Shiree/EEP nutritional surveys in 2013 and 2015: adolescent girls

Transcription

1 Dr Rie Goto and Professor Nick Mascie-Taylor University of Cambridge May 2015 Shiree/EEP nutritional surveys in 2013 and 2015: adolescent girls Key findings Regular iron and folate supplementation and deworming significantly reduced the prevalence of anaemia in adolescent girls living in extreme poor households: cross-sectional analysis showed a reduction of 25.8% (from 32.5% to 6.7%) between 2013 and 2015 well above the log frame target of 5% reduction in anaemia. Paired analysis of the same girls measured in both 2013 and 2015 indicated a 19% reduction in anaemia Regular iron and folate supplementation and deworming reduced the prevalence of thinness in adolescent girls living in extreme poor households: paired comparisons revealed a reduction of 7.6% (target 5%) but cross-sectional analysis only indicated a 1.2% reduction Delivery was high: over 92% of adolescent girls received IFA tablets supplied by the programme, 98% received the correct dose (two tablets per week) while 89% had taken deworming tablets supplied by the programme Almost no side effects were reported: and most 1 adolescents expressed their willingness to continue taking IFA and deworming after the programme ends

2 Executive Summary 1. Background: In 2013 UKAid implemented a nutrition supplementation programme for EEP/shiree adolescent girls. The girls received iron and folate twice a week and were dewormed using albendazole, a broad spectrum antihelminthic, every 6 months. In April 2013, before the programme started a baseline survey was conducted and 242 girls had their height, weight and haemoglobin concentration measured from which the prevalences of anaemia and thinness were determined. As there was a delay in procurement of the supplements no follow-up survey was conducted in April 2014 because of the lack of time to see any nutritional improvements. An endline study was conducted in April Sample and compliance: 43% of adolescent girls (N=105) who took part in the baseline in 2013 were measured at the endline survey. Comparison of adolescents who were only measured at baseline (non-compliant group, n=137) with those measured at both baseline and endline (complaint group) indicated some attrition. The non-compliant group were, on average, 1 year older than the compliant group (12.6 vs years of age at baseline, respectively) and nearly 0.4SD higher BMI z-score (-0.99 vs , respectively both <0.001) but there was no significant difference in mean haemoglobin concentration between the two groups. 3. Log frame target reduction in anaemia: Comparison of the 242 girls measured at baseline with the 105 girls measured at the endline survey (cross-sectional analysis) showed that the prevalence of anaemia in adolescent girls fell by 25.8% (target was 5%). Comparison of the same adolescents measured in 2013 and 2015 (paired analysis) revealed a reduction of 19%. 4. Log frame target reduction in thinness: Cross-sectional analysis of 2013 and 2015 surveys showed that the prevalence of thinness in adolescent girls reduced by 1.2% (target was 5%). However comparison of the same adolescent measured in 2013 and 2015 (paired analysis) revealed a reduction of 7.6%. 5. Delivery of IFA and deworming treatments: Most adolescent girls (92.4%) had been receiving IFA supplied by the programme and 97.9% of the girls were taking the correct dose. 89% of adolescents had taken deworming tablets supplied by the programme. 6. Side effects and acceptance of treatments: Almost no side effects were reported from adolescent girls; 86% of adolescent girls reported that deworming increased their appetite, 75% and 95% expressed their willingness to continue IFA intake and deworming treatment, respectively after the programme ended. 7. Recommendations: Continue to supply IFA and deworming to adolescent girls as there are beneficial effects on reducing anaemia and thinness. Consideration should be given to extending the IFA and deworming coverage from adolescence into adulthood so that women entering marriage, as well as newly married women, have adequate iron stores before their first pregnancy. Log frame targets should be based on within-adolescent changes, before and after interventions, i.e. paired analysis, rather than on cross-sectional samples. 2

3 List of Contents Executive Summary Introduction Abbreviations and Acronyms Interventions Survey methodology and data analyses Survey methodology Data analyses Test of selection and attrition bias Cross-sectional and paired analyses Nutritional indicators Log frame targets Impact of attrition Changes in nutritional status between baseline and endline surveys Cross-sectional analysis Paired analysis Comparison of CONCERN with the other NGOs Cross-sectional analysis Paired analysis Delivery and intake of IFA and deworming IFA Deworming Impact of, IFA and deworming treatments on nutritional status and anaemia in adolescent girls Impact of IFA duration Impact of deworming Knowledge, side effects and acceptance of IFA and deworming Knowledge of IFA and anaemia Knowledge of worm infection and deworming Causes of worm infection Identifying health problems of worm infection Understanding the benefits of deworming Effects of IFA treatments Effects of deworming treatment Willingness to continue IFA and deworming treatments IFA Deworming Recommendations List of Tables Table 1. Summary of interventions in adolescent girls... 5 Table 2. Definition of undernutrition and anaemia in adolescent girls... 6 Table 3. Log frame indicators, targets and outcome in Table 4. Characteristics of adolescent girls between compliant and non-compliant groups... 7 Table 5. Sample characteristics and nutritional status of adolescent girls in 2013 and 2015 (cross-sectional analysis)... 8 Table 6. Sample characteristics and nutritional status of adolescent girls with pair comparison between 2013 and

