anthropometric nutrition and mortality surveys. mindanao, philippines

8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES

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Anthropometric Nutrition and

Mortality Surveys

MINDANAO,PHILIPPINES

MUNICIPALITIES OF ARAKAN AND PRESIDENT ROXAS,NORTH COTABATO,REGION XII

AND

MUNICIPALITY OF KAPATAGAN,LANAO DEL SUR,ARMM

October-December 2010

Bernardette Cichon

Funded by :


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ACKNOWLEDGEMENTS

Firstly ACF would like to thank the municipalities of President Roxas, Arakan and Kapatagan

for their help in the implementation of these surveys in particular:

- Hon. Mayor Jaime Mahimpit, Mayor of the municipality President Roxas

- Hon. Mayor Gerardo B. Tuble, Mayor of the municipality of Arakan- Hon. Mayor Nashrudin B Maglangit, Mayor of the municipality of Kapatagan

Much appreciation is also extended to the DoH-ARMM and the DoH-Region XII.

ACF would also like to thank the surveyors for their hard work, as well as the barangay

officials, health workers and families who provided valuable information and allowed the

survey teams to measure their children.

Last but not least ACF thanks AECID for funding this survey and the upcoming project.


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TABLE OF CONTENTSAcknowledgements...............................................................................................................................2

Table of contents...................................................................................................................................3

List of Tables..........................................................................................................................................6

List of Figures.........................................................................................................................................9

List of Abbreviations............................................................................................................................10

Executive Summary .............................................................................................................................11

Background......................................................................................................................................11

Objectives ........................................................................................................................................11

Methodology ........................................................................................................................................11

Results..............................................................................................................................................12

Recommendations...........................................................................................................................14

1. Background......................................................................................................................................15

1.1. General .....................................................................................................................................15

1.2. Nutrition ...................................................................................................................................16

1.3. Food Security ............................................................................................................................17

1.4. Water and Sanitation................................................................................................................18

1.5. Infant and Young Child Feeding................................................................................................19

1.6. Health Care ...............................................................................................................................20

1.7. Nutrition programmes..............................................................................................................20

2. Objectives........................................................................................................................................22

Main Objective.................................................................................................................................22

Specific Objectives:..........................................................................................................................22

3. Methodology ...................................................................................................................................23

3.1. Type of Survey ..........................................................................................................................23

3.2. Taget Population.......................................................................................................................23

3.3. Sample Size ...............................................................................................................................23

3.4. Sampling Methodology.............................................................................................................28

3.4.1. Arakan ......................................................................................................................................28

3.4.2. Kapatagan and President Roxas...............................................................................................28

3.5. Special Cases.............................................................................................................................29

3.6. Data Analysis.............................................................................................................................30

3.7. Training .....................................................................................................................................30

3.8. Supervision ...............................................................................................................................31

3.9. Data Collection.........................................................................................................................31

3.9.1. Variables collected as part of the anthropometric survey: .....................................................31

3.9.2. Variables collected as part of the retrospective mortality survey:..........................................32

3.10. Indicators ...............................................................................................................................32

3.11. Limitations and Potential Bias ................................................................................................35


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4. Results .............................................................................................................................................36

4.1 Anthropometric and Mortality Survey of the Municipality of President Roxas.......................36

4.1.1. Description of the Sample........................................................................................................36

4.1.2. Age and Sex Distribution..........................................................................................................36

4.1.3. Acute Malnutrition...................................................................................................................37

4.1.3. Acute malnutrition according to Muac Measurements...........................................................394.1.4. Chronic Malnutrition................................................................................................................40

4.1.5. Underweight ............................................................................................................................41

4.1.6. Diarrhea ...................................................................................................................................42

4.1.7. Measles vaccination coverage .................................................................................................43

4.1.8. Deworming coverage...............................................................................................................43

4.1.9. Vitamin A supplementation coverage .....................................................................................43

4.1.10. Mortality Rates.......................................................................................................................44

4.2 Anthropometric and Mortality Survey of the Municipality of Arakan...................................44



4.2.3. Acute Malnutrition...................................................................................................................46

4.2.4. Acute malnutrition according to Muac Measurements...........................................................48

4.2.5 Chronic Malnutrition.................................................................................................................49

4.2.6. Underweight ............................................................................................................................50

4.2.7. Diarrhea ...................................................................................................................................51



4.2.10. Vitamin A supplementation coverage ...................................................................................52

4.2.11. Mortality Rates.......................................................................................................................52

4.3 Anthropometric and Mortality Survey of the Municipality of Kapatagan................................53



4.3.3. Acute Malnutrition..................................................................................................................55

4.3.4. Acute malnutrition according to Muac Measurements...........................................................57

4.3.4. Chronic Malnutrition................................................................................................................58

4.3.5. Underweight ............................................................................................................................59

4.3.6 .Diarrhea ...................................................................................................................................60



4.3.9. Vitamin A supplementation coverage .....................................................................................61

4.3.10. Mortality Rates.......................................................................................................................61

5. Discussion.. ...................................................................................................................................62

5.1. Acute Malnutrition...................................................................................................................62


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5.2. Stunting....................................................................................................................................64

5.3. Underweight .............................................................................................................................65

5.4. Health........................................................................................................................................65

6. Recommendations ..........................................................................................................................66

7. References.......................................................................................................................................68

8. Annexes ...........................................................................................................................................69Annex 1: Map of Mindanao....................................................................................................69

Annex 2. Map of Region XII (indicating location of the municipalities of Arakan and

President Roxas).....................................................................................................................70

Annex 3. Map of ARMM (Indicating location of the municipality of Kapatagan) ..................70

Annex 4: Map of the municipality of Arakan .........................................................................71

Annex 5: Map of the municipality of President Roxas ...........................................................72

Annex 6: Map of the municipality of Kapatagan....................................................................73

Annex 7. Anthropometric survey data form ..........................................................................74

Annex 8. Household enumeration data collection form for a death rate calculation survey

(one sheet/household)...........................................................................................................75

Annex 9. Cluster selection for the municipality of President Roxas ......................................76

Annex 10. Cluster Selection for Kapatagan............................................................................76

Annex 11. Plausibility Report Municipality of President Roxas .............................................77

Annex 12. Plausibility Report Municipality of Arakan............................................................88

Annex 13. Plausibility Report Municipality of Kapatagan ......................................................97

Annex 14. Anthropometric survey results according to NCHS standards

(Municipality of President Roxas) ........................................................................................109Annex 15. Anthropometric survey results according to NCHS standards

(Municipality of Arakan).......................................................................................................111

Annex 16. Anthropometric survey results according to NCHS standards

(Municipality of Kapatagan).................................................................................................113


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Table 4.13: Deworming Coverage (municipality of President Roxas, October/November

2010).........................................................................................................................................43

Table 4.14: Vitamin A supplementation (municipality of President Roxas, October/November

2010)43

Table 4.15: Births and deaths by age groups (municipality of President Roxas, October/November

2010)44

Table 4.16: Characteristics of the sample (municipality of Arakan, November 2010)..45

Table 4.17: Distribution of age and sex of the anthropometric sample (municipality of Arakan,November 2010).......................................................................................................................45

Table 4.18: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)

and by sex (municipality of Arakan, November 2010)..............................................................46

Table 4.19: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or

oedema (municipality of Arakan, November 2010)..................................................................47

