Attachment-13_Report_NNS_201.pdf

-National Nutrition Survey Report 2011-

National Nutrition Survey

Pakistan

Aga Khan University, Pakistan

Pakistan Medical Research Council (PMRC)

Nutrition Wing, Cabinet Division, Government of Pakistan

Supported by UNICEF Pakistan i -National Nutrition Survey Report 2011-

Survey Team, Aga Khan University, Pakistan

Principal Investigator Prof. Zulfiqar A Bhutta

FCPS, FRCPCH, PhD Founding Chair Division of Women & Child Health

Aga Khan University, Pakistan

National Survey Coordinator Dr. Sajid Bashir Soofi

Survey Coordinators

Mr. S. Shujaat H. Zaidi (Senior Social Scientist Research) Dr. Muhammad Atif Habib (Senior Instructor Research)

Mr. Imtiaz Hussain (Senior Social Scientist Research)

Regional Coordinators

Mr. Gul Nawaz, Mr. Maswar Hussain, Dr. Abdul Razzaq Lasi, Dr. Azam Baber, Dr. Tariq Samejo, Dr. Mushtaq Dero, Mr. Mushtaq Mirani, Dr. Noushad Ali & Mr. Asmatullah

Data Management & Analysis

Mr. Imran Ahmed (Data Manager) Mr. Zaid Shakoor Bhatti (Data Analyst)

Mr. Najeebur Rehman (Data Coordinator)

Management and Administration

Mir Asghar Ali Khan (Manager, Research and Outreach) Mr. Ishrat Abbas (Assistant Manager Budget and Finance)

Mr. Mohammad Siddque and Shukurullah Baig (Logistic Management) Rashid Khan and Khuram Noorani (Financial Managements)

Mr. Didar Alam (Laboratory Coordinator)

Collaborators

PMRC

Dr. Huma Qureshi (Deputy Director) Dr. Arif Munir

Mr. Mehmood & Mr. Rizwanullah

Nutrition Wing, Cabinet Division, Govt. of Pakistan Dr. Baseer Ahmed Achakzai

National Nutrition Focal Person

Federal Bureau of Statistics Mr. Muhammad Ramzan Khan (Ex-Director Sample Design) ii -National Nutrition Survey Report 2011-

INDEX

CHAPTER 1: INTRODUCTION --------------------------------------------- ------------------------------------------1

1.1 PAKISTAN – An Introduction ------------------------------------------ ------------------------------------------1

1.2 Malnutrition among Women and Children in Pakistan – Background ---------------------------------1

1.3 Review of Literature – Background and Magnitude of the Problem -----------------------------------2

1.4 Need for Nutrition Survey --------------------------------------------- ------------------------------------------3 CHAPTER 2: SURVEY DESIGN AND METHODS ------------------------- ------------------------------------------

2.1 Objectives ------------------------------------------------------------------ ------------------------------------------5

2.2 Indicators for National Nutrition Survey ---------------------------- ------------------------------------------5

2.3 Survey Design -------------------------------------------------------------- ------------------------------------------6

2.3.1 Universe ------------------------------------------------------------------ ------------------------------------------6

2.3.2 Sampling Frame -------------------------------------------------------- ------------------------------------------6

2.3.3 Listing Activity----------------------------------------------------------- ------------------------------------------7

2.3.4 Stratification ------------------------------------------------------------ ------------------------------------------7

2.3.5 Sample Size and its allocation --------------------------------------- ------------------------------------------8

2.3.6 Sample selection procedure --------------------------------------- ------------------------------------------8

2.3.7 Target Population ------------------------------------------------------ ------------------------------------------9

2.3.8 Survey Material and Methods -------------------------------------- ------------------------------------------9

2.3.9 Description of Questionnaire (Quantitative) -------------------- ------------------------------------------9

2.3.10 Description of qualitative research ------------------------------ ------------------------------------------10

2.3.11 Qualitative research sample and target population --------- ------------------------------------------11

2.3.12 Tools for qualitative data collection ----------------------------- ------------------------------------------11

2.3.13 Transcription and translation of qualitative data------------- ------------------------------------------12

2.3.14 Biochemical Analysis------------------------------------------------- ------------------------------------------12

2.3.15 Project Pre-Implementation Steps ------------------------------- ------------------------------------------12

2.3.16 Identification and Recruitment of Field Staff ----------------- ------------------------------------------13

2.3.17 Survey Teams ---------------------------------------------------------- ------------------------------------------13

2.3.18 Training ----------------------------------------------------------------- ------------------------------------------14

2.3.19 Coding Scheme for Assigning Processing Codes -------------- ------------------------------------------14

2.3.20 Plan of Operation, Training and Monitoring ------------------- ------------------------------------------14

2.3.21 Data Management, Transfer and Analysis Plan --------------- ------------------------------------------15

2.3.23 Ethical approval and Confidentiality ---------------------------- ------------------------------------------16 Results of National Nutrition Survey ----------------------------------- ------------------------------------------17 CHAPTER 3: BACKGROUND AND HOUSEHOLD CHARACTERISTICS -----------------------------------------18

