Initial findings from the 2000 Cambodia National ... · Initial findings from the 2000 Cambodia...

HELEN KELLER INTERNATIONAL

CAMBODIA

Supporting document to the Micronutrient Workshopheld on February 20, 2001, in Phnom Penh, Kingdom ofCambodia

Initial findings from the 2000Cambodia NationalMicronutrient Survey

Table ofcontents

Foreword ........................................................................................................................................... i

Executive Summary ........................................................................................................................ 1

Cambodia Nutrition Bulletins (related to Micronutrient Survey) ....................................... 3

Other Cambodia Nutrition Bulletins published by HKI/Cambodia .................................. 25

Acknowledgments ....................................................................................................................... 35

HKI/Cambodia Country Office Profile ..................................................................................... 37

Country Profile: Cambodia .........................................................................................................38

Foreword

Since its founding in 1915, Helen KellerWorldwide (HKW) has always been atthe forefront in the fight against

avoidable blindness. Through the years,increased technical capacity has enabled theagency to develop innovative and sustainablesolutions to combat this problem. Throughincreased scientific knowledge resulting fromour program-oriented research into vitamin Adeficiency (VAD) – a leading cause of blindnessand mortality among children inunderdeveloped countries – the agency hasexpanded the scope of its work into the field ofnutrition.

Today, Helen Keller International (HKI), theprogram division of HKW, operates in threemajor regions of the world – the Americas,Africa and the Asia-Pacific. In the Asia Pacificregion, we have given particular emphasis tonutrition activities, ranging from surveys onthe prevalence of micronutrient deficienciesto micronutrient interventions. Havingnurtured cutting-edge expertise in the field ofnutrition, HKI/Asia-Pacific plays a leading rolein providing technical assistance togovernments in the region in assessing thenutritional status of the populations we serveand helping to establish and implementnutrition programs.

Helen Keller International began working inCambodia in 1992, when the agency initiatedits first project to assess the extent of VAD inthe country. Early work focused on addressingthe problem of VAD through the distribution ofhigh-dose vitamin A capsules (VACs) to

preschool-aged children. Additionally, incollaboration with UNICEF and the RoyalGovernment of Cambodia (RCG), HKI wasinvolved in pilot studies that resulted in thesuccessful integration of VAC distributionthrough National Immunization Days (NIDs)for polio. Since 1995, with support from theUnited States Agency for InternationalDevelopment (USAID), the focus of HKI’sprogram in Cambodia was expanded to includeother sustainable nutrition interventions toimprove micronutrient status, and toinstitutionalize primary eye care. HKI remainsactive as a member of the National Vitamin AWorking Group (now the NationalMicronutrient Technical Working Group).

This document highlights some of the keyfindings and reports that have been generatedas a result of Cambodia’s first nationalmicronutrient survey. This important first steptoward establishing a system for the regularassessment of nutritional and health status inthe country was made possible through closecollaboration between the RCG and HKI, andwith funding from USAID, whose long-standingsupport to HKI’s work in the field of nutritionwe could not have done without. Currently, HKI/Cambodia receives funding from the USAID/Cambodia Mission for activities related tosupporting the national VAC distributionprogram, to providing technical assistance toNGOs in home gardening and nutritioneducation, and to institutionalizing primary eyecare.

i

Dora PanagidesCountry Director

HKI Cambodia

Caroline F. ConnollyDirector, Office of Public Health

USAID Cambodia

Martin W. BloemRegional Director

HKI Asia-Pacific

1

ExecutiveSummary

BackgroundMicronutrient malnutrition is increasinglybeing recognized as one of the main nutritionalproblems in the world because it affects morethan 3 billion people and has serious, long-lasting consequences. It can increase morbidityand mortality among children and women ofreproductive age, retard child growth andcognitive development, and reduce workproductivity. The immediate causes ofmicronutrient deficiencies are inadequateintake of micronutrient-rich foods and severeand repeated illness. Underlying causes includepoverty, general malnutrition, inadequateaccess to micronutrient-rich foods, less thanoptimal child care practices and limited accessto health care services.

In Cambodia, vitamin A deficiency (VAD) andother nutrient deficiencies have beenrecognized as public health problems. A 1999survey conducted by Helen Keller International(HKI) in five provinces showed that VAD andanemia were serious problems amongpreschool children and women. This was alsofound by surveys conducted by UNICEF andWFP. In addition, cases of xerophthalmia(clinical sign of VAD) were identified andreported regularly during 1999.

Since 1994, the Royal Government of Cambodia(RCG) has been implementing a nationalvitamin A capsule (VAC) distribution program.Until the end of 1997, VACs were distributedthrough National Immunization Days for Polio.Since then, the distribution channels forchildren aged 6-59 months have been routineimmunization outreach activities,supplementary supplementation activitiessuch as Sub-National Immunization Days(SNIDs), and measles outbreak response. Forpostpartum women, distribution is donethrough contact with health centers.

The 2000 micronutrient survey of ruralCambodia was conducted to (1) determinenational prevalence of vitamin A deficiency andanemia among women and children, (2)identify key determinants of vitamin A and irondeficiency, and (3) assess coverage andeffectiveness of Cambodia’s initiative to

integrate vitamin A capsule distribution intoroutine immunization services. In conjunctionwith this, an assessment of the national vitaminA capsule distribution program was conductedto (1) identify strengths and limitations of thenational VAC program, and 2) identify possiblemechanisms for achieving high VAC coverageamong each target group. The findings of thesurvey and the VAC program assessment canbe used to establish the basis for a long termmicronutrient program in Cambodia which inturn reduces the risk of child and maternalmorbidity and mortality. The survey andassessment were a collaborative effortbetween the Royal Government of Cambodiaand Helen Keller International and werefunded by the United States Agency forInternational Development (USAID).

Initial Findings• Vitamin A deficiency is still a problem of

public health significance amongCambodian children in many provinces.

• Vitamin A capsule coverage among childrenaged 6-59 months ranged from 10-55% andvaried widely among and within provinces.

• Vitamin A capsules reduced a child’s risk fornightblindness more than two times in allprovinces, irrespective of the prevalence ofnightblindness in the particular province.

• Nightblindness is a significant problemamong pregnant and lactating women.

• Coverage of vitamin A capsule distributionto postpartum women is very low.

• A large proportion of Cambodian women donot consume adequate vitamin A throughtheir diet.

• Anemia, wasting and other nutritionproblems are also highly prevalent amongwomen in Cambodia and these nutrientdeficiencies co-exist.

2

ExecutiveSummary

Recommendations• The distribution of high-dose vitamin A

capsules among Cambodian children aged6-59 months should be continuednationwide and VAC coverage amongchildren aged 6-59 months needs to beimproved. Immunization outreach activitiesprovide a good mechanism for deliveringvitamin A capsules to children of all ages andshould be continued.

• Expand programs to increase the intake ofvitamin A rich foods through socialmarketing, home gardening, poultry raising,and animal husbandry.

• Explore the feasibility of fortifying foodswith vitamin A or, preferably, with multiplemicronutrients.

• Improve coverage of postpartum vitamin Acapsule distribution program.

• Explore the feasibility of providing multi-micronutrients during pregnancy andadolescence.

• Acquire technical assistance to helptranslate the survey findings into a strategyand action plan to control vitamin Adeficiency in Cambodia, particularly for thefurther development of the vitamin Acapsule program.

• Organize and get financial support forworkshops and meetings in order to maketimely use of this information withinCambodia at the national and provinciallevels.

• Continue monitoring and surveillance ofVAD among women and children, and theeffectiveness of programs.

• Share the findings from the NationalMicronutrient Survey of Cambodia onvitamin A capsule distribution andimmunization outreach activities widelywith other countries in Asia and Africa,because they are clearly ‘lessons withoutborders.’

Financial SupportThe Cambodia National Micronutrient Surveyand Vitamin A Program Assessment were madepossible through funding from the UnitedStates Agency for International Development(USAID) under the terms of CooperativeAgreement No. HRN-A-00-98-00013-00.Special thanks to Dr. Frances Davidson and Dr.Timothy Quick of the Health and NutritionOffice, USAID/Washington, who wereinstrumental in making this possible.

We are also grateful for the commitment andsupport shown to Helen Keller International/Cambodia by Dr. Jeffrey Ashley (now withUSAID/Angola), Dr. Lois Bradshaw and Mr. CareyGordon of USAID/Cambodia. This project wouldnot have been possible without it.

3

Conducting the first Cambodia National Micronutrient Survey.Vol 2, Iss 1, October 2000 ................................................................................................................. 5

The need for increasing coverage of vitamin A capsule program to reducevitamin A deficiency among young children in Cambodia.Vol 2, Iss 2, November 2000 .......................................................................................................... 9

Routine immunization outreach is a good strategy for delivering vitamin A capsulesto Cambodian children. vol 2, Iss 3, December 2000 .............................................................. 13

The need for multiple strategies to combat vitamin A deficiency among women inCambodia. Vol 2, Iss 4, February 2001 ........................................................................................ 21

Cambodia Nutrition Bulletins(related to Micronutrient Survey)

The Cambodia Nutrition Bulletin is published by Helen Keller International – Cambodia

NUTRITION BULLETINVol. 2, Issue 1October 2000

c a m b o d i aHELEN KELLER INTERNATIONAL

Conducting the first Cambodia NationalMicronutrient Survey

Micronutrient malnutrition is increasinglybeing recognized as one of the main nutri-tional problems in the world because it affectsmore than 3 billion people and has serious,long-lasting consequences. It can increasemorbidity and mortality among children andwomen of reproductive age, retard childgrowth and cognitive development, and re-duce work productivity.

Vitamin A deficiency (VAD) and other nutri-ent deficiencies have been recognized as pub-lic health problems in Cambodia. A recentsurvey conducted by Helen Keller Interna-tional (HKI) in five provinces showed that VADand anemia were serious problems among pre-school children and women. In addition, casesof xerophthalmia (clinical VAD) have beenidentified and reported regularly in the pastyear.

In light of the serious consequences of mi-cronutrient malnutrition and the importantneed for information to advocate for and toformulate programs and policies to controlmalnutrition in Cambodia, HKI and the RoyalCambodian Government (RCG), with supportfrom USAID, designed the first national mi-cronutrient survey with the following objec-tives:1) To determine the national prevalence of

clinical and subclinical VAD and anemiaamong women and children.

2) To identify key determinants of vitamin Aand iron deficiency among women andchildren in Cambodia.

By oxcart, by motorbike, by car, by plane and on foot, more than 130enumerators, monitors and supervisors traveled throughout Cambodia,including to some of the most remote areas, to collect data from 15,000households, which will provide insight into the magnitude and key determinantsof micronutrient malnutrition in Cambodia. These data are very important forprioritizing health problems and directing future programming with the ultimategoal of reducing child and maternal morbidity and mortality.

