NEPAL MULTIPLE INDICATOR SURVEILLANCE

FOURTH CYCLE

EARLY CHILDHOOD FEEDING, NUTRITION

AND DEVELOPMENT

FINAL REPORT

AUGUST 1997
 EXECUTIVE SUMMARY
Introduction
The Nepal Multiple Indicator Surveillance (NMIS)
began with a multisectoral baseline survey in early 1995.
The NMIS was designed from the beginning as an-
ongoing monitoring scheme to produce information
useful for planning at national, district, community and
household levels, rather than as a one-off survey.
Nepal, as a signatory to the 1989 UN Convention on the
Rights of the Child, is committed to report on its
implementation. Among other things, the NMIS serves
as an important means of monitoring violations of
children’s rights in Nepal. It has also assisted HMG
Nepal to monitor progress towards the 1990s Goals and
Mid-decade Goals agreed at the World Summit for
Children as embodied in its National Plan of Action for
Children and Development for the 1990s.
The NMIS process comprises repeated cycles of data
collection, analysis, interpretation, and communication of
results to stimulate action. Each cycle focuses on a
priority issue or set of issues. Cycle 2 focused on
Primary Education in the spring and summer of 1995;
and cycle 3 on Diarrhoea, Water and Sanitation in the
first half of 1996. The first cycle of the NMIS produced
information about malnutrition and feeding practices
among young children and indicated the need for further
information on this issue. This fourth cycle of the NMIS
focuses particularly on issues of child feeding and
malnutrition and also provides some information about
child development milestones and levels of disability
among young children.
Childhood malnutrition is a serious problem in Nepal, as
in other countries of South Asia. Four national studies
over the last 20 years have reported on the level of
malnutrition in young children in Nepal and there is little
evidence of improvement. Over half of children under
three years old are stunted (low height-for-age; chronic
malnutrition). The first cycle of the NMIS in early 1995
reported stunting in 64% of children aged 6-36 months
and wasting (low weight-for-height; acute malnutrition)
in 6% of them. The Nepal Family Health Survey in 1996
reported stunting in 48% of children under 3 years old
(55% of children aged 6-35 months) and wasting in 11%
of them. This NMIS cycle is intended not only to
estimate the levels of malnutrition in different parts of
Nepal but also to investigate factors that change the risk
of malnutrition, to show potential effects of possible
interventions.
i
Methods
The NMIS employs Sentinel Community Surveillance
(SCS). Features of this method include:the focus of each
cycle on a small group of issues; the combination of
quantitative and qualitative data from the same
communities in a mesoanalysis; data analysis and risk
analysis to produce results in a form useful for planning;
revisiting of the same sites, making estimation of impact
of interventions easier.
A key feature of SCS is the ability to do risk
analysis to look at causes. In NMIS cycle four the
focus is on causes of childhood malnutrition.
The sample for the NMIS was drawn by the Central
Bureau of Statistics (CBS); the 144 sites are
representative of the country, of the five development
regions, of the three ecological zones, of the 15 eco-
development regions, and of urban and rural situations.
A total of 18,643 households were visited in the 144 sites
between September and November 1996. Information
was available for 16,955 households (91%).
Household data for NMIS 4 were collected from:
‘ 16,955 households
‘ 95,752 people
‘ 15,172 children 5 years old and below
‘ 8,060 children 36 months and below
In each of the 144 communities, a focus group of mothers
of children aged 5 years or below was held, the health
facility that most served the community was visited and
the most senior worker was interviewed.
Instruments used in NMIS cycle 4:
‘ Household questionnaire with
anthropometry
‘ Health facility interview schedule
‘ Focus group guides
The sample sizes in districts are not proportional to the
populations of the Districts; weights calculated to take
this into account were applied when producing national
indicators.
Results and risk analysis
1. Nutritional status
The rates of both acute malnutrition (low weight-for-
height) and chronic malnutrition (low height-for-age) are
high.
‘ 53% of children aged 6-36 months have
chronic malnutrition (stunting)
‘ 16% of children aged 6-36 months have
acute malnutrition (wasting)
There is a striking relationship with age, with the
proportion of children who are stunted and wasted rising
sharply between 6 and 24 months and then leveling off or
even falling in older children (Figure 1). But there is no
difference between boys and girls.
Over a third (38%) of children aged 12-36 months have
a mid upper arm circumference (MUAC) less than
13.5cm, indicating moderate malnutrition. More than a
tenth (12%) have a MUAC less than 12.5cm, indicating
severe malnutrition.
There is geographic variation in malnutrition rates. For
stunting, there is an increase from the terai (50%) to the
mountains (63%). For wasting, the rate is strikingly
higher in the terai (24%) than in the hills or mountains
(less than 10%) (see Figure 3). There are particularly
high rates of wasting in the Eastern and Central terai and
this probably relates to the serious flooding with food
shortage and infections in these areas during the
monsoon, just before data collection.
Most mothers in this survey (82%) report their children
are well grown for their age. There is an association
between their perception and anthropometry: children of
mothers reporting them well grown are of better
nutritional status than children whose mothers report
them not well grown. However, mothers tend to
underestimate malnutrition, especially stunting (see
Table 4).
Among children thought by their mothers to be
well grown for their age, nearly half (48%) are
stunted and one in seven (15%) is wasted.
Few communities in this sample are served by health
facilities able to identify acute malnutrition (low weight-
for-height) or chronic malnutrition (low height-for-age).
About half are able to identify general malnutrition (low
weight-for-age).
Only 59% of health facilities weigh children and
only 9% measure their height.
ii
Factors related to nutritional status
Mother’s food security
Most mothers (91%) had enough to eat in the previous
day, but a quarter reported limiting their own food in the
last week to give food to the child. Children whose
mothers report not having enough food to eat the
previous day are more likely to be stunted or wasted than
children whose mothers had enough to eat (see Table 5).
Breast feeding practices
Breast feeding is almost universal; only 0.3% of children
are said not to have been breast fed at all. For more than
half (54%) of children breast feeding is started within the
first two hours, but it is sometimes delayed for as long as
2-3 days. Nationally, just over a third (36%) of children
had the colostrum thrown away rather than fed to them.
There is variation by geographic area and by ethnicity: in
the terai it is more likely that the colostrum will be
thrown away and that the start of breast feeding will be
delayed.
Children who had the colostrum thrown away at their
birth are at increased risk of being malnourished; in
particular they have nearly twice the risk of being wasted
(see Table 10).
Breast feeding is generally prolonged, with nearly half
of children aged 36 months still being breast fed.
However, exclusive breast feeding does not last long
after birth and liquid or solid complements are often
added within the first three months. By three months,
nearly three-quarters of children are receiving liquid or
solid complements. The perceived benefits of breast
feeding, especially for the child, far outweigh the
perceived disadvantages. The commonest reasons for
stopping breast feeding are pregnancy (59%) and birth of
another child (12%).
The mean age of adding liquid complements is 4.9
months and of adding solid complements 6.8 months.
Children reported to have had liquids and solids added to
the diet relatively later are more likely to be
malnourished, especially wasted. There could be
confounding by socioeconomic status. Or the recognised
benefits of exclusive breast feeding up to 6 months may
not be experienced if the breast feeding is infrequent (see
below)and the child therefore receives insufficient total
calories and other nutrients.
Type of foods given to young children
Nearly two-thirds of mothers (or main caretakers) think
that watery porridge is better nutritionally for young
children. This is not surprising in light of the views of
health workers interviewed, who encourage this
misconception.

‘ 56% of health workers think liquid foods are
more nutritious for young children
‘ Nearly all health workers pass on their opinion
about the best type of food to parents
Almost all the focus groups felt that mothers would easily
accept the idea that solid food was best for young
children if the reasons were explained to them. They
found the explanation about the benefits of more solid
food given in the focus groups convincing.
Feeding frequency
About a third of children are breast fed 4 times or less in
the day (24 hours). One in seven children is fed less
than four times a day in total. The frequency in practice
is close to that believed by households to be correct.
Children in households where more frequent feeding is
thought desirable have more than twice the chance of
being fed frequently compared with those in households
advocating less frequent feeding (see Table 15). But still
13% of those in households advocating feeding more
than four times a day are fed less frequently than this.
The reported frequency of feeding is little different
between boys and girls.
‘ Only one in ten focus groups thought it would
be easy to feed young children at least 6 to 8 times
a day.
‘ Most common constraints noted were lack of
time and too much work (see Table 16)
Nearly all health workers interviewed think that young
children should be fed at least five times a day and give
this advice to parents.
Children from communities where the health
worker believes in more frequent feeding are fed
more frequently than those from communities
where the health worker advocates less frequent
feeding (see Table 17).
Children fed less frequently are 50% more at risk of
being stunted than children fed more frequently. But
children who are wasted are more likely (twice as likely)
than those who are not wasted to be fed more than 5
times a day (see Table 18). The probable explanation is
that sickly, thin children are fed more often in an attempt
to improve their condition. This survey took place soon
after a period when there was flooding and food shortage,
at a time when food was again available. Stunted
children are not recognised as malnourished and so do
not attract this extra feeding.
iii
Who feeds the child and how the child eats
In a third of households it is the grandmother who feeds
the child if the mother is not available and in one in ten
households it is the father; the mother is ‘always
available’ in only one household in four.
Children who are fed by the father or other male relative
when the mother is not available have a higher risk of
stunting (1.3 times) than those who are always fed by the
mother or a female relative (see Table 20).
Most (77%) children under three years have a separate
plate for their food and only a fifth are said to eat when
the rest of the family eats. A child who does not have a
separate plate for eating has a higher risk of wasting (1.3
times) than a child who has a separate plate. The lack of
effect on stunting may be because the effect is mainly in
older children when much of the stunting has already
occurred.
Diarrhoea incidence and management
The proportion of children with diarrhoea in the last two
weeks is similar to the figure of 18% for children up to 5
years old in NMIS cycle 38; both surveys were in non-
monsoon periods. In NMIS 4, 16% of children under 36
months old had diarrhoea in the last two weeks.
Nearly all children (93%) are said to have been looked
after by the mother during their most recent episode of
diarrhoea. The next most common carer for the child
with diarrhoea is the grandmother (5%).
Continuing feeding a child during an episode of diarrhoea
is important. If feeding is not continued this leads to
acute malnutrition. In this survey, two thirds of children
were reported to be given less food than usual during
their last episode of diarrhoea and one in ten were given
no food at all. Focus groups suggest that lack of time is
the main reason for not giving children with diarrhoea
fluids and food.
Almost all the health workers interviewed (98%) think a
child with an infection, such as ARI or diarrhoea, should
be given the same or more food to eat than usual and
most (97%) report giving this advice to parents. It seems
that they do not convince parents of this, or parents are
not able to put this advice into practice.
A child with recent diarrhoea has more than one and a
half times the risk of being wasted of a child without
recent diarrhoea. There is no effect on the risk of
stunting. Recent diarrhoea is here an indicator of
recurrent episodes of diarrhoea.
Status of women and child nutrition
In this survey, two indicators of women’s social status
are available: literacy of the mother (from the household
questionnaire) and whether beating of women is common
in each sentinel community (from the focus group
discussions).
Only 19% of the mothers (or other main carers) of the
children are reported to be literate. A child with an
illiterate mother has more than twice the risk of stunting
and more than one and a half times the risk of wasting of
a child with a literate mother (see Table 23).
Focus group discussions indicate that beating of women
is commonplace in many Nepali communities and that
women are understandably unhappy about this.
“We get beaten if we put too much or too little salt in
the curry and this is accepted by the society. But to get
beaten is not something simple or natural.”
In nearly half (43%) of the communities in this
survey, focus groups of women say that women are
beaten often in that community.
Nearly all (98%) the focus groups indicated that mothers
have to take permission from other family members
before doing something for the benefit of the child.
Punishments that the mother might be given if she did
something for the child without permission include
scolding (88%), beating (88%) and withholding of food
(17%). Most (76%) focus groups made a link between
the treatment of women and proper child feeding and
care.
Children in communities where women are reported to
be often beaten have a higher risk of stunting (1.5 times)
and wasting (1.75 times) than children in communities
where frequent beating of women is not reported. This
finding will hopefully lead to more detailed research on
this subject.
2. Child development and disabilities
Motor milestones
The mean age for children to be able to sit is 7.2 months,
to stand 10.2 months, and to walk 13.0 months.
Following international norms, the mean age to achieve
these milestones is slightly lower in girls than in boys.
Mothers quite often perceive their child to have had
serious delay in sitting, standing or walking.
‘ 19% of mothers think their child has
serious delay in sitting
‘ 24% think their child has serious delay in
standing
‘ 25% think their child has serious delay in
walking
iv
Mothers perceive only slightly more boy children than
girl children to be delayed in reaching the motor
milestones (about 1% difference between boys and girls).
Perception of delay is associated with reported delay in
reaching milestones; children thought to have delay reach
each milestone three months or more later than those
with no perceived delay.
Intellectual development
Among all the children aged up to 72 months, 5% are
said to act younger than other children of their own age.
By two years, virtually all children are said to understand
simple commands and nearly all are said to speak
intelligibly. There are no reported differences between
boys and girls in indices of intellectual development.
Disabilities
Among all children up to 72 months old, 2% are said by
their parents to have difficulty hearing. The percentage
recognised increases a little with age: it is 1% in children
up to 36 months old and 3% in children over this age. It
is difficult to detect hearing difficulties in very young
children.
Only 0.7% of children are said to have difficulty seeing
at night and 0.3% difficulty seeing in the day.
Parents report fits in 2% of children. Some of these
children may not be having true epileptiform seizures but
simply breath-holding or ‘temper’ episodes.
For children aged up to 36 months, the interviewer
observed the child and noted any disabilities, in
discussion with the mother. The great majority (98%)
were recorded as having no disability.
Some of the physical disabilities noted are very minor,
such as patches of skin depigmentation or lumps on the
ears, but they also include more serious problems like
major limb deformities.
There is no gender difference in reported disabilities.
Malnutrition and child development
If malnutrition affects the brain and nervous system as
well as the rest of the body, children with malnutrition,
especially with stunting (chronic malnutrition), would
have delay in reaching motor milestones compared with
children without malnutrition.
In this survey, each motor milestone (sitting,
standing, walking) is reached later among children
who are stunted. Children who are stunted walk
about one month later, on average, than children
who are not stunted.
Parents may not recognise that their children are stunted,
but they are nearly twice as likely to perceive delay in
reaching milestones in stunted children than in those not
stunted. Wasted children are also more likely (1.4 times)
to be perceived as delayed in their motor development.
Action analysis: possible effects of interventions
In this section of the analysis, the effects of the variables
found to affect the risk of malnutrition separately are
examined in combination. The focus is on those
variables amenable to change and the aim is to indicate
what sort of reduction in malnutrition might be produced
by different interventions.
Risk of stunting and wasting
The eight main variables that increase the risk of stunting
separately were considered together. First repeated
stratification was undertaken. The resulting tables were
fed into a logistic regression analysis. After undertaking
the logistic regression, three variables remained in the
model:, literacy of the mother, whether women are beaten
often in the community, and frequency of feeding the
child.
A similar process was followed for examining variables
that increase the risk of wasting. The variables in the
final model were: living in the terai, recent diarrhoea,
throwing away colostrum, whether women are beaten
often, age of adding liquids, and frequency of feeding.
Adding liquids sooner was protective, perhaps because
of low frequency of feeding in exclusively breast fed
infants. Feeding more often was associated with more
wasting, probably because of feeding sickly-looking
children more often.
v
Action to reduce the risk of stunting and wasting
Having carefully defined the variables that affect the risk
of stunting and wasting, taking into account the combined
effects of variables, it is possible to estimate the benefits
of different actions that could be taken to reduce
malnutrition in children.
Table 31 (reproduced below for convenience) indicates
the possible benefit of taking action to reduce the causes
of stunting found in this survey. The possible benefit to
individual children is derived from the combined Odds
Ratio from logistic regression. The possible population
benefit is derived from the combined Risk Difference
from logistic regression. The proportion of the
population who could benefit is the proportion who do
not currently have the beneficial situation (eg the
proportion of children who currently have illiterate
mothers). The relative costs of each possible
intervention are indicated, and the main players who
might need to take action.
Table 32 (reproduced below for convenience) shows a
similar analysis for wasting, with estimated benefits of
actions to change different possible causes of wasting.
The variables of timing of adding liquids and frequency
of feeding are not included in Table 32 as it seems very
likely that the earlier adding of liquids is not beneficial in
itself but rather related to low frequency of exclusive
breast feeding and that the increased feeding frequency in
wasted children results from rather than causes their
condition.
Table 31. Possible benefits of different actions to reduce the risk of stunting in young children

Action Individual benefit Population benefit Proportion of Relative financial Action needed by:
(based on OR) (based on RD) population who cost
could benefit

Increase female Two and a quarter More than one in ten Four out of five Moderate to high Education dept
literacy times less risk (12%) children Local govt
(2.3 times) protected NGOs
Communities

Prevent women One and a half times Nearly one in ten About half Moderate Individuals
being beaten less risk (9%) children Women’s groups
(1.5 times) protected NGOs
Opinion formers
Communities

Feed young children Nearly one and a half More than one in Nearly a quarter Low Individuals
six times a day or times less risk twenty (6%) children Communities
more (1.4 times) protected Health workers
NGOs

Table 32. Possible benefits of different actions to reduce the risk of wasting in young children

Action Individual benefit Population benefit Proportion of Relative financial Action needed by:
(based on OR) (based on RD) population who cost
could benefit

Situation in terai Nearly two and a half Nearly one in seven About half Moderate to high Central govt
(eg provide food times less risk (15%) children NGOs
after flooding) (2.4 times) protected Local govt

Prevent childhood Nearly one and a half More than one in Probably around a Moderate Individuals
diarrhoea (and times less twenty (6%) children third DWSS
manage better) risk protected NGOs
(1.4 times) Health workers

Feed colostrum to Nearly one and a half More than one in ten More than a third Low Individuals
babies times less risk (11%) children NGOs
(1.4 times) protected Health workers
Opinion formers

Prevent women Nearly one and a half More than one in ten About half Moderate Individuals
being beaten times less risk (12%) children Women’s groups
(1.3 times) protected NGOs
Opinion formers
Communities

vi
 CONTENTS
EXECUTIVE SUMMARY i

Contents vii
List of tables and figures ix
List of annexes x
Definitions and abbreviations xi

INTRODUCTION 1
Nepal Multiple Indicator Surveillance 1
Childhood malnutrition in Nepal 2

METHODS 3
Background: the NMIS methodology 3
NMIS cycle 4: sample sites 4
The population in NMIS cycle 4 4
Instruments 4
Training and fieldwork 5
Analysis 5

RESULTS I. BASIC INDICATORS AND RISK ANALYSIS 6

NUTRITIONAL STATUS 6
Geographic and ethnic variation in nutritional status 8
Mothers’ perceptions of children’s growth 9
Child nutrition monitoring by health facilities 9

Household food security 9

Mother’s food security and child nutritional status 10

Feeding practices 10
Breast feeding practices 10
Benefits and disadvantages of breast feeding 11
Breastfeeding practices and nutritional status 12
Liquid and solid food complements 12
Addition of complements to diet and nutritional status 13
Type of foods given to young children 13
Feeding frequency 14
Feeding frequency and nutritional status 16
Who feeds the child and how the child eats 16
How the child eats and risk of malnutrition 17

Diarrhoea incidence and management 17

Diarrhoea and risk of malnutrition 18

Status of women and child nutrition 18

Literacy of mothers 18
Beating of women 19
Beating of women and child nutrition 19

CHILD DEVELOPMENT AND DISABILITIES 19

Motor development milestones 19
Intellectual development 20
Disabilities 21
Geographic variation in child development 21
Malnutrition and child development 21

vii
RESULTS II. FURTHER RISK ANALYSIS 23

Risk of stunting 23
Risk of wasting 23
Action analysis 24
Reducing stunting 24
Literacy of women 24
Violence against women 24
Frequency of feeding 24
Reducing wasting 24
Special problems of the terai 24
Prevent diarrhoea 25
Feeding colostrum to babies 25
Violence against women 25

