Baseline Nutrition and Food Security Survey (BNFS) 2010
Baseline nutrition and food security survey
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Preface The 2010 Baseline Nutrition and Food Security Survey was a locally representative sample survey designed to provide information on nutrition and food security issues in the prefectures of Shkoder and Kukes and the periurban municipalities of Tirana (Kamez and Paskuqan). The survey was conducted by the National Institute of Statistics and the Institute of Public Health, under the lead of the Ministry of Health of Albania and in close collaboration with the World Health Organization Country Office Albania; the United Nations Children’s Fund Country Office Albania; the Nutrition and Consumer Protection Division of the Food and Agriculture Organization of the United Nations in Rome, Italy; the Food and Agriculture Organization of the United Nations Regional Office for Europe and Central Asia in Budapest, Hungary; and the National Research Institute for Food and Nutrition in Rome, Italy. The survey was carried out under the Joint Programme on Children, Food Security and Nutrition supported by the Spanish Millennium Development Goals Achievement Fund.
It provides recent information on the prevalence of anaemia among children aged 6–59 months, school-aged children 5–14 years and reproductive-aged women 15–49 years. It creates a baseline of knowledge, attitudes and practices on infant and young child feeding and care; identifies the most common information sources and communication channels; and assesses the food and nutrition security, dietary diversity and food management practices, including the decision-making process of resource-poor households in the three surveyed areas, using a gender-sensitive approach. The survey results contribute to the local planning and interventions in the area of health, nutrition and food security. Enver Roshi Ines Nurja Director General Director Institute of Public Health National Institute of Statistics
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Baseline nutrition and food security survey
Acronyms ADHS
Albania demographic and health survey (2008–2009)
BNFS
Baseline nutrition and food security (2010)
AFSS CI
CRP DD EA
EDTA FAO
GIS GDP Hb IDA
INRAN
INSTAT IPH IYCF
KAP LFS MAFCP MCH MCHC MCV MDG
MoH
PSU RBC RDW
SES SF sTfR
UNICEF UNU
WHO
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Albanian household food security measurement Scale confidence interval C-reactive protein dietary diversity
enumeration areas
ethylenediaminetetraacetic acid
Food and Agriculture Organization of the United Nations geographical information system gross domestic product haemoglobin
iron deficiency anaemia
Italian National Research Institute for Food and Nutrition Institute of Statistics
Institute of Public Health
infant and young child feeding
knowledge, attitudes and practices Labour Force Survey (2010)
Ministry of Agriculture and Food and Consumer Protection mean corpuscular haemoglobin
mean corpuscular haemoglobin concentration mean corpuscular volume
Millennium Development Goal Ministry of Health
primary sampling unit red blood cell
red cell distribution width socioeconomic status serum ferritin
soluble transferrin receptor
United Nations Children’s Fund United Nations University
World Health Organization
Acknowledgements The Albanian Institute of Public Health and the National Institute of Statistics wish to express their appreciation to those involved in the implementation of the 2010 Baseline nutrition and food security survey and the preparation of this report. We would like to thank:
• the Minster of Health for facilitating this study and providing technical support in drafting the questionnaire and training interviewers;
• the National Institute of Statistics for providing expertise on sampling procedures, cartography and the geographical information system; for participating in questionnaire adaptation, the coordination and planning of the study, data processing, data collection, data analysis and the final report writing; and for providing experts to train and supervise the field staff;
• the Institute of Public Health for participating in questionnaire adaptation, the coordination and planning of the study, data collection, data analysis and final report writing; for providing health technicians with the necessary medical background for fieldwork; for training the field staff; and for carrying out the financial and administrative procedures; • the World Health Organization, United Nations Children’s Fund, and Food and Agriculture Organization of the United Nations Country Offices in Albania for providing financial and technical support in drafting the questionnaire, planning the survey, supervising fieldwork and preparing the final report; • the National Research Institute for Food and Nutrition in Rome, Italy for providing technical support during the survey design, sampling procedure, fieldwork training, supervision of fieldwork, data processing and analysis, final report writing and scientific review;
• the technical staff of the survey for providing field staff and data quality teams and for the valuable contributions of all experts and organizations whose joint efforts ensured the effective implementation of the survey;
• the households whose participation made it possible to obtain the reliable information collected in the survey; • the staff who worked in the field, interviewers and nurses, for their willingness and commitment shown during the training and fieldwork; and • to the Public Health Directories of the survey areas and primary health care service providers, whose support made it possible to collect data for this survey. National Coordinators of the project: Elizana Petrela Lantona Sado Deputy Director Programme Coordinator Institute of Public Health National Institute of Statistics
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Baseline nutrition and food security survey
TABLE OF CONTENTS Preface
3
Contributors
8
Acronyms
Acknowledgements
Summary of findings 1. Introduction
1.1 Background
1.1.1 Agriculture and food security 1.1.2 Anaemia
1.1.3 Infant and young child feeding and nutrition
1.2 Survey topics
1.2.1 Food security and gender roles 1.2.2 Dietary diversity 1.2.3 Nutrition
1.2.4 Iron status
1.2.5 Infant and young child feeding practices
1.3 Survey context and partners 1.4 Survey objectives 1.5 References
2. Survey methodology 2.1 Methods
2.1.1 Sample size
2.1.2 Sample design
2.2 Questionnaires
2.2.1 Household questionnaire
