPULATION – BATTAGRAM, NWFP, PAKISTAN (APRIL/MAY

2006)............................................................................................................................................................................... 20 FIGURE 5 WEIGHT-FOR-HEIGHT DISTRIBUTION (Z-SCORE) – BATTAGRAM, NWFP, PAKISTAN (APRIL 2006) ......................... 23 FIGURE 6 AGE AND SEX DISTRIBUTION OF THE SAMPLE POPULATION – BALAKOT, NWFP, PAKISTAN (APRIL 2006) .............. 24 FIGURE 7 WEIGHT-FOR-HEIGHT DISTRIBUTION (Z-SCORE) – BALAKOT, NWFP, PAKISTAN (APRIL 2006) .............................. 26 FIGURE 8 AGE AND GENDER DISTRIBUTION OF THE SAMPLE POPULATION – MANSEHRA, NWFP, PAKISTAN (MAY 2006) ...... 28 FIGURE 9 WEIGHT-FOR-HEIGHT DISTRIBUTION (IN Z-SCORE) – MANSEHRA, NWFP, PAKISTAN (MAY 2006)......................... 30

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.I. INTRODUCTION

.I.1. Context

On 8thOctober, 2005, an earthquake measuring 7.6 on the Richter scale struck the northern regions of Pakistan. The epicenter of the earthquake was close to Muzaffarabad, the capital city of Azad Jammu and Kashmir province (AJK). It has been estimated that more than 75,000 people were killed, and as many as 2.8 million became homeless. The population affected by this earthquake was distributed over a relatively large region– encompassing AJK and the North West Frontier Province (NWFP), which in many places is extremely remote and mountainous (see Figure 1). Following an assessment done by WFP/UNICEF, it was estimated that 84% of the affected population was from rural areas. Figure 1 The Affected Area

Within days, the Pakistan military, the UN, and other international organizations started providing aid to people in and around the urban areas (particularly Muzaffarabad, Abbottabad, Mansehra and Battagram), and to assess the relief requirements in more remote locations. The impact of the earthquake, combined with poor weather conditions, made it extremely difficult to reach many of the affected areas. Numerous roads were completely impassable due to landslides, and organizations working in the area had to rely on a limited number of helicopters to transport shelter and other relief items. This led to a surfeit of organizations working in some locations, and few or none in others. At the end of October, it was estimated that 20% of the affected population had not received aid due to inaccessibility. Efforts were hampered further by the regular aftershocks that occurred in the weeks following the earthquake.

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Tent camps were established in or close to the urban centers by the Pakistan Army and UNHCR. Initially, only a minority of the population chose to move to these settlements. Many were extremely reluctant to leave their land, even in areas that had been rendered extremely unstable following the earthquake (for example Allai valley). NWFP and AJK are very conservative regions, and the men were unwilling to bring their wives and families to the populated areas. Tribal and village conflicts also complicated the movement of households to the camps. Over the next couple of months, a steady flow of people arrived to existing camps or established new settlements, but a large number remained in their villages. Many of the camps (spontaneous and official) had insufficient number of tents, and inadequate water and sanitation facilities for a number of weeks after the earthquake. Weather conditions in November and early December were not as severe as predicted, but by early January, heavy snow arrived to the mountain areas. This inevitably impeded the distribution of aid and prompted an influx of people from these regions to the camps. It was firmly stated that the camps would be only temporary and the Government announced that they would officially be closed at the end of March 2006. Interviews done in January among the displaced families indicated that while many were keen to return to their villages as soon as the winter ended and roads/bridges were repaired, some were reluctant to leave the camps. In a number of cases this was the result of the psychological trauma, and for others it was because their entire communities had been destroyed and they felt they had no reason to return. From February to early March, families gradually started to move back to their villages. IOM provided transportation to assist families in returning to their homes and by the beginning of April 2006, the camps were virtually empty. One or two camps have been left open to cater for people who are unable to return to their homes, however, only a small number of families currently live in these camps. In March 2006, the Government handed responsibility for the reconstruction of the affected area to ERRA (Earthquake Reconstruction and Rehabilitation Authority), marking the transition from the emergency phase to re-development. ERRA has identified 11 key areas (including housing, health, water/sanitation, livelihoods, agriculture, and education) for the rehabilitation process, and at the time of writing, also established strategies for a number of these areas. To compensate people affected by the earthquake, the Government gave 100,000 PKR (Pakistani rupees) for each family member that was killed as a result of the earthquake (this money was distributed at the end of 2005). At the beginning of 2006, they provided an initial 25,000 PKR for each house that was destroyed or damaged in order to assist families with short-term shelter. In May 2006, a further 75,000 PKR was distributed to all those that received the initial 25,000 PKR so that re-building can start. A second installment of 25,000 PKR will be given to each family on completion of the base of a house, and a final installment of 50,000 PKR on completion of the walls. The army will be responsible for overseeing this process.

.I.2. Security and Population Movement

The area of NWFP and AJK has historically been relatively volatile; AJK is involved in the long running dispute between India and Pakistan concerning Kashmir, and NWFP has a number of ‘tribal’ areas where Pakistani law does not apply. There are places that were affected by the earthquake that are difficult to access as a result of these issues. However, with the exception of some small scale fighting during distributions, the security situation in the region has not worsened as a result of the earthquake. The most significant security concern since October 2005 was the protests that took place in February 2006 as a result of the publication of cartoons depicting the Prophet Mohammed in the Danish media. During this period, movement of international humanitarian staff was more limited. As mentioned previously, since the initial earthquake in October 2005, there have been frequent aftershocks, and also, subsequent smaller earthquakes– particularly in Balakot and Battagram. This has led to frequent landslides, which obviously has affected movement in these regions. Many families who were not displaced by the earthquake, or who have since returned to their villages, are still sleeping in tents, but living during the day in their houses. The site of Balakot town has been declared unsafe and the Government has announced that it plans to relocate the town to an area closer to Mansehra. This has resulted in some unrest among the Balakot

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community. This population is not allowed to start any reconstruction, but there has been no set decision about when and exactly where the new town will be built. In addition to the population movement caused by the earthquake, there is a biannual movement of sheep/goat farmers between the lowland areas and the mountain pastures. In April/May 2006, Gujar families that had spent the winter in and around Mansehra and Balakot began their normal migration up in to the Kaghan valley. They will return to the lowland areas in September/October.

.I.3. Access to, and Availability of Food

Prior to the earthquake, the affected areas were already some of the most food insecure in Pakistan. It was estimated that food expenditure accounted for at least half the household income. In the rural areas of NWFP and AJK, families rely on farming, livestock and casual work. Planting of rice and maize starts in April/May and harvesting takes place in September/October. The second planting season (for wheat) starts in October/November, and the crop is harvested between June and August. Livestock is a particularly important asset for families living in the mountainous areas, where there is less arable land. During the winter months (October to February), people bring their animals down to the valleys, and keep them in shelters. In urban/semi-urban areas, sources of employment are more varied, and access to food is less precarious. While families living in urban areas have a relatively varied diet (including fresh fruits, vegetables and meat), in rural areas, this is more limited. The basic rural diet comprises wheat/maize flour flat bread, rice, vegetables (generally cooked in soy oil), lentils and black tea. If a household has access to livestock, they might also have buffalo milk, eggs and meat. Chicken is the least expensive meat, followed by buffalo, goat and sheep. When the earthquake struck, the rice and maize had only been partly harvested. It was difficult for families to access the remaining harvest because of damage caused by the earthquake. In addition, because wheat seed stocks tend to be kept inside houses, a large amount was buried during the earthquake. More than half the households surveyed by WFP/UNICEF in October 2005 reported that they had lost their entire seed stock. Furthermore, one-quarter of livestock was believed to have been killed, and there was a lack of adequate winter shelter for the surviving animals. A joint assessment by WFP/UNICEF/WHO/Ministry of Health (MoH) in December 2005 found that loss of employment following the earthquake had largely affected those that relied on casual laboring jobs (i.e. people from more rural areas). The livelihoods of the urban/semi-urban communities have been less severely affected, and during the WFP/UNICEF assessment in October 2005, it was anticipated that this population would recover more quickly than those from the rural areas. Although, the earthquake damaged the commercial areas, at the time of the surveys, shops and markets had been re-established in the main settlements. Even among the most affected population, households did not resort to extreme coping strategies, and in general, there was little selling of assets following the earthquake. As a result of the initial assessment by WFP/UNICEF, it was estimated that 2.3 million people were in need of food assistance for at least 2 months in urban zones and 4 months in rural areas. WFP, in conjunction with a number of implementing partners (including international NGOs) began distributing a food ration in October 2005. The standard ration provided by WFP comprises (per person per day): • 450 g wheat flour • 50 g pulses • 30 g vegetable oil • 5 g iodized salt • 100 g “high energy biscuits” (BP5) • 80 g dates The initial proposal by WFP was to distribute this ration to one million people for 6 months and, where possible, it has been provided on a monthly basis. Organizations have also supplied cooking equipment to replace the losses resulting from the earthquake, and in some camps cooked meals were provided to families. In December, the Government took responsibility for food distribution in a number of areas of Mansehra district.

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The last ration was provided to the camps in March 2006, but food is still being distributed to residents of affected areas. To ensure food security for affected families in the long-term, a number of organizations have distributed livestock, seeds and farming equipment. Wheat has certainly been planted in a number of areas covered by this survey, but it is not clear how this compares with the 2004/2005 season.

.I.4. Water and Sanitation

The water supply system in NWFP/AJK is mainly the responsibility of the Tehsil Municipal Administrations (TMA’s) or the Public Health Engineering division of the Government’s Works and Services Department. Before the earthquake, urban zones (including Battagram, Balakot and Mansehra) had water treatment plants, and a piped network serving parts of the community. There were numerous natural springs, wells, and hand pumps in rural areas, and also, in some locations in the urban areas. Latrines were common in urban/semi-urban settlements, and less so in rural regions. There do not seem to be any reliable statistics concerning the proportion of the population that had access to clean water or latrines prior to the earthquake. Research done by UNICEF/WFP/WHO/MoH in December 2005 found that hygiene practices among families were relatively poor. Although, people reported washing their hands before eating and after defecating, few stated that they washed their hands before feeding infants, preparing food or after disposing of infant/child feces. Following the earthquake, the water supply systems in the regions were heavily disrupted. Treatment plants, storage reservoirs, mains supplies, and distribution networks were destroyed or badly damaged. Wells and springs now have a lower yield, and in some places water sources dried up or were buried by landslides. Rivers and streams have become contaminated. Household latrines, sewage networks drains and solid waste management systems were also damaged. Immediately after the earthquake, the priority of humanitarian organizations was to provide clean water and latrines, particularly to the camps. In the months following the earthquake, temporary water treatment plants, storage tanks, water quality monitoring and solid waste disposal systems were implemented. Hygiene promotion has also been done in schools and communities, and families have been supplied with hygiene kits (including soap). Hand washing areas have been established in schools and community areas, and 10 ‘warm baths’ were constructed in and around Balakot. The rehabilitation of the water supply and waste disposal systems in the affected regions will be a long process– ERRA has developed a strategy for these activities, but at the time of writing, no work has started. It is felt that the semi-urban/urban areas are in the most critical state when it comes to water/sanitation. These communities live in close proximity to each other, and there are less springs, wells and hand pumps to compensate for the loss of the piped network. In the rural areas, water/sanitation conditions are not ideal, but do not appear to have deteriorated significantly as compared to the conditions before the earthquake.