REFERENCES 26

viii
 LIST OF TABLES, FIGURES AND ANNEXES

Tables
1. Low MUAC and anthropometry in children 12-36 months 6
2. Relation between stunting and wasting in children 6-36 months old 6
3. Zone of residence and risk of malnutrition 8
4. Mothers’ perceptions of child growth and anthropometry 9
5. Mothers’ food security and malnutrition in children 10
6. Perceived benefits of breast feeding for the child 11
7. Perceived benefits of breast feeding for the mother 12
8. Perceived disadvantages of breast feeding for the child 12
9. Perceived disadvantages of breast feeding for the mother 12
10. Throwing away colostrum and risk of malnutrition in children 12
11. Reasons given for stopping breast feeding 12
12. Age of adding liquid complements and risk of malnutrition 13
13. Age of adding solid complements and risk of malnutrition 13
14. Type of health worker and views about whether liquid or solid food is more nutritious 14
15. Feeding frequency in practice and opinion of desirable frequency 15
16. Difficulties in feeding children more often, mentioned in focus groups 15
17. Feeding frequency recommended by health workers and feeding frequencies in communities served 15
18. Feeding frequency and risk of malnutrition 16
19. Person who feeds the child when the mother is not available 16
20. Person who feeds the child when mother not available and risk of malnutrition 17
21. Whether the child has a separate plate and the risk of malnutrition 17
22. Recent diarrhoea and risk of malnutrition 18
23. Literacy of the mother and risk of malnutrition 18
24. Beating of women in communities and risk of malnutrition 19
25. Mean age to sit, stand and walk in boys and girls 20
26. Perception of delay in milestones and reported age of sitting, standing and walking 20
27. Nutritional status and age of reaching motor milestones 22
28. Malnutrition and perceived delay in walking 22
29. Odds Ratios and Risk Differences for stunting from logistic regression 23
30. Odds Ratios and Risk Differences for Wasting from logistic regression 24
31. Action analysis for stunting interventions 25
32. Action analysis for wasting interventions 25

Figures
1. Stunting and wasting in relation to age 7
2. Low MUAC in relation to age 7
3. Stunting and wasting by eco-zone 8
4. Low MUAC by eco-zone 8
5. Stunting by ethnic group 8
6. Wasting by ethnic group 9
7. Time to start breast feeding 10
8. Households opinions about when to start breast feeding 10
9. Throwing away colostrum, by ethnic group 10
10. Time to start breast feeding by ethnic group 11
11. Use of colostrum and time to start breast feeding by eco-zones 11
12. Breast feeding pattern by age 11
13. Mothers’ recall of time to start liquid and solid complements 13
14. Household opinions of when to add solids to the diet 13
15. Frequency of feeding per day 14
16. Household views of desirable feeding frequency 15
17. Use ofa separate plate and eating with the family by age 16
18. Feeding of children during most recent episode of diarrhoea 18
19. Proportion of children who began to sit, stand and walk at different ages 20

ix
20. Proportions of children able to sit, stand and walk at different ages 20
21. Ability to say understandable words, and speak intelligible words, by age 21
22. Using hands to pick up objects, by age 21
23. Proportion of children able to sit at different ages, by stunting 22
24. Proportion of children able to stand at different ages, by stunting 22
25. Proportion of children able to walk at different ages, by stunting 22

Annexes
Annex 1 Location of NMIS sites, and districts of Nepal by ecozone A1(1)-A1(3)

Annex 2 Instruments for NMIS cycle 4

Annex 3 Focus group themes, with proportions mentioning each one A3(1)

Annex 4 Weighting to give national figures A4(1)-A4(3)

Annex 5 Data disaggregated geographically and by ethnicity A5(1)-A5(22)

Annex 6 Comparison of anthropometry in NMIS 4 with NFHS and NMIS 1 A6(1)-A6(5)

Annex 7 Why is the stunting rate higher in NMIS 1 than in NMIS 4 and the NFHS? A7(1)-A7(5)

Annex 8 Age structure of the NMIS 4 sample population A8(1)-A8(2)

x
 DEFINITIONS AND ABBREVIATIONS

Definitions

Chronic malnutrition or stunting:

A child is considered to be suffering from chronic malnutrition or stunting if his or her height-for-age is more than two
standard deviations below the median value of an international reference population. The ‘proportion of children who
are stunted’ is the proportion with a height-for-age more than two standard deviations below the median value of the
reference population. The international reference population used is that defined by the United States National Centre
for Health Statistics (NCHS) and accepted by WHO. There is sometimes discussion about whether the NCHS reference
population is an appropriate reference population for Nepal; presently there is no choice but to use an international
reference standard and it at least allows international comparisons.

Acute malnutrition or wasting:

A child is considered to be suffering from acute malnutrition or wasting if his or her weight-for-height is more than two
standard deviations below the median value of an international reference population. The ‘proportion of children who
are wasted’ is the proportion with a weight-for-height more than two standard deviations below the median value for
the reference population. The same international reference population is used as for height-for-age.

Anthropometry:
This is the measurement of height and weight. When related to age and sex of children it provides evidence of
nutritional status (either acute or chronic malnutrition can be identified). It is generally valid to do anthropometry
between the ages of 6 and 36 months. Anthropometry in children below 6 months old is possible but it is more difficult
and the results are less reliable.

Mid Upper Arm Circumference (MUAC):

This measurement (in cm) is a more approximate way of estimating malnutrition in young children. The MUAC
indicator is thought to be valid between the ages of 12 and 36 months. A value below 12.5cm indicates severe
malnutrition. A value between 12.5 and 13.5 cm indicates moderate malnutrition.

Abbreviations:
95% CI 95% Confidence Interval
AHW Auxiliary Health Worker
ANM Assistant Nurse Midwife
CBS Central Bureau of Statistics
CEDAW Convention on Elimination of Discrimination Against Women
CRC Convention on the Rights of the Child
MUAC Mid Upper Arm Circumference
NMIS Nepal Multiple Indicator Surveillance
NPC National Planning Commission
OR Odds Ratio: one way of estimating Relative Risk (see below)
ORS Oral Rehydration Salts
ORT Oral Rehydration Therapy
WCHW Women and Child Health Worker
VHW Village Health Worker

xi
Statistical and epidemiological terms
This report is deliberately written avoiding too many specialised statistical and epidemiological terms. However, some
are unavoidable. A brief explanation of the main terms used in the report is given here; readers who are interested in
more detailed explanations could refer to a textbook on modern epidemiological methods.

95% confidence interval:

A measure of the accuracy of an estimate, based on the normal distribution curve. The ‘true’ value is 95% likely to lie
between the upper and lower values of the 95% confidence interval.

Standard Deviation:
A measure of the spread of the distribution of a variable, based on the normal distribution curve. 99% of the population
will have values within +/- two standard deviations from the mean value of the variable.

Odds Ratio:
One way of estimating Relative Risk. In a 2X2 table, with cells a,b,c,d, the Odds Ratio is calculated by ad/bc.

Relative Risk:
The risk in one group compared with another group (for example the risk of stunting in girls compared with the risk of
stunting in boys). When the actual rates in each group are known (for example, the total number and the number with
stunting), the relative risk can be estimated either by the Odds Ratio or by the Rate Ratio (the rate in one group divided
by the rate in the other group). In a case-referent study, only the Odds Ratio can be calculated. For relatively rare
conditions, the two estimates of Relative Risk give a similar answer. There is discussion about which estimate of
Relative Risk it is better to use. For further details, a textbook of modern epidemiology should be consulted. In SCS
methodology, the Odds Ratio is used as the estimate of Relative Risk.

The Relative Risk or Odds Ratio gives an idea of the risk for an individual in one group compared with an individual
in another group (for example, a child of a literate mother compared with a child of an illiterate mother). It is therefore
most useful when making decisions about the most benefit for an individual child (such as those taken by a mother for
her child).

Risk Difference:
The risk in one group minus the risk in another group (for example the risk in children of illiterate mothers minus the
risk in children of literate mothers). The risk idfference can only be calculated when the rates in both groups are known.

The Risk Difference gives an idea of the risk for a group and how this could be changed by an action. It is most useful
for planners who are considering how many children could benefit from an intervention.

xii
 INTRODUCTION
Nepal Multiple Indicator Surveillance
The Nepal Multiple Indicator Surveillance (NMIS)
began in 1994, with a first cycle in early 1995 on Health
and Nutrition1 that covered a number of indicators
necessary to assess progress towards development goals.
The NMIS was designed as an-ongoing monitoring
scheme rather than a one-off survey.
In 1989 the United Nations adopted the Convention on
the Rights of the Child and it came into force in 1990.
Nepal, as a signatory to this convention, is required to
submit periodic reports on its implementation2. Among
other things, the NMIS serves as an important means of
monitoring violations of children’s rights in Nepal. It has
also assisted HMG Nepal to monitor progress against the
1990s Goals and Mid-decade Goals agreed at the World
Summit for Children (WSC) as embodied in its National
Plan of Action (NPA) for Children and Development for
the 1990s3. These two purposes of the NMIS scheme are
closely linked: the failure to meet children’s needs as
specified in the WSC and the Nepal NPA is, in fact, a
violation of their rights4. The achievement of WSC goals
is a necessary but not sufficient condition for the
realisation of corresponding rights5. International
research is on-going on defining the best indicators for
children’s rights6. But some are clearly already included
in the NPA goals.
The NMIS process comprises repeated cycles of data
collection, analysis, interpretation, and communication of
results to stimulate action. Each cycle focuses on a set of
priority issues for the health, well-being and rights of
children also for the whole population of Nepal. A
steering group from the National Planning Commission,
Central Bureau of Statistics and relevant line ministries
agrees the focus of each cycle. The Steering Group
nominates a technical group to develop and agree the
cycle plan and instruments of data collection for each
cycle as well as to play a key role in interpreting NMIS
results and ensuring their use.
The three cycles of NMIS that have taken place so far
are: Cycle 1 on Health and Nutrition1 in early 1995; cycle
2 on Primary Education7 in spring/summer 1995; and
cycle 3 on Diarrhoea, Water and Sanitation8 in the first
half of 1996. Reports on these first three cycles are
available1,7,8. The first cycle of the NMIS produced
information about malnutrition and feeding practices
among young children and showed the need for further
information on this issue. This fourth cycle of the NMIS
focuses particularly on issues of child feeding and
malnutrition and also provides some information about
child development milestones and levels of disability
among young children.
1
This fourth report in the NMIS Series includes a section
in the Introduction on Nutrition in Nepal, giving the
background of information from other studies and the
government strategy for tackling malnutrition. The
Methods section includes a background to the
methodology used in the NMIS, which will be relevant
especially for those readers who have not seen the first
three reports in the NMIS Series1,7,8. The methods used
in the fourth cycle are described, including the
instruments used and the sources of data from
households, institutions, key informants and focus
groups. The Results section is in two parts: the first part
gives the results of a descriptive analysis of the levels of
relevant basic indicators and univariate risk analysis of
those variables having an effect of the risk of malnutrition
and delayed development; the second part gives the
results of the risk analysis to examine the effects of
variables in combination on the risk of malnutrition and
estimates the possible effects of different interventions.
Results disaggregated geographically and by ethnic
group are given in Annex 5. Annex 6 is a comparison of
the results of anthropometry in NMIS cycle 4, with the
results of anthropometry in NMIS cycle 11 and the recent
Nepal Family Health Survey9. Annex 7 examines the
reasons for the higher stunting rate found in NMIS cycle
1.
This report and the reports of cycles 1, 2 and 3 are only
part of the process of communicating the results of the
NMIS to those who need them for planning and
development at national, local, community and household
levels. As with cycles 1 to 3, the findings of cycle 4 have
already been discussed in a series of workshops. For
cycle 4, a one day seminar was held for senior
government officials in Kathmandu in January 1997,
followed by a two day analysis workshop for government
staff from the Central Bureau of Statistics (CBS) and
relevant line ministries and representatives from NGOs.
The results of the NMIS cycle 4 were also presented and
discussed at a two day workshop on malnutrition and
nutrition strategy for NGOs and government staff in
Dhulikel in January 1997.
A two week workshop on the methodology used in the
NMIS and the findings of the third cycle was held in
Kathmandu in May 1996. This was aimed at staff of the
Central Bureau of Statistics who are taking on the task of
data collection for the NMIS as from cycle 5 (the field
work of cycle 5 took place in early 1997). It is planned
that these staff, supported by New ERA and UNICEF
staff, will hold a series of regional workshops during
1997 to present and discuss the findings of NMIS cycles
3 and 4 with local government staff, local NGOs and
other relevant people.
Work on planning and implementing a communication
strategy on the results of the NMIS is currently being
undertaken, with the support of UNICEF. This includes
establishing a network of all organisations, mainly
NGOs, working on nutrition and other aspects of child
health and well being. This network can be a key
channel for communicating messages derived from the
NMIS cycles, since many of the organisations have
frequent contact with communities and part of their role
is the promotion of health through teaching people about
such things as good nutrition, immunisation and
prevention and management of diarrhoea.
Childhood malnutrition in Nepal
Childhood malnutrition is a serious problem in Nepal, as
in other countries of South Asia. Several studies over the
last 20 years have performed anthropometry in young
children and produced information about the national
level of malnutrition in Nepal. The Nepal Nutrition
Status Survey in 197510 surveyed 6,562 children aged 6-
48 months and reported that 50% were stunted (had low
height for age; chronic malnutrition). In 1986, a survey
of 4,000 households in five districts around the country11
reported stunting in 50% of children aged 6-36 months.
Two recent national surveys have provided data on the
rates of malnutrition at national and sub-national levels.
The first cycle of the NMIS1, carried out in early 1995,
included anthropometry on around 5,500 children aged
6-36 months. This survey reported stunting in 64% of
these children and wasting in 6% of them. The Nepal
Family Health Survey (NFHS)19969 covered around
7,500 households and included anthropometric
measurements on around 3,700 children under 3 years
old. This survey reported 48% of children under 3 years
old were stunted (55% of children aged 6-35 months)
and 11% of children under 3 years old were wasted (had
low weight for height; acute malnutrition). The results
from NMIS cycle 1, the NFHS and NMIS cycle 4 are
compared in Annex 6. The reason for the higher rates of
chronic malnutrition (stunting) found in NMIS cycle 1 is
examined in Annex 7.
2
Gautam reviewed the evidence about malnutrition in
Nepal in 199612 and in 1996 HMG Nepal adopted a
revised Nutrition Strategy13 as a framework for
interventions to tackle the problem of malnutrition.
The causes of malnutrition are complex14 and causes
beyond the immediate ones have to be tackled if
malnutrition is to be reduced. The problem of
malnutrition is greater in Asia than in Africa. This
cannot be explained on the grounds of, for example,
worse levels of poverty in Asia, and it has been suggested
that an important cause is the poorer status of women in
Asia15. The poor status of women makes them less able
to look after their children adequately. This suggests
that, as well as issues such as food availability and
childhood infections, issues apparently far removed from
nutrition might have to be addressed in order to make an
impact on the levels of childhood malnutrition in Asia.
Data on the relationship, if any, between the status of
women and childhood malnutrition in Nepal are needed.
The aim of NMIS cycle 4 is not only to produce data on
levels of malnutrition in the country and in different parts
of the country but also to collect information about
possible risk factors for increasing the risk of
malnutrition. Identifying those factors that are associated
with an increased risk of malnutrition is the first step in
planning interventions to reduce the risk.
Many different agencies, government and non-
governmental, are trying to intervene in different ways to
reduce malnutrition in Nepal. Information about the
factors increasing the risk of malnutrition in different
parts of Nepal could help to guide their efforts. The aim
of the work described in this report is to produce data
useful to those planning ways of reducing malnutrition at
household, community, service and policy levels.
 METHODS
BACKGROUND: THE NMIS METHODOLOGY
The NMIS uses a methodology known as Sentinel
Community Surveillance (SCS). This is described in
detail elsewhere16,17,18. It has the underlying aim of
'building the community voice into planning'. SCS can
be described as a multisectoral community based
information management system. There are a number of
particular features of the SCS methodology.
‘ Data are collected from cluster sites, selected to
be representative of a district, a region or a
country.
‘ Typically, cluster sites are communities of
around 120 households, and all households in
the site are included in data collection.
‘ SCS is a repeated cyclical process, with each
cycle including planning and instrument design,
data collection, data analysis and interpretation,
and communication of results.
‘ Each cycle focuses on a particular area or
problem, rather than trying to collect data on a
wide range of problems.
‘ Quantitative data from household
questionnaires are combined with qualitative
data from focus groups, key informant
interviews and institutional reviews from the
same communities (that is, the data are
coterminous) to allow a better understanding of
the quantitative data. This combined analysis is
called mesoanalysis18.
‘ Data analysis is not only in terms of indicators
(for example, rate of childhood diarrhoea) but
also in terms of risk (for example the risk of
diarrhoea in a child with access to safe water
compared with a child who does not have
access to safe water).
‘ Data analysis, and especially risk analysis, is
intended to produce results in a form that can
be useful for planning at household,
community, district and national levels.
‘ The same sites are revisited in subsequent
cycles of data collection, allowing easy
estimation of changes over time or as a result of
intervention.
‘ Each cycle of data collection and analysis
requires a communication strategy to get the
information to those who need it for planning.
‘ Transfer of skills of data collection, analysis
and communication over a number of cycles are
an explicit aim of the methodology.
3
A key feature of SCS is the ability to do risk
analysis to look at causes. In NMIS cycle four the
focus is on causes of childhood malnutrition.
SCS is deliberately designed to concentrate data
collection efforts: in time (a series of cycles in the
sentinel sites, at approximately 6 monthly intervals); in
space (representative communities are surveyed rather
than collecting data from all communities); and in subject
matter (each cycle focuses on one area at a time, rather
than trying to collect all possible data on every occasion).
SCS employs a type of cluster survey methodology, but
the clusters are larger than in many cluster surveys:
typically 100-120 households per site, rather than the 10-
50 used in most cluster surveys. And in the SCS method,
there is no sampling within each site; every household is
included. This gives greater statistical power in the data
analysis and also allows the linkage of data from the
household questionnaires to other, mainly qualitative,
data from the same sites. This data relating to the whole
site is combined with the household data in a
mesoanalysis18.
A key issue in the SCS methodology and in the NMIS is
the selection of sites so as to be representative. In some
countries, random sampling is not a possibility because
no adequate sampling frame exists. In these situations,
purposive selection is used, drawing on local knowledge
of conditions to choose sites as representative as possible
of the situation in a district, region or country. When
possible, random sampling methods are used and this is
the case in Nepal, where a reasonably good census
sampling frame exists. In both cases, stratification is first
used to ensure that certain types of site are included in
proportion to their occurrence in the population. For
example, stratification can be by urban and rural sites, or
by ecological zones. In the NMIS, the sample sites for
the NMIS were drawn by the Central Bureau of Statistics
(CBS), after stratification into development regions,
ecological zones and urban/rural sites. The details of the
sampling method and the selected sites are given in the
report of the first NMIS cycle1 and the annexes to that
report.
NMIS CYCLE 4: SAMPLE SITES
As mentioned above, these are the same sites as for the
first three NMIS cycles, selected by a multi-stage random
sampling method. As discussed in the report of the first
NMIS cycle, the sites are representative of the country,
of the five development regions, of the three ecological
zones, of the 15 eco-development regions, and of urban
and rural situations. The rural sites were selected
primarily to give representation of the 15 eco-
development regions but in 18 districts there are
sufficient sites (four or more) to ensure reasonable
district representativeness. In a further 19 districts, only
1-2 sites were selected so they cannot be relied upon to
be representative of that district. Note that representation
of the 15 eco-development regions is among the rural
sites only; the urban sites are stratified separately and are
not intended to be part of the representation of the
different eco-development regions. This reflects the high
proportion of the population living in rural communities
(around 90%) and the difficulty of having a large enough
urban sample to stratify separately among the 15 eco-
development regions.
There are a total of 144 sites in the sample: 126 rural and
18 urban. The location of the sites is shown on the map
in Annex 1. Annex 1 also gives the names of the
Districts in the NMIS sample, with the number of sites in
each. It also includes a list of all Districts in Nepal
grouped into the 15 eco-development regions. This is
intended for officials from non-NMIS Districts who read
the report to find which results most nearly approximate
to their situation (the results for the relevant eco-
development region).
A separate NMIS Technical Report with more details
about the sample selection and weighting is in
preparation.
THE POPULATION IN NMIS CYCLE 4
A total of 18,643 households were visited in the 144
sites. Information was available for 16,955 households
(91%). Only 17 (0.1%) households refused the interview.
Other reasons for not getting information from a
household were: the household had migrated (726,
3.9%); the household had moved to the cowshed (659,
4.0%); the household head had died and no family were
there (32, 0.2%); the previous household head was not
found (127, 0.7%); double counting (40, 0.2%); there
were only children in the house (23, 0.1%); two families
were now living together (64, 0.3%). The total
population in the households interviewed is 95,752
people. More detailed information was collected about
children 3 years old and below (nutrition and feeding
practices) and about children up to five years old
(development milestones and disabilities). There are
8,315 children 36 months old and below in the
4
population; information was available for 8060 (97%).
There are 15,525 children 5 years old and below in the
population; information was available for 15,172 (98%).
Household information was collected from:
‘ 16,955 households
‘ 95,752 people
‘ 15,172 children 5 years old and below
‘ 8,060 children 36 months and below
The age and sex structure of the NMIS sample poluation
is shown in Annex 8.
INSTRUMENTS
The instruments used in cycle 4 are reproduced in Annex
2. They include a household questionnaire, focus group
guides, and a health facility review/interview. The
instruments were designed in collaboration with
members of the NMIS Steering Committee, taking into
account the advice and views of UNICEF and
government staff working in health and child, particularly
in the field of nutrition.
Instruments used in NMIS cycle 4:
‘ Household questionnaire
‘ Health facility interview schedule
‘ Focus group guides
The household questionnaire includes questions about
literacy of the mother (or other caretaker) of children
aged 5 years and under, questions about development
milestones and motor and sensory abilities of children,
questions about feeding for children 36 months and
below and questions on beliefs about child feeding
practices. The ‘reference periods’ for the different
questions on the households questionnaire were generally
short (a day or a week). Details are shown in the
questionnaire itself (Annex 2).
At the time of administering the household questionnaire,
the interviewers weighed and measured each child
between 6 and 36 months old in each household and
measured the mid upper arm circumference (MUAC) of
each child 12-36 months old.
For each of the 144 communities, the health facility that
most served the community was visited and the most
senior worker was interviewed.
In each of the 144 communities, a focus group of mothers
of children aged 5 years or below was held to discuss the
feeding of young children and the best ways to give
messages about feeding practices to communities. A
second focus group of mothers was held in each
community to discuss the findings of NMIS cycle 3 (on
diarrhoea, water and sanitation) and the best way to pass
on the important messages to communities.
The focus group guide for cycle 4 covers feeding
frequency for young children, liquid and solid foods for
young children, food taboos and the position of women in
the community and their ability to take decisions about
care of their children. The focus group guide for
discussion of cycle 3 results covers treatment of water in
the home and hygiene practices and giving fluids
promptly to children with diarrhoea. The results of the
cycle 3 feedback are not given in this report but are being
used in development of the communication strategy
around NMIS findings.
Coding sheets and data entry formats were created for
each instrument. The data were entered and cleaned
using the FoxPro database programme and later
converted into EpiInfo (version 6)19 for epidemiological
analysis.
The questionnaires and other data collection instruments
were piloted several times to ensure that they were
appropriate to the households, health facility workers
and focus groups concerned and that the coding and data
entry arrangements were satisfactory.
TRAINING AND FIELDWORK
Field staff were recruited in August 1996. They were
recruited from and trained in three regional centres:
Kathmandu, Birgunj and Nepalgunj. Ten teams, each
containing five or six members, were recruited. Each
field team had two or three female members. The ten
field teams and ten field supervisors were trained in
Kathmandu. Four of these teams and supervisors then
went to undertake field work in the Hills ecozone. In
September 1996 four supervisors conducted training in
Birgunj and two in Nepalgunj, accompanied by the New
ERA NMIS Project Coordinator, Project Associate and
two Research Assistants. At least two field pilot tests of
the cycle 4 instruments were carried out, to check the
instruments and train the field staff. Four New ERA staff
intensively supervised the field data collection between
September and early November1996.
When communities were revisited during cycle 4, the
opportunity was taken to give them a summary of the
results of cycle 3 and conduct focus groups to discuss the
implications of the key findings and the ways in which
important messages might best be disseminated.
Data coding and entry began during the fieldwork
programme, with messengers bringing back as much data
as possible to Kathmandu from each of the field teams.
Data entry began in October 1997 and data entry and
5
cleaning of quantitative data was completed by the end of
December 1997. Data entry of qualitative data from
focus groups was completed by the end of January 1997.
ANALYSIS
The analysis had several aims: to produce national
indicators on childhood nutrition and development
milestones in Nepal; to examine variables that might be
related to malnutrition or development delay; and,
perhaps most importantly, to look for contrasts so as to
discover actionable factors that might help to improve the
situation. This required an analysis of the risk of
malnutrition or delayed development in relation to
possible explanatory variables (for example, feeding
frequency, household food security, advice from health
workers, ability of women to make decisions about child
care). The effects of variables in combination were
examined using multiple stratification and logistic
regression. The logistic regression was a step down from
a saturated model to find the best fitting, most
parsimonious model.
The analysis was performed using the EpiInfo package
(version 6)19. This public domain computer package that
assists with questionnaire creation, data entry and data
analysis. The strength and statistical significance of
associations was tested using the Mantel-Haenszel X2
test20 and the Mantel Extension of this test
21
. Logistic
22
regression was performed using Nanostat .
The quantitative analysis was supplemented by
qualitative data from focus groups, key informants and
observation. The records of the 144 focus groups (one
for each community) were reviewed to get an overview
of the ideas expressed. Each focus group was then coded
according to the issues raised by the participants. These
codes were then related to information from the
household questionnaires from the same community.
The focus group themes are shown in annex 3, with the
frequency of each one.
Weighting of results to give national indicators.
As explained in the report of the first cycle of the NMIS1,
the sample sizes of Districts were not proportional to the
populations of the Districts and weights were calculated
to take this into account when producing national
indicators. These same weights were used in this fourth
cycle of the NMIS when giving national level indicators.
The weighted and unweighted values for key indicators
are shown in annex 4. The Epi Info programme
CSAMPLE was used to calculate weighted values of key
indicators. In practice, the weighted values are very close
to the unweighted values for the key indicators. Unless
stated otherwise, values of indicators quoted in the
Results section for the whole of Nepal are weighted.
 RESULTS: I. BASIC INDICATORS AND RISK ANALYSIS
malnutrition (height for age) and acute malnutrition
NUTRITIONAL STATUS (weight for height).