3.1 Completion of Data Collection ---------------------------------------- ------------------------------------------18

3.1.1 Blood and Urine Specimen------------------------------------------- ------------------------------------------19

3.2 Background and Household Characteristics ----------------------- ------------------------------------------19

3.3 Formal Education – Head of Household ---------------------------- ------------------------------------------19

3.4 Occupation – Head of Household ------------------------------------ ------------------------------------------20

3.5 Nature of Dwelling by Type of Floor, Roof and Walls------------ ------------------------------------------20

3.6 Type of Cooking Fuel Used -------------------------------------------- ------------------------------------------22

3.7 Source of Drinking Water ----------------------------------------------- ------------------------------------------22 CHAPTER 4: FOOD INSECURITY IN PAKISTAN ------------------------- ------------------------------------------24 1-Food secure: ----------------------------------------------------------------- ------------------------------------------25 iii -National Nutrition Survey Report 2011-

2-Food insecure without hunger ------------------------------------------ ------------------------------------------25 3-Food insecure with hunger (moderate) ------------------------------ ------------------------------------------25 4-Food insecure with hunger (severe) ----------------------------------- ------------------------------------------25 CHAPTER 5: MATERNAL HEALTH AND NUTRITION ------------------ ------------------------------------------28 Section 1: Basic Data: Age, Education and Marital status (Mother of Index Child) --------------------28

5.1.1 Age Distribution of Index Mothers--------------------------------- ------------------------------------------28

5.1.2 Formal Education ------------------------------------------------------ ------------------------------------------28

5.1.3 Marital Status and Current Pregnancy Status (Mother of index child) ------------------------------28 Section 2: Reproductive History and Antenatal Care --------------- ------------------------------------------28

5.2.1 Reproductive History (Mother of Index Child) ------------------ ------------------------------------------28

5.2.2 Antenatal Care ---------------------------------------------------------- ------------------------------------------29 Section 3: Knowledge of micronutrients and vitamin rich foods ------------------------------------------32

5.3.1 Knowledge of Micronutrient ---------------------------------------- ------------------------------------------32 5.3.2-Knowledge of Vitamin Rich Foods --------------------------------- ------------------------------------------33

5.3.3 Knowledge about iodized salt and its usage: -------------------- ------------------------------------------34

5.3.4 Consequences of Micronutrient deficiencies ------------------- ------------------------------------------35 Section 4: Clinical Examination (Mothers of Index Child) ---------- ------------------------------------------36 Section 5: Anthropometry ------------------------------------------------ ------------------------------------------37 Section 6: Micronutrient Deficiency ------------------------------------- ------------------------------------------39 Section 7: Biochemical Analysis: ------------------------------------------ ------------------------------------------42 1-Hemoglobin Levels: -------------------------------------------------------- ------------------------------------------42 2-Ferritin Levels: --------------------------------------------------------------- ------------------------------------------44 3-Iron Deficiency Anemia ---------------------------------------------------- ------------------------------------------45 4-Vitamin A Deficiency (Mother of Index Child) ----------------------- ------------------------------------------46 5-Zinc Deficiency --------------------------------------------------------------- ------------------------------------------47 6-Calcium Deficiency:--------------------------------------------------------- ------------------------------------------49 7- Vitamin D Deficiency: ----------------------------------------------------- ------------------------------------------50 CHAPTER 6: CHILD HEALTH AND NUTRITION ------------------------- ------------------------------------------51 Section 1: Nutrition Status of the Index Children -------------------- ------------------------------------------51

6.1.1 Children 0 – 59 months ----------------------------------------------- ------------------------------------------51

6.1.2 Sex and Age Distribution of Index Children ---------------------- ------------------------------------------51

6.1.3 Anthropometry (Index Children) ---------------------------------- ------------------------------------------53

6.1.4 Stunting (Index Children) --------------------------------------------- ------------------------------------------53

6.1.5 Wasting (Index Children) --------------------------------------------- ------------------------------------------55

6.1.6 Underweight (Index Children) -------------------------------------- ------------------------------------------55

6.1.7 Education of Mothers and its Effect on Stunting, Wasting and Underweight Status ------------56

6.1.8 Anthropometry (All Children) -------------------------------------- ------------------------------------------57

6.1.9 Stunting (All Children <5) -------------------------------------------- ------------------------------------------58

6.1.10 Wasting (All Children <5) ------------------------------------------- ------------------------------------------58

6.1.11 Underweight (All Children <5) ------------------------------------ ------------------------------------------58

6.1.12 National Trends in Malnutrition (All Children) ---------------- ------------------------------------------59

6.1.13 Provincial Trends in Malnutrition (All Children) – Pakistan ------------------------------------------59

6.1.14 Regional Trends in Malnutrition (All Children) – SAARC Countries Comparison -----------------60 Section 2: Biochemical Analysis of index children ------------------ ------------------------------------------61 6.2.1: Hemoglobin Level - Index Child ------------------------------------ ------------------------------------------62 iv -National Nutrition Survey Report 2011-

