Somalia Nutrition Smart Survey Final Report Badhan

CARE INTERNATIONAL – SOMALIA

NUTRITION SMART SURVEY

FINAL REPORT

BADHAN DISTRICT, SANAG REGION, SOMALIA

OCTOBER 2019

ACKNOWLEDGMENT CARE Somalia would like to pleasantly acknowledge the support of everyone who was involved in successful execution of the SMART survey in Badhan District, Sanaag Region. The following played a key role;

▪ OFDA for their financial support to carry out the SMART survey ▪ Ministry of Health for their help in survey planning, coordination and implementation ▪ Community leaders for good reception and provision of household lists for their villages ▪ Parents and caretakers for availing their children for assessment as well as for providing other relevant data for the study ▪ Somalia Cluster’s Assessment and Information Management Working Group for their technical review and validation of the survey protocol and results. ▪ Care Somalia staff for the management of personnel, logistics planning and field implementation of the survey ▪ Field supervisors and data collectors for their hard work and dedication during data collection

Report compiled by: Epistat Research Consultants

TABLE OF CONTENTS ACKNOWLEDGMENT ...... I LIST OF TABLES ...... III LIST OF FIGURES ...... IV LIST OF ANNEXES ...... IV ACRONYMS AND ABBREVIATIONS ...... V EXECUTIVE SUMMARY ...... VI 1.0 INTRODUCTION ...... 1 1.1 Background ...... 1 1.2 Health and nutrition situation ...... 2 1.3 Justification of the survey ...... 2 1.4 Survey objectives ...... 3 1.4.1 Specific Objectives ...... 3 1.5 Survey location and timing ...... 3 2.0 METHODOLOGY ...... 4 2.1 Study design ...... 4 2.2 Target group ...... 4 2.3 Data and data collection methods ...... 4 2.4 Sample size determination ...... 5 2.4.1 Anthropometry sample size ...... 5 2.4.2 Summary of sampling methods ...... 6 2.5 Organization of the survey ...... 6 2.5.1 Recruitment and Composition of survey teams ...... 6 2.5.2 Training of the survey teams ...... 7 2.5.3 Field Data Collection ...... 7 2.6 Data Management ...... 7 2.6.1 Data Quality Control ...... 7 2.6.2 Data Collection Tools ...... 8 2.6.3 Data Entry and Analysis ...... 8 3.0 RESULTS- BADHAN DISTRICT ...... 9 3.1 Anthropometric Results...... 9 3.1.1 Distribution by age and sex ...... 9 3.1.2 Prevalence of Wasting (WHZ) ...... 10

3.1.3 Prevalence of Acute Malnutrition by MUAC ...... 12 3.1.4 Prevalence of Underweight (WAZ) ...... 14 3.1.5 Prevalence of Stunting (HAZ) ...... 15 3.1.6 Mean z-scores, Design Effects and excluded subjects ...... 16 3.2 Child morbidity and immunization coverage ...... 16 3.2.1. Child Morbidity ...... 16 3.2.2 Health seeking behaviour ...... 17 3.2.3 Child immunization, vitamin a supplementation, and deworming ...... 18 4.0 CONCLUSION ...... 20 5.0 RECOMMENDATIONS ...... 21 6.0 ANNEXES ...... 22

LIST OF TABLES Table 1: Summary of Main Survey Results ...... vi Table 2: Survey target group ...... 4 Table 3: Data and collection methods ...... 4 Table 4: Sample size determination ...... 5 Table 5: Summary of survey completeness ...... 9 Table 6: Distribution of age and sex of sample ...... 9 Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ...... 11 Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z- scores ...... 12 Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema ...... 12 Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex...... 13 Table 11: Prevalence of underweight based on weight-for-age z-scores by sex ...... 14 Table 12: Prevalence of stunting based on height-for-age z-scores and by sex ...... 15 Table 13: Mean z-scores, Design Effects and excluded subjects ...... 16

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LIST OF FIGURES Figure 1: Badhan Seasonal Calendar ...... 3 Figure 1: Age and sex pyramid ...... 10 Figure 2: Distribution of WHZ z-scores for the surveyed population ...... 11 Figure 3: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or edema ...... 14 Figure 4: Common illnesses reported ...... 17 Figure 5: Health seeking behavior ...... 17 Figure 6: Vitamin A Supplementation, Deworming and measles vaccination ...... 19

LIST OF ANNEXES Annex 1: List of sampled clusters ...... 22 Annex 2: Badhan District Plausibility report ...... 23 Annex 3: Badhan District Standardization test report ...... 24 Annex 4: Badhan District calendar of events, 2019 ...... 27

ACRONYMS AND ABBREVIATIONS AIMWG Assessment and Information Management Working Group CHW Community Health Worker CI Confidence Interval CMAM Community Management of Acute Malnutrition DEFF Design Effect ENA Emergency Nutrition Assessment FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition HAZ Height for Age Z-score HH/s Household/s IDPs Internally Displaced Persons IMCI Integrated Management of Childhood Illnesses IPC Integrated Phase Classification IYCF Infant and Young Child Feeding KAP Knowledge, Attitudes and Practices LCL Lower Confidence Limit MIYCN Maternal, Infant and Young Child Nutrition MOH Ministry of Health MUAC Mid Upper Arm Circumference ODK Open Data Kit OFDA Office of Foreign Disaster Assistance OTP Outpatient Therapeutic Programme. PPS Probability proportional to size SAM Severe Acute Malnutrition SD Standard Deviation Standardized Monitoring and Assessment of Relief and SMART Transitions TEM Technical Error of Measurement TSFP Targeted Supplementary Feeding Program UCL Upper Confidence Limit VAS Vitamin A Supplementation WASH Water, Sanitation and Hygiene WAZ Weight for Age Z-Score WHO World Health Organization WHZ Weight for Height Z- Score

EXECUTIVE SUMMARY CARE has been providing emergency relief and lifesaving assistance to the Somali people since 1981. Since then, its programs have evolved to include water and sanitation, Food security and livelihood, Nutrition and Education. CARE Somalia is currently operational in the northern regions of Puntland and Somaliland1. The nutrition program being implemented in 21 villages of Badhan and Lascanod Districts aims to address high malnutrition rates through treatment of Acutely Malnourished Children, pregnant and lactating women, referral and treatment of severely malnourished cases with medical complication as well as community based IYCF programs for improving IYCF practices in the community.