Nutritional status was estimated using the results of Although less reliable at older ages, there is a strong
anthropometry (measurement of height and weight) in association between low MUAC and acute and chronic
children between 6 and 36 months old in the survey. malnutrition assessed by anthropometry. This is shown
This was supplemented, in children between 12 and 36 in Table 1.
months old, by measurement of mid upper arm
circumference (MUAC). Table 1. Low MUAC and malnutrition assessed by
anthropometry in 4410 children aged 12-36 months
In this survey, undertaken just after the monsoon season,
the findings indicate that rates of both acute malnutrition MUAC % wasted % stunted
(low weight-for-height) and chronic malnutrition (low
height-for-age) are high. In both cases, children are said <12.5cm 51 85
to have malnutrition if their value is more than two
>12.5cm 13 55
standard deviations below the median value of the
international reference population. OR (95% CI) 6.67 4.47
(5.42-8.21) (3.43-5.83)

‘ 53% of children aged 6-36 months have <13.5cm 34 74

chronic malnutrition (stunting)
>13.5cm 8 49
‘ 16% of children aged 6-36 months have
acute malnutrition (wasting) OR (95% CI) 6.13 2.99
(5.13-7.34) (2.61-3.43)
OR=Odds Ratio. 95%CI= 95% confidence interval
There is a striking relationship with age, with the
proportion of children who are stunted and wasted rising As expected, there is a stronger relationship between low
sharply between 6 and 24 months and then leveling off or MUAC and wasting (acute malnutrition) than between
even falling in older children (Figure 1). This goes low MUAC and stunting (chronic malnutrition).
against the notion that ‘Nepalis are just small’; they are
born roughly the same length as children internationally Perhaps not surprisingly, there is an association between
and later become stunted. stunting and wasting such that children who are wasted
are nearly one and a half times more likely to be stunted
There is no significant difference between boys and girls; than children who are not wasted (Table 2).
the overall rate of stunting among boys is 53%, among
girls 52% and the overall rates of wasting 17% in boys Table 2. Relationship between stunting and wasting
and 16% in girls. The age pattern in boys and girls is the in 5754 children aged 6-36 months
same.
Stunted Wasted (low weight for height)
The MUAC is less than 12.5cm, indicating serious (low height for
malnutrition, in 12% of children aged 12-36 months. It age) Yes No
is less than 13.5cm, including also moderate
Yes 555 (59%) 2455 (51%)
malnutrition, in 38% of children aged 12-36 months.
The pattern of low MUAC in relation to age is different No 389 (41%) 2355 (49%)
from the age relationship with anthropometry (Figure 2). Odds ratio=1.37; 95% confidence interval=1.18-1.58

The proportion of children with a low MUAC decreases
steadily with age and there is no evidence of an increase
between the ages of 12 and 24 months to mirror the
increasing proportion of children with acute or chronic
malnutrition, based on anthropometry , in this age range.
While the causes of acute and chronic malnutrition are
believed to be different (not just in timing), it is not
surprising to find that sometimes the conditions for the
two problems coincide.

The different age relationship of anthropometry and

MUAC reflects the influenceof overall size of the child,
taken into account in the calculation of chronic

6
Figure 1. Stunting and wasting in relation to age of 5754 children aged 6-36
months

70
Stunted
60

50
% of children

40

30

20
Wasted
10

0
6 12 18 24 30 36
m m m m m m

Figure 2. Relationship between reduced MUAC and age in 4732 children aged
12-36 months

60
MUAC <13.5cm
50
% of children

40

30
MUAC <12.5cm
20

10

0
12 18 24 30 36
m m m m m

7
Geographic and ethnic variation in nutritional status measured in some parts of the terai just after the
There is important geographic variation in nutritional monsoon in 1996 are likely to be a reflection of the truth,
status as assessed by anthropometry. The variation by rather than a measurement error. This could be related
eco-zone is shown in Figure 3. to the heavy monsoon with serious flooding, leading to
crop destruction with food shortage and to high rates of
Figure 3. Stunting and wasting in children aged 6- diarrhoea among the children. Recovery had not taken
36 months, by eco-zone place by the time of the survey. The areas most affected
are those where food security is already marginal, so that
any disruption is rapidly translated into malnutrition
63
Mts
8
among vulnerable young children.

56 The effect of zone of residence on the risk of malnutrition

Hills
9 in young children is shown in Table 3.

50 Table 3. Zone of residence and malnutrition in

Terai
24
children aged 6-36 months (rural sites only)
0 20 40 60 80 Nutritional status Zone of residence
Stunted
% of children
Wasted Terai Hills/Mts

Stunted (%) 1224 (50) 1556 (58)

There is a higher proportion of children with chronic Not stunted (%) 1238 (50) 1147 (42)
malnutrition (stunting) from the terai (50%) to the
mountains (63%). The opposite is seen for acute Odds Ratio=0.73 (95% CI 0.65-0.81)
malnutrition (wasting); the proportion of children with
Wasted (%) 601 (24) 254 (9)
wasting is strikingly higher in the terai than in the hills or
mountains. Nearly a quarter of children in the terai Not wasted (%) 1861 (86) 2449 (91)
sample in this survey have acute malnutrition.
Odds Ratio=3.13 (95% CI 2.63-3.70)
The geographic pattern of low MUAC tends to follow See Results II for analysis of the effect of this variable in
that of acute malnutrition, with more children having a combination with others.
low MUAC in the terai than in the hills or mountains
(Figure 4). There is some variation in nutritional status by ethnic
group; this could be mainly due to different ethnic mixes
Figure 4. Low MUAC in children 12-36 months, by of the population in different parts of the country. The
eco-zone ethnic variation in stunting and wasting is shown in
Figures 5 and 6 and in Annex 5, Table A5.3.
35
Mts
11
Figure 5. Variation in rate of stunting among
children 6-36 months, by ethnic group
36
Hills
10

43
Terai
13

0 10 20 30 40 50
MUAC <13.5cm
% of children
MUAC <12.5cm

Disaggregation of the data by eco-development regions

and by districts reveals that certain districts in the Eastern
and Central terai have very high rates of wasting (up to
38%) among young children; there are proportions of
children with low MUAC readings in the same districts.
These data are shown in Annex 5, Tables A5.1 and A5.2.
So it seems that the very high rates of acute malnutrition

8
Figure 6. Variation in rate of wasting among Only 59% of health facilities weigh children and
children 6-36 months, by ethnic group only 9% measure their height.
34 34
35

30 28
Most (64%) of the health facilities visited were sub
25 health posts (SHP), with another 16% health posts (HP).
% of children

21
19 20 SHP, HP and similar facilities are less likely than health
20

15
centres (HC) and hospitals to weigh children (56% vs
11 11 71%) and less likely to measure their height (7% vs
9
10 7
5 6 6 18%).
5

0 Thus very few communities in this sample are served by

1 2 3 4 5 6 7 8 9 10 11 12 13 health facilities able to identify acute malnutrition (low
Ethnic groups weight for height) or chronic malnutrition (low height for
age). About half are able to identify general malnutrition
In figures 5 and 6, ethnic groups are as follows: (low weight for age).
1: Brahmins 2: Chhetri
3: Newar 4: Gurung/Ghale
5: Magar 6: Rai/Limbu
7: Tamang/Sherpa 8: Muslim Household food security
9: Occupational 10: Tharu Two questions on the household questionnaire gave
11: Yadav 12: Other (terai) information about the food security of households and of
13: Other (hills)
mothers in particular. Mothers were asked how many
times in the previous week they had limited their own
Mothers’ perceptions of children’s growth food so as to give to the child; and whether they had
Mothers were asked if they thought their child was well enough food themselves the previous day.
grown for his or her age. Nationally, 82% of mothers
report their children are well grown for their age. Their
perception is related to anthropometric measurements but ‘ 91% of mothers reported having enough
they tend to underestimate malnutrition. The relationship to eat the previous day
is shown in Table 4. ‘ 25% of mothers reported limiting their
own food at least once in the previous
Table 4. Mothers’ perceptions of child growth and week to give food to the child
anthropometry among 5744 children 6-36 months

‘Well grown for % stunted % wasted The question about food limitation in order to give to the
age’ child may reflect child care practices as much as general
No 70 25
food security of the household. The high proportion of
women reporting they had enough to eat the previous day
Yes 48 15 may be an over-estimation: interviewers mentioned there
was sometimes a problem asking this question if the
OR 0.40 0.52
(95% CI) (0.3-0.46) (0.44-0.61)
mother-in-law was nearby.

There was not much variation in the answers to these

Table 4 shows that among children thought by their
mothers to be well grown for their age, nearly half (48%)
are stunted and one in seven (15%) is wasted.
Child nutrition monitoring by health facilities
In each site, the interviewing team tried to visit and get
information from the health facility serving that
community. Each facility was asked about what clinics
they ran to weigh children or to measure children and
about how many children they had found to have acute or
chronic malnutrition in the last year.
questions between ethnic groups; the figures are shown
in Annex 5, Table A5.4. Similarly, the geographic
variation is not very marked. This is shown in Annex 5,
Table A5.5. There is no suggestion of more food
shortage currently in the terai to reflect the high rates of
acute malnutrition there. This may be because the
questions are not a very good index of food shortage,
because the food shortage related to the acute
malnutrition in the children was over by the time of the
survey, or because the acute malnutrition seen in the
children is mediated by other factors apart from
household food shortage.

9
Mother’s food security and child nutritional status
Children whose mothers report not having enough food
to eat the previous day are more likely to be stunted or
wasted than children whose mothers had enough to eat.
The relationship is shown in Table 5.
Table 5. Mother’s food security and malnutrition in
children aged 6-36 months
Nutritional status Mother has enough to eat
No
Stunted (%) 309 (60)
1996 Nepal Family Health Survey9.
All households with children aged 72 months and under
were asked how soon after birth they thought breast
feeding should start. Their responses are shown in
Figure 8. Comparing Figure 8 with Figure 7 shows that
in practice breast feeding is started rather later than
people believe it should be.
Figure 8. Household opinions about timing of start
Yes of breast feeding (9173 households)
2658 (52)

Not stunted (%) 203 (40) 2496 (48) <30min 23

30-60min 36

Odds Ratio=1.43 (95% CI 1.18-1.72) 1-2hr 20

2-4hr 5

Wasted (%) 102 (20) 821 (16) 4-24hr 4

24-48hr 3
Not wasted (%) 410 (80) 4333 (84) 48-72hr 9
>72hr 0
Odds Ratio=1.32 (95% CI 1.03-1.67) 0 10 20 30 40

See Results II for analysis of the effect of this variable in % of households

combination with others.

Feeding practices
Mothers were asked about breast feeding practices and
other feeding practices for young children, including
feeding frequency.
Breast feeding practices
Breast feeding is almost universal; only 0.3% of children
are said not to have been breast fed at all. For more than
half of infants, breast feeding is started within the first
two hours, but it is sometimes delayed for 2-3 days. The
timing of starting breast feeding is shown in Figure 7.
Mothers were asked about whether they threw away the
colostrum (‘first milk’) or fed it to the infant. Nationally,
just over a third (36%) of children had the colostrum
thrown away rather than fed to them.
There is variation in breast feeding practice by area of the
country and by ethnic group. The variation by ethnic
group is shown in Figures 9 and 10.
Figure 9. Practice of throwing away colostrum, by
ethnic group
80
78

Figure 7. Timing of starting breast feeding in 7822 70 65

children 60
50 50 48
50
40
40
13 28
<30min 30 26 23 24
22
30-60min 24
20 17 19
1-2hr 17
10
2-4hr 8
0
4-24hr 11
1 2 3 4 5 6 7 8 9 10 11 12 13
24-48hr 8
Ethnic groups
48-72hr 16
>72hr 3

0 5 10 15 20 25
% of children

More than a third (37%) of children are said to have

breast feeding started within one hour of birth. This is
higher than the equivalent figure (18%) reported in the

10
Figure 10. Variation in timing of starting breast Figure 12. Pattern of breast feeding with age in
feeding by ethnic group children up to 36 months old

90 86 88
80 82 83
% starting b'feeding within 4 hrs

100
80
71 74 73 90 No breastfeeding
80
70
60 70

% of children
60 60
49 Breastfeeding with supplements
50 50
40
40 33 30
30 22 20

20
17 10 Exclusive breastfeeding
0
10 3 9 15 21 27 33

Age in months
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Ethnic groups
It is generally recommended to breast feed exclusively up
See Figures 5 and 6 for details of ethnic groups to four to six months of age. As shown in Figure 12, by
three months of age only 72% of children are exclusively
Practices of throwing away colostrum and starting breast breast fed. On the other hand, some mothers continue
feeding also vary geographically. Figure 11 shows the exclusive breast feeding beyond six months: 12% are still
variation by ecozone; more details of geographic being exclusively breast fed at 8 months and 2% at one
variation are shown in Annex 5, Table A5.6. Variation year. Ideally, exclusive breast feeding would be nearly
between ecozones probably reflects different ethnic mix universal up to six months and then drop sharply .
in different areas (see Annex 5, Tables A5.7)
Benefits and disadvantages of breast feeding
Figure 11. Timing of start of breast feeding and
Households were asked their views about the benefits
use of colostrum in different ecozones
and disadvantages of breast feeding for the mother and
the child. The responses show that perceived benefits,
68 especially for the child, far outweigh perceived
Mts disadvantages. Tables 6, 7, 8 and 9 summarise the
34
responses of households. Respondents could give up to
78 4 answers for each question.
Hills
16
Table 6. Perceived benefits of breast feeding for the
46 child (9452 households)
Terai
57
Perceived benefit No. (%) of responses
0 20 40 60 80
Start in <4 hrs No benefit 97 (1)
% of children
Discard colostrum
Good for growth, health 12508 (132)

Better mental development 251 (3)

There is no difference between boys and girls in the
Better digestion 42 (0.4)
proportion having the colostrum thrown away or in
timing of the start of breast feeding. Prevents diarrhoea 18 (0.2)

Breast feeding is generally prolonged, with nearly half Don’t know 623 (7)
of children aged 36 months still being breast fed. Note: The figure of 132% for the category of ‘good for growth, health’ is
produced because respondents could give up to four answers and the
However, exclusive breast feeding does not last long
answer categories were combined when producing this table. Thus the
after birth and liquid or solid complements are often 132% category is a combination of several catagories, all of which were
added within the first three months. The pattern of breast popular answers.
feeding and complementation with age is shown in figure
12. This pattern is similar to that reported in the 1996
Nepal Family Health Survey9.

