Macedonia - Multiple Indicator Cluster Survey - 1999

Publication date: 1999

unicefG UNICEF Skopje Office Ministry of Health of the Republic of Macedonia MULTIPLE INDICATOR CLUSTER SURVEY IN FYR MACEDONIA WITH MICRONUTRIENT COMPONENT • • • • • • • • • • • ~ • • • • • • • • • } • • • • April2000 National Institute of Nutrition · Italy MULTIPLE INDICATOR CLUSTER SURVEY IN FYR MACEDONI.A WITH MICRONUTRIENT COMPONENT April2000 CIP - KaTanorH3aQnja BO ny6nHKaQHja HapOAHa H yHHBep3HTeTcKa 6H6JIHoTeKa ,CB. KJIHMeHT OxpHACKH", CKonje 613.22( 497.7) MULTIPLE indicator cluster survey in FYR Macedonia with micronutrient component I [report prepared by F. Branca . [H ]:(p.]; survey coordinating team L. Rossi . [H ]:(p.].- Skopje: UNICEF: 3ApaBCTBeH AOM CKonje - 3aBOA 3a 3aiiiTF!Ta Ha MajKH H ]:(eQa , 2000. - 84 cTp. : Ta6enH, rpa¢., npnKa3F! ; 30 eM cl>ycHOTH KOH TeKCTOT ISBN 9989-830-19-3 ISBN 9989-883-08-4 1. Branca, F. a) HcxpaHa- ,O:eQa- MaKeAoHnja - - -~- Honourable guests, dear colleagues, ladies and gentlemen It gives me an immense pleasure, that already in a row, in the course of this week, I have had the honour to promote several extremely important public health projects, which are being implemented by our Ministry of Health through its specialised institutions in cooperation with the international organisations, in this case with UNICEF. Taking into consideration the meaning of the notion "healthy nation" for every Government, the pleasure is even larger in this case, in light of the fact that there is a word about a Project which offers us a cross-section of the nutritional status of the most important population group in the country - the children. For these reasons this segment is one of the key ones in our Health System Development Strategy, on which there has been an ongoing public debate these days. Being a doctor in the preventive medical branch, the public - health priority as well as the social-economic priority that the medically safe food and nutrition have had in the defining of the health profile of the population is quite clear to me. Namely, we should accept with utmost concern the statistical data which the UN agencies, such as WHO, UNICEF and others make public each year, and which are related to the morbidity and mortality rates of the population in the world, connected to the problem of deficiency or the problem of inappropriate quality of food. In line with all these, our Ministry of Health within the framework of the active cooperation with the Regional Bureau for Europe of WHO, has undertaken the obligation to prepare in the coming year, the National Nutrition Action Plan- an indispensable strategic document for creating the policy in this socially essential field. In this regard, taking into consideration the insufficient quantity and quality of the basic data on the nutritional status of our population, the Ministry of Health has accepted with pleasure the initiative of UNICEF and, the National Center for Nutrition in Rome, and through its highly specialized institutions - Republic Institute for Health Care, The Health Home of Skopje together with the Mother and Child Institute and the Childrens' Diseases Clinic, has implemented this study. I believe that the application of reference expert methods of evaluation of the level of the important micronutrients, as retinol and iron, the blood count status, the rickets and the breastfeeding as parameters applied on nearly 1800 children, are sufficient warranty for the validity of the data that we receive from this study. We will implement the further analysis of these findings as an introduction to even more intensive research in this field, already in the newly established National Committees or Councils for Food and Nutrition, the urgent establishment of which I shall personally initiate both within the framework of the Ministry of Health and at the inter - sectoral level of the Government, in order to gain in that way even more argumentative basis for the future public health activities for improvement of the health status. Therewith, although it is clear that there is a question about issues of inter-disciplinary character, the health sector must have in all those concepts a leading and coordinating role taking into consideration the food and nutrition ratio - the health of the population. With the hope that the activities within the framework of this study and the discussions which will be provoked by it, shall give an important contribution to the conceptualization of the future National Strategy for the improvement of the nutritional status of our population, and emphasizing from this aspect once more our gratitude towards UNICEF and its expert teams, I would like to wish you successful work. Ministry of health of Republic of Macedonia Minister Doc. d-r. sci Dragan Danilovski PREFACE The Multiple Indicator Cluster Survey (MICS) is a new tool, b)m of the World Summit for Children in 1990. On that occasion, world leaders committed themselves to achieving an ambitious set of quantifiable goals to improve the health and wellbeing of children. These goals were based on the belief that every child in every country has a right to survive and thrive. In just two years, 1995 and 1996, MICS collected data from more countries than any other tool except national censuses. So far, more than 60 countries have carried out a complete MICS, most as part of efforts to monitor interim progress towards the World Summit goals in 1995. More than 40 countries have added MICS modules to national surveys. The Former Yugoslav Republic of Macedonia conducted a first MICS in 1994. The aim was" to collect basic data on immunisation, nutrition and breastfeeding among children and women. Five years later, in September 1999 a new MICS was conducted with the broader aim to not only assess recent progress, but also to investigate further topics such as water and sanitation and micronutrient deficiencies that were not included in the previous MICS. The present publication is based on)the data collected during the 1999 MICS and is intended as a background document for long-range planning, and implementing and monitoring interven- tions to improve the conditions of women and children in the country. The 1999 MICS was the fruit of a collaborative effort by several actors. The Istituto Nazio- nale della Nutrizione from Rome was responsible for the original design of the survey, the supervision of its field implementation and compilation, and analysis of data in collaboration with the Institute of Mother and Child Health Care in Skopje, the Pediatric Clinic in Skopje and the Republican Institute of Health Protection. The World Health Organization was also involved with expert input from the Regional Office for Europe in Copenhagen. The Health and Nutrition Cluster of the UNICEF Office in Skopje was responsible for the preparation and field implementation including data collection and analysis. The 1999 MICS can be considered a success story thanks to the high professionalism and the spirit of collaboration and cooperation shown by all partners. To all of them goes UNICEF' s and my personal gra- titude. Created to survey the decade, MICS is demonstrating its potential for the millennium. To know how far we have come on the path to fulfillment of child rights, and how far we still have to go, we must be able to check the milestones along the way - at the end of the decade, and on to the future. Much has been achieved, but without renewed commitment at all levels, the gains will be lost. MICS is a proven tool to help us fulfil our promises as we begin the new millennium. Edmond McLoughney Head of Office UNICEF Skopje Data collectors Health Home Skopje Medical Center Kumanovo Public Health Institute, Skopje Teaml Biljana Todorova, pediatrician Stojka Davidovic Milan Lazic Team2 Roza Lakinska, pediatrician Gulbin Bekir - anketar Lidija Milic- laborant Team3 Radmila Stojanovic, pediatrician Julijana Madzoska Vera Spirovska Team4 Olga Jotovska, pediatrician Radmila Dimitrovska Grozda Ckalovska Team5 Nada Smokovska, pediatrician Mirjana Srbinovska, nutritionist Ljupco Arsovski Team6 Mitka Trencevska, pediatrician Vladimir Kandarovski, nutritionist Hadziu Zirap Team 7 Biljana Shandeva, pediatrician Emine Biljami Sonja Trajkovska Team8 Snezana Stankovic, pediatrician Violeta Tosic Dzelal Arifi Team9 Adnan Sulejmani, pediatrician Valentina Angelovska Lidija Jovanovska Team 10 Vida F oteva, pediatrician Letka Livrinska Jasmina Slezovic Jasmina A san A collaborative survey by: United Nations Children's Fund (UNICEF- Skopje) Ministry of Health of FYR Macedonia Mother and Child Health Care Department, Health Home Skopje Republic Institute for Health Protection - Skopje Clinic for Children's Diseases, Clinic Center Skopje National Institute of Nutrition, Rome, Italy Report prepared by F. Branca, G. Pastore, L. Rossi, S. Sette National Institute of Nutrition, Rome Biljana Ancevska-Stojanovska, Nadica Janeva Institute of Mother and Child Health, Health Home Skopje Lence Kolevska Republic Institute for Health Protection -Skopje Sonja Peova, Olivera Muratovska Clinic for Children's Diseases, Clinic Center Skopje Katerina Venovska United Nations Children's Fund (UNICEF- Skopje) Survey coordinating team F. Branca, L. Rossi, G. Pastore National Institute of Nutrition, Rome A. Seal Institute of Child Health, Landon (WHO consultant) B. Stojanovska-Ancevska, N. Janeva, S. Stefanovski Institute of Mother and Ch:'ld Health, Health Home Skopje L. Kolevska Republic Institute for HeaUh Protection- Skopje S. Peova, 0. Muratovska Clinic for Children's Disec:ses, Clinic Center Skopje K. Venovska United Nations Children's Fund (UNICEF- Skopje) Laboratory staff Clinic (or Children's Diseases, Clinic Center Skopje Vidanka Lukarevska, supervisor Svetlana Stojcevska Vladimir Dincevski Zaklina J ovanovska Pavlina Georgieva Violeta Ickovska Nada Atanaskovska Data entry specialists: Margareta Peic Nikola Ancevski Martin Desovski Ivica Smokovski UNICEF Skopje funded this Survey with funding provided by the USA Government, German NatCom for UNICEF, and WHO, Regional Office for Europe. TABLE OF CONTENTS ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 1 EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 2 PROGREES TOWARDS THE ACHIEVEMENT OF THE GOALS FOR YEAR 2000 OF THE WORLD SUMMIT FOR CHILDREN . . . . . . . 7 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3 .1. Household information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3.2. Individual data . . . . . . . . . . . . . . . 33 3.2.1. Women . . . . . . . . . . . . . . . . 33 3.2.2. Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 4. DISCUSSION AND CONCLUSIONS . . . . . . . . . . . 68 5. RECOMMENDATIONS FOR ACTION . . . . . . . . . . . . . . . . . . . . 70 ANNEX I (Sample 2nd stage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 ANNEX ll (Guidelines for interviewers and measurers) . . . . . . . 74 ANNEX III (Questionnaire) . . . . . . . . . . . . . . . . . . 79 ACKNOWLEDGEMENTS Dr. Aileen Robertson, Regional Advisor for Nutrition, contributed to the design of the child feeding section and helped us solve field problems. Special thanks to Dr. Elaine Gunter, Head of the NHANES Laboratory at the CDC in Atlanta, who helped design the field methodology for the assessment of serum alkaline phosphatase and of serum retinol, and kindly provided the quality control and the standards required to measure serum retinol, together with her staff. In particular, Sarah Courts, who prepared all the QC/calibrator materials and Anne Sowell, the CDC expert on vitamin A, who answered all our questions. Finally thanks for the support provided by Mr. Edmon McLoughney, Head of UNICEF Office, for the overall implementation of the MICS, Dr. Enrico Davoli, Dr. Giuseppe Domenico Annunziata, and Ms Suncica Arsovska. 1 EXECUTIVE SUMMARY 1. A survey to investigate the health and nutritional status of children and mothers in Ma- cedonia was carried out in September 1999. A two-stage cluster sampling procedure was applied to select a population representative sample of households, in two strata (urban and rural). The survey was carried out on 1036 households and included 1765 children under 5 (6-59 months) and 1749 women of fertile age (15-45 years). 2. The survey involved the administration of a questionnaire, the implementation of phy- sical measurements in children under 5 (weight and height, or length, clinical assessment of rickets signs and vision impairment) and their mothers (weight, height, clinical assess- ment of thyroid size) and biochemical assessment of micronutrient status (serum haemo- globin in women and children, serum ferritin, serum retinol and serum alkaline phospha- tase in children). 3. Low BMI ( <18.5 kg/m2) was observed only in about 6% of the mothers, while more than one third of the women aged 25 years and above were overweight or obese (38% ). Higher degrees of obesity were uncommon (10% of BMI 30.1-40 kg/m2 and 1% of BMI > 40 kg/m2). 4. Mild and moderate anaemia was observed in 12% of the mothers, with no differences by strata. There were no cases of severe anaemia. 5. Thyroid was palpable in 9% of mothers with a very small percentage (0.6%) of the mothers with visible goitre. There were no differences between urban and rural areas. 6. Low height-for-age was observed in 7% of the entire sample of children (6-59 months), with a higher proportion in rural areas (9%) than in urban areas (6%). 7. The overall prevalence of low weight-for-height was low (3.5%), and no differences were seen between the two strata nor between gender. 8. Mild and moderate anaemia was observed in 26% of the children (6-59 months). The prevalence of anaemia was significantly higher in rural children (29% of which 2% severe cases) compared to children living in urban areas (23% of which less than 1% severe cases). 9. Half of the children studied had low values of ferritin with significant differences between urban (47%) and rural (54%) strata. In rural areas severe cases of iron deficiency (17%) were more common than in urban areas (11 %).There were no cases of iron overload. 10. Observed rickets signs in children varied with the chosen method of detection. Frontal and parietal bossing was present in 15% of the children, more often in rural areas; the prevalence of the other signs was very uncommon (less than 3% ). Biochemical confirma- tion of rickets was only obtained in 2% of the children studied with no differences by strata. The analysis of the distribution by age did not identify any particularly vulnerable age. 11. Poor night vision in children was reported by 1% of the mothers, with no differences bet- ween strata. However, low values of serum retinol were present in 30% of the children studied. In urban areas vitamin A deficiency (31%) was more common than in rural areas (28%) but severe cases of vitamin A deficiency were higher in rural (2%) than in urban children (1% ). 2 12. The vast majority of children under 2 years of age were being breastfed, at least partially (92%), with no significant differences between urban and rural areas. Forty five percent of the children under 4 months were exclusively breastfed. Exclusive breastfeeding dropped to 30% at the age of 6 months. In rural areas, exclusive breastfeeding was less common than in urban areas. Up to 4 months, 38% of the infants living in urban areas were receiving breast milk and other liquids. Predominant breastfeeding increased up to age of 3 months, when 50% of the children in urban areas and 37% of the children in rural areas were fed in this way. After the age of 3 months predominant breastfeeding dropped progressively as in urban and in rural areas as well. 13. One fifth of the children were using infant formula, usually as a substitute for breast milk, with no differences were found between urban and rural areas. Cow's milk was used as an alternative to breast milk for infants under 6 months in 5% of the cases in urban areas, but in 12% in rural areas. Cow's milk became a major food after the age of 6 months, but it is worth pointing out that, even in the second year of age, one fifth of the children were not consuming it. Fermented milk was not used in the first six months of life and was therefore not used as a breast milk substitute. 14. The early introduction of liquids other than breast milk is a very popular habit in Mace- donia, particularly in rural areas. Water is introduced as early as the first week of life; tea is also used in the same way, in addition or in alternative to water. Only herbal teas are consumed (camomile, mint), while black tea is not used and is almost unavailable in the country. Fruit juices are also popular, and they are introduced at around 3-4 months of age, one month earlier than that recommended by the MCH Institute. 15. Complementary foods were given to the children starting from the fourth to fifth month. Fruit is the item that is introduced first. Vegetables are introduced one to two months later. Carbohydrate rich foods (porridges, pasta, biscuits, potatoes) are also introduced in the second semester of life. Meat is not introduced until 6 months with approximately half of the older children consuming it; fish is also introduced in the second semester, but less than one fourth of the children had consumed it; the consumption of cheese and eggs was reported by half of the children in the second semester of life. 16. Bread, vegetables, fruit, milk and dairy products were consumed almost every day both in urban and rural areas. Meat or fish and pasta, rice and potatoes were consumed appro- ximately every second day. Pulses were consumed once-twice a week. There were no significant differences between urban and rural areas. 17. The quality of the water supplied to urban households was good, with almost the entire sample being served by piped water (98%) with virtually no use of water from unpro- tected wells. In rural areas 64% of people were served by piped water, 12% had a tube well, 17% had a protected dug well and the percentage of cases of unprotected wells came to 6%. The total sample of people living in urban areas had constant access to wa- ter. In rural areas this percentage was lower (86%) and in 13% of the households water was available only every second day. 18. In urban areas, toilet facilities were good and connected to a sewage system for a large majority of the households (88%). Approximately 6% of the households in urban areas use latrines and 0.6% have no toilet facilities at all. In rural areas, latrines were used by 41% of households surveyed and in general the quality of the latrines in this case was poorer, even lacking a cover. 