3) To assess the current coverage andeffectiveness of Cambodia’s initiative tointegrate vitamin A capsule distributioninto routine immunization services.

The survey, conducted from February toSeptember 2000, was a collaborative effort ofthe RCG, HKI and other key institutions inCambodia. The survey was designed alongthe UNICEF conceptual framework formalnutrition. HKI has successfully conductedmicronutrient surveys in other countries inthe Asia-Pacific region, which have been usedto guide policy and develop programs. Basedon these experiences, information wascollected on different nutritional outcomes(e.g. anemia, VAD, stunting, women’s bodymass index), food consumption and vitaminA intake, demographics and socioeconomicstatus, and program adequacy. Using arandom multistage cluster sampling design,data were collected from 15,000 householdsin 10 rural provinces by trained interviewers.Blood indicators (e.g. hemoglobin, serumretinol, malaria) were collected from a randomsubsample of these households.

The timeline that follows outlines the keyactivities and experiences in implementing thesurvey, describes the successful collaborationand highlights how challenges encounteredin carrying out the survey were transformedinto opportunities andsuccesses.

HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 1, October 2000

6

Challenges in the fieldNecessity – the mother of innovation?

Obtaining serum from blood samples is no easy task, particularly in remote rural areas where blood collec-tion teams do not have the luxury of a nearby laboratory. Serum is obtained from blood by means of a high-speed centrifuging process that, in a laboratory setting, would be performed by electrically-powered ma-chines. In the field, where there is often a lack of electricity, HKI survey personnel had to resort to usinghand-driven centrifuge devices from Bangladesh and Indonesia, which required operators to continually‘hand-crank’ them.

The centrifuge devices were tried out a few times in field practice. Despite nearly an hour of operating thedevice, the blood collection teams found that it was almost impossible to obtain serum. Teams becamediscouraged and they grew worried about the effort required to hand-centrifuge and the prospect of gettingpoor results. It was, in fact, the case that serum could not really be obtained with these hand-driven devices.

In the face of a possible inability to obtain serum samples in the field, HKI/Bangladesh was consulted.Within a single day, the innovative Bangladesh office successfully converted the hand-driven devices tobecome battery-operated. Tests conducted on the converted devices proved they were effective in obtain-ing serum from blood samples. Enough of the devices were then converted and shipped to Cambodia in timefor the implementation of the National Micronutrient Survey. Car batteries were purchased for the teams andthese were relatively easy to charge, even in the most remote places. Thanks to the ingenuity of the HKI/Bangladesh’s team of experts, the survey was carried out as planned.

Figure 1. Timeline of activities (February-September 2000)

Survey design and initialpreparations• Advocacy for conducting the

survey• Worked with RCG and

HKI/Asia-Pacific RegionalOffice in designing survey,including:– Development of conceptual

framework– Identification of objectives– Design of sampling strategy– Selection of target groups– Finalization of survey

protocol

Feb Mar Apr May2000

Preparation of sinstruments• HKI/Banglades

technical assistquestionnaire d

• Pretested and fsurvey question

• Developed survfor data collectquality control

Survey partners• RCG/MOH: Department of Nutrition, National Maternal and

Child Health Center involved in– Development of survey questionnaire– Training of field staff

• National Prevention of Blindness office– Assisted with training enumerators in detection of clinical signs of

vitamin A deficiency• Ministry of Planning

– Assisted with logistical support and coordination in the provinces• National Institute of Public Health

– Contracted to assist with training of nurses and laboratorytechnicians for blood collection and related procedures

• National Malaria Center– Assisted with reading malaria slides

• USAID– Provided financial support to conduct the survey– Strongly advocated for the implementation of a ‘programmatic’

survey• Given their substantial role in guiding and supporting health

and nutrition activities in Cambodia, RCG/MOH engagedUNICEF and WHO in planning for the survey

Survey preparat• Ethical review• Manpower asse

including identoutside technicsupport

• Terms of refere• Initial plans for

country• Budget prepara• Plans for procu

equipment (i.e.where, how to

• Workshops anddetermine partresponsibilities

In all his years – to deliver a refrom blood. Csupplier of ice cone day help tohis work that needed for bMicronutrient

Dry ice is solidfrozen serum otemperature anfrom a frozen countries, that


7

Field supervision and qualitycontrol• Senior staff from RCG/MOH

and HKI conducted regularvisits throughout the survey

• Special re-visits tohouseholds where thesurvey team identified achild with xerophthalmiawere undertaken by speciallytrained nurses (Basic EyeNurses)

• 6 quality control teamsconducted random re-visitsto households

2000Jun Jul Aug Sept

survey

h providedance fordevelopmentinalizednnairevey schedulesion andteams

Data collection• 40 two-person teams were

employed to collectinformation fromapproximately fivehouseholds daily

• 12 of the teams had a nurseand a lab technician to assistwith blood collection,preparation and storage ofserum samples (see boxbelow), measurement ofhemoglobin concentrationwith the HemoCue, andpreparation of malaria slides

Data entry• Nutritionist from HKI/Asia-

Pacific Regional Officeconducted training for 6 dataentry operators

• 2 HKI/Indonesia staff assistedwith supervision of dataentry, including– Quality control of data entry– Data validation

Training and fieldpreparations• Began preparations for

training– Developed lesson plans– Organized schedule for

sessions and trainers– Trainers identified from

MOH/Dept. of Nutrition,National Institute of PublicHealth, HKI/Cambodia andHKI/Indonesia

• Conducted training for– Enumerators– Monitors– Supervisors

• Finalized questionnaire• Planned and finalized

logistics and surveymanagement plan

• Excellent coordination withthe Ministry of Health andthe Ministry of Planning wasinstrumental in motivatingprovincial departments toassist survey teams withsecurity, logistics, andsupport for data and bloodcollection in communities

tion

essment,tification ofal assistance

ncetravel within

ationring. what, fromget)

d meetings toners’ roles and

Challenges in the fieldDelivering dry ice during the monsoon season

airport, breweries and supermarkets were scoured in search of dry ice.But when all conventional sources for obtaining it had turned up ‘dry,’HKI staff had to look to the unconventional. That was when they foundin Mr. Khim’s seemingly mundane weekly deliveries a veritable goldmineof dry ice.

On his part, Mr. Khim was determined to ensure that the dry ice wasdelivered on time on the designated day to HKI field personnel responsiblefor collecting blood samples that will show how many mothers, fathersand children have anemia and vitamin A deficiency in Cambodia. Earlymonsoon rains and difficult roads meant that he had to be resourceful. Insome cases, the dry ice had to be transported not just over land but alsoacross rivers where bridges had collapsed. Despite the odds, Mr. Khimdelivered his supply as scheduled each week, for more than 12 weeks.

of work, Mr. Khim had never received such an odd requestegular supply of dry ice to transport frozen serum obtainedertainly, he had never imagined that, through his job as acream from Thailand to Cambodian supermarkets, he wouldo improve the lives of many fellow Cambodians. Yet it wasled HKI/Cambodia to contract him to supply the dry ice

blood sample collection activities for the NationalSurvey.

ified carbon dioxide, which is often prefered for transportingobtained from blood samples because of its extremely coldnd the fact that it does not turn into liquid but evaporatesstate. Although it is usually quite easy to obtain in many

t was not the case in Cambodia. Ice cream factories, the

© 2000 Helen Keller InternationalReprints or reproductions of portions or all of this document are encouraged provided dueacknowledgement is given to the publication and publisher.

The Cambodia National Micronutrient Survey was made possible through funding from theUnited States Agency for International Development (USAID) under the terms of CooperativeAgreement No. HRN-A-00-98-00013-00.

This publication was made possible through support by the USAID/Cambodia Mission underthe terms of Award No. 442-G-00-95-00515-00. The opinions expressed herein are those ofthe author(s) and do not necessarily reflect the views of USAID.

Helen Keller Internationala division ofHelen Keller Worldwide

C A M B O D I A


Helen Keller International, Regional OfficeP.O. Box 4338, Jakarta PusatIndonesiaTelephone: 62-21-7198147/7199163Fax: 62-21-7198148

Dr. Martin W. Bloem, Regional DirectorE-mail: [email protected]

Dr. Regina Moench Pfanner, Regional CoordinatorE-mail: [email protected]

Dr. Saskia de Pee, Regional Nutrition Research AdvisorE-mail: [email protected]

Ms. Lynnda Kiess, Regional AdvisorE-mail: [email protected]

Helen Keller InternationalNutrition BulletinFor information and correspondence, contact:

Helen Keller International, CambodiaP.O. Box 168, Phnom PenhKingdom of CambodiaTelephone: 855-23-210851Fax: 855-23-210852

Ms. Dora Panagides, Country DirectorE-mail: [email protected]

Ms. La-Ong Tokmoh, IEC AdvisorEmail: [email protected]

Next Steps

• Given the successful design and implementation of thefirst national micronutrient survey in Cambodia, thenext steps are to analyze and interpret the data. Workingclosely with the RCG/MOH and other survey partners,HKI will help to ensure timely analysis anddissemination of the findings.

• Now that the findings of the survey will becomeavailable, they should be shared and discussed withkey players at both national and provincial level in orderto set priorities to control and prevent micronutrientdeficiencies. The findings will first of all becomeavailable through the Cambodia Nutrition Bulletin andshould then be discussed by different fora.

• A systems review of the vitamin A capsule programwas conducted in tandem with the micronutrient surveyto provide detailed information on the vitamin A capsule(VAC) program, postpartum VAC distribution, and useof iron supplements. The analysis of this assessmentis also ongoing and findings will be linked to the surveyresults to help guide program modifications.


NUTRITION BULLETINVol. 2, Issue 2November 2000


The need for increasing coverage of vitamin Acapsule program to reduce vitamin A deficiency

among young children in Cambodia

Vitamin A deficiency

Vitamin A deficiency is a serious publichealth problem. It is associated withincreased morbidity and mortality amongpreschool children and extensive evidencenow shows that the survival chances ofchildren aged 6 months to 5 years areincreased by 20-25%1 when vitamin A

Since 1993, the Royal Government of Cambodia (RCG), in collaboration withUNICEF, WHO and Helen Keller International (HKI) have been activelyinvolved in combating vitamin A deficiency through the distribution of vitaminA capsules (VAC). Results from the Cambodia National Micronutrient Survey(April – August 2000) reveal that night blindness is a problem of public healthsignificance in many provinces and that VAC markedly reduce the risk of vitaminA deficiency and its consequences such as increased morbidity and mortality.Thus, VAC distribution must be continued nationwide and the current coverageof 10-55% needs to be increased.

status is improved through twice yearlydistribution of high-dose VAC. However,while night blindness is the first clinicalsign of vitamin A deficiency, many morechildren, who do not yet show clinical signsof vitamin A deficiency, may already beat risk of increased morbidity andmortality. The prevalence of night

(cont’d on p2, col. 2)

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Figure 1. Prevalence of night blindness among children aged 18-59 months, by province(n=12,820). Bars indicate 95% CI (Confidence Interval) corrected for design effect.

HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 2, November 2000

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Vitamin AWhat vitamin A doesi

Vitamin A stored normally in the liver, is crucial for effectiveimmune-system functioning, protecting the integrity ofepithelial cells lining the skin, the surface of the eyes, theinside of the mouth and the alimentary and respiratory tracts.

Signs and consequences of vitamin A deficiency

When the body’s defense breaks down as a consequence ofvitamin A deficiency (VAD), the person is more likely todevelop infections, and the severity of an infection is likelyto be greater. Also, in case of relatively severe deficiency, arange of abnormalities may appear in the eyes. In the mildestform, night blindness occurs. In more severe forms, lesionsoccur on the conjunctiva and cornea that if left untreated cancause irreversible damage, including partial or total blindness.Such lesions can be grouped together under the termxerophthalmia.

Night blindness

Night blindness, the first clinical sign of VAD, is a wellrecognized indicator of VAD. It was added to the classificationof signs of VAD in 1980 when it was found that a mother orguardian’s history of night blindness in a young child (fromthe age of 18-24 months), particularly one employing a locallyrecognized term, was highly reliable.ii, iii Field workers withadequate training can reliably identify a history of nightblindness, especially when using local terms.

The World Health Organization (WHO) and IVACG haveestablished that if night blindness prevalence among youngchildren (18-59 or 24-59 months) in a community is greaterthan or equal to 1%, VAD constitutes a “problem of publichealth significance” within that communityiv, v . And, a largerproportion of that community is thus likely to suffer otherconsequences of vitamin A deficiency such as increasedmorbidity and mortality.

i Partly reprinted from The State Of The World’s Children 1998,UNICEF, Oxford University Press, 1998, p76ii Sommer A, West K. Vitamin A Deficiency: health Survival andVision. New York: Oxford University Press, 1996.iii Sommer A, Hussaini G, Muhilal, Tarwotjo I, Susanto J, SarosoJS. History of night blindness: A simple tool for xerophthalmiascreening. Am J. Clin Nutr 1980;33:887-891.iv Control of vitamin A deficiency and xerophthalmia. Report of ajoint WHO/UNICEF/USAID/Helen Keller International IVACGMeeting. WHO Technical Report Series 672. Geneva: World HealthOrganization 1982:1-70.v Sommer A. Vitamin A Deficiency and Its Consequences: A FieldGuide to Detection and Control. Third Edition. Geneva: WorldHealth Organization 1994.

blindness is thus an indicator of whethervitamin A deficiency is a problem atcommunity level. WHO and the InternationalVitamin A Consultative Group (IVACG)have established a cut-off for the prevalenceof night blindness of 1%, which indicates thatvitamin A deficiency is a public healthproblem.

Prevalence of night blindness

Results from the first national micronutrientsurvey of rural Cambodia show that vitaminA deficiency is still a problem of public healthsignificance in at least five of the 10provinces surveyed. Figure 1 (p1) showsthe prevalence of night blindness amongchildren aged 18-59 months by province.Night blindness prevalence varies by provinceand in Preah Vihear, Rattanakiri, OtarMeanchey, Koh Kong and Kampong Thomit is above the cut-off indicating a public healthproblem. For the other provinces, where theoverall prevalence is below the cut-off of1%, the prevalence may still be above 1% inparticular communes of the province, at othertimes of the year, or under less favorableagricultural or financial conditions. Thisparticularly applies to Svay Rieng, KampongCham and Kampot. In fact, the survey wasconducted shortly after the mango season,which may have caused a slight, seasonal,improvement of vitamin A status andtherefore reduced the prevalence of nightblindness.

VAC coverage

One strategy for combating vitamin Adeficiency among children 6 – 59 months ofage is to provide them with a high-dosevitamin A capsule twice a year. The RCGinitiated a VAC distribution program in 1994.Initially, VAC were distributed through theNational Immunization Days (NIDS) forpolio. Since 1998, when the NIDS for poliowere over, VAC have been distributed twiceyearly during routine immunization outreachactivities and through sub-NIDS2 .

Figure 2 shows the coverage of VAC duringthe March 2000 distribution, by province andchild age group. Six years after thedistribution of the first VAC and two yearsafter a change of delivery strategy which

(cont’d from p1)

HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 2, November 2000

11

presented the RCG with a difficult challenge,nationwide coverage varied from approximately 10%to 55%. Given the circumstances, this level ofcoverage is a good achievement and it is likely thatthis has reduced the prevalence and severity of VADin the country over the past years. Figure 2 also showsthat coverage was very similar among the differentage groups. More detailed analysis however alsoshowed that at commune level, VAC coverage couldbe as low as 5% but also as high as 80%. The nextCambodia Nutrition Bulletin will assess VACdistribution in more detail, including its relationshipwith the immunization outreach activities.

Importance of VAC

The protection against night blindness provided bythe VAC is shown in Figure 3. Both among the

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Figure 2. Vitamin A capsule coverage in March 2000, byprovince and child age group (n=16,121). Bars indicate95% CI (Confidence Interval) corrected for design effect.

Figure 3. Prevalence of night blindness among childrenaged 6-59 months in provinces with night blindnessprevalence greater or equal, or below the cut-off of 1%and by whether they received a VAC. Bars indicate 95%CI (Confidence Interval) corrected for design effect.

provinces where the prevalence of night blindnesswas equal to or greater than the cut-off of 1% aswell as among the provinces where the prevalenceof night blindness was below this cut-off, childrenthat had received a VAC had a 2.2 - 2.3 times lowerrisk to be night blind3 than those who had not receiveda VAC. This shows that VAC are protective againstvitamin A deficiency, also in the provinces wherethe prevalence of night blindness was below the cut-off of 1%.

Thus, in order to reduce the risk of morbidity andmortality associated with vitamin A deficiency, andof clinical signs of vitamin A deficiency, VACdistribution should be continued nationwide,irrespective of the observed prevalence of VAD.

Conclusions

• Vitamin A deficiency is still a problemof public health significance amongCambodian children in many provinces.

• Vitamin A capsule coverage ranged from10-55% and varied widely among and withinprovinces.

• Vitamin A capsules reduced a child’s riskfor night blindness more than two times inall provinces, irrespective of the prevalenceof night blindness in the particular province.

Recommendations

• The distribution of high dose vitamin Acapsules among Cambodian children aged6-59 months should be continued nationwide.

• Factors associated with VAC coverageshould be determined in order to try toimprove coverage.

• Meetings should be held with health staff atthe provincial- operational district- andhealth center-levels to share survey findingsand discuss ways in which VAC coveragecould be improved.

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Prevalence of night blindness above or below the WHO/IVACG cut-off for a public health problem

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VAC not receivedVAC received





C A M B O D I A










Ms. La-Ong Tokmoh, IEC AdvisorE-mail: [email protected]

Endnotes

1 Reference: Beaton GH, Martorell R, L’Abbe KA,Edmonston B, McCabe G, Ross AC, Harvey B. Effec-tiveness of vitamin A supplementation in the controlof young child morbidity and mortality in develop-ing countries. ACC/SCN Nutrition Policy Paper.Geneva: United Nations Administrative Committeeon Coordination/Sub-Committee on Nutrition, 1993.

2 More details on the history of the VA program canbe found in the HKI/Cambodia Nutrition BulletinVol. 1, Issue 2, January 2000.

3 Logistic regression analysis controlling for otherfactors such as age, socio-economic status, remote-ness of the commune, breastfeeding status, dietaryvitamin A intake and morbidity.


NUTRITION BULLETINVol. 2, Issue 3December 2000


• Routine immunization outreachactivities – This is carried out by healthcenter staff who visit 10-20 villages,approximately three to four times peryear, for immunization services. VACsshould be taken by the outreach teamstwice yearly, around the months ofMarch and November

• Supplementary supplementationactivities such as Sub-NationalImmunization Days (SNIDs), and

• Measles outbreak response.

Routine immunization outreach is a goodstrategy for delivering vitamin A capsules to

Cambodian children

VAC coverage by province and bycommunes

The Royal Government of Cambodia(RCG) has, as one of its goals, theelimination of vitamin A deficiency as aproblem of public health significance bythe year 2005. To achieve this target, theRCG has taken steps to distribute highdose vitamin A capsules (VACs) tochildren aged 6-59 months, through thefollowing channels:

The national micronutrient survey by HKI (Apr-Aug 2000) found that coverageof the national vitamin A capsule (VAC) distribution program variesconsiderably, from 10-55% between provinces and from 0-100% betweencommunes within provinces. Immunization outreach activities appear to be agood strategy for delivering VAC: VAC coverage is higher where immunizationcoverage is higher, and VAC coverage among older children (36-59 mo) is thesame as coverage among younger children (6-11 mo). Therefore, VACdistribution through the immunization outreach activities should be continuedand increased among all age groups.

Figure 1. Vitamin A capsule coverage in March 2000 among children aged 6-59 months,by province. Bars indicate 95% confidence intervals corrected for design effect.

0102030405060708090

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HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 3, December 2000

14

VAC distribution was started in 1994. The NationalMicronutrient Survey found, as shown in Figure 1,that in March 2000, VAC coverage by provinceranged from 10-55%. Since VACs are protectiveagainst childhood night blindness and otherconsequences of vitamin A deficiency, such as moresevere morbidity and increased mortality, VACcoverage should be increased throughout the country(see Nutrition Bulletin, vol. 2, issue 2, November2000).

Between communes, VAC coverage varied from 0-100%. The map on pages 4-5 shows VAC coveragein March 2000 per commune for those communesthat were included in the National MicronutrientSurvey. It can be seen that the performance of theNational VAC Distribution Program varies widely,even within provinces. Several factors could becontributing to this and are described in more detaillater.

Immunization outreach and VAC distribution

The vitamin A program in Cambodia is fairly new.In 1998, the main strategy changed from linking itwith National Immunization Days, to delivering VACsthrough routine immunization outreach. Figure 2combines VAC coverage from Figure 1 with measlesimmunization coverage, by province. VAC coveragewas calculated for all children who were eligible toreceive a VAC in the March 2000 distribution

campaign (i.e. children aged 6-59 months), whilecoverage of measles immunization was calculatedamong children who were 12-14 months old at thetime of the interview. That age was chosen becausechildren should have been immunized against measlesby the time they reach their first birthday. Figure 2thus shows recent performance of immunizationoutreach, as indicated by coverage of measlesimmunization, and recent VAC coverage, as assessedfor the March 2000 distribution round.

Measles immunization coverage ranged from 28-87%, and in all provinces it was higher than VACcoverage. However, in 2 of the 10 provinces (OtarMeanchey and Kampong Thom) measlesimmunization coverage and VAC coverage were verysimilar. This is a very good achievement, especiallygiven the fact that immunization outreach only targetsthe younger children, while VACs need to bedistributed to all children aged 6-59 months of age.

