A Snapshot of Poor Adolescent Girlsâ€&#x; Nutrition and Related Issues in Pakistan
ACKNOWEDGEMENT Studying the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition and on the sources of nutrition information the adolescents have access to and use’ is a project funded by the Maternal and Newborn Health Programme Research and Advocacy Fund (RAF) and is implemented by Fatima Memorial Hospital (FMH), in partnership with the Nur Center for Research and Policy (NCRP). On behalf of the Fatima Memorial Hospital (FMH), I would like to whole heartedly acknowledge the support of Research & Advocacy Fund (RAF) towards undertaking this vital piece of research. For all of us who were part of this project, it was not merely a research study but one of the most cherished and memorable times of our lives. During this period we entered into fruitful collaborations with provincial partners; experienced the diversity of cultures in the four provinces; gained support of the provincial health and nutrition departments; and received valuable insights from leading nutrition technical experts across the country. The project helped strengthen the research infrastructure at the Nur Center for Research & Policy, the implementing partner of the FMH. Under the technical leadership of Dr Tasleem Akhtar, the entire team was committed to following high level standards in research. Innovative data collection techniques were explored and all efforts were made to involve the policy and decision makers through all stages of research. It was an ambitious project that was expected to be delivered in four provinces in a limited time period. The dedication of the entire Nur Team deserves a high note of appreciation. Without their devotion and commitment beyond the call of duty, it would not have been possible to accomplish what we did in such limited time span. The RAF Research Project was a tremendous learning experience that we shall all cherish forever. We sincerely hope that the evidence generated will help transform lives of the marginalized adolescent girls in our country.
For RAF Declaration
Dr Shabnum Sarfraz Principal Investigator Page 1
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
DISCLAIMER This document is an output from a project funded by the UK Department for International Development (DFID) and the Australian Department of Foreign Affairs and Trade (DFAT) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, DFAT or the Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF), which can accept no responsibility or liability for such views, for completeness or accuracy of the information, or for any reliance placed on them.
DECLARATION We/I have read the report titled: “A Snapshot of poor adolescent girls‟ nutrition and related issues in Pakistan” and acknowledge and agree with the information, data and findings contained.
For RAF Declaration
Dr. Shabnum Sarfraz, Principal Investigator RAF Project Office – Fatima Memorial Hospital (FMH)
Authors Dr. Tasleem Akhtar (Senior Technical Advisor) Dr. Shabnum Sarfraz (Principal Investigator) Dr. Roomi Aziz (Project Director)
Provincial Contributors Maha Rehman and Ali Rizvi – Sindh Prof. Dr. Mukhtiar Zaman and Dr. Zeeshan Kibria- Khyber Pakhtunkhwa Dr. Tahira Kamal- Balochistan
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
CONTENTS ACKNOWEDGEMENT................................................................................................................. 1 DISCLAIMER ................................................................................................................................ 2 CONTENTS .................................................................................................................................... 3 LIST OF FIGURES ........................................................................................................................ 5 LIST OF TABLES ........................................................................................................................ 12 LIST OF APPENDICES ............................................................................................................... 14 LIST OF ABBREVIATIONS ....................................................................................................... 15 EXECUTIVE SUMMARY .......................................................................................................... 17 Methodology ............................................................................................................................. 18 Results ....................................................................................................................................... 19 Conclusion................................................................................................................................. 22 Recommendations ..................................................................................................................... 23 RESEARCH REPORT ................................................................................................................. 26 1.
Introduction and Background ............................................................................................ 26 1.1 Aims and Study Objectives ............................................................................................. 28
2.
Literature Review............................................................................................................... 30 2.1. Historical Developments and Laws affecting women‟s rights and empowerment ........ 30 2.2. Social Status, Marriage and Education ........................................................................... 33 2.3. Anti-Women Practices .................................................................................................... 35 2.4. Health and Nutrition ....................................................................................................... 36
3.
Project Implementation ...................................................................................................... 40 3.1. Inception & Development Phase .................................................................................... 40 3.2. Study Design and Methodology ..................................................................................... 43 3.3. Data Analysis & Reporting............................................................................................. 55 3.4. Ethical Approval ............................................................................................................. 60
4.
Results ................................................................................................................................ 62 4.1. Study adolescent girls‟ background and characterization .............................................. 64 4.2. Social Status and Financial Empowerment .................................................................... 77 Page 3
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4.3. Dietary Patterns and Nutritional Status ........................................................................ 102 4.4. Study adolescent girls‟ access to and utilisation of available health and nutrition services ................................................................................................................................ 141 DISCUSSION AND CONCLUSIONS ...................................................................................... 183 6.1 Discussion ......................................................................................................................... 183 6.2 Conclusion......................................................................................................................... 188 RECOMMENDATIONS ............................................................................................................ 190 REFERENCES ........................................................................................................................... 193
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LIST OF FIGURES Fig.2.2a: Marital status among females of age group 15-19 years in the region (UNFPA & PopulationCouncil, 2007) ............................................................................................................. 34 Fig.2.2b: Percentage of 20-24 year old females who were married by ages 15 and 18 (UNFPA & PopulationCouncil, 2007) ............................................................................................................. 34 Fig.2.4.1: Percentage of females entering puberty, work or marriage by age (UNFPA & PopulationCouncil, 2007) ............................................................................................................. 38 Fig.2.4.2: Body Mass Index (BMI) of women of reproductive age (15-49 years)(Planning Commission, 2011) ....................................................................................................................... 39 Fig.3.2.4: Multi-stage sampling flow chart ................................................................................... 49 Fig.4.1.1a: Provincial distribution of study adolescent girls‟ age................................................. 65 Fig.4.1.1b: Rural and urban distribution of age of study adolescent girls ................................... 65 Fig.4.1.2a: Provincial distribution of age at menarche of the study adolescent girls ................... 66 Fig.4.1.2b: Urban and rural distribution of age at menarche of study adolescent girls ................ 67 Table4.1.3a: Median household income and range across provinces and urban and rural location ....................................................................................................................................................... 68 Fig.4.1.3a: Provincial distribution of study adolescent girls‟ households‟ monthly income ........ 68 Fig.4.1.3b: Rural and urban distribution of study adolescent girls‟ household Income ............. 69 Fig.4.1.4a: Provincial distribution of household size of study adolescent girls .......................... 70 Fig.4.1.4b: Urban and rural distribution of household size of study adolescent girls ................. 71 Fig.4.1.5a: Provincial distribution of type of houses of the study adolescent girls ...................... 72 Fig.4.1.5b: Urban and rural distribution of house types of study adolescent girls ....................... 72 Fig.4.1.6a: Provincial distribution of number of rooms used for sleeping in the study adolescent girls houses.................................................................................................................................... 73 Fig.4.1.6 b: Rural and urban distribution of number of rooms used for sleeping in the houses of study adolescent girls .................................................................................................................... 74 Fig.4.2.1a: Provincial distribution of age at marriage of study adolescent girls .......................... 78 Fig.4.2.1b: Rural and urban distribution of ages at marriage of study adolescent girls ............... 78 Table 4.2.2a: Median age and range of age difference with spouses of study married girls ........ 81 Fig.4.2.2a: Provincial distribution of age difference with spouses of study married adolescent girls ............................................................................................................................................... 82 Page 5
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
Fig.4.2.2b: Rural and urban distribution of age difference with spouse of study married adolescent girls.............................................................................................................................. 82 Fig.4.2.3a: Provincial distribution of level of education of study adolescent girls ..................... 85 Fig.4.2.3b: Rural and urban distribution of level of education of study adolescent girls ............. 85 Fig.4.2.4a: Provincial distribution of education of spouses of the study married adolescent girls ....................................................................................................................................................... 86 Fig.4.2.4b: Rural and urban distribution of education of spouses of study married adolescent girls ....................................................................................................................................................... 86 Fig. 4.2.5a: Provincial distribution of households‟ opinion on women employment ................... 89 Fig. 4.2.5b: Rural and urban distribution of households‟ opinion on women employment ......... 90 Fig. 4.2.5c: Provincial distribution of ever-employed status of study adolescent girls ................ 90 Fig. 4.2.5d: Urban and rural distribution of ever employed status of study adolescent girls ....... 91 Fig.4.2.5e: Provincial distribution of currently- employed status of study adolescent girls ........ 92 Fig.4.2.5f: Rural and urban distribution of currently- employed status of study adolescent girls 92 Fig.4.2.5g: Provincial distribution of type of employment of ever-employed study adolescent girls ............................................................................................................................................... 93 Fig.4.2.5h: Rural and urban distribution of type of employment of ever-employed study adolescent girls.............................................................................................................................. 94 Fig.4.2.5i: Provincial distribution of type of employment of spouses of married adolescent girls ....................................................................................................................................................... 94 Fig.4.2.5j: Provincial distribution of employment status of spouses of married adolescent girls 95 Fig.4.2.5k: Provincial distribution of mean monthly incomes/salaries earned by ever-employed study adolescent girls .................................................................................................................... 96 Fig.4.2.5l: Rural and urban distribution of mean monthly income/salaries of ever-employed participants .................................................................................................................................... 96 Fig.4.2.5m: Comparison of monthly incomes earned by ever- employed married adolescent girls with that of spouses across provinces ........................................................................................... 97 Fig.4.2.5m: Provincial distribution of control over spending of the study adolescent girls on the income earned by them ................................................................................................................. 98 Fig.4.2.5n: Rural and urban distribution of control over spending of study adolescent girls on the income earned by them ................................................................................................................. 98 Fig.4.2.5o: Provincial distribution of percentage of self-earned income spent on own needs ..... 99 Page 6
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Fig.4.2.5p: Rural and urban distribution of percentage of self-earned income spent on own needs ..................................................................................................................................................... 100 Fig.4.2.5q: Provincial distribution of level of financial empowerment of the study adolescent girls ............................................................................................................................................. 100 Fig.4.2.5r: Rural and urban distribution of level of financial empowerment of the study adolescent girls............................................................................................................................ 101 Fig.4.3.2a: Provincial distribution of Households‟ spending on food ....................................... 105 Fig.4.3.2b: Urban and rural distribution of households‟ spending on food ................................ 106 Fig.4.3.3a: Provincial distribution of reported food shortage in the households of study adolescent girls............................................................................................................................ 107 Fig.4.3.3b: Urban and rural distribution of reported food shortage in households of study adolescent girls............................................................................................................................ 107 Fig.4.3.3c: Provincial distribution of adolescent girls reporting whether they had enough food to eat ................................................................................................................................................ 108 Fig.4.3.3d: Urban and rural distribution of adolescent girls reporting whether they had enough food to eat ................................................................................................................................... 109 Fig.4.3.4a: Provincial distribution of number of meals taken daily in study adolescent girls‟ households................................................................................................................................... 110 Fig.4.3.4b: Rural and urban distribution of daily meals taken by the study adolescent girls‟ households................................................................................................................................... 111 Fig.4.3.4c: Provincial distribution of meals missed by study adolescents girls‟ households .... 111 Fig.4.3.4d: Rural and urban distribution of meals missed by study adolescents girls‟ households ..................................................................................................................................................... 112 Fig.4.3.5a: Provincial distribution of knowledge about micronutrients among the study adolescent girls............................................................................................................................ 119 Fig.4.3.5b: Rural and urban distribution of knowledge about micronutrients among the study adolescent girls............................................................................................................................ 119 Fig.4.3.5d: Rural and urban distribution of intake of nutritional supplements among the study adolescent girls............................................................................................................................ 120 Fig.4.3.5c: Provincial distribution of intake of nutritional supplements among the study adolescent girls............................................................................................................................ 121 Fig.4.3.5e: Provincial distribution of type of nutritional supplement being taken by the study adolescent girls............................................................................................................................ 122 Page 7
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Fig.4.3.5 f: Rural and urban distribution of type of nutritional supplement taken by the study adolescent girls............................................................................................................................ 122 Fig.4.3.5g: Provincial distribution of persons who advised nutritional supplements ................ 123 Fig.4.3.5h: Rural and urban distribution of persons who advised nutritional supplements....... 123 Fig.4.3.5i: Provincial distribution of knowledge about iodised salt in the households of study adolescent girls............................................................................................................................ 124 Fig.4.3.5j: Rural and urban distribution of knowledge about iodised salt in the study adolescent girls‟ households ......................................................................................................................... 125 Fig.4.3.5k: Provincial distribution of use of iodised salt by households of the study adolescent girls ............................................................................................................................................. 125 Fig.4.3.5l: Rural and urban distribution of use of iodised by households of study adolescent girls. ..................................................................................................................................................... 126 Fig.4.3.5m: Provincial distribution of mean calorie intake from different daily meals of study girls‟ households ......................................................................................................................... 126 Fig.4.3.5n: Urban and rural distribution of mean calories intake from different meals of study girls‟ households ......................................................................................................................... 127 Fig.4.3.5o: Provincial distribution of the study girls‟ satisfaction with their own health .......... 131 Fig.4.3.5p: Rural and urban distribution of the study girls‟ satisfaction with their own health . 131 Fig.4.3.5q: Provincial distribution of the study adolescent girls‟ satisfaction with their weight 132 Fig.4.3.5r: Rural and urban distribution of the study adolescent girls‟ satisfaction with their weight .......................................................................................................................................... 133 Fig.4.3.6a: Provincial distribution of weight for age of the study adolescent girls .................... 134 Fig.4.3.6b: Urban and rural distribution of weight for age of the study adolescent girls ........... 134 Fig.4.3.6c: Provincial distribution of ranking of height for age of the study adolescent girls ... 135 Fig. 4.3.6d: Rural and urban distribution of ranking of height for age of the study adolescent girls ............................................................................................................................................. 135 Fig.4.3.6e: Provincial distribution MUAC with cutoffs of <22cm, <23 cms and <24 cms of the study adolescent girls .................................................................................................................. 137 Fig.4.3.6f: Rural and urban distribution of MUAC of the study adolescent girls ..................... 138 Fig.4.3.6g: Provincial distribution of BMI of study adolescent girls ......................................... 139 Fig.4.3.6h: Urban and rural distribution of BMI of study adolescent girls ................................ 140
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Fig.4.4.1a: Provincial distribution of frequency of receipt of nutrition advice by the study adolescent girls............................................................................................................................ 144 Fig.4.4.1b: Rural and urban distribution of frequency of receipt of nutrition advice by the study adolescent girls............................................................................................................................ 145 Fig.4.4.1c: Provincial distribution of sources of nutrition advice of the study adolescent girls . 146 Fig. 4.4.1d: Rural and urban distribution of sources of nutrition advice of the study adolescent girls ............................................................................................................................................. 146 Fig.4.4.1e: Provincial distribution of access to school teachers of the study adolescent girls for health and nutrition advice .......................................................................................................... 148 Fig.4.4.1f: Rural and urban distribution of access to school teachers of the study adolescent girls for health and nutrition advice .................................................................................................... 148 Fig.4.4.1g: Provincial distribution of frequency of consultation with school teachers for health and nutrition advice..................................................................................................................... 149 Fig. 4.4.1h: Rural and urban distribution of frequency of consultation with school teachers for health and nutrition advice .......................................................................................................... 150 Fig.4.4.1i: Provincial distribution of availability of different categories of health care providers to the study adolescent girls‟ community ................................................................................... 150 Fig.4.4.1j: Rural and urban distribution of availability of different categories of health care providers to the study adolescent girls‟ community ................................................................... 151 Fig.4.4.1k: Provincial distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls .................................................................... 152 Fig.4.4.1l: Rural and urban distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls ............................................................ 152 Fig.4.4.1m: Provincial distribution of the study adolescent girls‟ access to health facility ....... 153 Fig.4.4.1n: Rural and urban distribution of the study adolescent girls‟ access to health facility 153 Fig.4.4.1o: Provincial distribution of type of nearby facility available to the study adolescent girls ............................................................................................................................................. 154 Fig.4.4.1p: Rural and urban distribution of type of nearby facility available to the study adolescent girls‟ access to health facility .................................................................................... 154 Fig.4.4.1q: Provincial distribution of travel time to the nearest health facility for the study adolescent girls............................................................................................................................ 156 Fig.4.4.1r: Rural and urban distribution of travel time to the nearest health facility for the study adolescent girls............................................................................................................................ 157 Page 9
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Fig. 4.4.1s: Provincial distribution of frequency of visits of the study adolescent girls to a health facility ......................................................................................................................................... 157 Fig.4.4.1t: Rural and urban distribution of frequency of visits of the study adolescent girls to health facility .............................................................................................................................. 158 Fig.4.4.1u: Provincial distribution of frequency of receipt of health and nutrition advice at health facility ......................................................................................................................................... 158 Fig.4.4.1v: Urban and Rural distribution of frequency of receipt of health and nutrition advice at health facility .............................................................................................................................. 159 Fig.4.4.2a: Provincial distribution of parity of married adolescent girls and the number of children borne ............................................................................................................................. 160 Fig.4.4.2b: Urban and rural distribution of ever-pregnant married adolescent girls and the number of children borne ............................................................................................................ 160 Fig.4.4.2c: Provincial distribution of mean age at first pregnancy of ever-pregnant married adolescent girls n=379 ................................................................................................................ 161 Fig.4.4.2d: Provincial distribution of the study married adolescent girls‟ opinion on whether women should use family planning ............................................................................................ 163 Fig.4.4.2e: Urban and rural distribution of the study married adolescent girls‟ opinion on whether women should use family planning ............................................................................................ 164 Fig.4.4.2f: Provincial distribution of households‟ opinion on family planning as reported by the study married adolescent girls .................................................................................................... 164 Fig.4.4.2g: Urban and rural distribution of households‟ opinion on family planning as reported by the study married adolescent girls.......................................................................................... 165 Fig.4.4.2h: Provincial distribution of community opinion on family planning as reported by the study married adolescent girls .................................................................................................... 165 Fig.4.4.2i: Urban and rural distribution of community opinion on family planning as reported by the study married adolescent girls............................................................................................... 166 Fig.4.4.2j: Provincial distribution of study married adolescent girls‟ willingness to use family planning....................................................................................................................................... 166 Fig.4.4.2k: Urban and rural distribution of study married adolescent girls‟ willingness to use family planning ........................................................................................................................... 167 Fig.4.4.2l: Provincial distribution of study married adolescent girls allowed to use family planning....................................................................................................................................... 167
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Fig.4.4.2m: Urban and rural distribution of study married adolescent girls allowed to use family planning....................................................................................................................................... 168 Fig.4.4.2n: Provincial distribution of study married adolescent girls using contraceptive methods ..................................................................................................................................................... 168 Fig.4.4.2o: Urban and rural distribution of study married adolescent girls using contraceptive methods ....................................................................................................................................... 169 Fig.4.4.2p: Provincial distribution of use of contraceptives by married adolescent girls allowed and not allowed to use contraception .......................................................................................... 169 Fig.4.4.2q: Provincial distribution of opinions on women visiting health facilities for antenatal care .............................................................................................................................................. 170 Fig.4.4.2r: Urban and rural distribution of opinions on women visiting health facilities during pregnancy .................................................................................................................................... 171 Fig.4.4.2s: Provincial distribution of adolescent girls opinion on who should be consulted during pregnancy .................................................................................................................................... 171 Fig.4.4.2t: Rural and urban distribution of adolescent girls opinion on who should be consulted during pregnancy ........................................................................................................................ 172 Fig.4.4.2u: Provincial distribution of preferred place for delivery of married adolescent girls . 172 Fig.4.4.2v: Urban and rural distribution of preferred place for delivery of married adolescent girls ............................................................................................................................................. 173 Fig.4.4.2w: Provincial distribution of opinions of married adolescent girls on duration of breast feeding......................................................................................................................................... 173 Fig.4.4.2x: Urban and rural distribution of opinion of married adolescent girls on duration of breast feeding .............................................................................................................................. 174
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LIST OF TABLES Table 3.1.9: Provincial Teams‟ Advance Field Visits .................................................................. 42 Table 3.2.3: Data collection tools and research questions ............................................................ 44 Table 3.2.4a: Provincial distribution of study locations and sites ................................................ 47 Table 3.2.4b: Provincial distribution of study locations and sites ................................................ 48 Table 3.2.4c: Site-wise Respondent Breakdown of Quantitative Survey ..................................... 48 Table 3.2.4d: Quantitative Survey Sample Distribution ............................................................... 49 Table 3.2.4e: Distribution of groups participating in FGDs ......................................................... 51 Table 3.2.6a: Number of FGD participants across the provinces ................................................. 52 Table 3.2.6b: Breakdown of IDI respondents across the provinces ............................................. 52 Table 3.3: Themes for analysis of data ......................................................................................... 55 Table 3.3.2: Financial Empowerment Index (FEI) ...................................................................... 56 Table 3.3.3a: WHO classification of nutritional status of adolescent girls on the basis of BMI for age for adolescent girls ................................................................................................................. 58 Table 3.3.3b: CDC classification of weight for age of adolescent girls ....................................... 58 Table 3.3.3c: WHO percentile ranking of height for age for adolescent girls .............................. 58 Table 3.3.3d: Correlation of BMI of study adolescent girls with different MUAC cut-offs ........ 59 Table 3.3.3e Mean MUAC of groups of study adolescent girls at BMI cut-off value of 18.5 ..... 59 Table 3.3.4: Evidence and information extracted from qualitative data ....................................... 60 Table 4.1.1a: Median age of study participants, married and unmarried and across provinces and urban and rural location ................................................................................................................ 64 Table 4.1.4a: Median family size with range across provinces, urban and rural and married and unmarried study adolescent girls .................................................................................................. 69 Table 4.2.1a: Association of education and age at marriage of the study married adolescent girls ....................................................................................................................................................... 79 Table 4.3.5a: Provincial distribution of food types consumed and frequency of daily intake of different foods by study adolescent girls‟ households ................................................................ 113 Table 4.3.5b: Rural and urban distribution of food types consumed and frequency of daily intake of different foods by study adolescent girls‟ households............................................................ 114 Table 4.3.5c: Breakfast foods combinations of study adolescent girls households .................... 116
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Table 4.3.5d: Lunch food combinations of study adolescent girls‟ households ......................... 117 Table 4.3.5e: Dinner food combinations of study adolescent girls households.......................... 118 Table 4.3.5f: Provincial distribution of nutrition related symptoms among study adolescent girls ..................................................................................................................................................... 129 Table 4.3.5g: Rural and urban distribution of nutrition related symptoms among study adolescent girls ............................................................................................................................................. 130 Table 4.3.6: Correlation between BMI ≤18.5 and different cutoffs of MUAC .......................... 136
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LIST OF APPENDICES
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LIST OF ABBREVIATIONS AFV AGALI AJK ANC BHU BISP BMI CBOs CDC CDMU CEDAW CEO CMAM CMO CMWs CNIC DGHS DHS DMC DMU EDO EPI FANTA FAO FATA FBS FEI FFQ FGDs FMH FP FS GoP HDI HDI IBA ICRW IDIs IMR KP LHVs LHWs LUMS MCH MDGs MFLO MMR
Advanced Field Visits Adolescent Girls‟ Advocacy & Leadership Initiative Azad Jammu and Kashmir Antenatal Care Basic Health Unit Benazir Income Support Programme Body Mass Index Community based Organisations Center for Disease Control Central Data Management Unit Convention to Eliminate Discrimination and Violence against Women Chief Executive Officer Community Management of Acute Malnutrition Chief Medical Officer Community Midwives Computerised National Identity Card Director General Health Services Demographic Health Survey Data Management Cell Data Management Unit Executive District Officer Expanded Programme on Immunization Food and Nutrition Technical Assistance Food and Agriculture Organisation Federally Administered Tribal Areas Federal Bureau of Statistics Financial Empowerment Index Food Frequency Questionnaire Focus Group Discussions Fatima Memorial Hospital Focal Person Field Supervisor Government of Pakistan Human Development Index Human Development Index Institute of Business Administration International Center for Research on Women In-depth Interviews Infant Mortality Rate Khyber Pakhtunkhwa Lady Health Visitors Lady Health Workers Lahore University of Management Sciences Maternal and Child Health Millennium Development Goals Muslim Family Laws Ordinance Maternal Mortality Ratio
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MNCH MO MUAC N NCRP NGO NNS ODI OECD PC PD PDHS PHC PI PKR PKR PM PSU RAF RDA RHC SIGI SPSS SSU TBAs U5MR UC UN UNFPA US WHO WMOs WRA
Maternal, Newborn and Child Health Medical Officer Mid Upper Arm Circumference Number of respondents Nur Center for Research and Policy Non-governmental Organisation National Nutrition Survey Overseas Development Institute Organisation for Economic Co-operation and Development Project Cycle Project Director Pakistan Health and Demographic Survey Primary Health Care Principal Investigator Pakistani Rupee Pakistani Rupees Provincial Managers Primary Sampling Unit Research Advocacy Fund Recommended Daily Allowance Rural Health Center Social Institutions and Gender Index Statistical Package for the Social Sciences Secondary Sampling Unit Traditional Birth Attendants under 5 Mortality Rate Union Council United Nations United Nations Fund for Population Activities United Sates World Health Organisation Women Medical Officers Nurses Women of Reproductive Age
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EXECUTIVE SUMMARY The special significance of adolescent girls‟ health, nutritional and social status for the achievement of Millennium Development Goals (MDGs) 4 and 5 is being brought increasingly under focus at the global level. According to a UNFPA and Population Council report, the MDGs along with the Convention on the “Elimination of All Forms of Discrimination against Women” and the Convention on the Rights of the Child – provide a framework of values and desirable actions with respect to children and adolescents. None of these goals can be achieved without substantial and prioritized investment in vulnerable and marginalised adolescent girls. Adolescence is a period which is critical for developing capabilities in children of both genders and it is in this period that the girls experience heightened vulnerability. In Pakistan like other South Asian countries, girls have a comparatively low social status, are marginalised and are unable to avail opportunities restricting their socio-economic empowerment. The two major adverse manifestation of adolescent girls‟ disempowerment are their early marriages and poor nutritional status. Early marriages of girls have adverse health consequences due to teenage pregnancies and births. Adolescent and teenage mothers from poor and marginalised communities contribute significantly to maternal, newborn and child mortality and morbidity. As regards infant and child mortality, according to a UNFPA 2007 report “one million babies born to adolescent mothers will not make it to their first birthday and several hundred thousand more will be dead by age 5”. Despite the large number of targeted Maternal, New-born and Child Health (MNCH) interventions over the last decade, Pakistan is still struggling to achieve MDGs 4 and 5 which call for reducing the country‟s Infant Mortality Rate (IMR) to 40, under 5 Mortality Rate (U5MR) to 52 per 1000 live births and Maternal Mortality Ratio (MMR) to 140 per 100,000 live births. Malnutrition is a major contributor to the poor maternal and new born outcomes of teenage pregnancies and child births. Adolescence is a critical phase of human lifecycle during which physical, psychosocial and hormonal development occurs. During adolescence there is accelerated linear growth along with increases in body weight and changes in body composition. Also approximately half of adult bone mass is obtained during this period. Inadequate and poor dietary intake during this period prevents attainment of full physical development. For girls this results in stunting and incomplete development of pelvic bones along with anaemia and micronutrient deficiencies which result in pregnancy complications and obstructed deliveries. To accelerate progress towards the achievement of MDGs 4 & 5, Pakistan needs to adopt a holistic approach with due focus on the complex interrelated socio-cultural, biological and health services related factors responsible for the health and nutritional well-being of women generally and adolescent girls specifically. MNCH policies and programmes need to recognise these Page 17
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factors and devise short, medium and long term strategies to address them effectively. For this purpose good quality evidence is required. Most research undertaken in the field of MNCH in Pakistan is quantitative and focused on women of childbearing age and children. Adolescent girls‟ specific research is scarce. This has created a knowledge gap in MNCH policies and strategies in the context specific to adolescent girls and more so poor and marginalised adolescent girls. The study being reported was undertaken with the purpose of generating data to strengthen advocacy for improving existing health and MNCH policies and strategies and for improving the training curricula of community health workers to increase their capacity for more focused and effective health and nutrition counselling of adolescent girls and their families. The target population was poor adolescent girls aged 15-19 years, both married and unmarried from the four major provinces of the country. The aim of the study was to generate evidence on the nutritional status, knowledge, beliefs and practices of unmarried and married adolescent girls and the sources of nutrition information that adolescents have access to and use.
Methodology For the quantitative component of the study multistage sampling was done to select a total of two hundred adolescent girls; one hundred each unmarried and married, from each province of Pakistan. The provinces included Balochistan, Khyber Pakhtunkhwa (KP), Punjab and Sindh. One district each was selected in the study provinces on the basis of being security wise safe and logistically convenient for the study provincial collaborating partners. The selected districts were Quetta in Balochistan, Kohat in KP, Chakwal in Punjab and Sukkur in Sindh. Random selection of one union council in each selected district was made and then two urban and two rural sites were randomly selected from each selected UC. Fifty poor households were selected in each selected urban and rural site using the cluster sampling method. Quantitative data included the adolescent girls‟ households‟ socio-economic status data and the adolescent girls‟ social and financial empowerment data to provide context to the nutritional status, dietary patterns and dietary information and beliefs of the study adolescent girls. Since the main purpose of the study was to advocate for a specific focus on adolescent girls nutrition and health in Maternal, Newborn and Child Health Policies and strategies, some data related to reproductive health was also collected from the selected married adolescent girls. Purposive sampling of adolescent study girls, their family and community members, school teachers, health services providers and health and nutrition managers in the selected households, districts and provinces was done for selecting participants of in-depth interviews (IDI) and focus group discussions (FGDs) to record their views on the social status, financial empowerment and nutrition needs and concerns of adolescent girls and the response of the current policies and programmes to these needs. Page 18
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Results This study has documented low literacy, low age at marriage, low employment and financial disempowerment of poor adolescent girls. These indicators confirm the low social status of the poor study adolescent girls. The study has found a positive association between education and age at marriage and literacy status and number of children borne by the married adolescent girls. Households Food availability Household spending on food: In Balochistan 20%, in KP 80%, in Punjab 32% and in Sindh 810% of the adolescent girls‟ households spend ≥75% of their income on food. Household food shortages: In Sindh 62%, in Punjab 50%, in KP 15% and in Balochistan 32% households have experienced frequent or occasional food shortage in the last year. Daily number of meals: Overall 25% of unmarried and 30% of married girls‟ households have two meals or less per day. In Punjab 30%-40%, in Sindh 32%, in KP 12% and 22% unmarried and married girls‟ households respectively and in Balochistan 25% of households have two meals or less. Breakfast and/or lunch are the most frequently meals missed. Hunger: Overall 60% of both unmarried and married girls said they never had enough food to eat. In Balochistan and Punjab 80% each married and unmarried girls never had enough food. Dietary patterns, knowledge and opinions and sources of nutrition information: Poor adolescent girls, their households and community members are generally aware of the enhanced nutrition needs in the adolescent period. Poverty and lack of understanding of food substitution prevents them from providing healthy diets to the girls. Access to quality foods is limited. Meat, eggs, dairy products and lentils are eaten 3 times or less a month by a large proportion (?) of the households. Mean daily calorie intake of the study adolescent girls came to 1500 Cal. Some knowledge of dietary supplements was found among 88% of both categories of study adolescent girls and dietary supplements are taken by 22% of unmarried and 38% of married girls.
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Main sources of nutrition advice and information are parents and siblings (70% for unmarried girls) and in-laws (55% for married girls). Health workers are the source of information for 2% unmarried girls and 11% married girls overall. School teachers are accessible to 62% of unmarried and 50% of married girls but they are not consulted for health and nutrition advice by 70% of the unmarried and 95% married girls to whom they are accessible. Nutritional status: When ranked according to weight for age, 45% of the unmarried and 72% of the married study adolescent girls overall are found to be in the lowest quartile. On height for age ranking 78% of unmarried and 72% of married are in the lowest quartile. Twenty eight percent of unmarried and 16% of married girls were found to have Mid Arm Upper Circumference (MUAC) measurement of <23 cm. While there is no agreement on cut off measurement of MUAC in adolescent girls, some studies have given measurement below 23 cm as predictors of pregnancy complication. The body mass index (BMI) of the study adolescent girls puts 18% of the unmarried and 12% of the married girls in the thin and severely thin categories. Access to health professionals: Overall 60% of the study adolescent girls were found to have access to Lady Health Workers (LHWs), 8% unmarried and 12% married to lady doctors and 2% in each category to both. For 58% unmarried and 52% married a nearby health facility is available. The nearby health facilities are private hospitals (34%) and Basic Health Units (34%) for both categories of girls. Forty percent of both married and unmarried girls have never visited their nearby health facility. Reproductive health related opinion and practices: Among the total 379 married adolescent girls, 247 (65%) have experienced pregnancy with 5.6% primigravida, 55% having borne one child, 28% two children, and the rest three children or more (maximum 5 children). Mean age at first pregnancy is 16.44 years overall. Balochistan has the lowest mean age at marriage of 16.18 years while Sindh has the highest of 16.45 years. Forty four percent of the study married girls are not in favour of family planning; In Balochistan 35%, KP 45%, Punjab 12% and Sindh 76% are not in favour of women practicing family Page 20
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planning. In Balochistan 55%, in KP22%, in Punjab 40% and in Sindh75% of the families and communities are not in favour of family planning. Sindh has the highest proportion (90%) of girls unwilling to use contraception. Overall 80% are not using any contraceptives; 95% in Sindh, 70%in KP, and 80% each in Punjab and Balochistan. Thirty five percent of the married girls are not in favour of visiting health facilities for antenatal care and 30% want antenatal care from lady doctor. For 65% the preferred place of delivery is hospital. About 30% prefer home delivery.
Discussion and Conclusions This study was aimed at documenting the nutritional status, nutrition knowledge, beliefs and sources of nutrition information of poor adolescent girls both married and unmarried for the purpose of bringing them under focus in MNCH and youth related policies and strategies. The background household data and the study girls social status and financial empowerment data clearly indicate their poverty, low social status and lack of financial empowerment. Poverty is a barrier to access to good quality nutritious foods and also severely restricts food choices. Lack of education is related to deficient knowledge of good foods and dietary needs. A study in rural Bangladesh on adolescent girls‟ nutrition reported positive correlation between less frequent consumption of non-staple good-quality food items with the household asset quintile. Girls of the highest asset quintile ate fish/meat 2.1 (55%) days more and egg/milk two (91%) days more than the girls in the lowest asset quintile (Alam, Roy, Ahmed, & Ahmed, 2010). The study findings of high prevalence of food insecurity, high proportion of income spent on food, poor dietary patterns and inadequate dietary intake among the study adolescent girls‟ households are not surprising. The girls‟ poor nutritional status is also not unexpected. What is of note is the high prevalence of overweight and obesity and the fact that overall and across provinces only about 10-12% of the study girls have a normal BMI. The under- nutrition data has implications for their reproductive health and pregnancy outcomes and achieving the Maternal, Newborn and Child Health (MNCH) and Millennium Development Goals (MDGs) of the country. The overweight and obesity findings have implication for their risk of acquiring chronic diseases and increasing the chronic diseases burden in the country.
The above findings along with the study girls and their families‟ unfavourable opinion of family planning, antenatal care and access to and utilisation of health services and their low use of contraceptives add to the uncertainty of achieving family planning and reproductive health and MNCH targets and goals of the country. At the current high rate of adolescent marriages, confirmed again by this study, 50% of all pregnancies are likely to be among adolescent mothers Page 21
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by the year 2030. Therefore there is a clear need for specific focus on improving adolescent girls‟ social and nutritional status in all relevant health, education and social welfare policies and strategies.
Conclusion From the findings of this study it can be concluded that:
Poor adolescent girls have low social status and are marginalised as indicated by their low literacy rates, low age at marriage and financial disempowerment.
Food insecurity, hunger, poor diets and malnutrition are prevalent in poor households and among poor adolescent girls
The poor adolescent girls, their household members and community members have understanding of the enhanced nutritional needs in adolescence and families‟ practices on access to nutrition are not generally discriminatory against girls. Nevertheless the girls‟ diets are poor quantitatively and qualitatively owing mainly to poverty and lack of knowledge of food substitutions.
Household members are the main sources of the girls‟ nutrition and health information. LHWs and other community services providers including school teachers are currently not playing any role in the promotion of adolescent girls‟ health and nutrition. However they are available to the community and have the interest and potential of creating awareness and providing counselling services on regular basis.
A high proportion of married adolescent girls, their families and communities have unfavourable opinion of family planning and the use of contraception is very low at less than 20% compared to the national rate of 35%.
While access to health workers is present, the utilisation of the services of community based health care providers like LHWs and Community Midwives (CMWs) is low. Awareness about their availability and satisfaction with the services provided by them is lower in rural areas as compared to urban areas. Hardly any married adolescent girl mentioned them as their source of health and nutrition advice or their preferred consultants for antenatal care.
Health and nutrition services providers need better and continuing nutrition training and education and counselling skills to be effective in creating nutrition awareness and behaviour change. Page 22
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Current health policies and programmes need to recognise adolescent girls‟ needs and concerns and develop effective strategies for reaching out to them.
Recommendations The recommendations given below are based on the findings of this study and recommendation made by health managers and services providers in interactions with them during the course of the study and in the provincial dissemination seminars. Recommendations of the (AGALI) relevant to Pakistan‟s situation and in line with the findings of this study have also been incorporated (Fewer, Ramos, & Dunning, 2013). Recommendations given can be incorporated in the provincial Health, nutrition and MNCH policies and programmes along with education and youth development policies and strategies and implemented in coordination by the relevant public sector departments including health, education, youth affairs, education, and social welfare etc. and NGOs. Nutrition and health promotion Current policies and programmes must include poor adolescent girls‟ nutrition and health as specific areas of focus. Strategies must focus on awareness creation and behaviour change at the household and community level. Policies and programmes in the development phase or to be developed must recognise the specific needs of poor adolescent girls and their implementation strategies must extend to the household level and community levels to reach these girls. Community health services providers as change agents The community health service providers need to be recognised as agents for change and their capacities developed as promoters of and counsellors on nutrition and health to adolescent girls and their households. While the current training programmes transfer knowledge to the services providers they fail to develop their capacity for applying and adapting the knowledge to specific situations. This was evident from the IDIs held with services providers who appear to be recommending foods to poor families like milk, eggs, chicken and fruit, which are beyond their financial resources. The health services provider need to understand the nutritional value of inexpensive and easily available food items and their combinations to be able to make more practical suggestions for the improvement of dietary intake. Training of school teachers and involvement of schools in awareness creation, capacity building and overall community development activities:
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School teachers as community members are available to the adolescent girls even if they are not school going. They have some knowledge of health and nutrition and are generally respected by the community. Additionally with the increasing recognition of school health programmes a number of them will be getting training on school children health and nutrition. Therefore LHWs and MNCH programmes must link up with school teachers and schools to scale up awareness creation on nutrition and health promotion. Volunteer female school teachers can be trained and encouraged to reach out to out of school adolescent girls. Schools have the facilities of space and infrastructure to undertake and/or facilitate, with community participation, nutrition and lifestyle change awareness creation activities and capacity building activities. Capacity building of health professionals working in health facilities Health care providers and health facilities need to develop their capacities to provide technical leadership to nutrition and health promotion activities at the community level. They can develop training curricula and trainers and facilitators for training activities of all different types of stakeholders mobilised by programmes for awareness creation and behaviour change of households and communities. Coordination and integration of all adolescent girlsâ&#x20AC;&#x2122; empowerment and health and nutritional status promotion activities Local governments are best placed to provide, integrate, coordinate, supervise and monitor all activities at the community level. Capacity building for undertaking this role and responsibility must be developed among the officials and employees of local government. Economic Empowerment for Adolescent Girls The recently developed youth policies by the provinces do not recognise poor adolescent girls as a specific component of the youth populations with very different needs from the middle class youth they are focusing on. The following recommendations from AGALI need to be incorporated in the youth policies and programmes. AGALI recommends three strategies for the economic empowerment of adolescent girls: financial services, employment, and life-skills and social support (Fewer, Ramos, & Dunning, 2013). Creation of Age-Appropriate Financial Services:
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This includes development of financial literacy and youth savings programmes relevant for all ages and provides a critical base for future economic advancement. Microcredit strategies are more appropriate for older adolescent girls and young women who have the mobility, resources, and social support to launch small businesses. Link Employment Programmes with Real Market Needs and Opportunities Develop Programmes that offer adolescent girls vocational training and employment opportunities. This approach requires designing a quality training process that builds girls‟ technical and soft skills. These programmes should also help address any health and social obstacles that negatively affect a participant‟s ability to work, such as lack of participation in the public sphere, early marriage, and adolescent pregnancy. In Pakistan where girls‟ mobility is restricted, innovative ways of reaching out to them need to be developed. One such way could be the enrolment of an older person from the household along with the target adolescent girl to ensure better participation in the programmes. Skills development for work which can be done at home may have better acceptance. Address the Intersection of Factors that Shape Girls’ Lives An integrated approach considering adolescent girls‟ overall well-being is critical to achieving economic empowerment. Programmes should combine life-skills training and social support with strategies to promote access to financial services and employment. Organising the trainings at sites accessible from their homes and acceptable to the families will have more uptake. Adult literacy, reproductive health and leadership training as well as financial training and job guidance can be integrated into the skills development programmes. Create Data-Driven Programmes Data should be a core component of girls‟ economic empowerment initiatives throughout programme development, implementation, monitoring, and impact assessment stages. To customise the programmes formative research on adolescent girls‟ needs and preferences should be made part of the programmes. Finally, organizations should measure short and long term programme outcomes to both assess impact and build the field‟s knowledge of successful models, as existing evaluations in the field are very limited.
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RESEARCH REPORT 1. Introduction and Background Globally, approximately 18 million girls under the age of 20 give birth each year. Two million of these pregnancies are borne by adolescent girls under the age of 15. Overall about one in ten babies are born to adolescent mothers, with more than 95% of those births occurring in low- and middle-income countries (Presler-Marshall & Jones, 2012). The adolescent girls‟ health, nutritional and social status has therefore a special significance for the achievement of MDGs 4 and 5. According to a UNFPA and Population Council report, the MDGs-along with the „Convention on the Elimination of All Forms of Discrimination against Women‟ and the „Convention on the Rights of the Child‟ – provide a framework of values and desirable actions with respect to children and adolescents and that none of the goals of these compacts can be reached without substantial and prioritized investment in adolescent girls and other vulnerable adolescents (UNFPA & PopulationCouncil, 2007). Adolescence is defined as the ages 10-19 years during which the individual‟s transition from childhood to adulthood occurs. Mensch et al. (1998 as quoted by Khan A.) state that, “It is a time of heightened vulnerability for girls and critical capability-building for children of both sexes” (Khan, 2000). In Pakistan and other south Asian countries girls are considered a responsibility - to be nurtured and prepared for marriage and handed over to a husband and his family. Her virginity is especially to be protected not only for family honour but also to ensure her marriage prospects. Her mobility is therefore restricted and she is married off early- about 13% by the time they are 15 and 40% by age 18 years (Daniels, 2007). The Pakistan Health and Demographic Survey (PHDS) 2006-2007 reported the median age of girl‟s marriage as 19.1 years, that is, half of women married off before 19.1 years of age (NIPS, 2008). Early marriages of girls have adverse health consequences due to teenage pregnancies and births. Adolescent and teenage mothers from poor and marginalised communities contribute significantly to maternal, newborn and child mortality and morbidity. Adolescents aged 15 through 19 years are twice as likely to die during pregnancy or child birth as those over age 20 and girls under the age of 15 years are five times more likely to die (WHO, 2010). As regards infant and child mortality, according to a UNFPA 2007 report “one million babies born to adolescent mothers will not make it to their first birthday and several hundred thousand more will be dead by age 5” (UNFPA & PopulationCouncil, 2007). The adverse outcomes of adolescence pregnancy are owing to biological and physiological factors. Adolescent and teenage mothers are at greater risk of post-partum haemorrhage, sepsis and eclampsia. Also since pelvic bones do not reach their maximum size until about the age of 18, the teenage mother may Page 26
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not be able to have vaginal delivery of a normal-sized baby. Restricted mobility and early marriage and childbearing deprive adolescent girls of availing opportunities for education and economic independence and as a result increase their marginalisation as regards access to and utilization of health and nutrition services. This has consequences both for them and their newborn‟s health. The UNFPA “Addis Call to Urgent Action for Maternal Health”, puts adolescent girls health among three key measures (with prioritizing family planning and strengthening health services being the other two) to reduce maternal mortality and achieve MDG 5(UNFPA, 2009). Another report of the agency advocates strategic investments in the health, education, and livelihoods of adolescent girls to empower them to avoid the trap of becoming mothers while still a child herself (UNICEF, 2008). Pakistan is currently struggling to achieve MDGs 4 and 5 which call for reducing the country‟s IMR to 40, U5MR to 52 per 1000 live births and MMR to 140 per 100,000 live births (UNICEF, 2004). Despite targeted interventions over the last decade in the field of MNCH, IMR remains high at 73, U5MR at 100 and MMR at 276 per 100,000 live births, with wide provincial and urban rural variations (Khan, Bhutta , Munim , & Bhutta, 2009). There are reported MMRs of 227 in Punjab, 275 in KP, 314 in Sindh and 785 in Balochistan (NIPS, 2008). Overall an estimated 30,000 deaths occur in Pakistan each year because of pregnancy related causes – the equivalent of one woman dying every 20 minutes (Khan, Wilson, Taylor, Varley, Dohad, & Hooper, 2009). The gap between the existing rates and ratios and the set MDGs to be achieved by 2015 is wide and Pakistan is not likely to achieve the goals and most of the targets (UNICEF, 2008). About 5.6% and 6.3% of all births are given by mothers aged 15-19 years in urban and rural populations respectively and it is estimated that adolescent girls‟ pregnancies will account for about 50% of total pregnancies in Pakistan by 2020, if current trends of adolescent girl‟s marriages continue (Rowbottom, 2007). These statistics underscore the significance of the adolescent girls‟ health and nutrition for the achievement of MDGs 4 & 5. To accelerate progress towards the achievement of MDGs 4 & 5, Pakistan needs to adopt a holistic approach with due focus on the complex and interrelated socio-cultural, biological and health service related factors responsible for the health and nutritional well-being of women generally and adolescent girls specifically. Socio-cultural factors include social status, gender discrimination and early marriages of girls; individual behaviour and psychological factors determining their dietary practices, reproductive patterns, and health seeking behaviour; biological factors include age of menarche, menstruation patterns, pregnancy and risk of infections; and health services related factor refer to the coverage and quality of available health and nutrition services (UNICEF, 2008). Gender discrimination and low status are pervasive and under pin all the other influencing factors. MNCH policies and programmes need to recognise these factors and devise short, medium and long term strategies to address them effectively.
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Most research undertaken in the field of MNCH in Pakistan is quantitative and focused on women of childbearing age and children. Adolescent girl specific research is scarce. This has created a knowledge gap in MNCH policies and strategies in the context specific to adolescent girls especially those who are poor and marginalised. Current MNCH policies and strategies donâ&#x20AC;&#x;t recognise adolescence as a specific and priority area for action. The study being reported was undertaken with the purpose of generating data to strengthen advocacy for improving existing health and MNCH policies and strategies and the training curricula of community health workers to increase their capacity for more focused and effective health and nutrition counselling of adolescent girls and their families. Data was collected from the provinces of Punjab, Sindh, KP and Balochistan. The target population was poor adolescent girls aged 15-19 years, both married and unmarried. Quantitative and qualitative methods were applied and a wide range of stakeholders were sampled to achieve a multi-dimensional view of the social determinants of the nutritional and health status of the target group.
1.1 Aims and Study Objectives 1.1.1 Aim To generate evidence on the nutrition status, knowledge, beliefs and practices of unmarried and married adolescent girls and the sources of nutrition information that adolescents have access to and use. 1.1.2 Specific Objectives a. To document the knowledge, beliefs and practices of poor unmarried and married adolescents with respect to nutrition b. To determine the perceptions of adolescent girls regarding their role and status in the community and household; c. To record the sources of nutrition information of married and unmarried poor adolescents girls; d. To determine the perception, beliefs and practices of the community and households regarding the status of adolescent girls; e. To assess the knowledge, beliefs and practices of the community and households regarding the nutritional needs of adolescent girls-married and unmarried; f. To document the knowledge, beliefs and practices of community health services providers regarding the nutrition of adolescent girls-married and unmarried; g. To determine the role and practice of school teachers in promoting the nutrition of adolescent girls;
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h. To determine the knowledge and views of health policy-makers and managers regarding the need for prioritising the nutrition of adolescent girls-married and unmarried, in health policies and strategies.
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2. Literature Review In Pakistan the status of women in society is determined by a mix of religious, cultural and legal influences resulting in diverse practices not only between but within the same regions of the country. There is an overall perception that the status of women in Pakistan varies considerably across classes, regions, and the rural/urban divide due to uneven socio-economic development and the impact of tribal, feudal, and capitalist social formations on women's lives. While women and girls belonging to the educated and socio-economically well off segment of society enjoy a higher status and more freedom in Pakistan as compared to other Muslim countries, the majority belonging to lower middle class and poor families suffer severe marginalisation and exclusion. Overall Pakistan is listed among the five worst countries for women to live (Jamal & Khan, 2007). The country is ranked 136 in the United Nations Gender Inequality Index, 2013 and in the 2012 World Economic Forum Global Gender Gap Report it is ranked among the worst countries along with Chad and Yemen.
2.1. Historical Developments and Laws affecting women’s rights and empowerment Since independence efforts have been made to improve the status of women in Pakistan. The country has ratified all United Nations‟ Human Rights Conventions. The Constitution of Pakistan upholds the principles of equal rights and equal treatment of all persons. In the area of women‟s rights and empowerment however progress has been uneven. This is largely owing to the fact that culture and religion are inextricably intertwined in Pakistan‟s society, resulting in divergent views on women status and a lack of consensus in identifying what constitutes women‟s rights and which legal reforms can best secure these rights. This makes it difficult for the state to articulate a clear definition of women rights and empowerment. Over the past decade a significant improvement has occurred but critical areas still need to be tackled. These include developing legislation recognizing women‟s general rights as citizens and family members; women‟s economic rights and opportunities to earn an income; ensuring women‟s safety as they enter public domains; and establishing new laws to protect women from harmful and discriminatory traditional practices (SDPI, 2009). Over the past decade some positive developments have occurred but much remains to be done (Weiss, 2012). The following is a chronology of women rights related events in the history of Pakistan: a) 1920s:
Child Marriage Restraint Act 1929: Under this pre-independence law the minimum age of marriage is 16 years for females and 18 years for males.
b) 1950s: ratification of: Page 30
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The 1953 Convention on the Political Rights of Women.
The UN Convention on the Consent to Marriage, Minimum Age for Marriage and Registration of Marriage.
c) 1960s:
Promulgation of 1961 Muslim Family Laws Ordinance (MFLO). The MFLO gives economic and legal protection to women by regulating marriage and divorce and restraining polygamy.
d) 1970s:
The 1973 constitution advanced women‟s legal rights in the country on a number of fronts. It affirms in its fundamental rights and principles that the state is committed to eliminating exploitation. Article 25 (1) guarantees that all citizens are equal under the law and are entitled to equal protection of law; Article 25 (2) adds, “There shall be no discrimination on the basis of sex.” Article 27 prohibits discrimination on the basis of sex, race, religion, or caste for government employment and Article 34 states that “steps shall be taken to ensure full participation of women in all spheres of national life.”
In 1979 the promulgation of the Hudood Laws and the Law of evidence during the General Zia ul Haq regime reversed the earlier positive developments and clearly gave men and women different legal rights, clearly indicated that the state did not regard women and men as equal. The adultery and fornication (zina) component of the Hudood Law made no legal distinction between adultery and rape and the Law of Evidence. It disallows women from testifying at all in certain cases and in other causes their testimony is irrelevant unless another woman corroborates it.
In 1979 the Women Division was established to improve women‟s standard of living and bring it on par with international standards. The Women Division and women‟s rights organizations were able to persuade the government to sign the Convention to Eliminate Discrimination and Violence against Women (CEDAW).
CEDAW adopted in 1979 by the UN General Assembly is often described as an international bill of rights for women. Consisting of a preamble and 30 articles, it defines what constitutes discrimination against women and sets up an agenda for national action to end such discrimination. Countries that have ratified or acceded to the Convention are legally bound to put its provisions into practice. They are also committed to submit Page 31
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national reports, at least every four years, on measures they have taken to comply with their treaty obligations. Pakistan became a signatory in 1996. e) 1990s:
The 1990 UN Convention on the Rights of the Child was ratified.
The 1993 Vienna Declaration recognizing women‟s rights as human rights was signed
In 1994, Pakistan‟s senate established a “high-powered commission” to review the country‟s laws as “a step toward ending the grosser iniquities against women.”
The 1994 Cairo Population and Development conference‟s Programme of Action and the 1995 Beijing Platform for Action were adopted.
The Women‟s Division‟s successor, the Ministry for Women‟s Development, prepared Pakistan‟s national report for the United Nations‟ 1995 4th World Conference on Women in Beijing, as well as the follow-up project to implement the promises made in Beijing, entitled the National Plan of Action. It also helped prepare the Beijing +5 Report for the May 2000 conference at UN headquarters and monitored Pakistan‟s progress in implementing CEDAW.
f) 2000s:
The new millennium came with a number of actions in the area of women rights and empowerment both under General Musharraf‟s rule and the People Party‟s government which followed. A National Policy for the Development and Empowerment of Women was prepared in 2002. It deals with the social empowerment (education, health, law and access to justice, violence against women, women in family and community, and the girl child) and economic independence through poverty alleviation measures, access to credit and remunerated work and recognition of women in the rural and informal sector in sustainable development. A women Commission was established, women seats in Parliament were increased and most significant of all, the Women‟s Protection Act 2006 was passed that offers women safeguards against false accusations of adultery. Also in 2006, the Gender Crime Cell was established within the National Police Bureau to gather, collate and analyse data on gender-based violence. While in August 2009 a Bill criminalizing domestic violence passed by the National Assembly lapsed because it was not introduced in the Senate, the bill has since been reintroduced as a private member‟s bill by a woman member of Parliament. Page 32
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g) 2010s:
Anti-Women Practices Act 2011: While women have inheritance rights under state and Islamic laws, they are often deprived of this right by male relatives. The anti –women Practices Act 2011 makes it a punishable offence to deprive women of their inheritance rights.
