this survey including, the staff of the Department of nutrition, Medical Research. Institute, health staff from Kalutara district and staff of the World Vision Lanka. Special ..... traditional preference for breast milk still continues despite the increased ...
Assessment of Nutritional Status Among Children Under Five Years In Some World Vision Lanka Operational Areas In Kalutara Districts
Dr. Renuka Jayatissa Lucia Mutowo and Diana
Department of Nutrition Medical Research Institute In collaboration with WORLD VISION LANKA (LTRT) 2006, JULY
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CONTENTS
ACKNOWLEDGEMENTS………………………………………………………....
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SUMMARY……………………………………………………………………....
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INTRODUCTION………………………………………………………………..
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METHODS……………………………………………………………………....
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RESULTS………………………………………………………………………..
9
CONCLUSIONS AND RECOMMENDATIONS……………………………………....
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REFERENCES…………………………………………………………………...
28
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ACKNOWLEDGEMENTS World Vision Lanka would like to thank all who have contributed to the completion of this survey including, the staff of the Department of nutrition, Medical Research Institute, health staff from Kalutara district and staff of the World Vision Lanka. Special thanks are also due to Dr. Athula Kahadaliyanagae, Director General of Health Services, Dr. Manil Fernando, Deputy Director General public health services and Provincial Director Western Province, Deputy Provincial Director, Kalutara and Director NIHS, Medical officers of Health in Kalutara, Beruwala and Panadura. Last but not least the parents who supported by providing the information and by giving their consent for their children to participate in the study.
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SUMMARY Background: Rapid rates of improvement in health indicators have been achieved in Sri Lanka but not within nutrition indicators. World Vision Lanka conducts nutrition interventions in selected areas of Kalutara district to combat malnutrition at individual level. It was important to identify the causes of malnutrition and baseline data for monitoring the impact of interventions to achieve the significant reduction or elimination of this problem. Objectives: To determine the current levels of malnutrition among children 6 – 59 months in some World Vision Lanka operational areas in Kalutara districts. Methods: A cross sectional 30-cluster study. Clusters were identified as public health midwife areas. Thirty children under five years from each cluster were studied. Data was collected by interviewing the caretaker of the child. Weight, height and mid arm circumference were measured. Results: A total of 909 children were assessed of whom 13.2%, 9% and 22.6% were wasted, stunted and underweight respectively. The prevalence of wasting in Beruwala, Kalutara and Panadura Medical Officer of Health areas (MOH) were 17.4%, 11.9% and 11% respectively. This study revealed that the highest prevalence of wasting was observed in children aged between 12-23.9 months. Nearly 57% of the children suffered from acute respiratory tract infections (ARI) and 5.5% had diarrhoeal diseases and the highest percentage of children with ARI was reported from the age group of 6-11 months. Although the frequency of feeding was satisfactory, it lacked diversity especially children between the age of 6-11 months. About one third of children had not consumed fruits during the last 24 hours. Wasting was significantly related to the age. Conclusions and Recommendations: Acute under nutrition among children is still a public health problem in the Kalutara district, especially in Beruwala MOH area. There is a need to strengthen the feeding practices among children between 6-59 months. It is recommended to provide fortified food as supplements for the children aged 6-59 months.
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INTRODUCTION Rapid rates of improvement in health indicators have been achieved in Sri Lanka but not with in nutrition indicators. Understanding the success of nutrition in others countries indicated that it is not primarily dependent on overcoming poverty. It is a combination of favorable context and deliberate local actions. The common feature of successes in other countries in reducing malnutrition is that the solving of causes of malnutrition at individual level. A Demographic and Health survey in 2000 indicated 14%, 13.5% and 29.4% of children under five years were wasted, stunted and underweight [1]. The prevalence of anaemia among preschoolers was 30% and 33.3% of preschoolers had biochemical deficiency of Vitamin A [2,3]. The literacy level is 90.7% with over 89% of female education level and life expectancy at birth exceeds 70 years [4]. Although Sri Lanka has made impressive achievements in child survival, under nutrition among children remains to be a significant public health problem. Sri Lanka shows the wide variation of malnutrition in different districts, ranging from 22% underweight in the Western province to 37.5% in Central province. A similar percentage of children are deficient in one or more micronutrients [2,3]. This burden of malnutrition contributes a huge toll in morbidity and premature mortality, in intellectual development and future productivity. It is virtually all preventable [5]. The tidal wave hit Sri Lanka taking lot of people away and giving extensive damages to infrastructure facilities on the 26th of December 2004. Even before the tsunami disaster, under nutrition was the single developmental challenge for Sri Lankan children. This situation expected to increase the risk of under nutrition among the vulnerable groups in particular children and women.
