nnfsp.gov.npnnfsp.gov.np/PublicationFiles/0f569fa0-0687-4cb2-a406-20f7c15562… · II NEPAL IODINE...

New ERA

NepalIodine Deficiency Disorders

Status Survey 2005

Ministry of Health and PopulationDepartment of Health Services

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The mention of specific companies or of certain manufacturers' products in this report does not imply thatthey are endorsed or recommended by the Micronutrient Initiative in preference to others of a similar naturethat are not mentioned.

Any part of this publication may be freely reproduced with appropriate acknowledgement. Recommended citation:Nepal Iodine Deficiency Disorders Status Survey 2005 (Revised Print). Kathmandu, Nepal: Ministry of Healthand Population, Child Health Division, The Micronutrient Initiative, and New ERA.

The Front Cover Graphic: structural formula of thyroxine (a thyroid hormone), a molecule of which contains fouratoms of Iodine (I).

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TABLE OF CONTENTS

PageFOREWORD .................................................................................................................................. IIIPREFACE ....................................................................................................................................... IVACKNOWLEDGEMENTS...................................................................................................................... VTABLE OF CONTENTS ......................................................................................................................VIILIST OF TABLES ............................................................................................................................. IXACRONYMS AND ABBREVIATIONS..................................................................................................... XIEXECUTIVE SUMMARY .................................................................................................................. XIII

CHAPTER 1.0: INTRODUCTION, OBJECTIVES AND METHODOLOGY------------------------------------------- 1-9

1.1 Introduction ------------------------------------------------------------------------------------------ 11.2 Justification for the Study --------------------------------------------------------------------------- 31.3 Objectives and Scope -------------------------------------------------------------------------------- 31.4 Study Methodology ----------------------------------------------------------------------------------- 3

1.4.1 Sample Design and Coverage ----------------------------------------------------------------- 31.4.2 Method of Sampling --------------------------------------------------------------------------- 41.4.3 Sample Weighting------------------------------------------------------------------------------ 51.4.4 Survey Instruments ---------------------------------------------------------------------------- 51.4.5 Recruitment, Training and Field work -------------------------------------------------------- 6

1.5 Quality Assurance Measures ------------------------------------------------------------------------- 71.6 Data Processing and Analysis ----------------------------------------------------------------------- 71.7 Collection of Urine and Validation of Urinary Iodine and Iodine in Salt ------------------------ 8

CHAPTER 2.0: SOCIO-ECONOMIC CHARACTERISTICS ------------------------------------------------------- 11-14

2.1 Household Composition ---------------------------------------------------------------------------- 112.2 Housing Characteristics ---------------------------------------------------------------------------- 122.3 Occupation of Household Head ------------------------------------------------------------------- 132.4 Landholding and Livestock ---------------------------------------------------------------------- 132.5 Disadvantaged Group (DAG) Classification ----------------------------------------------------- 142.6 Background Characteristics ---------------------------------------------------------------------- 14

CHAPTER 3.0: URINARY IODINE EXCRETION -------------------------------------------------------------- 17-19

CHAPTER 4.0 STATUS OF SALT IODIZATION ---------------------------------------------------------------- 21-36

4.1 Types of Salt Used at Household Level ----------------------------------------------------------- 224.2 Types of Salt Sold at Retail Outlets --------------------------------------------------------------- 264.3 Iodine Content of Salt at Household and Retail Levels ----------------------------------------- 274.4 Knowledge on Iodized Salt ------------------------------------------------------------------------ 30

4.4.1 Knowledge at Households Level ------------------------------------------------------------ 304.4.2 Knowledge at Retail Outlets ---------------------------------------------------------------- 31

4.5 Knowledge on Two-child Logo--------------------------------------------------------------------- 324.5.1 Knowledge about 2-Child Logo Salt at the Household Level ---------------------------- 334.5.2 Knowledge at the Retail Outlets ----------------------------------------------------------- 35

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Page

CHAPTER 5.0: RELATIONSHIP BETWEEN IDD INDICATORS------------------------------------------------- 37-39

5.1 Urinary Iodine and Salt Iodine Content ---------------------------------------------------------- 37

CHAPTER 6.0: SALT PROCUREMENT AND STORAGE -------------------------------------------------------- 41- 49

6.1 Salt Procurement Patterns ------------------------------------------------------------------------- 416.1.1 Salt Procurement at Household Level ------------------------------------------------------ 416.1.2 Salt Procurement at Retail Outlets --------------------------------------------------------- 43

6.2 Source of Salt Procurement ------------------------------------------------------------------------ 446.2.1 Source of Salt Procurement at Household Level ------------------------------------------ 446.2.2 Source of salt Procurement at Retail Outlets --------------------------------------------- 45

6.3 Storage Practice of Salt ---------------------------------------------------------------------------- 466.3.1 Household Level Storage Practice ---------------------------------------------------------- 466.3.2 Storage Practice at Retail Shops ----------------------------------------------------------- 48

CHAPTER 7.0: SUMMARY OBSERVATIONS AND RECOMMENDATIONS -------------------------------------- 51-55

7.1 Urinary Iodine Excretion (UIE) -------------------------------------------------------------------- 527.2 Status of Salt Iodisation --------------------------------------------------------------------------- 527.3 Relationship between IDD Indicators------------------------------------------------------------- 53

REFERENCE --------------------------------------------------------------------------------------------------------- 57

APPENDICES ------------------------------------------------------------------------------------------------------- 59

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LIST OF TABLES

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Table 1.1: Iodine deficiency disorders: Summary of major survey findings 3Table 1.2: The sample size determination for the survey 4Table 1.3: Actual sample size of households, SAC, retail shops, salt and urine sample 5Table 1.4: Statistical weights to account for sample frame in aggregate analysis 5Table 1.5 Comparison of results using field test kits and lab titration for salt iodine content 9Table 1.6: Comparison of RTK and titration – 0 ppm 9Table 1.7: Comparison of RTK and titration – 15 ppm 9

Table 2.1: Percentage distribution of household by sex, caste and religion 12Table 2.2: Percentage distribution of household by housing characteristics 12Table 2.3: Percentage distribution of household head by type of occupation 13Table 2.4: Percentage distribution of households by land and animal holding 13Table 2.5: Proportion of DAG Households 15Table 2.6: Percentage distribution of school age children by age and education 15

Table 3.1: Urinary iodine status among school aged-children 18Table 3.2: UIE: A comparative assessment over 1998-2005 18

Table 4.1: Types of salt mostly used in households for human consumption bygeographical location 23

Table 4.2: Types of salt consumed by household characteristics 23Table 4.3: Duration of use of different types of salt in the households 24Table 4.4: Separate salt for livestock in households 24Table 4.5: Types of salt used for livestock by geographical location 24Table 4.6: Reasons for using particular type of salt for human consumption 25Table 4.7: Reasons for using particular salt by the types of salts 25Table 4.8: Types of salt sold in the shop by geographical location 26Table 4.9: Most popular type of salt sold in the area 26Table 4.10: Reasons for popularity of salt in the area by type of salt 27Table 4.11: Households salt iodine content 28Table 4.12: Adequately iodized salt (>= 15 ppm) in the households 28Table 4.13: Type of salt with iodine content 28Table 4.14: Iodine content of different types of salt by stratums 29Table 4.15: Salt iodine content at the retail outlets 29Table 4.16: Iodine content in salt collected at retail outlets by type of salt 30Table 4.17: Awareness about iodized salt among women 30Table 4.18: Source of knowledge on iodized salt among women who reported knowing

about iodized salt 31Table 4.19: Awareness on importance of iodized salt among women 31Table 4.20: Awareness about iodized salt among retailers 31Table 4.21: Source of information for retailers on iodized salt by location 32Table 4.22: Knowledge on importance of iodized salt as reported by retailers 32Table 4.23: Awareness about two-child logo among women 33Table 4.24: Message provided by two-child logo as reported by women 33Table 4.25: Awareness about two-child logo among retailers 34

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Table 4.26: Message provided by two-child logo as reported by retailers 34Table 4.27: Shop not selling salt with two-child logo 35Table 4.28: Reasons for not selling salt with two-child logo 35

Table 5.1: Relationship between iodized salt and UIE for school-aged children 38Table 5.2: Regional assessment of relationship between iodized salt and UIE for school-aged children 38Table 5.3: Relationship between type of salt consumed and UIE for school-aged children 38Table 5.4: Regional Assessment of Relationship between type of salt

and UIE for school-aged children 39

Table 6.1: Salt procurement patterns in the households 42Table 6.2: Salt procurement patterns in the households by SES, knowledge

on iodized salt and two-child logo 42Table 6.3: Amount of salt purchased at a time 43Table 6.4: Price paid per Kg (in NRS) 43Table 6.5: Frequency of salt procured at a time by type of salt 43Table 6.6: Amount of salt procured at a time by type of salt 44Table 6.7: Price sold per Kg by type of salt 44Table 6.8: Source of salt procurement at household level 45Table 6.9: Source of salt in the retail shops by location 45Table 6.10: Source of salt in the retail shop by type of salt 45Table 6.11: Place of storage of salt in the kitchen 46Table 6.12: Storage practice of big quantity of salt (as reported) 47Table 6.13: Storage practice and iodine content in salt used for kitchen use 47Table 6.14: Storage practice of different types of salt 47Table 6.15: Storage practice of different types of salt by education level of the respondents 47Table 6.16: Storing practice of salt in the kitchen by geographical location and type of salt

(as reported) 48Table 6.17: Storing practice of salt in the retail shop by geographical location and type of salt 48

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ACRONYMS AND ABBREVIATIONS

BCHIMES Between Census Household Information, Monitoring and Evaluation SystemCBS Central Bureau of StatisticsDACAW Decentralized Action for Children and WomenDAG Disadvantaged GroupDPCP Decentralized Planning for the Child ProgrammeFCHV Female Community Health VolunteersGCEP Goitre Control and Elimination ProgrammeICPMR Institute of Clinical Pathology and Medical ResearchICCIDD International Council for Control of Iodine Deficiency DisordersID IdentificationIDD Iodine Deficiency DisordersISSMAC Iodized Salt Social Marketing CampaignJICA Japan International Cooperation AgencyMI Micronutrient InitiativeMOHP Ministry of Health and PopulationMPHBS Multipurpose Household Budget SurveyNDHS Nepal Demographic and Health Survey, 2001PPM Parts per MillionPPS Probability Proportional to SizePSU Primary Sampling UnitRTK Rapid Test KitSEARO South East Asia Regional OfficeSPSS Software Programme for Social ScienceSTC Salt Trading CorporationTOR Terms of ReferenceUIE Urinary Iodine ExcretionUN United NationsUNICEF United Nations Children’s FundUSI Universal Salt IodizationVDC Village Development CommitteeWHO World Health Organisation

In order to improve the problem of iodine deficiencydisorders (IDD) in Nepal, the Government implementeda five year Plan of Action (1998-2003) in collaborationwith various partners including UNICEF and JICA. Thepresent survey provides information on progressachieved towards the elimination of IDD since the lastnational survey undertaken in 1998.

This survey provides national estimates on the statusof IDD in the country, which are directly comparablewith those collected as part of the NationalMicronutrient Status Survey (NMSS) in 1998. For bothof the surveys, urinary iodine excretion (UIE) has beenemployed for the assessment of iodine intake and theprevalence of IDD in the population. In addition, theadequacy of the iodine content in salt used inhouseholds and sold in markets has been included asmajor indicators to track efforts to improve thesituation. The study further explored the knowledge,attitude and behaviour patterns of consumers towardsiodized salt and salt in general.

A representative sample was derived throughprobability proportional to size (PPS) methods andallowed for national and sub-national estimates,stratified by six eco-development strata. Data regardingsalt procurement practices and the iodine content in saltwere collected at the household level, while the prevalence

Executive Summary

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of IDD and low iodine intake was assessed among school-age children from the same sample of households.

Urinary Iodine Excretion (UIE)

For the country as a whole, the median urinaryiodine excretion (UIE) value increased from143.8 µg/l in 1998 to 188 µg/l in 2005 amongschool-aged children indicating continuedprogress towards the sustained elimination ofIDD. The proportion of school aged children withlow urinary iodine excretion (UIE) below theWHO cut-off value of 100 µg/l decreased from35 percent in 1998 to 27 percent in 2005.

However, the improvement in the UIE has notbeen consistent across the country, although themedian UIE exceeded the minimum leveldesignated by WHO to indicate adequate iodineintake, i.e., 100 µg/L, in each eco-developmentstrata. Significant improvement in UIE wasobserved in the Terai region from a median of108.9 µg/l to 182.7 µg/l in large part due to thehigh UIE level observed in the Western Terai(206.0 µg/l). At the same time, the median UIEdeclined from 196.6 µg/l to 164.6 µg/l in theMountains between 1998 and 2005,demonstrating the importance of sustained andvigilant efforts to ensure long term results.

Urinary iodine levels were higher among boys(202.0 µg/l) than girls (178.8 µg/l), a findingconsistent with observations from 1998.

The median UIE value for urban areas showed adramatic increase from 259 µg/l in 1998 to361.0 µg/l in 2005 while there was animprovement in rural areas from 133.7 µg/l to169 µg/l. In fact, the increase in UIE in urbanareas does raise some concern about a risk ofexcessive iodine intake that may result from theconsumption of salt that has been over iodized.

Status of Salt Iodisation

The survey indicated that overall, 95 percent ofhouseholds consumed salt with some iodine,

which represented an improvement from 1998when 83 percent of households were found tobe using salt with some iodine.

Over forty percent (41.5%) of the householdswere found to be consuming large crystal salt(phoda), which was a decline from 1998 when63 percent of households consumed this type ofsalt. Although iodized, this type of salt tendsto have marginal levels of iodine and issusceptible to losses due to high moisturecontent and the fact that the salt is oftenpurchased in bulk.

The promotion of branded, crushed powder saltwith the ‘two-child’ logo, a major component ofthe program, has been successful in increasingthe availability of adequately iodized salt. While38 percent of households used two-child logosalt, virtually all contained adequate levels ofiodine (> 15 ppm). This type of salt was mostlyconsumed in urban locations (76%) rather thanamong rural households (31%).

Among brands of refined salt with two-childlogo, 33 percent of households consumed Aayoin the country, compared to only 9 percent in1998.

The proportion of households using adequatelyiodised salt has improved only slightly from 55%to 58 percent between 1998 and 2003 and therewas considerable variability across strata. Therehas been a significant rise in the proportion ofhouseholds consuming adequately iodized saltin the Western Terai stratum (35% to 54%),while there has been a decline in the EasternTerai stratum (58% to 52%) overshadowingoverall progress. One of the main factors behindthis decrease in the Eastern Terai was theinfiltration of inadequately iodized salt from theborder areas, which was found to havepenetrated local markets.

The survey observed that approximately 75percent of the salt samples at the retail levelhad iodine content of 15 ppm or more. Virtuallyall of the samples (99.7 %) from retail shopshad at least some iodine.

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Most households (64%) stored salt near thecooking stove. The survey revealed that therewas a direct correlation between storagepractices and the salt iodine content at thehousehold level. For instance, 85 percent of thehouseholds having good storage practices hadadequate levels of iodine in salt, while only 40percent of households with poor storagepractices had adequate levels of iodine in salt.

Relationship between IDD Indicators

The survey indicated that there was a positivelinear relationship between UIE and salt iodinecontent. School-aged children from householdsconsuming salt with no iodine were much morelikely to have UIE levels below the WHO cut-offof 100 µg/l than SAC consuming adequately

iodised salt (>15ppm). At a population level,consumption of adequately iodized salt wasdirectly linked to the probability of sufficientUIE levels. The median UIE level was as high as343 µg/l in households consuming adequatelyiodized salt in the Eastern and Central Hills and284 µg/l in the Eastern and Central Teraistratum. However, in the East Central Mountainstratum, the median UIE level was slightly lowerat 189 µg/l among households consumingadequately iodized salt. In these same strata,SAC from households using salt with no iodinehad median UIE values of 58.5 µg/l, 60.0 µg/land 88.5 µg/l, respectively.

Children from households consuming Aayo salt had amedian UIE value of 366 µg/l, while children fromhouseholds consuming granular salt had a median UIEvalue of 69 µg/l.

Introduction,Objectives and Methodology

C H A P T E R 11111

1.1 Introduction

The Nepal Micronutrient Status Survey 1998 indicatedsignificant progress towards the control of IDD in thecountry with biochemical indicators (urinary iodineexcretion) indicating adequate iodine intake amongschool-aged children and women. However, theproportion of households consuming adequatelyiodized salt (with 15 ppm or more iodine) was just55 percent, which fell below the target for UniversalSalt Iodization (USI) of at least 90 percent of thehouseholds using adequately iodized salt. One of theprime constraints hinted by the 1998 survey was thewidespread use of big crystal salt (in loose form),which was found to contain marginal levels of iodine.

In order to improve the situation in the country, theGovernment of Nepal implemented a five year Plan ofAction for the Control of IDD (1998-2003) incollaboration with various partners including UNICEFand JICA. The main activities focused onstrengthening the distribution of packet iodized saltin remote areas, construction of additionalwarehouses at import entry sites, launching of a socialmarketing campaign for promotion of packet iodizedsalt and strengthening of on-going salt monitoringat various distribution levels. Following seven yearsof intensive program implementation since the last

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national survey was undertaken, it was important thata survey be conducted in 2005 to assess theeffectiveness of program activities.

Iodine Deficiency Disorders (IDD)Iodine is an essential micronutrient for many humanfunctions. It is a natural element found in the topsoil,which is absorbed and utilized by plants. The normalrequirement of iodine for human beings averages 150µg per person per day (Karmarkar, 1985; Hetzel,1989). Geographic regions prone to frequent topsoilerosion due to landslides and torrential rainfalls areat elevated risk of iodine loss (Koutras, D.A.,Matovinovic, J., and Vought, R. 1980). Crops grownin such regions are more likely to be deficient iniodine, which directly influences the dietary intakeof this essential micronutrient. The topography ofNepal leaves it under such a vulnerable situations.

Iodine deficiency has important effects beyondcausing endemic goitre. Cretinism is the most extremeclinical condition that may result from severe iodinedeficiency. While clinical manifestations areimportant, the effects of iodine deficiency, even inmoderate stages, on cognitive and mentaldevelopment have gained increasing attention overthe past few years as a primary focus of IDD controlefforts. (Leslie, 1991). Iodine deficiency has beendescribed as the world’s single most significant causeof preventable brain damage and mental retardation.Moderate IDD in early childhood has been estimatedto lower the intelligence quotient by about 10-15points, while in adults it causes lethargy.

The most commonly employed intervention toincrease the intake of iodine is to iodize all saltintended for human and animal consumption (Mannar,V.M.G., and Dunn, J.T., 1995). The physiologicalrequirement for iodine is 150 µg per person per day.Assuming an average daily intake of 10 gm of saltper person, this can be realized if salt is iodized at alevel of 15 parts per million (15 ppm). If the iodinecontent is less than 15 ppm at consumption level, itmay not prevent IDD in the population. In additionto ensuring that the minimum physiologicalrequirement of iodine is satisfied, it is important tomonitor programs so that there is no risk of excessiveiodine intake, which may result from over-iodizationof salt at the point of production (Zimmermann,

M.B., et al.2005; Stanbury, J.B., et. al.1998; & Azizi,F., et. al. 2005).

Initiatives to Control IDDAmong the many goals of the 1990 UN Summit forChildren, the goal of virtual elimination of IDD standsout as one of the few that has shown considerableprogress. The initiatives undertaken by Governmentof Nepal towards the control of IDD since 1973 havebeen commendable. There were two projectsestablished by Ministry of Health in the 1970s, theGoitre Control Programme and the Goitre and CretinismControl Project, which consisted of a combinationof activities including universal salt iodization (USI)and iodine supplementation. The former wasconsidered to be a long-term strategy while the latterwas a shorter-term initiative to provide iodinesupplements through injections and oral iodinecapsules to target populations. The iodized oilinjection program (1979-1994) covered 40 Districtslocated in the hills and mountains, while iodized oilcapsules (1995-1998) were provided to women andchildren in 15 remote mountain districts. However,since the late 1990’s when supplementation wasphased out, universal salt iodization (USI) hasbecome the sole policy to control IDD in the country.

Assessment of IDD Control ProgrammeNepal had relied on the assessment of goiter as themain indicator of IDD in the past. This was based onthe WHO recommendation from 1993 and had beenadopted by many countries.1 However, it has becomeclear that goiter may not be the most appropriateindicator to measure changes in iodine status in thepopulation resulting from increasing coverage and useof iodized salt. There are two important problems withthe adoption of goiter as an indicator of IDD. First,there can be large inter-observer variability in themeasurement of goiter, usually done by palpation. Thisvariability increases as the goiters become smaller andthe subjectivity in the assessment leads tomisclassification, particularly among health workerswith little training and standardization. The secondissue has to do with the fact that the development ofgoiter in an individual usually takes years; and oncean individual’s iodine nutrition is corrected, it maytake years for their thyroid to return to “normal” size.For some individuals the thyroid may never return to“normal.” This characteristic of goiter as an indicator

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of IDD makes it less appropriate where salt iodizationprograms are being implemented, and as such doesnot reflect current iodine nutrition status (Gorstein,J., 2001). As an alternative, urinary iodine excretionhas become the most widely accepted `gold standard’for the assessment of iodine intake and to estimatethe prevalence of IDD in populations. Almost 90percent of all iodine is excreted in the urine; thereforeit provides an estimate of the current iodine intake.UIE was used to assess the prevalence of IDD in thecountry in 1985-86 and again as part of the NepalMicronutrient Status Survey (NMSS) in 1998. In turn,the current survey employed UIE as the primaryindicator. As in NMSS 1998, the primary processindicator for assessment of efforts to control iodinedeficiency is an assessment of the adequacy of iodinein salt at the household level.

1.2 Justification for the Survey

The overall objective of the 2005 National IDD Surveywas to assess the progress made towards eliminationof IDD in the country. The survey provides nationalestimates on the prevalence of IDD, as well as thecoverage of adequately iodized salt. These are the twoprimary indicators recommended by the WHO/UNICEF/ICCIDD to assess progress towards the elimination ofIDD (WHO, UNICEF, and ICCIDD. 2001).

Three major sub-national surveys were carried out overthe past forty years in Nepal (1965, 1979-82, and1985-86), although none of these studies provideddata for the entire country. It was not until 1998when the NMSS was implemented when nationalestimates of IDD were available. The following table

provides details on trends in the prevalence of IDDin Nepal (Table 1.1).

1.3 Objectives and Scope

The overall objective of the survey was to assessprogress towards the elimination of IDD in Nepal, withthe following specific objectives:

Assess the distribution of urinary iodineexcretion and prevalence of low UIE;Analyze the iodine content in salt and thepercentage of households using adequatelyiodized salt, andAssess knowledge, attitude and behaviourregarding the procurement, storage andconsumption of iodized salt.

1.4 Study Methodology

1.4.1 Sample Design and CoverageThe goal of the sample design was to provide astatistically representative sample of school-agedchildren in order to generate estimates of IDD for eachof the country’s six eco-development strata. Thesestrata were based on the three ecological zones, namely,Terai, Hills and Mountain, which were further dividedinto two major regions, i.e., Eastern/Central regionand Western region thus yielding a division of sixdistinct strata (Fig 1.1).

The minimum sample size requirement estimated foreach stratum was calculated based on the followingparameters:

Source: a Ministry of Health, Endemic Goitre in Nepal, WHO/SEA/26, October, 1967. b Nepal, MOH in Clugston, GA and K Bagchi, Iodine Deficiency Disorders in South-East Asia. WHO/SEARO Regional Health Papers No. 10, New Delhi 1985. c Acharya, S. Iodine Deficiency Disorders in Nepal: Assessment of Programme Impact, HMG/UNICEF, 1989.d GCEP-HMG/N, Situation Analysis of Iodine Deficiency Disorder in Nepal, December 1992.e Nepal Micronutrient Status Survey 1998. MOH/HMG-N, New ERA, MI, UNICEF Nepal and WHO.

Year Age group Area Total Goitre Prevalence Prevalence LowRate Cretinism Urinary Iodine

(< 100 µg/l)1965a Above 13 years 19 villages 55.0 - -1979/82b All ages 14 districts 57.6 2.8 -1985/86c All ages 15 districts 39.7 0.4 52.0

School aged 44.2 0.2 -1992d School-aged 2 districts 32.0 - 70.01998e School-aged National 40.0 - 35.1

Mothers 50.0 - 43.6

Table 1.1: Iodine deficiency disorders: Summary of major survey findings

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The sample size was further inflated to 600 Householdsfor each stratum in order to account for possible non-compliance or non-participation in the field. It wasdecided that one SAC would be sampled in eachHousehold from whom urine specimens would becollected and subjected to analysis for UIE. Thus, thetotal sample size was 3,600 SAC and Households forthe country as a whole. The sample was drawn from73 of the country’s 75 districts, with Doti andKhotang Districts, being the only exceptions.

1.4.2 Method of SamplingA two-stage cluster design was used to select thesample for the survey. These steps are described below.

