South Sudan NUTRITIONAL ANTHROPOMETRIC SURVEY

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER 5 YEARS OLD

NIMNI PAYAM, GUIT COUNTY, WESTERN UPPERNILE

October 21st – November 10th, 2005

Joyce Mukiri – Nutritionist Joseph Ngángá - Nutritionist Santino Gatkuoth - Nutrition Survey Program Officer (ACF-USA) 2

ACKNOWLEDGMENTS ACF-USA acknowledges the invaluable support and assistance of the following:

ECHO for funding the survey,

Sudan Relief and Rehabilitation Commission (SRRC), both in Lokichoggio and Nimni payam for facilitating the work in the field,

The local survey teams for working tirelessly,

Mothers and caretakers, local authorities, and community leaders for their co-operation. 3

TABLE OF CONTENTS .I. EXECUTIVE SUMMARY...... 5

.I.1. INTRODUCTION ...... 5 .I.2. OBJECTIVES ...... 5 .I.3. METHODOLOGY ...... 5 .I.4. SUMMARY OF FINDINGS AND RECOMMENDATIONS...... 6 .II. INTRODUCTION ...... 8

.III. OBJECTIVES ...... 8

.IV. METHODOLOGY...... 9

.IV.1. TYPE OF SURVEY AND SAMPLING SIZE ...... 9 .IV.2. SAMPLING METHODOLOGY...... 9 .IV.3. DATA COLLECTION ...... 9 .IV.4. INDICATORS, GUIDELINES, AND FORMULAS USED...... 10 .IV.4.1. Acute Malnutrition...... 10 .IV.4.2. Morality ...... 10 .IV.5. FIELD WORK ...... 11 .IV.6. DATA ANALYSIS ...... 11 .V. RESULTS OF THE QUALITATIVE ASSESSMENT...... 12

.V.1. INTERNALLY DISPLACED PERSONS (IDP’S) AND RETURNEES POPULATION ...... 12 .V.2. FOOD SECURITY ...... 12 .V.3. FEEDING AND CHILDCARE PRACTICES...... 13 .V.4. HEALTH...... 13 .V.5. WATER AND SANITATION ...... 13 .V.6. EDUCATION ...... 14 .V.7. AGENCIES INTERVENING IN THE AREA ...... 14 .VI. RESULTS OF THE ANTHROPOMETRIC SURVEY...... 15

.VI.1. DISTRIBUTION BY AGE AND SEX...... 15 .VI.2. ANTHROPOMETRIC ANALYSIS...... 16 .VI.2.1. Acute Malnutrition...... 16 .VI.2.2. Risk of Mortality: Children’s MUAC...... 20 .VI.3. MEASLES VACCINATION COVERAGE...... 20 .VI.4. HOUSEHOLD STATUS...... 21 .VI.5. COMPOSITION OF THE HOUSEHOLD ...... 21 .VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY...... 21

.VII.1. MORTALITY RATE ...... 21 .VIII. CONCLUSION ...... 22

.IX. RECOMMENDATIONS...... 22

.X. APPENDIX...... 23

.X.1. LIST OF VILLAGES AND CLUSTERS ...... 23 .X.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE ...... 24 .X.3. CALENDAR OF EVENTS IN NIMNI PAYAM – OCTOBER, 2005 ...... 25 .X.4. MORTALITY SURVEY QUESTIONNAIRE (CLUSTER ENUMERATION DATA COLLECTION FORM)...... 27 .X.5. MORTALITY SURVEY QUESTIONNAIRE FORM (HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY)...... 28 .X.6. ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN SIX MONTHS ...... 34 4