2.2. Social Status, Marriage and Education Pakistan is ranked 55th out of 86 countries in the 2012 Social Institutions and Gender Index (SIGI). SIGI captures, on a quantitative level, the influence of social institutions on girls‟ lives. The SIGI uses 12 indicators, ranging from preference for a male child, family law that allows child marriage, to women‟s freedom of movement (OECD, 2012). While Pakistan‟s SIGI ranking has improved since 2009 when it was ranked 94th out of 102, the latest ranking still underscores the low status of women and gender discrimination. In relation to parental authority, fathers are considered the natural guardians of children, whereas mothers are merely “custodians”. Women‟s right to divorce is limited under Sharia law to certain specific circumstances (e.g. if she has been deserted, if the husband is abusive, or if the marriage was never consummated), or if she requests a „Khula‟ divorce, in which case she forfeits her dowry. In contrast, Pakistani men can divorce their wives unilaterally. The requirement of a three-month arbitration process with the local council before the divorce becomes final is little known among women and therefore not generally followed. Pakistani women have the right to pass citizenship onto their children and they have inheritance rights (OECD, 2012). Adolescent girls are grouped with older women as „women of child bearing age‟. Socioculturally a girl is considered a woman when she starts menstruating. The estimated number of adolescent girls of age 15-19 years is 6.5 million of the population. Of the adolescent girls population 35.5% live in urban and 64.5% in rural areas. At the national level 53% of 15-19 years old adolescent girls are not in school, with % being higher in rural (67.7%) than the urban areas (25.7%). Distribution of out of school adolescent girls 15-19 years is 43% in Punjab, 64.7% in Sindh, 66% in KP and 62.2% Balochistan. Overall 63.8% of girls 15-19 years are illiterate. Under the Child Marriage Restraint Act of 1929, the minimum age of marriage is 16 years for females and 18 years for males and under Pakistani law all citizens have the right to choose their spouses freely. In practice, the majority of the women and particularly adolescent girls are denied this right. The 2007 Pew Survey (Pew Research Center, 2010) found that 55% of respondents believed that a family should select a spouse for a woman; just 6% believed that a woman should be free to choose her own husband without pressures from her family. The incidence of early marriage has fallen in the last decade. At the national level 15.4% of the girls 15-19 years are Page 33
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married: 9.7% in urban and 18.4% in rural areas (Fig.2.2a). In the provinces the distribution of married girls 15-19 years is 13% in Punjab, 20% Sindh, 16.7% KP and 14% Balochistan. Of the married girls aged 15-24 years, 20.4% have a husband who is 10 years or older than them. Only 1.9% of the married girls 15-19 years are in school as compared to 36% of unmarried adolescent girls in this age group. Three percent of the urban married 15-19 years old adolescent girls and 1.7% of the rural married adolescent girls are in school. Fig.2.2b shows the breakdown of adolescent girls into age by which they are married, across provinces and urban and rural distribution. Fig.2.2a: Marital status among females of age group 15-19 years in the region (UNFPA & PopulationCouncil, 2007) Never Married
Separated/ divorced / widowed
Currently married or in union
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Punjab
Sindh
Khyber Balochistan Pakhtunkhwa
Urban
Rural
National
Fig.2.2b: Percentage of 20-24 year old females who were married by ages 15 and 18 (UNFPA & PopulationCouncil, 2007) Married by 15
Married by 18
100 80 60 40 20 0 Punjab
Sindh
Khyber Pakhtunkhwa
Balochistan
Urban
Rural
National
In South Asia and Sub-Saharan Africa, a relationship between girlsâ&#x20AC;&#x; education and child marriage has been reported. Girls who stay in school are much less likely than their peers to marry early. One study ( Presler-Marshall & Jones , Charting the future: Empowering girls to Page 34
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prevent early pregnancy, 2012)found that compared with girls with no education, girls who stayed in school for ten years were likely to marry six years later. Education empowers girls and in addition to promoting consciousness and self-awareness, education can increase young womenâ&#x20AC;&#x;s autonomy and decision-making skills and further their options for economic independence, with lifelong impacts on their fertility choices (UNFPA & PopulationCouncil, 2007)
2.3. Anti-Women Practices Most of the anti-women practices in Pakistan and other similar societies are done in the name of family honour. Family honour is an abstract concept (Bruce, 2001), involving the perceived quality of worthiness and respectability that affects the social standing and the self-evaluation of a group of related people, both corporately and individually (Mosquera, Antony, & Agneta, 2002) . The vulnerability of women and more especially young girls owing to their sexuality and physical disadvantage is perceived as a threat to family honour. Their mobility and autonomy are therefore restricted as a measure to protect family honour. Following are some of the more prevalent anti-women practices in Pakistani society. 2.3.1. Purdah Purdah is a social system of secluding women and enforcing high standards of female modesty (Papanek, 1971). Purdah norms are followed in many rural and middle class communities of Pakistan but in recent years a revival is being observed among upper middle and socially emancipated sections of society where it had previously been given up. The restriction on mobility imposed by purdah is responsible for the seclusion and marginalisation of women from education, employment, restricting their access and utilization of health services. 2.3.2. Child marriage (Vani) Although the Child Marriage Restraint Act makes it illegal for girls under the age of 16 to be married, and a 2004 amendment to the Code of Criminal Procedure prohibits and punishes this by imprisonment of three to ten years, instances of child marriages continue to occur. Vani is a child marriage custom, followed in different forms across Pakistan, under which young girls are forcibly married in order to resolve feuds between different clans. The different terms used in different areas include Swara, Pait likkhi and Addo Baddo. This custom not only exposes girls, some as young as five years old, to harm from the risks attached to early marriages but also lowers their social status further and exposes them to multiple sorts of abuse.
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2.3.3. Watta satta In literal terms, watta satta means give and take. Here the give is “my daughter for your son” and the take is “your daughter for my son”. Watta satta involves the simultaneous marriage of a brother-sister pair from two households. In some cases, it involves uncle-niece pairs or cousin pairs as well. Women are often forced into watta satta marriages. 2.3.4. Honour killings A majority of the victims of honour killings are women and the punishments meted out to the murderers often tend to be lenient. The practice of summary killing of a person suspected of an illicit liaison is known as karo kari in Sindh and Balochistan. Many cases of honour killings are reported of women who marry against their family wishes: seek divorce; or who have been raped. In December 2004, Government passed a bill that made karo kari punishable under the same penal provisions as murder. 2.3.5. Marriage to Quran In some parts of Sindh, the practice of marrying a woman to the Holy Book i.e. the Quran is prevalent among feudals and landlords. The practice, that condemns the girl never to marry, is often used by men to deprive the women of their land and property rights. When a suitable partner is not found amongst the extended family, this form of marriage is undertaken to keep hold of the portion of property and land that is the girl‟s inheritance right. The family forces the girls to “marry” the Quran at an early age and thereafter she lives in seclusion. Although done in the name of religion, this practise is alien to Islam and has no religious basis. The tradition popularly known as the “Haq Bakshish”, is punishable under the Pakistani legislature, but is often not reported.
2.4. Health and Nutrition 2.4.1. Reproductive Health Adolescence is a period of rapid physical, hormonal and psychosocial changes. Adolescents are therefore prone to mood changes and risky behaviours and are in need of understanding, support and guidance as they pass though this difficult transformational period. In communities like that of Pakistan, with low literacy and inadequate understanding of the concept of adolescence, undue expectations are attached to adolescents, particularly girls, and undue responsibilities are put on their shoulders. Adolescent girls are treated as grown women ready for procreation when they Page 36
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
start menstruating. Their social value is firmly rooted in their capacity for reproduction and their reproductive behaviour is controlled by their spouse and his family. Globally, adolescent fertility rate (15–19 years) stands at 53 births per 1,000 women with the highest rate in South Asia of 72.8 per 1,000 (UNFPA & PopulationCouncil, 2007). Globally, approximately 18 million girls under the age of 20 give birth each year. Two million of these pregnancies are to adolescent girls under the age of 15. Overall about one in ten babies are born to adolescent mothers, with more than 95% of those births occurring in low- and middle-income countries (Presler-Marshall & Jones, 2012). In Pakistan about 5.6% and 6.3% of all births are given by mothers aged 15-19 years in urban and rural populations respectively and it is estimated that adolescent girls‟ pregnancies will account for about 50% of total pregnancies in Pakistan by 2020, if current trends of adolescent girl‟s marriages continue (UNICEF, 2008). There are many issues related with adolescents‟ knowledge of, access to and use of contraception. Married girls‟ access to contraceptives, and their beliefs regarding need, is largely determined by the adults in their marital families – their husbands and their in-laws – who most often encourage early fertility. Across all developing countries, the use of contraception among married adolescent girls is much less than older women and they are also less likely to report unmet needs. There is also a low rate of using modern contraceptive methods. At the national level, 74% of married girls aged 15-24 years have never used contraception-79% in rural areas and 61.5% in urban areas. While contraceptive use among all married women was over 20% in 2005, among married adolescents it was about 5% (UNFPA, 2009). Girls experience puberty at an average age of 13.5 years and the gap between puberty and marriage is an average of 4.4 years (Sultana, 2005); (Fig.2.4.1). The Pakistani society is still largely uncomfortable with discussing sexual and reproductive health with young people. Many adolescents are therefore poorly informed about sexual issues, reproductive biology and health. Although the education curriculum in Pakistan includes population, family planning and reproductive biology modules, sex education, remains a taboo subject (Monique Hennink, Henink, Rana, & Iqbal, 2004). According to a study undertaken in Karachi with adolescent girls aged 10-19 years from urban-based families with high literacy rates of parents (100% fathers and 90% mothers) and good access to information media, knowledge of menstruation and puberty was found to be low and 54% had no knowledge of sexually transmitted diseases (Ali, Ali, & Memon, 2006). This lack of reproductive health knowledge is responsible for the enhanced vulnerability of adolescent girls to sexual abuse and exploitation in the form of non-consensual, unprotected, and underage sexual relations; and subjection to pre-emptive marriage against their rights.
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
The risks of pregnancy and child bearing at an early age are well documented. Adolescents aged 15 through 19 are twice as likely to die during pregnancy or child birth as those over age 20 and girls under age 15 are five times more likely to die (NIPS, 2008). As regards infant and child mortality, according to a UNFPA 2007 report â&#x20AC;&#x153;one million babies born to adolescent mothers will not make it to their first birthday and several hundred thousand more will be dead by age 5â&#x20AC;? (Save the Children, 2004). Fig.2.4.1: Percentage of females entering puberty, work or marriage by age (UNFPA & PopulationCouncil, 2007) Puberty
Working
Ever Married
100 90 80
Percent
70 60 50 40 30 20 10 0 6
7
8
9
10
11
12
13
14 Age 15 16
17
18
19
20
21
22
23
24
Adolescent and teenage mothers are at greater risk of post-partum haemorrhage, sepsis and eclampsia. Also since pelvic bones do not reach their maximum size until about the age of 18, the teenage mother may not be able to have vaginal delivery of a normal-sized baby. A high prevalence of gynaecological morbidities is reported among Pakistani Women who had been married off in adolescence (Fatima & Fikree, 2002). 2.4.2. Nutritional Status The enhanced vulnerability of the adolescent and teenage mothers to adverse outcomes of pregnancy is underpinned by their poor nutritional status. Malnutrition on the other hand is worsened by repeated pregnancies and childbirths. Malnutrition is a pervasive and to date intractable health problem in Pakistan. According to the National Nutrition Survey (NNS) 2011, 59.5% of households in Punjab, 72% in Sindh, 28.2 % in KP, and 63.5% in Balochistan are food insecure (Planning Commission, 2011). The survey found that out of 58% that were food insecure, 28.4% were food insecure without hunger, 19.8% were food insecure with moderate Page 38
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
hunger and 9.8% were food insecure with severe hunger. There is as yet little data linking this highly prevalent food insecurity situation with adolescent girls‟ and mothers‟ nutrition. The NNS 2011 puts adolescent girls in the 15-49 years age group of women of child bearing age and their poor nutritional status can only be inferred from the poor nutrition of this group overall. According to the survey nutrition knowledge of women is poor. Among the micronutrients, iodine was known to the highest proportion while very few had heard of zinc. About one in four knew about iron and vitamin A and one in five about vitamin B and D. A large proportion could not name the foods which contained specific micronutrients. Knowledge about iodised salt was 74% overall with variations amongst respondents from Azad Kashmir (82%), Gilgit (79%) and Punjab (71.4%) who reflected relatively better awareness than respondents from Federally Administered Tribal Area (29.8%) and Balochistan (29.3%). An interesting finding of the survey was that while a large proportion of the respondents knew about iodised salt and a large proportion of households were using iodised salts, very few women knew what disease can result from the deficiency of iodine. While a fifth of the women of reproductive age (WRA) were found to be underweight, 15.7% urban women were obese (Fig.2.4.2). NNS 2011 reported a high prevalence of micronutrient deficiencies in WRA with 19.9% having iron deficiency anaemia, 43.1% Vitamin A deficiency, 41.6% Zinc deficiency, 51.1% hypocalcaemia, 85% Vitamin D deficiency and 48% iodine deficiency. Fig.2.4.2: Body Mass Index (BMI) of women of reproductive age (15-49 years) (Planning Commission, 2011)
53.2
Pakistan 56.6
Urban
Rural
46
18
14.4
19.7
Underweight ( <16 - 18.49)
19.3
23.9 17.1 9.5
Normal ( 18.5- 24.99)
Overweight ( 25- 29.99)
15.7 6.5
Obese ( >30 - 40)
Comparison of NNS 2011 data with NNS 2001 data shows that the nutritional status of women has worsened over the ten years period between the two surveys. Econometric studies to explain the determinants of nutritional status in Pakistan have shown that while economic status is positively correlated with good nutritional status, there are other important determinants like mother‟s education, childhood morbidity particularly diarrhoea, hygiene and sanitation.
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3. Project Implementation 3.1. Inception & Development Phase 3.1.1. Implementing Partner Nur Center for Research & Policy (NCRP), Lahore, Punjab is a partner organization of the Fatima Memorial Hospital (FMH). The Centre undertakes, collates and disseminates research and advocates the use of research generated evidence in policies and programmes development. The Centre also undertakes research and communication skill development and provides consultancy and advisory services for health system development. Under a formal collaboration agreement with FMH, NCRP is its primary implementing partner for research, training and advocacy initiatives. For the present study, NCRP entered into an agreement with FMH for implementing the RAF Research Study and for data collection in the Province of Punjab. The Centre will continue to advocate for the utilisation of the findings of the research beyond the project period for reforming specific MNH practices as part of its mission of linking research to policy and decision-making. 3.1.2. Collaborating Institutions for Provincial Data Collection NRCP/FMH signed formal agreements with the following institutions on collaboration for data collection in their respective study provinces: S. No.
Institution
Province
1
Nur Centre for Research & Policy (NCRP), Lahore
Punjab
2
Institute of Business Administration, Sukkur
Sindh
3
Khyber Medical University, Peshawar
Khyber Pakhtunkhwa (KP)
4
Institute of Public Health, Quetta
Balochistan
3.1.3. Project Team Recruitment The project office was set up at the NCRP secretariat and dedicated project staff was recruited for the term of the project. This included a Project Director, Finance and Admin Assistant. CoInvestigators were brought on board from the collaborating institutions in the four study provinces and provincial managers were recruited to manage and coordinate data collection.
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3.1.4. Constitution of Project Steering Committee A Project Steering Committee was constituted to supervise, monitor and facilitate the study implementation. The committee met on quarterly basis and reviewed project progress, provided direction to the project implementation team in view of any issues and challenges being faced by them. Members of the committee included the Vice Chairperson Executive Committee, FMH &Chief Executive Officer (Nur Foundation), Senior Technical Advisor (NCRP), the Principal Investigator (PI) RAF Project, Project Director RAF Project, the Finance Director (FMH), the Head of Department of Nutritional Sciences (FMH Institute of Allied Health Sciences) and the Head of Department of Community Health Sciences (FMH College of Medicine & Dentistry). 3.1.5. Development and Finalization of Data Collection Tools The initial draft tools were developed by the Senior Technical Advisor Research and the PI. Workshops were organized to present and discuss the study draft data collection tools with Punjab provincial health departments, health managers and nutrition experts. These workshops were held at FMH in May-June 2012. Detailed feedback was received and helped in refining the tools which were finalized after detailed review, discussion with and inputs from RAF Research Experts in meetings at FMH in June, 2013. The details of the tools developed are discussed in section 3.2. The research instruments used in the study are attached as Appendix C and D. 3.1.6. Development of Field Data Collection Guidelines Detailed field work guidelines and data collection protocols were developed to ensure uniformity in data collection in the provinces. The guidelines specified the data collection preparatory work; the structure of the provincial data collection teams; checklist for the advance field visits; methodology for sampling, data collection, data management and data transfer; details of different data collection techniques and tools to be used; overall and provincial sample size and data collection frameworks to be used. The field data collection guidelines used in the study are attached as Appendix A. 3.1.7. Advance Provincial Visits Advance visits to the provinces and meetings with provincial project managers and the collaborating institutions senior team members were undertaken. The study team headed by the PI visited Sukkur Institute of Business Administration (IBA) in from July 20 â&#x20AC;&#x201C; 24, 2013 and Khyber Medical University from June 12 - 14, 2013. The advance visit to the Institute of Public Health, Quetta, Balochistan was made from July 20- 24, 2013. Discussions were held with the Punjab Provincial Team at the NCRP, Lahore and the Punjab Provincial Project Manager at Chakwal on June 11-15, 2013. During these meetings all operational details for data collection Page 41
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
were discussed for developing a clear understanding of sampling criteria, research methods, and data collection protocol so as to ensure uniformity in field methods across all four provinces. 3.1.8. Inception Meetings with Provincial & District Health Authorities The PI together with the co-investigators of the respective provinces held meetings with Provincial and District Health Authorities and MNCH Managers. Overview presentations about the project were given and they were briefed about the data collection protocols. Their feedback was gathered on the overall project need and rationale and their facilitation and support was solicited for effective project implementation. 3.1.9. Advance Field Visits by Provincial Managers In each province an advance field visit of the selected district was made by a team headed by the Provincial Field Managers (Table 3.1.9a). With the help of previously identified local field assistants the following activities were undertaken:
Meeting with the local authorities for ensuring security & field arrangements for the data collection team as per field work guidelines.
Identification of a local focal person preferably Medical Officer (MO) working at the BHU or Rural Health Center (RHC) at each site and sharing of data collection plan with them
Identification of field site offices with the help of focal people, with enough space for undertaking FGDs
Meeting with the local community elders and leaders for sharing objectives of the study and soliciting their facilitation for the data collection teams
Visit of the selected urban and rural study sites.
Identifying Dais/Traditional Birth Attendants (TBAs), Lady Health Workers (LHWs), Community Mid Wives (CMWs), female school teachers and male CBO members for IDIs and FGDs.
Table 3.1.9: Provincial Teams’ Advance Field Visits Provinces Activities Punjab Balochistan
Khyber Pakhtunkhwa
Sindh
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Advance Field Visits (AFV)Date Field offices established Data Collection Sites visited
July 20 – 24, 2013
June 12- 28, 2013
July 20 - 24, 2013
At Kot Sarfraz
At Killi Shabbo
At Institute of Medical Sciences, Kohat
At IBA, New Sukkur
Dhudhial Bhaun Thaneel Fatohi Mohara Thaneel
Goal Mandi Ward 04 Pashtoon Abad Union Killi Shabbo Nohsar
Urban 4 Urban 5 Usterzai Sherkot
June 23 - 24, 2013
New Sukkur Old Sukkur Bagarji (Abad) Ali Wahan (Rohri)
3.1.10. Hiring & Training of Data Collection Teams The study team in each province comprised of a field team supervisor, 3-5 quantitative data interviewers and 2-3 qualitative data interviewers. Each field team was given two days training on the data collection tools. One field team member in each province was also sent for training to a qualitative research data collection workshop organized by the Lahore University of Management Sciences (LUMS) from 25th to 27th of May, 2013.
3.2. Study Design and Methodology 3.2.1. Study Location The study was undertaken in the four major provinces of Pakistan- Punjab, Sindh, KP and Balochistan. Gilgit-Baltistan and FATA were excluded from the present study because they did not have an independent constitutional status of a province. AJK was also not included, as it operates under an interim constitution. The magnitude of the problem under study is high in some of these areas as indicated in the NNS 2011 but owing to time constraints and the preceding given reason these areas were excluded. 3.2.2. Study Design The study used both quantitative and qualitative methods concurrently to achieve its objectives. These objectives cover adolescent girls‟ (both married and unmarried) nutritional status and dietary patterns; social and financial status and empowerment; health and nutrition services availability and utilisation and adolescent girls‟ and their households‟ knowledge, beliefs and practices regarding the status of adolescent girls and their nutritional needs.
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3.2.3. Data Collection Tools and Guides In table 3.2.3 the details of tools and corresponding research questions/ areas have been elaborated. Table 3.2.3: Data collection tools and research questions S. No Tool Research Questions/ Areas 1 Quantitative Socio-economic status Survey Tool for Financial empowerment unmarried and Food purchase and preparation married Dietary patterns( FFQ and 24-hours dietary recall) adolescent girls Food preferences Micronutrients Food security Malnutrition related symptoms Nutritional and health guidance Anthropometry Pregnancy related nutrition (married adolescent girls only) Lactation, infant and child related nutrition (married adolescent girls only) 2 FGD adolescent Perspective on early marriages, family planning etc. girls Dietary patterns Health status and diet requirements understanding of linkages between nutrition and pregnancy outcomes Perspectives on food security, gender empowerment to access, choice, preparation and distribution of food Sources of information Perceptions on health workers/ teachers as a source of information awareness and practices regarding nutritional supplements Access to and utilization of MNCH services Perception of barriers and facilitators to fulfilling the nutritional needs of adolescent girls 3 IDI Health Care Knowledge, attitudes and practices of the health care providers regarding Providers the nutritional needs of adolescent girls Perspective on role of nutrition in improving maternal and neonatal health, and barriers and facilitators in accomplishing fulfilment of nutritional needs of adolescent girls Perspective on current program practices, Perspective on training needs and gaps in current professional training, practices and possible role of health care providers in promotion of adolescent girlsâ&#x20AC;&#x; nutrition Recommendations on improvement of nutrition and empowerment of adolescent girls 4 IDI Health Perspective on role of nutrition in improving maternal and neonatal health,
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Managers
5
FGD household members female, male and community members male
6
FGD school teachers female
and barriers and facilitators in accomplishing fulfilment of nutritional needs of adolescent girls Do health managers and policy/decision makers recognize the nutritional needs and status of adolescent girls as an area of focus for achieving MDG 4&5? Views on the current status of nutritional information available to adolescent girls through different platforms Views on need of comprehensive and focused nutrition information for adolescent girls at school/ community/ household level Experiences on barriers encountered in implementing evidence-based recommendations to improve policies and programmes related to improving the nutritional status of adolescent girls Perspective on gaps in knowledge and evidence in mainstreaming nutrition counselling and management at community level Views on the adequacy of current policies and strategies for achieving MDGs 4 & 5 Perceptions on the role of evidence for enhancing the effectiveness of policies and strategies Knowledge, beliefs and practices of the household elders regarding the special nutritional needs of adolescent girls Perspective on status of married and unmarried adolescent girls with in family as regards to access to food, education and health services Practices on empowerment status of adolescent girls in the family as regards to access, choice, preparation and distribution of food? Perspective on role of nutrition in pregnancy/ MNCH outcomes? Perception on barriers and facilitators to fulfilling the nutritional needs of adolescent girls Knowledge, attitudes and practices of the school teachers regarding the nutritional needs of adolescent girls Perspective on role of nutrition in improving maternal and neonatal health, and barriers and facilitators in accomplishing fulfilment of nutritional needs of adolescent girls Perspective on nutritional requirements of adolescent girls and cultural practices Perspective on training needs and gaps in current professional training of teachers, practices and possible role of teachers in promotion of adolescent girlsâ&#x20AC;&#x; nutrition Opinions on empowerment of adolescent girls Perspective on role of schools in improving awareness in communities regarding nutritional needs of adolescent girls Recommendations on improvement of nutrition and empowerment of adolescent girls and possible role that schools can play
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
The data collection teams were provided with trainings on data collection in addition to the data collection guides. Food Frequency Questionnaires (FFQ) and 24- Hours Dietary Recall Questionnaire: The purpose of the FFQ was to document the different types of food items consumed in the households of the study adolescent girls and the frequency of their consumption over a month. The FFQ developed was based on an extensive list of food items that are commonly consumed in the study population. Forty-one items were listed in nine food groups, namely meat and poultry, dairy, vegetables, fats and oil, cereal groups, lentils, fruits, beverages and snacks. The FFQ was interviewer-administered where the study adolescent girls were asked to estimate how often a particular food or beverage was consumed in a month. Categories ranging from „never‟ or „less than once a month to six times per day were used as per standard FFQ design and the study adolescent girls were asked to choose from among the given options. The FFQs were used to develop food-consumption frequencies in the different study groups i.e. married and unmarried adolescent girls, urban and rural and across the provinces. The objective of the 24-hour dietary recall questionnaire was dietary intake and calories intake assessment of the study adolescent girls (The dietary recall used in the study is attached as Appendix C and D, Section 6). The girls were asked to recall foods and beverages they had consumed in the past twenty-four hours prior to the interview. This was administered by the interviewer. Props were used to assess the portion size consumed by the study adolescent girls. (The pictures of props/aids used in the study are attached as Appendix I). The interviewers were trained extensively on the correct usage of the props. The respondents were asked to indicate the consumption of specific quantities of foods (e.g. ½ a cup, ¾ cup etc.) by showing them usual utensils they used for eating and drinking. The interviewer then assessed the relevant portion size as per the standard props provided. 3.2.4. Sampling Methodology Participants Selection Criteria The following criteria/definitions were used to identify the different study respondents for data collection: 1. Poor Adolescent girl: A girl of age 14 – 19 years belonging to a poor household.
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
2. Poor Households: Households living below the national poverty line i.e. US $ 12 per person per month. It is the national poverty threshold deemed necessary to provide 2,350 calories per person per day1. 3. Household Members: Included heads of households/husbands, mothers and mothers-in-law. 4. Community Service Providers: Women Medical Officers (WMOs), Nurses, Lady Health Visitors (LHVs), Community Midwives (CMWs) and Lady Health Workers (LHWs), Traditional Birth Attendants (TBAs), Staff at Mobile Health Clinics and School Teachers. 5. Community Opinion leaders: Community members whose views and actions influence the views and actions of the community. These included senior respected members of the community, local elite, elected representatives, political leaders, high ranking officials, religious leaders, school teachers, CBO members etc. 6. Non-governmental Organizations (NGOs): Organization (international, national or regional) that are engaged in health and social services delivery, educational or development activities at community level e.g. Edhi Foundation, Citizen Foundation, NSRP, UNICEF, UNFPA etc. Quantitative Study Sampling Multistage sampling methodology was used for sample selection for the quantitative component of the study. In Balochistan however owing to security reasons convenience sampling was done. Step 1: One district in each province was selected from the provinceâ&#x20AC;&#x;s district sampling frames (Table 3.2.4a). The districts were selected on the basis of security and logistic considerations. Quetta district in Balochistan, Kohat in KP, Chakwal in Punjab and Sukkur in Sindh were selected. Table 3.2.4a: Provincial distribution of study locations and sites Province
District
District HDI
Punjab
Chakwal
0.698
Sindh
Sukkur
0.691
Khyber Pakhtunkhwa
Kohat
0.673
Balochistan
Quetta
0.540
1
National Poverty Line notified wide notification. No. 1(41) POVERTY/PC/2002 dated 16 August 2002
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
Step 2: Sampling frames of poor rural and urban sites of each selected district were prepared. Random selection of two union councils one rural and one urban, was made in each selected district and then one urban and one rural site were randomly selected from each selected UC. . A total of eight rural and eight urban sites were selected in the four provinces (Table 3.2.4 b). Table 3.2.4b: Provincial distribution of study locations and sites Province Punjab
District Chakwal
Urban site Dhudhial Bhaun
H.holds 50 50
Sindh
Sukkur
Khyber Pakhtunkhwa Balochistan
Kohat
New Sukkur Old Sukkur Urban Union Council 4 Urban Union Council 5 Goal Mandi Ward 04 Pashtoonabad
50 50 50 50 50 50
Quetta
Rural site Kalial Thaneel FatohiKheenger Abad Bagarji Rohri (Ali Wahan) Ustarzai Sherkot Killi Shabbo Nawa Killi & Sirah Ghurgai
H.holds 50 50 50 50 50 50 50 50
Step 3: Using cluster sampling methodology 25 households with unmarried and 25 with married adolescent girls were selected in each rural (Mozas and villages) and urban site (blocks) based on the following criteria:
Living below the national poverty line i.e. US $ 12 per person per month Has at least one adolescent girl, married and or unmarried
Step 4: Married and unmarried adolescent girls aged 14-19 years were recruited from the selected clusters of poor households, 25 unmarried and 25 married (Table 3.2.4c). Table 3.2.4c: Site-wise Respondent Breakdown of Quantitative Survey Study method Study sites
Quantitative Survey to collect demographic, dietary, Anthropometric and health services access and utilization data
Rural site 1:
Rural site 2:
Urban site 1:
Urban site 2:
Study Units 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
Study Units 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
Study Units 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
Study Units 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
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A total of 100 rural and 100 urban households were selected in each district, with a provincial total of 200 households, and national total of 800 households {Table 3.2.4 d for detailed breakdown of study sample, discarded data and final data points included in analysis). Fig.3.2.4 presents the multistage methodology flow chart. Table 3.2.4d: Quantitative Survey Sample Distribution Survey Adolescent Girls Married Unmarried Province/ Region Urban Rural Urban Rural Balochistan 50 50 50 50 Khyber Pakhtunkhwa 50 50 50 50 Punjab 50 50 50 50 Sindh 50 50 50 50 Total 200 200 200 200
Total 200 200 200 200 800
Discarded
Completed
19 0 14 7 40
181 200 186 193 760
Fig.3.2.4: Multi-stage sampling flow chart Country
4 Provinces
Federal
IDI Health Managers, & Policy Makers
IDI Health Managers & Policy Makers
1 District in each province
Each Rural Site
Each Urban Site
2 Rural Sites
Poor Household Cluster
Poor Household Cluster
2 Urban Sites
Adolescent Married & Unmarried Girls • Survey • FGD
Adolescent Married & Unmarried Girls • Survey • FGD
FGD Male & Female Household Memebers
FGD Male & Female Household Memebers
FGD Male Community Members
FGD Male Community Members
FGD Female School Teachers
FGD Female School Teachers
IDI Community Healthcare Providers
IDI Community Healthcare Providers
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Qualitative Data Sampling Methodology Focus Group Discussions: Purposive sampling was done for FGDs. The following six groups were selected for FGDs. Two groups for each FGD one urban and one rural were selected in each province, with a total of twelve FGDs in each province. Thus in total 48 FGDs were undertaken across provinces (details are attached as Appendix H).
Unmarried adolescent girls: Purposive typical group sampling was done to select participants from among the households selected for the study, for one each urban and rural FGD.
Married adolescent girls: Purposive typical group sampling was done to select participants for one urban and one rural FGD.
Female Household Members: Purposive critical group sampling was done of mothers and mothers-in-law of unmarried and married adolescent girls for one each urban and rural FGD.
Male Household Members: Purposive critical group sampling was done of fathers, fathers-in-law and husbands of adolescent girls for one each urban and rural FGD.
Male Community Members: Purposive critical group sampling was done of male community opinion-makers for one each rural and urban FGD.
Female Community Members - School Teachers: Purposive critical group sampling was done of female school teachers for one each rural and urban FGDs.
In-depth Interviews (IDI) with key informants: The following key informants were identified for IDIs. Community Health Care Providers: Purposive critical case sampling was done to select CMWs and LHWs for FGDs in the selected study sites. A total of 4 health care providers were interviewed from each province. Policy-makers and Managers: Purposive critical case sampling was done to select health managers and policy-makers related to the MNCH and Nutrition Programmes, for IDIs at the federal, provincial and selected district levels (Please refer to Table 3.2.4e for distribution of participants of FGDs with actual number of FGDs that took place and the total number of participants in the FGDs).The local field assistants used different approaches to find their real ages. They asked about the age of the girl from different household members separately and Page 50
A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
checked health and other records. In Chakwal, the local field assistant discovered the actual age of a married girl as 17 while as per her Computerized National Identity Card (CNIC) she was 21. She had been married at age 14 and not 18 as indicated by her CNIC. 3.2.5. Data Collection Pilot Testing of Study Tools The study tools were pilot-tested in the selected districts in each province in May-June 2013 in Nainsukh and Malikpur, suburbs of Lahore. Following the pilot, necessary adjustments were made both in the tools and the field guidelines.
R 1 1 1 1 4
U 1 1 1 1 4
R 1 1 1 1 4
U 1 1 1 1 4
R 1 1 1 1 4
U 1 1 1 1 4
School Teachers
76 72 83 57
12 12 12 12 48
Female
Community Members Male
Female
Household Members
U 1 1 1 1 4
Completed
R 1 1 1 1 4
Total # of Participants
Balochistan KP Punjab Sindh Total
U 1 1 1 1 4
Male
Province/ Region
Unmarried
Married
Adolescent Girls
Table 3.2.4e: Distribution of groups participating in FGDs Focus Group Discussions
R 1 1 1 1 4
U 1 1 1 1 4
R 1 1 1 1 4
For the distribution of participants per group per province, refer to Table 3.2.6a. 3.2.6. Data Collection Schedules and Duration Each provincial team prepared their data collection schedules. The number of days to be spent at each field site was calculated keeping the travel time to site, the time taken in completing questionnaires and undertaking IDIs and FGDs, in mind. Data collection was undertaken in the months of July, August and September 2013. In Punjab data collection was undertaken from July 7 to September 25, in Sindh from July 10 to September 20, in KP from July 14 to September 10 and in Balochistan from July 25 to December 3, 2013.
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Table 3.2.6a: Number of FGD participants across the provinces
Respondents Category
Rural
Urban
Rural
Urban
Rural
KP
Urban
Balochistan
Rural
Sindh
Urban
Punjab
Unmarried Adolescent Girls
9
7
6
4
7
6
5
7
Married Adolescent Girls
7
6
4
4
8
8
6
6
Female Household Members
6
6
6
4
8
7
7
5
Male Household Members
8
8
5
6
8
8
6
6
Male Community Members
8
8
6
6
8
8
7
6
Female School Teachers
5
5
6
5
8
5
6
5
Total
83
62
89
72
Please refer to table 3.2.6b for distribution of IDI respondents across the provinces. Table 3.2.6b: Breakdown of IDI respondents across the provinces Punjab Sindh
Balochistan
KP
Health Managers
8
5
6
4
Lady Health Workers
2
2
2
2
Community Mid-wives
2
1
2
2
Dais/ Traditional Birth Attendants
2
1
2
2
Total
14
9
12
10
3.2.7. Quantitative Data Collection and Data Transfer Quantitative data was collected electronically on tablets. The senior statistician created a coding sheet for the entire questionnaire in consultation with the PI and the Technical Advisor Research who had developed the questionnaire so as to develop clarity on the types of responses. The initial survey tool designed was structured as per the analysis plan. However, at time of tool adaptation for digitization, it was decided to follow a flow most logical and user-friendly for the respondent. The survey tool involved a lot of skip- and if-scenarios as well as 2-3 possible paths for the respondent to follow. There was a collaborative effort by the PI, Technical Advisor Research and tool interface developer on creation of logic flows in interface. The designed questionnaire was uploaded to a live link and the technical team was asked to pilot test it. Once approved, the software was developed for live link as well as an offline application ready to be loaded on to tablets. The data collection teams were trained on the software. During the data
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
collection period, the field supervisor visited each interview site for quality checks during the survey. At the end of each day, all the tablets used for quantitative data collection were submitted to the field team supervisor. The supervisor then retrieved the dayâ&#x20AC;&#x;s data in SPSS format from each tablet and emailed it to the Central Data Management Unit (CDMU) the same night. The data entry operators at the CDMU compiled all the received data in one master SPSS sheet. This daily transfer enabled the team to receive live data feedback during the process of data collection. Throughout the data collection phase, all the collected data was available in real time to the data analysis team as both SPSS and excel files for approval and verification. This eliminated the onerous tasks of on-site verification, desk editing, data entry and double entry as well the time conservation. Following is a list of activities undertaken by the field team supervisor as the protocol for quantitative data transfer: a) Review of the data collected b) Syncing of the software updates at the end of every data collection day c) Sending the daily report on number of data points collected, incomplete surveys and remaining surveys to the Provincial Manager The Provincial Manager emailed the data to the Project Director at NCRP who shared it with the Data Entry Operators for compilation in a master SPSS sheet. 3.2.8. Qualitative Data Collection and Data Transfer Qualitative data collection involved the use of topic guides which were developed for both the IDIs and the FGDs (topic guides used in the study are attached as Appendix E and F).Detailed guides offered a more structured approach and included two levels of questions i.e. the primary discussion questions that served as suggestions for getting the discussion going and the probing questions that were asked based on the responses to the primary discussion questions. The primary questions were open to adaptation and could be rephrased as part of the FGD/IDI depending on how the discussion evolved. This allowed both freedom and adaptability while getting information from the interviewee. All primary discussion questions were followed by probing topics enlisted as bullets. These probes were used to encourage further discussion. The interviewers were trained to ensure that all key themes were covered by the end of the FGD or IDI. Interviews and FGDs were not recorded. Research associates accompanied the interviewer and took detailed hand written notes. The notes were finalized by the interviewer the same evening.
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The field supervisor visited each FGD site for quality checks during the on-going FGDs. The first transcripts developed by the junior research associates were reviewed and updated by the FGD Moderator. All the notes and recordings were submitted to the field team supervisor who reviewed them for any missing entries, labelled the notes and archived the data. At the culmination of the qualitative data collection, the field team supervisor compiled all the data and delivered the hard copies to the provincial manager. The provincial manager delivered the data to the project director at NCRP. The qualitative data was assigned to translators and transcribers at the CCDMU for preparation of comprehensive transcripts. All the data were transcribed and translated directly from native language into English. The validity of the translations and transcripts was checked through back translation of sample sections. The final transcripts were then shared with the qualitative expert for analysis. 3.2.9. Problems faced during Data Collection Data collection was undertaken in the months of July and August, the hottest months of the year and on top of this the month of Ramadan (fasting month) came in this period. As a result both the interviewers and the respondents were affected and the activity took longer than planned. In Kohat district male household members who came back from work earlier during Ramadan, showed their resentment on the presence of interviewers in the house and some incidents of their turning out the interviewers occurred. The Punjab and the KP data collection teams reported a certain level of mistrust and hostility in the communities they visited for data collection. At Bhaun urban site in Chakwal district the community was particularly bitter and unfriendly as is evident from the following remarks of some community members: All provinces reported that household members of the study adolescent girls were expecting some remuneration for participation in the study. There were some incidents of interviews being cut short and participants leaving FGDs halfway through the discussion on discovering that no payments will be made in lieu of their participation. In the analysis phase it was found that Balochistan had not applied the income criteria strictly and as a result the mean income of the study households in the province was way above that of the other provinces. They were directed to replace the households with high income with those which met the income criteria. In the Punjab province 14 households were found to be above the poverty line. The data from these households was therefore not included in data analysis. â&#x20AC;&#x153;Blue plaiton wali gariyon main madamain ati hain, aur hum itni der jawab date hain, itne wadey karti hain, aur phir jakar koi poochta bhi nahi zinda hai ke marr gayeâ&#x20AC;? Translation: Madams come in cars with blue plates (international agencies), we spent a long time answering to all their queries and once they leave, they never turn back to see if we are alive or dead. Page 54
A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
These difficulties and unpleasant incidents were largely overcome through the support of the officials and community elders who had been briefed during advance field visits and the focal persons and local field assistants who had been recruited for the study. In Balochistan province where this protocol was not followed, resistance was experienced because senior health officials were not briefed during advance visit. The data collection team experienced delays in securing their permission for organizing FGDs with public sector community services providers like LHWs and CMWs, who refused to participate without permission from the DGHS and EDO Health Offices.
3.3. Data Analysis & Reporting Data analysis was done in four thematic areas to achieve the objectives of the research study as presented in table 3.4a: Table 3.3: Themes for analysis of data Specific Objectives i To determine the perceptions of adolescent girls regarding their role and status in the community and household; ii
iii
iv v
vi
vii viii
Analysis Key Area Study adolescent girlsâ&#x20AC;&#x; background and characterization to determine the context in which the knowledge, beliefs and practices of the study adolescent girls occur
Status and empowerment of adolescent To determine the perception, beliefs and practices of girls as a determining factor of the study the community and households regarding the status adolescent girls knowledge, beliefs and practices. of adolescent girls; To document the knowledge, beliefs and practices of Dietary knowledge and beliefs, sources of poor unmarried and married adolescents with respect nutrition information, meals and dietary to nutrition patterns, anthropometric measurements dietary supplements use etc. To record the sources of nutrition information of married and unmarried poor adolescents girls; To assess the knowledge, beliefs and practices of the community and households regarding the nutritional needs of adolescent girls-married and unmarried; To document the knowledge, beliefs and practices of community health services providers regarding the nutrition of adolescent girls-married and unmarried; To determine the role and practice of school teachers in promoting the nutrition of adolescent girls; To determine the knowledge and views of health policy-makers and managers regarding the need for prioritising the nutrition of adolescent girls-married and unmarried, in health policies and strategies.
Participantsâ&#x20AC;&#x; access to and utilisation of available health and nutrition services including availability of services, reproductive health knowledge and practices as determining as well as outcome factors of the adolescent girls nutrition knowledge, beliefs, and practices
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3.3.1. Participants background and characterization Participants‟ background includes age of respondents, age at menarche, socio-economic status of household, type of houses they live in, number of rooms in houses, assets in the house. Quantitative data descriptive analysis was done using SPSS 20.0 and MS Excel 2010. Means, medians, ranges, percentages were calculated. 3.3.2. Status and empowerment of adolescent girls Analysis included age at marriage, age differential with spouses, education, education of spouses, employment of participants, control over spending income earned by them, spouses employment and income, control over spouses income. Descriptive analysis was undertaken with some correlation and regression analysis, taking significance level as p<0.05. Results presented were in means, medians, proportions, percent distributions, and multiple‐way cross‐tabulation of relevant variables, and aggregate counts of events. Regression analysis reflected the significance of differences that existed between unmarried and married population, and between urban and rural population along those parameters which showed variance etc. A Financial Empowerment Index (FEI) was constructed to determine the financial empowerment status of the adolescent girls. It was determined that factors like household income, personal expenditure and control on income are some areas that directly affect the empowerment status of a female in society. In order to capture the essence of empowerment in one variable, references were sought from the internet and due to non-availability of a custom-designed variable, an index was designed (Table 3.3.2). Table 3.3.2: Financial Empowerment Index (FEI) Criteria Categorization Score Personal monthly Income
Control on spending own income Expense on personal needs monthly
Nil ≤ PKR 1000 PKR 1001 – 3000 > 3000 Nil Partial Full Nil ≥ PKR 500 PKR 5001 – 1000 PKR 1001 – 3000 > PKR 3000
1 2 3 4 1 2 3 1 2 3 4 5
Level of Empowerment Score Level 3 -5 Not empowered
6- 9
10 – 12
Partially empowered Fully empowered
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3.3.3. Dietary Patterns The nutritional status and dietary patterns include household spending on food, households food shortages, adolescent girls reporting of sufficient food for them to eat, frequency of intake of different food items, meal patterns, daily calorie intake, , knowledge and intake of nutritional supplements, Body Mass Index (BMI), Mid upper Arm circumference measurement, weight for age and height for age. Data such as percentage of income spent on food, shortage and hunger was presented in percentage distributions. Correlation of BMI and MUAC was assessed using Spearman correlation coefficient. Cross tabulations and a logistic regression model were used for analysis of association of different socio-economic factors with nutritional status of adolescent girls, financial empowerment with BMI, household income with BMI etc. FFQ: The FFQ yielded the frequencies with which specific food items in food groups were consumed over a one month period by the households. The respondents were asked to mark one frequency for each food item out of multiple frequency choices. A frequency chart was prepared, showing the food items respondents were having daily, multiple times in a week, weekly, monthly or less frequently. The 24 hour dietary recall: The recall yielded portions of food items consumed by adolescent girls at different meal times in the past 24 hours. For foods such as Paratha, Salan (plain curry made of fried onions water and seasoning), meat, vegetables and lentils curries. The caloric value was calculated by the technical experts at the Nutrition Department at FMH prior to undertaking the survey (the caloric values of food items used to analyse the 24 hour dietary recall are attached as Appendix K).Through this method, the total caloric value of individual food items taken by the study respondent girls was calculated. This also yielded the mean caloric value of breakfast, lunch and dinner across urban rural, provincial and married unmarried distributions. WHO recommended daily energy intake for adolescent girls was used for comparison. The 24-hour dietary recall was also used to find the common food item combinations eaten at breakfast, lunch and dinner, to develop dietary patterns of the study adolescent girls. The information of micronutrients has been described in percentage distributions. Nutritional Status: The WHO classification was used to categorize the nutritional status of the study adolescent girls on the basis of BMI (Table 3.3.3a).
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Table 3.3.3a: WHO classification of nutritional status of adolescent girls on the basis of BMI for age for adolescent girls Percentile Classification 14yrs 15yrs 16yrs 17yrs 18yrs 19yrs BMI BMI BMI BMI BMI BMI rd 3 Severe Thinness 15.6 16.1 16.4 16.6 16.7 16.7 15th
Thinness
17.2
17.7
18.1
18.3
18.5
18.6
50th
Normal
19.6
20.2
20.7
21
21.3
21.4
85th
Over-weight
22.9
23.7
24.2
24.7
24.9
25.1
Obesity
26.7
27.6
28.2
28.6
28.9
29
97
th
Pregnant adolescent girls amongst the study group were excluded from the analysis of anthropometric data. Weight for Age: In the absence of WHO classification for weight for age, the United States Center for Disease Control (CDC) classification for weight for age was used to categorize the study respondent in quartiles according to their weights (Table 3.3.1c). Table 3.3.3b: CDC classification of weight for age of adolescent girls Percentile 14 yrs. 15 yrs. 16 yrs. 17 yrs. 25
th
50
th
75
th
18 yrs.
19 yrs.
44
46
49
50
51
51
49
53
54
55
56
57
56
59
62
63
64
64
Height for Age: The WHO classification of height for age of adolescent girls was applied to rank the participants (Table 3.3.1d). Table 3.3.3c: WHO percentile ranking of height for age for adolescent girls Percentile 14 yrs. 15 yrs. 16 yrs. 17 yrs. 18 yrs. 25
th
50
th
75
th
19 yrs.
155.1
157
157.9
158.3
158.6
158.7
159.8
161.7
162.5
162.9
163.1
163.2
164.5
166.3
167.1
167.4
167.5
167.6
Mid Upper Arm Circumference (MUAC): As per the Asian references provided in Food and Nutrition Technical Assistance III (FANTA) Report of 2013, (Tang, et al., 2013), three cut offs were selected: 22, 23 and 24cm. Mean BMI for both lower and higher groups for each cut-off MUAC was calculated. The results are given in Table 3.4.1e.
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
Table 3.3.3d: Correlation of BMI of study adolescent girls with different MUAC cut-offs Unmarried n=381 <
Married n=379 >=
<
>=
Cut off MUAC
n
mean BMI
n
mean BMI
n
mean BMI
n
mean BMI
22.0 cm
66
20
315
22.5
27
20.1
352
24.1
23.0 cm
102
19.7
279
23
55
20.6
324
24.3
24.0 cm
139
20
242
23.3
88
20.7
291
24.7
Table 3.3.3e Mean MUAC of groups of study adolescent girls at BMI cut-off value of 18.5 Unmarried n=381 < Cut off BMI 18.5
n 83
Married n= 294 >=
<
>=
mean MUAC
n
mean MUAC
n
mean MUAC
n
mean MUAC
16.8
298
23.6
42
15.7
252
25.1
3.3.4. Participants access to and utilisation of available health and nutrition services The data collected was on contact of adolescent girls with services provider, sources of nutrition and health information, knowledge of nutrition and health, reporting of nutrition related symptoms of ill health etc. 3.3.5 Knowledge, opinion, beliefs and practices FGDs and IDIâ&#x20AC;&#x;s generated qualitative data was analysed for the different beliefs and opinions expressed by the participants on adolescent girls education, age at marriage, employment, status within their households, their access to available food, food appropriate for adolescent girls, effectiveness of services providers as sources of health and nutrition counselling etc. The analysed data was integrated in the relevant thematic areas of the research results. Credibility of the recorded data was established using the technique of persistent observation i.e. recurring observations of household members during FGDs, responses of household members during the FGDs of adolescent girls and establishing triangulation. The evidence generated is briefly outlined in Table 3.3.4.
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Table 3.3.4: Evidence and information extracted from qualitative data
S. No.
Group
Evidence generated
Married Adolescent girls
To develop understanding the girls‟ perspective on their social status, access to food, food choices, understanding of nutrition and trusted sources of information.
2
Parents
To Develop insight into the microenvironment of the adolescent girl‟s household and influences on their beliefs and practices, to understand the factors affecting their nutritional and health status and the extent of their empowerment.
3
Community Opinion Leaders
To develop understanding of societal the influences on shaping the adolescent girls nutritional beliefs and practices and their social status.
4
School Teachers
To elucidate the role teachers are playing or can play in bringing about a positive change in adolescent girls knowledge and beliefs on nutrition and dietary intake.
5
Community Health care providers
To understand the role they are playing in adolescent girls‟ nutrition and health promotion, the barriers they are facing and what they need to strengthen their role as counsellors and promoters of adolescent girls‟ nutrition.
Health Managers
To understand the managers and policy makers perspective on the importance of adolescent girls health and nutritional status towards achievement of MNCH and nutrition goals and target and where is the girls nutritional status placed in the policy and programmes priorities. Also to get their suggestions and recommendations on promotion of adolescent girls nutrition
1
6
3.4. Ethical Approval Ethical approval was given by
Institutional Review Board of the FMS Centre of Health Research Page 60
A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
National Bioethics Committee
Informed consent of participants was take as well as their families‟ heads. There are several issues with informed consent in the study adolescent girls‟ population. A number of them were underage and illiterate and owing to cultural reasons not autonomous. As reported, “Pakistan, in common with other eastern collectivist cultures, places great value on communal wellbeing and family harmony, including obedience to parents, than on personal autonomy” (Hamid, 2011). Therefore permission from heads of households, fathers, husbands or whoever had the authority to give permission, was needed. The consent script (attached as Appendix L) was translated into local languages and was read out to the respondent in local language. Thumb impressions or signatures were taken on the consent form in the presence of a witness. There anthropometric measurements were done in the presence of another female household member. The young adolescents‟ girls were interviewed by females only. Confidentiality Interviews with the adolescent girls were undertaken in their houses and while difficult the interviewers tried to ensure confidentiality by separating them from the other household members in a room if available or corner of the courtyard or where ever else allowed by the families.. However for some socio-demographic data like family income or age determination help from family members was taken. The confidentiality and safety of data in transmission from field sites and in processing at the DMU was ensured by making two persons responsible for the handling of the data. All filled questionnaires and forms were kept locked in the custody of the responsible computer scientist. Social and environmental Considerations Conduct of the research: Keeping in view the socio cultural context, all interviews of female respondents were undertaken by female interviewers and of male respondents by male interviewers. Data collection teams were trained and informed about respecting cultural sensitivities of the communities from where data was collected. Dress codes were communicated to the field teams and strict adherence was ensured. Stakeholder consultations and a participatory approach were adopted during the design and implementation stage to build rapport with the data providers and end users. Research approaches were shared both through formal and informal meetings.
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4. Results The study has generated both quantitative and qualitative data. Quantitative data has been generated from 800 households, 400 each with unmarried and married adolescent girls and 200 from each province. During analysis some households‟ data was discarded because these were not conforming to the selection criteria of a maximum of PKR 25000 monthly income. In the final analysis a total of 760 households were included; Punjab 186, Sindh 193, KP 200 and Balochistan 181. The total number of unmarried girls included in the analysis was 381 including 93 from Punjab, 97 from Sindh, 100 from KP and 91 from Balochistan. Married adolescent girls included in analysis totalled 379, 93 from Punjab, 96 from Sindh, 100 from KP and 90 from Balochistan. For collecting qualitative data 12 FGDs were undertaken in each province with a total of 48 across provinces. These included four FGDs in each province with adolescent girls-2 each unmarried and married, four with household members of the study adolescent girls-2 each male and female members and four with community members-two with male members and two with female school teachers from the community. The total number of participants in each province was 76 in Balochistan, 72 in KP, 83 in Punjab and 57 in Sindh. IDIs were undertaken with two LHWs each per province, two CMWs each in Balochistan, KP and Punjab and one in Sindh, two TBAs each in Balochistan, KP and Punjab and one in Sindh and six health managers in Balochistan, four in KP, eight in Punjab and five in Sindh. The IDIs total in Balochistan was 12, in KP 10, in Punjab 14 and in Sindh 9 (sampling details are provided in section 3.2.4 of Methodology). The integrated quantitative and qualitative data are presented under four main heads. Any specific themes emerging from qualitative data are described. 4.1 Study adolescent girls’ background and characterization: includes age, socio-economic status of household, type of houses they live in, number of rooms in houses. 4.2 Social status and financial empowerment include age at marriage, age differential with spouses, education, education of spouses, employment, control over spending income earned by them, spouses employment and income, control over spouses income. FGD participants‟ opinions and beliefs on age at marriage, girls‟ education and employment are included in this section. 4.3 Dietary patterns and nutritional status include household spending on food, households food shortages, adolescent girls reporting of sufficient food for them to eat, frequency of intake
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of different food items, meal patterns daily calorie intake, , knowledge and intake of nutritional supplements, Body Mass Index (BMI), weight for age and height for age data. The FGDs participants‟ perceptions on nutritional needs of adolescent girls, food taboos, girls‟ access to available food in the house, the priority given to their preferences, and sources of nutrition information are discussed in the section. 4.4 Study adolescent girls’ access to and utilisation of available health and nutrition services include availability of services, contact with services provider, sources of nutrition and health information, knowledge of nutrition and health, reporting of nutrition related symptoms of ill health. The FGDs participants and the health services providers perspectives on the latter role in providing information and counselling to adolescent girls on nutrition and health are discussed in the section. The health managers‟ experiences, views and opinions and suggestions are described in a separate narrative following the four main heads of results presentation. The study girls background, social status and financial empowerment data provide the context in which their nutrition knowledge, beliefs and practices have developed. It is with this perspective in mind that the girls‟ nutritional issues need to be placed and relevant and practicable recommendations developed. The reproductive health knowledge and practices data has been included to indicate some of the other critical factors which influence the reproductive health outcomes of nutritionally compromised adolescent girls. The purpose is to present a near complete picture of the poor adolescent girls‟ nutrition and dietary issues across Pakistan. (The source data tables to all the frequency graphs discussed in this section are attached as Appendix G).