Selection of Cluster (First Stage Sampling)The primary sampling unit (PSU) in this survey was a“cluster”, which was defined as a ward. In each stratum,30 clusters were selected following the procedure ofprobability proportional to size (PPS), using

Sample Size DeterminationProportion of population consuming iodized salt 90%Confidence level 95%Absolute precision +/- 5%Design effect 4Total estimated sample size in each stratum(no of households/children) 554

Table 1.2: The sample size determination for thesurvey

population data from the 2001 census. For theselection of 30 clusters, a listing was prepared of allVillage Development Committees (VDC) in alphabeticalorder with their corresponding wards and population.An additional column with the cumulative populationwas prepared of all wards. Once this procedure wascompleted, the total population was divided by thenumber of allocated clusters (i.e. 30) to obtain thesystematic selection interval. A random numberbetween one and the sampling interval was generatedwith the help of a computer and was used for theselection of the first cluster. Subsequent to this, thesampling interval was added to the random number toselect the second cluster, and this continued until allthirty clusters were identified. This procedure wasfollowed for each of the six strata, leading to a totalof 180 clusters (30 clusters in each six stratum)selected to conduct the survey.

Selection of Households (Second Stage Sampling)Once the clusters were selected, the next stage ofsampling involved selection of households. In orderto select households, field teams constructed a listof all eligible households within each selected cluster.The household selection criterion was the presenceof a woman with at least one school aged child (6to 11 years). If there was more than one school agedchild in the household, only one child was randomlyselected to be included in the sample.

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Fig 1.1: Nepal Map, Eco-development stratum

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From the list of eligible households, 20 were selected.The first household was identified randomly, while theremaining 19 households were selected systematically.

Within each of selected cluster, 1-5 retail shops wereselected for an interview. In order to select the retailshops, field teams made a list of shops situated inthe sampled cluster. Then if there were more than 5shops, only five shops were selected randomly for thesurvey. Actual sample sizes for the different levelsinclude in the survey are presented in Table 1.3.

In each selected household, salt was analysed usinga rapid test kit (MBI, India) to provide a semi-quantitative estimate of the iodine content.2 Inaddition, salt samples from 10 percent of thehouseholds (2 per cluster) were collected and sentto a lab for analysis by iodometric titration for moreprecise measurement of the iodine content. A totalof 360 salt samples (about 20 grams of salt) werecollected in moisture free envelopes for titration fromthe household level. In addition to the collection ofa sub-sample of household salt for quantitativetesting, salt samples were collected for titrationanalysis from the retail shops.

1.4.3 Sample WeightingAs equal samples were collected from each of the sixeco-development strata, it was necessary to developstatistical weights to derive national estimates. Theseweights were developed based on the proportion ofthe national population living in each stratum (Table1.4). These weights were added to each individualrecord in all of the databases, and were applied toall statistical analysis of national-level parameters.

1.4.4 Survey InstrumentsThe survey instruments were designed as simply aspossible keeping the basic objectives of the surveyin mind. There were three different data collectioninstruments developed3, which included thefollowing:

1. Structured Household Questionnaire2. Structured Mothers’ Questionnaire3. Semi-Structured Retail Shopkeepers’

Questionnaires4. Form for biochemical sample (Urine) collected

from SAC5. Form for salt collected from households and

retailers

Table 1.3: Actual sample size of households, SAC, retail shops, salt and urine sample

Stratum

1. East and Central Terai2. East and Central Hills3. East & Central Mountains4. All West Terai5. All West Hills6. All West MountainsTotal estimated sampleTotal enumeratedResponse rate (%)

Number ofSample

Households

600600600600600600

3,6003,599

99.9

Number ofSchool-aged

children

600600600600600600

3,6003,596

99.9

Number ofSample Retail

shops

122104

91139

7861

-595

-

Total saltsamples from

retail shops

167128

75209103

18-

700-

Total householdsalt collected for

quantitativetesting

606060606060

360360100

Total Numberof Urine

Sample ofchildren

600600600600600600

3,6003,564*

98.9* Please refer to section 1.7 for urine sample details

Table 1.4: Statistical weights to account for sample frame in aggregate analysis

Stratum

B

EC TeraiEC HillEC MountainAll West TeraiAll West HillAll West Mts.Total

Total HHs

C

1,292,979994,461188,020651,318978,179130,738

4,235,695

CompleteInterview

D

599600600600600600

3,599

Adjusted forCompletion Rate

E(C/D)*100

215,856165,744

31,337108,553163,030

21,790

NormalizedWeight

FE*(∑∑∑∑∑D/ ∑∑∑∑∑C)

183.41 140.83

26.63 92.24

138.52 18.51

600.14

HHs AfterWeight

G (F*D)/100

1,099845160553831111

3,599

NormalizedWeight

HE*(∑∑∑∑∑D/ ∑∑∑∑∑C)/100

1.8341.4080.2660.9221.3850.1856.001

A

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In addition to the questionnaire forms, a number ofadditional materials were developed to facilitate datacollection, including a household listing form,supervisors assignment sheet, interviewers’ assignmentsheet and a field manual. These were important tosupport the systematic implementation of the surveyand to monitor the progress of fieldwork.

Pre-test of the Survey InstrumentsAfter the questionnaires were developed, they weresubjected to pre-testing in non-sample areas ofChunikhel VDC of Kathmandu district in order tofinalize the questionnaires. The objective of the pre-test was to examine the adequacy, clarity and flowof the questions. Moreover, it examined the accuracyof possible responses, skip patterns and length oftime for conducting the interview.

1.4.5 Recruitment, Training and Field Work

Recruitment of Field StaffA total of 18 teams (54 field staff) were assigned fordata collection (Appendix 1.1.4). Each team wascomprised of three members of whom one was a fieldsupervisor and the other two were female interviewers.All field researchers had considerable data collectionexperience especially in the area of maternal and childhealth. Those field staff who had worked in thebaseline surveys of Decentralised Action for Childrenand Women (DACAW), Decentralised Planning for theChild Programme (DPCP), Nepal Demographic andHealth Survey (NDHS) and/or Nepal MicronutrientStatus Survey 1998 were given priority.

Training of the Survey TeamTraining commenced immediately after the selectionof field staff. A five-day intensive training for thesurvey teams was conducted between 22-27 May 2005at the Women Development Centre in Jawalakhel. Thetraining included an introduction to the survey,objectives and methodology of the survey; fieldprocedures, theoretical knowledge about the subjectmatter and other necessary issues. In addition to theclassroom lectures, trainees were facilitated throughgroup discussion, classroom practice, and role-playduring the training.

Key resource personnel from MI and the Child HealthDivision were invited to highlight different aspects

of the IDD control program and importance of thesurvey. Resource persons were responsible for specifictechnical sessions, such as the identification ofdifferent types of salt, salt testing procedures, etc.

One-day field practice was also conducted on 26 May2005 during the training period in Lubhu andLamatar VDC of Lalitpur District in order to visualizethe real field situation and also to identify anyoperational problems. After this, a review session wasorganized at Women Development Centre in Jawalakhelfor the trainees that provided an opportunity forteams to discuss and share relevant experiences facingduring fieldwork.

Field WorkInitially the field staff were divided into 11 teamsand were assigned to initiate field work in 11 clustersof Kathmandu, Bhaktapur and Lalitpur districts in orderto ensure the close supervision for the better dataquality. This initial fieldwork was scheduled for threedays from May 30 to June 1, 2005. A review sessionwas organized for the teams before they started theirwork in the remaining 169 sampled clusters in thecountry. After the review session, the field workerswere divided into the 18 teams to carry out theremaining fieldwork. Three teams were assigned in eachstratum. Once the teams were in the sample district,they contacted the concerned authorities to informthem about the study objectives and the fieldschedule. The field team then departed to the sampledcluster. The fieldwork commenced on 5th June 2005and ended on 14th August 2005.

Field supervisors were responsible for householdselection, assigning households to the team members,building rapport with the community, arranging traveland logistics, conducting interviews with retailers,collecting salt samples for titration and, mostimportantly, maintaining quality of informationcollected. Interviewers were responsible foradministering the questionnaires with householdheads and sampled mothers and to collect urine samplesfrom SAC in 1.8 ml vials, label them with proper ID,storing and preparing samples for dispatch to laboratory.

In addition to the field teams, two couriers wererecruited to transport questionnaires, salt samples andurine specimens from the field to Kathmandu.

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The core researcher team provided supervisionthroughout all stages of the fieldwork. The ResearchAssistant made continuous fieldwork supervision andalso collected completed questionnaires to prepare fordata entry and collected the samples of urine as well.

1.5 Quality Assurance Measures

The collection of quality data required properplanning, implementation and management of thewhole research process. However, the data collectionstage was the most crucial stage for better dataquality. Therefore, the following measures were takenduring the data collection period to ensure gatheringof valid and reliable data:

A schedule of data collection for each team wasdeveloped, which helped not only the fieldteams but also other personnel for supervision.Check lists were prepared for monitoring qualityand progress of fieldwork.Field teams checked whether all questionnaireswere filled out completely and properly beforeterminating each interview.Field supervisors checked whether thequestionnaires were filled properly at the endof each day and if needed sent the enumeratorsback to verify.Supervisors also made sporadic post visits wherethe interview was completed to check if theinterview was conducted properly.Field teams were under constant supervisionfrom the core team members using a checklist4 .The names and ID of the interviewers were clearlyplaced on each form so that clarification couldbe made with the particular staff in cases ofconfusion.Data Analyst reviewed the data during the datacoding and entry stage to check for consistency.Initial fieldwork started from Kathmandu,Lalitpur and Bhaktapur districts under closesupervision of the study team members ensuringbetter data quality for the rest of the survey. Areview session was held after the initial workso that the teams could share problems andlook for solution.The field teams kept urine samples in refrigeratorsof the district public health office in order to

maintain the integrity of urine specimens andthese were further maintained under refrigerationfrom the time they arrived in Kathmandu andsent to Australia for lab analysis.

1.6 Data Processing and Analysis

Data EntryImmediately after mobilizing the field teams, a softwarepackage for data entry was developed (Fox Pro Version2.6 and SPSS Version 11). The computer programmingfor data entry and analysis was based on thequestionnaires and expected outputs. A number ofquality check mechanisms were included in the datamanagement software, including range checks and skipinstructions, which helped to detect the errors duringthe data entry stage. Errors not identified during thisstage were detected by running the frequencies. Errorsnot solved through these procedures were resolvedagain by reviewing the filled-up questionnaires.

All data entry and processing was conducted withintwo weeks of the completion of fieldwork. It wasessential that all completed questionnaires, urine andsalt samples be brought to the office immediately.To ensure immediate collection of the questionnaires,urine and salt samples, two runners were hired for thefieldwork period, whose major responsibility was totransport all completed forms and pertinent specimens.Moreover, they also facilitated communicationbetween the main office and the field teams.

Data entry was done directly from the questionnaires.However, before entering data into the computer, allcompleted questionnaires were thoroughly checked.Trained New ERA personnel carried out the data entry.In addition, an experienced programmer was alsoassigned to closely monitor the data entry activities.

Data AnalysisStatistical analysis of data was carried out using SPSSfor Windows (version 10.0) in keeping with theobjectives of the study. Simple descriptive analysiswas performed of major variables such as estimationof proportions, means, medians, etc , while moreelaborate measures of association were used to analyzerelationships between variables. In general, thefollowing methods were used:

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1. Estimation of parameters (proportions andmeans) with their corresponding standard errorsand confidence intervals as specified earlier.

2. Comparison of the proportions or means andmeasures of association or relationships amongselected variables were made to help explainbehaviour of key indicators: Use of correlationor chi-square tests and various regressionmodels (linear, logistic, etc.) were applied formore in-depth analyses.

Once the results of the biochemical samples werecompleted, the data were linked to the master database on key identification fields so that all parametersfrom the survey could be analysed together.

The main part of the final report presents relevanttables, graphs, and the interpretations of the resultssuitable for general readers.

1.7 Collection of Urine andValidation of Urinary Iodineand Iodine in Salt

Urine Sample CollectionUrine was collected in sterile, clean containers withtight-fitting, leak proof lids and then transferred toclean, dry screw-capped plastic test-tubes (which hada mark at 1.8 ml). Then tubes were labelled with thestratum ID, cluster ID, household ID and child ID clearly.The screw-capped tubes were then placed in a smallbox (with a capacity for 80 tubes) for shipping to alaboratory where the urine samples were analyzed(accommodates sample for 4 clusters). Once the urinesamples were collected for 4 clusters they weregathered by a runner who transported them back toNew ERA store room in Kathmandu, where they werethen kept under refrigeration. The urine samples wereanalyzed for their iodine content and the results wereentered into the master database. The analysis wasdone in the Institute of Clinical Pathology and MedicalResearch (ICPMR),Australia.

Transporting Urine Samples to LaboratoryAs the study demanded the regular collection of urinesamples, two runners were mobilized to cover the stratain the east and west. The field teams made an effortto have a common collection centre wherever possible,such as health posts or district level health facilities

to enable quick collection. However, where this wasnot possible, the runners were require to meet the teams.

Analysis of Iodine Concentration in UrineThe method of laboratory analysis of UIE was the sameas that used for NMSS 1998 (Appendix 1.3), whichallows for direct comparison of the results. Theanalysis was conducted using an ammonium persulfatedigestion method based on the Sandell-Koltoffreaction with a unique format using microtiterplatesdeveloped by Hitachi Corporation (Japan) that hasbeen validated against conventional methods.

During the analysis any results >500 ug/l were dilutedwith distilled water to quantify the actual amount.Around 15 percent of the samples required furtherdilutions. The ICPMR method was used to confirmsome of the results >500 ug/l. It was found that allsample contained iodine and no interferingsubstances detected to interfere with the assay.

A total of 3,587 urine samples were collected. Theresponse rate for urine sample collection was as highas 99.7 percent, with the remaining 0.3 percent ofmothers refused to have their children providesamples. Of the total number of specimens collected,23 partly spilled during transport to the laboratoryand therefore could not be analysed due toinsufficient volume. Further, during the analysis ofthe UIE results the outliers were excluded using theinterquartile range criteria5 .

Iodine Content of Household SaltAs described above, the iodine levels in salt can bemeasured through two methods, namely, rapid testkits (RTK) and titration. The RTK involves testing saltwith drops of stabilized starch-based solution, whichcauses a chemical reaction associated with a colourchange. This provides a semi-quantitative estimateof iodine concentration at three levels, 0 ppm, <15ppm and >=15 ppm based on intensity of colourchange. In contrast to this, titration provides morereliable and precise estimate of the iodine contentof salt but this requires laboratory facilities toperform the measurement6 .

In this survey, salt samples from every household werecollected and analysed by RTK. In addition, salt wascollected from a random 10% of households, storedin moisture-free envelopes, and transported to

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Kathmandu where they were subjected to titrationanalysis. Quantitative analysis of salt iodine wascarried out in CEMAT Water Lab P. Ltd., an accreditedlaboratory, in Kathmandu.

The results of a comparison analysis of salt iodinelevels between the two methods are presented in Table1.5. It was evident that estimation of iodine contentin salt by both the methods was comparable. Forexample, the proportion of households usingadequately iodized salt as revealed by RTK was 66.9%while it was 67.2% by titration. However, therelationship was not so strong in classifying salt withno iodine, as RTK detected 6.4 percent of the saltwith no iodine, compared to 13.1 percent classifiedas having no iodine by titration.

Table 1.6 and Table 1.7 provide additional analysisof the correspondence between salt testing by thetwo methods. The data is dichotomised at 0 ppm i.e.,with some or no iodine in Table 1.6., while Table 1.7

dichotomises the data at 15 ppm which assesses therelationship between the methods in theclassification of adequately iodized salt, using thecut-off point that the Government of Nepal has setas the minimum required at the household level.Table 1.6 indicates that RTK was very good indistinguishing salt that contained some iodine(Specificity of 97.1%), although there were severalfalse positives, e.g. samples detected as having someiodine by RTK but when tested by titration had noiodine. Table 1.7, where the cut-off point of 15 ppmwas considered, indicates that the performance of theRTK had reasonable specificity (80.2%) and sensitivity(60.2%), but there were a high number of both falsepositives and false negatives. Interestingly, in spiteof the misclassification, the estimates of adequatelyiodized salt coverage by the two methods werevirtually identical.

Table 1.5: Comparison of results using field test kits andlab titration for salt iodine content

Rap

id t

est

at H

H le

vel

Results of titration (%)

0 ppm

<15 ppm

>= 15 ppm

Total

0 ppm14

(60.9)18

(18.7)15

(6.2)47

(13.1)

< 15 ppm5

(21.7)34

(35.4)32

(13.3)71

(19.7)

>= 15 ppm4

(17.4)44

(45.8)194

(80.5)242

(67.2)

Total23

(6.4)96

(26.7)241

(66.9)360

(100.0)

Table 1.6: Comparison of RTK and titration - 0 ppm

Results of titration (%)Rapid Test KitresultsNo iodineSome IodineTotal

No Iodine14 (60.9%)

33 (9.8%)47 (13.1%)

Some Iodine9 (39.1%)

304 (90.2%)313 (86.9%)

Total23 (6.4%)

337 (93.6%)360 (100%)

Sensitivity = 29.8 Specificity =97.1

Table 1.7: Comparison of RTK and titration - 15 ppm

Results of titration (%)Rapid Test Kitresults <15 ppm >15 ppmTotal

<15 ppm71 (59.7%)47 (19.5%)

118 (32.8%)

>15 ppm48 (40.3%)

194 (80.5%)242 (67.2%)

Total119 (33.1%)241 (66.9%)360 (100%)

Sensitivity = 60.2 Specificity =80.2

ENDNOTES1

WHO/UNICEF/ICCIDD Joint Consultation.Indicators for Assessing Iodine Deficiency Disorders and Their Control Through Salt

Iodization. WHO (WHO/NUT/94.6), Geneva, Switzerland, 1994.2

The rapid test kits included stabilized starch-based solution that caused a chemical reaction associated with change in colour when

dropped on the salt sample. Recheck solution was used where salt showed no reaction with the test solution. The level of iodine

content in salt was classified into one of three categories: 0 ppm, less than 15 ppm and those having 15 ppm and more of iodine.3

Please refer to Appendix 1.1.1- 1.1.3 for the survey instruments.4

Please refer to the Appendix 1.2 for the checklist.5

The median and the lower and upper quartiles (defined as the 25th and 75

th percentiles) were used. The difference between the

lower quartile (Q1) and the upper quartile (Q2) was taken as interquartile range (IQ). In order to identify the extreme cases the

upper outer fence was accounted for. The points beyond the outer fence were considered as extreme outlier and thus excluded. A

total of 125 cases were considered as extreme outliers and excluded.6

In order to categorize the distribution of titration results to approximate the RTK categorization, the following three levels were

used: < 3.99 ppm, 4-13.99 ppm, >14 ppm. This adjustment has been made for comparability with the NMSS, 1998.

C H A P T E R 22222

This chapter describes the socio-economiccharacteristics of the sampled households. Theprimary indicators covered in this chapter includegender, ethnicity and religion of heads ofhouseholds, as well as household size, land and animalholding, occupational structure and the housingcharacteristics.

2.1 Household Composition

Table 2.1 provides the classification of householdsenumerated in the sample by key characteristics ofthe heads of households. Among all householdssurveyed, a significant majority of the householdswere headed by men (94%). There was a notablyhigher percentage of female-headed households in theWestern Hills (12%) than in other strata.

One in five households belonged to the Chhetri castewhile Brahmins comprised 11.3% of all households.About 13 percent of the households belonged tooccupational caste group, which is designated on thebasis of the type of work done1 (Table 2.1).

On the whole, the majority of heads of householdswere Hindu (87.4%), which was followed by Buddhists(6.7%). Buddhist households were most common in

Socio-EconiomicCharacteristics

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the East and Central Mountain stratum (25.3%). Almostall Muslim households were located in the Terai belt.

The average household size in this sample was 6.5,which was higher than the national average (5.7).The average household size was largest in the Teraibelt (not shown in the Table).

2.2 Housing Characteristics

Housing characteristics were taken to reflect theeconomic status of households. Specifically, thephysical type of house was used to stratifyhouseholds based on a classification adopted fromthe Multipurpose Household Budget Survey (MPHBS)(Nepal Rastra Bank, 1988). This classification

considers houses which are temporary structureswith a thatched roof as kachhi. Houses with apermanent structure having concrete roofs orgalvanized sheets were considered pucca, whilehouses falling in-between were partly pucca. Of allhouseholds included in the sample, 46.9% werePucca houses, 32.3% were Partially pucca houseswhile the remaining 20.9% were Kachhi houses(Table 2.2). Pucca houses were most common in theEast and Central Mountain strata (75.2%) and Hills(56,3%), while only 29.4% of houses in East andCentral Terai were classified as Pucca.

Kachhi houses are an indicator of poor economicstatus, and these were most common in the Easternand Central Terai stratum (47.1%), more than twicethe number observed in any other stratum.

Table 2.2: Percentage distribution of household by housing characteristics

a Sample sizes are weighted to account for sample design

East and central All WesternHousingCharacteristicsPuccaPartially PuccaKachhiTotalValid N

Terai29.423.547.1

100.0599

Hills56.331.712.0

100.0600

Mountains75.213.811.0

100.0600

Terai36.340.023.7

100.0600

Hills37.243.319.5

100.0600


100.0600

Nationala

46.932.320.9

100.03599

Table 2.1: Percentage distribution of household by sex, caste and religion


East and central All WesternBackgroundCharacteristicSexMaleFemaleCasteBrahminChhetriNewarGurungTamangMagarTharu/RajbansiYadav/AhirMuslimRai/LimbuOccupationalOther TeraiOther HillReligionHinduBuddhistMuslimChristianKiratOthersTotalValid N

Terai

96.04.0

8.84.32.21.33.01.35.78.8

10.21.79.5

41.41.7

84.64.2

10.40.50.30.0

100.0599

Hills

94.85.2

13.328.014.3

2.014.7

2.51.30.20.2

13.88.50.21.0

80.314.2

0.20.34.80.2

100.0600

Mountain

94.75.3

9.226.8

9.33.3

25.51.30.00.00.0

11.58.00.05.0

69.325.3

0.00.54.80.0

100.0600

Terai

96.73.3

10.717.2

0.50.50.83.2

30.82.05.50.09.7

17.22.0

93.01.25.50.30.00.0

100.0600

Hills

88.211.8

13.727.0

3.04.20.0

22.81.50.00.00.0

24.50.03.3

97.81.80.00.30.00.0

100.0600

Mountain

95.34.7

8.352.3

0.06.53.32.20.00.00.00.2

22.00.05.2

88.211.8

0.00.00.00.0

100.0600

Nationala

93.96.1

11.319.6

5.22.35.76.97.13.04.04.3

13.115.3

2.2

87.46.74.00.41.50.0

100.03599

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2.3 Occupation of HouseholdHead

The occupation of the head of households was alsoexplored as an additional parameter of economic well-being of households. For this analysis, different typesof occupation were categorized based on theclassification of the Central Bureau of Statistics (CBS),which included professional/technical workers, clericalworkers, sales, service, skilled manual labour, unskilledmanual labour and agricultural work.

The findings indicated that employment in theagricultural sector was the most dominant economicactivity in the surveyed households (57.1%). Morethan two thirds of the households in the Westernregion were engaged in agriculture. As opportunitiesoutside of agricultural were available in the Easternand Central Hills and Terai, about half of the headsof households in these strata were involved with other

sectors. About 13 percent of the household headsin these strata were employed in sales (Table 2.3).

2.4 Landholding and Livestock

An additional important indicator of economic statusof households was the amount of land and animalsowned by households, which was particularlyimportant in rural areas. Information collected onthese assets is presented in Table 2.4. About one infive households in the country did not have land anda similar proportion of households did not own anylivestock. Households with no land were most commonin the Eastern and Central Terai and Hills. As thereare others sources of economic activities, people tendto be less dependent on agriculture in these regions.In contrast to this, livelihoods are very muchdependent on agriculture in the Western Hills andWestern Mountain strata. For instance, only 1.7% of

Table 2.4: Percentage distribution of households by land and animal holding

East and central All WesternBackgroundCharacteristicLand holding size*No holdingUltra-PoorPoorNon-poorMean holdingStatus of animal holdingNo animal holdingCow/OxHe/she buffaloGoat/SheepPigPoultryOthersTotal

Terai

30.744.211.413.7

0.7

24.942.431.747.7

3.315.712.2599

Hills

26.238.210.325.2

0.5

31.252.030.349.816.550.310.3600

Mountains

4.232.817.045.9

0.6

3.868.544.778.217.779.8

9.3600

Terai

10.241.522.226.1

1.1

16.062.028.848.214.235.714.3600

Hills

7.242.817.732.3

0.6

8.868.870.060.710.356.7

6.3600

Mountains

1.745.521.731.1

0.5

3.793.338.335.3

0.028.313.2600

Nationala

19.038.915.426.7

0.7

19.756.040.652.310.239.610.63599

a Sample size is weighted to account for sample design* Including all types of land

Table 2.3: Percentage distribution of household head by type of occupation

East and central All WesternOccupation ofHousehold HeadProfessionalClericalSalesServiceSkilled ManualUnskilled ManualAgriculturalHouse WorkPensionNo WorkDo not KnowOthersTotalValid N

Terai5.77.0

12.91.7

11.75.5

50.90.50.31.00.22.7

100.0599

Hills5.88.3

13.05.27.37.3

49.00.80.30.80.02.0

100.0600

Mountains6.84.74.53.88.85.8

61.80.00.20.21.22.2

100.0600

Terai3.86.25.82.77.38.3

63.21.00.50.30.00.8

100.0600

Hills4.03.73.83.26.86.3

67.21.51.50.50.01.5

100.0600

Mountains5.23.32.81.74.0

12.768.8

0.30.00.30.00.8

100.0600

Nationala

5.16.29.03.18.56.8

57.10.90.60.70.11.9

100.03599

a Sample size is weighted to account for sample design

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households in the Western Mountains had no landholding and 4.2% had no animal holding in the Eastand Central Mountains (Table 2.4).