4 Table 7. Sample characteristics and nutritional status of adolescent girls between CONCERN and other NGOs in 2013 and 2015 (cross-sectional analysis)... 9 Table 8. Delivery and compliance of IFA and deworming for adolescent girls... 9 Table 9. Estimated Mean and SD (in brackets) of BMI and haemoglobin concentration (g/l) at baseline, endline and changes between baseline to endline after controlling for age and NGO effects by groups of different deworming intakes Table 10. Prevalence of thinness and anaemia at baseline, endline and changes between baseline to endline by the groups of different deworming intakes List of Figures Figure 1. BMIZ changes by age (in years) of adolescent girls

5 1. Introduction This report examines the changes in nutritional status of EEP/shiree adolescent girls who were measured in March/April 2013 (baseline) and again in March/April 2015 (endline). In 2013 UKAid started to implement a supplementation nutrition programme for EEP/shiree households targeted at pregnant mothers, adolescent girls and children under 5 years of age. All adolescent girls (defined as between 10 and 16 years of age) received iron and folate supplementation (IFA) twice weekly and were dewormed at 6 monthly intervals using albendazole, a broad based antihelminthic, active against parasitic worms. The baseline survey was conducted before any interventions had taken place. Due to the late procurement of supplements no follow-up survey was conducted in 2014 due to the lack of time to see any nutritional improvements. The 2015 survey was the endline survey as there will be no further follow-up in This report describes the survey methodology, the log frame nutritional indicators, targets and achievements, the impact of attrition, the delivery and intake of IFA and deworming and their impact on nutritional status and knowledge, side effects and acceptance of IFA and deworming. 2. Abbreviations and Acronyms BMI CMS3 CPK DW IFA Body Mass Index Change Monitoring System Annual Surveys Community Pusti Kormi health workers Deworming/ Deworming suspension or tablets Iron and Folate tablets 3. Interventions The interventions received by adolescent girls are summarised in Table 1. The girls received iron and folate tablets twice weekly and were dewormed at 6 monthly intervals. Health education by Community Pusti Kormi (CPK, health workers) was given to all households with one or more members receiving the intervention. Some NGOs provided health consultation by CPKs to mothers, adolescent girls and children in the households, as well as deworming tablets to all family members. Table 1. Summary of interventions in adolescent girls Micronutrients Deworming Education IFA: 2 tablets/ week Once every 6 months Nutrition, hygiene practices, menstruation care 4. Survey methodology and data analyses 4.1 Survey methodology The baseline nutritional survey was conducted along with the CMS3 annual nutrition survey After 12 days of training the survey commenced on 7 th March 2013 and finished on 5 th April 2013 with the exception of OXFAM households where information was collected later on 18 th April due to the political situation. The UKAid nutritional supplementation programme provided interventions to three groups namely under two year old children, pregnant and 5