With financial support from the Office of Foreign Disaster assistance (OFDA), CARE Somalia conducted a SMART survey in Badhan District in October 2019. The goal of the survey was to determine a district representative prevalence of acute malnutrition in Badhan district. The survey was also a follow up to the last FSNAU Post Deyr 2019 survey and its findings will be used to inform for baseline/continuation of the project beyond 2019

The SMART survey adopted a cross-sectional study design applying two-stage cluster sampling based on the probability proportional to population size (PPS). The first stage involved the selection of 36 clusters/villages by the ENA software while the second stage involved the selection of 16 households in each of the sampled clusters to be surveyed through simple random sampling. The survey targeted 522 children from 564 households for the anthropometric survey as determined by ENA for SMART (July 19, 2015 update). Eventually, a total of 552 households from 36 clusters were surveyed with 689 children 6-59 months included in the survey. The key findings of the survey are shown in the table below;

Table 1: Summary of Main Survey Results

SUMMARY OF SURVEY RESULTS, OCTOBER 2019 INDICATOR N n % 95% CI ANTHROPOMETRIC RESULTS (6-59 MONTHS) WHO 2006 Wasting (WHZ) Prevalence of global malnutrition 678 91 13.4 10.5 – 17.0 (<-2 z-score and/or oedema) Prevalence of moderate malnutrition (<-2 80 11.8 9.0-15.4 z-score and >=-3 z-score, no oedema)

1 https://www.care-international.org/where-we-work/somalia vi

Prevalence of severe malnutrition (<-3 z- 11 1.6 0.9 – 2.8 score and/or oedema) Prevalence of GAM by MUAC Prevalence of global malnutrition (< 125 689 24 3.5 2.1-5.8 mm and/or oedema) Prevalence of global malnutrition (< 125 22 3.2 1.9-5.4 mm and >= 115 mm, no oedema) Prevalence of global malnutrition (< 115 2 0.3 0.1-1.2 mm and/or oedema) Underweight (WAZ) Prevalence of underweight (<-2 z-score) 685 90 13.1 11.0-15.6 Prevalence of moderate underweight (<-2 86 12.6 10.5-14.9 z-score and >=-3 z-score) Prevalence of severe underweight (<-3 z- 4 0.6 0.2-1.5 score) Stunting (HAZ) Prevalence of stunting (<-2 z-score) 673 83 12.3 9.9-15.3 Prevalence of moderate stunting (<-2 z- 69 10.3 8.3-12.7 score and >=-3 z-score) Prevalence of severe stunting (<-3 z- 14 2.1 1.2-3.6 score) CHILD IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND DEWORMING Measles immunization( 9-59 months) –( 660 420 63.6 58.5-69.2 Card and Recall) Vitamin A supplementation coverage 689 454 65.9 62.3- 69.3 children 6-59 months Deworming for Children (12-59 months) in 615 252 41.0 37.2-45.0 the last 6 months CHILD MORBIDITY AND HEALTH SEEKING BEHAVIOR Prevalence of reported illness (6-59 689 256 37.2 33.6-40.8 months) 14 days mothers/caregivers recall Fever 224 87.5 82.8-91.3 Cough 172 67.2 61.1-72.9 Diarrhea 40 15.6 11.4-20.7 Skin infections 10 3.9 1.9-7.1 Eye infections 1 0.4 0.01-2.7

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Other illnesses 24 9.4 6.1-13.6 Health seeking for sick children 129 50.4 44.1-56.7 Main location of health seeking –Private 129 36 37.2 28.9-46.2 health facilities

The findings revealed a nutrition situation which is serious as evidenced by the GAM prevalence of 13.4% (10.5 – 17.0 95% C.I.) based on the WHO emergency thresholds. Based on the survey findings, the following actions were recommended to improve delivery of health and nutrition services in Badhan District;

1) CARE Somalia should continue with nutrition services in Badhan District and scale up to uncovered locations in order to address the serious levels of malnutrition. Outreach services need to be considered in volatile or hard to reach areas. 2) Screening for malnourished cases by MUAC at the community level needs to be enhanced. This will help contain the situation and avoid at risk cases getting malnourished, while also having moderately malnourished cases treated early. 3) The indicators for Deworming, Vitamin A supplementation and immunization performed below the WHO targets. There is therefore nee to scale up community activities to promote the uptake of vitamin A and deworming, as well as promoting the uptake of other immunization services. 4) Strengthen the routine Vitamin A supplementation and deworming. This should be given more priority to improve the indicators considering the stability in the area, coverage and access to the health facilities. 5) Enhance health facility documentation. A training can be conducted on the health facility staff on documentation of routine activities. This can be accompanied by periodic data audits and verification exercises. 6) Considering the effect malnutrition has on the younger children, there is need to strengthen the MIYCN activities in the district, with a key focus on Exclusive breastfeeding and complimentary feeding, while also improving on poor practices such as bottle feeding. A significant proportion of 38.5% of the children in the KAP survey conducted in the area had been bottle fed. 7) A capacity assessment should be done on the public health facilities, including the lower levels of care in the community with a view of promoting customer service and promoting services access.

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1.0 INTRODUCTION 1.1 Background Badhan district is among the four administrative districts of Sanaag region located on the north eastern tip of Somaliland neighboring Sool and Togdheer regions. The population of Sanaag region is estimated at 270,367 (UNDP 2005)2. More than 79% of the population live in the rural areas predominantly practicing pastoral as the main source of livelihood with pockets of agro-pastoral areas. Over the years, the region has experienced recurring droughts and floods which depleted livestock herds adversely and resulted in urban migration. Approximately, 5,000 people from the region were displaced due to riverine and flash floods in May 20193. Most of the affected internally displaced persons (IDPs) have left rural areas in Sanaag, Lower Shabelle, Bakool and Bay to areas within or outside their region Political instability surrounding administrative ownership of the region between Somaliland and Puntland remain a huge challenge to the security and overall humanitarian effort in Badhan District and the entire Sanaag region.

CARE has been providing emergency relief and lifesaving assistance to the Somali people since 1981. Its main program activities since then have included projects in water and sanitation, sustainable pastoralist activities, civil society and media development, small-scale enterprise development, primary school education, teacher training, adult literacy and vocational training. CARE Somalia is currently operational in the northern regions of Puntland and Somaliland4.

Since 2018 CARE has been implementing Nutrition, health and FSL services in Badhan and Lascanod covering 21 villages. The CARE nutrition program aimed to address the high malnutrition rates through treatment of Acutely Malnourished Children under 5, pregnant and lactating women, referral and treatment of complicated cases of SAM and improving IYCF practices amongst the community through community based IYCF programs.