6.2.2: Ferritin Level - Index Child ------------------------------------------ ------------------------------------------63 6.2.3: Iron Deficiency Anemia (IDA) - Index Child --------------------- ------------------------------------------64 6.2.4: Vitamin A Deficiency - Index Child ------------------------------- ------------------------------------------65 6.2.5: Zinc Deficiency - Index Child ---------------------------------------- ------------------------------------------66 6.2.6: Vitamin D Deficiency - Index Child -------------------------------- ------------------------------------------67 6.2.7: Urinary Iodine - 6-12 years Children ------------------------------ ------------------------------------------67 Section 3: Child Immunization: -------------------------------------------- ------------------------------------------70 Section 4: Morbidity Trends in Children: ------------------------------- ------------------------------------------73 6.4.1: Prevalence of ARI------------------------------------------------------ ------------------------------------------73 6.4.2: Prevalence of Diarrhea: ---------------------------------------------- ------------------------------------------73 CHAPTER 7: INFANT AND YOUNG CHILD FEEDING PRACTICES --- ------------------------------------------76 CHAPTER 8: FOOD INTAKE & PRACTICES ------------------------------- ------------------------------------------80 Section 1: Food consumption in Children 0-23 months of age: -- ------------------------------------------80 Section 2: Food consumption in Mothers of Index Child: ---------- ------------------------------------------84 CHAPTER 9: ELDER PERSONS HEALTH STATUS ------------------------ ------------------------------------------89 CHAPTER 10: QUALITATIVE COMPONENT OF NNS 2011 ----------- ------------------------------------------93 Motherhood -------------------------------------------------------------------- ------------------------------------------93 Children’s Need, Pre-lacteal Feeding and Breastfeeding ------------ ------------------------------------------93 Introduction of Complementary Feeding -------------------------------- ------------------------------------------94 Breastfeeding and Complementary Food Duration ------------------- ------------------------------------------94 Perception regarding Health and Illness (Mother and Child) ------- ------------------------------------------95 Differences in Dietary Intake between Girls and Adult women Intra HH Food Distribution -----------96 Common Perception and Physiological Effects of “Hot”/“Cold” Food --------------------------------------97 Purchasing Practices – Local versus Imported Food ----------------- ------------------------------------------97 Purchasing Practices – Foods and Affordability ------------------------ ------------------------------------------97 Food Safety – Thawing and Food Storage ------------------------------- ------------------------------------------98 Violence against Women --------------------------------------------------- ------------------------------------------98 Chapter 11: WHAT NEXT? -------------------------------------------------- ------------------------------------------99 Chapter 12: REFERENCES & BIBLIOGRAPHY --------------------------- ------------------------------------------104 v -National Nutrition Survey Report 2011-

List of Tables Table 2.1: No of enumeration blocks and villages -------------------- ------------------------------------------ Table 2.2: Description of Blood and Urine Specimen Collected---- ------------------------------------------ Table 2.4: A detail distribution of in-depth interviews and focus group discussions ------------------- Table 2.5: Description of Biochemical Analysis/Tests ---------------- ------------------------------------------ Table 2.6: Pre-implementation Steps------------------------------------- ------------------------------------------ Table 2.7: Details of Training Agenda ------------------------------------ ------------------------------------------ Table 3.1: Details of Sample Size and Achievement ------------------ ------------------------------------------ Table 5.1: Did you seek any one for antenatal care during your last pregnancy ------------------------- Table 5.11: Vitamin A Deficiency – pregnant and Non Pregnant Mothers -------------------------------- Table 5.12 Zinc Deficiency In mothers of Index Child: ---------------- ------------------------------------------ Table 5.14: Vitamin D Deficiency – Pregnant and Non Pregnant Mothers --------------------------------- Table 5.2 Knowledge about Micronutrients ---------------------------- ------------------------------------------ Table 5.3 Salt Test Results --------------------------------------------------- ------------------------------------------ Table 6.1 haemoglobin levels Index child ------------------------------- ------------------------------------------ Table 6.10: Vaccinations by source of information ------------------- ------------------------------------------ Table 6.11: Pakistan and Regional Immunization Trends by Source of Information -------------------- Table 6.2 comparison of hemoglobin levels --------------------------- ------------------------------------------ Table 6.3 Ferritin deficiency level- Index Child ------------------------ ------------------------------------------ Table 6.4 Iron Deficiency Anemia (IDA) - Index Child ----------------- ------------------------------------------ Table 6.5 Vitamin A Deficiency - Index Child --------------------------- ------------------------------------------ Table 6.6 Zinc Deficiency - Index Child ----------------------------------- ------------------------------------------ Table 6.7 Vitamin D Deficiency - Index Child --------------------------- ------------------------------------------ Table 6.8 Urinary Iodine - 6-12 years Children ------------------------ ------------------------------------------ Table 8.1: Share of Calories & Nutrients - Children (0-23 months) ------------------------------------------ Table 8.3: Consumption of Food Groups -------------------------------- ------------------------------------------ Table 8.4: Share of Calories & Nutrients – Mothers ------------------ ------------------------------------------ Table 8.5: Comparison of Nutrient Intake with the RDA------------- ------------------------------------------ Table 8.6: Consumption of food groups --------------------------------- ------------------------------------------ Table 9.1: Morbidities in Elderly person --------------------------------- ------------------------------------------ Table 9.2: Body Mass Index of Elderly person -------------------------- ------------------------------------------ Table: 5.10 Iron Deficiency Anemia --------------------------------------- ------------------------------------------ Table: 5.13 Calcium Deficiency --------------------------------------------- ------------------------------------------ Table: 5.4 Clinical Examinations (Mother of Index Child) ------------ ------------------------------------------ Table: 5.6 Comparison of night blindness ------------------------------ ------------------------------------------ Table: 5.7 Hemoglobin Levels Non Pregnant mother ---------------- ------------------------------------------ Table: 5.8 Hemoglobin Level Pregnant mothers: ---------------------- ------------------------------------------ Table: 5.9 Ferritin Levels of mothers of index child ------------------- ------------------------------------------ Table: 6.9 Clinical Examinations (Index Child) -------------------------- ------------------------------------------ Table: 8.2: Comparison of Nutrient Intake with the RDA ------------ ------------------------------------------vi -National Nutrition Survey Report 2011-

