Ernährungssituation in Nord-Laos [Elektronische Ressource] : Determinanten der Unterernährung und Veränderungen nach vier Jahren intensiver Interventionen / eingereicht von Silvia Kaufmann
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English
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Ernährungssituation in Nord-Laos [Elektronische Ressource] : Determinanten der Unterernährung und Veränderungen nach vier Jahren intensiver Interventionen / eingereicht von Silvia Kaufmann

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245 Pages
English

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Justus-Liebig-Universität Giessen Fachbereich Agrarwissenschaften, Ökotrophologie und Umweltmanagement Institut für Ernährungswissenschaft Dissertation Ernährungssituation in Nord-Laos – Determinanten der Unterernährung und Veränderungen nach vier Jahren intensiver Interventionen Eingereicht von: Dipl. oec. troph. Silvia Kaufmann aus Alsfeld Betreut von: Prof. Dr. Claus Leitzmann Giessen, Oktober 2008 iiJustus Liebig University Giessen Faculty of Agricultural Science, Nutritional Science and Environmental Management Institute of Nutritional Sciences Dissertation The nutrition situation in Northern Laos – determinants of malnutrition and changes after four years of intensive interventions Submitted by: Dipl. oec. troph. Silvia Kaufmann Alsfeld Supervised by: Prof. Dr. Claus Leitzmann Giessen, October 2008 iiiTable of contents List of tables .............................................................................................................vi List of figures...........................................................................................................iix List of abbreviations .................................................................................................x 1 Introduction.............................................................................................1 1.

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Justus-Liebig-Universität Giessen
Fachbereich Agrarwissenschaften,
Ökotrophologie und Umweltmanagement
Institut für Ernährungswissenschaft





Dissertation


Ernährungssituation in Nord-Laos –
Determinanten der Unterernährung und Veränderungen
nach vier Jahren intensiver Interventionen



Eingereicht von:

Dipl. oec. troph. Silvia Kaufmann

aus Alsfeld



Betreut von:

Prof. Dr. Claus Leitzmann

Giessen, Oktober 2008




iiJustus Liebig University Giessen
Faculty of Agricultural Science, Nutritional Science and
Environmental Management
Institute of Nutritional Sciences





Dissertation


The nutrition situation in Northern Laos –
determinants of malnutrition and changes after four years of
intensive interventions



Submitted by:

Dipl. oec. troph. Silvia Kaufmann

Alsfeld



Supervised by:

Prof. Dr. Claus Leitzmann

Giessen, October 2008




iiiTable of contents

List of tables .............................................................................................................vi

List of figures...........................................................................................................iix

List of abbreviations .................................................................................................x

1 Introduction.............................................................................................1
1.1 Subject and objectives of the study ..........................................................1
1.2 Conceptual framework of malnutrition ......................................................3
1.2.1 Introduction to the framework .................................................................. 3
1.2.2 The different levels of the framework – content and indicators................ 6
1.3 The global nutrition and food situation and trends..................................16
1.4 Food and nutrition security assistance within the German
Development Co-operation.....................................................................22
1.5 The situation in Lao People’s Democratic Republic................................23
1.6 The Lao-German Integrated Food Security Programme Nalae and
Sing district, Northern Laos ....................................................................29

2 Methodology .........................................................................................31
2.1 Sample size calculation and procedure of data collection ......................31
2.2 Methods of data collection......................................................................34
2.3 Anthropometric assessment ...................................................................39
2.4 Qualitative information and secondary data............................................43
2.5 Statistical analysis ..................................................................................44

3 Results...................................................................................................46
3.1 Outcome level46
3.1.1 Nutritional status of children and mothers.............................................. 46
3.1.2 Child mortality........................................................................................ 53
3.2 Direct causes..........................................................................................56
3.2.1 Family’s food intake............................................................................... 56
3.2.2 Infant and young child feeding............................................................... 62
3.2.3 Health status 71
3.3 Indirect causes .......................................................................................77
3.3.1 Access and use of health services ........................................................ 77
3.3.2 Water, sanitation and hygiene 86
3.3.3 Food security and livelihood .................................................................. 92
3.4 Basic causes ........................................................................................108
3.4.1 Education..............................................................................................108
3.4.2 Social status of women.........................................................................113
3.4.3 Accessibility of the location...................................................................118
3.4.4 Basic causes and nutritional status (multifactorial analysis) .................121