11
Table 7. Perceived benefits of breast feeding for the birth are at increased risk of being malnourished; mainly
mother (9452 households) at increased risk of being wasted. This relationship is
Perceived benefit No. (%) of responses
shown in Table 10.

No benefit 5319 (56) Table 10. Throwing away colostrum and

malnutrition in children aged 6-36 months
Physical comfort (eg breasts) 1333 (14)
Nutritional status Colostrum thrown away
Satisfied with child growth 284 (3)
Yes No
Better general health 131 (1)
Stunted (%) 1160 (54) 1783 (51)
Birth spacing 94 (1)
Not stunted (%) 997 (46) 1712 (49)
Saves times and money 59 (1)
Odds Ratio=1.11 (95% CI 1.00-1.25)
Prevents breast diseases 23 (0.2)
Wasted (%) 483 (22) 445 (13)
Don’t know 2223 (24)
Not wasted (%) 1674 (78) 3050 (87)
Table 8. Perceived disadvantages of breast feeding
for the child (9452 households) Odds Ratio=1.96 (95% CI 1.69-2.27)

Perceived disadvantages No. (%) of responses

See Results II for analysis of the effect of this variable in
combination with others.
No disadvantages 6934 (73)

Sickness due to illness, diet, or 174 (2)

pregnancy of mother
Diarrhoea, worm infections
Teeth decay
Sick if fed for 2 years plus
Weaning practices
Mothers were asked, for children under 36 months no
124 (1) longer breast fed, at what age breast feeding stopped and
what were the reasons for stopping breast feeding. The
24 (0.2)
mean age of stopping breast feeding, among those who
5 (0.1) had already stopped, was 19.5 months.

Don’t know 2059 (22) The reasons given for stopping breast feeding are shown
in Table 11.
Table 9. Perceived disadvantages of breast feeding
for the mother (9452 households) Table 11. Reasons given by 1265 mothers for
Perceived disadvantages No. (%) of responses stopping breast feeding in children up to 36 months
Reason for stopping No. (%) of responders
No disadvantages 2288 (24)
Pregnancy 743 (59%)
Weakness, weight loss, illness 5749 (61)
Birth of another child 153 (12%)
Some foods not allowed 207 (2)
No milk; mother weak 123 (10%)
Takes too much time 196 (2)
Child refused, got sick 119 (9%)
Painful, damaged nipples 41 (0.4)
Other maternal problems 88 (7%)
Don’t know 1481 (16)
Weaning to other foods 56 (4%)

Households seem more aware of benefits of breast

feeding for the child than for the mother.
Four out of five households know of no benefits of
breast feeding for mothers
Breast feeding practices and nutritional status
Children who had the colostrum thrown away at their
Liquid and solid food complements
The complements added to breast milk are partly liquids
and partly solids. Mothers were asked at what age they
added liquids and solids to the child’s diet (for children
no longer exclusively breast fed) and from their
responses it is possible to calculate the age distribution
of complementation with liquids and solids. The ages at
which liquids and solids were added to the diet are shown

12
in Figure 13. Children reported to have had liquids and solids added to
the diet relatively later are more likely to be stunted or
Figure 13. Mothers’ recall of age of starting liquid wasted. These relationships are shown in Tables 12 and
and solid complements for children no longer 13.
exclusively breast fed
Table 12. Age of adding complementary liquids and
malnutrition
35
Liquids
30
Solids
Nutritional status Age of adding liquids
% of children

25
20 4+ mnths 0-3 mnths
15
10 Stunted (%) 2266 (55) 693 (48)
5
0 Not stunted (%) 1880 (45) 738 (52)
<1 1 2 3 4 5 6 7 8 9 10 11 12
Age in months Odds Ratio=1.28 (95% CI 1.13-1.45)

Wasted 758 (18) 149 (10)

As shown in Figure 13, at ages below six months more Not wasted (%) 3388 (88) 1282 (90)
children have liquid complements started than solid
Odds Ratio=1.92 (95% CI 1.59-2.34)
complements. The mean age of starting liquid
complements is 4.9 months, and that of starting solid See Results II for analysis of the effect of this variable in
complements 6.8 months. The nutritional value of these combination with others.
liquid complements was not assessed directly in this
survey, but discussions in communities and with Table 13. Age of adding complementary solids and
government and NGO staff working in communities malnutrition
suggest that liquids given to young children are often of Nutritional status Age of adding solids
low nutritional value.
5+ mnths 0-4 mnths
Households were asked at what age they thought solids Stunted (%) 2599 (54) 330 (47)
should be added to the diet of young children and their
responses are shown in Figure 14. Not stunted (%) 2178 (46) 376 (53)

Odds Ratio=1.36 (95% CI 1.15-1.60)

Figure 14. Household opinions of when to add
solids to a child’s diet (9282 households) Wasted 831 (17) 54 (8)

Not wasted (%) 3946 (83) 652 (92)

50 47
Odds Ratio=2.54 (95% CI 1.89-3.44)
% of households

40

30 See Results II for analysis of the effect of this variable in

20
combination with others.
12 11
10 5 7 6
3 3
0 1 2 2 0 The reason for this apparent benefit of adding
0
<1 1 2 3 4 5 6 7 8 9 10 11 12
complementary liquids and solids earlier is not clear. It
Age in months could be due to confounding by socioeconomic status of
the household, not measured in this survey. Literate
mothers add liquid and solid complementary foods at an
earlier age. But the increased risk of malnutrition in
Comparing Figure 13 and Figure 14 shows that practice children with complementary foods added later persists
accords closely with beliefs about when solid food should when literacy of the mother is taken into account. It could
be added to a child’s diet. be that when exclusively breast fed infants are fed
infrequently (as in this sample - see below), they do not
Ethnic and geographic variations in the age of adding get enough nutrient intake to thrive. Further analysis in
liquid and solid complements are shown in Annex 5, combination with other variables is shown in Results II.
Tables A5.8 and A5.9. The average age of adding both
liquids and solids is somewhat higher in the terai than in Type of foods given to young children
the hills or mountains. Households were asked if they thought ‘porridge or
watery porridge’ was better for the nutrition of a young
Addition of complements to diet and nutritional status

13
child. Of the 9090 households who were able to give an
opinion, 60% think that watery porridge is better
nutritionally for young children. 197 were not able to say
and information was missing from 165 households.
The household opinions are not surprising in light of the
views of health workers, sought in the institutional
reviews of health facilities serving the sample sites.
Among health workers, 56% think liquid foods are more
nutritious for young children, 22% think solid foods more
nutritious, and 22% think they are equally nutritious.
Their views are the same for boy and girl children.
Nearly all (97%) of health workers interviewed report
passing on their views about the nutritional value of
liquids and solids to parents.
‘ 60% of parents think liquid foods are
more nutritious for young children
‘ 56% of health workers think liquid foods
are more nutritious
‘ Nearly all health workers pass on their
opinion to parents
The views of health workers depend on the type of health
worker concerned. The proportions of the different types
of health workers interviewed and their differing views
about the nutritional value of liquid food are shown in
Table 14.
Table 14. Types of health worker and views of
whether liquid or solid food is more nutritious
Type of worker % thinking liquid food is more
under half (47%) of the groups thought solid food best,
similar to the household questionnaire responses.
Almost all the groups felt that mothers would easily
accept the idea that solid food was best for young
children if the reasons were explained to them. They
found the explanation about the benefits of solid food
given in the focus groups convincing.
“We did not know that solid food is better until your
explanation. Other mothers also do not know but if they
are shown and informed they will understand and
accept this.”
The household questionnaire included a specific question
on the use of tinned milk for children under 36 months.
Only 3% of children in the sample are given tinned milk.
Feeding frequency
The household questionnaire sought information about
how often children up to 36 months old were fed (during
the previous day), in total and for breast feeding
specifically. Figure 15 illustrates the responses to these
questions. Breast feeding is quite often 4 times or less in
the day (24 hours), reflecting the high proportion of
children given complementary liquid and solid food even
from an early age. About one in seven children is fed
less than four times a day in total.
Figure 15. Frequency of feeding per day in
children up to 36 months old
40 36 37 All feeding
35 31 Breastfeeding
30 28
% of children

(% of total) nutritious 25 22
20 18
16
WCHW (16%) 61% 15
14

10
VHW (18%) 52%
5
0
AHW / CA AHW (48%) 62%
0-4 5-6 7-8 9+
times times times times
Med Rec Asst / Health Asst 38%
(7%)

Medical Officer (4%) 25%

Households also gave their views on how often they think
Nurse / ANM (7%) 50%
a young child should be fed (including breast feeding).
WCHW=Women and Child Health Worker;
VHW=Village Health Worker;
Their responses are summarised in Figure 16.
AHW=Auxiliary Health Worker;
ANM=Assistant Nurse Midwife

Focus groups of mothers in each of the 144 sample

communities discussed issues of child feeding and
nutrition. The themes from the groups are shown in
Annex 3. The discussion included if solid or liquid food
was better for young children (under two years). Just

14
Figure 16. Household opinions of how often a
young child should be fed
35
35 33
30
% of households
25 23
20
15
9
10
5
0 Lack of time
0-4 5-6 7-8 9+
times times times times
The feeding frequency in practice (Figure 15) is close to
the frequency that households believe to be correct
(Figure 16). Considering individual children, those in
households where more frequent feeding is thought
desirable have more than twice the chance of being fed
frequently compared with those in households advocating
less frequent feeding (Table 15). But still 13% of those
in households advocating feeding more than four times a
day are fed less frequently than this.
Table 15. Feeding frequency in practice in relation to
opinion of desirable frequency
Opinion of desirable Feeding frequency of child
feeding frequency
0-4/day
0-4 times/day 178 (26%)
5+ times/day 888 (13%)
Odds ratio= 2.34; 95% confidence interval 1.93-2.83
The mean reported frequency of breast feeding in 24
hours is 6.1 times and of all feeding is 7.9 times. The
mean desirable frequency of feeding as stated by
households is 7.9 times. The reported frequency of
feeding is little different between boys and girls: breast
feeding 6.1 times in boys and 6.0 times in girls; and total
feeding 8.1 times in boys and 7.8 times in girls.
When mothers in focus groups were asked how often
they and others in that community fed young children,
their responses suggested a lower mean frequency (4.8
times) than that stated by individual households (7.9
times). Focus group discussions are shown in Annex 3.
In only 68 of the 144 groups (47%) is the feeding
frequency said to be five times a day or more. This is
much lower than the 86% of mothers responding to the
household questionnaire claiming to feed the child five
times a day or more (see Figure 15). The reason for this
discrepancy is not clear; it may be that mothers in a
group are more likely to admit to feeding less frequently
but overestimate feeding frequency when asked
individually.
Only one in ten focus groups thought it would be easy to
feed young children at least 6 to 8 times a day (see Annex
3). Constraints mentioned are shown in Table 16.
Table 16. Difficulties in feeding young children more
often, as identified in 144 focus groups
Type of difficulty % of groups
88%
Too much work 76%
Lack of food to give more often 34%
Lack of money 24%
More than one reason was given by each group
But groups readily accepted that feeding children more
often was good practice and could, in fact, save money in
the end:
“A healthy child does not get sick, which saves money.
Parents feel happy to see their children healthy so they
have to feed them 6-8 times a day.”
Among the health workers interviewed, nearly all (92%)
think that children (under one year old) should be fed at
least five times a day. The lowest proportion thinking
5+/day this was among VHWs (86%). More than 90% report
giving this advice to parents and nearly all think it is
518 (74%) equally true for boys and girls. There is some evidence
that this advice might be helpful. Children from
6039 (87%)
communities where the health worker believes in more
frequent feeding are fed more frequently than those from
communities where the health worker advocates less
frequent feeding (Table 17).
Table 17. Frequency of feeding recommended by
health workers and frequency of feeding among
children from the communities served
Health worker Frequency of feeding per day
recommended
frequency 0-4 5+
0-4 x per day 87 (20%) 358 (80%)
5+ x per day 753 (13%) 4972 (87%)
Odds Ratio=1.60; 95% confidence interval 1.24 - 2.07
There is some geographic and ethnic variation in how
often young children are fed. This is shown in Annex 5,
Tables A5.10-A5.12. The mean frequency is higher in
the terai (9.0 times per day) than in the hills (6.8) or
mountains (7.1).
Feeding frequency and nutritional status
15
Children fed less frequently have more risk of being Table 19. Person who feeds child when mother is not
stunted than children fed more frequently. However, the available
relationship between feeding frequency and wasting is Person who feeds the child if Number (%)
more complex, with children who are wasted reported to mother is not available
be fed more frequently than those who are not wasted.
The relationships are shown in Table 18. Mother always feeds child 2256 (28)

Grandmother 2570 (32)

Table 18. Feeding frequency and malnutrition
among children 6-36 months old Elder sister 1512 (19)

Nutritional status Frequency of feeding per day Father 831 (10)

1-5 times 6+ times Other female relative 381 (5)

Stunted (%) 774 (60) 2217 (50) Elder brother 339 (4)

Not stunted (%) 523 (40) 2206 (50) Other male relative 144 (2)

Odds Ratio=1.47 (95% CI 1.23-1.67) Servant, neighbour (? sex) 47 (1)

Wasted 146 (11) 791 (18) Respondents were allowed more than one choice

Not wasted (%) 1151 (89) 3632 (82)
Odds Ratio=0.58 (95% CI 0.48-0.71)
See Results II for analysis of the effect of this variable in
combination with others.
The probable explanation for the relationship between
wasting and more frequent feeding is that sickly, thin
children are fed more often in an attempt to improve their
condition. This might be particularly the case in this
survey, since it took place soon after a period when there
was flooding and food shortage but at a time when food
was again available. Children who are stunted seem not
to be recognised as malnourished to the same extent and
so do not attract this extra feeding. For stunting,
therefore, the underlying effect of chronic undernutrition
associated with less frequent feeding is apparent.
Among all children up to 36 months old, most are said to
have a separate plate for their food and only a minority
are said to eat when the rest of the family eats.
‘ 19% of children eat with the rest of the
family (15% take breast milk only)
‘ 77% of children have a separate plate for
their food
There is some variation with age in the proportion of
children who feed with the rest of the family and have
their own plate. This is shown in Figure 17.
Figure 17. Use of a separate plate and eating with
the rest of the family by age

Who feeds the child and how the child eats 90

Usually the mother is responsible for feeding children up 80
Separate plate
70
to 36 months old. Questions about child feeding in the
% of children

60
household interview were addressed where possible to 50
the child’s mother or otherwise to the ‘main carer’ of the 40
Eats with family
child. 30
20
‘ For 83% of children up to 36 months the 10

mother responded as the main carer 0

3 9 15 21 27 33
‘ 93% of children have a female as their
Age in months
main carer

It seems that less children have their own plate between

Households were asked who fed the child if the mother the ages of about 6 and 18 months than younger or older
was not available. Answers are shown in Table 19. children. By nine months, nearly a third of children eat
with the family and this proportion stays fairly stable with
increasing age.

16
How the child eats and risk of malnutrition Table 21. Whether child has separate plate and
In some focus groups it was suggested that children malnutrition among children 6-36 months old
would do better if the fathers took more part in their care. Nutritional status Child has separate plate
For example:
“The children would do better if our husbands looked No Yes
after them instead of the baby sitter who eats up the
Stunted (%) 695 (53) 2264 (53)
child’s meal left by the mother.”
Not stunted (%) 613 (47) 2007 (47)
However, children who are fed by the father or other
Odds Ratio=1.01 (95% CI 0.88-1.14)
male relative when the mother is not available have a
higher risk of malnutrition than those who are always fed Wasted (%) 253 (19) 654 (15)
by the mother or fed by a female relative. The effect is
mainly confined to stunting, with little effect for wasting. Not wasted (%) 1055 (81) 3617 (85)
The relationships are shown in Table 20.
Odds Ratio=1.33 (95% CI 1.12-1.56)

Table 20. Person who feeds the child and See Results II for analysis of the effect of this variable in
malnutrition among children 6-36 months old combination with others.
Nutritional status Who feeds child other than mother

Father/male Mother/female Diarrhoea incidence and management

relative relative Childhood diarrhoea, water and sanitation was the focus
of NMIS cycle 35. The household questionnaire for cycle
Stunted (%) 635 (58) 2373 (51) 4 also included a few questions about childhood
Not stunted (%) 459 (42) 2282 (49) diarrhoea and its management, since this can have an
important effect on malnutrition in young children.
Odds Ratio=1.33 (95% CI 1.16-1.52)
16% of children under 36 months old had diarrhoea
Wasted (%) 182 (17) 762 (16)
within the last two weeks. The proportion with diarrhoea
Not wasted (%) 912 (83) 3893 (84) in the last two weeks is similar to the figure of 18% for
children up to 5 years old in NMIS cycle 35; both surveys
Odds Ratio=1.02 (95% CI 0.85-1.22)
were in non-monsoon periods.
See Results II for analysis of the effect of this variable in
combination with others. Just over half (51%) of the most recent episodes of
diarrhoea lasted three days or less; again similar to the
A child who does not have a separate plate for eating has finding in NMIS cycle 35. Nearly all children (93%) are
a higher risk of malnutrition than a child who has a said to have been looked after by the mother during their
separate plate. In this case, the effect is on wasting rather most recent episode of diarrhoea. The next most
than on stunting. The effect may be mediated through an common carer for the child with diarrhoea is the
increased risk of diarrhoea in children who do not have grandmother (5%).
a separate plate. The effect of having a separate is shown
in Table 21. Continuing feeding a child during an episode of diarrhoea
is important and, together with giving increased fluids,
forms the basis of the correct ORT (oral rehydration
therapy) for a child with diarrhoea. If feeding is not
continued this effectively leads to acute malnutrition due
to the increased metabolic requirements and poor
absorption from the gut at this time. But only about 20%
of children with diarrhoea are given increased fluids and
continued feeding in Nepal (see NMIS cycle 35). In cycle
4, parents were asked how much food the child was
offered during the most recent episode of diarrhoea. The
feeding of children with diarrhoea is shown in Figure 18.