LIST OF TABLES TABLE 1 RESULTS OF ANTHROPOMETRIC SURVEY...... 7 TABLE 2 ORGANIZATIONS INTERVENING IN NIMNI PAYAM ...... 14 TABLE 3 DISTRIBUTION OF THE SAMPLE BY AGE AND SEX...... 15 TABLE 4 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORES ...... 16 TABLE 5 WEIGHT FOR HEIGHT VS. OEDEMA IN Z-SCORE ...... 16 TABLE 6 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN Z-SCORES ...... 17 TABLE 7 NUTRITIONAL STATUS IN Z-SCORES BY GENDER...... 17 TABLE 8 WEIGHT/HEIGHT: DISTRIBUTION BY AGE IN PERCENTAGE OF MEDIAN...... 18 TABLE 9 WEIGHT FOR HEIGHT VS. OEDEMA IN PERCENTAGE OF MEDIAN...... 18 TABLE 10 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN PERCENTAGE OF MEDIAN ...... 18 TABLE 11 NUTRITIONAL STATUS BY SEX IN PERCENTAGE OF MEDIAN...... 19 TABLE 12 AGE DISTRIBUTION OF THE UNDER SIX MONTHS...... 19 TABLE 13 FEEDING PRACTICES...... 19 TABLE 14 NUTRITIONAL STATUS BY MUAC...... 20 TABLE 15 MEASLES VACCINATION COVERAGE ...... 20 TABLE 16 HOUSEHOLD STATUS ...... 21 TABLE 17 HOUSEHOLD COMPOSITION...... 21

LIST OF FIGURES FIGURE 1 DISTRIBUTION OF THE SAMPLE BY AGE AND SEX, NIMNI PAYAM...... 15 FIGURE 2 Z-SCORES DISTRIBUTION WEIGHT-FOR-HEIGHT, NIMNI PAYAM ...... 17 5

.I. EXECUTIVE SUMMARY

.I.1. Introduction

Guit County with an approximate total area of 450 square km lies within the highlands of leech state (the state is divided into two zones namely highlands (Northern Leech) and Lowlands (Southern Leech). It is bordered by Ruweng County to the north, Kouch County to the south, Fangak to the east, Rubkona County to the west and Lake No to the north east. The County comprises of four payams namely Nimni, Nyathoar, Kadet and Kuac, which are further subdivided into villages. Nimni payam is characterized by a flat landscape with fertile black cotton soil and several rivers cutting across it. These rivers provide drinking water, fish and pastures for both human and livestock through out the year.

The WFP interagency rapid needs assessment in Guit in April 2005 reported that rainfall during the year 2004 started late, was erratic and unevenly distributed with prolonged dry spells in between May and October 2004. This had severely affected crop performance and eventually the harvest. It also led to scarcity of wild foods that act as a buffer during hunger gaps. Also, the skirmishes that started in March 2005 between the Bul tribe of Mayoum County and the Leek tribe of Rubkoana County displaced people and cattle from Rubkona County into Guit County. These IDP’s burdened the host community through sharing their meagre resources. Additionally, information provided by MSF-H staff revealed observable signs of malnutrition among the resident community.

.I.2. Objectives

From 21st October to 10th November, ACF-USA carried out a nutritional survey in Nimni payam with the following objectives:

• To evaluate the nutritional status of children aged 6 to 59 months.

• To estimate the measles immunisation coverage of children aged 9 to 59 months.

• To identify groups at higher risk to malnutrition: age group and sex.

• To estimate the crude mortality rate through a retrospective survey.

.I.3. Methodology

A two-stage cluster survey methodology was applied. The survey planned to use a 30 by 30 cluster methodology that requires a minimum of 900 children. However, since the target population was less than 4,500, but above 1,000 infants, the formula was revised to give 22 children per cluster with a total of 788 being surveyed. This sample size was taken to provide the estimates of the prevalence of malnutrition with a 95 % confidence interval.

This sampling frame covered all the villages falling within Nimni payam. In each cluster, households were randomly selected and surveyed. All the children 6 to 59 months of age of the same family, defined as a woman and her children, were included in the survey.

A retrospective mortality survey following the Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology (over the past three months) was simultaneously conducted with the anthropometric survey. 6

Focus group discussions with key informants and observations were also done to capture food security and health information.

.I.4. Summary of Findings and Recommendations

Nimni payam harbors people of Nuer tribe belonging to Jikany clan which is further subdivided into various sub- clan sections namely: Cieng Rueh, Cieng Yol, Cieng Dholeak, Cieng Wangkai, Gaagong, Thieng Cienggai and Thieng Cieng Kouth with each section being ruled by a chief head. The population are agro-pastoralists with cattle keeping being the main livelihood.