CARE International received a grant from OFDA/USAID to carry out humanitarian assistance in Bari, Galgadud, Mudug, Nugaal, Sanaag, Sool, and Togdheer regions of Puntland, Galgadud and Somaliland. The interventions happened over 1-year period from October 2018 to September 2019. The project provided temporary employment, treatment services for acutely malnourished children and pregnant and lactating women, basic health services, protection services, safe water to communities including hygiene promotion as well as provision of WASH Non-Food Items (mainly hygiene kits)

2 UNDP population Figure - 2005 3 Food and Nutrition Analysis Post Gu 2019, Technical Report No xI. 50, august 18, 2019 4 https://www.care-international.org/where-we-work/somalia 1

to vulnerable households. The project aimed a total reach of 247,671 people for assistance; equivalent to 22% of the population in IPC 3 and 4 in these regions5.

1.2 Health and nutrition situation Sanaag region has consistently recorded serious GAM levels. Based on the FSNAU assessments conducted in the region, the Post Deyr in 2017 recorded a GAM rate of 13.8%, with 12.6% recorded in a similar assessment in 2018. The post Gu 2019 recorded a GAM rate of 15.8% (11.6-21.1) which showed a deteriorating nutrition situation. In the absence of large-scale humanitarian assistance, food security is expected to rapidly deteriorate to emergency IPC Phase 4 in Northern Inland Pastoral, East Golis Pastoral of Sanaag6.

CARE Somalia, with the support of the ministry of health Puntland are supporting Infant and Young Child Feeding (IYCF) programming at all levels of the nutrition system in order to have an integrated and comprehensive approach of delivering basic nutrition services. With financial support from OFDA/USAID, CARE has been supporting 18 sites covering 14 villages through 2 mobile teams and 2 static sites.

A baseline IYCF survey was conducted in September 2018 in Sool and Sanag region in our areas of operation (Badhan, Ceelafweyn, Erigavo, Lascanod). The IYCF end line study was conducted in Bari, Sool and Sanag region (Bosaso, Badhan, Ceelafweyn, Erigavo, Lascanod and Taleh) in September 2019. The survey findings showed that exclusive breastfeeding was at 75.8%, while 84% of the children 6-8 months had been introduced to complimentary foods on a timely manner. Only 29.6 had continued breastfeeding beyond 2 years with 58.4% breastfeeding beyond one year. Dietary diversity was low at 4.5% with a meal frequency of 63%.

1.3 Justification of the survey CARE had been implementing Nutrition, health and FSL services in Badhan District aimed to address the high malnutrition rates through treatment of Acutely Malnourished Children below 5 years of age, pregnant and lactating women, referral and treatment of complicated cases of SAM and improving IYCF practices amongst the community through community based IYCF programs.

To understand malnutrition situation, CARE planned and conducted the first SMART survey to determine district representative prevalence of acute malnutrition in Badhan

5 https://reliefweb.int/job/3305148/terms-reference-tor-smart-survey-sool-and-sanag-regions- drought-response-and-recovery 6 SOMALIA Food Security Outlook, June 2019 to January 2020 2

district. The survey was also a follow up to the last FSNAU Post Deyr 2019 survey report. The findings of this survey will also be used by CARE to inform for baseline and continuation of the project into 2020.

1.4 Survey objectives The overall objective of this survey was to assess the prevalence of acute malnutrition among children 6-59 months in Badhan District.

1.4.1 Specific Objectives i) To estimate the current prevalence of acute malnutrition among children aged 6 – 59 Months. ii) To estimate the coverage of measles vaccination (9-59 months), Vitamin A supplementation (6-59 months) and deworming (12-59 months) iii) To assess common morbidity among children 6-59 months based on a 2 weeks’ recall iv) To draft actionable and localized recommendations based on the findings. Using assessment for action approach clearly indicating the finding, recommendations actions, timelines and responsibility and monitoring.

1.5 Survey location and timing The survey was conducted in Somalia’s Badhan District located in Sanag Region in October 2019. The survey timing fell on post Gu season as shown in Figure 1 below.

Figure 1: Badhan Seasonal Calendar

2.0 METHODOLOGY 2.1 Study design The SMART survey adopted a cross-sectional study design applying two-stage cluster sampling based on the probability proportional to population size (PPS). The first stage involved selection of clusters/villages by the ENA software while the second stage involved the selection of households to be surveyed through simple random sampling.

2.2 Target group Based on the objectives of this study, the survey targeted children age 6-59 months. Table 2: Survey target group Key Indicators Targeted Population Prevalence of acute malnutrition Children 6-59 months Child morbidity and health seeking Children 6-59 months Vitamin A supplementation Children 6-59 months Measles immunization Children 9-59 months Deworming Children 12-59 months

2.3 Data and data collection methods Table 3: Data and collection methods

Data and collection methods Anthropometric Data Age - Health cards and birth certificates were used to determine precise age of the child. Local calendar of events was used in the absence of documentation for children 6-59 months Sex – Was recorded as either ‘f’ for female or ‘m’ for male Weight - Standardized SECA scales were used Height - Standard height boards were used for taking length and height. Children less than 24 months were measured lying down and children greater than or equal to 24 months were measured in standing position MUAC – Was taken using standardized and MOH approved MUAC tape. All children 6- 59 months were measured on the left arm to the nearest 0.1cm or 1.0 mm Bilateral oedema - All children were checked for oedema; minimal thumb pressure was applied to the top of the feet for about 3 seconds Vitamin A supplementation – All children 6-59 months were assessed for Vitamin A supplementation in the past one year. Prevalence of child morbidity – this was assessed based on a 2 weeks (14 days) recall period for all the children 6-59 months

Health seeking behavior – For all the children reported ill, the caregivers were assessed on if and where they sought assistance for their sick children Measles vaccination – Measles vaccination either by recall or by card was assessed in all children aged 9-59 months in the survey Deworming - Supplementation with deworming tablets was assessed in children 12- 59 months in the survey.

2.4 Sample size determination 2.4.1 Anthropometry sample size The sample size for anthropometric survey was determined using ENA for SMART software (July 9, 2015 version). As shown below, the population parameters for Badhan Districts, Sanaag region were used to obtain the number of children and households to be included in the survey.

Table 4: Sample size determination Population Parameters Value Rationale/Source Somalia June-July 2019 surveys, FSNAU. Estimated Prevalence of 15.8% East Golis (Sanag) reported a GAM of GAM (%) 15.8% (11.6-21.1) Reasonable precision in consideration of Desired precision 4 estimated GAM and associated resources Was adjusted due to high DEFF 2.9 Design Effect 1.5 reported for East Golis survey Children to be included 522 Average HH Size 5.3 Somalia June-July 2019 surveys, FSNAU Adjusted from the Somalia June-July % Children under 5s 20% 2019 surveys, FSNAU of 26.8% for East Golis (Sanag) %Non-response Households 3% Anticipated Non-Response Rate Households to be included 564

Number of households per cluster The number of households to be completed per day in each cluster was determined according to the time each team could spend conducting the survey excluding travel time to the field and back, initial introduction and breaks.