4 Discussion and conclusions .............................................................125
4.1 Outcome level.......................................................................................125
4.2 Direct causes132
4.2.1 Family’s food intake..............................................................................132
4.2.2 Infant and young child feeding practices ..............................................139
4.2.3 Health status.........................................................................................143
4.3 Indirect causes .....................................................................................146
iv4.3.1 Access and use of health services .......................................................146
4.3.2 Water, sanitation and hygiene ..............................................................148
4.3.3 Food security and livelihood .................................................................150
4.4 Basic causes ........................................................................................161
4.5 Determinants of malnutrition – multi-factorial analysis..........................167
4.6 Overall conclusions ..............................................................................171

Summary .............................................................................................................173

Zusammenfassung................................................................................................177

Literature181

Annex .............................................................................................................200



v
List of tables

Table 1: Global and regional trends in chronic malnutrition from 1980 to
2005 .....................................................................................................16
Table 2: Sample size calculation....................................................................... 32
Table 3: Number of households, mothers and children studied by district in
1997 and 2001 .....................................................................................32
Table 4: Demographic information by district in 1997 and 2001........................ 33
Table 5: Comparison of death and mortality rate, Nalae district 38
Table 6: Degree of malnutrition in children........................................................ 41
Table 7: Classification of severity of malnutrition within a population by
prevalence rates of children under 5 years.......................................... 41
Table 8: Degree of chronic energy deficiency in adults..................................... 42
Table 9: Chronic malnutrition by district in 1997 and 2001................................ 46
Table 10: Acute malnutrition by1997 and 2001 ................................... 49
Table 11: Underweight by district in ............................................ 50
Table 12: Prevalence of malnutrition by sex and district in 1997 and 2001......... 50
Table 13: Malnutrition of mothers by grade in 1997 and 2001 ............................ 51
Table 14: Malnutrition of mothers by age in 1997................................................ 52
Table 15: Mothers and children’s nutritional status in 1997................................. 52
Table 16: Prevalence of anaemia by district in 1997 and 2001 ........................... 53
1Table 17: Child death by age and district in 1997 .............................................. 53
Table 18: Infant and child death rate by district in 1997 and 200) ....................... 54
Table 19: Evolution of mortality rates in Nalae district from 1997 to 2001........... 54
Table 20: Number of meals, snacks and nutritional status in 1997 ..................... 57
Table 21: Number of food items and nutritional status by source in 1997 ........... 62
Table 22: Initiation of breastfeeding in 1997........................................................ 63
Table 23: Type of first feeding by district in 1997 ................................................ 63
Table 24: Time of first introduction of complementary food by district in 1997 .... 64
Table 25: Age of first introduction of plant and animal products by
district in 1997 ......................................................................................65
Table 26: Accessibility of location and introduction of complementary
food in 1997..........................................................................................65
Table 27: Duration of breastfeeding by age group and district in 1997 ............... 66
Table 28: Introduction of common complementary food, plant and animal
products and height-for-age in 1997.....................................................67
Table 29: Introduction of complementary food, plant and animal products and
weight-for-height in 1997..................................................................... 67
Table 30: Time of weaning and morbidity in 1997............................................... 68
Table 31: Initiation of breastfeeding and introduction of complementary food
in 1997 and 2001..................................................................................70
Table 32: Morbidity by age groups in 1997 ......................................................... 72
Table 33: Morbidity and height-for-age in 1997................................................... 74
Table 34: Morbidity and weight-for-height in 1997 74
Table 35: Morbidity and anaemia in 1997 ........................................................... 75
Table 36: Morbidity by district in 1997 and 2001 ................................................. 76
Table 37: Diarrhoeal diseases by district in 1997 and 2001 ................................ 76
Table 38: Persons consulted for treatment of diarrhoea diseases in
1997 and 2001 .................................................................................... 78
Table 39: Participation in growth monitoring and promotion 82
viTable 40: Number of birth and child death per mother by district in
1997 and 2001 .....................................................................................84
Table 41: Natal health care by district in 1997 and 2001..................................... 85
Table 42: Possession and use of bed nets in 2001............................................. 86
Table 43: Water supply systems in 1997 and 2001 88