.I.5. Health and Child Care Practices

.I.5.1. The Health Care Systems

Before October 2005, there was a reasonable public and private health care system operating in the region. The public health care system operated on a four-tier system: (i) basic health units (BHU’s), (ii) regional health centers (RHC’s), (iii) tertiary head quarter (THQ) hospitals, and (iv) district head quarter (DHQ) hospitals. In addition, there were a number of ‘health houses’ that were operated by lady health workers (LHW’s), which provided primary health care, family planning, growth monitoring, immunizations and antenatal care. Within the public health system, there is no cost for consultations, but families are required to pay for medication and investigations (there is also a 5 PKR prescription charge). In some areas affected by the earthquake, women (and their children) have limited access to adequate health care, because it is not culturally acceptable for them (i) to leave the home without their husband, or (ii) to be seen by a male doctor.

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Public buildings (including schools and health centers) were some of the most seriously affected by the earthquake. It has been estimated that 40.9% of health centers in NWFP and AJK were completely destroyed, 23.2% are in need of rehabilitation, and the remaining 35.9% require assessment to establish whether they will be able to withstand subsequent earthquakes. 58.7% of health houses in NWFP were completely destroyed. The health system was paralyzed further by the damage/destruction of medical equipment and transport, and most significantly, by the death of hundreds of health workers. In response, the MoH, national and international organizations established a number of field hospitals and medical facilities in the affected areas, and many of these will continue to operate during the rehabilitation phase. ERRA has released the strategy for the re-development of the health system, known as the Essential Services Delivery Package. The basic structure will remain the same as before the earthquake, but it is planned that smaller centers will be integrated into the RHC’s, and that mobile health units will cover more remote areas. It is also planned that LHW’s will provide nutrition education, and THQ/DHQ hospitals will incorporate therapeutic feeding centers (TFC’s) to treat severe acute malnutrition. As for the water/sanitation strategy, no significant work has started as yet regarding the permanent rehabilitation of the health system.

.I.5.2. Morbidity and Mortality

The common diseases affecting young children in this part of Pakistan are acute respiratory infections (ARI’s – generally during the winter period), and diarrhea (mainly during the rainy season, June to August). There are occasional outbreaks of measles, and malaria is relatively common (although prevalence is low during the winter months). Tuberculosis (TB) and hepatitis are also a problem in some areas. Prior to the earthquake, the MoH ran an Extended Program of Immunization (EPI) from the health centers, and children were routinely vaccinated against measles, polio and a number of other diseases, including hepatitis B and tetanus. Only polio vaccinations were done on a house-by-house basis, for others, the EPI program relied on families to go to the health centers. Iron and iodine deficiencies are both common in Pakistan. It has been estimated that 55% of children have sub-clinical iron-deficiency anemia. Although iodized salt is readily available in urban/semi-urban areas, it is not thought to be commonly used in rural areas. It is difficult to assess the extent to which the health of young children deteriorated as a result of the earthquake. However, it is likely that incidence of ARI’s and diarrhea increased compared to before the earthquake because of the lack of appropriate accommodation, camp living conditions and poor sanitation/hygiene. Prevalence of ARI’s and diarrhea/bloody diarrhea was high in the months following the earthquake, and there were some cases of cholera reported from the tent camps. The drop in temperatures in early January led to an increased morbidity and mortality due to ARI’s, particularly pneumonia. Scabies has become a problem in many communities, and a prevention campaign was launched in the beginning of December 2005. As a result of the damage to the water systems, hepatitis (particularly E) has become more prevalent in some areas (for example in parts of Balakot tehsil). There were a number of cases of measles reported following the earthquake, which prompted a vaccination campaign throughout the region. The first phase of this campaign took place in October 2005, and the second phase in November 2005. A third phase was done in Mansehra district in February 2006. During the first phase, not all children were given vaccination cards. In Battagra, the coverage from these campaigns was estimated to be 75%. Coverage in Mansehra is not clear because the numbers vaccinated seem to exceed the target population. National polio immunization days were held in March 2006. Routine vaccinations have continued from the remaining health centers, with children being given vitamin A supplements in addition to normal immunizations due to ‘outbreaks’ of night blindness. In a study done by UNICEF/WFP/WHO/MoH in December 2005, the crude mortality rate based on the camp populations in NWFP for the day of the earthquake was estimated to be 489 deaths/10 000 persons/day (95% CI: 425–560). The risk of mortality among the children under 5 year of age on this day (based on the NWFP camp population) was 7.6%.

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.I.5.3. Childcare Practices

The majority of women in NWFP and AJK claim to breastfeed their infants. In a survey done by UNICEF/WFP/WHO/MoH in December 2005, 90% of women reported breastfeeding their infants at some point between 0 and 24 months. However, few women breastfeed exclusively (data from UNICEF states that as few as 16% of infants <6 months are breastfed exclusively), and weaning can be abrupt. Infants tend not to be put to the breast immediately as there is a common belief that breast milk is not appropriate until the child is at least a day old. Instead they are given honey, rose water, black tea or cow/goat milk (the milk is warmed before being given to the child, but not always boiled). The colostrum is discarded. Breastfeeding is done on demand, but in majority of cases, it is stopped when the mother becomes pregnant again. In an assessment done by Action Against Hunger (ACF-USA) in December 2005, mothers reported that they introduced complementary foods prior to 6 months if they felt they did not have sufficient breast milk. The early complementary diet generally consists of cow/buffalo milk (in fact there is a tendency to give cow’s milk to relatively young infants), black tea, powdered infant formula and water. After 6 months, semi-solid foods are introduced, for example, eggs, rice, pulses/lentils, bread, biscuits, potatoes and fruit. Families start to give more solid foods when the child develops teeth. Following the earthquake, it was estimated that as many as 20% of women completely stopped breastfeeding as a result of psychological trauma. Psychological disturbance also resulted in loss of appetite among children. The assessment done by AAH in December 2005 found that half the families interviewed had not changed the frequency or composition of meals given to their children following the earthquake. Reasons given for changing the diet of the children included (i) lack of money to purchase foods, (ii) loss of animals (traditionally a source of milk for children), (iii) depression/psychological trauma for the mother.

.I.6. Malnutrition

There were a number of risk factors for malnutrition that were common throughout the region covered by these surveys before the earthquake. Many of these have already been discussed, for example, breastfeeding and hygiene practices, complementary diet, access to health care and lack of dietary diversity. This is clearly illustrated by the fact that chronic malnutrition in NWFP has consistently been high over the last 15 years or so (prevalence around 35 to 40%). Acute malnutrition has also remained poor throughout this same period. In the 1990/1991 (December–May) Demographic and Health Survey, global acute malnutrition (GAM) was estimated to be 6.7% and severe acute malnutrition (SAM) 1.9% for children <5 years of age in NWFP. The WHO Global Database on Child Growth and Malnutrition notes that for NWFP, GAM was 9.1% and SAM 1.1% in February–August 1994 and 11.0% and 2.7% in September/October 2001. A survey completed by UNICEF/WFP/WHO/MoH soon after the earthquake (December 2005) found 10.5% GAM and 4.7% SAM in Mansehra district, and 6.0% GAM and 3.2% SAM in the camps in NWFP (SAM may actually have been lower than this because it has been suggested that a number of oedema cases were misdiagnosed during this survey). Although, the survey indicated that a prevalence of acute malnutrition did not significantly increase in the months immediately following the earthquake, assessments done in the affected areas in December/January suggested that risk factors for malnutrition were likely to increase over the winter period. The possibility of extreme cold, lack of adequate shelter and food stocks, and poor sanitation in the camps prompted ACF-USA to establish supplementary feeding centers (SFC’s) in key areas in Mansehra, Balakot and Battagram tehsils in February 2006. The seven centers provide a wheat soya blend (WSB)-based dry ration on a weekly basis to children with moderate acute malnutrition. The centers include a CTC program (using Plumpy Nut) for children with severe acute malnutrition. In April 2006, the centers started ‘passive’ screening within the communities referring children based on mid-upper arm circumference (MUAC). In March 2006, UNICEF established a TFC in Mansehra DHQ hospital to treat severe acute malnutrition. A TFC has also been set up in the field hospital in Battagram town As shown in Figure 2, the number of admissions to the SFC’s in Battagram, Balakot and Mansehra tehsils has tended to decrease since the initial opening of the program. The conditions during the winter months (and hence, some of the risk factors for malnutrition) were not as severe as anticipated. The current surveys were

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done in order to establish whether acute malnutrition has in fact been exacerbated as a result of the earthquake, and whether a supplementary feeding program (SFP) is still required in these regions at this point. Figure 2 Admissions of moderate acute malnutrition to the AAH SFCs (the x-axis shows each month divided into reporting week).

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February March April May

Num

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Battagram Balakot Mansehra

.I.7. The Survey Area

.I.7.1. Battagram

The region of Battagram tehsil that was covered by the survey is traditionally relatively poor, and extremely conservative. It is also extremely mountainous with the steep valley of the Indus River marking the boundary between Battagram and the neighboring Changla and Besham districts. Pashto is the predominant language. Battagram was heavily affected by the earthquake, but humanitarian assistance was distributed to people living close to the urban centers relatively quickly. More remote settlements did not receive assistance immediately; however, a number of organizations have provided relief items in the months since the earthquake.

.I.7.2. Balakot

Settlements far from the urban areas in Balakot tehsil are also traditionally poor, and relatively conservative. The area was a popular tourist destination (particularly for Pakistani families), and many small settlements up in to the Kaghan valley heavily relied on the income from this industry. Hindko is the main language spoken in the region. Balakot was one of the most severely affected regions. Balakot town itself was almost entirely destroyed, and the death toll was significant. Access to the mountainous areas was particularly difficult due to the destruction of the main roads. Reconstruction in and around Balakot has been delayed because the area has been designated a seismic ‘red zone’.

13


.I.7.3. Mansehra

Mansehra tehsil is less mountainous and less conservative when compared with Battagram and Balakot. It is a relatively cosmopolitan area as many families from other parts of the country (and from Afghanistan) have moved to the region over the last few decades. Pashto, Hindko and Urdu are the main languages spoken in the region. The urban/semi-urban areas around Mansehra city have generally not been as affected by the earthquake as compared to Battagram and Balakot. Unfortunately, it has not been possible to include the most affected areas to the north of the tehsil in these surveys

Figure 3 The areas covered by the surveys (NB, not all areas shown on this map were included in the survey, refer to Appendix 1 for details)

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.II. OBJECTIVES

• To estimate the global and severe acute malnutrition (GAM and SAM respectively) rates among children ages 6–59 months in Battagram, Balakot and Mansehra tehsils.

• To identify groups at higher risk of malnutrition.

• To estimate the mortality rate among children less than 5 years of age, and the crude mortality rate of the total population living in the area covered by the surveys.

• To assess the measles immunization coverage among children ages 9–59 months.