17
Figure 18. Feeding of children up to 36 months old Not stunted (%) 432 (46) 2296 (48)
during most recent episode of diarrhoea Odds Ratio=1.05 (95% CI 0.92-1.22)

Wasted (%) 208 (22) 731 (15)

70 65 Not wasted (%) 721 (78) 4066 (85)

60
% of children

50 Odds Ratio=1.61 (95% CI 1.33-1.92)

40
30
20
20
11
10 4
0
None Less Same More
Amount of food given
The amount of food given to children with diarrhoea is
similar to that reported in the NMIS cycle 3.
Almost all the health workers interviewed (98%) think a
child with an infection, such as ARI or diarrhoea, should
be given the same or more food to eat than usual and
most (97%) report giving this advice to parents. It seems
that parents are not able to put this advice into practice.
Indeed, in NMIS cycle 3 the evidence is that far more
parents know about correct ORT than are able to give it
in practice.
Diarrhoea and risk of malnutrition
Diarrhoea is expected to increase the risk of malnutrition,
partly because of its weakening effect and the lack of
adequate feeding that often accompanies episodes of
diarrhoea. This is likely to affect acute rather than
chronic malnutrition rates. In this survey: a child with
recent diarrhoea has a greater risk of being wasted than
a child without diarrhoea, but there is no measurable
association with stunting (a longer term consequence of
malnutrition). Recent diarrhoea is here an indicator of
recurrent episodes of diarrhoea. The effect of diarrhoea
on the risk of malnutrition in young children is shown in
Table 22.
See Results II for analysis of the effect of this variable in
combination with others.
Status of women and child nutrition
Since the mother is mainly responsible for the care and
feeding of young children, her situation might be
expected to have an impact on a child’s nutritional status.
It has been postulated that an important reason for the
higher level of malnutrition in Asia than in Africa is the
poorer status of women in Asia14. In this survey, two
indicators of women’s status are available: literacy of the
mother (from the household questionnaire) and whether
women are beaten often in the community or not (from
the focus group discussions).
Literacy of mothers
Literate mothers are distinctly a minority. In this cycle,
19% of the mothers (or other main carers) of the children
are reported to be literate. This is similar to the
proportion of literate mothers found in NMIS cycle 3.
A child of an illiterate mother has an increased risk of
both stunting and wasting, as shown in Table 23. This
illustrates a convergence of many factors associated with
poverty.
Table 23. Literacy of the mother and malnutrition
among children 6-36 months old
Nutritional status Literacy of mother
Illiterate Literate
Stunted (%) 2594 (56) 416 (36)
Not stunted (%) 2003 (44) 741 (64)

Odds Ratio=2.33 (95% CI 2.00-2.63)

Wasted (%) 816 (18) 128 (11)

Not wasted (%) 3781 (82) 1029 (89)

Odds Ratio=1.72 (95% CI 1.41-2.13)

Table 22. Recent diarrhoea and malnutrition among See Results II for analysis of the effect of this variable in
children 6-36 months old combination with others.
Nutritional status Diarrhoea within last 2 weeks

Yes No

Stunted (%) 497 (54) 2501 (52)

18
Beating of women
This is a sensitive issue and the decision was made not to
ask women in the household questionnaire about whether
they had been beaten recently (usually by a male member
of the same household). Instead, the issue was raised in
the focus group of mothers held in each community. (See
Annex 3). The views emerging from focus groups
indicate that beating of women is commonplace in many
Nepali communities and that women are unhappy about
this.
“More than half the men in this community gamble and
drink and beat their wives when they come home,
making up some reason of their own.”
“We get beaten if we put too much or too little salt in
the curry and this is accepted by the society. But to get
beaten is not something simple or natural.”
The proportions of focus groups saying that women are
beaten often in different areas are shown in Annex 5,
Table A5.13.
In nearly half (43%) of the communities in this
survey, focus groups of women say that women are
beaten often in that community.
In addition, nearly all (98%) the focus groups indicated
that mothers have to get permission from other family
members before doing something for the benefit of the
child and mentioned punishments that the mother might
be given if she did something for the child without
permission. Punishments mentioned include scolding
(88%), beating (88%) and withholding of food (17%).
(See Annex 3).
Beating of women and child nutrition
Many (76%) focus groups made a link between the
treatment of women and proper child feeding and care
(see Annex 3).
“The flow of breast milk will stop if mothers are ill-
treated so they cannot feed the child properly.”
“If the mother is not treated properly by the family she
gets depressed and is not able to give attention to the
child’s feeding.”
Children in communities where women are reported to
be often beaten have a higher risk of malnutrition than
children in communities where frequent beating of
women is not reported. This is shown in Table 24.
19
Table 24. Beating of women and malnutrition among
children 6-36 months old
Nutritional status Women beaten often in the community
Yes No
Stunted (%) 1502 (57) 1360 (47)
Not stunted (%) 1115 (43) 1516 (53)
Odds Ratio=1.49 (95% CI 1.35-1.67)
Wasted (%) 542 (21) 370 (13)
Not wasted (%) 2075 (79) 2506 (87)
Odds Ratio=1.75 (95% CI 1.52-2.04)
See Results II for analysis of the effect of this variable in
combination with others.
CHILD DEVELOPMENT AND DISABILITIES
A number of questions on the household questionnaire
asked about development of motor abilities, presence of
some key motor and sensory abilities, and about the
presence of disabilities.
Motor development milestones
Mothers were asked about the age at which children of
72 months and below had achieved the classical motor
development milestones of sitting, standing and walking.
From this is was possible to calculate the percentage of
children who had achieved each milestone at different
ages, the mean age of achieving each milestone, and also
what proportion of children of different ages had each of
these motor abilities.
The questions were necessarily simple and did not go
into great detail about what was meant by sitting,
standing and walking (for instance, that standing was
independent of support etc). However, the findings give
at least an indication of the ages of reaching motor
development milestones among Nepali children. They
can also be used to compare motor development in
different areas and with other factors, such as nutritional
status.
Table 25 shows the mean age of achieving each
milestone among all children and among boys and girls
separately. The mean age to achieve these milestones is
slightly lower in girls than in boys, as expected.
 Table 25. Mean age to sit, stand and walk among Mothers were asked if they thought their child had
children already able to do each activity serious delay in sitting, standing or walking.
Group Mean age (mnths) to start to:

Sit Stand Walk

‘ 19% of mothers think their child has
(n=13452) (n=12392) (n=11500) serious delay in sitting
‘ 24% think their child has serious delay in
All 7.2 10.2 13.0 standing
Boys 7.2 10.2 13.1
‘ 25% think their child has serious delay in
walking
Girls 7.1 10.1 12.9

Mothers perceive only slightly more of their boy children

The ages at which children began to sit, walk and stand
than of their girl children to be delayed in reaching the
are shown in Figure 19.
motor milestones (about 1% difference between boys and
girls). Perception of delay is associated with reported
Figure 19. Proportion of children who began to sit, delay in reaching milestones, as shown in Table 26.
walk and stand at different ages
Table 26. Mothers’ perception of delay and reported
age of sitting, standing and walking
40
Milestone Mean age to achieve (months)
35
perceived delay no perceived delay
% of children

30
25 Sitting
20 Standing Sitting 9.3 6.7
15 Walking
10 Standing 12.9 9.4
5
0 Walking 16.4 11.9
3 9 15 21
Age in months
All the differences in means shown in Table 26 are very
statistically significant.

Mothers whose children were already walking were

asked if their child needed help with walking. Only 1%
The proportions of children of each age able to sit, stand
of children are said to need help with walking. This
and walk have also been calculated and are shown in
proportion is the same if only children 3 years old and
Figure 20.
above are considered.
Figure 20. Proportions of children of different ages
who are able to sit, stand and walk Intellectual development
This area was addressed by questions about whether the
child could understand simple commands, whether the
child spoke words recognisable to others, whether the
100
child used his or her hands to pick up things and whether
80 the child acted younger than other children of the same
% of children

60 Sitting age.
Standing
40 Walking
Among all the children aged up to 72 months, 5% are
20
said to act younger than other children of their own age.
0 The development of understanding of speech and ability
3 9 15 21 to speak intelligibly is shown in Figure 21.
Age in months

20
 by their parents to have fits (explained as becoming rigid
Figure 21. Ability to understand simple
or losing consciousness). Some of the children reported
commands and speak intelligible words in children
as having fits on this basis may not be having true
of different ages
epileptiform seizures but simply breath-holding or
‘temper’ episodes.

100 For children aged up to 36 months, the interviewer

80 observed the child and noted any disabilities, in
% of children

60 Understanding
discussion with the mother. The great majority (98%)
40 Speaking were recorded as having no disability.
20

0 Among children up to 36 months old:

3 6 9 12 15 18 21 24 27 30 33 ‘ 2% have some form of physical disability
Age in months ‘ 0.1% are noted to be blind or deaf
‘ 0.2% are noted to have some mental disability

The proportions of children of different ages who are said Comparing the interviewers’ recordings with the
to use their hands to pick up things are shown in Figure responses to the questionnaire, there is a higher rate of
22. hearing loss on the basis of the questionnaire. But the
Figure 22. Ability to use hands to pick up objects interviewers only noted deafness or blindness if they
in children of diffrent ages were total. The 0.25% unable to hear at all from the
household questionnaire in children up to 36 months (one
quarter of 1%) is comparable to the 0.1% for deafness
100 recorded by interviewers.
80
% of children

60 Some of the physical disabilities noted are very minor,

40 such as patches of skin depigmentation or lumps on the
20 ears, but they also include more serious problems like
0 major limb deformities.
3 9 15 21
Age in months
There is no gender difference in reported disabilities.

Geographic variation in child development

There are no reported differences between boys and girls
in any of these indices of intellectual development.
Disabilities
Among all children up to 72 months old, 2% are said by
their parents to have difficulty hearing. The percentage
increases a little with age: it is 1% in children up to 36
months old and 3% in children over this age. Of children
36 months and below with hearing difficulty, a quarter
(26%) are thought by their parents to be unable to hear
at all; the equivalent proportion among older children is
a fifth (21%). The differences between older and
younger children probably reflect the difficulty of
detecting hearing difficulties in very young children
unless they are very profound.
Reported sight impairment is less common. Only 0.7%
of children are said to have difficulty seeing at night and
0.3% difficulty seeing in the day.
There is no very marked geographic variation in the
mean age at which children reach the major motor
milestones, or in the proportions of children thought by
their mothers to have serious delay in reaching the
milestones. The mean age for sitting, standing and
walking is a little lower in the terai than in the hills and
mountains and fewer children in the terai are thought to
have serious delay in the motor milestones. The results
by geographic areas and ethnicity are shown in Annex 5,
Table A5.14 -A5.17. The proportion of children with
night blindness is less than 1% in all regions.
Malnutrition and child development
If malnutrition affects the brain and nervous system as
well as the rest of the body, it might be expected that
children in this survey with malnutrition, especially those
with stunting (chronic malnutrition), would have delay in
reaching milestones compared with children without
malnutrition.

Among children up to 72 months of age, 2% are reported Figures 23, 24 and 25 show the proportion of children
able to sit, stand and walk at different ages, among those

21
who are stunted and not stunted. Each milestone tends to Table 27 shows the mean age of reaching the motor
be reached later among children who are stunted. development milestones in relation to nutritional status.

Figure 23. Proportion of children able to sit at Table 27. Nutritional status and reported age of
different ages in those with and without stunting sitting, standing and walking
Milestone Mean age to achieve (months)
100

80
Children who are Children who are not
stunted stunted
% of children

60 Not stunted
40
Stunted Sitting 7.5 6.9
20
Standing 10.6 9.8
0
6 9 12 15 Walking 13.3 12.4
Age in months

Children who are stunted walk about one month later, on

Figure 24. Proportion of children able to stand at average, than children who are not stunted.
different ages in those with and without stunting
Even though parents may not recognise that their
100 children are stunted, they do perceive more delay in
80
reaching milestones among stunted children than among
% of children

60
those not stunted. Wasted children are also more likely
Not stunted
Stunted to be perceived as delayed in their motor development.
40
The effects of stunting and wasting on the likelihood of
20
parental perception of delay in walking are shown in
0
6 8 10 12 14 16 18 20
Table 28.
Age in months
Table 28. Malnutrition and parental perceptions of
delay in walking
Figure 25. Proportion of children able to walk at Nutritional status Serious delay in walking
different ages in those with and without stunting Yes (%) No (%)

100
Stunted 841 (34) 1654 (66)

80 Not stunted 421 (22) 1531 (78)

% of children

60 Not stunted
Stunted Odds Ratio=1.85 (95% CI 1.61-2.13)
40

20 Wasted 248 (34) 478 (66)

0
Not wasted 1014 (27) 2707 (73)
6 8 10 12 14 16 18 20 22 24
Age in months
Odds Ratio=1.39 (95% CI 1.16-1.65)

22
 RESULTS: II. ANALYSIS FOR ACTION

This cycle of the NMIS has provided information about Table 29. Combined Odds Ratios and Risk
a number of variables that apparently increase the risk Differences of variables affecting the risk of
of acute and chronic malnutrition in young children. stunting, from logistic regression analysis
The effect of each of these variables separately is
shown in the relevant part of the Results I section. Variable Odds Ratio Risk Difference
However, the apparent effect of a variable might in (95% CI) (95% CI)
reality be due to its association with another variable
(confounding) or two or more variables might interact Mother illiterate 2.27 12.3%
(1.96-2.63) (10.2-14.4)
to produce the effect on malnutrition risk (effect
modification). In this section of the analysis, the effects Women beaten in 1.45 8.5%
of the variables found to affect the risk of malnutrition community (1.29-1.63) (5.8-9.5)
separately are examined in combination. The focus is
Feeding less than 1.37 6.0%
on those variables amenable to change and the aim is
6x /day (1.19-1.58) (3.7-8.2)
to indicate what sort of reduction in malnutrition might
be produced by different interventions.

Since there is some difference in the variables that Risk of wasting

affect the risks of stunting and wasting, the analysis of
variables in combination is done for stunting and
wasting separately.
Risk of stunting
Eight main variables that increase the risk of
malnutrition separately were considered together. First
simultaneous stratification was undertaken. The
resulting tables were fed into a logistic regression
analysis. Step down from a saturated model was used
to find the best fitting, most parsimonious model. The
model was then resaturated with interaction terms
(combinations of variables).
Variables included in combined analysis of risk
of stunting:
‘ Colostrum thrown away
‘ Male feeds child when mother unavailable
‘ Child does not have a separate plate
‘ Mother does not have enough to eat
‘ Liquid complements added before four months
‘ Women beaten often in community
‘ Mother illiterate
‘ Child fed less than 6 times per day
Variables that increase the risk of wasting separately
were considered together, and analysed in the same
way as the variables for stunting. A logistic regression
was performed, with seven variables. Variables
excluded in preliminary models were: child does not
have separate plate; mother does not have enough to
eat.
Variables included in combined analysis of risk
of wasting:
‘ Colostrum thrown away
‘ Diarrhoea in the last two weeks
‘ Residence in terai ecozone
‘ Liquid complements added before four months
‘ Women beaten often in community
‘ Mother illiterate
‘ Child fed less than 6 times per day
Six variables remained in the final model and
contributed significantly to the risk of wasting. Table
30 shows the combined Relative Risk (Odds Ratio) and
Risk Difference for each of these six variables.

Three variables remained in the final model. This

means that the effects of the other variables could be
explained by the effects of these three in combination.
The three remaining variables are: frequency of feeding
the child, literacy of the mother, and whether women
are beaten often in the community. Table 29 shows the
combined Relative Risk (Odds Ratio) and Risk
Difference for each of the three variables.

23
Table 30. Combined Odds Ratios and Risk situation (eg the proportion of children who currently
Differences of variables affecting the risk of have illiterate mothers). The relative costs of each
stunting, from logistic regression analysis possible intervention are indicated, and the main
players who might need to take action.
Variable Odds Ratio Risk Difference
(95% CI) (95% CI) In the case of stunting, the main areas identified for
possible action are: violence against women, literacy of
Living in terai 2.36 14.8% mothers and increasing feeding frequency of young
(1.94-2.85) (11.7-18.0)
children.
Diarrhoea in last 1.40 6.3%
two weeks (1.14-1.72) (2.7-9.8) Literacy of women
The importance of literacy of mothers for children’s
Colostrum thrown 1.37 11.4%
care is a consistent theme in different cycles of the
away (1.15-1.63) (5.1-17.7)
NMIS. For example, in NMIS cycle 3 it was found that
Liquids added 0.67 5.2% the risk and severity of diarrhoea is reduced in children
before 4 mths (0.54-0.84) (2.4-8.0) with literate mothers. It is likely to be associated
features, rather than the literacy itself, which are
Women beaten in 1.34 12.0%
community (1.13-1.59) (5.3-19.0) important. This finding of a reduced risk of childhood
malnutrition when the mother is literate is another
Feeding less than 0.65 2.9% encouragement to support and expand programmes
6x /day (0.52-0.82) (1.2-4.7) designed to increase female literacy.
Note: Adding liquids before 4 months is associated
with a reduced risk of wasting, as is feeding less than Violence against women
six times per day. The increased risk of malnutrition in communities
where women are reportedly beaten often supports the
The finding of less risk of wasting in children who have hypothesis that the poor status of women in South Asia
liquids added before 4 months of age persists after could be an important part of the explanation for the
taking account of the other variables. It may be that high rates of childhood malnutrition here14. Dealing
exclusively breast fed children are not being fed often with this problem of violence against women is
enough and so complements actually increase the difficult; this evidence of a link with childhood
nutrient intake usefully. Or there could be undetected malnutrition is yet another reason why it is important to
confounding by socioeconomic status. The effect is tackle it.
found in both urban and rural sites separately.
Frequency of feeding
The finding of less wasting in children fed less This finding supports the advice to feed young children
frequently is probably because children who are sickly at least six times a day. However, this cycle also
and obviously wasted are fed more often in an attempt indicates that many mothers know they should feed
to improve their condition. This is also discussed in their children often but practical constraints mean they
the section of the results on feeding frequency (see cannot manage to do so. Intervention will need to be
above). more than giving the message to feed more often;
finding practical ways to help mothers do this will be
Action analysis necessary.
Having carefully defined the variables that affect the
risk of stunting and wasting, taking into account the Reducing wasting
combined effects of variables, it is possible to estimate Table 32 shows a similar analysis for wasting, with
the benefits of different actions that could be taken to estimated benefits of actions to change different
reduce malnutrition in children. possible causes of wasting. The variables of timing of
adding liquids and frequency of feeding are not
Reducing stunting included in Table 32 as it seems very likely that the
Table 31 indicates the possible benefit of taking action earlier adding of liquids is not beneficial in itself but
to improve the causes of stunting found in this survey. rather confounded and that the increased feeding
The possible benefit to individual children is derived frequency in wasted children results from rather than
from the Odds Ratio; the possible population benefit is causes their condition.
derived from the Risk Difference (Table 29). The
proportion of the population who could benefit is the Special problems of the terai
proportion who do not currently have the beneficial Flooding is hard to prevent but it is possible to predict
the problems that follow. This cycle indicates the very

24
serious nutritional consequences of flooding and
suggests that plans to provide emergency supplies in
these circumstances should be developed.
Prevent diarrhoea
The issues around prevention of diarrhoea and
reduction of severity of episodes have been examined
and discussed in the report of the NMIS cycle 37. They
include increasing literacy of women, finding ways to
treat water in the home, providing safe water supplies
and giving fluids on the first day of an episode of
diarrhoea.
Feeding colostrum to babies
The use of colostrum varies very much between
different ethnic groups. Thus action to reduce this
cause of malnutrition will need to be tailored to those
groups who do not already use the colostrum, mainly
ethnic groups living in the terai.
Violence against women
It seems that reducing violence against women could
reduce wasting as well as stunting among children.

Table 31. Possible benefits of different actions to reduce the risk of stunting in young children
Action Individual benefit Population benefit Proportion of Relative financial Action needed by:
(based on OR) (based on RD) population who cost
could benefit

Increase female Two and a quarter More than one in ten Four out of five Moderate to high Education dept
literacy times less risk (12%) children Local govt
protected NGOs
Communities

Prevent women One and a half times Nearly one in ten About half Moderate Individuals
being beaten less risk (9%) children Women’s groups
protected NGOs
Opinion formers
Communities

Feed young children Nearly one and a half More than one in Nearly a quarter Low Individuals
six times a day or times less risk twenty (6%) children Communities
more protected Health workers
NGOs

Table 32. Possible benefits of different actions to reduce the risk of wasting in young children
Action Individual benefit Population benefit Proportion of Relative financial Action needed by:
(based on OR) (based on RD) population who cost
could benefit

Situation in terai Nearly two and a half Nearly one in seven About half Moderate to high Central govt
(eg provide food times less risk (15%) children NGOs
after flooding) protected Local govt

Prevent childhood Nearly one and a half More than one in Probably around a Moderate Individuals
diarrhoea (and times less risk twenty (6%) children third DWSS
manage better) protected NGOs
Health workers

Feed colostrum to Nearly one and a half More than one in ten More than a third Low Individuals
babies times less risk (11%) children NGOs
protected Health workers
Opinion formers

Prevent women Nearly one and a half More than one in ten About half Moderate Individuals
being beaten times less risk (12%) children Women’s groups
protected NGOs
Opinion formers
Communities

25
 REFERENCES

1. National Planning Commission, HMG Nepal and

UNICEF Nepal. Nepal Multiple Indicator Surveillance:
Cycle 1, Health and Nutrition, 1995.(NMIS Report
Series, number 1) Kathmandu, March 1996

2. Vitit Muntarbhorn. A sourcebook for reporting under

the convention on the rights of the child. Bangkok:
UNICEF, EAPRO and Child Rights ASIANET, 1997.