1Table 44: Purification of drinking water in 1997 and 2001.................................. 88
Table 45: Water quality and height-for-age in 1997 and 2001............................. 89
Table 46: Sanitary facilities by district in 1997 and 2001..................................... 90
Table 47: Hygiene conditions and height-for-age in 1997 ................................... 91
Table 48: Rice production system by district .............................. 93
Table 49: Harvest situation in December 1996 and December 2000 .................. 93
Table 50: Rice sufficiency in 1997 and 2001, villagers self-assessment ............. 94
Table 51: Production system and chronic malnutrition in 1997 and 2001 ........... 95
Table 52: Production system, rice yields and height-for-age in 1997
and 2001 ..............................................................................................95
Table 53: Wealth categories by possession of livestock and death rates
in 1997 and 2001..................................................................................97
Table 54: Annual cash income per household by district in 1997 and 2001 ........ 99
Table 55: Income groups by district in 1997 and 2001 .......................................100
Table 56: Income and height-for-age in 1997 and 2001.....................................102
Table 57: Income and weight-for-height and acute malnutrition in 1997 ............103
Table 58: Occupation and nutritional status in 1997...........................................103
Table 59: Income and morbidity in 1997 ............................................................104
Table 60: Change in quality of housing by district in 1997 and 2001..................105
Table 61: Housing conditions, income and height-for-age in 1997 and 2001.....107
Table 62: Possession of household commodities in 2001..................................107
Table 63: Education of mothers and fathers in 1997..........................................108
Table 64: Education of mothers and fathers and nutritional status in 1997 ........109
Table 65: Nutritional status and determinants by parent’s literacy status
in 1997................................................................................................111
Table 66: Education, social status of women and height-for-age in 1997 ..........112
Table 67: Attendance to non-formal classes and ability to read and write by
district in 1997 and 2001 ....................................................................113
Table 68: Women’s decision power and height-for-age and chronic
malnutrition in 1997 ............................................................................115
Table 69: Nutritional status and determinants by women’s decision power .......117
Table 70: Women’s decision power, head of household and height-for-age
in 1997118
Table 71: Nutritional status and determinants by accessibility of location
in 1997 ...............................................................................................120
Table 72: Basic causes and nutritional status in 1997........................................122
Table 73: Basic causes and acute malnutrition in 1997 .....................................122
Table 74: Chronic malnutrition and determinants in 1997 ..................................123
Table 75: Comparison of chronic malnutrition and annual rate of change..........125
Table 76: Comparison of underweight and annual rate of change .....................128
Table 77: Comparison of chronic dietary energy deficiency in mothers and
annual rate of change by grade..........................................................130
Table 78:
annual rate of change.........................................................................130
Table 79: Comparison of mortality rates in Nalae district and national
averages.............................................................................................132
Table 80: Estimated daily intake of energy and protein derived from rice ..........134
viiTable 81: Changes in infant and young child feeding practices .........................142
Table 82: Changes in morbidity..........................................................................143
Table 83: Changes in water, hygiene and health care .......................................150
Table 84: Changes in food production and livelihood.........................................160
Table 85: Determinants of malnutrition, regression, multi-factorial model,
inter-sectorial analysis........................................................................168
Table 86: Determinants of change in malnutrition, multi-factorial model ............170


viiiList of figures

Figure 1: Conceptual framework of malnutrition ................................................... 2
Figure 2: Context-specific conceptual framework, levels and sectors assessed 15
Figure 3: Population pyramid of Lao PDR .......................................................... 24
Figure 4: Changes in moderate and severe chronic malnutrition by district in
1997 and 2001 .....................................................................................47
Figure 5: Chronic and acute malnutrition by age groups in 1997 and 2001.........48
Figure 6: Causes of child death in 1997 ............................................................. 55
Figure 7: Proportion of food group items out of total number of items
consumed in 1997 ................................................................................58
Figure 8: Immunisation coverage and vitamin A supplementation by district
in 1997 and 2001..................................................................................80
Figure 9: Decision making power of mothers and fathers in 1997.....................114
Figure 10: Decision making and chronic malnutrition in 1997 .............................116
Figure 11: Morbidity, water quality and height-for-age.........................................148
Figure 12: Income and height-for-age .................................................................159
Figure 13: Causalities between women’s social status, literacy and height-for-
age .....................................................................................................165
Figure 14: Significant determinants and their association with height-for-age.....169