6 lactating mothers and adolescent girls. Sixty-four households with children under 2 years of age were randomly selected from villages from each NGO in the 9 Scale Fund NGOs (CARE, DSK, NETZ, PAB, SCI, UTTARAN, CARITAS, CONCERN and OXFAM). All adolescent girls living in these villages were selected. The endline nutritional survey was conducted along with the CMS3 annual nutritional survey and commenced on 15 th April 2015 (after 12 days of training) and finished on 2 nd June The later start of the survey was as result of the political situation which had impeded movement in rural areas. All participants had their weight and height and haemoglobin concentration measured (from a finger prick of blood using a HemoCue) by trained personnel. An interview was conducted and background information (age, marital status, schooling and occupation) was collected as well as details of morbidity (diarrhoea, fever, cough, skin, eye and worm infections), consumption of supplementation and deworming and frequency of CPK s home visits. 4.2 Data analyses Test of selection and attrition bias At the baseline survey 242 adolescent girls participated of whom 105 (43%) were remeasured in Comparison of adolescents who were only measured at baseline (noncompliant group, n=137) with those measured at both baseline and endline (complaint group) were made in order to test for any selection/attrition bias Cross-sectional and paired analyses In order to see whether the log frame targets had been reached two sets of comparisons were undertaken. The first compared the 242 girls measured at baseline with the 105 girls measured at endline survey (cross-sectional analysis). The second comparison only measured the same adolescents in 2013 and 2015 (paired analysis). The main problem with a cross-sectional analysis is that there is a risk that the baseline and endline samples are heterogeneous and any differences in nutritional status may be due to this heterogeneity and not due to the intervention, per se. 5. Nutritional indicators Nutritional status was determined using anthropometry (by measuring weight and height) and haemoglobin concentration from a finger prick of blood. (Table 2). The Body Mass Index (BMI) was calculated for each girl (weight (kg) /height (m) 2. Thinness using BMI z-scores (BMIZ) was defined as a BMIZ <-2 and severe thinness as a BMIZ <-3. The same cut-offs were used for height-for-age. The haemoglobin concentration cut-off for anaemia was <115g/l in year old adolescent girls, and <120g/l for girls aged 12 years and above. Severe anaemia was defined as 80g/l in all adolescent girls. Table 2. Definition of undernutrition and anaemia in adolescent girls Cut-off points of undernutrition Cut-off points of anaemia Thinness: < BMIZ -2 Anaemia: - Severe thinness < BMIZ years olds: < 115g/l Stunting: HAZ < years and above: < 120g/l - Severe stunting < BMIZ -3 - Severe anaemia: < 80/l for all adolescent girls NB: Anaemia is measured using haemoglobin concentration (g/l), BMI (Body Mass Index) is calculated as weight in kg / (height in metres) 2 ; HAZ (height-for-age), WAZ (weight-for-age), WHZ (weight-forage) and BMIZ (BMI-for-age) were calculated using international standards created by WHO in

7 6. Log frame targets The log frame indicators and targets are shown in Table 3. The target reductions, which are based on cross-sectional changes, were 5% in the prevalence of thinness and 5% in the prevalence of anaemia. Between 2013 and 2015, the prevalence of thinness in adolescent girls reduced by 1.2% and anaemia by 25.8%. Table 3. Log frame indicators, targets and outcome in 2015 Outcome indicator Target for 2015 Outcome in 2015 Sources 2.2 Improved nutritional status of target groups for the Accelerated Improved Nutrition for Extreme Poor in Bangladesh project- pregnant and breastfeeding mothers and adolescent girls 5% point reduction in anaemia in adolescents. 5% point reduction in thinness in adolescent girls Thinness; 1.2% reduction (24.8% in 2013 and 26.0% in 2015) Anaemia; 25.8% reduction (32.5% in 2013 and 6.7% in 2015) IYCF data in 2013* and 2015 *Goto and Mascie-Taylor (2015), IYCF Report 1: Baseline nutritional status survey of mothers, pregnant women, adolescent girls and under 5 year old children in Impact of attrition Of the 242 adolescent girls measured at baseline, 105 of them (43.4%) were also measured at the endline survey (Table 4). The majority of the adolescent girls were missing because they were absent on the day of the endline survey, because they were attending school), married, or lived separately. The non-compliant group were, on average, 1 year older than the compliant group (12.6 vs years of age at baseline, respectively) and nearly 0.4SD higher mean BMI z-score (-0.99 vs , respectively) than the compliant group (both <0.001). No significant differences were found in mean haemoglobin concentration between the groups (121.2 vs g/l for compliant and non-compliant groups, respectively). Table 4. Characteristics of adolescent girls between compliant and non-compliant groups Characteristics Compliant Non-compliant p N Age (years) (1.44) (1.80) <0.001 BMIZ (1.13) (1.23) Haemoglobin (g/l) (12.31) (13.02) NS 8. Changes in nutritional status between baseline and endline surveys In 2013, the mean age was years of age (SD 1.80) and 82.6% of adolescent girls were attending school. In 2015, the mean age was 13.6 years of age (SD 1.5) and 83.3% of adolescent girls were attending school. The mean BMI in 2015 of indicated that the girls were mildly thin (mean z-score of BMI -1.16) and about a quarter of them were thin (24.8%), although only 7% suffered from anaemia and no severe anaemia cases were found (Table 5). 8.1 Cross-sectional analysis The results of the cross-sectional analyses comparing the nutritional status of adolescent girls in 2013 and 2015 are presented in Table 5. There was a 26% reduction in anaemia 7