2.2.2 Individual questionnaires
2.3 Training
2.4 Data and blood collection
2.4.1 Field staff and data collection 2.4.2 Blood collection
2.5 Data processing and analysis
2.5.1 Field staff and data collection 2.5.2 Blood collection
2.6 Response rates 2.7 Limitations 2.8 References
3. Characteristics of surveyed households 3.1 Overview of survey strata
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3.1.1 Kukes prefecture
3.1.2 Shkoder prefecture
4 5 9
13 13 13 14 14 15 15 15 16 16 17 17 17 18 21 22 22 23 24 24 24 25 25 25 26 26 26 27 28 28 29 31 31 31 31
3.1.3 Tirana prefecture: Kamez and Paskuqan
3.2 Background characteristics of respondents
3.3 Socioeconomic characteristics of households 3.4 Housing characteristics 3.5 References
4. Household food security and gender roles 4.1 Introduction
4.2 Description of food security indicators 4.2.1 Food security classification 4.2.2 Women’s dietary diversity
4.3 Associations between food security and socioeconomic indicators 4.4 Results
4.4.1 Kukes
4.4.2 Shkoder
4.4.3 Kamez and Paskuqan
4.4.4 Comparison across the strata
4.5 Discussion
4.6 Recommendations 4.7 References
5. Anaemia and iron status 5.1 Introduction
5.2 Description of iron status indicators 5.3 Results
5.3.1 Children aged 6–59 months 5.3.2 Children aged 5–14 years
5.3.3 Women aged 15–49 years
5.4 Discussion
5.5 Recommendations 5.6 References
6. Nutrition and feeding practices 6.1 Introduction
6.2 Description of infant and young child feeding indicators 6.3 Results
6.3.1 KAP on nutrition and feeding practices for children under five 6.3.2 KAP on nutrition for children aged 5–14 years
6.3.3 KAP on nutrition for women aged 15–49 years
6.4 Discussion
6.5 Recommendations 6.6 References
ANNEX 1. SAMPLING METHODOLOGY
ANNEX 2. BNFS 2010 QUESTIONNAIRES
ANNEX 3. PEOPLE INVOLVED IN THE BNFS SURVEY 2010
32 33 35 38 40 41 41 42 42 42 44 45 45 49 53 56 59 60 61 63 63 63 64 64 67 70 72 73 74 76 76 78 79 79 90 94
100 101 101 103 109 147
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Baseline nutrition and food security survey
Contributors The Baseline nutrition and food security survey report was prepared by the following experts: • Elizana Petrela, Deputy Director, Institute of Public Health
• Lantona Sado, Programme Coordinator, National Institute of Statistics
• Ehadu Mersini, National Professional Officer, World Health Organization Country Office Albania • Mariana Bukli, Health and Nutrition Programme, United Nations Children’s Fund
• Terri Ballard, International Nutrition Expert, Food and Agriculture Organization of the United Nations • Genc Burazeri, Vice-Director, Institute of Public Health
• Alban Ylli, Chief, Sector of Health Policies and Noncommunicable Diseases, Institute of Public Health
• Eneida Topulli, Head, Statistics Department, Ministry of Agriculture, Food and Consumer Protection • Nurije Caushi, Head, Health Sector, National Institute of Statistics
• Alma Kondi, Specialist, Methodology Sector, National Institute of Statistics
• Zef Gjeta, Sustainable Development Expert, Food and Agriculture Organization of the United Nations
The scientific review of the report was conducted by the following panel of experts from the National Research Institute for Food and Nutrition in Rome, Italy: • Giuseppe Maiani, Diet and Nutrition Programme Director • Marina Adrianopoli, Food Security Advisor • Lorenza Mistura, Researcher Statistician • Elisabetta Toti, Nutritionist
• Marika Ferrari, Researcher Biologist
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Summary of findings The nutrition situation in Albania has improved over the past decade. The 2008–2009 Albania Demographic and Health Survey (ADHS) shows that, among children under five, stunting rates decreased from 32% in 2000 to 19% in 2008–2009 and wasting rates decreased from 11% to 9% in the same time period.
Despite this progress, key challenges remain to ensure food and nutrition security to all Albanians. The prevalence of anaemia in children under five years of age in rural areas is 20%, with higher rates observed in children in the mountain and coastal regions (ADHS); these areas are also particularly vulnerable to nutrition insecurity. The Joint Programme on Children, Food Security and Nutrition, “Reducing malnutrition in Albanian children”, targeted the prefectures of Kukes and Shkoder and the periurban Tirana municipalities of Kamez and Paskuqan to address these challenges. The Joint Programme is implemented by the Ministry of Health and the Ministry of Agriculture and Food and Consumer Protection, in collaboration with the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the Food and Agriculture Organization of the United Nations (FAO), with funding provided by the Spanish Millennium Development Goals Achievement Fund. The 2010 Baseline Nutrition and Food Security (BNFS) survey provides a baseline of information to plan food and nutrition interventions under the Joint Programme and creates a knowledge base for preparing the new Food and Nutrition Action Plan for Albania.
Characteristics of surveyed households
The BNFS survey was carried out in three areas known to have high rates of child malnutrition (especially stunting) and are considered vulnerable to nutrition insecurity due to a large Roma population, high incidence of poverty (rural) or unemployment (urban). The survey was based on a representative sample of 1584 households, provided separate analyses for the three strata of study (Kukes, Shkoder, and Kamez and Paskuqan) and collected information on children under five, children aged 5–14 and women aged 15–49 years.
Results from the BNFS survey show that the average size of households (4.8 members), appears to differ slightly from one stratum to another; Kukes has the highest number of household members with a mean of 5.5 members per household, followed by Shkoder (4.8 members) and Kamez and Paskuqan (4.6 members). Among those interviewed, 67% of households in Kukes, 50% of households in Shkoder and 18% of households in Kamez and Paskuqan report they cultivate land. Only one out of four households own livestock such as sheep, cattle, pigs, bees, rabbits or poultry: animal ownership rates are higher in Kukes (53%) than in Shkoder (48%) and just 0.1% of households in Kamez and Paskuqan own livestock. Eighty-one per cent of households in the three strata say they use an improved source of drinkingwater, including safe bottled water. Ninety-four per cent of all households have sanitation facilities inside the dwelling and the majority of them (ninety-seven per cent) are not shared.
