Nutritionand Mortality Survey In

Nutritionand Mortality Survey in

Aden governorate

Yemen

8 – 13August 2015

Ministry of Public Health and Population

Aden Governorate Health Office

United Nations Children’s Fund (UNICEF)

Nutritionand Mortality Survey Report

Aden Governorate, Yemen

Conducted 8 – 13 August 2015

ACKNOWLEDGEMENTS

The Yemen Ministry of Public Health and Population (MoPHP)/ Aden Governorate Public Health and Population Office, in collaboration with UNICEF Yemen Country Office and UNICEF Aden Zone, and Field Medical Foundation (FMF), acknowledge the contribution of the various stakeholders in this survey.

The UNICEF Yemen Country Office provided technical support, employing SMART methodology. The Survey Manager and his assistant were provided by IOM and CSSW. Survey enumerators, team leaders, and data entry team were provided by GHOs of Lahj and Aden. The data analysis and report writing were made by two FMF consultants. UNICEF YCO provided the overall technical assistance especially on sampling, questionnaire and the guideline.

The Aden Governorate Public Health and Population with FMF oversaw the political and logistical arrangements for the survey, ensuring its smooth operation. The Nutrition survey was supported financially by UNICEF under a grant from the UK Department for International Development (DfID); this support is greatly appreciated. The contribution of local authorities in ensuring the survey teams’ security during fieldwork and in providing office facilities is gratefully appreciated.

The data could not have been obtained without the co-operation and support of the communities assessed, especially the mothers and caretakers who took time off from their busy schedules to respond to the interviewers. Their involvement and cooperation is highly appreciated.

UNICEF and MoPHP also express their sincere appreciation to the entire assessment team for the high level of commitment and diligence demonstrated during all stages of the assessment to ensure high quality of data collected, and the successful accomplishment of the exercise.

List of acronyms

ARIAcute Respiratory Infection

WFP-CFSSWorld food programme- Comprehensive Food Security Survey

CIConfidence Interval

CMAMCommunity Management of Acute Malnutrition

CSOCentral Statistical Organization

DHSDemographic Health Survey

ENAEmergency Nutrition Assessment

FHSFamily Health Survey

GAMGlobal Acute Malnutrition

HAZHeight for age z-score

IYCFInfant and Young Child Feeding

MAMModerate Acute Malnutrition

MDDMinimum Dietary Diversity

MoPHPMinistry of Public Health and Population

MUACMid-Upper Arm Circumference

OTPOut-patient Therapeutic Programme

SAMSevere Acute Malnutrition

SDStandard Deviation

SMARTStandardized Monitoring and Assessment of Relief and Transitions

U5Under-five

UNICEFUnited Nations Children’s Fund

WAZWeight for Age z-scores

WHZWeight for Height z-scores

Table of contents

Executive summary

Introduction / background

Assessmentobjectives

Methodology

Sampling Design and Sample Size Determination

Sampling Procedure:

Survey Population and Data Collection Process

Data Entry and Analysis

Data Entry Verification and Cleaning

Results

Household Characteristics of Study Population:

Morbidity, Immunization Status of the U5 children:

Infant and young child feeding (IYCF) practices:

Nutrition Status

Mortality:

Discussion and variable association

Levels of Malnutrition:

Vitamin A Supplementation and Malnutrition Levels:

Morbidity and Malnutrition Levels:

Child Feeding and Malnutrition Levels

Nutrition Status and Household Access to Food and Coping Strategies:

Water and sanitation with Nutrition situation:

Recommendations:

Annexes

Annex 1: Aden governorate Nutrition Survey Questionnaire

Annex 2: Aden governorate Mortality Survey Questionnaire

Annex 3: Aden governorate Nutrition Survey Team, 8 – 13 Aug 2015

Annex 4: job descriptions for Survey Teams (Extracted from SMART Training Materials)

Annex 5: Aden governorate Assessment Quality Checks

Annex 6: Cluster Sampling for Aden governorate

Executive summary

Between 8 and 13August 2015, MoPHP and Aden Governorate Public Health and Population Office supported by UNICEF conducted a nutrition and mortality survey in Aden Governorate using the Standardized Monitoring and Assessment for Relief and Transition (SMART) methodology to assess nutritional status, mainly the levels of acute malnutrition among children aged 6-59 months, and to identify some of the factors associated with malnutrition, estimate the under-five and crude death rates, and inform on the appropriate responses.