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4.1. Study adolescent girls’ background and characterization 4.1.1. Age of study adolescent girls Age distribution There is an even distribution of ages in the unmarried group while 60% of the married adolescent girls are in the 19 years age group (Table 4.1.1a). In poor and illiterate communities in Pakistan getting the real ages of persons is always a challenge. Getting the real ages of married adolescent girls is even more so owing to the legal issues involved. A major barrier to getting the real age of married adolescents girls is the requirement of the National Identity Card (NIC) at the time of marriage. The NIC is issued after the age of 18 years. Therefore practically, no girl could be married before the age of 18 years. To get around this requirement the practice of recording higher ages of girls about to be married in CNICs is common. As mentioned in the methodology section, the age of a girl who was 17 years old was given as 21 years to hide the fact that she was married at 15 years age. Interviewers need to be diligent and creative in getting at the real age of their study population. In this study the interviewers used information sources triangulation to ensure the validity of the data. As presented in Figs. 6a & 6b there are no significant differences across provinces and between urban and rural adolescents except KP where 10% married adolescent girls are of age 15 years and below while in the other provinces less than 3% are in this age group. Table 4.1.1a: Median age of study participants, married and unmarried and across provinces and urban and rural location Median Age Range Respondent 18 14 – 19 Pakistan 18 14 – 19 Balochistan 18 14 – 19 KP 18 14 – 19 Punjab 18 14 – 19 Sindh 18 14 – 19 Urban 18 14– 19 Rural 19 14 – 19 Married 17 14– 19 Unmarried
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.1.1a: Provincial distribution of study adolescent girls‟ age 100% 90% 80% 70% 19.00
60%
18.00
50%
17.00 40%
16.00
30%
15.00
20%
14.00
10% 0% Pakistan Baluchistan KPK n=100 n=381 n=91
Punjab n=93
Sindh n=97 Pakistan Baluchistan KPK n=100 n=379 n=90
UNMARRIED N=381
Punjab n=93
Sindh n=96
MARRIED N=379
Fig.4.1.1b: Rural and urban distribution of age of study adolescent girls 100% 90%
80% 70% 19.00 60%
18.00
50%
17.00
40%
16.00
30%
15.00
20%
14.00
10% 0% Pakistan n=381
Rural n=188 UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
4.1.2. Age at menarche Across Pakistan, 72% of unmarried (n=381) and 66% of married (n=379) adolescent girls reported 13 years as their age at menarche (Figs. 7a &7b). Overall, the median age at menarche is 13 years. The lowest proportion of 16% of unmarried and married adolescent girls having menarche at ages ≤12 years has been recorded in KP and Sindh compared to the 32% and 40% of Page 65
A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
married and unmarried girls from Balochistan and 30% and 40% from Punjab respectively (Fig. 4.1.2a). This is a significant finding and needs further validation since low age at menarche is an established risk factor for breast cancer and its determinants include among many others, socioeconomic status, energy intake, physical activity and stunting (Karapanou & Papadimitriou, 2010). Rural and urban difference in age at menarche in both unmarried and married adolescent girls is apparent (Fig. 4.1.2b). Among unmarried adolescent girls, 20% of rural and 26% of urban girls reported having menarche at age â&#x2030;¤ 12 years while among the married adolescents 25% of rural and 30% of urban girls reported having menarche at â&#x2030;¤ 12 years. Fig.4.1.2a: Provincial distribution of age at menarche of the study adolescent girls Less than or equal to 12
13 to 14 years
More than 14 years
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED N=381
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90 MARRIED N=379
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
Fig.4.1.2b: Urban and rural distribution of age at menarche of study adolescent girls Less than or equal to 12
13 to 14 years
More than 14 years
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
4.1.3. Household Monthly Income Table 4.1.3a shows that the median monthly incomes are similar for unmarried and married adolescent girls‟ households in Punjab and Sindh provinces, both in the urban and rural locations. KP has the lowest median income of PKR 6000 and Balochistan has the highest of PKR 15,000. Balochistan also doesn‟t report income less than PKR 4000 and has included 65% households in the income range of PKR 10,001 – PKR 20,000. This is because the Balochistan sample of households comes from Quetta, the capital city of the province and includes households of school teachers and lower grade government employees. As explained in the methodology section, the Balochistan team was very concerned about security and was not willing to go outside Quetta and its suburbs. Variation in reported household income across provinces is apparent in Fig. 8a. KP has the highest proportion of 20% households with income of ≤ PKR 5000 and the lowest proportion of 10% with above PKR 10,000 income. Punjab and Sindh have similar distribution of households‟ income for both unmarried and married adolescent girls while as is evident from the median household income, Balochistan households of both unmarried and married are financially better off with 56% and 53% respectively in the income range PKR 10,000 – 20,000 and 15% each in the above PKR 20,000 range. Variation in the income of rural and urban households of the study adolescent girls is minimal (Fig.4.1.3b). Among the unmarried adolescent girls households, 8% rural and 10% urban have income of PKR ≤ 5000 while 5% rural and 8% urban have income above PKR 20,000. Among the married girls households, 11% rural and 13% urban have income of ≤ PKR 5000 while 27% rural and 25% urban households have income of PKR 10,000 to PKR 20,000.
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan
Table4.1.3a: Median household income and range across provinces and urban and rural location Median Monthly Income in PKR
Range in PKR
Respondent 1000 – 25000 4000 – 25000 1000 – 25000 1000 -25000 1000 – 25000 1000 – 25000 1000 – 25000 1000 – 25000 1000 – 25000
9000 15000 6000 8000 9000 8000 9000 8000 9000
Pakistan Balochistan KP Punjab Sindh Urban Rural Married Unmarried
Fig.4.1.3a: Provincial distribution of study adolescent girls‟ households‟ monthly income <5,000 Rs.
5,000 - 10,000 (Rs.)
10,001 - 20,000 (Rs.)
>20,000 Rs.
100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED N=381
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90 MARRIED N=379
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.1.3b: Rural and urban distribution of study adolescent girls‟ household Income <5,000 Rs.
5,000 - 10,000 (Rs.)
10,001 - 20,000 (Rs.)
>20,000 Rs.
100% 90% 80% 70% 60% 50%
40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
Urban n=193
Pakistan n=379
UNMARRIED N=381
Rural n=190
Urban n=189
MARRIED N=379
4.1.4. Household Size A clear difference between the number of household members of unmarried and married adolescent girls is evident in Table 4.1.4a and Figs.4.1.4a and 4.1.4b. Overall 12% of the households of unmarried girls and 38% of the households of married girls reported having less than five members. Of the 54 households who reported to have two members only, 48 are of married participants. Balochistan has the highest number of households with more than 10 members (28%) while Punjab has the lowest at 5%. Balochistan also has the largest household size with 30 members and the largest median household size of 8 members. Urban and rural differences are present in the number of household members in both unmarried and married girls‟ households. Among the unmarried adolescent girls households, 11% rural and 12% urban have ≤ 5 members while 18% rural and 10% urban have more than 10 members. Among the households of married adolescent girls, 35% rural and 38% urban have ≤ 5 members while 20% rural and 11% urban have more than 10 members. Table 4.1.4a: Median family size with range across provinces, urban and rural and married and unmarried study adolescent girls Range Median Family Size Household members (No. of households) 7 2 (54)- 30 (1) Pakistan Balochistan
8
2(10) -30 (1)
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KP
7
2(11) -23 (1)
Punjab
6
2(13) -15 (2)
Sindh
6
2(20) -21 (1)
Urban
7
2 -23
Rural
7
2 -30
Married
6
2(48) -22
Unmarried
7
2(6) -30
Fig.4.1.4a: Provincial distribution of household size of study adolescent girls <5 Members
5 - 7 Members
8 - 10 Members
>10 Members
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED N=381
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90 MARRIED N=379
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Fig.4.1.4b: Urban and rural distribution of household size of study adolescent girls <5 Members
5 - 7 Members
8 - 10 Members
>10 Members
100% 90% 80% 70% 60%
50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
4.1.5. Housing In Balochistan, the houses of both unmarried and married adolescent girls were found to be either kucha (made of mud) or mixed kucha and pacca (mud and concrete). 38% of married adolescent girls live in kucha houses as compared to 15% unmarried adolescent girls. As shown in Fig.10a, 10% in KP, 16% in Punjab and 40% houses of unmarried adolescent girls in Sindh are pacca (concrete). In Punjab, 45% of unmarried and 35% of married adolescent girls‟ houses are mud houses (kucha). In Sindh, about 40% of unmarried and married adolescent girls‟ houses are pacca while in KP, over 70% of the houses are mixed (mud and concrete). The type of house distribution in rural and urban locations is similar. Over 80% of rural houses of both groups of adolescent girls are either kucha or mixed with 15% and 20% of houses of rural and urban unmarried girls respectively being pacca. 20% each of rural and urban married adolescent girls reported to be living in pacca houses.
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Fig.4.1.5a: Provincial distribution of type of houses of the study adolescent girls All Pacca
All Kacha
Mixed
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90
UNMARRIED N=381
MARRIED N=379
Fig.4.1.5b: Urban and rural distribution of house types of study adolescent girls All Pacca
All Kacha
Mixed
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
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4.1.6. Number of rooms used for sleeping in the house Distribution of number of rooms used for sleeping in the study population‟s households is shown at provincial and rural/urban level in Fig. 4.1.6a and b respectively. Two or less rooms are available for sleeping to 80% or more of study adolescent girls in Punjab and Sindh. Similar availability is reported by 80% of unmarried and 64% of married adolescent girls in KP. Contrastingly, 38% of unmarried and 50% of married girls‟ houses have availability of two or less rooms in Balochistan, whereas 20% of unmarried and 10% of married study adolescent girls‟ houses have five rooms or more available for sleeping (Fig. 4.1.6a). Among the unmarried girls‟ houses, 68% in rural and 75% in urban residential areas have two rooms or less for sleeping. No difference appears to be present between married girls‟ houses in urban and rural residential areas, as 69% and 68% respectively have two rooms or less for sleeping. 8 % of rural and 4% of unmarried girls‟ houses in urban residential areas have five or more rooms available for sleeping. Similarly, of married girls‟ houses, 4% have five or more rooms to sleep. (Fig. 4.1.6b). Fig.4.1.6a: Provincial distribution of number of rooms used for sleeping in the study adolescent girls houses 2 or less rooms
3 to 4 rooms
5 rooms and above
100%
80%
60%
40%
20%
0% Pakistan n=381
Baluchistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Baluchistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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Fig.4.1.6 b: Rural and urban distribution of number of rooms used for sleeping in the houses of study adolescent girls 2 or less rooms
3 to 4 rooms
5 rooms and above
100%
80%
60%
40%
20%
0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
4.1.7. Description of study sites In district Kohat, UC 4 and UC 5 were chosen as rural sites and UC Ustarzai and UC Sherkot as urban sites. The sites chosen were amidst agricultural land, bearing Laukat and Guava. The primary occupation of the population is agriculture and labour. There are a higher number of educated adolescent girls and a very small number works as domestic help. In Chakwal district of Punjab the urban sites chosen were Dhudhial and Bhaun. Dhudhial is a fast developing populous town in District Chakwal with a population of around 35,000. The town has a „Rural Health Centre and one high school each for boys and girls. The area is politically very active and a large proportion of the population was reported to be recipients of the Benazir Income Support Programme (BISP). The study team sensed a certain anxiety in the community regarding the post-election continuation of BISP. The community‟s poverty and dependence on support programme was expressed by one of the community members as below: Hum ne to manna kiya hua hai yeh rehrhiwalon ko, ke na hi idhar aya karain na hamarey bachay royain. (Translation: We have stopped the vendors/street hawker from coming to our streets. Neither will they come nor will our children cry).
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Bhaun too has a population of 35,000, one Basic Health Unit (BHU) and a high school for girls and boys each. An ancient settlement with its mention both in Hindu mythology and Greek history, the town is famous for its cattle and horses. The rural sites in Chakwal included Thaneel Fatohi/ Kheenger and Mohara Thaneel /Kalial. Thaneel Fatohi is a rural settlement in Union Council (UC) Balokasr on the outskirts of Chakwal city about 45 minutes from the main city. The village has 3 schools, 2 mosques and a small stadium. There is one BHU, which also serves 3-4 other rural settlements nearby. The village has a central ground where the elders gather together in the evening, hold informal discussions and resolve feuds within the community. Women are the main bread winners of most households, working in houses in the city as house-maids. The village was found to be relatively inhospitable. The villagers were reluctant to initiate discussion or respond to generic questions like 'how are you?' .The mothers did not allow their young children to interact with the visiting team. The prospective participants were suspicious and critical of outsiders coming in to survey them. They were reluctant to sit for a FGD or for an interview. During one of the discussions, two people left when they found out that there was no monetary/material compensation for their participation. The other rural site in Chakwal district selected for the study was Mohara Thaneel. Mohara Thaneel is 35 minutes away from the motorway turning in Odherwal Union Council. In contrast to Thaneel Fatohi, the villagers were friendly and their children inquisitive. It is a larger settlement than Thaneel Fatohi, comprising of 3/5 smaller villages. The settlement has 2 primary and 1 secondary schools and one rural health centre which serves the entire area. There are grounds in the villages where the males of the community hang out in the evenings, chat and smoke hookah etc. The men were mostly unemployed and didnâ&#x20AC;&#x;t appear to be concerned about it. Women, on the other hand, appeared more in control of their households and the related decision making. This community also expected monetary compensation for participation in the study as is evident from the following remark of one of the older women: Yeh baatain asan hain lekin in se to pait nahi bharta. Madad karni hai to karo. Baatain mat karo. (Translation: It is easier said than done. Mere talk cannot fill our stomachs. If you can help us, please help. Donâ&#x20AC;&#x;t just talk). New and Old Sukkur were the selected urban sites in Sukkur district of Sindh. New Sukkur is located in the west of Sukkur city. The area has many small and large scale industries. A large proportion of the population is therefore that of industrial labourers. There are insufficient education and health facilities. Old Sukkur is the most ancient part of Sukkur City and is heavily populated. While the area has a large numbers of schools, the poor are deprived owing to their inability to bear related financial burden. Page 75
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The Sukkur district rural site, Abad (Bagarji) is well known for its agricultural produce especially rice of good quality. Almost every family of Abad have their involvement in agriculture, majority as labourers since the land is owned by big land owners (wadera). Due to tribal clashes the area is considered unsafe for outsiders. Literacy rate is low and health facilities are inadequate. The other Sukkur rural site Rohri (Ali Wahan) is known as „City of Muhammad Bin Qasim‟ , „City of Sufis‟ , ‟ City of Seven Sisters‟ , ‟ City of Historical Heritage‟ and the ancient Capital of Sindh in Ror Dynasty. Rohri city covers the left bank of Indus River with its beautiful buildings. Tehsil Rohri consisted of 75% rural and 25 % of urban area. Ali Wahan, Saleh Pat, Sangrar are its main towns. In district Quetta the urban sites selected were Goal Mandi Ward 04 and Pashtoonabad. Goal Mandi Ward 4 is a populous urban site with a mixed community representing different ethnic groups. Despite being poor and deprived, education is comparatively high in this community. Health and education facilities in public sector include girls‟ schools and college, Maternal and Child Health (MCH) Centre and a children hospital. The rural site in Quetta, UC Killi Shabo selected has a population of 125,000. The community is poor. The source of income for women is hand embroidery whereas majority of the men work as labourers. There is no sewerage system and no public sector health facilities in the area. However there is one middle public school for girls and few private schools and clinics.
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4.2. Social Status and Financial Empowerment The indicators used for determination of social status and empowerment of the study adolescent girls in this study are age at marriage, age differential with spouse, education and education differential with spouse, employment status, salaries earned, and control over spending of salaries earned. The data is consistent and results of one variable are corroborated by that of another except for the data from Balochistan, where the study sites chosen are near the provincial capital and the study households are mostly of lower grade government employees or school teachers. 4.2.1. Age at Marriage The mean age at marriage of the married study adolescent girls was found to be 16.19 years with a SD of ±1.69 (confidence limits 16.02- 16.36). Fig. 4.2.1a shows the distribution of mean ages at marriage of married adolescent girls across provinces. In Sindh, only 1% girls while 11% in Balochistan, 7% in KP and 8% in Punjab are married at ages 12-13 years. 38% of girls in KP while 19% in Balochistan and Sindh, and 25% in Punjab are married at ages 18-19 years. Across the provinces, 61% to 68% were found to be married at the ages of 16 – 19 years and 32% to 39% married at or before the age of 15 years. Urban and rural differences in age at marriage are shown in Fig. 4.2.1b. The differences are present for all age groups, with 7.9% of rural and 5.3% of urban girls married at age 12-13 years and 21% of rural and 29.6% of urban girls married at age 18- 19 years. When looked at in the legal context, 33.2% of rural and 35.5% of urban girls are married at age 15 years or younger. The positive influence of education on age at marriage has been found and presented in Table 4.2.1a. The mean age at marriage of girls with education of five years or less is 15.9 years, of girls with 6-12 years education is 16.25 years and of girls more than 12 years education, is 17 years. The difference between the five years and less category and 6-12 years category is not statistically significant (p=0.746). There is a significant difference between the five years and less category, and more than the 12 years of education category (p=0.019) and between 6-12 years and over 12 years education categories, (p=0.030). Opinions of the adolescent girls‟ family and community members on appropriate age at marriage were explored in FGDs. Three strong themes emerged: religious/cultural norms, mental and physical maturity, and male preferences. Emergent Theme: Deeply rooted religious and cultural beliefs along with financial burden on families have entrenched young age marriages in the poor communities
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Fig.4.2.1a: Provincial distribution of age at marriage of study adolescent girls 100%
80%
60% 49% 42%
40%
38%
40% 28%
42%
28%
25%
26%
31%
29%
26%
25%
19%
20%
11%
19% 8%
7%
7%
1% 0% Pakistan n=379
Baluchistan n=90 12 - 13 years
KP n=100 14 - 15 years
Punjab n=93
16 -17 years
Sindh n=96
18 - 19 years
Fig.4.2.1b: Rural and urban distribution of ages at marriage of study adolescent girls 100%
80%
60% 45.8% 40% 40%
34.9% 30.2%
28%
25%
29.6%
25.3% 21.1%
20% 7.9%
7%
5.3%
0% Pakistan n= 379 12 to 13 years
Rural n=190 14 to 15 years
16 to 17 years
Urban n=189 18 to 19 years
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Table 4.2.1a: Association of education and age at marriage of the study married adolescent girls Education Vs. Age at Marriage
Category
Levels of Education
n
Mean Age at Marriage
95% Confidence Interval for Mean Lower Bound
Upper Bound
I
5 years of education or less
246
15.9
15.71
16.09
II
6-12 years of education
106
16.25
15.95
16.55
III
More than 12 years of education
27
17
16.56
17.44
Significance of difference ANOVA and Multiple Comparisons With II With III With I With III With I
0.746 0.019 0.746 0.03 0.019
With II
0.03
Those in favour of young marriage age of 14-16 years quoted economic and social problems as justification. These participants thought that parents should fulfil their responsibilities as soon as possible. Another justification given for early age at marriage was that men like to have young wives and that they want them to stay young for a longer period of time. “Getting married at this age is our culture.” -FGD with Female Household Members category, Kohat, KP Proponents of early marriage were of the view that there is no impact of early marriage on maternal and neonatal health, and that they have never found any kind of complications in early age marriage. They expressed the belief that late marriages lead to difficulties in child bearing. “We are Muslims and as per religious rules, girls should be married early and why should this have any impact on their health.”-FGD with Community Members, Sukkur, Sindh Within the proponents of early marriages there were some who thought 15 years and below inappropriate because the girls are not mentally mature and don‟t understand marital responsibilities. They supported 15-18 years as an appropriate age. Some married adolescent girls, stated that according to religion, a girl should be married by the time she passes her second menstrual cycle, but none of the participants were in favour of less than 15 years of age as appropriate age for girls‟ marriage. Page 79
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Participants who thought 18-20 as a favourable age said that growth of girls is complete by this time and she is able to take up responsibilities of household as well as children. She can also carry her domestic and marital responsibilities. The girl is mentally mature and ready for marriage. She can decide what is good and bad for her. By this age her education is also complete, she understands marriage and can manage children as well as local social and cultural matters. Some said that they had always heard that 18 is the perfect age but did not know the reasons behind this. Those in favour of age 25-26 years said that education and physical and mental maturity is achieved by this age and girls of this age can take on household and reproduction responsibilities. According to them at this age they can also comprehend the new environment in their husbands‟ homes. They felt that education should come before marriage and girls should first complete their education and then get married. Teachers in particular favoured 25 years of age as appropriate for marriage. Some of the participants in favour of later age at marriage said that early marriage is a social crime. “It is suicide.”-FGD with School Teachers, Sukkur, Sindh According to them it can prove lethal for mother and her child, and may cause many complications for her in future because the girls are physically not ready for marriage. They believed that young mothers are more likely to become anaemic. “It is due to early marriage that number of (maternal) deaths has increased.”FGD with School Teachers, Chakwal, Punjab “In early marriages the girls are not capable of looking after themselves and their babies, and there are more chances of miscarriages in teen age pregnancies and lots of other complications.”-FGD with School Teachers, Quetta, Balochistan “Early marriages lead to teenage pregnancies which ultimately lead to more complications physically.”-FGD with School Teachers, Kohat, KP “It‟s dangerous for the health of mother. The baby can be born abnormal.”FGD with Male Household Members, Chakwal, Punjab
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Health services providers (LHWs, CMWs, TBAs/Dais) with whom IDIs were undertaken were mostly concerned about the physical and obstetric complications of early age marriages. They considered 18-22 years age appropriate for marriage. “Early age marriages are dangerous for girls, they and the child may die.”-IDI with Health Worker, Quetta, Balochistan “It is my own experience that early age marriages cause many problems.”-IDI with Health Worker, Kohat, KP “She is not strong enough to cope with the complications and challenges of pregnancy and delivery.”-IDI with Health Worker, Quetta, Balochistan 4.2.2. Age differential with spouse A median differential of 5–7 years has been found by the study with the highest median age difference of seven years in Punjab and KP and the lowest of five years in Balochistan (Table4.2.2a). The highest age difference of 34 years was reported in KP by a rural adolescent girl. Differences across provinces are evident as shown in Fig. 4.2.2a. In Balochistan 54%, KP 27%. Punjab 34% and Sindh 39% have an age difference of 5 years or less with their spouses. Age difference of >8 years is reported by 20% in Balochistan, 39% in KP, 29% in Punjab and 15% in Sindh. None of the study married adolescent girls reported a husband younger than themselves. Table 4.2.2a: Median age and range of age difference with spouses of study married girls Range Median Age difference with spouse (yrs.) Yrs. (No. of couples) Pakistan 6 0– 34 (1) Balochistan 5 0 - 21 (1) Khyber Pakhtunkhwa 7 0 – 34 (1) Punjab Sindh Urban Rural
7 6 6 6
1 – 20 (1) 1 – 21 (1) 0 – 28 (1) 0 – 34 (1)
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Fig.4.2.2a: Provincial distribution of age difference with spouses of study married adolescent girls 100% 80% 60% 40% 20%
30%
46%
41%
36%
34% 26%
26%
39%
37% 30%
29%
20%
13%
8%
28%
22% 15%
11% 5%
4%
0% Pakistan n=379
Baluchistan n=90 <3 years
KP n=100 3 - 5 (years)
Punjab n=93
6 - 8 (years)
Sindh n=96
>8 years
Some rural urban differences in age differential with spouses are apparent in Fig. 4.2.2b. 40% of rural and 36% of urban adolescent girls reported an age differential of ≤5 years or less with their spouses. 34% of rural and 37% of urban have an age difference of 6-8 years while 25% and 26% of rural and urban girls have more than eight years age difference respectively. Fig.4.2.2b: Rural and urban distribution of age difference with spouse of study married adolescent girls 100% 90% 80% 70% 60% 50% 36%
40%
30%
30%
37%
32% 34% 26%
28%
25%
26%
20% 10%
8%
8%
8%
0% Pakistan n = 379
Rural n= 190 <3 years
3 - 5 (years)
6 - 8 (years)
Urban n= 189 >8 years
4.2.3. Education of Study Adolescent Girls The FGDs participants generally had a favourable opinion on girls‟ education. Four themes emerged from the discussions on female education: 1) education as a basic right of girls 2.girls‟ education as education of entire family and society and guarantor of country‟s bright future, 3) Page 82
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educated girls providing financial support to family) education likely to make girls independent which could lead them to engage in socially unacceptable acts. Emergent Theme: There is a general acceptance of the need for girls‟ education and an understanding of girls‟ education role in enhancing family and societal wellbeing. There were participants who expressed their support for girls‟ education in very clear and strong terms. To them female education is vital for society‟s success and as much a basic right of girls as it is of boys. “It is the right of the girl to get as much education as she wants to.”(FGD with Male Household Members category, Kohat, KP Those who considered girls‟ education vital for society said that a girls‟ education not only leads to good individual character development but also a well-organized home and an educated family and future generations. They considered education as a need of society since it reduced gender discrimination. They stated that if a mother is educated, the entire family is educated. There were some who wanted their daughters to complete at least college and graduate level education. They said that education for a girl is important for her better understanding and knowledge and for knowing the difference between right and wrong. According to them an educated mother can take better care of her children. Girls‟ education, they felt, will lead to an educated Pakistan. „Female education is in fact more important than male education since a mother educates the entire family.‟-FGD with School Teachers, Chakwal, Punjab These participants believed that an educated female can guide her household better and if the family is facing ill times, can support the household financially. Girls‟ education must be made mandatory so that they have a better future of their own choice and if the need arises they can lead an independent and self-sufficient life. „An illiterate person is no different from an animal. Education enables one to fight for his/her rights.‟ -FGD with Male Household Members, Quetta, Balochistan Many FGDs‟ participants however informed that female higher education is out of their reach owing to high costs. Some mentioned that girls‟ higher education is of little value since there are few employment opportunities available for them. There were participants whose female Page 83
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household members were not educated. The reasons given for this included lack of resources, lack of awareness, absence of school in vicinity, lack of responsibility and support among other household members and girls education being considered as deviation from social norms. “There is no use of girls‟ education because jobs are not available. But still we will get them educated.”-FGD with Male Household Members Category, Sukkur, Sindh No one came up with a total rejection of female education. Majority however were in favour of education up to the matriculation level for girls. They expressed the fear that higher education can make girls too independent and stubborn. They were of the opinion that educated girls could misuse their independence and get engaged in socially unacceptable activities. “They misuse their freedom.”-FGD with Community Members category, Quetta, Balochistan The quantitative data on the study girls‟ education which follows gives a mix picture. This coupled with the overall positive opinion on girls education may be an indication that cultural barriers to girls education may be diminishing. Fig. 4.2.3a shows the variation in levels of education of the study unmarried and married adolescent girls across provinces. Overall, 20% of the unmarried and 40% of the married adolescent girls are illiterate2. Only 15% of unmarried girls and 5% of married girls have managed to reach the college level. Differences across provinces are noticeable with Sindh having 40% illiteracy amongst the unmarried and 50% amongst the married girls. 10% unmarried and 30% married adolescent study girls are illiterate in KP. KP has higher proportion of girls having college level education as compared to the other provinces with 20% of unmarried and 10% of married girls having reached college. Informal education as a means of becoming literate appears to be more prevalent in Punjab than the other provinces with 5% of unmarried and 10% of married girls having received informal education. Rural and urban differences in educational levels are present for unmarried girls with 30% of rural being illiterate compared to 12% of urban girls. Among married girls, urban-rural differences are not obvious except that rural girls have slightly more informal education and urban girls have a little more college education (Fig. 4.2.3b).
2
Illiterate is being defined as an individual who can neither read nor write, in any language.
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Fig.4.2.3a: Provincial distribution of level of education of study adolescent girls Illiterate
Literate but without formal education Primary (upto 5 yrs of education)
Secondary (6-10 yrs of education)
College (11-14 yrs of education)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90
UNMARRIED N=381
MARRIED N=379
Fig.4.2.3b: Rural and urban distribution of level of education of study adolescent girls Illiterate
Literate but without formal education Primary (Upto 5 yrs of education)
Secondary (6- 10 yrs of education)
College (11- 14 yrs of education)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
4.2.4. Education of Spouses There doesnâ&#x20AC;&#x;t appear to be any clear educational differential between the married adolescent girls and their spouses except that among spouses, few have university level education. Overall illiteracy among spouses is 28% and KPs figures are better than the other provinces with only Page 85
A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan
15% of spouses being illiterate. Sindh has the highest illiteracy rate of 42%. College and university education is 20% each in KP and Balochistan, 10% in Sindh and 5% in Punjab. Punjab doesnâ&#x20AC;&#x;t appear to have any university education amongst spouses of respondents (Fig.4.2.4a and b). Fig.4.2.4a: Provincial distribution of education of spouses of the study married adolescent girls Illiterate
Literate but without formal education Primary (Upto 5 yrs of education)
Secondary (6- 10 yrs of education)
College (11- 14 yrs of education)
Higher (15+ yrs of education)
100% 90% 80% 70% 60% 50% 40% 30%
20% 10% 0% Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Fig.4.2.4b: Rural and urban distribution of education of spouses of study married adolescent girls Illiterate
Literate but without formal education Primary (Upto 5 yrs of education)
Secondary (6- 10 yrs of education)
College (11- 14 yrs of education)
Higher (15+ yrs of education)
100% 90% 80% 70%
60% 50% 40% 30% 20% 10% 0% Pakistan n=379
Rural n=190
Urban n=189
A difference in education levels of spouses in rural and urban settings is prevalent. Among the rural spouses, 33% are illiterate while 13% have primary, 34% have secondary, 10% college and Page 86
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2% spouses have university education. Among the urban spouses, 28% are illiterate, while 15% have primary, 40% secondary, 12% college and 3% spouses have university education. 2% of rural and 3% of urban spouses have received informal education. 4.2.5. Employment and income generation The quantitative data shows provincial variations in the employment of girls and their type of employment. These are explained by the mixed opinions on women employment in the FGDs. Four sub-themes emerged from the discussion on employment: 1) employment builds girls‟ confidence and gives them independence; 2) girls employment is a source of financial contribution to family income; 3) employment is not a girls‟ societal role and is a source of family dishonour. Emergent Theme: There are mixed and evolving opinions on girls‟ employment underpinned by concerns about the work environment safety as regards their young age and femininity. In Punjab the participants were mostly in favour of women working outside of their homes. They argued that since the girls are getting educated they should be allowed to work and be independent. “Women should work; society can only progress if we all work together.”-FGD with Community Members category, Chakwal, Punjab These participants felt that females should work so that they can live an independent life and support their families. Their education would also result in economic benefits and good education for their children since if she works, she will realize the need of education for her children as good education enables one to have good jobs. Most respondents felt that working women are more respected by the community as they contribute to household expenses. “With increasing inflation and expenses, it is best that a woman contributes to the household income, so that the economic condition of the entire family improves.” -FGD with Unmarried Adolescent Girls category, Kohat, KP Most of the participants had very clear notions about the type of professions a woman should adopt. They were of the view that not every type of work is suitable for women. Women should only adopt professions which make them feel secure and respected. Most felt that teaching is the most suitable profession for women. Some considered handicraft and stitching industry also acceptable for women.
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The opponents of female employment were mostly among male household members who felt that women should stay at home for religious reasons. “It is not only forbidden in Islam but against our traditions as well.”-FGD with Community Members category, Sukkur, Sindh These participants were of the view that working women are not considered good by society and they are not treated with respect because of the unfriendly environment they have to face outside of their homes. Additionally according to them, it is a male‟s responsibility to work and provide for his family and not for females to financially support their families. Some of the females said that men think that if a woman works, she will not be able to pay proper attention to her family. “It is a male dominated society and it is the role of the man, not the woman, to run the household.”-FGD with School Teachers category, Sukkur, Sindh Respondents who were against working women said that this impacts societal norms. They said that while education is of utmost importance, employment of women is not. Due to cultural and security issues women should not be working. Also because of the possible impact on their families, girls should stay at home and do domestic work, and dedicate their entire time to their families. Some teachers said that community considers working women bad as they think that these women interact with men and have moral/character issues. Due to this reason only teaching profession is considered respectable as there is minimal chance of male female interaction and this is culturally acceptable. Female household members, as well as school teachers, felt that men may feel threatened by women working outside the home as it would imply that men are unable to provide for their family and may thereby feel a sense of shame. “Our males feel that they will face unwanted comments from society that it is shame to let your woman work.”-FGD with School Teachers, Sukkur, Sindh An interesting perspective was uncovered during FGDs with women household members. Most participants at the beginning of the FGD would inform that they were housewives with no employment. As the FGDs proceeded it was discovered that a number of them were employed as domestic help but had felt ashamed in admitting this fact. This fact came to light during several FGDs, where as soon as female household members being surveyed found out that there was no monetary compensation to participate in this research, they started complaining that they were getting late to go to their jobs and would get in trouble with their „Bajis,‟ (employer-ladies of the house). Page 88
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The quantitative data which follows reveals overall low employment among the study adolescent girls with marked differences across provinces, reflecting the variation in opinions which came out during the FGDs. Households‟ opinion on employment of women Across Pakistan, 70% of unmarried girls and 82% of married girls‟ households favoured women employment according to the adolescent girls interviewed. A little difference in unmarried and married adolescent girls‟ households across provinces is present with a favourable opinion being lower in households of unmarried adolescent girls in Balochistan and Punjab (63% each) and higher in households of married adolescents in KP (87%) and Sindh (90%) (Fig. 4.2.5a). The proportion of rural households in favour of women employment is higher than that of urban households for both unmarried and married girls (Fig. 4.2.5b). Among unmarried girls‟ households, 75% of rural and 60% of urban are in favour of employment while among married girls‟ households, 83% of rural and 80% of urban households have favourable opinion on the employment of women. Ever employed status The households‟ favourable opinion and the ever-employed status of the adolescent girls do not match in Punjab and Balochistan; 12% of unmarried and 22% of married girls in Punjab while, 12% of unmarried and 10% of married girls in Balochistan reported of being ever employed. Contrastingly, only 4% of unmarried and 2% of married girls in KP reported of being ever employed. Ever-employed unmarried and married girls in Sindh are 13% and 10% respectively (Fig.4.2.5c). Fig. 4.2.5a: Provincial distribution of households‟ opinion on women employment % Favourable Opinion
% Unfavourable Opinion
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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Unfavourable Opinion
100% 90% 80% 70% 60% 50%
40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
Urban n=193
Pakistan n=379
UNMARRIED n=381
Rural n=190
Urban n=189
MARRIED n=379
No major urban-rural difference was observed. 12% of rural and 10% of urban unmarried girls while, 10% of rural and 12% of urban married adolescents reported of being ever employed. Fig. 4.2.5c: Provincial distribution of ever-employed status of study adolescent girls Ever worked
Never Worked
100% 90% 80%
70% 60% 50% 40% 30%
20% 10% 0% Pakistan n=381
Baluchistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED N=381
Pakistan n=379
Baluchistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED N=379
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Fig. 4.2.5d: Urban and rural distribution of ever employed status of study adolescent girls Ever worked
Never Worked
100% 90% 80% 70% 60% 50%
40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
Currently employed status Marked differences are present in the current employment status of the 47 unmarried and 45 married girls who reported of being ever employed (Fig.4.2.5e). Overall, 72% of unmarried and 32% of married girls reported being currently-employed. Interprovincial differences are also present with the lowest figures of 10% and 12% of ever-employed married adolescents in Balochistan and Punjab respectively. 80% married girls in Sindh reported of being currently employed. Among the unmarried ever-employed adolescents, current employment is much higher but interprovincial variation is not significantly different. Rural and urban difference in current employment status is more prominent for married rather than the unmarried adolescent girls. 42% of the ever employed rural married adolescents reported of being currently employed as compared to 22% of urban married adolescent girls. 70% of rural and 78% of urban ever employed unmarried girls also reported of being currently employed.
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Fig.4.2.5e: Provincial distribution of currently- employed status of study adolescent girls Currently Working
Currently Not Working
100% 90% 80% 70% 60% 50%
40% 30% 20% 10% 0% Pakistan n=47
Baluchistan n=13
KP n=7
Punjab n=12 Sindh n=15
Pakistan n=45
Baluchistan n=9
UNMARRIED N=47
KP n=3
Punjab n=22 Sindh n=11
MARRIED N=45
Fig.4.2.5f: Rural and urban distribution of currently- employed status of study adolescent girls Currently Working
Currently Not Working
100% 90% 80% 70% 60% 50% 40%
30% 20% 10% 0%
Pakistan n=47
Rural n=25 UNMARRIED N=47
Urban n=22
Pakistan n=45
Rural n=19
Urban n=26
MARRIED N=45
Type of Employment Figs. 4.2.5g& h present the types of employment of ever-employed unmarried and married adolescent girls across provinces and urban and rural locations respectively. Frequency of ever employed study adolescent girls across provinces is low with 13 unmarried and 9 married girls in Balochistan, 7 unmarried and 3 married girls in KP, 12 each unmarried and married girls in Page 92
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Punjab, and 15 unmarried and 11 married girls in Sindh. Nevertheless, differences are apparent across provinces. In Sindh, 55% each of both unmarried and married girls reported working as domestic servants while in Punjab, 42% of unmarried and 70% of married girls worked/ are working as housemaids. In Balochistan, 55% of married adolescents were/are working as teachers and 68% of unmarried girls were/ are working as daily wage earners. In KP, two-thirds (66%) of the everemployed married employed adolescents were/are engaged as polio workers and the remaining in beauty parlour. Overall teaching, domestic service and daily wage work come out as the main employment types in all provinces. The rural and urban distribution of type of employment of the ever-employed adolescent girls presented in Fig. 4.2.5h shows that 38% of both rural and urban unmarried adolescent and 48% each of rural and urban married adolescents were/are employed as housemaids. More rural adolescents are employed as daily wage earners both unmarried and married (44% and 34% respectively) than urban girls (20% and 10% respectively). Employment as teachers is the reverse of daily wage earners with 6% rural and 26% urban unmarried adolescents and 10% rural and 25% urban married adolescents employed as teachers. Fig.4.2.5g: Provincial distribution of type of employment of ever-employed study adolescent girls Other
home sewing
Teaching
Labour/ Daily Wager
Housemaid
100% 90%
80% 70% 60% 50% 40%
30% 20% 10% 0% Pakistan n=47
Baluchistan n=13
KP n=7
Punjab n=12 Sindh n=15
UNMARRIED n=47
Pakistan n=45
Baluchistan n=9
KP n=3
Punjab n=22 Sindh n=11
MARRIED n=45
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Fig.4.2.5h: Rural and urban distribution of type of employment of ever-employed study adolescent girls Other (specify)
home sewing
Teaching
Labour/ Daily Wager
Housemaid
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=47
Rural n=25
Urban n=22
Pakistan n=45
Rural n=19
UNMARRIED n=47
Urban n=26
MARRIED n=45
Spouses‟ Employment Overall 84.4% of spouses of married adolescent girls were reported to be employed. There is no marked variation across provinces. 84% in Punjab, 88% in Sindh and 72 % spouses in KP are employed as labourers or daily wage earners. Balochistan has a higher proportion of office workers (49%) than labourers (38%). The „others‟ category includes vehicle drivers, gardeners, guards and mechanics etc. (Fig. 4.2.5i). Fig.4.2.5i: Provincial distribution of type of employment of spouses of married adolescent girls 100% 88%
84% 80%
72%
70%
60%
49% 38%
40%
21% 16%
20%
12%
11%
10% 3%
2%
2% 5%
0%
3% 4% 5%
5%
0% Pakistan n=320
Baluchistan n=79
Labour/ Daily Wager/ Factory Worker
KP n=85
Punjab n=81
Farming
Office Jobs/ Teaching
Sindh n=75 Other
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Fig.4.2.5j: Provincial distribution of employment status of spouses of married adolescent girls Working
Not working
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=379
Baluchistan n=90
KPK n=100
Punjab n=93
Sindh n=96
MARRIED N=379
Income earned by the study ever-employed adolescent girls Mean monthly income /salaries Overall salaries paid to the ever- employed adolescent girls are low, varying from PKR 11072382 for unmarried and PKR 1227- 4222 for married adolescent girls across the provinces (Fig. 16k). Differences across provinces are present. Punjab has the highest mean salaries for both unmarried (PKR 2382) and married girls (PKR 2190) while Sindh has the lowest for unmarried both (PKR 1107) and married girls (PKR 1227). In KP, mean remunerations of PKR 1543 for unmarried and PKR 3000 for married adolescents are reported. The PKR 4000 of married adolescents in Balochistan is comparatively higher than the other provinces because a higher proportion of their study adolescent girls are teachers. Some differences in the earned mean incomes of rural and urban adolescent girls are apparent in Fig. 4.2.5l. Unmarried rural adolescent girls have mean salaries of PKR 1458 as compared to their urban counterparts whose mean salaries amount to PKR 1952 and married rural adolescents have mean remunerations of PKR 1908 compared to urban married adolescents with mean earned incomes of PKR 2800. In Fig. 4.2.5m a comparison of monthly income earned by ever- employed married adolescent girls and their employed spouses, is presented. From this data, spouses who are mostly labourers and daily-wage earners, appear to be receiving three times the salary paid to their wives (KP is the exception but the number of employed females is very small). Working hours are not specified, but never the less the salary differential is very wide.
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Fig.4.2.5k: Provincial distribution of mean monthly incomes/salaries earned by ever-employed study adolescent girls 4500
4222
4000 3500 3000
3000 2426
2382
2500
2190 2008
2000
1733 1543
1500
1227
1107 1000
500 0 Pakistan n=47
Baluchistan n=13
KPK n=7 Punjab n=12 Sindh n=15
Pakistan n=45
Baluchistan n=9
UNMARRIED n=47
KPK n=3 Punjab n=22 Sindh n=11
MARRIED n=45
Fig.4.2.5l: Rural and urban distribution of mean monthly income/salaries of ever-employed participants 3000
2800 2426
2500
1952
2000
1906
1733 1548
1500
1000
500
0 Pakistan n=47
Rural n=25 UNMARRIED n=47
Urban n=22
Pakistan n=45
Rural n=19
Urban n=26
MARRIED n=45
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Fig.4.2.5m: Comparison of monthly incomes earned by ever- employed married adolescent girls with that of spouses across provinces
12690
8323
8310 6798 5194 4222 3000 2426
2190 1227
Spouses n=320
Respondent n=45
Pakistan
Spouses n=79
Respondents n=9
Baluchistan
Spouses n=85
Respondents n=3 KP
Spouses n=81
Respondents n=22
Punjab
Spouses n=75
Respondents n=11
Sindh
Study adolescent girls‟ control over spending of income earned by them Control over spending of the salaries earned by the adolescent girls themselves, was used as a direct indicator of the financial independence and empowerment of the study adolescent girls. Overall 42% of unmarried and 32% of married girls reported spending the money they earn themselves. In Sindh, 40% of unmarried and 60% of married spend their own earnings and in Balochistan, 90% of unmarried and 50% of married girls have this independence. In KP, none of the married adolescents (n=3) and 30% of unmarried (n=7) have the freedom to spend their income themselves. Parents-in-law are reported to be in control in most of the remaining households except Punjab where in about 20% cases, husbands are reported to be spending the money earned by their wives. In the rural study site of Chakwal district of Punjab, the interviewers found mostly women as the family earners with husband not employed in any significant earning activity but “ sitting in Baithuk solving problems” as reported by some wives.
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Fig.4.2.5m: Provincial distribution of control over spending of the study adolescent girls on the income earned by them Myself
Parents
Husband
Parents In-law
All of us
100% 80% 60%
40% 20% 0% Pakistan n=47
Balochistan n=13
KP n=7
Punjab n=12 Sindh n=15
Pakistan n=23
Balochistan n=4
Unmarried n=47
KP n=2
Punjab n=9
Sindh n=8
Married n =23*
*Married girls who started working after marriage.
Rural and urban differences in control over spending are also present (Fig. 4.2.5n). Thirty five percent of rural unmarried adolescent girls reported spending the money themselves while, 44% said their parents spend the money and the rest spend it together with their parents. Among urban unmarried girls, 55% are allowed to spend the money they earn themselves and 32% have reported of their parents spending their money and the rest spend it together with their parents. Fig.4.2.5n: Rural and urban distribution of control over spending of study adolescent girls on the income earned by them Myself
Parents
Husband
Parents In-law
All of us
100% 80% 60% 40% 20% 0% Pakistan n=47
Rural n=25 Unmarried n=47
Urban n=22
Pakistan n=23
Rural n=14
Urban n=9
Married n=23*
*Married girls who started working after marriage.
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Among married earning adolescents, 42% of rural and 32% of urban are spending the money they earn themselves while 22% of rural and 42% of urban girls‟ parents-in-law spend their money. 22% of the rural married girls‟ husbands spend the money they earn and 20% in each group spend their money together with their parents-in-law and husbands. To further elucidate control over earnings, adolescent girls‟ spending on their personal needs was explored. The yellow vertical lines in the bars in Figs. 16o &p denote the percent spending on own needs among the different categories of control over spending. Overall the 42% of unmarried girls who spend their earnings themselves, reported spending 94.8% of the earned income on their personal needs. There is no variation across provinces or between urban and rural locations (Fig. 16o). The 40% whose income is spent by their parents reported spending 25.2% of their earnings on their personal needs. Similarly the 15%, whose income is being spent by them and their parents, reported spending 32.5% of their earnings on their personal needs. Among the different categories of control over spending of married girls overall, the 32% who spend their earnings themselves reported that they spend 88.5% of their earnings on their personal needs. In the 50% group whose earning is spent by their parents-in-law or husbands, about 12% of the earned income is spent on their own needs (Fig. 16p). Interprovincial and rural and urban differences are present. Fig.4.2.5o: Provincial distribution of percentage of self-earned income spent on own needs
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Fig.4.2.5p: Rural and urban distribution of percentage of self-earned income spent on own needs
Financial Empowerment Index (FEI) Fig. 4.2.5q and r present the distribution of the FEI of the study adolescent girls. Overall 90% of both unmarried and married girls are not empowered. In Balochistan and KP, almost 100% are not empowered in both groups. In Sindh, 20% in each group are partially or fully empowered and in Punjab, 20% of unmarried and 10% of married girls are partially or fully empowered. No remarkable differences are apparent between urban and rural areas for both categories of the study adolescent girls. Among rural unmarried adolescent girls 12% are partially or fully empowered and of the urban unmarried adolescents 10% are partially or fully empowered. Among the rural and urban married adolescent girls, 10% of unmarried and 8% of married girls are partially or fully empowered. Fig.4.2.5q: Provincial distribution of level of financial empowerment of the study adolescent girls Not empowered
Partially empowered
Empowered
100% 80% 60% 40%
20% 0% Pakistan n=381
Baluchistan KPK n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED N=381
Pakistan n=379
Baluchistan KPK n=100 Punjab n=93 Sindh n=96 n=90 MARRIED N=379
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Fig.4.2.5r: Rural and urban distribution of level of financial empowerment of the study adolescent girls Not empowered
Partially empowered
Empowered
100% 80% 60% 40% 20% 0% Pakistan n=381
Rural n=188 UNMARRIED N=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED N=379
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4.3. Dietary Patterns and Nutritional Status 4.3.1. Knowledge and perceptions on adolescent girls nutritional needs In the FGDs with adolescent girls, their household members and their community members including school teachers, perspectives on food distribution in households and awareness about nutritional needs of adolescent girls both married and unmarried and differences in needs of boys and girls emerged. Most participants were of the view that the nutritional requirements of boys and girls are the same because both are human beings and both are equal in the eyes of their mothers. Some expressed the view that the needs of girls and boys cannot be the same since boys have to work and take care of their families. They are therefore given whatever they demand to eat. These participants informed that more non-vegetarian food, milk and fruit is given to male children as compared to female children since they (male children) have to go out of the home and burn more energy. Emergent Themes: Enhanced nutritional needs of pregnant women are well accepted. No particular awareness of nutrition needs of adolescent girls is present. Poverty is a major barrier to providing good nutrition to married adolescent girls. Some participants were found to be aware of the changing nutritional requirement of girls with age, marriage and childbearing and realised the need for special attention to their nutritional intake. Some teachers were of the view that adolescent girls in particular should have different nutritional requirements because of their menstrual cycle. “Girls face different biological issues every month on particular days. Hence girls have different requirements as well.” -FGD with Community Members, Sukkur, Sindh Some adolescent married girls stated that girls need to be provided good diet so that they can be healthy enough to care for their children in future. “Women get pregnant so they need the right food from the beginning.” -FGD with Married Adolescent Girls, Kohat, KP The increased nutrition needs of married adolescent girls were specially mentioned for the reasons that they need to be prepared for the increase in their work load and responsibilities and to avoid any complications during pregnancy.
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“Females need more food during pregnancy and lactation as she has to feed another life.” FGD with Male Household Members category, Sukkur, Sindh The participants considered diets rich in milk and fruits as appropriate for pregnant and lactating girls because they have to bear healthy babies. Other healthy foods mentioned were „churi‟3, butter, meat, and „desi ghee‟4 Many participants were also aware that calcium requirements increase during pregnancy and lactation, and food intake should therefore be increased accordingly to cater to the needs of the baby. Participant mentioned increased food cravings during pregnancy. “The foetus takes nutrition from the mother, hence the mother needs more and a balanced diet during pregnancy. After delivery, desi ghee, meat and fruits are very important in diet. During pregnancy, the body becomes weak and in weakness delivery is very difficult. If good food is not given, the girls‟ health deteriorates rapidly. Milk, meat and fruits should be given to pregnant and lactating adolescent girls, more than anyone else in the household.”-FGD with Married Adolescent Girls, Chakwal, Punjab “Diet requirements increase because she is lactating. If she doesn‟t eat and drink properly, how will she feed the baby?”-FGD with Community Members, Chakwal, Punjab Some participants also felt that it is important to consult a doctor for advice on a pregnant woman‟s dietary requirements. Some school teachers were of the view that if husbands are supportive married girls are more likely to have healthy foods “A girl gets good diet if her husband is supportive.”(FGD with School Teachers, Quetta, Balochistan Some unusual beliefs were expressed by some participants, like the view that dietary intake should increase in lactation but not during pregnancy as it would lead to an obese child or the belief of some that girls should not be given more food because it can lead to obesity and can speed up their process of maturation and early onset of their menstrual cycle.
3
Churi refers to a traditional preparation made from wheat flour, sugar and butter/ clarified oil, and is often given as a supplement to boost a person‟s overall health. 4
Desi ghee refers to clarified oil.
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The knowledge and favourable opinion on the nutritional needs of married adolescent girls don‟t translate in to practice because of poverty. This fact emerged from FGD with married adolescent girls who informed that they cannot eat what they need and like because of the poverty and poor socio-economic status of their families. The knowledge and opinions of health services providers emerged from the IDIs undertaken with them. All respondents considered milk, fruits, meat, pulses, vegetables (especially green leafy vegetables), and eggs as good for health. They felt that these foods ensure good health, produce energy in body and fulfil the calcium and protein requirements of the body. Among „bad foods‟ for adolescent girls, they listed spicy and sour foods (tamarind) and foods prepared in ghee as according to them these foods may lead to disturbances in menstrual cycle, cause kidney problems and obesity. Emergent Theme: Health services providers have some generic knowledge of nutrition but have no understanding of food substitution and the need for adapting their nutrition counselling to the household financial situation. They didn‟t have any specific opinion on the needs of adolescent girls but thought that as girls grow older they need more food. They were more emphatic about the increased food needs of pregnant women. According to them pregnant women should eat fruits, pulses, meat, vegetables, milk, and „yakhni‟( thin soup)in their diet and take lots of vitamins and calcium rich food to avoid getting anaemic and weak. They said that they specifically recommend women to take „Sujikahalwa‟5 made in „desi ghee‟6, tomato, onion and garlic boiled in „desi ghee,‟ (clarified butter), mutton soup, and chicken during post natal period. They stated that since the mother is weak and lacks energy after delivery, so all these foods will benefit both her and her child. “When she (a girl) is small she does not need more but with age her responsibility increases and later when she gets married she needs more to keep physically healthy.“-IDI with Health Worker, Kohat, KP Some respondents didn‟t think there was any difference in the nutritional requirements of females of different age groups. They felt that everyone should be given the same kind of food.
5
SujikaHalwa refers to a traditional dessert made form Semolina and sugar, and is often cooked in oil or clarified butter.
6
Desi ghee refers to clarified butter
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4.3.2. Household monthly income spent on food Fig. 4.3.2a shows the percentage household income spent on food across provinces. In Balochistan, 60% of the unmarried girls‟ households spend 50-75% of their monthly income on food with only 20% spending ≥75%. The spending on food of the married girls‟ households is similar. In KP, 80% of households of both unmarried and married adolescent girls reported spending ≥ 75% of their monthly income on food. In Punjab, 32% of unmarried adolescent girls‟ households spend ≥ 75% while, 34% spend 50-75% and 33% spend 20-50% of their total monthly income on food. Among married adolescent girls, 26% spend ≥ 75% while, 42% spend 50-75% and 25% spend 20-50% of their total monthly income on food. In Sindh 8-10% of the married girls‟ households reported spending ≥75% of their income on food with 70% and 20% spending 50-75% and 20-50% respectively on food. Fifty-five percent and 35% of the married girls‟ households spend 50-75% and 20-50% of their monthly income on food. No obvious differences are apparent between urban and rural households of unmarried adolescent girls with 40% households spending ≥ 75%, 42% spending 50-75% and 18% spending 20-50% of their monthly income on food. Among married adolescent girls household some difference appears to be present with 40% of rural households spending ≥75%, 40% spending 50-75% and 20% spending 20-50% of their income on food while among urban households 35%, 40% and 25% spending respectively ≥ 75%, 50-75% and 20-50% on food (Fig. 4.3.2b). Fig.4.3.2a: Provincial distribution of Households‟ spending on food 20% or less
20 - 50 %
50 - 75 %
Above 75%
100% 80% 60% 40% 20% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.3.2b: Urban and rural distribution of households‟ spending on food 20% or less
20 - 50 %
50 - 75 %
Above 75%
100% 80% 60% 40% 20% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
4.3.3. Household food availability Overall 62% households of the study adolescent girls had not experienced any food shortage, 18% households had occasional food shortage and 20% households had frequent food shortage. In Sindh, over 58% of unmarried girls‟ households had occasional or frequent food shortage whereas 62% of married girls‟ households had occasional or frequent food shortage. In Punjab, 50% of households in each group while in KP, 15% and in Balochistan, 32% in both groups of household had experienced frequent or occasional food shortage. The household food shortages and the study adolescent girls reporting of not having sufficient food to eat as given in Figs 4.3.3 a & b, emerged in the FGDs in different contexts. While as mentioned previously participants generally knew about the increased nutritional requirements of adolescent girls, more especially married adolescent and lactating mothers, some married adolescent girls informed that they were not eating the foods they needed because of poverty and the poor socio-economic status of their families. In FGDs on household food distribution, preferential attention to male family members food preferences and allocation of more and better food to them, many participants across provinces informed that the women of the house are well aware of everyone‟s likes and dislikes, including those of the female household members and they try to keep everyone‟s preferences in mind while cooking. Emergent Theme: There are no generalised discriminatory practices in households as regards girls‟ access to available food and acceding to their food choices. The main determining factor is resources
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Fig.4.3.3a: Provincial distribution of reported food shortage in the households of study adolescent girls Rare or no food shortage in last one year
Occasional Food Shortage in last one year
Frequent or always food shortage in last one year
100%
80%
60%
40%
20%
0% Pakistan n = Baluchistan KPK n = 100 Punjab = 93 Sindh n = 97 Pakistan n = Baluchistan KPK n = 100 Punjab n = Sindh n = 96 381 n = 91 379 n = 90 93 UNMARRIED n = 381
MARRIED n = 379
Fig.4.3.3b: Urban and rural distribution of reported food shortage in households of study adolescent girls Rare or no food shortage in last one year
Occasional Food Shortage in last one year
Frequent or always food shortage in last one year 100%
80%
60%
40%
20%
0% Pakistan n = 381
Rural n = 188 UNMARRIED n = 381
Urban n = 193
Pakistan = 379
Rural n = 190
Urban n = 189
MARRIED n = 189
Female household members clearly stated that the preferences of the females in the family are especially taken into account when they are elders such as mothers, mothers-in-law, sisters-inlaw, elder sisters and younger daughters in the household.