Table 4.20: Distribution of acute malnutrition and oedema based on weight-for-height z-scores

(municipality of Arakan, November 2010)................................................................................47

Table 4.21: MUAC distribution (municipality of Arakan, November 2010)..48

Table 4.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of

Arakan, November 2010)..........................................................................................................49

Table 4.23: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan,November 2010).......................................................................................................................49

Table 4.24: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of

Arakan, November 2010)..........................................................................................................50

Table 4.25: Prevalence of underweight by age, based on weight-for-height z-scores and oedema

(municipality of Arakan, November 2010)................................................................................50

Table 4.26: Association between diarrhoea and malnutrition (municipality of Arakan, November

2010)51

Table 4.27: Measles Vaccination Coverage (municipality of Arakan, November 2010)51

Table 4.28: Deworming Coverage (municipality of Arakan, November 2010)52

Table 4.29: Vitamin A supplementation (municipality of Arakan, November 2010)..52

Table 4.30: Births and deaths by age groups (municipality of Arakan, November2010)....................53Table 4.31: Characteristics of the sample (municipality of Kapatagan, November/December

2010)53

Table 4.32: Distribution of age and sex of the anthropometric sample (municipality of Kapatagan,

November/December 2010).....................................................................................................53


and by sex (municipality of Kapatagan, November/December 2010)......................................55


oedema (municipality of Kapatagan, November/December 2010)..........................................55


(municipality of Kapatagan November/December 2010)........................................................ 56

Table 4.36: MUAC distribution (municipality of Kapatagan, November/December 2010)57Table 4.37: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of

Kapatagan, November/December 2010)..................................................................................57

Table 4.38: Prevalence of stunting by age based on height-for-age z-scores (municipality of

Kapatagan, November/December 2010)..................................................................................58


Kapatagan November/December 2010)...................................................................................59


(municipality of Kapatagan November/December 2010).........................................................59

Table 4.41: Association between diarrhea and malnutrition (municipality of Kapatagan,

November/December 2010)60

Table 4.42: Measles Vaccination Coverage (municipality of Kapatagan, November/December

2010)...61


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Table 4.43: Deworming Coverage (municipality of Kapatagan, November/December 2010).61

Table 4.44: Vitamin A supplementation (municipality Kapatagan, November/December 2010).61

Table 4.45: Births and Deaths by age groups (municipality of Kapatagan, November/December

2007).........................................................................................................................................61


and by sex (municipality of President Roxas, October-November 2010).108


oedema (municipality of President Roxas, October-November 2010)108Table 8.3: Distribution of acute malnutrition and oedema based on weight-for-height z-scores

(municipality of President Roxas, October-November 2010)108


President Roxas, October-November 2010).108


municipality of President Roxas, October-November 2010).109

Table 8.6: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of

President Roxas, October-November 2010).109

Table 8.7: Prevalence of stunting by age based on height-for-age z-scores (municipality of President

Roxas, October-November 2010).109

Table 8.8: Mean z-scores, Design Effects and excluded subjects (municipality of President Roxas,October-November 2010)..109


and by sex (municipality of Arakan, November 2010)110


oedema (municipality of Arakan, November 2010).110


(municipality of Arakan, November 2010).110


Arakan, November 2010)110


(municipality of Arakan, November 2010).111Table 8.14: Prevalence of stunting based on height-for-age z-scores and by sex (municipality of

Arakan, November 2010)111

Table 8.15: Prevalence of stunting by age based on height-for-age z-scores (municipality of Arakan,

November 2010)..111

Table 8.16: Mean z-scores, Design Effects and excluded subjects (municipality of Arakan, November

2010).111


and by sex (municipality Kapatagan, November/December 2010)..112


oedema (municipality Kapatagan, November/December 2010)112

Table 8.19: Distribution of acute malnutrition and oedema based on weight-for-height z-scores(municipality Kapatagan, November/December 2010).112

Table 8.20: Prevalence of underweight based on weight-for-age z-scores by sex (municipality

Kapatagan, November/December 2010).112


(municipality Kapatagan, November/December 2010).113

Table 8.22: Prevalence of stunting based on height-for-age z-scores and by sex (municipality

Kapatagan, November/December 2010).113

Table 8.23: Prevalence of stunting by age based on height-for-age z-scores (municipality Kapatagan,


Table 8.24: Mean z-scores, Design Effects and excluded subjects (municipality Kapatagan,



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LIST OF FIGURESFigure 4.1:Population age and sex pyramid (Municipality of President Roxas October/November

2010).........................................................................................................................................37

Figure 4.2: Distribution of weight-for-height z-scores (Muncipality of President Roxas,

October/November 2010)39

Figure 4.3: Distribution of height-for-age z-scores (Municipality of President Roxas,

October/November 2010)41

Figure 4.4:Population age and sex pyramid (Municipality of Arakan, November 2010)...................46

Figure 4.5: Distribution of weight-for-height z-scores (Muncipality of Arakan, November 2010)48

Figure 4.6: Distribution of height-for-age z-scores (Municipality of Arakan, November 2010)..50

Figure 4.7:Population age and sex pyramid (Municipality of Kapatagan, November/December

2010)......... . .............................................................................................................................54

Figure 4.8: Distribution of weight-for-height z-scores (Municipality of Kapatagan,

November/December 2010)..56

Figure 4.9: Distribution of height-for-age z-scores (Muncipality of Kapatagan, November/December

2010)58


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LIST OF ABBREVIATIONS

ACF-SAECID

AFP

ARMM

BHC

BHW

BNS

CDR

DHS

DoH

ENAFGD

FNRI

FS

GAM

HH

INGO

IYCF

LGU

MAM

MERN

MILF

MUAC

MSF

NCHS

NGOs

NNC

NNS

NPA

OTP

PD

RHU

RR

SAM

SMART

UN

UNFPA

UNICEF

WASH

WHO

WFP

Action Contre la Faim - SpainAgencia Espaola de Cooperacin Internacional para el Desarrollo

Armed Forces of the Philippines

Autonomus Region of Muslim Mindanao

Barangay Health Centre

Barangay Health Workers

Barangay Nutrition Scholars

Crude Death Rate

Demographic and Health Surveys

Department of Health

Emergency Nutrition AssessmentFocus Group Discussion

Food and Nutrition Research Institute

Food Security

Global Acute Malnutrition

Households

International Non-governmental Organisations

Infant and Young Child Feeding

Local Government Units

Moderate Acute Malnutrition

Mindanao Emergency Response Network

Moro Islamic Liberation Front

Mid Upper Arm Circumference

Mdecins sans Frontires

National Centre for Health Statistics

Non-governmental Organisation

National Nutrition Council

National Nutrition Survey

New Peoples Army

Outpatient Therapeutic Programme

Positive Deviance

Rural Health Unit

Risk Ratio

Severe Acute Malnutrition

Standardized Monitoring and Assessment of Relief and Transitions

United Nations

United Nations Population Fund

United Nations Childrens Fund

Water, Sanitation and Hygiene

World Health Organisation

World Food Programme


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EXECUTIVE SUMMARY

BACKGROUND

All types of malnutrition are a problem in the Philippines. This is caused by inadequateconsumption of food, inadequate access to health care and sanitation facilities as well as

food insecurity. In April 2010, ACF-S carried out a rapid assessment in Central Mindanao

and decided, with support from AECID, to launch a four year integrated Food Security,

Nutrition and Water and Sanitation programme in three municipalities, namely the

municipality of Kapatagan, Lanao del Sur, ARMM and the municipalities of President Roxas

and Arakan in the Province of North Cotabato, Region XII. These surveys serve as a baseline

survey for this programme.