3 19. The survey indicates good progress towards the achievement of the year 2000 goals of the World Summit for Children (see table) and an overall good nutritional situation of mothers and children. There is however a widespread micronutrient problem, which although not severe, can be dealt with by dietary modifications and improvements. 20. Public health measures should be taken to ensure maintenance and surveillance of the immunisation programme and to promote dietary recommendations in adults: control body weight; promote fruit and vegetable consumption. 21. Actions should be taken to increase the efforts in the BFHI: improvement in the timely initiation of breastfeeding; promotion of exclusive and continued breastfeeding; early introduction of liquids should be discouraged; promoting of recommendations for com- plementary feeding: including meat, dairy products, fruit and vegetables from about the sixth month. 22. Actions might be taken among vulnerable groups or regions to evaluate the feasibility of nutrition support programmes, using food coupons or distribution of food products with normal or modified nutrient composition, under the surveillance of the health service. 23. A multi-sectoral approach is most likely to yield sustained improvements in tackling the nutrition problems identified in this report. For maximum effect, this approach must include the mitigation of relative poverty which plays a key role in the causation of many nutritional problems. SUMMARY TABLE OF INDICATORS -Household Information Urban Rural Total Safe water supply % 98.6 98.7 98.7 C.I. 95% 97.1-100.1 97.5-100.0 97.6-99.7 Adequate sanitation % 99.9 82.9 92.9 C.I. 95% 99.6-100.1 70.9-94.8 88.0-97.8 SUMMARY TABLE OF INDICATORS- Mothers Urban Rural Total Thinness % 5.5 7.9 6.4 C.I. 95% 3.9-7.1 4.7-11.0 4.8-7.9 Overweight/obesity % 37.6 38.2 37.8 C.I. 95% 33.2-41.9 30.5-46.0 33.9-41.8 Goitre (Stage I) % 8.6 10.4 9.3 C.I. 95% 3.6-13.5 6.7-14.2 6.0-12.7 Goitre (Stage II) % 0.9 0.2 0.6 C.I. 95% 0.0-1.8 0.2-0.6 0.1-1.2 Mild/moderate anaemia % 11.7 12.4 12.0 C.I. 95% 8.8-14.6 9.1-15.6 9.8-14.1 4 SUMMARY TABLE OF INDICATORS - Children Urban Rural Total BCG Coverage % 98.7 99.7 99.1 C.l. 95% 97.1-100.2 99.0-100.3 98.2-100.0 DPT Coverage % 98.7 96.9 97.9 C.I. 95% 97.4-99.8 94.5-99.4 96.6-99.2 OPV Coverage % 98.3 97.3 97.9 C.I. 95% 96.9-99.7 94.9-99.7 96.6-99.2 MMR Coverage % 93.4 90.2 92.0 C.I. 95% 89.4-97.4 85.5-94.9 88.9-95.0 ORTUse % 20.5 15.2 18.5 C.I. 95% 11.9-29.0 5.0-25.3 11.9-25.1 Weight-for-Age Z % 0.5 0.9 0.7 score< -3 SD C.I. 95% 0.0-1.1 -0.3-2.2 0.1-1.3 Weight-for-Age Z % 4.8 7.6 6.0 score< -2 SD C.I. 95% 2.9-6.8 3.7-11.4 4.0-7.9 Height-for-Age Z % 1.0 2.6 1.7 score< -3 SD C.I. 95% 0.3-1.8 0.7-4.6 0.8-2.6 Height-for-Age Z % 5.7 8.4 6.9 score< -2 SD C.I. 95% 2.8-8.7 1.8-5.0 1.1-4.7 ~- Weight-for-Height Z % 0.5 0.4 0.7 score< -3 SD C.I. 95% -0.1-1.1 -0.1-0.9 0.1-1.3 5 Weight-for-Height Z % 3.5 3.8 3.6 score< -2 SD C.l. 95% 2.0-5.0 2.1-5.4 2.5-4.7 Exclusive Breastfeeding % 46.8 42.7 45.3 (0-4 months) C.l. 95% 38.0-55.7 28.2-57.1 33.6-53.0 Exclusive Breastfeeding % 38.6 33.6 36.6 (0-6 months) C.l. 95% 29.2-47.9 21.5-45.6 29.2-43.9 Predominant Breastfeeding % 31.9 27.9 30.3 (0-6 months) C.l. 95% 24.3-39.6 18.4-37.3 24.4-36.2 Timely complementary % 6.9 8.5 7.6 feeding (6-9 months) C.l. 95% 2.2-11.6 2.8-13.1 4.1-11.1 Continued breastfeeding % 34.3 32.4 33.4 at 1 year C.I. 95% 24.8-43.8 25.1-39.8 27.3-39.6 Continued breastfeeding % 9.8 10.9 10.3 at 2 years C.l. 95% 2.4-17.2 4.9-16.8 5.3-15.1 Bottle-feeding rate % 55.6 60.7 57.8 (0-12 months) C.l. 95% 49.4-61.8 52.6-68.8 52.8-62.8 Ever breastfed rate % 94.1 91.7 93.1 (0-12 months) C.l. 95% 90.0-98.2 87.2-96.3 90.1-96.1 Mild/moderate anaemia % 22.8 27.3 24.8 C.I. 95% 17.4-28.2 22.0-32.6 20.9-28.6 Severe anaemia % 0.4 1.9 1.0 C.l. 95% -0.1-0.9 0.8-3.0 0.5-1.6 Severe low serum ferritin % 11.0 17.1 13.7 C.l. 95% 8.0-14.1 12.6-21.7 11.0-16.3 Mild low serum ferritin % 36.1 37.3 36.7 C.l. 95% 32.0-40.3 32.4-42.3 33.5-39.8 High serum alkaline % 2.2 2.4 2.3 phosphatase C.I. 95% 1.0-3.3 0.7-4.1 1.3-3.2 Severe low serum retinol % 1.1 1.9 1.4 C.l. 95% 0.0-2.1 0.0-3.8 0.4-2.5 Mild low serum retinol % 30.3 25.7 28.3 C.I. 95% 23.8-36.8 18.3-33.2 23.3-33.2 6 PROGRESS TOWARDS THE ACHIEVEMENT OF THE GOALS FOR YEAR 2000 OF THE WORLD SUMMIT FOR CHILDREN Year 2000 Goal 1994MICS Present MICS Progress Maintenance of a high level of immu- nisation coverage (at least 90% of DPT III=> 97% 1 DPT III=> 98% children under one year of age by the Good year 2000) against diphtheria, pertussis, Polio III=> 97%1 achievement tetanus, measles, poliomyelitis, MMR=>98%1 MMR=>92% of the goal tuberculosis, and against tetanus for women of child-bearing age Severe low serum Public health Virtual elimination of vitamin A retinol => 1.4% problem that deficiency, and its consequences, No information including blindness Mild serum requires retinol=> intervention 28.3% 9% of mothers Low Virtual elimination of iodine with palpable prevalence but deficiency disorders No information goitre and 0.6% continued of mothers with distribution of visible goitre iodised salt Empowerment of all women to 0-4 months 0-4 months Good achievement of breastfeed their children exclusively Exclusive BF => Exclusive BF for four to six months and to continue 8% =>45% the goal that breastfeeding, with complementary still needs Predominant BF => Predominant BF educational food, well into the second year 78% =>34% efforts HAZ<-2 => Between 1990 and the year 2000, HAZ<-2=>9% 10% (13% in Low reduction of severe and moderate (12% in rural rural areas) 2 prevalence but malnutrition among under-five areas) 2 dietary children by half WHZ<-2=> modification WHZ <-2 => low2 6.5 (6% in rural required areas)2 Good Universal access to safe drinking water 64% 99% achievement of the goal Universal access to sanitary means of Good excreta disposal No information 93% achievement of the goal 1 Data collected in 1996 2 6-12 months old children 7 INTRODUCTION The health and nutritional status of children in FYROM, although close to standards of the developed world, is still affected by a number of problems, resulting from poor economic development, environmental constraints and inadequate child care habits. The infant mortality rate was 22.7 per thousand live births in 1995, largely accounted for by intestinal and respiratory infections. Child immunisation rates are high, and the country maintains a sound record of achievements, with the exception of a short period after inde- pendence when the supply of vaccines was interrupted. In 1996 DPT III had been regularly administered to 96.6% of the children, Polio III to 97.4% and MMR to 97.8% of children under one year of age. The majority ofthe urban population (64%) has access to water from a main supply although in the rural population this proportion is only 20%. The nutritional status of Macedonian children, particularly in early infancy, has created some concerns. In 1994, UNICEF MICS survey1 showed a low prevalence of low weight-for- height, other than in children 6-12 months in the rural areas; but pointed out a higher preva- lence of low height-for-age (9%), in the rural areas reaching 12%. Although acute forms of malnutrition do not seem to be a public health problem, marginal forms, particularly as far as micronutrients are concerned, may occur in some population groups. According to clinicians and to public health specialists, anaemia seems to be a public health concern, although there is no quantitative information. A clinical study on 1 00 infants aged 1-12 months showed a 25.6% prevalence of mild/moderate anaemia, attributed to im- proper child feeding habits, i.e. use of cow's milk feeding2 from the first few months of life. Other causes of anaemia may be attributed, such as ~-thalassemia, gluten sensitive entero- pathy and folate deficiency, but iron deficiency is likely to be a major cause of anaemia, as diagnosed children promptly respond to treatment with iron and folic acid supplements. According to the 1994 MICS survey\ signs of rickets were present in 16% of the children examined. In a selected sample of 150 children affected by rickets, insufficient exposure to sun was detected3. No information is available on the vitamin A status of children. Clinical studies show decreased serum retinol in children affected by repeated infections (Peova S. and Stavrik K., personal communication). A survey carried out in 1995-96 showed the pre- sence of thyroid enlargement in 18% of the children4. However, the median urinary excre- tion of iodine is 11.7 J.Lg/dL, indicative of good iodine intakes, as a result of a salt fortifica- tion policy. Children's feeding practices may be responsible for the nutritional problems observed. In 1994 78% of the infants under the age of 4 months were predominantly breastfed, but only 8% of the children were exclusively breastfed. Furthermore, diluted cow's milk is widely used to feed infants and fruit and vegetables are not commonly used as complementary foods. 1 Anonymous. The results of the nutritional survey of children under 5 years in Macedonia. Mimeo. S.d. 2 Gocevska L., Trencevska M., lvanova N. Pandova N. Zisovki N. Mini study on the prevalence of iron defi- ciency anaemia among infants. Mimeo s.d. 3 Gocevska L. Ivanovska N., Trencevska N., Lazova D. Prevalence of rickets in infants from o to 12 months of age. Mimeo s.d. 4 Karanfilski B., Bogdanova V., Vaskova 0., Loparska S., Ristevska S.M., Shestakov G. Iodine deficiency in the FY Republic of Macedonia. UNICEF 1998. 8 After consideration of the unavailability of recent data on the nutritional status of children, UNICEF and the Ministry of Health of the FYROM promoted a survey on the health and nutrition of mothers and children. This resulted in the decision to conduct a nation-wide survey during November 1999. The information collected and presented in this report will be used in preparation of an Action Plan for children's nutrition in FYROM and as a baseline for Nutrition Monitoring Activities. OBJECTIVES The purpose of the survey is to monitor the progress towards the achievement of the goals of the World Summit for Children and to investigate the nutritional status of mothers and children. The specific objectives of the survey are: 1. to measure the indicators envisaged by the MICS survey; 2. to measure indicators of nutritional status of mothers and children; 3. to measure indicators of micronutrient deficiencies; 4. to evaluate feeding patterns of infants and young children. 9 METHODS Definition of the indicators Table 2.1 - Household Information Indicator Numerator Denominator Number of households in which 1. source of drinking water is piped-in or public 2. tap or tube well or borehole or protected dug Total number of Safe Water Supply well or protected spring; household surveyed 3. water is constant or once a day 4. the source of water is on premises or less than lOOm. Number of households in which 1. the toilet facility has flush to sewage system or Adequate flush to septic tank or pour flush latrine or Total number of Sanitation covered by dry latrine; household surveyed 2. the toilet facility is within dwelling or at less than 50 m. Table 2.2- Mother's Indicators Indicator Numerator Denominator Thinness Number of mothers 25-45 years with Total number of mothers BMI < 18.5 k:g/m2 25-45 years observed Overweight/ Number of mothers 25-45 years with Total number of mothers Obesity BMI > 25 kg/m2 25-45 years observed Goitre (Stage I) Number of mothers 15-45 years with Total number of mothers goitre detectable only by palpation and not visible 15-45 years observed Goitre (Stage II) Number of mothers 15-45 years with palpable and Total number of mothers visible goitre 15-45 years observed Mild/moderate Number of mothers 15-45 with Haemoglobin Total number of mothers anaelTila 7-11.9 g/dL 15-45 years observed Table 2.3- Children's Indicators Indicator Numerator Denominator BCG Coverage Number 13-24 month-olds receiving BCG vaccine Total number of 13-24 before 13 months1 month-olds surveyed DPT Coverage Number 13-24 month-olds receiving DPT3 vaccine Total number of 13-24 before 13 months 1 month-olds surveyed 1 The 13-24 month age interval rates were chosen over the 12-23, as required by the MICS methodology, because the administration ofMMR in Macedonia is scheduled at 13 months. 10 Number 13-24 month-olds receiving OPV3 Total number of 13-24 OPV Coverage vaccine before 13 months 1 month-olds surveyed MMR Coverage Number 13-24 month-olds receiving MMR Total number of 12-23 vaccine before 13 months1 month-olds surveyed Number of diarrhoea cases in children 0-59 months Total number of ORTUse during 2 weeks before the survey who receiving diarrhoea cases among under-five in two weeks ORT preceding survey Number of 6-59 month-olds who fall below -2 Weight-for-Age Z standard deviations from the median weight-for- Total number of 6-59 age of the NCHS/WHO standard; number who fall month-olds weighted score (WAZ) below -3 SDs Number of 6-59 month-olds who fall below -2 Height-for-Age Z standard deviations from the median height-for-age Total number of 6-59 score (HAZ) of the NCHS/WHO standard; number who fall month-olds measured below-3 SDs Number of 6-59 month-olds who fall below -2 Weight-for-Height standard deviations from the median weight-for- Total number of 6-59 age of the NCHS/WHO standard; number who fall month-olds measured Z score (HAZ) below-3 SDs Number of infants less than 4 months of age who Exclusive receive only breastmilk with no other liquids or Total number of infants Breastfeeding solid with the exception of drops or syrups 0-3 months of age consisting of vitamins, mineral supplements, or surveyed (0-4 months) medicines2• Number of infants less than 6 months of age who Exclusive receive only breastmilk with no other liquids or Total number of infants Breastfeeding solid with the exception of drops or syrups 0-5 months of age consisting of vitamins, mineral supplements, or surveyed (0-6 months) medicines2• Number of infants less than 6 months of age who receive breastmilk along with water, water-based Predominant drinks (sweetened and flavored water, teas, Total number of infants Breastfeeding infusions, etc.), fruit juice, oral rehydratation salts 0-5 months of age (0-6 months) solution, but does not receive any other liquids or surveyed solids. No food-based fluids (except fruit juice and sugar-water) are allowed2• Timely complementary Number of children 6-9 month-olds receiving Total number of infants feeding (6-9 breast milk and complementary foods2 6-9 months old surveyed months) Continued Number of infants 12-15 months still Total number of 12-15 breastfeeding at 1 breastfeeding2 month-olds surveyed year 2 The information about infant feeding pattern were collected with a 24 hour recall questionnaire; the methodology suggested by the Tool Kit Monitoring and Evaluating Breastfeeding Practices and Programs of the Wellstart International's Expanded Promotion of Breastfeeding Program was followed. 11 Continued Number of infants 20-23 months still Total number of 20-23 breastfeeding at 2 breastfeeding2 month-olds surveyed year Bottle-feeding rate Number of infants less than 12 months old Total number of under- (0-12 months) receiving any food or drink from a bottle2 ones surveyed Ever breastfed rate Number of infants less than 12 months old ever Total number of under- (0-12 months) breastfed2 ones surveyed Low birth weight Number of children 0-59 months in whom a birth Total number of children weight of less than 2.5 kg is reported 0-59 months surveyed Mild/moderate Number of children 6-59 months with Total number of children anaemia Haemoglobin 7-10.9 g/dL 6-59 months observed Severe anaemia Number of children 6-59 months with Total number of children Haemoglobin < 7 g/dL 6-59 months observed Severe Low serum Number of children 6-59 months with serum Total number of children ferritin ferritin < 10 ng/mL 6-59 months observed Mild Low serum Number of children 6-59 months with serum Total number of children ferritin ferritin 10-20 ng/mL 6-59 months observed Number of children: High serum 6-12 months (male) ALKP > 300 lUlL Total number of children alkaline 6-12 months (female) ALKP > 330 lUlL 6-59 months observed phosphatase 12-36 months (both sex) ALKP > 320 lUlL 36-59 months (both sex) ALKP > 380 lUlL Severe low serum Number of children 6-59 months with serum Total number of children retinol retinol < 10 !lg/dL 6-59 months observed Mild low serum Number of children 6-59 months with serum Total number of children retinol retinoll0-20 j.lg/dL 6-59 months observed Sampling The survey was carried out on a nationally representative sample of rural and urban house- holds to estimate national levels of the selected indicators. Table 2.1 shows the sample size required to calculate the prevalence of the main conditions in children and adult women with a relative precision of 5%, a 95% confidence level and a 10% sample loss. The calculation of the sample size was based on the expected prevalence of the main target conditions listed in the objectives, using estimates given by previous surveys. Table 2.1 - Calculation of sample size in children and women Indicator Population Estimated Exp. Cl. Sample +10%non Prevalence Precision Factor size participation Immunisation coverage in children 13-24 30,490 91 5 2 251 276 months Ht-for-age <-2 SD in 137,210 9 5 2 252 277 children 6-59 mos. Exclusive breastfeeding 10,163 8 5 2 224 246 in children 0-4 mos. 12 Anaemia in children 137,210 25 6-59 mos. 5 2 576 633 Rickets in children 137,210 16 5 2 413 454 6-59 mas Anaemia in mothers 362,616 10 5 2 277 305 15-44 yrs. A sample size of 633 children aged 6-59 months and 305 mothers aged 15-44 years is sufficient to give estimates of the proportions of all indicators