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“Our daughters are very dear to us and we give importance to them in deciding what to cook.” -FGD with Female Household Members, Kohat, KP The participants who said that they give priority to family male members‟ food choices said that they do this because men are the primary bread earners and source of income of the household. “My parents give special importance to my brother‟s choice as he works.” FGD with Unmarried Adolescent Girls, Kohat, KP While some participants didn‟t believe in the increased nutritional need of adolescents and thought the needs of all, young or old, male or female, are the same, some of the ones who understood the enhanced needs of adolescents for growth informed that they were not able to provide them more and better food because they cannot afford the extra expenses. “Whatever food we have, we give to them for a healthy future life.” -FGD with Male Household Members, Sukkur, Sindh Fig.4.3.3c: Provincial distribution of adolescent girls reporting whether they had enough food to eat Never Hungry
Sometimes Hungry
Always Hungry
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n = Baluchistan 381 n = 91
KPK n = 100
Punjab = 93 Sindh n = 97 Pakistan n = Baluchistan 379 n = 90
UNMARRIED n = 381
KPK n = 100
Punjab n = Sindh n = 96 93
MARRIED n = 379
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Fig.4.3.3d: Urban and rural distribution of adolescent girls reporting whether they had enough food to eat Never Hungry
Sometimes Hunger
Always Hungry
100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
4.3.4. Meal patterns Overall, 25% of unmarried and 30% of married girls‟ households reported having two meals or less per day. In Punjab, 30% of unmarried and 40% of married households reported having two meals or less and in Sindh, 30% of unmarried and 32% of married households have two meals or less. In KP, 12% and 22% respectively and in Balochistan about 25 and 22% respectively of unmarried and married girls‟ households have two meals or less (Fig. 4.3.4a). Twenty percent of both rural and urban households of unmarried girls have two meals or less while 25% of both rural and urban households of married adolescent girls have two meals or less (Fig. 4.3.4b). Across Pakistan, breakfast is missed by 45% of the unmarried and 50% of the married girls‟ households. 50% of the unmarried and 75% of the married in KP, 62% of the unmarried and 52% of the married in Punjab, 60% of the unmarried and 70% of the married girls‟ households in Balochistan, who take two meals or less each day, miss breakfast meal. In Sindh, lunch is missed by a higher proportion of households (50% and 65% of unmarried and married girls‟ households respectively) as compared to breakfast and dinner (Fig. 4.3.4c and d). Among rural unmarried girls‟ households 40%, 32% and 15% miss breakfast, lunch and dinner respectively and among urban unmarried girls‟ households 58% skip breakfast and 20% have no lunch. Dinner is missed by 5% or less. Page 109
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In FGDs meal intake patterns were discussed. Most participants informed that in their households they did not usually eat together for the reasons that:
It is traditional for men to be served first, and for women to eat afterwards.
All the household members have different timings, especially the male members who often come home late from work.
The families are too large to eat together and time constraints do not allow everyone to eat together.
Food is consumed on self-service basis and, “not served. “
Across provinces the most consistent reasons for families not eating together came out to be the male members going out for work and being not available at home during meal times. “We eat whenever we get time, and whoever gets home at whatever time will eat then”. (FGD with Unmarried Adolescent Girls, Sukkur, Sindh Fig.4.3.4a: Provincial distribution of number of meals taken daily in study adolescent girls‟ households
MARRIED n=379
Sindh n=96 Punjab n=93 KP n=100 Baluchistan n=90 1
Pakistan n=379
2 UNMARRIED n=381
Sindh n=97
3 4
Punjab n=93 KP n=100 Baluchistan n=91 Pakistan n=381 0%
20%
40%
60%
80%
100%
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.3.4b: Rural and urban distribution of daily meals taken by the study adolescent girls‟ households
MARRIED n=379
Urban n=189
Rural n=190
Pakistan n=379
1
UNMARRIED n=381
2 3
Urban n=193
4 Rural n=188
Pakistan n=381 0%
20%
40%
60%
80%
100%
Fig.4.3.4c: Provincial distribution of meals missed by study adolescents girls‟ households Breakfast
Lunch
Dinner
Breakfast & Lunch
Breakfast & Dinner
100% 90% 80% 70% 60% 50% 40%
30% 20% 10% 0% Pakistan n=88
Balochistan n= 11
KP n=17 Punjab n=36 Sindh =24
UNMARRIED n=88
Pakistan n=67
Balochistan n=12
KP n=8
Punjab n=26 Sindh n=21
MARRIED n=67
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.3.4d: Rural and urban distribution of meals missed by study adolescents girls‟ households Breakfast
Lunch
Dinner
Breakfast & Lunch
Breakfast & Dinner
100% 90%
80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=88
Rural n=46
Urban n=42
UNMARRIED n=88
Pakistan n=67
Rural n=35
Urban n=32
MARRIED n=67
4.3.5. Dietary Intake Types of food eaten and frequency of daily intake Based on the FFQ, the most frequently consumed food types and the frequency of their intake across provinces is presented in Table 4.3.4a. No differences in unmarried and married girl‟s households were found therefore disaggregation on this count is not presented. Daily intake of grains is similar in Balochistan (96%), KP (94%) and Punjab (96%). In Sindh, 54% of households are consuming grain on a daily basis. Sindh also has the highest proportion of 24% households eating meat daily compared to 8% in Balochistan, 1% in KP and 2% in Punjab. Tea is being consumed on daily basis by 98% households in Balochistan, 84% in KP, 77% in Punjab and 68% households in Sindh. 28% in Balochistan and Punjab, and 26% households in Sindh do not eat vegetables on daily basis. In KP, consumption is somewhat lower with 34% not eating vegetables daily. Daily consumption of fruit is lowest in KP with 98% not eating fruit daily, followed by Punjab with 86% not able to eat fruit daily. In Balochistan and Sindh, 50% are able to eat fruit daily (Table 4.3.5a). Daily intake of fat is higher in Balochistan and KP with 14% and 17% respective households‟ not taking fat daily compared to Punjab and Sindh where 48% and 31% don‟t consume fat daily. Balochistan also has comparatively higher consumption of dairy products where 63% of households consume fat daily compared to the 12% of KP and 20% in Punjab and 18% in Sindh. Daily consumption of eggs is low across provinces (KP 2%, Punjab 7%, Sindh 1%) except Page 112
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Balochistan where 26% households eat eggs daily. Snacks are eaten by 6% in Balochistan, 1% in KP and Punjab and 17% in Sindh (4.3.5a). 62% and 46% of rural houses eat vegetables and fruit daily while in urban area, 24% and 13% respectively eat vegetables and fruit (4.3.5b). The urban differences are not remarkable as shown in Table 4.3.4b, except for the consumption of fruit and vegetables where 62% and 46% of rural houses eat vegetables and fruit respectively daily while in urban area 24% and 13% respectively eat vegetables and fruit (4.3.5b). Table 4.3.5a: Provincial distribution of food types consumed and frequency of daily intake of different foods by study adolescent girls’ households Balochistan KP Punjab Sindh
Daily
Less than once a month
1-3/months
2-4/ week
5-6/ week
Daily
Less than once a month
1-3/months
2-4/ week
5-6/ week
Daily
Snacks
5-6/ week
Tea
2-4/ week
Grains
1-3/months
Fruit Dairy Products Lentils
Less than once a month
Vegetable
Daily
Fats
5-6/ week
Eggs
n=193 Frequency of intake % households
2-4/ week
Meat
n=186 Frequency of intake % households
1-3/months
Food Types
n=200 Frequency of intake % households
Less than once a month
n= 181 Frequency of intake % households
13 % 51 % 0 % 2 % 12 %
28 % 9 % 0 % 6 % 8 %
31 % 11 % 14 % 19 % 31 %
19 % 2 % 8 % 17 % 19 %
8 % 26 % 78 % 56 % 30 %
49 % 73 % 15 % 2 % 23 %
38 % 14 % 1 % 5 % 58 %
12 % 10 % 1 % 27 % 17 %
1 % 2 % 2 % 10 % 1 %
1 % 2 % 82 % 57 % 2 %
26 % 45 % 49 % 1 % 12 %
47 % 20 % 1 % 6 % 26 %
25 % 22 % 0 % 22 % 42 %
1 % 7 % 1 % 24 % 7 %
2 % 7 % 49 % 47 % 14 %
15 % 86 % 24 % 17 % 28 %
7 % 9 % 1 % 0 % 7 %
37 % 3 % 6 % 9 % 18 %
17 % 1 % 10 % 18 % 18 %
24 % 1 % 60 % 56 % 30 %
14 %
8 %
10 %
4 %
63 %
54 %
12 %
20 %
3 %
12 %
38 %
16 %
23 %
2 %
20 %
51 %
9 %
15 %
7 %
18 %
10 % 1 % 2 % 59 %
19 % 1 % 0 % 17 %
27 % 1 % 0 % 14 %
19 % 2 % 1 % 3 %
25 % 96 % 98 % 6 %
8 % 1 % 15 % 73 %
63 % 2 % 0 % 18 %
21 % 1 % 1 % 8 %
6 % 3 % 0 % 0 %
3 % 94 % 84 % 1 %
7 % 0 % 17 % 45 %
42 % 0 % 1 % 31 %
38 % 2 % 3 % 21 %
5 % 1 % 3 % 2 %
8 % 98 % 77 % 1 %
1 % 24 % 15 % 38 %
7 % 2 % 4 % 9 %
25 % 12 % 5 % 25 %
20 % 8 % 9 % 11 %
47 % 54 % 68 % 17 %
The adolescent girls and their household and community members‟ perception on what are good and bad foods and what food should not be eaten by adolescent girls were discussed in FGDs. Most participants said that there are no good or bad foods and that all foods are sources of energy. Some however felt that certain food should be avoided by adolescent girls because they have a bad effect on the body. Page 113
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The foods mentioned include fats and oily foods, spicy foods, junk food, raw onions and sour and cold foods like chaat,7chutney, lassi‟8yogurt, juices, tamarind, pickles, „Amchur‟9etc. These participants felt that consumption of some of these items, especially „lassi‟10, yogurt, juices, ice cream, tamarind, pickles, and other sour items could lead to disruption of normal menstrual flow if consumed at the onset of the menstrual period (all p value greater than 0.05 at confidence levels of 95%).
Less than once a month
1-3/months
2-4/ week
5-6/ week
Daily
Less than once a month
1-3/months
2-4/ week
5-6/ week
Daily
Table 4.3.5b: Rural and urban distribution of food types consumed and frequency of daily intake of different foods by study adolescent girls’ households Rural n= 379 Urban n=382 Frequency of intake Frequency of intake % households % households
28% 66% 24% 8% 3% 41% 4% 7% 10% 56%
26% 11% 1% 2% 6% 11% 35% 2% 2% 15%
26% 10% 6% 16% 22% 17% 28% 4% 1% 20%
9% 3% 3% 12% 22% 3% 12% 2% 3% 3%
11% 10% 66% 62% 46% 28% 21% 86% 85% 6%
24% 63% 19% 14% 24% 39% 9% 7% 15% 52%
33% 15% 0% 25% 25% 12% 31% 1% 1% 22%
26% 13% 4% 25% 28% 17% 27% 4% 4% 14%
10% 2% 7% 12% 10% 5% 13% 4% 3% 5%
7% 7% 69% 24% 13% 27% 21% 84% 78% 7%
Food Types
Meat Eggs Fats Vegetable Fruits Dairy Products Lentils Grains Tea Snacks
Participants were also of the view that consumption of fatty, oily, spicy and sour items could lead to menstrual pain and irregularity and also cause throat infections, abdomen problems, acidity and headache. Some respondents felt that consumption of eggs is not good for girls as it affects their hormones. All respondents felt that food from outside the home, particularly sour and spicy food should not be consumed because a person could fall ill. Almost all of the adolescent girl
7
Chaat refers to a traditional spicy and often sweet and/ or sour snack commonly consumed in Pakistan.
8
Lassi refers to buttermilk.
9
Amchur refers to a sour tasting snack made from dried mangoes
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participants reported taste as the primary reason for their wanting to eat particular types of food like biryani (spicy rice and meat dish), milk, fruits, meat, rice, dry fruits, ice cream, and noodles. Some thought that these foods not only taste good but also improve complexion and are good for health. They however informed that they were not able to eat foods they like because of poverty. Food purchasing and dietary patterns In the FGDs opinions and practices on allowing females to purchase food for the family were discussed. Some participants were of the opinion that males should purchase food because they are the elders of the family, they know all about purchasing and it is easier for them to go out and do the shopping. “Males are more sensible than females in purchasing household items.” -FGD with Community Members, Chakwal, Punjab In some families, fathers-in law were reported to be involved in purchasing groceries. Some male participants said that they had given the authority to their elder daughters after their wives died. Others thought that it is a female‟s job as she knows well what to buy and how to buy. She knows everyone‟s likes and dislikes and what to buy to meet these needs. Participants, who said that in their households females were allowed to purchase food, reported that mothers and mother-in-laws purchase food. These participants were of the opinion that females are good at buying quality food in less money and can easily manage household expenditure. “Wife does the right thing.”-FGD with Community Members, Kohat, KP Both male and female participants stated that they try to buy things according to their children‟s choice and also try to cook food of their children preference. From the discussions it emerged that generally men have considerable influence on what is cooked in their homes since not only are they the heads of households but also because they are responsible for purchasing groceries. Another group whose preferences are considered include elders such as mothers, mothers-in-law, sisters-in-law, elder sisters and younger daughters in the household. “My parents give special importance to my brother‟s choice as he works.”-FGD with Unmarried Adolescent Girls category, Kohat, KP
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Data presented in Tables 4.3.5c, d and e, is from the 24 hour recall of food eaten, in the households of the study adolescent girls. Aggregated data of provinces and urban rural locations is presented owing to the small numbers in each group if further broken down into unmarried and married girls. Chapatti is the main food taken at all three meal times- 23% at breakfast, 63.3% at lunch and 68% at dinner. Table 4.3.5c: Breakfast foods combinations of study adolescent girlsâ&#x20AC;&#x2122; households % of Main Staple % (n) Combinations combination
Paratha
Chappati
53 (n=400)
23 (n=175)
Bread
8 (n=62)
Tea only Skipped
10 25
Miscellaneous
1
Total
Paratha alone Paratha and Tea alone Paratha with Egg and Tea Paratha, Tea with Salan Serving Paratha with combinations of Vegetable curry, Salan(plain curry), Lentils, Murabba and Yoghurt Chappatti alone Chapatti and Tea alone Chapati, Tea with Egg Chapati, Tea with Salan Chappati with combinations of Vegetable curry, Salan (plain curry), Lentils, Murabba and Yoghurt Bread alone Bread with Tea alone Bread with Tea and Egg
Combinations like milk/ egg/ rice/ yoghurt
n
% of 760
6% 1% 3% 14%
23 4 11 56
3% 1% 1% 7%
77%
306
40%
9% 37% 6% 18%
15 65 11 32
2% 9% 1% 4%
30%
52
7%
15% 77% 8%
9 48 5
1% 6% 1%
100% 100%
76 38
10% 5%
100%
9
1%
760
100%
Chappati is flat very thin round of bread made from unleavened whole wheat flour. In KP and Balochistan roti made with leavened bread is eaten by most households. Salan is a major food item taken in combination with chappati by over a third of the households at all meals. Salan is a thin soup made with water and seasoning added to fried onions in which the chappati is dipped to soften it and give it a spicy flavour. It has no nutritional value. Paratha, which is a chapatti fried in vegetable ghee (oil), is eaten in over half of the study adolescent girls households for breakfast and a small percentage (7-8%) for lunch and dinner. Rice appears to be eaten mostly at dinner by Page 116
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24% (mostly in urban Sindh). Highly sweetened tea is drunk once or more by a high proportion of poor households with chapatti as a substitute for other foods. A quarter of the households reported skipping breakfast or lunch. Dinner is not eaten by about 2% of the households. Table 4.3.5d: Lunch food combinations of study adolescent girlsâ&#x20AC;&#x2122; households % of Main Staple % (n) Combinations combination
Paratha
Chappati
7 (n=54)
62.4(n=474)
Rice
6 (n=45)
Skipped Total
25(n=187)
Paratha with Meat Paratha with Vegetables/ Salan Paratha with Lentils Paratha with combinations of Vegetable curry, Salan(plain curry), Lentils Chappati alone Chappati with Meat Chapatti with Vegetables Chappati with Salan Chappati with Lentils Chappati with Tea Chappati with combinations of Vegetable curry, Salan (plain curry), Lentils, Murabba and Yoghurt Rice with Lentils Rice with vegetables/ Salan/ Meat/Yoghurt
n
% of 760
20% 48% 22%
11 26 12
1% 3% 2%
9%
5
1%
6% 9% 47% 23% 9% 6%
27 41 221 108 44 28
4% 5% 29% 14% 6% 4%
1%
5
1%
42%
19
3%
58%
26
3%
100%
187 760
25% 100%
Knowledge about and intake of micronutrient supplements Majority of the participants of FGDs had heard of nutritional supplements and their sources of information included their schools, doctors, LHWs, elders and books. They said that they were aware that supplements are used to improve health. A few participants had never been prescribed any kind of nutritional supplement.
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Table 4.3.5e: Dinner food combinations of study adolescent girls households
Main Staple
Paratha
Chappati
Rice
% of combination
N
% of 760
Paratha with Meat
10%
6
1%
Paratha with Vegetables/ Salan
46%
27
4%
Paratha with Lentils
25%
15
2%
Paratha with combinations of Vegetable curry, Salan(plain curry), Lentils
19%
11
1%
Chappati alone
6%
29
4%
Chappati with Meat
13%
64
8%
Chapatti with Vegetables
44%
219
29%
Chappati with Salan
23%
113
15%
11%
54
7%
Chappati with Yoghurt
2%
11
1%
Chappati with combinations of Vegetable curry, Salan(plain curry), Lentils, Murabba and Yoghurt
1%
7
1%
Rice alone
15%
27
4%
Rice with Meat
12%
23
3%
24%
44
6%
24%
45
6%
25%
47
6%
100%
18
2%
760
100%
% (n)
8(59)
Combinations
65(497 Chappati with Lentils )
24(186 Rice with Vegetables ) Rice with Salan Rice with Lentils
Skipped Total
2(18)
Of those who have been advised to take nutritional supplements (Surbex Z, Ca-C, Neurobion, folic acid, iron and multi-vitamin etc.), to cure problems of renal pain, pus in urine, fatigue, weakness, iron and calcium deficiency and low blood pressure, stated that because of financial problems in the family, they were unable to take the supplements regularly. Some of the respondents stated that they forget to take these supplements regularly.
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“Heard about them (nutritional supplements) from the doctor. He said that they are used to overcome nutritional deficiencies and weakness.” -FGD with Married Adolescent Girls, Kohat, KP In the quantitative survey, knowledge of micronutrients was found to be better among married adolescent girls as compared to unmarried and among the unmarried in Balochistan and KP as compared to Punjab and Sindh. As shown in Fig.4.3.5a, 95% of the unmarried and 90% of the married girls in Balochistan, 94% of the unmarried and 97% of the married in KP, 70% of the unmarried and 55% of the married in Punjab and 85% of the unmarried and 95% of the married in Sindh have self-reported knowledge and partial knowledge of micronutrients. Fig.4.3.5a: Provincial distribution of knowledge about micronutrients among the study adolescent girls Not aware
Somewhat aware
Aware
100% 80% 60% 40% 20% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90
Unmarried n=381
Married n=379
Fig.4.3.5b: Rural and urban distribution of knowledge about micronutrients among the study adolescent girls Not aware
100%
Somewhat aware
Aware
80%
60% 40% 20% 0% Pakistan n=381
Rural n=188 Unmarried n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
Married n=379
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Urban adolescent girls have more knowledge of micronutrients than rural girls as shown in Fig. 20b. Among the unmarried study girls, 15% of rural and 18% of urban girls have self-reported knowledge of micronutrients and 60% of rural and 78% of urban girls have partial knowledge of micronutrients. Among the married adolescents, 28% rural and 38% urban have knowledge while 42% and 60% have partial knowledge (Fig.4.3.5 b). Intake of nutritional supplements The intake of nutritional supplements is more among married adolescent girls than the unmarried ones across provinces (Fig. 4.3.5c). In Balochistan 18%, in KP 32%, in Punjab 12% and in Sindh 30% unmarried adolescents reported taking nutritional supplements. Among the married adolescents, 40% in Balochistan, 48% in KP, 18% in Punjab and 43% in Sindh reported taking nutritional supplements. Fig.4.3.5d: Rural and urban distribution of intake of nutritional supplements among the study adolescent girls No
Yes
100% 90% 80% 70% 60% 50% 40% 30% 20% 10%
0% Pakistan n=324
Rural n=168 UNMARRIED n=324
Urban n=156
Pakistan n=317
Rural n=158
Urban n=159
MARRIED n=317
Rural and urban differences in intake of nutritional supplements are shown in Fig, 4.3.5d. Twenty percent rural and 25% urban unmarried adolescent girls, and 38% rural and 40% urban married girls are taking nutritional supplements. Type of nutritional supplements taken Overall 74 unmarried and 119 married adolescent study girls reported taking nutritional supplement (Fig.4.3.5e). Among the unmarried girls, overall 60% are taking multivitamins alone Page 120
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or in combination with other supplements, 10% are taking iron and folic acid and 30% are taking other unspecified supplements. Fig.4.3.5c: Provincial distribution of intake of nutritional supplements among the study adolescent girls No
Yes
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=324
Balochistan n=85
KP n=92 Punjab n=66 Sindh n=81
UNMARRIED n=324
Pakistan n=317
Balochistan n=81
KP n=95 Punjab n=52 Sindh n=89
MARRIED n=317
8% unmarried girls in Balochistan, 20% in KP and Punjab are having iron and folic acid supplementation with none in Sindh having this supplement. Among the married group, multivitamins are being taken by 68%, iron and folic acid by 16% and others by 15%. None of the girls from Punjab reported taking iron and folic acid, while in the other provinces the proportion of girls taking iron and folic acid is the same (18-20%). Difference in the intake of iron and folic acid by rural unmarried and married girls is apparent with 10% of the unmarried and 24% of the married group taking iron and folic acid (Fig.4.3.5f). Multivitamins alone or in combination with other supplements are being taken by 68% rural and 58% urban unmarried girls and 62% rural and 70% urban married girls. Overall 50% (n=74) of unmarried and 42% (n=119) of the married girls taking supplements were advised by health workers including Lady Health workers (LHWs), Lady Health Visitors (LHVs), doctors, dais/traditional birth attendants.
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Fig.4.3.5e: Provincial distribution of type of nutritional supplement being taken by the study adolescent girls Multivitamin
Multivitamin & Others
Iron & Folic acid
Others
100%
80%
60%
40%
20%
0% Pakistan n=74
Balochistan n=14
KP n=27 Punjab n=10 Sindh n=23
Pakistan n=119
Balochistan n=31
UNMARRIED n=74
KP n=42
Punjab n=8 Sindh n=38
MARRIED n=119
Fig.4.3.5 f: Rural and urban distribution of type of nutritional supplement taken by the study adolescent girls Multivitamin
Multivitamin & Others
Iron & Folic acid
Others
100%
80%
60%
40%
20%
0% Pakistan n=74
Rural n=28 UNMARRIED n=74
Urban n=46
Pakistan n=119
Rural n=58
Urban n=61
MARRIED n=119
In Punjab, all the unmarried girls (n=10) were advised by their parents or siblings and in Sindh (n=23), 80% were advised by health workers and 20% by community elders. Twenty two percent of the married girls (n= 8) in Punjab and 15% in KP (n= 42) reported that their husbands or parents-in-law advised them to take the supplement. In Balochistan (n=31), 85% received the advice from health workers (Fig. 4.3.5g).
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Parents and siblings, community elders and health workers advised the intake of supplements to the unmarried adolescent girls (Fig. 4.3.5h). Fig.4.3.5g: Provincial distribution of persons who advised nutritional supplements Parents and Siblings
Community Elders/ Friends
Health Workers( LHW/LHV/Doctor/Dai/TBA)
In-Laws/ Husband
Multiple sources 100% 90% 80% 70% 60%
50% 40% 30% 20%
10% 0% Pakistan n=74
Balochistan n=14
KP n=27 Punjab n=10 Sindh n=23
Pakistan n=119
Balochistan =31
Unmarried n=74
KP n=42
Punjab n=8 Sindh n=38
Married n=119
Fig.4.3.5h: Rural and urban distribution of persons who advised nutritional supplements Parents and Siblings
Community Elders/ Friends
Health Workers( LHW/LHV/Doctor/Dai/TBA)
In-Laws/ Husband
Multiple sources 100% 90% 80% 70% 60% 50%
40% 30% 20% 10% 0%
Pakistan n=74
Rural n=28 Unmarried n=74
Urban n=46
Pakistan n=119
Rural n=58
Urban n=61
Married n=119
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Rural and urban difference is not remarkable. Fifty percent of the rural married girls and 40% of the urban girls were advised supplements by health workers. Husbands and in laws were the advisors of supplements for 5% and 10% rural and urban married girls respectively. Knowledge of Iodized salt Overall 28% of the unmarried girlsâ&#x20AC;&#x; households with 15% in Balochistan and Punjab each, 30% in KP and 40% in Sindh have knowledge of iodised salt (Fig. 4.3.5i). Overall 40% married girls have knowledge while 28% in Balochistan, 40% in KP and Punjab each and 50% in Sindh knowing about iodised salt. The same level of difference in knowledge of iodised salt is present among rural and urban households within unmarried and married adolescent girls. The proportion of households of unmarried girls having knowledge of iodised salt is less (29% rural and 29% urban) than that of married girls (32% rural and 45% urban) (4.3.5 j). Fig.4.3.5i: Provincial distribution of knowledge about iodised salt in the households of study adolescent girls. Not aware
Aware
100%
80%
60%
40%
20%
0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91 Unmarried n=381
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90 Married n=379
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A Snapshot of Poor Adolescent Girls‟ Nutrition and Related Issues in Pakistan Fig.4.3.5j: Rural and urban distribution of knowledge about iodised salt in the study adolescent girls‟ households Not aware
Aware
100% 80% 60% 40% 20% 0% Pakistan n=379
Rural n=188
Urban n=193
Pakistan n=379
Rural n=190
Unmarried n=381
Urban n=189
Married n=379
Use of iodised salt The use of iodised salt appears to vary across provinces (Fig.4.3.5k) with 31% of the unmarried and 30% of the married girls‟ households in Balochistan, 20% of unmarried and 29% of married in KP, 11% of unmarried and 11% of married in Punjab and 22% of unmarried and 14% of married in Sindh reporting using iodised salts regularly. Those not using iodised salts at all are 35% of unmarried and 38% of married girls‟ households in Balochistan, 30% of unmarried and 15% of married in KP, 30% of unmarried and 58% of married in Punjab and 30% and 52% respectively in Sindh. Fig.4.3.5k: Provincial distribution of use of iodised salt by households of the study adolescent girls
Never
Sometimes
Most of the times
100% 80%
60% 40% 20% 0% Pakistan n=275
Balochistan n=75
KP n=68 Punjab n=76 Sindh n=56
Unmarried n=275
Pakistan n=226
Balochistan n=65
KP n=59 Punjab n=55 Sindh n=47
Married n=226
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Among rural households, 28% and 20% of unmarried and married girls‟ households respectively use iodised salt while among urban households, 15% and 20% of unmarried and married girls‟ households respectively use iodised salt on regular basis. Households which do not use iodised salt are 20% and 30% of rural unmarried and married girls‟ households respectively and 32% and 42% of urban unmarried and married girls‟ households (4.3.5 l). Fig.4.3.5l: Rural and urban distribution of use of iodised by households of study adolescent girls. Never
Sometimes
Most of the times
100% 80%
60% 40% 20% 0% Pakistan n=275
Rural n=134
Urban n=141
Pakistan n=226
Unmarried n=275
Rural n=126
Urban n=100
Married n=226
Daily calorie intake from different meals Calorie intake from different meals was calculated from the measured portions of different foods taken by the girls as mentioned in section 3.3.3. Portions were measured using a pre-measured chappati and cups and spoons. Fig.4.3.5m: Provincial distribution of mean calorie intake from different daily meals of study girls‟ households Breakfast
Lunch
Dinner
Sindh n=97
Pakistan n=379
800.0
Calories provided
700.0 600.0 500.0 400.0 300.0 200.0 100.0 0.0 Pakistan n=381
Balochistan KP n=100 n=91
Punjab n=93
UNMARRIED n=381
Balochistan KP n=100 n=90
Punjab n=93
Sindh n=96
MARRIED n=379
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Breakfast and dinner provide about 550 mean number of calories each and lunch 380 mean number of calories adding up to a daily intake of about 1500 mean number of calories. The urban and rural patterns show some variation with lunch and dinner meals of rural unmarried girls‟ households providing more calories than that of urban unmarried girls‟ households and rural and urban married girls‟ households. The overall daily intake of calories however is about the same in both unmarried and married rural and urban households (4.3.5n). Fig.4.3.5n: Urban and rural distribution of mean calories intake from different meals of study girls‟ households Breakfast
800.0
Lunch
Dinner
700.0 600.0 500.0 400.0 300.0 200.0 100.0 0.0 Pakistan n=381
Rural n=188
Urban n=193
Pakistan n=379
UNMARRIED n=381
Rural n=190
Urban n=189
MARRIED n=379
Barriers to fulfilling nutritional needs of adolescent girls Three reasons emerged from the FGDs for the lack of intake of nutritious foods: poverty, cultural norms, and lack of knowledge regarding affordable nutritious food items. Of these, poverty was mentioned more frequently. A community member from Sindh stated this succinctly as given below. Emergent Theme: Poverty and lack of knowledge on foods as barriers to providing good nutrition to adolescent girls were the recurring themes in discussions and interviews with health services providers. School Teachers were of the opinion that poverty, lack of awareness, bad dietary habits, unaffordable food items and weight consciousness are the major barriers to the healthy eating of adolescent girls. They said that poor socioeconomic conditions and high prices of food items make the adolescent‟s girls vulnerable to under nutrition, They also mentioned misconceptions about the consumption of certain foods in certain conditions like menstrual periods, along with some girls weight conscious as reasons for girls eating less than their needs.
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“There is no money to buy food, how can we think of „good food‟?-FGD with Community Members, Sukkur, Sindh A rare perspective on low intake of food by adolescent girls came out in KP. Some married adolescent girls mentioned that traditionally males are preferred and young girls are neglected by their own families. Due to this girls feel neglected and become depressed, resulting in their further reduced intake of food. This was stated thus by one of them: “Our cultural neglect makes females shy and timid and they hesitate to ask for things they want”-FGD with Married Adolescent Girls category, Kohat, KP Another interesting information on the topic was that parents are more worried about the dowry and marriage issues of their daughters and save money for this purpose; nutritional needs of daughters is not their priority. School Teachers were of the opinion that poverty, lack of awareness, bad dietary habits, unaffordable food items and weight consciousness are the major barriers to the healthy eating of adolescent girls. They said that poor socioeconomic conditions and high prices of food items make the adolescent‟s girls vulnerable to under nutrition, They also mentioned misconceptions about the consumption of certain foods in certain conditions like menstrual periods, along with some girls weight conscious as reasons for girls eating less than their needs. Health services providers also considered poverty as the biggest barrier to the good nutrition of adolescent girls as it leads to food insecurity in their households. Health workers from KP gave cultural practices as a reason for preventing girls in the province to take good food. According to them most families follow the tradition of serving elders and males first, and giving the leftovers to females. They also mentioned restricted mobility of girls who observe purdah (veil) as a reason for their not being able to access food of their choice. When asked to suggest measures to improve dietary intake in poor families, community members recommended awareness creation among parents. According to them the more educated and aware the people around the adolescent girls are, the lower the risk to her health, the more the government resolves the cost of food issue the more the access to nutritious diets and the more availability of health institutions and doctors the less health issues will occur. The interviewers noted that while there was general awareness about the need for healthy and nutritious foods among the participants of FGDs, there was little understanding of Food substitution. Even the health workers interviewed were found to be advising costly foods like
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meat and eggs as sources of protein to these poor families instead of cheaper alternatives and food combinations within their financial capacity. Perception of self-health and nutrition-related symptoms Adolescent girl participants of FGDs, both unmarried and married, were generally not satisfied with their health. They said they had problems of feeling weak, bone pains, anaemia, and menstruation cramps. Some reported that they get tired quickly and cannot work for long. Some said they always have headaches and watery eyes. Married adolescent girls cited surgeries and child birth as reasons for their feeling weak. Emergent Theme: The adolescent girls have negative perception of their health and complain of symptoms attributable to inadequate nutrition.
Symptoms
%
Unmarried
Married
Unmarried
Married
Unmarried
Married
Unmarried
Married
Table 4.3.5f: Provincial distribution of nutrition related symptoms among study adolescent girls Balochistan % KP % Punjab % Sindh % Over
Cramps
65
59
75
58
45
75
86
61
62
Breathlessness
54
46
62
35
35
68
90
35
58
Constipation
30
52
58
22
22
20
32
22
18
13.5
20
30
10
10
10
8
10
10
Hair Loss
48
46
45
60
52
23
30
78
79
Acne
48
27
41
74
80
51
33
11
17
Dry Hair
26
19
17
21
8
10
18
83
75
Eye Dryness
12
23
17
12
0
0
3
22
21
Dryness of skin
17
35
34
14
0
10
12
17
29
Mouth Ulcers
13
4
0
33
24
3
0
0
4
all
Worms in stools
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The distribution of some nutrition-related symptoms among the study adolescent girls is presented in Tables 4.3.5f &g. Symptoms include cramps, breathlessness, constipation, passage of worms in stools, dryness of eyes, hair, skin and nail changes, and mouth ulcers. Overall 65% of both unmarried and married girls reported having cramps off and on or frequently. In Punjab, 75% of unmarried and 86% of married, in Sindh 61% of unmarried and 62% of married, in Balochistan 59% of unmarried and 75% of married and in KP 58% of unmarried and 45% of married girls have this complaint (Table4.3.5f). Breathlessness and constipation are other complaints reported by both married and unmarried girls in all the provinces. Passage of worms in stools was reported by 20% of unmarried and 30% of married girls in Balochistan with the prevalence being 8% - 10% in other provinces. Among complaints related to skin, hair and eyes, hair loss has the highest prevalence across all provinces varying from 23% among unmarried girls in Punjab to 79% among married urban girls in Sindh. Dryness of eyes is not present in KP but 22% and 23% unmarried girls in Balochistan and Sindh have this complaint. Table 4.3.5g: Rural and urban distribution of nutrition related symptoms among study adolescent girls Rural Urban Symptoms Unmarried % Married % Unmarried % Married % Cramps
68
68
60
68
Breathlessness
48
60
48
60
Constipation
30
30
30
30
Worms in stools
15
15
10
15
Hair Loss
56
47
40
52
Acne
48
53
48
31
Dry Hair
30
31
23
25
Dryness of eyes
13
0
11
21
Dryness of skin
13
5
23
35
Mouth Ulcers
17
7
8
6
Rural and urban differences are not present among both unmarried and married girls with 68% rural and urban unmarried girls each complaining of cramps, and 60% rural and 68% urban married girls suffering from cramps off and on or frequently (Table-4.3.5g). Passage of worms in stool was reported by 15% among both rural and urban unmarried girls and 10% rural married and 15% urban married girls. Distribution of other symptoms is about the same as across provinces.
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Despite the FGD participant adolescent girls complaints of ill health and a large proportion of the study adolescent girls many physical complaints, well over 63% of unmarried girls and 61% married girls across provinces said they were satisfied with their health. Rural urban differences in the proportion of unmarried and married girls satisfied with their health are not remarkable (4.3.5o & p). Fig.4.3.5o: Provincial distribution of the study girls‟ satisfaction with their own health Satisfied
Not Satisfied
100%
80%
60%
40%
20%
0% Pakistan n=381
Baluchistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Baluchistan KP n=100 Punjab n=93 Sindh n=96 n=90
UNMARRIED n=381
MARRIED n=379
Fig.4.3.5p: Rural and urban distribution of the study girls‟ satisfaction with their own health Satisfied
Not Satisfied
100%
80%
60%
40%
20%
0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
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4.3.6. Nutritional status Adolescent girls opinions on weight and satisfaction with their weight In FGDs participants generally considered slim and normal weight (neither thin nor fat) as ideal for girls. Those who thought girls should be slim were of the view that slim girls are more active, they look good in whatever they wear, they can do their work more efficiently “and run faster. These participants also stated that slim girls receive better marriage proposals because “a normal size girl looks very pretty.” Those who thought normal body weight is good for girls said that girls with normal body weight are healthy and don‟t catch diseases easily. Overweight and obesity were not preferred by any participant. As put by one participant, “they don‟t look good, can‟t walk properly, and have trouble doing physical work.” Participants also felt that obese women are at higher risk of disease and are unable to do physical work. “Obese women can‟t do physical work properly.” -FGD with Unmarried Adolescent Girls, Kohat, KP Among the respondents of the quantitative survey, over 80% of unmarried and married girls were satisfied with their weight across provinces. Rural and urban distribution of satisfaction with weight, as shown in Figs. 4.3.5q & r, is also about the same for both unmarried and married girls. Fig.4.3.5q: Provincial distribution of the study adolescent girls‟ satisfaction with their weight Satisfied
Not Satisfied
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Baluchistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Baluchistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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Not Satisfied
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
Weight for Age The weight distribution across provinces shows 45% of unmarried and 72% of married study adolescent girls overall in the lowest quartile for weight for age. When the proportion of girls in the second quartile is added then 70% of unmarried and 85% of married fall in the lower quartiles. Variation across provinces is present with 58% in Balochistan, 30% in KP, 48% in Punjab and 45% in Sindh unmarried adolescents in the lowest quartile for weight for age. Among the married girls, 62% in Balochistan, 80% in KP, 70% in Punjab and 80% in Sindh are in the lowest quartile. On the other hand, overall 15% of the unmarried and 8% of the married girls are in the top quartile for weight. Across provinces among unmarried girls, 12% in Balochistan, 18% in KP and 10% in both Punjab and Sindh are in the top quartile while among the married adolescents, 4% in Balochistan, 1% in KP, 4% in Punjab and 18% in Sindh are in the top quartile (4.3.6a). Among the rural unmarried and the rural married adolescent girls, 42% and 75% respectively are in the lowest quartile for weight for age and among the urban unmarried and married girls, 48% and 70% respectively are in the lowest quartile for weight for age. The proportion of girls in the top quartile is 10% rural and 18% urban unmarried and 8% rural and 4% urban married girls (4.3.6b).
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Fig.4.3.6a: Provincial distribution of weight for age of the study adolescent girls 1st quartile
2nd quartile
3rd quartile
4th quartile
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=291
Balochistan n=70
KP n=81 Punjab n=68 Sindh n=72
Unmarried
Married
Fig.4.3.6b: Urban and rural distribution of weight for age of the study adolescent girls 1st quartile
2nd quartile
3rd quartile
4th quartile
100% 90% 80% 70% 60%
50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
Urban n=193
Unmarried
Pakistan n=291
Rural n=146
Urban n=145
Married
Height for Age ranking of the study participants The WHO classification for height for age of adolescent girls was applied to rank the study adolescent girls. The classification is given in section 3.3.1 of methodology.
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As presented in Fig. 4.3.6c, overall 80% of the unmarried and 72% of the married adolescent girls are in the lowest quartile of height for age. In Balochistan and Sindh 80%, in KP 90% and in Punjab 62% of the unmarried adolescents are in the lowest quartile while among the married adolescent 62% in Balochistan, 80% in KP, 72% in Punjab and 75% in Sindh are in the lowest quartile of height for age. Urban and rural differences are not remarkable with 79% of both the rural unmarried and married girls and 74% and 72% of the rural and urban married girls in the lowest quartile of height for age. Among both unmarried and married girls, 10% rural and 5% urban are in the top quartile of height for age (4.3.6d). Fig.4.3.6c: Provincial distribution of ranking of height for age of the study adolescent girls 1st quartile
2nd quartile
3rd quartile
4th quartile
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90
Unmarried
Married
Fig. 4.3.6d: Rural and urban distribution of ranking of height for age of the study adolescent girls 1st quartile
2nd quartile
3rd quartile
4th quartile
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 Unmarried
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
Married
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Mid upper Arm Circumference (MUAC) The distributions of study adolescent girls with MUAC cut-offs of < 22 cm, <23 cm and <24 cm across provinces and in rural and urban areas are presented in Figs. 4.3.6 e & 4.3.6 f. In the absence of as yet agreed cut-off for adolescent girls‟ MUAC all three possible cut-offs are presented. Studies in pregnant women have shown association between low MUAC (<21.5 cm to ≤27.6 cm) and adverse birth outcomes and maternal health outcomes (Tang A. , Dong, Deitcher, Chung, & et al, 2013). MUAC, being low cost, is also being assessed for use as a replacement of BMI in low resource and emergency situations for identifying individuals at-risk of adverse outcome. In Table 4.3.6, correlation between BMI of ≤18.5 and MUAC cut-offs of <22 cm, < 23 cm and < 24 cm is presented. A weak positive statistically significant correlation with all cut-offs has been found; rs 0.209, rs 0.266 and rs 0.288 respectively for 22 cm, 23 cm and 24 cm. Among unmarried girls, 18%, 29%, 37% of unmarried girls have MUAC of <22 cm, < 23 cm and <24 cm respectively. Among married girls, 8%, 16% and 25% have MUAC of < 22 cm, <23 cm and < 24 cm respectively. Across provinces, Balochistan and Sindh have the highest proportion of 28% of unmarried girls with MUAC < 22 cm. KP has 6% and Punjab 12% with MUAC of < 22 cm. Across provinces, 5% in Balochistan, 4% in KP, 2% Punjab and 15% in Sindh have MUAC of < 22 cm. Among rural unmarried 15%, 22% and 33% and urban unmarried 21%, 30% and 40% have MUAC of <22 cm, < 23 cm and < 24 cm respectively and among rural married 5%, 10% and 20% and urban married 9%, 15% and 25% have MUAC of < 22 cm, < 23 cm and 24cm respectively. Table 4.3.6: Correlation between BMI ≤18.5 and different cut-offs of MUAC Correlation between BMI ≤18.5 and different cut-offs of MUAC MUAC Cut-offs (cm)
Spearman's rho
22
23
24
n=760
n=760
n=760
0
0
0
Correlation Coefficient
0.209
0.266
0.288
Strength of Correlation
4%
7%
8%
BMI cut off at 18.5 Sig. (2-tailed)
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Fig.4.3.6e: Provincial distribution MUAC with cut-offs of <22cm, <23 cms and <24 cms of the study adolescent girls
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Fig.4.3.6f: Rural and urban distribution of MUAC of the study adolescent girls
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Body Mass Index (BMI) The provincial distribution of BMI of the study adolescent girls is given in Fig.4.3.6g. The proportions of underweight (<BMI 18.5) girls is 18% among unmarried and 14% among married study girls overall. Sindh has 20% underweight among unmarried and 22% among married adolescent girls. Punjab 25% underweight among unmarried and 15% among married adolescent girls. KP has similar proportion of underweight girls among the married (13%) and unmarried (14%) groups. However, in Balochistan 13% unmarried and 2% of married adolescent girls are underweight. Urban rural differences are not apparent in both groups. Proportion of unmarried girls in the normal range of BMI is 23% overall with Balochistan having the highest proportion of 30% in this range and KP the lowest of 18% with normal BMI. Fig.4.3.6g: Provincial distribution of BMI of study adolescent girls Severe Thin-ness
Thin-ness
Normal
Overweight
Obesity
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91 Unmarried
Pakistan n=291
Balochistan n=70
KP n=81 Punjab n=68 Sindh n=72 Married
In Balochistan, 52% of unmarried adolescents, in KP 78%, in Punjab 50% and in Sindh 55% are overweight or obese. Among married adolescent girls 52% in Balochistan, 78% in KP, 62 in Punjab and 65% in Sindh are overweight or obese. Among the unmarried girls, hardly 36% in Balochistan, 18% in KP, 22% in Punjab and 18% in Sindh have normal BMI. Among the married girls, 12% in Balochistan, 14% in KP, 22% in Punjab and 10% in Sindh have normal BMI. Among both the rural and urban unmarried adolescent girls, the prevalence of underweight is 18%. Among rural and 20% among urban girls, among the rural married adolescent girls the prevalence is 12% and among the urban married adolescent girls 14% (Fig. 4.3.6h).
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Fig.4.3.6h: Urban and rural distribution of BMI of study adolescent girls Severe Thin-ness
Thin-ness
Normal
Overweight
Obesity
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188 Unmarried
Urban n=193
Pakistan n=291
Rural n=146
Urban n=145
Married
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4.4. Study adolescent girls’ access to and utilisation of available health and nutrition services 4.4.1. Access to and opinions on available health services Themes which emerged in FGDs on the topic of access to health care providers and sources of information included limited access to health care providers and an urban and rural divide on opinions and experience with LHWs‟, preference for doctors as providers of health and nutrition advisors, cost of consultation with doctors and family elders and mothers, mothers-in-law knowledge and responsibility to provide nutrition information. Emergent Theme: Rural areas have limited access to community health care providers and they have unfavourable opinion of the knowledge and competence of community health workers. Providing good nutrition and guiding their children to eat healthy was considered a responsibility of mothers by some participants. According to them their mothers know about these things and they didn‟t feel the need for consulting health workers or anyone else. They also informed that they are poor and can‟t afford to consult doctors. There were others who were of the view that family elders and mothers don‟t necessarily have accurate knowledge about nutrition and health workers/ doctors need to be consulted when required. “Mother knows about all these things and also we can‟t afford doctor fees due to financial problems.”-FGD with Community Members, Quetta, Balochistan As regards the role of LHWs in improving the health and nutrition status of adolescent girls a clear urban and rural divide on LHW programme effectiveness emerged in all provinces. Participants from rural areas of Balochistan expressed complete ignorance on the existence of any LHW programme in their areas. On the contrary, some participants from urban areas of the province informed that LHWs are visiting their homes, advising them to eat fruits and take folic acid tablets, offering other counselling services, providing all necessary and relevant information on pre and postnatal health care and providing medicines when required. In the Punjab Province, participants from rural all agreed that CMWs and LHWs are not playing any kind of role in improving the health of adolescent girls. Of those surveyed in the urban areas stated that the LHWs in their area do come and visit them sometime, but often do not provide any kind of advice or guidance to them. Participants from rural areas of Sindh stated that the majority of LHWs do not visit their houses at all. Of those who do visit, most are neither well educated nor properly trained and all they do is give medicines; hence they do not find their visits useful. Participants from urban areas, on the other hand, found LHWs‟ visits useful and productive. They felt that they are good at their work and their door to door service is very beneficial.
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Similar to the other provinces there was an urban and rural divide in opinions and experiences with LHWs among participants from KP with rural participants having negative feelings and urban positive experiences with LHWs. “LHWs never visit our homes. Not even 10% (of required visits); otherwise things would have been better.”-FGD with Married Adolescent Girls, Kohat, KP Participants had mixed opinions on the role of community midwives (CMWs) as their source of nutrition and health information. Some participants felt that CMWs don‟t have a good attitude and often lack appropriate training and experience. Others were satisfies with their local CMWs and preferred consulting them because they are more accessible as compared to doctors. Some participants mentioned that CMWs give more time to pregnant females. “CMWs are within our reach rather than going to a doctor who is away from our home.”-FGD with Community Members category, Sukkur, Sindh Most participants informed that MNCH services are not available in their community and they have to go to the nearest civil hospital for treatment. They said that when consulted doctors‟ advice of their household females to take milk, energy supplements and proper diet to avoid weakness and to take hygienic home-cooked food and have proper breakfast. Participants were of the opinion that where available doctors are generally knowledgeable and trustworthy. It emerged that participants who have access to doctors prefer them to other health care providers for consultation on health and nutrition. IDIs undertaken with LHWs, CMWs and TBAs/Dais indicate that their focus of attention is mostly pregnant married women including adolescent girls and that their services to unmarried adolescent girls are limited to menstruation and its problems. According to them they give advice about diet during menstruation and personal hygiene to all adolescent girls and diet before, during and after pregnancy to married adolescent girls. They also provide solutions to menstrual problems of married girls and prescribe medicines needed during and after pregnancy. In case of a serious problem, they said, they advise their patients to see a local physician. Emergent Theme: Community health services providers are providing services mostly to pregnant women. Nutrition counselling and promotion of adolescent girls don‟t feature their responsibilities list LHWs from Punjab, KP and Balochistan informed that they register between 30 to 180 women each and that they pay a visit to each registered women at least once every month. Respondents
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from Sindh said that about 100 to 1000 women were registered with each LHW and that most LHWs visit as many as 5 houses per day and spend about 30 minutes per visit with each family. In the opinion of the LHWs interviewed, the MNCH programme doesn‟t address the MNCH needs of adolescent girls. Respondents from all provinces stated that they do not have all the necessary and updated information about nutrition. According to them, the curriculum taught to them (CMW/LHW) is not comprehensive and does not cover issues related to adolescent girls‟ nutrition. They felt that they need more information about the type of foods which are considered good for unmarried, married, pregnant and lactating women. They all stated that there is a need to revise the training curricula of CMW/LHW programmes to include nutrition, counselling and management of nutrition needs of adolescent girl. Most of the respondents stated that they do not have the necessary and updated information about nutrition. The curriculum taught to them (CMW/LHW) is not comprehensive and does not cover issues related to adolescent girls. Respondents stated that they need more information about the type of food which is considered good for unmarried, married, pregnant and lactating women. According to them there is a need to revise the training curricula of CMW/LHW programme. They should include the nutrition, counselling and management needs of adolescent girls. They felt that they need to build their nutritional counselling capacity so that when they visit the girls, they are able to better guide them about nutrition. Emergent Theme: LHWs and CMWs informed that adolescent girls‟ nutrition and health are not addressed in MNCH programme. They also expressed a need for revision of training curricula to enhance their capability for more effective nutrition counselling. They recommended that adolescent should be made aware of the importance of balanced diet, personal hygiene, puberty changes and given sex education and made aware of the consequences of early marriage and pregnancy. Such information would enable them to better fulfil their responsibilities towards their families and children. “12-19 years old adolescent girls should be given awareness about their future as married girls. After marriage, she has to look after the whole family and also cope with future challenges so, she must be a healthy person and a healthy mother.” -IDI with Health Worker, Quetta, Balochistan. Most of the health workers interviewed in KP province said that they do not know much about micro and macro nutrients or vitamins and refer to all of them as “Taqat ki Golian.”11 These supplements are prescribed by the doctors on the request of the patient. In their view the
11
Taqatki Golian refers to any tablet/ supplements which can boost a person‟s strength.
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community is already aware of their nutritional needs, but in order to guide and mobilize parents and guardians of adolescent girls, special programmes or workshops should be conducted to disseminate nutrition information and create awareness about the nutrition needs of adolescent girls. Frequency of receipt of nutrition advice Overall, 38% among the unmarried adolescent girls and 68% in Balochistan, 28% in KP, 12% in Punjab and 58% in Sindh have never received any nutrition advice. Among the married girls, overall 40% and 56% in Balochistan, 25% in KP, 30% in Punjab and 55% in Sindh have never received nutrition advice. Rural and urban distribution is similar as provincial distribution. 38% of the rural and urban unmarried girls, and 40% and 39% of rural and urban married girls respectively having not received any nutrition advice ever. Fig.4.4.1a: Provincial distribution of frequency of receipt of nutrition advice by the study adolescent girls Never Advised
Sometimes Advised
Frequently Advised
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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Fig.4.4.1b: Rural and urban distribution of frequency of receipt of nutrition advice by the study adolescent girls Never Advised
Sometimes Advised
Frequently Advised
100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=381
Rural n=188
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
Sources of nutrition advice For the 240 unmarried adolescent girls who reported having received nutrition advice the source of advice is parents and siblings (70%), community members (5%), health workers (2%) and miscellaneous sources (18%) overall. Differences across provinces are narrow except in KP where none of the girls mentioned health workers as their source of advice. For the married girls, the major source of advice is in-laws- 55% overall, 68% in Balochistan, 62% in KP, 43% in Punjab and 35% in Sindh. Parents and siblings are the source of advice of 12% in Balochistan, 18% in KP, 19% in Punjab and 28% in Sindh. Health workers are the source of information for 8% in Balochistan, 10% in KP, 13% in Punjab and 9% in Sindh (Fig. 4.4.1c). Rural and urban distribution of sources of information are a reflection of the interprovincial distribution with parents and siblings as the main source of information for 75% rural and 72% urban unmarried girls and in-laws for 51% rural and 59% urban married girls. Health workers as a source of advice are mentioned by 2% rural unmarried and 5% urban unmarried and 10% rural married and 12% urban married girls (Fig. 4.4.1d).
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Fig.4.4.1c: Provincial distribution of sources of nutrition advice of the study adolescent girls Parents and Siblings
Community Members
Health Care Providers
In-Laws
Misc. combinations
100% 90% 80% 70% 60% 50% 40% 30% 20%
10% 0% Pakistan n=240
Balochistan n=38
KP n=72
Punjab n=80 Sindh n=50
Pakistan n=229
Balochistan n=39
UNMARRIED n=240
KP n=74
Punjab n=65 Sindh n=51
MARRIED n=229
Fig. 4.4.1d: Rural and urban distribution of sources of nutrition advice of the study adolescent girls Parents and Siblings
Community Members
Health Care Providers
In-Laws
Misc. combinations
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=240
Rural n=119 UNMARRIED n=240
Urban n=121
Pakistan n=229
Rural n=114
Urban n=115
MARRIED n=229
Many felt that provision of school meals can be an effective way of improving the nutritional status of school going poor girls. They recalled that in the past this was being done and can be started again. Page 146
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Emergent Theme: The role of school teachers and schools in nutrition promotion is favoured by the community. A need of supplementing child diets with school meals is felt by the poor. “In the past milk and one apple was given to school children up to 5th class. This can be started again with Government support to schools.” -FGD with School Teachers, Chakwal, Province Punjab Some school going unmarried adolescent girl participants informed that they were being advised by their teachers to drink milk regularly and avoid unhygienic street food. “My teacher tells me to avoid unhygienic street food (bazar kagandakhana)12.”FGD with Unmarried Adolescent Girls, Kohat, KP Some of participants informed that no teachers are available in their area, while some others stated that the teachers did not even come to school let alone guide them. School teachers were of the view that periodic training needs to be given to them by the health department. Many felt that health should be taught as a subject in schools, and a trained nutrition teacher should be hired. “There should be a score card of health related statistics girls maintained at school. The school should refer sick and under nourished girls to a health facility or should communicated their condition to their parents.” -FGD with School Teachers, Sukkur, Sindh The role of teachers as a source of health and nutrition advice was specially explored in the quantitative survey for all girls whether formally educated or not. The availability of school teacher as community members and source of advice is therefore documented and presented in Figs.4.4.1e & f. Among unmarried girls, 68% in Balochistan, 70% in KP, 65% in Punjab, and 48% in Sindh have a school teacher available in the community. Among the married girls, 58% in Balochistan, 68% in KP, 40% in Punjab and 37% in Sindh have access to school teachers. Rural and urban differences in access to school teachers of the unmarried and married girls are presented in Fig.4.4.1f. Sixty nine percent of the rural unmarried and 57% of urban unmarried girls have access to school teachers and 52% rural and 48% urban married have access.