The total amount of time available to work in a day was 9 hours (8:00 am – 5:00 pm). After exclusion of the travelling time, the initial introduction and household and lunch break, the amount of time left to conduct the survey was 7 hours. The amount of time

to be spent conduct the survey in one households was 25 minutes. The details below were taken into consideration when performing this calculation based on the Badhan District context:

▪ Departure from the base at 8:00 am and back at 5:00 pm. ▪ Average return travel time for each cluster: 1 hours ▪ Duration for initial introduction and selection of households: 0.5 hours ▪ Time spent to move from one household to the next: 5 minutes ▪ Average time in the household: 20 minutes ▪ Breaks: 1 lunch/prayer break of 0.5 hours

(9−1−0.5−0.5)60min 푛 = = 16.8 households (this is rounded down to 16). ℎℎ 20+5

Based on this calculation, 16 households were planned per village/cluster to be included in the survey.

Number of Clusters for Badhan District The number of clusters for Badhan district was determined by dividing the total households sample and 16 households (representing one cluster) i.e. number of clusters =564/16 = 35.3, this was rounded up to 36 clusters.

2.4.2 Summary of sampling methods First stage Cluster sampling The first stage involved the selection of 36 clusters in Badhan district using the ENA for SMART software based on population proportion to size (PPS). This was done using most recent list of villages with their population sizes.

Second stage sampling The second stage involved selection of 16 households in each of the 36 sampled clusters. With the assistance of village leaders, household listing was done on the survey day followed by simple random sampling using a random number generator mobile application. Clusters with households above 200 or sparsely populated were segmented before applying simple random selection of the households.

2.5 Organization of the survey 2.5.1 Recruitment and Composition of survey teams Care Somalia, with the guidance of the consultant developed the criteria for recruiting 7 survey teams, composed of 1 team leader and 2 data collectors. In total the survey recruited 21 enumerators to form 7 teams each composed of 3 persons. The selection process considered key factors such as the level of education, previous experience in

conducting surveys, the ability to read and communicate in English and undoubted fluency in Somali dialects.

2.5.2 Training of the survey teams The survey teams were trained over a period of 4 days in Garowe town. The training mainly focused on anthropometric measurements, survey teams, field procedures translation and back-translation of the questionnaires, data recording using ODK and second stage sampling. On day 3, standardization test was conducted using 10 healthy children (6-59 months) to determine enumerators’ precision and accuracy in recording measurements.

The pre-test was conducted on the fourth day in two non-sampled villages; Badhan- 30ka and Dhanaha. The results from the pre-test were analyzed, feedback shared and the identified gaps addressed appropriately for each team prior to data collection and final team formation.

2.5.3 Field Data Collection The implementation of field data collection was conducted for 7 days. Data was collected using ODK mobile application. Each team used one mobile phone with two back-up phones. Close Supervision of the teams was done by the survey consultant, CARE staff and MOH representative. At the end of each day’s data collection, the survey manager reviewed all questionnaires for completeness, errors and corrections done prior to sending the data to the server. Plausibility checks were done on a daily basis and feedback given to the teams.

2.6 Data Management 2.6.1 Data Quality Control To ensure data quality, the following measures were put in place; ▪ Review and validation of the protocol and report by the AIMWG ▪ 4-day comprehensive training including standardization and pilot test ▪ Field supervision of the survey teams during data collection by the Ministry of Health representative, consultant, the CARE program staff ▪ Distribution of enumerator strengths across the teams ▪ Calibration and standardization of the survey equipment ▪ Use ODK platform to collect and organize data ▪ Use of Cluster Control forms for survey outcome for every sampled household ▪ Daily plausibility checks and sharing feedback with the teams every morning before proceeding to the field ▪ Adequate logistic planning during field work

2.6.2 Data Collection Tools The SMART methodology approved anthropometry tool was used. The guidance of the Somalia AIMWG was applied designing the additional variables tool. The final tool combined anthropometry and additional variables (child morbidity, deworming, measles and vitamin A coverage).

2.6.3 Data Entry and Analysis The ODK collected was exported into MS Excel, organized and subsequently analyzed. The anthropometric data was uploaded into ENA for SMART 2011 software (July 9, 2015 version) for quality checks and analysis. Data obtained from additional variables was reviewed and analyzed using EPI Info 7.

3.0 RESULTS- Badhan District The anthropometric survey in Badhan district targeted 522 children 6-59 months from 564 households. The process of determining clusters led to an adjustment of the households to 576 households were sampled, after which 5527 households were surveyed with a cumulative total of 689 children. The summary of the survey completeness is shown in the table below;

Table 5: Summary of survey completeness CLUSTERS HOUSEHOLDS CHILDREN 6-59 MONTHS Planned 36 Planned 564 Planned 522 Surveyed 36 Surveyed 552 Surveyed 689 % surveyed 100% % surveyed 97.9% % surveyed 130%

3.1 Anthropometric Results All the children aged 6-59 months in the sampled households were included in the anthropometric survey. This involved taking their requisite measurements (age, sex, weight, height, MUAC and oedema) to determine their nutritional status based on the different anthropometric indices.

3.1.1 Distribution by age and sex There were a total of 689 children in the survey. Among the children, 357 were boys while 332 were girls hence achieving a boy: girl ratio of 1.1. This shows an equal representation of both sexes as evidenced by the resulting p-value = 0.3421. The age ratio of children 6-29 months (younger children) to children 30-59 months (older children) was 1.02 (The value should be around 0.85). Despite this value showing a significant difference (p-value = 0.016), the ration was near the expected value of 1.02 the representation of younger and older children in the survey was acceptable.

Table 6: Distribution of age and sex of sample

Boys Girls Total Ratio AGE (mo) no. % no. % no. % Boy:girl 6-17 91 51.1 87 48.9 178 25.8 1.0 18-29 94 55.3 76 44.7 170 24.7 1.2 30-41 78 49.7 79 50.3 157 22.8 1.0 42-53 74 51.0 71 49.0 145 21.0 1.0 54-59 20 51.3 19 48.7 39 5.7 1.1 Total 357 51.8 332 48.2 689 100.0 1.1

7 There were 24 absent households absent across the 36 clusters 9

The age and sex distribution is further presented in the graph below, showing an equal representation of boys and girls in the survey.