with a 5% error at the 95% confidence level in each stratum. For the assessment of exclusive breastfeeding a sample of 246 children aged 0-4 months is required and for the assessment of immunization coverage a sample of 275 children aged 13-24 months is required. Households with at least one child under 5 (0-59 months) were included. Calculating that an average of 1.1 children 6-59 months old could be found in each household with children under 5, a number of 575 households should have been surveyed. Considering a further 5% sample loss due to the unavailability of the selected families, a total number of 604 households should have been surveyed in each stratum. This number could be achieved by selecting 30 clusters of 20 households in each stratum. The selection of the households was based on the 1 994 census. In each stratum only 60 children 0-4 months old and 180 children 13-24 months old were likely to be found; therefore, 186 additional 0-4 months old infants (7 per cluster) and 95 additional 13-24 months old children (4 per cluster) had then to be identified by going to additional households. Anthropometry, biochemical and clinical assessments were not per- formed in the additional sample of children aged 0-4 months and 13-24 months. This samp- ling procedure was necessary to ensure adequate numbers of individuals in the age classes required to describe the main MICS indicators. The data on households and on mothers obtained in the additional sample of children 0-4 months and 13-24 months were not pooled with those obtained in the main sample of 6-59 months old children. In the absence of detailed census data with such an age breakdown, it is not possible to calculate weighting factors that could balance the sample. Sampling strategy The location of the clusters was decided with a two-stage procedure. At the first stage, the number of individuals that could be classified in each of the two strata (urban and rural) was listed by region, using 1994 census information. In the absence of a clear definition of rural, all centres below 8,000 inhabitants, in which agriculture was the main occupation, and houses the main dwelling type, were considered as rural. Clusters were allocated to each of the regions with a probability proportional to size methodology. At the second stage, within each region and within each stratum, clusters were allocated to smaller administrative units (cities, villages, settlements) with a probability proportional to size methodology. The list of administrative units chosen is provided in Annex I. In each location a household selected at random was chosen as a starting point of a random walk. Household selection procedures are specified in the guidelines for field staff, provided in Annex II and summarised by the flow chart presented. 13 Questionnaire A questionnaire was designed to provide relevant indicators of the health/nutrition status of the children below 5 years old and women in reproductive age as outlined in the survey objectives. The questions were translated into Macedonian and back translated into English. The questionnaire covered the following areas: • Household characteristics: number of people in different age groups; gender and educa- tional level of the head of household. • Household vulnerability and food security: presence of disabled people; income source, sale of assets, meal skipping, home production of fruit and vegetables or animal products; availability of food in the past week; humanitarian aid received. • Mortality: number and age of household members who died in the past year. • Water and sanitation • Child health and infant feeding: immunisation coverage (DPT, OPV, MMR, and BCG); morbidity for diarrhoea; infant feeding practices (breastfeeding and complementary feed- ing). • Women's health status: family status; mother's education and job; number of pregnan- cies; pregnancy status; access to antenatal care. The full questionnaire is provided in Annex III. Anthropometry Weight and supine length were measured in all children 6-23 months; weight and standing height in all children 24-59 months; weight and height in all mothers. Neither weight or height were measured in pregnant women. Anthropometric measurement procedures have been standardised using guidelines published by the United Nations (1989) and WHO (1995)5. Measurers were adequately trained and performed a quality control exercise. Weight Women were weighed on digital electronic scales (UNICEF cat. no.**) and the measurements recorded to the nearest 0.1 kg. The subjects were dressed in a standard way, with skirt, blouse and underwear and without shoes hence a fixed value of 1 kg was subtracted from the recorded weight during data analysis. Children 6-59 months able to stand were measured like their mothers. Children unable to stand were weighed with an adult and their weight determined as the difference between the woman's individual weight and combined weight with the child. The scale allowed for subtraction of the mother's weight so that net values of the child's weight could be directly displayed. In children a fixed value of 0.3 kg corresponding to shirt and underpants, was subtracted during the data analysis. Height Women and children were measured to the nearest 0.1 em using portable stadiometers (UNICEF) suitably modified to hold a height measuring tape. Survey teams were instructed to repeat measuring the subjects until two measures differed by no more than 0.5 em and then to record the second of the two measures. 5 United Nations (1989). How to weight and measure children: assessing the nutritional status of young children in household surveys. New York World Health Organisation (1995). Physical status: the use and interpretation of anthropometry report of a WHO expert committee. WHO Technical Report Series 854. 14 Clinical assessment Clinical assessments were performed by team paediatricians during the household visits. The presence of rickets signs was assessed in all children under 5. Physicians looked for the presence of the following signs: a) epiphyseal enlargement at the wrist; b) presence of areas of softening of the skull (usually involving the occipital and parietal bones); c) frontal and parietal bossing; d) persistently open anterior fontanella on palpation after the age of 18 months; e) beading of the ribs (symmetrical nodular enlargement of the costochondral junctions, producing a «rosary» effect). In all mothers in the house, thyroid palpation was carried out. Physicians evaluated the presence of palpable and visible thyroid and recorded their findings with simplified WHO (1995)6 criteria as stage 0 (no goitre), stage 1 (goitre detectable only by palpation and not visible) or stage 2 (goitre palpable and visible). Biochemical assessment In all children 6-59 months and in non-pregnant mothers, capillary blood was collected for the measurements of haemoglobin, ferritin, serum retinol and alkaline phosphatase. Laboratory staff were extensively trained to obtain good capillary samples. The subjects were asked to sit and relax, their middle finger of the left hand was massaged gently and pricked with a sterile lancet. The first drop of blood was removed and the second one was sucked by capillarity with a cuvette containing dry Drabkin reagent. Subsequently, laboratory technicians collected approximately 300 ~L blood with a capillary. The blood was collected in a tube (Tervuo) containing serum separator gel with amber wells. The labelled tube was put in a cold box and kept until the team returned to the base, at the end of the day. The blood sample was then transferred to a central laboratory and analysed within 24 hours from collection. The samples were then centrifuged for serum separation and aliquoted for the single determinations. Haemoglobin A field haemoglobin analyser (Hemocue™) was used to assess haemoglobin to the nearest O.lg/dL. Haemoglobinometers were checked several times a day with a control cuvette. The instruments were only used if the reading was within ±0.3 g/dL of the cuvette factory value. The cut-off points used to define the different classes of anaemia are shown in table 2.27 . 6 World Health Organisation (1995). Regional office for the Eastern Mediterranean. Iodine deficiency: What is and how to prevent it. Alexandria Egypt. 7 World Health Organisation, United Nations Children's Fund, United Nations University (1998). Iron Deficiency Anaemia: Assessment, Prevention and Control. WHO Geneva. 15 Tab. 2.2- Definition of anaemia based on blood haemoglobin concentrations {g/dL) AGE Severe anemia Moderate anemia Mild anemia No anemia Children (6-59 months) <7 7-9.9 10-10.9 ~11 Women (15-45 years) <7 7-9.9 10-11.9 ~12 In considering the public health significance of this indicator, WHO/UNICEF/UNU (1996)8 propose to classify "high" a prevalence of anemia of at least 40%, "medium" a prevalence of 15-40% and "low" a prevalence of less than 15%. Ferritin Ferritin is an important iron-binding protein and its main function is iron storage. Low serum ferritin indicates low iron stores while iron overload conditions are recognisable by elevated serum ferritin concentrations. However, serum ferritin is also an acute-phase reactant protein that is elevated in response to infection. A 60 ~L serum sample was aliquoted and analysed in a Cobas Mira analyser with an immu- noturbidimetric method (UNIMATE 3 FERR by Roche). The human serum ferritin forms a precipitate with the suspended anti-ferritin coated latex particles. This results in an increase in turbidity that is determined turbidimetrically. The measurement of cloudiness occurs at 600nm after a fixed time and the ferritin concentration is expressed in ng/ml. A calibration curve was generated by using the 0, 12.5, 50, 100, 200 and 300 ng/ml of a stan- dard solution of human liver ferritin (FERR T Standard by Roche). The concentration of the standard solutions have been determined using a turbidimetric technique and are traceable to the World Health Organisation Reference Preparation for Human Liver Ferritin9. The instrument was calibrated at the start of the work. The calibration is stable for up to 30 days. A quality control (FERR/MYO Control T by Roche) was utilised daily to monitor accuracy and precision. Figure 2.1 shows the quality control chart. The coefficient of variation was 3.7%; the fluctuations were random and within the given ranges (111-135 ng/ml). 8 World Health Organisation, United Nations Children's Fund, United Nations University (1996). Indicators for assessing iron deficiency and strategies for its prevention (draft based on a WHOIUNICEFIUNU Consul- tation, 6-10 December 1993). WHO, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland. 9 World Health Organisation (1985). Biological standardisation. Thirty-fifth report of a WHO Expert Commit- tee. WHO Technical Report Series 725 16 Figure 2.1 -Quality control chart of serum ferritin measurements 140 135 130 ::::::- E 125 . m • • • • • • • • • • .:. 120 ~ 115 • • Cll LL. 110 • ---- --· -· · ···----- ----· -·-·· ·· ·--··· ·· ········ ·· ···-···· · ················· -········· ··· ····· ·· ··-·········------······ 105 100 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Day of analysis In order to test the stability of the samples at 4 oc and at room temperature a pool of serum collected from healthy children was analysed daily for 7 days. Figure 2.2 shows the results of these determinations. The coefficient of variation at 4°C was 8% and at room temperature was 10%. Ferritin concentration increased under the two condition of storage. Besides the concentration of ferritin in serum kept at 4 oc (76±6) was significantly higher than that in serum kept at room temperature (57±6). However, in 24 hours, there was no significant change of concentration in samples kept refrigerated. Figure 2.2 - Stability of serum for ferritin measurements 4•c Room temperature 90 • 88 70 86 68 66 ::::::- 84 ::::::-E 64 • E • . 82 • Cl . .:. m 62 80 .:. ~ :S 60 . 78 58 . 'E Cl> • LL. 76 Cll LL. 56 74 • • 54 • • • • • • 72 52 • 70 50 0 2 3 4 5 6 7 0 2 3 4 5 6 7 Day of analysis Day of analysis 17 In infants and young children there are still some uncertainties about the appropriate cut -off values for serum ferritin levels. These reference ranges have been obtained by another immunoturbidimetric test (Tina-quant Ferritin 2nd generation), giving similar results. For children 4 months-16 years old normal values lie between 20-200 ng/ml 10• Values lower than 10 ng/ml indicate virtual exhaustion of the body iron stores (severe deficiency) and values over 200 indicate iron overload. Retinol Laboratory assessment was carried out by measuring serum retinol in all children 6-59 months. After centrifugation (5 minutes at 2500 rpm), 40 j.LL serum were mixed with 2 ml of 0.1m NaCl. The tubes were thoroughly mixed with a vortex. Serum retinol was measured with a fluorometric method. The instrument used was a Turner Fluorometer TD-700 equipped with a mercury lamp with an excitation filter NB313 and an emission filter SC450. The reading was carried out in a quartz cuvette, in a fixed time of 12 seconds to control for fluctuations in fluorescence with changes in temperature. The instrument was calibrated daily with three standards, the concentration of which had been determined by HPLC (STD1low=23.6 j.Lg/dL; STD2 medium=35.0 j.Lg/dL; STD3 high=50:6 j.Lg/dL), after blanking the instrument. Quality controls were used for testing the instrument conditions. Standards and quality controls were kindly provided by CDC and prepared as samples. Twice a day, at the beginning and at the end of the determination series, a serum quality control with a low concentration (14.5 j.Lg/dL) and a quality control with a high concentration (37.9 j.Lg/dL) were analysed. Figure 2.3 shows the quality control chart for the two concentrations. The coefficient of variation of low quality controls was 11% and of high quality controls was 8%. Figure 2.3 also shows that the fluctuation was random. Figure 2.3- Quality control chart of serum retinol measurements 50 45 • 40 • • . 35 • -I • • • I • • • I • 'C • I • • • • • • • • ~ 30 . 25 0 c 20 ;:: • • • • • • Cl) 15 • a: I • I 10 5 0 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Day of analysis • High quality control (37.9 J.LQ/dl) • Low quality control (14.5 J.LQ/dl) 1 ° Fischbach F. (1990). Ermittlung altersabhangiger referenzwerte des transferrins in plasma und des ferritins in serum und plasma. Diatrend 15:7 18 In order to test the stability of serum retinol within the present survey, two pairs of quality controls were measured daily for six days. One of the pair was kept at 4 oc and the other left at room temperature. Figure 2.4 shows the results of these determinations. At 4 oc the coefficient of variation was 10% for low quality controls and 7% for high quality controls. At room temperature the values were more variable with wider fluctuations: low quality controls showed a coefficient of variation of 19% and high quality controls of 23%. In both cases there was no drift. Samples kept at 4 oc for 24 hours did not show significant changes in retinol concentrations. Figure 2.4 - Stability of serum retinol quality controls 4•c Room temperature 50 50 • 45 45 40 40 ::I • • • :g, 35 • ::I • • • • • 35 • :g, • 2: 30 30 0 25 ::::1. -- 25 1: 0 ;:; 20 Gl 1: 20 a: 15 ;:; • • Gl • • a: 15 • • • • • • 10 • • 10 5 5 0 0 0 2 3 4 5 6 0 2 3 4 5 6 Day of analysis Day of analysis • High quality control (37.9) • Low quality control (14.5) For children, a serum retinol concentration below 10 11g/dL indicates severe deficiency; a value between 10 and 20 11g/dL indicates mild/moderate deficiency; values ~20 11g/dL are considered normal11 (FAO, 1989). When more than 10% of the population has serum retinol below 20 11g/dL (0.7 Jlmol/L) vitamin A deficiency is considered a public health problem12. Alkaline phosphatase Serum total alkaline phosphatase activity is the most commonly used biochemical marker of rickets. Serum alkaline phosphatase is elevated in nutritional rickets and is instead decreased in growth retardation. 11 Food and Agriculture Organisation 1989. Besoins en vitamine A, fer, acide folique et vitamine B12. Rapport d'une consultation conjointe FAO/OMS d'experts. Roma. 12 World Health Organisation (1996). Indicators for assessing vitamin a deficiency and their application in mo- nitoring and evaluating intervention programmes. Miconutrient Series. WHO/NUT/96.10. WHO, Geneva. 19 Measurement of serum alkaline phosphatase was carried out in all children 6-59 months. Alkaline phosphatase was measured with a micromethod on a dry-slide chemistry analyzer. The equipment utilised was a Vitros System Ektachem 250 (Johnson & Johnson). The method is based on the enzymatic hydrolysis of p-nitrophenil phosphate, catalyzed by alkaline phosphatase in the serum sample; the products formed are H3P04 and p-nitrophenol. The reaction occurs on a multi stratum dry-slide. The dry-slides were kept at 4 oc and were left at room temperature for at least 30 minutes before use. The determination required 20 ~-tL of serum that was placed in a sample cup. An automated system collected 11 ~-tL serum from the cup and dispensed it onto the top diffusion stratum of the dry slide, isotropic porotic structure that ensures a uniform distribution. The diffusion stratum also contains the substratum for enzymatic hydrolysis. In an alkaline environment and in the presence of a buffer and aminometilpropanol, a yellow complex is produced that migrates in the underlying stratum, where it is measured by reflection photometry. The activity of alkaline phosphatase is proportional to the rate of p-nitrophenol formation measured by kinetic determination. The time of incubation was 5 minutes at 37°C, the wavelength 400nm and the enzymatic activity was expressed in IU/ L. Hemolysis interferes with the phosphatase alkaline measurement. Thus, hemolyzed samples could not be used. The instrument was calibrated daily with a calibrator kit. A quality control with a physiologi- al concentration was used for testing instrument performance. Figure 2.5 shows the quality control chart. The coefficient of variation was 4.5%; the fluctuations were random and within the given ranges (340-548 lUlL). .J ._ ::I ~ Cll VI ! as .c. c. VI 0 .c. c. Cll c: as ~ <t Figure 2.5 -Quality control chart of serum alkaline phosphatase m e as u rem en ts 600 550 500 450 • • • • • • • 400 • • • 350 300 • • 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Day of analysis To test the stability of serum at 4 oc and at room temperature, an aliquot from a pool of children's sera was analysed daily for 7 days, as for the other analytes. Figure 2.6 shows the results of these determinations. The coefficient of variation was 2.5% at 4°C and 5.7% at room temperature. Concentration increased with time. The serum concentration of alkaline phospatase at 4°C (147±4) was significantly lower than at room temperature (157±9). In samples kept refrigerated for 24 hours alkaline phophatase concentration was not different from that of the fresh sample. 