Figure 3 shows the relationship between VACcoverage and measles immunization coverage atcommune level for different age groups of children.In communes where measles immunization coveragewas higher, VAC coverage was also higher. And,interestingly, VAC coverage was not different amongdifferent ages; it was the same among the youngestchildren aged 6-11 months, as among the oldestchildren aged 36-59 months. Thus, while there hasbeen much discussion that older children might not

Figure 2. Coverage of VAC distribution among children aged 6-59 mo in Mar 2000 and of measlesimmunization among children aged 12-14 mo at the time of interview in Apr-Aug 2000, by province. Bars indicate95% confidence intervals corrected for design effect.

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Svay Rieng Preah Vihear Rattanakiri OtarMeanchey


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15

How the RCG/MOH nationalvitamin A and immunizationprograms are linkedThe national vitamin A program was initiated inCambodia in 1994; in 1995 National Immunization Days(NIDS) for polio began. While the NIDS were beingorganized, it was recognized early on that it would begood for VAC distribution to “piggy-back” on to theNIDS. The National Vitamin A Working Group,consisting of members from the MOH/Departments ofNutrition, polio eradication and Expanded Program forImmunization (EPI), UNICEF, WHO, and HKI agreed toconduct a pilot to see how well distribution of VACswith NIDS would work. Results of the pilot were verypromising and led to the RCG adopting VAC distributionvia NIDs as one of the main strategies for distributionof VAC. By 1996 VAC distribution became fullyintegrated into NIDS.

Distribution of VACs via this strategy continued untilthe end of 1997 after which the NIDs for polio ended. Itwas then decided that VACs would be distributedthrough routine immunization services. In 1998, VACdistribution was integrated into the NationalImmunization Program (NIP) and is currently beingdistributed twice a year to children 6-59 months of agethrough routine immunization outreach and throughspecial supplemental campaigns such as SNIDS.

be reached very well through immunizationoutreach activities because they are not part ofthe immunization target group, these data showthat this was not the case in Cambodia.

But the data collected also showed that coverageamong children aged 6-11 months was moresimilar among different communes (a small designeffect was found), than the coverage among olderchildren, particularly those aged 36-59 months (alarge design effect was found). This indicates thatalthough overall VAC coverage of younger andolder children was very similar, the differencesof coverage among communes were larger forolder children. Thus, for young children, theimmunization program and VAC distributionperform more similarly across communes thanfor older children.

One of the main causes of the relatively goodVAC coverage among older children may be thatthe village chief, who is often engaged in assistingthe immunization teams with communitymobilization, is doing a good job in getting allpreschool-aged children to come for the healthservices being provided by the teams. This wouldalso explain why VAC coverage among olderchildren varies more widely between communesthan VAC coverage among younger children,because some village chiefs put more efforts intomobilizing the older children than others.

(cont’d on p6)

Figure 3. Relationship between VAC coverage and measles immunization coverage at commune level for differentage groups of children (n=500 communes). Median VAC coverage in March 2000 at commune level by measlesimmunization coverage among children aged 12-20 mo at the time of the interview.

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16

Map: Vitamin A capsule coverage among children aged 6-59 mo old in March 2000, by commune.(Map courtesy of the World Food Programmme/Cambodia)

NoteIt can be seen from the map that datawere actually collected from 12provinces of Cambodia and not onlythe 10 provinces reported on.However, data from the two‘additional’ provinces, Siem Reap andPrey Veang, are not representative ofthose provinces as a whole.Communes in Siem Reap and PreyVeang were surveyed because therewere not enough communes inKampong Thom and Svay Riengrespectively, to obtain the requiredsample.

Otar Meanchey

Banteay Meanchey

Siem Reap

Pailin

Battambang

Pursat

Kampong Chhnang

Kampong T

Preah V

Koh Kong

Krong Sihanoukville Kampot

Krong Kep

Takeo

Kampong Speu

Kanda


17

hom

Kampong Cham

Kratie

Stueng Treng

Rattanakiri

Mondulkiri

Vihear

al

Prey Veang

Svay Rieng


18

National Vitamin A ProgramAssessmentMethodology

The Cambodia National Vitamin A Program Assessment,conducted by HKI, was carried out in the same 10provinces as the National Micronutrient Surveyconducted by HKI, in an additional two provinces (SiemReap and Preah Vihear), and in Phnom Penh. Data werecollected during the months of July and August 2000. Ineach province, the provincial health department (PHD),2 operational districts (ODs) and 4 health centers (HCs)were selected for semi-structured interviews in such away that the widest possible range from poor to goodprogram performance was covered. In addition, in-depthinterviews were conducted with one or two NGOsworking with the vitamin A program in these provinces.At the national level, MOH Units/Departments and UNorganizations involved in the vitamin A program wereselected for in-depth interviews.

The question guides were developed by HKI staff, withassistance from Cambodia’s Micronutrient TechnicalWorking Group, which consists of representatives ofRCG, and national and international agencies. Allquestion guides were developed in English and for theOD and HC levels, translated into Khmer. To ensure thattranslation was correct, guides were translated back intoEnglish and if necessary Khmer versions were corrected.The main topics of the interviews were vitamin A policy,VAC supply and distribution, personnel, training,supervision, reporting, and program costs.

Interviews with government and NGO representativesat national level were conducted by HKI staff at theinterviewee’s work place or at the HKI office, and recordedin English. Data collection at the PHD, OD, and HC levelswas conducted in Khmer by 5 teams of 2 interviewersfrom the Ministry of Planning, MOH and HKI. Theinterviewers received a 5-day training. Interviews wereheld at the interviewee’s work place, using face-to-faceinterview techniques and answers were recorded inKhmer.

After data collection, the interviewers tabulated theanswers of interviews at the PHD, OD and HC level bytopic, after which they were translated into English. Datawere then analyzed by organizational level andseparately for rural provinces and Phnom Penh.

Because VACs are very protective againstchildhood morbidity and mortality, and becausetheir coverage was found to range from 10-55%,coverage should be increased among all childrenaged 6-59 months. Also, the performance of thedistribution system has to become more similaracross villages.

Factors affecting VAC coverage

In order to understand how VAC coverage canbe improved, HKI conducted an assessment ofthe National Vitamin A Capsule DistributionProgram in July and August 2000. Resultsindicate that poor coverage is due to a range offactors at different levels of the health system.These factors are shown diagrammatically inFigure 4.

VAC coverage varies widely between differentcommunes within a province, because healthcenters face different challenges with respect todelivery of the capsules. The more remote areasare the most difficult to reach and are oftenneglected due to poor infrastructure and the highcosts associated with getting there, whichbecomes increasingly difficult during the rainyseason. Also, some health centers have a largeturnover of staff, in which case new staff is oftenunaware of the VAC distribution policy anddistribution schedule. Associated with this is anoften poor understanding of staff roles andresponsibilities, which could also be due toinsufficient coordination at the national level. Itoften happens that VACs are not taken forimmunization outreach activities because theimmunization staff think that VAC distributionis not one of their responsibilities or because thehealth center staff think that VACs are not meantfor distribution outside the health center.

Another important underlying factor related topoor VAC coverage is budget constraints facedby the national VAC program. This affects allstages of VAC distribution, including overallplanning, training, supervision, outreach activitiesand social marketing of VAC. In addition, healthworker salaries are low, which may result in lowmotivation and absenteeism.

(cont’d from p3)

HKI Cam

bodia Nutrition Bulletin Vol. 2, Iss. 3, D

ecember 2000

19

Figure 4. Factors contributing to low VA

C coverage in C

ambodia

Lack of clarityamong staff about

their roles andresponsibilities

VAC supply/logistics

problems

Inadequatesupervision

activitiesLack of training

activities

Lack of ‘socialmarketing’

materials andactivities

Poor skills andknowledge

Low motivationand high staff

turnoverLow salaries

Seasonalmigration due to

rice planting/harvesting

Low communityparticipation in

mobilization

Low VACcoverage

National Level

Provincial OD andHC Levels

Community Level

Coordination problemsbetween government

departments and partneragencies

Poor infrastructure inremote areas making access

difficult and expensive

Inadequate numberof qualified staff

Budget constraints

Low awareness ofVAC/people do not

go for services

Low budget foroutreachactivities





C A M B O D I A










Ms. La-Ong Tokmoh, IEC AdvisorE-mail: [email protected]

Recommendations

• Vitamin A capsule coverage among children aged 6-59 months needs to be improved.Immunization outreach activities provide a good mechanism for delivering vitamin Acapsules to children of all ages and should be continued.

• The findings from this survey on VAC distribution and immunizationoutreach activities are clearly ‘lessons without borders.’ The information needs to beshared widely with other countries in Asia and Africa.

• Technical assistance is required to help translate the survey findings into a strategy andaction plan to control vitamin A deficiency in Cambodia, particularly for the furtherdevelopment of the VAC program.

• Workshops and meetings will need to be organized and supported in order to maketimely use of this information within Cambodia at the national and provincial level.


NUTRITION BULLETINVol. 2, Issue 4February 2001


blindness or low serum retinolconcentration), are limited. With supportfrom USAID and UNICEF, severalsurveys have been conducted recently inAsia, showing that the prevalence of VADamong women is very high in manycountries.

The recent Cambodia NationalMicronutrient survey included functionaland biochemical assessments of vitaminA status, as well as other indicators ofnutritional status of women and children,and comprehensive information on dietaryintake, morbidity and the coverage ofnutrition and health programs. This bulletinprovides information that can help to guidefuture policies and programs to improvevitamin A status of women in Cambodia.The data from this survey is alsocontributing to international discussionsabout the use of maternal night blindnessas an indicator to monitorprogress in controlling VAD.

The need for multiple strategies to combatvitamin A deficiency among women in Cambodia

Vitamin A deficiency among women

Vitamin A deficiency (VAD) has beencharacterized mainly as a problem amongpreschool children because of theincreased risk of mortality and its clinicalmanifestations of xerophthalmia andblindness. The role of vitamin A in childmorbidity and mortality, although originallydiscovered in the early 1900’s, has been‘re-established’ over the past 15 years andthis has increased efforts to control VADamong children. It has only been in thepast five years however that the extentof VAD and its link to increased morbidityand mortality among women has beenrecognized and this information is just nowbeing brought to international and nationalattention (see sidebar, p3).

National or large-scale surveys of themagnitude of VAD among women,estimated by the prevalence of clinical orbiochemical indicators (such as night

Results from the Cambodia National Micronutrient Survey reveal that nightblindness is a major public health problem among pregnant and lactatingwomen. Night blindness rates among lactating women were 1.0-6.8% and 2.5-8.4 % of women reported suffering from night blindness during their mostrecent pregnancy. Given the increased risk of morbidity and mortality, thisproblem should receive high priority for program planning and resourceallocation in Cambodia. The most effective way to improve vitamin A statusamong women is through a combination of approaches, including improvingvitamin A intake, promoting vitamin A and multi-micronutrientsupplementation during pregnancy and adolescence, and improving thecoverage of postpartum vitamin A capsule (VAC) supplementation.

HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 4, February 2001

22

Prevalence of night blindness

Results from the Cambodia survey show that VADis a large problem among lactating mothers and duringpregnancy. Figure 1 shows the prevalence of nightblindness, the first clinical sign of VAD, by province.Night blindness among lactating women ranged from1.1-6.8% in the 10 provinces included in the nationalsurvey. The reported prevalence of night blindnessduring the last pregnancy in the previous 3 yearsranged from 2.0-9.3%. Provinces with the highestprevalence rates include Rattanakiri, Otar Meanchey,Preah Vihear, Kampot, Svay Rieng and KampongThom. Night blindness is only the tip of the icebergand a much larger proportion of women in Cambodiaprobably suffer from VAD and would benefit froman increased intake of vitamin A.

Vitamin A programs for women

Programs to improve vitamin A status in a directway are generally categorized into three approaches,supplementation, food fortification and dietdiversification. These approaches were developedmainly to address VAD in children but with somemodifications, can be applied to prevent and controlVAD among women of reproductive age and othergroups, such as adolescents and school-age children.

Daily low-dose supplementsBi-annual high-dose VAC supplementation cannot beimplemented for women of reproductive age becauseof the risk of teratogenic effects in the first trimesterof pregnancy. However, a recent study in Nepal

showed that daily, low-dose supplementation withvitamin A can effectively reduce VAD and itsconsequences among women. Other studies are beingcarried out to confirm the efficacy of dailysupplementation as well as to test the feasibility ofimplementing these programs for women duringpregnancy. In the meantime, supplementation withmultiple micronutrients for women during pregnancy,for adolescent girls, and for preschool children isbecoming accepted internationally as an importantstrategy to improve nutrition and is increasingly beingdiscussed as a future program in many countries.

Postpartum high-dose VACPostpartum VAC supplementation is promoted toboost the vitamin A stores of women after pregnancyand to increase vitamin A content of breastmilk. Since1994 the Royal Government of Cambodia hasincluded postpartum women as one of the targetgroups for receiving a high-dose vitamin A capsule.1The survey data show that postpartum VAC coverageis still very low in all provinces, ranging from 1-10%.However, in Kandal, coverage increased from 8.7%by mid-1999 to 12.5% by mid-2000, suggesting thatcoverage can be increased if women have morecontact with health centers or outreach activities.The post partum VAC program is important, butshould not be the sole strategy to improve vitamin Astatus among women because it is difficult to reachwomen when births are not regularly attended bytrained health staff and because the protection of

Figure 1. Prevalence of night blindness among lactating women (child < 24 mos; n=9,050) and during the mother’smost recent pregnancy (< 3 yrs ago; n=14,933), by province. Bars indicate 95% CI (Confidence Interval) correctedfor design effect.

1 WHO/IVACG recommend that high-dose vitamin A capsulescan be provided without risk up to eight weeks postpartum

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HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 4, February 2001

23

Recent evidence from Asia abouthealth consequences of vitamin Adeficiency in women

1994: Risk of diarrhea was higher among nightblind women. (Bloem et al. Vitamin Adeficiency among women in thereproductive years: an ignored problem.IVACG Abstract)

1995: A large proportion of women in Nepal andLaos experienced night blindness duringpregnancy and lactation. (Katz etal. Nightblindness is prevalent during pregnancyand lactation in rural Nepal. J. Nutr 125:2122-7; Malyavin et al. National vitamin A surveyof Laos)

1998: Morbidity was higher among night blindwomen during pregnancy. (Christian et al.Night blindness of pregnancy in rural Nepal– nutritional and health risks. Int J Epidemiol1998;27:231-37 )

1999: Maternal mortality was reduced by 42%when women of reproductive age receiveda daily low-dose of vitamin A. (West et al.Double-blind, cluster-randomized trial of lowdose supplementation with vitamin A or ß-carotene on mortality related to pregnancyin Nepal. Br Med J;318: 570-5)

2000: Night blind women were more likely to diefrom infections. (Christian et al. Nightblindness during pregnancy andsubsequent mortality among women inNepal: effects of vitamin A and beta-carotene supplementation. Am J Epidemiol2000;152[6]:542-7)

the VAC does not extend beyond several monthsafter delivery.

Dietary vitamin A intakeIncreasing vitamin A intake from natural sources canalso be part of a strategy to improve vitamin Astatus. The survey showed that the majority ofwomen in Cambodia consumed much less than therecommended daily allowance (RDA) of vitamin A.Less than 6% of lactating women consumed theRDA of 1200 retinol equivalents (RE) and less than11% of pregnant women consumed the RDA of 1000RE. Median vitamin A intake was 181 RE/day amongpregnant women and 201 RE/day among lactatingmothers.

Social marketingIn areas where there is adequate availability ofvitamin A rich foods and these foods are within theeconomic reach of households, social marketing hasbeen shown to be an effective way to improve vitaminA intake of women.2 Similar activities may also befeasible and effective in specific provinces or amongparticular risk groups in Cambodia.

Home gardeningIn areas where availability and access to vitamin A-rich foods are limited, homestead gardening, fisheriesand small animal husbandry can increase theiravailability and consumption. An assessment of homegardening in Bangladesh using the data from the HKI/GOB national vitamin A survey showed that the riskof night blindness among women and children waslower in households with home gardens comparedto those living in households without home gardens.Based on HKI’s experience in Bangladesh, a homegardening program was recently initiated in severalprovinces in Cambodia. An assessment of this pilotprogram suggests that it can be further expanded.In addition to protecting against night blindness, theseprograms provide a way to reach women with otherservices and information, such as micro-enterpriseopportunities, literacy programs, health education forHIV/AIDs, micronutrient supplementation, and childhealth programs.

Food fortificationFortifying foods with vitamin A and othermicronutrients has also been shown to be an effectiveand sustainable way to increase the intake ofessential vitamins and minerals for special sub-groupsof the population, such as infant foods, as well as forall household members, such as iodization of salt.The first step is to identify potential foods that canbe fortified and a viable food industry. Because

Cambodia relies heavily on neighboring countries forprocessed foods, regional initiatives will be required.

As found in other countries, VAD co-exists withother micronutrient deficiencies in Cambodia. Amongpregnant women, 68% were anemic and more than50% of non pregnant women were anemic. Similarly,children of mothers who were night blind were eighttimes more likely to be night blind than were childrenof mothers who were not night blind. This suggeststhat programs reaching multiple household members,such as food fortification and food-based approaches,and those that provide multiple nutrientssimultaneously may be the most effective over thelong-term.2 de Pee S, Bloem MW, Satoto, Yip R, Sukaton A, Tjiong R,Shrimpton R, Muhilal, Kodyat B. Impact of a Social MarketingCampaign in Promoting Dark-green Leafy Vegetables and Eggsin Central Java, Indonesia, Int J Vit Nutr Res 1998;68:389-98.





C A M B O D I A










Ms. La-Ong Tokmoh, Program ManagerE-mail: [email protected]

Conclusions

• Night blindness is a significant health problem among pregnant and lactating women.• A large proportion of Cambodian women do not consume adequate vitamin A from their

diet.• Coverage of the VAC distribution among postpartum women is very low.• Anemia, wasting and other nutrition problems are also highly prevalent among women in

Cambodia and these nutrient deficiencies co-exist.

Recommendations

• Expand programs to increase the intake of vitamin A rich foods through social marketing,home gardening, poultry and small animal husbandry.

• Explore the feasibility of fortifying foods with vitamin A or preferably, with multiplemicronutrients.

• Improve coverage of postpartum VAC distribution program.• Explore the feasibility of providing multi-micronutrients during pregnancy and adolescence.• Continue monitoring and surveillance of VAD among women and the effectiveness of

programs.

Iron Deficiency in Cambodia – A threat to the development of young Cambodian children and the country’sfuture. Vol 1, Iss 1, October 1999 ...................................................................................................................................... 27

Vitamin A capsule distribution after the NIDs – lessons learned from Cambodia.Vol 1, Iss 2, January 2000 .................................................................................................................................................. 31

Other Cambodia Nutrition Bulletins

25


NUTRITION BULLETINVol. 1, Issue 1October 1999

C A M B O D I A

HELEN KELLERINTERNATIONAL


Cambodia is in a period of transition leaving behind a long history of conflictand struggle and is in the process of building a strong and viable society.

Iron Deficiency in Cambodia –A threat to the development of young

Cambodian children and the country’s future

Cambodia has a rich culture and greateconomic potential; however, it still has ahigh underfive mortality (115 deaths/1,000live births)1, high population growth(2.5%)2 and low GNP (US$300)3. Tobuild a strong future, Cambodia cannotneglect the development of its children.

Several recent studies show that anemiaamong young children in rural Cambodiais a serious public health problem. Ac-cording to a study conducted by HelenKeller International (HKI) in five ruralprovinces, almost 9 out of 10 children lessthan 24 months of age are anemic (he-moglobin less than 11 g/dl). This is alarm-ing because research confirms that IDA(iron deficiency anemia) during childhoodcauses long-lasting impairments in cogni-tive development, ultimately resulting inlower school and work performance.Children with IDA are also at greater riskof becoming ill and may grow moreslowly.4

In 1993, Cambodia joined other countriesto commit to achieving the 1990 WorldSummit for Children goals to reduce IDAamong women and children by one-thirdby the year 2000. In order to reach thisgoal, awareness of the magnitude of theproblem must be raised among policymakers, program managers and commu-

nities. Simultaneously, multifaceted pro-grams should be developed to tackle IDAamong women, children and adolescents.Programs to control IDA, such as supple-mentation, food fortification, and increasedconsumption of iron-rich foods, are suc-cessfully implemented in other countriesand have been shown to be highly cost-effective.5 To prevent the loss of anotherfuture generation, infants and young chil-dren must be given the opportunity togrow and develop into healthy adults whowill be able to contribute to Cambodia’sfuture development.

IDA among children in ruralCambodia

The lack of programs to address child-hood IDA is largely because data on themagnitude of IDA is not available in manycountries and because decision-makersare not aware of the serious consequencesof IDA during childhood. The HKI sur-

1 National Health Survey 1998, National Institute ofPublic Health, Ministry of Health, Cambodia.2 General Population Census of Cambodia 1998, Fi-nal Census Results, National Institute of Statistics,MOP, Cambodia.3 IBRD. World Development Report 1998/99.4 Gillespie S. Major Issues in the Control of Iron De-ficiency. Micronutrient Initiative/UNICEF, 1998.5 Murray C, Lopez A (eds). Global Burden of Diseaseand Injury (Vol. 1), 1996. Harvard University Press,Cambridge, MA, USA.