The proportion of households that report their economic level as low and very low is 40% in Kukes, 30% in Shkoder and 25% in Kamez and Paskuqan. Thirty per cent of households in the survey say that their income is not sufficient to cover basic needs; the proportion is higher in Kukes (50%) than in Shkoder (28%) and Kamez and Paskuqan (22%). The proportion of households using three-fourths of household income to purchase food is 45% in Kamez and Paskuqan, 39% in Shkoder and 25% in Kukes.
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Baseline nutrition and food security survey
Previous national studies (including the ADHS) have documented that basic education is almost universal in Albania and the BNFS survey confirms this result.
Household food security and gender roles
The BNFS survey shows that Kukes is the most food-insecure area of the three strata; in Kukes, 42.9% of households are food insecure and rural areas are particularly vulnerable. Despite the limited amount of agricultural land available in mountain areas, Kukes has high rates of home production of fruits and vegetables, and ownership of livestock, whereas a small number of households produce their own food in Kamez and Paskuqan.
In Shkoder and Kukes, urban food-insecure households are as likely as rural food-insecure households, suggesting that they face similar problems accessing affordable foods to process and preserve for future use. The main factor influencing food security is access to a cash-based source of income (daily wage earners). People with full-time employment are more likely to be food secure; among daily wage earners, the proportion of food secure households is higher in Shkoder (60%) than in Kukes (26%) and Kamez and Paskuqan (43%). Women are less likely to make household budgetary decisions in food-insecure households than in food-secure households in Kukes and Shkoder, particularly in rural areas.
Anaemia
The BNFS survey shows that the prevalence of anaemia is 19.6% among children aged 6–59 months, 8.8% among school-aged children and 17.5% among reproductive-aged women. Anaemia prevalence among children aged 6–59 months is higher in Kamez and Paskuqan (26.5%) than in Kukes (18.2%) and Shkoder (17.9%). Among school-aged children, the figure is higher in Shkoder (10.4%) than in either Kukes (8.4%) or Kamez and Paskuqan (4.8%). Anaemia prevalence among women is higher in Kamez and Paskuqan (21.7%) than Shkoder (16.9%) and Kukes (13.8%). These findings reveal that anaemia represents a moderate public health problem in Kamez and Paskuqan and a mild problem in Kukes and Shkoder according to WHO’s criteria on the public health significance of anaemia. The highest prevalence of anaemia is found among children 6–22 months old compared with the age groups: 23–36, 37–50 and 51–60 months. It is higher in school-aged girls than in boys, suggesting that girls and young women may benefit from national measures to reduce anaemia status using a long-term approach to prevent future mothers from being anaemic during pregnancy and breastfeeding.
A core element of the survey was the assessment of iron deficiency anaemia (IDA). IDA prevalence among anaemic children aged 6–59 months is higher in Kamez and Paskuqan than in Kukes and Shkoder. Among school-aged anaemic children, the prevalence is higher in Shkoder than in Kamez and Paskuqan, and Kukes. Among women aged 15–49 years, the highest rate is in Kamez and Paskuqan then Shkoder and it is lowest in Kukes. The survey shows that some groups are particularly vulnerable to iron deficiency; iron deficiency is the cause of anaemia in 40% of anaemic children aged 6–59 months, 23% of anaemic school-aged children and 40% of anaemic women.
Nutrition and feeding practices
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Appropriate nutrition and feeding practices for infants, children and women are influential factors to counteract anaemia and improve overall health. Children of different age groups were assessed using the WHO and UNICEF recommendations on infant and young child feeding practices such as
early initiation, exclusivity and duration of breastfeeding, and timely and adequate introduction of complementary food.
Findings reveal that 93% of children under five are ever breastfed, however, only 57% of ever breastfed children started breastfeeding within one hour of birth. Among children under six months of age, 42% are exclusively breastfed with higher rates for males. The median duration of exclusive breastfeeding is slightly below three months, with a longer duration observed in Kamez and Paskuqan. Among breastfed children aged 6–23 months, 40% have an acceptable diet. In nonbreastfed children in this age group, 36% are fed according to all recommended feeding practices. Among all children aged 6–23 months, more children are fed with food from three or four food groups in Kamez and Paskuqan, however, in Kukes and Shkoder, a higher percentage of children are fed the recommended minimum times during the day. In general, the level of consumption of foods rich in macronutrients and iron is higher in families with a higher economic level.
Knowledge, attitudes and practices on nutrition were assessed for all survey target groups, paying particular attention to the consumption of iron-rich foods. The mean number of days of consumption of iron-rich foods is lower in school-aged children in Shkoder and in Kamez and Paskuqan, particularly in areas where high levels of anaemia were observed.
The level of women’s knowledge regarding foods rich in iron, proteins or carbohydrates is not adequate. Gaps in nutrition-related knowledge, attitude and practices were observed in all survey areas, and were mainly related to infant feeding practices. More women rely on family traditions for advice on infant feeding practices than on scientific recommendations.
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Baseline nutrition and food security survey
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1. Introduction Albania is a country in eastern Europe with a relatively young population. Agriculture still accounts for an important share of the gross domestic product (GDP) and the Albanian National Institute of Statistics (INSTAT) measured GDP at 19% in 2009 (INSTAT, 2010). According to the Ministry of Agriculture and Food and Consumer Protection (MAFCP, 2009), the level of mechanization used in agriculture is low and farm sizes are small, averaging 1.2 ha in 2009. Agricultural exports are limited and production is mostly for subsistence. After the end of the communist regime in 1991, Albania experienced a difficult economic transition and suffered two economic shocks in the late 1990s due to the financial collapse of the pyramid schemes in 1997 and the Kosovo crisis in 1999. In the last decade, the GDP continued to increase and national surveys measured improved health care conditions. In 2010, INSTAT, the Institute of Public Health (IPH) & ICF Macro published the 2008–2009 Albania Demographic and Health Survey (ADHS). According to the ADHS, fertility rates, infant and child mortality rates and women’s use of traditional contraceptive methods have decreased in the five years preceding the survey. Other national surveys demonstrate that the nutritional status of children in Albania is improving (INSTAT, 2000; INSTAT, 2005; ADHS).