• To make recommendations for future orientations of the programs.

.III. METHODOLOGY

.III.1. Sampling

.III.1.1. The Survey Area

Three anthropometric surveys were done in the earthquake-affected zones in Battagram, Balakot and Mansehra tehsils1. The region that will be covered by each survey is the approximate ‘catchment’ area of the ACF-USA nutrition activities. At present, three SFC’s are operating in Battagram tehsil, two in Balakot tehsil and two in Mansehra tehsil. The earthquake has not directly affected the area around the centers, and majority of the population that was displaced to the region following the earthquake has now left. All settlements that are within approximately 10km of the SFC’s in Battagram, Balakot and Mansehra tehsils were eligible for inclusion in these surveys, with the following exceptions: • Settlements with an estimated population of less than 250 (or 35 households). Due to population

displacement, many smaller villages are only partly inhabited at present, and some population data has been based on the number of houses in a settlement (inhabited or uninhabited) rather than on the number of actual people present.

• Villages in areas currently inaccessible due to dangerous/poor road conditions. • Areas that have been covered recently by surveys done by other organizations (mainly in Allai tehsil to the

north of Battagram tehsil). For both/three areas, the supervisors and screeners working in the SFP were consulted to confirm the approximate distance of the settlements from the SFC’s.

1 A tehsil is a sub-division of a district; Balakot tehsil is part of Mansehra district and Battagram tehsil is part of Battagram district.

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.III.1.2. Population Data

Population estimates for the survey area in Battagram tehsil were obtained from the TMA in Battagram. This information was given by ‘mauza’ – a mauza encompasses a group of small villages in close proximity to each other, and was updated at the beginning of 2006. There are seven communities within the catchment area of one SFC in Battagram that are located in the Changla district and Allai tehsil (not within the boundary of Battagram tehsil). The Nutrition Survey Manager and the supervisor from the SFC estimated the population for these villages during the visits to the area. Similar data (categorized by mauza) were made available for Balakot and Mansehra tehsils by the UN Humanitarian Information Center. The tent camps that were established following the earthquake were officially closed at the end of March 2005. It was anticipated that the majority of the population would have left by this date, and in fact the anticipated population figures for the camps in and around Battagram, Balakot and Mansehra (obtained from UNHCR) for the period of the survey was less than 350. Any remaining tent camps that were located within the boundaries of one of the 30 clusters were considered to be part of that settlement and included in the survey. It is important to acknowledge that the population figures for this area are not likely to be particularly reliable. There has been a lot of population movement since the earthquake and even prior to this, there was no accurate system for establishing population numbers in more remote areas. The cluster selection for each survey can be found in Appendix 1.

.III.1.3. Sample Size

A two-stage random cluster sampling method was used for each survey. In order to estimate the prevalence of GAM with 95% confidence, using cluster sampling, assuming a design effect of 2, it is necessary to survey at least 900 children between ages 6–59 months per survey. Hence, a standard 30×30 survey was done in each area described above. As a safety margin, two additional children were surveyed per cluster (making a total of 32) to allow for replacement of aberrant data. At least 32 households per cluster were interviewed for the anthropometrics and mortality survey.

.III.1.4. Cluster Selection

Recent studies in the region have shown that there are on average 1.2 children <5 years of age per household. The average household size is reported to be approximately 7, which means that 17% of the total population is less than 5 years old. The under 5 years of age population was calculated using the estimated total population figures and proportional sampling was then used to select 30 clusters for each survey (Battagram, Balakot and Mansehra). First, the sampling interval was calculated as follows: Sampling interval = total number of children ages 6–59 months/number of clusters Next, a number between 1 and the sampling interval was selected using a random number table, and this determined the position of the first cluster. The remaining clusters were then chosen by adding the sampling interval to this random number until a total of 30 clusters had been selected. Each selected cluster was visited prior to starting the survey so as to meet with community members, to discuss the survey and identify the boundary and center of the cluster. During the visits for the Battagram survey, it became apparent that one village originally selected for inclusion had less than 35 houses (Bishkot), and so it was replaced by a village that was randomly chosen from those that are geographically close to the original village (Battley). One village (Habib Banda) was extremely difficult to access due to road damage caused by an earthquake that occurred a few days before the visit, and this was also replaced with a village (Jesol) randomly chosen from those nearby (see Appendix 1). During the preparation for the Balakot survey, one village (Kanshian) was found to be inaccessible due to severe landslides, and this was replaced by a village that was randomly selected from those that that were geographically close to Kanshian (Batkerrer).

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.III.1.5. Household Selection

In order to select the households to include in the survey, the survey team started at the center of each cluster. The team leader threw a pen into the air, and then walked in the direction indicated by the pen from the center of the area to the boundary. They made a note of each house along this route, and then numbered the houses. Using a random number table, they selected the first house to visit from this list. After visiting this house, they went to the nearest house to the right of this first house, continuing in this manner until the required number of children and houses had been surveyed. When the teams reached the boundary of the village, or returned to the center, they spun the pen again, and repeated the above procedure in a different direction.

.III.1.6. Selection of Subjects

All children between the ages 6 to 59 months, from all families living in the selected households were included in the survey. The survey teams were asked to make note of any children who were temporarily absent from the house, and arranged a time later in the day when the child had returned to ensure that all the children from each household were included in the survey. If the child still can not be found on the second visit, they are registered as absent, and are not be replaced by another child. If more than 5% of children are found to be absent during the survey (48 in total), then additional clusters will be selected at random and surveyed to ensure a sufficient sample size. The survey teams will be required to locate and take measurements from any children from a selected household who are in a treatment center (TFC, hospital etc.) at the time of the survey. Orphans in the care of another mother/grandparents etc. were considered as part of the family, and thus, were also included in the survey. Children who had a physical disability or abnormality, or who were only visiting a selected household, were not included. The survey teams were asked to refer to the Nutrition Survey Manager in the event that they were unable to decide which households or children to select. If a team is unable to complete a cluster, they will go to the nearest settlement (within the pre-defined survey area) that has not already been selected for the survey.

.III.2. Data Collection and Measurement Techniques

Data were collected from each of the selected households in order to achieve the objectives stated above. The majority of this information related only to the children in the household who were 6 to 59 months of age, however, some applied to the household in general.

.III.2.1. The 6 to 59 months old Age Group

In order to assess nutritional status and measles immunization history, the following information was recorded by the survey team for each child ages 6 to 59 months in the selected households (see Appendix 2): • Age: The age (in months) of the children was, in the first instance, established by asking the mother for the

birth date of the child. If the mother did not know the birth date, the approximate age was determined using a local events calendar (which was developed prior to starting the survey).

• Sex: Male children were recorded as ‘1’ and females as ‘2’. • Weight: Children were weighed in kilograms, to the nearest 0.1kg, using 25kg hanging sprint Salter scales,

graduated to 100g. The scale was hung from a stick held by two measurers, and recalibrated to zero before the child was put into the weighing pants. Although the teams attempted to weigh all children without clothing, in some areas this was not culturally acceptable. For children who were weighed with clothing, 0.1kg was subtracted if they were half dressed (trousers or top) and 0.2kg if they were fully dressed (the average weight of children’s clothing was calculated from beneficiaries attending the SFC’s). Each morning the scales were checked by the Nutrition Survey Manager using a standard weight of 2kg.

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• Height: The height of the children was recorded in centimeters, to the nearest 0.1cm, using a measuring

board graduated to 0.1cm. Children less than 24 months (<85cm) were measured lying down and those ≥24 months (≥85cm) standing up. All children were measured barefoot. For children measured standing up, the measurers were trained to ensure that the child’s head, shoulder blades, buttocks, calves and heels were touching the board and that they were looking straight ahead. Children measured lying down were placed in the middle of the board with the head touching the fixed end, the knees pressed down and the heels touching the movable base of the board.

• Mid upper arm circumference (MUAC): MUAC was measured in centimeters, to the nearest 0.1cm, using

a MUAC tape. The measurers were trained to locate the mid-point between the shoulder and the tip of the elbow on the left arm with the arm bent at a right angle, and marked using a pen. The measurement was taken at this mid-point with the arm extended and relaxed. MUAC was measured on all children regardless of their height.

• Oedema: In order to determine whether nutritional oedema was present, normal thumb pressure was

applied to both feet, hands and to the forehead for three seconds. If the imprint persisted the child was recorded as having oedema (1= ‘+’, 2=‘++’, 3= ‘+++’ oedema). If the thumb imprint did not persist, or if the oedema was not bilateral, the child was recorded as not having oedema (0= no oedema). If the survey teams could not decide whether a child has oedema, they recorded this as ‘4’. The Nutrition Survey Manager checked all reported cases of oedema found in this survey.

• Measles immunization status: The mother/caretaker was asked whether the children have been

vaccinated against measles. If an immunization card was available confirming that a measles vaccination had been given, the date was checked and the child recorded as having received the vaccination (1=yes). If the caretaker stated that the child was vaccinated, but they did not have an immunization card, the child was recorded as having a history of measles vaccination (3=history). If the caretaker stated that the child had not been vaccinated or if they were not sure, the child was recorded as not having had the measles vaccine (2=no).

.III.2.2. The Household

The following information was recorded for each household selected in order to establish the under 5 years and crude mortality rate. To ensure accuracy of the data collected, a household tally sheet was completed for each household visited and the information transferred to the household and mortality questionnaire (see Appendix 2). • Mortality: The head of each household selected (regardless of whether there were any children ages 6 to

59 months living in the house) was asked to list all the household members (currently present or not) and to indicate whether each member (i) was currently living in the house, (ii) was living in the house during the Moharram holiday (12th February), and (iii) whether they were born or died in the period since Moharram. The age of each family member was also recorded. The survey teams then recorded (i) how many people were currently living in the house, (ii) how many of the current household members arrived since Moharram (total and <5 years – excluding births); (ii) how many former household members left during this period (total and <5 years – excluding deaths); (iii) the number of births since Moharram; and (iv) the number of deaths (total and <5 years).

• Residential status: The head of each household surveyed (including those without children ages 6 to 59

months) was asked whether they were a resident (‘1’) or whether they were currently displaced as a result of the earthquake (‘2’).

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.III.2.3. The Survey Team

Five survey teams were used, each comprising one team leader and two measurers. To ensure that the teams had a good knowledge of the survey area, the measurers were recruited locally for each survey. The same team leaders were used for all three surveys to ensure that data collection was consistent, and to a high standard. Due to the cultural context, each team comprised at least one female member. The team leaders undertook two days of theory training in the survey objectives, methodology and questionnaires. They, and the measurers, then received at least two days training in measurement techniques, which concluded with a standardization test. Prior to starting the surveys, the teams completed a series of field tests to ensure complete understanding of the methodology and questionnaires. Each team was allocated one cluster per day and was required to confirm the center and boundary of their cluster with the community members before starting work. The teams were asked to verify that the questionnaires had been completed before leaving each household, and that the data was legible.

.III.2.4. Data Collection and Entry

The survey teams returned all completed questionnaires to the Nutrition Survey Manager at the end of each day. Data were inputted to the SMART survey software each evening, and checked thoroughly.