List of Figures Fig: 3.1 Population density -------------------------------------------------- ------------------------------------------ Fig: 3.2 National Nutrition Survey coverage ---------------------------- ------------------------------------------ Fig: 3.3 Formal schooling of head of household ---------------------- ------------------------------------------ Fig 3.4 Type of walls ---------------------------------------------------------- ------------------------------------------ Fig 3.5 Type of Roof ----------------------------------------------------------- ------------------------------------------ Fig 3.6 Type of Floor --------------------------------------------------------- ------------------------------------------ Fig 3.7 source of fuel for cooking ----------------------------------------- ------------------------------------------ Fig 3.8 source of drinking water at national level -------------------- ------------------------------------------ Fig 3.9 Source of drinking water at provincial level ------------------- ------------------------------------------ Fig 4.1 Food insecurity status ---------------------------------------------- ------------------------------------------ Fig 5.1 components of care during ANC visits ------------------------- ------------------------------------------ Fig 5.10 Maternal Anemia (Mothers - Non Pregnant ----------------- ------------------------------------------ Fig 5.11 Maternal Anemia (Mothers – Pregnant----------------------- ------------------------------------------ Fig 5.12 Comparison of Ferritin Levels ----------------------------------- ------------------------------------------ Fig 5.13 Comparison of VAD among mothers ------------------------- ------------------------------------------ Fig 5.14 Zinc deficiency ------------------------------------------------------ ------------------------------------------ Fig 5.2 Supplementation during the Last Pregnancy ----------------- ------------------------------------------ Fig 5.3 Knowledge and reported use of iodized salt ------------------ ------------------------------------------ Fig 5.4 Clinical Examination among Mothers -------------------------- ------------------------------------------ Fig 5.5 BMI for all WRA------------------------------------------------------- ------------------------------------------ Fig 5.6 BMI of Mothers (Non Pregnant)---------------------------------- ------------------------------------------ Fig 5.7consequences of vitamin a and mineral deficiencies ------- ------------------------------------------ Fig 5.8 Urinary Iodine Excretion ------------------------------------------- ------------------------------------------ Fig 5.9 Night Blindness in Women----------------------------------------- ------------------------------------------ Fig 6.1 Household with Children Under 5 Years ----------------------- ------------------------------------------ Fig 6.10 Under Weight (Index child) – Provinces ---------------------- ------------------------------------------ Fig 6.11 Under Weight (Index child) – by age group ----------------- ------------------------------------------ Fig 6.12 Mother's Education and its Effect on Children's Stunting, Wasting and Underweight ------ Fig 6.13 Prevalence of Malnutrition in Pakistan (All Children <5) ------------------------------------------ Fig 6.14 Stunting Rates (All Under 5) – National ----------------------- ------------------------------------------ Fig 6.15 Wasting Rates (All Under 5) – National ----------------------- ------------------------------------------ Fig 6.16 Underweight (All Children <5) National----------------------- ------------------------------------------ Fig 6.17 Malnutrition National Trends (All Children) ----------------- ------------------------------------------ Fig 6.18 Provincial Trends of Stunting, Wasting and Underweight (All Children -5) --------------------- Fig 6.19 SAARC Countries National Stunting Trends ------------------ ------------------------------------------ Fig 6.2 Age Distribution of Index Children - National ---------------- ------------------------------------------ Fig 6.20 SAARC Countries National Wasting Trends ------------------ ------------------------------------------ Fig 6.21 SAARC Countries National Underweight Trends ------------ ------------------------------------------ Fig 6.22 Comparison of Anemia- Index child --------------------------- ------------------------------------------ Fig 6.23 Comparison of Iron/Ferritin Level - Index Child ------------- ------------------------------------------ Fig 6.24 Comparison of Iron Deficiency Anemia - Index Child ------ ------------------------------------------ Fig 6.25 Comparison between NNS 2011 and 2001------------------- ------------------------------------------ Fig 6.26 Comparison of Zinc deficiency Index child ------------------ ------------------------------------------ Fig 6.27 Comparison of Iodine deficiency Index children ------------ ------------------------------------------vii -National Nutrition Survey Report 2011-