Despite this progress, poverty affects the Albanian population, particularly in rural and newly urbanized areas, limiting access to health care services and to adequate food. The double burden of malnutrition is clearly indicated by the co-existence of both stunting (19.3%) and overweight (21.7%) in children under five (ADHS). The 2010 Baseline nutrition and food security (BNFS) survey provides information used to plan food and nutrition interventions under the Joint Programme on Children, Food Security and Nutrition supported by the Spanish Millennium Development Goals (MDG) Achievement Fund. Research areas for this survey were planned in accordance with the main objectives of the Joint Programme and findings from the ADHS.
1.1. Background 1.1.1. Agriculture and food security Agriculture is the largest single sector of the Albanian economy, although arable land per capita is the lowest in Europe. Self-sufficiency in grain production was achieved in 1976, according to data provided by the government. Until 1990, Albania was largely self-sufficient in food production; thereafter, drought and political challenges undermined food security, creating the need for foreign food aid. Albania’s vineyard acreage was reduced to one-third of its level in 1991. In 1993 there were 3.2 million fruit trees (apples, pears, peaches, figs and citrus) compared with 8.3 million trees in 1990. (AgroWeb Albania Working Group, 2011). In the last decade, there have been improvements in the gross output of agriculture, forestry and fisheries. In 2000, the gross output was 58% above its lowest point in 1992 and it continued to increase, rising 45% in 2008 compared to 2000 (United Nations Statistics Division, 2010). Inefficient crops grown for self-sufficiency, such as rice and cotton, have been eliminated and more fodder is grown because livestock is privately owned. However, by international standards this sector remains inefficient (United States Agency for International Development, 2011).
Albanian agriculture has begun to diversify (satisfying about half of the nation’s cereal consumption) but the lack of agricultural equipment, limited transportation infrastructure and inadequate irrigation were not addressed until the late 1990s (ARCOTRASS Consortium, 2006).
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Baseline nutrition and food security survey
A survey (AgroWeb Albania Working Group, 2011) conducted in 1999 showed that 42% of farmers tilled their land using only animal and manpower. Farmer self-sufficiency remains high and the survey indicated that almost half of farm households never bought arable or animal products from outside their own farm.
Since the 1990s, the supply of many food groups has increased, particularly for dairy products, eggs, fruit and vegetables. Consequently, diets have become more diversified, especially in urban areas. Presently, at national level, the dietary energy supply is largely sufficient to meet the population’s energy requirements (Ministry of Health of Albania &WHO, 2008). Albania continues to remain dependent on grain imports, particularly wheat as its self-sufficiency rate does not exceed 55% according to a report by the Food and Agriculture Organization of the United Nations (FAO, 2005). As opportunities for non-farm employment are created, agriculture will continue to supply the domestic market with food products and may find specialized export markets for medicinal plants, wine and olive oil. Limited use of chemical pesticides and fertilizers could become an advantage for Albania in meeting the demand for organic foods in developed countries.
1.1.2. Anaemia
Anaemia is defined by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) & United Nations University (UNU) (2001) as having haemoglobin (Hb) concentrations below established cut-off levels (see Chapter 2). Iron deficiency is the most common nutritional deficiency in the world and it affects, in particular, reproductive-aged women and children in developing countries.
Prior to the ADHS, data on iron deficiency in Albania came from a small-scale survey conducted in 2000 (Buonomo et al., 2005) and documented in the FAO Nutrition Country Profile: Republic of Albania (2005). There have been localized studies conducted on iron supplementation but none at national level.
According to the results of the ADHS, about 17% of children aged 6 to 59 months have anaemia and of these 11% are mildly anaemic and 6% are moderately anaemic (see Chapter 5). Anaemia prevalence among children is higher in rural (20%) than in urban areas (13%) and more children are affected in the mountain (24%), coastal (21%) and central (16%) regions than in the urban region of Tirana. The ADHS reports that anaemia is slightly more prevalent in women showing similar patterns of dispersion to that of children; anaemia prevalence in women is 19% and of these, 16% are mildly anaemic and 3% are moderately anaemic. The rate is higher in rural (23%) than in urban areas (15%) and higher in the central (21%), coastal (20%) and mountain (17%) regions than in urban Tirana (12%).
1.1.3. Infant and young child feeding and nutrition
Findings from the ADHS highlighted the need for improvement in infant and young child feeding (IYCF) practices (see Chapter 6 for indicators) to meet the recommendations by WHO & UNICEF (2003). According to the ADHS results, 96% of children under five years of age are breastfed, however, only 43% of last-born breastfed children are breastfed within one hour of birth as recommended. The proportion of infants put to the breast within one hour of birth is lower in the mountain regions (39%) than in urban Tirana (55%). Almost 88% of children under five are breastfed within one day of birth. Half of the children aged 0–3 months and 39% of children aged 0–5 months ware exclusively breastfed.
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Complementary feeding results from the ADHS show that 16% of children aged 2–3 months and 33% of those aged 4–5 months receive complementary foods (solid and semi-solid) in addition
to breast milk, although exclusive breastfeeding is recommended by WHO & UNICEF (2003) for children under six months of age. Girls are less likely than boys to be fed in accordance with all three recommended IYCF practices. Similarly, children in rural areas are less likely than those in urban areas to be fed according to the IYCF practices. At age 6–8 months, 55% of children are receiving timely complementary feeding.
The level of complementary feeding increased to 66% at age 9–11 months and then decreased to 54% at age 12–17 months since 46% of children are no longer breastfed. At age 24–35 months, only 7% of children are breastfed and receive complementary foods according to the ADHS. Low adherence to recommended IYCF practices, coupled with high rates of poverty and lack of access to quality health care services might be reflected in the poor nutritional status of preschool children (ADHS).