HKI Cambodia Nutrition Bulletin Yr. 1, Iss. 1, October 1999

28

Figure 1. Prevalence of childhood anemia in Cambodia(n=344)Common Facts about Iron

Deficiency Anemia:• Anemia is the most common nutritional defi-

ciency in the world: Iron deficiency and itsanemia affects more than 3.5 billion people.

• Although there are other causes, iron defi-ciency is the leading cause of anemia.

• Iron deficiency anemia has few signs andsymptoms and therefore often goes unno-ticed – by families of those affected, by healthcare professionals and by policy makers.

• Iron in the diet comes in two forms: Hemeiron is found in animal foods and is well ab-sorbed by the body. Non heme iron is foundin plant foods and is less well absorbed. Eat-ing animal foods and foods rich in vitamin Cand avoiding foods that inhibit iron absorp-tion, such as tea, can improve the iron ab-sorption from plant foods.

• There are several stages of iron deficiency– what public health professionals most com-monly measure, anemia, is the final stage.Some experts suggest that the prevalenceof iron deficiency is almost twice the preva-lence of IDA.

• The costs of iron or micronutrient supple-mentation programs are minimal and the ben-efits are enormous.

• Children often suffer from deficiencies ofmultiple micronutrients at the same time be-cause their diets are simultaneously insuffi-cient in many nutrients and calories. VitaminA deficiency has also been shown to pre-cipitate anemia.

Major consequences of IDA:IDA can slow child physical development andmotor skills.

IDA during childhood reduces IQ similar to io-dine deficiency.

IDA has large economic costs:

– Current and future productivity is decreased.

– Education investments are not maximized.

– The burden on the health care system is in-creased.

Severe IDA, particularly during pregnancy, canlead to mortality.Source: Gillespie SR. Major Issues in the control of iron defi-ciency. The Micronutrient Initiative, 1998.

(continued from p1)

vey, conducted in five provinces of rural Cambodiain May 1999, found that 74% of children under fiveyears of age suffered from anemia (hemoglobin lessthan 11.0 g/dl). Although the survey was not nation-ally representative, it suggests that anemia is a seri-ous problem in Cambodia. These rates of anemia inchildren are considerably higher than even the highrates found in recent surveys by HKI in other coun-tries in Asia.

In addition to highlighting the high prevalence ofchildhood IDA in rural Cambodia, the HKI studyreveals several other important findings. As shownin Figure 1, IDA was already extremely high amongchildren less than 6 months of age (73%). The preva-lence of IDA rose even higher among children 6-11months of age when more than 9 of 10 children wereanemic. Rates were only slightly lower for children12-35 months of age.

The high rates of anemia most likely reflect an inad-equate consumption of iron-rich foods. The HKIstudy collected information on the dietary intake ofchildren, as well as infant feeding and breastfeedingpractices, revealing a number of important statistics.First, less than 20% of children 0-6 months of age inthe study areas were being exclusively breastfed.Breastmilk is the most important source of iron forchildren less than 6 months of age. Second, the con-sumption of animal foods, such as fish, meat, andeggs, was also low among Cambodian children, par-ticularly among children 6-23 months of age, amongwhom anemia rates were highest, and growth anddevelopment is greatest. Animal foods are crucialsources of iron and other micronutrients. When askedwhy they were not feeding micronutrient-rich foodsto their children, the majority of mothers reported

% a

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ic (h

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70

HKI Cambodia Nutrition Bulletin Yr. 1, Iss. 1, October 1999

29

that they could not afford to purchase these foods.In addition, mothers believed that giving certain foodsto their children may cause illness or was not appro-priate for younger children.

The HKI study reveals that childhood IDA is a seri-ous problem in parts of rural Cambodia. Althoughfood fortification and increased consumption of ani-mal and plant foods high in iron and other micronu-trients are the ultimate long-term solutions, immedi-ate action is required to prevent the potentially irre-versible slowed cognitive and physical developmentthat is occurring among young children in rural Cam-bodia. In the immediate future, iron supplementationprograms for infants and young children are needed.

Because the diets of mothers and children in thesestudy areas are also low in other important micronu-trients, supplementation with multi-micronutrientsshould be encouraged. More than 70% of pregnantwomen in the study areas had IDA, thus, mothersalso need to receive multi-micronutrient supplements– to protect their own health and their children’s aswell. Iron and multi-micronutrient supplementationprograms are not expensive and the immediate andfuture benefits of implementing these programs willbe enormous.

History of HKI in Cambodia

In the early 1990s, HKI provided technical consul-tations to investigate the magnitude of vitamin Adeficiency in Cambodia and provided technical as-sistance to international and local non governmen-tal organizations (NGOs) to integrate vitamin Ainterventions into their ongoing programs. In 1993HKI established an office in Phnom Penh. In 1995,the focus of the program was expanded to promot-ing sustainable nutrition interventions to improvemicronutrient status and institutionalizing primaryeye care. Specifically, in the area of nutrition, HKIhas been involved in:

• Piloting vitamin A capsule coverage programsand recommending strategies for the nationalprogram

• Promoting food-based approaches to alleviat-ing vitamin A deficiency

• Developing communications strategies for pro-moting vitamin A rich foods

• Supporting national efforts for the control ofiodine deficiency disorders

HKI’s work in Cambodia has been supported bythe US Agency for International for InternationalDevelopment (USAID), the United Nation’s Chil-dren Fund (UNICEF), the World Health Organiza-tion (WHO) and private donors.

History of RCG/HKI collaboration

Based on preliminary evidence from a hospital-based survey, HKI and the MOH conducted a vi-tamin A survey in 5 regions in 1993. The findingsof the survey suggested that clinical vitamin Adeficiency was a serious public health problemamong preschool children in Cambodia. Subse-quently, the collaboration between the RCG/MOHand HKI has included:

• Creating awareness of the link between VADand child survival

• The start-up of a program to distribute VACsbi-annually, which was subsequently linkedwith the National Immunization Day campaigns

• The establishment of a national vitamin A work-ing group consisting of members from theMOH, UNICEF, WHO and HKI

• Developing a National Food and NutritionPolicy

• Developing a National Vitamin A Policy

Recommendations• A national survey to assess anemia

prevalence and to explore the etiologyand key risk factors for childhood andmaternal anemia in Cambodia iswarranted.

• Provision of iron or multi-micronutrient supplements tochildren and women should beundertaken to prevent IDA in childrenand women. Supplements might bedelivered through ongoing NGOprograms or the health care system.

• Programs that increase the productionand availability of micronutrient-richfoods, both animal and plants, should beexpanded.

• Programs to improve breast feedingpractices and to improve the qualityand timely introduction ofappropriate foods for infants are alsoneeded.


C A M B O D I A

Helen Keller InternationalNutrition Bulletin

CA M B O D I A

For information and correspondence, contact:

Helen Keller International, Cambodia Helen Keller International, Regional OfficeP.O. Box 168 P.O. Box 4338Phnom Penh Jakarta PusatKingdom of Cambodia IndonesiaTelephone: 855-23-210851 Telephone: 62-21-5263872Fax: 855-23-210852 Fax: 62-21-5250529

Ms. Dora Panagides, Country Director Dr. Martin W. Bloem, Regional DirectorE-mail: [email protected] E-mail: [email protected]


Dr. Saskia de Pee, Regional Nutrition ResearchAdvisorE-mail: [email protected]


© 2000 Helen Keller InternationalReprints or reproductions of portions or all of this document are encouraged provided due acknowledgement is given to thepublication and publisher

Projects carried out by HKI-Cambodia in collaboration with the Ministry of Health, Royal Cambodian Government (MOH/RCG); the Adventist Development and Relief Agency (ADRA), Chamran Cheat Khmer (CCK), Partners For Development(PFD), Southeat Asian Outreach (SAO), the United Nations Children’s Fund (UNICEF); and the World Health Organization(WHO) are funded by the United States Agency for International Development (USAID).

This publication was made possible through support by the USAID/Cambodia Mission under the terms of Award No. 442-G-00-95-00515-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the USAgency for International Development.


NUTRITION BULLETINVol. 1, Issue 2January 2000

C A M B O D I A



Vitamin A capsule distribution after theNIDs – lessons learned from Cambodia

Vitamin A deficiency (VAD) is still aproblem of public health significanceamong Cambodian children and women.In 1999, Helen Keller International (HKI)conducted a survey in 5 provinces (Takeo,Kratie, Steung Treng, Seim Reap andKampong Thom), which found a preva-lence of nightblindness, the first clinicalsign of VAD, of 1.8% among childrenaged 24-59 months and of 4.3% and 6.8%among pregnant and non-pregnant moth-ers, respectively (see figure 1). Further-more, hospitals are reporting clinical casesof vitamin A deficiency. This high preva-lence and severity of VAD calls for im-mediate action. Assessment of the preva-lence of VAD in the different areas ofthe country is urgently needed, and ef-forts to combat vitamin A deficiency, par-ticularly through the distribution of high-dose vitamin A capsules, need to be im-proved.

Royal Government of Cambodia com-mitted to eliminating vitamin A defi-ciency

In 1993, the Royal Government of Cam-bodia (RCG) made a commitment toachieve the World Summit Goals for chil-

An alarming number of cases of nutritional blindness in the past year havebrought into question the effectiveness of the current national vitamin A cap-sule (VAC) distribution program in Cambodia. From 1996-1997, when VACdistribution was integrated with the National Immunization Days (NIDs), cov-erage was high. However, now that VAC distribution has been integrated withroutine EPI (Expanded Program for Immunization), because NIDS are no longernecessary, coverage has become much lower. Therefore, many Cambodianchildren are again at risk of going blind or dying from vitamin A deficiency.

Figure 1. Prevalence of nightblindnessamong children and women.Bars indicate 95% CI (Confidence Interval)corrected for design effect.

0123456789

10

children 24-59 months(n= 837)

pregnantwomen(n=127)

non-pregnantwomen(n=931)

Prop

ortio

n (%

)

dren which has, as a target, the virtualelimination of VAD by the year 2000. In1994, the first National Vitamin A policywas adopted and in 1999, the RCGadopted the Resolution of the NationalSeminar on Food Security and Nutritionin Cambodia. As part of this, the Gov-ernment made a commitment to adopt theCambodian Nutrition Investment Plan(CNIP), with one of the objectives beingthe elimination of VAD over the next ten

(continued on p2, col 2)

HKI Cambodia Nutrition Bulletin Yr. 1, Iss. 2, January 2000

32

Facts about vitamin A deficiency

What vitamin A does1

Vitamin A (VA), stored normally in the liver, is cru-cial for effective immune-system functioning, pro-tecting the integrity of epithelial cells lining theskin, the surface of the eyes, the inside of the mouthand the alimentary and respiratory tracts. Whenthis defence breaks down in a vitamin A-deficientchild, the child is more likely to develop infections,and the severity of an infection is likely to begreater.

