Nutrition and Food Security Assessment in Sri Lanka - 2009

JAFFNA DISTRICT

Dr. Renuka Jayatissa Dr. S.M. Moazzem Hossain

Medical Research Institute Sri Lanka

In collaboration with UNICEF and World Food Programme

September 2010

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LIST OF ABBREVIATIONS

ARI BMI DHS dl ECCD ECD FGD GN GRS HAZ Hb IYCF LBW LRI MDG MOH MoHN MRI MUAC NGO ORS PHI PHM RDHS SD SL UNICEF URI WAZ WFP WHO WHZ

Acute Respiratory Infection Body Mass Index Demographic and Health Survey Deciliter Early Childhood Care and Development Early Childhood Development Focus Group Discussion Grama SevaNiladari Growth Reference Standard Height-for-age Z score Hemoglobin concentration Infant and Young Child Feeding Low Birth Weight Lower Respiratory Tract Infection Millennium Development Goal Medical Officer of Health Ministry of HealthCare and Nutrition Medical Research Institute Mid Upper Arm Circumference Non Government Organization Oral Rehydration Solution Public Health Inspector Public Health Midwife Regional Director of Health Services Standard Deviation Sri Lanka United Nations Children’s Fund Upper Respiratory Tract Infection Weight-for-age Z score World Food Program World Health Organization Weight-for-height Z score

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PREFACE

This nutrition and food security survey was carried out by the Department of Nutrition of the Medical Research Institute in collaboration with the UNICEF and the World Food Programme. This survey was focused on the maternal and child under-nutrition which remains a major public health problem in Sri Lanka, despite improvements in many health indicators. This kind of research study is more than timely to assess years of efforts taken by the government and other organizations to prevent and control undernutrition in vulnerable age groups and populations. For a population to be vibrant and work towards its progress, its constituent members have to be of sound health. Nutrition and food security plays a vital role in achieving this end. There is much room for improvements and a tremendous effort has to be made to uplift the prevailing nutritional status in the country. The nutritional status of the majority is below the satisfactory level specially among the poverty stricken people. It is a pity to see that most of them are not aware of how much nutrition contributes to the sound growth of an individual. Relationship of undernutrition to socio-economic and other factors may be used to prioritize communities to which resources should be allocated to improve the situation, and I fervently hope that the findings of this survey will be beneficial to the future policy makers in their effort to oust under nutrition and create a hale and hearty society. I appreciate the efforts taken by the staff of the medical research institute who has successfully conducted this study. I take this opportunity to thank every member of the households in which this assessment was conducted, who gave their unstinted cooperation. I am grateful to UNICEF for being interested in our welfare and investing on a very important venture of this nature. This survey will be very helpful to mitigate this problem and create a Sri Lanka free from undernutrition.

Dr. Ravindra Ruberu Secretary Ministry of Health

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MESSAGE FROM UNICEF & WFP REPRESENTATIVES

The Food Security and Nutrition Survey is the first such survey in Sri Lanka to assess the nutrition situation across the country, the underlying causes of malnutrition and the related impact of the increase in global food prices. This detailed analysis of the relationship between food security and nutrition will be used to strengthen and monitor the impact of targeted interventions to mitigate malnutrition in Sri Lanka. The UN World Food Programme (WFP) and the United Nations Children’s Fund (UNICEF) are proud to be partners in this initiative. Effective joint nutrition interventions are required at all levels to achieve the first Millennium Development Goal (MDG) of halving the proportion of people who suffer from hunger and under-nutrition by 2015, and to contribute at the same time to achieving the MDGs related to child mortality, maternal health, primary education, gender equality, and HIV/AIDS. While Sri Lanka is largely on track to attaining most of the MDGs, significant challenges relating to poverty and child malnutrition remain including socio-economic and regional disparities, and the quality of public health care. While overall, with increasing wealth there has been a significant decline in the prevalence of stunting, wasting, underweight and anemia, this study reveals that there are still significant regional disparities affecting the nutritional status of the people of Sri Lanka. For example the prevalence of stunting and underweight was higher in rural areas such as the estate sector and Hambantota, while wasting was found to be higher in urban areas including Colombo. WFP and UNICEF have a 40 year long history in Sri Lanka in supporting programmes to reduce maternal and child malnutrition and micronutrient deficiencies. WFP and UNICEF will continue to work jointly to support the Government of Sri Lanka and all other relevant stakeholders to take the recommendations of this important study forward.