12
Bazar
kagandakhana refers to unhygienic street food.
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Fig.4.4.1e: Provincial distribution of access to school teachers of the study adolescent girls for health and nutrition advice Access to School/ School Teacher Nearby
No Access to school/ school teacher
100% 80% 60% 40% 20% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90
UNMARRIED n=381
MARRIED n=379
Consultation with school teachers for health and nutrition advice Provincial distribution of frequency of consultation with school teacher for health and nutrition advice is presented in Fig. 4.4.1g. Among the unmarried girls, 78% in Balochistan, 52% in KP, 62% in Punjab and 78% in Sindh have never consulted school teachers for nutrition advice. Fig.4.4.1f: Rural and urban distribution of access to school teachers of the study adolescent girls for health and nutrition advice Access to School/ School Teacher Nearby
No Access to school/ school teacher
100%
80%
60%
40%
20%
0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
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Among the married girls, 88% in Balochistan, 89% in KP, 81% in Punjab and 88% in Sindh have never consulted school teachers. Among both rural unmarried and urban unmarried, 70% each have never visited a school teacher for health and nutrition advice. Among the married girls, 94% rural and 92% urban have never sought advice from school teachers. Availability of female health care providers There is a lot of variation in the type of health services providers to the adolescent girls‟ communities across provinces. In Balochistan, Lady Health Workers (LHWs) alone are available to 81%, lady doctor alone to 2% and LHW and lady doctor to 3% unmarried girls communities. In KP, 32% are unmarried girls‟ communities are served by LHWs alone and 8% by lady doctors alone while the majority (58%) have a combination of services providers. In Punjab, 71% are served by LHWs, and 12% by a lady doctor and 2% have both. In Sindh the distribution is the same as Punjab. Among married girls‟ communities, LHWs alone are available to 82%, Lady Doctors to 2% and both LHW and lady doctors to 4% in Balochistan. In KP, LHWs alone and Lady Doctors alone serve 20% each of the married girls communities, the rest have a combination of services providers. Fig.4.4.1g: Provincial distribution of frequency of consultation with school teachers for health and nutrition advice Never
Sometimes
Frequently
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=241
Balochistan n=63
KP n=70 Punjab n=62 Sindh n=46
UNMARRIED n=241
Pakistan n=193
Balochistan n=52
KP n=67 Punjab n=38 Sindh n=36
MARRIED n=193
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Fig. 4.4.1h: Rural and urban distribution of frequency of consultation with school teachers for health and nutrition advice Never
Sometimes
Frequently
100% 90% 80% 70% 60%
50% 40% 30% 20% 10%
0% Pakistan n=241
Rural n=130
Urban n=111
Pakistan n=193
UNMARRIED n=241
Rural n=101
Urban n=92
MARRIED n=193
In Punjab, 62% and 4% respectively have services of LHWs and lady doctors alone, 2% have the services of both together and the rest have a combination of providers. In Sindh, lady doctors alone serve 20%, LHWs alone 70% and both together 4%. LHWs are available to a higher proportion of urban unmarried girls (70%) than rural unmarried girls (65%). Fig.4.4.1i: Provincial distribution of availability of different categories of health care providers to the study adolescent girlsâ&#x20AC;&#x; community Only Doctor
Only LHW
LHW and Doctor
Misc. combinations
Others
100% 90% 80% 70% 60% 50% 40% 30%
20% 10% 0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91 UNMARRIED n=381
Pakistan n=379
Balochistan KP n=100 Punjab n=93 Sindh n=96 n=90 MARRIED n=379
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Lady Doctors are available to 8% and 10% respectively and both together to 2-3% of unmarried and married girls. For married girls, LHWs alone provide service to 62% rural and 52% urban and lady doctors alone to 10% rural and 15% urban while 2% of the former and 5% of the later have the services of both. Fig.4.4.1j: Rural and urban distribution of availability of different categories of health care providers to the study adolescent girlsâ&#x20AC;&#x; community Only Doctor
Only LHW
LHW and Doctor
Misc. combinations
Others
100% 90%
80% 70% 60% 50% 40% 30% 20% 10% 0%
Pakistan n=381
Rural n=188
Urban n=193
UNMARRIED n=381
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
Frequency of advice from health care providers The frequency with which the adolescent girls seek advice on health and nutrition from health providers is presented in Figs. 4.4.2c and d. Among unmarried adolescent girls, 60% in Balochistan, 88% in KP, 62% in Punjab and 45% in Sindh have never been given advice on health and nutrition by the available health care providers. Among the married girls, 55% in Balochistan, 85% in KP, 60% in Punjab and 52% in Sindh have never received advice from health care providers on health and nutrition (Fig. 4.4.1k). Rural and urban differences are not present. Sixty two percent of rural unmarried and 65% of urban unmarried girls have never received advice on health and nutrition from health care providers while 65% of rural and 60% of urban married girls have never been advised (Fig. 4.4.1l).
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Fig.4.4.1k: Provincial distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls Never Advised
Sometimes Advised
Frequently Advised
100%
80%
60%
40%
20%
0% Pakistan n=381
Balochistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Balochistan n=90
UNMARRIED n=381
KP n=100 Punjab n=93 Sindh n=96
MARRIED n=379
Access to Health Facilities The study adolescent girlsâ&#x20AC;&#x; access to a health facility is presented in Figs. 33a and b. In Balochistan 45%, in KP 58% and in Punjab and Sindh 65% unmarried adolescent girls have a nearby health facility available. For married girls, 52% in Balochistan, 58% in KP, 30% in Punjab and 73% in Sindh have a nearby health facility available. (Fig. 4.4.1m) Fig.4.4.1l: Rural and urban distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls Never Advised
Sometimes Advised
Frequently Advised
100% 90% 80% 70% 60% 50% 40%
30% 20% 10% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
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Not available nearby
100% 80% 60% 40% 20% 0% Pakistan n=381
Baluchistan KP n=100 Punjab n=93 Sindh n=97 n=91
Pakistan n=379
Baluchistan KP n=100 Punjab n=93 Sindh n=96 n=90
UNMARRIED n=381
MARRIED n=379
For 52% rural unmarried girls and 62% urban unmarried girls, a nearby health facility is available. The situation is about the same for unmarried rural and urban girls with 50% of the former and 58% of the later having access to a nearby facility (Fig. 4.4.1n). Type of nearby available health facility The provincial distribution of different types of health facility available to the study adolescent girls is presented in Fig. 4.4.1o. In Balochistan, a private hospital is available nearby to 48% and a Basic Health Unit (BHU) to 42% of unmarried girls. Fig.4.4.1n: Rural and urban distribution of the study adolescent girls‟ access to health facility Available nearby
Not available nearby
100% 80% 60% 40% 20% 0% Pakistan n=381
Rural n=188 UNMARRIED n=381
Urban n=193
Pakistan n=379
Rural n=190
Urban n=189
MARRIED n=379
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In KP, a private hospital is available to 52% and other (unspecified) facilities to 28%. In Punjab for 20% have a nearby facility of a private hospital, 28% have a BHU and 36% have a Tehsil Head Quarter Hospital (THQ) nearby and in Sindh for 30% a private hospital and 65% a BHU are nearby facilities. For married girls, in Balochistan 52% have a private hospital and 40% have a BHU available; in KP, 42% have a nearby private hospital and 30% have other (unspecified) facility available; in Punjab 10% have private hospital, 30% have BHU and 40% have a THQ hospital available nearby; and in Sindh 28% have a private hospital and 605 have a BHU nearby. Fig.4.4.1o: Provincial distribution of type of nearby facility available to the study adolescent girls Private hospital/Clinic
Basic Health Unit
Rural Health Center
Tehsil Head Quarter
District Head Quarter
Other
100% 80%
60% 40% 20%
0% Pakistan n=223
Balochistan n=42
KP n=57
Punjab n=60 Sindh n=64
Pakistan n=206
Balochistan n=47
UNMARRIED n=223
KP n=59
Punjab n=28 Sindh n=72
MARRIED n=206
Fig.4.4.1p: Rural and urban distribution of type of nearby facility available to the study adolescent girlsâ&#x20AC;&#x; access to health facility Private hospital/Clinic
Basic Health Unit
Rural Health Center
Rural n=99
Urban n=124
Tehsil Head Quarter
District Head Quarter
Other
100%
80%
60%
40%
20%
0% Pakistan n=223
UNMARRIED n=223
Pakistan n=206
Rural n=94
Urban n=112
MARRIED n=206
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The distribution of type of health facility for rural and urban adolescent girls is presented in Fig. 4.4.1p. For 4% rural unmarried girls, a BHU is the nearest facility and for 42% a private hospital is the nearest facility. Among urban unmarried girls, BHU is the nearest facility for 32%, a private hospital for 28% and a THQ hospital for 15%. In case of married rural girls, a BHU is the nearest facility for 30%, a private hospital for 40% and a Rural Health Centre (RHC) for 16%. For urban married girls, a BHU is available for 40%, a private hospital for 30% and a THQ hospital for 10%. Travel time to nearest health facility Among the unmarried girls, 72% in Balochistan, 82% in KP, 28% in Punjab and 56% in Sindh have a travel time to the nearest health facility of 20 minutes or less and for 2% in Balochistan, 4% in KP, 42% in Punjab and 18% in Sindh the travel time is 30 minutes or more. For 60% married girls in Balochistan, 70% each in KP and Sindh and 12% in Punjab the nearest health facility is 20 minutes or less away while for 8% in Balochistan, 6% in KP, 52% in Punjab and 16% in Sindh the travel time is 30 minutes or more (Fig. 4.4.1q). For 64% rural and 51% urban unmarried girls, the travel time is 20 minutes or less while for 60% rural and 59% urban married girls the travel time in 20 minutes or less. For 10% rural and 25% urban unmarried and 18% of both rural and urban married girls, the travel time is 30 minutes or more (Fig. 4.4.1r).
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Fig.4.4.1q: Provincial distribution of travel time to the nearest health facility for the study adolescent girls Less than 10 minutes
10 to 20 minutes
21 to 30 minutes
More than 30 minutes
100%
80%
60%
40%
20%
0% Pakistan n=223
Balochistan n=42
KP n=57
Punjab n=60 Sindh n=64
UNMARRIED n=223
Pakistan n=206
Balochistan n=47
KP n=59
Punjab n=28 Sindh n=72
MARRIED n=206
Frequency of visits to a health facility In Balochistan, 38% of unmarried and 28% of married girls have never visited a health facility; in KP, 45% unmarried and 60% married; in Punjab, 41% unmarried and 33% married; and in Sindh, 40% unmarried and 30% married have never visited a health facility (Fig. 4.4.1s).
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Fig.4.4.1r: Rural and urban distribution of travel time to the nearest health facility for the study adolescent girls Less than 10 minutes
10 to 20 minutes
Rural n=99
Urban n=124
21 to 30 minutes
More than 30 minutes
100%
80% 60% 40% 20% 0% Pakistan n=223
Pakistan n=206
UNMARRIED n=223
Rural n=94
Urban n=112
MARRIED n=206
Among rural unmarried 35% and urban unmarried 45% have never visited a health facility, while among married girls 40% and 38% rural and urban girls respectively have not visited a health facility (Fig. 4.4.1t). Fig. 4.4.1s: Provincial distribution of frequency of visits of the study adolescent girls to a health facility Never Visit
Sometimes Visit
Frequently Visit
100% 80% 60% 40% 20% 0%
Pakistan n=223
Balochistan n=42
KP n=57
Punjab n=60 Sindh n=64
UNMARRIED n=223
Pakistan n=206
Balochistan n=47
KP n=59
Punjab n=28 Sindh n=72
MARRIED n=206
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Fig.4.4.1t: Rural and urban distribution of frequency of visits of the study adolescent girls to health facility Never Visit
Sometimes Visit
Frequently Visit
100% 80% 60% 40% 20% 0% Pakistan n=223
Rural n=99
Urban n=124
Pakistan n=206
UNMARRIED n=223
Rural n=94
Urban n=112
MARRIED n=206
Receipt of advice on health and nutrition at health facility The unmarried (n=130) and married (n=125) girls who reported visiting a health facility sometime or frequently were asked if they were given health and nutrition advice. The distribution of their responses is presented in Figs 4.4.2m&n. Among unmarried girls, 42% in Balochistan, 85% in KP, 50% in Punjab and 30% in Sindh reported having never received advice in a health facility. Fig.4.4.1u: Provincial distribution of frequency of receipt of health and nutrition advice at health facility Never Advised
Sometimes Advised
Frequently Advised
100%
80%
60%
40%
20%
0% Pakistan n=130
Balochistan n=26
KP n=31
Punjab n=35 Sindh n=38
UNMARRIED n=130
Pakistan n=125
Balochistan n=34
KP n=23
Punjab n=18 Sindh n=50
MARRIED n=125
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Among married girls, 75% in Balochistan, 95% in KP, 54% in Punjab and 50% in Sindh reported never having received any health and nutrition advice at the health facility they visited. Among unmarried girls, 38% rural and 62% urban reported having never received any health and nutrition advice during their visit to a health facility. Among married girls, 65% rural and 72% urban have never received such advice. Fig.4.4.1v: Urban and Rural distribution of frequency of receipt of health and nutrition advice at health facility Never Advised
Sometimes Advised
Frequently Advised
100%
80%
60%
40%
20%
0% Pakistan n=130
Rural n=63
Urban n=67
Pakistan n=125
UNMARRIED n=130
Rural n=56
Urban n=69
MARRIED n=125
4.4.2. Reproductive Health and Access to Health Care a. Parity and number of children borne by the study married adolescent girls Among the total 379 married adolescent girls, 132 have never been pregnant. Of the total 247 ever pregnant girls, overall 14 (5.6%) are primigravida, 55% have borne one child, 28% two children, 8% three children and 5% 4 and 5 children. In Balochistan 78%, in KP 43%, in Punjab 53% and in Sindh 30% have borne one child and 15%, 22%, 32% and 40% respectively have two children (Fig. 4.4.2a). Of the 111 rural married girls, 8% are primigravida, 46% have borne one child, 32% two children and 9% 3 or more children. Of the 136 urban married girls, 2% are primigravida and 61% have borne one child, 22% two children and 8% three children. Three percent have 4 or 5 children (Fig. 4.4.2b).
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A positive correlation between literacy and number of children borne by the married adolescent was found. The mean number of children borne by illiterate adolescent girls is 1.26 and that of literate married adolescent 1.43. This difference is statistically significant, p< 0.045. Fig.4.4.2a: Provincial distribution of parity of married adolescent girls and the number of children borne 100 90 80 70
0
60
1
50
2
40
3
30
4
20
5
10 0
Pakistan n=247
Balochistan n=74
KP n=43
Punjab n=83
Sindh n=47
Fig.4.4.2b: Urban and rural distribution of ever-pregnant married adolescent girls and the number of children borne 100 90 80 70
0
60
1
50
2
40
3 4
30
5
20 10 0 Pakistan n=247
Rural n=111
Urban n=136
Fig.4.4.2c presents the provincial distribution of mean age at first pregnancy. In Balochistan, the mean age is 16 years, in KP 16.6 years, in Punjab 16.2 years and in Sindh 16.8 years.
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Fig.4.4.2c: Provincial distribution of mean age at first pregnancy of ever-pregnant married adolescent girls n=379 Mean Age 17.00
16.80 16.60 16.40 16.20 16.00 15.80 Pakistan n=247
Balochistan n=74
KP n=43
Punjab n=83
Sindh n=47
b. Family Planning The emergent themes from FGDs on family planning for married adolescent include: Economic pressure/family welfare, better bringing up of children, well-being of the mother and anticultural/societal norms. Emergent Theme: The unfavourable family and community opinion of family planning is mirrored in the unfavourable opinion and low use of contraception by the married adolescent girls. Unfavourable opinion of family Few participants viewed family planning positively and accepted the right of women to plan their families. They gave increasing cost of living and other financial burdens on families as reasons for their support of family planning. These participants considered two as the appropriate number of children with some preferring 3 children with two sons among them as the ideal number. They also understood that birth spacing and fewer children are good for the health of mothers and their children. â&#x20AC;&#x153;Two children are ideal number of children as parents can manage them better. Things are becoming expensive and to avoid economic pressure, the number of children in the family should be small. For their education and better
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development, proper nutrition and care, less number of children is ideal.”-FGD with Married Adolescent Girls, Kohat, KP “Family planning carries advantage for the whole family and for parents, it is perceived as good in family.” -FGD with Married Adolescent Girls Category, Chakwal, Punjab Some participants considered family planning bad because of religious reasons while some felt that it increased the weight of girls and has negative effects on their health. “Family planning is haram.” -FGD with Male Household Members Category, Kohat, KP Married girl participants of the FGDs who were practicing family planning cited medical advice as the reason behind their decision to use family planning. Others thought family planning keeps them healthy. Those who did not use any type of methods cited different reasons varying from feeling no need for it, religion doesn‟t permit it or that they like more children and large families. A few participants informed that while they understood the benefit of family planning, their families didn‟t and they had to comply with their wishes. Some participants said that men do not like to use family planning methods and hence women suffer. “My mother in law does not like family planning and used to fight with me; being the head of the family the mother in law usually take decisions and she wants a large family.” -FGD with Female Household Members, Kohat, KP Other issues related to family planning which came up in the discussions included cultural taboos and unfavourable view of society. Some also said that children are a gift of God which cannot be denied by couples. “How can a father tell his daughter to practice family planning?”-FGD with Male Household Members, Quetta, Balochistan “Allah rewards with children so nothing should be done to stop it.” (FGD with School Teachers, Sukkur, Sindh Lactation should be the only allowed kind of family planning and no other method should be used. (FGD with Community Members, Chakwal, Punjab
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Overall family planning was viewed unfavourably and only a few household members openly supported it. c. Study Adolescent Girls‟ Opinion on Family Planning Overall 44% and in Balochistan 35%, KP 45%, Punjab 12% and Sindh 76% are not in favour of women practicing family planning. In rural areas 48% and in urban areas 39% are not in favour of women using family planning (Figs. 4.4.2d and e). KP, 40% in Punjab and 75% in Sindhi reported that their households are not in favour of family planning. Among 50% of rural married adolescent girls‟ households and 35% urban households family planning is not favoured (Fig. 4.4.2f and g). When asked about their households‟ opinion on family planning, 55% in Balochistan, 22% in the reported community opinion on family planning mirrors that of the households with 45% in Balochistan, 20% in KP, 42% in Punjab and 75% in Sindh having unfavourable opinion. Favourable opinion on family planning in the community is 22% in Balochistan, 30% in KP, 35% in Punjab and 8% in Sindh. Forty five percent of married rural adolescents and 35% of married urban girls have reported unfavourable opinion of their community towards family planning communities (Figs.4.4.2h and i). Fig.4.4.2d: Provincial distribution of the study married adolescent girls‟ opinion on whether women should use family planning Never
Sometimes
Always
100% 90% 80% 70% 60% 50% 40% 30% 20%
10% 0% Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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Sometimes
Always
100% 90% 80% 70% 60% 50% 40%
30% 20% 10% 0% Pakistan n=379
Rural n=190
Urban n=189
Married n=379
Fig.4.4.2f: Provincial distribution of households‟ opinion on family planning as reported by the study married adolescent girls Not at all favourable
Somewhat favourable
Extremely favourable
100 80 60 40 20 0
Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan Fig.4.4.2g: Urban and rural distribution of householdsâ&#x20AC;&#x; opinion on family planning as reported by the study married adolescent girls Not at all favourable
Somewhat favourable
Extremely favourable
100
80
60
40
20
0 Pakistan n=379
Rural n=190
Urban n=189
Married n=379
Fig.4.4.2h: Provincial distribution of community opinion on family planning as reported by the study married adolescent girls Not at all favourable
Somewhat favourable
Extremely favourable
100.0 80.0 60.0 40.0 20.0 0.0 Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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Fig.4.4.2i: Urban and rural distribution of community opinion on family planning as reported by the study married adolescent girls Not at all favourable
Somewhat favourable
Extremely favourable
100.0 80.0 60.0 40.0 20.0 0.0 Pakistan n=379
Rural n=190
Urban n=189
Married n=379
d. Use of family planning Figs.4.4.2x and y present the willingness of the study adolescent girls to use family planning. Sindh has the highest proportion (90%) of girls unwilling to use contraception. In Balochistan 60%, in KP 55% and in Punjab 40% are unwilling. More urban-(65%) than rural girls-(55%) are unwilling to practice family planning (Figs. 4.4.2i and k). Fig.4.4.2j: Provincial distribution of study married adolescent girlsâ&#x20AC;&#x; willingness to use family planning Would like to use
Would not like to use
100.0
80.0
60.0
40.0
20.0
0.0
Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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A Snapshot of Poor Adolescent Girlsâ&#x20AC;&#x; Nutrition and Related Issues in Pakistan Fig.4.4.2k: Urban and rural distribution of study married adolescent girlsâ&#x20AC;&#x; willingness to use family planning Would like to use
Would not like to use
100.0 80.0 60.0 40.0 20.0 0.0 Pakistan n=379
Rural n=190
Urban n=189
Married n=379
When asked if they are allowed to use family planning, 90% in Sindh and 60% overall said they are not allowed to use family planning. In Punjab 30%, in KP and Balochistan 60% and 50% respectively and in Punjab 30% are not allowed to use family planning. Urban and rural distributions are similar with 60% in each group not being allowed to use family planning (Figs. 4.4.2l and 4.4.2m). Fig.4.4.2l: Provincial distribution of study married adolescent girls allowed to use family planning Allowed to use
Not allowed to use
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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Fig.4.4.2m: Urban and rural distribution of study married adolescent girls allowed to use family planning Allowed to use
Not allowed to use
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=379
Rural n=190
Urban n=189
Married n=379
e. Adolescent married girls using contraceptives When asked if they are using contraceptives, overall 80% reported that they are not using any contraceptives. In Sindh 95%, in KP 70%, and 80% each in Punjab and Balochistan are not using contraceptives. In rural areas 75% and in urban areas over 80% reported of not using contraceptives (Figs. 4.4.2n & o). Fig.4.4.2n: Provincial distribution of study married adolescent girls using contraceptive methods Use contraceptives
Donâ&#x20AC;&#x;t use contraceptives
100% 80% 60% 40% 20% 0% Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married n=379
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Fig.4.4.2o: Urban and rural distribution of study married adolescent girls using contraceptive methods Donâ&#x20AC;&#x;t use contraceptives
Use contraceptives 100% 80% 60% 40% 20% 0% Pakistan n=379
Rural
Urban
Married n=379
Among girls who are allowed to use contraceptives, 40% in Balochistan, 58% in KP, 30% in Punjab and none in Sindh are using contraceptives. All girls who are not allowed to use contraceptives are complying with their families wishes and not using any contraceptives (Fig. 4.4.2p). There is no statistically significant association between the study girls education and family planning opinion and use. Statistical association between provincial place of residence and family planning opinion and use is present (Pearson Chi Square p=0.00). Positive correlation between rural and urban place of residence and family planning opinion and use by the married adolescent girls has also been found (Pearson Chi Square p< 0.038 with favourable opinion movement from urban to rural residence). Fig.4.4.2p: Provincial distribution of use of contraceptives by married adolescent girls allowed and not allowed to use contraception Using contraceptives
Not using contraceptives
100% 80% 60% 40% 20% 0% Pakistan n=142
Balochistan n =41
KP n=37 Punjab n=60 Sindh n=4
Pakistan n=237
Balochistan n = 49
KP n=63
Punjab n= Sindh n=92 33
Married women who are allowed to use contraceptives n= 142 Married women who are not allowed to use contraceptives n= 237
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The negative family planning sentiments of the girls, their families and communities were reflected strongly during the FGDs with them. The respondents were of the view that the community doesn‟t look at family planning favourably. The couples who practice family planning are most reluctant to share the fact publically. Some of the participants said that children are a gift of God and the process must not be blocked. According to some, “family planning is haram (forbidden)”. Majority only accepted lactation as a family planning method. f. Opinion on Antenatal Care Facility-based antenatal care Variation in opinion on whether women should visit health facilities for antenatal care has been recorded (Fig. 4.4.2q). Overall 30% are not in favour of women visiting health facilities for antenatal care. In KP 58% and in Sindh 50% are not in favour while in Punjab 10% and in Balochistan 18% said women shouldn‟t visit facilities for antenatal services. In rural areas 40% and in urban areas 30% don‟t want women to visit health facilities for antenatal care. Fig.4.4.2q: Provincial distribution of opinions on women visiting health facilities for antenatal care Should NOT visit
Should Visit
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
Married N=379
The married girls‟ opinion on who should be consulted for antenatal care was sought. 35% across Pakistan and 58% in Balochistan, 19% in KP, 58% in Punjab and 1% in Sindh are of the opinion that lady doctors should be consulted. In Balochistan 16%, in KP 21%, in Punjab 8% and 45% in Sindh are of the opinion that no consultation is needed. Twenty percent in Sindh and 10% in KP believe family members should be consulted (Fig. 4.4.2s).
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Fig.4.4.2r: Urban and rural distribution of opinions on women visiting health facilities during pregnancy Should NOT visit
Should Visit
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pakistan n=379
Rural n=190
Urban n=189
Married N=379
Twenty eight percent of rural unmarried girls and 35% urban think lady doctors should be consulted while 28% rural and 19% urban married girls believe there is no need for consulting any one. Ten percent in each group think family members should be consulted. Fig.4.4.2s: Provincial distribution of adolescent girlsâ&#x20AC;&#x; opinion on who should be consulted during pregnancy 100% No one Combination of family members and health workers
80%
Mother-in-law, Mother and Lady Doctor only Mother-in-law and Mother only
60%
Mother-in-law only 40%
Mother and sister Various combinations of health workers only
20%
Lady Doctor with different combinations Lady Doctor only 0% Pakistan n=379
Balochistan n=90
KP n=100
Punjab n=93
Sindh n=96
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Combination of family members and health workers Mother-in-law, Mother and Lady Doctor only Mother-in-law and Mother only
80%
60%
Mother-in-law only 40%
Mother and sister Various combinations of health workers only Lady Doctor with different combinations Lady Doctor only
20%
0% Pakistan n=379
Rural n=190
Urban n=189
g. Preferred Place of delivery Fig.4.4.2u & v present the married adolescent girlsâ&#x20AC;&#x; opinion on place of delivery. Twenty eight percent overall, 30% each in Balochistan, Punjab and Sindh, and 20% in KP prefer home delivery. Private clinic is the preferred place for about 5% overall and 7-8% in all provinces except for Sindh, where preference for delivery in clinic is only 2%. Urban (25%) and rural (30%) preference for home delivery is about the same. Fig.4.4.2u: Provincial distribution of preferred place for delivery of married adolescent girls
Sindh n=96
Married n=379
Punjab n=93 Home KP n=100
Clinic Hospital
Balochistan n=90
Pakistan n=379 0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
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Fig.4.4.2v: Urban and rural distribution of preferred place for delivery of married adolescent girls
Married n=379
Urban n=189
Home Rural n=190
Clinic Hospital
Pakistan n=379
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
h. Opinion on infant feeding In KP and Punjab, 85% believe infants should be breast fed for 18 – 24 months. Overall, 50% and in Balochistan, 25% think mothers should breast feeding for 18 – 24 months. In urban areas 45% and in rural area 55% are of the opinion that breast feeding should continue for one and half to two years (Fig. 4.4.2w). As regards the appropriate age for weaning, the majority expressed the opinion that it should be started between 5-6 months (Fig. 4.4.2x). Fig.4.4.2w: Provincial distribution of opinions of married adolescent girls on duration of breast feeding Four - Six months
Seven - Twelve Months
One to One and Half years
One and half -Two years
100% 80% 60% 40% 20% 0% Pakistan n=89
Balochistan n=27
KP n=21
Punjab n=12
Sindh n=29
Married with babies who have breast-fed n=89
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Fig.4.4.2x: Urban and rural distribution of opinion of married adolescent girls on duration of breast feeding Four - Six months
Seven - Twelve Months
One to One and Half years
One and half -Two years
100% 80% 60% 40% 20% 0% Pakistan n=89
Rural n=44
Urban n=45
Married with babies who have breast-fed n=89
4.4.3. Health managers perspectives on adolescent girls nutritional needs and associated issues IDIs were undertaken with a total of 20 health managers; five each from Balochistan and Sindh, six from Punjab and four from KP. All had experience of working in one or more projects related to family planning, nutrition, MNCH, Primary Health Care (PHC), Expanded Programme on Immunization (EPI), Polio Eradication, Community Management of Acute Malnutrition (CMAM), and awareness building through health education. The perspectives of the health managers on Pakistan‟s progress towards achievement of MDGs 4 and 5, the factors behind poor maternal and neonatal health care in Pakistan and how nutritional status of adolescent girls can play a role towards in achieving MDGs and MNCH targets and goals, were explored. The following perspectives emerged from the discussions. a. Unlikelihood of achieving MDGs 4 & 5 owing to security concerns, lack of integration, cultural and religious barriers: One respondent from Punjab however expressed optimism about achieving MDG 5 by 2015. “The rate with which we are progressing now will most probably make us achieve MDG 5by 2015 but not MDG 4. There is however a lot of variation in progress towards achievement of the goals at the Federal, Provincial and District levels.”-IDI with Health Manager, Lahore, Punjab The reasons put forward for failure to achieve MDGs include insufficient political commitment and thereby lack of necessary legislation and regulations, absence of social mobilization and inadequate monitoring & evaluation. Participants were of the view that Page 174
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current or previous projects have all been undertaken due to pressures from international organizations. Respondents from KP province highlighted volatile political situation and increasing security concerns as the major barriers hindering successful MDGs achievement in the province. They also stated that cultural and religious concerns over education of women have further limited the success of interventions. According to them success is further affected by lack of coordination and an integrated management approach. “We have very slow progress towards MDGs achievement. Even today‟s report of 276 MMR is not fully reflecting the actual Maternal Mortality Rate.”-IDI with Health Manager, Kohat, KP b. Disappointing progress with improvement of MNCH indicators in the country All the respondents interviewed across the four provinces were of the view that illiteracy, financial constraints, inability of hospitals to handle large load of neonatal illnesses are some of the reasons behind Pakistan‟s poor MNCH indicators. “There are basic causes while others are underlying. Some causes begin at home or community level, while others at provincial or national level. At the household level, females and children both are ignored as ours is a male dominant society. There is no field intervention, no progress, and no nutritional programs at community level. Furthermore at the national level, so far no health policy has been implemented properly, only drafts are being prepared.”IDI with Health Manager, Lahore, Punjab Respondents felt that the MNCH and nutritional programmes and policies suffer from insufficient funding, ineffective planning and lack of mid-term evaluation. Many projects are still in the form of PC-1 drafts, awaiting approval. Respondents stated that since most of the projects are funded by international donors, these projects often do not have the flexibility to cater to the needs of the local communities. A few of the respondents highlighted cultural barriers and lack of awareness about the importance of these programmes as contributing factors towards the ineffectiveness of these programs. c. Adolescent girls‟ nutritional status enhancement critical for achieving MNCH goals When respondents were asked to give their opinion on the role of nutritional status of adolescent girls towards reducing maternal and neonatal health outcomes all respondents expressed the need for a continuum of care from adolescence to adulthood, focusing on the nutritional needs of the girls growing bodies. They stated that nutritional balance in the body Page 175
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increases the body‟s immunity to fight against germs and diseases. Hence nutritional status of adolescents must be given preference. The Government should take steps to increase awareness on balanced diet because good nutrition status leads to healthy girls and healthy girls become successful mothers. “Today‟s girls are future mothers and if they are malnourished then they will produce malnourished and unhealthy babies”-IDI with Health Manager Category, Lahore, Punjab All of the participants agreed upon the fact that girls with better nutritional status are mentally and physically healthier and able to gain education more actively. Some of the respondents stated that since nutritional status plays a vital role in maternal and neonatal health outcomes, taking care of nutritional needs of adolescent girls would lead to a long standing social change, endorsing girls‟ education in the region. Respondents felt that better nutrition outcomes for girls would lead to reduced malnutrition, which in turn would lead to better education outcomes for women. This would likely have a positive effect on reducing early marriages as well. “Our main problem is malnutrition in the community, if we focus right at this age on their food and capacity building, they will become healthier and sharper citizens.” -IDI with Health Manager, Quetta, Balochistan d. Insufficient focus on adolescent girls‟ nutrition and related needs in current policies and programmes: Perspective on the effectiveness of current nutrition-related policies and MNCH programme in addressing the needs of adolescent girls varied immensely across provinces and among the respondents. The following themes emerged: lack of programme targets for adolescent girls and lack of baseline surveys in the field. Most respondents were of the view that current policies in place are not specific in terms of addressing adolescent‟s needs, and are hence not effective in terms of improving the nutritional status of adolescent girls. They were of the view that it is high time these policies are revised. “I will comment only on nutrition policy which needs to be revised. A lot of focus is being directed to nutrition after 2011. I hope things are going to turn better post 18th amendment.” -IDI with Health Manager, Lahore, Punjab “Effectiveness will be seen once there are adequate policies. There is a lack of a specific policy on Nutrition.”-IDI with Health Manager, Quetta, Balochistan
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Majority of the respondents of Balochistan province stressed upon the need for nutrition policies and strategies at school and college level, including school health services, meal services, and awareness on early marriages. “In order to decrease MMR, we have to start from the base and that age is adolescent age group.” -IDI with Health Manager, Lahore, Punjab Respondents from the Balochistan and KP Province stated that today‟s girl is tomorrow‟s mother. These girls are the basis of future generation so special attention should be paid to their health and dietary needs as no such nutritional needs of adolescent girls are being addressed by any of the current programmes. e. Need for a holistic approach to addressing adolescent girls nutrition issues Addressing Poverty Some respondents stated that the current MNCH and poverty alleviation programmes are not being implemented in coordination. “Poverty is a bigger issue not to be left to be addressed by UN agencies. The government is addressing poverty inadequately. We are restricted to advocacy for poverty elimination.‟- IDI with Health Manager, Lahore, Punjab Other respondents stated that the issue of poverty is being addressed through the programmes indirectly. They were of the view that these programmes were benefiting marginalised individuals by providing them free of cost services and giving them cost awareness and need based livelihood activities i.e. food for work, food for trainings and cash for work up to 5000/- rupees. They stated that a few of their programmes are solely focused on empowering women by providing them jobs. Addressing Social Exclusion Some managers stated that they were not aware of the concept of social exclusion with reference to nutrition. “I am not aware of the concept of social exclusion with reference to nutrition. – IDI with Health Manager, Kohat, KP
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Majority of the respondents accepted that issues of social exclusion are not being given priority by their programmes as these programmes are health focused. Some respondents said that the community is the biggest hurdle in addressing the issue of social exclusion. “The society is conservative and people are reluctant to talk about these issues.” –IDI with Health Manager, Quetta, Balochistan Some of the respondents surveyed from Balochistan, stated that certain programmes have been successful in addressing the issues of social exclusion in urban areas of Balochistan. However the overall opinion was that programmes have so far failed to address issues of social exclusion. Addressing Gender Inequality Majority of the respondents of the Balochistan and KP were of the view that most of the nutritional programmes do not focus on addressing the issue of gender inequality. Some of the respondents stated that the situation is far worse in rural areas than it is in urban areas. Even though communities are aware of the issue yet addressing it is not on top of their priority list. One of the respondents surveyed from KP stated that gender equality is a social issue; hence as per CMAM protocols it is not a part of the programme. Rather it is beyond the scope of the programme. On the contrary, respondents surveyed from Punjab and Sindh stated that they are somewhat able to address the issue of gender inequality through their programme. The main focus of their programme is to educate women about their rights and maternal health issues, and empower them by engaging them in activities that are related to improving the working conditions for women. Some respondents pointed out that LHW programme itself is the largest women empowerment programme and has provided more than 100,000 jobs to women. Addressing challenges at the household and community levels The respondents considered male dominance, gender bias, lack of awareness and lack of acceptability of current interventions as the major challenges to improving the nutritional, social and health status of adolescent girls. Respondents were of the view that misinterpretation of religion and social taboo and values of society hinder progress towards improvement of adolescent girls‟ condition. Respondents Page 178
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also stated that girls are usually ignored by their families as they are expected to leave their parent‟s house after marriage so their parents do no invest much in their health. Furthermore they are taught to sacrifice their wishes for the benefit their families. Challenges faced at Policy and Programmes‟ Level Respondents were of view that most of the policies were quite comprehensive with clear guidelines, but their implementation is weak. According to them there is a dearth of targeted financial allocations and inequity in resources distribution. Some respondents were critical of the current approach to policy-making. They were of the view that policies were often made without developing a proper understanding of the problem. They recommended that research should be conducted to identify major issues and provide baseline data for monitoring progress and evaluating outcomes. “Policy makers don‟t have the right approach. They are not professional.”- IDI with Health Manager, Quetta, Balochistan “Policies have not focused on this age (adolescent). This area requires more research as we lack evidence to guide our policy on this subject and to include it in next health policy. Those who are working on this issue should bring it onto agenda, as currently the issue is not even on the agenda.” -IDI with Health Manager, Lahore, Punjab “Adolescent girls nutrition is not a priority issue at policy level” -IDI with Health manager, Karachi, Sindh (Note: These views were echoed by stakeholders who attended the provincial inception meetings in all four provinces. They felt that the programmes were designed on perceived needs rather than actual needs). At the programme level poor management, lack of systematic monitoring and evaluation, inadequate human resources, inadequate and irrational funds allocation and poor advocacy were listed as the major barriers to achieving the planned outcomes and impact. Respondents informed that the PC-I of the MNCH programme is not operational and only guidelines are available. They stated that unrealistic targets, poor planning, lack of implementation and lack of monitoring and evaluation as well as lack of inter-sectoral coordination always have and always will hinder the process of achieving programmes‟ objectives. Effectiveness of LHWs and MNCH Programmes Page 179
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When respondents were asked to present their views on the effectiveness of LHWs and MNCH Programmes in the context of nutritional counselling and nutritional management of adolescent girls, they highlighted the strengths and weaknesses of the programmes. Some respondents were of the view that even though significant improvements have been observed in some areas, yet no substantial improvements have occurred in Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR) and Neonatal Maternal Rate (NMR). The problem according to them lies not in the programme but in its implementation. Certain projects have completed PC-I Phase and are awaiting approval for implementation. “I think Pakistan has the best LHV program in the world, planning and designing phase is excellent, we have good centres, but when time comes for the go, again the practical phase is missing.”-IDI with Health Manager, Kohat, KP “Maternal mortality is less in areas covered by LHW showing positive impact.” -IDI with Health Manager Category, Karachi, Sindh Majority of the respondents identified administration issue, low deployment ratio, lack of sustainability, lack of awareness and experience as contributing factors towards ineffectiveness of the programmes. They recommended that proper training and monitoring activities should be undertaken to improve LHWs‟ commitment and motivation. They also pointed out the undue work burden imposed upon the LHWs due to several programmes running simultaneously. All respondents were unanimous in recommending programmes should be integrated to enhance their effectiveness. Most of the respondents, especially those from Sindh, were of the view that the MNCH programme needs to be categorised to bring specific focus on to unmarried and married adolescent girls and pregnant women needs. They also emphasised the need for better coordination between programmes. “Coordination of MNCH programme with nutrition programme is essential.” IDI with Health Manager Category, Quetta, Balochistan There was agreement among the respondents on the need for improving the quality of training of LHWs and CMWs and the revision of their training curricula. They felt that a major chunk of the curricula is useless and out-dated, so it needs to be revised. Respondents felt that entry level requirements of education should also be revised to improve the effectiveness of the training.
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“The curricula need to be reduced, concise and narrowed down. Role of LHWs and CMWs needs to be specified.” -IDI with Health Manager, Sukkur, Sindh Some respondents from Sindh suggested that refresher trainings of LHWs and CMWs specifically on addressing nutritional and behavioural issues of adolescent girls should also be undertaken. Others were of the view that since the LHWs are working in a broader perspective as compared to the CMWs, they can prove to be more effective in providing nutritional counselling if they are trained properly. Respondents recommended that LHWs should be given specific responsibility to undertake adolescent girls‟ nutrition and reproductive health counselling and to motivate them they should be given additional incentives. Perspective on other countries‟ experiences Health managers were asked to share their learning from the successes of other countries in the fields of Nutrition and MNCH, especially from those with similar economic profile to Pakistan. Respondents were of the view that countries like Malaysia, Sri Lanka, India, Bangladesh, Nepal and Panama have successfully addressed the issues of illiteracy and poverty, and one should learn from their success. A respondent from KP shared his experience of visiting Sri Lanka. He praised Sri Lanka‟s decision to identify literacy as a priority issue for the achievement of MDGs. Respondents from the KP province opined that multiple implementation models should be introduced in the country through advocacy and lobbying. They were of the view that Pakistan has access to global policies and strategies and should model its national procedures and protocols accordingly. UN agencies and SAARC can also influence current policies and practices. “One way is to know more about issues. Send some policy makers to relevant countries to learn and implement the lessons learned from other countries. Panama is an example of multi-sectoral approach.” -IDI with Health Manager, Lahore, Punjab 4.4.4. Health managers recommendations for improving MNCH and nutrition programmes Many recommendations came from the health managers during the interviews. The frequently made recommendations included: 1) Enhanced allocation of funds; 2) Initiation of new nutrition programmes; 3) Infrastructure development; 4) Appropriate regulations; and 5) Stakeholders‟ involvement in policy formulation. They also recommended the redressing of the issues of empowerment and inequality and development of job opportunities and training workshops for Page 181
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women. Some respondents stressed upon the need for improving communication skills of both LHWs and CMWs, so that they are better able to get the correct message across, and are not perceived by community as having inadequate knowledge and brisk and rude. Most of the respondents recommended a nutrition programme specifically designed to address the needs of adolescent girls and mothers. There were some however, who felt that the current MNCH programmes could be modified to include a specific component on Nutrition, and that development of a new program was not required. â&#x20AC;&#x153;We can define / specify the intervention packages for adolescent girls and add them in the overall MNCH/ LHW/ Nutrition programme i.e. health, education, anaemia problems, etc.â&#x20AC;?-IDI with Health Manager, Lahore, Punjab On budgetary allocations, respondents recommended that these should be such that the issue of malnutrition, specifically that of children can be adequately addressed. They stated that an integrated approach needs to be followed to revise the overall health budget. One of the respondents from the Punjab province felt that every district should have its own specific budget allocation.
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DISCUSSION AND CONCLUSIONS 6.1 Discussion This study has tried to document a comprehensive picture of the social and nutritional status of poor adolescent girls in Pakistan to date. The purpose of the study is to focus attention on the need for adolescent girls‟ specific strategies in Pakistan‟s social sector programmes generally and health and MNCH programmes specifically. There is now a general agreement that the adolescent age group is being neglected in health and nutrition policies and programmes. Commitment to the upholding the rights, building the capabilities and expanding the choices of all members of society is increasing among development agencies are governments are being persuaded to create the enabling social, economic, political, and legal environment within which all young people can fully develop their potential for becoming productive and respected members of civil society. Among the youth girls and more especially poor girls are the most marginalised and the UN System is advocating with governments and civil society to ensure that national development plans don‟t ignore their needs and rights (UNFPA & PopulationCouncil, 2007). In this study the health managers interviewed in the four major provinces of Pakistan were unanimous in their opinion that there is as yet no focus on adolescent girls in current national health and nutrition programmes and no indication of any change in coming up policies and programmes. The findings of this study provide an evidence base for advocacy at both the national and provincial levels for the strengthening of existing programmes and including adolescent girls‟ needs in upcoming policies and programmes. While the sample selection for the study is a mix of convenience, random and purposive and not strictly representative of the poor adolescent girls population of Pakistan, generalisation of the results is warranted owing to the similarity of the poverty levels of the study girls households across provinces and the social and nutrition related beliefs and practices across provinces and in the study rural and urban areas. Urban and rural differences have not been clearly demonstrated because the selection of urban and rural areas was at the Union Council level in districts where urban development is not too far ahead of rural areas. The study finding of similarity of opinions and practices across provinces is important since it provides a rationale for the development of uniform strategies for improving the nutrition and reproductive health of adolescent girls across provinces and in urban and rural areas. Since in this study poor households and poor adolescent girls were purposively selected our results are not expected to be comparable to studies which surveyed the general population. Comparisons are also limited by the paucity of publications on the nutritional status and dietary patterns of adolescent girls both from Pakistan and other similar countries. In this study food insecurity is evident from the findings of 20% households having experienced frequent food shortages, 40% of the study girls being hungry (reporting having insufficient food) frequently or Page 183
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always and 30% households having 2 meals or less. The comparatively higher proportion of food insecure households in the provinces of Sindh (72%) and Punjab (50%) found in this study has also been reported by National Nutrition Survey 2011(NNS 2011). NNS 2011 found 58% food insecure household at the national level and 59.5% in Punjab and 72% in Sindh. Our study however didn‟t find any rural urban differences as reported by NNS 2011 due to sampling reasons as explained above. While not strictly comparable both for the reason of type of sample and indicators used for food insecurity, the findings of the two studies reinforce each other as regards the critical food security situation in the country. While the households of the study adolescent girls were poor on all indicators, the knowledge and beliefs of the household and community members on the dietary requirements of adolescent girls were not entirely negative. From the discussions held with them it emerged that they understood the increased nutrition requirements of girls especially during pregnancy and lactation. There also appeared to be no overt discrimination against girls as regards access to food in the household and within the limited resources of the households they are being provided what is available. The interviewers however noted that while there was general awareness about the need for healthy and nutritious foods among the participants of FGDs, there was little understanding of food substitution. Even the health workers interviewed were found to be advising costly foods like meat and eggs as sources of protein to these poor families instead of cheaper alternatives and food combinations within their financial reach. As a result, the girls‟ diets are inadequate. Thirty percent households having two meals or less per day, the missing of breakfast or lunch by a quarter of the poor households and the high proportion of households not taking daily essential food items which are sources of proteins and micronutrients are indirect indicators of the inadequacy of their diets both in quantitative and qualitative terms. Nutrition of adolescent girls is of importance on several counts since it is in this phase of their lifecycle that their physical, psychosocial and hormonal development occurs to prepare them for their childbearing role. Studies in the developed countries have established that girls generally begin their adolescent growth spurt at an earlier age (9 years of age) than boys (11 years of age); their pubertal growth spurt lasts between two to four years, with the average rate of linear growth being 5-6 cm/year (2-2.4 in/year). Gains in linear growth are accompanied by increases in body weight and changes in body composition. Weight gain in girls typically happens six months following the greatest gains in linear growth, and compared to boys, girls experience greater increases in adiposity, which is required for normal menstruation. Moreover, approximately half of adult bone mass is obtained during adolescence. The measurement of calorie intake in this study is not precise and the estimated mean per day calorie intake of about 1500 is way below the WHO and Food and Agriculture Organisation (FAO)‟s recommended 2430 - 2540 - kcal/day for ages 14 yrs. – 18 yrs. (FAO Corporate Repository). A study in rural Bangladesh estimated the average per-capita energy intake by rural Page 184
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adolescent girls as 81% of the recommended dietary allowance (RDA) for age (Amin et al). Our findings can be taken as indicative of low calories intake among poor girls. The anthropometric data is consistent with the dietary intake pattern data. From a third to two thirds of the study girls are in the lowest quartile for weight and over two thirds are in the lowest quartile for height. The low proportion of girls with normal BMI across provinces is a matter of concern and needs further investigation. While the anthropometric data has confirmed the expected high prevalence of underweight and stunting in the study adolescent girls, it has also uncovered overweight and obesity among 60% and 70% of the unmarried and married study adolescent girls respectively. NNS 2011 reported 31% overweight and obese among non-pregnant women of child bearing age. Studies on high school and college girls in Sialkot and Rawalpindi cities of Pakistan reported 21.5% and 3% overweight and obese respectively (Zaman, Iqbal, & Ali, 2013) (Shahid, Siddiqui, Bhatti, Ahmed, & Khan, 2009). High BMI can over estimate over weight and obesity in stunted population and needs to be interpreted carefully (Wilson, Dickinson, Griffiths, Azcorra, Bogin, & InES Varela-Silva, 2011). This is as yet an unresolved issue in malnourished adolescents and children (Schroeder & Martorell, 1999). Therefore while this finding needs cautious interpretation it could be a warning of the rising consumption of junk food among the adolescent under the influence of mass media aggressive advertising of these foods. Drewnowski and Specter in their review of „poverty and obesity: the role of energy density and energy costs‟, reported the relation between obesity and diet quality, dietary energy density, and energy costs. In the developed countries highest rates of obesity occur among population groups with the highest poverty rates and the least education (Drewnowski & Specter, 2004). According to Darmon et al a reduction in diet costs in linear programming models leads to high-fat, energydense diets that are similar in composition to those consumed by low-income groups (Darmon, Briend, & Ferguson, 2008). Among the poor population in Pakistan refined sugar consumption in tea and sugared drinks is high and coupled with limited physical activity of girls and women owing to their restricted mobility may be related to the high proportion of overweight among poor populations. A small study in Lahore was undertaken to look at this association but was not able to demonstrate it probably due to small sample size (Iram, Zulfiqar, Malik, & Bilal, 2011). The study girls and their households‟ main sources of information on nutrition and health come out to be family elders, mothers and mothers in law. Urban and rural divide emerged in opinions on the effectiveness of LHWs in improving the health and nutrition of girls specifically and the community generally. The rural participants across provinces were either ignorant about the existence of LHWs or sceptical about their knowledge and expertise. LHWs and CMWs themselves also informed that their services are mostly focused on pregnant women and that they find their training inadequate for providing effective nutrition and health counselling. The health managers‟ interviews corroborated the need for revision of LHWs and CMWs training curricula to improve the training effectiveness. Improving the motivation of LHWs by providing them
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incentives and better training were recommended by the health managers. Mass media were not mentioned by any participant as a source of health and nutrition information. While contact of the study adolescent girls with other health professionals including doctors has been reported to be low, and visits to health facilities infrequent but those who did have contact reported that they were not given any health or nutrition information, School teachers appear to be playing no role in providing health and nutrition information but were acknowledged as a good potential source if trained effectively Much has been written about the low social status and marginalisation of adolescent girls and women in Pakistan and other South Asian countries. In their „Opportunities and Choices Working Paper- 2004‟, Hennink, Rana and Iqbal point out the transformation of social roles, expectations and responsibilities in the adolescent period and the strong asymmetry in the experiences of young women and men in Pakistan in this context. While adolescent boys gain more autonomy, mobility, opportunity and responsibilities outside the home, adolescent girls are often restricted to a life centred around the home, are increasingly protected from the outside world and their mobility and independent actions are restricted. The restricted mobility of girls is a barrier to their receiving education, health and nutrition information and counselling and employment. This issue has been pointed out by others and also came out during FGDs with family and community members and health care providers. Education was favourably viewed by many but a fear that education makes girls more independent was also expressed. Educating girls creates many positive outcomes for economic development and poverty reduction by improving a girl‟s income-earning potential and socio-economic status (International Center for Research on Women-ICRW). According to an ICRW analysis of data from different countries, in middle-eastern countries marriage at the age of less than 18 years is 5% among girls with 8 years and more education as compared to 40% in girls with 3 years or less education. In this study we also found an association between education and age at marriageincreasing education increasing the age at marriage. This study also found illiteracy among married adolescent girls to be twice that among unmarried girls. The provincial differentials in illiteracy rates are surprising since the more conservative KP had the lowest illiteracy rate of 10% among unmarried, and the more aware Sindh and Punjab provinces had the higher rates of 20% and 40% for unmarried respectively and 40% and 50% respectively for married girls. Reasons for this variation could be due to sampling bias but needs to be further explored. Illiteracy is taken as an indicator of marginalisation. The high illiteracy rate among both the married girls and their spouses indicate overall marginalisation of the poor adolescent population. The employment rates of 5 – 10% among unmarried and 3 –23% among married girls across provinces can be interpreted in many different ways. Compared to boys these rates are low and looked at in a positive sense can be taken to indicate that girls are not being Page 186
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burdened with economic responsibility by their families. These rates can also be taken as a reflection of women participation in the labour market in Pakistan, which is the lowest in South Asia. On the other hand employment increases social status and can give girls financial empowerment. However with no or incomplete education poor adolescent girls can only be expected to get low paid exploitative jobs which are not likely to enhance their skills or develop their cognitive and creative potential. The type of employment and salaries earned by the employed girls in this study indicate this to be the situation. It is therefore important that policy makers and planners create such job opportunities which while providing financial independence to them also take care of developing their potentials for a better future. The Punjab government‟s Adolescent Strategy and Strategic Plan Document 2013 – 2017 is a good initiative which can be further improved by bringing under special focus the specific circumstances of poor adolescent girls and practical approaches for enhancing their educational, skills development and job opportunities. The other rather disturbing findings of the study are the anti-family planning and antenatal care sentiments of the study population. A study exploring gendered influences on women's uptake of antenatal care (ANC) services in Punjab, found that pregnancy and its associated decisions were the domain of older women in the households. The quality of a woman's inter-personal ties, particularly with her mother-in-law and husband, were found to be important in accessing resources, including ANC. Family finances and women education were important determinants of ANC use (Mumtaz & Salway, 2007). Similar to the finding of our study, low use of contraceptives among married adolescent girls (of less than 5%) was reported by Saleem and Bobak in their 2005 study (Saleem & Bobak, 2005). Education is reported to be associated with contraceptive use. We were not able to demonstrate the association but this could be because of the small sample size. In our study over 90% of the study adolescent married girls had had one or more pregnancy. The mean age at first pregnancy was reported to be 16.40 years overall while the median age at marriage was reported to be 16 years. These finding are about similar to the findings of others (Sultana, 2005). The IDIs and FGDs undertaken with household and community members, school teachers, health and nutrition services providers and health and nutrition managers have found that generally there is awareness about the deleterious effects of early marriages of girls. Most participants identified age 19 -24 years as the best age for marriage of girls. There was also a positive attitude to girls‟ education and employment especially among their family members. For promoting the nutritional status and health of adolescent girls these positive opinions and beliefs can be leveraged through institutionalised strategies to create awareness and facilitate households and communities to effectively practice what they believe. The households and communities must be recognised as the focus of policies and strategies for promotion of the health, nutrition and social and psychological wellbeing of adolescent girls.
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The recommendation and suggestions given by the different stakeholders are in accordance with current thinking on issues related to adolescent girls‟ reproductive health and nutritional status. In Pakistan there is also more discussion on the issues of adolescent girls and post 18th constitutional amendment the more empowered provincial governments have started developing youth development policies and strategies aimed at empowering the youth through education and skills development. The results of this study can provide the necessary evidence base for a focused approach to solving the issues related to poor adolescent girls.
6.2 Conclusion From the findings of this study it can be concluded that:
Poor adolescent girls have low social status and are marginalised as indicated by their low literacy rates, low age at marriage and financial disempowerment.