Fig 6.28 Availability of Vaccination Card --------------------------------- ------------------------------------------ Fig 6.29 Provincial Trend: Pentavalent Dose Rate --------------------- ------------------------------------------ Fig 6.3 Provincial Distribution by Age Group (Index Children) ----- ------------------------------------------ Fig 6.30 Provincial Trends for Availability of Vaccination Card ----- ------------------------------------------ Fig 6.31 Current ARI Status (Index Child) -------------------------------- ------------------------------------------ Fig 6.32 Prevalence of Diarrhea -------------------------------------------- ------------------------------------------ Fig 6.33 Worm Infestation among children ---------------------------- ------------------------------------------ Fig 6.4 Prevalence of Malnutrition (Index Children) ------------------ ------------------------------------------ Fig 6.5 Stunting Rates (Index Child) – National ------------------------- ------------------------------------------ Fig 6.5a Stunting Rates (Index Child) – Provinces---------------------- ------------------------------------------ Fig 6.6 Stunting rates (Index child) age group wise ------------------ ------------------------------------------ Fig 6.7 Wasting Rates (Index child) – Provinces ------------------------ ------------------------------------------ Fig 6.8 Wasting Rates (Index child) – National ------------------------- ------------------------------------------ Fig 6.9 Under Weight (Index child) – National ------------------------- ------------------------------------------ Fig 7.1: Initiation of breastfeeding within one hour ------------------ ------------------------------------------ Fig 7.2: Exclusive Breast Feeding ------------------------------------------ ------------------------------------------ Fig 7.3: Introduction of Semi solid food ---------------------------------- ------------------------------------------ Fig 7.4: Minimum Dietary Diversity (6-23 months) ------------------- ------------------------------------------ Fig 7.5: Minimum Meal Frequency (6-23 months) -------------------- ------------------------------------------ Fig 7.6: Minimum acceptable diet (6-23 months) --------------------- ------------------------------------------ Fig 7.7: Age appropriate Breastfeeding (0-23 months) -------------- ------------------------------------------ Fig 9.1: Age distribution of Elderly Person: ----------------------------- ------------------------------------------ Fig 9.3: Loss of Appetite Elderly person --------------------------------- ------------------------------------------ Fig 9.4: Weight loss in Elderly person (by recall) ---------------------- ------------------------------------------ Fig: 9.2: Gender distribution of Elderly person ------------------------ ------------------------------------------

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Chapter 1: INTRODUCTION

1.1 PAKISTAN – An Introduction

The nation of Pakistan is 63 years old and the population has surged from a 34 million in 1947 in the western wing to an estimated population exceeding 180 in 2011(1). Maternal and Child health and survival remain major challenges. Pakistan is a signatory to the Millen-nium declaration and a declared intent to reduce maternal and child mortality.

In addition to smoldering decades old conflict in neighboring Afghanistan, a debilitating in-surgency in the North and growing militancy in Southern Punjab and Balochistan, Pakistan has faced a spate of recent disasters. The earthquake in 2005 left over 75,000 dead with massive infrastructure damage (2) and the recent unprecedented floods in 2010 also af-fected close to 20 million people, displacing almost 8 million in its wake (3). The unprece-dented torrential rains in Sindh broke the last 60 years record and left 3 million people homeless and 2 million with food starvation affected the country thus faces the triple chal-lenge of political fragility, complex security issues and natural disasters. The security situa-tion in large parts of the country is fragile affecting the policy environment and distribution of key primary care programs. The relatively recent economic downturn has also affected overall purchasing power and household level food security. Other than the limited popula-tion based surveys undertaken following the recent floods in 2010, little systematic informa-tion is available on trends of maternal and childhood nutrition status over the last decade.

Given the critically important contribution of social determinants especially nutrition, to health and development outcomes, this is a key policy relevant information gap.

1.2 Malnutrition among Women and Children in Pakistan – Background

Directly or indirectly the concurrent vicious life cycle of malnutrition contributes to almost 35% of all under-5 deaths in the country consequently affecting the future health and socio-economic development and productive potential of the society. Over the past 20 years there has been little change in the prevalence of malnutrition in the population despite more food availability and an overall increase in caloric intake per capita. This may be re-lated to the cross sectorial and complex nature of malnutrition which also include issues re-lated to poverty and those that impact intra-household food security and contemporary so-cio-cultural factors determining dietary patterns in pregnancy and early childhood.

Although the problem of malnutrition has been never good throughout the history but the current situation is alarming because we did not make any significant progress in reducing malnutrition since many years. In Sindh alone, while the emergency standard is 15 percent the southern part of Sindh has reached 21 – 23 percent – the worst condition of malnutri-

2 -National Nutrition Survey Report 2011-tion in the world over the years. The purchasing power of people is decreasing day by day.

In Pakistan, large family size forced to expense 46 percent of the family income on food while food expenditures in India are 35 percent and the US 7 percent (Times Magazine March 2011, What We Spend in a Month by Stephen Gandel).

1.3 Review of Literature – Background and Magnitude of the Problem

Under-nutrition is one of the modifiable threats to global health and child survival especially in poor and under developed settings due to its interaction with infections. There are cer-tain solutions available but they require political will, economic advancement and research to attain the results (6). Under-nutrition is a recognized health problem in Pakistan and plays a substantial role in the country’s elevated child morbidity and mortality.