MSF-H and South Sudan Disabled Persons Association (SSDPA), an indigenous NGO are the only agencies on ground. MSF-H supports health services and is operating one PHCU offering both curative and preventive services as well as outpatient therapy. SSDPA is supporting education with funding from Stromme foundation- Norway.

There are two boreholes in the entire Payam, but only one is functional. Most community members draw water for household use from swamps. Water is not treated before use. There were no latrines observed in the villages save for the one in the SSRC compound; this was confirmed by the authorities as well. Lack of tools and equipment for digging were cited as a hindrance to owning latrines otherwise, if they were available the community would be willing to use them as there is no cultural prohibition to their use.

Most of the households reported to have exhausted their sorghum stock, hence they were surviving on little stocks of maize, wild foods, kinship support, relief food from NPA and WFP and fishing from the rivers and swamps surrounding Nimni. The September 2005 sorghum harvest was poor as a result of erratic rains and attack from pests.

A total of 788 children were measured during the nutritional survey; no record was excluded from the analysis because of incoherent data. The results of the anthropometric survey are presented on the table below: 7

Table 1 Results of Anthropometric Survey

AGE GROUP INDICATOR RESULTS1 Global Acute Malnutrition 13.5 % (10.3%-17.4%) W/H< -2 z and/or oedema Z-score Severe Acute Malnutrition 1.1% (0.4%-3.0%) 6-59 months W/H < -3 z and/or oedema (n = 788) Global Acute Malnutrition 7.1% (4.8%-10.3%) W/H < 80% and/or oedema % Median Severe Acute Malnutrition 0.1% (0.1%-1.4%) W/H < 70% and/or oedema Global Acute Malnutrition 13.3% (8.8%-19.3%) W/H < -2 z and/or oedema Z-score 6-29 months Severe Acute Malnutrition (n = 377) 1.3% (0.2%-4.6%) W/H < -3 z and/or oedema Global Acute Malnutrition 9.0% (5.4%-14.4%) W/H <80% and/or oedema % Median Severe Acute Malnutrition 0.3% (0.1%-2.9%) W/H <70% and/or oedema Total crude retrospective mortality (last 3 months) /10,000/day 0.44 [0.02 – 0.89] Under five crude retrospective mortality /10,000/day 0.27 (0.07-0.62) Percentage of children under five amongst death recorded 25% Measles immunization coverage By card 0.9% According to caretaker2 26.3 % Not immunized 72.8%

The nutritional survey was undertaken in one of the five payams of Guit County, sampling a total of 788 children 6-59 months of age. The analysis of the anthropometrics data showed that 13.5% of the children are acutely malnourished of which 1.1% is severely malnourished. Among children 6-29 months of age, the GAM rate is 13.3% while SAM is 1.3%. These rates are slightly below the emergency level benchmarks of 15% and 4% for GAM and SAM rates.

Although the results do not indicate critical nutritional status among the population in the payam, any slight deterioration of the situation would compromise this, and hence, several factors need to be enhanced and maintained. ACF-USA recommends the following:

• MSF-H and/or other health agencies to maintain the health intervention activities and consider increasing the coverage and access to its services, more so to primary health care package including EPI, health education, growth monitoring as well as nutritional monitoring while ensuring full implementation of the same.

• Agencies concerned with water and sanitation activities having the capacity to intervene to consider increasing access to safe water and latrine facilities and in addition offer education on the importance of the same.

• WFP and NPA to explore possibilities of ensuring that the community has a sustainable food source. Meanwhile, the two agencies to continue distributing relief food to the community so as to ensure that the vulnerable groups are cushioned from food insecurity.

1 The data into brackets are the Confidence Interval at 95%. 2 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker 8

.II. INTRODUCTION

Guit County, with an approximate total area of 450 square km, lies within the highlands of the Leech state.The state is divided into two zones namely highlands (Northern Leech) and Lowlands (Southern Leech). Ruweng County borders it to the north, Kouch County to the south, Fangak to the east, Rubkona County to the west and Lake No to the northeast. The County comprises of four payams namely Nimni, Nyathoar, Kadet and Kuac, which are further subdivided into villages. Nimni payam is characterized by a flat landscape with fertile black cotton soil and several rivers cutting across it. These rivers provide drinking water, fish and pastures for both human and livestock through out the year. The community is agro-pastoralist, giving more emphasis to cattle keeping than farming. The total population of the payam estimated at 5,8993, are mainly agro-pastoralists belonging to the Nuer Jikany tribe.