Food insecurity, hunger, poor diets and malnutrition are prevalent in poor households and among poor adolescent girls
The poor adolescent girls, their household members and community members have understanding of the enhanced nutritional needs in adolescence and families‟ practices on access to nutrition are not generally discriminatory against girls. Nevertheless the girls‟ diets are poor quantitatively and qualitatively owing mainly to poverty and lack of knowledge of food substitutions.
Household members are the main sources of the girls‟ nutrition and health information. LHWs and other community services providers including school teachers are currently not playing any role in the promotion of adolescent girls‟ health and nutrition. However they are available to the community and have the interest and potential of creating awareness and providing counselling services on regular basis.
A high proportion of married adolescent girls, their families and communities have unfavourable opinion of family planning and the use of contraception is very low at less than 20% compared to the national rate of 35%.
Access to health workers is low but utilisation of the services of community based health care providers like LHWs and Community Midwives (CMWs) is even lower. Awareness about their availability and satisfaction with the services provided by them is lower in rural areas Hardly any as compared to urban areas. Hardly any married adolescent girl mentioned them as their source of health and nutrition advice or their preferred consultants for antenatal care. Page 188
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Health and nutrition services providers need better and continuing nutrition training and education and counselling skills to be effective in creating nutrition awareness and behaviour change.
Current health policies and programmes need to recognise adolescent girls‟ needs and concerns and develop effective strategies for reaching out to them.
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RECOMMENDATIONS The recommendations given below are based on the findings of this study and recommendation made by health managers and services providers in interactions with them during the course of the study and in the provincial dissemination seminars. Recommendations of the Adolescent Girls‟ Advocacy & Leadership Initiative (AGALI) relevant to Pakistan‟s situation and in line with the findings of this study have also been incorporated (Fewer, Ramos and Dunning. 2013). Recommendations given can be incorporated in the provincial youth development policies and strategies and implemented in coordination by the relevant public sector departments including youth affairs, education, and social welfare etc. and NGOs. Nutrition and health promotion
Current policies and programmes must include poor adolescent girls‟ nutrition and health as specific areas of focus. Strategies must focus on awareness creation and behaviour change at the household and community level.
Policies and programmes in the development phase or to be developed must recognise the specific needs of poor adolescent girls and their implementation strategies must extend to the household level and community levels to reach these girls.
Community health services providers need to be recognised as agents for change and their capacities developed as promoters of and counsellors on nutrition and health to adolescent girls and their households. While the current training programmes transfer knowledge to the services providers they fail to develop their capacity for applying and adapting the knowledge to specific situations. This was evident from the IDIs held with services providers who appear to be recommending foods to poor families like milk, eggs, chicken and fruit, which are beyond their financial capacity. The health services provider need to understand the nutritional value of inexpensive and easily available food items and their combinations to be able to make more practical suggestions for the improvement of dietary intake.
Training of school teachers and involvement of schools in awareness creation, capacity building and overall community development activities School teachers as community members are available to the adolescent girls even if they are not school going. They have some knowledge of health and nutrition and are generally respected by the community. Additionally with the increasing recognition of school health programmes a number of them will be getting training of school children health and Page 190
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nutrition. Therefore LHWs and MNCH programmes must link up with school teachers and schools to scale up awareness creation and nutrition and health promotion. Volunteer female school teachers can be trained and encouraged to reach out to out of school adolescent girls. Schools have the facilities of space and infrastructure to undertake and/or facilitate, with community participation, nutrition and lifestyle change awareness creation activities and capacity building activities.
Capacity Building of health professionals working in health facilities Health care providers and health facilities need to develop their capacities to provide technical leadership to nutrition and health promotion activities at the community level. They can develop training curricula and trainers and facilitators for training activities of all different types of stake-holder mobilised by programmes for awareness creation and behaviour change of households and communities.
Coordination and integration of all adolescent girls‟ empowerment and health and nutritional status promotion activities Local governments are best placed to provide, integrate, coordinate, supervise and monitor all activities at the community level. Capacity building for undertaking this role and responsibility must be developed among the officials and employees to local government.
Economic Empowerment for Adolescent Girls The recently developed youth policies by the provinces do not recognise poor adolescent girls as a specific component of the youth populations with very different needs from the middle class youth they are focusing on. These following recommendations from AGALI need to be incorporated in the youth policies and programmes. AGAL recommends three strategies for the economic empowerment of adolescent girls: financial services, employment, and life-skills and social support (Fewer, Ramos and Dunning. 2013).
Creation of Age-Appropriate Financial Services This includes development of financial literacy and youth savings programmes relevant for all ages and provides a critical base for future economic advancement. Microcredit strategies are more appropriate for older adolescent girls and young women who have the mobility, resources, and social support to launch small businesses.
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Link Employment Programmes with Real Market Needs and Opportunities Develop Programmes that offer adolescent girls vocational training and employment opportunities. This approach requires designing a quality training process that builds girls‟ technical and soft skills. These programmes should also help address any health and social obstacles that negatively affect a participant‟s ability to work, such as lack of participation in the public sphere, early marriage, and adolescent pregnancy. In Pakistan where girls‟ mobility is restricted, innovative ways of reaching out to them need to be developed. One such way could be the enrolment of an older person from the household along with the target adolescent girl may ensure better participation in the programmes. Skills development for work which can be done at home may have better acceptance.
Address the Intersection of Factors that Shape Girls‟ Lives An integrated approach considering adolescent girls‟ overall well-being is critical to achieving economic empowerment. Programmes should combine life-skills training and social support with strategies to promote access to financial services and employment need to be developed. Organising the trainings at sites accessible from their homes and acceptable to the families will have more uptake. Reproductive health and leadership training as well as financial training and job guidance can be integrated into the skills development programmes.
Create Data-Driven Programmes Data should be a core component of girls‟ economic empowerment initiatives throughout programme development, implementation, monitoring, and impact assessment stages. To customise the programmes formative research on adolescent girls‟ needs and preferences should be made part of the programmes. Finally, organizations should measure short and long term programme outcomes to both assess impact and build the field‟s knowledge of successful models, as existing evaluations in the field are very limited.
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REFERENCES Presler-Marshall, E., & Jones, N. (2012). Charting the future: Empowering girls to prevent early pregnancy. Retrieved March 19, 2014, from http://www.odi.org.uk/sites/odi.org.uk/files/odi-assets/publications-opinionfiles/7724.pdf Ajzen, I. (1991). The theory of planned behaviour. Organ Behav Hum Decis Process, 50, 179211. Alam, N., Roy, S., Ahmed, T., & Ahmed, A. (2010). Nutritional status, dietary intake, and relevant knowledge of adolescent girls in rural Bangladesh. J Health Popul Nutr, 28(1), 86-94. Ali, S., Ali, A., & Memon, W. (2006, February 02). Understanding of Puberty and related Health Problems among Female Adolescents in Karachi, Pakistan. J Pak Med Assoc., 56(2). Bruce, J. M. (2001). The New Testament World: Insights from Cultural Anthropology. Westminster John Knox Press. Daniels, I. O. (2007). Child Poverty and Inequality: New Perspectives. New York: Division of Policy and Practice, UNICEF. Darmon, N., Briend, A., & Ferguson, E. (2008). Can Optimal Combinations of Local Foods Achieve the Nutrient Density of the F100 Catch-up Diet for Severe Malnutrition? Journal of Pediatric Gastroenterology and Nutrition, 94(9), 447-452. Drewnowski, A., & Specter, S. (2004). Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr, 79(1), 6-16. Fatima, F., & Fikree, F. (2002). Does Early Age at Marriage Influence Gynaecology Morbidities among Pakistani Women? Journal of Biological Science, 34, 407-417. Fewer, S., Ramos, J., & Dunning, D. (2013). Economic Empowerment Strategies for Adolescent Girls. Retrieved March 19, 2014, from AGALI: http://www.youtheconomicopportunities.org/sites/default/files/uploads/resource/AGALIEconomic-Empowerment-Report-2013-.pdf Hamid, N. (2011). Living in two worlds: experience of Pakistani cultural expectations for first generation Pakistani women living in the United States: a phenomenological Page 193
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investigation. Retrieved from HTTP://UDINI.PROQUEST.COM/VIEW/LIVING-INTWO-WORLDS-EXPERIENCE-OF-PQID:2435046301/ Iram, R., Zulfiqar, S., Malik, S., & Bilal, M. (2011). Carbonated Drink Consumption and BMI in Pakistani Adolescents. Esculapio, 7(4). Jamal, H., & Khan, A. J. (2007). Trends in Regional Human Development Indices. Islamabad: SPDC, Pakistan. Karapanou, O., & Papadimitriou, A. (2010). Determinants of menarche. Reproductive Biology and Endocrinology, 8(115). Khan, A. (2000). Adolescents and Reproductive Health in Pakistan: A Literature Review. Research Report No.1. Islamabad: Population Council. Khan, S., Wilson, A.-K., Taylor, G., Varley, E., Dohad, R., & Hooper, E. (2009). Poverty, Gender Inequality and Social Exclusion and their impact on maternal and newborn health in Pakistan. Maternal and Newborn Health Program, Research Advocacy Fund, Pakistan. Khan, Y., Bhutta , S., Munim , S., & Bhutta, Z. (2009). Maternal Health and Survival in Pakistan: Issues and Options. J Obstet Gynaecol Can., 31(10), 920-9. Kubik, M., Lytle, L., Hannan, P., Story, M., & Perry, C. (2002). Food-related beliefs, eating behaviour and class-room food practices of middle school teachers. Journal of SchoolHealth, 72(8), 339-345. Monique Hennink, I. R., Henink, M., Rana, I., & Iqbal, R. (2004). Knowledge of personal and sexual development amongst young people in Pakistan. Islamabad: Opportunities and Choices Working Paper No. 12. Mosquera, P., Antony, S., & Agneta, H. (2002). Honor in the Mediterranean and Northern Europe. Journal of Cross-Cultural Psychology, 33(1), 16-36. Mumtaz, Z., & Salway, S. (2007). Gender, Pregnancy and the Uptake of Antenatal Care Services in Pakistan. SOCIOL HEALTH ILLN, 29(1), 1-26. NIPS, P. (2008). Pakistan Demographic Health Survey 2006-2007. Islamabad: National Institute of Population Studies, The World Bank. Page 194
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OECD. (2012). Health Data 2012. Paris: OECD. OECD. (2012, 12 21). Social Institutions and Gender Index. Retrieved from OECD Development Study: http://genderindex.org/country/pakistan#_ftn8 Papanek, H. (1971). Purdah in Pakistan: Seclusion and Modern Occupations for Women. Journal of Marriage and Family, 517-520. Pew Research Center. (2010, November 18). The Decline of Marriage and Rise of New Families. Retrieved March 19, 2014, from pewsocialtrends.org: http://www.pewsocialtrends.org/files/2010/11/pew-social-trends-2010-families.pdf Planning Commission. (2011). National Nutrition Survey. Islamabad: Government of Pakistan. Presler-Marshall, E., & Jones, N. (2012). Charting the future- Empowering girls to prevent early Pregnancy. London: ODI and Save the Children. Rowbottom, S. (2007). Giving Girls Today and Tomorrow: Breaking the Cycle of Adolescent Pregnancy . New York : UNFPA. Saleem, S., & Bobak, M. (2005). Women Education and Contraception Use in Pakistan: A National Survey. Reprod Health, 1186-1742. Save the Children. (2004). Children Having Children- State of the World's Mothers 2004. Connecticut: Save the Children with support from David and Lucile Packard Foundation. Schroeder, D., & Martorell, R. (1999). Fatness and body mass index from birth to young adulthood in a rural Guatemalan population. Am J Clin Nutr, 70(1), 137s-144s. SDPI. (2009). Pakistan: Country Gender Profile Study 2007-2008. Islamabad: Sustainable Development Policy Institute. Shahid, A., Siddiqui, F., Bhatti, M., Ahmed, M., & Khan, M. (2009). Assessment of Nutritional Status of Adolescent College Girls at Rawalpindi. ANNALS, 15(1), 11-16. Sultana, M. (2005). A Brief on reproductive health of adolescent and youth in Pakistan: Culture of Silence. Islamabad: The Population Council.
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Tang, A. M., Dong, K., Deitchler, M., Chung, M., Maalouf-Manasseh, Z., Tumilowicz, A., et al. (2013). Food and Nutrition Technical Assistance III Project. Washington: USAID. Tang, A., Dong, K., Deitcher, M., Chung, M., & et al. (2013, November). Use of Cutoffs for Mid-Upper Arm as an indicator of predictor of nutritional and health related outcomes in adolescents and adults. Retrieved March 19, 2014, from Food and Nutrition Technical Assistance FANTA: http://www.fantaproject.org/sites/default/files/resources/MUAC%20Systematic%20Revie w%20_Nov%2019.pdf UNFPA. (2009, 10 26). Addis Call for Urgent Action for Maternal Health. Retrieved 2013, from UNFPA: http://www.unfpa.org/webdav/site/global/shared/documents/news/addis_call_action.pdf UNFPA & Population Council. (2007). The Adolescent Experience in-depth: Using data to identify and reach the most vulnerable young people- Pakistan 2006-2007. Population Council. New York: UNFPA. UNICEF. (2004). The State of the World's Children. London: Oxford University Press. UNICEF. (2008). Child Marriage and the Law: Legislative Reform Initiative Paper Series. UNICEF, Division of Policy & Planning. New York: UNICEF. Weiss, A. M. (2012). Moving Forward with the Legal Empowerment of Women in Pakistan. Washington: USIP. WHO. (2010). 10 Facts on Adolescent Health. Family and Community Health, Adolescent Health and Development Institute. Wilson, H., Dickinson, F., Griffiths, P., Azcorra, H., Bogin, B., & InES Varela-Silva, M. (2011). How useful is BMI in predicting adiposity indicators in a sample of Maya children and women with high levels of stunting? Am. J. Hum. Biol., 23, 780-789. Zaman, R., Iqbal, Z., & Ali, U. (2013). Dietary Intakes of Urban Adolescents of Sialkot, Pakistan do not meet the standards for adequacy. Pakistan Journal of Nutrition, 12(5), 460-467.
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LIST OF APPENDICES APPENDIX A: Field Data Collection Guidelines ........................................................................................... II APPENDIX B: DMU Guidelines ...................................................................................................................XV APPENDIX C: Research tools: Survey Questionnaire Married Adolescent Girl ..................................... XXI APPENDIX D: Research tools: Survey Questionnaire Unmarried Adolescent Girl ............................ XXXVI APPENDIX E: Research tools: FGD Topic Guides ................................................................................ XLVIII APPENDIX F: Research tools: IDI Topic Guides........................................................................................ LVI APPENDIX G: Root Tables ...................................................................................................................... XCVI APPENDIX H: Study methods and site wise breakdowns .................................................................. CXLVI APPENDIX I: Pictures of props used................................................................................................... CXLVII APPENDIX J: Pictures of data collection in field ............................................................................... CXLVIII APPENDIX K: Caloric values of food items used in 24 hour recall( 608 in research instrument) to calculate the total caloric values of meals .............................................................................................CLIII
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APPENDIX A: Field Data Collection Guidelines
Studying the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition and on the sources of nutrition information that adolescents have access to and use
FIELD WORK GUIDELINES NUR CENTER FOR RESEARCH & POLICY FATIMA MEMORIAL HOSPITAL MAY 2013
Definitions 1. Adolescent girl is a girl of age 14 – 19 years, belonging to a poor household 2. Poor Households are defined as households living below the national-poverty line i.e. US $ 12 (approx. PKR 1200/-) per person per month. It is the national poverty threshold deemed necessary to provide on an average 2,350 calories per person per day1.
1
NATIONAL POVERTY LINE NOTIFIED WIDE NOTIFICATION . NO. 1(41) POVERTY/PC/2002 DATED 16 AUGUST 2002
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3. Household is defined as family members who eat from the same kitchen. 4. Community Service Providers are all maternal, newborn and child health services providers who are providing services to study households. These include Obstetricians and Gynecologists, Pediatricians, Women Medical Officers (WMOs), Nurses, Lady Health Visitors (LHVs), Community Midwives (CMWs), Lady Health Workers (LHWs), Traditional Birth Attendants (TBAs), Staff at Mobile Health Clinics. 5. Community Opinion Leaders are members of the community, whose views and actions influence the views and actions of the community. These include community elders, local elite, elected representatives, political leaders, high ranking officials, religious leaders, school teachers, CBO members etc. 6. Community based non-governmental organizations are organizations (international, national or regional) engaged in MNCH services provision and/or development activities at community level. 7. Policy Makers and Health Managers are provincial health programme managers, CMWs and LHWs program managers, district health and MNCH managers.
Terms of Reference Lead Organisation – FMH Lahore
Overall Project Management
Communication and negotiation with Funding Agency Project fund management as per funding agency requirements Overall project management, coordination and monitoring Facilitation and trouble-shooting to ensure smooth implementation at the provincial level Submission of overall project progress reports to funding agency Data analysis of all data Preparation and submission of project technical reports Organization of national data dissemination seminar Preparation of national and Punjab province policy briefs
Data Collection Punjab Province
Data collection and field work in Punjab province Submission of Punjab provincial progress reports Dissemination of data at Punjab provincial level
Provincial Collaborating Partners
Management of respective provincial funds and submission of all purchase and expenditure details with documents to FMH. Hiring and training of provincial field teams, with backup arrangements Data collection and field work in respective province Submission of respective provincial progress reports to FMH APPENDICES PAGES | III
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Coordinating appointments with Policy Makers and Health Managers for IDIs Organization of district and provincial meetings Dissemination of data at respective provincial level
Management Guidelines Lead Organisation 1. Constitution of Project Steering Committee: 1.1. Members will include:
a. b. c. d. e.
Representative of FMH management (2-3) NCRP Senior Technical Advisor Project Principal Investigator Project Provincial Focal Persons (4) FMH Financial Manager (1)
1.2. Terms of reference:
a. Project monitoring and supervision – all project progress reports will be submitted to the committee by FMH b. Trouble-shooting and resolution of problems and issues arising among collaborating partners- meeting at FMH may be arranged as and when required. 2. Establishment of Data Management Unit (DMU) (Detail protocols attached as Annex 1) 2.1. Data Management Team
a. Appointment of statistician-part-time- will also be overall in-charge of data management cell b. Qualitative data expert part-time will be recruited c. Statistical team will include 2 computer/data-entry operators d. Protocols will be developed for data transfer from the provinces and e. Data management and confidentiality: One computer /data-entry operator will be given training and written instruction for questionnaire storage under lock and key and supervision of data entry. 2.2. Data Management Cell
a. b. c. d. e.
Office Computer room Computers and software Storage cabinets Miscellaneous items
3. Preparation of all Project Implementation Documents 3.1.Constitution of documentation team and training APPENDICES PAGES | IV
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3.2.Identification of documentation focal points in provinces for communication and provision of provincial documents 3.3.Preparation of data collection tools, protocols, reports etc. 3.4.Procurement of office technology for preparation of reports and other documents
Provincial Collaborating Partners 1. Constitution of Provincial Team Members: Provincial Project Focal Person-Co-Investigator Field Manager Field Supervisor 2. Recruitment of Data Collection teams: Quantitative o Interviewers o Junior Research Associate Qualitative o FGD Moderators Local study site team o Site Focal Person o Two Field Assistants
Data Collection Preparatory Work 1. Sample sites selection 1.1. Identification of district for data collection (PSU) Criteria- poor district according to Human Development Index (HDI) with urban and rural areas- This information can be obtained from provincial Federal Bureau of Statistics (FBS) Office or the Census Data. 1.2. Selection of Urban and Rural sites for data collection (SSU) 1.2.1. Sampling frames of urban and rural sites can be obtained from FBS office 1.2.2. Random selection of 2 urban and 2 rural sites using the sampling frames 1.2.3. Cluster Sampling of 50 households with adolescent girls at each urban and rural site 2. Logistics arrangement for data collection 2.1. Field visits scheduling for advance team and for data collection team. Schedules to be based on: 2.1.1. Number of days to be spent at each field site-this will depend on travel time to site and time taken in filling questionnaires and undertaking FGDs 2.1.2. Interval between site visits 2.1.3. Official holidays APPENDICES PAGES | V
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2.2. Vehicle hiring 2.2.1. Field site office identification 3. Data collection tools’ preparation 3.1. Pilot testing 3.2. Translation 3.3. Printing 4. Recruitment of data collection teams 4.1. Field team leader/supervisor (Male) 4.2. Quantitative team- 4 interviewers: qualification bachelors and above, preferably health professionals training programmes’ students – (All females) 4.3. Qualitative Team – 2 interviewers: qualification bachelors and above, preferably health professionals training programmes’ students with prior familiarity with quantitative data collection (one male and one female) 4.4. Local field assistants – 2 women residing in the same community, preferably lady health workers LHWs. 5. Training of field teams 5.1. At least 2 days training with each team will be undertaken on filling and use of questionnaires and checklists. 5.2. The 4 quantitative team interviewers will be trained on the adolescent girls’ anthropometry and FFQ questionnaire and IDI questionnaire. The IDI questionnaires have mixed open and close ended questions and therefore probing training needs also to be given to the team. 5.3. The qualitative team members will be trained on FGD and IDI with managers, services’ providers and community members. 6. Meetings with district stakeholders 6.1. Health and MNCH project managers and other relevant managers for briefing on the project and solicit their facilitation of the project implementation. 7. Advance Field Work 7.1. Constitution of Advance Team comprising of three members- including field team supervisor and two field assistants recruited from selected sites 7.2. The field team supervisor will give detailed briefing and training to field assistants on the work expected of them 7.3. Identification of local community elders and leaders through the support of field assistants 7.4. Advance visit to all 4 selected field sites: The 3 members team will visit each site according to a pre-prepared schedule and under take the following tasks: APPENDICES PAGES | VI
A Snapshot of poor adolescent girls’ nutrition and related issues in Pakistan
7.4.1. Identify a local focal person preferably MO with BHU or RHC at each site 7.4.2. Meet local community elders and leaders and solicit their facilitation of data collection teams 7.4.3. Arrange site office with the help of focal person, with enough space for undertaking FGDs 7.4.4. Meet district and local police and arrange security cover for the visit of data collection team 8. Sampling The field supervisor will train the local focal person and assistants in selecting households for the survey and respondents for the different types of data to be collected. o Household’s selection: 50 households will be selected at each urban and rural sampling site. Cluster sampling method will be used for selecting the households Of the 50 households at each site, 25 with unmarried adolescent girls and 25 with married adolescent girls will be selected o Selection of Respondents for Anthropometry and FFQ questionnaires: All the adolescent girls in the selected household- minimum 25 unmarried and 25 married, at each site, will have anthropometric measurement and will be interviewed for food recall and symptoms of malnutrition. o Selection of adolescent girls for IDI: From the sample households at each study site 3 unmarried and 3 married adolescent girls will be purposively selected for IDI. o Selection of adolescent girls for FGDs: From the sample households in one urban and one rural study sites, a total of 3-4 adolescent unmarried and 3-4 married will be purposively selected for one Urban FGD and one rural FGD. o Selection of family members of adolescent girls for FGDs: From the sample households, one urban and one rural group of 6-8 female and 6-8 male family members will be purposively selected. A total of 2 male and 2 female groups will be selected per province. o Selection of community members for FGDs: Purposive sampling will be done to select 6-8 female and 6-8 male community members for 2 urban and 2 rural FGDs from the communities of the selected district urban and rural sites. Total FGDs=4 one urban and one rural female and one urban and one rural male. o Selection of Health and MNCH services providers for FGD: Purposive sampling of 3 each CMWs and LHWs serving the selected rural sites communities will be done. One FGD per province will be undertaken APPENDICES PAGES | VII
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o Selection of female school-teachers for FGD: Purposive sampling of female schoolteachers serving the selected urban and rural sites communities will be done for one urban and one rural FGD. o Selection of Policy Makers and Health Managers for IDI: Senior and mid-level health and MNCH managers at the provincial and district level, minimum 2 each will be requested for IDI. Selection will be as per availability and consent of the managers The selected managers will be of the level of deputy directors and directors 4 IDIs per province will be undertaken. 9. Data Collection 9.1. Home visits for data collection from adolescent girls and FGDs with family and community members will be undertaken during the same time period 9.2. Teams will arrive at field site office together and supervisor will give them the list of houses to be visited and FGDs to be done 9.3. Visits to study households will be organized as follows: 9.3.1. Four interviewers of quantitative team will together visit households and will be facilitated by local field assistants (for safety and security) 9.3.2. The local female assistant will accompany the teams (one by one) and introduce them to the households. 9.3.3. Written consent forms will be signed by each participant/respondent 9.3.4. The local assistant will move from one household to another where the interviews are taking place, at intervals to ensure that data collection is going on smoothly and the interviewers are comfortable 9.3.5. In case of any issue arising, the field supervisor and local focal person will be called to resolve the issue 9.4. FGDs will be arranged at the field site office as follows: 9.4.1. Pre-selected FGD participants will be brought to the office on the project vehicles 9.4.2. Written consent forms will be filled and got signed by each participant 9.4.3. Female FGD will be conducted by the 2 female quantitative team members. Discussion will be recorded as well as notes will be taken by one member of the team 9.4.4. Male FGDs will be conducted by the field team leader with assistance from one female team member for recording discussion and taking notes. 9.4.5. FGDs will be transcribed the same evening by the moderators 10. Data Management 10.1. The field team supervisor will collect questionnaires, transcription, notes and recording each day from the interviewers and check the questionnaires for completion and consistency. APPENDICES PAGES | VIII
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10.2. The filled questionnaires, recordings, transcription and notes will be given over to the provincial project focal person on a daily basis if possible, otherwise after the completion of work at the field site. In the latter case the field team supervisor will be responsible for their safe storage. 10.3. The provincial project focal person will check the questionnaires for completeness and consistency and the other documents for consistency and accuracy. She/he will keep documents in safe custody under lock and key and send each site’ complete documents to the project principal investigator by courier. Adolescent Girls
Household Members
Community Members
• Married • Unmarried
• Heads of households • Husbands • Mothers-in-law • Mothers
• Local elite • Elected representatives • High ranking officials • Religious leaders • Media personnel • CBO members • Community based nongovernmental organizations incl. Edhi Foundation, Citizen Foundation, NRSP, UNICEF, UNFPA
Fig. A1: Respondent Categories
APPENDICES PAGES | IX
Community Service Providers
Health Managers & Policy Makers
• Lady Health Visitors (LHVs) • Community Midwives (CMWs) • Lady Health Workers (LHWs) • School Teachers engaged in Formal and Infromal Education
• Provincial health programme managers, CMWs and LHWs Program Managers • District Health and MNCH managers
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Table A1: Distribution of different data collection techniques and tools among provinces Data Collection No. of respondents/ Technique participants per field Site QUANTITIATIVE SURVEY Anthropometry and 25 per urban site= 50 food frequency 25 per rural site =50 questionnaire unmarried adolescent girls Anthropometry and 25 per urban site= 50 food frequency 25 per rural site =50 questionnaire married adolescent girls FOCUS GROUP DISCUSSIONS FGD with married 1 from rural site =1 adolescent girls 1 from urban site=1
Tools
Requirement per Province
Total Requirement for Project
Questionnaires
100 survey forms
400 survey forms
Questionnaires
100 survey forms
400 survey forms
Check list, note sheets, recorder,
8 recorders 8 note pads
FGD with 1 from rural site =1 unmarried 1 from urban site=1 adolescent girls Focus Group 1 from rural site =1 Discussions with 1 from urban site=1 male household members Focus Group 1 from rural site =1 Discussions with 1 from urban site=1 female household members Focus Group 1 from rural site =1 Discussions with 1 from urban site=1 community opinion makers Focus Group 2 from rural site =2 Discussions with CMWs and LHWs Focus Group 1 from rural site =1 Discussions with 1 from urban site=1 school teachers Focus Group 1 from rural site =1 Discussions with 1 from urban site=1 other health care providers IN DEPTH INTERVIEWS IDI unmarried 2 each urban site = 4 adolescent Girls 2 each rural site= 4
Check list, note sheets, recorder,
2 Check list 2 recorders 2 note pads 2 Check list 2 recorders 2 note pads 2 Check list 2 recorders 2 note pads
Check list, note sheets, recorder,
2 Check list 2 recorders 2 note pads
8 recorders 8 note pads
Check list, note sheets, recorder,
2 Check list 2 recorders 2 note pads
8 recorders 8 note pads
Check list, note sheets, recorder,
2 Check list 2 recorders 2 note pads 2 Check list 2 recorders 2 note pads 2 Check list 2 recorders 2 note pads
8 recorders 8 note pads
IDI married adolescent Girls
2 each urban site = 4 2 each rural site = 4
Questionnaires
IDI health and MNCH managers
Provincial manager 2 District managers 2
Questionnaires
IDI health and MNCH managers
Federal managers 4
Questionnaires
4 forms 4 note pad 1 recorder 4 forms 4 note pad 1 recorder 4 forms 4 note pad 1 recorder 4 forms 4 note pad 1 recorder
16 forms 16 note pad 4 recorder 16 forms 16 note pad 4 recorder 16 forms 16 note pad 4 recorder 4 forms 4 note pad 1 recorder
Check list, note sheets, recorder,
Check list, note sheets, recorder, Check list, note sheets, recorder,
Questionnaires
Data Collection Framework ď&#x201A;§
Primary Sampling Unit (PSU) is the district identified for data collection APPENDICES PAGES | X
8 recorders 8 note pads 8 recorders 8 note pads
8 recorders 8 note pads 8 recorders 8 note pads
A Snapshot of poor adolescent girls’ nutrition and related issues in Pakistan
Secondary Sampling Unit (SSU) are the 2 Urban and 2 Rural sites identified within the PSU for data collection Cluster Sampling of 50 households with adolescent girls at each urban and rural site
Data collection from married and unmarried adolescent girls
Table A2: Quantitative Methodology and No. of selected Respondents STUDY DISTRICT (PSU)
Quantitative Survey with Anthropometry and Food Recall Form
IDI with Anthropometry and Food Recall Form
FGDs
RURAL SITE 1: (SSU) Study population: 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old) Sampling:
RURAL SITE 2:(SSU) Study population: 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old) Sampling:
Study Study population: population: 2 married 2 married adolescent girls adolescent girls (14–19 year old) (14–19 year old) 2 unmarried 2 unmarried adolescent girls adolescent girls (14–19 year old) (14–19 year old) Sampling: Sampling: Purposive for IDI Purposive for IDI Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14– 19 year old) Sampling: Purposive for FGD
APPENDICES PAGES | XI
URBAN SITE 1: (SSU) Study population: 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old) Sampling:
URBAN SITE 2: (SSU) Study population: 25 married adolescent girls (14–19 year old) 25 unmarried adolescent girls (14–19 year old) Sampling:
Study Study population: population: 2 married 2 married adolescent girls adolescent girls (14–19 year old) (14–19 year old) 2 unmarried 2 unmarried adolescent girls adolescent girls (14–19 year old) (14–19 year old) Sampling: Sampling: Purposive for IDI Purposive for IDI Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14– 19 year old) Sampling: Purposive for FGD
A Snapshot of poor adolescent girls’ nutrition and related issues in Pakistan
Table A3: Qualitative Methodology and No. of selected Respondents STUDY DISTRICT (PSU)
FGD with married adolescent girls
FGD with unmarried adolescent girls
FOCUS GROUP DISCUSSIONS
Focus Group Discussions with male household members
Focus Group Discussions with female household members Focus Group Discussions with community opinion makers
RURAL SITE 1: RURAL SITE 2: (SSU) (SSU) Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14–19 year old) Sampling: Purposive for FGD Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14–19 year old) Sampling: Purposive for FGD Study population: 8-10 male household members (Husband, Father, Father-in laws, Uncles, Elder brother) Sampling: Purposive for FGD Study population: 8-10 female household members ( Mother, Mothers-in-laws, Aunt, Sister in law, Elder Sister) Sampling: Purposive for FGD Study population: 8-10 community opinion makers (Local elite, Elected representatives, High ranking officials, Religious leaders, Media personnel, CBO members, Community based non-governmental organizations incl. Edhi Foundation, Citizen Foundation, NRSP, UNICEF, UNFPA)
Sampling: Purposive for FGD
URBAN SITE URBAN SITE 2: 1: (SSU) (SSU) Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14– 19 year old) Sampling: Purposive for FGD Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14– 19 year old) Sampling: Purposive for FGD Study population: 8-10 male household members (Husband, Father, Father-in laws, Uncles, Elder brother) Sampling: Purposive for FGD Study population: 8-10 female household members ( Mother, Mothers-in-laws, Aunt, Sister in law, Elder Sister) Sampling: Purposive for FGD Study population: 8-10 community opinion makers (Local elite, Elected representatives, High ranking officials, Religious leaders, Media personnel, CBO members, Community based nongovernmental organizations incl. Edhi Foundation, Citizen Foundation, NRSP, UNICEF, UNFPA)
Sampling: Purposive for FGD Focus Group Discussions with CMWs and LHWs
Study population: 8-10 CMWs and LHWs Sampling: Purposive for FGD
Focus Group Discussions with school teachers
Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive for FGD Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive for FGD
Focus Group Discussions with other health care providers
Study population: 8-10 CMWs and LHWs Sampling: Purposive for FGD IDI
APPENDICES PAGES | XII
Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive for FGD Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive for FGD
A Snapshot of poor adolescent girls’ nutrition and related issues in Pakistan
Table A3: IDI Categories according to Data Collection Framework STUDY DISTRICT
In Depth Interviews with Health Managers and Policy Makers
1 DISTRICT LEVEL
2
EDO Health
Table A4: Comprehensive Data Collection Framework SITES FOR Number of Quantitative DATA Households Survey with COLLECTION Anthropometry and Food Recall Form
Total Completed 50 Instruments married RURAL SITE 2: 25 adolescent girls (SSU) (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
2
LHW Program Manager MNCH Provincial Program Manager
DG Health Person Program
Nutrition Program Focal Person MNCH Program Focal Person
PROVINCIAL LEVEL
married RURAL SITE 1: 25 adolescent girls (SSU) (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
1
25 married 1. adolescent girls (14–19 year old) 25 unmarried adolescent girls 2. (14–19 year old)
50 25 married 1. adolescent girls (14–19 year old) 25 unmarried adolescent girls 2. (14–19 year old)
IDI
IDI unmarri ed adolesce nt Girls =2 IDI unmarri ed adolesce nt Girls =2
FGDs
1. 2. 3. 4. 5.
4 IDI unmarri ed adolesce nt Girls =2 IDI unmarri ed adolesce nt Girls =2
APPENDICES PAGES | XIII
FGD with married adolescent girls Focus Group Discussions with school teachers Focus Group Discussions with male household members Focus Group Discussions with community opinion makers Focus Group Discussions with CMWs and LHWs
5 1. 2. 3. 4.
FGD with unmarried adolescent girls Focus Group Discussions with female household members Focus Group Discussions with CMWs and LHWs Focus Group Discussions with other health care providers
A Snapshot of poor adolescent girls’ nutrition and related issues in Pakistan Total Completed 50 Instruments married URBAN SITE 1: 25 adolescent girls (SSU) (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
Total Completed 50 Instruments married URBAN SITE 2: 25 adolescent girls (SSU) (14–19 year old) 25 unmarried adolescent girls (14–19 year old)
Total Completed 50 Instruments
4
50 25 married 1. adolescent girls (14–19 year old) 25 unmarried adolescent girls 2. (14–19 year old)
1. 2. 3. 4.
4
50 25 married 1. adolescent girls (14–19 year old) 25 unmarried adolescent girls 2. (14–19 year old)
50
IDI unmarri ed adolesce nt Girls =2 IDI unmarri ed adolesce nt Girls =2
5
IDI unmarri ed adolesce nt Girls =2 IDI unmarri ed adolesce nt Girls =2
3
APPENDICES PAGES | XIV
FGD with married adolescent girls Focus Group Discussions with school teachers Focus Group Discussions with male household members Focus Group Discussions with community opinion makers
4 5. 6. 7.
3
FGD with unmarried adolescent girls Focus Group Discussions with female household members Focus Group Discussions with other health care providers
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APPENDIX B: DMU Guidelines
Studying the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition and on the sources of nutrition information that adolescents have access to and use
DMU GUIDELINES NUR CENTER FOR RESEARCH & POLICY FATIMA MEMORIAL HOSPITAL JUNE 2013 (REV. JULY 2013)
Definitions 1. Survey: It is the main quantitative tool to assess the anthropometric measurements and knowledge, attitude and practices of the selected adolescent girls2.(800) 2. IDI: In-depth Interview is a more detailed qualitative assessment of some of the factors which contribute in nutritional choices. There are 64 IDIs of unmarried and married girls, and 20 IDIs of provincial and district stakeholders, all across the country. 3. FGDs: Focus Group Discussions are a detailed qualitative methodology aiming at identifying some of the socio-cultural factors and their basis of contributing in the nutritional decision-making. There are 16 FGDs for adolescent married and unmarried girls, and 52 FGDs for groups like community leaders, health care providers, male and female household members etc. 4. Field Office: Field Office is the first stop for local data collection.
2
To be used as an aid with provincial field work guidelines
APPENDICES PAGES | XV
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5. Data Management Unit/DMU: Based at Central Office, DMC is the center where all the data will be collected and tabulated.
Terms of Reference Lead Organisation – FMH Lahore
Overall Project DATA Management
Selection of suitable team for conduct of research Training of team for standardization of procedure Data collection protocol monitoring Creating a statistical analysis plan Collection of data from all four provinces Data analysis of all data collected Finalization of Project Report
Data Collection Punjab Province
Data collection in Punjab Transfer of Data into DMU, central office Time Management
Provincial Collaborating Partners
Data collection in respective provinces Transfer of Data into DMU, central office Time Management
Lead Organisation
Constitution of DMU Team: o Members will include: o Epidemiologist o Programmer o Statistician o Data Entry Operators o Desk Editors o Data Management Cell Office Computer room Computers and software Storage cabinets Miscellaneous items o Terms of Reference Ensuring quality, completeness and accuracy of the incoming data APPENDICES PAGES | XVI
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Data Collection monitoring and supervision Following on statistical analysis plan; preparation and checking of dummy tables Trouble-shooting and resolution of problems and issues arising among collaborating partners regarding the data collection
Provincial Collaborating Partners Data Collection teams
Quantitative o Interviewers o Junior Research Associates Qualitative o FGD Moderators Local study site team o Site Focal Persons o Field Assistants
DMU Activities The major activities undertaken from DMU will include; a) b) c) d) e) f) g) h)
Data organization and Storage Software development Meta-data standards and guidelines Archiving for long term preservation Ensuring security of confidential data Data Synchronization Data analysis and interpretation before publication Training other human resource, in computer literacy and data analysis
DMU Protocol Data Collection and Submission
Field Operation Team under the supervision of Field Manager
Data Cleaning
Data Merging
Desk Editor, Field Office
Data Compilation
Provincial Field Manager
Fig. B1 Data Flow and Responsibility Components
APPENDICES PAGES | XVII
Data Analysis
DMU
Report Preparation
DMU and Central Office
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Data Transfer Mode and Frequency Quantitative: Field Manager will sync software updates at the end of every data collecting day, after desk editing and reviewing the data in the afternoon. Qualitative: Field Manager will deliver the forms, audio recordings and transcripts of audio recordings by hand, from a member of provincial team to a Data Management Unit.
Data Collection Framework Primary Sampling Unit (PSU) is the district identified for data collection Secondary Sampling Unit (SSU) are the 2 Urban and 2 Rural sites identified within the PSU for data collection
DMU Reporting Responsibility The status on data collection and data cleaning is to be reported to the senior managers on a weekly basis using the formats provided in Table 3.
APPENDICES PAGES | XVIII
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Table B1: Distribution of different data collection techniques and tools among provinces Tools For Total Province/ Site1 Site2 Site 3 Site 4 District (Urban) (Urban) (Rural) (Rural) Survey Survey
Married Adolescent Girls Unmarried Adolescent Girls TOTAL SURVEY: 800 IDI Married Adolescent Girls IDI Unmarried Adolescent Girls IDI District Stakeholders IDI Provincial Stakeholders IDI Federal Level Stakeholders IDI LHWS IDI Dais/ TBAs IDI CMWs TOTAL IDIs : 84 FGD Married Adolescent Girls FGD Unmarried Adolescent Girls Male household members FGDs Female household members FGDs Community opinion makers FGDs School teachers FGDs TOTAL FGDs: 64
400 400
100 100
25 25
25 25
25 25
8 8
2 2
1
4 4 4 8 8 8
1 1 1 2 2 2
1 1 1 1 1
1
8 8
2 2
1
1
8 8 8 8
2 2 2 2
1
1 1
1
1 1
1
1
1 1
1 1 1
25 25
1 1 1
Quantitative Data Analysis Excel and SPSS 20.0 will be used as primary tools. Infographics software will be used to present the information generated.
Qualitative Data Analysis INVIVO/ATLAS/DEFT will be used as the primary tool.
APPENDICES PAGES | XIX
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Quant: Tablet Updates Qual: Survey Forms Audio recordings Transcripts
Field Data Collection
Data Interpretatio n and Reporting
Field Desk Editing
Data Analysis
Data Transfer
Fig B2: Process Flow
Quant: Tablet Software Sync Qual: Survey Forms Audio recordings Transcripts
APPENDICES PAGES | XX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
APPENDIX C: Research tools: Survey Questionnaire Married Adolescent Girl Entries Codes
FORM CODE to be entered by FMH Staff
Pr
-
Lt
-
Tl
-
Questionnaire Married Adolescent Girls Name of Interviewer
VERBAL CONSENT SCRIPT Assalam-o-Alaikum I am---------------. I have come from-------------------------------. We are doing a research study on the health, nutrition and eating habits of young girls like you. Our purpose is to identify your health and nutrition needs. The evidence generated will help us advise the current health programs, your family, the community and you, how to improve your diet so that your nutrition and health becomes better. These are very simple and basic questions about your day to day routine. Please try to answer all the questions that I will ask. If you don’t understand a question, please say so and I will clarify it. Thank you for agreeing to have this interview with your complete and unconditional consent .
Household No. Baluchistan 1
Pr- Province BACKGROUND Name (Optional) Contact Number (Optional) Address (optional) Education
Respondent Spouse
Punjab 3
Illiterate
Literate but without formal education
Total Family Size
KP 2
Date. LtLocation
Sindh 4
Primary (upto 5 yrs of education)
Secondary (6-10 yrs of education)
Adults ( In the household) Female
Male
Rural 1
College (11-14 yrs of education)
Urban 2
Higher (15+ yrs of education)
Children under 18( In the household) Male (Total)
Age of Respondent Age of Spouse
SECTION 1- PREGNANCY RELATED NUTRITION APPENDICES PAGES | XXI
Female (Total)
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 101
Age at Menarche
102
Age at Marriage
103
Number of Children
104
Ages of Children
105
Are you pregnant?
106
What month of pregnancy are you into
107
Number of pregnancies to date
108
Age at first pregnancy
0 (SKIP TO 105) 1 2 1st Born 2nd Born 3rd Born Yes-
3 4 5 4th Born 5th Born
0 (SKIP TO 122) 1 2
3 4 5
No (SKIP TO 107)
SKIP 109, 110 and 111 ONLY if answer to 103=0,105=yes and 107=1 109 What was the Delivery related: Premature delivery outcome of last Tick all that apply Normal delivery pregnancy? Abortion Mother related: No problems Tick all that apply Prolonged labour Excessive bleeding Baby related: Healthy baby Tick all that apply Small baby Birth Injury 110 Where did your last delivery take place? Home Clinic 111
Who was there to attend to you during your delivery?
112
Which community health worker did you consult during your pregnancy?
113
Enter the number of Antenatal Checkups you got in the duration of a pregnancy Did you visit a health facility during your pregnancy?
114
Who decided that you should visit the health facility?
116
What was the reason of not visiting?
Assisted delivery Operation Other(Specify) Vaginal tear Post-partum infection Others (specify) Infection Died Other (specify) Hospital Other___
LHW LHV CMW Lady Doctor Nurse Hakeem Other (specify) Lady Doctor Dai/TBA Other None Enter Number____________________ Grandmother Mother Mother-in-law Sister Sister-in-law Friend Dai LHW LHV CMW
Yes
Father in law Mother in law Husband Hiding pregnancy in early months Embarrassment/Shy Culturally inappropriate Male health providers at health facility Problematic access to health
115
APPENDICES PAGES | XXII
No
Self Other______________ ___ Didn’t get permission Didn’t feel the need Inadequate services at facility Inadequate staff at facility Didn’t know visiting was required
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES facility Other traditional care preferred 117
118
119
120
121
122
123
124 125
Did you receive any guidance/advice during your pregnancy?
Other___________________
Never( SKIP TO 119) Rarely Sometimes If yes by whom were you guided? Grandmother Mother Mother-in-law Sister Sister-in-law Friend Dai Did you get any of these care options in Weight checking your pregnancy? Blood pressure checking Urine Checking Physical Examination Have you ever been told to follow a Never( SKIP TO 122) special diet during pregnancy? Rarely Sometimes If yes, by whom? Grandmother Mother Mother-in-law Sister Sister-in-law Friend Dai Do you think women should visit a Never ( SKIP TO 124) health facility during their pregnancy? Rarely Sometimes Whom should Grandmother women consult Mother during their Mother-in-law pregnancy? Sister Sister-in-law Friend Dai Given a choice, where would you prefer to Home deliver? Clinic Should pregnant adolescent girls be given different nutrition as opposed to older pregnant women?
Never Rarely Sometimes
APPENDICES PAGES | XXIII
Most of the times Always
LHW LHV CMW Lady Doctor Nurse Hakeem Other (specify) Dietary advice Supplements None Other (specify) Most of the times Always
LHW LHV CMW Lady Doctor Nurse Hakeem Other (specify) Most of the times Always
LHW LHV CMW Lady Doctor Nurse Hakeem Other (specify) Hospital Other___
Most of the times Always
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES SECTION 2 – SOCIOECONOMIC STATUS 201 Family Monthly Income 202 Amount of Family Monthly Income spent on Food* every month: 203 Are you given any money for purchase of food each month? 204 205
206 207
208
209
210
211 212
213 214
215 216
217
PKR PKR
Never (SKIP TO 205) Most of the time Rarely Always Sometimes How much per month? PKR _________________________________________________ Are you given any money for your Never (SKIP TO 207) Most of the time personal needs* each month? Rarely Always Sometimes How much per month? PKR _________________________________________________ What type of fuel does your Cylinder Gas Coal household mainly use for Sui Gas Straw/Shrubs/Grass/Wood cooking? (CHECK ALL THAT Biogas Animal Dung APPLY) Kerosene Other (specify) Do you have birds/animals Hen Cow in the house? (CHECK ALL Goat Buffalo THAT APPLY) Sheep Camel None (SKIP TO 213) Who looks after these Myself Sister-in-law ( SKIP TO animals? (CHECK ALL THAT Husband( SKIP TO 211) 211) APPLY) Father-in-law ( SKIP TO Brother-in-law ( SKIP TO 211) 211) Mother-in-law ( SKIP TO Other ( SKIP TO 211) 211) Do you get tired while Never Most of the time caring for these animals? Rarely Always Sometimes Do you use products of your own animals in the Yes No( SKIP to 211) house? Which ones? (CHECK ALL Eggs Cream THAT APPLY) Milk Ghee Meat Butter Others-Please Specify ___ How many rooms are used Enter no.___ _________ for sleeping? This house is_______ Rented Owned Free Tenants who work Mortgaged for owners Other How often do you clean __________________times / Week your house? Does your family own or Yes No (Skip to 301) work on any agricultural land? How often do you work on Never Most of the time the agricultural land? Rarely Always Sometimes
*Food includes consumables purchased and cost of cooking.
APPENDICES PAGES | XXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES SECTION 3 - FINANCIAL EMPOWERMENT Question 301 Are you currently working? 302 Have you ever worked? 303 What was/is your income per month? 304 Was it before or after the marriage?
305
306
307 308
309
310 311 312 313
314 315
316
317 318
319 320
321
Response Yes (SKIP TO 303) No Yes No( SKIP to 311) PKR. _____________________________ Before (SKIP Both 308-310) After ( SKIP TO 308) Who spends/ spent the money you Myself Uncle earned before marriage? ( Tick all that Father Grandfather apply) Mother Others (specify---------------- Brother ------What type of work was/ is it? Industry/factor Farming y Teaching Housemaid Other (specify)________ Office job Labour/ Daily Wager How much of this income did/do you use for your personal needs? PKR ______________ Who spends/ spent the money you Myself Mother-in-law earned after marriage? ( Tick all that Husband Brother-in-law apply) Father-in-law Others _____ What type of work was/ is it? Industry/factory Farming Housemaid Teaching Office job Other Labour/ Daily Wager (specify)________ How much of this income did/do you use for your personal needs? PKR ______________ Is your husband working? Yes No (SKIP TO 3156 Where does he work? In Pakistan Abroad If yes, what sort of work does he do? Industry/factory Farming House-servant Teaching Office job Other Labour/ Daily Wager (specify)________ Do you know how much does he earn? Yes, PKR________ No Who spends the money he earns? Myself Mother-in-law (Check all that apply) Husband Brother-in-law Father-in-law Others _____ Does he give you any money for Never (SKIP TO 318) Most of the time purchase of food each month? Rarely Always Sometimes How much per month? PKR _______________________________________________ Does he give you any money for your Never (SKIP TO 320) Most of the time personal needs* each month? Rarely Always Sometimes How much per month? PKR _______________________________________________ Does your household have a Not at all favourable Moderately favourable opinion of girls who work? Slightly favourable favourable Somewhat favourable Extremely favourable Does your community have a Not at all favourable Moderately favourable opinion of girls who work? Slightly favourable favourable Somewhat favourable Extremely favourable
APPENDICES PAGES | XXV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES SECTION 4- FOOD PURCHASE 401 Who shops for food items in your household? Tick all that apply
402
Are you allowed to shop for your food?
403
Whose preferences are mostly considered by the family while purchasing food? Tick all that apply
404
Does your family consider your food preferences while purchasing food? SECTION 5- FOOD PREPARATION 501 Who prepares the food you eat at home? Tick all that apply 502 Are you allowed to eat what you like/want to eat? 503
Are you allowed to cook what you like to eat?
504
Whose preferences are mostly considered by the family while cooking food? Tick all that apply
505
Does your family consider your food preferences while preparing food?
Myself (SKIP TO 403) Husband Father-in-law Never Rarely Sometimes Myself (SKIP TO 501) Husband Father-in-law Never Rarely Sometimes
Myself Mother-in-law Never Rarely Sometimes Never Rarely Sometimes Myself (SKIP TO 601) Husband Father-in-law Never Rarely Sometimes
Mother-in-law Brother-in-law Others _____ Most of the time Always Mother-in-law Brother-in-law Others _____ Most of the time Always
Sister-in-law Other(Specify) ____ Most of the time Always
Most of the time Always Mother-in-law Brother-in-law Others _____ Most of the time Always
50 SECTION 6- DIETARY PATTERNS 601 Do you think that you have a good appetite? 602 How many meals do you have daily? 603 Do you take snacks between regular meals? 604 Do you skip meals?
605 606
607
Which meal do you normally skip? Tick all that apply How frequently do you skip your meals? Do you eat street food (food not cooked at home)?
1 2 Never Rarely Sometimes Never (SKIP TO 607) Rarely Sometimes Breakfast Lunch Never Rarely Sometimes Never Rarely Sometimes
APPENDICES PAGES | XXVI
Yes No 3 4 Most of the time Always
Most of the time Always
Dinner Most of the time Always Most of the time Always
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 608- 24 Hours Food Recall
This is called daily food intake. Listed below are food items. Please tick the box to indicate how often on average you have eaten the specified amount of each food yesterday. Example: Paratha, so if you ate 1 paratha yesterday, you mark 1 portion. If you had half a plate of curry, tick ½ portion
BREAKFAST
Y/ N
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat
¼ ¼ ¼ ¼
½ ½ ½ ½
¾ ¾ ¾ ¾
1 1 1 1
1½ 1½ 1½ 1½
2 2 2 2
2½ 2½ 2½ 2½
3 3 3 3
More than 3 More than 3 More than 3 More than 3
LUNCH
Y/ N
APPENDICES PAGES | XXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
DINNER
Y/ N
APPENDICES PAGES | XXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 608- FOOD INTAKE CHECKLIST IN PAST ONE MONTH This is called food intake. Listed below are food items divided into sections according to food types. Please encircle the box to indicate how often on average you have eaten the specified amount of each food during the last one month. Example: Chapati, so if you eat 6 chapattis a day, you should encircle the box titled 6+ per day.
Number of Portions Category/Type of Food MEAT & POULTRY Beef Chicken Mutton Fish Eggs DAIRY Milk Cheese/ Cream Yoghurt Lassi VEGETABLES Leafy- spinach, saag Starchy- potatoes, carrots Non-starchy- turnips, onions, tomatoes FATS AND OILS Oil Desi ghee Butter (makhan) CEREAL GROUPS Chapatti wheat ( Gandum) Chapatti maize ( Makayi) Chapatti millet ( Bajra) Chapatti oat (Jo/ Jayyi) Rice LENTILS Beans ( Lobiya) Pink Lentils (Masur Dal) Bengal Gram (Chana Dal)
Never
Less than 1/month
1-3/month
2-4/week
5-6/week
1/day
2-3/day
4-5/day
6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
APPENDICES PAGES | XXIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Green grams ( Moong Daal) Chick Peas( Kabul Channey/ Cholay) Black Lentils( Daal Mash) FRUITS Pineapple/ Grapes/Pomegranate/ Sweet Melon Water Melon Apples Mangoes/ Oranges Peaches/ Apricots/ Plums Dry Fruit( Nuts) Bananas BEVERAGES Tea Sherbat Soft Drinks SNACKS/ STREET FOOD Samosas Pakoras Aloo Chaat Fruit Chaat Jalebis/ Sweets
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never
Less than 1/month
1-3/month
2-4/week
5-6/week
1/day
2-3/day
4-5/day
6+ /day
Never Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
APPENDICES PAGES | XXX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
SECTION 7- FOOD PREFERENCES 701 Are there any foods that you would like to eat more? 702 What foods Meats(chicken, Beef, mutton would you like to & fish) eat more? Tick all Eggs that apply Vegetables Fruit Sweets 703 Have you ever experienced cravings for any non-food items? E.g. mud, chalk, paper, coal etc 704 What is the craving for? Mud/Clay Chalk
SECTION 8- MULTINUTRIENTS 801 Are you aware of any Nutritional Supplements? 802
Do you take any nutritional supplement?
803
If yes, which nutritional supplements do you take?
804
Who advised you to take the nutritional supplements?
805
Are you aware of iodized salt?
80 6
How did you find out about iodized salt?
807
Do you use iodized salt?
SECTION 9 -FOOD SECURITY 901 Do you have enough food at home to eat each day? 902
Have you ever had any food shortage in the house in last one year?
903
Do all household members have the same number of meals? Do all household members eat together at meal times?