20 Figure 2.6 - Stability of serum for alkaline phosphatase measurements Room te m p era tu re 4°C 160 170 • _, • .J 165 - 155 a> ::I Ill ~ Ill 160 a> • . • Ill 150 Ill • Ill • J: - • 155 • Ill c. J: • • Ill c. 145 • 0 150 Ill • 0 J: J: c. 145 c. 140 • a> • a> ~ .E 140 ftl ftl ~ 135 .:Jt. 135 <1: <1: 130 130 0 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Day of analysis Day of an a lysis Table 2.3 shows the reference values for the enzyme in different classes of age and for both sex13 . Tab. 2.3 - Reference values for serum alkaline phosphatase MALE FEMALE AGE (lUlL) (lUlL) 7-12 months 60-300 60-330 1-3 years 145-320 145-320 4-6 years 150-380 150-380 Field work Data collection was carried out by 9 teams of three people each. All teams were composed of 1 person with specific training in interview techniques, 1 paediatrician and 1 laboratory technician. A senior person was appointed to supervise a set of three teams. The supervisors were res- ponsible for selecting the cluster, controlling interview techniques, standardising measure- ment procedures, controlling data entry, controlling biological sample collection, storage and transport to the central laboratory. 13 Lockitch G., Halstead AC, Albersheim S, MacCallum C, Quigley G. (1988). Age- and sex-specific paediat- ric reference intervals for biochemistry ana1ytes as measured with the Ektachem-700 analyzer. Clin Chern 34(8):1622-5. Soldin SJ, Savwoir TV, GuoY. (1997). Paediatric reference ranges for alkaline phosphatase, aspartate amino- transferase, and alanine aminotranferase in children less than 1 year old on the Vitros 500. Clin Chern 43:Sl99. 21 Data Management Data Entry Daily input of information collected was carried out by a team of four data entry specialists, with a specifically designed Access software in order to reduce data entry errors. Data Cleaning Data sets were checked for outliers. Some outliers were real values, due to exceptional subjects being included in the sample (e.g. a 130 kg woman). In order to identify outliers, distributions for each variable were plotted. The following values were considered outliers and excluded from further data analysis: haemoglobin (g/dl): <5 and > 16; height-for-age, weight-for-age; weight-for-height: Z-score <-5 and >5; women's weight (kg): <30; women's height (em): <130. 'Don't know' was recorded as missing value. Calculating Population Weight In order to calculate national prevalence figures, a different weighting factor was applied to each of the two strata. This population weight was obtained by dividing the total number of children under 5 in each strata by the number of children under 5 included in the sample (Tab.2.4). According to this method, each weight is the number of individuals represented by the record in which it appears, and the sum of the weights for the entire sample corresponds to the size of the population from which the sample was drawn. Table 2.4 - Calculation of population weight POPW = Total Population/Studied Sample Total Population of Children Studied Sample of Children POPW Under5 Under 5 Urban 121385 1050 115,605 Rural 94724 1045 90,645 Data analysis Data analysis was carried out on using Epi6 and Access for Windows software packa- ges. In order to examine the results for each population strata, cross tabulations were produced for all variables in the data set. The same technique was followed for examining results by strata and by sex. For continuous variables (e.g. Haemoglobin, Alkaline Phosphatase, Serum Retinol, Weight-for-Height, Height-for-Age, Weight-for-Age, Birth weight, BMI) Student T-test was performed. Such variables were then transformed into categorical and cross tabulations were produced. Conjzdence Intervals ofproportions were calculated using Epi6 Cluster Sampling Analysis (CSAMPLE). The Primary Sampling Unit (PSU) was the cluster number. The primary stratum from which PSUs were chosen were the population strata. The sample weight was the population weight. In these calculations the "design effect" was also considered. 22 3. RESULTS Description of the sample Tables 3.1 to 3.4 report the number of children under 6-59 months, the number of children 0- 24 months, the number of children 13-24 months and the number of mothers in fertile age in- cluded in the sample. The required sample size was achieved for each age group considered. Tab. 3.1- Number of children 6-59 months by Population Strata Count Cumulative Count Target %Target Urban 873 873 633 138 Rural 892 1765 633 141 Tab. 3.2 -Number of children 0-24 months by Population Strata Count Cumulative Count Target %Target Urban 700 700 246 285 Rural 692 1392 246 281 Tab. 3.3- Number of children 13-24 months by Population Strata Count Cumulative Count Target %Target Urban 335 335 275 122 Rural 324 659 275 118 Tab. 3.4- Number of mothers 15-45 years by Population Strata Count Cumulative Count Target %Target Urban 906 906 . 305 297 Rural 843 1749 305 276 23 3.1. Household information Table 3.1.1 shows the type of dwelling of the household studied. Most of the population lived in houses (80% ). In urban areas the percentage of people that live in flats (32%) is bigger than in rural areas (3%). The households studied had a mean of 4 rooms (table 3.1.2) with no differences between urban and rural areas. Table 3.1.3 indicates the low percentage of the resident population hosting refugees. Figure 3.1.1 shows the ethnic composition of the population within the two strata. Albanian speakers comprised a smaller percentage of the urban population (11%) than the population of rural areas (28% ). Conversely, both Macedo- nian and Roma speaking groups are found more frequently in urban than in rural areas. Tab. 3.1.1 - Type of dwelling by Population Strata Type of dwelling Total Flat House Urban 177 391 568 *Row% 31.2 68.8 100.0 *95% C.l. 17.2-45.1 54.9-82.8 Rural 14 454 468 *Row% 3.0 97.0 100.0 95% C.I. 1.5-4.5 95.5-98.5 Total 191 845 1036 *Row% 20.1 79.9 100.0 *95% C.l. 11.2-28.9 71.0-88.8 *weighted Pearson Chi-square: 135.4l,p=0.0000; Missing Values=O Tab. 3.1.2 - Average Number of Rooms per House by Population Strata n Mean±SD Urban 568 3.53±1.47 Rural 465 3.73±1.50 Total 1033 3.61±1.49 t-Test: t=-2.09 and p=0.04; Missing Values=3. Tab. 3.1.3 - Residential Status by Population Strata Hosting of Refugees Total Households not Households Hosting Hosting Refugees Refugees Urban 567 1 568 *Row% 99.8 0.2 100.0 *95% C.I. 99.5-100.2 -0.2-0.5 Rural 466 2 468 *Row% 99.6 0.4 100.0 *95% C.l. 98.7-100.4 -0.4-1.3 24 Total 1033 3 1036 *Total% 99.7 0.3 100.0 *95% C.I. 99.3-100.1 -0.1-0.7 *weighted Pearson Chi-square: 0.56, p=0.45; Missing Values=O Figure 3.1.1 -Prevalence of Ethnic Group by Population Strata Others Turkish Rom a Albanian Macedon ian 0 10 20 30 40 50 60 70 80 Demographic information Household composition Percentage of population ll Rural • Urban In rural areas there were larger families than in urban areas (Tab. 3.1.4). Households inclu- ded in the survey had, on average, more than one child under 5 (1.3±0.6), with significantly more children in rural than in urban areas (Tab. 3.1.5). The ratio of dependent (boys and girls under 18 + adults above 65) to independent (adults 18-65 years) was less than 1 in the whole population, with a significantly higher ratio in rural areas than in urban areas (Tab. 3 .1.6). Tab. 3.1.4 -Average number of household members by Population Strata n Mean±SD Urban 568 4.82±1 .59 Rural 468 5.27±1 .85 Total 1036 5.03±1.73 t-Test: t=-4.16 and p=0.00003; Missing Values=O. 25 Urban Rural Total Tab. 3.1.5 - Average number of children 0-59 months per household by Population Strata n Mean±SD 568 1.27±0.53 468 1.40±0.62 1036 1.33±0.57 t-Test: t=-3.62 and p=0.0003; Missing Values=O. Tab. 3.1.6 - Distribution of Dependency Ratio by Population Strata n Mean±SD Urban 568 0.80±0.54 Rural 468 0.89+0.64 Total 1036 0.84±0.59 t-Test: t=-2.14 and p=0.016; Missing Values=O. Socio-economic characteristics of the households Almost all the households were headed by a man (table 3.1.7). Female headed households were more frequent in urban (4%) than in rural areas (1 %). In Table 3.1.8 the educational level of the household heads is shown. In both strata the majority of the interviewees had attended elementary or secondary schools; only 7% of the population had a university degree with a remarkable difference between urban ( 11%) and rural (1%) areas. Table 3 .1. 9 reports the declared sources of cash income. In urban and rural areas an official salary was the main source. In rural areas there was a higher percentage (21%) of people that lived off farming than in urban areas (2%). An important role in both strata must have been played by social aid, 14% in urban and 15% in rural areas. Measures to alleviate poverty, such as food donations, between friends and neighbours (table 3.1.10), were scarce (4% of the households) and more in urban (5%) than rural areas (2%). The sale of household goods (table 3 .1.11) was practised by a small percentage of population (3%) with a higher prevalence in rural (6%) than in urban areas (2%). Table 3.1.12 shows that 17% of the household studied received social assistance in food aid with small, insignificant differences by strata. A big part of the population ( 40%) had the possibility of growing fruit and vegetables (table 3.1.13). In rural areas the percentage was significantly higher (69%) than in urban areas (22% ). The same situation arose for the keeping of small animals for meat and milk production (table 3.1.14). Disabilities of various degrees (table 3 .1.15) were present in 10% of the households with higher prevalence in urban ( 12%) than in rural areas (7% ). The most common disability was blindness, present in 11% of urban house- holds and in 3% of rural households. Tab. 3.1.7- Gender of the Household Head by Population Strata Gender Total Male Female Urban 545 23 568 *Row% 95.9 4.1 100.0 *95% C.I. 92.8-99.1 0.8-7.2 26 Rural 461 6 467 *Row% 98.7 1.3 100.0 *95% C.I. 97.6-99.8 0.15-2.4 Total 1006 29 1035 *Row% 97.0 3.0 100.0 *95% C.I. 95.0-99.0 0.9-5.0 *weighted Pearson Chi-square: 7.19, p=0.007; Missing Values=1 Tab. 3.1.8 - Education of the Head of the Household by Population Strata Level of Education Total Incomplete Elementary Secondary Short University Long University Illiterate Elementary School School School Degree Degree Urban 19 39 108 322 20 60 568 *Row% 3.3 6.9 19.0 56.7 3.5 10.6 100.0 *95% C.I. 1.3-5.4 4.2-9.6 13.9-24.1 50.8-62.5 2.1-4.9 6.2-14.9 Rural 14 87 180 168 12 6 467 *Row % 3.0 18.6 38.5 36.0 2.6 1.3 100.0 *95% C.I. 0.6-5.4 11.6-25.6 31.2-45.8 26.6-45.4 0.9-4.2 0.2-2.3 Total 33 126 288 490 32 66 1035 *Row o/o 3.2 11.5 26.7 48.6 3.1 6.9 100.0 *95% C.I. 1.6-4.8 8.3-14.7 22.4-30.9 43.4-53.7 2.1-4.2 4.2-9.6 *weighted Pearson Chi-square: 122.94, p=O.OOOOO; Missing Values=l Tab.3.1.9 - Main Source of Household Income by Population Strata Source of Cash Income Total Private Official Pension Farming Social Aid No cash Business Salary income Urban 79 319 64 10 80 16 568 *Row% 13.9 56.2 11.3 1.8 14.1 2.8 100.0 *95%C.I. 9.6-18.2 50.2-62.1 7.2-15.3 -0.7-4.2 9.9-18.3 1.5-4.1 Rural 54 177 54 97 67 10 459 Row % 11.8 38.6 11.8 21.1 14.6 2.2 100.0 *95%C.I. 7.7-15.8 28.8-48.3 7.5-16.0 12.1-30.2 10.6-18.6 0.7-3.7 Total 133 496 118 107 147 26 1027 *Row% 13.1 49.3 11 .5 9.3 14.3 2.6 100.0 *95%C.I. 10.0-16.1 44.1-54.5 8.5-14.4 5.5-13.1 11.3-17.3 1.6-3.6 *weighted Pearson Chi-square: 109.13, p=O.OOOOO; Missing Values=9 27 Tab. 3.1.10 - Receiving Food from Relatives/Friends/Neighbours by Population Strata Receiving Food Total Yes No Urban 27 541 568 *Row% 4.8 95.2 100.0 *95% C.L 2.7-6.8 93.2-97.5 Rural 11 456 467 *Row% 2.4 97.6 100.0 *95% C.l. 0.9-3.8 96.2-99.1 Total 38 997 1035 *Row% 3.8 96.2 100.0 *95% C.l. 2.5-5.2 94.8-97.5 *weighted Pearson Chi-square: 4.17,p=0.04; Missing Values=1 Tab. 3.1.11 - Selling or Trading Household Goods in the Last Month by Population Strata Sellin2 Household Good Total Yes No Urban 10 558 568 *Row% 1.8 98.2 100.0 *95% C.I. 0.2-3.3 96.7-99.8 Rural 27 440 467 *Row% 5.8 94.2 100.0 *95% C.l. 1.0-10.6 89.4-99.0 Total 37 998 1035 *Row% 3.3 96.7 100.0 *95% C.I. 1.2-5.4 94.6-98.8 *weighted Pearson Chi-square: 12.02, p=O.OOOS; Missing Values= 1 Tab.3.1.12- Prevalence of Households receiving Humanitarian Food Aid during '97/'98 Humanitarian Food Aid Total Yes No Urban 95 471 566 *Row% 16.8 83.2 100.0 Rural 84 383 467 *Row% 18.0 82.0 100.0 Total 179 854 1033 *Row% 17.3 82.7 100.0 *weighted Pearson Chi-square: 0.26, p=0.61; Missing Values=3 28 Tab. 3.1.13 - Growing Fruit and Vegetables by Population Strata Growin!! Fruit and Ve!!etables Total Yes No Urban 123 445 568 *Row% 21.7 78.S 100.0 *95% C.I. 11.8-31.5 68.5-88.1 Rural 323 144 467 *Row% 69.2 30.8 100.0 *95% C.I. 59.0-79.4 20.6-41.0 Total 446 589 1035 *Row% 40.3 59.7 100.0 *95% C.I. 32.7-47.9 52.1-67.3 *weighted Pearson Chi-square: 235.90, p=O.OOOO; Missing Values= I Urban Rural Total Tab. 3.1.14 - Keeping Small Animals For Meat and Milk Production by Population Strata Keeping Small Animals Total Yes No 79 489 568 *Row% 13.9 86.1 100.0 *95% C.I. 6.4-21.4 78.6-93.6 295 172 467 *Row% 63.2 36.8 100.0 *95% C.I. 53.8-72.5 27.5-46.2 374 661 1035 *Row% 33.2 66.8 100.0 *95 % C.I. 26.9-39.5 60.5-73.1 *weighted Pearson Chi-square: 269.48, p=O.OOOO; Missing Values= I Tab. 3.1.15- Presence of Disabled Person by Population Strata Kind of Disability No Motor Mental Terminal Total disability Blind Deaf Disabili!r_ Disability Disease Urban 498 65 - - 1 4 568 *Row% 87.7 11.4 0.2 0.3 100.0 *95% C.I. 77.0-98.3 0.7-22.2 - - -0.2-0.5 0.0-1.4 Rural 433 15 1 9 6 3 467 *Row % 92.7 3.2 0.2 1.9 1.3 0.6 100.0 *95% C.I. 89.0-96.4 1.0-5.4 -0.2-0.6 0.7-3.2 0.1-2.4 1.3-2.4 29 Total 931 80 1 9 7 7 1035 *Row% 89.6 8.2 0.1 0.8 0.6 0.7 100.0 *95% C.I. 83.0-96.3 1.6-14.9 -0.1-0.2 0.3-1.2 0.1-1.1 0.2-1.2 *weighted Pearson Chi-square: 40.03, p=O.OOOOO; Missing Values= I Water and sanitation The quality of the drinking water supply system for urban households was good (table 3 .1.16), with almost the entire sample of households served by piped water (98%) with virtually no cases of use of water from unprotected wells. In rural areas 64% of people were served by piped water, 12% had a tube well, 17% had a protected dug well and the percentage of cases of unprotected wells came to 6%. In addition water availability was constant for all the people living in urban areas (table 3.1.17). In rural areas this percentage was lower (86%) and in 13% of the households water was available only every second day. In the majority of urban households water was easily accessible (table 3.1.18), the sources being located either on the premises (95%) themselves or within 100m (4% ). Only in 7% of the rural households did the distance of the water source exceed 100 m, in 60% the sources were on the premises and in 33% within 100m. In urban areas, toilet facilities (table 3.1.19) were good and connected to a sewage system for a large majority of households (89% ). Approximately 6% of the households in urban areas use latrines and there were no cases of uncovered latrines nor a total absence of facilities. In rural areas, latrines are used by 41% of the households and in general the quality of the latri- nes in this case was poorer, even lacking a cover. In urban areas toilet facilities are usually located in the house (91%), while in rural areas they are usually outside (57%), within 50 m from the premises (table 3.1.20). Tab.3.1.16 - Source of Drinking Water by Population Strata Source of Drinking Water Total Piped-in Public Tube Well or Protected Dug Pond, Well or River or dwelling Tap Borehole Protected Spring Stream Urban 557 6 5 - - 568 *Row% 98.0 1.1 0.9 100.0 *95%C.I. 96.4-99.7 -0.2-2.3 -0.3-2.1 - - Rural 312 51 70 32 1 466 *Row% 67.0 10.9 15.0 6.9 0.2 100.0 *95%C.I. 52.2-81.9 1.7-20.2 3.6-26.5 0.1-13.6 -0.2-0.6 Total 869 57 75 32 ] 1034 *Row% 85.9 4.9 6.4 2.7 0.1 100.0 *95%C.I. 80.1-91.7 1.2-8.6 1.9-10.9 0.1-5.3 -0.1-0.2 *weighted Pearson Chi-square: 185.68, p=O.OOOO; Missing Values=2 30 Tab. 3.1.17- Frequency of the Availability of Piped Water by Population Strata Water from Pipe Constantly Every day Every two or more day Urban 555 1 1 *Row% 99.6 0.2 0.2 *95% C.l. 99.2-100.1 -0.2-0.5 -0.2-0.5 Rural 267 - 39 *Row% 87.3 - 12.7 *95% C.l. 73.4-101.1 -1.1-26.6 Total 822 1 40 *Row% 95.9 0.1 4.0 *95% C.I. 91.7-100.1 -0.1-0.4 -0.2-8.2 Pearson Chi-square: 71.01,p=0.00000; Missing Values=173 Tab. 3.1.18- Distance of the Source of Drinking Water from Dwelling by Population Strata Distance of the Source of Drinking Water Total 557 100.0 306 100.0 863 100.0 *weighted Total On Less than From 100m From500m More than premises lOOm to 500 m to lkm lkm Urban 544 24 - - - 568 *Row% 95.8 4.2 - - - 100.0 *95% C.I. 93.1-98.5 1.6-6.9 Rural 302 135 18 1 11 467 *Row% 64.7 28.9 3.9 0.2 2.3 100.0 *95% C.I. 51.3-78.0 16.8-41.0 -0.6-8.3 -0.2-0.6 -2.3-7.0 Total 846 159 18 1 11 1035 *Row% 83.6 13.9 1.5 0.1 0.9 100.0 *95% C.l. 78.2-89.0 9.0-18.9 -0.2-3.2 -0.1-0.2 -0.9-2.7 *weighted Pearson Chi-square: 168.46, p=O.OOOO; Missing Values=1 Tab. 3.1.19 - Type of Toilet Facility by Population Strata Toilet Facility Total Flush to Flush to Pour flush Covered Uncovered sewage septic tank latrine by dry latrine system latrine Urban 506 30 24 7 - 567 *Row% 89.2 5.3 4.2 1.3 - 100.0 *95% C.I. 81.6-96.8 -0.1-10.7 -0.7-9.1 0.2-2.3 31 Rural 149 133 28 156 1 467 *Row% 31.9 28.5 6.0 33.4 0.2 *95% C.I. 17.2-46.6 14.3-42.6 0.7-11.3 17.9-48.9 -0.2-0.6 100.0 Total 655 163 52 163 1 1034 *Row% 66.7 14.4 4.9 13.9 0.1 *95% C.I. 58.9-74.6 7.7-21.0 1.3-8.5 7.6-20.1 -0.1-0.2 100.0 *weighted Pearson Chi-square: 391.16, p=O.OOOO; Missing Values=2 Tab. 3.1.20 - Distance of the Toilet Facility from Dwelling by Population Strata Distance from Dwelling Total In dwelling Less than 50 mormore 50m away Urban 516 47 5 568 *Row% 90.8 8.3 0.9 100.0 *95% C.I. 85.8-95.9 3.8-12.7 -0.1-1.9 Rural 201 263 3 467 *Row% 43.1 56.3 0.6 100.0 *95% C.I. 28.4-57.7 41.7-71.0 -0.1-1.3 Total 717 310 8 1035 *Row% 72.1 27.1 0.8 100.0 *95% C.l. 65.3-78.9 20.5-33.7 0.1-1.4 *weighted Pearson Chi-square: 282.22, p=O.OOOO; Missing Values= I Food intake Figure 3 .1. 