World Vision Lanka was established in 1977. At present World Vision Lanka assists over 44,000 children in over 765 villages in Sri Lanka, empowering the poor to organise their community and pool their resources in order to improve their lives. It included supply of safe water, sanitation, nutrition, health care, education and family income generation. Therefore a nutrition survey was urgently necessary to measure the extent and severity of malnutrition among children under five years to plan appropriate interventions, which
6 will be short term, medium and long term. The results of the nutrition survey provide an update on the nutritional status of the tsunami affected and non-affected population and can be used as baseline data for monitoring the impact of interventions. This survey was conducted under following objectives;
To determine the current levels of malnutrition among children 6 – 59 months in some World Vision Lanka operational areas in Kalutara districts.
To generate nutrition baseline information for supplementary feeding programs.
To describe the determinants of malnutrition among the study population.
To make recommendations to World Vision Lanka on the implementation of Nutrition interventions.
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METHODS A cross sectional 30-cluster rapid assessment survey was carried out in 3 MOH areas of the Kalutara disricts in Sri Lanka, i.e. Panadura, Kalutara and Beruwala. The study population was identified as children less than 5 years.
Sample size The required sample size for the district was calculated on the basis of the prevalence of wasting among children under 5 years was 14% with the 95% of confidence interval and 5% of error. The non-response rate was taken as 10%. Design effect was taken as 3. A total sample size of 900 for the whole district. Sampling A multi-stage sampling technique was used to identify the sample. All Public Health Midwives (PHM) areas were listed out by population by Medical Officer of Health (MOH) areas. Clusters were identified as PHM areas. Thirty PHM areas were selected using probability proportionate to the population in size sampling technique. From each PHM area 30 children were selected, starting from the selected location and moving to the closest house whose front door faced the first house, till the 30 children under 5 years were met. If there was more than one child in a household one child was randomly selected to include in the assessment of nutritional status. Data collection Field investigators were trained on two days prior to the data collection. The survey team consisted of 3 members, 1 or 2 from the staff in the Department of Nutrition who has had previous experience in collecting data for nutrition surveys. Five teams were deployed each covering 6 clusters during the survey. Data collection period was 16th – 21st
December 2005. All the MOHs and PHMs were informed about the study and
permission was obtained from the relevant health authorities. Verbal consent was taken from the parent or guardian of children prior to the study, after explaining the purpose and the study methods to them.
8 Data were collected using the following techniques. Interviewer administered questionnaire: An interviewer-administered questionnaire was used to collect information from the mother of the child or from a responsible caregiver. The following information was gathered: basic information (date of birth if not age, sex); morbidity and feeding data; access to water and sanitation; dietary diversity data; home garden etc. Anthropometric measurements: Weight, height/length of children and mid upper arm circumference was measured using standard techniques described by the World Health Organisation (WHO) [6]. Measurements were taken by the trained Public Health Inspectors (PHI) from the Department of Nutrition, Medical Research Institute. Weight was measured with minimal clothing and without shoes to the nearest 100 g with Seca electronic weighing scale and accuracy checked using the standard weights (no corrections have been made for the weight of the clothing). Length was measured for children under 2 years of age and height was measured for children over 2 years to the nearest 0.1 cm with a measuring board. Data analysis Data was entered in Epi6 software package and the analysis was carried out by using SPSS software package by the External Consultant of the World Vision Lanka. Age was calculated in months from the child's birthday. Weight-for-age, weight-for-height and height-for-age were calculated for children by using EPINUT software. The NCHS reference data was used and the Z score below -2SD was taken as cut off values to estimate prevalence of stunting, wasting and underweight according to the recommendations made by the World Health Organisation (WHO) [7]. Cut off points for mid upper arm circumference (MUAC) was taken as; ≤ 13.5mm for acute under nutrition and MUAC ≤ 11mm for severe under nutrition [8]. Chi square test was applied and the level of significance was taken when the P value is below the 0.05.