Results related to food intake indicate that, of children 6 to 35 months old, 88% consume foods rich in vitamin A and 84% consume foods rich in iron on a daily basis. The consumption of both vitamin A-rich and iron-rich foods increases with the age of the child and is higher in non-breastfed children than in those who are breastfed, revealing an improved diversity of children’s diets as they are weaned. Children are slightly more likely to consume foods rich in these two micronutrients in urban areas than in rural areas. Children in the urban areas of Tirana have the highest level of consumption of vitamin A-rich and iron-rich foods, while children in the mountain regions have the lowest level of consumption of these foods. The ADHS results indicate that in the 24 hours prior to the interview, 95% of mothers of young children consumed vitamin A-rich foods and 90% consumed iron-rich foods. As with micronutrient intake among children, women’s consumption of vitamin A-rich and iron-rich foods is influenced by their place of residence, the mother’s level of education and household income.
1.2. Survey topics
1.2.1. Food security and gender roles Food security exists when all people, at all times, have access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life (FAO, 2001). A number of factors influence a household’s food security status including economic policies, gender equality and access to and availability of food. Food insecurity may lead to inadequate diets of household members which may reduce their work productivity and negatively impact the household’s economic level. In addition, gender inequality in household decision-making and access to employment may have harmful effects on household nutrition and health and limit rural development (FAO, 2011).
This BNFS survey was conducted using a number of household-level questionnaire modules, including one composed by the Albanian Household Food Security Measurement Scale (AFSS) described in Chapter 4.
1.2.2. Dietary diversity
Dietary diversity (DD) is defined as the number of different foods or food groups consumed over a given reference period. DD is universally recognized as a key component for healthy diets. There is an association between child DD and nutritional status that is independent of socioeconomic factors, suggesting that DD may reflect diet quality and nutrient adequacy.
The survey assessed DD at an individual level for each of the recruited subjects and then the data were aggregated by age group: children aged 6–59 months, schoolchildren aged 5–14 years and
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Baseline nutrition and food security survey
women aged 15–49 years old.
The BNFS survey targeted six urban and rural districts in northern Albania (Kukes and Shkoder prefectures) and two periurban municipalities of Tirana (Kamez and Paskuqan). These areas are home to low-income population groups particularly vulnerable to food and nutrition insecurity.
In this study, DD was measured for all respondents, with particular attention paid to how women’s diets reflect their households’ economic levels and access to types of foods. The women’s DD indicator was included in the BNFS survey to: • assess the variety of women’s diets;
• identify subgroups with low dietary diversity; and
• investigate the association between household socioeconomic characteristics and women’s DD.
1.2.3. Nutrition Nutrition is the intake of food relative to the body’s dietary needs and its effects on health. Good and adequate nutrition promote good health. Poor nutrition can lead to an increased burden of disease, lower rates of immunity, impaired physical and mental development and lower productivity rates. Utilization, as a key dimension of food security, refers to food preparation and the individual’s biological capacity to make use of food consumed.
This survey collected information on women’s knowledge, attitude, behaviours and practices on the consumption of foods rich in iron and folic acid, including locally-available foods, and foods which reduce iron bioavailability in reproductive-aged women 15 to 49 years, including those who are pregnant and lactating (postpartum).
1.2.4 .Iron status Iron deficiency is a state in which there is insufficient iron to maintain the normal physiological functions of tissues such as the blood, brain and muscles. Iron deficiency can exist in the absence of anaemia. However, the more severe stages of iron deficiency are associated with anaemia. Anaemia is one of the most common nutritional problems in the world today. The main causes of anaemia are: dietary iron deficiency; infectious diseases such as malaria, hookworm infections and schistosomiasis; deficiencies of other key micronutrients; and genetic conditions that affect red blood cells (RBC), such as thalassaemia.
Iron deficiency with or without anaemia has important consequences for human health and child development: anaemic women and their infants are at greater risk of dying during the perinatal period; children’s mental and physical development may be delayed or impaired by iron deficiency; and the physical work capacity and productivity of manual workers may be reduced. Iron deficiency and anaemia are still common despite the numerous efforts to reduce it during the past two decades.
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In the absence of international agreement on how to assess the iron status of populations, the prevalence of iron deficiency has often been derived from the prevalence of anaemia using measurements of blood Hb concentration. In this survey, iron biomarkers, namely serum ferritin (SF) and serum transferrin receptor (sTfR), corrected by the C-reactive protein (CRP), have been assessed. In addition, a number of red blood parameters were measured to obtain a complete iron status profile, including Hb, RBC, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and red cell distribution width (RDW).
1.2.5 Infant and young child feeding practices Adequate nutrition during infancy and early childhood is essential to ensure the growth, health, and development of children to reach their full potential. WHO & UNICEF’s (2003) Global strategy for infant and young child feeding recommends optimal infant feeding practices including: • •
exclusive breastfeeding for the first six months of an infant’s life; and
nutritionally adequate and safe complementary feeding starting from the age of six months with continued breastfeeding up to two years of age or beyond.
Exclusive breastfeeding means that infants receive only breast milk from their mother or wet nurse, or expressed breast milk, and no other liquids or solids are consumed, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines.
Complementary feeding is defined as the process beginning when breast milk is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The target range for complementary feeding is generally 6 to 23 months, even though breastfeeding may continue beyond 2 years.
Based on WHO’s recommendations for feeding breastfed and non-breasted children, complementary feeding of children aged 6–23 months is reflected in the IYCF practices. The three IYCF practices include continued breastfeeding or feeding with appropriate calcium-rich foods if not breastfed; feeding solid or semi-solid food for a minimum number of times per day according to age and breastfeeding status; and including foods from a minimum number of food groups per day according to breastfeeding status. This survey collected information in order to evaluate the knowledge, attitude, behaviour and practices related to iron and folic acid supplementation for infants and young children; and to evaluate the knowledge, attitude and behaviour related to IYCF and care practices.