OBJECTIVES

MAIN OBJECTIVE

To assess nutritional status of children aged 6-59 months and the retrospective

mortality rate of the population in the municipalities of Arakan, President Roxas and

Kapatagan.

SPECIFIC OBJECTIVES:

- Determine the prevalence of acute malnutrition among children aged 6-59 months

in the three municipalities1.

- Determine the rates of stunting and underweight among children aged 6-59

months.

- Determine the crude death rate of children under 5 and the general population

(over a recall period of approximately 5 months in Arakan and President Roxas and

3 months in Kapatagan).

- Determine the coverage of vitamin A supplementation in the last 6 months.

- Determine coverage of measles vaccination among children aged 9-59 months.

- Determine coverage of deworming among children 12-59 months in last 6 months.

- Determine prevalence of diarrhea in the 2 weeks before the survey.

METHODOLOGY

In the municipalities of President Roxas and Kapatagan a two-stage cluster survey was

carried out. In Arakan simple random sampling was used since population lists were

available. All three surveys were carried out using the SMART methodology. The target

population for the anthropometric survey was all children aged 6-59 months. The target

population for the mortality survey was the entire population. The recall period for the

mortality surveys was 145, 152 and 88 days for President Roxas, Arakan and Kapatagan,

respectively. For the two cluster surveys households were selected using simple random

sampling at the second stage.

1Since the new WHO growth standards are being used in the Philippines, malnutrition rates in the main part of the report will be

presented according to WHO standards. Results according to NCHS standards will be presented in the Annexes.


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The total sample size calculated was of 768 children and 1704 HH (57 clusters of 30

households) in Presidents Roxas, 354 children and 784 households in Arakan and 560 and

1241 HH (62 clusters of 20 HH) in Kapatagan. During the surveys 3 clusters in President

Roxas and 6 in Kapatagan became inaccessible due to security reasons. This lead to a total

sample size of 1620 HH and 953 children in President Roxas, and 1112 HH and 903 children

in Kapatagan. The household list provided for the municipality of Arakan was more

inadequate than first expected and a total of 756 HH (398 children) were visited during the

survey.

RESULTS

GAM was 10.3%, 5.9% and 6.9% and SAM 2%, 0.9% and 1% in the muncicipalities of

President Roxas, Arakan and Kapatagan, respectively (see table 1). Malnutrition rates

according to MUAC measurements were a lot lower, namely 1.3%, 1.5% and 1.1% in

President Roxas, Arakan and Kapatagan, respectively (see table 2).

While acute malnutrition rates in Arakan and Kapatagan are below the 10% alert level,

rates of stunting are very high2

(see table 3).

Data collected about prevalence of diarrhea and coverage of basic health services are

shown in tables 4-7.

Retrospective mortality rates in the three municipalities are shown in table 8. While

mortality rates in Kapatagan are higher than those in the other two municipalities, all are

under alert level.

Table 1: Prevalence of acute malnutrition in the municipalities of President Roxas, Arakan,

Kapatagan (October-December 2010)

Table 2: MUAC distribution in the municipalities of President Roxas, Arakan and Kapatagan

(October December 2010)

President Roxas

n = 851

Arakan

n =329

Kapatagan

n = 807

MUAC < 115 0.2% (n=2) 0.3% (n=1) 0% (n=0)

MUAC >115 & 125 & 135 92.7% (n=789) 90.9% (n=299) 91.6 (n=739)

2According to the WHO classification 40% of stunting is considered very high. (WHO global database on Child Growth and Malnutrition

available at: http://whqlibdoc.who.int/hq/1997/WHO_NUT_97.4.pdf)

President Roxas

n = 861

Arakan

n = 338

Kapatagan

n = 829

Prevalence of GAM

(


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Table 3: Prevalence of stunting based on height-for-age z-scores (municipalities of

President Roxas, Arakan and Kapatagan, October-December 2010)

President Roxas

n = 860

Arakan

n = 334

Kapatagan

n = 806

Prevalence of stunting

(


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Table 7: Coverage of deworming in 12-59 months old children (municipalities of President

Roxas, Arakan and Kapatagan, October-December 2010)

Deworming Coverage President Roxas Arakan Kapatagan

Yes 33.8% 73.3% 34.8%

No 62.3% 23.9% 62.5%

Dont know 3.9% 2.7% 2.7%

Total 100% 100% 100%

Table 8. Mortality rates (municipalities of President Roxas, Arakan and Kapatagan, October-

December 2010)

RECOMMENDATIONS

- Set up OTPs in all three municipalities. Since rates are highest in President Roxas, this

municipality should be the priority.

- Because of the large difference in malnutrion rates according to MUAC and weight-

for-height, the possibility of using weight-for-height in active case finding instead of

MUAC to avoid missing many of the severe cases should be discussed.

- Substantial effort should be made towards reducing stunting over the next four years.

Stunting should be prevented through the community based component of the

programme (PD/Hearth, nutrition education and campaigns).

- Advocate for improved coverage of basic health services, such as immunizations,

vitamin A supplementation in particular in the municipality of Kapatagan.

- Since prevalence of acute malnutrition is not alarming, funds limited and the main

focus of the programme should be prevention of stunting, the option of reducing the

frequency and of SMART surveys and carrying out a coverage survey instead should

be considered.

Mortality Rates (deaths/10.000people/day)

Age President Roxas Arakan Kapatagan

Crude Mortality Rate 0.15

(95% CI: 0.09-0.25)

0.12

(95%CI=0.06-0.26)

0.27

95%CI=0.15-0.51).

Under five Mortality

Rate

0.21

(95% CI= 0.07-0.66)

0

(95% CI=0-0.54).

0.45

(95% CI=0.14-1.52)


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1.BACKGROUND

1.1.GENERAL

Mindanao is the second largest of the Philippines 7107 islands and is located in the southof the country (see map in Annex 1). It has a total population of 21.6 million (as of August

2007) [1], 61% of which are catholic, 20% are Muslim, the remaining 9% have other

christian faiths or indegenous beliefs [2]. Mindanao consists of regions IX, X, XI, XII, XIII and

ARMM, which are further divided into 26 provinces, 422 muncipalities and 33 cities [1].

While Muslims are a minority in the Philippines, in the Autonomous Region of Muslim

Mindanao (ARMM) they make up 90% of the population [2].

Despite an abundance of natural resources, ARMM and Region XII (also known as Central

Mindanao) are among the poorest in the country [3], which can partly be attributed to

political instability in the region. Mindanao has been affected by a conflict that consists of a

conflict between the AFP and MILF3, AFP and NPA4 as well as political and clan based

rivalries (Rido), for the last four decades. The conflict between AFP and MILF last flamed up

after the failed signing of a Memorandum of Agreement on Ancestral Domain in August

2008 and left more than 500,000 people displaced in the provinces of Lanao del Sur

(ARMM), Maguindanao (ARMM) and North Cotabato (Region XII) [4].

Many people in Central Mindanao do not have access to adequate healthcare, water and

sanitation facilities and nutritious food causing widespread malnutrition. In addition to

political instability, droughts, floods, poor productivity, under-investment in rural

infrastructure, unequal land and income distribution, high population growth and the low

quality of social services lie at the root of rural poverty in Central Mindanao [4].