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RESULTS A total of 909 children less than five years in the World Vision Lanka operated areas in Kalutara district were covered by the study. Table 1 Relationship of the main caregiver to the index child (n=909) Care giver
N
%
Mother
847
93.2
Father
16
1.8
Care giver
46
5.1
Total
909
100.0
Majority (93.2%) of respondents were mother of the child and 1.8% was father of the child and 5.1% were caregivers as shown in Table 1. Table 2 Frequency of study respondents by age group (n=909) Age (years)
Study respondents N
%
49 years
25
2.8
Unspecified
5
0.6
Total
909
100.0
Table 2 shows that 75.6% of the respondents were between 15-34 years of age and 21% were between 35-49 years. As shown in Table 3, 11.7% were infants over 6 months and 11% were between 48-59 months in the study sample. The highest number of children (30.1%) was present in the age group of 12-23 months. There were 50.4% boys and 49.6% girls.
10 Table 3 The age group distribution of children studied by sex (n=909) Age (months)
Female
Male
Both sex
n
%
N
%
N
%
6 – 11
48
45.3
58
54.7
106
11.7
12 – 23
149
54.4
125
45.6
274
30.1
24 – 35
103
46.2
120
53.8
223
24.5
36 – 47
96
46.6
110
53.4
206
22.7
48 – 59
55
55.0
45
45.0
100
11.0
Total
451
49.6
458
50.4
909
100.0
Nearly half of the household (49.2%) consisted of less than 4 members and 41% of household had about 5-7 members. Only 1.8% of household consisted of more than 10 members (Table 4). Table 4 Number of people per household (n=909) Number of people
N
%
10 (too big)
16
1.8
Total
909
100.0
Most of the household (98.9%) which were visited had less than 3 children under five years. Only 1.1% of the houses had children more than 3-4 children (Table 5). Table 5 Number of children under the age of five per household (n=909) Number of under fives
N
%
5 times
318
35.0
15 This study also revealed the frequency of feeding among children (Table 13). Over half of the children (58%) were fed 3-4 times per day. About two third (35%) of children were fed more than 4 times daily and only 1.5% were fed once per day. The recommended frequency of feeding is more than 3 times per day. Table 14 Twenty-four hour child feeding habits recall on selected food items (n=909) Food items Rice/rice flour preparations, bread/wheat flour preparations, maize None Once Twice 3 times 4 times 5 or more times Manioc, sweet potatoes, yam, potatoes None Once Twice 3 times 4 times 5 or more times Pulses/Soya None Once Twice 3 times 4 times Milk and milk products (excluding breast milk) None Once Twice 3 times 4 times 5 or more times Fish/dry fish, egg, meat None Once Twice 3 times 4 times
Age groups(months) 6-11 12-23 ≥ 24 (n=106) (n=274) (n=529) % % % 9.4 33.0 27.4 25.5 3.8 0.9
4.7 12.4 34.3 35.4 9.1 4.0
2.5 8.3 25.3 50.3 10.2 3.4
41.5 39.6 15.1 0.9 2.8 0.0
48.5 36.1 12.0 3.3 0.0 0.0
59.5 29.3 9.6 1.1 0.4 0.0
51.9 32.1 14.2 1.9 0.0
50.7 32.1 13.9 2.9 0.4
49.0 29.5 18.3 2.8 0.4
50.9 12.3 20.8 12.3 2.8 0.9
27.0 17.2 30.3 16.8 5.5 3.3
14.7 18.0 41.6 19.3 3.8 2.6
44.3 31.1 17.0 6.6 0.9
21.9 45.3 28.1 4.4 0.4
13.4 36.5 44.2 5.7 0.2
16 Sugar in tea & biscuits None Once Twice 3 times 4 times 5 or more times Fat, oil, margarine, coconut None Once Twice 3 times 4 times 5 or more times Fruits None Once Twice 3 times 4 times Yellow to orange fruits and vegetables None Once Twice 3 times 4 times 5 or more times Vegetables None Once Twice 3 times 4 times 5 or more times Green leafy vegetables None Once Twice 3 times 4 times Thriposha, CSB, other cereals None Once Twice 3 times 4 times
31.1 36.8 22.6 8.5 0.0 0.9
17.9 40.9 24.5 9.9 4.0 2.9
20.6 36.5 22.5 14.5 6.8 2.1
49.1 24.5 17.9 5.7 0.9 0.9
31.4 22.3 29.6 13.5 2.6 0.7
22.3 19.9 35.4 16.9 14.2 1.3
32.1 54.7 9.4 2.8 0.9
31.4 48.2 17.2 3.3 0.0
32.5 50.3 14.6 2.3 0.4
43.4 30.2 16.0 5.7 1.9 2.8
56.6 26.3 14.2 2.6 0.4 0.0
60.7 25.5 10.6 2.6 0.6 0.0
35.8 28.3 23.6 6.6 5.7 0.0
39.1 31.0 24.5 3.3 1.5 0.7
42.3 28.4 21.9 5.3 1.3 0.5
60.4 25.5 10.4 2.8 0.9
60.6 30.3 7.3 1.8 0.0
59.7 31.0 8.5 0.8 0.0
53.8 37.7 7.5 0.9 0.0
56.2 37.2 5.5 0.7 0.4
73.2 23.8 2.6 0.4 0.0