Depending on the degree of the deficiency, a rangeof abnormalities also appears in the eyes of vita-min A-deficient children. In the mildest form,nightblindness occurs. In more severe forms, le-sions occur on the conjunctiva and cornea that ifleft untreated can cause irreversible damage, in-cluding partial or total blindness.

Consequences of vitamin A deficiency

Studies show that the survival chances of childrenaged 6 months to 6 years are dramatically increasedby improving vitamin A status by twice yearly dis-tribution of high-dose VA capsules. Risk of mortal-ity from measles is reduced by about 50%, fromdiarrhea by about 40%, and overall mortality by 20-25%2. Improved vitamin A status among deficientchildren also reduces the severity of infectious ill-nesses, particularly measles and chronic diarrhea,and is associated with reduced need for outpatientservices, and therefore lowers the overall cost ofhealth services3.

A recent study in Nepal found a reduction of mater-nal mortality by 40-50% when women of reproduc-tive age received a daily low-dose of vitamin A4.This emphasizes the need to not only focus on VADamong children but also among women, especiallyduring pregnancy and lactation.

1 Reprinted from The State Of The World’s Children 1998,UNICEF, Oxford University Press, 1998, p762 Beaton GH, Martorell R, L’Abbe KA, Edmonston B,McCabe G, Ross AC, Harvey B. Effectiveness of vitamin Asupplementation in the control of young child morbidityand mortality in developing countries. ACC/SCN NutritionPolicy Paper. Geneva: United Nations Administrative Com-mittee on Coordination/Sub-Committee on Nutrition, 1993.3 Vitamin A Global Initiative – Strategy for Acceleration ofProgress in Combating Vitamin A Deficiency. (Consensusof an Informal Technical Consultation convened byUNICEF/MI/WHO/CIDA/USAID), December 1997.4 West Jr KP, Katz J, Khatry SK, LeClerq SC, Pradhan EK,Shresta SR, Conner PB, Dali SM, Christian P, Pokhrel RPand Sommer A. Double-blind, cluster-randomized trial oflow dose supplementation with vitamin A or B carotene onmortality related to pregnancy in Nepal. British MedicalJournal 1999; 318: 570-5.

(continued from p1)years. In order to reach this goal, awareness of themagnitude of the problem must be raised amongpolicy makers, program managers and communities.

Vitamin A capsule distribution

Because the VAC distribution program in Cambodiaalready started in 1994, there is a general sense thatthe program is being implemented successfully. How-ever, while coverage was high when distribution wasintegrated with the NIDS, it has become much lowersince it became part of routine EPI in 1998. The1999 HKI-survey found that only 35-40% of chil-dren aged 6-59 months had received a vitamin Acapsule in the six months prior to the survey (seefigure 2) and that less than 10% of the mothers in-terviewed had heard about vitamin A. Other datasuggest that there is a strong relationship betweenplace of residence and receipt of a capsule, withcoverage being far higher in the capital city than else-where, and especially low in remote and isolated prov-inces.5

The data collected by HKI also showed that cover-age among children aged 6-11 months was very simi-lar among different villages (a small design effectwas found), while the coverage among older chil-dren, particularly those aged 24-59 months, variedwidely among different villages (a large design ef-fect was found). Since the integration of capsule dis-tribution with EPI, young children can be reachedwhen they come for immunization, but older chil-dren need to be specifically targeted. The differenceof design effect found indicates that among differ-

05

101520253035404550

6-11 months 12-23 months 24-59 months

Prop

ortio

n (%

)

Age group

Figure 2. Vitamin A capsule coverage among children.Bars indicate 95% CI (Confidence Interval) corrected fordesign effect.

5 National Health Survey 1998. National Institute of Public Health/SAWA/Macro, 1999.

HKI Cambodia Nutrition Bulletin Yr. 1, Iss. 2, January 2000

33

ent villages the performance of the EPI program isvery similar, but that the exclusive targeting of olderchildren varies widely among villages. Thus, VACcoverage has to increase among all children aged 6-59 months and the performance of the distributionsystem has to become more similar across villages.

Among mothers, who should receive a vitamin Acapsule within 8 weeks of delivery, coverage wasbelow 5%.

History of National Vitamin AProgram

In 1993, a survey was conducted by the Ministry ofHealth/Center for Hygiene and Epidemiology(MOH/CNHE) and HKI in four rural provinces andin urban slums of Phnom Penh. In total, 10,116 chil-dren aged 12-71 months were examined for clinicalsigns of VAD. In every site, except Phnom Penh,their prevalence either matched or exceeded WHOcut-offs for classifying VAD as a public health prob-lem: Bitot’s spots, 0.6%, and night blindness, 5.6%6.The survey also found that consumption of vita-min A-rich foods was inadequate, especially dur-ing the dry season.

Immediately after the results of the 1993 MOH/HKIsurvey became known, a national VA workshopsupported by HKI and UNICEF was held, whichwas attended by representatives from all provincialhealth departments. As a result of the workshop, anational vitamin A working group was formed,which drafted a National Vitamin A Policy that wasadopted by the RCG in 1994. A national VA supple-mentation program was launched to provide VACsto all children 6-71 months of age every 3 - 6 months.

In 1996, following a pilot in 1995 by the MOH, WHO,UNICEF and NGOs, including HKI, VAC distribu-tion became fully integrated into the National Im-munization Days (NIDS). And in 1998, VAC distri-bution was fully integrated into the National Ex-panded Program for Immunization (EPI) in 15 majorprovinces with distribution three times per year andcoordinated with SNIDS (sub-national immuniza-tion days). In 1999, a revised national vitamin Apolicy was drafted with target groups for universalsupplementation being children 6-59 months of ageand women up to eight weeks post partum. Thestrategy includes improving VAC coverage throughroutine immunization outreach twice a year.

6 Results of Vitamin A Deficiency Survey, May-August1993. MOH/CHNE/HKI. Phnom Penh, 1994.

Recommendations

• A national vitamin A survey to assessthe prevalence of vitamin A deficiency, cap-sule coverage and VAC distribution mecha-nisms is necessary.

• Effective strategies to improve vitaminA capsule coverage among childrenaged 6-59 months nationwide need to bedeveloped and tested.

• Mechanisms to improve vitamin A cap-sule coverage among women up to 8weeks post partum need to be piloted.

Dietary vitamin A intake

With respect to dietary vitamin A intake, the 1999HKI survey found that total vitamin A intake of chil-dren was around 80 RE/day, which is much lowerthan the recommended intake of 350 RE/d. Moth-ers’ total vitamin A intake was found to be around185 RE/day, which is also much lower than the rec-ommended allowance of 500-850 RE/day (non-preg-nant non-lactating, and lactating, respectively). Thesurvey was conducted at the beginning of the rainyseason, which coincided with the end of the mangoseason. During this time, vegetable consumption islow, consumption of foods of animal-origin is aver-age, and fruit consumption, especially of mangoes,is high.

Conclusion

Vitamin A deficiency is a serious problem amongpre-school aged children and women in Cambodia.Dietary vitamin A intake is far below the recom-mended daily allowance and vitamin A capsule dis-tribution only reaches a small proportion of those thatneed it.

The best strategy for combating the problem is im-proving the national VAC distribution program. Inorder to do that successfully, information is urgentlyneeded on the prevalence of VAD in different partsof the country, on current channels of VAC distribu-tion, and on possible mechanisms for achieving highcapsule coverage.


C A M B O D I A

Helen Keller InternationalNutrition Bulletin

CAMBODIA

For information and correspondence, contact:

Helen Keller International, Cambodia Helen Keller International, Regional OfficeP.O. Box 168 P.O. Box 4338Phnom Penh Jakarta PusatKingdom of Cambodia Indonesia

Ms. Dora Panagides, Country Director Dr. Martin W. Bloem, Regional Director

Telephone: 855-23-210851 Telephone: 62-21-5263872Fax: 855-23-210852 Fax: 62-21-5250529E-mail: [email protected] E-mail: [email protected]

© 1999 Helen Keller InternationalReprints or reproductions of portions or all of this document are encouraged provided due acknowledgement is given to thepublication and publisher

Projects carried out by HKI-Cambodia in collaboration with the Ministry of Health, Royal Cambodian Government (MOH/RCG), the Adventist Development and Relief Agency (ADRA), Chamran Cheat Khmer (CCK), Partners For Development(PFD) and Southeast Asian Outreach (SAO) are funded by the United States Agency for International Development(USAID).

This publication was made possible through support by the USAID/Cambodia Mission under the terms of Award No. 442-G-00-95-00515-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the USAgency for International Development.

Cambodia

Phnom Penh

78 km48 mi

1

23

4

HKI survey areas:1. Siem Reap2. Kampong Thom3. Kratie4. Steung Treng5. Takeo

5

35

Helen Keller International/Cambodia would like to acknowledge the following for theirwork with the National Micronutrient Survey of Cambodia.

Acknowledgements

Royal Government of Cambodia – Central Level

• H.E. Dr. Mam Bunheng (Secretary of State for Health, MOH)• H.E. Prof. Dr. Eng Huot (Director General for Health, MOH)• Dr. Ouk Poly (Nutrition Program Manager, MOH)• Mr. Touch Dara (Technical Assistant for Nutrition, MOH)• Dr. Uch Yutho (National Eye Health Coordinator, MOH)• Dr. To Chhun Seng (Chairman, National Prevention of Blindness Sub-Committee, MOH)• H.E. Dr. Hou Taing Eng (Director General for Planning, MOP)• Mr. Kang Siphannara (Chief, Census and Survey Bureau, National Institute of Statistics, MOP)• Mr. Bopha Ker (Bureau Chief of National Accounts, MOP)• Dr. Sam An Ung (Acting Director, National Institute of Public Health, MOH)• Mr. Buth Sokal (Head, Quality Assurance Department/National Laboratory, National Institute of Public

Health, MOH)• Mr. Simuth Denna (Chief, National Laboratory, National Institute of Public Health, MOH)• Dr. Doung Socheat (Director, National Malaria Center)• Dr. Muth Sinoun (Bureau Chief, National Malaria Center, MOH)• Dr. Chea Samnang (Director, Department of Rural Health Care, MRD)• Dr. Lim Thai Pheang (Director, National Centre for Health Promotion, MOH)