In April 2010 ACF carried out a rapid assessment in Central Mindanao and decided, with

support from AECID, to launch an integrated Food Security, Nutrition and Water and

Sanitation programme in three municipalities with the overall objective to contribute to

poverty reduction in these areas. The municipalities chosen for this programme are the

municipality of Kapatagan in Lanao del Sur, ARMM as well as the municipalities of Arakan

and President Roxas in the province of North Cotabato, Region XII (see maps in Annex 2-6).

Some information about the three municipalities is shown in the table 1.1 below. There are

no IDPs resulting from the 2008 violence in the three chosen municipalities. However one

of the barangays (Salat) in President Roxas was affected by a local conflict, leading to

population displacement. This barangay was excluded from the survey.

Table 1.1. Municipalities of Arakan, President Roxas and Kapatagan [3,5,6,7]

Arakan President Roxas Kapatagan

Number of

barangays5

28 25 15

Total land area 69,432 hectares 61,825 hectares 11,640 Hectares

Total Population 47,000 (2007 estimate) 43,133 (2007 estimate) 10777 (2010 estimate)

3 The MILF or Moro Islamic Liberation Front is a muslim separatist group.4

The militant wing of the communist party of the Philippines.5

Barangay is the Filipino term for village or district.


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Population

Groups

Illongo (59%)

Cebuano (20%)

Manobo (7%)

Bagobo (7%)

Other (7%)

Illongo (47%)

Cebuano(24%)

Ilocano (16%)

Teroray (3.5%)

Manobo (5.0%)Other (4.5%)

Maranao (91%)

Illongo (2.5%)

Cabuano (2%)

Iranon (1%)

Other (3.5%)

Poverty

Incidence6

55% 55% 59%

1.2.NUTRITION

All types of malnutrition (stunting, underweight, acute malnutrition, micronutrient

deficiencies and nutrition related chronic diseases) are a problem in the Philippines.

Malnutrition is more common in Mindanao than in other parts of the Philippines and FGDscarried out as part of the rapid assessment in April 2010 have revealed that it is recognized

as a problem by both the population and health workers.

Surveys and assessments carried out in ARMM and Region XII have generally shown that

rates of acute malnutrition range from 5-10% (see table 1.2.).

Although acute malnutrition rates do currently not reach the emergency cut off of 15%, it

is, nevertheless, considered to be a concern by the local health authorities, INGOs and UN

agencies, especially since the presence of aggravating factors such as political instability,

droughts and floods, inadequate water and sanitation and widespread food insecurity

mean that rates of acute malnutrition could increase quite dramatically over a short periodof time.

Rates of stunting and underweight are high and range from 20-50% and 26.6-31.5%,

respectively (see table 1.2.) In addition to survey data, underweight data is available at

municipal level from Operation Timbang. Operation Timbang or Operation Weighing Scale

is a government run initiative that aims to measure children regularly using the weight-for-

age indicator. However this data is often questionable because of faulty equipment and

lack of representativeness of the sample. According to data collected as part of operation

Timbang in 2009, 9.6%, 20.5% and 13% of children are underweight in the muncipalities of

President Roxas, Arakan and Kapatagan, respectively.

Table 1.2. Overview of available data about acute malnutrition [8, 9, 10, 11, 12]

Date Type of Survey Organisation Acute

Malnutrition

Stunting Underweight

2006 Baseline Nutrition

and food security

Assessment in

Mindanao

UNICEF/WFP/

FNRI

Lanao del Sur:

5.9%

North Cotabato:

8.3 %

North

Cotabato:

21.9 %

Lanao del

Sur: 37.7%

North

Cotabato:

26.6%

Lanao del

Sur: 28.5%

6Data for poverty incidence is at provincial level


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2008 National Nutrition

Survey

FNRI Region XII: 5.4%

ARMM 9.6%

- -

January-

March

2009

Joint Emergency

Nutrition and Food

Security Assessment

of the conflict-affected Persons in

Central Mindanao7

UNICEF/FNRI 9.8% GAM

2.2% SAM8

47.3% 39.9%

March

2010

Follow-up

Emergency Nutrition

Assessment9

Save the

Children

GAM: 7.8%

SAM: 1.1%10

50.2% 31.5%

With regard to micronutrient deficiencies, anemia in particular is a problem. According to

the National Nutrition Survey in 2003, 32.4% of 6 month to 5 year old children suffered

from iron deficiency anemia, and 66.2% in children 6-11 months indicating a severe public

health problem for children of weaning age [12]. The Baseline Nutrition and Food Security

Assessment carried out in 2006 showed an anemia prevalence of 43.4% in Lanao del Sur

and 38.4% in North Cotabato [13]. According to the 2003 National Nutrition survey Iodine

deficiency was 35.8% and Vitamin A deficiency was 40.1% [12].

In addition to undernutrition, nutrition related chronic diseases including cardiovascular

disease, hypertension and diabetes were found to be a concern according to health records

provided by the municipalities. The Philippines are therefore affected by the so-called

double burden of malnutrition.

Malnutrition in Mindanao is caused by a combination of factors including: inadequateaccess to food, inadequate sanitation facilities and access to clean water, inadequate

dietary diversity and disease. 20% of children in Philippines are born with low birthweight

[13], indicating that malnutrition in some cases starts before birth and that nutrition for

mothers before, during and after pregnancy is a concern. Access to health care also

appears to be a problem especially in terms of cost, lack of staff and distance to health

centres [13,15]. The underlying conflict and poverty as well as a recent drought caused by

the el Nino phenomenon also impacts on malnutrition rates. These factors will be discussed

in more detail below.

1.3. FOOD SECURITY

Mindanao has been regarded as the food basket of the Philippines and yet, food

insecurity is wide spread. It has been estimated that in times of peace one in four

households in Mindanao is severely food insecure [14].

Agriculture is main source of income for the population [5,6,7,15]. The land is fertile and

ideal for year round crop production. The main crops produced include: coconut, banana,

sugar cane, corn, rice, pineapple, rubber, mango, sweet potato and coffee [5,6,7,10].

7This assessment covered the conflict affected population of Lanao Del Norte, Lanao Del Sur, Maguindanao and North Cotabato.

8 WHO Standards9

Carried out in Save the Children in their project areas (19 muncipalities in Maguindanao and North Cotabato)10

WHO Standards


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Farmers in Mindanao face many problems meaning that they are unable to produce food

to the lands full potential. Many do not have access to irrigation system, fertilizers,

pesticides and improved seeds, mainly due to lack of financial resources. In addition many

lack knowledge of improved farming practices. Farm inputs are expensive and since savings

are generally low, farmers are forced to buy farm inputs on credit. These credits usually

have to be paid back to the traders at high interest rates meaning that a large proportion of

their income usually goes directly to the traders to pay off debt.

Moreover, access to post harvest facilities such as storage, threshers and solar dryers are a

problem. Farmers that do not have access to post harvest facilities have to pay for use of

storage facilities or sell their produce straight after the harvest at low prices, again

reducing their income. Many farmers are tenants which means that they are not in control

of what they plant and have to give a large proportion of their income to the landowners as

payment for the rent of the land cultivated [10,15].