2 shows consumption of selected foods during the week preceding the survey. In Macedonia bread, vegetables, fruit, milk and dairy products were consumed almost every day both in urban and rural areas. Meat or fish and pasta, rice and potatoes were consumed approximately every second day. Pulses were consumed once to twice a week. There were no significant differences between urban and rural areas in food consumption. 32 Figure 3.1.2 - Mean Frequency Consumption of Selected Items by Population Strata Fruit Vegetables Pulses Pasta, rice & pot. Bread Milk & dairies Meat& Fish 0 1 2 3.2. Individual data 3.2.1. Mothers 15-45 years Most of the women were married (97% ), either officially (94%) or non-officially (3%). There was a small group of wo- men without a partner (2%) with no dif- ferences between strata (Tab. 3.2.1.1). One third of the women in urban areas had formal employment while in rural areas this percentage was dramatically lower (8%) (Tab. 3.2.1.2). The educa- tional level of women was high: almost half of the women had completed se- condary education (Tab. 3.2.1.3) how- ever the percentage differs for urban women (56%) and for rural women (35%) with significant differences by population strata. Less than 4% of the women were pregnant at the time of the survey. Table 3.2.1.4 shows the average number of pregnancies in mo- thers studied; rural mothers had more pregnancies than urban but the diffe- rences were slight and not significant. Abortions or miscarriages were not commonly reported (Tab.3 .2.1.5). The interruption of pregnancy was signifi- cantly more frequent in mothers that li- 3 4 5 N. of times/week 6 7 ~I Rural • Urban ved in urban areas than in rural. Registration at Women's clinics was common for most women (98%); more in urban (98%) than rural areas (96%) (Tab. 3.2.1.6). 33 Tab. 3.2.1.1 - Family Status by Population Strata Family Status Total Single Registered Non Registered Divorced Marriage Marriage Urban 13 545 19 3 580 *Row% 2.2 94.0 3.3 0.5 100.0 *95% C.I. 0.5-4.0 91.2-96.7 1.1-5.5 -0.0-1.1 Rural 10 458 18 5 491 *Row% 2.0 93.3 3.7 1.0 100.0 *95% C.I. 0.6-3.5 88.5-98.1 -0.8-8.1 0.0-2.0 Total 23 1003 37 8 1071 *Row% 2.2 93.7 3.4 0.7 100.0 95% C.I. 0.9-3.4 91.1-96.2 1.2-5.7 0.2-1.2 *weighted Pearson Chi-square: 1.08, p=0.78; Missing Values=1 Tab. 3.2.1.2 - Prevalence of Employment by Population Strata Employment Total Yes No Urban 172 408 580 *Row% 29.7 70.3 100.0 *95% C.I. 23.0-36.3 63.7-77.0 Rural 39 453 492 *Row% 7.9 92.1 100.0 *95% C.I. 3.5-12.3 87.7-96.5 Total 211 861 1072 *Row% 21.0 79.0 100.0 *95% C.I. 16.6-25.3 74.7-83.4 *weighted Pearson Chi-square: 79.50, p=O.OOOOO; Missing Values=O Tab. 3.2.1.3 - Level of Education by Population Strata Level of Education Total Incomplete Elemen- Secondary Short Uni- Long Dliterate Elementary tary School versity University School School Degree Degree Urban 20 28 113 326 27 66 580 *Row% 3.4 4.8 19.5 56.2 4.7 11.4 100.0 *95% C.I. 0.7-6.2 2.4-7.2 12.6-26.3 48.7-63.7 2.7-6.6 6.3-16.5 Rural 15 82 207 174 8 6 492 *Row% 3.0 16.7 42.1 35.4 1.6 1.2 100.0 *95% C.I. 0.9-5.2 9.4-23.9 32.4-51.7 24.7-46.0 0.0-3.2 0.2-2.2 Total 35 110 320 500 35 72 1072 *Row% 3.3 9.6 28.5 47.9 3.4 7.3 100.0 *95% C.I. 1.4-5.1 6.4-12.7 22.7-34.3 41.7-54.1 2.1-4.8 4.2-10.5 *weighted Pearson Chi-square: 155.18, p=O.OOOO; Missing Values=O 34 Tab. 3.2.1.4- N. of Pregnancies (Including Abortions and Still Births) by Population Strata n Mean±SD Urban 580 2.06+1.22 Rural 492 2.19+1.31 Total 1072 2.12±1.26 t-Test: t=-1.65 and p=0.10; Missing Values=O. Tab. 3.2.1.5 - N. of Miscarriages or Abortions by Population Strata n Mean±SD Urban 579 0.35+0.74 Rural 491 0.24±0.62 Total 1070 0.30±0.69 t-Test: t=2.65 and p=0.008; Missing Values=2. Tab. 3.2.1.6- Prevalence of Registration at Women's Clinics by Population Strata Registration Total Yes No Urban 568 9 577 *Row% 98.4 1.6 100.0 *95% C.l. 96.9-99.9 0.1-3.1 Rural 472 17 489 *Row% 96.5 3.5 100.0 *95% C.I. 93.5-99.5 0.5-6.5 Total 1040 26 1066 *Row% 97.7 2.3 100.0 *95% C.I. 96.2-99.2 0.8-3.8 *weighted Pearson Chi-square: 4.09, p=0.04; Missing Values=6 Thyroid was palpable in 9% of women with a very small percentage (0.6%) of the women with visible goitre. There were no differences between urban and rural areas (Tab. 3.2.1.7). Tab. 3.2.1.7- Prevalence of Goitre by Population Strata Goitre Total No Goitre Palpable Goitre Visible Goitre Urban 506 48 5 559 *Row% 90.5 8.6 0.9 100.0 *95% C.I. 85.6-95.4 3.6-13.5 0.0-1.8 Rural 420 49 1 470 *Row% 89.4 10.4 0.2 100.0 *95% C.I. 85.7-93.0 6.7-14.2 -0.2-0.6 Total 926 97 6 1029 *Row% 90.1 9.3 0.6 100.0 *95% C.I. 86.8-93.3 6.0-12.6 0.1-1.2 *weighted Pearson Chi-square: 2.99, p=0.22; Missing Va1ues=43 35 -----~ ~- Mothers in fertile age had mean blood haemoglobin of 13.4±0.1 g/dL with no differences by population strata (Tab. 3.2.1.8). Table 3.2.1.9 shows the prevalence of anaemia of mothers studied. There were no cases of severe anaemia; mild and moderate anaemia was observed in 12% of non pregnant mothers in both strata, there were no differences between urban and rural areas. Tab. 3.2.1.8 - Serum Haemoglobin Concentration by Population Strata n Mean±SD Urban 550 . 13.46+1.35 Rural 468 13.33±1.38 Total 1018 13.40+1.36 t-Test: t=1.42 and p=0.16; Missing Values=54. Tab. 3.2.1.9- Prevalence of Anaemia in NON-pregnant Mothers by Population Strata Anaemia Total Moderate(Hb7-9.9 g/dL) Mild (Hbl0-11.9 g/dL) No Anaemia (Hb2:12 g/dL) Urban 8 57 485 550 *Row% 1.5 10.4 88.2 100.0 *95% C.I. 0.4-2.5 7.8-13.0 85.3-91.1 Rural 14 45 409 468 *Row% 3.0 9.6 87.4 100.0 *95% C.I. 1.5-4.5 6.8-12.5 84.1-90.7 Total 22 102 894 1018 *Row% 2.1 10.1 87.9 100.0 *95% C.l. 1.2-2.9 8.1-12.0 85.7-90.1 *weighted Pearson Chi-square: 2.92, p=0.23; Missing Values=54 As shown in table 3.2.1.10 the higher prevalence of anaemia in mothers was observed in Roma speaking population (26%) with 4% of severe cases and in Albanian (18%) with 5% of severe cases. In the others groups the prevalence of anaemia was lower, 13% (3% of severe cases) in Turkish and 10% (2% of severe cases) in Macedonian. The concentration of haemoglobin of the mothers was not correlated to the concentration of haemoglobin in children. Also the analysis of ethnic groups did not show a significant corre- lation between the two concentration. Tab. 3.2.1.10 -Anaemia in NON-Pregnant Mothers of Different Ethnic Groups Anaemia Status Total Anaemia <12~g/dL No Anaemia ~12~g/dL Macedonian 70 647 717 *Row% 9.7 90.3 100.0 *95% C.I. 7.4-12.0 88.0-92.6 Albanian 32 153 185 *Row% 17.3 82.7 100.0 *95% C.I. 13.7-21.0 79.0-86.3 36 Rom a 10 38 48 *Row% 21.0 79.0 100.0 *95% C.I. 8.7-33.3 66.7-91.3 Turkish 5 28 33 *Row% 14.5 85.5 100.0 *95% C.I. 0.1-28.9 71.1-99.8 Others 7 27 34 *Row% 20.9 79.1 100.0 *95% C.I. 9.8-32.0 68.0-90.1 Total 124 893 1017 *Row% 12.1 87.9 100.0 *95% C.I. 9.9-14.3 85.7-90.1 *weighted Pearson Chi-square: 14.31, p=0.0064; Missing Values=55 As shown in table 3.2.1.11 low BMI (<18.5 kg/m2) was observed only in about 6% of the mothers, while 38% of the women were overweight or obese (BMI>25 kg/m2). Higher degrees of obesity (BMI>30 kg/m2) were uncommon (10% of moderate obesity and 1% of severe obesity). Tab. 3.2.1.11 -Distribution of Different Classes of BMI in NON Pregnant Mothers 25-45 Years by Population Strata Classes of BMI Total <16 16-16.9 17- 18.5-25 25.1-30 30.1-40 >40 18.4 Urban 1 2 19 227 111 37 2 399 *Row% 0.3 0.5 4.8 56.9 27 .8 9.3 0.5 100.0 *95% C.I. -0.2-0.7 -0.2-1.2 3.2-6.3 52.3-61.5 24.2-31.4 6.8-12.8 -0.2-1.2 Rural 0 6 17 158 76 32 4 293 *Row % 0.0 2.0 5.8 54.0 25.9 10.9 1.4 100.0 *95% C.I. 0.2-3.9 3.3-8.3 47.3-60.6 19.4-32.2 6.9-14.9 -0.2-2.9 Total 1 8 36 385 187 69 6 692 *Row % 0.2 1.1 5.1 55.8 27.1 9.9 0.8 100.0 *95% C.I. -0.1-0.5 0.3-1.9 3.8-6.5 52.0-59.6 23 .9-30.4 7.2-12.6 0.2-1.6 *weighted Pearson Chi-square: 6.98 p=0.32; Missing Values=380 Figure 3.2.1.1 shows the cumulative distribution of BMI in women 25-45 years , further illustrating the women's nutritional status, with a majority of individuals falling in the normal range. 37 Figure 3.2.1.1- Distribution of BMI in women 25-45 years by Population Strata 100 90 80 70 60 ~ 0 50 40 30 20 1 0 0 3.2.2. Children Morbidity -Urban - Rural 16 17 18.5 25 30 40 Body Mass Index Low birth weight was observed in 6% of children studied without differences by strata (Tab. 3.2.2.1). Diarrhoea (more than three loose stools a day) was reported for 12% of the children (Tab. 3.2.2.2), with similar rates in urban (13%) and rural (10%) areas. The use of oral re- hydratation salts (Tab. 3.2.2.3) in case of diarrhoea was generally low. It was more common in urban (20%) than in rural (15%) areas but the differences were not significant. Children that live in urban zones showed more frequent coughing episodes (22%) than rural children (14%) (Tab. 3.2.2.4). Children's vision impairment at night time was reported by 1% of the mothers with no differences by strata (Tab. 3.2.2.5). Urban Rural Total Tab. 3.2.2.1- Prevalence of Low (<2,5kg) Birth weight in Children 0-59 months by Population Strata Classes of Birth Weight <2,5 2,5-3,,8 >3,8 45 547 107 *Row% 6.4 78.3 15.3 *95% C.I. 3.9-8.9 74.9-81.6 12.7-17.9 41 526 67 *Row% 6.5 83.0 10.6 *95% C.I. 4.3-8.6 80.0-85.9 8.1-13.0 86 1073 174 *Row% 6.4 80.2 13.3 *95% C.I. 4.7-8.2 77.9-82.5 11.6-15.1 Pearson Chi-square: 6.64, p=O.Q4; Missing Values=12 38 Total 699 100.0 634 100.0 1333 100.0 *weighted Tab. 3.2.2.2 - Prevalence of Diarrhoea in the Two Weeks Preceding the Survey in Children 0-59 months by Population Strata Diarrhoea Total Yes No Urban 89 610 699 *Row% 12.7 87.3 100.0 *95% C.l. 8.7-16.8 83.2-91.3 Rural 65 572 637 *Row% 10.2 89.8 100.0 *95% C.l. 6.5-13.9 86.1-93.5 Total 154 1182 1336 *Row% 11.7 88.3 100.0 *95% C.I. 8.8-14.5 85.5-91.1 *weighted Pearson Chi-square: 2.09, p=O.JS; Missing Values=9 Urban Rural Total Tab. 3.2.2.3 - Use of Oral Rehydratation Salts in Case of Diarrhoea in Children 0-59 months by Population Strata Oral Rehydratation Salts Total Yes No 18 70 88 *Row% 20.5 79.5 100.0 *95% C.I. 11.9-29.0 71.0-88.1 10 56 66 *Row% 15.1 84.8 100.0 *95% C.l. 5.0-25.3 74.7-95.0 28 126 154 *Row% 18.5 81.5 100.0 *95% C.I. 11.9-25.1 74.9-88.1 *weighted Pearson Chi-square: 0.71, p=0.40; Missing Values=1191 Tab. 3.2.2.4 - Prevalence of Cough in the Two Weeks Preceding the Survey in Children 0-59 months by Population Strata Cou!!h Total Yes No Urban 156 543 699 *Row% 22.3 77.7 100.0 *95% C.I. 17.5-27.2 72.8-82.5 Rural 92 546 638 *Row% 14.4 85.6 100.0 *95% C.I. 9.9-19.0 81 .0-90.1 39 Total 248 1089 1337 *Row% 19.0 81.0 100.0 *95% C.I. 15.6-22.4 77.6-84.4 *weighted Pearson Chi-square: 13. 77, p=0.0002; Missing Values=8 Tab. 3.2.2.5 - Prevalence of Vision Problems at Night in Children 0-59 months by Population Strata Vision Problems at Night Total Urban 6 651 657 *Row% 0.9 99.1 100.0 *95% C.I. -0.3-2.2 97.8-100.3 Rural 6 609 615 *Row% 1.0 99.0 100.0 *95% C.I. -0.6-2.6 97.4-100.6 Total 12 1260 1272 *Row% 0.9 99.1 100.0 *95% C.I. -0.1-1.9 98.1-100.1 *weighted Pearson Chi-square: 0.01, p=0.91; Missing Values=73 Immunisation coverage was investigated in children aged 13-24 months and figure 3.2.2.1 shows the results. In general the majority of the children had had been vaccinated with no significant differences detected between urban and rural. The third dose of DPT had been administered to 98% of the children (99% urban and 97% rural). The third dose of OPV had been administered to 98% of children that live in urban areas and to 97% of children that live in rural areas. The coverage for measles immunisation was 93% for urban children and 90% for rural children. Virtually the entire child population (95%) was immunised for BCG. 40 Figure 3.2.2.1- Immunisation Coverage in Children 13-24 months by Population Strata BCG MMR OPV OPT 0 20 40 60 80 Percentage of Population 100 Ill Rural • Urban Feeding patterns Breastfeeding The vast majority of sampled children under 2 years of age had been breastfed, at least par- tially (92% ), with no significant differences between urban and rural areas (Tab. 3.2.2.6). Forty five percent of the children under 4 months were exclusively breastfed (Tab. 3.2.2.7). Exclusive breastfeeding dropped progressively, until it was practised almost by no one after the age of 5 months (Fig. 3.2.2.2). Thus, the figure for exclusive breastfeeding under the age of 6 months is lower (30% ). In rural areas, exclusive breastfeeding was less common than in urban areas. Up to 4 months, 35% of the infants living in urban areas were receiving breast milk and other liquids. Predominant breastfeeding increased up to the age of 3 months, when 50% of the children in urban areas and 38% of the children in rural areas were fed in this way (Fig. 3.2.2.3). After the age of 3 months predominant breastfeeding dropped progressively both in urban and in rural areas. Predominant, exclusive or any other pattern of breast milk consumption was not influenced by mother's education or source of cash income of the household. Breastfeeding patterns were instead different among ethnic groups (Tab. 3.2.2.8, Tab. 3.2.2.9 and Tab. 3.2.2.10). The Turkish had the highest rates of exclusive predominant and ever breastfed; Macedonian were lower than the mean of the population. Breastfeeding on demand was widely practised (97% of the infants Tab. 3.2.2.11). Feeding occasions were typically 6 in the morning and 3 at night in the first month, then 4 in the morning and 3 at night (Tab. 3.2.2.12 and Tab. 3.2.2.13). Breastfeeding was started within the first 6 hours after delivery in less than one third of the cases (Tab. 3.2.2.14) and often (40%) with no help from health professionals (Tab. 3.2.2.15). The main reason for stopping breastfeeding was the perception that the mother had insufficient milk to feed the baby. This perception was more common in rural areas (Tab. 3.2.2.16). Vitamin supplements are commonly given to the infants from the first month of life. Table 3.2.2.17 shows that almost all the children were receiving supplements or medicines in the twenty-four hours preceding the interview. Urban Rural Total Tab. 3.2.2.6- Prevalence of Breastfeeding in Children 0-24 months by Population Strata Breastfeeding Total Yes No 625 51 676 *Row% 92.5 7.5 100.0 *95% C.I. 87.4-97.5 2.5-12.6 609 60 669 *Row% 91.0 9.0 100.0 *95% C.I. 86.5-95.5 4.5-13 .5 1234 111 1345 *Row% 91.8 8.2 100.0 *95% C.I. 88.4-95.3 4.7-11.6 *weighted Pearson Chi-square: 0.90, p=0.34; Missing Values=47 41 Tab. 3.2.2.7- FeedJngP~ttern of Children 0-4 months (a) and ~ont~s ~) by Population Strata 0-4 Months Exclusive Predominant Non Breastfed Breastfed + other energetic foods Urban 52 42 16 1 *Row% 46.8 37.8 14.4 0.9 *95% C.l. 38.0-55.7 29.3-46.3 8.2-20.6 -0.8-2.6 Rural 35 28 17 2 *Row% 42.7 34.1 20.7 2.4 *95% C.I. 28.2-57.1 21.9-46.4 10.3-31.2 -0.8-5.6 Total 87 70 33 3 *Row% 45.3 36.5 16.7 1.5 *95% C.l. 33.6-53.0 29.5-43.5 11.3-22.1 -0.1-3.1 Pearson Chi-square: 2.18, p=0.54; Missing Values=1199 0-6Months Exclusive Predominant Non Breastfed Breastfed + other energetic foods Urban 64 53 48 1 *Row% 38.6 31.9 28.9 0.6 *95% C.I. 29.2-47.9 24.3-39.6 20.3-37.5 -0.5-1.7 Rural 47 39 49 5 *Row% 33.6 27.9 35.0 3.6 *95% C.I. 21.5-45.6 18.4-37.3 26.8-43.2 0.1-7.0 Total 111 92 97 6 *Row% 36.6 30.3 31.3 1.8 *95% C.I. 29.2-43.9 24.4-36.2 25.3-37.4 0.2-3.3 Pearson Chi-square: 5.24, p=0.15; Missing Values=1086 42 Total 111 100.0 82 100.0 193 100.0 *weighted Total 166 100.0 140 100.0 306 100.0 *weighted -J: -c 0 E -Q) c:n ca -0 Ul Q) Ul Ul ca () Figure 3.2.2.2 - Prevalence of Exclusive Breastfeeding in Children 0-24 months by Population Strata 13-2 4 -- 7 12 .s::. -c: 0 6 E Q) 5 01 CCI -0 4 Ul Q) Ill 3 Ul .!!! 