904
Yes No(SKIP TO 703) Dairy products Cereals (wheat, rice, potatoes, corn) Pulses Street Food Others (specify) Yes No (SKIP TO 801) Other(specify)_______ ______________
Not at all ever(SKIP TO 901) Slightly Aware Somewhat Aware Never (SKIP TO 805) Rarely Sometimes Iron Folic acid Multivitamin Grandmother Mother Mother-in-law Sister Sister-in-law Friend Husband Not at all ever(SKIP TO 901) Slightly Aware Somewhat Aware Radio Television Health workers Relatives Never Rarely Sometimes
Never Rarely Sometimes Never Rarely Sometimes Yes
Yes
APPENDICES PAGES | XXXI
Moderately aware Extremely Aware Most of the time Always Any other Don’t know type/name
LHW LHV CMW Lady Doctor Nurse Hakeem Dai Moderately aware Extremely Aware
Neighbours Newspaper Other Most of the time Always
Most of the time Always Most of the time Always
No- Females have more No- Males have more No- Females eat first No- Males eat first
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 905
Do all the household members have same quantity of food?
Yes
SECTION 10- MALNUTRITION-RELATED SYMPTOMS 1001 How satisfied are you with Not at all Satisfied your current health? Slightly Satisfied Somewhat Satisfied 1004 Are you satisfied with your Not at all Satisfied current weight? Slightly Satisfied Somewhat Satisfied 1005 Do you experience cramps in Never your legs? Rarely Sometimes 1006 Do you get breathless while Never walking/working/climbing Rarely stairs? Sometimes 1007 Do you get constipated? Never Rarely Sometimes 1008 Do you have small/dry stools? Never Rarely Sometimes 1009 Do you pass worms in your Never stool? Rarely Sometimes 1010 Have you noticed any recent changes to your skin, hair, eyes or mouth? (e.g., sores that won’t heal ulcers, or bruises, sudden loss of hair.) 1011 If yes, what type of change? Nail discoloration Brittle nail Dry hair Hair Loss Early greying of hair Skin dryness SECTION 11 -NUTRITIONAL AND HEALTH GUIDANCE 1101 Are you advised/encouraged to eat healthy food? 1102 If yes who advises/encourages you to eat healthy diet? 1103 Do you have a health facility nearby? 1104 What type of health facility is it? 1105 1106
Never(SKIP TO 1103) Rarely Sometimes Grandmother Mother Mother-in-law Sister Sister-in-law Friend Husband Yes Private hospital/Clinic Basic Health Unit Rural Health Center
How long does it take to reach the health facility? Do you visit the facility? Never(SKIP TO 1108)
APPENDICES PAGES | XXXII
No- Females have more No- Males have more
Moderately Satisfied Extremely Satisfied Moderately Satisfied Extremely Satisfied Most of the time Always Most of the time Always Most of the time Always Most of the time Always Most of the time Always No(SKIP TO 1101) Yes
Skin itching Eye dryness Mouth ulcers Acne Others(specify)________
Most of the time Always
LHW LHV CMW Lady Doctor Nurse Hakeem Dai No( SKIP to 1108)
Tehsil Head Quarter District Head Quarter Other _________min/hr Most of the time
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
1107
At the health facility, who sees you?
1108
Do you have the following health workers in your community? Tick all that apply
1109 : Questions A How often do you see her?
1110 1111
1112
1113
1114
1115
1116
1117
B
Are you advised on healthy diets by her?
C
Do you follow her advice?
Always
Rarely Sometimes Community Midwife Lady Health Worker
Lady health worker Lady doctor
Health workers in community ________times a week Or ________ times a month Or ________times a year Never( SKIP TO 1110) Rarely Sometimes Most of the time Always Never Rarely Sometimes Most of the time Always
Healthy workers in facility ________times a week Or ________ times a month Or _______times a year Never( SKIP TO 1110) Rarely Sometimes Most of the time Always Never Rarely Sometimes Most of the time Always
Do you have a school or a school teacher nearby? Yes Do you visit the school/ school Never teacher to consult about any Rarely matter? Sometimes Do you receive any health Never information from the school/ school Rarely teacher? Sometimes Do you receive any diet-related Never information from the school/ school Rarely teacher? Sometimes Do you receive any information Never(SKIP TO 1201) related to good diets from sources Rarely other than family? Sometimes From where? Tick all that apply. Neighbourhood Newspaper Radio Do you think women should use Never family planning methods? Rarely Sometimes Is family planning perceived as Not at all favourable favourable in your community? Slightly favourable Somewhat favourable
1118
Is family planning perceived as favourable in your household/ family?
Not at all favourable Slightly favourable Somewhat favourable
1119
Would you like to use
Yes
APPENDICES PAGES | XXXIII
Doctor Nurse Other Lady health visitor Other
No ( Skip to 1114) Most of the time Always Most of the time Always Most of the time Always Most of the time Always Television Other(specify)___ __ Most of the time Always Moderately favourable Extremely favourable Moderately favourable Extremely favourable No
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
1120 1121
contraceptives? Would you be allowed to use contraceptives? Do you use any contraceptive?
Yes
No
Yes
No
SECTION 12- LACTATION, INFANT AND CHILD RELATED SKIP to 1211 if no children 1201
1202
1203
1204
1205
1206
1207
1208
1209
1210
1211 1212
Not at all (SKIP TO Moderately 1203) Extremely Slightly Somewhat If yes, by whom? Grandmother LHW Mother LHV Mother-in-law CMW Sister Lady Doctor Sister-in-law Nurse Friend Hakeem Husband Dai Were you given a dietary advice Not at all Moderately after your delivery? Slightly Extremely Somewhat Were you given any food Never (SKIP TO 1206) Most of the time supplements to eat during this Rarely Always time? Sometimes Did you take supplements Never Most of the time REGULARLY? Rarely Always Sometimes Are you currently feeding your Never (SKIP TO 1208) Most of the time baby? Rarely Always Sometimes If no, have you previously breastfed Never (SKIP TO 1211) Most of the time a baby? Rarely Always Sometimes Have you ever been told to follow Never (SKIP TO 1209) Most of the time a special diet during lactation? Rarely Always Sometimes If yes, by whom? Grandmother LHW Mother LHV Mother-in-law CMW Sister Lady Doctor Sister-in-law Nurse Friend Hakeem Husband Dai For how long should mothers One – Three months One to One and Half years breastfeed? Four - Six months One and half -Two years Seven - Twelve Months At what age are solid foods for the baby started? At ______ months Were you provided any care after delivery?
Do you think women need special diet while they are lactating?
Never Rarely Sometimes
APPENDICES PAGES | XXXIV
Most of the time Always
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES SECTION 13 - ANTHROPOMETRIC MEASUREMENTS (SELF) 101 Mid left upper arm circumference 102 Height 103 Weight
cm cm kg
SECTION 14: ANTHROPOMETRIC MEASUREMENTS (RESPONDENT’S CHILDREN UNDER 5 YEARS) Skip to section 15 if no children CHILD 1 CHILD 2 CHILD 3 CHILD 4 Male Male Male Male Gender Female Female Female Female _____years _____years _____years _____years Age _____months _____months _____months _____months Mid-left upper-arm circumf. Cm Height Cm Weight Kg SECTION 15- OBSERVATION CHECKLIST: SOCIOECONOMIC STATUS 1501 Observe and mark items Electricity present in household Clock (CHECK ALL THAT APPLY) Radio Television Refrigerator Mobile / landline telephone Room cooler 1502 Record Observation | | Tick in the box Material Cement Bricks Wood Chips Stones Mud Plastic Iron/Tin sheets
APPENDICES PAGES | XXXV
Water(hand) pump/ Hand Pump Bed Chairs Almaari/ cabinet Dining Table Sofa Floor
Walls
Roof
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
APPENDIX D: Research tools: Survey Questionnaire Unmarried Adolescent Girl Entries Codes
FORM CODE to be entered by FMH Staff
Pr
-
Lt
-
Tl
-
Questionnaire Unmarried Adolescent Girls Name of Interviewer
VERBAL CONSENT SCRIPT Assalam-o-Alaikum I am---------------. I have come from-------------------------------. We are doing a research study on the health, nutrition and eating habits of young girls like you. Our purpose is to identify your health and nutrition needs. The evidence generated will help us advise the current health programs, your family, the community and you, how to improve your diet so that your nutrition and health becomes better. These are very simple and basic questions about your day to day routine. Please try to answer all the questions that I will ask. If you don’t understand a question, please say so and I will clarify it. Thank you for agreeing to have this interview with your complete and unconditional consent.
Household No. Baluchistan 1
Pr- Province BACKGROUND Name (Optional) Contact Number (Optional) Address (optional)
KP 2
Punjab 3
Education
Illiterate
Literate but without formal education
Respondent
Total Family Size Number of male siblings
Date. LtLocation
Sindh 4
Primary (upto 5 yrs of education)
Secondary (6-10 yrs of education)
Adults ( In the household) Female
Male
Rural 1
College (11-14 yrs of education)
Urban 2
Higher (15+ yrs of education)
Children under 18( In the household) Male (Total)
Number of female siblings
Age of Respondent
APPENDICES PAGES | XXXVI
Female (Total)
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Age of Menarche SECTION 1 - ANTHROPOMETRIC MEASUREMENTS (SELF) 101 Mid left upper arm circumference 102 Height 103 Weight SECTION 2 – SOCIOECONOMIC STATUS 201 Family Monthly Income 202 Amount of Family Monthly Income spent on Food* every month: 203 Are you given any money for purchase of food each month? 204 205
206 207
208
209
210
211 212
213 214
215 216
217
cm cm kg
PKR PKR
Never (SKIP TO 205) Most of the time Rarely Always Sometimes How much per month? PKR _________________________________________________ Are you given any money for your Never (SKIP TO 207) Most of the time personal needs* each month? Rarely Always Sometimes How much per month? PKR _________________________________________________ What type of fuel does Cylinder Gas Coal your household mainly use Sui Gas Straw/Shrubs/Grass/Wood for cooking? (CHECK ALL Biogas Animal Dung THAT APPLY) Kerosene Other (specify) Do you have birds/animals Hen Cow in the house? (CHECK ALL Goat Buffalo THAT APPLY) Sheep Camel None (SKIP TO 213) Who looks after these Myself Sister ( SKIP TO 211) animals? (CHECK ALL THAT Father ( SKIP TO 211) Brother ( SKIP TO 211) APPLY) Mother ( SKIP TO 211) Other ( SKIP TO 211) Do you get tired while Never Most of the time caring for these animals? Rarely Always Sometimes Do you use products of your own animals in the Yes No( SKIP to 211) house? Which ones? (CHECK ALL Eggs Cream THAT APPLY) Milk Ghee Meat Butter Others-Please Specify ___ How many rooms are used Enter no.___ _________ for sleeping? This house is_______ Rented Owned Free Tenants who work Mortgaged for owners Other How often do you clean __________________times / Week your house? Does your family own or Yes No (Skip to 301) work on any agricultural land? How often do you work on Never Most of the time the agricultural land? Rarely Always Sometimes
*Food includes consumables purchased and cost of cooking.
SECTION 3 - FINANCIAL EMPOWERMENT Question
Response
APPENDICES PAGES | XXXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 301 302 303 304
305
306 307
308
Yes (SKIP TO 303) No Yes No( SKIP to 307) PKR. _____________________________ Myself Uncle Father Grandfather Mother Others (specify---------------- Brother ------What type of work was/ is it? Industry/factor Farming y Teaching Housemaid Other (specify)________ Office job Labour/ Daily Wager How much of this income did/do you use for your personal needs? PKR ______________ Does your household have a Not at all favourable Moderately favourable opinion of girls who work? Slightly favourable favourable Somewhat favourable Extremely favourable Does your community have a Not at all favourable Moderately favourable opinion of girls who work? Slightly favourable favourable Somewhat favourable Extremely favourable Are you currently working? Have you ever worked? What was/is your income per month? Who spends/ spent the money you earned?
SECTION 4- FOOD PURCHASE 401 Who shops for food items in your household? Tick all that apply
402
Are you allowed to shop for your food?
403
Whose preferences are mostly considered by the family while purchasing food? Tick all that apply
404
Does your family consider your food preferences while purchasing food? SECTION 5- FOOD PREPARATION 501 Who prepares the food you eat at home? Tick all that apply 502 Are you allowed to eat what you like/want to eat? 503
Are you allowed to cook what you like to eat?
504
Whose preferences are mostly considered by the family while cooking food? Tick all that apply
505
Does your family consider your
Myself( skip to 403) Father Mother Brother Never Rarely Sometimes Myself( skip to 501) Father Mother Brother Never Rarely Sometimes
Myself Mother Never Rarely Sometimes Never Rarely Sometimes Myself (SKIP TO 601) Father Mother Never
APPENDICES PAGES | XXXVIII
Uncle Grandfather Others (specify---------------------- Most of the time Always Uncle Grandfather Others (specify---------------------- Most of the time Always
Sister Other(Specify) ____ Most of the time Always
Most of the time Always Brother Sister Other(specify)________ __ Most of the time
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES food preferences while preparing food?
Rarely Sometimes
Always
5 SECTION 6- DIETARY PATTERNS 601 Do you think that you have a good appetite? 602 How many meals do you have daily? 603 Do you take snacks between regular meals? 604 Do you skip meals?
605 606
607
Which meal do you normally skip? Tick all that apply How frequently do you skip your meals? Do you eat street food (food not cooked at home)?
1 2 Never Rarely Sometimes Never (SKIP TO 607) Rarely Sometimes Breakfast Lunch Never Rarely Sometimes Never Rarely Sometimes
APPENDICES PAGES | XXXIX
Yes No 3 4 Most of the time Always
Most of the time Always
Dinner Most of the time Always Most of the time Always
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 608- 24 Hours Food Recall
This is called daily food intake. Listed below are food items. Please tick the box to indicate how often on average you have eaten the specified amount of each food yesterday. Example: Paratha, so if you ate 1 paratha yesterday, you mark 1 portion. If you had half a plate of curry, tick ½ portion
BREAKFAST
Y/ N
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat
¼ ¼ ¼ ¼
½ ½ ½ ½
¾ ¾ ¾ ¾
1 1 1 1
1½ 1½ 1½ 1½
2 2 2 2
2½ 2½ 2½ 2½
3 3 3 3
More than 3 More than 3 More than 3 More than 3
LUNCH
Y/ N
APPENDICES PAGES | XL
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
¼ portion
½ portion
¾ portion
1 portion
1 ½ portions
2 portions
2 ½ portions
3 portions
More than 3 portions
A Paratha A Plain chapatti A Bread Slice 1 Tablespn Jam/ Chutni/ Murabba 1 Tablespn Butter
¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾
1 1 1 1 1
1½ 1½ 1½ 1½ 1½
2 2 2 2 2
2½ 2½ 2½ 2½ 2½
3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3
A cup of tea A glass of milk Egg 1 serving Meat 1 serving Vegetables 1 plate Curry/ Salan 1 bowl Yogurt 1 plate Lentils 1 plate rice 1 glass of lassi 1 glass of sharbat
¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
½ ½ ½ ½ ½ ½ ½ ½ ½ ½ ½
¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
1 1 1 1 1 1 1 1 1 1 1
1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½ 1½
2 2 2 2 2 2 2 2 2 2 2
2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½ 2½
3 3 3 3 3 3 3 3 3 3 3
More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3 More than 3
DINNER
Y/ N
APPENDICES PAGES | XLI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 608- FOOD INTAKE CHECKLIST IN PAST ONE MONTH This is called food intake. Listed below are food items divided into sections according to food types. Please encircle the box to indicate how often on average you have eaten the specified amount of each food during the last one month. Example: Chapati, so if you eat 6 chapattis a day, you should encircle the box titled 6+ per day.
Number of Portions Category/Type of Food MEAT & POULTRY Beef Chicken Mutton Fish Eggs DAIRY Milk Cheese/ Cream Yoghurt Lassi VEGETABLES Leafy- spinach, saag Starchy- potatoes, carrots Non-starchy- turnips, onions, tomatoes FATS AND OILS Oil Desi ghee Butter (makhan) CEREAL GROUPS Chapatti wheat ( Gandum) Chapatti maize ( Makayi) Chapatti millet ( Bajra) Chappati oat (Jo/ Jayyi) Rice LENTILS Beans ( Lobiya) Pink Lentils (Masur Dal) Bengal Gram (Chana Dal)
Never
Less than 1/month
1-3/month
2-4/week
5-6/week
1/day
2-3/day
4-5/day
6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
APPENDICES PAGES | XLII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Green grams ( Moong Daal) Chick Peas( Kabul Channey/ Cholay) Black Lentils( Daal Mash) FRUITS Pineapple/ Grapes/Pomegranate/ Sweet Melon Water Melon Apples Mangoes/ Oranges Peaches/ Apricots/ Plums Dry Fruit( Nuts) Bananas BEVERAGES Tea Sherbat Soft Drinks SNACKS/ STREET FOOD Samosas Pakoras Aloo Chaat Fruit Chaat Jalebis/ Sweets
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never
Less than 1/month
1-3/month
2-4/week
5-6/week
1/day
2-3/day
4-5/day
6+ /day
Never Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
Never Never Never
Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week
1/day 1/day 1/day
2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day
Never Never Never Never Never
Less than 1/month Less than 1/month Less than 1/month Less than 1/month Less than 1/month
1-3/month 1-3/month 1-3/month 1-3/month 1-3/month
2-4/week 2-4/week 2-4/week 2-4/week 2-4/week
5-6/week 5-6/week 5-6/week 5-6/week 5-6/week
1/day 1/day 1/day 1/day 1/day
2-3/day 2-3/day 2-3/day 2-3/day 2-3/day
4-5/day 4-5/day 4-5/day 4-5/day 4-5/day
6+ /day 6+ /day 6+ /day 6+ /day 6+ /day
APPENDICES PAGES | XLIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
SECTION 7- FOOD PREFERENCES 701 Are there any foods that you would Yes like to eat more? 702 What foods Meats(chicken, Beef, mutton would you like to & fish) eat more? Tick all Eggs that apply Vegetables Fruit Sweets 703 Have you ever experienced cravings Yes for any non-food items? E.g. mud, chalk, paper, coal etc 704 What is the craving for? Mud/Clay Chalk
SECTION 8- MULTINUTRIENTS 801 Are you aware of any Nutritional Supplements? 802
Do you take any nutritional supplement?
803
If yes, which nutritional supplements do you take?
804
Who advised you to take the nutritional supplements?
805
Are you aware of iodized salt?
80 6
How did you find out about iodized salt?
807
Do you use iodized salt?
SECTION 9 -FOOD SECURITY 901 Do you have enough food at home to eat each day? 902
Have you ever had any food shortage in the house in last one year?
No(SKIP TO 703) Dairy products Cereals (wheat, rice, potatoes, corn) Pulses Street Food Others (specify) No (SKIP TO 801)
Not at all ever(SKIP TO 901) Slightly Aware Somewhat Aware Never (SKIP TO 805) Rarely Sometimes Iron Folic acid Multivitamin Grandmother Mother Sister Friend School Teacher Not at all ever(SKIP TO 901) Slightly Aware Somewhat Aware Radio Television Health workers Relatives Never Rarely Sometimes
Never Rarely Sometimes Never Rarely Sometimes
APPENDICES PAGES | XLIV
Other(specify)_______ ______________
Moderately aware Extremely Aware Most of the time Always Any other Don’t know type/name
Lady health worker Lady Doctor Nurse Hakeem Other (specify) Moderately aware Extremely Aware
Neighbours Newspaper Other Most of the time Always
Most of the time Always Most of the time Always
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 903 904 905
Do all household members have the same number of meals? Do all household members eat together at meal times? Do all the household members have same quantity of food?
Yes
Yes Yes
SECTION 10- MALNUTRITION-RELATED SYMPTOMS 1001 How satisfied are you with Not at all Satisfied your current health? Slightly Satisfied Somewhat Satisfied 1004 Are you satisfied with your Not at all Satisfied current weight? Slightly Satisfied Somewhat Satisfied 1005 Do you experience cramps in Never your legs? Rarely Sometimes 1006 Do you get breathless while Never walking/working/climbing Rarely stairs? Sometimes 1007 Do you get constipated? Never Rarely Sometimes 1008 Do you have small/dry stools? Never Rarely Sometimes 1009 Do you pass worms in your Never stool? Rarely Sometimes 1010 Have you noticed any recent changes to your skin, hair, eyes or mouth? (e.g., sores that won’t heal ulcers, or bruises, sudden loss of hair.) 1011 If yes, what type of change? Nail discoloration Brittle nail Dry hair Hair Loss Early greying of hair Skin dryness SECTION 11 -NUTRITIONAL AND HEALTH GUIDANCE 1101 Are you advised/encouraged to eat healthy food? 1102 If yes who advises/encourages you to eat healthy diet? 1103 Do you have a health facility nearby?
Never(SKIP TO 1103) Rarely Sometimes Grandmother Mother Sister Friend School Teacher Yes
APPENDICES PAGES | XLV
No- Females have more No- Males have more No- Females eat first No- Males eat first No- Females have more No- Males have more
Moderately Satisfied Extremely Satisfied Moderately Satisfied Extremely Satisfied Most of the time Always Most of the time Always Most of the time Always Most of the time Always Most of the time Always No(SKIP TO 1101) Yes
Skin itching Eye dryness Mouth ulcers Acne Others(specify)________
Most of the time Always
Lady health worker Lady Doctor Nurse Hakeem Other (specify) No( SKIP to 1108)
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Private hospital/Clinic Basic Health Unit Rural Health Center
1104
What type of health facility is it?
1105 1106
How long does it take to reach the health facility? Do you visit the facility? Never(SKIP TO 1108) Rarely Sometimes At the health facility, who sees you? Community Midwife Lady Health Worker
1107
1108
Do you have the following health workers in your community? Tick all that apply
1109 : Questions A How often do you see her?
1110 1111
1112
1113
1114
1115
B
Are you advised on healthy diets by her?
C
Do you follow her advice?
Lady health worker Lady doctor
Health workers in community ________times a week Or ________ times a month Or ________times a year Never( SKIP TO 1110) Rarely Sometimes Most of the time Always Never Rarely Sometimes Most of the time Always
Do you have a school or a school teacher nearby? Do you visit the school/ school teacher to consult about any matter? Do you receive any health information from the school/ school teacher? Do you receive any diet-related information from the school/ school teacher? Do you receive any information related to good diets from sources other than family? From where? Tick all that apply.
Tehsil Head Quarter District Head Quarter Other _________min/hr Most of the time Always
Doctor Nurse Other Lady health visitor Other
Healthy workers in facility ________times a week Or ________ times a month Or _______times a year Never( SKIP TO 1110) Rarely Sometimes Most of the time Always Never Rarely Sometimes Most of the time Always
Yes
No ( Skip to 1114)
Most of the time Always
Never Rarely Sometimes Never Rarely Sometimes Never Rarely Sometimes Never(SKIP TO 1201) Rarely Sometimes Neighbourhood Newspaper Radio
APPENDICES PAGES | XLVI
Most of the time Always Most of the time Always Most of the time Always Television Other(specify)___ __
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES SECTION 12- OBSERVATION CHECKLIST: SOCIOECONOMIC STATUS 1201 Observe and mark items present Electricity in household Clock (CHECK ALL THAT APPLY) Radio Television Refrigerator Mobile / landline telephone Room cooler 1202 Record Observation | | Tick in the box Material Cement Bricks Wood Chips Stones Mud Plastic Iron/Tin sheets
APPENDICES PAGES | XLVII
Water(hand) pump/ Hand Pump Bed Chairs Almaari/ cabinet Dining Table Sofa Floor
Walls
Roof
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
APPENDIX E: Research tools: FGD Topic Guides FGD: MARRIED ADOLESCENT GIRLS Themes to be explored Demographic information
Perspectives marriages
Perspectives Planning
on
on
early
Family
Dietary Patterns
Health Status requirements
&
Diet
Understanding of linkage between nutrition and pregnancies outcome Food security and utilization/Gender/ Empowerment to access, choice, preparation and distribution of food
Questions for FGD Age Education Employment Status Age at menarche Age at marriage Age at first child Number of children Any Miscarriages Current Pregnancy Status Are you living in your own home? Who all live with you? In your opinion what should be earliest age of marriage for girls? Why do you think so? Is there an impact of early marriage on maternal and neonatal health? If yes how? In your opinion, how many children should one have? Why? How is Family planning perceived in your family? Why do they think so? Did you ever use any FP Methods? Why? If yes, which one? Is food requirement of Adolescents given special consideration in your home? How & Why? Are certain foods considered good or bad for girls? Why? What would you like to eat more? Why? What stops you from doing so? Are you satisfied/ happy with your current health status? Why do you think so? What body image/shape/size for females, do you consider as healthy and ideal? Why you think so? In your opinion for how long should a child be exclusively breastfed? Why? In your opinion when should young children be started on solids? What solids to be given? Are food requirements of adolescent girls in your household given special consideration during Pregnancy and Lactation? How & Why? Do you think girls should be allowed to work and earn? Why? In your household do all family members usually eat together? If not why not? In your household do some family members eat different food? How is it different? Why? Who usually makes the choice of what food items should be bought? Why? Who usually makes the choice of what food should be cooked? Why? Who distributes the food? How is it distributed? Are you allowed to buy what you like to eat? Do you often feel you eat less food than what you wish for? APPENDICES PAGES | XLVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Sources of information
Perceptions on Community Health Workers/Teachers as a source of information
Nutritional Supplements
Access to and utilization of MNCH services Perception of barriers and facilitators to fulfilling the nutritional needs of adolescent girls
If you need any health related advice, who do you consult? Why do you consult them? In your community who advises/counsels adolescent girls on diet and nutrition? Have you ever been advised to eat a special diet? Why? Who advised you? What was advised? Would you like to know more about good dietary practices and nutrition? Who should be providing you with this information? Do the school teachers provide any health related information to adolescent girls? How? Have you ever been visited by the LHW? If yes, for what purpose? Do you find their visit useful? How? Have you ever visited the CMW? If yes, for what purpose? Do you find their care useful? How? Have you been given any nutritional supplements? Which ones? By Whom? Do you take them regularly? Why? Have you heard of vitamins? From whom? What do you think vitamins do? Have you heard of iron and its role related to health? From whom? What do you think iron does? Which MNCH services are available in the community? Do you ever use them? If yes, when? If not, why not? Do you follow the advice given to you by health workers? Why? In your opinion, what is the major barrier in improving the nutritional status of young adolescent girls? Why? Who could play the major role in improving the nutritional status of young adolescent girls? How?
FGD: UNMARRIED ADOLESCENT GIRLS Themes to be explored Demographic information
Perspectives on early marriages
Perspectives on Family Planning
Dietary Patterns
Questions for FGD Age Education Employment Status Age at menarche Are you engaged When are you expected to be married In your opinion what should be earliest age of marriage for girls? Why do you think so? Is there an impact of early marriage on maternal and neonatal health? If yes how? In your opinion, how many children should one have? Why? How is Family planning perceived in your family? Why do they think so? Do you think Family planning should be practiced? Why? Is food requirement of Adolescents given special consideration in your home? How & Why? Are certain foods considered good or bad for girls? Why? What would you like to eat more? Why? What stops you from APPENDICES PAGES | XLIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES doing so? Diet Are you satisfied/ happy with your current health status? Why do you think so? What body image/shape/size for females, do you consider as healthy and ideal? Why you think so? In your opinion for how long should a mother exclusively breastfed her baby? Why? In your opinion when should young children be started on solids? What solids to be given? Understanding of linkage Are food requirements of adolescent girls in your household given between nutrition and special consideration during Pregnancy and Lactation? How & Why? pregnancies outcome Food security and Do you think girls should be allowed to work and earn? Why? In your household do all family members usually eat together? If utilization/Gender/ Empowerment to access, choice, not why not? preparation and distribution of In your household do some family members eat different food? How is it different? Why? food Who usually makes the choice of what food items should be bought? Why? Who usually makes the choice of what food should be cooked? Why? Who distributes the food? How is it distributed? Are you allowed to buy what you like to eat? Do you often feel you eat less food than what you wish for? If you need any health related advice, who do you consult? Why do Sources of information you consult them? In your community who advises/counsels adolescent girls on diet and nutrition? Have you ever been advised to eat a special diet? Why? Who advised you? What was advised? Would you like to know more about good dietary practices and nutrition? Who should be providing you with this information? Perceptions on Community Do the school teachers provide any health related information to Health Workers/Teachers as a adolescent girls? How? Do any of the health workers provide you with any nutrition related source of information advice? Who provides it? What advice is given? Do you follow the advice given to you by health workers? Why? Have you been given any nutritional supplements? Which ones? By Nutritional Supplements Whom? Do you take them regularly? Why? Have you heard of vitamins? From whom? What do you think vitamins do? Have you heard of iron and its role related to health? From whom? What do you think iron does? Access to and utilization of Which MNCH services are available in the community? Does anyone in your household ever use them? If yes, who? when? If not, MNCH services why not? Perception of barriers and In your opinion, what is the major barrier in improving the facilitators to fulfilling the nutritional status of young adolescent girls? Why? nutritional needs of adolescent Who could play the major role in improving the nutritional status of Health Status requirements
&
APPENDICES PAGES | L
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES young adolescent girls? How?
girls
FGD: FEMALE HOUSEHOLD MEMBERS Themes to be explored Demographic information
Perspectives on Girls’ Education Perspectives Employment
on
Girls’
Perspectives on Girls’ Nutrition Requirements
Food security and utilization/Gender/ Empowerment to access, choice, preparation and distribution of food
Perspectives on early marriages
Perspectives on Family Planning
Understanding of linkage between nutrition and pregnancies
Questions for FGD Age Age at marriage Age at first child Number of children (M:F) Education Level Employment Status/ Profession Location In your opinion should girls be educated? To what level? Why? Are females in your family educated? (Mother, Aunts, Sisters, Daughters)? If yes, to what level? If not, why not? How does your family view women who work? Why is it so? Are any females in your family employed? (Mother, Aunts, Sisters, Daughters)? If yes, how? Do you think nutritional requirement of boys and girls of the same age are different? Why? Does the nutritional requirement of the girls change with age and marital status? Why? Does pregnancy/Lactation modify the girls’ nutritional requirement? How? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Are certain foods considered good or bad for girls? Why? In your community do all family members usually eat together? If not why not? In your community do all family members usually eat the same food? If not why not? In your community do all family members usually eat the same quantity? If not how is it different? Whose preference in the household is given importance when buying food? Why? Whose preference in the household is given importance in deciding what to cook? Why? Who distributes the food? How is it distributed? In your opinion what should be earliest age of marriage of girls? Why? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? How is Family planning perceived in your family? Why do they think so? Did you ever use any FP Methods? Why? How? Do you encourage your daughter/daughter in law to use FP method? Why? How? Are food requirements of boys and girls in your household given special preference during Adolescence? How & Why? APPENDICES PAGES | LI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES outcome Perceptions on Community Health Workers/Teachers as a source of information
Perception of barriers and facilitators to fulfilling the nutritional needs of adolescent girls
Are food requirements of adolescent girls in your household given special preference during Pregnancy and Lactation? How & Why? In your community who advises/counsels adolescent girls on diet and nutrition? Is the current LHW Program playing any role in improving the health of adolescent girls? How? Are the community midwifes playing any role in improving the health of adolescent girls? How? Do the school teachers provide any health related information to adolescent girls? How? What is the major barrier in improving the nutritional status of young adolescent girls? Why Who could play the major role in improving the nutritional status of young adolescent girls? How?
FGD: MALE HOUSEHOLD MEMBERS Themes to be explored Demographic information
Perspectives Education
on
Girls’
Perspectives on Employment
Girls’
Perspectives on Girls’ Nutrition Requirements
Food security and utilization/Gender/ Empowerment to access, choice, preparation and distribution of food
Questions for FGD Age Marital Status/Number of children/M:F Adolescent girls in the household Education Level Profession Location In your opinion should girls be educated? To what level? Why? Are females in your family educated? (Mother, Aunts, Sisters, Daughters)? If yes, to what level? If not, why not? How does your family view women who work? Why is it so? Are any females in your family employed? (Mother, Aunts, Sisters, Daughters)? If yes, how? Do you think nutritional requirement of boys and girls of the same age are different? Why? Does the nutritional requirement of the girls change with age and marital status? Why? Does pregnancy/Lactation modify the girls’ nutritional requirement? How? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Are certain foods considered good or bad for girls? Why? In your community do all family members usually eat together? If not why not? In your community do all family members usually eat the same food? If not why not? In your community do all family members usually eat the same quantity? If not how is it different? Whose preference in the household is given importance when buying food? Why? Whose preference in the household is given importance in deciding what to cook? Why? Who distributes the food? How is it distributed? APPENDICES PAGES | LII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES early In your opinion what should be earliest age of marriage of girls? Why? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Perspectives on Family How is Family planning perceived in your community/family? Why do they think so? Planning Did you ever use any FP Methods? Why? Do you encourage your household to use FP method? Why? Understanding of linkage Are food requirements of boys and girls in your household given special between nutrition and preference during Adolescence? How & Why? Are food requirements of adolescent girls in your household given special pregnancies outcome preference during Pregnancy and Lactation? How & Why? Perceptions on In your community who advises/counsels adolescent girls on diet and Community Health nutrition? Workers/Teachers as a Is the current LHW Program playing any role in improving the health of adolescent girls? How? source of information Are the community midwifes playing any role in improving the health of adolescent girls? How? Do the school teachers provide any health related information to adolescent girls? How? Perception of barriers What is the major barrier in improving the nutritional status of young and facilitators to adolescent girls? Why fulfilling the nutritional Who could play the major role in improving the nutritional status of young adolescent girls? How? needs of adolescent girls Perspectives marriages
on
FGD: FEMALE SCHOOL TEACHERS Themes to be explored Demographic information
Knowledge of the school teachers regarding the nutritional needs of adolescent girls
Attitudes of the school teachers towards social determinants of nutrition Practices of the school teachers regarding the nutritional needs of adolescent girls
Questions for FGD Age Marital Status Education Level Subject being taught Do you think nutritional requirement of boys and girls of the same age are different? Why? Does the nutritional requirement of the girls change with age and marital status? Why? Does pregnancy/Lactation modify the girlsâ&#x20AC;&#x2122; nutritional requirement? How? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Are certain foods considered good or bad for girls? Why? In your opinion what should be earliest age of marriage of girls? Why? In your opinion what is an ideal body weight/shape of adolescents? Why? In your experience, how does the community view women who work? Why? Have you ever discussed good dietary practices with adolescent girls in school? How? Is nutrition and healthy diets covered in the syllabi? How? Any nutritional supplement program undertaken at school? How? Have the teachers been provided any formal or informal training on health awareness? How? APPENDICES PAGES | LIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Is there a role of schools in building health awareness? How? Should schools be allocating special time for health and nutritional counseling? How? Do you think school teachers should be trained on nutritional counseling? If yes, how should the trainings be structured? Would you be willing to receive training on nutritional counseling of adolescent girls? Why? Perception of barriers What is the major barrier in improving the nutritional status of young and facilitators to adolescent girls? Why? fulfilling the nutritional How can schools play an effective role towards improving the nutritional status of young adolescent girls? Why? needs of adolescent girls Perceptions regarding role of schools in improving nutrition of adolescent students
FGD: MALE COMMUNITY MEMBERS Themes to be explored Demographic information
Perspectives Education
on
Girls’
Perspectives Employment
on
Girls’
Perspectives on Girls’ Nutrition Requirements
Food security and utilization/Gender/ Empowerment to access, choice, preparation and distribution of food
Perspectives
on
early
Questions for FGD Age Marital Status Education Level Profession Location In your opinion should girls be educated? To what level? Why? Are females in your family educated? (Mother, Aunts, Sisters, Daughters)? If yes, to what level? If not, why not? In your experience, how does the community view women who work? Why is it so? Are any females in your family employed? (Mother, Aunts, Sisters, Daughters)? If yes, how? Do you think nutritional requirement of boys and girls of the same age are different? Why? Does the nutritional requirement of the girls change with age and marital status? Why? Does pregnancy/Lactation modify the girls’ nutritional requirement? How? Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Are certain foods considered good or bad for girls? Why? In your community do all family members usually eat together? If not why not? In your community do all family members usually eat the same food? If not why not? In your community do all family members usually eat the same quantity? If not how is it different? Whose preference in the household is given importance when buying food? Why? Whose preference in the household is given importance in deciding what to cook? Why? Who distributes the food? How is it distributed? In your opinion what should be earliest age of marriage of girls? Why? APPENDICES PAGES | LIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES marriages Understanding of linkage between nutrition and pregnancies outcome Perceptions on Community Health Workers/Teachers as a source of information
Perception of barriers and facilitators to fulfilling the nutritional needs of adolescent girls
Is there an impact of early marriage on maternal and neonatal health outcomes? If yes how? Are food requirements of boys and girls in your household given special preference during Adolescence? How & Why? Are food requirements of adolescent girls in your household given special preference during Pregnancy and Lactation? How & Why? In your community who advises/counsels adolescent girls on diet and nutrition? Is the current LHW Program playing any role in improving the health of adolescent girls? How? Are the community midwifes playing any role in improving the health of adolescent girls? How? Do the school teachers provide any health related information to adolescent girls? How? What is the major barrier in improving the nutritional status of young adolescent girls? Why Who could play the major role in improving the nutritional status of young adolescent girls? How?
APPENDICES PAGES | LV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
APPENDIX F: Research tools: IDI Topic Guides IDI: HEALTH AND MNCH MANAGERS
In-depth Interviews Health and MNCH Managers Assalam-o-Alaikum There are gaps in present policies addressing issues of nutrition in adolescent girls. I am sure you would agree with me. One reason behind these gaps is not having enough evidence. The purpose of this study is to generate the very evidence that would identify the gaps in present policies and the needs in adolescent girls regarding nutrition. This would help in fine tuning the policies and strategy programs focussed towards adolescent girls. We appreciate your cooperation in our endeavour and look forward to your continuous support throughout the duration of this study and beyond it, while applying the evidence generated in this study. Your input is of utmost value to us. IDI No. Pr- Province St- Site
Baluchistan KP Punjab 1 2 3 District Provincial Tt- Type of Tool 3 4
Name (Optional) Contact Number (optional) Address (optional) Age ( in years) Designation Department Organization SECTION 1: PROFESSIONAL BACKGROUND 101 Qualifications
APPENDICES PAGES | LVI
Date. Sindh 4 Survey IDI 1 2
Federal 5 FGD 3
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
102
Duration of current employment
103
Total experience in health sector
104
Elaborate on your experience with MNCH policies and programs
105
Elaborate on your experience with Nutrition programs
SECTION 2: PERSPECTIVE ON ROLE OF NUTRITION IN IMPROVING MATERNAL AND NEONATAL CHILD HEALTH 201 Are you aware of the Millennium Development Goals? Yes / No 202 What are your views on Pakistan’s progress towards achievement of MDG4 and MDG5?
APPENDICES PAGES | LVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
203
In your opinion what are the main reasons behind Pakistanâ&#x20AC;&#x2122;s poor maternal and neonatal health indicators?
204
In your opinion what role can nutritional status of adolescent girls play towards reducing maternal and neonatal health outcomes?
205
In your opinion which age groups are the priority groups for nutritional interventions amongst women?
206
Why?
SECTION 3: PERSPECTIVE ON CURRENT PROGRAM 301 In your opinion how effective are the current MNCH & Nutrition policies in addressing the needs of adolescent girls?
APPENDICES PAGES | LVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
302
If so how?
303
If not, what is the reason behind?
304
305
Are you aware of any programs in Pakistan with a focus on specific nutrition and/or MNCH needs of adolescent girls? Yes / No If yes which ones?
306
Have they been successful?
307
Do you feel adolescent health and nutrition needs a special focus in our reproductive and maternal health policies and programs? Yes / No
308
Why?
309
Are there any specific nutrition and MNCH needs of adolescent girls being addressed by the program you APPENDICES PAGES | LIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
310
311
are working with/for? Yes /No If yes, which ones?
312
Through your program, are you able to address the issues of poverty? Yes / No If yes, in what ways?
313
If no, why not?
314 315
Through your program, are you able to address the issues of social exclusion? Yes / No If yes, in what ways?
316
If no, why not?
317
Through your program, are you able to address the issues of gender inequality? Yes / No If yes, in what ways?
318
APPENDICES PAGES | LX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
319
If no, why not?
320
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at Household level?
321
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at Community level?
322
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at Policy level?
323
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at Programming level?
324
In your opinion, can Nutrition and MNCH policy and programmatic objectives be achieved?
325
If yes?
326
If not, what is the reason behind it?
327
How can Pakistan learn from the successes of other countries, in the fields of Nutrition and MNCH especially those with similar economic profile? APPENDICES PAGES | LXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
SECTION 4: PERSPECTIVE ON LHWS TRAINING 401 In your opinion is the LHWs Program effective in the context of nutritional counselling and nutritional management of adolescent girls? Yes / No 402 How?
403
In your opinion is the MNCH Program effective in the context of nutritional counselling and nutritional management of adolescent girls? Yes / No 404 If so, how?
405
Can LHWs Program be improved for a positive impact on the nutritional status of adolescent girls? Yes/ No 406 How?
APPENDICES PAGES | LXII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
407
Can CMW Program be improved for a positive impact on the nutritional status of adolescent girls? Yes / No 408 If yes, how?
409 In your opinion do LHWs and CMWs have the requisite nutritional counselling capability?
410
411
Is there any need for improving the training curricula of LHWs and CMWs as regards nutritional counselling and management of adolescent girls? Yes / No If yes, what?
412
How?
413
What are your recommendations on improving the effectiveness of the nutritional counselling and communication skills training of LHWs and CMWs?
APPENDICES PAGES | LXIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
SECTION 5: RECOMMENDATIONS 501 Would you support recommendations for a separate focus on the nutritional needs of adolescentsâ&#x20AC;&#x2122; girls and mothers in MNCH Policies and Programs? Yes / No 502 If yes, how?
503
504
505
506
507
508
In your opinion should there be separate allocations within the district and provincial health budget for health interventions targeted at improving the nutritional status of adolescent girls and mothers? Yes / No If yes how?
In your opinion should there be separate focus within the MNCH/LHW/Nutrition Program for health interventions targeted at improving the nutritional status of adolescent girls and mothers? Yes / No If so, how?
Do you think financial resources can be mobilized for health interventions for improving the nutritional status of adolescent girls and mothers? Yes / No If so, why?
APPENDICES PAGES | LXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
509 510
511 512
Can social exclusion be addressed in our Nutrition and MNCH programs and policies? Yes / No If yes, how?
Can gender inequality be addressed in our Nutrition and MNCH programs and policies? Yes / No If yes, how?
513
What in your opinion is the most effective way of improving the nutritional status of adolescent mothers at household level?
514
What in your opinion is the most effective way of improving the nutritional status of adolescent mothers at community level?
515
What in your opinion is the most effective way of improving the nutritional status of adolescent mothers at policy level?
APPENDICES PAGES | LXV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Name
Signature
Interviewer Date
IDI: DAI/ TRADITIONAL BIRTH ATTENDANT
In-depth Interviews DAI/TRADITIONAL BIRTH ATTENDANTS Assalam-o-Alaikum There are gaps in present policies addressing issues of nutrition in adolescent girls. I am sure you would agree with me. One reason behind these gaps is not having enough evidence. The purpose of this study is to generate the very evidence that would identify the gaps in present policies and the needs in adolescent girls regarding nutrition. This would help in fine tuning the policies and strategy programs focussed towards adolescent girls. We appreciate your cooperation in our endeavour and look forward to your continuous support throughout the duration of this study and beyond it, while applying the evidence generated in this study. Your input is of utmost value to us. IDI No. Pr- Province St- Site
Baluchistan KP Punjab 1 2 3 District Provincial Tt- Type of Tool 3 4
Name (Optional) Contact Number (optional) Address (optional) Age ( in years) Marital Status Single Married
Children
Date. Sindh 4 Survey IDI 1 2
Federal 5 FGD 3
No Yes
APPENDICES PAGES | LXVI
Number
of
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Children Age of youngest child BA/B. Sc Any other (specify)
Middle Matric FA/FSC SECTION 1: PROFESSIONAL BACKGROUND 101 Did you ever receive any training? Yes/ No 102 If yes, by whom? Education
103
If yes, on what?
104
Total experience in this community
105
How many pregnant women do you see in a month?
106
How often do you see them during their pregnancy?
107
How much time do you spend on them during each visit?
108
What services do you provide to married adolescents during prenatal period?
109
What services do you provide to married adolescents during antenatal period?
110
What services do you provide to married adolescents during natal period?
APPENDICES PAGES | LXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
111
What services do you provide to married adolescents during postnatal period?
112
Who among the family members use your services mostly?
113
What proportion of women visiting you are under 19 years?
114 115
Do you provide any services to unmarried adolescent girls? Yes / No If yes, what services?
116
What do you think should be the earliest appropriate age to get married?
117
Why?
118
Are there foods which are considered good for adolescent girls in the community? APPENDICES PAGES | LXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
119
Yes / No Which ones?
120
Why?
121 122
Are there foods which are not considered good for adolescent girls in the community? Yes / No Which ones?
123
Why?
124
In your opinion are the food needs of all age groups of female the same? Yes / No Why?
125
126 127
Do you recommend any foods to the women in the community you serve? Yes / No Which foods do you recommend to unmarried adolescent girls?
APPENDICES PAGES | LXIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
128
Why?
129
Which foods do you recommend to adolescent pregnant or lactating mothers?
130
Why?
131
Which foods do you recommend to adolescent mothers in post natal period?
132
Why?
SECTION 2: PERSPECTIVE ON ROLE OF NUTRITION IN IMPROVING MATERNAL AND NEONATAL CHILD HEALTH 201 In your opinion what are the main reasons for poor maternal and neonatal health outcomes? APPENDICES PAGES | LXX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
202 203
204 205
Is there an impact of early marriage on maternal morbidity and mortality? Yes / No How?
In your opinion is there an influence of nutrition and diet on maternal and neonatal health outcomes? Yes / No If yes, how?
SECTION 3: PERSPECTIVE ON CURRENT ROLE 301 Are there any specific MNCH needs of adolescent girls being addressed by you in your community? Yes / No 302 If yes which ones?
APPENDICES PAGES | LXXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
303 304
Are you approached by women in the community for nutritional advice? Yes / No If yes who approaches you?
305
Why?
306
307
Do you think the community you serve requires any nutritional information for adolescent girls in particular? Yes / No If so what information?
308
Why?
309 310
Do you prescribe adolescent girls any micronutrient/nutritional supplements? Yes / No Which ones?
311
Why?
312
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at household level?
APPENDICES PAGES | LXXII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
313
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at community level?
314
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at health program level?
SECTION 4: PERSPECTIIVES ON NUTRITION, KNOWLEDGE AND ATTITUDE 401 In your opinion so you have the essential knowledge about nutrition? Yes / No 402 Have you ever received any refresher trainings Yes / No 403 If yes, on what?
404 By whom?
APPENDICES PAGES | LXXIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
405
Would you like to build your nutritional counselling capability with focus on adolescent girls? Yes/ No
406 If yes, why?
407
How?
SECTION 5: RECOMMENDATIONS 501 Are you aware of any programs with a focus on specific nutrition and/or MNCH needs of adolescent girls being run in your community? Yes / No 502 If yes, which ones?
503 504
Is there any nutritional counselling facility available to adolescent girls in the community? Yes / No If yes which ones?
505
Is there a need for establishing nutritional counselling facility for adolescent girls in the community? APPENDICES PAGES | LXXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
506
Yes / No Why?
507
How?
508
509
Are there any other services that could be provided through you for improving the nutritional status of adolescent girls? Yes / No If yes, which ones?
510
How?
Name Interviewer Date
APPENDICES PAGES | LXXV
Signature
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
IDI: COMMUNITY MIDWIVES
In-depth Interviews Community Mid-wives Assalam-o-Alaikum There are gaps in present policies addressing issues of nutrition in adolescent girls. I am sure you would agree with me. One reason behind these gaps is not having enough evidence. The purpose of this study is to generate the very evidence that would identify the gaps in present policies and the needs in adolescent girls regarding nutrition. This would help in fine tuning the policies and strategy programs focussed towards adolescent girls. We appreciate your cooperation in our endeavour and look forward to your continuous support throughout the duration of this study and beyond it, while applying the evidence generated in this study. Your input is of utmost value to us. IDI No. Pr- Province St- Site
Date. Sindh 4 Survey IDI 1 2
Baluchistan KP Punjab 1 2 3 District Provincial Tt- Type of Tool 3 4
Name (Optional) Contact Number (optional) Address (optional) Age ( in years) Marital Status Single Married
Children
No Yes
Education
Middle Matric FA/FSC
SECTION 1: PROFESSIONAL BACKGROUND 101 When did you receive your training as CMW?
APPENDICES PAGES | LXXVI
Number of Children Age of youngest child BA/B. Sc Ma/M.Sc LHW Training only Any other (specify)
Federal 5 FGD 3
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
102
From where did you receive your training as CMW?
103
Where are you working?
104
Since when?
105
Total experience in this community
106
How many women are registered with you?
107
How often do they visit you?
108
How much time do you spend on each client?
109
What services do you provide to them?
110
Who among the family members use your services mostly?
111
What proportion of women visiting you are under 19 years?
112
Do you provide any services to adolescent girls? Yes / No If yes, what services?
113
APPENDICES PAGES | LXXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 114
What do you think should be the earliest appropriate age to get married?
115
Why?
116 118
Are there foods which are considered good for adolescent girls in the community? Yes / No Which ones?
119
Why?
120 121
Are there foods which are not considered good for adolescent girls in the community? Yes / No Which ones?
122
Why?
123
In your opinion are the food needs of all age groups of female the same? Yes / No Why?
124
APPENDICES PAGES | LXXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
125 126
Do you recommend any foods to the women who visit you? Yes / No Which foods do you recommend to unmarried adolescent girls?
127
Why?
128
Which foods do you recommend to adolescent pregnant or lactating mothers?
129
Why?
130
Which foods do you recommend to adolescent mothers in post natal period?
131
Why?
APPENDICES PAGES | LXXIX
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SECTION 2: PERSPECTIVE ON ROLE OF NUTRITION IN IMPROVING MATERNAL AND NEONATAL CHILD HEALTH 201 In your opinion what are the main reasons for poor maternal and neonatal health outcomes?
202 203
204 205
Is there an impact of early marriage on maternal morbidity and mortality? Yes / No How?
In your opinion is there an influence of nutrition and diet on maternal and neonatal health outcomes? Yes / No If yes, how?
SECTION 3: PERSPECTIVE ON CURRENT PROGRAM 301 Are there any specific MNCH needs of adolescent girls being addressed by the CMW program you are APPENDICES PAGES | LXXX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
302
303
working with/for? Yes / No If yes which ones?
304
Do you think the community you serve requires any nutritional information for adolescent girls in particular? Yes / No If so what information?
305
Why?
306 307
Do you give adolescent girls you visit any micronutrient supplements? Yes / No Which ones?
308
Why?
307
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at household level?
APPENDICES PAGES | LXXXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
308
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at community level?
309
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at program level?
SECTION 4: PERSPECTIVE ON LHWS TRAINING 401 In your opinion does your training equip you with essential knowledge about nutrition? If so how? Yes / No 402 How?
403
Do you think nutrition and MNCH curricula taught is comprehensive and cover adolescence specific issues? Yes / No 404 If so, how?
APPENDICES PAGES | LXXXII
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405
Is there any need for improving the training curricula of CMWs Program as regards nutritional counselling and management of adolescent girls? Yes/ No 406 Why?
407
After completing the CMW training, did you receive any refresher trainings Yes / No 408 If yes, on what?
409 By whom?
407
Would you like to build your nutritional counselling capability with focus on adolescent girls? Yes/ No
408 If yes, why?
APPENDICES PAGES | LXXXIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
409 How?
SECTION 5: RECOMMENDATIONS 501 Are you aware of any programs with a focus on specific nutrition and/or MNCH needs of adolescent girls being run in your community? If yes which ones? Yes / No 502 If yes, which ones?
503 504
505
Is there any nutritional counselling facility available to adolescent girls in the community? Yes / No If yes which ones?
506
Is there a need for establishing nutritional counselling facility for adolescent girls in the community? Yes / No Why?
507
How?
APPENDICES PAGES | LXXXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
508
509
Are there any other services that could be provided through the CMW Program for improving the nutritional status of adolescent girls? Yes / No If yes, which ones?
510
How?
Name Interviewer Date
APPENDICES PAGES | LXXXV
Signature
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
IDI: LADY HEALTH WORKERS
In-depth Interviews Lady Health Workers Assalam-o-Alaikum There are gaps in present policies addressing issues of nutrition in adolescent girls. I am sure you would agree with me. One reason behind these gaps is not having enough evidence. The purpose of this study is to generate the very evidence that would identify the gaps in present policies and the needs in adolescent girls regarding nutrition. This would help in fine tuning the policies and strategy programs focussed towards adolescent girls. We appreciate your cooperation in our endeavour and look forward to your continuous support throughout the duration of this study and beyond it, while applying the evidence generated in this study. Your input is of utmost value to us. IDI No. Pr- Province St- Site
Date. Sindh 4 Survey IDI 1 2
Baluchistan KP Punjab 1 2 3 District Provincial Tt- Type of Tool 3 4
Name (Optional) Contact Number (optional) Address (optional) Age ( in years) Marital Status Single Married
Children
No Yes
Education
Middle Matric FA/FSC
Number of Children Age of youngest child BA/B. Sc Ma/M.Sc LHW Training only Any other (specify)
SECTION 1: PROFESSIONAL BACKGROUND 101 When did you receive your training as LHW?
APPENDICES PAGES | LXXXVI
Federal 5 FGD 3
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
102
From where did you receive your training as LHW?
103
Where are you working?
104
Since when?
105
Total experience in this community
106
How many families are registered with you?
107
How often do you visit the families registered with you?
108
How much time do you spend on each visit?
109
What services do you provide to your client families?
110
Who among the family members use your services mostly?
111 112
Do you provide any services to adolescent girls? Yes / No If yes what services to married?
113
If yes, what services to unmarried? APPENDICES PAGES | LXXXVII
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114
What do you think should be the earliest appropriate age to get married?
115
Why?
116 118
Are there foods which are considered good for adolescent girls in the community? Yes / No Which ones?
119
Why?
120 121
Are there foods which are not considered good for adolescent girls in the community? Yes / No Which ones?
122
Why?
123
In your opinion are the food needs of all age groups of female the same? Yes / No APPENDICES PAGES | LXXXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES 124
Why?
125 126
Do you recommend any foods to the women who visit you? Yes / No Which foods do you recommend to unmarried adolescent girls?
127
Why?
128
Which foods do you recommend to adolescent pregnant or lactating mothers?
129
Why?
130
Which foods do you recommend to adolescent mothers in post natal period?
APPENDICES PAGES | LXXXIX
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131
Why?
SECTION 2: PERSPECTIVE ON ROLE OF NUTRITION IN IMPROVING MATERNAL AND NEONATAL CHILD HEALTH 201 In your opinion what are the main reasons for poor maternal and neonatal health outcomes?
202 203
204 205
Is there an impact of early marriage on maternal morbidity and mortality? Yes / No How?
In your opinion is there an influence of nutrition and diet on maternal and neonatal health outcomes? Yes / No If yes, how?
APPENDICES PAGES | XC
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
SECTION 3: PERSPECTIVE ON CURRENT PROGRAM 301 Are there any specific MNCH needs of adolescent girls being addressed by the LHW program you are working with/for? Yes / No 302 If yes which ones?