1.3 Survey context and partners Many of the MDGs – particularly MDG1 to eradicate extreme poverty and hunger, MDG3 to promote gender equality and empower women, MDG4 to reduce child mortality and MDG5 to improve maternal health – will not be reached unless the nutrition of women and children is prioritized in national development programmes and strategies. The survey was carried out under the MDG Achievement Fund, in close collaboration with the national team of fieldworkers assigned by the IPH, INSTAT, the WHO Country Office Albania, the UNICEF Country Office Albania, the FAO Nutrition and Consumer Protection Division, the FAO Regional Office for Europe and Central Asia and INRAN.
1.4 Survey objectives The overall objectives of the survey were: 1. to measure the prevalence of anaemia and the burden of iron-deficiency anaemia in highprevalence areas as defined in the ADHS, in light of programme planning and targeted actions for prevention and reduction of the current high prevalence;
2. to assess food and nutrition security, DD and food management practices, including the
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Baseline nutrition and food security survey
decision-making process of resource-poor households in the target areas, with a gendersensitive approach; and
3. to create a baseline of knowledge, attitudes and practices (KAP) on IYCF and care (including breastfeeding, complementary feeding, care for sick children) in the target areas, and identify the most common information sources and communication channels to use to assist the community to improve nutrition practices. The specific objectives of the nutrition survey were:
• to assess the levels of IDA in children aged 6–59 months, in school-aged children 5–14 years and reproductive-aged women 15–49 years; • to assess the consumption of locally available foods rich in iron (micronutrients) by children and women;
• to evaluate the knowledge, attitude, behaviour and practices related to the consumption of locally-available foods rich in iron (micronutrients) and iron-fortified foods for reproductiveaged women; • to evaluate the knowledge, attitude, behaviour and practices related to iron supplementation for infants and young children and iron and folic acid supplementation for women; • to evaluate the knowledge, attitude, behaviour and practices related to IYCF;
• to identify knowledge gaps in infant and young child care practices and identify effective communication strategies to help communities improve their nutrition status; and
• to assess the food security status of households and to explore associations between food security and food access, DD, gender roles and intra-household decision-making related to household budgets and family feeding. The following chapters describe the results of the BNFS survey. Findings and interpretations focus on the key issues explored and are supported by recommendations for further actions to improve food and nutrition security in Albania.
References 1. AgroWeb Albania Working Group (2011). Albania-agroweb [web site]. AgroWeb Albania Working Group (http://www.agrowebcee.net/awal/country-profile/, accessed 16 March 2013). 2. ARCOTRASS Consortium (2006). Study on the State of Agriculture in Five Applicant Countries: Albania Country Report. (http://ec.europa.eu/agriculture/analysis/external/applicant/ albania_en.Pdf, Accessed 4 March 2013).
3. Buonomo E et al. (2005). Iron deficiency anemia and feeding practices in Albanian children. Annali di igiene: medicina preventiva e di comunità, 17(1):27–33.
4. FAO (2001). The State of Food Insecurity in the World 2001. Rome, FAO (http://www.fao.org/ docrep/003/y1500e/y1500e00.htm, accessed 4 March 2013). 5. FAO (2005). Nutrition Country Profile: Republic of Albania 2005. Rome, FAO (http://www. bvsde.paho.org/texcom/nutricion/alb.pdf, accessed 7 March 2013).
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6. FAO (2011). The State of Food and Agriculture 2010–2011. Women in agriculture: Closing the gender gap for development. Rome, FAO (http://www.fao.org/docrep/013/i2050e/i2050e00.
htm, accessed 4 March 2013).
7. INSTAT (2000). Multiple Indicator Cluster Survey Report Albania 2000. Tirana, INSTAT. 8. INSTAT (2005). Multiple Indicator Cluster Survey Report Albania 2005. Tirana, INSTAT.
9. INSTAT (2010). Albania in Figures 2010. Tirana, INSTAT (http://www.instat.gov.al/ media/100318/shqiperia_ne_shifra_2010.pdf, accessed 4 March 2013).
10. INSTAT, IPH, ICF Macro (2010). Albania Demographic and Health Survey 2008–2009. Tirana, INSTAT, IPH, ICF Macro (http://www.measuredhs.com/pubs/pdf/FR230/FR230.pdf, accessed 4 March 2013). 11. MAFCP (2009). 2009 Statistical Yearbook. Tirana, MAFCP.
12. Ministry of Health of Albania, WHO (2008). Recommendation on Healthy Nutrition in Albania. Tirana, Department of Public Health (http://www.docstoc.com/docs/75743439/ RECOMANDATION-ON-HEALTHY-NUTRITION-IN-ALBANIA, accessed 4 March 2013). 13. United Nations Statistics Division (2010). National Accounts Official Country Data (http:// www.oecd.org/topicstatsportal/0,3398,en_2825_495684_1_1_1_1_1,00.html, accessed 15 March 2013). 14. United States Agency for International Development (2011). USAID Country Profile: Property Rights and Resource Governance Albania. United States Agency for International Development (http://usaidlandtenure.net/sites/default/files/country-profiles/full-reports/USAID_Land_ Tenure_Albania_Profile_0.pdf, accessed 7 March 2013). 15. WHO, UNICEF (2003). Global strategy for infant and young child feeding. Geneva, WHO (http:// www.who.int/maternal_child_adolescent/documents/9241562218/en/, accessed 4 March 2013).
16. WHO, UNICEF, UNU (2001). Iron deficiency anaemia: assessment, prevention and control. A guide for programme managers. Geneva, WHO (http://whqlibdoc.who.int/hq/2001/WHO_ NHD_01.3.pdf, accessed 4 March 2013).