.III.3. Indicators and Formulae

.III.3.1. Acute Malnutrition

The main indicator of nutritional status used throughout this report is weight-for-height, which assesses how thin the sample population is relative to their height, compared with a reference population (in this case the National Center for Health Statistics – NCHS – reference data are used). Weight-for-height is expressed either in Z-score or percentage of the median. Because the Z-score system is statistically more rigorous than percentage of the median, prevalence of malnutrition has been expressed using this method so that comparisons can be made with previous surveys done in the area or with surveys from other locations. However, prevalence of malnutrition as classified using percentage of the median is more relevant to the ACF-USA nutrition programs because this system is used when admitting children to the feeding centers. There is also a stronger association between percentage of the median and morbidity/mortality; hence, this method has been used for the analysis risk of malnutrition. The classification of GAM (Global Acute malnutrition) and SAM (Severe Acute Malnutrition) using Z-score and percentage of the median is as follows (it should be noted that any children with oedema, regardless of their weight-for-height, are classified as severely malnourished): Table 1 GAM and SAM using Z-Score and Percentage of the Median

<-2 Z-score Global Acute malnutrition <80% of the median <-3 Z-score Severe Acute Malnutrition <70% of the median

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.III.3.2. Mid-Upper Arm Circumference (MUAC)

Although weight-for-height is a more sensitive measure of nutritional status, MUAC is frequently used as a screening tool to estimate prevalence of malnutrition. In this study, MUAC was recorded for every child, but analyses have been done stratified by height– MUAC is less accurate for estimating acute malnutrition in shorter (<75cm) and taller (≥90cm) children. Classification of the nutritional status using MUAC is as follows: Table 2 Classification of the Nutritional Status using MUAC

At-risk for malnutrition: MUAC 12.0–13.4 cm Moderate acute malnutrition MUAC 11.0–119 cm Severe acute malnutrition MUAC <11.0 cm

.III.3.3. Mortality

The crude mortality rate (CMR), expressed as number of deaths/10,000 persons/day, is calculated using the following formula: Death rate (DR) = (Pnow + Pbefore) 2 Where, Pnow = population now Pbefore = Pnow – (deaths + departures during recall period) + (births + arrivals during recall period) CMR = total number of deaths/DR × 10,000 number of days in recall period The under-5 mortality rate (U5MR), again expressed as number of deaths/10,000 under-5s/day, is calculated in a similar way: Under-5 death rate (U5DR) = (U5Pnow + U5Pbefore) 2 Where, U5Pnow = Under-5 population now U5Pbefore = U5Pnow – (U5 deaths + U5 departures during recall period) + (births + U5 arrivals during recall period) U5MR = total number of under-5 deaths/U5DR × 10,000 number of days in recall period The alert and emergency levels for CMR are 1 death/10,000 persons/day and 2 deaths/10,000 persons/day, respectively. For U5MR, 2 deaths/10,000/day is considered to be the alert level and 4 deaths/10,000/day is the emergency level.

.III.3.4. Measles Vaccination Coverage

Because measles vaccinations should be given to children at 9 months of age (children younger than this require a repeat dose after 12 months), immunization history will only be analyzed for children ≥9 months of age, but will be recorded for all the children surveyed. Therefore, the coverage for measles vaccination is based on only the data from children ages 9–59 months. In these surveys, coverage was calculated as follows: = Number of children ages 9–59 months reported to have been vaccinated × 100 Total number of children ages 9–59 months in the sample population

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.IV. RESULTS

.IV.1. Nutrition

.IV.1.1. Battagram tehsil

The field work for the survey was done from the 10th to the 17th April. Information was recorded from a total of 960 children, two children were absent and data from 11 children were excluded due to inaccuracies in the measurements. Hence, the following analyses are based on data from 947 children ages 6–59 months. One child was excluded because he had a physical abnormality. 3 households refused to participate to the survey. The age and sex distribution of the sample population is illustrated in Table 3 and Figure 4. The ratio of males to females is relatively balanced in the age groups 6 to 53 months. It is not clear why there are more males than females in the 54–59 month age group. Battagram is quite conservativ,e and it is possible that families preferred not to allow their older female children to be included in the survey. Due to the fact that the survey teams were not allowed to enter houses in Battagram, it would have been relatively simple for families to ‘hide’ children inside the homes. Table 3 Age and sex distribution of the sample population– Battagram, NWFP, Pakistan (April/May 2006)

Age (months) Males (%) Females (%) Total (%) Sex Ratio

(males: females)6–17 97 (47.3) 108 (52.7) 205 (21.6) 0.9 18–29 112 (51.1) 107 (48.9) 219 (23.1) 1.0 30–41 118 (52.4) 107 (47.6) 225 (23.8) 1.1 42–53 90 (47.1) 101 (52.9) 191 (20.2) 0.9 54–59 66 (61.7) 41 (38.3) 107 (11.3) 1.6 Total 483 (51.0) 464 (49.0) 947 (100.0) 1.0

Figure 4 Age and gender distribution of the sample population – Battagram, NWFP, Pakistan (April/May 2006)

0 20 40 60 80 100 120 140

6 to 17

18 to 29

30 to 41

42 to 53

54 to 59

Age

(mon

ths)

Number of children

FemaleMale

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Overall prevalence of malnutrition The prevalence of GAM and SAM is shown in Table 4. No cases of oedema were found during this survey. Table 4 Percentage severe and global acute malnutrition– Battagram, NWFP, Pakistan (April 2006)

Severe Acute Malnutrition

Global Acute Malnutrition

6–59 MONTHS

Z-score 0.1% (0.0–1.2%)2

8.6% (6.2–11.6%)

Percentage of the median 0.0% (0.0–1.0%)

3.7% (2.2–6.0%)

6–29 MONTHS

Z-score 0.2% (0.0–2.6%)

10.6% (6.9–15.9%)


5.7% (3.0–10.0%)

Table 5 Prevalence of the types of malnutrition– Battagram, NWFP, Pakistan (April 2006)

(A) Z-SCORE

Weight For height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiork

or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus 81 8.6%

No malnutrition 866 91.4%

(B) PERCENTAGE OF THE MEDIAN

Weight For height < 80% ≥ 80%


or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus

35 3.7%


Prevalence of malnutrition by sex and age

It is interesting to note that prevalence of moderate acute malnutrition among boys in this survey is twice that in girls (Relative risk=2.02, Confidence interval: 1.30 – 3.18 at 95%; χ2 = 10.12, P = 0.001) (Table 6), when using the Z-score index. The prevalence of acute malnutrition is similar in both genders when analyzed with the percentage of the median index (χ2 =0.0).

2 Confidence interval at 95%.

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Table 6 Severe and moderate acute malnutrition by sex– Battagram, NWFP, Pakistan (April 2006)

(A) Z-score

Severe acute malnutrition (%)

Moderate acute malnutrition (%) Normal Total

Males 0 (0%) 55 (11.4%) 428 (88.6%) 483 Females 1 (0.2%) 25 (5.4%) 438 (94.4%) 464

Total 1 (0.1%) 80 (8.4%) 866 (91.4%) 947 (B) Percentage of the median



Males 0 (0.0%) 18 (3.7%) 465 (96.3%) 483 Females 0 (0.0%) 17 (3.7%) 447 (96.3%) 464

Total 0 (0.0%) 35 (3.7%) 912 (96.3%) 947 Prevalence of malnutrition, stratified by age, is given in Table 7. The Z-score index analysis shows no difference in the prevalence of acute malnutrition in the 6-29 months and the 30-59 months age groups (χ2 =4.16). The percentage of the median index analysis shows a difference: the 6-29 months age group present a relative risk of 2.69 (Confidence interval =1.33 – 5.43, at 95%; χ2 =8.32). This difference in both analyses is due to the shape of the reference curves: the Z-scores reference curve includes more older/taller children than the % of the median one. Table 7 Severe and moderate acute malnutrition by ag – Battagram, NWFP, Pakistan (April 2006)

(A) Z-SCORE Severe acute malnutrition

Moderate acute malnutrition Normal Total Age

(months) N (%) N (%) N (%) N 6–17 1 (0.5%) 18 (8.8%) 186 (90.7%) 205 18–29 0 (0.0%) 26 (11.9%) 193 (88.1%) 219 30–41 0 (0.0%) 13 (5.8%) 212 (94.2%) 225 42–53 0 (0.0%) 14 (7.3%) 177 (92.7%) 191 54–59 0 (0.0%) 9 (8.4%) 98 (91.6%) 107 Total 1 (0.1%) 80 (8.4%) 866 (91.4%) 947

(B) Percentage of the median

Severe acute malnutrition

Moderate acute malnutrition Normal Total Age

(months) N (%) N (%) N (%) N 6–17 0 0.0% 10 (4.9%) 195 (95.1%) 205 18–29 0 0.0% 14 (6.4%) 205 (93.6%) 219 30–41 0 0.0% 6 (2.7%) 219 (97.3%) 225 42–53 0 0.0% 2 (1.0%) 189 (99.0%) 191 54–59 0 0.0% 3 (2.8%) 104 (97.2%) 107 Total 0 0.0% 35 (3.7%) 912 (96.3%) 947

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Weight-for-height distribution compared with the NCHS reference data The weight-for-height distribution of the sample population, compared with the NCHS reference, is illustrated in Figure 5. Figure 5 Weight-for-height distribution (Z-score) – Battagram, NWFP, Pakistan (April 2006)

0

5

10

15

20

25

-4.75

-4.25

-3.25

-2.25

-1.25

-0.25 0.7

51.7

52.7

53.7

54.7

5

Weight-for-height (Z-score)

Freq

uenc

y

Reference

Surveypopulation

The average of the curve is at -0.82. The standard deviation is equal to 0.91. This value shows that the sample is representative of the population, and that the data is in accordance with the distribution of a normal population (standard deviation in the bracket 0.80 – 1.20).

Nutritional status measured by MUAC The prevalence of malnutrition by MUAC is shown in Table 8. Overall, these results have a reasonable correlation with prevalence of malnutrition in percentage of the median. Table 8 Mid-upper arm circumference – Battagram, NWFP, Pakistan (April 2006)

Nutrition status measured using MUAC Height (cm) Severely

malnourished Moderately

malnourishedAt-risk Normal Total

<75 7 (2.9%) 29 (12.0%) 130 (53.7%) 76 (31.4%) 242 75–89.9 0 (0.0%) 2 (0.5%) 137 (32.7%) 280 (66.8%) 419 90–110 1 (0.3%) 0 (0.0%) 25 (8.8%) 259 (90.9%) 285 Total 8 (0.8%) 31 (3.3%) 292 (30.9%) 615 (65.0%) 946

MUAC was not recorded for one child.

Prevalence of malnutrition by residential status 8.3% of the children included in the survey were from families that were still displaced as a result of the earthquake. Although the prevalence of malnutrition among this group was higher than among resident children (11.4 versus 8.4%) this difference was not statistically significant (χ2 = 0.81, P = 0.367).