In addition to the problems faced by many farmers, food insecurity is caused by lack of

financial and physical access to food. Markets are far away for a large proportion of thepopulation, access is difficult in the rainy season

11and transport expensive. FGDs carried

out in April 2010 by ACF revealed that many families do not have enough money to buy

food for their families and can only afford 1-2 meals per day. Households usually consume

rice, vegetables or fish. If rice and other foods are not available, which is often the case,

households substitute it with root crops such as sweet or wild potato or cassava. Meat is

usually only consumed at special occasions [15]. If income is low families are forced to

reduce quality and quantity of food eaten which can have a long term impact on nutritional

status and health, especially for young children.

1.4.WATER AND SANITATION

Access to safe water is a problem in Lanao del Sur and North Cotabato, particularly in rural

communities. 39.7% and 99.8% of the population in Lanao del Sur and North Cotabato,

respectively have access to safe water [16]. There are however big differences between

municipalities within these provinces and locations within the muncipalities. Those in rural

areas further away from the centre of the municipalities and the indigenous population are

the most vulnerable to unsafe water sources. A study conducted by ACF in 2005 indicated

that Lanao del Sur is among the worst off with regard access to safe water and ranking 75th

out of 82 provinces in the Philippines [17]. Access to safe water is better in Arakan and

President Roxas than in Kapatagan, with 32.4% and 15% of the population getting water

from a doubtful source [18]. Springs are the main source of water in all areas. Spring water

is generally considered safe but many springs are unprotected and so water often gets

contaminated during the rainy season due to overflowing and in the dry season water

often runs out [15,17].

Hygiene and sanitation facilities as well as hygiene practices are a cause for concern in the

area. 14.6% and 51% of households have access to sanitary facilities in Lanao del Sur and

North Cotabato, respectively [16]. Access to sanitary facilities differs between areas and

11

The wet or rainy season also known as first monsoon lasts from May until September. A second monsoonexists between november and february, this is however not considered as wet season since rainfall is small

compared to the first monsoon.


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ethnic groups and is worse among the indigenous people [17]. In addition to poor access to

safe water and hygiene and sanitation facilities, poor sanitation practices are also major

cause of disease and the resulting malnutrition. FGDs carried out by ACF as part of the

rapid assessment in April 2010 revealed that while the population was aware that

handwashing is essential for good health and practice it regularly when soap and water are

available, the latter two are, however, often lacking. At the time of these surveys a more

detailed WASH assessment was being carried out by ACF that will shed more light on the

situation.

1.5.INFANT AND YOUNG CHILD FEEDING

Adequate infant and young child feeding is crucial for health as well as mental and physical

development of children. WHO recommends exclusive breastfeeding for the first six months

of life followed by progressive introduction of safe and nutritious complementary food with

continued breastfeeding until the age of two years [19]. Breastmilk is a safe and convenient

food that provides all the energy and nutrients a child needs as well as antibodies to protect

the child from infection. Breastfeeding is therefore particularly important in an environment

where access to safe water and sanitation facilities are a concern. The risk of disease and

thus malnutrition for young children increases when they start interacting more with their

environment (crawling and walking) and are being weaned from breastmilk to

complementary foods.

Previous assessments in Mindanao have expressed a concern with regard to infant feeding

practices [10, 11, 13]. According to the DHS survey 2008, 40.5% and 52.3% of children 6-23

month old children were adequately fed according to infant feeding recommendations in

ARMM and region 12 respectively. Similarly a short survey carried out as part of ACFs rapidassessment in April 2010 revealed that many mothers do not have access to adeqaute

information about infant feeding and as a result only 35.7%, 25% and 16.6% of

respondents infants and young children were adequately fed12

in Arakan, President Roxas

and Kapatagan, respectively [15].

According to the latest DHS survey 34% of under six months old children were exclusively

breastfed at national level and dietary diversity was lower than recommended13

. In

addition to lack of knowledge about IYCF practices and financial means to provide

nutritious food for their children, cultural beliefs play an important role. In Kapatagan it

was stated that feeding children with water with sugar for the first 3 days after delivery,before starting to breastfeed, is a common practice in Maranao women. It is believed that

this cleanses the body [15].

Inadequate infant and young child feeding practices explain the finding of surveys that

acute malnutrition is higher in the 6-24 months group [9, 10]. The UNICEF/WFP survey

carried out in early 2009 showed that while GAM was just under 10%, in the younger age

group (6-24 months) it was over 22% [10]. Similar results were demonstrated by the 2008

NNS where at national level GAM was 6.1% but 14% in those 12-23 months [9].

12Here defined as: children under six months that are exclusively breastfed; children between 6-24 months who are breastfed and

receive the minimum number of meals (2 times for six to eight months old children; 3 times for bf 9-24 months old children, 4 times 6-24

months old non breastfed children) and the minimum number of food groups.


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1.6.HEALTH CARE

Disease increases energy and nutrient needs, reduces appetite and in case of diarrhea

reduces nutrient absorption. Morbidity rates, in particular diarrhea, are therefore often

related to prevalence of malnutrition. The assessment carried out by WFP/UNICEF showed

that 72% of acutely malnourished children had been ill in the previous 2 weeks [10].

The most common diseases in the three municipalities include upper respiratory tract

infection, fever/flu, diarrhea, hypertension, intestinal parasitism, diabetes, pulmonary TB,

anemia and skin diseases[5,6,7,15]. Underfive mortality was 34 and 94 per 1000 live births

in region XII and ARMM respectively [13].

Access to health facilities in the three municipalities is a concern. There are rural health

units (RHUs) in the centre of the municipalities and a few baranagay health stations.

Barangay Health stations are present in most barangays in Arakan and President Roxas, but

in Kapatagan there is only one in addition to the RHU. Medicines and staff are often

lacking, doctors are rarely available and midwives or BHWs and BNSs are usually

overworked. In addition high cost of treatment and transport makes it impossible for some

families to seek care [13, 15]. If money is not enough, people tend to go see a traditional

healer. There are 3 hospitals within reach from Arakan and President Roxas: a private

hospital in Antipas, the government run hospital in Kidapawan and the German Doctors

hospital in Buda and two within reach from Kapatagan: Malabang hospital and the hospital

in Cotabato City. However, most can not afford to pay for the transport to get there.

Appropriate care for women and children is crucial to preventing childhood malnutrition.

Women need care before during and after pregnancy. According to the DHS survey only a

small amount of women receive appropriate pre-natal care [13]. Currently a largeproportion of girls and women deliver their children at home [7, 13], and during FGDs many

mentioned that they learn about child care and infant feeding either from a relative of have

to teach themselves.

Immunization rounds are usually carried out every month by nurses or BHWs that visit the

BHCs [15]. According to latest DHS survey vaccination coverage needs to be improved since

30.6% and 77% of children have received all basic vaccinations in ARMM and Region 12

respectively [13].Similarly measles vaccination coverage was 24.5 % In Lanao del sur 75%

in North Cotabato according to the 2006 Baseline Nutrition and food security assessment

[8].

1.7.NUTRITION PROGRAMMES

In Mindanao a number of stakeholders are working towards improving nutritional status of

the population. These include the Department of Health, the National Nutrition Council, UN

agencies (UNICEF and WFP) as well as a number of NGOs (MERN, the Assissi Foundation

and PIE for Life) and INGOs (Save the children, MSF, The Committee of German Doctors and

ACF).