54-59

42-53

30-41

18-29

6-17

-100 -80 -60 -40 -20 0 20 40 60 80 100 Girls Boys

Figure 2: Age and sex pyramid

3.1.2 Prevalence of Wasting (WHZ) Global acute malnutrition (GAM) was defined as <-2 z-scores weight-for-height and/or oedema and severe acute malnutrition (SAM) was defined as <-3 z-scores weight-for height and/or oedema.

The survey made exclusions using the SMART flags (WHZ -3 to 3) based on the observed mean. This is as recommended by the SMART methodology for small scale surveys. The final sample used for the determination of GAM was 678 children after 11 children were excluded with z-scores out of range.

Based on the WHZ, the analysis recoded a Global Acute Malnutrition (GAM) rate of 13.4 %( 10.5 - 17.0 95% C.I) and a SAM prevalence of 1.6 %( 0.9 - 2.8 95% C.I.). According the to the WHO standards, the results indicate a serious nutrition situation in the district. Boys in the survey were evidently more malnourished than the girls, as depicted by their respective GAM prevalence in different thresholds.

Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex All Boys Girls n = 678 n = 353 n = 325 Prevalence of global malnutrition (91) 13.4 % (59) 16.7 % (32) 9.8 % (<-2 z-score and/or oedema) (10.5 - 17.0 (11.9 - 23.0 (6.6 - 14.5 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate (80) 11.8 % (54) 15.3 % (26) 8.0 % malnutrition (9.0 - 15.4 (10.6 - 21.6 (4.8 - 13.1 (<-2 z-score and >=-3 z-score, no 95% C.I.) 95% C.I.) 95% C.I.) oedema) Prevalence of severe malnutrition (11) 1.6 % (5) 1.4 % (6) 1.8 % (<-3 z-score and/or oedema) (0.9 - 2.8 95% (0.6 - 3.3 95% (0.9 - 3.7 95% C.I.) C.I.) C.I.)

The graphical presentation of the surveyed population shows a resulting mean of -0.79 and a standard deviation of ±1.04. The deviation of the population curve to the left indicates a population with a poorly nourished population, as compared to the WHO reference population.

Figure 3: Distribution of WHZ z-scores for the surveyed population

The survey did not record any oedema case, with only 1.7% of the children classified as marasmic. This is shown in the table below;

Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z- scores <-3 z-score >=-3 z-score Oedema present Marasmic kwashiorkor Kwashiorkor No. 0 No. 0 (0.0 %) (0.0 %) Oedema absent Marasmic Not severely malnourished No. 12 No. 677 (1.7 %) (98.3 %)

The analysis of wasting by age groups showed that younger children were more affected by malnutrition more than the older children for both severe and moderate wasting. This is the group on transition from exclusive breast feeding and complementary feeding, hence more vulnerable to the effects of inadequate nutrition. The findings may also indicate poor child care practices within this group.

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Severe Moderate Normal Oedema wasting wasting (> = -2 z (<-3 z-score) (>= -3 and <-2 score) z-score ) Age Tota No. % No. % No. % No. % (mo) l no. 6-17 176 3 1.7 23 13.1 150 85.2 0 0.0 18-29 166 2 1.2 17 10.2 147 88.6 0 0.0 30-41 153 5 3.3 20 13.1 128 83.7 0 0.0 42-53 144 1 0.7 13 9.0 130 90.3 0 0.0 54-59 39 0 0.0 7 17.9 32 82.1 0 0.0 Total 678 11 1.6 80 11.8 587 86.6 0 0.0

3.1.3 Prevalence of Acute Malnutrition by MUAC In children aged 6-59 months, the Mid-Upper Arm Circumference (MUAC), with simple cut-offs of MAM (>=115 mm to <125 mm) and SAM (<115 mm has shown to be a better

predictor of mortality risk that is associated with malnutrition8. MUAC is used to monitor malnutrition trends and for admission and discharge in nutrition programmes since its measurements can be done easily, quickly and affordably

The analysis of GAM by MUAC involved all the 689 children in the survey. This was in consideration of the MUAC cut offs applied in Somalia, where GAM is defined as MUAC <125mm and SAM defined as MUAC <115 mm. The results showed a GAM prevalence of 3.5 % (2.1 - 5.8 95% C.I.) and a SAM prevalence of 0.3 % (0.1 - 1.2 95% C.I.). Girls and boys in the survey were equally malnourished.

Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex All Boys Girls n = 689 n = 357 n = 332 Prevalence of global malnutrition (24) 3.5 % (11) 3.1 % (13) 3.9 % (< 125 mm and/or oedema) (2.1 - 5.8 95% (1.5 - 6.2 95% (2.0 - 7.6 95% C.I.) C.I.) C.I.) Prevalence of moderate (22) 3.2 % (10) 2.8 % (12) 3.6 % malnutrition (1.9 - 5.4 95% (1.4 - 5.4 95% (1.8 - 7.3 95% (< 125 mm and >= 115 mm, no C.I.) C.I.) C.I.) oedema) Prevalence of severe malnutrition (2) 0.3 % (1) 0.3 % (1) 0.3 % (< 115 mm and/or oedema) (0.1 - 1.2 95% (0.0 - 2.1 95% (0.0 - 2.3 95% C.I.) C.I.) C.I.)

Further analysis of the wasting by MUAC based on the age groups shows that younger children 6-17 months and 18-29 months were most affected by malnutrition with most of the severely acutely malnourished children falling in the 6-17 months category. This may be indicative of a gap in infant and young child nutrition, where the children transitioning from exclusive breastfeeding to complimentary feeding may not be getting adequate nutrition. The findings indicate poor IYCF practices in the district.

8 Chiabi, Andreas, et al. "Weight-for-height z score and mid-upper arm circumference as predictors of mortality in children with severe acute malnutrition." Journal of tropical pediatrics63.4 (2016): 260-266 13

Figure 4: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or edema

3.1.4 Prevalence of Underweight (WAZ) Underweight refers to inadequate weight relative to age and is measured using weight- for-age z-scores (WHO 2006). A child can have a low weight-for-age because they are short, thin or a bit of both and therefore underweight is considered a composite indicator for stunting and wasting9. The analysis of underweight involved 685 children after 4 children were excluded with z-scores out of range. The survey recorded an underweight prevalence of 13.1 %(11.0 - 15.6 95% C.I.) with a severe underwiehgt prevalence of 0.6 % (0.2 - 1.5 95% C.I.). This indicates an alert nutrition situation based on the WHO classification of underweight10. Boys in the survey had a higher prevalence of underweight than girls, with a 0.0% underweight prevalence in girls. This is detailed in the table below;

Table 11: Prevalence of underweight based on weight-for-age z-scores by sex All Boys Girls n = 685 n = 356 n = 329 Prevalence of underweight (90) 13.1 % (60) 16.9 % (30) 9.1 % (<-2 z-score) (11.0 - 15.6 (13.3 - 21.1 (6.7 - 12.3 95% C.I.) 95% C.I.) 95% C.I.)