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Baseline nutrition and food security survey
20
2. Survey methodology This chapter provides an overview of the survey methodology. The BNFS survey was carried out in 2010 on a representative sample of 1584 households in the areas targeted by the Joint Programme on Children, Food Security and Nutrition: Kukes, Shkoder and the periurban municipalities of Tirana: Kamez and Paskuqan (Fig. 2.1). These areas are severely affected by child malnutrition, especially stunting, have a large and vulnerable Roma population and have high incidence of poverty (rural) or unemployment (urban). Fig. 2.1. Map of Albania
21
Baseline nutrition and food security survey
2.1. Methods 2.1.1. Sample size The survey is based on a representative sample of children aged 6–59 months, children aged 5–14 years and reproductive-aged women 15–49 years. The sample size to assess the prevalence of anaemia in the targeted age groups for each stratum is given by the following formula: (1)
+ 25%
Where: n = Sample size z = Standard normal deviation corresponding to a=0.05 (z = 1.96) p = Expected prevalence m = Expected precision Deff = Design effect 25% = Nonresponse rate
The expected prevalence data for the target population groups, expected precision and the design effect are the same as those used in the ADHS. Table 2.1. shows the sample size for each indicator and target population groups in each of the strata. Table 2.1. Sample size for each indicator and target population groups of in each of the strata
Target population groups Children 6–59 months old School-aged children 6–14 years old Women 15–49 years old
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Estimated prevalence
Expected precision
Design effect
Sample size (n)
0.20
0.065
1.5
218
0.24
0.25
0.065
0.065
1.5
2
249
341
2.1.2. Sample design A stratified two-stage cluster sampling methodology was performed to collect data (Annex 1).
In the first stage, primary sampling units (PSU) were selected in each of the three strata and allocated to the administrative areas’ enumeration areas (EA) for urban zones and the villages for rural zones. The probability proportional to size method (PPS) was used to select the PSU in the three strata of Kukes, Shkoder, and Kamez and Paskuqan. In total, 160 PSU were selected for the BNFS survey sample including 20 PSU in Kukes and 48 PSU in Shkoder. These 68 PSU, selected for the strata of Kukes and Shkoder, are from the 2010 annual Labour Force Survey (LFS) frame list (INSTAT, 2010). There were 92 PSU selected for the stratum of Kamez and Paskuqan as suburban zones from the 2001 Census of Population and Housing frame (INSTAT, 2004).
The sample frame design was based on the urban/rural zone proportion to the population size urban/rural in each of the strata. Thus, all the PSU were allocated on the basis of the percentage of urban/rural in the total number of the PSU for the whole prefecture.
In the second stage, households were selected randomly using a list of addresses compiled for each of the PSU.
The BNFS survey planned to interview 10 households in each PSU using the method of simple random sample with replacement. Therefore, 15 households (10 households + 5 replacing households from a reserve list) were selected for each PSU according to a random procedure and the selection was made from the household listing in each PSU. From the selected 10 households, those without eligible individuals were replaced with eligible individuals from the reserve list of five households for the given PSU. The final list of selected households was used in the field. Within each sampled household, the following categories were surveyed: •
women aged 15–49 years
•
children aged 0– 59 months.
•
schoolchildren aged 5–14years
Further selection took place in order to identify the target population eligible for blood collection which was determined by the following three inclusion criteria: 1.
not thalassemic;
3.
not pregnant or lactating (postpartum) at the time of the survey, for women aged 15–49 years).
2.
not suffering from pathologies of digestive apparatus such as gastric ulcer, Crohn’s disease, celiac disease; and
Logistical complexity and high costs of blood tests limited blood collection in each household to: •
one woman aged 15–49 years
•
all children aged 6–59 months.
•
one school-aged child 5–14 years
If more than one woman or school-aged child was eligible for blood collection in the household, the individual whose date of birth was closest to the interview date was chosen.
23
Baseline nutrition and food security survey
2.2. Questionnaires Four questionnaires were designed for the BNFS survey: 1) household questionnaire, 2) children’s questionnaire; 3) schoolchildren’s questionnaire and 4) women’s questionnaire (Annex 2) Questionnaires were approved by the Advisory Technical Staff (Annex 3) and were translated from English into Albanian.
Field staff comprised of supervisors and interviewers administered the questionnaires on their first visit to the selected households. During this visit, they identified individuals eligible for blood collection in each household and informed them of the date (within the same week that the interview took place) and place (closest health centre) of the blood test. Blood collection information was recorded using the forms in Annex 2.
2.2.1. Household questionnaire
After obtaining the informed consent from the respondent, the field staff administered the six modules of the household questionnaire.
The first module, the family listing, was used to register information about the household’s members such as age, sex, education level and relationship with the head of the household. It identified subjects who were eligible for a follow-up individual interview and might be eligible for blood collection.
The second module was designed to collect information on the sociodemographic household characteristics such as religion, ethnic affiliation, and characteristics of the household dwelling including the source of water, type of sanitation facilities, ownership of land cultivated and types of animals owned by the household. The perceived economic level of the household was also recorded according to the interviewees’ self assessment. The third and fourth modules were designed to collect information on household food security and nutrition such as home food production and consumption.
The fifth module gathered data on the months of inadequate food provisions experienced by the household the past year and five years prior to the interview. Finally, the last module was created to collect information on household activities and responsibilities, with a specific focus on gender roles.
2.2.2. Individual questionnaires
Once the household questionnaire was completed, the remaining three individual questionnaires were administered.
The children’s questionnaire collected information on all children aged 0–59 months in the household with responses given by the mother or caretaker on: •
KAP on IYCF and care practices for children aged 0–24 months
•
food consumption and DD for children aged 6–59 months (WHO et al., 2008).
•
KAP on iron and folic acid supplementation for children aged 6–59 months
The schoolchildren’s questionnaire collected information on food consumption patterns for children aged 5–14 years with responses provided by the mother or the caretaker.
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The women’s questionnaire collected information on all women aged 15–49 years in the household on: • •
food consumption and DD
KAP on the nutritional benefits of iron in a diet.
2.3. Training
Training of field personnel took place over several days in mid-September 2010 in Tirana. INRAN conducted a one-day “Training of the Trainers” for selected participants from the IPH and INSTAT and provided them with training materials developed for this study.