The government has made a significant effort towards tackling malnutrition by establishing

the Barangay Nutrition Scholar (BNS) scheme14

. In Arakan and President Roxas these are

14BNSs are community volunteers that receive a basic training in nutrition. They are involved in Operation Timbang and provide

information about health and nutrition to the community.


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present in nearly every barangay. In Kapatagan this scheme is currently in the initial stages.

The National Nutrition Council was a key player in setting this up.

In 2007 the NNC created the anti-hunger task-force. The anti-hunger taskforce conducts

training, advocacy and education with regard to malnutrition. Their priorities include

infant feeding and treatment for SAM.

The health centres carry out quarterly growth monitoring as part of what is known as

Operation Timbang (Operation weighing scale). In order to combat micronutrient

deficiencies the government provides iron supplements and conducts universal vitamin A

supplementation twice a year. The vitamin A supplementation rounds, also known as

Garantisadong Pambata, are accompanied by other basic health services, such as

deworming and immunisation

According to the DHS survey carried out in 2008 coverage of vitamin A supplementation in

the six months before the survey for 6-59 months old children was 48% and 72.7 % in

ARMM and Region 12 respectively and 46% of women received a vitamin A supplement

postpartum. Coverage of deworming was 29.3% in ARMM and 42.6% in Region XII [13].

Iron supplementation coverage among children remains low: according to the DHS survey15.6% and 25.4% of 6 to 59 months old children received iron supplements in the 7 days

preceding the survey in ARMM and Region 12 respectively.

UNFPA has built a birthing clinic in Kapatagan in order to provide adequate facilities

especially in far flung areas. PIE for life has recently started community nutrition workshops

in the barangay Kapatagan proper. The Assisi Foundation is involved with Water and

Sanitation programmes in Kapatagan and have recently started a supplementary feeding

programme in the barangay Minimao, Kapatagan.

WFP and the Department of Education provide supplementary food and Save the Childrenand UNICEF are providing SAM treatment in some municipalities with support from the

DoH and local partners. SAM treatment is however not available in the three municipalities

chosen for ACF activities. The Committee of German doctors runs a hospital in Buda where

SAM treatment is available and is reachable from Arakan and President Roxas. Transport to

the hospital is however too expensive for most families and most parents are not able to

stay in the hospital with their children for long periods of time.

It is for this reason that ACF has chosen these 3 municipalities for a new four year

integrated Nutrition, Food Security and Water and Sanitation programme. The objective of

this programme is to make SAM treatment available in the communities, according to the

CMAM strategy promoted by WHO/UNICEF, and to prevent all types of malnutritionthrough community based activities including PD Hearth, Nutrition Education as well as

WASH and FS interventions. The anthropometric and mortality surveys carried out from

October to December 2010 serve as a baseline for this project.


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2. OBJECTIVES

MAIN OBJECTIVE

To assess nutritional status of children aged 6-59 months and the mortality rate of the

population in the municipalities of Arakan, President Roxas and Kapatagan.

SPECIFIC OBJECTIVES:

- Determine the prevalence of acute malnutrition among children aged 6-59 months in the

three municipalities15.- Determine the rates of stunting and underweight among children aged 6-59 months.

- Determine the crude death rate of children under 5 and the general population (over a

recall period of approximately 5 months in Arakan and President Roxas and 3 months in

Kapatagan).

- Determine the coverage of vitamin A supplementation in the last 6 months.

- Determine coverage of measles vaccination among children aged 9-59 months.

- Determine coverage of deworming among children 12-59 months in last 6 months.

- Determine prevalence of diarrhea in the 2 weeks before the survey.

15Since the new WHO growth standards are being used in the Philippines, malnutrition rates in the main part of the report will be presented according to

WHO standards. Results according to NCHS standards will be presented in the Annexes.


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3.METHODOLOGY

3.1. TYPE OF SURVEY

Three anthropometric and mortality surveys were carried out. One in the municipality

of Kapatagan, Autonomus Region of Muslim Mindanao, one in the municipality of

President Roxas and one in the municipality of Arakan, Province of North Cotabato

Region XII according to the SMART (Standardized Monitoring and Assessment of Relief

and Transitions) methodology.

Data collection was carried out from 29th

of October- 2nd

of December over a total of

27 working days. Data on malnutrition and mortality rates were collected

simultaneously.

Since household lists were available for the municipality of Arakan and the area

covered by the survey is relatively small, simple random sampling was used to selectHHs. The HH lists were compiled in 2009, and since there are no IDPs in the area and

no major population movements have taken place since 2009 it was believed that

these lists were adequate enough.

In President Roxas and Kapatagan household lists were too incomplete and

unavailable, respectively, to enable simple random sampling. A two stage cluster

survey was therefore carried out in these municipalities with the barangays as the

primary sampling unit. For barangays that contained more than one cluster and/or

more than 250 HH, a segmentation was carried out (see section 3.4). Within clusters

households were selected using simple random sampling.

The surveys cover the whole of each municipality, however 1 barangay in President

Roxas (Salat), and one in Kapatagan (Matimos) had to be excluded before the start of

the survey for security reasons. Maps of each municipality are shown in Annexes 3-6.

3.2.TARGETPOPULATION

The target population for the anthropometric survey was all children aged between 6

and 59 months of age because they represent the most vulnerable portion of the

population. The target group for the mortality survey included the whole population.

The mortality questionnaire was administered in all households even those with no

children aged 6-59 months. Where possible the head of the household was chosen asthe primary respondent. If he or she was unavailable the mothers or carers of the

children were asked. The anthropometric and mortality questionnaire can be found in

Annex 7 and 8. The questionnaires used were standard ENA questionnaires slightly

adapted to this survey. The questionnaires were in English and interviews were carried

out in the local language.

3.3. SAMPLE SIZE

Since it is impossible to measure the entire population a representative sample of the

population was selected for the survey. The sample size calculation for the

anthropometric and mortality components for all three surveys was carried out using


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ENA software (Emergency Nutrition Assessment)16

. The sample size calculations for all

three surveys are shown in tables 3.1-3.6.

The calculated sample sizes consisted of 784 households in Arakan, 1704 households

for President Roxas and 1241 for Kapatagan. Since simple random sampling was used

in Arakan the sample size there was much smaller.

The number of HH to be visited for the mortality survey was slightly lower than for the

anthropometric survey. Nevertheless, the mortality questionnaire was completed in all

HH, even those without children.

Table 3.1: Sample size calculation for the anthropometric survey in the municipality of

Arakan

16September 2010 Version.

17Population in Arakan according to the 2009 community census was 41,619. An annual population growth of 1.95%

(http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp) was added to estimate the population

number for 2010. In order to quality check the results of the 2009 community census, this value was compared to the results of the 2007

census plus annual population growth which lead to a similar result (41026)18

Since the estimated target population is less than 4500, the correction for small population size was applied in ENA.

Amount Source/Justification

Total population 42430 2009 community census ofArakan plus annual population

growth17

% of children under 5 11.6%National average according to

the DHS survey (2008).

