NUTRITION CAUSAL ANALYSIS and SMART SURVEY Combined report

NUTRITION CAUSAL ANALYSIS and SMART SURVEY Combined report Khaknar Block, Burhanpur Madhya Pradesh - India April August 2014 With the support of:

Nutrition Causal Analysis (NCA) study ACF together with scientific partners and the support of Fight Hunger Foundation have developed a standardized method to analyse the causes of malnutrition and consequently improve the relevance and effectiveness of stakeholders programming in a given context. A NCA is a structured, participatory, holistic, multi-sectorial study, based on the UNICEF causal framework, to build a case for nutrition causality in a local context. Main Objective The overall objective of the NCA conducted in Burhanpur was to provide a greater level of understanding regarding the possible causes of child under-nutrition in the operational area of Khaknar block of Bhuranpur district, Madhya Pradesh, India. Specific Objectives To estimate the prevalence of known risk factors for under-nutrition among the population and key nutrition vulnerable groups To identify main causes of wasting in order to inform the technical strategy and programs for the prevention of the same at a local level To determine which causal pathways of malnourishment are likely to explain most under-nutrition cases in the target area To understand the local seasonal and historical pathways to wasting To support technical advocacy on causes of wasting so as to support technical strategy. Methodology The NCA study followed these main steps of implementation: 1. Preparatory Phase: The preparatory phase aims to ensure that recruitment process are on time; objectives are clear and the choice of NCA methodology (comprehensive, qualitative, quick) done. 2. Development of causal hypotheses: a literature review, data review and stakeholders interviews (Community Health and Nutrition Workers (CHNW) and NRC staff) were undertaken to generate an overall understanding of the local context of under-nutrition and design a set of local causal hypothesis of under-nutrition. These hypotheses have been validated to be field tested by Technical Experts at a workshop hold on the 9th May 2014 in New Delhi. 3. Data Collection: Both quantitative and qualitative data were collected to provide much needed evidence on levels of under-nutrition, key risk factors and community perceptions, practices and constraints. 4. Identification of highest priority causes of under-nutrition: Based on the evidence gathered as part of the NCA, the causal hypotheses were then ranked by order of importance paying particular attention to seasonal differences and vulnerable groups. The results were then validated with the local community before being presented at a final workshop on the 18th July 2014, where technical experts and NCA expert tried to reach a consensus on the evidence of the most important risk factors and priorities for action. NCA/SMART Burhanpur 2014 2

Extract from preface of the NCA report: Focusing on the Khaknar tribal block of Bhrhanpur district of Madhya Pradesh, the present report is basically an attempt to identify the causal factors of under nutrition among the children of the local population, in order to design a strategy and programme for the prevention of the same ( ). In the present study causal hypotheses pertaining to different risk factors of under nutrition among the children from among different group of causes, such as, environmental, work pattern, access to food and safe drinking water, general health of the mother and child, prevalent child rearing practices, etcetera, were firstly built up based on the literature survey and the qualitative and quantitative data collected from the field ( ). Besides the methodological exercise of developing a clear understanding of the concept of good nutrition, mal nutrition and critical condition, pinpointing the causes of under nutrition within the target population and the seasonal and historical pathways to wasting, the report also crystallizes specific recommendations at the policy and execution level to mitigate the problem at various levels, such as, food security, livelihood, health and nutrition, mental health and care practices, water, sanitation and hygiene and other cross-cutting issues ( ). The outcome of this Nutritional Causal Analysis is expected to add both to the theoretical and practical knowledge. On the theoretical side the study paves a way for developing a better understanding of the causal pathway of under nutrition ( ). On the operational side, the outcome of the present analysis may be helpful for the government and various action groups to plan and execute intervention strategies for alleviating the problem of under nutrition in the target areas in a holistic manner. Pr. Yashwant Govind Joshi Professor Emeritus, M.P. Institute of Social Science Research, Ujjain NCA/SMART Burhanpur 2014 3