ixList of abbreviations

ACC/SCN United Nation’s Administrative Committee on Coordination / Sub-
Committee on Nutrition
ADB Asian Development Bank
AIDS Acquired immune deficiency syndrome
ANOVA Analysis of variance
ANCOVA is of Covariance
ARI Acute respiratory infections
BCG Bacille Calmette-Guérin, vaccine
BMI Body-mass-index
BMZ Bundesministerium für Wirtschaftliche Zusammenarbeit und
Entwicklung (Federal Ministry for Economic Co-operation and
Development)
CDC Centers for Disease Control
CDR Child death rate
CFSVA Comprehensive Food Security and Vulnerability Analysis
CIA Central Intelligence Agency
CMR Child mortality rate
DAFO District Agriculture and Forestry Office
DEO District Education Office
DGLV Dark green leafy vegetables
DHO District Health Office
DPT Diphtheria, Pertussis, Tetanus
DSE-ZEL Deutsche Stiftung für Entwicklung - Zentralstelle für Ernährung und
Landwirtschaft
EPI Expanded Programme on Immunisation
EC European Commission
FANTA Food and Nutrition Technical Assistance
FAO Food and Agriculture Organisation
FIVIMS Food Insecurity and Vulnerability Information and Mapping Systems
GDP Gross Domestic Product
GoL Government of Lao PDR
GTZ Gesellschaft für Technische Zusammenarbeit (Agency for Technical
Cooperation)
HAZ Height-for-age z-score
HIV Human Immunodeficiency Virus
HDI Human Development Index
ICCIDD International Council for the Control of Iodine Deficiency Disorders
IDD Iodine deficiency disorders
IDR Infant death rate
IFPRI International Food Policy Research Institute
IFSP Integrated Food Security Programme
IISD International Institute for Sustainable Development
IMF International Monetary Fund
IMR Infant mortality rate
Inwent Internationale Weiterbildung und Entwicklung
IRRI International Rice Research Institute
IU International unit
IUNS International Union of Nutritional Sciences
IUCN The World Conservation Union
IYCF Infant and young child feeding
xLao PDR Lao’s People’s Democratic Republic
LECS Lao Expenditure and Consumption Survey
LNAS Lao Nutritional Assessment Survey
LBW Low birth weight
MDGs Millennium Development Goals
MI Micronutrient Initiative
MoAF Ministry of Agriculture and Forestry
MoH Ministry of Health
MSG Mono-sodium glutamate
MSF Médecins Sans Frontières
NAFRI National Agriculture and Forestry Research Institute
NCHS National Centre for Health Statistics
NNP National Nutrition Policy
NSC l Statistical Center
NTFP Non-timber forest products
NWSEHP National Water Supply and Environmental Health Programme
ODI Overseas Development Institute
SCN Standing Committee on Nutrition
SE Standard error
SEAMEO Southeast Asian Ministers Education Organisation
SD Standard deviation
SIWI Stockholm International Water Institute
SMART Standardized Monitoring and Assessment of Relief and Transition
TBA Traditional Birth Attendant (trained)
UN United Nations
UNAIDS United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nations Fund for Population Activities (since 1987: United
Nations Population Fund)
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations (International) Children's Fund
UNSIAP United Nations Statistical Institute for Asia and the Pacific
UNU United Nations University
USAID United States Agency for International Development
USA United States of America
USD United States Dollar (currency of the United States of America)
VHW Village Health Worker
WAZ Weight-for-age z-score
WFP World Food Programme
WFS World Food Summit
WHO World Health Organisation
WHZ Weight-for-height z-score
xi