3. National Planning Commission, HMG Nepal. National

Programme of Action for Children and Development for
the 1990s. Kathmandu, 1992.

4. Maggie Black. Monitoring the rights of children.

Innocenti global seminar summary report. UNICEF:
Florence, 1994.

5. Regional Office for South Asia. Priorities and

workplan 1997. ROSA report series no. 15. UNICEF
ROSA: Kathmandu, March 1997

6. Childwatch International. Research project: indicators

for children’s rights. Oslo, Norway, October 1996.

7. National Planning Commission, HMG Nepal and

UNICEF Nepal. Nepal Multiple Indicator Surveillance:
Cycle 2, Primary Education, 1995. (NMIS Report Series,
number 2). Kathmandu, November 1996.

8. National Planning Commission, HMG Nepal and

UNICEF Nepal. Nepal Multiple Indicator Surveillance:
Cycle 3, Diarrhoea, Water and Sanitation, 1996. (NMIS
Report Series, number 3). Kathmandu, June 1997.

9. Pradhan A, Aryal RH, Regmi G, Ban B, Govindasamy

P, 1997. Nepal Family Health Survey 1996. Kathmandu,
Nepal and Calverton, Maryland: Ministry of Health
(Nepal), New ERA and Macro International Inc.

10. Ministry of Health, HMG Nepal. Nepal Nutrition

Status Survey 1975.

11. New ERA. A Baseline Survey for the Joint Nutrition

Support Programme. Kathmandu, 1986

12. Gautam M. Malnutrition in Nepal: a review. Journal

of the Nepal Medical Association, 1996; 34: 141-151

13. HMG Nepal. National Nutrition Strategy 1996

14. UNICEF. Strategy for improved nutrition of children

and women in developing countries. New York:
UNICEF, 1990

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15. Ramalingaswami V, Jonsson U, Rhode J. The Asian
enigma. Commentary: The Progress of nations, 1996,
UNICEF, pp 11-17.

16. Andersson N. Impact, coverage and costs: An

operational framework for monitoring child survival and
development emerging from two UNICEF projects in
Central America. UNICEF: Guatemala, September 1985

17. Andersson N, Martinez E, Cerrato F, Morales E,

Ledogar RJ. The use of community-base data in health
planning in Mexico and Central America. Health Policy
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18. Andersson N. Evidence-based planning: the

philosophy and methods of sentinel community
surveillance. CIETinternational/EDI World Bank:
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system for epidemiology of microcomputers.
Epidemiology program office, Centers for Disease
Control and Prevention, Atlanta, Georgia, USA. Version
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20. Mantel N, Haenszel W. Statistical aspects of the

analysis of data from retrospective studies of disease. J
Natl Cancer Inst 1959; 22: 719-748

21. Mantel N. Chi-square tests with one degree of

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Tropical Medicine, London, 1982.

27
 ANNEX 1. SITES IN THE NMIS SAMPLE
Table A1.1 Districts in the NMIS sample, with number of sites.
Eco-region District Rural sites Urban sites

Eastern - Hills Ilam 3

Bhojpur 3

Udayapur 4

Eastern -Terai Morang 10 1

Siraha 8 1

Saptari 1

Jhapa 1

Sunsari 1

Eastern - Mountains Sankhuwasabha 3

Central - Hills Kathmandu 5 4

Dhading 5

Lalitpur 1

Kavrepalanchok 1

Makwanpur 1

Ramenchhap 4

Central - Terai Dhanusha 11

Parsa 1

Rautahat 9

Central - Mountains Sindhupalchok 4

Western - Hills Gorkha 5

Syangja 5

Myagdi 2

Gulmi 5

Kaski 1

Palpa 1

Western -Terai Rupandehi 8

Kapilvastu 1

Western - Mountains Mustang 2

Mid West - Hills Dailekh 4

Rolpa 4

Mid West - Terai Bardiya 6

Banke 1

Mid West - Mountains Jumla 2

Kalikot 2

Far West - Hills Achham 5

Far West - Terai Kailali 4 1

Far West - Mountains Darchula 3

A1(1)
MAP OF NEPAL WITH NMIS SITES MARKED

A1(2)
Table A1.2 Districts in Nepal by ecozones and eco-development regions

Region Terai Hills Mountains

Eastern Jhapa Morang Ilam Panchthar Taplejung

(16 districts) Sunsari Saptari Tehrathum Dhankuta Sankhuwasabha
Siraha Bhojpur Udayapur Solukhumbu
Khotang Okhaldhunga

Central Dhanusha Sarlahi Sindhuli Ramenchhap Dolakha

(19 districts) Mahottari Bara Kavrepalanchok Kathmandu Sindhupalchok
Rautahat Chitwan Makwanpur Bhaktapur Rasuwa
Parsa Lalitpur Dhading
Nuwakot

Western Nawalparasi Gorkha Lamjung Manang

(16 districts) Rupandehi Tanahu Kaski Mustang
Kapilvastu Syangja Palpa
Parbat Argakhachi
Gulmi Baglung
Myagdi

Mid West Dang Pyuthan Rolpa Dolpa

(15 districts) Banke Salyan Surkhet Humla
Bardiya Dailekh Jajarkot Kalikot
Rukum Mugu
Jumla

Far West Kailali Achham Doti Darchula

(9 districts) Kanchanpur Dadeldhura Baitadi Bajhang
Bajura

NMIS districts are shown in bold type.

A1(3)
 ANNEX 2: INSTRUMENTS USED IN NMIS CYCLE 4

1. Household questionnaire
2. Focus group guide for cycle 4
3. Focus group guide for cycle 4; reporting format
4. Focus group guide for feedback of cycle 3 findings
5. Focus group guide for feedack of cycle 3 findings; reporting format
6. Health facility interview

A2(1)
 ANNEX 3: FOCUS GROUP THEMES AND FREQUENCIES

How often are children fed? Would mothers come to agree that solid food is
Mean 4.8 times per day better for young children?
Yes, could agree 96%
Would it be easy to feed more often?
Yes, easy: 9% What foods should not be fed to young children?
Cereals 17%
What are constraints to feeding more often? Cold/stale food 57%
No time 88% Vegetables 6%
No money 24% Alcohol/cigarettes 35%
Workload 76% Foods hard to digest 60%
Lack of food 34%
What foods should not be eaten by pregnant, post-
What would convince you to feed more often or to partum and lactating women?
feed more solid foods? Cereals 32%
Hearing it makes baby strong and healthy 58% Sugar 11%
Hearing it gives better development 15% Animal protein 29%
Seeing examples 29% Pulses/nuts 11%
Meetings/discussions 50% Vegetable oil and fats 13%
Fact that solid foods last longer 62% Cold/stale food 44%
Various vegetables 72%
Who would you need to hear messages from? Alcohol/cigarettes 67%
Government 34% Stimulants and spices 91%
VDCs 44%
Educated people 77%
NGOs 51% If mothers here want to do something to benefit their
Womens groups 16% children, do they need to take permission from other
Health workers 61% family members?
Female comm. workers 52% Yes, must take permission 98%

What could communities do to help increase feeding If mothers do things for children without permission,
frequency and feed more solid foods? what is likely to happen to them?
Hold meetings/discussions 56% Scolding 88%
Take children to field with mothers 3% Beating 88%
Help from other family members 18% Denied food 17%
Form mothers groups 34%
Set up child care centres 8% Do you think feeding of children is related to the way
Community income generation 17% women are treated in their homes?
Yes, it is related 76%
What could government do to help increase feeding
frequency and feed more solid foods? Are women in this community often beaten by their
Set up care centres 13% men?
Food and financial aid 97% Yes, beaten often 43%
Income generation and employment 39%
Better land/more land 10%
Health education programmes 56%

Is solid of liquid food better for young children?

Solid 47%
Liquid 42%
Both 11%

A3(1)
 ANNEX 4: WEIGHTED AND UNWEIGHTED VALUES OF KEY INDICATORS

The derivation of the weights applied is given in the report of NMIS cycle 1 and in an Annex to that report. In this
cycle, the same weights were used. They were applied using the EpiInfo CSAMPLE programme.

Table A4.1 Weights applied to each District (actually each group of rural or urban sites).

Rural sites Urban sites

District Weight District Weight

1. Udayapur 1.50 27. Lalitpur 0.48

2. Morang (r) 0.94 28. Kavrepalanchok 0.29

3. Siraha (r) 1.24 29. Makwanpur 0.46

4. Sindhupalchok 0.55 30. Saptari 0.21

5. Kathmandu (r) 1.50 31. Parsa 0.27

6. Dhading 1.59 32. Kaski 0.48

7. Ramenchhap 1.92 33. Palpa 0.34

8. Dhanusha 1.04 34. Kapilvastu 0.19

9. Rautahat 1.26 35. Banke 0.32

10. Gorkha 1.71 36. Jhapa 0.27

11. Syangja 0.34 37. Sunsari 0.51

12. Gulmi 1.51 38. Kathmandu (u) 0.48

13. Rupandehi 0.54 39. Kailali (u) 0.33

14. Rolpa 1.27 40. Morang (u) 0.26

15. Dialekh 1.26 41. Siraha (u) 0.35

16. Bardiya 0.44

17. Achham 0.51

18. Kailali (r) 0.44

19. Sankhuwasabha 0.53

20. Ilam 1.93

21. Bhojpur 2.06

22. Mustang 0.006

23. Myagdi 4.03

24. Jumla 0.53

25. Kalikot 0.45

26. Darchula 0.46

A4(1)
(r)= rural sites within the district; (u)=urban sites within the district

Table A4.1 Unweighted and weighted values of key national indicators

Indicator Unweighted value Weighted value 95% CI of weighted value

% children 6-36 months who are 52% 53% 50%-56%

stunted

% children 6-36 months who are 16% 16% 13%-20%

wasted

% children 12-36 months who have 38% 38% 34%-42%

MUAC <13.5cm

% children 12-36 months who have 11% 12% 10%-13%

MUAC <12.5cm

% children 0-36 months with 15% 16% 14%-18%

diarrhoea in last two weeks

% mothers of children aged 0-36 20% 19% 14%-23%

months who are literate

% of children who had colostrum 38% 36% 27%-45%

thrown away

The weighted values are close to the unweighted values for all the key indicators. The wieghted values of indicators at
national level are used in the Results section unless specified otherwise.

A4(2)
 ANNEX 5: RESULTS BY GEOGRAPHIC LOCATION AND ETHNIC GROUP

List of tables and maps

Tables

A5.1 Stunting, wasting and low MUAC by regions, eco-zones, urban/rural split and eco-development regions A5(2)
A5.2 Stunting, wasting and low MUAC by district, for districts with 4 or more sites A5(4)
A5.3 Stunting and wasting by ethnicity A5(5)
A5.4 Food security by ethnicity A5(5)
A5.5 Food security by regions, eco-zones, urban/rural split and eco-development regions A5(6)
A5.6 Time of starting breast feeding and use of colostrum by regions, eco-zones, urban/rural split and
eco-development regions A5(8)
A5.7 Time of starting breast feeding and use of colostrum by ethnicity A5(10)
A5.8 Mean age of adding liquid and solid complements by ethnicity A5 (10)
A5.9 Mean age of starting liquid and solid complements by regions, eco-zones, urban/rural split and
eco-development regions A5(11)
A5.10 Mean feeding frequency and proportion of children fed less than five times a day by regions, eco-zones,
urban/rural split and eco-development regions A5(13)
A5.11 Proportion of children fed less than five times a day by district, for districts with at least 4 sites A5(15)
A5.12 Feeding frequency and proportion fed less than five times per day by ethnicity A5(16)
A5.13 Beating of women noted in focus groups by region, eco-zones and urban/rural split A5(17)
A5.14 Mean age to reach motor development milestones by regions, eco-zones, urban/rural split and
eco-development regions A5(18)
A5.15 Perceived delay in motor milestones by regions, eco-zones, urban/rural split and
eco-development regions A5(20)
A5.16 Mean age to reach motor development milestones by ethnicity A5(22)
A5.17 Perceived delay in motor milestones by ethnicity A5(22)

Figures (maps)

A5.1 Stunting by eco-development region (map) A5(3)

A5.2 Wasting by eco-development region (map) A5(3)
A5.3 Mother has sufficient food by eco-development region (map) A5(7)
A5.4 Mother limits food to give to child by eco-developmet region (map) A5(7)
A5.5 Time of starting breast feedin by eco-development region (map) A5(9)
A5.6 Use of colostrum by eco-development region (map) A5(9)
A5.7 Time of adding liquid complements by eco-development region (map) A5(12)
A5.8 Time of adding solid complements by eco-development region (map) A5(12)
A5.9 Children fed less than five times per day by eco-development region (map) A5(14)
A5.10 Mean age to sit by eco-development region (map) A5(19)
A5.11 Mean age to stand by eco-development region (map) A5(19)
A5.12 Mean age to walk by eco-development region (map) A5(19)
A5.13 Perceived delay in sitting by eco-development region (map) A5(21)
A5.14 Perceived delay in standing by eco-development region (map) A5(21)
A5.15 Perceived delay in walking by eco-development region (map) A5(21)

A5(1)
Table A5.1 Stunting , wasting low MUAC by regions, eco-zones, urban/rural split and eco-development
regions

Location Children 6-36 mnths Children 6-36 Children 12-36 mnths

% stunted (n) mnths % MUAC<12.5cm (n)
%wasted (n)

Development regions Eastern 47 (1287) 18 (1287) 10 (1066)

Central 55 (1453) 21 (1453) 16 (1194)

Western 55 (1028) 12 (1028) 6 (861)

Mid-Western 60 (837) 12 (837) 15 (669)

Far-Western 53 (560) 17 (560) 9 (477)

Eco-zones Terai 50 (2462) 24 (2462) 13 (1985)

Hills 56 (2152) 9 (2152) 10 (1839)

Mountains 63 (551) 8 (551) 11 (443)

Urban/rural split Urban 39 (589) 15 (589) 8 (465)

Rural 54 (5165) 17 (5165) 12 (4267)

Eco-development regions Eastern - terai 47 (718) 23 (718) 12 (586)

Eastern - hills 46 (473) 11 (473) 8 (403)

Eastern - mountains 58 (96) 7 (96) 7 (77)

Central -terai 54 (818) 33 (818) 23 (634)

Central - hills 52 (504) 6 (504) 9 (448)

Central - mountains 69 (131) 5 (131) 6 (112)

Western - terai 54 (309) 18 (309) 6 (260)

Western- hills 56 (698) 9 (698) 7 (588)

Western -mountains 43 (21) 0 (21) 8 (13)

Mid-Western - terai 42 (362) 15 (362) 9 (289)

Mid-Western - hills 71 (296) 12 (296) 18 (240)

Mid-Western - mountains 80 (179) 7 (179) 20 (140)

Far-Western - terai 49 (255) 19 (255) 4 (216)

Far-Western - hills 69 (181) 17 (181) 18 (160)

Far-Western - mountains 40 (124) 13 (124) 7 (101)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(2)
Figure A5.1 and A5.2 (Maps of stunting and wasting by eco-development region)

A5(3)
Table A5.2 Stunting, wasting and low MUAC by district, for the 18 districts with 4 or more sites

District Children 6-36 mnths Children 6-36 mnths Children 12-36 mnths
% stunted (n) % wasted (n) % MUAC <12.5cm (n)

Udayapur 43 (215) 13 (215) 10 (183)

Morang (rural) 38 (376) 12 (376) 7 (297)

Siraha (rural) 56 (342) 36 (342) 17 (289)

Sindhupalchok 69 (131) 5 (131) 6 (112)

Kathmandu (rural) 53 (180) 3 (180) 5 (154)

Dhading 58 (172) 9 (172) 14 (151)

Ramenchhap 44 (152) 7 (152) 6 (143)

Dhanusha 54 (435) 29 (435) 24 (349)

Rautahat 55 (383) 38 (383) 23 (285)

Gorkha 63 (137) 15 (137) 8 (109)

Syangja 51 (203) 3 (203) 5 (174)

Gulmi 57 (322) 10 (322) 7 (270)

Rupandehi 54 (309) 18 (309) 6 (260)

Rolpa 75 (159) 11 (159) 11 (134)

Dialekh 66 (137) 14 (137) 27 (106)

Bardiya 42 (362) 15 (362) 9 (289)

Achham 69 (181) 17 (181) 18 (160)

Kailali (rural) 49 (255) 19 (255) 4(216)

A5(4)
Table A5.3 Stunting and wasting by ethnicity
Ethnic group Children aged 6-36 months:

Number % stunted % wasted

Brahmins 793 46 11

Chhetri 1111 54 11

Newar 196 30 5

Gurung/Ghale 125 59 9

Magar 271 53 6

Rai/Limbu 293 45 6

Tamang/Sherpa 189 49 7

Muslim 241 63 34

Occupational 855 64 19

Tharu 583 39 20

Yadav 305 58 34

Other (terai) 582 53 8

Other (hills) 210 63 21

Table A5.4 Food security by ethnicity

Ethnic group Mothers of children aged 0-36 months:

% enough food in last day % limited own food to give child in

(n) last week (n)

Brahmins 94 (1042) 17 (954)

Chhetri 93 (1483) 24 (1345)

Newar 95 (277) 16 (246)

Gurung/Ghale 98 (204) 30 (171)

Magar 92 (365) 25 (323)

Rai/Limbu 91 (359) 30 (336)

Tamang/Sherpa 94 (293) 20 (249)

Muslim 91 (340) 33 (273)

Occupational 80 (1214) 35 (1002)

Tharu 95 (786) 12 (645)

Yadav 93 (450) 26 (359)

Other (terai) 92 (827) 26 (672)

Other (hills) 91 (282) 39 (239)

A5(5)
Table A5.5 Food security by regions, eco-zones, urban/rural split and eco-development regions

Location % of mothers with enough to eat in % of mothers limiting food to give to

last day (n) child in last week (n)

Development regions Eastern 88 (1716) 31 (1508)

Central 95 (2093) 28 (1760)

Western 91 (1439) 18 (1285)

Mid-Western 94 (1115) 22 (912)

Far-Western 85 (748) 28 (651)

Eco-zones Terai 92 (3392) 24 (2803)

Hills 90 (2955) 24 (2645)

Mountains 91 (764) 36 (668)

Urban/rural split Urban 92 (811) 17 (698)

Rural 91 (7111) 25 (6116)

Eco-development regions Eastern - terai 85 (967) 32 (820)

Eastern - hills 93 (627) 25 (575)

Eastern - mountains 84 (122) 50 (113)

Central -terai 96 (1156) 33 (912)

Central - hills 91 (717) 26 (650)

Central - mountains 99 (220) 6 (198)

Western - terai 85 (468) 16 (404)

Western- hills 94 (941) 19 (858)

Western -mountains 97 (30) 9 (23)

Mid-Western - terai 100 (459) 2 (380)

Mid-Western - hills 89 (419) 33 (339)

Mid-Western - mountains 89 (237) 44 (193)

Far-Western - terai 95 (342) 13 (287)

Far-Western - hills 69 (251) 27 (223)

Far-Western - mountains 87 (155) 58 (141)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately. This survey was carried out in September 1996

A5(6)
Figures A5.3, A5.4 (Maps of the two types of food security by eco-development region)

A5(7)
Table A5.6 Timing of starting breastfeeding and use of colostrum by regions, eco-zones, urban/rural split and
eco-development regions

Location % of children with breast feeding % of children who had colostrum

started within 4hrs (n) discarded (n)

Development regions Eastern 52 (1706) 48 (1712)