Standardized Monitoring and Assessment of Relief and Transition (SMART) The SMART (Standardized Monitoring and Assessment for Relief and Transitions) is a standardised, simplified field survey methodology for conducting nutrition surveys. The method produces a snapshot of the current nutrition situation within relatively a short period of time. The methodology was developed in 2006 by a panel of experts in epidemiology, nutrition, food security, early warning systems and demography; SMART was originally devised to assess acute malnutrition and mortality in emergencies. It is now used in all settings, including development and displaced populations. Surveys using SMART produce representative, accurate and precise estimates of global acute malnutrition (GAM), stunting (chronic malnutrition), underweight and retrospective mortality. These four indicators gathered through the SMART methodology provide the best available validated data that can be used for effective decision-making and resource allocation. Main objectives To assess and provide updated information on the nutritional status of children in Khaknar block, Burhanpur district. Specific objectives To estimate the prevalence of acute malnutrition in children aged 6 to 59 months To estimate the prevalence of chronic malnutrition in children aged 6 to 59 months To estimate the morbidity rate in the two weeks prior to the survey date among children aged 6 to 59 months To estimate the retrospective mortality rate in all the population (CMR) and among under-five children (U5MR); expressed per 10,000/day Methodology SMART is a cross sectional methodology which uses two stage cluster random sampling method. The sample size was estimated for this survey at 841 households to be assessed within 48 clusters. The study focuses on children between 6 to 59 months. The results are expressed with a 95% of Confidence Interval. The methodology is complemented by user-friendly software (ENA) that has automated functions for sample size calculations, sample selection, quality checks, standardisation for anthropometry measurements, and report generation. The data have been analysed using this software. The indicators such as prevalence of diarrhea and ARI have been analysed on Epi-ENA software. NCA/SMART Burhanpur 2014 4

Context of the Study Action Contre La Faim/Action against Hunger (ACF) is working in India since 2009 with actions in Madhya Pradesh, Rajasthan, Odisha and Maharashtra. Being present in Khaknar Block, Burhanpur District of Madhya Pradesh since 2012, ACF focuses in the management of acute malnutrition, its prevention and its treatment. Fight Hunger Foundation, created in 2012, is totally dedicated to the fight against malnutrition, and more specifically to the promotion of good practices, the research of alternative therapeutic treatment, and the training of frontline practitioners so as to improve coverage and impact of nutrition programmes. In Burhanpur District where Fight Hunger Foundation is about to extend its activities, ACF is working closely with the NRHM and ICDS at district and village level. Actions are focused on prevention and detection of acute malnutrition, referral of children with severe acute malnutrition (SAM) to nutrition rehabilitation centres (NRCs) and their follow-up with an integrated IYCF approach. Study Area Madhya Pradesh is considered as one of the poorest states of India. Burhanpur district is marked by sensitive issues as inter-state migrations and high landless population rate. A very small proportion of lands being irrigated, lands remain not cultivable for a part of the year, usually for the entire summer season (3 months from late March to late June). The area is highly dependent on rainfalls from the monsoon (3-4 months from June to September). Agriculture is the main economic source of the majority of the population, while a large part of it is landless (63.5%). Major occupation of household is related to agriculture with a large proportion of workers (69.9%) and a small portion of cultivators (16,3%) while less than 10% of the population referred working in business, service or as artisans. The population being mainly field workers, hot summers are leading to a period with less employment that often conduct villagers to migrate for work. Meanwhile, no real peak of hunger season has been observed as food production within the country allows the area to be supplied with essential food throughout the year. Yet, the zone has persistently high levels of GAM (Global Acute Malnutrition), which peak after the summer season. Khaknar block was selected for the present NCA study as well as for SMART Survey since ACF is present in 80 villages of the area and the study would serve as important baseline study for future interventions and advocacy. Context of the study Even if some studies exist at state level, the composition of Madhya Pradesh is too much heterogeneous to get an accurate view of the district situation. Therefore presentation of the context is mainly based on the National Institute of Nutrition (NIN) survey of Burhanpur, done in 2011. Child under-nutrition remains to be a major public health issue in the block reflected by high rates of malnutrition. In 2011, NIN survey presented alarming nutritional situation with 26,7% of global acute malnutrition (GAM), 8,3% of SAM and 48,6% of stunting among the district. ACF conducted a SMART survey in Khaknar block in November 2013 in which the prevalence of GAM was found as 24,6% [20,4%-29,3% - 95% CI] and SAM as 3,4% [1,9%- 6,1% - 95% CI] according to WHO criteria. In June 2014, the GAM prevalence rises up to 34.7% [30.6%-38.8% - 95% CI] and SAM to 4.7 % [3.3% - 6.0% - 95% CI]. NCA/SMART Burhanpur 2014 5