9 Tanya K and Carmel D. the relationship between wasting and stunting, policy programming and research implications, 1915-1918. "Technical Briefing Paper 12.4 (July 2014): 8-9 10 Alert/medium 10-19.9 14

Prevalence of moderate (86) 12.6 % (56) 15.7 % (30) 9.1 % underweight (10.5 - 14.9 (12.4 - 19.8 (6.7 - 12.3 (<-2 z-score and >=-3 z-score) 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe (4) 0.6 % (4) 1.1 % (0) 0.0 % underweight (0.2 - 1.5 (0.4 - 3.0 (0.0 - 0.0 (<-3 z-score) 95% C.I.) 95% C.I.) 95% C.I.)

3.1.5 Prevalence of Stunting (HAZ) Stunting is defined as a slowing or halting of linear growth or ‘linear growth faltering’. This is commonly identified by a child falling off the standard growth trajectory compared to their age as described by the WHO growth standards11. A child is classified as stunted when their height-for-age is more than two standard deviations below the WHO Child Growth Standards median.

After exclusion of 16 children whose measurement were out of range, a total of 673 children were included in the analysis of stunting. The survey recording a low stunting12 prevalence of 12.3 %( 9.9 - 15.3 95% C.I.). Boys and girls in the survey were equally stunted as shown in the table below;

Table 12: Prevalence of stunting based on height-for-age z-scores and by sex

All Boys Girls n = 673 n = 348 n = 325 Prevalence of stunting (83) 12.3 % (48) 13.8 % (35) 10.8 % (<-2 z-score) (9.9 - 15.3 (10.3 - 18.2 (7.6 - 15.0 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of moderate stunting (69) 10.3 % (38) 10.9 % (31) 9.5 % (<-2 z-score and >=-3 z-score) (8.3 - 12.7 (8.1 - 14.6 (6.7 - 13.4 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe stunting (14) 2.1 % (10) 2.9 % (4) 1.2 % (<-3 z-score) (1.2 - 3.6 95% (1.7 - 4.9 (0.5 - 3.1 C.I.) 95% C.I.) 95% C.I.)

11 Tanya K and Carmel D. the relationship between wasting and stunting, policy programming and research implications, 1915-1918. "Technical Briefing Paper 12.4 (July 2014): 8-9)

12 WHO classification of stunting , Low <20% 15

3.1.6 Mean z-scores, Design Effects and excluded subjects The table below presents a summary of the three anthropometric indices as analysed in the survey. The total number of children 6-59 months included in the survey was 689. Exclusions were made before analysis for each anthropometric index using the smart flags, which are based on the observed mean. The final sample used in analysis of wasting, (WHZ), underweight (WAZ) and stunting (HAZ) is provided in the table below, with the corresponding mean and the design effect for each index. The standard deviation for all the indices was within the acceptable range of 0.85 - 1.2 indicating quality measurements. Details are shown in the table below;

Table 13: Mean z-scores, Design Effects and excluded subjects Indicator n Mean z- Design Effect z-scores not z-scores out scores ± SD (z-score < -2) available* of range

Weight-for-Height 678 -0.79±1.04 1.51 0 11 Weight-for-Age 685 -0.89±0.97 1.00 0 4 Height-for-Age 673 -0.69±1.13 1.11 0 16 * contains for WHZ and WAZ the children with oedema.

3.2 Child morbidity and immunization coverage 3.2.1. Child Morbidity Morbidity data was collected retrospectively based on a two week recall period. All the caregivers were asked whether their child had suffered any illness and the type of illness two weeks prior to the survey. The findings of the survey show that 37.6% of the children in the survey had suffered at least one illness two weeks prior to the survey. Fever and cough were the predominant illnesses, suffered by 87.5% and 67.2% of the sick children respectively. The other illnesses reported in the survey are shown in the graph below;

ILLNESSES REPORTED 100% 87.5% 90%

80%

70% 67.2%

60%

50%

40%

30%

20% 15.6% 9.4% 10% 3.9% 0.4% 0% FEVER COUGH DIARRHOEA SKIN INFECTION EYE INFECTIONSOTHER ILLNESES

Figure 5: Common illnesses reported

3.2.2 Health seeking behaviour To assess the health seeking behaviour, caregivers were asked what they did the last time their child was sick. A notable proportioning (49.6%) of the caregivers did not seek any type of assistance when their child was ill. This may be as a result of the caregivers’ assumption that the illness was not serious enough to warrant any external assistance. Most of the caregivers who sought assistance preferred private clinics (37.2%) and public health facilities (27.9%). The other places where the caregivers sought assistance are shown in the figure below;

Health Seeking Behaviour 2.3% Religious leaders Traditional healer 3.1% CHW/Community Nutrition worker 9.3% Shop 10.1% Phamarcy/chemist 10.1% 27.9% Public health facilities/hospital Private clinic 37.2% 0% 5% 10% 15% 20% 25% 30% 35% 40%

Figure 6: Health seeking behavior

3.2.3 Child immunization, vitamin a supplementation, and deworming WHO recommends that Children be supplemented with Vitamin A at 6 months and subsequently at 6 months’ intervals until a child reaches 5 years old13. Deworming at least biannually using single doses of albendazole (400 mg) or mebendazole (500 mg) is recommended as a public health intervention for all young children 12–23 months of age, preschool children 1–4 years of age, and school-age children 5–12 years of age14.

To assess the coverage of vitamin A supplementation and deworming, the caregivers were shown vitamin A (6-59 months) and deworming tablets (12-59 months), which was meant to aid them recall if their children had received such in the past 12 months and past 6 months respectively. Measles vaccination was also assessed in all children 9-59 months in the survey based on the EPI card or on recall where the cards were not available.

The survey findings show that 65.9% of the children 6-59 months had been supplemented with vitamin A in the past 12 months, while less than half (44.9% of the children 12-59 months had been dewormed 6 months prior to the survey. More than half (63.6%) of the children 9-59 months in the sample had been immunized against measles with only 4.4% being verified by the EPI card. The routine program data in the district reported a measles coverage of 62.2%15, which is similar to the coverage found in the survey. The performance of Vitamin A, deworming and also measles fall below the WHO recommended coverage of 80%, hence the need to put in place measures for scale up to achieve the desired public health significance.