Due to its proximity to the Bentiu oilfields, the area has had unstable security with frequent air and ground attacks from GoS leading to a significant displacement of the community. However, with the signing of the comprehensive peace agreement early in the year, no major incidents have been reported apart from one, which involved SPLA and GoS militia in Chotyiel village whereby 480 heads of cattle were raided and five people killed. Some areas are also suspected to have landmines, but there have been no reported cases of landmine explosions in the recent past in this particular location.

The WFP interagency rapid needs assessment in Guit County in April, 2005 reported that rainfall in 2004 started late, was erratic and unevenly distributed with prolonged dry spells between May and October 2004. This had severely affected crop performance, and eventually the harvest. It also led to scarcity of wild foods, which act as a buffer during hunger gaps. Also, the skirmishes that started in March 2005 between the Bul and Leek tribes of Mayoum and Rubkoana Counties respectively, displaced people and cattle from Rubkona County into Guit. These IDP’s burdened the host community through sharing their meagre resources. Additionally, information provided by MSF-H staff revealed observable signs of malnutrition among the resident community.

.III. OBJECTIVES

A nutritional survey was then carried out by ACF-USA in Nimni payam from 21st October to 10th November 2005 with the following objectives:

• To evaluate the nutritional status of children aged 6 to 59 months. • To estimate the measles immunisation coverage of children aged 9 to 59 months. • To identify groups at higher risk to malnutrition: age group and sex. • To estimate the crude mortality rate through a retrospective survey.

3 SRRC records 9

.IV. METHODOLOGY

.IV.1. Type of Survey and Sampling Size

According to SRRC, population figures were estimated at 5,899 persons, hence the number of children under 5 years of age was estimated at 1,180 (20% of the entire population).

A two-stage cluster survey methodology was applied. The survey planned to use a 30 by 30 cluster methodology that requires a minimum of 900 children. However, since the target population was less than 4,500 but above 1,000 infants, the formula was revised to give 22 children per cluster with a total of 788 being surveyed. This sample size was taken to provide the estimates of the prevalence of malnutrition with a 95 % confidence interval.

This sampling frame covered all the villages falling within the Nimni payam. In each cluster, households were randomly selected and surveyed. All the children between 6 to 59 months of age of the same family, defined as a woman and her children, were included in the survey.

A retrospective mortality survey following the SMART methodology (over the past 3 months) was conducted simultaneously with the anthropometric survey. Focus group discussions and observations were also done to capture food security and health information.

.IV.2. Sampling Methodology

A two-stage cluster sampling was used:

• At the first stage, 30 clusters were randomly selected from the list of the accessible villages (see appendix 1 for list of villages and estimated population). The probability of selection was proportional to the village population size. Each cluster included a minimum of 22 children as the formula was revised. • At the second stage, i.e. the selection of the households within each cluster, the standard EPI methodology was used: a pen was spun while being at the central point of the selected cluster, defining a random direction. All the children 6-59 months of age of the households encountered in that direction were measured. A household was defined by a mother and her children.

.IV.3. Data Collection

During the anthropometric survey, for each selected child 6 to 59 months of age, the following information was recorded (See appendix 2 for the anthropometric questionnaire): • Age: recorded with the help of a local calendar of events (See appendix 3 for the calendar of events). • Gender: male or female. • Weight: children were weighed without clothes, with a SALTER weighing scale of 25kg (precision of 100g). • Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm were measured lying down, while those greater than or equal to 85 cm were measured standing up. • Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1cm). • Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet. • Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking caretakers. • Household status: for the surveyed children, households were asked if they were permanent residents, temporarily in the area, displaced or returnees. 10

During the retrospective mortality survey, in all the visited households including those that had no children less than five years old – the teams asked for the number of household members alive per age groups, the number of people present within the recall period, the number of deaths and births over the last three months and the number of persons who left or arrived in the last three months (See appendices 4 and 5 for the mortality questionnaires- enumeration data collection forms for households and clusters).