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.IV.1.2. Balakot tehsil

The field work for this survey was done from the 25th April to the 1st May. Data were recorded from a total of 960 children; however one child was absent during the survey, and information from a further 7 children was excluded from subsequent analyses due to errors in the measurements. 4 children were excluded because they had very recently been circumcised. 3 households refused to participate to the survey. The age and sex distribution for the sample population in Balakot is illustrated in Table 9 and Figure 6. The male to female ratio was more balanced than in Battagram– the exception being the 6 to 17 month age group. Table 9 Age and gender distribution of the sample population – Balakot, NWFP, Pakistan (April 2006)


(males: females) 6–17 124 (53.7%) 107 (46.3%) 231 (24.3%) 1.2 18–29 104 (50.5%) 102 (49.5%) 206 (21.6%) 1.0 30–41 104 (47.3%) 116 (52.7%) 220 (23.1%) 0.9 42–53 93 (51.1%) 89 (48.9%) 182 (19.1%) 1.0 54–59 56 (49.6%) 57 (50.4%) 113 (11.9%) 1.0 Total 481 (50.5%) 471 (49.5%) 952 (100.0%) 1.0

Figure 6 Age and sex distribution of the sample population – Balakot, NWFP, Pakistan (April 2006)

0 20 40 60 80 100 120 140

6 to 17

18 to 29

30 to 41

42 to 53

54 to 59

Age

(mon

ths)

Number of children

FemaleMale

25


Overall prevalence of malnutrition Prevalence of GAM and SAM are shown in Table 10. There were no cases of oedema found during this survey. Table 10 Percentage severe and global acute malnutrition – Balakot, NWFP, Pakistan (April 2006)


Global Acute Malnutrition

6–59 MONTHS

Z-score 0.7% (0.2–2.2%)

5.4% (3.5–7.9%)


3.7% (2.2–5.9%)

6–29 MONTHS

Z-score 1.4% (0.3–4.3%)

6.9% (4.0–11.4%)


4.6% (2.3–8.6%)

Table 11 Prevalence of the types of malnutrition – Balakot, NWFP, Pakistan (April 2006)

(A) Z-SCORE



or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus 51 5.4%





or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus

35 3.7%



The prevalence of malnutrition was not significantly higher in boys when compared with girls, both with the Z-score and the percentage of the median analysis (χ2 =0.87 and χ2 =0.06 respectively) (see Table 12). Table 12 Severe and moderate acute malnutrition by sex – Balakot, NWFP, Pakistan (April 2006)

(A) Z-score



Males 6 (1.2%) 23 (4.8%) 452 (94.0%) 481 Females 1 (0.2%) 21 (4.5%) 449 (95.3%) 471

Total 7 (0.7%) 44 (4.6%) 901 (94.6%) 952

26





Males 0 (0.0%) 17 (3.5%) 464 (96.5%) 481 Females 0 (0.0%) 18 (3.8%) 453 (96.2%) 471

Total 0 (0.0%) 35 (3.7%) 917 (96.3%) 952 Prevalence of malnutrition is similar for both 6-29 months and 30-59 months old age groups (χ2 =3.12 in Z-score and 1.57 in % of the median). Table 13 Severe and moderate acute malnutrition by age– Balakot, NWFP, Pakistan (April 2006)

(A) Z-SCORE Age

(months) Severe acute

malnutrition (%) Moderate acute

malnutrition Normal (%) Total

6–17 4 (1.7%) 12 (5.2%) 215 (93.1%) 231 18–29 2 (1.0%) 12 (5.8%) 192 (93.2%) 206 30–41 1 (0.5%) 11 (5.0%) 208 (94.5%) 220 42–53 0 (0.0%) 5 (2.7%) 177 (97.3%) 182 54–59 0 (0.0%) 4 (3.5%) 109 (96.5%) 113 Total 7 (0.7%) 44 (4.6%) 901 (94.6%) 952


Age (months)


Moderate acute malnutrition Normal (%) Total

6–17 0 (0.0%) 14 (6.1%) 217 (93.9%) 231 18–29 0 (0.0%) 6 (2.9%) 200 (97.1%) 206 30–41 0 (0.0%) 8 (3.6%) 212 (96.4%) 220 42–53 0 (0.0%) 3 (1.6%) 179 (98.4%) 182 54–59 0 (0.0%) 4 (3.5%) 109 (96..5%) 113 Total 0 (0.0%) 33 (3.5%) 919 (96.5%) 952

Weight-for-height distribution compared with the NCHS reference data

The weight-for-height distribution for the Balakot survey is illustrated in Figure 7. Figure 7 Weight-for-height distribution (Z-score) – Balakot, NWFP, Pakistan (April 2006)

0

5

10

15

20

25

-4.75

-4.25

-3.25

-2.25

-1.25

-0.25 0.7

51.7

52.7

53.7

54.7

5


Freq

uenc

y

Reference

Surveypopulation

27



Nutritional status measured by MUAC The prevalence of severe and moderate acute malnutrition, as measured by MUAC is shown in Table 14. Table 14 Mid-upper arm circumference – Balakot, NWFP, Pakistan (April 2006)



malnourished At-risk Normal Total

<75 2 (0.9%) 14 (6.5%) 99 (46.0%) 100 (46.5%) 215 75–89.9 1 (0.2%) 4 (1.0%) 65 (16.3%) 330 (82.5%) 400 90–110 0 (0.0%) 0 (0.0%) 9 (2.7%) 327 (97.3%) 336 Total 3 (0.3%) 18 (1.9%) 173 (18.3%) 757 (79.6%) 951

MUAC was not recorded for one child.

Prevalence of malnutrition by residential status 8.0% of the children included in these analyses were from families that were still displaced as a result of the earthquake. There was no significant difference in prevalence of GAM when comparing displaced with resident children (3.6 versus 5.5%; χ2 = 0.32, P = 0.569).

.IV.1.3. Mansehra tehsil

The field work for this survey was done from the 8th to the 13th May. Information was recorded from a total of 960 children, no children were absent but data from eight children have been excluded from the following analyses as a result of inaccuracies in the measurements. No household refused to participate to the survey. The age and sex distribution of the 952 children included in the nutrition analyses is illustrated in Table 15 and Figure 8. The sex distribution is uneven in all age groups. Overall more girls were surveyed than boys. It is difficult to ascertain why this is the case. There are noticeably fewer children in the 54-59 month age group. Although survey teams were explicitly asked to follow up the children that were at school, it is possible that some were still missed. In many places, Mansehra is more developed than Battagram or Balakot, which may be why this is an issue in this survey and not in the other two.

Table 15 Age and sex distribution of the sample population – Mansehra, NWFP, Pakistan (May 2006)


(males: females) 6–17 101 (45.5%) 121 (54.5%) 222 (23.3%) 0.8 18–29 97 (43.3%) 127 (56.7%) 224 (23.5%) 0.8 30–41 114 (49.4%) 117 (50.6%) 231 (24.3%) 1.0 42–53 101 (46.8%) 115 (53.2%) 216 (22.7%) 0.9 54–59 33 (55.9%) 26 (44.1%) 59 (6.2%) 1.3 Total 446 (46.8%) 506 (53.2%) 952 (100.0%) 0.9

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Figure 8 Age and gender distribution of the sample population – Mansehra, NWFP, Pakistan (May 2006)

0 20 40 60 80 100 120 140

6 to 17

18 to 29

30 to 41

42 to 53

54 to 59

Age

(in

mon

ths)

Number of children

FemaleMale

Overall prevalence of malnutrition Prevalence of GAM and SAM is shown in Table 16. No cases of oedema were found during this survey. Table 16 Percentage severe and global acute malnutrition – Mansehra, NWFP, Pakistan (May 2006)


Global Acute

Malnutrition 6–59 MONTHS

Z-score 0.5% (0.1–1.8%)

8.2% (5.9–11.2%)


3.8% (2.3–6.1%)

6–29 MONTHS

Z-score 0.2% (0.0–2.5%)

8.1% (4.9–12.7%)


4.3% (2.1–8.1%)

Table 17 Prevalence of the types of malnutrition – Mansehra, NWFP, Pakistan (May 2006)

(A) Z-SCORE



or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus 78 8.2%


29





or 0 0.0%

Kwashiorkor 0 0.0%

Oedema

NO Marasmus

36 3.8%



Severe and moderate acute malnutrition by sex and age are shown in Tables 18 and 19. There is a significant difference in GAM when comparing boys with girls using Z-scores (χ2 = 9.35, P = 0.002). However, there is no significant difference between boys and girls when using percentage of the median (χ2 = 0.05). Table 18 Severe and moderate acute malnutrition by sex – Mansehra, NWFP, Pakistan (May 2006)

(A) Z-SCORE



Males 2 (0.4%) 48 (10.8%) 396 (88.8%) 446 Females 3 (0.6%) 26 (5.1%) 477 (94.3%) 506

Total 5 (0.5%) 74 (7.8%) 873 (91.7%) 952 (B) Percentage of the median



Males 1 (0.1%) 12 (1.3%) 433 (45.5%) 446 Females 1 (0.1%) 15 (1.6%) 490 (51.5%) 506

Total 2 (0.2%) 27 (2.8%) 923 (97.0%) 952 Prevalence of malnutrition is similar for both 6-29 months and 30-59 months old age groups (χ2 =0.95 in Z-score and 1.21 in % of the median). Table 19 Severe and moderate acute malnutrition by age – Mansehra, NWFP, Pakistan (May 2006)

(A) Z-SCORE Age

(months) Severe acute

malnutrition (%) Moderate acute

malnutrition Normal (%) Total

6–17 0 (0.0%) 18 (8.1%) 204 (91.9%) 222 18–29 1 (0.4%) 17 (7.6%) 206 (92.0%) 224 30–41 1 (0.4%) 16 (6.9%) 214 (92.6%) 231 42–53 1 (0.5%) 17 (7.9%) 198 (91.7%) 216 54–59 2 (3.4%) 6 (10.2%) 51 (86.4%) 59 Total 5 (0.5%) 74 (7.8%) 873 (91.7%) 952


Age (months)


Moderate acute malnutrition Normal (%) Total

6–17 1 (0.1%) 7 (0.7%) 214 (22.5%) 222 18–29 0 (0.0%) 9 (0.9%) 215 (22.6%) 224 30–41 0 (0.0%) 5 (0.5%) 226 (23.7%) 231 42–53 0 (0.0%) 3 (0.3%) 213 (22.4%) 216 54–59 1 (0.1%) 3 (0.3%) 55 (5.8%) 59 Total 2 (0.2%) 27 (2.8%) 923 (97.0%) 952

30


Weight-for-height distribution compared with the NCHS reference data The weight-for-height distribution for the survey population is shown in Figure 9. Figure 9 Weight-for-height distribution (in Z-score) – Mansehra, NWFP, Pakistan (May 2006)

0

5

10

15

20

25

30

-4.75

-4.25

-3.25

-2.25

-1.25

-0.25 0.7

51.7

52.7

53.7

54.7

5


Freq

uenc

y

Reference

Surveypopulation


Nutritional status measured by MUAC The prevalence of acute malnutrition as measured by MUAC is shown in Table 20. Table 20 Mid-upper arm circumference – Mansehra, NWFP, Pakistan (May 2006)



malnourished At-risk Normal Total

<75 5 (2.4%) 9 (4.3%) 96 (46.2%) 98 (47.1%) 208 75–89.9 0 (0.0%) 3 (0.7%) 80 (19.3%) 331 (80.0%) 414 90–110 0 (0.0%) 0 (0.0%) 31 (9.5%) 297 (90.5%) 328 Total 5 (0.5%) 12 (1.2%) 207 (21.8%) 726 (76.4%) 950

MUAC was not recorded for two children.