Global estimates suggest that there are more than 150 million malnourished children under the age of 5 years. It is also well recognized that close to 35 percent of the estimated 9.2 million deaths among children under-five is associated with under nutrition (7). Studies sug-gest that malnutrition exerts a multiplicative effect on the risk of mortality from infectious diseases (8). Like other major health issues malnutrition is widely prevalent in South Asian Region where half of the world’s malnourished children are to be found in just 3 countries Bangladesh, India and Pakistan. South Asia is the worst affected region and presents an “Asian Enigma” due to high rates of low birth weight (LBW), unhygienic conditions, unsatis-factory breastfeeding and weaning practices and the poor status of women (9).

The prevalence of underweight is very high in South Asian Region and between a quarter to a third of all newborns are born low birth weight and over half of women of reproductive age weigh less than 45 kg (10). It is recognized that malnourished women have a significant higher risk of giving birth to low birth weight infants. Moreover low birth weight infants are at a higher risk of morbidity and mortality in the neonatal period or later infancy (11). Fur-thermore LBW infants who survive are often poorly breast-fed and weaned, resulting in stunted, malnourished children and when grown up are less productive in society, thus add-ing to poverty and unemployment in the country. Not only this, LBW female infants develop into malnourished mothers who in turn produce LBW babies in a vicious cycle.

Stunting is used as a reliable indicator of growth retardation in developing countries. The stunting rates in Pakistan have fallen from 47 percent in 1980 to 33percent in 2000 (12). De-spite a reduction in overall prevalence, child malnutrition remains a major public health problem in developing countries, where a third of all children under five are stunted; 70 percent of them live in South Asia (13, 14). Factors associated with reduction in childhood stunting include availability of high-energy nutrients, female literacy and rise in gross na-tional product (15). It can be stated that these very factors or lack of interventions are the reason of widespread malnutrition affecting children as well as young girls and women (16).

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In comparison with other neighboring countries of South Asia (except Sri Lanka), the mater-nal and child health and nutrition situation Pakistan is a cause of much concern (17). Al-though the prevalence of stunting in Pakistan declined from 67 percent in 1977 to an esti-mated 40-50 percent by then end of the 1990s (18), subsequent progress has been very slow.

According to the national health survey (1990-94), the prevalence of stunting among the urban middle to lower economic groups was approximately 30-36 percent and as high as 35- 45 percent in the same economic group in the rural areas (19). The national survey catego-rized economic status on the basis of material possessions and facilities owned by the household but with different criteria for urban and rural households. Pakistan’s urban-rural difference may partially be explained by the relatively higher level of education among the urban population as well as their facilitated access to basic health services (20).

Available evidence for under nutrition signifies that growth faltering in majority of such children begins at around four to six months of age, this is the time when an infant starts receiving complementary foods in addition to breast milk (21). This divergence from normal growth is actually a combination of poor nutrition and intra-uterine growth restriction (22), further aggravated by the burden of morbidity especially diarrheal diseases (23). Poor quality and quantity of complementary foods, as well as inadequate caring practices are the key determinants for this early phase of childhood growth retardation (24), which has long-term consequences in determining the late onset of the childhood growth spurt and subsequent retardation (25). The process of growth faltering is essentially a series of events throughout childhood. The child suffers from repeated illnesses, inadequate appetite, deficient food and poor standard care. Many such children face premature mortality before their first birthday and those who do survive carry long-term consequences such as week stature and challenged mental capacity (26).

1.4 Need for Nutrition Survey

Nutrition surveys are useful tools that provide estimate of the severity and geographical ex-tent of the problem and possibly the groups most affected or at risk. The surveys also as-sess the likely evolution and impact of the problem on health and nutritional status, taking into account secondary information, including food security and food distributions. They al-so identify the need for nutrition interventions and the most effective measures to prevent or minimize the problem. Through such surveys the governments can determine the need to establish or expand existing surveillance, so that the effectiveness of measures taken can be monitored overtime. To assess the magnitude of the problem we also need to understand the population size and, if possible, the demographic characteristics of the population and distribution of cases therein.

To understand the reasons for the problem of under nutrition and to plan and implement appropriate interventions and programs, the usual situation for that population, the evolu-

4 -National Nutrition Survey Report 2011-tion of the changes, and the context in which the situation has arisen each needs to be con-sidered. There are many sources of information that are relevant in understanding the con-text and potential responses that may be appropriate and effective. The effects of these fac-tors on livelihoods and the ability of the affected population to cope at a household level are frequently assessed using food security surveys. Additionally formal nutrition surveys remain the best way to estimate accurately prevalence of malnutrition. Records of cases of malnutrition at health centers or during screening cannot be considered sufficiently repre-sentative of the population. They do, however, provide an indication of trends in the num-ber of cases of malnutrition and opportunities for action.

The last National Nutrition Survey was conducted in 2001-02, almost 15 years after the 1985-1987 National Nutrition Survey. After another lapse of almost a decade, the current survey was undertaken with specific aims of:

Establishing the current benchmark of nutrition and related indicators for gauging progress along the targets set for the Millennium Development Goals (MDG);

Establishing a benchmark for missing data/indicators, especially as the recent DHS survey (2007) did not include anthropometric indicators.