.IV.4. Indicators, Guidelines, and Formulas Used

.IV.4.1. Acute Malnutrition

¾ Weight for Height Index For the children, acute malnutrition rates were estimated from the weight for height (WFH) index values combined with the presence of oedema. The WFH indices are compared with NCHS4 references. WFH indices were expressed both in Z-scores and percentage of the median. The expression in Z-scores has true statistical meaning and allows inter-study comparisons. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs.

Guidelines for the results expressed in Z-scores: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child. • Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema

Guidelines for the results expressed in percentage according to the median of reference: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs. • Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema.

¾ Children’s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However, the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC is only taken for children with a height of 75 cm and more. The guidelines are as follows:

MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC ≥ 120 mm and <125 mm high risk of malnutrition MUAC ≥ 125 mm and <135 mm moderate risk of malnutrition MUAC ≥ 135 mm ‘adequate’ nutritional status

.IV.4.2. Morality

The crude mortality rate (CMR) is determined for the entire population surveyed for a given period.

The formula used for calculating the CMR according to ENA software is as follows:

CMR = 10,000/a*f/ (b+f/2-e/2+d/2-c/2)

Where: a = Number of recall days (period corresponds to 3 months (90 days) preceding the survey) b = Number of current household residents c = Number of people who joined household d = Number of people who left household

4 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 11

e = Number of births during the recall period f = Number of deaths during recall period

Therefore, CMR is expressed per 10,000-people / day.

The thresholds are defined as follows5:

Total CMR: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

CMR of the under five: Alert level: 2/10,000 under five/day Emergency level: 4/10,000 under five/day

.IV.5. Field Work

All the surveyors participating in the survey underwent a four-day training, which included a pilot survey. Three teams of three surveyors each executed the fieldwork. ACF-USA staff supervised all the teams in some villages, but due to deep swamps in most of the villages, the team was not able to give maximum supervision as required. Accessibility to the whole county was limited since the team was not able to get a vehicle while on ground. Due to this, the sampling frame only included the Nimni payam whereby all the villages within the payam were surveyed.

The survey, including the training and travelling days, lasted for a period of 21 days.

.IV.6. Data Analysis

Data processing and analysis were carried out using EPI-INFO 5.0 software and EPINUT 2.2 program. Mortality data was processed and analyzed using the Nutrisurvey for SMART software.

5 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95. 12

.V. RESULTS OF THE QUALITATIVE ASSESSMENT

.V.1. Internally Displaced Persons (IDP’s) and Returnees Population

SRRC estimated that 980 returnees had arrived in the location between July and October, 2005. There is no documented information on the IDP’s who might have arrived in the location. The returnees were reported to be arriving from different regions such as Malakal, Khartoum and Fangak among others.

.V.2. Food Security

Nimni falls under the western flood plains of river Nile. Residents are more reliant on cattle keeping as compared to farming. Insecurity and frequent displacement in the past years has led to a reduction in the area cultivated making cattle-keeping the major activity. The main crops grown in the area are sorghum and maize. Groundnuts, okra, pumpkins, and tobacco are also grown but on a smaller scale. In a normal year, rains start in May; however, this year rains commenced late, followed by a dry spell and finally floods which led to poor harvest of sorghum in September as reported by the community. Apart from erratic rains, infestation of young crops by pests, lack of adequate seeds; tools and equipment for use in clearing larger pieces of land for cultivation were also cited as factors that influenced the harvests.

The community’s diet mainly consists of maize and sorghum. Pumpkin leaves, okra, fish and milk accompany the maize/sorghum diet depending on their availability. At the time of the survey, the community reported that most the households had depleted their sorghum stocks, and were surviving on the little stocks of maize that had been harvested in August, wild foods and relief food given by NPA and WFP in the months of September and August respectively. Sorghum, pulses, sugar, oil and biscuits were distributed by WFP while NPA gave sorghum and oil. During the “hunger gap” period between March and August, the community depends on wild foods which are a major source of food for all, particularly the poor households. The most common wild foods are water lily, nabak, ardap and lalop (desert date). In a normal year, the dietary contribution of wild foods is estimated at 15% and increases to about 20% in a bad year.