Using a Probability Proportionate to Population Size (PPS) sampling methodology, 36 clusters were randomly selected for both anthropometric and mortality assessments. A minimum of 13 households per cluster were randomly selected and assessed. A total of 479 households were surveyed, covering a total of 333 children aged 6-59 months.

Results indicated that acute malnutrition is above the WHO ‘critical’ threshold (15 per cent) with 19.2 per cent,underweight is above the WHO ‘serious’ threshold (20 per cent) with 23.4 per centwhile stunting is ‘normal’ with 16.7 per cent as shown in table (1) below. The severe acute malnutrition (SAM) rate found was 2.5 per cent without any oedema case. Both GAM and stunting rates were found insignificantly higher in boys than in girls, whileunderweight was found significantly higher in boys than in girls.

The main source of drinking water in the Governorate is the house-connected piped water 78 per cent of households and majority of households latrine type was pour flush with level of 97.5 per cent.

There is high prevalence of common disease, as recorded two weeks prior to the survey (diarrhoea, acute respiratory infection (ARI) and fever prevalence). Vitamin A coverage is lower than the Sphere Standard’s recommendation of 95 per cent coverage (69.6 per cent). About 23 per centof children aged 0-6 months was being exclusive breastfed. Among children 12to 15months of age, 64 per cent still on breastfeedingand only 40 per cent of children aged 6-23 months met the recommended minimum dietary diversity.

Around 89 per cent of household used to reduce the size of meals and 78.3 per centused to reduce the number of meals. Almost 80 per cent of household borrowed food or money to buy food or buy in credit and 67.6per cent reduced the expenditure on education and/or health to save money for buying food and 62 per centreported sleeping hungry because of shortage in food.

There is no statistically significant relationship between malnutrition and feeding patterns, or with vitamin A supplementation, but diarrhoea has shown relation to stunting. Reduction the expenditure on education or health to save money to purchase food has shown close relation with underweight.

The crude death rate found is 0.41 per 10000 per day, while the under-five (U5) death rate is 0.00 per 10000 per day and both are within the acceptable levels of less than 1/10,000/day.

Specific recommendations include:

Immediate Interventions

• Government along with development partners need to urgently restore security and basic services such as water, electricity and sanitation. As hundreds of internally displaced families have returned to their homes a general food distribution and provide food rations is important. Pre-positioned supplies in WASH, child protection and nutrition are important for response to reach the larger population.
• Develop detailed integrated multi-sectoral micro-plan to address the high levels of acute malnutrition among U5 children as well as underweight.
• Conduct mobile clinics to Aden suburbsto deliver CMAM services integrated with childhood illnesses management services.
• Establish a mobile targeted supplementary feeding programme to cap a rise in moderate malnutrition and prevent an increase in severe acute malnutrition.

Medium term Interventions

• Approach Aden Radio and TV to broadcast messages on the current situation and alert people to utilize the available services.
• The nutrition package that includes the management of acute malnutrition, the growth monitoring and promotion (GMP), IYCF counselling, and supplementation with micronutrients for child and mother should be entered to the minimum official service list at the governorate level to assure provision of this package by all working health facilities. This should be complemented by a relevant media educational package to be disseminated by Aden Radio and TV.
• Expand the MAM supplementary feeding programme to all fixed and outreach health service delivery sites.
• Closely monitor the food security situation and develop a contingency plan to provide prompt emergency relief as appropriate.
• Improve vaccination coverage by enhancing the governorate’s mobile health service initiative and implement SPHERE standards with special focus to vitamin A supplementation as well.
• Improve management of ARI and diarrhea in the communities with focus on preventive measures and possible curative responses.