ACF and Fight Hunger Foundation Program in Burhanpur Since 2011, ACF has been implementing in collaboration with Cecoedecon a project aiming at raising the prevention of acute malnutrition in Khaknar block of Burhanpur district. Through an integrated nutrition and MHCP approach, 3 Nutrition Rehabilitation Centres (NRCs) of the block have received technical trainings and human resources support, with a total of 42 NRC staff trained. Besides these facility-based activities, the community component of the program has reached over an average of 10,000 screenings per month, assessing more than 90% of the total under-5 children present in the first 80 villages of intervention. Trainings addressing the issue of acute malnutrition and its determinants have gathered more than 450 governmental community workers (ASHA, ANM, LHS), with the final objective to reach women, mothers and caregivers of children below 5 years and enhance in Khaknar block the understanding of the population on the priority that SAM represents. The last phase of the project have counted up to 629 SAM and 1150 MAM children detected through the active screening intervention. Nevertheless, the deplorable nutritional situation in the block persists, as underlined in the SMART survey carried out in June 2014 by ACF and Fight Hunger Foundation, and showing a worrying GAM prevalence of 34.7% [30.6-38.8 95% CI] and a SAM prevalence of 4.7% [3.3%-6.0% 95% CI] (based on WHZ, MUAC and oedema). Although 4 NRCs are currently operational in Burhanpur district, the sole facility-based solution designed by the national policies does not seem to overcome the tragic issue of acute malnutrition in India. Up to now, SAM children detected through the program are referred to the nearest nutritional centre, where children along with a caretaker would be hospitalized for a minimum of 14 days until they get to an expected 15% of weight gain. The MP protocol observed by the centres does comply with the national guidelines on Facilitybased management of severe acute malnutrition (IAP and GoI, 2011), lapsed and not following the latest recommendations on SAM management (WHO, 2013). Besides this operational concern, the equally issue of access to care is also predominant in India. Indeed, out of the 70 new SAM cases detected on average by the program (based on the initial 80 villages of intervention), only 45 beds for hospitalization do exist in the district. While the program has achieved an increase of 22% of the admissions to the NRCs by improving the detection and referral of SAM children from the community, the centers are regularly confronted by a high occupancy rate, leading to the rejection of SAM children being at high risk of death. Since the inception of its program in Burhanpur and through the gradual acknowledgement of ACF technical expertise in India, the mission has strived to approach national, state and local leaders in order to advocate for an alternative to the current situation. The actual political context intends to modify the existing nutrition policies through a better convergence between the two ministries in place, the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Women and Child Development (MWCD). A Communitybased Management of Acute Malnutrition (CMAM) guideline, under draft version since 2012, should be released in the coming months, although some major technical aspects such as the authorization of home-based therapeutic products are still unspecified. NCA/SMART Burhanpur 2014 6

NCA main findings and results Through literature review, qualitative and quantitative enquiries, along with the validation of a wide range of experts, the following risk factors have been identified as major, important and minor causes of undernutrition in Khaknar block, Burhanpur District, Madhya Pradesh: RISK FACTORS RATING ARGUMENTATION Inappropriate breastfeeding Major As per the Risk Factor Survey (RFS), Exclusive breast-feeding rate is 36%. The lower rates also reflect practices the perceived beliefs of the mother that they have insufficient milk for their babies Inappropriate feeding practices complementary Major Only 50% (34.2-65.8 95% CI) of the children received a timely introduction of complementary feeding. Furthermore, knowledge on child s balanced diet lack also in the area. The feeding of the child is depending upon the workload of the mother, identified as heavy Low Birth Weight Major The proportion of LBW children in the Khaknar block is around 28.83% (19.88-27.86 95% CI). The study suggests that major causes of LBW children in this area could be High workload, short birth spacing, lack of knowledge about care of pregnant women and inappropriate food intake Caregiver workload Major Around 48.63% mother felt that they are having high workload post pregnancy. Among all caretakers, 61.45% (56.22-66.67 95% CI) resumed their work less than 40 days after the delivery. Low income is concluded as a one of the main causes of having heavy workload on caregivers. The workload of mothers have negative impact on children`s feeding since other works need to be prioritized Poor psychosocial care of children Major The RFS shows that 72.4% child-caregivers interactions were appropriate. However qualitative data shows that mother cannot be able to be with children for a major part of the day, being under the supervision of his/her siblings or grandparents, which could affect the child- mother bonding. Inadequate access to water Major The RFS suggests that pipeline supply is shared by 46.63%. The data also highlights the fact that 48% of the water supply have severe source of contaminations. The inaccessibility of clean water leads to higher prevalence of waterborne diseases, such as diarrhea (14.43%) and fever (33.37%) Low agricultural production Major In Khaknar block, the main production is cash crops such as cotton, sugar cane, soya bean etc. Lack of finances also has impact on irrigation and lack of irrigation results in low availability of food, in a context where dependence to the weather and especially monsoon season is highly important Poor diet diversity Major The diet of the family has more grain, pulses, cereals and leguminous diet, The intake of fruits and vegetables are very low mainly because of the high cost in summer as well as means of preservation are limited due to hot climate Poor access to food Major Recent governmental survey led to the cancellation of BPL cards in villages and also application of new one, requiring a long list of documents (due to corruptive practices). Low income is one of the main pathways that hinder the accessibility to food for the population