303
304
Do you think the community you serve requires any nutritional information for adolescent girls in particular? Yes / No If so what information?
305
Why?
306 307
Do you give adolescent girls you visit any micronutrient supplements? Yes / No Which ones?
308
Why?
APPENDICES PAGES | XCI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
307
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at household level?
308
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at community level?
309
What do you think is the biggest challenge towards improving the nutritional status and health outcomes of adolescent girls at program level?
SECTION 4: PERSPECTIVE ON LHWS TRAINING 401 In your opinion does your training equip you with essential knowledge about nutrition? If so how? Yes / No 402 How?
403
Do you think nutrition and MNCH curricula taught is comprehensive and cover adolescence specific issues? APPENDICES PAGES | XCII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Yes / No 404 If so, how?
405
Is there any need for improving the training curricula of LHWs Program as regards nutritional counselling and management of adolescent girls? Yes/ No 406 Why?
407
After completing the LHW training, did you receive any refresher trainings Yes / No 408 If yes, on what?
409 By whom?
407
Would you like to build your nutritional counselling capability with focus on adolescent girls? Yes/ No
408 If yes, why?
APPENDICES PAGES | XCIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
409 How?
SECTION 5: RECOMMENDATIONS 501 Are you aware of any programs with a focus on specific nutrition and/or MNCH needs of adolescent girls being run in your community? If yes which ones? Yes / No 502 If yes, which ones?
503 504
505 506
Is there any nutritional counselling facility available to adolescent girls in the community? Yes / No If yes which ones?
Is there a need for establishing nutritional counselling facility for adolescent girls in the community? Yes / No Why?
APPENDICES PAGES | XCIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
507
How?
508
509
Are there any other services that could be provided through the LHW Program for improving the nutritional status of adolescent girls? Yes / No If yes, which ones?
510
How?
Name Interviewer Date
APPENDICES PAGES | XCV
Signature
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
APPENDIX G: Root Tables Index of Root Tables Table A1: Distribution of different data collection techniques and tools among provinces ................... X Table A2: Quantitative Methodology and No. of selected Respondents ................................................ XI Table A3: Qualitative Methodology and No. of selected Respondents ..................................................XII Table A3: IDI Categories according to Data Collection Framework ...................................................... XIII Table A4: Comprehensive Data Collection Framework ......................................................................... XIII Table B1: Distribution of different data collection techniques and tools among provinces................ XIX Table G1: Distribution of study adolescent girls’ age (Fig.2a).................................................................... C Table G2: Distribution of age at menarche of the study adolescent girls (Fig. 4.1.2a) ............................ CI Table G3: Distribution of study adolescent girls’ households monthly income (Fig.4.1.3a) ..................CII Table G4: Distribution of household size of study adolescent girls (Fig.4.1.4a &b) ..............................CIII Table G5: Distribution of type of houses of the study adolescent girls (Fig.4.1.5a &b) ........................CIV Table G6: Distribution of number of rooms used for sleeping in the study adolescent girls houses (Fig. 4.1.6a &b)....................................................................................................................................................CV Table G7: Distribution of age at marriage of study adolescent girls (Fig.4.2.1a &b) ..............................CV Table G8: Distribution of age difference with spouses of study married adolescent girls (Fig.4.2.2a &b) .............................................................................................................................................................CVI Table G9: Distribution of level of education of study adolescent girls (Fig.4.2.3a &b) .........................CVI Table G10: Distribution of education of spouses of the study married adolescent girls (Fig.4.2.4a &b) ................................................................................................................................................................. CVII Table G11: Distribution of households’ opinion on women employment (Fig.4.2.5a &b) ................... CVII Table G12: Distribution of ever employment status of study adolescent girls (Fig. 4.2.5c &d) ......... CVIII Table G13: Distribution of currently- employed status of study adolescent girls (Fig.4.2.5e &f) ........ CIX Table G14: Distribution of type of employment of ever-employed study adolescent girls (Fig.4.2.5g)CX Table G15: Distribution of type of employment of spouses of married adolescent girls (Fig.4.2.5h) ...CX Table G16: Distribution of employment status of spouses of married adolescent girls (Fig.4.2.5i) .... CXI Table G17: Distribution of control over spending of the study adolescent girls on the income earned by them (Fig.4.2.5m &n) .......................................................................................................................... CXI Table G18: Distribution of level of financial empowerment of the study adolescent girls (Fig.4.2.5q &r) ................................................................................................................................................................. CXII APPENDICES PAGES | XCVI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Table G19: Distribution of Households’ spending on food (Fig.4.3.2a &b) ......................................... CXIII Table G20: Distribution of reported food shortage in the households of study adolescent girls (Fig.4.3.3a &b) ........................................................................................................................................ CXIV Table G21: Distribution of adolescent girls reporting whether they had enough food to eat (Fig.4.3.3c &d) ........................................................................................................................................................... CXV Table G22: Distribution of number of meals taken daily in study adolescent girls’ households (Fig.4.3.4a and b) ................................................................................................................................... CXVI Table G23: Distribution of meals missed by study adolescents girls’ households (Fig.4.3.4c &d) ... CXVII Table G24: Distribution of knowledge about micronutrients among the study adolescent girls (Fig.4.3.5a &b) ...................................................................................................................................... CXVIII Table G25: Distribution of intake of nutritional supplements among the study adolescent girls (Fig.4.3.5c &d) ........................................................................................................................................ CXIX Table G26: Distribution of type of micronutrients taken (Fig.4.3.5e &f) ............................................. CXX Table G27: Distribution of persons who advised nutritional supplements to adolescent girls (Fig.4.3.5g &h) ........................................................................................................................................ CXXI Table G28: Distribution of knowledge of iodised salt (Fig.4.3.5i &j) .................................................. CXXII Table G29: Distribution of use of iodized salt in households (Fig.4.3.5k &l) .................................... CXXIII Table G30: Distribution of mean calorie intake from different meals of study girls’ households (Fig.4.3.5m &n)..................................................................................................................................... CXXIV Table G31: Distribution of the study girls’ satisfaction with their own health (Fig.4.3.5o &p) ......... CXXV Table G32: Distribution of the study adolescent girls’ satisfaction with their weight (Fig.4.3.5q &r) .............................................................................................................................................................. CXXVI Table G33: Distribution of percentile ranking of height for age of the study adolescent girls (Fig.4.3.6c &d) ....................................................................................................................................................... CXXVII Table G34: Distribution of BMI of study adolescent girls (Fig.4.3.6g &h) ...................................... CXXVIII Table G35: Distribution of frequency of receipt of nutrition advice by the study adolescent girls (Fig.4.4.1a &b) ...................................................................................................................................... CXXIX Table G36: Distribution of sources of nutrition advice of the study adolescent girls (Fig.4.4.1c &d) ............................................................................................................................................................... CXXX Table G37: Distribution of access to school teachers of the study adolescent girls for health and nutrition advice (Fig.4.4.1e &f) ............................................................................................................ CXXXI Table G38: Distribution of frequency of consultation with school teachers for health and nutrition advice (Fig.4.4.1g &h) ......................................................................................................................... CXXXII
APPENDICES PAGES | XCVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Table G39: Distribution of availability of different categories of health care providers to the study adolescent girls’ community (Fig.4.4.1i &j)....................................................................................... CXXXIII Table G40: Distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls (Fig.4.4.1k &l) .................................................................... CXXXIV Table G41: Distribution of the study adolescent girls’ access to health facility (Fig.4.4.1n &o) ..... CXXXV Table G42: Distribution of type of nearby facility available to the study adolescent girls’ access to health facility (Fig.4.4.1p &q)............................................................................................................. CXXXVI Table G43: Distribution of travel time to the nearest health facility for the study adolescent girls (Fig.4.4.1q &r) .................................................................................................................................... CXXXVII Table G44: Distribution of frequency of visits of the study adolescent girls to health facility (Fig.4.4.1s &t) .....................................................................................................................................................CXXXVIII Table G45: Distribution of frequency of receipt of health and nutrition advice at health facility (Fig.4.4.1u &v) .................................................................................................................................... CXXXIX Table G46: Distribution of parity of married adolescent girls and the number of children borne (Fig.4.4.2a).......................................................................................................................................... CXXXIX Table G47: Distribution of the study married adolescent girls’ opinion on whether women should use family planning (Fig.4.4.2d) ..................................................................................................................... CXL Table G48: Distribution of households’ opinion on family planning as reported by the study married adolescent girls (Fig.4.4.2f &g) ............................................................................................................... CXL Table G49: Distribution of community opinion on family planning as reported by the study married adolescent girls (Fig.4.4.2h &i) ...............................................................................................................CXLI Table G50: Distribution of study married adolescent girls’ willingness to use family planning (Fig.4.4.2j &k) ...........................................................................................................................................................CXLI Table G51: Distribution of study married adolescent girls allowed to use family planning (Fig.4.4.2l &m) ........................................................................................................................................................ CXLII Table G52: Distribution of study married adolescent girls using contraceptive methods (Fig.4.4.2n &o) ............................................................................................................................................................... CXLII Table G53: Distribution of use of contraceptives by married adolescent girls allowed and not allowed to use contraception (Fig.4.4.2p) ....................................................................................................... CXLIII Table G54: Distribution of opinions on women visiting health facilities for antenatal care (Fig.4.4.2q) .............................................................................................................................................................. CXLIII Table G55: Distribution of adolescent girls opinion on who should be consulted during pregnancy (Fig.4.4.2s &t) ....................................................................................................................................... CXLIV Table G56: Distribution of preferred place for delivery of married adolescent girls (Fig.4.4.2u &v) .............................................................................................................................................................. CXLIV APPENDICES PAGES | XCVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES Table G57: Distribution of opinions of married adolescent girls on duration of breast feeding (Fig.4.4.2w &x) ...................................................................................................................................... CXLV
APPENDICES PAGES | XCIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G1: Distribution of study adolescent girls’ age (Fig.2a) UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
14
15
16
17
18
19
Pakistan n=381
63
62
59
64
74
59
Balochistan n=91
18
15
9
16
16
17
KP n=100
20
18
10
19
20
13
Punjab n=93
9
11
14
16
23
20
Sindh n=97
16
18
26
13
15
9
Pakistan n=379
6
7
16
44
89
217
Balochistan n=90
2
1
10
10
23
44
KP n=100
3
6
3
15
16
57
Punjab n=93
0
0
1
10
30
52
Sindh n=96
1
0
2
9
20
64
Pakistan n=381
63
62
59
64
74
59
Rural n=188
30
31
28
39
37
23
Urban n=193
33
31
31
25
37
36
Pakistan n=379
6
7
16
44
89
217
Rural n=190
2
5
9
21
44
109
Urban n=189
4
2
7
23
45
108
APPENDICES PAGES | C
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G2: Distribution of age at menarche of the study adolescent girls (Fig. 4.1.2a)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Less than or equal to 12
13 to 14 years
More than 14 years
Pakistan n=381
92
271
18
Balochistan n=91
30
57
4
KP n=100
17
81
2
Punjab n=93
28
57
8
Sindh n=97
17
76
4
108
252
19
Balochistan n=90
37
49
4
KP n=100
17
77
6
Punjab n=93
38
48
7
Sindh n=96
16
78
2
Pakistan n=381
92
271
18
Rural n=188
40
138
10
Urban n=193
52
133
8
108
252
19
Rural n=190
48
133
9
Urban n=189
60
119
10
Pakistan n=379
Pakistan n=379
APPENDICES PAGES | CI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G3: Distribution of study adolescent girls’ households monthly income (Fig.4.1.3a)
UNMARRIED n=381
<5,000 Rs.
5,000 10,000 (Rs.)
10,001 20,000 (Rs.)
>20,000 Rs.
39
215
101
26
1
22
54
14
KP n=100
21
71
6
2
Punjab n=93
10
56
22
5
Sindh n=97
7
66
19
5
48
207
106
18
0
30
47
13
KP n=100
28
59
12
1
Punjab n=93
11
56
25
1
Sindh n=96
9
62
22
3
Pakistan n=381
39
215
101
26
Rural n=188
16
113
49
10
Urban n=193
23
102
52
16
Pakistan n=379
48
207
106
18
Rural n=190
21
108
53
8
Urban n=189
27
99
53
10
Pakistan n=381 Balochistan n=91
MARRIED n=379
Pakistan n=379 Balochistan n=90
UNMARRIED n=381
MARRIED n=379
APPENDICES PAGES | CII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G4: Distribution of household size of study adolescent girls (Fig.4.1.4a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
<5 Members
5-7 Members
8 - 10 Members
>10 Members
Pakistan n=381
48
167
114
52
Balochistan n=91
16
26
25
24
KP n=100
11
55
23
11
Punjab n=93
16
48
25
4
Sindh n=97
5
38
41
13
140
115
63
61
Balochistan n=90
19
29
18
24
KP n=100
23
40
15
22
Punjab n=93
38
33
17
5
Sindh n=96
60
13
13
10
Pakistan n=381
48
167
114
52
Rural n=188
23
76
57
32
Urban n=193
25
91
57
20
140
115
63
61
Rural n=190
68
58
26
38
Urban n=189
72
57
37
23
Pakistan n=379
Pakistan n=379
APPENDICES PAGES | CIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G5: Distribution of type of houses of the study adolescent girls (Fig.4.1.5a &b) UNMARRIED n=381
All Pacca
All Kacha
Mixed
65
100
216
0
15
76
KP n=100
10
13
77
Punjab n=93
15
44
34
Sindh n=97
40
28
29
Pakistan n=379
KP n=100
76 1 23
90 36 10
213 53 67
Punjab n=93
15
31
47
Sindh n=96
37
13
46
Pakistan n=381
65
100
216
Rural n=188
27
54
107
Urban n=193
37
46
110
Pakistan n=379
76
90
213
Rural n=190
39
47
104
Urban n=189
37
43
109
Pakistan n=381 Balochistan n=91
MARRIED n=379
Balochistan n=90
UNMARRIED n=381
MARRIED n=379
APPENDICES PAGES | CIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G6: Distribution of number of rooms used for sleeping in the study adolescent girls houses (Fig. 4.1.6a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
2 or less rooms
3 to 4 rooms
5 rooms and above
276
85
20
Balochistan n=91
35
40
16
KP n=100
84
14
2
Punjab n=93
75
18
0
Sindh n=97
82
13
2
260
105
14
Balochistan n=90
45
37
8
KP n=100
65
33
2
Punjab n=93
74
17
2
Sindh n=96
76
18
2
Pakistan n=381
276
85
20
Rural n=188
130
45
13
Urban n=193
146
40
7
Pakistan n=379
260
105
14
Rural n=190
132
46
12
Urban n=189
128
59
2
Pakistan n=381
Pakistan n=379
Table G7: Distribution of age at marriage of study adolescent girls (Fig.4.2.1a &b)
MARRIED n=379
MARRIED n=379
12 - 13 years
14 - 15 years
16 - 17 years
18 - 19 years
Pakistan n=379
25
105
153
96
Balochistan n=90
10
25
38
17
KP n=100
7
26
29
38
Punjab n=93
7
24
39
23
Sindh n=96
1
30
47
18
Pakistan n=379
25
105
153
96
Rural n=190
15
48
87
40
Urban n=189
10
57
66
56
APPENDICES PAGES | CV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G8: Distribution of age difference with spouses of study married adolescent girls (Fig.4.2.2a &b)
MARRIED n=379
MARRIED n=379
<3 years
3 - 5 (years)
6 - 8 (years)
>8 years
Pakistan n=379
32
114
135
98
Balochistan n=90
12
37
23
18
KP n=100
5
22
34
39
Punjab n=93
4
28
34
27
Sindh n=96
11
27
44
14
Pakistan n=379
32
114
135
98
Rural n=190
16
61
65
48
Urban n=189
16
53
70
50
Table G9: Distribution of level of education of study adolescent girls (Fig.4.2.3a &b) Illiterate
Literate but without formal education
Primary (Upto 5 yrs of education)
Secondary (6- 10 yrs of education)
College (1114 yrs of education)
84
13
80
147
57
Balochistan n=91
19
1
24
26
21
KP n=100
11
0
20
50
19
Punjab n=93
16
6
15
46
10
Sindh n=97
38
6
21
25
7
156
18
72
106
27
Balochistan n=90
40
3
17
21
9
KP n=100
32
2
12
44
10
Punjab n=93
36
9
22
22
4
Sindh n=96
48
4
21
19
4
84
13
80
147
57
Rural n=188
57
6
42
62
21
Urban n=193
27
7
38
85
36
156
18
72
106
27
Rural n=190
81
13
30
55
11
Urban n=189
75
5
42
51
16
UNMARRIED n=381 Pakistan n=381
MARRIED n=379
Pakistan n=379
UNMARRIED n=381 Pakistan n=381
MARRIED n=379
Pakistan n=379
APPENDICES PAGES | CVI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G10: Distribution of education of spouses of the study married adolescent girls (Fig.4.2.4a &b)
MARRIED n=379
MARRIED n=379
Illiterate
Literate but without formal educatio n
Primary (Upto 5 yrs of education )
Secondar y (6- 10 yrs of education )
College (11- 14 yrs of education )
Higher (15+ yrs of education )
117
10
58
139
43
12
Balochistan n=90
30
4
7
30
10
9
KP n=100
15
1
13
50
19
2
Punjab n=93
31
3
20
35
4
0
Sindh n=96
41
2
18
24
10
1
117
10
58
139
43
12
Rural n=190
66
4
28
65
22
5
Urban n=189
51
6
30
74
21
7
Pakistan n=379
Pakistan n=379
Table G11: Distribution of householdsâ&#x20AC;&#x2122; opinion on women employment (Fig.4.2.5a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Unfavourable Opinion
Favourable Opinion
120
261
Balochistan n=91
33
58
KP n=100
30
70
Punjab n=93
34
59
Sindh n=97
23
74
Pakistan n=379
68
311
Balochistan n=90
16
74
KP n=100
13
87
Punjab n=93
29
64
Sindh n=96
10
86
120
261
Rural n=188
45
143
Urban n=193
75
118
Pakistan n=379
68
311
Rural n=190
30
160
Urban n=189
38
151
Pakistan n=381
Pakistan n=381
APPENDICES PAGES | CVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G12: Distribution of ever employment status of study adolescent girls (Fig. 4.2.5c &d)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Never Worked
Ever worked
334
47
Balochistan n=91
78
13
KP n=100
93
7
Punjab n=93
81
12
Sindh n=97
82
15
334
45
Balochistan n=90
81
9
KP n=100
97
3
Punjab n=93
71
22
Sindh n=96
85
11
Pakistan n=381
334
47
Rural n=188
163
25
Urban n=193
171
22
Pakistan n=379
334
45
Rural n=190
171
19
Urban n=189
163
26
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G13: Distribution of currently- employed status of study adolescent girls (Fig.4.2.5e &f)
UNMARRIED n=47
MARRIED n=45
UNMARRIED n=47
MARRIED n=45
Currently not Working
Currently working
12
35
Balochistan n=13
5
8
KP n=7
2
5
Punjab n=12
3
9
Sindh n=15
2
13
31
14
Balochistan n=9
8
1
KP n=3
2
1
Punjab n=22
19
3
Sindh n=11
2
9
12
35
Rural n=25
7
18
Urban n=22
5
17
Pakistan n=45
31
14
Rural n=19
11
8
Urban n=26
20
6
Pakistan n=47
Pakistan n=45
Pakistan n=47
APPENDICES PAGES | CIX
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Table G14: Distribution of type of employment of ever-employed study adolescent girls (Fig.4.2.5g)
UNMARRIED n=47
MARRIED n=45
UNMARRIED n=47
MARRIED n=45
Housemaid
Labour/ Daily wager
Teaching
Home sewing
Others
17
17
8
5
0
Balochistan n=13
1
9
2
1
0
KP n=7
3
2
2
0
0
Punjab n=12
5
4
2
1
0
Sindh n=15
8
2
2
3
0
21
10
9
1
4
Balochistan n=9
0
2
5
0
2
KP n=3
0
0
1
0
2
Punjab n=22
15
5
2
0
0
Sindh n=11
6
3
1
1
0
17
17
8
5
0
Rural n=25
9
12
2
2
0
Urban n=22
8
5
6
3
0
21
10
9
1
4
Rural n=19
9
7
2
1
0
Urban n=26
12
3
7
0
4
Pakistan n=47
Pakistan n=45
Pakistan n=47
Pakistan n=45
Table G15: Distribution of type of employment of spouses of married adolescent girls (Fig.4.2.5h) Labour/ Daily wager/ factory worker
Farming
Office jobs/Teaching
Other
225
6
50
39
Balochistan n=79
30
2
39
8
KP n=85
61
2
4
18
Punjab n=81
68
0
4
9
Sindh n=75
66
2
3
4
Pakistan n=320
APPENDICES PAGES | CX
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Table G16: Distribution of employment status of spouses of married adolescent girls (Fig.4.2.5i) Not working
Working
Pakistan n=379
59
320
Balochistan n=90
11
79
KP n=100
15
85
Punjab n=93
12
81
Sindh n=96
21
75
Table G17: Distribution of control over spending of the study adolescent girls on the income earned by them (Fig.4.2.5m &n)
UNMARRIED n=47
MARRIED n=23
UNMARRIED n=47
MARRIED n=23
Myself
Parents
Husband
Parents Inlaws
All
Pakistan n=47
21
19
0
0
7
Balochistan n=13
12
0
0
0
1
KP n=7
2
4
0
0
1
Punjab n=12
1
7
0
0
4
Sindh n=15
6
8
0
0
1
Pakistan n=23
9
0
2
7
5
Balochistan n=4
2
0
0
2
0
KP n=2
0
0
0
2
0
Punjab n=9
2
0
2
2
3
Sindh n=8
5
0
0
1
2
21
19
0
0
7
Rural n=25
9
12
0
0
4
Urban n=22
12
7
0
0
3
Pakistan n=23
9
0
2
7
5
Rural n=14
6
0
2
3
3
Urban n=9
3
0
0
4
2
Pakistan n=47
APPENDICES PAGES | CXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G18: Distribution of level of financial empowerment of the study adolescent girls (Fig.4.2.5q &r)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Not empowered
Partially empowered
Empowered
340
35
6
Balochistan n=91
91
0
0
KP n=100
96
4
0
Punjab n=93
74
15
4
Sindh n=97
79
16
2
346
25
8
Balochistan n=90
88
2
0
KP n=100
98
2
0
Punjab n=93
84
5
4
Sindh n=96
76
16
4
Pakistan n=381
340
35
6
Rural n=188
164
19
5
Urban n=193
176
16
1
Pakistan n=379
346
25
8
Rural n=190
171
14
5
Urban n=189
175
11
3
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXII
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Table G19: Distribution of Households’ spending on food (Fig.4.3.2a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Less than 20%
20 - 50 %
51 - 75 %
More than 75%
Pakistan n=381
2
68
161
150
Balochistan n=91
0
17
54
20
KP n=100
0
1
8
91
Punjab n=93
1
29
33
30
Sindh n=97
1
21
66
9
Pakistan n=379
3
82
148
146
Balochistan n=90
0
18
50
22
KP n=100
1
4
3
92
Punjab n=93
2
25
42
24
Sindh n=96
0
35
53
8
Pakistan n=381
2
68
161
150
Rural n=188
0
36
76
76
Urban n=193
2
32
85
74
Pakistan n=379
3
82
148
146
Rural n=190
1
36
72
81
Urban n=189
2
46
76
65
APPENDICES PAGES | CXIII
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Table G20: Distribution of reported food shortage in the households of study adolescent girls (Fig.4.3.3a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Rare or no food shortage in last one year
Occasional Food shortage in last one year
Frequent or always food shortage in last one year
235
71
75
Balochistan n=91
60
26
5
KP n=100
85
8
7
Punjab n=93
48
15
30
Sindh n=97
42
22
33
228
84
67
Balochistan n=90
58
23
9
KP n=100
87
9
4
Punjab n=93
48
21
24
Sindh n=96
35
31
30
Pakistan n=381
235
71
75
Rural n=188
117
31
40
Urban n=193
118
40
35
Pakistan n=379
228
84
67
Rural n=190
109
43
38
Urban n=189
119
41
29
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G21: Distribution of adolescent girls reporting whether they had enough food to eat (Fig.4.3.3c &d)
UNMARRIED n=381
Never Hungry
Sometimes Hungry
Always Hungry
81
66
234
4
11
76
36
8
56
Punjab n=93
5
18
70
Sindh n=97
36
29
32
Pakistan n=379
89
65
225
8
18
64
43
4
53
Punjab n=93
5
14
74
Sindh n=96
33
29
34
Pakistan n=381
81
66
234
Rural n=188
41
31
116
Urban n=193
40
35
118
Pakistan n=379
89
65
225
Rural n=190
47
47
96
Urban n=189
42
18
129
Pakistan n=381 Balochistan n=91 KP n=100
MARRIED n=379
Balochistan n=90 KP n=100
UNMARRIED n=381
MARRIED n=379
APPENDICES PAGES | CXV
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Table G22: Distribution of number of meals taken daily in study adolescent girls’ households (Fig.4.3.4a and b) UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
1 11
2 100
3 260
4 10
Balochistan n=91
0
20
71
0
KP n=100
3
19
77
1
Punjab n=93
7
30
51
5
Sindh n=97
1
31
61
4
Pakistan n=379
6
85
273
15
Balochistan n=90
0
21
68
1
KP n=100
3
10
86
1
Punjab n=93
3
25
56
9
Sindh n=96
0
29
63
4
11
100
260
10
Rural n=188
6
49
130
3
Urban n=193
5
51
130
7
Pakistan n=379
6
85
273
15
Rural n=190
3
42
138
7
Urban n=189
3
43
135
8
Pakistan n=381
Pakistan n=381
APPENDICES PAGES | CXVI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G23: Distribution of meals missed by study adolescents girls’ households (Fig.4.3.4c &d)
UNMARRIED n=88
MARRIED n=67
UNMARRIED n=88
MARRIED n=67
Breakfast
Lunch
Dinner
Breakfast & Lunch
Breakfast & Dinner
43
23
10
7
5
Balochistan n=11
8
1
1
1
0
KP n=17
9
5
2
1
0
Punjab n=36
23
5
2
3
3
Sindh n=24
3
12
5
2
2
29
24
4
7
3
Balochistan n=12
7
2
1
1
1
KP n=8
6
0
1
0
1
Punjab n=26
14
8
0
3
1
Sindh n=21
2
14
2
3
0
Pakistan n=88
43
23
10
7
5
Rural n=46
19
15
8
2
2
Urban n=42
24
8
2
5
3
Pakistan n=67
29
24
4
7
3
Rural n=35
11
16
2
4
2
Urban n=32
18
8
2
3
1
Pakistan n=88
Pakistan n=67
APPENDICES PAGES | CXVII
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Table G24: Distribution of knowledge about micronutrients among the study adolescent girls (Fig.4.3.5a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Not aware
somewhat aware
Aware
57
267
58
Balochistan n=91
6
69
16
KP n=100
8
59
34
Punjab n=93
27
66
0
Sindh n=97
16
77
4
Pakistan n=379
62
198
119
Balochistan n=90
9
57
24
KP n=100
5
46
49
Punjab n=93
41
45
7
Sindh n=96
7
52
37
Pakistan n=381
57
267
58
Rural n=188
48
114
26
Urban n=193
9
152
32
Pakistan n=379
62
198
119
Rural n=190
54
85
51
Urban n=189
8
113
68
Pakistan n=381
APPENDICES PAGES | CXVIII
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Table G25: Distribution of intake of nutritional supplements among the study adolescent girls (Fig.4.3.5c &d) UNMARRIED n=324
Pakistan n=324 Balochistan n=85 KP n=92
No
Yes
250
74
71
14
65
27
56
10
58
23
198
119
50
31
53
42
44
8
51
38
250
74
132
36
Punjab n=66 Sindh n=81
MARRIED n=317
Pakistan n=317 Balochistan n=81 KP n=95 Punjab n=52 Sindh n=89
UNMARRIED n=324
Pakistan n=324 Rural n=168 Urban n=156
MARRIED n=317
Pakistan n=317 Rural n=158
118
38
198
119
95
63
103
56
Urban n=159
APPENDICES PAGES | CXIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G26: Distribution of type of micronutrients taken (Fig.4.3.5e &f)
UNMARRIED n=74
Pakistan n=74 Balochistan n=14 KP n=27 Punjab n=10 Sindh n=23
MARRIED n=119
Pakistan n=119 Balochistan n=31 KP n=42 Punjab n=8 Sindh n=38
UNMARRIED n=74
Pakistan n=74 Rural n=28 Urban n=46
MARRIED n=119
Pakistan n=119 Rural n=58 Urban n=61
Multivitamin
Multivitamin & Others
Iron & Folic acid
Others
16 2 5 4 5 39
29 5 9 4 11 40
8 1 5 2 0 21
21 6 8 0 7 19
5
18
6
2
12 5 17 16 5 11 39 13 26
7 3 12 29 14 15 40 24 16
7 0 8 8 2 6 21 14 7
16 0 1 21 7 14 19 7 12
APPENDICES PAGES | CXX
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Multiple sources
MARRIED n=119
In-Laws /Husband
UNMARRIED n=74
Health workers
MARRIED n=119
Community elders/Friends
UNMARRIED n=74
Parents & Siblings
Table G27: Distribution of persons who advised nutritional supplements to adolescent girls (Fig.4.3.5g &h)
Pakistan n=74
21
15
38
0
0
Balochistan n=14
6
3
5
0
0
KP n=27
5
7
15
0
0
Punjab n=10
10
0
0
0
0
Sindh n=23
0
5
18
0
0
Pakistan n=119
9
13
55
9
33
Balochistan n=31
0
4
25
0
2
KP n=42
2
3
14
7
16
Punjab n=8
0
1
1
2
4
Sindh n=38
7
5
15
0
11
Pakistan n=74
21
15
38
0
0
Rural n=28
7
5
16
0
0
Urban n=46
14
10
22
0
0
Pakistan n=119
9
13
55
9
33
Rural n=58
4
3
29
3
19
Urban n=61
5
10
26
6
14
APPENDICES PAGES | CXXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G28: Distribution of knowledge of iodised salt (Fig.4.3.5i &j) UNMARRIED n=381
Pakistan n=381 Balochistan n=91 KP n=100 Punjab n=93 Sindh n=97
MARRIED n=379
Pakistan n=379 Balochistan n=90 KP n=100 Punjab n=93 Sindh n=96
UNMARRIED n=381
MARRIED n=379
Pakistan n=381 Rural n=188
Not Aware
Aware
106
275
16
75
32
68
17
76
41
56
153
226
36
65
41
59
38
55
49 106
47 275
54
134
Urban n=193
52
141
Pakistan n=379 Rural n=190
153
226
64
126
Urban n=189
89
100
APPENDICES PAGES | CXXII
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Table G29: Distribution of use of iodized salt in households (Fig.4.3.5k &l)
UNMARRIED n=275
MARRIED n=226
UNMARRIED n=275
Never 89
Sometimes 128
Most of the times 58
27
24
24
KP n=68
21
35
12
Punjab n=76
24
43
9
Sindh n=56
17
26
13
Pakistan n=226 Balochistan n=65
91
87
48
25
21
19
KP n=59
9
34
16
Punjab n=55
32
17
6
Sindh n=47
25
15
7
Pakistan n=275 Rural n=134
89 27 62 91 37 54
128 69 59 87 63 24
58 38 20 48 26 22
Pakistan n=275 Balochistan n=75
Urban n=141
MARRIED n=226
Pakistan n=226 Rural n=126 Urban n=100
APPENDICES PAGES | CXXIII
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Table G30: Distribution of mean calorie intake from different meals of study girls’ households (Fig.4.3.5m &n)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
Breakfast 549.9
Lunch 379.4
Dinner 557.1
316.2
370.8
479.1
KP n=100
667.3
326.7
496.2
Punjab n=93
637.2
400.5
691.4
Sindh n=97
514.1
396.6
492.4
Pakistan n=379 Balochistan n=90
574.9
377.4
454.1
546.5
428.0
376.8
KP n=100
716.0
318.2
693.7
Punjab n=93
639.2
405.4
458.7
Sindh n=96
470.1
340.1
398.2
Pakistan n=381 Rural n=188
549.9
379.4
557.1
557.6 542.2
468.9 291.5
623.2 492.2
574.9
377.4
454.1
532.2 616.6
388.9 366.1
425.3 482.3
Pakistan n=381 Balochistan n=91
Urban n=193
MARRIED n=379
Pakistan n=379 Rural n=190 Urban n=189
APPENDICES PAGES | CXXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G31: Distribution of the study girls’ satisfaction with their own health (Fig.4.3.5o &p)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Not Satisfied
Satisfied
131
250
Balochistan n=91
39
52
KP n=100
28
72
Punjab n=93
33
60
Sindh n=97
31
66
137
242
Balochistan n=90
42
48
KP n=100
22
78
Punjab n=93
40
53
Sindh n=96
33
63
131
250
Rural n=188
61
127
Urban n=193
70
123
137
242
Rural n=190
65
125
Urban n=189
72
117
Pakistan n=381
Pakistan n=379
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G32: Distribution of the study adolescent girls’ satisfaction with their weight (Fig.4.3.5q &r)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Not Satisfied
Satisfied
128
253
Balochistan n=91
39
52
KP n=100
28
72
Punjab n=93
26
67
Sindh n=97
35
62
141
238
Balochistan n=90
38
52
KP n=100
21
79
Punjab n=93
40
53
Sindh n=96
42
54
128
253
Rural n=188
68
120
Urban n=193
60
133
141
238
Rural n=190
72
118
Urban n=189
69
120
Pakistan n=381
Pakistan n=379
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXVI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G33: Distribution of percentile ranking of height for age of the study adolescent girls (Fig.4.3.6c &d) UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
1th quartile
2th quartile
3th quartile
4th quartile
299
35
16
31
Balochistan n=91
74
10
3
4
KP n=100
88
7
3
2
Punjab n=93
59
18
8
8
Sindh n=97
78
0
2
17
280
48
24
27
Balochistan n=90
57
20
9
4
KP n=100
82
10
7
1
Punjab n=93
67
16
5
5
Sindh n=96
74
2
3
17
Pakistan n=381
299
35
16
31
Rural n=188
147
14
7
20
Urban n=193
152
21
9
11
Pakistan n=379
280
48
24
27
Rural n=190
143
22
9
16
Urban n=189
137
26
15
11
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G34: Distribution of BMI of study adolescent girls (Fig.4.3.6g &h) Obesity
Overweight
Normal
Thin-ness
Sever Thinness
89
127
95
47
23
Balochistan n=91
17
31
31
8
4
KP n=100
31
36
20
11
2
Punjab n=93
17
30
22
16
8
Sindh n=97
24
30
22
12
9
116
80
54
20
22
Balochistan n=70
37
18
13
0
2
KP n=81
34
21
15
4
7
Punjab n=68
17
23
16
9
3
Sindh n=72
27
18
10
7
10
89
127
95
47
23
Rural n=188
37
67
50
23
11
Urban n=193
52
60
45
24
12
116
80
54
20
22
Rural n=146
58
39
31
8
11
Urban n=145
58
41
23
12
11
UNMARRIED n=381 Pakistan n=381
MARRIED n=291
Pakistan n=291
UNMARRIED n=381 Pakistan n=381
MARRIED n=291
Pakistan n=291
APPENDICES PAGES | CXXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G35: Distribution of frequency of receipt of nutrition advice by the study adolescent girls (Fig.4.4.1a &b)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Never Advised
Sometimes Advised
Frequently Advised
141
150
90
Balochistan n=91
53
27
11
KP n=100
28
48
24
Punjab n=93
13
31
49
Sindh n=97
47
44
6
150
139
90
Balochistan n=90
51
24
15
KP n=100
26
50
24
Punjab n=93
28
25
40
Sindh n=96
45
40
11
141
150
90
Rural n=188
69
84
35
Urban n=193
72
66
55
150
139
90
Rural n=190
76
73
41
Urban n=189
74
66
49
Pakistan n=381
Pakistan n=379
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G36: Distribution of sources of nutrition advice of the study adolescent girls (Fig.4.4.1c &d) Parents and Siblings
Community Members
Health care Providers
In-Laws
Misc. Combinations
178
14
11
0
37
Balochistan n=38
27
4
2
0
5
KP n=72
52
4
0
0
16
Punjab n=80
64
4
4
0
8
Sindh n=50
35
2
5
0
8
Pakistan n=229
43
1
27
123
35
Balochistan n=39
5
0
3
26
5
KP n=74
5
48
8
1
12
Punjab n=65
12
30
11
0
12
Sindh n=51
13
19
5
0
14
178
14
11
0
37
Rural n=119
90
7
3
0
19
Urban n=121
88
7
8
0
18
Pakistan n=229
43
1
27
123
35
Rural n=114
23
0
11
59
21
Urban n=115
20
1
16
64
14
UNMARRIED n=240 Pakistan n=240
MARRIED n=229
UNMARRIED n=240 Pakistan n=240
MARRIED n=229
APPENDICES PAGES | CXXX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G37: Distribution of access to school teachers of the study adolescent girls for health and nutrition advice (Fig.4.4.1e &f)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
No Access to school/ School teacher
Access to school/ School teacher nearby
140
241
Balochistan n=91
28
63
KP n=100
30
70
Punjab n=93
31
62
Sindh n=97
51
46
186
193
Balochistan n=90
38
52
KP n=100
33
67
Punjab n=93
55
38
Sindh n=96
60
36
140
241
Rural n=188
58
130
Urban n=193
82
111
186
193
Rural n=190
89
101
Urban n=189
97
92
Pakistan n=381
Pakistan n=379
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXXI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G38: Distribution of frequency of consultation with school teachers for health and nutrition advice (Fig.4.4.1g &h)
UNMARRIED n=241
MARRIED n=193
UNMARRIED n=241
MARRIED n=193
Never
Sometimes
Frequently
171
43
27
Balochistan n=63
51
8
4
KP n=70
39
19
12
Punjab n=62
39
12
11
Sindh n=46
42
4
0
183
9
1
Balochistan n=52
52
0
0
KP n=67
63
4
0
Punjab n=38
35
2
1
Sindh n=36
33
3
0
171
43
27
Rural n=130
93
22
15
Urban n=111
78
21
12
183
9
1
Rural n=101
97
3
1
Urban n=92
86
6
0
Pakistan n=241
Pakistan n=193
Pakistan n=241
Pakistan n=193
APPENDICES PAGES | CXXXII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G39: Distribution of availability of different categories of health care providers to the study adolescent girlsâ&#x20AC;&#x2122; community (Fig.4.4.1i &j) Only Doctor
Only LHW
LHW and Doctor
Misc. Combinations
Others
34
246
12
22
67
Balochistan n=91
2
75
4
8
2
KP n=100
8
35
0
3
54
Punjab n=93
12
66
3
6
6
Sindh n=97
12
70
5
5
5
Pakistan n=379
52
225
15
37
50
3
75
6
6
0
22
21
1
13
43
Punjab n=93
6
63
3
16
5
Sindh n=96
21
66
5
2
2
34
246
12
22
67
Rural n=188
17
106
7
14
44
Urban n=193
17
140
5
8
23
Pakistan n=379
52
225
15
37
50
Rural n=190
20
122
4
15
29
Urban n=189
32
103
11
22
21
UNMARRIED n=381 Pakistan n=381
MARRIED n=379
Balochistan n=90 KP n=100
UNMARRIED n=381 Pakistan n=381
MARRIED n=379
APPENDICES PAGES | CXXXIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G40: Distribution of frequency of seeking advice on health and nutrition from health care providers by the study adolescent girls (Fig.4.4.1k &l)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Never Advised
Sometimes Advised
Frequently Advised
247
112
22
Balochistan n=91
56
33
2
KP n=100
87
7
6
Punjab n=93
60
21
12
Sindh n=97
44
51
2
243
114
22
Balochistan n=90
50
38
2
KP n=100
85
12
3
Punjab n=93
57
27
9
Sindh n=96
51
37
8
Pakistan n=381
247
112
22
Rural n=188
119
58
11
Urban n=193
128
54
11
Pakistan n=379
243
114
22
Rural n=190
126
51
13
Urban n=189
117
63
9
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXXIV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G41: Distribution of the study adolescent girls’ access to health facility (Fig.4.4.1n &o)
UNMARRIED n=381
MARRIED n=379
UNMARRIED n=381
MARRIED n=379
Not available nearby
Available nearby
158
223
Balochistan n=91
49
42
KP n=100
43
57
Punjab n=93
33
60
Sindh n=97
33
64
173
206
Balochistan n=90
43
47
KP n=100
41
59
Punjab n=93
65
28
Sindh n=96
24
72
158
223
Rural n=188
89
99
Urban n=193
69
124
173
206
Rural n=190
96
94
Urban n=189
77
112
Pakistan n=381
Pakistan n=379
Pakistan n=381
Pakistan n=379
APPENDICES PAGES | CXXXV
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G42: Distribution of type of nearby facility available to the study adolescent girlsâ&#x20AC;&#x2122; access to health facility (Fig.4.4.1p &q) Private hospital/ Clinic
Basic Health Unit
Rural Health Center
Tehsil Head quarter
District head quarter
Others
81
80
16
24
4
18
Balochistan n=42
20
18
1
1
0
2
KP n=57
30
2
6
0
3
16
Punjab n=60
12
17
9
21
1
0
Sindh n=64
19
43
0
2
0
0
Pakistan n=206
73
75
18
13
5
22
Balochistan n=47
25
19
1
0
0
2
KP n=59
26
2
8
1
4
18
Punjab n=28
3
9
3
11
1
1
Sindh n=72
19
45
6
1
0
1
81
80
16
24
4
18
Rural n=99
40
45
6
4
1
3
Urban n=124
41
35
10
20
3
15
Pakistan n=206
73
75
18
13
5
22
Rural n=94
29
40
14
1
2
8
Urban n=112
44
35
4
12
3
14
UNMARRIED n=223 Pakistan n=223
MARRIED n=206
UNMARRIED n=223 Pakistan n=223
MARRIED n=206
APPENDICES PAGES | CXXXVI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G43: Distribution of travel time to the nearest health facility for the study adolescent girls (Fig.4.4.1q &r) UNMARRIED n=223
Less than 10 minutes
10 to 20 minutes
21 to 30 minutes
More than 30 minutes
36
95
52
40
4
27
10
1
17
31
6
3
Punjab n=60
4
12
19
25
Sindh n=64
11
25
17
11
Pakistan n=206 Balochistan n=47
23
101
48
34
4
24
15
4
KP n=59
8
33
14
4
Punjab n=28
2
2
9
15
Sindh n=72
9
42
10
11
Pakistan n=223
36
95
52
40
Rural n=99
16
49
24
10
Urban n=124
20
46
28
30
Pakistan n=206
23
101
48
34
Rural n=94
10
48
21
15
Urban n=112
13
53
27
19
Pakistan n=223 Balochistan n=42 KP n=57
MARRIED n=206
UNMARRIED n=223
MARRIED n=206
APPENDICES PAGES | CXXXVII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G44: Distribution of frequency of visits of the study adolescent girls to health facility (Fig.4.4.1s &t)
UNMARRIED n=223
MARRIED n=206
UNMARRIED n=223
MARRIED n=206
Never visit
Sometimes visit
Frequently visit
Pakistan n=223
93
116
14
Balochistan n=42
16
26
0
KP n=57
26
27
4
Punjab n=60
25
32
3
Sindh n=64
26
31
7
Pakistan n=206
81
109
16
Balochistan n=47
13
30
4
KP n=59
36
19
4
Punjab n=28
10
16
2
Sindh n=72
22
44
6
Pakistan n=223
93
116
14
Rural n=99
36
58
5
Urban n=124
57
58
9
Pakistan n=206
81
109
16
Rural n=94
38
50
6
Urban n=112
43
59
10
APPENDICES PAGES | CXXXVIII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G45: Distribution of frequency of receipt of health and nutrition advice at health facility (Fig.4.4.1u &v) Never Advised
Sometimes Advised
Frequently Advised
68
55
7
Balochistan n=26
11
14
1
KP n=31
27
4
0
Punjab n=35
18
12
5
Sindh n=38
12
25
1
Pakistan n=125
26
40
59
Balochistan n=34
6
11
17
KP n=23
8
5
10
Punjab n=18
7
6
5
Sindh n=50
5
18
27
68
55
7
Rural n=63
24
34
5
Urban n=67
44
21
2
Pakistan n=125
26
40
59
Rural n=56
16
30
10
Urban n=69
10
10
49
UNMARRIED n=130 Pakistan n=130
MARRIED n=125
UNMARRIED n=130 Pakistan n=130
MARRIED n=125
Table G46: Distribution of parity of married adolescent girls and the number of children borne (Fig.4.4.2a) MARRIED n=247
MARRIED n=247
0
1
2
3
4
14
135
67
17
6
5 8
Balochistan n=74
1
57
11
2
1
2
KP n=43
4
19
10
7
2
1
Punjab n=83
2
45
27
5
2
2
Sindh n=47
7
14
19
3
1
3
14
135
67
17
6
8
Rural n=111
9
51
36
6
4
5
Urban n=136
5
84
31
11
2
3
Pakistan n=247
Pakistan n=247
APPENDICES PAGES | CXXXIX
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G47: Distribution of the study married adolescent girls’ opinion on whether women should use family planning (Fig.4.4.2d) MARRIED n=379
MARRIED n=379
Never
Sometimes
Always
163
101
115
Balochistan n=90
31
38
21
KP n=100
46
25
29
Punjab n=93
12
25
56
Sindh n=96
74
13
9
163
101
115
Rural n=190
89
42
59
Urban n=189
74
59
56
Pakistan n=379
Pakistan n=379
Table G48: Distribution of households’ opinion on family planning as reported by the study married adolescent girls (Fig.4.4.2f &g) Not at all favourable Somewhat favourable Extremely Favourable MARRIED n=379 Pakistan n=379
205
89
85
Balochistan n=90
48
22
20
KP n=100
31
38
31
Punjab n=93
45
20
28
Sindh n=96
81
9
6
205
89
85
Rural n=190
116
42
32
Urban n=189
89
47
53
MARRIED n=379 Pakistan n=379
APPENDICES PAGES | CXL
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G49: Distribution of community opinion on family planning as reported by the study married adolescent girls (Fig.4.4.2h &i)
MARRIED n=379
MARRIED n=379
Not at all favourable
Sometwhat favourable
Extremely Favourable
209
88
82
Balochistan n=90
50
29
11
KP n=100
31
38
31
Punjab n=93
45
15
33
Sindh n=96
83
6
7
Pakistan n=379
209
88
82
Rural n=190
116
44
30
Urban n=189
93
44
52
Pakistan n=379
Table G50: Distribution of study married adolescent girlsâ&#x20AC;&#x2122; willingness to use family planning (Fig.4.4.2j &k) MARRIED n=379
MARRIED n=379
Would not like to use
Would like to use
258
121
Balochistan n=90
60
30
KP n=100
64
36
Punjab n=93
43
50
Sindh n=96
91
5
Pakistan n=379
258
121
Rural n=190
122
68
Urban n=189
136
53
Pakistan n=379
APPENDICES PAGES | CXLI
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G51: Distribution of study married adolescent girls allowed to use family planning (Fig.4.4.2l &m) MARRIED n=379
MARRIED n=379
Not allowed to use
Allowed to use
237
142
Balochistan n=90
49
41
KP n=100
63
37
Punjab n=93
33
60
Sindh n=96
92
4
Pakistan n=379
237
142
Rural n=190
116
74
Urban n=189
121
68
Pakistan n=379
Table G52: Distribution of study married adolescent girls using contraceptive methods (Fig.4.4.2n &o) MARRIED n=379
MARRIED n=379
Donâ&#x20AC;&#x2122;t use contraceptives
Use contraceptives
327
52
Balochistan n=90
75
15
KP n=100
77
23
Punjab n=93
79
14
Sindh n=96
96
0
Pakistan n=379
327
52
Rural n=190
157
33
Urban n=189
170
19
Pakistan n=379
APPENDICES PAGES | CXLII
DRAFT RESEARCH REPORT: STUDY ON NUTRITION KNOWLEDGE, BELIEFS AND PRACTICES OF ADOLESCENT GIRLS IN PAKISTAN APPENDICES
Table G53: Distribution of use of contraceptives by married adolescent girls allowed and not allowed to use contraception (Fig.4.4.2p)
Married who are allowed to use contraceptives n=142
Not using contraceptives
Using contraceptives
Pakistan n=142
92
50
Balochistan n=41
26
15
KP n=37
16
21
Punjab n=60
46
14
4
0
235
2
Balochistan n=49
49
0
KP n=63
61
2
Punjab n=33
33
0
Sindh n=92
92
0
Sindh n=4
Married who are not allowed to use contraceptives n=237
Pakistan n=237
Table G54: Distribution of opinions on women visiting health facilities for antenatal care (Fig.4.4.2q) MARRIED n=379
MARRIED n=379
Should not visit
Should visit
132
247
Balochistan n=90
16
74
KP n=100
57
43
Punjab n=93
10
83
Sindh n=96
49
47
132
247
Rural n=190
79
111
Urban n=189
53
136
Pakistan n=379
Pakistan n=379
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Various combinations of health workers only
Mother and sister
Mother in law
Mother in law and mother only
Mother in law, Mother and Lady doctor
Combination of family members and health workers
None
MARRIED n=379
Lady Doctor with different combination
MARRIED n=379
Lady Doctor Only
Table G55: Distribution of adolescent girls opinion on who should be consulted during pregnancy (Fig.4.4.2s &t)
118
24
28
20
57
21
14
11
86
Balochistan n=90
52
4
13
1
0
1
1
3
15
KP n=100
19
8
7
4
27
9
2
3
21
Punjab n=93
46
9
3
4
13
2
8
0
8
Sindh n=96
1
3
5
11
17
9
3
5
42
118
24
28
20
57
21
14
11
86
Rural n=190
51
12
10
11
31
12
8
4
51
Urban n=189
67
12
18
9
26
9
6
7
35
Pakistan n=379
Pakistan n=379
Table G56: Distribution of preferred place for delivery of married adolescent girls (Fig.4.4.2u &v) MARRIED n=379
MARRIED n=379
Hospital
Clinic
Home
254
25
100
Balochistan n=90
58
6
26
KP n=100
72
9
19
Punjab n=93
55
9
29
Sindh n=96
69
1
26
Pakistan n=379
254
25
100
Rural n=190
126
8
56
Urban n=189
128
17
44
Pakistan n=379
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Table G57: Distribution of opinions of married adolescent girls on duration of breast feeding (Fig.4.4.2w &x)
MARRIED n=89
MARRIED n=89
Four - Six months
Seven - twelve Months
one to one and half years
One and half - Two years
Pakistan n=89
4
9
31
45
Balochista n n=27
2
6
12
7
KP n=21
1
0
2
18
Punjab n=12 Sindh n=29
0
0
2
10
1
3
15
10
Pakistan n=89
4
9
31
45
Rural n=44 Urban n=45
0
5
14
25
4
4
17
20
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APPENDIX H: Study methods and site wise breakdowns
In depth interviews with Health Managers
In depth interviews with Community Health Workers
Focus Group Focus Group Discussions Focus Group Discussions with male community Discussions with with female members male household school teachers members
Focus Group Discussions with female household members
Focus Group Discussion of Adolescent Girls
Study Method
STUDY DISTRICT Rural site 1:
Rural site 2:
Urban site 1:
Urban site 2:
Study population: Study population: 8-10 married 8-10 married adolescent adolescent girls (14–19 girls (14–19 year old) year old) 8-10 unmarried 8-10 unmarried adolescent girls (14–19 adolescent girls (14–19 year old) year old) Sampling: Purposive Sampling: Purposive typical group sampling typical group sampling for FGD for FGD Study population: 8-10 female household members ( Mother, Mothers-in-laws, Aunt, Sister in law, Elder Sister) Sampling: Purposive for FGD
Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14–19 year old) Sampling: Purposive typical group sampling for FGD
Study population: 8-10 married adolescent girls (14–19 year old) 8-10 unmarried adolescent girls (14–19 year old) Sampling: Purposive typical group sampling for FGD
Study population: 8-10 male household members (Husband, Father, Father-in laws, Uncles, Elder brother) Sampling: Purposive for FGD
Study population: 8-10 male household members (Husband, Father, Father-in laws, Uncles, Elder brother) Sampling: Purposive for FGD
Study population: 8-10 community opinion makers (Local elite, Elected representatives, High ranking officials, Religious leaders, Media personnel, CBO members, Community based non-governmental organizations incl. Edhi Foundation, Citizen Foundation, NRSP, UNICEF, UNFPA) Sampling: Purposive critical group for FGD
Study population: 8-10 community opinion makers (Local elite, Elected representatives, High ranking officials, Religious leaders, Media personnel, CBO members, Community based non-governmental organizations incl. Edhi Foundation, Citizen Foundation, NRSP, UNICEF, UNFPA) Sampling: Purposive critical group for FGD
Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive critical group for FGD
Study population: 8-10 female School Teachers engaged in Formal and In formal Education Sampling: Purposive critical group for FGD
Study population: 8-10 female household members ( Mother, Mothers-in-laws, Aunt, Sister in law, Elder Sister) Sampling: Purposive for FGD
Study population: Preferably 2 CMWs, 2 LHWs and 2 TBAs for IDIs from the selected sites Sampling: Purposive critical case sampling for IDIs
Study population: Preferably 2 district level health managers and 2 provincial level health managers 4 health managers federal Sampling: Purposive critical case sampling for IDIs
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APPENDIX I: Pictures of props used
Standard Utensils Roti sized cardboard Dinner Plate Table spoon Glass Tea cup
Size/Capacity 6 inches 10 inches 15 ml 237 ml 250 ml
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APPENDIX J: Pictures of data collection in field
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APPENDIX K: Caloric values of food items used in 24 hour recall( 608 in research instrument) to calculate the total caloric values of meals Meals
Size
Calories (kcal)
A Paratha
325
A Bread Slice
6 inches/100g 6 inches/100g 41.5 mg
1 Tablespoon Jam/ Chutni/ Murabba
15 ml
55
1 Tablespoon Butter
15 ml
102
A cup of tea
250 ml
30
A glass of milk Egg
237 ml 1 large
146 74
1 serving Meat
1 oz
81
1 serving Vegetables
½ cup
50
1 plate Curry/ Salan *Salan is a thin soup made with water and seasoning added to fried onions 1 bowl Yogurt
1 serving
200
230 ml
154
1 plate Lentils
10 inches
323
1 plate rice
10 inches
377
1 glass of lassi
237 ml
31
1 glass of sharbat
237 ml
88
A Plain chapatti
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APPENDIX L: Verbal consent script Assalam-o-Alaikum I am---------------. I have come from-------------------------------. We are doing a research study on the health, nutrition and eating habits of young girls like you. Our purpose is to identify your health and nutrition needs. The evidence generated will help us advise the current health programs, your family, the community and you, how to improve your diet so that your nutrition and health becomes better. These are very simple and basic questions about your day to day routine. Please try to answer all the questions that I will ask. If you donâ&#x20AC;&#x2122;t understand a question, please say so and I will clarify it. Thank you for agreeing to have this interview with your complete and unconditional consent.
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