For the purpose of this survey, households weredivided into four groups according to size of landholding that they own: no operational holding; landholding of less than 0.55 hectares in Terai and 0.33in hills to be ultra-poor households; those with 0.55to 1.15 hectares in Terai and 0.33-0.52 in Hills tobe poor and those owning more than 1.15 hectaresin Terai and 0.52 in Hills are considered non-poor.This classification is based on the classificationadopted by the Multipurpose Household BudgetSurvey of Nepal Rastra Bank.

Table 2.4 indicated that 81.0% of households ownedsome land, and using the classification outlined above,38.9% of the households were considerd ultra-poor,15.4% were identified as poor, while the remaining26.7% of households were categorized as non-poor.

The average size of operational land ownership wasfound to be 0.7 hectares, with some regional variation.

Livestock is an integral part of farming in Nepal. Evenlandless farmers raise some animals for cash incomeand other purposes such as for the preparation ofcooking fuel (dung cakes).

Of all households surveyed, 80.3% reported to haveowned some livestock. The most commonly ownedanimals were either cows or ox (56.0%), which wasfollowed by goats or sheep (52.3%), buffalo (40.6%),and poultry (39.6%). Pigs were raised mostly in theEast and Central Mountain (17.7%) and Hills (16.5%),poultry was more common in the East and CentralMountain stratum (79.8%) compared to other strataand buffalo were mostly reported in the Western Hills.

2.5 Disadvantaged Group (DAG)Classification

Finally, the survey attempted to classify the“deprivation” status of households by developing aDisadvantaged Group (DAG) composite index from keyindicators collected at the household level, including(i) size of land holding, (ii) annual food sufficiencyat the household level (from main source of income)

and (iii) type of house. The classifications of type ofhouse and land size were categorized as described above.

Once constructed, the DAG index was ‘validated’against key economic indicators, such as the typeof house, ownership of land, type of land (irrigatedor non-irrigated), ownership of livestock and foodsecurity. As an additional objective measure, theenumerators indicated their perception of the socio-economic status of households they visited. There wasa significant correlation between these three measuresof disadvantaged group status (Please refer toAppendix-2 for details).

The distribution of households based on the DAGclassification is presented in Table 2.5. For thecountry as a whole, 16.0% were considered poor,47.9% as medium and 36.1% as rich. The proportionof households in each of these three categories wasmore or less equally distributed in the differentstrata, although the proportion of rich householdswas highest in the Eastern and Central Hills (49.2%)and Western Terai (45.3%).

The analysis and categorization of households basedon the classification of DAG has been used in theanalysis of the survey data and to stratify key resultson economic status.

2.6 Background Characteristics

The following section elaborates on the backgroundcharacteristics of mothers and school age children(SAC) in the survey. The main indicators of interestinclude age, literacy status and occupation ofmothers, and age and educational status of SAC.

Of the mothers, a majority were between the ages of30 and 39 years (45.9%), 33.9% were between 20-29 years or age, and 20.2% were over 40 years ofage. Over all, 69.2% of the mothers were illiterate,with the Western Mountains having the highestproportion of illiterate mothers (84.1%), and theEastern and Central Hills reporting the lowestpercentage of maternal illiteracy (59.4%).

In terms of occupation, there was a roughly equalpercentage engaged in agricultural activities (46.5%)as in domestic work (44.8%). As expected, there was

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a relatively low proportion of mothers involved inprofessional, clerical, sales, services, skilled andunskilled manual work. A high proportion of motherswas involved with agricultural activities in the Eastand Central Mountains (89.3%) and in the WesternMountains (81.8%), while mothers in the Terai weremore often involved in household work than in theagricultural sector.

The age distribution of children was similar for theentire sample, with about 18 percent of children fallingin each age group between 6 and 10 years, with arelatively smaller proportion of children who were 11years of age (Table 2.6), although there was some

regional variation. The highest proportion of youngchildren was observed in the Western Mountain stratum(24.5%).

To analyze the educational status of school agechildren, the level of education was categorized intothree groups: No education, primary (0-5) leveleducation and lower secondary (6-7) level education.

Among all SAC surveyed, 10.6% had no education,while 88.5% had completed primary education. Theproportion of children with no education was highestin the Western Mountains (24.5%) and lowest in theEast and Central Hills (3.7%).

ENDNOTES1

The occupational caste group comprise of blacksmith, tailor, cobbler, sweeper, laundry man, etc. being the most prominent groups.

Table 2.6: Percentage distribution of school age children by age and education

East and central All WesternBackgroundCharacteristicAge in years67891011Education statusNo educationPrimaryLower secondary

Terai

17.721.218.416.616.9

9.2

14.584.6

0.8

Hills

16.215.018.719.418.012.7

3.795.3

1.0

Mountains

15.816.015.320.515.317.0

6.391.3

2.3

Terai

19.316.716.814.519.713.0

14.285.0

0.8

Hills

19.218.020.213.717.311.7

8.890.3

0.8

Mountains

24.517.718.010.715.913.2

24.574.6

0.8

Nationala

18.118.018.516.217.611.6

10.688.5

0.9a Sample sizes are weighted to account for sample design

Table 2.5: Proportion of DAG households

East and central All WesternDAG Status

DAG householdsPoorMediumRichTotalhouseholds

Terai

19.551.329.2599

Hills

13.337.549.2600

Mountains

17.548.234.3600

Terai

12.242.545.3600

Hills

17.849.732.5600

Mountains

15.758.525.8600

National

16.047.936.13599

Note: Please refer to appendix 2.1 for DAG index

Urinary Iodine Excretion

C H A P T E R 33333

Urinary Iodine Excretion (UIE) was employed as theprimary indicator of iodine intake and to estimatethe prevalence of IDD in this survey. Urine specimenswere collected from each school-aged child (6-11years) in the survey for analysis. To classify the statusof IDD in the population, criteria recommended byWHO/UNICEF/ICCIDD (2001) were adopted. In thisclassification, a population whose median UIEconcentration is <20 µg/l is categorized as havingsevere deficiency, 20-49 µg/l as moderate deficiency,50-99 µg/l as mild deficiency, 100-199 µg/l asadequate or optimal, 200-299 µg/l as more thanadequate and >300 µg/l as excessive.

The protocol and methods used in this study wereidentical to those implemented in the NMSS 1998 toensure comparability. As in the NMSS 1998, thepresent study used casual samples instead of 24-hoururine samples due to obvious logistical reasons. Theanalysis of urinary iodine was carried out by theInstitute of Clinical Pathology and Medical Research(ICPMR) Australia.

The median UIE for SAC in the country as a wholewas 188 µg/l, while the median UIE values in four ofsix strata were within the range recommended by WHOto reflect adequate or optimal iodine intake, and twowere classified as being more than adequate

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(Table 3.1). Nearly three out of four children (72.6%)had UIE values >100 µg/l, while almost one third(31.3%) had UIE values of more than 300 µg/l.Overall, 1.1 % of children had UIE values of less than20 µg/l and 9.5 % had less than 50 µg/l. Theproportion of children with UIE values in the rangeof 50-99 µg/l was 17.6%.

There was a significant difference in the urinaryiodine level found between urban and rural locations.For instance, the median UIE among urban children

was 361.0 µg/l, while the median UIE was 169.0 µg/l among rural children (Table 3.1).

The median UIE in the current survey (188 µg/l) washigher than that indicated by the NMSS 1998 (143.8µg/l), and is comparable to the UIE level (201 µg/l)observed recently among SAC in 3 districts-Parsa,Kavre and Lalitpur- of the Central region (Joshi,2004) This result indicates that there has been ageneral improvement in iodine intake over the pastseven years (Table 3.2).

Table 3.1: Urinary iodine status among school aged-children

Prevalence of low urinary iodine (µg/l )BackgroundCharacteristicStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Agea

6 years7 years8 years9 years10 years11 yearsSexa

MaleFemaleLocationa

UrbanRuralNationala

N

569568580552585585

640595614548602440

17571682

38330563439

Median

163.0217.5163.5206.0199.0165.0

197.0164.8178.0174.0215.5202.0

202.0178.8

361.0169.0188.0

<20

1.12.10.70.20.53.1

1.01.61.11.30.51.1

1.11.1

0.41.21.1

20-49

11.17.97.16.36.88.5

8.29.19.3

10.87.44.1

7.29.7

2.69.48.4

50-99

19.917.119.016.815.417.3

17.918.817.917.615.018.5

16.618.6

8.519.217.6

<100

32.327.327.123.723.429.2

27.630.028.830.023.223.8

25.229.8

11.430.327.4

>100

67.772.772.976.376.670.8

72.470.071.270.076.876.1

74.870.2

88.6*69.772.6

a Sample size weighted to account for sample design *Denotes statistically significant difference at 95% confidence level in urban and rural location

Table 3.2: UIE:A comparative assessment over 1998-2005

IDD 2005BackgroundCharacteristic

Eco-Zonea

TeraiHillsMountainAgea

6 years7 years8 years9 years10 years11 yearsSexa

MaleFemaleLocationa

UrbanRuralNationala

n

677660113

293292325215211113

733716

22012301,450

Median

108.9183.0196.6

144.9157.6143.1120.6156.0154.0

149.0139.8

259.0133.7143.8

<100

46.725.321.1

36.032.240.038.230.929.5

33.037.2

17.438.335.1

>100

53.374.778.9

64.067.860.061.869.170.5

67.062.8

82.661.764.9

n

112111531165

640595614548602440

17571682

3833056

3,439

Median

182.7204.0164.6

197.0164.8178.0174.0215.5202.0

202.0178.8

361.0169.0188.0

<100

29.525.328.0

27.630.028.830.023.223.8

25.229.8

11.430.327.4

a Sample size weighted to account for sample design*Denotes statistically significant difference at 0.05 confidence level in urban and rural location

>100

70.5*74.772.0

72.4*70.0

71.2*70.0*76.8*76.1

74.8*70.2*

88.669.7*72.6*

UIE(µg/l) UIE(µg/l)NMSS 1998

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The proportion of SAC with low UIE values below theWHO cut-off value of 100 µg/l decreased significantlyfrom 35.1% to 27.4% between 1998 and 2005 (p<0.05). However, this improvement has not beenuniform across the country. For example, there was asignificant improvement observed in the Terai regionfrom 108.9 µg/l in 1998 to 182.7 µg/l in 2005, withthe very high UIE levels of the Western Terai (206.0µg/l) contributing to this.

There has been a slight increase in median UIE in theHills over the last eight year period from 183.0 µg/lto 204.0 µg/l, while there was a slight decline inmedian UIE observed in the Mountain ecological zonefrom 196.6 µg/l to 164.6 µg/l. This is notable sincethe Mountains had long been considered to be themost endemic area for IDD, and intense efforts towards

salt iodization and iodized oil supplementation wereimplemented there. The positive impact of these effortswas observed in the NMSS 1998, while the presentsurvey indicates that the situation seems to haveslightly deteriorated over the years.

The median UIE was found to be higher among boys(202.0 µg/l) than girls (178.8 µg/l), an observationwhich was consistent with the pattern seen in 1998.The median values for the urban areas also showed amarked increase from 259.0 µg/l to 361.0 µg/l,although this level is reflective of a potential exposureto excessive iodine and will require attention. Therewas improvement in the UIE values in rural areas,which were more modest, increasing from 133.7 µg/lto 169.0 µg/l.The trends in UIE can be seen visuallyin Figure 3.1.

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Figure 3.1.: Trends in UIE between 1998 and 2005 – stratified by ecological zone, gender and urban-rural location

Status of Salt Iodization

C H A P T E R 44444

Virtually all salt in Nepal is imported from India. TheSalt Trading Corporation (STC) is the sole agencyauthorized by the Government of Nepal for importingand distributing iodized salt throughout the country.The only exception is a small quantity of Tibetan salt,which enters some Western Mountain districts bytraditional trading routes, accounting for about1,250 metric tons in Humla and Mustang annually(Joshi, 2000). In addition, a small amount of salt(6 metric tons per annum) is produced in MustangDistrict.

There are three main types of salt commonly used forhuman consumption in Nepal. These include crystalvarieties of salt (Dhike noon) which include IndianPhoda (extracted from subsoil brine underground),Tibetan salt, and mid size granular salt mainly fromthe sea (Kurkutch). In general, phoda has highmoisture content and is purchased in large quantities.The second major type of salt is crushed, while thethird type is powdered or refined. Crushed salt isunrefined and is sold either in packets or in bulksacks. Crushed, unrefined salt sold in packets includebrand names such as Shakti, Tej and Bhanu, whichare generally available in one kilogram (kg) packet(Fig 4.1). Refined salt is typically only sold in smallpackets under brand names such as Aayo.

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For the purpose of the present survey, salt types havebeen classified into two broad categories; 1) thosethat have a “two-child logo” specified by theGovernment to indicate adequately iodized salt and2) those types of salt that do not contain the logoand have not necessarily been adequately iodized. TheMinistry of Health and Population launched thepromotion of salt with the ‘two-child logo’ in 1999,as a strategy for social marketing to promote thedemand for certain varieties of salt that are more likelyto be adequately iodized (Fig 4.2). The logo is usedon packet refined salt with brands like Aayo, as wellas packed crushed salt with brands like Shakti, Bhanuand Tej. The remaining types of salt, includingunpacked crushed salt, granular salt and large crystalsalt do not have the logo.

The other objective of social marketing was raisingawareness and knowledge on the importance ofiodized salt. This has been facilitated through thedevelopment and introduction of IEC materials usingradio and television.

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� ��

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#��

$��% ��&�� '��

�(�� )��&��

%$�� &��

Fig 4.1: Technical Classification of Salt Types Used in Nepal

4.1 Types of Salt Used atHousehold Level

The survey indicated that 33.0% of the householdsconsumed refined salt with ‘Aayo’ brand, which was asignificant improvement over the situation observedin 1998 when only 9% of households used this brandof salt (NMSS, 1998). Overall, 37.7% of householdsused packet salt with two-child logo (Table 4.1).Households in the Eastern and Central Hill stratumused packet salt with two-child logo more often(47.6%) than other strata. Although ‘Aayo’ salt wasthe most popular brand of packet salt with two-childlogo in the country as a whole, Bhanu salt was themost popular brand in the Western Mountain stratum,with 36.7% of the households reporting its use.

Salt brands with the two-child logo were morecommon among households in urban areas (76.1%)than in rural locations (30.5%). Still this was animprovement from the 4% of rural households, whichused refined salt in 1998 (NMSS, 1998).

The proportion of households using crystal salt(Phoda) has decreased over the past eight years inall areas of the country (Fig.4.3). In 1998, it wasestimated that 63 percent of households used phodasalt, and this has decreased to 41.5% in 2005. Whilethere has been a general decline in the demand forphoda salt, the geographic distribution of its use wasfound to be almost universal. That is to say that theuse of phoda salt has remained the most popular typeof salt in a majority of households in all strataexcept for the East and Central Terai and East andCentral Hills.

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There was a significant difference in the demand forPhoda salt between urban households (13.7%) andhouseholds in rural locations (46.8%). The onestratum with a relatively high use of granular salt wasthe East and Central Terai (11.9%). In addition, about31% of households in this stratum used packet saltwith other Indian brand names (Jain salt, Taja salt,Bharatiya Salt, Sajan salt, Jay Bharat, Tata etc.) - adirect consequence of informal trade along the longborder with India.

There was a direct association between economic statusand choice of salt. For example, households with literateheads were more likely to use packet salt with thetwo-child logo (45.9%) than households whose headwas not literate (23.7%). Similarly, households withbetter socio-economic status were more likely toconsume salt with the two-child logo (52.3%) ascompared to households classified as poor (28.1%).

Households with small family size were more likely touse packet salt with two-child logo compared tohouseholds with large family size. For instance, 61.7%of households with less than 5 members used packetsalt with two-child logo, while only 21.8% ofhouseholds with 10 or more members used this typeof salt, and were more likely to use crystal salt(Phoda) (Table 4.2).

Table 4.1: Types of salt mostly used in households for human consumption by geographical location

No Two-child logoGeographicallocation

StratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Locationa

UrbanRuralNationala

Aayo

27.946.922.729.034.5

1.8

73.425.433.0

Shakti

5.50.71.03.70.80.0

0.93.02.6

Bhanu

0.00.06.70.01.8

36.7

0.82.11.9

Tej

0.50.00.00.00.00.2

1.00.00.2

LooseCrushed(powder)

11.013.712.2

0.00.03.3

5.47.67.2

LooseCrystal salt

(Tibetan)

0.00.00.00.00.09.3

0.00.30.3

a Sample size weighted to account for sample design

LooseCrystal salt

(phoda)

12.038.157.367.262.848.6

13.746.841.5

Packet Salt with Two-child LogoOther

packetsalt

31.10.70.00.20.00.0

4.810.6

9.7

Total

100100100100100100

100100100

ValidN

598599600600600599

42031763596

LooseGranu-lar

11.90.00.00.00.00.0

0.04.33.6

Table 4.2: Types of salt consumed by household characteristics

No Two-child logoBackgroundcharacteristics

Literacy of HHhead a

LiterateIlliterateSES Levela

PoorMediumRichSize of HHsa

<5 members5-10 members10+ membersNationala

Aayo

41.917.8

21.424.049.3

57.028.716.333.0

Shakti

2.33.3

4.52.81.6

2.92.53.02.6

Bhanu

1.62.3

1.62.31.4

1.52.01.81.9

Tej

0.10.3

0.60.00.1

0.30.10.70.2


6.38.7

8.29.44.0

6.97.46.37.2

LooseCrystal

(Tibetan)

0.10.6

0.10.50.1

0.20.30.30.3


LooseCrystal

(phoda)

37.548.5

46.944.435.6

26.644.252.041.5


packet

8.112.3

12.511.2

6.5

4.410.416.0

9.7

Total

100100

100100100

100100100100

ValidN

22371359

57517231298

6332735

2283596

LooseGranu-lar

2.16.2

4.15.31.4

0.34.43.63.6

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Fig 4.3: Households Consuming Crystal (phoda) Salt

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The proportion of households using crystal salt(Phoda) has decreased over the past eight years inall areas of the country (Fig.4.3). In 1998, crushedsalt and crystal salt have been used for much longerperiods, and the practice of using these ‘traditional’salt types is a challenge to alter.

One interesting observation was the fact that withinthe year prior to the survey, 20.1% of householdsreported that they had started using non-brandedpacket salt without the two-child logo, includingdifferent Indian brands.

The survey noted that more than four out of fivehouseholds reported that the salt purchased forhousehold consumption was also used to feedlivestock. Among those households reporting thatthey owned livestock, 17.2% bought separate typesof salt for their livestock (Table 4.4).

Households in the Western Mountain stratum had ahigh proportion of households with some livestock,but only 3.5% provided a separate salt type for theirlivestock. As they mostly used crystal salt, it was alsogiven to their livestock.

About 25% of households in the Western Hills boughtseparate salt for their livestock. The practice of givingcrystal salt to livestock was common throughout thecountry. About 49.0% of households gave crystal(phoda) salt to their livestock (Table 4.5), whereas5.6% gave Aayo salt to their livestock. These includedboth the households that bought and did not buyseparate salt for the livestock. Overall, 8.2% of thehouseholds in the country gave packet salt with two-child logo to their livestock.

Respondents were asked for the reasons behindpreferences for different types of salt for householdconsumption. This question was considered based onthe strata and the type of salt. The importance of

Table 4.3: Duration of use of different types of salt in the households

Duration of use (in years)Type of salt

Packet salt two-child logoAayo saltShaktiBhanuTejSalt no two-child logoCrushed salt (powder)GranularCrystal salt (Tibetan)Crystal salt (phoda)Other packet saltTotal

<=1

10.923.9

3.0*

2.30.00.00.4

20.16.7

2-5

40.756.143.3

*

4.711.3

0.00.0

41.020.7

6-10

41.417.546.8

0.0

5.112.7

0.00.3

26.918.4

11+

7.02.56.90.0

87.976.1

100.099.311.954.2

Total

100100100100

100100100100100100

N

97488

2714

2397156

1712172

3587a Sample size weighted to account for sample design Excluded 9 missing cases* Percentage not shown due to few cases

Table 4.5: Types of salt used for livestock by geographical location


StratumEast & Cen TeraiEast & Cen. HillsEast & Cen. Mts.All west TeraiAll west HillsAll west Mts.Nationala

Aayo

7.24.54.37.53.91.55.6

Shakti

3.20.00.80.90.20.01.2

Tej

0.30.00.00.00.00.20.1

Bhanu

0.00.03.90.00.5

30.71.3


15.215.912.8

0.00.03.39.0

LooseCrystal

(Tibetan)

0.00.00.00.00.0

10.00.3


LooseCrystal

(phoda)

11.244.471.273.383.249.649.0


packet

22.60.00.20.00.00.06.9

Salt notgiven to

livestock

3.00.31.70.70.50.01.3

N olive-

stock

26.634.6

5.017.311.7

4.721.9

LooseGranular

10.70.00.00.20.00.03.3

Missing

0.00.30.00.00.00.00.1

Total

100.0100.0100.0100.0100.0100.0100.0

ValidN

598599600600600599

3595

Table 4.4: Separate salt for livestock in households


Stratum

East & Central TeraiEast & Central HillsEast & Central Mts.All West TeraiAll West HillsAll West Mts.Totala

Bought separatesalt13.515.616.616.025.3

3.517.2

No separatesalt86.584.683.484.074.796.582.8

n

439392570496530571

2808

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salt containing iodine was reported by only 23.8%of households as being the reason for choosing aparticular type of salt. More than half of thehouseholds mentioned that the main reason for usinga particular type of salt was that it was their usualpractice (Table 4.6). In case of the Western Mountainstratum, some 71.3% stated that their decision wasdriven by availability, which was primarily Phoda andBhanu salt. In the case of the Terai strata, a mainfactor influencing salt choice was cost, with 60.0%of households in the Western Terai and 45.3% in theEastern and Central Terai reporting this. The maintypes of salt consumed in these strata were phoda(Western Terai) and Indian brands like Jain, Taja,Bharatiya, Sajan, Jay Bharat, Tata and Rani (Easternand Central Terai).

Table 4.6: Reasons for using particular type of salt for human consumption

East and central All WesternReasons for using the salt

AvailableCheaperHousehold practiceHas iodineGood for healthImproves learning abilityRecommended by the govt.Has two child logoEasy to useBecause of tasteLess amount isenoughIodized salt not availableOtherDon't knowNumber of cases

Terai41.545.344.020.228.6

2.50.70.22.70.30.20.00.70.2598

Hills30.435.955.327.731.1

2.30.50.53.82.00.00.01.20.8599

Mountains22.334.058.315.021.2

1.80.20.55.81.22.50.01.20.0600

Terai20.060.043.823.526.2

3.50.01.20.70.71.80.00.21.3600

Hills32.844.762.727.229.0

1.30.30.04.70.71.30.01.00.8600

Mountains71.319.059.819.213.9

0.09.50.20.00.00.01.70.80.2599

Totala

33.643.952.123.828.1

2.20.70.43.20.90.80.10.80.7

3596a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

When the same analysis was done based on the particulartype of salt used, respondents who used salt with thetwo-child logo cited that their decision was mainlybased on the fact that the salt was good for health andthat it was iodized. For instance, 64.6% of therespondents mentioned that Aayo salt was preferredas it had iodine, while 73.5% reported that they choseAayo because it was good for health (Table 4.7).

Loose, crushed (powdered) salt and phoda salt weremostly used in households which made their decisionbased on prices, as this was mentioned by 78.5% and70.7% of households respectively. Beyond theeconomic rationale, these varieties of loose salt werealso preferred owing to the fact that this had beenthe practice of households for many generations.

Table 4.7: Reasons for using particular salt by the types of salts

No Two-child logo

Reasons for using theparticular type of saltAvailableCheaperHousehold practiceHas iodineGood for healthImproves learning abilityRecommended by the govt.Has two child logoEasy to useBecause of tasteLess amount isenoughIodized salt not availableOtherDon't knowNumber of households

Aayo

17.21.9

21.364.673.5

6.61.00.96.10.30.10.01.41.1

976

Shakti

22.119.919.937.964.2

3.20.02.16.30.00.00.00.00.070

Loose Crushed(powder)

36.578.566.2

0.40.40.00.00.00.40.40.00.00.00.0241

Bhanu

52.238.817.941.831.3

0.019.4

0.02.90.00.00.02.94.5271

LooseCrystal(Tibetan)

90.00.0

90.00.00.00.00.00.00.00.00.0

10.00.00.056

Note: excluded 4 missing cases.

LooseCrystal(phoda)

35.070.775.9

0.50.90.00.00.02.01.81.70.00.30.5

1,715

Packet Salt with Two-child Logo

Otherpacket

70.048.454.8

4.612.1

0.00.00.00.60.00.00.00.00.0192

LooseGranu-lar

57.759.960.8

0.00.00.00.00.00.00.01.50.03.10.071

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Among those households using Bhanu salt, 19.4%reported that it was due to recommendations by thegovernment, a finding that was influenced by the factthat this type of salt has been promoted at asubsidized rate in some areas, such as the WesternMountain stratum.

4.2 Types of Salt Sold at RetailOutlets

The type of salt consumed at the household level ispartly a function of the types of salt available in localmarkets. For the survey, a small sample of retailoutlets was enumerated in order to assess the typesof salt sold. Table 4.8 indicates that there was a widevariation in the types of salt sold in different regionsof the country. For instance, Aayo salt was availablein most areas of the country, except for the WestMountains, where only 5.9% of retailers reported thatthey offered it. More than seventy percent of retailshops in the West Hills, West Mountains and East andCentral Mountains sold crystal salt (Phoda).