Table 1: Summary of Nutrition Survey in Aden governorate, Aug2015
Indicator / N / % / 95% CI
Child Malnutrition
Total number of households assessed for children / 479/ 480 / 99.8
Mean household size / 6.5
Total number of children assessed (6-60 months) / 333/ 362 / 91.9
Number of children less than 6 months / 37 / 9.3
Child sexofU5 children
Males (boys) / 218 / 54.6
Females (girls) / 181 / 45.4
Global acute malnutrition (WHZ<-2 z-score or oedema) / 62 / 19.2 / (15.4 - 23.6)
Moderate acute Malnutrition (-2 z-score >=-3, no oedema) / 54 / 16.7 / (13.2 - 20.9)
Severe acute Malnutrition (WHZ<-3 z score or oedema) / 8 / 2.5 / (1.2 - 5.1)
Oedema / 0 / 0.0
Chronic malnutrition (H/A<-2 z score) / 54 / 16.7 / (11.7 - 23.3)
Moderate chronic Malnutrition(-2 >z-score >=-3( / 40 / 12.4 / (8.7 - 17.3)
Severe chronic Malnutrition (H/A<-3 Z score) / 14 / 4.3 / (2.2 - 8.4)
Underweight prevalence (W/A<-2 Z score) / 77 / 23.4 / (17.5 - 30.6)
Moderate underweight(-2 >z-score >=-3( / 61 / 18.5 / (14.0 - 24.1)
Severe underweight (W/A<-3 z score) / 16 / 4.9 / (2.6 - 9.0)
Child Morbidity
Children reported with suspected measles within one month prior to assessment / 25 / 6.3 / (3.9 - 8.7)
Children reported with diarrhoea in 2 weeks prior to assessment / 166 / 41.9 / (37.1 - 46.8)
Children reported with ARI within 2 weeks prior to assessment / 174 / 43.8 / (39.0 - 48.7)
Children reported with fever in 2 weeks prior to assessment / 178 / 44.8 / (39.9 - 49.7)
Immunization and Supplementation Status
Children aged 9 – 59 months immunised against measles
Confirmed by vaccination cards / 181 / 52.3 / (47.1 - 57.6)
Confirmed by recall / 101 / 29.2 / (24.4 - 34.0)
Children who have received 3 doses of polio vaccine / 314 / 86.7 / (83.3 - 90.2)
Children reported to have received vitamin A supplementation in last 6 months / 252 / 69.6 / (64.9 - 74.4)
Child Feeding
Exclusive breastfeeding under 6 months / 8 / 22.9 / (8.9 - 36.8)
Continued breast feeding at one year / 25 / 64.1 / (49.1 - 79.2)
Continued breast feeding at two years / 12 / 37.5 / (20.7 - 54.3)
Minimum diversity diet at 6-23 months / 57 / 40.4 / (32.3 - 48.5)
Mortality
0-5 Death Rate (U5DR) as deaths/10,000/ day / 0.00 / (0.00-0.00)
Crude Death Rate (CDR) as deaths/10,000/ day / 0.41 / (0.26-0.66)

1

Introduction / background

Historical

Aden was one of the ancient large Arabian markets. It used to be the port used by the Himyarites, which was known as the Awsani Port. The oldest historical landmarks are found in the Old City of Aden and its periphery. In general, contains many historical fortresses and old tunnels, which were used by the population until 1940 to move their livestock and their camels laden with goods. The Western Gate of Aden and these tunnels were the inlets to the Old City of "Crater" which is at the footsteps of Jabal (Mount) Shamsan on the northeast. The tunnels and the Aden Gate, the arch of which was removed in 1964, as well as Seira Fort can still be seen today. The Forts of JabalGhadir, Jabal 'Alyan and the Water Reservoirs of Al-Taweelah are considered among the most important historical sites that are visited today, in addition to the Lighthouse in Crater. Crater is the oldest city in the governorate and contains the most crowded markets such as the Za'afaran Market, the Buhara Market and the Al-Taweel Market. In Crater one will also find the oldest mosques, such as the historical Mosque of Abban and the Al-'Aidarous Mosque.

Between January 19, 1839 and November 30, 1979, it was colonised by the Great Britain during which Aden was geographically expanded to include more districts. Before it was colonised, Aden was limited to areas of Crater, Al-Malla Al-Tawahi and part of Khormaksar, but during the colonization, Al-Mansoura was established, Al-Buraiqa was constructed mainly for the oil refinery and was given the name of Little Aden, while Al-Sheikh Othman and Dar Sa’d were rented from the Sultan of Lahj as a response to the enlarged population size due to internal and external migration to Aden.

Recently, the city of Aden is the commercial capital of the Republic of Yemen. It overlooks the Arabian Sea and the Gulf of Aden. It is situated 346 km south of the City of Sana'a and 160 km east of the Strait of Bab Al-Mandab. The climate in the summer is hot and moderate in the Winter and rainfall is rare.Aden can be divided into two areas, Aden the Sea that is composed from peninsulas of Main Aden (Crater, Al-Malla, Tawahi, and Khormaksar) and Little Aden ( Al-Buraiqa) and Aden the Land that is composed of Dar Sa’d, Al-Mansoura, and Al-Shaikh Othman.