Royal Government of Cambodia – Provincial Level

• Dr. Bun Cheam (Director, Provincial Department of Health/Siem Reap)• Mr. Mony (Bureau Chief of Statistics, Provincial Department of Planning/Siem Reap)• Dr. Pen Sona (Vice Director, Provincial Department of Health/Svay Rieng)• Mr. So Tith (Director, Provincial Department of Planning/Svay Rieng)• Mr. Seng Lay (Vice Director, Provincial Department of Planning/Kampot)• Dr. Lim Kaing Eang (Director, Provincial Department of Health/Kampot)• Mr. Ith Sovann Da (Director, Provincial Department of Planning/Koh Kong)• Dr. Chhun Huor (Director, Provincial Department of Health/Koh Kong)• Dr. Meas Sokha (Vice Director, Provincial Department of Health/Kampong Thom)• Mr. Sam Ravuth (Director, Provincial Department of Planning/Kampong Thom)• Dr. Ou Phan (Vice Director, Provincial Department of Health/Kandal)• Mr. Meas Sophan Rith (Director, Provincial Department of Planning/Kandal)• Mr. Chem Ran (Director, Provincial Department of Planning/Kampong Cham)• Dr. Ngoung Sim An (Director, Provincial Department of Health/Kampong Cham)• Mr. Samreth Makara (Vice Director, Provincial Department of Planning/Prey Veang)• Mr. Ouk Oeun (Director, Provincial Department of Health/Prey Veang)• Mr. Yath Sokhann (Director, Provincial Department of Planning/Rattanakiri)• Dr. Sim San Lay (Director, Provincial Department of Health/Rattanakiri)• Dr. Mel Yuong (Director, Provincial Department of Health/Battambang)• Mr. Tev Chou Long (Vice Director, Provincial Department of Planning/Battambang)• Dr. Ouk Kim So (Director, Provincial Department of Health/Otar Meanchey)• Mr. Lun Gnagn (Vice Director, Provincial Department of Planning/Otar Meanchey)• Dr. Khouy Buntany (Vice Director, Provincial Department of Health/Preah Vihear)• Mr. Chann Sorn (Director, Provincial Department of Planning/Preah Vihear)

36

Acknowledgements

Others

District and Commune Level Authorities and community members from the provincesof Battambang, Koh Kong, Siem Reap, Kampong Cham, Svay Rieng, Prey Veang,Kampot, Kampong Thom, Preah Vihear, Rattanakiri, Kandal and Otar Meanchey

Enumerators, nurses and laboratory technicians

Helen Keller International Asia-Pacific Technical Team

37

HKI/CambodiaCountry OfficeProfile

Activities during 1999 and 20001. National vitamin A capsule distribution

program

• As an active member of the NationalMicronutrient Working Group, HKI was verymuch involved in developing the revisedNational Vitamin A Policy, 2000. This policyprovides clear guidelines for treatment andprevention of vitamin A deficiency and is tobe used as a guide for health center staff.

2. Food-based approach to addressing vitaminA deficiency

• In partnership with seven NGOs, in nineprovinces and one urban slum area ofPhnom Penh, established 221 village modelgardens and 6,532 household gardens. Thesegardens are important for household foodsecurity, health, income generation andempowerment of women.

• Monitoring reports show an improvementin the number of varieties of fruits andvegetables produced, consumed and soldand an improvement in consumptionfrequency per week. This is expected topositively affect the health and well beingof family members.

3. Nutrition education materials development

• Developed and produced numerousnutrition education materials which arebeing used widely throughout Cambodia.Materials include posters, counseling cards,songs, games, leaflets and referencedocuments on topics such as theimportance of vitamin A, good nutrition, foodgroups, infant and maternal feeding, homegardening, etc. The demand for thesematerials is high and reproduction of manymaterials has already occurred many timesin order to meet the needs. We receive lotsof requests not only for these materials butalso for training in nutrition and homegardening.

• HKI was the main agency responsible forrevising the Cambodian “Road to Health” or“Yellow Card”. This card is now improved in

that it has a space to record vitamin Acapsules given to the child, it has nutritioneducation messages on the card and it ismulti-color making it more attractive formothers or caretakers and thus improvingthe likelihood of card retention.

4. Improving basic eye care services

• Approximately 380,000 persons have accessto basic eye care services as a result of thetraining that HKI has conducted for healthcenter staff and village health volunteersin basic eye care treatment and prevention.

• Various training materials, educationalmaterials and reference manuals have beendeveloped for use by health center staff andvillage health volunteers. These haveformed part of the National Prevention ofBlindness (PBL) Program of the Ministry ofHealth.

• The primary eye care curriculum, developedby HKI, HelpAge International and the PBLOffice, has successfully been integrated intothe MOH Minimum Package of ActivitiesTraining Curriculum.

5. Research studies/surveys

• Conducted a baseline survey for the homegardening program. Results from the surveywere widely disseminated to raiseawareness about micronutrientdeficiencies through the publication, HKICambodia Nutrition Bulletin, which isdisseminated within and outside Cambodia.

• Conducted a study on young child feedingin order to make recommendations for the“Counsel the Mother” card, which is part ofthe Integrated Management of ChildhoodIllnesses, a program the MOH is piloting.

• Conducted the first ever Cambodia NationalMicronutrient Survey and MicronutrientProgram Assessment. Results from thesurvey and assessment will be important forassessing the current vitamin A programand for directing future programming inmicronutrients in Cambodia.

38

CountryProfile

Currency: 3900 Riel = US$ 1Ethnic groups: Khmer 90%, Chinese and Vietnamese, small numbers of Mon Khmer hill tribes,

Chams, Burmese.Weather: Tropical monsoon

Political and administrative systems:Sub-divisions: 24 provinces, 182 districts, 1,623 communes, 13,408 villagesCapital: Phnom PenhHead of state: King Norodom SihanoukHead of govt.: Prime Minister Hun SenLegislative body: After the election of July 1998, ten out of 120 members of the National Assembly

are women.Highlights: Cambodia gained independence from France in 1953 and Prince Sihanouk

became head of state. Prince Sihanouk was ousted in a coup in 1970. In April1975, the Khmer Rouge captured Phnom Penh, establishing a radical agrariansociety under which more than 1 million people died of executions, starvation,disease and overwork. In 1979, the Vietnamese Army ousted the Khmer Rougeand established a new Cambodian government against which for the nextdecade a guerrilla war was waged by a coalition of the Khmer Rouge and non-communist resistance groups. In 1991, the warring Cambodian factions signed aUnited Nations sponsored peace agreement. UN-organized elections took placein 1993, following which a coalition government was formed. The stability of thegovernment was threatened by the power struggle between the ruling parties(FUNCINPEC & CPP), which reached a crisis in July 1997. The crisis led to thedeparture of the first Prime Minister, Prince Ranariddh. No party gained asufficient majority to govern alone in the July 1998 elections and a coalitiongovernment was formed in November 1998 with the CPP of Prime Minister HunSen as the biggest party. Cambodia became a member of ASEAN in 1999.

CAMBODIAAdapted from the UNICEF Cambodia Country Profile, December 13, 1999

39

Major determinants underscoring the health situation ofchildren and women:

• Infrastructure and social services have been destroyed by decades of war, civilstrife, political instability and economic depletion. These problems are mostpronounced in rural areas.

• 36% of households live below the poverty line. Illness continues to push largenumbers deeper into debt and destitution because of the high cost of healthcare.

• Cambodians who are poor, illiterate, lack schooling and live in remote areas,are the most likely to have higher malnutrition and mortality rates, suffermore from diarrhea, benefit less from health care (vaccination, antenatal care,trained birth attendance) or education.

• An unusual high proportion (2%) of the population is disabled by war and civilstrife. The number of amputees, widows, neglected and exploited children,and victims of recurrent flood and drought is large.

• HIV/AIDS is spreading dramatically with almost 50% of prostitutes and 2.4%of married women infected with HIV. An estimated 241,000 people are infectedwith HIV, 5,000 have died already of AIDS and a further 5,000 are expected todie this year, out of which 1,000 children.

• Basic education faces serious problems with access, achievement and quality,high drop-out rates and pronounced disparities between socio-economiclevels, geographic areas and gender.

• Among 1-4 year olds, ARI, malaria and diarrhea are the main causes of death.• Resources are scarce; key departments such as Education, Health, Rural

Development and Women’s Affairs lack minimum qualified staffing, basicequipment, supplies and operational funds.

• 22% of households are headed by women. Women have, on average, 20% lowerliteracy rate than men.

CountryProfile

40

CountryProfile

STATISTICAL DATA DemographyPopulation (‘000’)1 .............................................................. 11,426 (1998)Population under 5 (‘000’)1 ................................................ 1,463 (1998)Population under 18 (‘000’)1 ............................................... 5,747 (1998)% Population growth rate1 ...................................................... 2.5 (1998)Land area (‘000’ km2)2 ............................................................. 177 (1995)Density (per km2)1 ..................................................................... 64 (1998)% urbanized1 ................................................................................ 16 (1998)Total fertility rate (per woman)3 ............................................ 4.1 (1998)Life expectancy (male/female; years)4 ........................... 50/59 (1995)Crude birth rate3 ....................................................................... 29 (1998)Crude death rate5 ...................................................................... 13 (1996)Number of births (‘000’)4 ...................................................... 330 (1998)Number of under-5 deaths (‘000’)4 ....................................... 38 (1998)

Socio-economic environmentGNP per capita (US$)4 ........................................................... 300 (1997)Human development index6 .............................................. 0.422 (1995)Health exp. (% of planned govt. exp.)7 .................................... 6 (1997)Education exp. (% of planned govt. exp.)7 .......................... 10.3 (1998)Military exp. (% of actual govt. exp.)7 ................................... 50 (1997)Radio sets per 1000 pop.5 ........................................................ 40 (1997)TV sets per 1000 pop.5 ............................................................. 20 (1997)% female participation in labor force5 .................................. 65 (1997)% child labor force (% of age 10-14 yrs)5 ................................ 17 (1997)

HealthMaternal mortality rate8 ....................................................... 473 (1996)Infant mortality rate (per 1,000 live births)3 ....................... 89 (1998)Under five mortality rate3 ....................................................... 115 (1998)

References:

1. General population Census ofCambodia, NIS, 1998.

2. IBRD, World Development Report1998/1999.

3. National Health Survey, NIPH,1998.

4. The State of the World’s Children,UNICEF, 1999.

5. Cambodia Socio-Economic Survey1997.

6. Cambodia Human DevelopmentReport, UNDP, 1998.

7. Common Country Assessment,UNDP, 1998.

8. Health Statistics, Ministry ofHealth, Kingdom of Cambodia

Project CoordinatorsDora PanagidesRegina Moench-Pfanner

EditorFederico Graciano

ContributorsHKI Asia-Pacific Technical Team

Martin W. BloemSaskia de PeeLynnda Kiess

HKW HeadquartersIan Darnton-Hill

ProductionHKI/APRO Public Relations Team

Cover PhotographHKI Cambodia/La-Ong Tokmoh

© Helen Keller Worldwide 2001

Reproduction of part or all of this document is encouraged, provided dueacknowledgement is given to the publisher and the publication.

This supporting document to the Micronutrient Workshop was made possiblethrough support by the United States Agency for International Development(USAID) under the terms of Cooperative Agreement No. HRN-A-00-98-00013-00.

The opinions experessed herein are those of the author(s) and do not necessarilyreflect the views of the US Agency for International Development.

42

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