Prevalence of malnutrition by residential status Only 0.6% of the 952 children in Mansehra were from families that reported they were still displaced as a result of the earthquake. It is not meaningful to compare prevalence of malnutrition between resident and displaced children with such a small sample size.

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.IV.2. Mortality

.IV.2.1. Battagram

960 households were surveyed for the retrospective mortality survey. The results collected are presented as follow:

• 7392 people were present the day of the survey. 1378 of them were children below 5 years of age (18.6%).

• 61 people have left the household during the past 3 months. 11 of them were children below 5 years of age.

• 98 people have left the household during the past 3 months. 11 of them were children below 5 years of age.

• 75 births occurred during the past 3 months. • 13 deaths occurred. 2 of them affected children below 5 years of age.

The crude mortality rate is 0.28/10000 people x day (Confidence interval at 95%: 0.14–0.41). The under five mortality rate is 0.23/10000 people x day (0.02–0.44).

.IV.2.2. Balakot



• 15 people have left the household during the past 3 months. None of them was below 5 years of age. • 23 people have left the household during the past 3 months. 2 of them were children below 5 years of

age. • 52 births occurred during the past 3 months. • 7 deaths occurred. 2 of them affected children below 5 years of age.


.IV.2.3. Mansehra



• 16 people have left the household during the past 3 months. None of them was below 5 years of age. • 25 people have left the household during the past 3 months. 5 of them were children below 5 years of

age. • 46 births occurred during the past 3 months. • 4 deaths occurred. 1 of them affected a child below 5 years of age.


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.IV.3. Measles Vaccination Coverage

Measles vaccination coverage was measured for children 9 months or more of age. The results are shown in Table 21. It appears that relatively few children have a history of being vaccinated against measles in Battagram (41.1%) and Balakot (40.2%) tehsils. Coverage in Mansehra was marginally higher (50.6%). Table 21 Measles vaccination coverage for children ≥9 months – NWFP, Pakistan (April/May 2006)

Measles vaccination status Battagram Balakot Mansehra Confirmed with immunization card 179 (19.5%) 173 (19.0%) 309 (35.3%)

Confirmed verbally by caretaker but no card

199 (21.7%) 193 (21.2%) 135 (15.4%)

Not immunized according to the caretaker 541 (58.9%) 543 (59.7%) 433 (49.4%) Total 919 909 877a

aMeasles vaccination history was not recorded from one cluster.

.IV.4. Residential Status and Household Size

Table 22 Household information – NWFP, Pakistan (April/May2006)

Battagram (960 households)

Balakot (961 households)

Mansehra (963 households)

Proportion of people displaced as a result of the

earthquake 7.5% 7.8% 1.6%

Mean number of people per household 7.7 6.4 6.5

.V. DISCUSSION

.V.1. Prevalence of Malnutrition

The prevalence of GAM found in these surveys (8.6% for Battagram, 5.4% for Balakot and 8.3% for Mansehra) fall in to the ‘poor’ category according to the WHO grading of acute malnutrition. These results are similar to those seen in previous surveys in NWFP. Overall, the children surveyed in all three areas are thinner for their height when compared to the NCHS reference population. However, there are families in some parts of the region who are relatively affluent, and there is evidence of a nutrition/epidemiological transition in this part of Pakistan. In urban/semi-urban areas there is greater availability of cheap vegetable oils and processed, sugary foods, and an increasing prevalence of type 2 diabetes and cardiovascular diseases among adults. In the Mansehra survey in particular, there was a larger proportion of children who had a higher than average weight-for-height than who had a lower than average weight-for-height. These children were not necessarily overweight; their weight-for-height was often still less than the NCHS reference. The lower rate of malnutrition has been found in Balakot. This observation is not statically valid, as the confidence interval of prevalence is still in the same range. However, given that Balakot was more affected by

33


the earthquake, this result is interesting. One hypothesis as to why this is the case is that the population in Balakot may have received more support following the earthquake than the populations in Mansehra and Battagram. Although the earthquake has had a serious impact on the population of NWFP, it does not seem to have increased risk of malnutrition in young children. Hence, the aid that has been provided to Balakot may have worked to reduce prevalence of acute malnutrition below ‘baseline’ prevalence. The survey done by UNICEF/WFP/WHO/MoH in December 2005 found a lower prevalence of malnutrition in the NWFP camp population (6.0% GAM) compared with the residents of Mansehra district (10.5% GAM). The camp populations would also have had greater access to humanitarian assistance compared with the residents. The other hypothesis that has been suggested to explain this difference is that greater focus has been placed on the health and welfare of children since the earthquake. It would be interesting to undertake a similar survey in Balakot tehsil in 6 months to establish whether prevalence of acute malnutrition has changed. The fact that the earthquake has not exacerbated acute malnutrition suggests that SFP’s are unlikely to be the most appropriate approach for the areas covered by these surveys. It seems that the communities in Battagram, Balakot and Mansehra are not experiencing significant food insecurity, and that families do not place a great deal of value in the SFP’s. This program distributes a product (WSB) that is readily available in the markets in many of the affected areas. In many cases, beneficiaries have gone to the centers to receive non-food items (for example, shawls and hygiene kits), but not specifically for the food supplement. The default rate for the centers in April was consistently well above 15% and in most cases >80%. It is therefore recommended that the SFP’s are closed as soon as possible. There are clearly a number of risk factors for malnutrition that have been affected by the earthquake (particularly breastfeeding practices and water/sanitation conditions). It would be useful to develop nutrition activities within the public health system to help minimize the prevalence of acute malnutrition, and also, to reduce chronic malnutrition (which is a serious problem in NWFP). These activities should focus on nutrition education, particularly composition of complementary diets, hygiene practices and breastfeeding. Nutrition is part of the re-development strategy for the health care system, and support should be provided to the MoH to ensure that health workers can provide appropriate nutrition information to the community. Breastfeeding practices are of particular concern in this area. However, the conservative nature of the region means that any program to promote breastfeeding should involve local women and men, as well as religious leaders and health care workers. It is still not clear the extent to which livelihoods and food security have been affected by the earthquake in the long-term. Hence, it would be useful to monitor the prevalence of acute malnutrition among young children in this region. Again, nutrition surveillance could easily be integrated into the health care system in NWFP. Care should be taken to identify appropriate sentinel sites, taking account of the fact that remote as well as urban/semi-urban areas should be covered. Prevalence of SAM found in these surveys was relatively low (0.1% in Battagram, 0.7% in Balakot and 0.5% in Mansehra). There is very little understanding of severe acute malnutrition in this region, even among health workers. Although the number of severe cases is not high, it is important to ensure that health workers have an understanding of how to treat severe acute malnutrition. The re-development strategy for health proposes that TFC’s should be established in the THQ and DHQ hospitals. It is essential that adequate training and support be provided for these centers to ensure that treatment is done according to the WHO guidelines. Prevalence of chronic acute malnutrition has not been presented in this study because there is likely to be considerable error in the ages of the children included in the surveys. Few families keep note of the date of birth of their children, and even less have birth certificates. Although a local events calendar was used by the teams to estimate age, it was common to hear mothers state that their child was, for example, 2 years old, when in fact it became apparent that the child was born in 2001. However, chronic malnutrition is clearly a major issue in this region. Nutrition education and hygiene promotion will go part of the way to reduce this problem, eliminating chronic malnutrition will involve major re-development of the health and education systems in Pakistan.

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.V.2. At Risk Groups

Prevalence of GAM was significantly higher among the 6–29 month age group in Battagram, marginally higher in the Balakot survey, and the same in the Mansehra survey, when compared with the 30–59 month age group. It is common for younger children to be at higher risk of acute malnutrition. This tends to be the product of inadequate breastfeeding practices and complementary diets, and a lower resistance to disease. The nutrition element of the health strategy (see above) should incorporate training for health care staff about groups that are at higher risk of malnutrition (i.e., young children). As discussed, there is likely to be error in the ages of children in these surveys, and hence, there may be some misclassification of subjects when looking at malnutrition by age. The effect of this would be to lessen any difference in prevalence of malnutrition when comparing the two age groups. Interestingly, in both Battagram and Mansehra, prevalence of GAM (in Z-score) among boys was almost double that seen in girls. There was no significant difference between boys and girls when using percentage of the median. This means that the boys included in the survey were more likely to be thinner relative to their height than the girls, but not more likely to be within criteria for the SFP. It is difficult to find sex-specific data for this region of Pakistan, the UNICEF/WFP/WHO/MoH surveys also found a higher prevalence of GAM among boys than girls. In one survey in the camps in AJK province, GAM in boys was twice that in girls (5.6 versus 2.8%). Traditionally in Pakistan, male children are preferred to female children because the boys will look after the family in the future, and will continue the family line, whereas girls leave the home when they marry. Given this tradition, it is surprising that risk of malnutrition is so much higher among boys. It has been observed that boys tend to be at higher risk of malnutrition than girls (Wells, 2000). However, the reasons for this are not clear. At the end of the surveys, informal interviews were done with health workers (including LHW’s), and focus groups were held with groups of women and men in rural and urban areas (in Mansehra tehsil) in an attempt to identify differences in attitudes towards male and female children that could explain this result (note that this research was relatively ad-hoc and thus is only useful for generating hypotheses). None of the people interviewed claimed to treat their male and female children differently. It was common to hear mothers and fathers state that the children are equal. Women did not differentiate between boys and girls when it came to breastfeeding or to food (there are no foods in this culture that are taboo for male or female children). However, all the women interviewed (including the LHW’s) mentioned that “today’s girl is the mother of the future”. This is a message that has been passed to the community over the last few years. Women who had met with LHW’s said that they were specifically told that female children needed more food. Many mothers and fathers said that they worried about their daughters because they would eventually leave the home. The fathers in the urban area said that it was part of their religion to take care of the girls, and that they should be given the same respect and treatment as visitors. In the rural areas, girls were discouraged from playing outside the home, the mothers said that the “atmosphere is bad”. Although boys and girls were not allowed to play outside the home in the urban setting, the fathers stated that the boys tend to play outside more than the girls, and that the activities they are involved in are more physically demanding (in the rural areas this included swimming, which is strictly forbidden for the girls). Fathers in the rural areas said that meal times were less formal or structured for boys because they are generally playing outside the house. They said that the mothers “loved the girls,” and that less attention was given to the boys during the day because they were away from the home. In both urban and rural areas, the fathers said that the boys were spoilt, and that they were badly behaved as a result. The women all said that they found their sons more difficult to control, the boys were punished more than the girls. Fathers said that their daughters were more obedient and more “intelligent” than their sons. From this, there appear to be three main themes that could partly explain the gender difference in malnutrition in Battagram and Mansehra.

(i) There has been greater focus over the last few years on improving the situation for girls, and this may have led to girls being more well-nourished than boys.

(ii) Girls tend to spend more time with their mothers in the home, and thus, their meal times may be more structured and better supervised.