0 2 1 0 1 0 20 30 40 50 Percentage of Population 60 70 l'il R u ra I • Urban Figure 3.2.2.3 - Prevalence of Predominant Breastfeeding in 0-24 months old Children 13-24 7 1 2 - 6 5 4 3 2 1 0 1 0 20 30 40 50 Percentage of Population 60 70 II Rural • Urban 43 Tab. 3.2.2.8 - Prevalence of Breastfeeding in Different Ethnic Groups in Children 0-24 months Ever breastfed Total Yes No Macedonian 853 54 907 *Row % 94.1 5.9 100.0 *95% C.I. 91.6-96.7 3.3-8.4 Albanian 216 48 264 *Row% 81.2 18.8 100.0 *95% C.l. 69.9-92.5 7.5-30.1 Roma 63 2 65 *Row% 96.8 3.2 100.0 *95% C.I. 92.8-100.9 -0.9-7.2 Turkish 42 0 42 *Row% 100.0 0.0 100.0 *95% C.I. 100-100 Others 59 7 66 *Row % 89.5 10.5 100.0 *95% C.I. 82.4-96.6 3.4-17.6 Total 1233 111 1344 *Row % 91.8 8.2 100.0 *95% C.I. 88.4-95.3 4.7-11.6 *weighted Pearson Chi-square: 47.23, p=O.OOOO; Missing Values=48 Tab. 3.2.2.9 - Prevalence of Exclusive Breastfeeding in Different Ethnic Groups in Children 0-6 months Exclusive Breastfeeding Total Yes No Macedonian 73 161 234 *Row % 32.0 68.0 100.0 *95% C.I. 24.4-39.5 60.5-75.6 Albanian 20 36 56 *Row% 36.0 64.0 100.0 *95% C.I. 19.9-52.1 47.9-80.1 Rom a 6 11 17 *Row % 35.4 64.6 100.0 *95% C.l. 11.3-59.4 40.6-88.7 Turkish 7 6 13 *Row % 50.6 49.4 100.0 *95% C.I. 13.1-88.1 11.9-86.9 44 Others 5 5 10 *Row% 47.5 52.5 100.0 *95% C.I. 18.7-76.3 23.7-81.3 Total 111 219 330 *Row% 34.0 66.0 100.0 *95% C.l. 27.1-40.9 59.1-72.9 *weighted Pearson Chi-square: 4.33, p=0.36; Missing Values=l062 Tab. 3.2.2.10- Prevalence of Predominant Breastfeeding in Different Ethnic Groups in Children 0-6 months Predominant Breastfeeding Total Yes No Macedonian 67 167 234 *Row% 28.5 71.5 100.0 *95% C.I. 22.1-34.8 66.2-77.9 Albanian 13 43 56 *Row% 23.9 76.1 100.0 *95% C.l. 12.2-35.6 64.4-87.8 Rom a 7 10 17 *Row% 41.5 58.5 100.0 *95% C.l. 23.1-59.9 40.1-76.9 Turkish 3 10 13 *Row% 24.7 75.3 100.0 *95% C.I. 6.8-42.6 57.4-93.2 Others 2 8 10 *Row% 23.0 77.0 100.0 *95% C.l. -8.3-54.2 45.8-108.3 Total 92 238 330 *Row% 28.1 71.9 100.0 *95% C.I. 22.6-33.7 66.3-77.4 *weighted Pearson Chi-square: 3.22, p=0.52; Missing Values=998 Tab. 3.2.2.11 - Habit of Breastfeeding in Children 0-24 months by Population Strata Habit Total On Demand At Fixed Intervals Urban 289 14 303 *Row% 95.4 4.6 100.0 *95% C.I. 92.5-98.3 1.7-7.6 45 Rural 262 4 266 *Row% 98.5 1.5 100.0 *95% C.I. 96.7-100.3 -0.3-3.3 Total 551 18 569 *Row% 96.6 3.4 100.0 *95% C.I. 94.8-98.5 1.5-5.2 *weighted Pearson Chi-square: 4.49, p=0.03; Missing Values=823 Urban Rural Total Urban Rural Total 46 Tab. 3.2.2.12- N. of Suckles During the Night in Children 0-24 Months by Population Strata n Median 0-6 months 163 3 7-12 months 73 3 13-24 months 58 3 0-6 months 128 3 7-12 months 81 3 13-24 months 55 2 0-6 months 291 3 7-12 months 154 3 13-24 months 113 2 Tab. 3.2.2.13 - N. of Suckles During the Day in Children 0-24 Months by Population Strata n Median 0-6 months 165 6 7-12 months 77 4 13-24 months 58 4 0-6 months 127 5 7-12 months 81 4 13-24 months 55 4 0-6 months 292 5 7-12 months 158 4 13-24 months 113 4 Tab. 3.2.2.14- Time Lapse After Birth for Breastfeeding Children 0-24 months by Population Strata Time Lapse After Birth Total 30 minutes 6 hours > 6hours Urban 20 183 410 613 *Row% 3.3 29.9 66.9 100.0 *95% C.l. 1.6-5.0 21.8-37.9 58.0-75.8 Rural 77 167 356 600 *Row% 12.8 27.8 59.3 100.0 *95% C.l. 4.6-21.0 17.7-37.9 47.6-71.0 Total 97 350 766 1213 *Row% 7.4 29.0 63.6 100.0 *95% C.l. 3.7-11.1 22.7-35.3 56.4-70.8 *weighted Pearson Chi-square: 37.90, p=O.OOOOO; Missing Values=179 Tab. 3.2.2.15 -Help in Breastfeeding Children 0-24 months by Population Strata Kind of Help Total Health Other Nobody Professional Urban 386 11 227 624 *Row% 61.9 1.8 36.4 100.0 *95% C.l. 52.1-71.7 0.8-2.7 26.5-46.3 Rural 316 13 279 608 *Row% 52.0 2.1 45.9 100.0 *95% C.l. 39.6-64.3 0.1-4.2 33.1-58.6 Total 702 24 506 1232 *Row% 57.6 1.9 40.5 100.0 *95% C.l. 49.9-65.3 0.9-3.0 32.6-48.3 *weighted Pearson Chi-square: 12.28, p=0.002; Missing Values=160 Tab. 3.2.2.16 - Reasons for Breastfeeding Cessation for Children 0-24 Months by Population Strata Reasons to Stop Breastfeeding Total No Milk Mother's Baby's No No Pregnant illness illness weight time Urban 148 30 12 12 7 15 224 *Row% 66.1 13.4 5.4 5.4 3.1 6.7 100.0 *95% C.l. 58.6-73.6 8.7-18.1 2.2-8.6 2.3-8.4 0.7-5.5 2.5-10.9 47 Rural 211 14 9 10 - 11 255 *Row% 82.7 5.5 3.5 3.9 4.3 100.0 *95% C.I. 76.6-88.9 2.5-8.5 1.2-5.9 1.3-6.5 - 1.7-6.9 Total 359 44 21 22 7 26 479 *Total% 73.9 9.7 4.5 4.7 1.7 5.6 100.0 *95% C.I. 68.9-78.9 6.8-12.6 2.5-6.5 2.7-6.7 0.4-2.9 3.0-8.1 *weighted Pearson Chi-square: 23.19, p=0.0003; Missing Values=913 Tab. 3.2.2.17- Prevalence of Use of Vitamins, Mineral Supplements or Medicines in Children 0-24 months by Population Strata Breastfeeding Total Urban 407 268 675 *Row% 60.3 39.7 100.0 *95% C.I. 54.5-66.1 33.9-45.5 Rural 258 412 670 *Row% 38.5 61.5 100.0 *95% C.I. 30.7-46.3 53.7-69.3 Total 665 680 1345 *Row% 50.8 49.2 100.0 *95% C.I. 46.0-55.5 44.5-54.0 *weighted Pearson Chi-square: 63.86, p=O.OOOOO; Missing Values=47 Breast Milk substitution One fifth of the children were using infant formula, usually as a substitute for breast milk, with no differences between urban and rural areas. Infant formula was used in more cases at around the age of 5-6 months, as a transition to other foods at the cessation of breastfeeding (Fig. 3.2.2.4). Cow's milk was used as an alternative to breast milk for infants under 6 months in 5% of the cases in urban areas, but in 12% in rural areas. Cow's milk became a major food after the age of 6 months, but it is worth pointing out that, even in the second year of age, one fifth of the children were reported as having consumed it in the 24 hours before the survey (Fig. 3.2.2.5). The use of cow's milk was not related to the prevalence of anaemia in children 6-12 months old but the prevalence of severe cases of anaemia was higher in infants that consumed cow's milk (not shown). Fermented milk was not used in the first six months of life and was therefore not used as a breast milk substitute (Fig. 3.2.2.6). The dilution of cow's milk was more common (65%) in children under 6 (Tab. 3.2.2.18) than in older children (13%) (Tab. 3.2.2.19) and in more than half of the sample with the addition of sugar (Tab. 3.2.2.20). Indeed, sugar was added by almost three quarters of carers in rural areas. 48 Figure 3.2.2.4 - Prevalence of Use of Infant Formula in Children 0-24 months by Population Strata 13-2 4 -J: - 7 1 2 s::::: - 0 E 6 Q) tn 5 C'CI -0 1/) Q) 4 3 B R u ra I • Urban 1/) 1/) C'CI 2 (.) 1 0 5 10 15 20 25 30 Percentage of Pop u Ia tio n Figure 3.2.2.5 - Prevalence of Use of Cow's Milk in Children 0-24 months by Population Strata -J: -c 0 E Q) tn C'CI -0 1/) Q) 1/) 1/) C'CI (.) 13-24 7 1 2 - 6 5 4 3 2 1 0 10 20 30 40 50 60 70 80 Percentage of Population II R u ra I • Urban 49 1 i Figure 3.2.2.6- Prevalence of Use of Yoghurt or Fermented Milk in Children 0-24 months by Population Strata 1 3-2 4 ,-. .= . 7 1 2 c - Q e 6 '-' ~ t:lll 5 cu . Q 4 "' ~ 3 "' "' cu 2 -u 1 0 1 0 20 30 40 50 Percentage of Pop u Ia tio n 60 70 II R u ra I • Urban Tab. 3.2.2.18 - Use of Diluted Cow's Milk in Children 0-6 Months by Population Strata Diluted Cow's Milk Total Yes No Urban 8 4 12 *Row% 66.7 33.3 100.0 *95% C.I. 38.4-94.9 5.1-61.6 Rural 16 9 25 *Row% 64.0 36.0 100.0 *95% C.I. 44.5-83.5 16.5-55.5 Total 24 13 37 *Total% 65.0 35.0 100.0 *95% C.I. 48.9-81.1 18.9-51.1 *weighted Pearson Chi-square: 0.02, p=0.87; Missing Values=293 Urban 50 Tab. 3.2.2.19 -Use of Diluted Cow's Milk in Children 6-24 Months by Population Strata Diluted Cow's Milk Total Yes No 39 321 360 *Row% 10.8 89.2 100.0 *95% C.I. 7.6-14.0 86.92.4 Rural 63 317 380 *Row% 16.6 83.4 100.0 *95% C.I. 10.1-23.1 76.9-89.9 Total 102 638 740 *Total% 13.4 86.6 100.0 *95% C.I. 10.0-16.9 83.1-90.0 *weighted Pearson Chi-square: 5.13, p=0.02; Missing Values=322 Tab. 3.2.2.20- Sugar Addition to the Cow's Milk in Children 0-24 Months by Population Strata Sugar Addition Total Yes No Urban 177 194 371 *Row% 47.7 52.3 100.0 *95% C.I. 38.8-56.6 43.4-61.2 Rural 296 107 403 *Row% 73.4 26.6 100.0 *95% C.l. 64.8-82.1 17.9-35.2 Total 473 301 774 *Row% 65.3 34.7 100.0 *95% C.l. 53.1-66.0 34.0-46.9 *weighted Pearson Chi-square: 53.85, p=O.OOOOO; Missing Values=618 Other liquids The early introduction of liquids other than breast milk is a very popular habit in Macedonia, particularly in rural areas (Fig. 3.2.2.7). Water is introduced as early as the first week of life and by the age of 3 months more than half of the children are given water. Tea is also used in the same way, in addition or as an alternative to water. Only herbal teas are consumed (camomile, mint), while black tea is seldom used and is almost unavailable in the country. Fruit juices are also popular, and they are started introduced at around 3-4 months of age, one month earlier than the recommendation given by the MCH Institute. 51 Figure 3.2.2. 7 - Introduction of Liquids in Children 0-24 months by Population Strata f 13-24 ~ 7 _ 12 §. . "' m 0 . . . . m 0 "£ 13-24 ~ 7 _ 12 §. G "' m 0 . & . . . 0 Plain water 20 40 60 80 100 Percentage of Population Black tea :; 13·24 :; 7 _ 12 §. ~ 13-24 :; 7_12 §. . "' m 0 . . . . !! 0 Herbal tea 20 40 60 80 100 Percentage of Population Fruit juice 0 1 2 3 4 5 6 7 8 9 10 20 40 60 80 100 Percentage of Population Percentage of Population Sugar is added to drinks in less than half of the cases (Tab. 3.2.2.21). It may be presumed that liquids were given to the infants with a bottle, as almost two thirds of the mothers said they had used a bottle with a nipple for feeding within the last 24 hours. 40% of children under 6 months (Tab. 3.2.2.22) and 83% of children 6-24 months (Tab. 3.2.2.23) were using them with no differences between urban and rural areas. Urban Rural Total Tab. 3.2.2.21 - Sugar Addition to the Liquids in Children 0-24 Months by Population Strata . Sugar Addition Total Yes No 224 447 671 *Row% 33.4 66.6 100.0 *95% C.l. 27.1-39.7 60.3-72.9 320 346 666 *Row% 48.0 52.0 100.0 *95% C.I. 39.7-56.4 43.6-60.3 544 793 1337 *Row% 39.8 60.2 100.0 *95% C.I. 34.7-44.9 55.1-65.3 *weighted Pearson Chi-square: 29.70, p=O.OOOOO; Missing Values=55 52 Tab. 3.2.2.22 - Drinking from a Bottle with a Nipple in Children 0-6 Months by Population Strata Bottle with a Nipple Total Yes No Urban 61 108 169 *Row% 36.1 63.9 100.0 *95% C.I. 27.1-45.1 54.9-72.9 Rural 65 80 145 *Row% 44.8 55.2 100.0 *95% C.I. 34.7-54.9 45.1-65.2 Total 126 188 314 *Row% 39.6 60.4 100.0 *95% C.l. 32.8-46.4 53.6-67.2 *weighted Pearson Chi-square: 2.48, p=0.12; Missing Values=l6 Tab. 3.2.2.23 -Drinking from a Bottle with a Nipple in Children 6-24 Months by Population Strata Bottle with a Nipple Total Yes No Urban 417 88 505 *Row% 82.6 17.4 100.0 *95% C.I. 78.9-86.2 13.8-21.1 Rural 433 89 522 *Row% 83.0 17.0 100.0 *95% C.I. 78.0-87.9 12.1-22.0 Total 850 177 1027 *Row% 82.7 17.3 100.0 *95% C.I. 79.7-85.7 14.2-20.2 *weighted Pearson Chi-square: 0.02, p=0.87; Missing Values=35 Complementary Foods Complementary foods were given to the children starting from the fourth to fifth month. Fruit was the foodstuff that is introduced first. One fourth of the four month old infants had consumed fruit in the twenty-four hours preceding the interview (Fig. 3.2.2.8) Vegetables were introduced one to two months later, as the consumption was reported in five-six month old infants (Fig. 3.2.2.8). It must also be pointed out that there still was a proportion of children in the second semester of life, and even in the second year, that were not consuming 53 fruit and vegetables. Carbohydrate rich foods (porridges, pasta, biscuits, potatoes) were also introduced in the second semester of life (Fig. 3.2.2.9). Biscuits had been given to one third of the 5 month old children; porridges were less common, as only one fifth of the six month old children had had it and the proportion of consumers did not exceed 25% even in the following semester; bread, pasta and rice had the same initiation pattern, however by the second semester two thirds of the children had consumed them (Fig. 3.2.2.9); potatoes were consumed by more than half of the infants above the age of 6 months (Fig. 3.2.2.9). Meat is not introduced until 6 months and in approximately half of the older children consumed it (Fig. 3.2.2.10); fish is also introduced in the second semester, but less than one fourth of the children had consumed it (Fig. 3.2.2.10); the consumption of cheese and eggs was reported for half of the children in the second semester of life (Fig. 3.2.2.1 0). Figure 3.2.2.8 - Introduction of Fruit and Vegetables in Children 0-24 months by Population Strata £ 13-24 ~ 7 _ 12 ~ $ "' . 0 0 ~ 0 0 . 0 Fruit 20 40 60 80 Percentage of Population 100 ~ 13-24 ~ 7 _12 ~ . . . Vegetables 20 40 60 80 100 Percentage of Population Figure 3.2.2.9 - Introduction of Carbohydrate Rich Foods in Children 0-24 months by Population Strata 54 £ 13-24 ~ 7-12 ~ . . . 0 . . . u ~ 13-24 ~ 7-1 2 ~ . . . 0 . . . . . u Potatoes 20 40 60 80 100 Percentage of Population Bread. pasta & rice 20 40 60 80 100 Percentage of Population s 13-24 c ! i ~ . . 0 . . . u 7 _12 ~ 13-24 c 0 7 - 12 ~ . . . 0 0 . u Porridge 20 40 60 80 100 Percentage of Population Biscuits 20 40 60 80 100 Percentage of Population Nutritional status Anthropometry Anthropometric measurements were taken in children aged 6-59 months. Figure 3.2.2.10 shows the distribution of height-for-age Z score in the two population strata. The mean value for the whole population was -0.08±1.33, with significantly lower values for children living in rural areas. In rural children the mean of height-for-age Z score was below the internatio- nal references (-0.26±1.33) while in urban areas this value was near zero. The distribution of height-for-age Z score was the same in male and female children with no significantly differences ofthe mean values by sex (Fig. 3.2.2.11). 55 Urban Rural Total Approximately 7% of the children aged 6-59 months had height-for-age below - 2 Z score (Tab. 3.2.2.24), a figure in excess of the 3% that can be expected in a population of well nouri- shed children. A significant higher proportion (9%) of low height-for-age was observed in rural than in urban children (6%). The prevalence of low height-for age was particularly elevated in Roma children (32%) followed by Albanian (11 %); the other ethnic groups showed preva- lence lower than 5% (Tab. 3.2.2.25). One fourth (24%) of the children with low birth weight con- tinued to be small up to 5 years of age (Tab. 3.2.2.26). The percentage of children with low birth weight that remain small was particularly higher in rural areas (31%) than in urban areas (19%). Tab. 3.2.2.24 -Prevalence of Low Height-for-Age z score (HAZ) in children 6-59 months by Population Strata HAZ Total < -3 <2 Normal 6 27 541 574 *Row% 1.0 4.7 94.3 100.0 *95% C.I. 0.3-1.8 1.9-7.5 91.3-97.2 14 31 488 533 *Row% 2.6 5.8 91.6 100.0 *95% C.I. 0.7-4.6 3.3-8.3 88.1-95.0 20 58 1029 1107 *Row% 1.7 5.2 93.1 100.0 *95% C.I. 0.8-2.6 3.2-7.1 90.9-95.3 *weighted Pearson Chi-square: 4.69, p=0.09; Missing Va1ues=66 56 Tab. 3.2.2.25 -Prevalence of Low Height-for-Age z score (HAZ) in Children 6-59 Months of Different Ethnic Groups HAZ Total <-2 >-2 Macedonian 32 706 738 *Row% 4.2 95.8 100.0 *95% C.l. 2.2-6.2 93.8-97.8 Albanian 27 211 238 *Row% 10.8 89.2 100.0 *95% C.l. 5.9-15.7 84.3-94.1 Rom a 17 35 52 *Row% 32.4 67.6 100.0 *95% C.l. 15.8-49.0 51.0-84.2 Turkish 2 36 38 *Row% 5.3 94.7 100.0 *95% C.l. -1.1-11.7 88.3-101.1 Others - 40 40 *Row% - 100.0 100.0 *95% C.I. 100.0-100.0 Total 78 1028 1106 *Row% 6.9 93.1 100.0 *95% C.l. 4.7-9.1 90.9-95.3 Pearson Chi-square: 70.37, p=O.OOOO; Missing Values=67 *weighted Tab. 3.2.2.26- Birth Weight and Stunting in Children 6-59 Months HAZ Total <-2 >-2 Low 19 59 78 *Row% 23.7 76.3 100.0 *95% C.I. 11.5-35.8 64.2-88.5 Normal 52 816 868 *Row% 5.8 94.2 100.0 *95% C.l. 3.5-8.2 91.8-96.5 High 6 144 150 *Row% 4.1 95.9 100.0 *95% C.l. 0.9-7.2 92.8-99.1 Total 77 1019 1096 *Row% 6.9 93.1 100.0 *95% C.l. 4.6-9.1 90.9-95.4 *weighted Pearson Chi-square: 39.40, p=O.OOOO; Missing Values=77 57 The weight-for-height distributions of the Macedonian children was corresponding to the international reference with no differences between urban and rural areas (Fig. 3.2.2.13) and no differences by sex (Fig. 3.2.2.14). 58 - Reference ._ Both -+- Urban ·+· Rural - Reference -.- Both sexes -+- Boys ··•· Girls The prevalence of low weight-for-height was not much greater (3.5%) without appreciable differences between the different strata (Tab. 3.2.2.27). The prevalence of high weight-for- height (>2 z score), an indicator of being overweight, was 6% with no differences between urban and rural areas. Tab.3.2.2.27- Prevalence of Low Weight-for-Height Z score (WHZ) in children 6-59 months by Population Strata WHZ <-3 <2 Normal >2 Urban 3 17 520 30 *Row% 0.5 3.0 91.2 5.3 *95% C.I. -0.1-1.1 1.6-4.3 88.7-93 .8 3.4-7.2 Rural 2 18 489 23 *Row% 0.4 3.4 91.9 4.3 *95% C.I. -0.1-0.9 1.8-4.9 89.6-94.2 2.7-5.9 Total 5 35 1009 53 *Row% 0.5 3.1 91.5 4.9 *95% C.I. 0.1-0.9 2.1-4.2 89.8-93.3 3.6-6.2 *weighted Pearson Chi-square: 0.80, p=0.85; Missing Values=71 Total 570 100.0 532 100.0 1102 100.0 The weight-for-age indicator combines the effects of height and soft tissue growth in children. The distribution of weight-for-age by population strata is shown in figure 3.2.2.15 and the distribution by sex in figure 3.2.2.16. According to this indicator, most Macedonian children were classified as normal (Tab. 3.2.2.28), with 6% below -2 z score, this percentage is higher in rural areas (7%) than in urban (5%). 59 Tab. 3.2.2.28- Prevalence of low Weight-for-Age z score (WAZ) in Children 6-59 Months by Population Strata WAZ <-3 <2 Urban 3 25 *Row% 0.5 4.3 *95% C.I. 0.0-1.1 2.5-6.1 Rural 5 36 *Row% 0.9 6.6 *95% C.I. -0.3-2.2 3.3-9.9 Total 8 61 *Row% 0.7 5.3 *95% C.I. 0.1-1.3 3.6-7.0 Pearson Chi-square: 8.16, p=0.04; Missing Values=52 Micronutrients Normal 550 95.2 93.2-97.1 502 92.5 88.6-96.3 1052 94.0 92.0-96.0 Total 578 100.0 543 100.0 1121 100.0 *weighted Figure 3 .2.2.17 shows the haemoglobin distribution in children 6-59 months. The left side of the distribution is skewed, indicating the presence of anaemia. 60 Mild to Severe Anaemia ,//// .-•' ,' I I .- The mean haemoglobin value of children aged 6-59 months was significantly lower in rural than in urban areas (Tab. 3.2.2.29). The prevalence of anaemia (Tab. 3.2.2.30) was significantly higher in rural children (29% with 2% of severe cases) compared with the children living in urban areas (23% with virtual absence of severe cases). Tab. 3.2.2.29- Haemoglobin Concentration (g/dL) in Children 6-59 Months by Population Strata n Mean±SD Urban 544 1 1.95±1.43 Rural 535 11.60±1.68 Total 1079 11.77+1.57 t-Test: t=3.66 and p=0.0003; Missing Values=94. Tab. 3.2.2.30-Prevalence of Anaemia in Children 6-59 Months by Population Strata Anaemia Total Severe Moderate Mild No Anaemia (Hb <7 g!dL) (Hb7-9.9 g!dL) (Hbl0-10.9 gldL) (Hb>ll gldL) Urban 2 45 79 418 544 *Row% 0.4 8.3 14.5 76.8 100.0 . *95% C.l. -0.1-0.9 5.3-11.2 10.7-18.3 71.0-82.7 61 Rural 10 67 79 379 535 *Row% 1.9 12.5 14.8 70.8 100.0 *95% C.I. 0.8-3.0 8.8-16.2 11.2-18.3 65.0-76.6 Total 12 112 158 797 1079 *Row% 1.0 10.1 14.6 74.2 100.0 *95% C.I. 0.5-1.6 7.8-12.4 12.0-17.3 70.1-78.3 *weighted Pearson Chi-square: 11.49, p=0.009; Missing Values=94 Table 3.2.2.31 shows the prevalence of anaemia in different age classes. Anaemia was more common in the first and second years of life that were particularly critical with almost 40% of the children having less than 12 g/dL. The prevalence decreased in older children reaching 12% at 5 years of age. Tab. 3.2.2.31-Prevalence of Anaemia in Children 6-59 Months at Different Ages Anaemia Status Total Anaemia No Anaemia <12gldL 2:,12gldL 6-12 months 47 76 123 *Row% 37.4 62.6 100.0 *95% C.I. 27.3-47.4 52.6-72.6 12-24 months 116 169 285 *Row% 39.8 60.2 100.0 *95% C.I. 34.1-45.5 54.5-65.9 24-36 months 60 165 225 *Row% 25.8 74.2 100.0 *95% C.I. 18.0-33.7 66.3-82.0 36-48 months 33 201 234 *Row% 14.3 85.7 100.0 *95% C.I. 9.1-19.6 80.4-90.9 48-59 months 26 186 212 *Row% 12.4 87.6 100.0 *95% C.l. 7.0-17.7 82.3-93.0 Total 282 797 1079 *Row% 25.8 74.2 100.0 *95% C.I. 21.6-29.9 70.1-78.4 *weighted Pearson Chi-square: 79.33, p=O.OOOO; Missing Values=94 62 The highest prevalence of anaemia (Tab. 3.2.2.32) was observed among the Albanians (45%) followed by the Turkish (36%) and the Roma (33% ). Macedonians had the lowest prevalence of anaemia (19%). Severe anaemia was present in a very small percentage of Macedonians (0.5%) and in a higher percentage of Albanians (3%). Tab. 3.2.2.32 - Prevalence of Anaemia in Children 6-59 Months of Different Ethnic Groups HB concentration <12g/dL ~12g/dL Macedonian 135 577 *Row% 18.6 81.4 *95% C.I. 15.6-21.6 78.5-84.4 Albanian 106 131 *Row% 45.1 54.9 *95% C.I. 34.6-55.5 44.5-65.4 Roma 17 35 *Row% 32.8 67.2 *95% C.I. 23 .0-42.6 57.4-77.0 Turkish 13 25 *Row% 36.3 63.7 *95% C.l. 18.2-54.4 45.6-81.8 Others 11 28 *Row% 27.7 72.3 *95% C.I. 19.0-36.4 63.6-81.0 Total 282 796 *Row% 25.8 74.2 *95% C.I. 21.6-29.9 70.1-78.4 *weighted Pearson Chi-square: 63.90, p=O.OOOO; Missing Values=95 Total 712 100.0 237 100.0 52 100.0 38 100.0 39 100.0 1078 100.0 Serum ferritin concentration, as indicator of iron deficiency, was significantly higher in urban than in rural children. (Tab. 3.2.2.33). Table 3.2.2.34 shows the frequency distribution of ferritin levels. Half of the children studied had .low values of ferritin with significant differences between urban (47%) and rural (54%). In rural areas severe cases of iron deficiency ( 17%) were more common than in urban areas ( 11%). There were no cases of overloaded of iron. Tab. 3.2.2.33- Serum Ferritin Concentration (ng/mL) in Children 6-59 Months by Population Strata n Mean±SD Urban 534 25.34+41.79 Rural 514 21.45+14.27 Total 1048 23.43±31.50 t-Test: t=2.00 and p=0.04; Missing Values=125. 