17 Table 14 shows the food consumption of children during the past 24 hours prior to the interview day. In this population 68.9% of children between 6-11 months and 82.1% of children aged 12-23 months were given biscuits, sugar added in tea and beverages. About 44.3% of infants were not given animal products like fish, meat, dry fish or eggs during the past 24 hours. It is recommended to consume at least once a day. However, there was an improvement in the consumption pattern among older age groups. Around 50% of children in all age groups were fed with pulses or soya products. The consumption of fats or oils was less among the infants (49.1%) than among other age groups. Consumption of fats or oils had improved with the increasing age. However, the main portion of food came from cereal group.
About 43.4% of infants had not received yellow to orange fruits and vegetables and the consumption had got decreased with increasing age. About two third of children did not consume green leafy vegetables irrespective to the age. Only about one third of children had not consumed vegetables and fruits during the last 24 hours. The similar consumption pattern for fruits and vegetables was observed between age groups. Around half (53.8%) of children under one year had not received any supplementary foods like Triposha (fortified supplementary food produced in Sri Lanka by the Government), Corn Soya Blend (CSB) or any other commercial products available in the markets. It goes up to 73.2% among the children above 24 months. Table 15 Households receiving free food from Government and NGOs (n=909) Households receiving free food
N
%
Yes
265
29.2
No
644
70.8
Total
909
100.0
from Government and NGOs
As indicated in Table 15, 29.2% of them received free food from the Government such as Samurdhi and other income supportive programmes existing in the country. Table 16 shows that only 8.6% maintain a home garden to grow vegetables and fruits for their consumption or sale. However, 35.6% of them use green leaves and vegetables
18 available in the environment freely. They plucked those whenever necessary for their daily cooking. Table 16 Use of home garden and the immediate environment to obtain food Availability of Household garden (n=909) Yes No Consumption of wild vegetables by those without gardens (n=831) Yes No Frequency of consumption of garden produce (n=78) Every day 4 – 6 days a week 2 – 3 days a week None Seasonal availability of vegetables in HH gardens in months (n=78) 1 –2 months 3 – 5 months 6 – 9 months 10 – 12 months Unspecified Sale of HH garden produce (n=78) Yes No Seasons with no vegetables from HH gardens (n=46) January – March April – June July – September October – December Unspecified Reasons for not having vegetables during these seasons (n=46) Dry season Rainy days Land preparation period Threat of insects Unspecified
N 78 831
% 8.6 91.4
296 535
35.6 64.4
9 17 50 2
11.5 21.8 64.1 2.6
13 21 11 32 1
16.7 26.9 14.1 41.0 1.3
4 74
5.1 94.9
9 6 11 16 4
19.6 13.0 23.9 34.8 8.7
19 5 5 2 15
41.3 10.9 10.9 4.3 32.6
19 Out of the people who had a home garden majority (64.1%) use it 2-3 days a week and only 11.5% of them use it for daily consumption. About 41% indicated availability of products in the garden even for 10-12 months per year, which shows the food availability is satisfactory through out the year. Few (5.1%) sold vegetables. Sixteen of them indicated vegetables were not available during the period of October to December mainly due to reasons indicated in Table 16. Table 17 Use of drinking water and toilets Type of drinking water source (n=909)
N
%
Treated tap water
565
62.5
Protected well
229
25.2
Tube well
88
9.7
Unprotected well
26
2.9
River/ Dam/tank
1
0.1
Bowser
0
0.0
Bottled
0
0.0
Safe
882
97.0
Unsafe
27
3.0
Yes
792
87.1
No
117
12.9
Flush
775
97.9
Pit latrine
17
2.1
Communal flush toilet
82
70.1
Communal pit toilet
3
2.6
Other
32
27.4
Type of drinking water source by safety status
Household ownership of a toilet (n=909)
Type of household toilet (n=792)
If no HH toilet what is used (n=117)
20 Table 17 shows that 62.5% of them got drinking water from the tap and that 25.2% got water from the protected well. It indicates that the 97% use safe drinking water. About 87.1% owned a toilet and 97.9% used water sealed toilets. 70.1% who did not own a toilet use communal flush toilets. It is noted that 2.1% still used pit latrines, which is not a sanitary toilet. The distribution of the pit latrine in MOH areas is as follows; Panadura (2.6%), Kalutara (1.4%) and Beruwala (2.4%).