13 www.who.int/nutrition/publications/vitamins_minerals/en/index.html 14 Deworming and adjuvant interventions for improving the developmental health and well-being of children in low- and middle-income countries: a systematic review and meta-analysis 15 EPI coverage, Badhan district 18

Vaccination and Immunization 70% 65.9% 63.6% 60%

50% 44.9%

40%

30%

20%

10%

0% Vitamin A (6-59 months) Deworming (12-59 months) Measles (9-59 months)

Figure 7: Vitamin A Supplementation, Deworming and measles vaccination

4.0 conclusion The nutrition situation in Badhan district is serious as evidenced by the GAM prevalence of 13.4% (10.5 – 17.0 95% C.I.) based on the WHO emergency thresholds. A nutrition and food security assessment had been conducted in East Golis (Sanaag) where Badhan district is included, which showed a GAM of 15.8% (11.6-21.1). The area has consistently recorded serious nutrition levels based on the GAM prevalence from the FSNAU assessments. The Post Deyr Food security and nutrition assessment conducted in 2017 recorded a GAM rate of 13.8%, with 12.6% recorded in a similar assessment in 2018. GAM prevalence by MUAC was low 3.5% (2.1- 5.8 95% CI) as compared to the prevalence by WHZ. This is expected as MUAC is more sensitive at high specificity levels than WHZ for identifying children at high risk of death. It is worth noting that MUAC and WHZ do not always identify the same children as having SAM hence the difference in the prevalence of malnutrition by the 2 criteria16. The 2 criteria should be used in management of acute malnutrition, with MUAC being the most effective for screening children at the community level.

Based on the SMART survey results, the younger children (6-29 months) were the most affected by acute malnutrition as compared to the older children. Malnutrition at such an early age can be attributed to the fact that infants have high nutrient requirements and are more susceptible to infection especially at this age when they are being introduced to solid and semi-solid foods. The high rates of wasting in this group may be suggestive of inadequate nutrition and care practices within this group, hence a need to enhance child care practices through MIYCN programs in the district. The prevalence of underweight was alert at 13.1% (11.0 - 15.6 95% C.I.) while the prevalence of stunting was low at 12.3% (9.9 – 15.3, 95% C.I).

The assessment of child morbidity showed a morbidity rate of 37.6%, with the main illnesses reported being fever and cough at 81.5% and 67.2% respectively. It is however concerning that almost half (49.6%) of the caregivers with sick children did not seek any kind of assistance when the children were sick. This may be due to factors like the caregivers not prioritizing some illnesses, distance to the health facilities or the caregivers not well informed on when and where to seek assistance when the child is sick. Private facilities were the most preferred by the caregivers (37.2%) as compared to the public health facilities (27.9%). The cost associated with the private facilities, and the low preference to public health facilities may be a contributing factor for some caregivers not seeking treatment for their sick children.

Although vitamin A supplementation was below the WHO recommended threshold of 80%, it was commendable that 65.9% of the children had been supplemented at least

16 Grellety E, Golden MH. Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr. 2016;2:10. 20

once in the past 12 months. Deworming was low at 44.9% for children 12-59 months while measles vaccination was 63.6%. measles vaccination was majorly confirmed by recall, hence the need to improve on the documentation of vaccinations through the EPI program, as well as documenting the births, which will help in timely and effective immunizations. There is a need to improve the awareness on immunizations and vaccinations so as to reach levels which can bring a public health significance.

5.0 Recommendations 1) CARE Somalia should continue with nutrition services in Badhan District and scale up to uncovered locations in order to address the serious levels of malnutrition. Outreach services need to be considered in volatile or hard to reach areas. 2) Screening for malnourished cases by MUAC at the community level needs to be enhanced. This will help contain the situation and avoid at risk cases getting malnourished, while also having moderately malnourished cases treated early. 3) The indicators for Deworming, Vitamin A supplementation and immunization performed below the WHO targets. There is therefore nee to scale up community activities to promote the uptake of vitamin A and deworming, as well as promoting the uptake of other immunization services. 4) Strengthen the routine Vitamin A supplementation and deworming. This should be given more priority to improve the indicators considering the stability in the area, coverage and access to the health facilities. 5) Enhance health facility documentation. A training can be conducted on the health facility staff on documentation of routine activities. This can be accompanied by periodic data audits and verification exercises. 6) Considering the effect malnutrition has on the younger children, there is need to strengthen the MIYCN activities in the district, with a key focus on Exclusive breastfeeding and complimentary feeding, while also improving on poor practices such as bottle feeding. A significant proportion of 38.5% of the children in the KAP survey conducted in the area had been bottle fed. 7) A capacity assessment should be done on the public health facilities, including the lower levels of care in the community with a view of promoting customer service and promoting services access.

6.0 Annexes Annex 1: List of sampled clusters Village name Population size Cluster Number Badhan-Geeldoora 1 1272 1 Badhan-Geeldoora 2 2 Badhan-Waaberi 1 2915 3 Badhan-Waaberi 2 4 Badhan-Horseed 1 3074 5 Badhan-Horseed 2 6 Badhan-Horseed 3 7 Badhan-Iftin 1 2385 8 Badhan-Iftin 2 9 Badhan-Iftin 3 10 Mindigale 1 2862 11 Mindigale 2 12 Ceelbuh 1 2385 13 Ceelbuh 2 14 Ceelbuh 3 15 Rad 1 1590 16 Rad 2 17 Laako 1166 18 Cawsane 1 2385 19 Cawsane 2 20 Gumar 1219 21 Xarka-Dheere 636 22 Mindhicir 1272 23 Haylaan 1 2385 24 Haylaan 2 25 Haylaan 3 26 Caadsaaran 1590 27 Dooxadheer 1060 28 Faracad 689 29 Hadaftimo 1 4134 30 Hadaftimo 2 31 Hadaftimo 3 32 Gurmalle 398 33 Qoyan 636 34 Gooraan 795 35 Habarshiro 1113 36

Badhan-Golis 1034 RC Jiicanyo 636 RC Bendersamo 636 RC Hadaftimo 4134 RC Badhan-30ka 530 Pretest Dhanaha 795 Pretest

Annex 2: Badhan District Plausibility report Plausibility check for: SOM_102019_CARE_BADHAN.as

Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report are more for advanced users and can be skipped for a standard evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (1.6 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.341)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 4 (p=0.016)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (5)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 2 (10)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (6)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 0 (1.04)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (0.14)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.17)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.054)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 6 %

The overall score of this survey is 6 %, this is excellent.