Reza Hossaini UNICEF Representative

Adnan Khan WFP Representative

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ACKNOWLEDGEMENTS Many people have contributed to the realisation of the study and it is our desire to express our deep gratitude to all, while it is, unfortunately, impossibly to name them all. We gratefully acknowledge the continued valuable and constructive advise provided by Dr. Athula Kahadaliyanage, Former Secretary, Ministry of Healthcare and Nutrition. We also deeply acknowledge the fruitful and motivating discussions and support from the members of the National Nutrition Steering Committee and many experts, especially during the final stage of the data analysis. Special thanks go to Mr.K.Dharmawardana, Accountant, National Health Fund and his staff for their patient assistance throughout the study. Many thanks go to Dr. Lulu Raschid, Director MRI for the support. Dr. Ayesha Lokubalasuriya, Dr. Neli Rajaratna from Family Health Bureau and Dr. Senaka Thalagala, RDHS Ampara for the support extended to conduct the pilot study. Director General Census and statistics for providing census data for sample selection and providing equipment. Deep gratitude goes to the UNICEF, particularly Mr. Phillipe Duamelle, Country Representative, UNICEF, Mrs. Desiree Jongsman (Deputy country Representatives), Dr. Indra Tudawe (Monitoring and Evaluation Specialist), Mr. Adnan Khan, Country Director, WFP, Mrs. Abbes Aziz (Deputy country representative,WFP), Giancarlor (Programme coordinator,WFP) for the motivation to start and complete the study, the support to conduct the field survey. Special thanks deserve the staff of the RDHS offices, staff of the MOH officers, the District Secretaries’ Offices and Gramaseva Niradari officers. They all worked tremendously hard to complete data collection to ensure accuracy. Even when circumstances were extremely difficult, they were never tired to carry on and their passionate contribution, personal and technical, was crucial to the completion of this survey. We deeply acknowledge the villagers’, the families’, the mothers’ and the children’s willingness and openness to cooperate with us. They, patiently, answered all questions and provided valuable insights. They showed great hospitality, staying with them was always a pleasure as well as a learning experience, and we are full of respect for the way they manage their daily life.

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RESEARCH TEAM Principal investigator Dr. Renuka Jayatissa Co-investigators Dr. C.L. Piyasena Dr. S.M. Moazzem Hossaine Collaborative Partners Dr. Dula De Silva Mr. Laksiri Nanayakkara Miss Analeena International Advisors Prof. Abbas Bhuiya Prof. Peter Kalestron Local Advisors and Report writing Prof. Dulitha Fernando Dr. Upul Senarath Survey Manager Mr. J.M. Ranbanda Field Coordinators Dr. A.T.D. Dabare Mr. T. Mahadeva Survey Team Leaders Mr. A.P. Senevirathne Mr. P.V.N. Ravindra Mr. E.G.S. Kulasinghe Mr. W.A.P.I. Pieris Mr. E.C. Paranagama Mr. P.A.K.Y. Wijesundara Mr. H.N.P. Caldera Field support Mr. S.P. Priyantha Administrative support Mrs. K.H.R. Shyamalee Mrs. W.R.T.S. Perera Miss H.I.K.N. Hevawitharana Mrs. K.M.H.N. Kulathunga Dr. Chaturangi Liyanarachchi Dr. Nuwan Jayawardana Dr. Supun de Silva Mr. Piyadasa Gamage Mrs. P.P. Wimalamathie

- Consultant Medical Nutritionist, MRI - Nutritionist - Chief Health and Nutrition, UNICEF - Programme officer, WFP - Programme Assistant, WFP - Junior Programme officer, WFP - Senior Scientist & Head, IC DDR, Bangladesh - Child Health & Nutrition Unit, Belgium - Prof. of Community Medicine - Senior Lecturer, Faculty of Medicine - Nutrition Assistant - Medical Officer - Food and Drug Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Labourer - Development Assistant - Development Assistant - Development Assistant - Medical Laboratory Technologist - Pre-intern Medical Officer - Pre-intern Medical Officer - Pre-intern Medical Officer - Laboratory Ordely - Laboratory Ordely

