anthropometric nutrition and mortality surveys. mindanao, philippines
TRANSCRIPT
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
1/115
1
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 :
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
2/115
2
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
3/115
3
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
4/115
4
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
4.2.1. Description of the Sample........................................................................................................44
4.2.2. Age and Sex Distribution..........................................................................................................45
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
4.2.8. Measles vaccination coverage .................................................................................................51
4.2.9. Deworming coverage...............................................................................................................52
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
4.3.1. Description of the Sample........................................................................................................53
4.3.2. Age and Sex Distribution..........................................................................................................54
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
4.3.7. Measles vaccination coverage .................................................................................................60
4.3.8. Deworming coverage...............................................................................................................61
4.3.9. Vitamin A supplementation coverage .....................................................................................61
4.3.10. Mortality Rates.......................................................................................................................61
5. Discussion.. ...................................................................................................................................62
5.1. Acute Malnutrition...................................................................................................................62
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
5/115
5
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
6/115
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
7/115
7
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
Table 4.33: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)
and by sex (municipality of Kapatagan, November/December 2010)......................................55
Table 4.34: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or
oedema (municipality of Kapatagan, November/December 2010)..........................................55
Table 4.35: Distribution of acute malnutrition and oedema based on weight-for-height z-scores
(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
Table 4.39: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of
Kapatagan November/December 2010)...................................................................................59
Table 4.40: Prevalence of underweight by age, based on weight-for-height z-scores and oedema
(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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
8/115
8
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
Table 8.1: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)
and by sex (municipality of President Roxas, October-November 2010).108
Table 8.2: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or
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
Table 8.4: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of
President Roxas, October-November 2010).108
Table 8.5: Prevalence of underweight by age, based on weight-for-height z-scores and oedema
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
Table 8.9: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)
and by sex (municipality of Arakan, November 2010)110
Table 8.10: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or
oedema (municipality of Arakan, November 2010).110
Table 8.11: Distribution of acute malnutrition and oedema based on weight-for-height z-scores
(municipality of Arakan, November 2010).110
Table 8.12: Prevalence of underweight based on weight-for-age z-scores by sex (municipality of
Arakan, November 2010)110
Table 8.13: Prevalence of underweight by age, based on weight-for-height z-scores and oedema
(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
Table 8.17: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)
and by sex (municipality Kapatagan, November/December 2010)..112
Table 8.18: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or
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
Table 8.21: Prevalence of underweight by age, based on weight-for-height z-scores and oedema
(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,
November/December 2010)113
Table 8.24: Mean z-scores, Design Effects and excluded subjects (municipality Kapatagan,
November/December 2010)113
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
9/115
9
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
10/115
10
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
11/115
11
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
12/115
12
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
(
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
13/115
13
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
(
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
14/115
14
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)
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
15/115
15
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
16/115
16
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
17/115
17
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
18/115
18
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
19/115
19
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
20/115
20
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
21/115
21
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
22/115
22
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
23/115
23
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
24/115
24
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
Estimated number of children
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
25/115
25
Table 3.2: Sample size calculation for the anthropometric survey in the municipality of
President Roxas
Amount Source/Justification
Total population
44,668 2009 community census plusannual population growth
19,20
% of children under 5 11.6%National average according to
the DHS survey (2008).
Estimated number of children
under five5181
Estimated number of children
between 6-59 months4663
90% of all under five year old
children
Average HH size 4.8 According to DHS survey (2008)
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 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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
26/115
26
Table 3.4: Sample size calculation for the anthropometric survey in the municipality of
Kapatagan
Amount Source/Justification
Total population19,713
2007 population census +
anuual population growth21,22
% of children under 5 11.6%National average according to
the DHS survey (2008).
Estimated number of children
under five2287
Estimated number of children
between 6-59 months (90% of
all under five year old
children)
205823
Average HH size 4.8 According to DHS survey (2008).
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 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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
27/115
27
Table 3.4: Sample size calculation for the mortality survey in the municipality of Arakan
Amount Source/Justification
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
Non response (HH) 10%
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
Estimated mortality rate
(deaths/10000/day) 0.13/10000/dayCDR= 4.8/1000 population/ year
25
according to UN data
Precision 0.12
Design effect 2
Non response (HH) 10%
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
Amount Source/Justification
Estimated mortality rate
(deaths/10000/day)0.13/10000/day CDR= 4.8/1000
26according to UN data
Precision 0.125Design effect 2
Non response (HH) 10%
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
25http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65
26http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A65
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
28/115
28
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
29/115
29
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
30/115
30
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
31/115
31
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.
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
32/115
32
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
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
33/115
33
W/H
-
8/2/2019 Anthropometric Nutrition and Mortality Surveys. MINDANAO, PHILIPPINES
34/115
34
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