35


(iii) Boys are more likely to play outside, and hence, may be more exposed to parasitic infections and other diseases.

It is important to acknowledge that this result may, in part, be the result of selection bias. In many villages, people did not understand the fact that the survey teams were required to randomly select households. Although the teams measured MUAC from children not included in the survey, it is possible that some children were said to live in a house when in fact they did not just so that they could be measured. The cultural context means that teams were not able to enter the houses (although female measurers were permitted), and so it could have been relatively simple for this to happen. It is possible that families tended to try to get the teams to measure their sons rather than their daughters. The survey teams said that they thought this would have happened very rarely because they were generally able to make the community understand what they were doing. Also, they said that they did not feel that families preferred to have boys measured rather than girls. Prevalence of GAM was higher in boys than in girls in Balakot, but not significantly. One suggestion as to why there was no difference in this survey is that, since the earthquake, families in Balakot may be more protective of all their children. Mortality was particularly high in the Balakot region, particularly for young children, and this may have made people more concerned for the health and welfare of those that remained. During the focus groups in Mansehra tehsil, it was common to hear families’ say that they were more worried for their children since the earthquake. It will be extremely difficult to establish exactly why there might be a difference in risk of malnutrition among boys and girls in NWFP. The cultural context varies considerably between settlements due to differences in ethnicity, religious messages, levels of education, wealth and living conditions. It is extremely important that organizations continue to promote the welfare of females in NWFP; inequalities still exist. However, nutrition and hygiene education should emphasize that male and female children are equally vulnerable, and that families should not differentiate between children based on their sex. .

.V.3. Measles Vaccination Coverage

The measles vaccination coverage found in these surveys is relatively low. However, vaccination cards were lost or buried during the earthquake, and were not routinely distributed during the subsequent campaigns. It also seems that existing cards were not updated when a child received the vaccine. Very few families completely understood which vaccination the teams were asking about; the children are given many immunizations, and it is possible that the EPI teams do not explain exactly which has been given. The fact that coverage in Mansehra is higher in not surprising. The area is less mountainous, and thus, it will have been easier to reach this population. There have been a number of cases of measles in NWFP since the earthquake. It is important that the EPI teams focus on reaching the more remote areas, and that vaccination cards are updated. This program has been disrupted since the earthquake due to the l lack of health workers. To ensure that vaccination coverage improves, recruitment and training will need to be done of EPI staff as soon as possible.

.V.4. Limitations to the Study

There are clearly some limitations to this study; however, they are relatively minor and therefore the results are likely to be reasonably reliable. The main concern is that teams did not have free access to the homes or to the mothers. This is likely to have caused some error in the ages of the children. It also may have made it easier for families to ‘hide’ certain children, or to claim that other children were residents of the selected household. This latter issue was most probably not particularly common, because the female measurers were able to enter the houses. There have been problems in the region between local communities and humanitarian organizations. Because of this, the survey teams tended to move around the villages with a community leader. Although this increased

36


acceptability of the survey, it also increased the possibility that the community could have influenced the teams. Throughout each survey, the teams were reminded to ensure that household selection was random, and techniques were discussed to help satisfy the requests of the community without comprising the methodology. Families in this area of Pakistan tend to be large and extremely extended. Following the earthquake, many families have resorted to sharing houses/tents, and thus, it was at times quite confusing to establish exactly who lived in which house. This means that statistics relating to household size should be taken with caution. There have been suggestions that prevalence of acute malnutrition is highest in the most remote areas of NWFP. Unfortunately, due to logistical constraints, it was not possible to reach these regions. Prevalence of malnutrition found in this study is representative only of the areas covered by the surveys, and should not be extrapolated to the remote regions. It would be useful to include some of these locations as sentinel sites for a nutrition surveillance program so as to assess whether acute malnutrition is a particular issue for these communities.

.V.5. Conclusion

The prevalence of acute malnutrition found during these surveys does not differ significantly to that seen in surveys done prior to the earthquake. Based on the WHO grading of acute malnutrition, the situation in the region remains poor. It is likely that a combination of factors contribute to malnutrition among the 6 to 59 month age group in NWFP. These include (i) poor hygiene practices, (ii) a lack of understanding among families regarding nutrition in young children, and (iii) breastfeeding practices. The humanitarian response to the earthquake has been relatively comprehensive, and it does not seem that families are facing serious food insecurity. Hence, it is unlikely that the existing SFP is meeting the requirements of this community. This program is distributing a product that is widely available in the region, and therefore, families place little value in the SFC’s. This is reflected in the high default rate seen over the last month in all the centers. It is clear that work needs to be done to improve the nutritional status of young children in NWFP. However, activities should focus more on nutrition and hygiene education, and breastfeeding promotion and support. This is certainly a vulnerable population and acute malnutrition should continue to be monitored. The health system in the area is in the process of being rehabilitated, and hence, this would be an ideal time to incorporate a nutrition surveillance program within this structure. It would also be useful to ensure that the therapeutic feeding program is established/continues in the tertiary hospitals (in accordance with the rehabilitation strategy developed by ERRA) to ensure appropriate treatment for severe acute malnutrition. Finally, the measles vaccination coverage found in these surveys is relatively low. Many vaccination cards were lost or destroyed during the earthquake, and were not given during subsequent vaccination campaigns. It is likely that in some cases, children had in fact been vaccinated against measles, but because the parents had no card, they were not clear about exactly which vaccinations had been given. A significant number of health workers were killed during the earthquake, and as a result the EPI program in some areas is understaffed. It does seem that from these surveys the coverage is lower in the more remote/mountainous areas, and therefore, the focus of the EPI program should be on reaching these locations.

37


.VI. RECOMMENDATIONS

It is recommended that:

• The existing supplementary feeding program is closed. • Sentinel sites are identified and a nutrition surveillance program established. • A nutrition and hygiene education program is established that could ultimately be incorporated within the

health care structure. • A culturally adapted breastfeeding promotion/support program is developed– again with the view to

integrating this into the health care structure. • Training is done for health care workers in nutrition/malnutrition, hygiene and breastfeeding promotion

and monitoring of weight and height in young children. • Support continues for the therapeutic feeding program. • Recruitment/training for EPI staff is done and that emphasis is placed on reaching more remote

locations.

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.VII. REFERENCES

ACF-USA (2005/2006) Nutrition assessment – Mansehra and Battagram districts (internal document). ACF-USA (2005/2006) Mission situation reports (internal documents). DHS (1991) Pakistan Demographic and Health Survey. ERRA (2006) Reconstruction and Rehabilitation Strategy – health sector (http://www.erra.gov.pk). ERRA (2006) Reconstruction and Rehabilitation Strategy – water/sanitation sector (http://www.erra.gov.pk). ERRA (2006) Rural housing reconstruction program (http://www.erra.gov.pk). UNICEF/WFP/WHO/MoH (2006) Health and nutrition survey in earthquake affected areas of Pakistan (February). Islamabad, Pakistan. Wells, J.C. (2000) Natural selection and sex differences in morbidity and mortality in early life. J Theor Biol.; 202, 65-76. WHO (2005/2006) Health situation reports– Pakistan. Health emergency cell, Islamabad, Pakistan. WHO (2006) Global database on child growth and malnutrition (http://www.who.int). WFP (2003) Country program: Pakistan. 10269.0 (http://www.wfp.org/eb). WFP (2005) Food assistance to affected persons – South Asia earthquake. EMOP 10491.0. WFP/UNICEF (2005) Pakistan Earthquake – Joint WFP/UNICEF rapid emergency food security and nutrition assessment (October).

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.VIII. APPENDICES

.VIII.1. Population Data and Cluster Selection

(A) BATTAGRAM Sampling interval: 974 Random number: 27

District/tehsil Union Council Mauza/village Total population U5 population Cumulative

total From To Cluster

Changla district Daroot 350 60 60 1 60 1Allai tehsil Batkul Batkool 3546 603 662 61 662

Kanai 5619 955 1618 663 1618 2Battagram tehsil Takhot Takhot 5453 927 2545 1619 2545 3

Qinchbori 911 155 2699 2546 2699Chanjal 2863 487 3186 2700 3186 4Battley 2863 487 3673 3187 3673 6Hutal 5295 900 4573 3674 4573 5

Bishkot 2855 485 5058 4574 5058 6Paimal Shairaf Paimal Shairaf 2979 506 5565 5059 5565

Dabri 3488 593 6158 5566 6158 7Shamarad 2984 507 6665 6159 6665

Rangeenabad 2978 506 7171 6666 7171 8Peshora Peshora 5968 1015 8186 7172 8186 9

Kotgalla 3552 604 8790 8187 8790Aughaz Banda 2412 410 9200 8791 9200 10Shingli Payeen 3271 556 9756 9201 9756

Gijbori Gijbori 8816 1499 11255 9757 11255 11,12Shingli Bala 7370 1253 12507 11256 12507 13

Kuza Banda Kuza Banda 4629 787 13294 12508 13294 14Tickri 2175 370 13664 13295 13664 15Maira 5991 1018 14683 13665 14683 16Sofian 2221 378 15060 14684 15060

Rajdahri Phagora 5543 942 16002 15061 16002 17Neelishang Sharqi 3278 557 16560 16003 16560Neelishang Gharbi 2796 475 17035 16561 17035 18Rajdahri Shamali 1812 308 17343 17036 17343Rajdahri Jonobi 2565 436 17779 17344 17779 19

Batamori Batamori Shamali 2250 383 18162 17780 18162Batamori Jonobi 2622 446 18607 18163 18607 20

Kakarshang 2262 385 18992 18608 18992Kadlay 3033 516 19508 18993 19508 21Jesol 3072 522 20030 19509 20030 22

Habib Banda 2805 477 20507 20031 20507 22Chita Bata 2419 411 20918 20508 20918Rajmera 3925 667 21585 20919 21585 23

Batagram Batagram 13779 2342 23928 21586 23928 24,25Arghashori 2671 454 24382 23929 24382 26

Ajmera Ajmera 8954 1522 25904 24383 25904 27Matta 1640 279 26183 25905 26183

Maidan 997 169 26352 26184 26352 28Chapargram 7097 1206 27559 26353 27559 29

Tamai 2741 466 28025 27560 28025Trand Trand 3739 636 28660 28026 28660 30

Gidri 3223 548 29208 28661 29208Total 171812 29208

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(B) Balakot Sampling interval: 746 Random number: 211

District/tehsil Union Council Village/settlement Total population Under-5 population Cumulative total From To Cluster

Balakot Kawai Kawai 3093 526 526 1 526 1Paras 5059 860 1386 527 1386 2

Ghanool Ghanool 7869 1338 2724 1387 2724 3,4Sangar 6626 1126 3850 2725 3850 5

Hassamabad 505 86 3936 3851 3936Hangrai Hangrai 3506 596 4532 3937 4532 6

Ghaneela 3721 633 5164 4533 5164 7Satbani Khetsarash 4176 710 5874 5165 5874 8

Banbara Patlang 3093 526 6400 5875 6400 9Balakot Balkot 11351 1930 8330 6401 8330 10,11