Central 42 (2082) 48 (2088)

Western 76 (1428) 14 (1442)

Mid-Western 75 (1084) 43 (1092)

Far-Western 92 (726) 22 (731)

Eco-zones Terai 46 (3369) 57 (3395)

Hills 78 (2905) 16 (2922)

Mountains 68 (752) 34 (748)

Urban/rural split Urban 61 (796) 40 (802)

Rural 62 (7026) 38 (7065)

Eco-development regions Eastern - terai 34 (973) 72 (970)

Eastern - hills 73 (612) 19 (623)

Eastern - mountains 84 (121) 4 (119)

Central -terai 12 (1179) 70 (1176)

Central - hills 81 (688) 17 (695)

Central - mountains 82 (215) 31 (217)

Western - terai 80 (454) 17 (462)

Western- hills 73 (944) 13 (950)

Western -mountains 83 (30) 20 (30)

Mid-Western - terai 92 (437) 56 (449)

Mid-Western - hills 81 (415) 15 (413)

Mid-Western - mountains 35 (232) 67 (230)

Far-Western - terai 93 (326) 31 (338)

Far-Western - hills 96 (246) 14 (241)

Far-Western - mountains 84 (154) 17 (152)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(8)
Figures A5.5, A5.6 (Starting breastfeeding and throwing away colostrum by eco-development region -maps)

A5(9)
Table A5.7 Time to start breast feeding and use of colostrum by ethnicity
Ethnic group % children with breast % children with colostrum
feeding started within 4 thrown away (n)
hours (n)

Brahmins 71 (1034) 26 (1050)

Chhetri 74 (1454) 23 (1457)

Newar 80 (263) 28 (266)

Gurung/Ghale 82 (198) 22 (200)

Magar 83 (359) 17 (360)

Rai/Limbu 86 (353) 19 (353)

Tamang/Sherpa 88 (290) 24 (289)

Muslim 33 (342) 50 (337)

Occupational 60 (1198) 40 (1203)

Tharu 73 (757) 50 (776)

Yadav 17 (453) 78 (455)

Other (terai) 22 (833) 65 (832)

Other (hills) 49 (288) 48 (289)

Table A5.8 Mean age of adding liquid and solid complements by ethnicity
Ethnic group Mean age of adding liquids Mean age of adding solids
in mnths (n) in mnths (n)

Brahmins 4.0 (957) 6.2 (907)

Chhetri 4.4 (1350) 6.2 (1268)

Newar 4.3 (248) 5.7 (240)

Gurung/Ghale 4.6 (171) 5.8 (16)

Magar 4.7 (321) 6.0 (312)

Rai/Limbu 4.0 (337) 5.2 (332)

Tamang/Sherpa 4.3 (251) 5.6 (245)

Muslim 5.6 (273) 8.1 (251)

Occupational 5.3 (1002) 7.0 (963)

Tharu 5.5 (649) 6.9 (622)

Yadav 6.4 (357) 8.9 (343)

Other (terai) 6.3 (677) 8.7 (637)

Other (hills) 5.7 (239) 7.1 (232)

A5(10)
Table A5.9 Mean ages of adding complementary liquids and solids by regions, eco-zones, urban/rural split and
eco-development regions

Location Mean age of adding complementary Mean age of adding complementary

liquids in mnths (n) solids in mnths (n)

Development regions Eastern 4.5 (1508) 6.0 (1465)

Central 5.6 (1763) 7.5 (1683)

Western 4.3 (1283) 6.9 (1194)

Mid-Western 5.5 (923) 6.7 (885)

Far-Western 5.0 (653) 6.6 (615)

Eco-zones Terai 5.6 (2817) 7.6 (2693)

Hills 4.5 (2642) 6.1 (2513)

Mountains 4.5 (671) 6.0 (636)

Urban/rural split Urban 4.6 (702) 6.6 (672)

Rural 5.0 (6130) 6.8 (5842)

Eco-development regions Eastern - terai 5.2 (821) 7.0 (795)

Eastern - hills 3.7 (573) 4.9 (556)

Eastern - mountains 3.4 (114) 4.1 (114)

Central -terai 7.0 (914) 9.3 (867)

Central - hills 4.0 (651) 5.6 (628)

Central - mountains 3.9 (198) 5.3 (188)

Western - terai 3.6 (406) 6.9 (374)

Western- hills 4.6 (854) 6.9 (797)

Western -mountains 4.3 (23) 5.9 (23)

Mid-Western - terai 5.2 (387) 6.3 (378)

Mid-Western - hills 5.7 (341) 7.0 (318)

Mid-Western - mountains 5.9 (195) 7.3 (189)

Far-Western - terai 5.2 (289) 6.5 (279)

Far-Western - hills 5.2 (223) 6.6 (214)

Far-Western - mountains 4.3 (141) 7.0 (122)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(11)
Figures A5.7, A5.8 (starting liquid ans solid complements by eco-development regions - maps)

A5(12)
Table A5.9 Frequency of feeding by regions, eco-zones, urban/rural split and eco-development regions

Location Number Mean no. of % of children fed less than five times
times fed per per day
day

Development regions Eastern 1663 7.9 17

Central 2058 8.7 10

Western 1363 8.0 12

Mid-Western 1080 6.7 18

Far-Western 733 7.1 17

Eco-zones Terai 3288 9.0 7

Hills 2867 6.8 22

Mountains 742 7.1 16

Urban/rural split Urban 780 8.5 11

Rural 6897 7.9 14

Eco-development regions Eastern - terai 930 8.6 12

Eastern - hills 611 7.1 24

Eastern - mountains 122 6.5 26

Central -terai 1164 9.7 5

Central - hills 682 7.3 20

Central - mountains 212 7.6 13

Western - terai 420 10.0 3

Western- hills 913 7.0 16

Western -mountains 30 7.8 20

Mid-Western - terai 444 7.5 9

Mid-Western - hills 411 6.1 29

Mid-Western - mountains 225 6.3 21

Far-Western - terai 330 8.0 8

Far-Western - hills 250 5.5 34

Far-Western - mountains 153 7.8 7

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(13)
Figure A5.9 (map of % children fed less than 5 times/day by eco-development region)

A5(14)
Table A5.11 Proportion of children fed less than 5 times a day by district, for 18 districts with at least 4 sites

District % of children fed less than five

times a day (n)

Udayapur 20 (278)

Morang (rural) 13 (460)

Siraha (rural) 12 (470)

Sindhupalchok 13 (212)

Kathmandu (rural) 23 (219)

Dhading 19 (255)

Ramenchhap 16 (208)

Dhanusha 4 (647)

Rautahat 5 (517)

Gorkha 23 (194)

Syangja 10 (251)

Gulmi 16 (402)

Rupandehi 3 (420)

Rolpa 27 (215)

Dialekh 31 (196)

Bardiya 9 (444)

Achham 34 (250)

Kailali (rural) 8 (330)

A5(15)
Table A5.12 Mean feeding frequency and proportion of children fed less than five times daily by ethnicity

Ethnic group Number Mean frequency of % children fed less than 5

feeding per day times per day

Brahmins 1005 8.0 12

Chhetri 1434 7.2 18

Newar 253 7.6 17

Gurung/Ghale 192 7.0 15

Magar 360 7.4 16

Rai/Limbu 354 7.7 22

Tamang/Sherpa 286 7.4 19

Muslim 342 9.2 12

Occupational 1185 7.4 18

Tharu 746 8.5 6

Yadav 428 9.0 7

Other (terai) 808 9.2 6

Other (hills) 284 8.0 15

A5(16)
Table A5.13 Proportion of focus groups reporting women beaten oftne in the community by regions, eco-zones
and urban/rural split

Location Number of focus % focus groups saying women

groups beaten often

Development regions Eastern 31 48

Central 38 37

Western 24 38

Mid-Western 16 75

Far-Western 10 70

Eco-zones Terai 56 57

Hills 50 40

Mountains 39 39

Urban/rural split Urban 19 26

Rural 119 48

Note: Results by region, and eco-zone are for rural sites only. The urban sites were selected separately.

A5(17)
Table A5.14 Mean age to reach motor development milestones by regions, eco-zones, urban/rural split and
eco-development regions

Location Mean age to sit in Mean age to stand in Mean age to walk in
months (n) months (n) months (n)

Development regions Eastern 7.1 (2864) 9.9 (2677) 12.6 (2499)

Central 7.3 (3538) 10.3 (3249) 13.2 (2993)

Western 7.2 (2479) 10.3 (2308) 13.1 (2112)

Mid-Western 7.3 (1884) 10.4 (1702) 13.2 (1598)

Far-Western 7.2 (1280) 9.9 (1173) 12.9 (1106)

Eco-zones Terai 6.9 (5684) 9.7 (5196) 12.7 (4819)

Hills 7.5 (5060) 10.7 (4714) 13.4 (4374)

Mountains 7.1 (1301) 10.3 (1199) 13.0 (1115)

Urban/rural split Urban 6.8 (1407) 9.9 (1283) 12.8 (1192)

Rural 7.2 (12045) 10.2 (11109) 13.0 (10308)

Eco-development regions Eastern - terai 6.9 (1601) 9.5 (1503) 12.5 (1403)

Eastern - hills 7.4 (1041) 10.4 (971) 12.8 (910)

Eastern - mountains 7.2 (222) 10.3 (203) 12.3 (186)

Central -terai 7.1 (1931) 9.8 (1751) 12.7 (1608)

Central - hills 7.6 (1259) 10.9 (1172) 13.7 (1091)

Central - mountains 7.5 (348) 10.7 (326) 14.4 (294)

Western - terai 6.9 (805) 9.8 (729) 12.8 (666)

Western- hills 7.4 (1625) 10.6 (1534) 13.2 (1405)

Western -mountains 6.8 (49) 10.1 (45) 13.0 (41)

Mid-Western - terai 6.7 (783) 9.9 (699) 13.1 (656)

Mid-Western - hills 7.9 (701) 11.0 (642) 13.8 (600)

Mid-Western - mountains 7.3 (400) 10.5 (361) 12.6 (342)

Far-Western - terai 7.0 (564) 9.6 (514) 12.8 (486)

Far-Western - hills 7.8 (434) 10.5 (395) 13.3 (368)

Far-Western - mountains 6.5 (282) 9.6 (264) 12.4 (252)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(18)
Figures A5.10, A5.11, A5.12 (maps of mean age to sit, stand and walk by eco-development region)

A5(19)
Table A5.15 Parents’ perceptions of delay in motor development milestones by regions, eco-zones, urban/rural
split and eco-development regions

Location % with serious delay % with serious delay % with serious delay
sitting (n) standing (n) walking (n)

Development regions Eastern 19 (3011) 23 (2836) 26 (2656)

Central 19 (3669) 25 (3490) 24 (3227)

Western 20 (2518) 25 (2385) 27 (2223)

Mid-Western 24 (1928) 28 (1786) 29 (1671)

Far-Western 18 (1297) 18 (1224) 20 (1146)

Eco-zones Terai 14 (5896) 18 (5498) 20 (5102)

Hills 25 (5192) 30 (4956) 31 (4639)

Mountains 24 (1335) 28 (1267) 29 (1182)

Urban/rural split Urban 15 (1451) 21 (1368) 23 (1265)

Rural 20 (12423) 24 (11721) 26 (10923)

Eco-development regions Eastern - terai 18 (1704) 21 (1584) 25 (1488)

Eastern - hills 22 (1081) 26 (1034) 29 (970)

Eastern - mountains 19 (226) 22 (218) 27 (198)

Central -terai 12 (2025) 16 (1920) 15 (1745)

Central - hills 27 (1290) 34 (1223) 34 (1156)

Central - mountains 33 (354) 40 (347) 41 (326)

Western - terai 12 (812) 20 (756) 21 (695)

Western- hills 23 (1652) 28 (1580) 30 (1483)

Western -mountains 6 (54) 8 (49) 16 (45)

Mid-Western - terai 12 (785) 18 (713) 20 (676)

Mid-Western - hills 36 (729) 38 (691) 39 (640)

Mid-Western - mountains 28 (414) 31 (382) 30 (355)

Far-Western - terai 18 (570) 18 (525) 22 (498)

Far-Western - hills 18 (440) 19 (428) 20 (390)

Far-Western - mountains 16 (287) 18 (271) 18 (258)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A5(20)
Figures A5.13, A5.14, A5.15 (Maps of perceived motor delay by eco-development region)

A5(21)
Table A5.16 Mean age to reach motor milestones by ethnicity
Ethnic group Mean age to sit in Mean age to stand in Mean age to walk in
mnths (n) mnths (n) mnths (n)

Brahmins 7.3 (1908) 10.4 (1811) 13.2 (1686)

Chhetri 7.4 (2608) 10.5 (2429) 13.2 (2250)

Newar 6.8 (445) 9.9 (415) 12.6 (379)

Gurung/Ghale 7.0 (334) 10.7 (305) 13.5 (290)

Magar 7.2 (635) 10.3 (582) 13.4 (550)

Rai/Limbu 7.0 (656) 9.9 (599) 12.5 (555)

Tamang/Sherpa 7.0 (482) 10.1 (448) 13.0 (415)

Muslim 6.9 (546) 10.3 (474) 13.0 (443)

Occupational 7.3 (1958) 10.2 (1792) 13.1 (1664)

Tharu 6.8 (1299) 9.8 (1163) 12.8 (1089)

Yadav 6.9 (733) 9.5 (690) 12.4 (636)

Other (terai) 7.1 (1355) 9.7 (1233) 12.6 (1128)

Other (hills) 7.6 (493) 10.5 (451) 13.2 (415)

Table A5.17 Parental perception of delay in motor milestones by ethnicity

Ethnic group % children % children % children
serious delay serious delay serious delay
sitting (n) standing (n) walking (n)

Brahmins 21 (1949) 25 (1871) 27 (1776)

Chhetri 25 (2682) 28 (2557) 28 (2378)

Newar 15 (463) 22 (438) 22 (412)

Gurung/Ghale 25 (341) 31 (314) 32 (302)

Magar 25 (644) 29 (616) 31 (576)

Rai/Limbu 17 (669) 23 (650) 29 (594)

Tamang/Sherpa 20 (495) 27 (474) 30 (444)

Muslim 17 (565) 25 (524) 26 (466)

Occupational 20 (2025) 23 (1897) 25 (1748)

Tharu 12 (1321) 18 (1210) 21 (1139)

Yadav 13 (792) 14 (727) 17 (684)

Other (terai) 14 (1413) 18 (1332) 18 (1228)

Other (hills) 25 (515) 31 (479) 31 (441)

A5(22)
 ANNEX 6

COMPARISON OF NMIS 4, NFHS 1996 AND NMIS 1

There have been three national surveys in Nepal including anthropometry on young children since 1995. These are:

‘ NMIS cycle 1, field work carried out in January-March 1995

‘ NFHS (Nepal Family Health Survey) 1996, field work carried out in January-June 1996
‘ NMIS cycle 4, field work carried out in September-November 1996

The unusual occurrence of three national surveys of anthropometry within less than two years provides an opportunity
to make comparisons between the findings of the three surveys and investigate the causes of any discrepancies. This
Annex is a preliminary comparison; more detailed comparisons using the raw data from all three surveys are planned.

1. Comparison of NMIS cycle 4 and NFHS

These two surveys were carried out very close to one another in 1996. Both are designed to give national data. Both
use stratified cluster samples, but the cluster size in the NMIS is larger than in the NFHS. The NFHS includes about
7,500 households, while the NMIS includes about 19,000 households.

As well as providing national figures for indicators of malnutrition, both the NMIS and the NFHS are intended to give
figures for urban and rural areas separately, for the three eco-zones and for the five development regions. In addition,
both surveys are designed to be able to give estimates of the levels of indicators for each of the 15 eco-development
regions (recognising that for some of the mountain eco-development regions the accuracy of these estimates is low).

Table A6.1 shows the findings at national level for stunting and wasting in the NFHS and the NMIS 4, for three age
groups of children. NMIS 4 does not have anthropometry on children less than six months old. The 95% Confidence
Intervals for the NMIS 4 data are also shown; these are not known for the NFHS from the published report. It is clear
that the figures for stunting from the two surveys are very similar. Both show a pattern of increasing stunting with age.
The proportion of stunted children in the lowest age group (0-5 months) is notably low.

The figures for wasting from the two surveys show a similar age pattern: the middle age group have a higher rate of
wasting. The figures from the NMIS 4 are higher than those from the NFHS. This could well be because of the different
time of year of the two surveys. Wasting in Nepal is known to have a marked seasonal variation.

Table A6.1. Stunting and wasting in NMIS cycle 4 and NFHS, taking age into account

Age group Stunting Wasting

NFHS NMIS 4 NFHS NMIS 4

n % stunted n % stunted n % wasted n % wasted

(95% CI) (95% CI)

0-5 m 594 15 - - 594 4 - -

6-11 m 658 29 1305 32 (29-34) 658 7 1305 12 (11-14)

12-23 m 1290 59 2193 58 (55-60) 1290 21 2193 24 (22-26)

24-35 m 1162 64 2095 59 (57-61) 2095 7 2095 11 (10-13)

In order to compare the published figures for stunting and wasting from the NFHS with those from the NMIS (for
example for comparisons of geographically disaggregated figures) it is necessary to ‘correct’ the NFHS figures to allow
for the inclusion of the 0-5 months age group. The calculation of the correction factor is shown in Table A6.2.

A6(1)
Table A6.2. Calculation of correction factor for NFHS data to allow direct comparison with NMIS 4 data

Age group Stunting Wasting

n children % stunted n stunted n children % wasted n wasted

0-5 m 594 14.9 89 594 3.8 23

6-11 m 658 29.2 192 658 7.7 48

12-23 m 1290 59.4 766 1290 20.5 264

24-35 m 1162 64.1 745 1162 7.0 81

Total 3704 48.4 1792 3704 11.2 416

Total -(0-5m) 3110 54.7 1703 3110 12.6 393

Correction factor 6.3 1.4

As can be seen from Table A6.2, the correction factor is 6% for stunting figures and 1% for wasting figures. The
national comparison figures for stunting and wasting in NMIS 4 and NFHS (for children 6-36 months old) are therefore:

‘ Stunting: NMIS 4 53% (Note: this is after weighting the national figure)
NFHS 55% (After correcting to same age group)

‘ Wasting: NMIS 4 16% (Note: this is after weighting the national figure)
NFHS 13% (After correcting to same age group)

Table A6.3 shows the anthropometric data from the NFHS and the NMIS 4 disaggregated by regions, urban/rural split,
eco-zones and eco-development regions. As can be seen from Table 3, the findings on stunting from the two surveys
are similar for most areas. The corrected NFHS figure for stunting is nearly always within the 95% Confidence Interval
of the NMIS 4 figure. The confidence intervals for the NFHS data are not available by eco-development regions in the
published report, only by regions, eco-zones and urban/rural split.

The comparison for wasting figures is interesting. There is a major discrepancy for the figures in the Eastern and Central
terai eco-development regions. This may well reflect the flooding in these areas that happened during the monsoon: just
after the NFHS data collection and shortly before the NMIS 4 data collection. This seems to have caused a high rate
of acute malnutrition in these areas, presumably due to a combination of food shortage and diarrhoeal infections.