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Data Analysis Mr. Sarath Gamage (Family Health Bureau), Mr. Abdullah-Al-Harun (Save the children, Bangladesh), Mr. Mokalus Rahuman (Bangledesh), Mr. Mohammed Sadeq (Bangladesh), Mr. Mohammed Rashid (Bangladesh) Mr. Indika Siriwardana Dr. Danushka Keerthiratne - Pre-intern Medical Officer Enumerators K. Ainkaran, S. Anojithan, T. Theiventhiran, L.S. Pakirathan, R. Jeevananth, A. Kaneshamoorthy, P. Kiritharan, J. Kanakasundramswamy, P. Paramanathan, M. Nirothayan, N. Sivapuththiran, S. Kandasaamy, K. Kunaseelan, K. Velan, T. Thurairajah, S. Thusyanthan, M.L. Keethaponkalan, K. Theiventhiran, M. Suthagar, P. Parameswaran, S. Nathan, I. Purusoththaman, T. Sivapalan, T. Sunthareswaran Data Entry Adeesha Hewawasam, Surangi Pitigala, Samanthi kumara, Harshani Randika, Dinesh Wijayarathna, D.K. Hemali Iresha District support staff (Gramaniladari, Samurdi Officer, Public Health Inspector, Public Health Midwife) Thevarajah Mary Jarina, Priskilda Anthonipillai, Sinnarajha Rajitha, Anthonipillai Priyatharshini, Anton Konsiliya, Kanthasamy Prishanthy, Varnakulasingam Kajenthini, Thampimutthu Sarbana

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KEY FINDINGS OF THE SURVEY Nutrition status of children:  Among all children in the age group 0–59 months, 15.2 percent were stunted, 9.5 percent wasted and 14.3 percent were underweight.  34.0 percent of children in the age group 6–59 months were anaemic.  The prevalence of LBW of 16.6 percent. Nutrition status of women:  Among non-pregnant women aged between 15 to 49 years, 20.5 percent were underweight, 15.5 percent were overweight and 6.4 percent were obese.  Prevalence of anaemia among pregnant women was 14.8 percent. Among lactating women, the prevalence was 35.1 and 35.3 percent among non-pregnant women. Childhood illness:  Among the total group, 22.2 percent reported to have had symptoms related to respiratory illness and 5.2 percent had diarrhoea during the specified period in the total sample. Dietary intake: 

The percentage of children yet to achieve the target of dietary diversity was 66.4 which decreased with increasing income categories and wealth quintiles. Caring:  42.7 percent of children under 24 months had been bottle fed.  Of the children aged 36-59 months, 61.0 percent had attended an early childhood educational programme. Health services and sanitation:  All children aged 36 months and over, only 70.8 percent had been given 3 mega doses of Vitamin A.  50.9 percent of the children who had diarrhoea or respiratory symptoms had obtained services from the government sector, 47.4 percent from the private sector and 1.8 percent from other sources.  Of all pregnant mothers, 89.5 percent received iron tablets of whom 72.2 percent took them daily while 69.6 percent received Thriposaha and 66.7 percent women had received “poshana malla”.  Only 73.6 percent of households used both improved water source and sanitary means of excreta disposal. Food security  The percentage of households yet to achieve the target of dietary diversity was 77.2 which do not show any consistent pattern with increasing income and wealth quintiles.  14.4 percent of the households in the poorest wealth quintile have not received any food aids.  49.1 percent of households had taken loans within the preceding month and 53.3 percent out of that used to purchase food.  23.3 percent of households were ‘food insecure’.