8 between the surveys, a highly significant change (p<0.0001) but the reduction in thinness prevalence of 1.2% was not significant. There were no significant differences in mean BMI z- score or haemoglobin concentration score between 2013 and Table 5. Sample characteristics and nutritional status of adolescent girls in 2013 and 2015 (cross-sectional analysis) All girls at baseline All girls at endline Differences Age (Mean, SD) (1.72) (1.53) NS BMI z-score (Mean, SD) (1.20) (1.13) NS Thinness (%) NS Severe thinness (%) NS Haemoglobin (g/l Mean, SD) (12.6) (10.4) <0.001 Anaemia (%) <0.001 Severe anaemia (%) Paired analysis The paired analysis revealed that mean BMIZ score (thinness) improved significantly between baseline and endline by, on average 0.22SD (p<0.001) (Table 6). Although the prevalence of thinness fell by 7.6% between baseline and endline, the reduction was not significant. The mean concentration of haemoglobin did not show any significant improvement but the prevalence of anaemia reduced very significantly by 19% between baseline and endline (p<0.001). Table 6. Sample characteristics and nutritional status of adolescent girls with pair comparison between 2013 and 2015 Girls only studied in 2013 and 2015 Within-changes Baseline Endline BMI z-score (Mean, SD) (1.13) (1.13) <0.001 Thinness (%) NS Severe thinness (%) Haemoglobin (g/l Mean, SD) (12.3) (10.4) NS Anaemia (%) <0.001 Severe anaemia (%) Comparison of CONCERN with the other NGOs 9.1 Cross-sectional analysis The results of cross-sectional comparing nutritional status of adolescent girls between CONCERN and other NGOs in 2013 and 2015 are shown in Table 7. There were no significant differences in mean age, BMI z-score and haemoglobin concentration as well as prevalences of thinness and anaemia in adolescent girls between CONCERN and the other NGOs in both 2013 and

9 Table 7. Sample characteristics and nutritional status of adolescent girls between CONCERN and other NGOs in 2013 and 2015 (cross-sectional analysis) All girls at baseline All girls at endline Concern Others p Concern Others p N Age (mean, SD) (2.11) (1.68) NS (1.00) (1.54) NS BMI z-score (Mean, SD) (1.41) (1.19) NS (1.06) (1.14) NS Thinness (%) NS Severe thinness (%) NS Haemoglobin (g/l Mean, SD) (14.55) (12.59) NS (13.86) (10.55) NS Anaemia (%) NS Severe anaemia (%) Paired analysis As there were very few (N = 3) adolescent girls from CONCERN at endline no statistical analyses were undertaken. 10. Delivery and intake of IFA and deworming 10.1 IFA 92.4% (N=97) of the adolescents received IFA tablets from the CPK (Table 6), with an average duration of 14.2 months (SD 6.0). 99.8% of them received IFA tablets from CPK within a month of enrolment and 97.9% of them were taking the correct dose (two tablets per week). IFA tablets were distributed from June 2013, therefore maximum duration of IFA supplementation which adolescent girls can receive was expected for 18 months. There were 44% of girls received supplementation for 18 months and 53% of girls received IFA more than 16 months Deworming 88.6% of adolescent girls had taken deworming tablets from the CPK and 31% of adolescent girls received deworming tablets from non-cpk sources in the last 24 months (Table 8). The distribution of deworming started soon after the baseline survey therefore the maximum dose which the adolescent girls could receive was 4 doses in the last 2 years, however only one in five of girls received 4 doses of deworming (19.4%) while between a quarter and a third of the girls received deworming twice or three times, respectively. Most of the adolescent girls except for 2 cases received deworming within the last 6 months. Table 8. Delivery and compliance of IFA and deworming for adolescent girls Interventions Activities % CPK visit Monthly visit 92.4 IFA Delivery Received IFA from CPK 92.4 Doses 2 tablets per week 97.9 Delivery Receiving IFA within a month 90.1 Duration Receiving maximum duration (18 months) 44.3 Deworming Delivery Receiving deworming from CPK 88.6 Doses Once 19.4 Twice times times 19.4 Timing of delivery Receiving deworming from CPK in the last 6 months

10 11. Impact of, IFA and deworming treatments on nutritional status and anaemia in adolescent girls There were no significant age relationship between BMIZ and age. Haemoglobin concentration showed a negative association with age bordering on significance (p=0.055). Figure 1 shows the change in BMIZ by age with younger girls showing greater improvements than older girls (p=0.007) which might be a reflection of growth, maturation and age of menarche. Figure 1. BMIZ changes by age (in years) of adolescent girls 11.1 Impact of IFA duration There was no significant relationship between duration of IFA intake and mean BMIZ or haemoglobin concentration. There were no mean differences between normal and thinness (or including severe thinness). Taking IFA for longer does not necessarily indicate the BMIZ or haemoglobin concentration will improve. Anaemic adolescents were found to take IFA for a significantly longer duration than non-anaemic adolescents girls (19.80 vs months, p=0.034) Impact of deworming Tables 9 and 10 present a breakdown of the relationship between the number of deworming doses taken and nutritional status. There were no significant differences in mean BMIZ and haemoglobin concentration and prevalences of thinness and anaemia between girls who took different numbers of doses or in the mean changes in BMIZ and haemoglobin concentration. 10