Estimated number of children

under five4922


between 6-59 months (90% of

all under five year old

children)

443018

Average HH size 4.8

According to DHS survey (2008)

and HH community census of

Arakan

Estimated prevalence 10%

Estimation based on a number

of surveys carried out in the

region between 2006 and 2010

(see section 1.2)

Precision 3%

Design effect 1Since cluster sampling is not

used the design effect is one

Non response (HH) 10%Number of children 354

Number of HH to be visited 784


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President Roxas


Total population

44,668 2009 community census plusannual population growth

19,20




under five5181


between 6-59 months4663

90% of all under five year old

children

Average HH size 4.8 According to DHS survey (2008)




region between 2006 and 2010(see section 1.2)

Precision 3%

Design effect 2

The population was believed to

be heterogeneous but the

design effect was unknown. A

design effect of two was

therefore chosen by default.

Non response (HH) 10%

Number of children 768

Number of HH to visit 1704

0.5011 children aged 6-59

months per HH.

768/0.5011=1533 HH.

Plus 10% for non response =

1704

Number of clusters 57

Number of clusters chosen so

that each team can finish one

cluster per day

Number of HH per cluster 30Number of HH divided by

Number of clusters.

19Population in President Roxas according to the 2009 community census was 43,814. An annual population growth of 1.95%

(http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp) was added to estimate the population

size for 2010. In order to quality check the results of the 2009 community census, this value was compared to the results of the 2007

census plus annual population growth which lead to a similar result according to which it was 43262.20

Data excludes the barangay of Salat, since this one could not be visited due to security reasons. 1284 persons had to be excluded.


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Kapatagan


Total population19,713

2007 population census +

anuual population growth21,22




under five2287


between 6-59 months (90% of

all under five year old

children)

205823

Average HH size 4.8 According to DHS survey (2008).




region between 2006 and 2010(see section 1.2)

Precision 3%

Design effect 2

The population was believed to

be heterogeneous but the

design effect was unknown. A

design effect of two was

therefore chosen by default.Non response (HH) 10%

Number of children 560

Number of HH to visit 1241Number of children/ number of

children per HH +10%

Number of clusters 62

Number of clusters chosen so

that each team can finish one

cluster per day

Number of HH per cluster 20Number of HH divided by

Number of clusters.

21Population in Kapatagan according to the 2007 Census was 18.603 (excluding the Barangay of Matimos). Annual population growth rate

in Philippines is 1.95% according to the National Statistical coordination board

(http://www.nscb.gov.ph/pressreleases/2006/27April06_PR-2006-04-SS2-03_popnprojection.asp).22

The Barangay of Matimos had to be excluded due to security reasons.23

Since the target population is less than 4500, the correction for small population sizes was applied in ENA


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Table 3.4: Sample size calculation for the mortality survey in the municipality of Arakan


Estimated mortality rate

(deaths/10000/day)

0.13/10000/

day

CDR= 4.8/1000/year24

population

according to UN data

Precision 0.1Design effect 1


Recall period (days) 152

Calculated from independence day (14th

of June) until the midpoint point of the

survey (11th of November)

Sample size 3068

Number of HH to visit 682 Sample size/average HH size

Table 3.5: Sample size calculation for the mortality survey in the municipality of

President RoxasAmount Source/Justification


(deaths/10000/day) 0.13/10000/dayCDR= 4.8/1000 population/ year

25

according to UN data

Precision 0.12

Design effect 2


Recall period (days) 145

Calculated from Independence Day

(14th of June) until the Midpoint of

the survey (4th of November)Sample size 4375

Number of HH to visit 911 Sample size/ average HH size

Table 3.6: Sample size calculation for the mortality survey in the municipality of

Kapatagan



(deaths/10000/day)0.13/10000/day CDR= 4.8/1000

26according to UN data

Precision 0.125Design effect 2


Recall period (days) 88 days

Calculated from National Heroes Day

(30th of August) until the midpoint

of the survey (25th of November)

Sample size 5353

Number of HH to visit 1239 Sample size/ average HH size

24http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65




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3.4. SAMPLING METHODOLOGY

In order to be able to project the results of the survey sample onto the whole

population, the sample must be representative of the whole population. A sample is

believed to be representative of the population if every household in that population

has the same chance of being selected. Random sampling enables us to do this. Twodifferent survey types and thus different kinds of sampling methodologies were used.

For Arakan, simple random sampling, the best and simplest method was used. For

Kapatagan and President Roxas a two-stage sampling methodology was used since the

population data available were not recent, reliable and detailed enough. Both methods

are described in more detail below. In each selected household all children aged

between 6-59 months were measured and the mortality questionnaire was filled out.

3.4.1.ARAKAN

Each HH in this municipality was assigned a number. The ENA software was then used

to randomly select the needed number of HHs to be visited. The list of households is

not included in the Annexes but is available upon request.

3.4.2.KAPATAGAN AND PRESIDENT ROXAS

Selection of Clusters

The ENA software was used to select clusters. All barangays and their population were

entered into ENA and clusters were then selected according to probability proportional

to size in order to ensure that each HH has the same chance of being selected. Cluster

allocations for both municipalities are shown in Annex 9 and 10.

Selection of HHs

Within each cluster a total of 30 and 20 HH were selected for President Roxas andKapatagan, respectively, using simple random sampling. The teams started by

numbering all HH in the cluster at the beginning of each day. Once all HHs in the

cluster were given a number the adequate number of HH to be visited was chosen

using simple random sampling. The definition of a household is all people living under

the same roof and sharing the same meal.

Barangays that had more than one cluster were divided into equal parts and each part

contained 1 cluster. For clusters that were bigger than 250 HH a segmentation was

carried out and one segment was chosen at random.

Steps for segmentation are shown below:

1.Division of the cluster into equal parts of no more than 250 HH together with the

chief.

2.Calculation of the cumulative population of all segments

Example:

Cumulative population

Segment A = 150 150

Segment B = 200 350

Segment C = 150 500


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3.Choice of a segment:

A number is chosen at random using a random number table. For example if the

cumulative population is 500, a random number between 1 and 500 has to be

chosen. If the randomly chosen number is between 1 and 150 segment A should be

chosen, if the number is between 150 and 350 segment B etc.

4.Within each segment the HH will be numbered and the adequate number of HHs

will be chosen at random using simple random sampling, as described above.

3.5. SPECIAL CASES

If the home was empty

If the residents were absent, the teams returned to the households at the end of the

day. If the family was still absent the mortality questionnaire was filled out with the

help of the neighbours and the children were marked as absent. If the neighbours

were unable to provide information the household was marked as absent.

If the home was completely abandoned, the teams tried to out why. If the home is

empty because all members had died or the family left because of a death, the

questionnaires were filled out with the help of the neighbours answers. In this case

the household was part of the households in the cluster and was not replaced by

another one.

If another event caused the family to abandon the home, the teams noted it down but

did not give a number to this family in the questionnaires. For the survey in Arakan,

where simple random sampling was used, the teams made a note if a selected address

no longer existed. The households were not replaced with another one intially.

However, the survey officer pre-selected an extra 10% of households, these would be

visited only if the household lists were so inadequate that more than 10% of HH no

longer existed or were inaccessible.

Households without children

If a selected household did not have any children between 6-59 months of age, the

mortality questionnaire was filled out.

Absent children

If children were absent the reason behind the childs absence was identified. If the

child (or children) was close to the home, the surveyors asked someone to go and get

the child. If the child was expected to return before the survey team left the barangay,the team revisited the household at the end of the day to measure the child. If the

child was not found before the team left the village, the child was given a number and

marked as absent.

Children in nutritional or health centres

If children were located in health centres within reach the survey team were supposed

to visit the child in the health centre. If this was not possible the child was given an ID

number and marked as absent.