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TABLE OF CONTENTS LIST OF ABBREVIATIONS................................................................................................................ II PREFACE ........................................................................................................................................... III MESSAGE FROM UNICEF & WFP REPRESENTATIVES ........................................................... IV ACKNOWLEDGEMENTS................................................................................................................... V RESEARCH TEAM ............................................................................................................................ VI KEY FINDINGS OF THE SURVEY ............................................................................................... VIII TABLE OF CONTENTS .................................................................................................................... IX LIST OF TABLES .............................................................................................................................. XI LIST OF FIGURES.......................................................................................................................... XIII 1. METHODS ......................................................................................................................................... 3 1.1 SELECTION OF HOUSEHOLDS ............................................................................................................................. 3 1.2 COMPOSITION OF THE SURVEY TEAMS ................................................................................................................ 3 1.3 THE HOUSEHOLD SURVEY ................................................................................................................................. 3 1.4 SUPERVISION AND QUALITY ASSURANCE ............................................................................................................. 4 1.5 DATA PROCESSING AND ANALYSIS ..................................................................................................................... 4 2. RESULTS ........................................................................................................................................... 5 2.1 NUTRITIONAL STATUS ...................................................................................................................................... 5 2.1.1 Nutritional status of children................................................................................................... 5 2.1.2 Anaemia in children ................................................................................................................ 7 2.1.3 Birth weight ............................................................................................................................ 8 2.2 NUTRITIONAL STATUS OF WOMEN OF 15-49 YEARS .............................................................................................. 9 2.2.1 Non pregnant women (using Body Mass Index) ....................................................................... 9 2.2.2 Nutritional status of pregnant women (using Mid Upper Arm Circumference - MUAC) .......... 10 2.2.3 Anaemia in women ................................................................................................................ 10 2.3 CHILDHOOD ILLNESSES .................................................................................................................................. 12 2.3.1 Respiratory illness ................................................................................................................ 12 2.3.2 Diarrhoea ............................................................................................................................. 12 2.4 DIETARY INTAKE AND FEEDING PRACTICES ........................................................................................................ 12 2.4.1 Breastfeeding practices ......................................................................................................... 12 2.4.2 Complementary feeding and bottle-feeding practices ............................................................. 12 2.4.3 Food Consumption among children in the age group 6 – 59 months ...................................... 13 2.4.4 Dietary diversity ................................................................................................................... 13 2.4.5 Individual dietary diversity score for children aged 6-59 months ........................................... 13 2.5 CARE PRACTICES .......................................................................................................................................... 13 2.5.1 Promoting early learning at household level ......................................................................... 14 2.5.2 Childhood education ............................................................................................................. 14 2.6 USE OF HEALTH SERVICES .............................................................................................................................. 14 2.6.1 Attendance at Child Welfare Clinic ....................................................................................... 14 2.6.2 Vitamin A supplementation for children ................................................................................ 14 2.6.3 Source of medical care for common childhood illnesses......................................................... 14 2.6.4 Use of services at antenatal clinics ........................................................................................ 15 2.6.5 Food and nutrient supplementation for women ...................................................................... 15 2.6.6 Samurdhi beneficiaries ......................................................................................................... 15 2.7 WATER AND SANITATION ................................................................................................................................ 15 2.7.1 Use of improved water sources.............................................................................................. 15 2.7.2 Use of sanitary means of excreta disposal ............................................................................. 16 2.7.3 Use of improved water sources and sanitary means of excreta disposal ................................. 16

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2.8 FOOD SECURITY AND COPING STRATEGIES ....................................................................................................... 16 2.8.1 Household food consumption ................................................................................................ 16 2.8.2 Household dietary diversity................................................................................................... 17 2.8.3 Expenditure on food and other goods and services ................................................................ 17 2.8.4 Coping Strategies ................................................................................................................. 17 2.8.5 Food insecurity ..................................................................................................................... 18 2.8.5.1 Household food consumption adequacy score (HFCAS)...................................................... 18 2.8.5.2 Food insecurity categories ................................................................................................. 18 ANNEX I .............................................................................................................................................. 19 ANNEX II ............................................................................................................................................. 52

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LIST OF TABLES Table 1: Table 2: Table 3: Table 4: Table 5:

Table A 1: Table A 2: Table A 3: Table A 4: Table A 5: Table A 6:

Table A 7: Table A 8: Table A 9: Table A 10: Table A 11: Table A 12: Table A 13: Table A 14: Table A 15:

Prevalence of malnutrition: stunting, wasting, overweight and underweight by background characteristics ..................................................................................... 6 Prevalence of anaemia among children 6-59 months of age by background characteristics ........................................................................................................ 7 Prevalence of low birth weight, and mean birth weight among children born in the 5 years preceding the survey, by background characteristics ............................. 8 Distribution of non-pregnant women 15-49 years by BMI levels, by background characteristics .......................................................................................................10 Prevalence of Anaemia*, among i) pregnant women, ii) lactating women and iii) All non-pregnant women by background characteristics ..................................11 Percentage of under-5 children who reported symptoms of respiratory illness and diarrhoea by background characteristics .........................................................19 Infant and young child feeding practices by background characteristics.................20 Percentage of children aged 6-59 months, who were given different food items on the day preceding the interview, by background characteristics ........................21 Individual dietary diversity score in children (IDDS) according to background characteristics fro children 6 – 59 months .............................................................22 Minimum meal frequency, dietary diversity, and minimum acceptable diet in children 6-23 months, by background characteristics ............................................23 Participation of adult members in activities of children aged 2 to 5 years, and percentage of under 5 children cared for by a child