11 Table 9. Estimated Mean and SD (in brackets) of BMI and haemoglobin concentration (g/l) at baseline, endline and changes between baseline to endline after controlling for age and NGO effects by groups of different deworming intakes No intake 1 dose 2 doses 3 doses +4 doses p N Age at (1.58) (1.91) (1.58) (1.41) (1.40) NS endline Baseline BMIZ (1.40) 1.27 (1.21) (1.28) (1.19) (1.36) NS Hb (12.77) (11.05) (11.73) (10.85) (12.49) NS Endline BMIZ (1.45) (1.24) (1.33) (1.23) (1.25) NS Hb (12.11) (10.48) (11.11) (10.28) (11.83) NS Changes BMIZ (1.03) (0.89) (0.95) (0.88) (1.01) NS Hb (13.76) (11.91) (12.63) (11.69) (13.46) NS Table 10. Prevalence of thinness and anaemia at baseline, endline and changes between baseline to endline by the groups of different deworming intakes No intake 1 dose 2 doses 3 doses +4 doses p N Baseline Thinness NS Anaemia NS Endline Thinness NS Anaemia NS Changes Thinness to normal vs. Normal to thinness (%) Anaemia to normal vs. Normal to anaemia (%) 0 vs. 0 0 vs vs vs vs vs vs vs vs vs Knowledge, side effects and acceptance of IFA and deworming Knowledge of IFA and anaemia 88% of adolescent girls understood that IFA tablets treat anaemia, and 23% thought IFA tablets reduced menstruation pain, 21% thought IFA regulated the menstrual cycle, 2% thought IFA helped to have a proper pregnancy and 1% thought IFA improved the quality of breast milk. 12% of girls did not know why they received IFA but thought it was good because CPK provided it to them Knowledge of worm infection and deworming Causes of worm infection 81% of adolescent girls said that walking barefoot caused worm infection. 45% of them explained the relationships between worm infection, unhygienic foods and unwashed hands, although 23% of them said that eating sweets caused worm infection. 10% of them could not explain the causes of worm infection. 11

12 Identifying health problems of worm infection 71% of adolescent girls said that worms caused sickness and vomiting, 63% said that worms enlarge the stomach, 40% felt that worms reduced appetite and 22% said that worms caused anaemia. 5% of the adolescent girls could not explain what health problems were caused by worm infections Understanding the benefits of deworming The majority of adolescent girls understood that taking deworming tablets killed worms (83%). 24% took deworming tablets because of increased appetite, 22% and 13% thought that deworming reduced anaemia and reduced sickness, respectively. Only 7% of the girls took deworming tablets because it was provided from CPK Effects of IFA treatments Most of the girls found that physical weakness was reduced by taking IFA (94%). Some of them found that taking IFA reduced sickness such as dizziness (45%), headache (19%), paleness of the face (18%), menstruation pain (11%) and regulated the menstrual cycle (7%). Only 3% of girls did not report any good impact on health. There were no reports of any side effects Effects of deworming treatment The majority of adolescent girls found that they had an increased appetite (86%). Some of them reported reduced sickness and vomiting (16%), headache (18%), dizziness (13%), pale face (10%). Only 4% of them did not find any good changes. There were no reports of any side effects Willingness to continue IFA and deworming treatments IFA Three quarters of adolescent girls (75.3%) reported their willingness to continue taking IFA after the programme ended Deworming 93% of the adolescent girls reported their willingness to continue taking deworming tablets after the programme ended. 79% of adolescent girls understood the correct interval for deworming (every 6 months). 13. Recommendations Continue to supply IFA and deworming to adolescent girls as there are beneficial effects on reducing anaemia and thinness. Consideration should be given to extending the IFA and deworming coverage from adolescence into adulthood so that women entering marriage, as well as newly married women, have adequate iron stores before their first pregnancy. Log frame targets should be based on within-adolescent changes, before and after interventions, rather than on cross-sectional samples because of there is a risk that the baseline and endline samples might be heterogeneous and any differences in nutritional status may be due to this heterogeneity and not due to the intervention, per se. 12