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Disabled children

Disabled children were included in the survey. If a physical deformity prevented the

measurement of childs weight or height, the child was given an ID number and the

data was recorded as missing.

Homes that could not be visited

If the residents of the household refused to participate in the survey or could not

participate the family was not replaced by another household.

Not enough households in the village

If after visiting all the households in a cluster area it was determined that there were

not enough households to complete the cluster, the closest neighbouring barangay or

sitio was supposed to be used to complete the cluster. The same sampling

methodology was applied for the remaining households.

Houses with several women and their children

In case of polygamous families it was determined whether they can be considered asone household or more. The definition of a HH is living under the same roof and

sharing meals. If it was determined that there were several HH each one was assigned

a number and one was chosen randomly.

3.6.DATA ANALYSIS

Data was entered into the ENA software27

. Data analysis was carried out using ENA,

Excel and EPI info28

. Anthropometric measurements were compared to the new WHO

growth standards to determine the malnutrition rates. Malnutrition rates according to

NCHS standards can be found in Annexes 14-16. Data cleaning was done by the survey

officer at the end of each survey. Boundaries for SMART flags were defined as -3SD to

+3SD of the survey population.

3.7. TRAININGA total of 12 surveyors were recruited. These, together with 9 ACF nutritionists,

received a total of four days of training between the 20th

and 28th

of October 2010.

The training consisted of 2 days theoretical training and 2 days of practical training.

Topics included in the theoretical training were: Malnutrition, anthropometry, survey

methodology, the use of weight-for-height tables, events calendar and survey

questionnaires.

The practical part of the training consisted of a standardisation test and a field test.

During the standardisation test each surveyor practiced anthropometric

measurements on ten children. During the field test all teams visited 1 barangay in the

municipality of President Roxas to practice HH selection, measurements and filling out

of questionnaires.

At the end of the training all surveyors had to pass a test to evaluate the quality of the

training and the comprehension of the surveyors. Results of the written test as well as

the standardisation test influenced the composition of the teams and the role of each

surveyor within a team. Teams were composed of three people, one team leader and

two measurers.

27Emergency Nutrition Assessment, September 2010 version.

28EPI Info version 3.5.1., August 2008.


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The team leaders were in charge of ensuring that the correct methodology for

household selection was followed, presenting the objectives to the local authorities

and families, conducting the interviews and filling out questionnaires.

The measurers took anthropometric measurements, evaluated presence of nutritional

oedema and were responsible for the material.

3.8. SUPERVISION

The teams were supervised by the survey officer during the survey. During the first

two surveys the survey officer accompanied the teams every day. Supervision was

reduced during the last survey in order to allow time for data collection and analysis.

In addition the survey officer entered data at the end of every day in order to quality

check the data and enable improvement of the teams during the survey.

3.9 DATA COLLECTION

3.9.1.VARIABLES COLLECTED AS PART OF THE ANTHROPOMETRIC SURVEY:

Sex: The sex of all children was entered in the anthropometric questionnaire and

coded m for male and f for female.

Age: The age of the children was recorded in months. The parents were asked to show

the surveyors a proof of age. If this is not possible the surveyors used the events

calendar to ensure that the age stated by the parents was correct.

Weight: Weight was measured using electronic scales. The children were measured

naked. If it was not possible to measure a child naked the team leader indicated

this on the questionnaire. Weight was recorded to the nearest 100g. Every daybefore the departure the teams tested the scales with a standard weight of 5 kgs.

Height: Height was measured using plastic height boards produced by the company

Seca. Children taller than 87cm were measured standing up and those shorter

than 87cm were measured lying down.

Oedema: The measurers checked children for oedema by applying pressure with the

thumbs to both feet for three seconds. Children were considered to suffer from

oedema if an imprint was left on both feet for at least a few seconds. In the

questionnaire oedema was coded Y for yes and N for no.

MUAC: MUAC measurements were taken on all children taller than 65cm. MUAC was

measured on the left arm at midpoint between shoulder and elbow using acoloured MUAC tape. MUAC was measured in mm to the nearest mm.

Measles Vaccination Coverage: The survey teams asked the mother to see the

vaccination card, in order to find out whether the child has been vaccinated. If

the mother did not have the card she was asked whether the child has been

vaccinated. The response was coded as follows : 1=vaccination confirmed by

card, 2=vaccination confirmed by mother, 3=no and 4=dont know.

Morbidity: The surveyors asked the mother or guardian whether the child suffered

from diarrhea in the two weeks prior to the survey. The response was coded as

follows : 1=yes, 2=no and 3=dont know.

Vitamin A supplementation: The mother was asked whether the child has received avitamin A supplement in the last 6 months before the survey. The response was

coded as 1=yes, 2=no and 3=dont know.


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Deworming: The mothers were asked whether children received deworming

treatment. The response was coded as 1=yes, 2=no and 3=dont know.

3.9.2.VARIABLES COLLECTED AS PART OF THE RETROSPECTIVE MORTALITY SURVEY:

The recall period covered by the retrospective mortality surveys differed between the

three surveys and is stated in tables 3.4-3.6 above.

In all households the mortality interview was conducted with the head of the

household or the mother of the children. The following information was recorded:

-The sex, age and number of people that were part of the households at the beginning

of the recall period.

-The number of people that left and joined the households since the beginning of the

recall period.

-The number of births during the recall period.

-The number of deaths during the recall period.

-The cause of death: Diarrhea, fever, measles, difficulty breathing, malnutrition,violence or other. Diarrhea was defined as the passing of three liquid stools per day

with or without blood. Suspicion of measles was be defined as a rash accompanied by

fever and cough.

-Location of death: Current location, during migration, in place of last residence or

other.

3.10. INDICATORS

Weight-for-Height

The prevalence of acute malnutrition (or wasting) was determined using the weight-forheight-index as an indicator of current nutritional status. A childs nutritional status is

estimated by comparing it to the weight-for-height curve of a reference population (WHO

growth standards29

). This curve has a normal shape and is characterized by the median

weight and its standard deviation (SD or z-score).

The weight-for-height index of a child from the sample was expressed in z-scores for

WHO standards and in z-scores and % of the median for NCHS standards. In addition a

child was also considered to suffer from SAM if he/she had bilateral oedema. Table 3.7

below shows the definition of acute malnutrition.

Table 3.7: Definition of severity of acute mlanutrition according to weight-for-height, MUAC

and Oedema

Moderate Acute malnutrition (MAM)

z-score% of the Median (for NCHS standards

only)

W/H


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W/H


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Vitamin A coverage rate

The vitamin A supplementation coverage rate was calculated as follows:

Number of children having received a vitamin A

supplement in the last 6 months

Vitamin A coverage Rate = x 100

Total number of children aged 6-59 months in the sample

Deworming coverage

The deworming coverage will be calculated for all children aged between 12-59

months as follows :

Number of vaccinated children aged 12-59 months x 100

Deworming Coverage Rate=

Total number of children aged 12-59 months in the sample

Retrospective mortality Rate

Determination of the mortality rate gives a good indication of the sanitary conditions

in the surveyed area. The mortality rate for children under 5 and for the whole

population was calculated according to the following formula:

Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), where:

a = Number of recall days (see tables 4-6)

b = Number of current household residents

c = Number of people who joined householdd = Number of people who left household

e = Number of bi

anthropometric nutrition and mortality surveys. mindanao, philippines

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