Caregivers level of education Important The RFS shows a high level of illiteracy (59.68%), which is even higher among the tribal (ST) population i.e. 71.81%. This needs to be considered in the awareness and preventive programs implemented, targeting knowledge and practices components Inappropriate reproductive health Important Early first pregnancy rate (<18 years old) is high (8.99%). RFS shows that this rate is higher among ST (13.24%). Additionally, Ante and Post natal care consultation are very low, although most of the women reported delivering within a health structure Lack of hygiene Important Regarding personal hygiene, RFS shows that 74.93% of the respondents use soap but only 45.95% of the caregivers adopt a good hand-washing behaviour. Finally a correlation can be made between Acute Respiratory Infections (ARI) and hand washing. Indeed, hand washing is known to have a positive impact on lower spreading of ARI Low income Important Population being in its majority casual labour workers, qualitative enquiry shows that they are also highly dependent on seasonality. Indeed, peak of employment appears at the monsoon season and families generally save money at this time of the year, for the coming yearly expenses Poor health seeking behaviour Minor Antenatal care rate are very low as only 37.65% of the caregivers consulted a health professional for ANC during their pregnancy and among them only 32.25% received the minimum of four recommended visits. Qualitative enquiries reflect that mothers who do not consult a health professional do not consult elsewhere either. Indeed, most of the women explained that no consultations were required during their pregnancy as they were not feeling sick, which demonstrate a lack of awareness on the importance of antenatal care Land size v/s ownership Minor According to the RFS findings, 60% of the population of the block is landless, the situation being worst amongst the ST (62% versus 57% for the other categories). Qualitative enquiries reflected that almost all the migrants are landless. Absence of land is considered as a major underlying cause of malnutrition. Lack of labour employment during summer season is having a huge impact on family income. Traditional beliefs Minor Qualitative enquiries show that population may refer to traditional spiritual practitioners in specific circumstances, as Bagath or Moltani. Indeed, qualitative findings reflect that the majority of the caregivers will first consult a private doctor or go to a health centre in case of illness. Traditional spiritual practitioners are considered as magic persons who may help recovery by providing protection or enchanted water to the sick person. For example, the community explained that children affected by sookharog disease, a traditional disease with the same symptoms as marasmus, are considered at higher risk of death if they consult a traditional spiritual practitioner only.

SMART survey main results Results of June 2014 SMART survey of Kkaknar block, MP The main anthropometric and mortality indicators resulting from the SMART survey conducted in June 2014 are presented in the table below: Indicators Prevalence (%) Confidence Interval (95%) Acute Malnutrition GAM 34.7% 28.5% - 38.8% (WHZ/ MUAC/Oedema) SAM 4.7% 3.3% - 6% Acute Malnutrition GAM 32.2% 28.5% - 36.2% (WHZ and/ or Oedema) SAM 4.4% 3.2% - 5.9% Acute Malnutrition GAM 12.8% 10.3% - 15.8% (MUAC and/ or oedema) SAM 1.7% 0.9% - 2.9% Underweight GUW 64.4% 59.6% - 68.9% (WAZ) SUW 25.4% 21.5% - 29.9% Chronic Malnutrition GCM 64% 59.2% - 68.5% (HAZ) SCM 25.8% 22.3% - 29.6% Death Rate ( per 10000/ day) CDR 0.32 0.19 0.54 U5DR 0.7 0.27 1.83 Comparison of the two SMARTs conducted in November 2013 and June 2014 A comparison of the last results with November 2013 SMART survey shows that there is a statistically significant increase in the prevalence of GAM, reflecting the seasonality factor of these indicators: November is related to the post-monsoon season, whilst June 2014 is related to the pre-monsoon season, considered as highly food insecure. 70,0% 60,0% 50,0% 58,9% 64,0% 40,0% 30,0% 20,0% 21,0% 32,2% Nov-13 Jun-14 10,0% 0,0% GAM Stunting NCA/SMART Burhanpur 2014 9