Packet salt that did not have the two child logo wassold almost exclusively in the Eastern and Central Teraistratum, with the exception of a small number of shopsin the Western Terai which sold other packet salt.

Among the different types of salt sold in the market,retailers were asked to specify the salt that was mostpreferred by customers. For the country as a whole,50.6% of retailers mentioned that packet salt with thetwo-child logo was most preferred in the community.

In the Eastern and Central Hills, 62.9% of the retailersmentioned that packet salt with the two-child logowas the most popular type of salt in the locality withalmost all stating that Aayo was the most preferred.A question arising from this is how to translate the‘preference’ reported by retailers to actualprocurement, as the household-level data indicatedthat only 37.7% of the households actually purchasepacket salt with the two-child logo.

In the West Mountains stratum, 70.6% of the retailers(12 out of 17) mentioned that phoda was the mostpopular type of salt in the area (Table 4.9). It wasthe most popular among retailers in the Mountainstrata and the Western Terai, while it was least popularin the Eastern and Central Terai and Hill strata.

As was consistent with other parameters of saltavailability, 26.9% of the retailers in the Eastern andCentral Terai stratum mentioned that the most populartype of salt was non-logo packet salt, which wereprimarily Indian brands.

Table 4.9: Most popular type of salt sold in the area


StratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Total

Aayo

28.661.937.545.755.2

5.943.8

Shakti

10.91.06.27.20.05.95.8

Bhanu

0.00.02.10.00.05.90.4

Tej

2.50.00.00.00.00.00.6


12.610.3

4.20.00.0

11.85.9

LooseCrystal

(phoda)

11.826.849.947.144.870.635.2


Total

100100100100100100100

ValidN

1199748

1386717

486

LooseGranu-lar

6.70.00.00.00.00.01.6

Tata

3.40.00.00.00.00.00.8

Other packetTaja

5.90.00.00.00.00.01.4

Other

17.60.00.00.00.00.04.4

Table 4.8: Types of salt sold in the shop by geographical location



Aayo

54.693.883.372.574.6

5.971.4

Shakti

26.94.1

18.821.7

7.511.816.9

Bhanu

0.00.04.20.01.55.90.8

Tej

3.41.00.00.00.00.01.0


19.311.3

6.30.00.0

11.88.0

LooseCrystal

(Tibetan)

0.01.00.00.00.00.00.2

Note: Multiple responses possible.

LooseCrystal

(phoda)

16.028.970.865.976.170.648.4

Packet Salt with Two-child LogoTotal

100.0100.0100.0100.0100.0100.0100.0

ValidN

1199748

1386717

486

LooseGranu-lar

8.40.00.00.00.00.02.1

Tata

5.90.00.00.70.00.01.6

Other packetTaja

13.40.00.00.70.00.03.5

Other

24.41.00.00.70.00.06.4

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Table 4.10: Reasons for popularity of salt in the area by type of salt

No Two-child logoReasons for popularity

Practice in the communityFor tasteEasy to storeFor good healthAvailableCheapAwareness promotionHas iodineNeed for livestockOtherNumber of cases

Aayo

46.714.413.248.413.835.436.0

4.011.214.4347

Shakti

40.29.83.7

29.33.7

62.219.5

6.112.213.4

82

Bhanu

**********4

Tej

**********5


64.17.70.0

15.417.979.515.4

2.615.412.8

39

LooseCrystal

(Tibetan)**********1


ValidN

2516949

18176

231132

174862

486

LooseGranu-lar

**********

10

LooseCrystal

(phoda)61.714.0

7.223.4

9.862.117.9

2.517.413.2235

Otherpacket

salt42.910.7

1.814.316.173.2

8.95.41.88.956

* Percentages not shown due to few cases.

The retailers were asked for the reasons for thepopularity of the particular types of salt in theirlocality. Different reasons were cited for the saltpreference of consumers, and reflected the opinionof retailers. Table 4.10 indicates that 48.4% of theretailers thought that Aayo salt was preferred byconsumers because they thought it was good forhealth. In addition, 46.7% of retailers reported thatAayo salt was preferred since it was the practice inthe community, and only 4.0% mentioned that Aayowas preferred because of the fact that it containediodine.

Of those retailers selling Shakti salt, 62.2% stated thatthis salt was preferred due to its low cost, as it wasrelatively cheaper than other types of salt. Only onein five retailers thought that it was due to promotionalactivities by the government that there was a demandfor Shakti in the locality. In this context, 36% of retailersselling Aayo salt reported that the demand was the resultof awareness promotion by the government.

Crushed powder salt and crystal salt (phoda) werepreferred for its low cost. About 80 percent of theretailers mentioned that it was the low cost that ledto high consumer demand of unpacked crushedpowder salt, while 62.1% of retailers mentioned thatphoda was preferred for its cost. Among those retailersoffering other packet salt, 73.2% claimed that thissalt was preferred among consumers for its low cost,thereby highlighting a major obstacle in the program.To sum up, if varieties of salt with inadequate iodineare less expensive, they will continue to be preferred,because decision-making is driven by economicconstraints.

4.3 Iodine Content of Salt atHousehold and Retail Levels

The target of the Universal Salt Iodization (USI)Programme of Nepal requires that the salt should beiodized at a level of at least 50 ppm of iodine (85ppm of Potassium Iodate) at the factory level (at thetime of iodization in India). This applies to all typesof salt imported by Nepal. It is expected that all saltin retail shops should contain at least 30 ppm ofiodine, and by the time salt reaches households forconsumption, it should have at least 15 ppm ofiodine. These levels are based on the fact that thedietary requirement for iodine is 150 µg/day, whichwould be satisfied through the consumption of 10grams of salt per day with an iodine concentrationof 15 ppm. A recent Fortification Feasibility Study2001 (New ERA & MI, 2001) indicated that theaverageintake of salt by women was 8.76gramsperday.

In addition to urinary iodine, the World HealthOrganization has recommended that a processindicator be used to track efforts towards the controlof iodine deficiency. The goal of at least 90%household coverage of adequately iodized salt (inNepal, > 15 ppm) has been established as a criteriato indicate the achievement of Universal SaltIodisation (USI), a step towards the elimination ofIDD as a public health problem.

For the survey, the iodine content in salt was measuredin all households using a rapid test kit (RTK), a semi-quantitative tool that provides an estimate of theiodine content in salt in one of three levels: 0 ppm,

2828282828

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<15 ppm and >=15 ppm. Salt samples which wereinitially found to contain no iodine were subjectedto repeat testing using a recheck solution. About 16percent of all salt samples initially were found tocontain no iodine. Of these, 65 percent weresubsequently found to have some iodine when usingthe re-check solution. Consquently, about 95% of allsalt samples tested were found to contain some iodineby RTK, either on the initial test or upon re-checking,which represented an improvement over the results ofthe NMSS, 1998 when 83% of the salt samples werefound to contain some iodine. In addition to the RTKtesting, salt samples from 10 percent of all householdswere collected in the field and brought back to alaboratory at Kathmandu for quantitative analysis bytitration methods. The results of the two testingprocedures indicated a positive correlation as reportedin Chapter 1.

In addition to the overall finding that 95 percent ofthe households were using salt that contained someiodine, the survey noted that 57.7% of householdshad salt that was adequately iodized, e.g. > 15 ppm(Table 4.11). The proportion of households usingadequately iodized salt remained similar to the levelsobserved in 1998 despite that fact that the proportionof households consuming packet salt has increasedsignificantly from about 10% in 1998 to 38% in 2005.The main factors responsible for this situation arediscussed later.

The survey indicated a similar pattern in the distributionof iodized salt coverage to that noted in 1998 withthe East and Central Mountain stratum having thehighest proportion of households consuming adequatelyiodised salt (71.2%), followed by the West Mountains(65.3%) and the East and Central Hills (63.4%).

There was some variation in the coverage ofadequately iodized salt between urban areas (82.9%)and rural areas (53.0%), which were virtually the samelevels as noted in 1998 (Table 4.12).

While there has only been a negligible improvement inthe coverage of adequately iodized salt for the entirecountry, there were some strata that stood out. Forexample, there has been a significant increase in theproportion of households consuming adequatelyiodized salt in the Western Terai from 34.7% in 1998to 53.8%. This reflects the impact realized from nationalcontrol program efforts. At the same time, the situationin the Eastern and Central Terai was not so bright, asthere was a decline in the coverage of households withadequately iodized salt from 57.7% to 51.7% over thepast seven years. This is likely a result of the infiltrationof inadequately iodized (or non-iodized) salt from theborder areas, which has penetrated the local markets.

Among all types of salt, packet salt with the two-childlogo was much more likely to be adequately iodized.In fact, virtually all brands of salt with the two child-

Table 4.11: Households salt iodine content

GeographicalLocationStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Locationa

UrbanRuralNationala

0ppm

9.52.31.75.51.5

13.4

1.55.85.1

< 15ppm

38.634.127.240.539.521.0

15.341.137.0

>= 15ppm

51.763.471.253.859.065.3

82.953.057.7

Total

100100100100100100

100100100

Valid N

597598600599600597

41931723591

a Sample size weighted to account for sample designExcluded 5 missing

Table 4.12: Adequately iodized salt (>= 15 ppm) in thehouseholds

GeographicalLocationStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Locationa

UrbanRuralNationala

NMSS1998

57.760.866.934.751.952.7

81.851.955.2

N

237623922386356035761193

16881379215480

IDD2005

51.763.471.253.859.065.3

82.953.057.7

N

597598600599600597

41931713590

a Sample size weighted to account for sample design Excluded 5 missing

Table 4.13: Type of salt with iodine content

Type of salt

Packet salt (Two-child logo)Aayo saltShaktiBhanuTejSalt (No two-child logo)Crushed salt (powder)Granular saltCrystal salt (Tibetan)Crystal salt (phoda)Other packet saltNational

0ppm

0.00.00.00.0

8.318.31005.0

15.35.1

< 15ppm

1.012.9

1.8*

45.774.6

0.062.344.737.0

>= 15ppm

98.987.197.9

*

45.57.00.0

32.639.857.7

Total

100100100100

100100100100100100

a Sample size weighted to account for sample design Excluded 4 missing* Percentage not shown due to few cases.

N

97670

2714

2417156

1715192

3596

2929292929

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logo tested was found to be adequately iodized (Table4.13). Both Aayo and Bhanu salt were found to bealmost universally iodized with adequate iodine (98.9%and 97.9%, respectively). There was also a very highproportion of Shakti salt adequately iodized (87.1%).However, the situation among varieties of salt withoutthe two-child logo was not as positive.

Crushed salt did have the highest iodine levels amongthose types of salt that did not contain the two-child logo as 45.5% was adequately iodized, while45.7% had some iodine but less than 15 ppm. Forphoda salt, the most widely consumed salt in Nepal,32.6% was found to be adequately iodized, and62.3% had iodine levels that were too low. Perhapsencouraging was the observation that only 5% ofphoda was found to contain no iodine. This pointsto the importance of having robust monitoringsystems in place to monitor the adequacy of iodinelevels in salt through all stages of distribution. Notone sample of Tibetan crystal had any iodine amongall samples tested.

The other packet salts with no two-child logo, wasmostly inadequately iodized with 15.3% of these salttype having no iodine at all1 , while 39.9% were foundto be adequately iodized.

Table 4.15: Salt iodine content at the retail outlets

GeographicalLocationStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Total

0ppm

0.60.00.00.50.00.00.3

< 15ppm

31.220

23.221.523.344.424.6

>= 15ppm

68.279.976.878.076.755.675.1

Total

100100100100100100100

N

176130

82214103

18723

Table 4.14 presents data on the iodine content ofdifferent types of salt by strata. Packet salt with two-child logo was found to be adequately iodized in allareas of the country.

Granular salt was found almost exclusively in the Eastand Central Terai, and because of the low levels ofiodine, impacted the overall coverage of adequatelyiodized salt in the stratum.

As expected, granular salt and phoda had the lowestlevels of iodine, and its use should be discouraged asfar as possible. While these types of salt are subjectedto iodization, the low iodine content is due to thepoor retention of iodine by the time it reaches theconsumers. The current survey showed that the iodinecontent of these types of salt in 2005 had actuallydecreased since 1998. While 47 percent of phoda saltwas found to be adequately iodized in 1998, only 33percent of this salt was found to have adequate iodinecontent in 2005. One possible cause of this situationcould be that the infiltration of inadequately iodisedPhoda salt might have taken place in greater frequencyin 2005 than in 1998. Simillarly, the proportion ofgranular salt with adequate iodine was 56 percent in1998 but had fallen dramatically to only 7 percent in2005. The main factor behind this decline could bethe fact that granular salt found during this surveymight have been infiltrated or from an old stock asSTC had stopped importing this type of salt since manyyears.2

An assessment of the iodine content in salt was alsocarried out at retail shops in the sample clusters.Among 723 salt samples tested, 75.1% had iodinelevels of at least 15 ppm (Table 4.15), 24.6%contained less than 15 ppm of iodine and 0.3% ofthe salt had no iodine. Salt with no iodine was foundin the retail outlets of East and Central Terai (0.6%)and the Western Terai (0.5%). Several strata had more

Table 4.14: Iodine content of different types of saltby stratums

Stratum

East & CentralTerai

East & CentralHills

East & CentralMts.

All West Terai

All West Hills

All West Mts.

Nationala

Type of salt

Salt Two child logoLoose crushedGranular saltCrystal saltOther packetSalt Two child logoLoose crushedCrystal saltSalt Two child logoLoose crushedCrystal saltSalt Two child logoCrystal saltSalt Two child logoCrystal saltSalt Two child logoLoose crushedCrystal saltSalt Two child logoLoose crushedGranular saltCrystal saltOther packet

0ppm

0.07.6

18.314.115.6

0.07.43.50.01.42.30.08.20.02.40.0

100.017.3

0.08.5

18.55.7

15.3

<15ppm

4.459.174.663.445.7

0.738.374.9

1.617.842.7

0.560.0

2.261.5

2.20.0

34.92.1

45.974.661.944.8

>=15ppm95.633.3

7.022.538.799.354.321.598.480.854.999.531.897.836.197.8

0.047.897.945.6

6.932.439.9

N

203667171

186285

81228182

73344195403223377230

203471321241

711771192


3030303030

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than 75% of all salt samples from retail markets withiodine levels of 15 ppm or more, while the WestMountains and East and Central Terai strata hadsomewhat higher percentages of samples with lowiodine at the retail outlets. The findings hint at thefact that there could be a loss of iodine duringstorage in the shops, as well as at the householdlevel.

As was the case with salt tested at the householdlevel, virtually all of the packet salt with two-childlogo analyzed at from retail outlets had iodine contentof at least 15 ppm (Table 4.16).

Other types of salt did not fare so well; for e.g. only51.6% of crystal salt found to contain iodine levelsof 15 ppm or more.

4.4 Knowledge of Iodized Salt

4.4.1 Knowledge at Household Level

The objectives of the social marketing and promotioncomponent of the IDD control programme has been toencourage the use of adequately iodized salt, and to

increase awareness about the two-child logo in thecountry. Both the print media and electronic mediahave been employed to this end. Overall, 68.1% ofthe respondents mentioned that they had heard aboutiodized salt. The level of awareness was highest amongrespondents in the East and Central Hills (82.3%),and was lowest in the East and Central Terai (57.4%)and the Western Mountains (57.8%) (Table 4.17).

Women in urban locations were more likely to have heardabout iodized salt (84.2%) as compared to women inrural areas (65.1%). Similarly, literate women were morelikely to be aware about iodized salt, as compared towomen in DAG households.

Among those women who indicated that they knewabout iodized salt, most mentioned that they hadheard about it from the radio (83.4%) which seemedto be an important source of information in all areasof the country, including urban areas (Table 4.18).In fact, 77.7% of urban women mentioned radio asa source of information on iodized salt, where as thisproportion was 84.8% in rural households. Televisionwas also an important source of information with39.7% of all respondents reporting that they had beenexposed to messages on iodized salt through thismedia, although a significantly higher percentage ofwomen in urban areas had access (73.9%) to TVmessages than those in rural areas (31.4%).

Friends and relatives were also reported to be animportant source of information with 26.5% of allrespondents mentioning that they heard aboutiodized salt from their friends and relatives. The roleof Female Community Health Volunteers (FCHVs) indisseminating knowledge on iodized salt was relativelylow, with only 6.9% of respondents receivinginformation from them. The role of FCHVs was moreprominent in rural areas than in urban locations. TheFCHVs have been more efficient in impartingknowledge on iodized salt in the Western Terai regionswith 27.7% than in other parts of the country.

Newspapers and magazines were also cited asimportant sources of information in urban locations(12.2%), while teachers, posters and banners playeda limited role in certain strata for disseminatingknowledge on iodized salt.

Those respondents who had heard about iodized saltwere asked to provide their opinion on the importance

Table 4.17: Awareness about iodized salt among women

Geographical location

StratumEast and Central TeraiEast and Central HillsEast and Central Mts.All west TeraiAll west HillsAll west Mts.Locationa

UrbanRuralLiteracyLiterateIlliterateDAG GroupDAG womenNon-DAG womenNationala

Heard

57.482.369.767.569.557.8

84.265.1

93.856.7

57.370.268.1

Total

598599600600600599

4203176

11062489

57530213596

Women


Table 4.16: Iodine content in salt collected at retail outletsby type of salt

Type of salt

Salt Two child logoLoose crushedGranular saltCrystal saltOther packet saltTotal

0ppm

0.00.00.00.42.00.3

<15ppm

3.964.166.747.950.024.6

>=15ppm96.035.933.351.647.975.1

N

40439

9223

48723

3131313131

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of iodized salt. More than three in four respondentsmentioned that it was good for health (76.5%). Thiswas a general response across the different strata (Table4.19). Some 36.5% of the respondents mentioned thatiodized salt helped prevent goitre, and 40.0% of thewomen mentioned that iodized salt helps preventphysical disability. Of note was the low associationrespondents made between use of iodized salt andimproving learning ability (16.5%) and the preventionof mental impairment (16.6%) in spite of promotionalefforts promoting these benefits.

4.4.2 Knowledge at Retail Outlets

The survey also explored the knowledge of iodized saltamong retail shopkeepers (Table 4.20). Of the 486retailers surveyed, 95.1% were aware about iodizedsalt, although there was some regional variation withretailers in the Eastern and Central Terai strata beingsomewhat less aware about iodized salt (89.1%).

Most retailers mentioned that they had heard aboutiodized salt from radio (89.0%) while television wasalso indicated as a source of information among59.1% (Table 4.21). Radio was effective in all areasexcept for the Eastern and Central Terai, wheretelevision was more important.

As was the case with household respondents, retailersin the Western Terai mentioned that they had heardabout iodized salt from posters (26.9%) and FCHVs (16.9%).

Most retailers were aware that iodized salt was goodfor health (80.1%), while 53.9% mentioned thatiodized salt was important for the prevention ofgoitre and physical disability (Table 4.22). About onein five retailers mentioned that iodized salt wasrequired for sharp brain (19.9%) and 27.7% reportedthat potential benefit was the prevention of mentalimpairment.

Retailers in all the regions were basically aware thatiodized salt was important for health.

Table 4.20: Awareness about iodized salt among retailers

Geographical location


Yes

89.197.9100

94.298.5100

95.1

Total

1199748

1386717

486

Retailers

Table 4.19: Awareness on importance of iodized salt among women

East and central All WesternImportance of Iodized salt

For good healthTo prevent goiterFor improving learning abilityPrevent mental impairmentPrevent physical disabilityGood for pregnant womenOtherDon't knowMissingNumber of cases

Terai78.123.322.414.031.2

2.90.97.00.0343

Hills79.535.314.218.739.6

0.61.02.60.6493

Mountains77.519.417.517.234.9

4.80.23.60.0418

Terai79.544.417.022.039.5

0.20.24.20.0405

Hills69.349.913.713.250.4

1.20.26.70.5417

Mountains72.041.6

5.219.749.4

0.60.62.60.9346

Totala

76.536.516.516.640.0

1.50.65.00.3

2422Note: a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

East and central All WesternSource of Knowledge

RadioTelevisionPoster/bannerFriends/relativesFCHVHealth workerSchool teachersSalt packetMagazine/newspaperOtherNumber of cases

Terai70.865.9

2.630.0

3.83.82.90.03.51.5343

Hills82.942.7

2.821.3

3.35.13.33.30.46.7492

Mountains89.710.8

0.222.2

1.75.30.50.21.21.2418

Terai84.738.5

5.428.427.7

5.77.20.03.02.2405

Hills95.218.2

1.027.6

2.66.22.40.71.90.5417

Mountains87.9

2.90.0

33.83.59.03.50.60.60.6346

Urban77.773.9

4.729.9

2.23.34.90.9

12.21.6348

Note: a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

Nationala

83.439.7

2.526.5

6.95.23.40.33.81.2

2421

Rural84.831.4

2.025.7

8.05.73.10.21.71.1

2073

Locationa

Table 4.18: Source of knowledge on Iodized salt among women who reported knowing about iodized salt

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4.5 Knowledge on Two-childLogo

Though the survey noted that most of the saltavailable in the market had been iodized, it is wellestablished that salt types that are not packed aremore likely to lose their iodine content, particularlyphoda, which is exposed to sun and rain and is keptin storage for a long duration. Moreover, the practiceof washing this type of salt before using it leads tomore loss of iodine, but this typically occurs afterthe salt is purchased. With this in mind, the Ministryof Health launched a social marketing strategy topromote iodized salt in packets. However, due to aninformal open border trade, salt in packets is alsoavailable from India, which could be adequately orinadequately iodised (or even not iodised at all insome cases). In order to address this potentialprogram obstacle, UNICEF and the Ministry of Healthinitiated the Iodized Salt Social Marketing Campaign(ISSMAC) in 1999. The program promotes the use ofa Government endorsed “2-child logo” on packet saltthat contains more than 15 ppm of iodine. The typesof salts with the two-child logo are iodized at an

iodine concentration 50 ppm at production beforeimportation by the Salt Trading Corporation (STC).During the 6 year period since the introduction ofthe campaign, the ISSMAC has successfully increasedthe market share of 2-child logo packet salt atnational level from 15 percent in 1999 to 36 percentin 20053 , which is similar to the coverage observedfrom this survey (38 %). It should be noted that thecommunity-based promotional activities of theIodized Salt Social Marketing Campaign had focusedon Western districts of Nepal until 2005 althoughthere was simultaneous nationwide awarenesscampaign through mass media (TV and Radio).

The findings of the NMSS 1998 revealed that therewas some infiltration of inadequately iodized salt fromthe Indian border of Western Terai. Therefore, theISSMAC program implemented a ‘Video in WheelsProgram’ in 2001-2002 in 8 border districts, as wellas in Kapilbastu, Nawalparasi, Dang and Rupendehi in2002-2003, to promote community awareness on theimportance of iodized salt and salt with two-childlogo through radio and television.The month ofFebruary was specified by the government for

Table 4.21: Source of information for retailers on iodized salt by location

East and central All WesternSource

RadioTelevisionMagazineBannerPosterFriends/ relativesFCHVHealth workerSchool teacherCourse booksAdvertisementSalt packetOtherNumber of cases

Terai77.473.615.1

2.84.7

26.45.76.63.85.70.00.96.6106

Hills91.675.826.3

2.15.39.53.2

10.52.15.31.12.11.195


2.16.3

20.84.2

10.42.12.10.04.26.348

Terai89.256.917.7

8.526.920.816.9

6.96.26.23.81.53.8130

Hills97.043.919.7

6.113.613.6

7.612.1

7.69.10.03.01.566

Mountains94.123.5

0.00.00.0

11.80.0

11.80.00.00.00.00.017

Total

89.059.118.2

4.512.318.4

8.28.94.35.61.31.93.7462

Table 4.22: Knowledge on importance of iodized salt as reported by retailers

East and central All WesternMessage

Good for HealthPrevent goiterFor sharp brainPrevent mental impairmentPrevent physical disabilitySalt with good qualityEasy to useOtherDon't knowValid N

Terai80.248.117.917.940.621.7

4.714.2

0.9106

Hills83.256.822.124.249.522.1

5.314.7

0.095

Mountains68.870.816.739.668.8

8.32.1

10.40.048

Terai81.552.320.830.058.524.6

5.46.20.0130

Hills78.853.024.230.360.616.7

9.16.10.066

Mountains88.241.2

5.947.158.811.8

0.00.00.017

Total

80.153.919.927.753.920.1

5.210.0

0.2462

3333333333

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promoting awareness on IDD and its health problems.This survey explored the penetration of these differentpromotional activities and the awareness among thewomen at household level and retailers.

4.5.1 Knowledge about 2-Child Logo Salt at theHousehold Level

Overall, 61.4% of the women in the country mentionedthat they had heard about the two-child logo (Table4.23). Women in the Eastern and Central Hill stratumwere most likely to report that they were familiar withthe logo (74.1%), while women in the WesternMountains were least likely to have heard about thetwo-child logo (47.4%). Women in urban locationswere more likely to have heard about the logo (80.9%)than those in the rural locations (57.7%).