With availability of many rivers (rivers Tiac, Jiel, Nam, Lakeno and Wichbar), streams and tributaries, fish is an important source of food among the Nimni community. The fish catch is higher during January and April when the water levels are low. Contribution of fish to the household basket is estimated at 27% for the better-off, 49% for the middle and 15.3% for the poor socio-economic classes. Apart from being a major component of the household diet, dry fish is also sold in exchange for or to purchase non-food items from the external markets. Although, fish is regarded as an important source of food for most of the households, the community expressed lack of canoes and fishing gear as being major constraints to its access.

Livestock production plays a major role in the food economy especially of people living in the highlands. Livestock kept by the community include cattle, sheep, goat and chicken. Although, majority in the community keeps cattle, frequent insecurity and lack of adequate veterinary services has reduced herd sizes tremendously. Apart from providing milk and meat, livestock are also used as a medium of exchange and for payment of dowry. Cattle are also used by the Nuer to determine socio-economic classes whereby persons with number of cattle ranging from 50-70 are ranked among the rich, 20-30, belong to the middle class while those owning below 10 heads of cattle are considered to be of poor class. Therefore, through the ranking most of the community is classified as being poor. At the time of the survey, the community reported that there was enough pasture for livestock but feared that it would be depleted soon as a result of poor rains. During the months of December and January, cattle are moved to cattle camps that are located along the Nile River. Those that are being milked are taken back to the homesteads around the month of May and the rest follow as soon as water for drinking is available and in most cases when the rains have commenced. Veterinary services in the payam are offered by VSF-CH. The agency implements this through a county veterinary co-ordinator who supervises activities of different payams from the county headquarters in Guit. There are 5 community animal health workers trained by VSF-CH basically on livestock and poultry disease control through vaccination and treatment 13 of livestock diseases. Services given to livestock owners in the community by the veterinary department are on a cost recovery basis hence the CAHWs are able to get a small incentive as they are entitled to some percentage of the money for every animal treated. The common diseases of livestock as reported by one of the CAHWs are: caprine contagious pleural pneumonia, foot and mouth disease, rinderpest disease, liver flukes, trypanosomiasis, contagious bovine plural pneumonia and brucellosis. This compares well with information that has been documented by Starbase (2004).

Trade takes place among the local residents within the internal markets of Nimni, Leer and Wichok. In addition to these, there are external markets of the GOS controlled towns located in Bentiu and Malakal. Commodities traded in the internal markets include livestock, grains, clothes, sugar, onions and salt among others while in the main markets of Bentiu and Malakal, fish is the main commodity with Sudanese dinar being the main medium of exchange.

.V.3. Feeding and Childcare Practices

Weaning of most children starts at the age of three months with cow milk as reported by the interviewed mothers. The infants are introduced to solid food like walwal, kisra with okra soup, maize porridge and fish soup and at the age of five months. Breastfeeding stops at the age of one and half years. Pregnant and lactating mothers are responsible for almost all household chores without receiving any special care in terms of special diets and antenatal care. This has an effect on the time and care given to infants, which in turn affects their nutritional status as they are only fed when they cry. All household members consume one meal per day regardless of the age. All the children 2 years and above, are served food in the same bowl.

.V.4. Health

There is only one PHCU in the entire payam run by MSF-Holland, the only agency providing health care in the location. The unit offers both curative and preventive services as well as outpatient therapy. Local staffs trained by MSF-H run the unit with a community health worker (CHW) manning it. Severe cases are referred to MSF- H’s health unit in Leer town within the Western Upper Nile region. The agency also offers outreach activities whereby follow–up of patients in the villages is done by the CHW’s. Most common ailments among the community are malaria, diarrhoea, eye infections, respiratory infections and urethral tract infections. Other causes of morbidity are TB, bilharzias, brucellosis, gastroenteritis, STD’s, skin diseases and measles as reported by MSF-Hs’ staff on ground. On the other hand, causes of mortality according to records from the health unit are malaria, pneumonia and meningitis (common during the dry season). Most people consult the locally called “magicians” when an illness sets in and only seek medical attention from the health unit if it advances. Also, those closest to the clinic are more willing to utilise its services due to proximity as compared to those living far away.