Prevalence of wasting, stunting and underweight The findings of the study revealed (Figure 1) that the prevalence of wasting (percentage below the -2SD of NCHS/WHO weight-for-height reference) was 13.2%. The prevalence of stunting (percentage below the -2SD of NCHS/WHO height-for-age reference) was 9%. The prevalence of underweight (percentage below the -2SD of NCHS/WHO weight-for-age reference) was 22.6%.
Figure 1 Prevalence of wasting, stunting and under weight with severity
Normal
100%
Moderate
80% 60%
Severe 79.2
86.8
91
12.4
7.5
40% 20% 0%
20.6 0.8
1.5
Wasting
Stunting
2
Under weight
However, only 0.8% was severely wasted (percentage below the -3SD of NCHS/WHO weight-for-height reference), 1.5% was severely stunted (percentage below the -3SD of NCHS/WHO height-for-age reference) and 2% was severely underweight (percentage below the -3SD of NCHS/WHO weight-for-age reference). The majority of the wasted,
21 stunted and underweight children were within the moderate category (between the -2SD and -3SD of NCHS/WHO reference) as shown in the Figure 1. Figure 2 Mid-Upper Arm Circumference (MUAC) >12 months (n=795) 87
90 80 70 60 50 % 40 30 20 10 0
11.1 1.6
0.3 13.5
MUAC (cm)
During the study nutritional status among children over one year was determined using the mid arm circumference (MUAC). Figure 2 shows the distribution of MUAC among children over one year. It indicates that 13% of children were below the cut-off point and suffering from acute under nutrition. This value is comparative to the prevalence of wasting. Table 18 Malnutrition (Wasting, Underweight and Stunting by age group (n=909) Age (months)
Wasting*
Underweight
Stunting
n
%
n
%
N
%
6 – 11
4
3.8
12
11.3
8
7.5
12 – 23
42
15.3
57
20.8
31
11.3
24 – 35
31
13.9
60
26.9
9
4.0
36 – 47
28
13.6
57
27.7
27
13.1
48 – 59
15
15.0
19
19.0
7
7.0
Total
120
13.2
205
22.6
82
9.0
(*Chi square=9.71, df = 4, P-value=0.045 13.5 cm
n
%
N
%
n
%
n
%
12 – 23
1
0.4
7
2.6
54
19.9
210
77.2
24 – 35
1
0.5
3
1.4
16
7.2
201
91.0
36 – 47
0
0.0
3
1.5
11
5.4
189
93.1
48 – 59
0
0.0
0
0.0
7
7.1
92
92.9
Beruwala
1
0.4
6
2.6
24
10.3
203
86.8
Kalutara
0
0.0
5
1.8
38
13.6
236
84.6
Panadura 1
0.4
2
0.7
26
9.2
253
89.7
2
0.3
13
1.6
88
11.1
692
87.0
MOH areas
Total
In Table 21, it is noted that boys appeared to have higher prevalence of wasting than girls (13.2% in boys and 13.1% in girls). The prevalence of severe wasting among boys (0.9%) was higher than that of the girls (0.7%). But the difference is not significant. Table 21 Weight for height Z- score (wasting) by sex Sex
Wasting Normal
Moderate
Severe
>-2
> -3 & -3 &