NCA and SMART Combined recommendations Recommendations to the districts and state authorities Advocate for improvement of the treatment of SAM children in the NRC and possibly at home with the relevant product to scale-up the treatment to the needs Advocate for a better diversification of cereals and leguminous provided by Public System Distribution shops Additional research on local allocation of below poverty line ration card to advocate on risk of corruption toward BPL ration card allocation Advocacy for a better implementation of the MNREGA, especially to reduce time for payment. Reduce price of livestock immunization and treatment, and improve access to governmental veterinary. Work with policy makers to improve access to irrigation system Recommendations regarding the on-going program Carry on and scale-up existing nutritional programs at block and district levels Improve efforts on acute malnutrition recognition (MAM and SAM), knowledge on stunting and treatment of undernutrition, including CMAM programs Advocate for MUAC measurement as a legitimate single value for referral to NRC by local workers and volunteers in the village Emphasize on active screening among children less than five years in the villages; with a particular attention to the group of 6 to 29 months. Strengthen health system to improve access to NRC and health center Strengthen capacity building of health workers on SAM and MAM management within NRC and community-based structure Strengthen the work with front line workers regarding the referral and follow up after NRC treatment Promote dietary diversification and improve nutrition knowledge at community level with a specific target on pregnant mother and children under 5 Awareness through FGD and campaign on appropriate maternal nutrition to reduce low-birth weight Implementation of an Assisting Behavior Change (ABC) strategy to better support mothers and pregnant women on issues related to inadequate child and maternal care practices Reinforcement of awareness program about weaning practices Strengthen knowledge on importance of ANC and relationship between ANM and pregnant mothers, in order to improve health condition and nutritional status of the mothers Awareness on danger related to early child bearing and short birth spacing Continue the monitoring of the nutritional situation in Khaknar block, Burhanpur district NCA/SMART Burhanpur 2014 10

Recommendations for expansion of activities in Burhanpur: Additional research and understanding on mother wellbeing to understand how mothers cope with their difficult living conditions. Identify positive coping mechanisms of traditional migrants to complement the ABC strategy toward health and care practices for traditional and new migrants Involve traditional spiritual practitioners for an improvement of adequate health seeking behaviour Introduction of model of treatment that achieves both coverage and effectiveness (as CMAM) which will be of considerable help to tackle the problem of severe acute malnutrition. To consider WASH activities to address the high levels of chronic malnutrition among children under five years Improve knowledge of diarrhoea and mosquitoes-borne diseases determinants through community education Improve access to safe drinking water sources locally Advocate for a better implementation of safe toilets in each villages Awareness on hand washing, specifically before breastfeeding Reduce risk of water contamination through providing practical education on water management at household level, with an emphasis on the importance of boiling drinking water before human consumption Connect with NGO working on landless issues to advocate on an improvement on land distribution Promote income-generating activities for women to improve their decision making power with regards to financial decisions, paying special attention not to increase women s workload with such activities Improve nutrient women supplementation, including beginning of iron supplementation at puberty Additional research and understanding on castes discrimination. NCA/SMART Burhanpur 2014 11

Conclusion The analysis provided by both Nutrition Causal Analysis (NCA) study and SMART (Standardised Monitoring and Assessment of Relief and Transitions) survey aimed at dealing with in-depth understanding of the nutritional situation in the environment of Khaknar block, Burhanpur district, Madhya Pradesh. Beyond the nutritional statement only, specific and contextualised risk factors and pathways to under-nutrition mean to be identified, with structured analysis regarding their importance in a given area. After 3 years of program implementation in MP and besides the absence of existing and appropriate therapeutic response to acute malnutrition issue in India, the prevalence of Global Acute Malnutrition (GAM) and particularly Severe Acute Malnutrition (SAM) remain alarmingly high (respectively 34.7% and 4.7%) in Khaknar block, far above the emergency thresholds admitted by WHO (ref. classification of the severity of malnutrition). Not only acute, but also chronic malnutrition and underweight are adjacent concerns that complement and reinforce the persistence of a deeply rooted issue, challenging to eradicate, and evidently multi-factorial. Interventions towards the fight against under-nutrition could not be restricted to Nutrition and MHCP (Mental Health and Care Practices) sectors only. Moreover, program decisionmakers need to ensure that their current actions do significantly impact the underlying causes of the problem. If under-nutrition issue is multi-factorial, each and every elements need to be recognised and tackled in order to reach the ultimate goal. Through these both analysis and thanks to a set of targeted and precise recommendations, the results of the NCA and the SMART would be critically incorporated into ACF actual interventions with greater adjustments; complementary recommendations will be strategically disseminated to identified partners and stakeholders, able to complete the global action to tackle the risk factors leading to undernutrition. NCA/SMART Burhanpur 2014 12