To prioritize the programs/initiatives at the national and provincial level and refining planning and implementation of initiatives on the basis of identified priorities.

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Chapter 2: SURVEY DESIGN AND METHODS

2.1 Objectives

The specific objectives of the NNS 2011 included the following targets

To assess the population nutritional status; especially of women and children To collect data on height, weight and age of children, 6 – 59 months, mothers of these children, adolescent girls, adults and elderly.

To collect blood samples for the assessment of micronutrient status of children mainly iron Vitamin A, Zinc, Vitamin D, calcium, and iron status of mothers To collect urine samples for the assessment of iodine status of women of repro-ductive ages and children To assess infant and young child feeding and care practices, including exclusive breastfeeding and complementary feeding rate To collect data on food intake and food security To collect data on demographic, socio economic and cultural variables (Income, education, etc.)

2.2 Indicators for National Nutrition Survey

2.2.1 Anthropometric Indicators

Stunting rates Wasting Rates

2.2.2 Clinical Indicators

Clinical prevalence of Anemia (Physical examination) Prevalence of Visible Goiter (Physical examination) Prevalence of worm infestation (History based) Co morbidities (Diarrhea, ARI and Pneumonia) Immunization status (history + Immunization cards) Micronutrient supplementation status

2.2.3 Core Biochemical Indicators

IDA among MWRA and WRA and children under five years Serum Vitamin A, D, Zinc and Calcium concentrations among mothers and child-ren under five years of age Urinary Iodine deficiency among MWRA, WRA and children 6 to 12 years Alpha-1 Glycoprotein levels (acute phase reactant)

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2.3 Survey Design

A Cross-Sectional Survey Design was chosen to collect data to make inferences of a given population at one point in time. Cross-sectional surveys provide a snapshot of the preva-lence and attributes of problems or normalcy in specific target population. A cross-sectional survey is a descriptive survey in which disease and exposure status is measured simulta-neously along with to elucidate the information regarding households, physical examination, and anthropometry and biochemical indicators (27).

2.3.1 Universe

The universe consists of all urban and rural areas of all four provinces of Pakistan, Federally Administered Tribal Areas (FATA), Azad Jammu Kashmir and Gilgit-Baltistan defined as such by Population Census 1998, and the subsequent changes made by the provincial govern-ments periodically. The population of military restricted areas and cantonments has been excluded from the scope of this survey. The population of excluded areas constitutes less than 1% of the total population.

2.3.2 Sampling Frame

A. Urban Areas Federal Bureau of Statistics has developed its own sampling frame for all urban areas of the country. This frame is an area frame wherein each city/town has been divided into a num-ber of small compact areas called Enumeration Blocks (EBs).Each enumeration block con-sists of about 200 to 250 households with well-defined boundaries recorded on the pre-scribed forms and maps thereof with physical features.

There are important land marks indicated on the sketch map of the boundary of each block.

Each enumeration block has also been classified into low, middle and high income groups keeping in view the majority of the households located in the enumeration block belonging to a particular income class. This information is useful to formulate sub-stratification. This sampling frame now comprises all urban areas of the Baluchistan except military restricted areas. There is a continuous process of updating in case of emerging newly built in apart-ments /houses or extension in the municipal limits of urban localities/towns/cities. The frame is regularly up-dated completely after every 5 to 7 years due to rapid growth in ci-ties/towns/urban areas. It was entirely updated during 2004. There are 26,753 enumeration blocks in all urban areas of the country

B. Rural Areas The sampling frame for rural domain consists of list of mouzas/dehs/villages prepared by the Population Census Organization (PCO) as a result of Population Census conducted in 1998 in the country. A mouza/deh/village is the smallest revenue estate identified by its name, had-best number, cadastral map and name of Tehsil, District and Province in which it is located. The rural sampling frame, comprising 50,572 mouzas/dehs/villages, has been used for drawing the sample for this survey.

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The detail of number of enumeration blocks in urban and numbers of mouzas/dehs/villages in rural areas of the country are given as under:

Table 2.1: No of enumeration blocks and villages

Province Number of Enumeration Blocks Number of Villages

Islamabad 351 132 Punjab 14,549 25,875 Sindh 9,025 5,871 Khyber Pakhtoon Khawa(KPK) 1,936 7,334 Balochistan 618 6,555 Federally Admn. Tribal Areas(FATA) 0 2596 Azad Jammu Kashmir 210 1643 Gilgit-Baltistan 64 566 Total 26753 50572

2.3.3 Listing Activity

Fresh listing of households has been undertaken in all sample areas. For this purpose, a comprehensive training to the listers has been imparted. In urban areas, enumeration blocks have been considered as Primary sampling units (PSUs). The sketch map of enumera-tion blocks demarcated by Federal Bureau of Statistics (FBS) in urban area of Baluchistan province has been used to perform listing work. In rural areas, villages as per Population Census 1998 have been treated as Primary sampling units (PSUs). Large sample villages hav-ing population more than 2000 as per Population Census 1998 have been split up into ham-lets/blocks of equal size. One block has been selected randomly for data collection. Small villages have completely been listed. The listing of households has been used to select a specified number of households from urban and rural sample areas.