In order to verify the accuracy of responses, womenwere shown three different two-child logos, of whichtwo were wrong. They were asked to identify the

Table 4.23: Awareness about two-child logo among women

Ever heard of Logo Logo identificationGeographical location


UrbanRuralNationala

Ever heard of Logo

54.074.164.559.560.747.4

80.957.761.4

Never heard

46.025.935.540.539.352.6

19.142.338.6

Correct logo

53.771.150.854.259.038.1

81.254.258.5

Not correct

8.03.59.39.8

11.010.4

5.78.58.1

Don't know

38.325.439.836.030.051.6

13.137.433.4

N

598599600600600599

42031763596

a Sample size weighted to account for sample designPercentage may add to more than 100 due to multiple responses

Table 4.24: Message provided by two-child logo as reported by women

East and central All WesternMessage provided by theLogoSalt had iodineSalt has enough iodineGood quality saltGood for HealthGood for child growthImproves learning abilityRecommended by the govt.Prevent physical disabilityPrevent mental impairmentGood for pregnant womenPrevent goiterOtherDon't knowMissingNumber of cases

Terai20.9

2.832.444.527.1

5.03.1

17.13.71.20.30.0

27.41.2321

Hills22.5

3.827.550.021.1

5.20.9

23.52.60.91.21.2

25.10.2426

Mountains9.52.0

17.449.232.1

7.93.0

24.64.30.71.60.3

24.90.0305

Terai27.1

4.624.941.214.5

1.81.2

22.26.20.30.60.0

33.22.8325

Hills20.9

2.829.432.816.1

2.50.0

20.91.40.30.30.3

41.80.6354

Mountains24.6

1.322.825.0

8.31.30.4

15.41.30.00.40.4

51.31.3228

Nationala

21.93.3

28.442.720.8

4.11.4

20.83.20.80.60.4

31.31.0

1959a Sample size weighted to account for sample designPercentage may add to more than 100 due to multiple responses

correct logo. Those who had heard of the logo andcould correctly identify the logo were considered ashaving the correct knowledge.

Although 61.4% of the women had heard about thelogo, only 58.5% could correctly identify the logoindicating that a small proportion had heard aboutthe logo but not seen it (Table 4.23).

The awareness of the two-child logo was lowest inthe Western Mountain strata with 47.4% reportingthat they had heard about the logo and only 38.1%being able to identify the logo.

Between one quarter and one half of all women hadno idea about the logo as they had never heardabout it, nor were able to identify the logo.

Women were further asked if they were aware aboutthe message provided by the logo. Overall, 42.7% ofthe women mentioned that the logo indicated that

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the salt was good for health, while 28.4% associatedthe logo with good quality salt (Table 4.24). Only 3.3%of the respondents indicated that the logo reflectedthe fact that the salt in the packet had enough iodine,suggesting that the awareness program has set someimpact on the level of awareness among women.

About one-fifth of the women in most strata, exceptfor the East and Central Terai and Western Mountains,mentioned that the two-child logo indicated that thesalt in the packet helps prevent physical disability.

Although most women associated the logo with someissues related to iodine deficiency, 31.3% reported

that they had no idea what the logo hinted at eventhough they had heard about the logo and many couldrecognize it. Of interest was the observation that asmall number of women (0.4%) mentioned that thelogo indicated small family and promoted familyplanning.

The study indicated that knowledge plays animportant role in brining about change in practice.Figure 4.4 show that households where there wasknowledge on iodised salt were more likely to use thesalt with two-child logo and thereby more likely toconsume the adequately iodised salt.

Knowledge was relatively high in the eastern andcentral hill regions and the proportion of householdsusing the adequately iodised was more than 63%. Theproportion of households using the salt with two-child logo was highest in the east and central hillregion (47.6%).

However, in case of the mountain regions, thelikelihood of consuming adequately iodised salt washigh even when the knowledge was moderate. On thecontrary, households in the Terai regions were lesslikely to use the adequately iodized salt even when

Table 4.26: Message provided by two-child logo as reported by retailers

East and central All WesternMessage by the Logo

Salt had iodineSalt has enough iodineGood saltGood for HealthGood for child growthImproves learning abilityRecommended by the govt.Prevent physical disabilityPrevent mental retardationOtherDon't knowNumber of cases

Terai28.4

5.930.436.330.4

4.98.8

10.82.92.9

26.5102

Hills31.2

8.617.236.640.911.8

1.129.0

6.53.2

24.793

Mountains30.4

8.719.658.739.1

4.34.3

39.113.0

6.513.0

46

Terai30.110.519.539.844.4

9.06.0

30.89.01.5

25.6133

Hills39.7

7.920.641.365.1

9.53.2

42.911.1

0.011.1

63

Mountains21.428.6

7.142.978.628.6

0.035.7

7.10.0

14.314

Total31.0

9.121.340.643.9

8.94.9

28.67.82.4

22.0451

Note: Percent more than 100 possible due to multiple responses

Table 4.25: Awareness about two-child logo among retailersEver heard of Logo Logo identificationGeographical location

StratumEast and Central TeraiEast and Central HillsEast and CentralMountainsAll west TeraiAll west HillsAll west MountainsTotal

Ever heard of Logo

83.297.9

91.792.897.088.291.8

Never heard

16.82.1

8.37.23.0

11.88.2

Correct logo

85.795.8

95.896.394.082.392.8

Not correct

7.53.0

4.21.45.90.04.1

Don't know

6.71.0

0.02.20.0

17.63.1

Total

11997

48138

6717

486

�

��

��

��

��

��

��

��

��

��

��

��

��

Fig: 4.4: Knowledge and use of adequately iodized salt

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they were aware about the iodized salt. In such cases,the availability of salt in the locality and thebehaviour of the consumers play a vital role.

4.5.2 Knowledge at the Retail Outlets

Knowledge about the two-child logo was alsoconsidered among retailers, as it is important for the

Table 4.27: Shop not selling salt with two-child logo

RegionStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Total

Selling

67.294.887.589.179.123.581.1

Total

100100100100100100100

Valid N

1199748

1386717

486

Table 4.28: Reasons for not selling salt with two-child logoRegionStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.National

Expensive

64.140.033.379.942.923.154.3

Not available

25.620.016.7

0.028.669.227.2

Consumer do not like

7.740.049.953.357.123.129.3

Other

7.70.00.00.07.17.75.4

Don't know

5.10.00.00.00.00.02.2

Valid N

3956

15141392

retailers to be aware about the importance of iodizedsalt and the message given by the logo in order tobe effective promoters of iodized salt.

In fact, 91.8% of the sampled retailers were aware ofthe two child logo (Table 4.25). Retailers in the Eastand Central Terai and those in the Western Mountainswere least likely to know about the two-child logo,though this proportion was not very low (above 80%).

The retailers were asked to explain as to what wasindicated by the two-child logo. Some 31.0%mentioned that the logo indicated that salt hadiodine while 9.1% stated that the logo indicated thatsalt had enough iodine (Table 4.26). As with thewomen respondents, 40.6% percent of the retailersstated that the logo indicated that the packet saltwas good for health, while a higher percentage(43.9%) associated the logo with good child growth.

However, more than one fourth of all retailers in theWestern Terai (25.6%) and the East and Central Terai(26.5%) did not know what message was indicated bythe logo which is a matter of concern, given thatthese are the areas where salt infiltration from Indiais most pervasive.

Even though most of retailers were aware about thetwo-child logo, 18.9% did not sell this type of salt.Most of the retailers in the Eastern and Central Hills(94.8%) sold salt with two-child logo (Table 4.27).It was encouraging to note that a high proportionof retailers in the Western Terai regions sold salt withthe two-child logo (89%), despite of the fact thatthey seemed to demonstrate a lack of knowledgeabout what the logo represented.

Of those who did not sell salt with the two-child logo,54.3% mentioned that it was more expensive thanother types of salt (Table 4.28). Another major factorfor not selling packet salt with the logo was its lackof availability, particular in the West Mountains(69.2%). In addition, the fact that consumers didnot like this type of salt was cited by 29.3% of allretailers for not selling salt with the logo, clearlypresenting a challenge for further advocacy efforts.

Of those retailers who were not selling salt with thetwo-child logo, about 83 percent were willing to sellit in the future, while 3 percent were unwilling, andabout 6 percent were not sure if they would sell itin the future.

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ENDNOTES1

Some teams in the Terai (east & central) were able to find Indian Origin packet salt branded as Shakti Salt with similar

packaging and two child logo but had no Batch No. These were produced in Rajasthan, India.2

Based on External Monitoring Data maintained at Nutrition Section/Child Health Division.3

Based on External Monitoring Data maintained at Nutrition Section, Child Health Division.

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Relationship between IDDIndicators

C H A P T E R 55555

5.1 Urinary Iodine and SaltIodine Content

The previous chapters highlighted the currentsituation on IDD and progress towards the goal ofUSI in the country through the application of twokey indicators; urinary iodine and the coverage ofadequately iodised salt (>15ppm). The present chapteroutlines the relationship between these two keyindicators assessed in this survey.

The urinary iodine results correlated well with dataon the adequacy of iodine in household salt. Table5.1 presents the median UIE values for school-agedchildren, stratified by the iodine content ofhousehold salt. As was the case in 1998, the 2005survey showed that there is a direct positive linearrelationship between these two parameters, wherebymedian UIE levels increase among individuals fromhouseholds consuming salt that contains more iodine.

School aged children who were in households wheresalt consumed contained no iodine had UIE valuessignificantly lower than the WHO cut-off pointdesignating adequacy. The survey found that themedian UIE value among these children was 71.0 µg/l, and two of every three children in households withno iodine in salt had UIE below the WHO cut-off of

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100 µg/l. In contrast to this, the median UIE amongSAC with adequate iodine in their household salt was252 µg/l, with only 17.7% of the children havingUIE values below the WHO cut-off point of 100 µg/l.The relationship between these two parameters forboth 1998 and 2005 is presented graphically in Figure5.1.

The association between these two indicators was alsoconsidered between eco-development strata, andfound consistent results with SAC from householdsconsuming salt with no iodine having significantlylower UIE than SAC from households consuming saltwith some iodine or adequate iodine (Table 5.2).

The median UIE level was high among SAC fromhouseholds which were consuming salt withadequately iodized salt in all strata and was as highas 343.0 µg/l in the Eastern and Central Hills, and284.0 µg/l in the Eastern and Central Terai stratum.However, in the East and Central Mountain stratum,the median UIE level was only 189 µg/l among SACfrom households consuming adequately iodized salt,though this was still above the WHO cut-offindicating adequate iodine intake.

The relationship between the content of iodine insalt and UIE was further analyzed with respect to thetype of salt consumed. As in Chapter 4, packet saltwith the two-child logo was generally adequatelyiodized. Table 5.3 indicates that only 9.1% of childrenfrom households consuming packet salt with the logohad UIE less than the WHO cut-off point of 100 µg/l. The table also shows that 65.2% of children fromhouseholds consuming granular salt had UIE less thanthe WHO cut-off, a reflection of the fact that thistype of salt was often inadequately iodized1 .

With respect to phoda salt, 34.3% of children fromhouseholds consuming this type of salt had UIE belowthe WHO cut-off, although almost half of the SAC fromhouseholds consuming loose crushed salt had marginalUIE < 100 µg/l.

The association between UIE, iodine levels in salt andtype of salt is described in Table 5.4. The resultsclearly indicate that SAC from households consumingAayo and Shakti salt had median UIE of 366.0 mg/land 332.0 mg/l respectively, with levels even higherwithin some strata. This indicates that the iodinecontent in these types of salt may actually be too

Table 5.2: Regional assessment of relationship between iodized salt and UIE for school-aged children

Urinary Iodine Excretion (µg/l)Salt iodine

0 ppm<15 ppm>15ppm

Median60.0

112.0284.0

N57

226285

East Central Terai East Central Hills East Central Mts. All West Terai All West Hills All West Mts.

Median58.5

107.0343.0

N14

199355

Median88.5

121.0189.0

N10

162410

Median100.0162.0273.0

N33

237281

Median101.0147.0238.5

N9

235342

Median62.0

137.5215.0

N78

124381

Table 5.3: Relationship between type of salt consumedand UIE for school-aged children

Type of Salt

Salt two-child logoLoose crushed saltGranular saltPhodasaltOther packet salt

Number ofchildren

1207239

691737

186

Urinary Iodine Excretion (µg/l)Median

341.0101.0

69.0142.0123.5

%<100

9.149.465.234.337.6

Table 5.1: Relationship between iodized salt and UIE for school-aged children

Urinary Iodine Excretion (µg/l)Salt (RTK results)

0 ppm<15 ppm>=15ppm

Median75.0

104.0-

%<10062.148.422.7

Number of children211373862

Median71.0

131.0252.0

%<10065.237.417.7

Number of children201

11832054

NMSS 1998 IDD Survey 2005

�

��

��

!�

��

��

��

�� #��

�$$� ��

Fig 5.1: Percent of school aged children with low UIE(<100mg/l) by level of household salt iodine (1998-2005)

3939393939

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high and should be addressed so that there is no riskof iodine induced thyrotoxicosis. Those consumingthis type of salt consistently had high median UIElevel across the regions of the country, suggestingthat this result is systemic.

SAC from households consuming granular salt andTibetan salt had median UIE below the WHO cut-offpoint of 100 µg/l, while in case of SAC from

households consuming phoda salt, there was avariation in median UIE levels across strata, observedto be as high as 170 µg/l l in the Western Terai andas low as 108 µg/l in the East and Central Hills.

There are no median UIE value for certain strata, typesof salt and iodine levels - due to the small numbersin the cells, such as for granular salt, crushed saltand other packed salt.

Table 5.4: Regional Assessment of Relationship between type of salt and UIE for school-aged children

Urinary Iodine Excretion (µg/l)Salt iodine

Salt two-child logoAayo saltShaktiBhanuTej

Salt no two-child logoLoose crushed saltGranularCrystal salt (Tibetan)Crystal salt (phoda)Other packet salt

Median

366.0332.0263.0223.5

101.569.093.5

143.5123.5

N

88560

2614

2406954

1684186

Median

382.0309.0

-152.0

122.069.0

-140.0119.5

N

15129

-3

6569

-72

180

Median

402.0248.0

--

96.0--

108.0175.5

N

2564--

82--

2234

Median

372.0345.5156.0

-

111.0--

138.0107.0

N

1256

39-

73--

3381

Median

359.5385.0

--

---

170.0418.0

N

14617

--

---

3881

Median

297.0368.0130.0

-

---

159.5-

N

1974

11-

---

374-

Median

348.0-

290.0295.0

16.0-

93.5129.0

-

N

10-

2111

20-

54289

-

IDD Survey 2005 East Central Terai East Central Hills East Central Mts. All West Terai All West Hills All West Mts.

Salt Procurement and Storage

C H A P T E R 66666

6.1 Salt Procurement Patterns

6.1.1 Salt Procurement at Household Level

Salt procurement patterns among households providesome insight concerning the quantity of saltpurchased and the duration of time that salt getsstored at the household level. Storage for long periodsof time under unprotected conditions increases therisk of iodine loss in salt. The survey found thatabout one third of all households purchase salt onceevery two weeks (32.3%) while 19.4% of householdspurchased salt on a weekly basis. Householdsprocuring salt once a week tended to be in theEastern and Central Terai stratum, and were leastcommon in the Mountain strata, where fewer than 6percent of households purchased salt every week.

Households in the Mountains were most inclined topurchase salt once a month or even less frequently,particularly in the Western Mountain stratum. Thisimplies that they buy salt in large quantity, whichlasts for a long duration, a situation which isexacerbated by the fact that the households in thesestrata mostly purchase Phoda salt which is vulnerableto having significant iodine loss by the time thatsalt is actually consumed. (Table 6.1).

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Households with lower socio-economic status moreoften procured salt in small amount (24%) thanhouseholds with better socio-economic status (16%).

Table 6.2 indicated that households with noknowledge on iodized salt and those with noknowledge on the two-child logo more often boughtsalt in bulks (about one in three households).

Table 6.3 provides details on the average quantityof salt bought each time. About half of thehouseholds in the country purchased 1 kg of salt ata time, with this practice being most common in theEastern and Central Terai (68%), Eastern and CentralHills (50%) and Western Terai (53%) strata. Asexpected, based on the frequency of procurement amajority of households purchased more than 5 kg ofsalt each time in the Western Mountains (68.3%).Similarly, 45.7% of households in the Eastern andCentral Mountain stratum procured more than 5 kgof salt at a time. On an average, households in theWestern Mountains purchased 17.7 Kg on eachoccasion, while households in the East and CentralTerai stratum purchased 7.7 kg of salt at a time. Themaximum amount of salt procured at one time by asingle household was found to be 200 kg, and 12percent of the households in the Western Mountainsprocured 50 kg or more of salt at a time.

Table 6.1: Salt procurement patterns in the households

East and Central All WesternProcurement pattern

Human consumptionOnce a weekOnce in two weeksOnce a monthLess often than once amonthNumber of householdsAnimal consumptionOnce a weekOnce in two weeksOnce a monthLess often than once amonthNumber of households

Terai

18.037.821.522.7

600

8.935.436.719.0

79

Hills

12.524.826.736.0

600

2.214.947.835.1

134

Mountains

5.36.2

18.969.6

599

0.00.0

10.090.0

20

Nationala

19.432.320.727.6

3596

7.118.141.633.2

448a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

Hills

13.733.223.529.5

599

6.616.442.634.4

61

Terai

33.138.612.715.6

598

15.315.337.332.2

59

Mountains

5.722.227.045.2

600

6.311.630.551.6

95

Table 6.2: Salt procurement patterns in the households by SES, knowledge on iodized salt and two-child logo

Socio-Economic Statusa Knowledge on iodized saltaProcurement pattern

Human consumptionOnce a weekOnce in two weeksOnce a monthLess often than once amonthNumber of households

Yes

16.435.621.826.2

2422

N o

25.825.318.230.7

1174

Totala

19.432.320.727.6

3596

Medium

20.729.820.528.9

1723

Poor

24.134.919.421.5

575

Rich

15.734.221.328.7

1298

Heard of Logoa

Yes

16.037.822.723.5

2159

N o

24.823.617.434.2

1437

Most households which purchased different types ofsalt for household use and livestock use procured saltonce a month (41.6%) while one third of thehouseholds bought it more frequently than once amonth (Table 6.1). Most of these householdspurchased 2 to 5 kg of salt (41.5%) at a time (Table6.3). In general, a higher percentage of householdspurchased larger quantities of salt for livestock usethan for human consumption.

There was significant variation in the price paid forsalt in different parts of the country, with about onein three households paying Rs.9-Rs.10 (37.3%),although the average price ranged from 6.000 Rs inthe East and Central Terai to 12.9 Rs. in the East andCentral Mountains. (Table 6.4).

About one third of households in the Eastern andCentral Terai paid Rs.5 or less per kg of salt, which wasinfluenced by the availability of salt crossing the Nepal-India border. Similarly, 23.2% of households in theWestern Terai stratum bought salt for Rs. 5 or less.

In contrast to this, 42.7% of households in the Eastand Central Mountain stratum paid more than Rs.10per kg of salt, with some households reporting that

a Sample size weighted to account for sample design.

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Table 6.5: Frequency of salt procured at a time by type of salt

Geographical regionPacket salt with two-child logoSalt with no two-child logoCrushed salt (powder)Crystal salt (phoda)Other packet salt

30 days45.7

51.343.943.4

6 months22.6

17.936.224.5

>6 months1.5

0.05.35.7

7 days10.2

30.85.39.4

14 days20.1

0.09.3

16.9

Total394

39246

53

Table 6.3: Amount of salt purchased at a time

Human LivestockGeographical location


UrbanRuralNationala

1 kg

39.023.015.843.019.4

0.0

24.428.027.7

5+kg

33.934.442.113.929.185.0

18.131.229.9

Mean

17.414.313.5

7.710.222.1

9.612.712.4

a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

2-3 kg

9.99.9

12.417.510.711.2

10.911.511.4

1/2 kg

1.80.20.00.00.30.0

1.00.60.7

5+ kg

14.229.345.718.034.068.3

5.829.826.0

1 kg

68.150.222.553.340.8

4.7

76.246.651.3

4-5 kg

6.010.519.411.214.215.9

6.211.510.7

N

598598599600600599

42031743594

Mean

7.710.910.2

9.810.717.7

3.511.1

9.9

½ kg

0.01.60.00.01.50.0

0.01.00.9

2-5 kg

27.141.042.243.050.015.0

57.539.841.5

N

59619579

13420

35413448

Table 6.4: Price paid per Kg (in NRS)

Human LivestockGeographical location


UrbanRuralNationala

10+

0.014.836.8

0.017.965.0

2.313.012.0

Mean

5.78.3

12.35.98.6

14.8

6.697.837.72

a Sample size weighted to account for sample design Percentage may add to more than 100 due to multiple responses

9-10.0

29.648.230.829.544.327.0

72.330.737.3

<=5

32.80.30.0

23.23.20.3

9.515.314.4

Mean

6.910.212.9

6.99.8

11.3

8.818.758.76

5.50-8.75

37.533.126.547.225.048.9

16.738.334.9

10+

0.218.442.7

0.227.523.7

1.515.613.4

<5

33.93.31.1

20.33.00.0

7.813.012.5

5.50-8.70

66.177.024.279.755.230.0

90.060.663.4

9-10.0

0.04.9

37.90.0

23.95.0

0.013.412.1

they paid up to Rs.70 for a kg of salt in the stratum.Overall, about 3 percent of the households in thisarea paid Rs.50 or more per kg of salt.

There were differences observed in the price of saltpaid between urban and rural areas. The price of saltpaid among urban households was more constant with72.3% paying Rs.9-10 per kg of salt. In ruralhouseholds, 53.6% paid less than Rs.9 while 15.6%paid more than Rs.10 for 1 kg of salt. Obviously, thisanalysis must be interpreted with respect to specifictypes of salt which will be presented below.

6.1.2 Salt Procurement at Retail Outlets

This survey also explored the salt procurement patternsamong retail outlets. Table 6.5 indicates that retailerstended to purchase all types of salt once a month,although the frequency of purchasing powder saltwithout the two child-logo was much higher than for

other types of salt as 30.8% was purchased on aweekly basis. Retailers purchased larger varieties ofsalt, e.g. phoda and other packet salt least frequently,with more than 30% reporting that these types ofsalt were purchased every six months or more. Thispattern indicates a longer shelf life prior to purchaseby consumers, which is again a factor contributingto the risk of iodine loss (Table 6.5).

Table 6.6 also shows that retailers bought an averageof 236.2 Kg of crushed salt (powder) each time,which was greater than the average quantity ofphoda purchased on each occasion (181.1 kg).

Retailers purchased smaller quantities of packet saltwith the two-child logo, with about 85% buyingup to 50 kg of Aayo and 80% buying up to 50 kgof Shakti salt each time. This same pattern was alsotrue for other packet salt.

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Among packet salt with the two-child logo, about76 percent of the retailers sold Shakti brand salt atRs.8 or less, Aayo salt was all sold for Rs.9 or more,with almost 20% of retailers selling it for more thanRs.10/kg. Similarly, 23.2% of retailers sold Shakti saltfor more than Rs.10 per kg. The wide variation inthe prices of the same type of salt is caused by thetransport cost which in turn is dependent ongeographical locations: farther from the Nepal-Indiaborder, the higher the transportation cost.Furthermore, the transportation cost is especiallymuch higher for the remote districts in the countrythat are not accessible by motorable road.

The survey indicated that phoda salt was sold atrelatively lower prices than other types of salt, with67.1% of retailers selling it at Rs.8 or less per kg.The lowest price reported for phoda salt was Rs. 4 perkg (Table 6.7). Packet salt without the two-child logowas sold at Rs.8 or less by 86.8% of retailers. Ingeneral, packet salt with the two-child logo was 40-50% more expensive than salt without the logo, andmore than twice the cost of granular salt. This hasimportant implications on the affordability ofthose types of salt that are most likely to beadequately iodized.

6.2 Source of Salt Procurement

This survey also examined the source of salt purchasedby household level and the source of salt amongretailers. The first section deals with the results atthe household level and the second section on thestatus at retail shops. This information is particularlyimportant in helping to identify targets for socialmobilization and promotional messages.

6.2.1 Source of Salt Procurement at HouseholdLevel

A vast majority (85.7%) of households in the countrypurchased salt from retail outlets in their locality (Table6.8), with 11.7% of households buying salt from localmarkets ‘Haat1 ’. The practice of buying salt from the‘Haat’ was more common in the Terai strata with 17.4%of households in the Eastern and Central Terai and 19.5%of households in the Western Terai buying salt from the‘Haat’markets. Vendors were also reported to be a source ofsalt for households in the Eastern and Central Terai (5.5%).

Government distributors were an important source forprocuring salt in the Western Mountain stratum, with18.7% of households reporting this to be their source.

Table 6.6: Amount of salt procured at a time by type of salt

Total

34782

45

3910

1235

53

Mean

76.965.4

**

236.2117.5

*181.1

37.1

100+ kg.

6.68.5

**

53.810.0

*34.0

0.0

51-100 kg.

8.411.0

**

33.360.0

*47.2

5.7

41-50 kg.

52.445.1

**

10.320.0

*10.252.8

11-40 kg.

27.726.8

**

2.610.0

*7.2

30.2

<10 Kg.

4.98.5

**

0.00.0

*1.3

11.3

Type of saltPacket salt with two-childlogoAayoShaktiBhanuTejSalt with no two-child logoCrushed salt (powder)GranularCrystal salt (Tibetan)Crystal salt (phoda)Other packet salt

* Figures not shown due to few cases.

Table 6.7: Price sold per Kg by type of salt

Minimum(Rs.)