Current situation

The escalated conflict and heavy ongoing fight on the ground, combined with the full absence of basic food, and absence of physical and financial access because of the damage to the livelihood means. The severe deterioration of food availability (foods are not available even in the black market), physical and financial access due to loss of income sources and absence of humanitarian access will have very serious effect on the life and livelihoods of the population.

Within Aden Governorate around 4500 families (31500 people) are displaced[1]. The IDPs continued to arrive in Al Bureiqa District from Al-Tawwhai, Crater, Khourmaksar and Al Mualla Districts and to the other southern Governorates mainly to Lahj, Abyan, Shabowa and Hadramout till the mid July 2015. In fact, the number of IDPs are much bigger than the one registered, as IDPs are staying with their relatives, some of the families hosting more than four displaced families, which increases protection concerns for hosted IDPs around the risk of violence and forced domestic work.

Assessmentobjectives

The overall objective of the survey was to establish the nutrition situation in Aden governorate, determine some of the factors influencing malnutrition.

Specific objectives were:

1. To estimate the level of acute malnutrition (wasting), stunting and underweight among children aged 6-59 months in Aden governorate.
2. To identify health and nutrition underlying causes for malnutrition with a particular focus on IYCF practices for initiating corrective actions.
3. To estimate the prevalence of some common diseases (suspected measles, diarrhoea, fever and ARI) in Aden governorate.
4. To estimate the measles and polio vaccination and vitamin A supplementation coverage among children in Aden governorate.
5. To assess distribution of baby milk gifts.
6. To determine the average households in Aden governorate who did reduce meal size, lower number of meals, experience sleeping hungry, use debts to buy food, and lower expenditures in health and education to buy food.
7. To assess effect of the primary source of income for household head on nutritional status in Aden governorate.
8. To assess situation of income losingduring crisis among household heads in Aden governorate.
9. To estimate the crude and under-five mortality rates in Aden governorate.

Methodology

Sampling Design and Sample Size Determination

Aden is one ecological zone composed form eight districts so that there was no need to divide the governorate to more than one ecological zone that is almost an urban setting.

One cross-sectional cluster survey was conducted between 8 and 13 August 2015 in Aden Governorate. As Aden was one of the governorate where heavily armed conflict has taken place, displacement from districts of Crater, Kormakser, Mualla and Attwahi to other district and to other governorates has been reported. Because of this displacement, the selection of clusters was through three stages. In the first stage, the current distribution of population in the 8 districts as prepared by the GHO office after consulting the local authorities and the Relief Committee in Aden has been used to identify the number of clusters per district using the Proportionate to Population Size (PPS) approach. The second stage it select cluster sites for each district independently using the same PPS approach. 36 clusters were randomly selected for both anthropometric and mortality assessments.

Dataset of nutrition survey conducted in Aden in 2012 were visited for sifting values of parameters that have been used for calculating of sample size as shown in table (2) below.

Table 2. Parameters used in the Sample Size Determination

Anthropometry / Mortality
Number of clusters / 36 / Number of clusters / 36
Probability / 0.05 / Probability / 0.05
T / 2.030 / T / 2.030
Expected prevalence (p) / 18.2 / Estimated crude death rate (CDR) per 10000/day / 0.18
Relative desired precision (d) / 3.8 / Relative desired precision (d) per 10000/day / 0.2
Design Effect (DEFF) / 1.2 / Design Effect (DEFF) / 1.5
n (children 6 – 59 months) / 425 / Recall period in days (RP) / 135
Average household size / 7.37 / n (population) / 2065
% of U5 in population / 14.5 / Average household size / 7.37
Proportion of 6 - 59 months in U5 population / 0.92 / % Non response / 3
% Non response / 3
n (households) / 445 / n (households) / 288
Households per cluster / 13 / Households per cluster / 8

Calculation of sample size was not made using ENA for SMART, as ENA software uses only one default t value that is linked to a number of clusters of 30 and probability of 0.05. Since number of clusters in this survey is 36, then different t value was used. Equations used for calculation of sample size for both anthropometry and mortality are:

For anthropometry

For mortality

The number of households decided per both household questionnaire including anthropometry and for mortality form is 13 which is the number that is calculated for anthropometry as shown in the table (2) above.

Sampling Procedure:

As mentioned above, there was a large displacement in the governorate due to the armed conflict, so that, the first stage was the identification of cluster numbers per district based on the most accepted population distribution. PPS was followed for this process table (3) below shows the distribution of clusters per districts.