63 Urban Rural Total Tab. 3.2.2.34 - Prevalence of Normal and Abnormal Values of Ferritin in Children 6-59 Months by Population Strata Ferritin Levels Severe Mild Normal Over (<10 ng/ml) (1 0-20 ng/ml) (20-200 ng/ml) (>200 ng/ml) 59 193 281 1 *Row % 11.0 36.1 52.6 0.2 95% C.I. 8.0-14.1 32.0-40.3 48.2-57.0 -0.2-0.6 88 192 234 - *Row% 17.1 37.3 45.5 - 95% C.I. 12.6-21.7 32.4-42.3 39.9-51.1 147 385 515 1 *Row% 13.7 36.7 49.6 0.1 95% C.I. 11.0-16.3 33.5-39.8 46.1-53.0 -0.1-0.3 Total 534 100.0 514 100.0 1048 100.0 *weighted Pearson Chi-square: 10.63, p=O.Ol; Missing Values=125 Anaemia was associated to low ferritin in almost 70% of the cases, indicating that the cause of the condition is low iron status (Tab. 3.2.2.35). 64 Tab. 3.2.2.35 - Anaemia and Iron Status in Children 6-59 months Iron Status Total Low Normal Anaemia 190 85 275 *Row% 68.6 31.4 100.0 *95% C.l. 63.1-74.1 25.9-36.9 No Anaemia 341 427 768 *Row% 44.1 55.9 100.0 *95% C.l. 40.6-47.6 52.3-59.4 Total 531 512 1043 *Row% 50.5 49.5 100.0 *95% C.l. 47.0-53.9 46.1-53.0 *weighted Pearson Chi-square: 49.39, p=O. 0000; Missing Values= 130 The children's vitamin A status was investigated by the evaluation of serum retinol. Mean retinol concentration was significant higher in rural children than in urban (Tab. 3.2.2.36). In table 3.2.2.37 the frequency distribution of different levels of retinol in the two population strata is shown. In urban areas vitamin A deficiency (31%) was more common than in rural areas (28%) but severe cases of vitamin A deficiency were higher in rural (2%) than in urban children (1 %). Low retinol was present in 39% of anaemic children, significantly more than in non anaemic children (Tab. 3.2.2.38) Tab. 3.2.2.36 - Serum Retinol Concentration (Jlg/dL) in Children 6-59 Months by Population Strata n Mean±SD Urban 465 22.50+5.78 Rural 474 23.78±6.88 Total 939 22.94+6.37 t-Test: t=-2.35 and p=0.02; Missing Values=234. Urban Tab. 3.2.2.37- Prevalence of Normal and Abnormal Values of Retinol in Children 6-59 Months by Population Strata Retinol Levels Total Severe Mild Normal ( < 10 Jlg/dL) (10-20 _l!g/dL) (> 20 Jlg/dL) 5 141 319 465 *Row% 1.1 30.3 68.6 100.0 *95% C.I. 0.0-2.1 23.8-36.8 61.7-75.4 65 Rural 9 122 343 474 *Row% 1.9 25.7 72.4 100.0 *95% C.I. 0.0-3 .8 18.3-33.2 63.6-81.1 Total 14 263 662 939 *Row% 1.4 28.3 70.3 100.0 *95% C.I. 0.4-2.5 23.3-33.2 64.8-75.7 *weighted Pearson Chi-square: 3.30, p=0.19; Missing Values=234 Tab. 3.2.2.38 - Anaemia and Retinol Status in Children 6-59 Months Retinol Status Low Normal Anaemia 93 147 *Row% 39.4 60.6 *95% C.I. 31.5-47.2 52.8-68.5 No Anaemia 182 512 *Row% 26.4 73.6 *95% C.I. 20.8-32.0 68.0-79.2 Total 275 659 *Row% 29.7 70.3 *95% C.I. 24.3-35.1 64.9-75.7 Pearson Chi-square: 13.47, p=0.0002; Missing Values=239 Tab. 3.2.2.39- Serum Alkaline Phosphatase Concentration (lUlL) in Children 6-59 Months by Population Strata n Mean±SD Urban 509 177.98+91.40 Rural 501 178.61+52.23 Total 1010 178 .26+77 .55 t-Test: t=-0.13 and p=0.89; Missing Values=l63. Total 240 100.0 694 100.0 934 100.0 *weighted Tab. 3.2.2.40- Prevalence of Normal and Abnormal Values of Alkaline Phosphatase in Children 6-59 Months by Population Strata Alkaline Phosphatase Levels Total Low Normal High Urban 127 371 11 509 *Row% 24.9 72.9 2.2 100.0 *95% C.I. 19.3-30.5 67.4-78.3 1.0-3.3 66 Rural 106 383 12 501 *Row% 21.2 76.4 2.4 100.0 *95% C.l. 16.9-25.4 71.8-81.1 0.7-4.1 Total 233 754 23 1010 *Row% 23.3 74.4 2.3 100.0 *95% C.l. 19.6-27.0 70.7-78.1 1.3-3.2 *weighted Pearson Chi-square: 2. 06, p=0.3 6; Missing Values= 163 A high level of serum alkaline phosphatase was used as a biochemical indicator of the pre- sence of rickets. This pointed to a prevalence of 2% in the children studied with no signi- ficant differences by strata (Tab. 3.2.2.40). The analysis of the distribution by age classes did not show a particularly critical age. Low values of alkaline phosphatase may be indicative of poor growth, but the observed prevalence of 23% contrasts with the stunting observed preva- lence (7%). Rickets signs were observed in a variable proportion of children (Fig. 3 .2.2.18). The most common was frontal and parietal bossing (FPB), observed in 15% of the children with a significant higher prevalence in rural (20%) than in urban areas (12%). The second most common signs was beading of the ribs (R 3%); here rural children (4%) also had a significantly higher prevalence than urban children (2% ). The epiphyseal enlargement of the wrist (W 2%), the delay of the closure of anterior fontanella (AF) beyond 18 months (2%) and craniotabes (CT) were the least commonly observed signs (1 %) with no differences between urban and rural areas. Figure 3.2.2.18 - Prevalence of Clinical Signs of Rickets in Children 0-59 months by Population Strata Craniotabes Anterior Fontanella Enlargement of the Wrist Beading of the Ribs Frontal and Parietal Bossing 0 2 4 6 8101214161820 Percentage of population a Rural • Urban 67 DISCUSSION AND CONCLUSIONS The survey has shown a good achievement of the UNICEF programme objectives in the a of immunisation. Coverage is very high, with rates close to 100% for DPT and OPV :: slightly lower rates (90-95%) for MMR and BCG. Continuous surveillance and maintena1 of the system is required, but the present programme organisation seems to be satisfacto with regards to population impact. However, limitations in survey data due to problems locating all record cards makes a full evaluation difficult. In as far as access to water and sanitation, the survey has shown that some rural areas nt improvements, particularly for sanitation facilities. Microbiological monitoring of wa supplies and effective chlorination should be ensured in remote rural areas. As far as the nutrition component is concerned, the survey did not show major deficienc in adults. Low BMI was present in 6% of the women and anaemia was present in 12% of mothers, mainly in a mild and moderate form. On the other hand, high BMI (above 30) v present in 11% of the women, more in rural than urban areas. Goitre still affects 10% women and can be dealt with via simple dietary modifications. The development of diet guidelines, still not achieved in Macedonia, should therefore be supported and included part of a National Action Plan for Nutrition. In children, low weig for-height was low, p sent in 6% of the c1 dren as was stunt (7% ). Both values slightly higher than ceptable, indicating t although there are major nutritional pn lems are not present the whole populati they do exist but in srr population sub-grou Poverty, particularly urban areas, is a rna contributing factor. Sub-groups of the population, characterised by different culture and fc patterns may be affected by chronic malnutrition and should be the target for specific hea interventions. The observed micronutrient deficiencies may constitute more of a public health problem large proportion of the children had mild retinol deficiency (30% ), with higher rates in url areas. Low retinol is likely to have an impact on immune function and should be correct Due to an absence of severe forms, vitamin A supplementation programmes are not advis Existing moderate manifestations might be dealt with by dietary modifications, particula by improved complementary feeding practices. Low haemoglobin was present in 27% of the children, but again only mild forms were det ted. The measurement of serum ferritin confirmed that in most instances anaemia was caw by iron deficiency. Severe iron deficiency was observed in 14% of the cases; mild in 37o/c the cases; severe forms were more common in rural areas. Dietary modification might a 68 overcome iron deficiency in young children. The use of cow's milk as a breast milk substi- tute, often undiluted, is a cause of microscopic intestinal blood loss, and the poor accessibi- lity and availability of products with high iron bioavailability, such as meat, in some popula- tion groups may be another explanation. There is a presence of Rickets in Macedonia, but in a lower proportion of children than expected. High alkaline phosphatase was only observed in 2% of the cases. Again, the con- sumption of dairy products in winter and the early exposure to the sun during the summer are the best way of preventing the development of this condition. Observation of children's feeding patterns suggest that educational efforts in this area might be rewarding in terms of public health impact. Levels of exclusive breastfeeding are still unsatisfactory, received by less than half of the children under 4 months. This is due to the bad practice of early liquid introduction. The use of breastmilk substitutes is not widespread, but it could be further reduced. Better support should be given by the health staff at the time of delivery, as only a minority seems to be helping mothers to breastfeed and very few follow the advice to put the child to the breast as early as possible. Complementary feeding practices can also be improved. Meat, milk, fruit and vegetables are not given as often as is recommended, probably for reasons of availability and affordability. 69 RECOMMENDATIONS As a result of the survey findings, the following recommendations can be formulated: For the general population 1. Continue maintenance and surveillance of the immunisation system; 2. Children's feeding practices; a) Objectives + increase exclusive BF rates until the age of 6 months + improve complementary feeding practices b) Actions + Implementation of BFHI: improvements in the timely initiation of breastfeeding is one priority area + Implementation ofiMCI + adaptation of IMCI feeding recommendations • training of health staff • implementation of public health education c) Training messages + breastfeeding counselling: promote exclusive and continued breastfeeding in the community and early introduction of liquids should be discouraged + feeding recommendations: promote recommendations for complementary feeding including the introduction of meat, dairy products, fruit and vegetables from the sixth month + management of diarrhoeal diseases + diagnosis and management of rickets d) Health education messages + Infant feeding ( <6 months) • earlier BF initiation • Promote exclusive breastfeeding • Discourage early introduction of li~uids • Discourage tea • Discourage cow's milk + Infant feeding ( 6-12 months) • Encourage mashed fruit and vegetables • Encourage earlier introduction of meat and fish + ORTuse + Child care + Encourage exposure to sunshine 3) Antenatal care a) Objectives + Reduce anaemia in women of fertile age 70 b) Actions • training of health staff • preparation of educational materials • nutritional advice to women c) Health education message • use fresh fruit juices • use vegetables • use meat and fish, if available 4) Dietary improvement in the general population a) Objectives • Increase the consumption of fruit and vegetables • Improve dietary variety • Control body weight b) Actions • Design of Dietary Guidelines as part of a National Action Plan for Nutrition • Promote dietary recommendations in adults: control body weight; promote fruit and vegetable consumption; 5) Micronutrient fortification of food a) The rates of anaemia observed in children under 5 years (26%) and in non pregnant women (12%) in reproductive age place Macedonia in a low risk category. Iron fortification is not considered a priority nor justified at present. b) The high prevalence of low serum retinol in children place Macedonia in a high risk category. Food fortification strategies may be considered, although the feasibility, cost and beneficiaries that can be reached should be carefully evaluated. 6) Micronutrient supplementation • Supplementation may be considered a provisional measure, while more long term strategies, such as dietary improvement and food fortification are established. Supplementation requires a capillary distribution system and careful monitoring. Decisions should be taken as to which age group should be included and to which protocol should be adopted (dose/frequency of administration). • Vitamin supplements may have disadvantages: side effects, cause nutrient imbalances, toxicity, malabsorption, create long-term dependency and lack of confidence in locally supplements; cost of programme implementation 7) Health and nutrition surveillance a) Objectives • monitor nutrition related diseases and nutrition risk factors • formulate nutrition policy recommendations • evaluate impact of nutrition programmes 71 b) Actions • Design the system • area 1 :children and women in reproductive age • area 2 : adults and elderly • Training of health staff and standardisation of data collection and management • Provision of equipment • to sentinel sites • to central food safety laboratory • Implement pilot collection for 1-2 years • in health centers • in sentinel sites For population sub-groups with poorer nutritional status Evaluate the feasibility of nutrition support programmes, using food coupons or distribution of food products with normal or modified nutrient composition, under the surveillance of the health service. 8) Improvement of dietary quality a) Objectives • to improve fruit and vegetable consumption • to improve availability throughout the year • to improve accessibility b) Actions • food donations • subsidised purchases • support to home gardening • improvements of production and marketing infrastructure 9) Improvements in water and sanitation 1 0) Micronutrient supplementation 72 SAMPLE 2"d STAGE Urban Rural Cluster Number Municipality Cluster Number Municipality 1 Kicevo 31 Bito1a 2 Kochani 32 Bosilovo 3 Kumanovo 33 Va1andovo 4 Kumanovo 34 Veles 5 Ohrid 35 Vrapciste 6 Ohrid 36 Gostivar 7 Prilep 37 Demir Kapija 8 Probistip 38 Dolneni 9 Sveti Niko1e 39 Zelino 10 Strumica 40 Ilinden 11 Tetovo 41 Kavadarci 12 Stip 42 Klecevce 13 Gazi Baba 43 Kriva Palanka 14 Gazi Baba 44 Kukurecani 15 Gorche Petrov 45 Labunista 16 Karposh 46 Lozovo 17 Karposh 47 Mogila 18 Kisela Voda 48 Negotino 19 Kise1a Voda 49 Orizari 20 Kisela Voda 50 Petro vee 21 Centar 51 Radovis 22 Centar 52 Rostusa 23 Chair 53 Saraj 24 Chair 54 Star Dojran 25 Bitola 55 Strumica 26 Bitola 56 Tearce 27 Veles 57 Tetovo 28 Vinica 58 Cesinovo 29 Gostivar 59 Gazi Baba 30 Delcevo 60 Kise1a Voda 73 GIDDELINES FOR INTERVIEWERS AND MEASURERS I. Choosing Clusters The Team Supervisors and Team Leader are responsible for choosing clusters. They should proceed in the following order, with the suggestions listed in order of desirability. You may have to use a combi-nation of these methods. Option 1. Ask the local Authorities to provide you with a list of households and their add- resses. Number progressively the households listed and randomly pick a single household. Option 2. Map the area and number all dwellings. Randomly pick a single household. Option 3. Divide the area into segments of approximately equal population and randomly choose a single segment. Continue to segment that area until you have a small area, then count and number the households and randomly choose the first household. Option 4. Divide the cluster by natural boundaries, e.g. a stream and a mountain range, then approximate the number of persons living in each segment. Number the population in each segment consecutively, e.g. if segment A contains 450 people, assign the number 1 - 450 to that segment. Randomly choose a number between 1 and the total population of that cluster. Choose the segment that includes that number. Continue to segment that area until you have a small area, then count and number the households, and randomly choose the first household. Option 5. Allocate a number of starting points spread out on the boundary map. Put these points on easy to locate spots along the boundary of the map, with at least two points in the middle of the map. Link points to a landmark so they can be identified. Randomly choose one of the numbers, and make that your starting point. Option 6. Locate the center of your cluster. Spin a bottle. Follow a line out of the edge of the village/area of the town, count all the households that fall on that line. Pick a random number between 1 and the total number of households that fall on that line. That will be your first household. II. Choosing households • Begin at the single household that was randomly chosen. Ask if among the household members there is a child under 5 or an elderly man or woman. If there are members of that category of people you are looking for, proceed with your survey. If there are not, continue to the next closest house to your left, as you exit the house. This is the next house that you survey. Always proceed to the next house to the left, until you have completed your cluster. • If you arrive at the edge of town before you have completed your quota of interviews, continue to the next closest house to the left, even if it is in the next town/village. • If you visit 10 consecutive households whose members do not include any of the people you are looking for, ask a local person where the next suitable household can be found in the same direction you were heading (i.e. to the left). Proceed to that household. 