9678

54*43

Mean

11.210.2

**

7.04.8

*9.67.0

Rs.10+

19.723.2

**

5.10.0

*18.4

7.5

Rs.10

55.81.2

**

2.60.0

*12.3

3.8

Rs.9

24.50.0

**

0.00.0

*2.11.9

Rs.8

0.034.1

**

10.20.0

*6.41.9

<8

0.041.5

**

82.1100.0

*60.784.9

Type of salt

Packet salt with two-child logoAayoShaktiBhanuTejSalt with no two-child logoCrushed salt (powder)GranularCrystal salt (Tibetan)Crystal salt (phoda)Other packet salt

Excluded 10 missing cases.* Figures not shown due to few cases.

Maximum(Rs.)

503230

8

206*

5012

Valid N

34682

45

3910

1234

53

Total

100100100100

100100100100100

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Further to this, the Salt Trading Corporation was thesource of salt for 11.0% of households in the WesternMountains, while an additional 5.7% claimed that theypurchased their salt from district administrationoffices. All the above sources distribute Bhanu salt atsubsidised rates under the government programme.

Households which reported to purchase salt directlyfrom border markets in India or Tibet were relativelylimited to the East and Central Terai (1.3%) and theWestern Mountains (3.3%).

6.2.2 Source of Salt Procurement at RetailOutlets

Most of the retailers procured salt from localwholesalers (76.5%) while 7.6% purchased their salt

from distributors. The role of the distributors wasmore prominent in the Mountain strata than in theother regions (Table 6.9). Municipality dealers playeda particularly vital role in the West Terai relative toother strata, with 17.9% of retailers obtaining theirsalt through this source.

As was the case with households, 2.9% retailersprocured salt from the border areas, although thepercentage was significantly higher in the WestMountains (11.8%) and in the East and Central Terai(6.7%). These were the main points where saltinfiltration has been taking place from neighbouringcountries.

The association between sources of salt and specificsalt types was also considered. In this analysis, it was

Table 6.8: Source of salt procurement at household level

Wholesale/Dealer

0.20.70.00.30.02.7

0.30.30.3

Salttrading

0.20.00.00.00.0

11.0

0.30.40.4

Govt.distributors

0.00.00.20.00.0

18.7

0.00.70.6

DistrictAdministration

0.00.03.00.01.55.7

0.00.80.7

Vendor

5.52.30.22.50.02.3

4.22.42.7

Haat

17.48.53.0

19.54.73.3

8.612.411.6

Retailshop

78.689.394.282.096.751.3

86.585.585.7

Geographical region


UrbanRuralNationala

Sajha

0.00.02.70.20.00.0

0.70.00.1

Outsideborder

1.30.00.00.80.03.3

0.60.60.6

Other

0.00.20.70.50.06.2

0.00.40.3

ValidN

598599600600600599

42031763596

Table 6.10: Source of salt in the retail shop by type of salt

Geographical region

Packet Two-child logoAayo saltShaktiBhanuTejNo two-child logoCrushed salt (powder)Granular saltCrystal salt (Tibetan)Crystal salt (phoda)Other packet saltTotal

Wholesale

79.578.0

**

64.190.0

*81.760.776.5

Village shop

10.712.2

**

2.610.0

0.011.914.311.1

Distributor

7.27.3

**

20.50.00.04.7

12.57.6

Municipalitydealer

6.18.5

**

2.60.0.0.06.00.05.8

India

0.34.9

**

5.10.00.01.7

14.33.9

Others

1.44.9

**

5.10.00.03.8

17.94.1

* Percentage not shown due to few cases.

Total

34782

45

3910

1235

56486

Total

1199748

1386717

486

Other

0.81.00.00.02.21.51.2

India

6.70.00.02.90.0

11.82.9

Municipality dealer

1.72.10.0

17.40.00.05.8

Distributor

10.17.2

12.53.67.5

11.87.6

Village shop

9.212.420.8

5.817.9

5.911.1

Wholesale

73.176.368.876.189.676.576.5

Geographical regionStratumEast & Central TeraiEast & Central HillsEast & Central Mts.All west TeraiAll west HillsAll west Mts.Total

Table 6.9: Source of salt in the retail shops by location

a Sample size weighted to account for sample design.

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noted that packet salt with two-child logo, granularsalt and phoda salt were mostly procured fromwholesalers (Table 6.10). Indian border markets havebeen the source of other packet salt for 14.3% of allretailers, although these types of salt with no logo werealso obtained by retailers from wholesalers anddistributors.

6.3 Storage Practice of Salt

Knowledge of good salt storage practices helps toretain sufficient levels of iodine before it is actuallyconsumed at the household level. In order to assessthe possible iodine loss at the household level, thesalt storage practices were also assessed as part ofthe survey. In addition, the duration of storage ofsalt at retail outlets also influences the stability ofiodine, with longer shelf life increasing the risk ofloss. Therefore, the practice of storage was assessedat the two levels. The first section deals with thestorage at the household level and the second sectiondeals with the retail outlets.

6.3.1 Household Level Storage Practice

The storage practice of salt was considered both interms of where salt for everyday use was stored inthe kitchen, as well as where larger quantities werestored in the household.

Table 6.11 shows that most households stored saltnear the cooking stove (63.8%). Only 14.7% stored itin the shelf or cupboard. This latter practicewas generally reported in the East and Central Hillstrata (27%).

A detailed assessment of where the salt was storedand how it was stored is presented in Appendix3.1. About one in three households in the countrystored salt near the cooking stove in an opencontainer, while 25 percent stored it near thecooking stove in an airtight container. The practiceof keeping salt near the cooking stove in opencontainers was most common in the Mountainstrata (Appendix 3.2).

In terms of storage of bulk salt, most households keptit in some corner of the kitchen (51.8%). The nextmost common practice was to store salt in storerooms(12.9%), but was particularly popular in the Mountains.About one in ten households did not have a specificplace to store salt in large quantities (Table 6.12).

The practice of hanging large quantities of salt overthe cooking stove should be discouraged as thisleads to iodine loss in the salt. This practice wasmostly seen in the Eastern and Central Hills (7.8%)and the Eastern and Central Mountains (6.1%). Thus,messages targeted to these areas concerning storagepractices may be particularly critical.

The storage practice of salt as reported by therespondents and those observed by the interviewersare presented in Appendix 3.3 and are very similarand consistent.

In order to assess storage practices in a more practicaland simpler manner, an index was created bycategorizing the different storage practices; as“Good”, “Moderate” and “Poor” based on empiricalevidence of the risk of iodine loss.

Table 6.11: Place of storage of salt in the kitchen

East and central All WesternPlace of Storage in the kitchen

Nearthe cooking stoveWindowIn the shelf / cup boardOn the floorTakhataRackOn the tableNo fixed placeIn some corner in the kitchenKhopaStore room/separate roomHang above the stoveOthersValid N

Terai63.7

4.011.4

1.53.96.91.71.92.60.00.60.21.8598

Hills57.1

1.626.9

0.82.58.00.20.21.40.20.50.20.5599

Mountains66.8

3.015.0

0.31.89.90.20.02.00.00.20.80.2600

Terai64.8

8.912.5

0.22.43.80.71.00.92.20.21.31.4600

Hills67.811.0

9.00.01.35.20.30.20.91.50.40.01.4600

Mountains74.3

5.68.90.20.36.30.00.01.00.52.50.00.0599

Nationala

63.86.2

14.70.62.56.40.80.81.50.70.50.41.2

3596a Sample sizes are weighted to account for sample design; Note: 3 missing cases

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Table 6.12: Storage practice of big quantity of salt (as reported)

East and central All WesternStorage practice

Store roomCupboardIn some corner of the kitchenNo specific placeRackNear the cooking stoveWindowTakhataHang above cook stoveTalaBoxOthersValid N

Terai15.9

7.451.515.9

1.84.90.00.00.00.00.61.8163

Hills10.416.841.0

4.12.99.30.03.47.80.40.42.5267

Mountains19.2

4.546.4

2.25.6

11.40.81.96.10.80.30.0379

Terai9.74.8

52.817.7

0.01.12.60.01.00.00.03.2186

Hills11.2

4.157.910.2

0.64.11.70.00.75.11.31.4291

Mountains27.2

9.738.1

5.42.50.40.60.00.20.21.70.2519

Nationala

12.98.7

51.89.61.85.80.90.92.81.50.71.9

1805a Sample sizes are weighted to account for sample design Note: 2 missing cases

A. Good storage practice included: stored in anyplace (except above the stove and near thestove) in an airtight container

B. Moderate storage practices included: stored ina shelf or storeroom, on the floor, hung in theplastic bag and near the stove in an air tightcontainer, closed sack or box.

C. Bad storage practices included: stored in anopen container, exposed to air and light, orstored in a plastic bag.

Using this classification, an analysis was carried outto consider the association between storage practicesand the iodine content in salt at the household level(Table 6.13). There was a positive association betweengood storage practices and the amount of iodine inthe salt. For instance, only 2 percent of the salt whichhad been stored properly had no iodine at all, while85 percent of the salt stored well was found to haveadequate iodine content.

Further, it was observed that salt stored poorly wasat higher risk of inadequate iodine, with 6.9% ofhouseholds with poor practices having no iodine insalt, but 53 percent of households with poor storagehaving inadequately iodized salt at household level.The findings clearly show that storage has someimpact on the iodine levels of salt. Overall, 22% of

the households stored salt properly, 24.7% hadmoderate storage practices while the remaining 53.3%stored improperly.

There was also a relationship between storagepractices and type of salt, possible reflecting the factthat socio-economic status played a role in theserelationships. For example, the survey indicated thatpacket salt with the two-child logo (mostly Aayo) wasgenerally stored well (Table 6.14). The majority ofhouseholds stored this type of salt in closedcontainers and away from the cooking stove. However,

Pable 6.14: Storage practice of different types of salt

Storage practices of saltIodine content

Packet Two-child logoAayo saltShaktiBhanuTejNo two-child logoLoose crushed saltLoose granularLoose crystal salt (T)Loose crystal saltOther packet saltValid N

Nationala

97670

2714

2387056

1707192

3584a Sample sizes are weighted to account for sample design* Percentage not shown due to few cases.

Moderate

32.932.418.9

*

19.816.916.121.720.625.2

Good

51.713.818.1

*

13.65.6

14.310.218.124.9

Bad

15.553.863.0

*

65.476.169.667.661.349.5

Table 6.15: Storage practice of different types of salt byeducation level of the respondents

Storage practices of saltEducation level ofmothersLiteracy StatusLiterateIlliterateEducation LevelNo schoolingNon-formal educationPrimary educationSecondary educationHigher educationValid N

Nationala

10002584

2524243396271147

3584a Sample sizes are weighted to account for sample design Excluded 12 missing cases

Moderate

24.725.6

25.523.824.927.622.325.2

Good

46.615.4

15.426.640.251.565.824.9

Bad

28.759.0

59.149.534.920.811.949.5

Table 6.13: Storage practice and iodine content in saltused for kitchen use

Storage practices of saltIodine content

0 ppm<15 ppm>=15 ppmTotalValid n

Nationala

5.137.057.7

100.03584

Moderate5.0

28.466.5100.0886

Good1.7

13.584.8100.0788

Bad6.9

53.040.0

100.01910


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in the case of loose salt, more than two-thirds of thehouseholds did not store it well.

Table 6.15 indicates that the storage practice amongthe literate respondents was better when comparedto the respondents who were illiterate. For instance,while 46.6% of the literate respondents had goodstorage practice only 15.4% of those who wereilliterate had such practice. Further, 59% of theilliterate respondents followed bad storage practices.

Similarly, the storage practice was assessed in relationto the geographical regions. Good storage practiceswere highest in the Eastern and Central Hill stratum(34.6%). In general, poor storage practices wereobserved in the Mountains, particularly in the WesternMountain stratum (11.9%).

In the case of the Eastern and Central Hill stratum,salt with the two-child logo was often stored wellcompared to the loose salt. That is, 63.0% ofhouseholds using Aayo salt had good storage

Table 6.16: Storing practice of salt in the kitchen by geographical location and type of salt (as reported)

Salt Type

Packet Two-child logoAayo saltShaktiBhanuNo two-child logoLoose crushed saltLoose granularLoose crystal salt (T)Loose crystal salt (phoda)Other packet saltTotal

Terai

51.518.2

-

15.25.6

--

16.122.7

Hills

63.0--

13.4--

7.075.034.6

Mts.

41.2-

35.0

6.8--

6.7-

16.3

Hills

39.1-

18.2

---

13.5-

22.3

Mts.

9.1-

13.6

5.0-

14.310.7

-11.9

East and Central All WesternGood storage practices of salt

Terai

49.422.7

-

---

12.7-

23.7

practices, whereas only 7.0% of those using crystalsalt had good practice.

Phoda salt was generally not stored well. Householdsin the Western Hills tended to have better storageof phoda than in other areas of the country.

6.3.2 Storage Practice at Retail Shop

The other important aspect of storage concerns thepractice at the retail outlets. The survey alsoexamined storage practices in retail shops. Theinterviewers observed how different types of salt werestored and recorded their observations. There werefour categories developed to observe the storagepractice. These were 1) salt with the two-child logo,2) crushed salt (loose), 3) crystal salt and 4) otherpacket salt. It was noted that packet salt with thetwo-child logo was usually stored well in the closedsack or plastic bags (81%) as indicated in Table 6.16.This was generally true in all the strata.

Table 6.17: Storing practice of salt in the retail shop by geographical location and type of salt

Type of salt

Packet salt with two child logo

Number of cases

Crushed salt (loose)

Number of retailers

Crystal salt

Number of retailers

Other packet salt

Number of cases

StoragepracticeGoodModerateBad

GoodModerateBad

GoodModerateBad

GoodModerateBad

Terai92.42.55.180

21.613.065.423

31.010.358.429

61.34.1

34.649

Hills89.17.63.392

18.227.354.511

20.724.155.129

100.00.00.01

East and centralMts.90.40.09.642

33.30.0

66.73

35.32.9

61.7340.00.00.00

All Western Total

91.24.44.439423.115.461.539

35.415.449.224664.13.6

32.353

Hills98.11.90.0530.00.0

-0

33.413.752.9510.00.00.00

Terai89.45.74.91230.00.0

-0

38.522.039.591

100.00.00.03

Mts.100.0

0.00.04

50.00.0

50.02

91.70.08.3120.00.00.00

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In contrast to this, the storage of crushed salt didnot seem to be as satisfactory, as 38 percent of theretailers just left it outside the shop exposed to airand light. Similarly, the storage practice of the crystalsalt was also not was not very satisfactory. For

instance about 20 percent of shops stored the crystalsalt in some corner of the shop in open containersor sacks. About 35 percent of the retailers in the eastand central mountain regions had this type of storagepractice (Table 6.17).

ENDNOTES 1

Local markets usually in specified locations of rural areas that are open only once or twice a week.

Summary Observations andRecommendations

C H A P T E R 77777

The 2005 Nepal IDD Status Survey was conducted toassess progress made towards the elimination ofIodine Deficiency Disorders (IDD) and reaching thegoal of Universal Salt Iodization (USI) in the country.The survey was initiated under the aegis of the ChildHealth Division of the Ministry of Health andPopulation with support from the MicronutrientInitiative-Nepal.

The survey provided national estimates on theprevalence of IDD through the assessment of urinaryiodine excretion (UIE) as the primary indicator ofiodine intake among school-age children (SAC). Theiodine content in salt used at the household leveland in retail shops was employed to provide animpression of the coverage and penetration ofadequately iodized salt among the population. Thesurvey also examined the knowledge, attitude andpractices of consumers regarding the procurement,storage and consumption of iodized salt.

A national sample of 3,600 households and school-aged children was drawn from 180 clusters usingprobability proportional to size (PPS) methods,providing statistically representative data for each ofsix eco-development strata allowing for sub-regionaland national estimates. The methodology adopted forthis survey was identical to that of the Nepal

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Micronutrient Status Survey of 1998, facilitatingdirect comparisons and evaluation of trends over time.The following sections highlight the major findingssurvey and propose recommendations.

7.1 Urinary Iodine Excretion (UIE)

There has been an improvement in the urinary iodineexcretion (UIE) among school-aged children over thepast seven years. For the country as a whole, themedian UIE increased from 143.8 µg/l to 188.0 µg/lamong SAC, indicating significant progress towardsthe sustained elimination of IDD in the country. Theproportion of SAC with low UIE values, below the WHOcut-off value of 100 µg/l, decreased from 35.1percent to 27.4 percent in 2005 (p <0.05).

However, the increases in UIE were not consistentacross the country. The lowest median UIE was foundin the Mountain strata (163.5 µg/l in the East andCentral Mountains and 165 µg/l in the West Mountainstratum) and the East and Central Terai (163.0 µg/l).The median UIE was highest in the East and CentralHills (217.5 µg/l). A dramatic improvement in UIE wasobserved in the Terai ecological zone from 108.9 µg/l in 1998 to 182.7 µg/l in 2005. The Western Terai,where the median UIE was 206 µg/l, was a major factorin this overall improvement. At the same time, thesurvey revealed that there was a slight decline in UIEin the Mountain ecological zone from 196.6 µg/l in1998 to 164.6 µg/l in 2005. This indicates that inspite of the success in these areas in terms ofimproving iodine status, there is a need for continuedefforts to ensure sustained impact.

The UIE was higher among boys (202.0 µg/l) thangirls (178.8 µg/I), which was a finding consistentwith the pattern indicated by NMSS 1998. There wasalso a notable increase in the median UIE among SACliving in urban areas, rising from 259.0 µg/l in 1998 to361.0 µg/l in 2005, and does raise some concerns aboutthe possibility of exposure to excessive iodine intake.

7.2 Status of Salt Iodisation

The major intervention strategy implemented for thecontrol of IDD in Nepal has been Universal Salt

Iodisation which aims to ensure that all edible saltis adequately iodised and reaches all segments of thepopulation. In order to meet the physiologicalrequirement for iodine, assuming that the averageNepali consumes 10 grams of salt per day, the iodinecontent in salt should be at least 15 ppm when it isconsumed. The survey collected information on thetype of salt consumed, the iodine content in salt atthe household level and retail outlets, as well as andthe knowledge, awareness and practices regardingiodized salt. The assessment of KAP was a particularlyimportant consideration in the survey as a majoremphasis of the USI program over the past years hasbeen on encouraging the use of adequately iodizedpacket salt, as denoted by a special ‘two-child’ logothat had been widely promoted.

The survey showed an increase in the proportion ofhouseholds consuming packet salt over the pastseven years, with more than one of every threehouseholds reporting use of packet salt with the two-child logo (37.7%). This compares with a coverageof only 9 percent in 1998. Of all brands of packetsalt with the logo, Aayo brand was the most popular,with 33.0% of all households indicating that this wasthe type of salt most commonly used for humanconsumption, and was particularly popular in the Eastand Central Hills (46.9%) and the Western Hills(34.5%). Bhanu salt, distributed by government atsubsidized rates, was the most popular brand ofpacket salt with the two-child logo in the WesternMountain stratum (36.5%). In spite of efforts putforth by the government to shift consumer demandaway from large crystal salt (phoda), some 41.5% ofall households in the country still reported that thiswas their preferred type of salt. Nonetheless, thisrepresented a decline from 1998 when 63 percent ofthe households consumed phoda salt.

The iodine content in salt at the household levelwas measured using rapid test kits (RTK) whichprovided a semi-quantitative assessment of thepresence and adequacy of iodized salt. The surveyfound that overall, 94.9% of households consumedsalt with some iodine, which was an improvementfrom the NMSS 1998 when the coverage of salt withsome iodine was 83%. In addition, 57.7% of allhouseholds in the country used adequately iodisedsalt, which was slightly better than the situation in

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1998 (55.2%). The proportion of households usingadequately iodised salt was highest in the East andCentral Mountain strata (71.2%) and was lowest inthe East and Central Terai (51.7%).

The survey showed that virtually all salt with the two-child logo was adequately iodized (98.9% with iodine> 15 ppm), while only one of every three samples ofphoda salt, the most widely consumed type of salt,contained adequate iodine (32.6%). There were someregional differences in the coverage of householdsusing adequately iodized salt, as well as trends incoverage since 1998.

There was a significant increase in the proportion ofhouseholds consuming adequately iodized salt in theWestern Terai, rising from only 35 percent in 1998to 54 percent in the current survey. This positivefinding is a result of the focused efforts put forthby the Ministry of Health and Population and UNICEF.However, the situation in the Eastern and CentralTerai was not as positive, with the proportion ofhouseholds consuming adequately iodized saltreducing from 58 percent in 1998 to 52 percent in2005. This reduction may be the consequence ofpersistent infiltration of inadequately iodized andnon-iodized salt from the border areas, which haspenetrated the local markets.

A large number of salt samples were collected fromretail outlets and were subjected to analysis bytitration. The results indicated that about 75 percentof all salt samples tested from retail outlets had iodinecontent of 15 ppm or more. The fact that this wassomewhat higher than the coverage observed at thehousehold level in the general population may reflectthe fact that some salt loses its iodine content afterbeing purchased due to the large quantities procuredat a single time and improper storage practices.

To better understand the point of degradation ofiodine in salt, the survey explored the storagepractices both at the household level and amongretailers. A large proportion of households stored saltnear the cooking stove (63.8%), which clearlyrepresented a potential risk to iodine stability. Anindex was created to categorize storage practices as“good”, “moderate” and “poor”, based on empiricaldata of the risks of iodine loss. Using this

classification, the survey found a direct correlationbetween storage and the iodine content of salt atthe household level. For instance, 85 percent ofhouseholds having “good” storage practices hadadequate salt iodine levels, while only 40 ofhouseholds with poor practices had salt that wasadequately iodized. While this relationship may beconfounded by the type of salt used, it doeshighlight an area that could be strengthened in theprogram.

7.3 Relationship between IDDIndicators

The survey found that there was a positive linearrelationship between UIE levels and salt iodinecontent, confirming the fact that UIE provides a goodestimation of current iodine intake at the populationlevel. Individuals from households consuming salt thatwas adequately iodized had high UIE levels (median252.0 µg/l), while school-aged children fromhouseholds consuming salt with no iodine hadsignificantly lower UIE values (median 71.0 µg/l).These children were almost four times as likely to haveUIE levels below the WHO cut-off of 100 µg/l (65.2%)as compared with SAC from households consumingadequately iodized salt (17.7%). When this analysiswas extended to take into account the type of saltbeing consumed in households, two importantgroupings emerged.

On the one hand, there were some householdsconsuming crushed/powder salt in small packets withthe two-child logo, that were being promoted by theGovernment as being adequately iodized. Schoolchildren from these households have high iodine levelsthat are well above the WHO cut-off point consideredto reflect sufficient iodine status, and in some casesmay have been excessive. On the other hand, there werehouseholds which use large crystal (phoda), crushed andgranular salt which was much less likely to be adequatelyiodized. Children from these households had low UIE,which would imply that these segments of thepopulation remain at risk of iodine deficiency.

The relationship between iodine content in salt andUIE was reasonably consistent between differentregions of the country, although there were some

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variations that have important programmaticimplications. Households consuming granular orcrushed salt were most unlikely to meet theirphysiological needs for iodine and efforts are necessaryto either improve the iodine levels in these types ofsalt, improve storage practices to enhance iodineretention or shift consumer preference to other typesof salt with higher iodine content. The persistent useof phoda salt poses an interesting dilemma. Still, thepreferred salt of 41.5% of households throughout thecountry, virtually all phoda salt was iodized (95.0%with some iodine), although a large percentage wasfound to contain inadequate iodine content (62.3%was found to have iodine levels <15 ppm). While theapparent solution would be to encourage the wideruse of salt with the two-child logo (that was morelikely to be adequately iodized), the reasons for usingphoda salt may be difficult to overcome. A largeproportion of households using phoda salt, many ofwhich are in the mountains, reported that theirselection was based on tradition, availability andperhaps most critical of all, the cost. Unless there is away to reduce the cost differential between alternativetypes of salt, it may be quite complex to alter demandpatterns.

Children from households consuming salt with the two-child logo had UIE levels that were consideredacceptable, and in some cases, even excessive. Forexample, SAC from households using Aayo salt hadmedian UIE values of 366 µg/l.

RecommendationsThrough this comprehensive survey on the status ofIDD in the country and the penetration and effortstowards USI, there were a number of clearrecommendations which emerged as critical for futureaction to ensure progress towards sustainedelimination of IDD in the country. Therecommendations are highlighted below:

1. Though urinary iodine excretion values haveshown improvement over the years in thecountry, an assessment at the sub-national levelshows that the Mountain regions has somewhatlower iodine intake than other areas. The medianUIE values have reduced over the years from 196.6µg/I to 164.6 µg/I, and while this is still withinthe range of acceptable iodine intake, the decline

does reinforce the importance of continuedefforts to sustain the achievements made. Themain barriers noted in both the West Mountainsand the East and Central Mountains was thepersistent use of phoda salt, a high percentageof which was sub-optimally iodized. Moreintensive quality control and monitoring toensure distribution of only adequately iodizedphoda salt will be important, coupled withpromotion of better storage practices and theprocurement of smaller quantities of salt on eachoccasion.

2. In addition to the demand for phoda, just overten percent of households were using eithergranular salt (3.6%) or loose crushed salt(7.2%), both these contained marginal amountsof iodine. There were distinct regional patternsin the demand for these types of salt which mayfacilitate targeted campaigns to discourage theuse of granular and loose crushed salt sold inbulk. Social marketing activities which promotethe use of two-child logo packet salt in theseareas, as well as those where phoda salt is used,are appropriate, while the practical issue ofprice needs to be addressed.