Then, specialists from the MoH, INSTAT, IPH and the FAO Office in Albania attended a six-day training class for field-based workers. Of the 65 candidates, 30 people were selected – based on their educational level, previous experience in conducting similar surveys and their performance during the selection interview – and trained. Staff training was conducted in the Albanian language. All participants were trained in interviewing techniques, the content of the survey questionnaires and blood collection. An ad hoc training module was developed for nurses and staff involved in drawing blood samples to provide general knowledge of the study and its logistics, to ensure blood drawing procedures were in accordance with the study protocol and to educate the staff on how to fill out the questionnaires. Training included classroom presentations, discussions, simulated interviews and a written test.
The trainees participated in a 3-day field test in Kamez and Paskuqan to get practical experience with interview techniques, blood collection and field logistics; to test the questionnaires; and to promote teamwork. This test provided the opportunity to review the content and language of the questionnaires, logistics, equipment needs and the study protocol. During the field test, the trainees interviewed about 80 families and took blood samples in accordance with the survey’s protocol. Lessons learned from the field test were used to refine and finalize the survey instruments and logistics. Supervisors received an extra day of training on how to supervise fieldwork to ensure the collection of valid and reliable data. Interviewers and supervisors were selected based on their active participation in the training and field practices and the results of four theoretical assessment tests.
2.4. Data and blood collection
2.4.1. Field staff and data collection Six teams – consisting of one supervisor, three interviewers and one driver – performed the fieldwork. IPH and INSTAT, supported by INRAN and the WHO Country Office Albania, supervised all aspects of the fieldwork activities. Two quality control (QC) teams were formed with one staff member from each institution participating in each team. Member selection of the QC teams was based on full participation in the field test or the survey training and practice, experience with the survey questionnaires and a demonstrated ability to resolve fieldwork problems, particularly those related to blood collection. Coordinators from IPH, INSTAT, WHO and UNICEF and QC team members monitored the field teams, reviewed their progress and checked the quality of their fieldwork.
Once the interviews were completed and all data for a PSU were received by the supervisor, the questionnaires were checked for completeness before being transferred to the IPH central office in Tirana. QC was performed throughout the data collection process, data were corrected as needed
25
Baseline nutrition and food security survey
and constant support was provided to the field staff.
Data collection took place from early October to mid-December 2010. On average, each team took about one day to complete one PSU with 10 households, administering the questionnaires in the early morning and late evening to increase the likelihood of finding respondents at home.
2.4.2 Blood collection
The BNFS survey included blood collection to test the prevalence of anaemia and iron deficiency in children aged 6–59 months, school-aged children and reproductive-aged women. Anaemia levels were determined by measuring the level of Hb in the blood and comparing it with WHOestablished guidelines (WHO, UNICEF & UNU, 2001).
A blood collection form was used to gather basic personal data and assigned an individual code to the subject giving blood. In order to ensure that every step in the blood collection process was properly documented, this form included: 1) the name of the person sending and receiving the blood samples, 2) the date of blood collection and blood delivery, 3) the date of serum centrifugation and freezing and 4) the signed confirmation from a nurse on the accuracy and validity of the code. Relevant sections of the form were filled out by nurses at the time of the blood collection with supervisors controlling the completeness and quality of the entered information. Laboratory staff completed the remaining sections of the form. Blood collection took place in the morning after subjects fasted overnight. Samples were drawn from the antecubital vein by vacutainers; 2 ml of the sample was placed in an ethylenediaminetetraacetic acid (EDTA) tube and 5 ml in tubes which did not contain any additives or anticoagulant for iron markers analyses. Each tube was labelled with the subject’s code, temporarily stored in vaccine carriers and safely transported from the field to the Clinical Biochemistry Laboratory of the Mother Teresa University Hospital, in Tirana, within 12 hours of collection.
2.5 Data processing and analysis 2.5.1 Questionnaire data
This section presents general data processing and analysis information. Information pertaining only to blood analysis is in Section 2.5.2.
Once fieldwork was completed, data entry and data processing began. The data were entered on five computers using the Census and Survey Processing System (CSPro) software. To ensure quality control, all data from questionnaires were entered twice and internal consistency checks were performed. Procedures and standard programmes were developed at INSTAT, following international standards.
Data processing began in January 2011 and finished in March 2011. The data were edited and cleaned and the sampling weights were computed in order to prepare data files for analysis. INRAN supervised the data processing phase. Data were analysed using the SPSS 17.0 statistical software program on the basis of the tabulation plan developed for this survey. INRAN and FAO performed the data analysis. Chi-square and Fisher’s exact test were used to assess the difference in prevalence rates of anaemia by categorical variables (socioeconomic groups, educational level and strata). For all analyses a P-value < 0.05 was considered statistically significant.
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2.5.2 Blood analysis Blood analysis was performed at the Mother Teresa University Hospital from January to midMarch 2011. Vacutainers containing EDTA were tested for red blood parameters (Hb, RBC, MCV, MCH, MCHC and RDW), white blood cells and different leukocytes within 24 hours of arrival at the hospital.
Vacutainers not containing any anticoagulant for iron analyses (SF, sTfR, and CRP) were centrifuged at 2500 rpm for 10 minutes. The separate serums were distributed in vials (800 μl in each) and stored at -20 °C before testing procedures and analyses were performed. The definitions of anaemia by haemoglobin concentration and iron depletion for the target groups, namely women and children, are shown in Tables 2.2 and 2.3. Table. 2.2.Haemoglobin levels below which anaemia is present in a population
Target groups
Hemoglobin concentration (g/dl)
Children 6 - 59 months 11.0 Children 5–11 years 11.5 Children 12–14 years 12.0
Non-pregnant women >15 years
(Source WHO, UNICEF & UNU, 2001).
12.0
Table. 2.3. Ferritin levels below which iron stores are considered to be depleted
Ferritin level (µg/l) Target groups Ferritin level (µg/l) In the presence of infection CRP>10.0 mg/ml Children 6 - 59 months