74 • If you come across an apartment block or other multi-storied building, choose a random number between 1 and the total number of floors and begin your next interview at the first door to the left as you come into that floor. After surveying all households on that floor, flip a coin. If the coin is "heads", proceed with the next floors up, until all households above have been surveyed and proceed with the next dwelling to the left of the apartment building. Likewise, if that coin is ''tails" proceed with the next floors down. • Watch the running totals for different target groups (children 0-59 months; children 0-24 months; men >65 and women >65). Until you survey 22 children aged 0-59 months, complete all relevant parts of the questionnaire for those children and their mothers. After you have completed your quota of children aged 0-59 months, carry on looking only for other households containing target individuals for whom you have not yet completed a quota (i.e. children 0-24 months and elderly people). • For the additional households that only include children 0-24 months complete the relevant parts of the questionnaire, but do not perform anthropometry, clinical or laboratory measurements. • For the additional households that only include elderly people, complete the household section and the relevant parts of the questionnaire. + If you have completed the quota for elderly, do not include additional elderly even if you find them in the households that are included because of children. + If you have completed the quota for children under 5, do not include additional children even if you find them in the households that are included because of elderly people. II. Definitions • Dwelling: a building or residential unit. It may contain one or more households. • Households: a group of persons who live together and share their meals and share their resources . III. What each interviewer should do • Follow the instructions to select the next household in the cluster (look at flow chart). • Fill out the cluster control sheet for each cluster. Note the time of second visit. Each empty house, refusal, or house where not all the women or children were at,home, must be revisited at least once. If the mothers are not back within the day, go to the next house and do not include data on children. • Introduce yourself to household members and conduct the interview. • Apply the questionnaire to the mother of every selected child. Measure all the selected children and all their mothers. Don't measure weight, height or haemoglobin, nor examine the thyroid of pregnant women. • If the household also has elderly men and women, administer the elderly questionnaire. If the household has elderly people but not children under 5, only apply the household and elderly questionnaire. 75 • If the household is composed of multiple couples, but all share their meals and income source, they should be treated as a single household, and information about women, children and elderly should be included in the same questionnaire. If the couples only share the dwelling, they should be treated as separate households. • If the household hosts other individuals temporarily (i.e. for less than 1 year) and if they qualify for the assessment, do not include them' as the other members of that household; if other individuals or relatives are hosted for longer periods, regard them as members of that household. • Fill out the data collection sheet carefully, with neat handwriting. • Check all answer sheets at the end of the day to validate accuracy, completeness and legibility. Then review again with the supervisor. Special situations in the field I. The selected small area can not be reached. Survey the closest area to the original one that cannot be reached. Record all replacements in the field notebook. 2. The selected small area contains fewer households that the required cluster size. Survey all houses in the area, then move to the area that is closest to the last household you did in the original area. 3. The household contains refugees in addition to residents. Survey the residents only, if the household complies with inclusion criteria. Note the presence of refugees in the questionnaire (Q.3) 4. Some members of the household are not at home. If the missing household members are persons we would measure, ask if the household member will be home at a later time and make arrangements to return, if possible. If it is not possible to meet the missing person later, record the _information for this person as "don't know/no answer" on the answer sheet. 5. The residents refuse to be interviewed Never accept a refusal as definite. Encourage the household members to participate, offer to return later in the day, etc. Ask the other team interviewer to try later in the day. Make at least one additional attempt to convince the household member to participate. If they still refuse, do not add any additional households. 76 Strata (Urban or Rural): ______ _ CLUSTER CONTROL SHEET Cluster name: ------------ Remember you need a total of: 11 men > 65 years 11 women >65 years Cluster Number: I I I Team Leader: Team Number: I I 22 children 0-59 months ----------------- Continue on a new sheet if necessary (remember to fill in all the information at the top of the sheet). and their mothers plus additional children to give a total of 24 children aged 0-24 months FLOW CHART FOR ACTION BY TEAM LEADERS I Locate house and knock or ring bell I I 0 I I Does anyone answer? I 0 ~ I l Are the people in the house ~ a refugee family? Are there any of the following people normally living in the house? 0 Ask neighbours ( 1) people > 65 years old, ~ (2) children < 5 years old, (3) children < 2 years old Do they know details of who lives 0 in the house ? Check on your cluster control sheet. Do you need more people -0 in any of these age groups? 0 0 Go back in 1-2 Try and fill in the household questionnaire and collect the information hours about all the people in all the required age groups that live in the household. The mother or her permanent replacement, (or the elderly person or their carer) must answer questions. 0 0 I Were all <he people in <he hou«hold you ~ Is anyone in the I needed to interview in the house ? 0 house? .___ Did they agree to take part? Try to make an appointment to go back later and find them. If 0 0 the mother (or the elderly per- 0 son) are still not there replace Fill in a questionnaire them with another household. number on the cluster Do NOT give them a number control sheet on the cluster control sheet Replace them with another household d Do you need more people in any age group? l Do NOT give them a questionnaire 0 I number on the ~ cluster control sheet Go to the next house and start again at the top of this sheet I You have finished the cluster! I 78 QUESTIONNAIRE Household information: to be observed and registered by the interviewer 1 I Type of dwelling 1=flat; 2= house; 2 I No. of rooms Enter number Household interview Respondent : mother 3 Status 1 =Residents; 2 =Residents hosting refugees; 4 Ethnic group 1 = Macedonian; 2 = Albanian; 3 = Roma; 4 = Turkish; 5 = others 5 Report age (in years and months) and sex of each household member. List mothers with codes W1-W4; children under 5 with codes C1-C4; elderly people with codes E1-E4 and other individuals with codes 01-04 6 Gender of the household head ? 1=male; 2=female 7 What is the head of household level of 1 =illiterate education? 2 = incomplete elementary school; 3 = elementary school; 4 = secondary school; 5 = short university degree; 6 = long university degree; 9 =don't know/no answer 8 What is your family's main source of cash 1 =private business; income? 2 =salary; 3 =pension; 4 = farming; 5 = social aid; 6 = no cash income; 9 =don't know/no answer 9 In the last week did your family receive food 1 = yes; 2=no; from your relatives/ friends/neighbours? 9 =don't know/no answer 10 Did your family sell or trade any household 1 = yes; 2=no; goods in the past month? 9 =don't know/no answer 11 Did you receive social assistance in food aid in 1 = yes; 2=no; the last six months? 9 =don't know/no answer 12 Do you grow fruit or vegetables? 1 = yes; 2=no; 9 =don't know/no answer 13 Do you keep small animals for meat and milk 1 = yes; 2=no; production? 9 =don't know/no answer 14 Are there any disabled among the household 1 =no; members? 2 = yes, blind; 3 =yes, deaf; 4 = yes, motor disability; 5 = yes, mental disability; 6 =yes, terminal disease; 9 =don't know/no answer 79 15 In the last week how many times did the family Enter number (0-7times/week); meals include meat or fish? 9 =don't know/no answer 16 In the last week how many times did the family Enter number (0-7 times/week); meals include milk, sour milk, yoghurt or 9 =don't know/no answer cheese? 17 In the last week how many times did the family Enter number (0-7 times/week); meals include bread? 9 =don't know/no answer 18 In the last week how many times did the family Enter number (0-7 times/week); meals include pasta, rice or potatoes? 9 =don't know/no answer 19 In the last week how many times did the family Enter number (0-7 times/week); meals include pulses (beans, lentils, peas, etc.)? 9 =don't know/no answer 20 In the last week how many times did the family Enter number (0-7 times/week); meals include vegetables? 9 =don't know/no answer 21 In the last week how many times did the family Enter number (0-7 times/week); meals include fruit? 9 =don't know/no answer 22 In the last year, did any members of your family 1 = yes; 2=no; die? (if no, jump to 24) 9 = don't know /no answer 23 At what age did the person die (for children Enter number of years aged<12 months, write 1 year) (more than one 999 =don't know/no answer answer is allowed). 24 What is the source of drinking water for 1 =Piped-in dwelling; members of your household? 2 = Public tap; 3 = Tube well or borehole; 4 = Protected dug well or protected spring; 5 = Unprotected dug well or spring, rainwater; 6 =Pond, river or stream; 7 =Tanker/truck; 8 =other; 9 =don't know/no answer 25 How far is this source from your dwelling? 1 = On premises; 2 =Less than 100 metres; 3 =lOOm- 500 m; 4 = 500m-lkm; 5 = More than 1 km; 9 =Don't know/no answer; 26 If there is a pipe, how often do you have water? 1 = constantly; 2=once a day; 3 = every two or more days and so on; 9 =don't know/no answer 27 What kind of toilet facility does your household 1 = Flush to sewage system; use? 2 = Flush to septic tank; 3 = Pour flush latrine; 4 = Covered by dry latrine (luftcloset); 5 = Uncovered latrine; 6 = No facilities at all 9 =Don't know/no answer; 80 28 How far is the facility from your dwelling? 1 = In dwelling; 2 = Less than 50 m away; 3 = 50 m or more away; 9 =Don't know; Child health and infant feeding interview: all children 0-59 months (beginning with the youngest) Respondent : mother or permanent replacement 29 Child code Report code from question 5 30 Mother's code ReQ_ort code from _guestion 5 31 What is [your child's] date of birth? Enter day/month/year 32 What was [your child's] birth weight? Enter child's birth weight in Kg 9.9 =don't know/no answer 33 Has [your child] had diarrhoea (more than three 1 = yes; 2 =no; loose stools day) in the past two weeks? (if no 9 =don't know/no answer jump to 35) 34 Did you use Oral Rehydration Salts? 1 =yes; 2 =no; 9 =don't know/no answer 35 Did [your child] have cough in the past 2 1 = yes; 2 = no; weeks? 9 =don't know/no answer 36 Does [your child] have vision problems at nigh? 1 =yes; 2 =no; (vision adaptation to darkness) 9 =don't know/no answer If the child is aged 13-24 months: (check immunization card or accept mother's report) 37 Has the child taken DPT dose III? 1 = yes; 2 = no; 9 =don't know/no answer 38 Has the child taken OPV dose III? 1 = yes; 2=no; 9 =don't know/no answer 39 Has the child been administered MMR? 1 = yes; 2=no; 9 =don't know/no answer 40 Has the child been administered BCG? 1 = yes: scar present; 2 =yes: documented with card; 3 = no: documented with card; 9 =don't know/no answer How was the information in questions 37-40 1 = immunization card; obtained? 2 = mother's report; If the child is aged 0-24 months: 41 Has [your child] ever been breastfed? 1 = yes; 2 = no; (if no or don't know, skip to 49) 9 =don't know/no answer 42 Since this time yesterday, has [your child] been 1 = yes; 2 = no; breastfed? 9 =don't know/no answer (If no, skip to 46) 43 How many times did you breastfeed [your Enter number of times child] last night between sunset and sunrise? 81 44 How many times did you breastfeed [your Enter number of times child] yesterday during the daylight hours? 45 How do you breastfeed [your child]? 1 = on demand; 2 =at fixed intervals; 9 =don't know/no answer 46 How long after birth did you put [your child] to 1 = within the first 30 minutes the breast? from delivery; 2 =within the first 6 hours; 3 = more than 6 hours after delivery; 9 =don't know/no answer 47 Did somebody help you with BF, in the first 1 = health professional; week? 2 =other; 3 =nobody; 9 = don't know /no answer 48 Why did you stop breastfeeding? 1 = not enough milk; 2 =mother's illness; 3 =baby's illness; 4 = baby was not gaining enough weight; 5 =no time; 6 = mother became pregnant; 9 = don't know /no answer 49 Since this time yesterday, has [your child] 1= yes; 2 = no; received any of the following drinks? 9 =don't know/no answer a) Plain water b) Herbal tea (camomille, fennel, hibiscus) c) Black tea (Indian, Chinese) d) Fruit juices (if not to all of them, jump to 51) 50 Did you add sugar to the above drinks? 1 = yes; 2 = no; 9 =don't know/no answer 51 Since this time yesterday, has [your child] 1 =yes; 2 =no; received any of the following items? 9 =don't know/no answer a) Vitamins, mineral supplements, medicines b) Infant formula c) Yoghurt or other fermented milk d) Vegetables e) Potatoes f) Fruit g) Porridge (polenta, kachamak) h) Bread, pasta, rice i) Meat j) Fish k) Cheese 1) Eggs m) Biscuits 82 52 Since this time yesterday, did you give cow's 1 =yes; 2 =no milk to [your child]? (if the answer is no, jump 9 =don't know/no answer to 55) 53 Did you dilute the cow's milk? 1 = yes; 2 = no; 9 =don't know/no answer 54 Did you add sugar to the cow's milk? 1 =yes; 2 =no; 9 =don't know/no answer 55 Since this time yesterday, did [your child] drink 1 = yes; 2 = no; anything from a bottle with a n~le? 9 =don't know/no answer Mothers' interview: (include pregnant women) 56 Woman's code Rt1:'_ort code from _question 5 57 What is your family status? 1 =single; 2 = registered marriage; 3 = not registered marriage; 4 =divorced or lived apart from husband; 5 =widow; 9 =don't know/no answer 58 What is your level of education? 1 = illiterate; 2 = incomplete elementary school; 3 = elementary school; 4 = secondary school; 5 =short university degree; 6 = long university degree; 9 = don't know /no answer 59 Are you employed? 1 = employed; 2 = no employment outside the household; 9 =don't know/no answer 60 How many pregnancies did you have? Enter number; 0 = none; (including abortions and still births) 99 =don't know/no answer 61 How many miscarriages or abortions did you Enter number; 0 = none; have? 99 =don't kpow/no answer 62 If pregnant, which is the month of current Enter number; 0 = not pregnant; pregnancy? (completed months) 99 =don't know/no answer 63 When you were pregnant, did you register at 1 = yes; 2 = no; well women's clinic? (pregnant women should 9=don't know/no answer reply for the present pregnancy) Mothers' anthropometry, laboratory and clinical examination: (Exclude pregnant women) 64 Height. Measure woman's height in em to the Enter value; 888.8 = refused; nearest 0.1 em 65 Weight. Measure woman's weight in kg to the Enter value; 888.8 =refused; nearest 0.1 kg 83 66 Examine woman' s thyroid 1 = no goitre; 2 = goitre detectable only by palpation and not visible; 3 = goitre palpable and visible; 8 = refused; 9=not examined 67 Anaemia. Record haemoglobin value (from Enter value; 88.8 =refused; Hemocue) to the nearest 0.1 g/dL Children's anthropometry and laboratory examination: all children a2ed 6-59 months (until you have filled the quota) 68 Child code Report code from question 5 69 Height. Measure recumbent length for Enter value; 888.8 = refused; children 6- 23.9 months old (in em, to the 999.9 =not present nearest 0.1 em); measure standing height for children ~24 months old (in em, to the nearest 0.1 em) 70 Weight. If the child is unable to stand, Enter value; 0 =the child is measure the weight of the adult who will be able to stand; 888.8 = refused; holding the child for weighing (in kg, to the 999.9 =not present nearest 0.1 kg) 71 Weight. If the child is able to stand, measure Enter value; 888.8 = refused; the weight of the child (in kg, to the nearest 999.9 =not present 0.1 kg); if the child is unable to stand, measure the weight of the child plus adult (in k_g, to the nearest 0.1 kg) 72 Anaemia. Record haemoglobin value (from Enter the value; 88.8 =refused; Hemocue) to the nearest 0.1 g/dL 99.9 = not present Collect blood sample Children's clinical examination: all children aged 0-59 months 73 Presence of epiphyseal enlargement of the 1 =yes; 2 =no; 8 =refused; wrist 9 = not examined 74 Presence of craniotabes 1 = yes; 2 = no; 8 = refused; 9 = not examined 75 Presence of frontal and parietal bossing 1 = yes; 2 = no; 8 = refused; 9 = not examined 76 Presence of beading of the ribs 1 = yes; 2 = no; 8 = refused; 9 = not examined 77 If the child is more than 18 months : 1 =yes; 2 =no; 8 =refused; presence of open anterior fontanelle on 9 = not examined _Q_alpation; 84 ISBN 9989·883·08·4 ISBN 9989·830·19·3

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