3. The progress in households consumingadequately iodized salt has been somewhat overshadowed in the Eastern and Central Terai stratumwhere the infiltration of inadequately iodizedsalt affects supply and availability in localmarkets. In this stratum, the proportion ofhouseholds consuming adequately iodized salthas reduced from 58 percent in 1998 to 52percent in 2005. This fact demands immediateattention for action which may include makingavailable cheaper brands of two child logo salt(Tej and Shakti) in border VDCs at rates equivalentto rates of similar Indian brands, advocacy amongretailers to discourage the purchase of salt fromacross the border, working with local Governmentofficials to monitor the flow of inadequatelyiodised or non-iodized salt and take appropriateaction in cases of non-compliance, and toincrease awareness among consumers in thisstratum regarding the advantages anddisadvantages of different types of salt.

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4. As Tibetan salt is not iodised yet, efforts shouldbe made to explore feasibility of iodising thissalt. Although the consumption of this salt isonly confined to some areas (9.3% amonghouseholds in the Western Mountains),iodisation of this salt will help achieve goal ofUniversal Salt Iodisation Program of Nepal.

5. The storage practice of salt at the householdlevel and retail outlets deserves proper attentionas the survey provided evidence that poorstorage practices led to a higher risk of iodineloss in salt. The on-going IEC campaigns needto take this fact into consideration duringprogram implementation.

6. Efforts should be pursued to identify how toimprove the iodization and subsequent stabilityof iodine in phoda salt and other types of saltwithout the two-child logo.

7. There is a need for review of salt iodization levelat the production site. The current level of 50ppm of iodine at production seems to be higherfor salt sold in small moisture proof packs. Thisis reflected in the ‘excessive’ iodine intakeamong those who consume ‘Aayo’ and ‘Shakti’brand salt, especially in urban areas.

Reference

Acharya, S (1989). Iodine Deficiency Disorders in Nepal: Assessment of Programme Impact, HMG/UNICEF, 1989.Azizi, F., Hedayati, M., Rahmani, M., Sheikholeslam, R ;, Allahverdian, S.and Salarkia, N. Reappraisal of therisk of iodine-induced hyperthyroidism : an epidemiological population survey. J. Endocrinol. Invest. 28 :23-29, 2005.

CBS/NPC (2001). Between Census Household Information, Monitoring and Evaluation System (BCHIMES). March-May 2000. HMG-N/NPC/CBS in collaboration with UNICEF Nepal.

Dunn, J.T. and F. Delange (2003). Damaged Reproduction: The Most Important Consequence of Iodine Deficiency,IDD Newsletter, February 2003.

GCEP-HMG/Nepal (1992), Situation Analysis of Iodine Deficiency Disorder in Nepal, December 1992.

Gorstein, J. Goiter assessment: help or hindrance in tracking progress in iodine deficiency disorders controlprogram? Thyroid (2001) 11(12).

Hetzel, B.S. The Story of Iodine Deficiency: An International Challenge. New York : Oxford University Press, 1989.

HMG, Ministry of Health (1967). Endemic Goiter in Nepal, WHO/SEA/26, October, 1967.

ICCIDD, UNICEF and WHO (2001). Assessment of Iodine Deficiency Disorders and Monitoring their Elimination:A Guide for Programme Managers (Second Edition). World Health Organization.

Joshi, A. B.; Banjara, M. R.; Rikimaru, T; and Pandey, S (2004). Assessment of Current Status of Iodine DeficiencyDisorders (IDD) for the Development of Future Control Program. Child Health Division, JICA Nepal, Institute ofMedicine, Kathmandu, April 2004.

Joshi, R.P. (2000). Reports from Regions: Nepal, Salt Trading Corporation Ltd., IDD Newsletter, August 2000.

Karmakar, M.G. & C.S. Pandav (1885). Iodine Deficiency Disorders in Nepal: Monitoring and Quality Control ofIodated Salt, A Report, All India Institute of Medical Sciences, New Delhi, May-June 1985.

Koutras, D.A., Matovinovic, J., and Vought, R. 1980. The ecology of iodine. In Endemic goiter and endemiccretinism. J.B. Stanbury, and B.S. Hetzel, editors. New York: John Wiley publ. 185-195.

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Leslie J. Women’s Nutrition: the key to improving family health in developing countries? Health Policy Plann1991; 6(1): 1-9.

Mannar, V.M.G., and Dunn, J.T. 1995. Salt iodization for the elimination of iodine deficiency. MI, ICCIDD,UNICEF, WHO publ:1-126.

MARG Nepal, (1997). Feasibility Study of Fortification for the Control of Micro-nutrient Malnutrition, Kathmandu,1997.

MOH in Clugston, GA and K Bagchi, Iodine Deficiency Disorders in South-East Asia. WHO/SEARO Regional HealthPapers No. 10, New Delhi 1985.

Ministry of Health, New ERA and ORC Macro (2002). Nepal Demographic and Health Survey 2001 (Calverton,Maryland USA: Family Health Division, Ministry of Health, New ERA and ORC Macro).

MI, WHO, ICCIDD, USAID, PAMM, and UNICEF (1999). Assessing Country Progress in Universal Salt Iodization Programs:Iodised Salt Program Assessment Tools (ISPAT). The Micronutrient Initiative, Ottawa.

Nepal Rastra Bank (1988). Multipurpose Household Budget Survey, Kathmandu, Nepal: Nepal Rastra Bank.

New ERA (2001). A Fortification Feasibility Study for the Control of Micronutrient Malnutrition-II Consumption andMarket Study of Food Vehicles, Micronutrient Initiative-Nepal, Kathmandu, New ERA, November 2000.

New ERA (2002). Assessment of Iron Intake through 24 Hour Recall among Women and Preschool Children,Micronutrient Initiative-Nepal, Kathmandu, New ERA, September 2002.

NMSS (1998). Nepal Micronutrient Status Survey 1998. Kathmandu, Nepal: Ministry of Health, Child Health Division,HMG/N, New ERA, Micronutrient Initiative, UNICEF Nepal, and WHO.

Stanbury, J.B., Ermans, A.E., Bourdoux, P., Todd, C., Oken, E., Tonglet, R., Vidor, G., Braverman, L.E., andMedeiros-Neto, G. 1998. Iodine-induced hyperthyroidism : occurrence and epidemiology. Thyroid 8:83-100.

UNICEF, PAMM, MI, ICCIDD, and WHO (1995). Monitoring Universal Salt Iodisation Programs. The PAMM, MI, ICCIDD,Atlanta, Ann Arbor and Ottawa.

World Health Organization. The world health report 1997: conquering suffering, enriching humanity. Geneva:WHO; 1997.

WHO, UNICEF and ICCIDD (1994). Indicators for assessing Iodine deficiency Disorders and their Control throughSalt Iodisation. WHO, NUT 94.6, Geneva, Switzerland.

WHO (1996). Trace Elements in Human Nutrition and Health. In collaboration with FAO of the UN and IAEA,World Health Organization, Geneva.

WHO, UNICEF, and ICCIDD. 2001. Assessment of the Iodine Deficiency Disorders and monitoring their elimination.Geneva: WHO publ. WHO/NHD/01.1. 1-107 pp.

Zimmermann, M.B., Ito, Y., Hess, S.Y., Fujieda, K., and Molinari, L. 2005. High thyroid volume in childrenwith excess dietary iodine intakes. Am. J. Clin. Nutr. 81 :840-844.

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Form for Households Interview

A P P E N D I X 1.1.11.1.11.1.11.1.11.1.1

INTERVIEWER VISITS

ATTEMPTS

1

2

3

FINAL VISIT

DATE INTERVIEWER'S NAME NEXT VISIT

TOTAL NO. OF VISITS

RESULT

**RESULT CODES:1 COMPLETED2 NOT AT HOME3 POSTPONED4 REFUSED5 PARTLY COMPLETED6 INCAPACITATED9 OTHER

(SPECIFY)

TOTAL PERSONS IN HOUSEHOLD NAME AND CODE OF SELECTED ELIGIBLEMOTHER

NAME AND CODE OF SELECTED ELIGIBLESCHOOL AGE CHILD

FIELD SUPERVISOR

NAME

DATE

EXTERNAL SUPERVISOR

NAME

DATE

OFFICE EDITOR KEYED BY

IDENTIFICATION

STRATUM CODE .........................................................................................

CLUSTER NUMBER .......................................................................................

WARD NUMBER ..........................................................................................

HOUSEHOLD NUMBER ..................................................................................

NAME AND CODE OF DISTRICT ........................................................................

NAME OF VILLAGE/MUNICIPALITY .....................................................................

VDC=1 Municipality=2

NAME OF HOUSEHOLD HEAD ..........................................................................

NAME OF RESPONDENT .................................................................................

HOUSEHOLD SELECTED FOR TITRATION YES=1 NO=2

SALT SAMPLE COLLECTED FOR TITRATION ...................................... YES=1 NO=2

IF NO, WHAT IS THE REASONS? .......................................................................

..............................................................................................................

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HOU

SEH

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SCH

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we

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abou

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you

now.

LIN

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.

(1)

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18

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(4)

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12

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12

12

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12

12

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AGE

How

old

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(NAM

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(IN

YEAR

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(5)

6-11

YEAR

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(6)

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18

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2=No

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(10)

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CODES FOR Q.301 = HEAD02 = WIFE OR HUSBAND03 = SON OR DAUGHTER04 = SON-IN-LAW OR DAUGHTER-IN-LAW05 = GRANDCHILD06 = PARENT07 = PARENT-IN-LAW08 = BROTHER OR SISTER, (IN-LAW)09 = NEPHEW, NIECE BROTHER-IN-LAW10 = CO-WIFE11 = OTHER RELATIVE12 = ADOPTED/FOSTER/STEPCHILD13 = NOT RELATED14 = WORKER/SERVANT15 = GRAND PARENTS16 = SISTER-IN-LAW17 = OTHER (SPECIFY)98 = DON'T KNOW

CODES FOR EDUCATION (Q10)00 = < GRADE 101 = GRADE 102 = GRADE 203 = GRADE 304 = GRADE 405 = GRADE 506 = GRADE 607 = GRADE 708 = GRADE 809 = GRADE 910 = COMPLETED SLC11 = INTERMEDIATE 1ST YEAR/ 10+112 = INTERMEDIATE COMPLETE/ 10+213 = BACHELOR'S NOT COMPLETE14 = BACHELOR'S COMPLETE15 = MASTERS NOT COMPLETE16 = MASTERS COMPLETE17 = PHD or EQUIVALENT18 = NON-FORMAL EDUCATION

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200. BACKGROUND OF THE HOUSEHOLDS

NO.

201

202

203

204

205

206

207

208

CODING CATEGORIES

HINDU 1

BUDDHIST 2

MUSLIM 3

CHRISTIAN 4

KIRAT 5

OTHER (SPECIFY) 6

(CASTE)

PUCCA HOUSE 1

PARTIALLY PUCCA HOUSE 2

KACCHA HOUSE 3

OTHER (SPECIFY) 6

YES 1

NO 2

Rented-out Rented-in

HOUSE RENT 01

TRADE 02

SMALL/LARGE INDUSTRY 03

SERVICE 04

WAGE LABOR 05

OCCUPATION BY CASTE 06

AGRICULTURE 07

OTHER (SPECIFY) 96

MONTHS .........................

POOR HOUSEHOLD 1

MEDIUM HOUSEHOLD 2

RICH HOUSEHOLD 3

OTHER (SPECIFY) 6

SKIP

--<206

QUESTIONS AND FILTERS

What is the religion of the head of the household?

What is the caste of the head of the household?

WRITE CASTE ON LINE PROVIDED. LEAVE BOX BLANK. CODE WILL

BE FILLED LATER.

OBSERVE THE TYPE OF HOUSE:

RECORD OBSERVATION.

Does your household own or rent in farmland?

How much land does your household own? Owner operated

Khet (irrigated) ...............................

Khet (unirrigated) ..............................

Bari ...............................................

Other .............................................

What is the main source of income of your household?

How many months of a year is the main income source sufficient

for feeding your household members?

Instruction: Please assess the three indicators above and circle

the status of the household.

(Observation)

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300. LIVESTOCK HOLDING

NO.

301

302

CODING CATEGORIES

YES 1

NO 2

COW/OX/YAK

BUFFALO

GOAT/SHEEP

PIG

RABBIT

POULTRY

DUCK

PIGEON

OTHER (SPECIFY)

SKIP

--<END


Do you have livestock?

If yes, which livestock, how many do you have?

THANK YOU

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Form for Mother's Interview

IDENTIFICATION

STRATUM CODE .........................................................................................

CLUSTER NUMBER .......................................................................................

WARD NUMBER ..........................................................................................

HOUSEHOLD NUMBER ..................................................................................




NAME OF HOUSEHOLD HEAD ..........................................................................


NAME OFELIGIBLE SCHOOL AGE CHILD

SEX OF ELIGIBLE SCHOOL AGE CHILD

Male=1 Female =2

INTERVIEWER VISITS

ATTEMPTS

1

2

3

FINAL VISIT


TOTAL NO. OF VISITS

RESULT

**RESULT CODES:1 COMPLETED2 NOT AT HOME3 POSTPONED4 REFUSED5 PARTLY COMPLETED6 INCAPACITATED9 OTHER

(SPECIFY)

FIELD SUPERVISOR

NAME

DATE

EXTERNAL SUPERVISOR

NAME

DATE


A P P E N D I X 1.1.21.1.21.1.21.1.21.1.2

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100. BACKGROUND OF THE RESPONDENT

NO.

101

102

103

104

CODING CATEGORIES

AGE IN COMPLETED YEARS

YES 1

NO 2

GRADE ……………......……

GRADE …………………......

SKIP

Go to 104


How old were you at your last birthday?

Have you ever attended school?

What is the highest grade you completed

What is your occupation?

200. BACKGROUND OF THE CHILD

NO.

201

202

203

204

CODING CATEGORIES

NAME ......................................

MALE 1

FEMALE 2

YES 1

NO 2

GRADE ……………......……

SKIP

Go to 301


Please check the number of school age children (6-11 years) the

respondent has and select one randomly for the survey. Write

the name and line number of the child selected.

Is (NAME) male or female?

Has (NAME) ever attended school?

What is the highest grade (NAME) completed?

INFORMED CONSENTNamaste. My name is ........................................................... and I am working for the Ministry of Health.We are conducting a national survey about the iodine deficiency disorders status. We would very muchappreciate your participation in this survey. I would like to ask you about your knowledge and practiceof using iodized salt, storage, consumption practice of particular food items like wheat flour, biscuits,instant noodles and cooking oil. We will also be taking a sample of salt you are currently using for analyzingiodine content in it as well as urine sample of one of your school age child for analyzing urinary iodineexcretion. This information will help the government to plan health services. The survey usually takesabout 20 minutes to complete. Whatever information you provide will be kept strictly confidential and willnot be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or allof the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey? May I begin the interview now?

Signature of interviewer: ................................................................... Date: ................................

RESPONDENT AGREES TO BE INTERVIEWED 1¦? RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 --<END

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300. SALT IODIZATION

I would like to ask you some questions on consumption practice of salt

NO.

301

302

303

CODING CATEGORIES

SALT WITH TWO CHILD LOGO

AAYO SALT 01

SHAKTI SALT 02

BHANU SALT 03

TEJ SALT 04

LOOSE SALT (No two child logo)

CRUSHED (POWDER) 05

GRANULAR SALT (KURKUTCH) 06

CRYSTAL SALT (TIBETAN) 07

CRYSTAL SALT (PHODA) 08

OTHER (SPECIFY) 96

YES 1

NO 2

NO LIVESTOCK 3


AAYO SALT 01

SHAKTI SALT 02

BHANU SALT 03

TEJ SALT 04


CRUSHED (POWDER) 05




OTHER (SPECIFY) 96

SKIP

Go to 304


What is the main type of salt you use for the household purpose?

Do you purchase separate type of salt for livestock?

If yes, what type of salt do you purchase for livestock?

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NO. CODING CATEGORIES SKIPQUESTIONS AND FILTERS

304

305

What is the reason for using that salt?

(Multiple answers are possible)

For Human?………..

For Livestock?…………………..

How often do you purchase salt for household use?

For human?………………………..

For Livestock?……………….

FOR HUMAN

AVAILABILITY A

LOWER COST B

PRACTICE C

HAS IODINE D

GOOD HEALTH E

IMPROVES LEARNING ABILITY F

RECOMMENDED/PROMOTED

BY THE GOVERNMENT G

HAS TWO CHILD LOGO H

OTHER (SPECIFY) ______________ X

DON'T KNOW Z

FOR LIVESTOCK

AVAILABILITY A

LOWER COST B

PRACTICE C

HAS IODINE D

GOOD HEALTH E


BY THE GOVERNMENT F


NO LIVESTOCK Y

DON'T KNOW Z

FOR HUMAN

ONCE A WEEK 1

ONCE IN TWO WEEKS 2

ONCE A MONTH 3

LESS OFTEN THAN ONCE A MONTH

(SPECIFY) ____________________ 4

DON'T KNOW 8

FOR LIVESTOCK

ONCE A WEEK 1

ONCE IN TWO WEEKS 2

ONCE A MONTH 3

LESS OFTEN THAN ONCE A MONTH

(SPECIFY) ____________________ 4

NO LIVESTOCK 5

DON'T KNOW 8

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NO. CODING CATEGORIES SKIP

Go to 313

Go to 313

Go to 316

Go to 316

Go to 319


306

307

308

309

310

311

312

313

314

315

316

How much salt do you purchase at a time?

(Amount in Kgs)

Where do you buy salt from?

(Multiple response possible)

How much do you pay for one kg (Rupees per Kg.)?

How long have you been using this particular salt for human

consumption in the household?

Check Q. 301:

If response is 05-08, 96 If response is 01 - 04

Do you sometimes buy the packet salt (refined and crushed)?

If yes, why do you buy the packet salt sometimes?


Check Q. 301:

If response is 01-04 If response is 05-08, 96

Do you sometimes buy the crystal salt?

If yes, why do you buy the crystal salt sometimes?


Have you ever heard about iodized salt?

FOR HUMAN 1

FOR LIVESTOCK 2

SHOP 1

HAAT 2

LOCAL MOBILE VENDOR 3

DDC 4

OTHER (SPECIFY) 6

FOR HUMAN 1

FOR LIVESTOCK 2

COMPLETED YEARS

FROM GENERATIONS 95

YES 1

NO 2

FOR FESTIVAL A

AVAILABILITY B

SHOPKEEPER'S MOTIVATION C

SALT USED NOT AVAILABLE D

OTHER (SPECIFY) X

YES 1

NO 2

FOR FESTIVAL A

AVAILABILITY B

FOR LIVESTOCK C

LOW COST D

FOR HEALTH E

FOR TASTE F

SALT USED NOT AVAILABLE G

OTHER (SPECIFY) X

YES 1

NO 2

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NO. CODING CATEGORIES SKIP

Go to 401


317

318

319

320

321

If yes, from which source(s) did you hear about iodized salt?


What is the iodized salt important for?


Have you ever heard of salt with "two-child logo"?

Could you please identify which of these logos is related to salt

(seen in salt packet)?

(Show the three logos)

Do you know what the two-child logo means?

(Multiple responses possible)

RADIO A

TELEVISION B

MAGAZINE/NEWSPAPER C

BANNER D

POSTER E

FRIENDS/NEIGHBORS F

FCHV G

HEALTH WORKERS H

SCHOOL TEACHERS I

OTHER (SPECIFY) X

GOOD HEALTH A

TO PREVENT GOITER B

FOR IMPROVING LEARNING ABILITY C

PREVENT BEING DEAF/DUMB D

PREVENT PHYSICAL DEFORMITY E

OTHER (SPECIFY) X

YES 1

NO 2

LOGO A 1

LOGO B 2

LOGO C 3

DON'T KNOW 8

SALT HAS IODINE A

SALT HAS ENOUGH IODINE B

GOOD SALT C

GOOD FOR HEALTH D

GOOD FOR CHILD GROWTH E



BY THE GOVERNMENT G

PREVENTS PHYSICAL DISABILITY H

PREVENTS MENTAL RETARDATION I


DON'T KNOW Z

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400. STORAGE PRACTICE OF SALT IN THE HOUSEHOLD

Now I would like to ask you some questions on how you store salt in the household

NO.

401

402

CODING CATEGORIES

SALT FOR KITCHEN USE

NEAR THE COOKING STOVE 1

WINDOW PANE 2

IN SHELF 3

OTHER (SPECIFY) 6

BULK SALT

STORE ROOM 1

CUPBOARD 2

IN SOME CORNER 3

NO SPECIFIC PLACE 4

OTHER (SPECIFY) 6

SALT FOR KITCHEN USE

AIR TIGHT CONTAINER 11

SALT PLASTIC BAG 12

OPEN CONTIANER 13

OTHER (SPECIFY) 16

BULK SALT

CLOSED SACK 21

CLOSED PLASTIC BAG 22

EXPOSED TO AIR/LIGHT 23

OTHER (SPECIFY) 26

SKIPQUESTIONS AND FILTERS

Where do you store the salt?Salt for kitchen use?Bulk salt?

How do you store the salt?Salt for kitchen use?Bulk salt?

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Salt Storage practice

How? (406)

AIR TIGHT CONTAINER 1

SALT PLASTIC BAG 2

OPEN CONTIANER 3

OTHER (SPECIFY) 6

CLOSED SACK 1

CLOSED PLASTIC BAG 2


OTHER (SPECIFY) 6

Remarks

(407)Where? (405)

NEAR THE COOKING

STOVE 1

WINDOW PANE 2

IN SHELF 3

OTHER (SPECIFY) 6

STORE ROOM 1

CUPBOARD 2

IN SOME CORNER 3

NO SPECIFIC PLACE 4

OTHER (SPECIFY) 6

NO.

403

404

1.

2.

408

409

410

411

412

CODING CATEGORIES

EXPENSIVE A

NOT AVAILABLE B

DO NOT LIKE IT/ TOO SALTY C

DID NOT KNOW ABOUT SALT WITH

TWO CHILD LOGO D

OTHER (SPECIFY) X

YES 1

NO 2

YES 1

NO 2

DON'T KNOW 8

0 PPM 1

<15 PPM 2

> 15 PPM 3

SKIP

Go to 411


Make an observation of storage practice of salt and fill up the

table below:(Should be filled up by the interviewer)

Salt at the

house level

Kitchen use

Bulk

Why are you not using salt with two-child logo?

Will you use salt with two child logo in the future if is made

available the way you like it?

DO you know that the salt you use has iodine?

Check the salt for Iodine content and record:

Ask for the salt that is mostly consumed by the household for consumption.

Check if the household is already using salt with two child logo:

If response is `NO' If response is `YES'

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CODING CATEGORIES SKIP

Go to 415

500


413

414

415

416

417

Check Q 412:

If response is `1' If response is `2 or 3 '

Use the Re-check solution and check the salt for Iodine content

and record:

0 PPM 1

<15 PPM 2

> 15 PPM 3

500. FORM FOR BIOCHEMICAL SAMPLE

Please fill in the following form for collection of urine sample

ID

501

502

503

504

Status of urine sample collection

YES 1

NO 2

REFUSED 1

CHILD ABSENT 2

CHILD WAS SICK 3

OTHER (SPECIFY) 6

Stratum.......................

Cluster........................

HH.............................

Child ID==....................

CODE OF COLLECTOR ______________

SKIP

Go to 503

Name of school age child ___________________________

Was the urine sample collected for (NAME)?

If not collected please mention why?

Please verify ID on the tube

Name of the sample collector

Check Q 301:

If response is `1' to `4' If response is other than `1 to 4 '

Batch Number Number ___________________________

Not found ____________________ 98888

Packing Date Month _____________ Year _____________

Not found ____________________ 98888

THANK YOU

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Retail Shopkeeper Interview Schedule

IDENTIFICATION

STRATUM CODE .........................................................................................

CLUSTER NUMBER .......................................................................................

WARD NUMBER ..........................................................................................

RETAIL SHOP NAME AND NUMBER ...................................................................





Owner =1 Employee=2

YEARS SINCE ESTABLISHMENT OF THE SHOP (completed years) ................................

SALT SAMPLE COLLECTED FOR TITRATION ...................................... YES=1 NO=2

IF YES, TYPE OF SALT COLLECTED .....................................................................

IF NO, WHAT IS THE REASONS? .......................................................................

..............................................................................................................

A P P E N D I X 1.1.31.1.31.1.31.1.31.1.3

REFINE 1

CRUSHED 2

PHODA 3

INTERVIEWER VISITS

ATTEMPTS

1

2

3

FINAL VISIT


TOTAL NO. OF VISITS

RESULT

**RESULT CODES:1 COMPLETED2 SHOP CLOSED3 POSTPONED4 REFUSED5 PARTLY COMPLETED9 OTHER

(SPECIFY)

FIELD SUPERVISOR

NAME

DATE

EXTERNAL SUPERVISOR

NAME

DATE


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100. GENERAL

NO.

101

CODING CATEGORIES

INSTANT NOODLES 01

WHEAT FLOUR 02

REFINED WHEAT FLOUR 03

BISCUITS 04

COOKING OIL 05

SALT 06

TEA 07

MILK POWDER 08

OTHER (SPECIFY) 96


What products do you sell?

200. SALT

NO.

201

202

CODING CATEGORIES


AAYO SALT 01

SHAKTI SALT 02

BHANU SALT 03

TEJ SALT 04


CRUSHED (POWDER) 05




OTHER (SPECIFY) 96

DISTRIBUTOR A

WHOLESALER B

ANOTHER RETAILER C

MUNICIALITY DEALER D

MANUFACTURER E

OTHER (SPECIFY) X


What types of salt do you sell (Salt in stock) ?