Tarana 742 126 8456 8331 8456 12Shohal Najif 4877 829 9285 8457 9285 13

Garlat Garlat 11956 2033 11318 9286 11318 14,15Nokot 323 55 11372 11319 11372 16

Batkerrer 575 98 11470 11373 11470 17Hassa 578 98 11569 11471 11569

Kanshian 5094 866 12434 11570 12434 17Shohal Mazullah Shohal Mazullah 1794 305 12739 12435 12739

Jabri Kalish 4180 711 13450 12740 13450 18Kanwara 338 57 13508 13451 13508Patseri 686 117 13624 13509 13624

Kumi Khangirl 3722 633 14257 13625 14257 19Talhatta Talhatta 2649 450 14707 14258 14707 20

Lunda 601 102 14809 14708 14809Jabi 476 81 14890 14810 14890

Gut Maira 2374 404 15294 14891 15294 21Sughdar 934 159 15453 15295 15453Batora 1622 276 15728 15454 15728Hasara 757 129 15857 15729 15857

Kashterra 1472 250 16107 15858 16107 22KotBhala 1450 247 16354 16108 16354Pateka 777 132 16486 16355 16486

Gahri Habibullah Gahri Habibullah 15753 2678 19164 16487 19164 23,24,25,26Bararkot 3553 604 19768 19165 19768 27

Karnol Doga 3802 646 20414 19769 20414 28Basian 3107 528 20942 20415 20942

Jabri Balola 4189 712 21655 20943 21655 29Bhoraj 1110 189 21843 21656 21843

Sial 353 60 21903 21844 21903 30Karnol 2856 486 22389 21904 22389

Total 131699 22389 (C) Mansehra (Continued on following pages) Sampling interval: 2429 Random number: 1862

District/tehsil Union Council Village/settlement Totalpopulation

Under-5population

Cumulativetotal From To Cluster

Mansehra Attershsha Atteshesha 2265 385 385 1 385Mandhiar 1352 230 615 386 615Phagla 2946 501 1116 616 1116Kahoter 830 141 1257 1117 1257Jabba 5615 955 2211 1258 2211 1

Arabkhan 871 148 2359 2212 2359Pairan Pairan 4261 724 3084 2360 3084

Narrbeer 1831 311 3395 3085 3395Banda Sydean 263 45 3440 3396 3440

Shahkhail Garhi 1267 215 3655 3441 3655Cherh 2890 491 4146 3656 4146

Mara Amjad Ali 1849 314 4461 4147 4461 2Sandasar Sandasar 3058 520 4981 4462 4981

Chittabatta 3840 653 5633 4982 5633Reerh 2248 382 6016 5634 6016

Mongan 3955 672 6688 6017 6688Hathi Maira 1624 276 6964 6689 6964 3Machipol 904 154 7118 6965 7118

Laber kot Laberkot 7566 1286 8404 7119 8404Kotkey 5810 988 9392 8405 9392 4

Mansehra Rural Mansehra 10652 1811 11202 9393 11202Ganda 2064 351 11553 11203 11553Sufeda 2058 350 11903 11554 11903 5

Hadobandi 2109 359 12262 11904 12262Mansehra City No1 Mansehra 13095 2226 14488 12263 14488 6Mansehra City No2 Mansehra 12036 2046 16534 14489 16534 7Mansehra City No3 Mansehra 13133 2233 18767 16535 18767Mansehra City No4 Mansehra 13831 2351 21118 18768 21118 8

Datta Datta 4619 785 21903 21119 21903 9Ghazikot 5222 888 22791 21904 22791Harryala 1699 289 23080 22792 23080Khushala 1028 175 23254 23081 23254Chakya 2933 499 23753 23255 23753 10

41


Union Council Village/settlement Total population

Under-5 population

Cumulative total From To Cluster

Behali Behali 3544 602 24356 23754 24356Garala 934 159 24514 24357 24514

Husenian 538 91 24606 24515 24606Reharr 2306 392 24998 24607 24998Matyal 1069 182 25180 24999 25180Potha 2902 493 25673 25181 25673Ogra 3480 592 26264 25674 26264 11

Pakhwal 1748 297 26562 26265 26562Lassan Thakral Lassan Thakral 2602 442 27004 26563 27004

Narwan 448 76 27080 27005 27080Nanoha 710 121 27201 27081 27201

Morebaffa Klan 1946 331 27532 27202 27532Mangloor 743 126 27658 27533 27658Khawari 2309 393 28051 27659 28051Jankiari 412 70 28121 28052 28121Barat 653 111 28232 28122 28232

Mohaian 1648 280 28512 28233 28512Karerr 1421 242 28753 28513 28753 12

Jallo Jallo 2545 433 29186 28754 29186Bhoraj 788 134 29320 29187 29320

Blhag Bala 1595 271 29591 29321 29591Blhag Payeen 1720 292 29883 29592 29883

Morbaffa Khurd 600 102 29985 29884 29985Shehlia 1703 290 30275 29986 30275Debgran 1626 276 30551 30276 30551

Sheikhabad 632 107 30659 30552 30659Basund 1127 192 30850 30660 30850Madan 1000 170 31020 30851 31020 13

Lalobandi 283 48 31069 31021 31069Chanja 521 89 31157 31070 31157

Baobandi 346 59 31216 31158 31216Baidrra 1834 312 31528 31217 31528

Hamsherian Hamsherian 2411 410 31938 31529 31938Timberkhola 1157 197 32134 31939 32134

Marri Muqarab Shah 438 74 32209 32135 32209Marri Shahwali 1584 269 32478 32210 32478

Maswal 1619 275 32753 32479 32753Mairajia 1438 244 32998 32754 32998

Panodheri 3104 528 33525 32999 33525 14Bherkund Tarla 2656 452 33977 33526 33977

Inayatabad Inayatabad 4175 710 34687 33978 34687Banda Piran 6136 1043 35730 34688 35730

Chittgati 1968 335 36064 35731 36064 15Ghandian 1587 270 36334 36065 36334

Lung 1382 235 36569 36335 36569Hafizbandi Utli 753 128 36697 36570 36697Hafizbandi Tarli 345 59 36756 36698 36756

Dhodial Dhodial Malkal 8280 1408 38163 36757 38163Shanai Bala 3460 588 38752 38164 38752 16

Gerrwal 1995 339 39091 38753 39091Dhodial Aroghoshal 7311 1243 40334 39092 40334

Shinkiari Shinkiari 15652 2661 42994 40335 42994 17Okhrrifa 1192 203 43197 42995 43197 18Bedadi 5982 1017 44214 43198 44214

Sum Elahi Mong Dharryal 9836 1672 45886 44215 45886 19Timbri 1414 240 46126 45887 46126

Sum Elahi Mong 5425 922 47049 46127 47049Bhogerr Mong Bhogermong 6084 1034 48083 47050 48083 20

Barribekh 313 53 48136 48084 48136Andrasi 267 45 48182 48137 48182

Granthalli 1521 259 48440 48183 48440Rathi 854 145 48585 48441 48585Bakl 2677 455 49040 48586 49040

Chittabatta 1132 192 49233 49041 49233Icherrian Icherrian 5687 967 50200 49234 50200

Kotli Bala 2699 459 50658 50201 50658 21Kund Tarla 505 86 50744 50659 50744Kotli Tarli 2576 438 51182 50745 51182Terkanal 551 94 51276 51183 51276

Tanda Tanda 5311 903 52179 51277 52179Bajna 7084 1204 53383 52180 53383 22

42


Union Council Village/settlement Total population

Under-5 population

Cumulative total From To Cluster

Baffa Town Baffa Bajor K-Khell 2027 345 53728 53384 53728Baffa Lughmani 3617 615 54343 53729 54343Baffa Dhadlori 1302 221 54564 54344 54564

Baffa Lughmani , Titwal, Liarri 4329 736 55300 54565 55300 23

Baffa Town 11842 2013 57313 55301 57313Trangri Sabir Shah Guli Bagh 3747 637 57950 57314 57950 24

Trangri Sabir Shah (both) 6675 1135 59085 57951 59085

Nokot 3829 651 59736 59086 59736Terha Bala 1466 249 59985 59737 59985

Terha Payeen 1897 322 60307 59986 60307 25Shoukat Abad Afzal Abad 13073 2222 62530 60308 62530

Susal 2436 414 62944 62531 62944 26Malikpur Malikpur 3694 628 63572 62945 63572

Shanai Terli 394 67 63639 63573 63639Khwagan 2877 489 64128 63640 64128Sikandra 891 151 64279 64129 64279Sherpur 3047 518 64797 64280 64797

Muradpur 1255 213 65011 64798 65011Bherkund Bherkund Utla 6199 1054 66065 65012 66065 27

Harri Maira 895 152 66217 66066 66217Kehnian 865 147 66364 66218 66364

Marri Saffdar Shah 838 142 66506 66365 66506Neelor 690 117 66624 66507 66624Khaki 7641 1299 67922 66625 67922 28

Perhanna Perhanna 3292 560 68482 67923 68482Jhangi 3397 577 69060 68483 69060

Goojran 2100 357 69417 69061 69417Thaker Maira 1948 331 69748 69418 69748

Kala Maira 2267 385 70133 69749 70133 29Thathi Klan 2187 372 70505 70134 70505Bandi Kenth 3137 533 71038 70506 71038

Phulrah Phulrah 1888 321 71359 71039 71359Karrka 463 79 71438 71360 71438Koterra 376 64 71502 71439 71502Gojra 508 86 71588 71503 71588

Mondgran 882 150 71738 71589 71738Teleyla 494 84 71822 71739 71822

Bandi Ghulam Haider 439 75 71897 71823 71897Sarni 579 98 71995 71898 71995

Garrwal 905 154 72149 71996 72149Patian 1507 256 72405 72150 72405 30

Sawan Mara Khel 698 119 72524 72406 72524Shah Kot 836 142 72666 72525 72666

Trappi 1145 195 72861 72667 72861428592 72861

43

.VIII.2. Anthropometrics and Retrospective Mortality Survey Questionnaires (the same basic questionnaires were used for each survey)

.VIII.3. ed for each survey)

Child NB

HHNB

Status1=residen

2=displaced

Age(month

s)

Se1=mal

e2=female

Weight in (00.0

)

Height in cm (000.0

)W/H %

Oedema0=n

o1=+ 2=++3=++

+?=unsure

MUAC inc

m(00.0)

Measles 1=yes

2=no 3=histor

y

Registered in feedin

programme? 1=no

3=HT 4=TFC

12345678911111111112222222222333

44

Total < 5 Total <5 Total < 5 Total < 5123456789

1011121314151617181920212223242526272829303132

Current HH members who arrived since Moharram

(exclude births)Current HH members HH status

1=resident2=displaced

HH Nb

Transfer information from the Household and Mortality Tally SheetPast HH members who left since

Moharram(exclude deaths)

Births since Moharram

Deaths since Moharram

45


ID HH member Present now Present during Moharram?

Age in years or months

Born since Moharram?

Died since Moharram?

123456789

1011121314151617181920

Documents

NUTRITION ANTHROPOMETRIC SURVEY Final report Battagram ... · PDF file1 NUTRITION ANTHROPOMETRIC SURVEY Final report Battagram, Balakot and Mansehra Districts Pakistan 10th April to