Annex 3: Badhan District Standardization test report

Standardisation test results Precision Accuracy OUTCOME Coef Bias Techni of Bias from subje me ma cal TEM/m reliabi from media Weight cts an SD x error ean lity superv n result TEM Bias Bias # kg kg kg (kg) TEM (%) R (%) (kg) (kg) 12. 2. 0. TEM Supervisor 10 7 5 2 0.07 0.6 99.9 - 0.81 acceptable R value good Bias reject Enumerator 12. 2. 0. TEM 1 10 7 5 1 0.06 0.5 99.9 -0.01 0.81 acceptable R value good Bias reject Enumerator 12. 2. 0. TEM 2 10 7 4 2 0.05 0.4 99.9 0 0.81 acceptable R value good Bias reject Enumerator 12. 2. 1. R value 3 10 7 5 5 0.36 2.9 97.9 -0.01 0.81 TEM reject acceptable Bias reject Enumerator 12. 2. 0. 4 10 7 5 7 0.18 1.4 99.5 -0.04 0.77 TEM poor R value good Bias reject Enumerator 12. 2. 0. 5 10 7 4 1 0.02 0.2 100 0 0.81 TEM good R value good Bias reject Enumerator 12. 2. 0. 6 10 7 5 1 0.03 0.2 100 0 0.81 TEM good R value good Bias reject enum inter 12. 2. TEM 1st 6x10 7 4 - 0.13 1 99.7 - - acceptable R value good enum inter 12. 2. 2nd 6x10 7 4 - 0.23 1.8 99.1 - - TEM poor R value good inter enum + 12. 2. TEM sup 7x10 7 4 - 0.16 1.3 99.5 - - acceptable R value good TOTAL R value intra+inter 6x10 - - - 0.25 2 98.9 -0.01 0.8 TEM reject acceptable Bias reject TOTAL+ sup 7x10 - - - 0.23 1.8 99.1 - - TEM poor R value good Techni Bias subje me ma cal TEM/m Coef from Bias Height cts an SD x error ean of superv from result

reliabi media lity n TEM Bias Bias # cm cm cm (cm) TEM (%) R (%) (cm) (cm) 92. 10 3. Supervisor 10 3 .7 8 0.91 1 99.3 - -1.11 TEM poor R value good Bias good Enumerator 93. 10 19 R value 1 10 2 .4 .1 4.33 4.6 82.6 0.93 -0.19 TEM reject reject Bias good Enumerator 11 2 10 92 .3 1 0.35 0.4 99.9 -0.24 -1.35 TEM good R value good Bias good Enumerator 92. 3 10 4 11 1 0.31 0.3 99.9 0.07 -1.04 TEM good R value good Bias good Enumerator 91. 11 3. 4 10 7 .5 5 0.97 1.1 99.3 -0.57 -1.69 TEM poor R value good Bias good Enumerator 92. 10 0. 5 10 4 .9 8 0.19 0.2 100 0.14 -0.97 TEM good R value good Bias good Enumerator 91. 10 10 6 10 9 .1 .1 2.28 2.5 94.9 -0.39 -1.5 TEM reject R value poor Bias good enum inter 10 R value 1st 6x10 92 .8 - 1.62 1.8 97.7 - - TEM reject acceptable enum inter 92. 10 2nd 6x10 6 .7 - 2.56 2.8 94.2 - - TEM reject R value poor inter enum + 92. 10 R value sup 7x10 3 .6 - 1.91 2.1 96.6 - - TEM reject acceptable TOTAL intra+inter 6x10 - - - 2.96 3.2 92.3 -0.01 -1.12 TEM reject R value poor Bias good TOTAL+ sup 7x10 - - - 2.75 3 93.3 - - TEM reject R value poor Coef Bias Techni of Bias from subje me ma cal TEM/m reliabi from media MUAC cts an SD x error ean lity superv n result m m TEM Bias Bias # mm m m (mm) TEM (%) R (%) (mm) (mm)

144 10 4. R value Supervisor 10 .7 .6 5 1.76 1.2 97.3 - -0.29 TEM good acceptable Bias good Enumerator 146 10 R value Bias 1 10 .4 .9 25 5.83 4 71.2 1.64 1.35 TEM reject reject acceptable Enumerator 141 2 10 .6 11 10 2.91 2.1 93.1 -3.07 -3.35 TEM poor R value poor Bias good Enumerator 143 10 R value 3 10 .1 .6 8 1.96 1.4 96.6 -1.57 -1.85 TEM good acceptable Bias good Enumerator 145 10 R value 4 10 .6 .4 10 4.25 2.9 83.3 0.89 0.6 TEM reject reject Bias good Enumerator 145 12 R value 5 10 .2 .3 6 1.9 1.3 97.6 0.49 0.2 TEM good acceptable Bias good Enumerator 146 13 R value Bias 6 10 .3 .1 23 6.23 4.3 77.4 1.59 1.3 TEM reject reject acceptable enum inter 144 11 R value 1st 6x10 .8 .9 - 4.61 3.2 85.1 - - TEM reject reject enum inter 144 10 R value 2nd 6x10 .6 .8 - 5.21 3.6 76.6 - - TEM reject reject inter enum + 144 11 R value sup 7x10 .7 .2 - 4.48 3.1 84 - - TEM reject reject TOTAL R value intra+inter 6x10 - - - 6.48 4.5 67.3 -0.01 -0.29 TEM reject reject Bias good R value TOTAL+ sup 7x10 - - - 5.99 4.1 71.4 - - TEM reject reject

Annex 4: Badhan District calendar of events, 2019

Badhan District Calender of Events MONTH SEASONS 2014 2015 2016 2017 2018 2019 January 57 45 33 21 9 Mawlid War between Campaing Tukoraq war Puntland alshabab and Period for Farmajo visited election puntland presidency Jubaland president February 56 44 32 20 8 Death of Prof Daalo airline Farmajo Diraac Mohamed Tobeel explossion election March 55 43 31 19 7 Many immigrants Sima drought from yemen Election of Magclay war Hassan Khayre (Prime minister April 54 42 30 18 6 Explossion in Heavy rains Sima drought Tukoraq Garowe killing UN and flooding war staff

May 53 41 29 17 5 GU Sima drought Tukoraq war Ramadhan June 52 40 28 16 4 Ramadhan Ramadhan Ramadhan Tukoraq war Ramadhan Idd Ul fitri

July 51 39 27 15 3 Dabshid Somalia Prime Minister visited Puntland August 50 38 26 14 2 Xagaa Jubaland Idd ul fitri Garacad Port presidential Started elections September 49 37 25 13 1 Idd al Adha Idd Al Adha Idd Al Adha Idd Al Adha

October 48 36 24 12 0 War between Scobe?Zoobe Abdiwali Ali visited Puntland and (Bomb attack) Badhan Galmudug November Deyr 59 47 35 23 11 Qandala war December 58 46 34 22 10 Bosaso airport Mowlid Mowlid Mowlid rebuild