From where do you procure salt?

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NO.

203

204

205

CODING CATEGORIES SKIPQUESTIONS AND FILTERS

How often do you buy the salt?

Packet salt with two child logo? …………………………….……

Crushed salt (loose, no two child logo)? …………………………

Crystal salt (loose, no two child logo)? …………………………..

Other packet salt without two child logo?

7 days

1

1

1

1

14

days

2

2

2

2

30

days

3

3

3

3

6

month

4

4

4

4

>6

months

5

5

5

5

Not

bought

7

7

7

7

Usually, how much salt do you buy at a time (in Kgs)? What is the price of the different types of salt per kg?

S.No. Type of salts Brands of salt Kg purchased at a time Selling Price per kg (in Rs)

1 Two child logo salt Aayo

2 Shakti

3 Bhanu

4 Tej

5 Crushed salt (loose)

6 Crystal salt Granular salt (Kurkutch)

7 Crystal salt (Tibetan)

8 Crystal salt (Phoda)

9 Other packet salt

without logo

10

11

12

13

Which type of salt has the maximum sale? SALT WITH TWO CHILD LOGO

AAYO SALT 01

SHAKTI SALT 02

BHANU SALT 03

TEJ SALT 04


CRUSHED (POWDER) 05




OTHER (SPECIFY) 96

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NO.

206

207

208

209

210

211

CODING CATEGORIES

PRACTICE IN THE COMMUNITY A

MORE PROFIT MARGINS B

BECAUSE OF TASTE C

EASY TO STORE D

HEALTH REASONS E

AVAILABLE F

LOWER COST G

DUE TO PROMOTION FROM MEDIA H

PROMOTION/INCENTIVES I

OTHER (SPECIFY) X

YES 1

NO 2

RADIO A

TELEVISION B

MAGAZINE/NEWSPAPER C

BANNER D

POSTER E

FRIENDS/NEIGHBORS F

FCHV G

HEALTH WORKERS H

SCHOOL TEACHERS I

SCHOOL COURSE BOOKS J

OTHER (SPECIFY) X

FOR GOOD HEALTH A

TO PREVENT GOITER B

FOR IMPROVING LEARNING ABILITY C

PREVENT BEING DEAF/DUMB D

PREVENT PHYSICAL DEFORMITY E

TASTES BETTER F

BETTER QUALITY G

EASY TO USE H

OTHER (SPECIFY) X

YES 1

NO 2

SKIP

Go to 208

Go to 211


What are the reasons behind the maximum sales for that salt?

What type of incentives are you getting for that type of salt?

Have you heard about iodized salt?

If yes, from which source(s) did you hear about iodized salt?


If yes, why do you think that we should take iodized salt?

Have you ever heard of salt with "two-child logo"?

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NO.

212

213

214

215

216

CODING CATEGORIES

LOGO A 1

LOGO B 2

LOGO C 3

DON'T KNOW 8

SALT HAS IODINE A

SALT HAS ENOUGH IODINE B

GOOD SALT C

GOOD FOR HEALTH D

GOOD FOR CHILD GROWTH E



BY THE GOVERNMENT G

PREVENTS PHYSICAL DISABILITY H

PREVENTS MENTAL RETARDATION I

OTHER (SPECIFY) X

DON'T KNOW Z

EXPENSIVE A

NOT AVAILABLE B

CONSUMERS DO NOT LIKE IT C

OTHER (SPECIFY) X

YES 1

NO 2

NOT SURE 3

SKIP

Go to 214

Go to 217


Could you please identify which of these logos is related to salt

(seen in salt packet)?

(Show the three logos)

Do you know what the two-child logo means?

(Multiple responses possible)

Check if the retailer is already selling salt with two child logo:

If `NO' If `YES'

Why are you not selling salt with two-child logo?

Will you promote/salt with two child logo in the future if is

made available the way you like it?

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Salt Storage practice Remarks

(220)

NO.

217

S. No.

1.

2.

3.

4.

CODING CATEGORIES SKIPQUESTIONS AND FILTERS

Make a general observation on the storage practices of salts in

the shop and fill up the table below

Salt in the

retail shop

Packet salt

with two

child logo

Crushed salt

(loose)

Crystal salt

Other packet

salt (no two

child logo)

Where? (218)

STORE ROOM 1

SHELF 2

IN SOME CORNER 3

OUTSIDE THE SHOP 4

OTHER (SPECIFY) 6

STORE ROOM 1

SHELF 2

IN SOME CORNER 3

OUTSIDE THE SHOP 4

OTHER (SPECIFY) 6

STORE ROOM 1

SHELF 2

IN SOME CORNER 3

OUTSIDE THE SHOP 4

OTHER (SPECIFY) 6

STORE ROOM 1

SHELF 2

IN SOME CORNER 3

OUTSIDE THE SHOP 4

OTHER (SPECIFY) 6

How? (219)

OPEN CONTAINER 1

CLOSED PLACTIC BAG 2

CLOSED SACK 3


OTHER (SPECIFY) 6

OPEN CONTAINER 1


CLOSED SACK 3


OTHER (SPECIFY) 6

OPEN CONTAINER 1


CLOSED SACK 3


OTHER (SPECIFY) 6

OPEN CONTAINER 1


CLOSED SACK 3


OTHER (SPECIFY) 6

THANK YOU

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Survey Team

A P P E N D I X 1.1.41.1.41.1.41.1.41.1.4

Core Team

1. Ms. Anjushree Pradhan - Project Director

2. Ms. Shova Thapa - Research Officer

3. Mr. Bharat Adhikari - Statistician

5. Ms. Sarita Vaidya - Asst. Data Processing Officer

7. Mr. Min Bahadur K.C. - Research Assistant

8. Mr. Netra Dangal - Research Assistant

Field Teams:

Supervisors

1. Manoj Pyakurel 7. Keshav Uprety 13. Bhagawati Sharma Rijal

2. Baidehee Mallik 8. Mohan Baniya, 14. Saraswati Katuwal

3. Babita Bhattarai 9. Bandana Thapa 15. Harka Bahadur Karki

4. Pramila Sharma 10. Tara Shrestha 16. Durga Nath Maraseni

5. Dhana Maya Adhikari 11. Bijaya Pyakurel 17. Mandeep Regmi

6. Ganga Basnet 12. Mitra Luxmi Rai 18. Nava Raj Adhikari

Enumerators

1. Anita Kumari Dev 13. Geeta Tamang 25. Poonam Shrestha

2. Anu Shrestha 14. Hema Rai 26. Prahlaad Mainali

3. Ashok Sigdel 15. Indra Raj Adhikari 27. Pushpa Sharma Khadka

4. Baidehee Karn 16. Jhechun Lama 28. Rita Rayamajhi

5. Bimala Budhathoki 17. Kalpana Bhatta 29. Sabita Parajuli

6. Bipana Bhatta 18. Kushal Bhatta 30. Santosh G. C

7. Bishnu Rijal 19. Laxmi Thapa 31. Shree Ram Dahal

8. Buddhi Narayan Shrestha 20. Maharudra Prasad Pokharel 32. Sapana Bhatta

9. Chandanee Bajracharya 21. Mandeera Bhandari 33. Saraswati Thapa

10. Deva Sharma 22. Mandeera Neupane 34. Shalu Gurung

11. Durga Shrestha 23. Maneesh Khadka 35. Sita Lama

12. Geeta Pokharel 24. Menuka Shrestha 36. Sumitra Shrestha

Runners

1. Ram Kumar Rijal 2. Durga Prasad Phuyal

Administrative Team

1. Ms. Geeta Shrestha - Amatya - Sr. Word Processor

2. Mr. Sanu Raja Shakya - Sr. Word Processor

3. Mr. Rajendra Kumar Shrestha - Office Assistant

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Checklist - 1 (Individual Questionnaires)

1. Name of District: ............................................................ VDC/Municipality Name: .............................

2. Name of the Cluster: ........................................................ Ward number: ..........................................

3. Name of Household Head: ................................................. Family Members: ......................................

4. Total number of eligible Mother at home: ..............................

5. Total number of eligible school age children at home: ..............

6. Name of selected eligible mother: ....................................................................................................

7. Name of selected eligible school age child: .........................................................................................

8. Age of selected school age child: ........................................

9. Was urine sample collected from selected eligible child or not?

Yes 1 No 2

If not collected, please mention why?

..........................................................................................................................................

..........................................................................................................................................

10. Type of salt used for the household purpose: .......................................................................................

12. Iodine content in the salt at household level:

0 PPM 1 Less than15 PPM 2 More than15 PPM 3

13. Remarks

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

A P P E N D I X 1.21.21.21.21.2

Checklist - 2 (Retailers questionnaires)

1. Name of District: ............................................................ VDC/Municipality Name: .............................

2. Cluster Number: ............................................................. Ward number: .........................................

3. Total number of Households in the cluster .............................

4. Total number of Retailers in the cluster: ................................

5. Retailers' selected procedure

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

6. Name of the selected retail shop ......................................................................................................

7. Type of salt, Wheat flour, Maida, Biscuits, Instant noodles and Cooking oil in the shop

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

8. Type of salt collected from the shop: .................................................................................................

9. Remarks

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

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Method of Urinary Iodine Analysis

A P P E N D I X 1.31.31.31.31.3

Material for Laboratory Analysis: Reagents

Ammonium persulfate solution (35% w/v): 35g of ammonium persulfate (NH4)2S2O8 was dissolved in distilled water and

finally made up to 100 ml with distilled water.

Arsenious acid solution (1% w/v, 0.05 mol/l) -5g of arsenic trioxide (As2O3) was dissolved in 100 ml (NaOH 93.5%

w/v). In an ice bath, 16 ml of concentrated H2SO4 was added slowly to solution. After cooling, 12.5g of NaCl were

added and the mixture was diluted with cooled distilled water to 500 ml. The final solution was filtered with Whatman

No 1 filter paper.

Ceric ammonium sulphate solution (1.2% w/v, 0.02 mol/l): 6g of ceric ammonium sulphate dehydrate were dissolved in

3.5N H2SO4 and adjusted to a final volume of 500 ml with the same acid solution.

Standard iodine standard solution (100µg I/ml): In a 100 ml volumetric flask, 168.8 mg of KIO3 was dissolved in distilled

water as a stock solution. After making 100 and 10,000-fold dilutions, working solutions of 25, 50, 75, 100, 200, 300,

400, 500 and 600 µg I/ml were prepared by diluting with distilled water.

Procedure:

50µl of iodine standards and urine samples was pipetted into wells of heat resistance Plate A (Polypropylene 96 well

microtiterplate SEROCLUSTER (Corning Coster Co.), followed by the addition of 100 µl of ammonium persulfate solution.

Plate A was sealed with Teflon fluorinated ethylene propylene (FEP) laminated silicon rubber in a cassette. The cassette

was tightly closed and then placed in a fan forced oven (HLS Scientific, Australia) for 90 minutes at 90 0C for digestion.

After digestion, the bottom of the cassette was cooled in a cold water bath to room temperature. Then, the cassette

was opened and 50 µl of each sample in the wells of Plate A were transferred to the same wells of Plate B Polypropylene

96 well microtiterplate NUNC 96 well plate (Nalge Nunc International). After mixing, 100 µl of arsenic acid solution

were added and 50µl of ceric ammonium sulphate solution were added quickly with a multi-channel pipette. The contents

of Plate B were incubated at room temperature for 30 minutes before absorbency was measured at 405 nm with a

microtiterplate reader (DHERMO Labsystem Multiskam Ascend, Australia).

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DAG Index: An assessment

Vulnerable Households -Composite Index

A P P E N D I X 22222

Indicators Poor Medium Non-poor (rich)

Land Terai: 0 - 0.5488 = A Terai: 0.5489 - 1.1510 =B Terai: 1.1511+ = C

MPHBS classification Hills: 0 - 0.3316 = A Hills: 0.3317 - 0.5172 =B Hills: 0.5172+ = C

Food security <=6 months = D 7-11 months = E 12+ months = F

House type Kacchi =G Ardha pucca =H Pucca =I

1. Land poor + <=6 months + kacchi (ADG) = 1

2. Land poor + <=6 months + ardha pucca (ADH) = 1

3. Land poor + <=6 months + pucca (ADI) = 1

4. Land poor + 7-11 months + kacchi (AEG) = 1

5. Land poor + 7-11 months + pucca (AEI) = 2

6. Land poor + 7-11 months + ardha pucca (AEH) = 2

7. Land poor + 12+ months + kacchi (AFG) = 2

8. Land poor + 12+ months + ardha pucca (AFH) = 2

9. Land poor + 12+ months + pucca (AFI) = 3

10. Land medium + <=6 months + kacchi (BDG) = 1

11. Land medium + <=6 months + ardha pucca (BDH) = 2

12. Land medium + <=6 months + pucca (BDI) = 2

13. Land medium + 7-11 months + kacchi (BEG) = 2

14. Land medium + 7-11 months + ardha pucca (BEH) = 2

15. Land medium + 7-11 months + pucca (BEI) = 2

16. Land medium + 12+ months + kacchi (BFG) = 2

17. Land medium + 12+ months + ardha pucca (BFH) = 3

18. Land medium + 12+ months + pucca (BFI) = 3

19. Land rich + <=6 months + kacchi (CDG) = 1

20. Land rich + <=6 months + ardha pucca (CDH) = 2

21. Land rich + <=6 months + pucca (CDI) = 2

22. Land rich + 7-11 months + kacchi (CEG) = 2

23. Land rich + 7-11 months + ardha pucca (CEH) = 2

24. Land rich + 7-11 months + pucca (CEI) = 2

25. Land rich + 12+ months + kacchi (CFG) = 2

26. Land rich + 12+ months + ardha pucca (CFH) = 3

27. Land rich + 12+ months + pucca (CFI) = 3

NOTE: 1 = Poor 2 = Medium 3 = Rich

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House type: Pucca house = 5

Ardha pucca = 2

Kacchi = 0

Land ownership:

Terai (stratum 01/04):

1.1511+ = 5

0.5489-1.1510= 4

<0.5489=2

No land =0

Hill (Stratum 02/03/05/06):

0.5172+ = 5

0.3317-0.5172= 4

<0.3317=2

No land =0

Irrigated land: Irrigated land = 3

Non-irrigated land = 1

No land = 0

Ownership of livestock: Yes = 2

None=0

Food Security: 12+ months = 5

7-11 months = 4

<6 months = 2

Highest score: 20

Lowest score: 2

Poor = <7

Medium = 8-15

Rich = 16-20

Disadvantaged Index Scores

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Result Assessment

a. DAG Composite Index and Disadvantaged Index Score

Poor

164 (49.8%)

412 (19.9%)

0 (0.0%)

576 (16%)

Medium

165 (50.2%)

1149 (55.4%)

411 (34.3%)

1725 (47.9%)

Rich

0 (0%)

511 (24.7%)

787 (65.7%)

1298 (36.1%)

Poor (<=7)

Medium (8-15)

Rich (>16)

DAG composite index

Scor

ing

Chi-Square Value DF Significance

Pearson 1002.80661 4 .00000

Likelihood Ratio 1182.07294 4 .00000

b. DAG Composite Index and Perception of Interviewers

Poor

392 (36.8%)

181 (8.3%)

3 (0.8%)

576 (16%)

Medium

626 (58.8%)

1075 (49.4%)

24 (6.7%)

1725 (47.9%)

Rich

46 (4.3%)

922 (42.3%)

330 (92.4%)

1298 (36.1%)

Poor

Medium

Rich

DAG composite index

Perc

epti

on


Pearson 1209.84374 4 .00000


Total

329 (9.1%)

2072 (57.6%)

1198 (33.3%)

3599 (100.0%)

Total

1064 (29.6%)

2178 (60.5%)

357 (9.9%)

3599 (100.0%)

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c. Disadvantaged Index Score and Perception of Interviewers

Poor (<=7)

248 (23.3%)

78 (3.6%)

3 (0.8%)

329 (9.1%)

Medium (8-15)

720 (67.7%)

1257 (57.7%)

95 (26.6%)

2072 (57.6%)

Rich (>16)

96 (9.0%)

843 (38.7%)

259 (72.5%)

1198 (33.3%)

Poor

Medium

Rich

DAG composite index

Perc

epti

on


Pearson 785.19009 4 .00000


Total

1064 (29.6%)

2178 (60.5%)

357 (9.9%)

3599 (100.0%)

8686868686

NEP

AL IO

DIN

E D

EFIC

IEN

CY

DIS

ORD

ERS

STAT

US

SURV

EY 2

005

Iodine Content by Type of Salt Collected at RetailOutlets

(Tested by Titration Method)

A P P E N D I X 3.1.3.1.3.1.3.1.3.1.

Type of saltAayo saltShakti saltBhanu saltTej saltPowder saltGranular saltCrystal salt (phoda)Jain saltTaja saltBharatiya saltSajan saltJay Bharat saltTata saltRani saltSun saltAnnapura saltNirmal saltKailash saltSahayog saltSanjog saltParas saltDandi saltCaptain CookSilfarTotalPercentage

* Figures not shown due to few cases.

>=15 ppm318

6244

143

11506111301320111011

54375.1

0 ppm0000001000000000010000002

0.3

Maximum120.3156.0

**

82.985.0

148.4*****************

<15 ppm8701

256

10719103223020000100

17824.6

Minimum0.92.0

**

1.01.00.0

*****************

Mean59.946.5

**

17.923.623.8

*****************

Median59.942.2

**

11.711.016.0

*****************

Valid N326

6945

399

2231

15214524341111111

723100

8787878787

NEP

AL IO

DIN

E D

EFIC

IEN

CY

DIS

ORD

ERS

STAT

US

SURV

EY 2

005

Storage of Salt for Kitchen Use by GeographicalLocation

(As Reported by the Respondents)

A P P E N D I X 3.2.3.2.3.2.3.2.3.2.

East and central All WesternHow

Air tight containerSalt plastic bagOpen container /sack/plastic bagOthersAir tight containerSalt plastic bagOpen container /sack/plastic bagAir tight containerSalt plastic bagOpen containerAir tight containerOpen container /sack/plastic bagOthersAir tight containerSalt plastic bagOpen containerOthersAir tight containerSalt plastic bagOpen container /sack/plastic bagAir tight containerSalt plastic bagOpen containerAir tight containerOpen container /sack/plastic bagAir tight containerSalt plastic bagOpen container /sack/plastic bagOthersAir tight containerSalt plastic bagOpen containerAir tight containerSalt plastic bagOpen container /sack/plastic bagHang in the sack/plastic bagAir tight containerSalt plastic bagOpen container/sack/plastic bagAir tight containerSalt plastic bagOpen container /sack/plastic bagValid N

Terai24.9

8.929.9

0.01.30.52.29.00.71.70.51.00.02.50.21.2.0.06.20.20.51.30.20.20.21.70.70.21.70.00.00.00.00.20.20.20.00.00.00.20.80.80.2

598

Hills18.9

4.033.9

0.30.80.30.5

23.51.22.20.30.30.21.70.00.80.06.70.31.00.20.00.00.20.00.50.00.90.00.00.00.20.30.00.20.00.00.00.20.30.00.2

599

Mountains19.7

3.243.9

0.00.20.82.08.80.75.50.00.30.00.80.20.80.06.00.73.20.00.00.20.00.00.50.01.50.00.00.00.00.00.00.20.00.30.20.30.00.00.2

600

Terai29.5

5.229.6

0.54.70.73.5

11.20.31.00.00.20.01.70.20.30.23.30.50.00.70.00.00.30.70.20.00.50.21.00.21.00.00.00.20.00.20.50.60.70.20.5

600

Hills30.3

4.533.0

0.07.20.33.57.50.80.70.0

0.0]0.00.80.30.20.04.20.30.70.30.00.00.20.00.50.00.20.21.20.00.30.00.20.20.00.00.00.00.50.00.9

600


0.02.31.32.03.72.23.00.20.00.00.00.30.00.03.71.31.30.00.00.00.00.00.70.00.30.00.00.00.51.30.00.70.50.00.00.00.00.00.0

599

Nationala

25.26.0

32.40.23.10.52.6

12.20.81.70.20.40.01.60.20.70.05.30.40.70.60.10.10.20.60.50.10.80.10.40.00.30.20.10.20.00.00.10.30.60.30.3

3596a Sample sizes are weighted to account for sample designNote: missing (3)

Where

Near the cookingstove

Window

In shelf /cupboard

On the floor

Takhata

Rack

On the table

N ofixed placeIn some corner inthe kitchen

Khopa

Store room/separate room

Hang above thestove

Others

8888888888

NEP

AL IO

DIN

E D

EFIC

IEN

CY

DIS

ORD

ERS

STAT

US

SURV

EY 2

005

Storing Practice of Salt for Big Quantityby Geographical Location

(As Reported by the Respondents)

A P P E N D I X 3.3.3.3.3.3.3.3.3.3.

East and central All WesternHow

Closed sack or containerOpen container /sack/clay potExposed to air and lightOthersClosed sack or containerOpen container/sackExposed to air and lightClosed sack or containerOpen container/sack/clay potExposed to air and lightOthersClosed sack or containerOpen container/sackExposed to air and lightOthersClosed sack or containerOpen container/sackExposed to air and lightClosed sack or containerOpen container/sackExposed to air and lightClosed sack or containerOpen sackExposed to air and lightClosed sack or containerOpen containerExposed to air and lightClosed sack/plastic bagOpen container /sackExposed to air and lightClosed sack or containerOpen sackExposed to air / lightOthersClosed sack or containerOthersClosed sack or containerOpen sack/clay potExposed to air and lightValid N

Terai13.5

1.80.60.06.80.60.0

23.39.8

18.40.08.52.54.90.01.80.00.03.71.20.00.00.00.00.00.00.00.00.00.00.00.00.00.00.60.00.60.60.6

163

Hills8.21.50.70.0

16.10.70.0

28.03.39.70.02.60.80.70.02.20.70.05.63.30.40.00.00.02.60.40.46.01.40.40.40.00.00.00.40.01.80.70.0

267

Mountains17.1

0.51.60.03.90.60.0

32.06.28.20.01.40.00.80.04.70.60.35.36.10.00.00.50.31.60.30.05.00.80.30.30.50.00.00.30.00.00.00.0

379

Terai6.50.52.70.03.80.50.5

40.45.96.50.0

11.30.55.90.00.00.00.01.10.00.02.10.00.50.00.00.00.50.50.00.00.00.00.00.00.01.60.51.1

186

Hills7.20.63.40.04.10.00.0

36.011.610.0

0.36.11.03.10.00.30.30.02.71.40.01.40.00.30.00.00.00.00.70.02.71.40.70.31.00.30.00.70.7

291

Mountains24.4

1.20.41.29.50.20.0

28.34.04.81.05.20.00.00.22.50.00.00.40.00.00.60.00.00.00.00.00.20.00.00.20.00.00.01.50.20.20.00.0

519

Nationala

10.40.71.70.18.20.40.1

31.89.0

10.80.25.71.12.80.01.50.30.03.52.20.10.70.00.20.70.10.12.00.70.10.90.40.10.10.60.11.10.40.4

1805a Sample sizes are weighted to account for sample designNote: 2 missing cases

Where

Store room

Cupboard

In some corner ofthe kitchen

No specific place

Rack

Near the cookingstove

Window

Takhata

Hang above cookstove

Tala

Box

Others

8989898989

NEP

AL IO

DIN

E D

EFIC

IEN

CY

DIS

ORD

ERS

STAT

US

SURV

EY 2

005

Storage Practice Reported and Observed

A P P E N D I X 3.4.3.4.3.4.3.4.3.4.

ReportedStorage practice

Near the cooking stoveOpen containerAir tight containerOn window paneAirtight containerOpen containerIn the shelfAirtight containerOn the floorAirtight containerOpen containerTakhataAirtight containerRackAirtight containerOn the tableAirtight containerNo specific placeOpen containerIn some corner in the kitchenOpen containerKhopaAirtight containerStore room/ separate roomAirtight containerHang in the plastic bagOpen containerCould not observeOthersAirtight containerOpen container

%

32.623.3

2.82.4

9.8

0.20.2

1.1

5.1

0.3

0.3

0.7

0.4

0.4

0.201

0.40.4

%

30.924.5

2.82.4

10.6

0.20.2

1.3

5.0

0.4

0.4

0.7

0.4

0.3

0.2-

-

No.

1110881

9985

382

68

45

180

15

13

25

13

11

6-

-

No.

1173837

10085

354

76

38

184

12

11

25

14

13

64

1514

Observed ReportedStorage practice

Store roomClosed sackClosed plastic bagCup boardClosed plastic bagIn some cornerClosed sackNo specific placeClosed plastic bagRackClosed plastic bagNear to the cooking stoveClosed sackHang over the cooking stoveClosed sackWindowClosed sackTakhataClosed sackTalaClosed sackBoxClosed plastic bagMissingOthersExposed to air and lightClosed sackClosed plastic bagCould not observe

%

5.54.5

5.2

18.1

2.5

0.9

1.6

1.6

1.6

0.3

0.4

0.00.1

0.00.40.42.5

%

5.35.3

5.9

18.2

2.8

1.8

1.7

1.6

0.3

0.4

0.3

0.60.1

0.30.00.00.0

No.

9595

107

329

51

32

31

29

5

8

6

112

5000

No.

10082

94

327

45

16

29

28

28

5

8

0.01

088

45

Observed

Storage practice of salt for kitchen use Storage practice of large quantity of salt

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