A6(2)
Table A6.3. Stunting and wasting in NMIS cycle 4 and NFHS by regions, eco-zones, urban/rural split and eco-
development regions

Location % of children 6-36 mnths stunted % of children 6-36 mnths wasted

NFHS* NMIS 4 NFHS* NMIS 4

(95% CI) (95% CI) (95% CI) (95% CI)

Development regions Eastern 44 (40-49) 47 (45-50) 11 (9-14) 18 (16-20)

Central 57 (52-62) 55 (52-57) 11 (9-13) 21 (19-24)

Western 56 (51-61) 55 (52-58) 12 (8-16) 12 (10-14)

Mid-Western 57 (51-63) 61 (57-64) 13 (11-15) 12 (10-15)

Far-Western 59 (55-64) 53 (49-58) 18 (15-20) 17 (14-20)

Eco-zones Terai 53 (49-57) 50 (48-52) 14 (12-16) 24 (23-26)

Hills 55 (51-59) 56 (54-58) 10 (9-12) 10 (9-11)

Mountains 63 (57-68) 63 (59-67) 15 (12-18) 8 (6-10)

Urban/rural split Urban 41 (35-48) 39 (35-43) 7 (4-9) 15 (12-18)

Rural 55 (53-58) 54 (53-55) 13 (11-14) 17 (16-18)

Eco-development regions Eastern - terai 41 47 (43-50) 13 23 (20-27)

Eastern - hills 48 46 (42-51) 10 11 (8-14)

Eastern - mountains 50 58 (48-68) 8 7 (3-14)

Central -terai 61 54 (51-58) 12 33 (30-37)

Central - hills 50 52 (48-56) 9 6 (4-9)

Central - mountains 59 69 (60-77) 14 5 (2-11)

Western - terai 58 54 (48-59) 19 18 (14-23)

Western- hills 55 56 (53-60) 8 9 (7-12)

Western -mountains 72 43 (22-66) 19 0 (0-17)

Mid-West - terai 45 42 (37-48) 12 15 (12-19)

Mid-West - hills 62 71 (65-76) 12 12 (9-16)

Mid-West - mountains - 80 (73-86) - 7 (4-11)

Far-West - terai 50 49 (43-56) 14 19 (15-25)

Far-West - hills 65 69 (62-75) 21 17 (12-23)

Far-West - mountains - 40 (31-49) - 13 (8-20)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

*NFHS results have been ‘corrected’ by adding 6% for stunting figures and 1% for wasting figures (see Table A6.2).

A6(3)
2. Comparison of NMIS 4 and NMIS 1
These two surveys used the same methodology and indeed they collected data from the same sites. The supervisors were
carefully trained in the techniques of anthropometry on both occasions. NMIS 1 used mechanical weighing scales and
NMIS 4 used electronic weighing scales (the same ones as used in the NFHS).

Table A6.4 shows the data for wasting and stunting by geographic areas for the NMIS 1 and NMIS 4. The 95%
Confidence Intervals for NMIS 4 data are also shown. It can be seen that stunting figures from NMIS 1 are around 10%
lower than the stunting figures from NMIS 4. This is a consistent pattern across all parts of the country.

For wasting, the figures for NMIS 1 are generally much lower than those from NMIS 4. NMIS 1 was undertaken at a
time of the year following a period when food shortage would not be expected, whereas NMIS 4 was undertaken after
the food shortage period of the monsoon. Again, the high rates of wasting in the Eastern and Central terai in NMIS 4
are quite different from the NMIS 1 rates of wasting in these same areas.

3. Conclusions
1. The findings of NMIS 4 and the NFHS are remarkably similar for stunting, once the same age groups are compared.
This similarity is not only at national level, but also down to comparisons of eco-development regions. This similarity
tends to validate both surveys.

2. NMIS 4 found a higher rate of wasting than either NMIS 1 or the NFHS. This probably reflects seasonal variation
in this indicator, which is known to be strong in Nepal. The very high rates of wasting found in the Eastern and Central
terai in NMIS 4 probably reflect a serious acute situation in these areas following heavy flooding during the monsoon.

3. There is a notable difference between the rates of stunting found in NMIS 1 and NMIS 4 (and the NFHS). The rate
of stunting in NMIS 1 is about 10% higher than that found in the other two surveys. The age pattern of stunting in NMIS
1 is very similar to that in NMIS 4 and the excess is consistent across the country. The reason for this higher rate of
stunting in NMIS 1 is not explained at present. There are several possible explanations:

‘ There is a real reduction in stunting between the beginning of 1995 and mid 1996. The magnitude (10%) is
large for such a short time. Certainly it is not possible to extrapolate a trend with only two time points so close
together. If this is the beginning of a downward trend, the slope of the decrease is likely to be much less than
it would appear from just these two points.

‘ There was a systematic measurement error made in NMIS cycle 1, with the height of children being
systematically underestimated. This seems rather unlikely, given the careful training of the operators
beforehand. It could explain low rates of acute malnutrition (since the weight would be compared with a lower
height than the actual height of the child) but the wasting rates are not unrealistically low for the time of year
and accord with the MUAC measurements made at the same time.

‘ This is a chance occurrence, due to ‘noise’ in the measurement. This is possible, but the consistent pattern
across all parts of the country makes it less likely. If it were due to a large random error, it would be surprising
to see such a consistent pattern of difference across all areas.

4. Further investigation of the difference between NMIS 1 and NMIS 4 (and the NFHS) is being undertaken. This will
involve further examination of the raw data, examination of the measuring equipment and interviews with the operators.
The issue may only be clarified when a further NMIS cycle including anthropometry is undertaken, perhaps in early
1998.

A6(4)
Table A6.4. Stunting and wasting in NMIS cycles 1 and 4 by regions, eco-zones, urban/rural split and eco-
development regions

Location % of children 6-36 mnths stunted % of children 6-36 mnths wasted

NMIS 1 NMIS 4 (95% CI) NMIS 1 NMIS 4 (95% CI)

Development regions Eastern 57 47 (45-50) 6 18 (16-20)

Central 65 55 (52-57) 7 21 (19-24)

Western 67 55 (52-58) 4 12 (10-14)

Mid-Western 74 61 (57-64) 4 12 (10-15)

Far-Western 64 53 (49-58) 7 17 (14-20)

Eco-zones Terai 61 50 (48-52) 9 24 (23-26)

Hills 66 56 (54-58) 4 10 (9-11)

Mountains 69 63 (59-67) 3 8 (6-10)

Urban/rural split Urban 49 39 (35-43) 3 15 (12-18)

Rural 64 54 (53-55) 6 17 (16-18)

Eco-development regions Eastern - terai 57 47 (43-50) 9 23 (20-27)

Eastern - hills 56 46 (42-51) 4 11 (8-14)

Eastern - mountains 69 58 (48-68) 6 7 (3-14)

Central -terai 62 54 (51-58) 10 33 (30-37)

Central - hills 67 52 (48-56) 4 6 (4-9)

Central - mountains 74 69 (60-77) 4 5 (2-11)

Western - terai 68 54 (48-59) 7 18 (14-23)

Western- hills 67 56 (53-60) 3 9 (7-12)

Western -mountains 71 43 (22-66) 5 0 (0-17)

Mid-West - terai 61 42 (37-48) 7 15 (12-19)

Mid-West - hills 79 71 (65-76) 3 12 (9-16)

Mid-West - mountains 78 80 (73-86) 2 7 (4-11)

Far-West - terai 62 49 (43-56) 10 19 (15-25)

Far-West - hills 72 69 (62-75) 7 17 (12-23)

Far-West - mountains 47 40 (31-49) 2 13 (8-20)

Note: Results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.

A6(5)
 ANNEX 7

WHY IS THE STUNTING RATE HIGHER IN NMIS1 THAN IN NMIS4 OR NFHS?

NMIS TECHNICAL PAPER

Background
There have been three national surveys in Nepal including anthropometry on young children since 1995. These are:

‘ Nepal Multiple Indicator Surveillance (NMIS) cycle 1, field work carried out in January-March 1995
‘ Nepal Family Health Survey (NFHS)1996, field work carried out in January-June 1996
‘ NMIS cycle 4, field work carried out in September-November 1996

Stunting (chronic malnutrition) is a relatively stable indicator and would not be expected to be much different between
the three surveys, within the limits of measurement error. And indeed, the proportion of children aged 6-35 months who
are stunted is very similar between NMIS4 (53%) and the NFHS (54%), despite their different sampling strategies,
tending to validate both surveys. The similarity between the two surveys is found not only nationally but also in
individual eco-development regions. However, the proportion of children aged 6-35 months who are stunted in the
NMIS1 survey is higher at 64%. The question arises: what is the cause of this discrepancy?

Characteristics of the discrepancy

The higher rate of stunting in NMIS1 is remarkably consistent across all areas of the country, the NMIS1 result being
about 10% higher than the NMIS4 result in all eco-development regions (see Table 2).

This highly consistent pattern tends to suggest a systematic error in one or the other measurement, rather than the
difference arising due to chance and variability of the estimate of the indicator. The fact that the NMIS4 result is close
to the result of a third survey (the NFHS) makes it more likely that any error is in the NMIS1 measurement.

The age relationship with stunting is very similar in NMIS1, NMIS4 and the NFHS. In all three surveys the stunting
rate rises up to about two years old and then remains relatively constant in older children. Again, this suggests some
sort of systematic measurement difference, unrelated to the age of the child, between NMIS1 and the other two surveys.

Investigation of the discrepancy

The practical procedures of each of the three surveys were reviewed. Table 1 shows the instruments and procedures
used in the three surveys.

Table A7.1. Instruments and procedures for anthropometry in NMIS1, NFHS and NMIS4
Procedure/instrument NMIS1 NFHS NMIS4

Estimation of age of children Local calendar, with key Local calendar as for NMIS1 Local calendar as for NMIS1
under 3 years events noted for different Tibetan calendar
sites

Weighing scales Mechanical; child placed in Electronic; child placed in Same scale and method as for
sling to be weighed mother’s arms and weight NFHS
difference shown

Measuring children All children up to 36 months Children above 23 months Children above 23 months
measured lying down measured standing measured standing

Measuring board UNICEF board with attached DHS board (Irwin Shorr Same board as for DHS
tape (Cowhead brand, from Productions, Maryland, USA)
China). Produced especially
for NMIS1

Fortunately, some supervisors undertook field work in all three surveys. A meeting was held to discuss with them their

A7(1)
practices in the three surveys and examine the instruments that were used.

The two main possibilities to explain the difference in stunting between NMIS1 and NMIS4 seemed to be:
˜ The age of children was systematically overestimated in NMIS1 relative to NMIS4
or
˜ The height of children was systematically underestimated in NMIS1 relative to NMIS4

Estimating the age of the children

The supervisors confirmed that the same type of calendar was used in all three surveys and that they used it in the same
way. In both NMIS1 and NMIS4 it was possible to examine the age distribution of the children and the ‘heaping’ at
the one year and six month points in the distribution was not too marked. This suggests that not too much rounding to
these points occurred in either cycle.

A systematic difference in the estimation of age between NMIS1 and NMIS4/NFHS can be excluded with some
confidence.

Measuring the height of the children

The boards used in NMIS1 and NFHS/NMIS4 were examined and their use was discussed with the supervisors and the
overall New ERA field supervisor for NMIS1. The overall supervisor recalled a problem with the tape attached to the
board used in NMIS1, in that the interviewers had to be asked to read centimetres at what were apparently half-
centimetre marks on the tape. However, when the four field supervisors were asked to read the tape as they had done
in the data collection for NMIS1, all four of them read to the normal centimetre marks.

Experiments were made measuring objects on both types of board (NMIS1 board and DHS board). Objects above
about 50cm were measured as 0.5cm shorter on the NMIS1 board compared with the DHS board. Further examination
of the NMIS1 board and the DHS board revealed the reason for the problem: the tape attached to the NMIS1 board (an
ordinary tape made of plastic coated cloth) was apparently stretched. A measurement of 70cm on the board was actually
70.5cm in length (measured with a separate tape). It is not clear whether the tape became stretched during attachment
to the board or whether this is a manufacturing fault; no unattached tape was available to check this.

Apparently the problem with the tape on the NMIS1 board was noted towards the end of the training/preparatory phase
of NMIS1 and an attempt was made to overcome it by asking the interviewers to read to the half centimetre marks to
compensate for the under-reading of the tape (in other words they were asked to record a measurement of 70.5cm as
71cm). However, the request during training was not enough to prevent the supervisors and interviewers from using
the tape in the ‘normal’ way once in the field. This was confirmed by the way in which the four supervisors interviewed
all read the tape. The problem with the tape thus resulted in a systematic underestimation of the height of children of
0.5cm.

The NMIS1 data were reanalysed for stunting frequency, after correcting the height of all the children by +0.5cm. This
resulted in a stunting rate of 54% nationally, very close to the figures for NMIS4 and the NFHS. The original and
‘corrected’ stunting rates in NMIS1, by region, ecozone, urban/rural split and eco-development region are shown next
to the equivalent figures for NMIS4 and NFHS in Table 2. The ‘corrected’ stunting rate from NMIS1 is close to that
estimated in the NFHS and NMIS4 in all areas.

Correcting the height of children by +0.5cm also changes the wasting rate (proportion with low weight-for-height),
tending to increase this indicator. Table 3 shows the wasting rates in all three surveys by geographic area, including
the ‘corrected’ rates from NMIS1. There is still variation between the surveys in wasting rates; this is not surprising
given the marked seasonal variation in this indicator. In particular, the wasting rates in the central and eastern terai are
much higher in NMIS4 than in NMIS1 and NFHS; this is likely to be because NMIS4 was undertaken just after the
monsoon, when there was serious flooding in this part of the country, with food shortage and infections.

Discussion
Nepal is in the fortunate position of having data from three large national surveys including anthropometry on young
children within less than two years. This allows validation of the results against one another. The discrepancy between
NMIS1 and the other two surveys was therefore highlighted. Because the discrepancy was relatively large and
consistent, this raised the possibility of a systematic measurement difference. This would not have been recognised but

A7(2)
for the two further studies and the implausibility of there being a real reduction in stunting of that magnitude in such a
short time. In many other situations, a small consistent measurement error such as that in NMIS1 would not be
recognised and could lead to overestimation (or underestimation) of malnutrition in a country.

The problem with the measuring boards used in NMIS1, which were specially made for the survey, argues in favour
of using standardised equipment for measurement of height and weight, as far as possible. This is particularly true when
the results are to be used for international comparison or for comparison over time (as is the intention in the NMIS
process).

Conclusions
The discrepancy in stunting rates between NMIS1 and NFHS/NMIS4 can be explained by a small systematic
underestimation of height in NMIS1. This arose because of a problem with the measuring board used in NMIS1. The
problem with the board was recognised an attempt was made to train interviewers to compensate for it, but this was
unsuccessful. When the height measurements from NMIS1 are corrected by +0.5cm, the stunting rates in NMIS1 are
similar to those in NMIS4 and the NFHS in all areas.

A7(3)
Table A7.2. Stunting in NMIS1, NFHS and NMIS4 by regions, eco-zones, urban/rural split and eco-
development regions

Location % of children 6-36 mnths stunted

NMIS1 NMIS1 NFHS NMIS 4

(uncorrected) (corrected) (95% CI) (95% CI)

Development regions Eastern 57 47 44 (40-49) 47 (45-50)

Central 65 57 57 (52-62) 55 (52-57)

Western 67 56 56 (51-61) 55 (52-58)

Mid-Western 74 63 57 (51-63) 61 (57-64)

Far-Western 63 53 59 (55-64) 53 (49-58)

Eco-zones Terai 61 53 53 (49-57) 50 (48-52)

Hills 66 57 55 (51-59) 56 (54-58)

Mountains 69 60 63 (57-68) 63 (59-67)

Urban/rural split Urban 49 43 41 (35-48) 39 (35-43)

Rural 64 55 55 (53-58) 54 (53-55)

Eco-development regions Eastern - terai 57 47 41 47 (43-50)

Eastern - hills 56 44 48 46 (42-51)

Eastern - mountains 69 61 50 58 (48-68)

Central -terai 62 53 61 54 (51-58)

Central - hills 67 60 50 52 (48-56)

Central - mountains 74 65 59 69 (60-77)

Western - terai 68 63 58 54 (48-59)

Western- hills 67 54 55 56 (53-60)

Western -mountains 71 52 72 43 (22-66)

Mid-West - terai 61 55 45 42 (37-48)

Mid-West - hills 79 70 62 71 (65-76)

Mid-West - mountains 78 68 - 80 (73-86)

Far-West - terai 62 51 50 49 (43-56)

Far-West - hills 72 64 65 69 (62-75)

Far-West - mountains 47 38 - 40 (31-49)

Note:
(1) NMIS results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.
(2) NFHS figures are corrected to exclude children under 6 months old
(3) NMIS1(corrected) figures are calculated after adding 0.5cm to the height of all children

A7(4)
Table A7.3. Wasting in NMIS1, NFHS and NMIS4 by regions, eco-zones, urban/rural split and eco-
development regions

Location % of children 6-36 mnths wasted

NMIS1 NMIS1 NFHS* NMIS 4

(uncorrected) (corrected) (95% CI) (95% CI)

Development regions Eastern 6 10 11 (9-14) 18 (16-20)

Central 7 11 11 (9-13) 21 (19-24)

Western 4 6 12 (8-16) 12 (10-14)

Mid-Western 4 6 13 (11-15) 12 (10-15)

Far-Western 7 8 18 (15-20) 17 (14-20)

Eco-zones Terai 9 12 14 (12-16) 24 (23-26)

Hills 4 5 10 (9-12) 10 (9-11)

Mountains 3 5 15 (12-18) 8 (6-10)

Urban/rural split Urban 3 4 7 (4-9) 15 (12-18)

Rural 6 9 13 (11-14) 17 (16-18)

Eco-development regions Eastern - terai 9 12 13 23 (20-27)

Eastern - hills 4 7 10 11 (8-14)

Eastern - mountains 6 5 8 7 (3-14)

Central -terai 10 16 12 33 (30-37)

Central - hills 4 6 9 6 (4-9)

Central - mountains 4 8 14 5 (2-11)

Western - terai 7 10 19 18 (14-23)

Western- hills 3 5 8 9 (7-12)

Western -mountains 5 3 19 0 (0-17)

Mid-West - terai 7 8 12 15 (12-19)

Mid-West - hills 3 4 12 12 (9-16)

Mid-West - mountains 2 5 - 7 (4-11)

Far-West - terai 10 11 14 19 (15-25)

Far-West - hills 7 8 21 17 (12-23)

Far-West - mountains 2 3 - 13 (8-20)

Note:
(1)NMIS results by region, eco-zone and eco-development region are for rural sites only. The urban sites were selected
separately.
(2) NFHS figures are corrected to exclude children under 6 months old
(3) NMIS1(corrected) figures are calculated after adding 0.5cm to the height of all children

A7(5)
 ANNEX 8

AGE STRUCTURE OF THE SAMPLE POPULATION

The age and sex structure of the sample population fron the NMIS 4 survey is shown in Table A8.1.

Table A8.1 Age and sex of the sample population

Age group Males Females Total

n (% of population) n (% of population) n (% of population)

0-4 yr 5762 (6) 5629 (6) 11391 (12)

5-9 yr 6473 (7) 6292 (7) 12765 (14)

10-14 yr 6750 (7) 6121 (7) 12871 (14)

15-19 yr 4966 (5) 5087 (5) 10053 (11)

20-24 yr 3615 (4) 3993 (4) 7608 (8)

25-29 yr 3421 (4) 3728 (4) 7149 (8)

30-34 yr 2600 (3) 3060 (3) 5660 (6)

35-39 yr 2746 (3) 2880 (3) 5626 (6)

40-44 yr 2384 (3) 2309 (2) 4693 (5)

45-49 yr 1986 (2) 1931 (2) 3917 (4)

50-54 yr 1727 (2) 1497 (3) 3224 (3)

55-59 yr 1301 (1) 1135 (1) 2436 (3)

60-64 yr 1198 (1) 1216 (1) 2414 (3)

65-69 yr 810 (1) 748 (1) 1558 (2)

70-74 yr 585 (0.5) 478 (0.5) 1063 (1)

75-79 yr 289 (0.3) 320 (0.3) 609 (0.6)

80 + yr 252 (0.25) 260 (0.25) 512 (0.5)

Total 46865 46684 93549

A8(1)
The age structure of the sample population is similar to that in the 1991 census and the 1996 Nepal Family Health
Survey9. The comparison of the age strcuture from these different sources is shown in Table A8.2.

Table A8.2 Age structure of the population from different sources

Age group (% of 1991 Census 1991 NFHS 1996 NFHS NMIS 4, 1996
population)

<15 yr 42 44 44 40

15-64 yr 54 53 52 56

65 + yr 4 4 4 4

In the NMIS sample there is a slightly lower proportion of the population in the youngest (<15 yr) age group than in the
1991 census, whereas in the NFHS there is a slightly higher proportion in this age group than in the 1991 census.

A8(2)