2.3.4 Stratification

A. URBAN DOMAIN

i. Large Sized Cities Karachi, Lahore, Gujranwala, Faisalabad, Rawalpindi, Multan, Sialkot, Sargodha, Bahawalpur, Hyderabad, Sukkur, Peshawar, Quetta and Islamabad have been considered as large sized cities. Each of these cities constitutes a separate stratum which has been further sub-stratified according to low, middle, high income groups based on the information collected in respect of each enumeration block at the time of demarcation/up-dating of urban area sampling frame.

ii. Remaining Urban Areas

After excluding the population of large sized cities from the population of respective administrative division, the remaining urban population of each administrative division of four provinces has been grouped together to form a stratum called other urban areas. Thus each adm. division in remaining urban areas in the four provinces constitutes a stratum. In Azad Jammu &Kashmir, FATA and Gilgit-Baltistan, all urban areas have been grouped to-gether within each region/state separately.

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B. Rural Domain

In rural domain, each administrative district in the Punjab, Sindh and KPK Provinces has been considered, as independent and explicit stratum, whereas in Balochistan province each ad-ministrative division constitutes a stratum. In Azad Jammu &Kashmir, FATA and Gilgit- Baltistan, all rural areas have been grouped together to form stratum within each re-gion/state separately.

2.3.5 Sample Size and its Allocation

Considering the variability of characteristics for which estimates are prepared, population distribution, and field resources available, a sample size of 30, 0000 sample households has been considered appropriate to provide reliable estimates of key characteristics at the de-sired level. An exercise to compute sample size based on the prevalence rate of three key variables namely wasting and stunting in children less than five years , mother iron deficien-cy and mother iron deficiency anemia was undertaken keeping in view 95% level of 5% margin of error . Further, 5% non-response rate was also considered. The design effect of

1.6 was used to finalize and fix overall sample size. The entire sample of 30,000 households (SSUs) has been fixed comprising 1500 Primary Sampling Units (PSUs) out of which 618 were urban and 882 were rural. As urban population was more heterogeneous therefore, a high-er proportion of sample size was allocated to urban domain. Similarly NWFP and Balochistan being the smaller province and to get reliable estimates, a higher proportion of sample was assigned to these provinces. After fixing the sample size at provincial level, further distribu-tion of sample PSUs to different strata in rural and urban domains in each province has been made proportionately.

The distribution of PSUs and SSUs enumerated in the urban and rural domain of the prov-inces, states/regions are as under:

Table 2.2 Sample Size and Allocation Plan

Province/Region

Number of sample PSUs Number of sample SSUs Total Urban Rural Total Urban Rural

Punjab* 682 307 375 13640 6140 7500 Sindh 323 157 166 6460 3140 3320

KPK 218 67 151 4360 1340 3020

Blochistan 110 44 66 2200 880 1320

FATA 67 0 67 1340 0 1340

AJK 66 28 38 1320 560 760

GB. 34 15 19 680 300 380

Total 1500 618 882 30,000 12,360 17640

* Including Islamabad

2.3.6 Sample selection procedure

a) Selection of Primary Sampling Units (PSUs) Enumeration blocks in urban domain and mouzas/dehs/villages in rural domain have been taken as primary sampling units (PSUs). In the urban domain, sample PSUs from each ulti-mate stratum/sub-stratum have been selected with probability proportional to size (PPS)

9 -National Nutrition Survey Report 2011-method of sampling scheme. In urban domain, the number of households in enumeration block Economic Census 2004 and population of 1998 Census for each village/mouza/deh have been considered as measure of size.

b) Selection of Secondary Sampling Units (SSUs)

Households within sample PSUs have been taken as secondary sampling units (SSUs). A specified number of households i.e. 20 from each urban sample each urban and rural sample PSU have been selected with equal probability using systematic sampling technique with a random start.

2.3.7 Target Population

Women of reproductive ages (15-49 years), Children 6-59 months and Elderly (> 50 years)

2.3.8 Survey Methods

A method mix of quantitative and qualitative methods was adopted. A comparison of both methods is given in the following Table 2.1.

Table 2.3: A comparison of quantitative and qualitative methods (28) Components Qualitative Research Quantitative Research Focus of research Quality (nature, essence) Quantity (how much, how many) Philosophical roots Phenomenology, symbolic interaction Positivism, logical empiricism Associated phrases Fieldwork, ethnographic, naturalistic, grounded, subjective Experimental, empirical, statistical

Goal of investigation Understanding, description, discovery, hy-pothesis generating

Prediction, control, description, confirmation, hypothesis testing

Design characteristics Flexible, evolving, emergent Predetermined, structured Setting Natural, familiar Unfamiliar, artificial Sample Small, non-random, theoretical Large, random, representative Data collection Researcher as primary instrument, inter-views, observations

Inanimate instruments (scales, tests, surveys, questionnaires, computers)

Mode of analysis Inductive (by researcher) Deductive (by statistical methods) Findings…