.V.5. Water and Sanitation

Population with access to clean drinking water and to pit latrines in the payam is relatively low which makes water and sanitation an issue of concern. There are only two water points in the payam of which only one is operational. The distance to the borehole for most of the households is quite enormous hence the community mainly relies on seasonal rivers, the Nile River and hand-dug shallow wells for water. Due to the volatile security situation in the past years, it has been difficult for agencies to construct boreholes. As a result, no new ones have been dug, nor has there been adequate maintenance on the already existing ones.

Awareness on improved hygiene and sanitation in the community is poor as observed by the ACF-USA team on ground. Most people defecate in the open, treatment or boiling of drinking water is not practised, water for household use is not covered and containers used to draw water are not kept clean. Use of latrines is not common except for those living in the NGO compounds. The community is receptive to the idea of latrine use, but none were observed in the villages during the survey. The reason given for this was lack of tools and 14 equipment to dig the latrines. There are no hygiene promoters in the payam as reported by the community and the counterpart.

.V.6. Education

Constant insecurity and displacement of population had made it almost impossible for the community to settle, for children to attend school and agencies to carry out systematic education programs. There is only 1 primary school in the payam (offering levels 1-4 education); no secondary or tertiary levels of education are offered. Education is supported by a local NGO, SSDPA who get funding from Stromme Foundation-Norway. Apart from offering supplies for learning materials and school uniforms, the foundation also supports capacity building of teachers through the indigenous NGO. The total number of pupils enrolled at the primary school is 276 of which 73 are girls and 203 are boys with 7 trained teachers/educators, all men and working on voluntary basis. Lack of investment in the education sector due to fluidity of the situation in the past years has caused low education rates in the community.

.V.7. Agencies Intervening in the Area

Due to years of unpredictable and destructive factional fighting, Operation Lifeline Sudan (OLS) agencies have been reluctant to set up permanent bases within the area, and instead have been operating on a hit-and-run basis. The long absence of international agencies has therefore, affected the organization and running of social services which has made the location lag far behind other regions in Southern Sudan.

The humanitarian agencies supporting social services in Nimni are implementing programs on health and education as outlined below.

Table 2 Organizations intervening in Nimni Payam Agency Activities MSF-H • Health:1 PHCU SSDPA • Education 15

.VI. RESULTS OF THE ANTHROPOMETRIC SURVEY

A total of 788 children were measured and analysed in this survey.

.VI.1. Distribution by Age and Sex

Table 3 Distribution of the sample by age and sex

AGE BOYS GIRLS TOTAL Sex (In months) N % N % N % Ratio 06 – 17 75 44.4 94 55.6 169 21.4 0.80 18 – 29 102 49.0 106 51.0 208 26.4 0.96 30 – 41 61 56.5 47 43.5 108 13.7 1.30 42 – 53 72 54.5 60 45.5 132 16.8 1.20 54 – 59 76 44.4 95 55.6 171 21.7 0.80 Total 386 49.0 402 51.0 788 100.0 0.96

The distribution of the sample by gender shows that girls are slightly more than boys. However, the sex ratio, which is 0.96, indicates a random selection of the sample.

Figure 1 Distribution of the sample by age and sex, Nimni Payam

Distribution by age and sex, Nimni payam, 2005

54-59

42-53 h

30-41 Boys girls Age in in mont Age

18-29

06-17

-60% -40% -20% 0% 20% 40% 60% Percentage

There is a slight imbalance in the age distribution as indicated by the results on the diagram above. The most conspicuous imbalance being among the age groups 30-41 and 42-53 months, whereby there is an over representation of boys. This may be explained by the fact that ages approximated by parents (caretakers) are subject to strong recall bias; dates of birth were not known and a local calendar of events had to be used to estimate the ages. 16

.VI.2. Anthropometric Analysis

.VI.2.1. Acute Malnutrition

¾ Distribution of Malnutrition in Z-Scores for Children 6-59 months of age The distribution of acute malnutrition in Z-scores shows that the global acute malnutrition is equal to 13.5% with 1.1% of the children being severely malnourished and 12.3% moderately malnourished.

Table 4 Weight for Height Distribution by age in Z-scores

Severe Moderate No malnutrition Oedema Malnutrition malnutrition AGE Total (in months) < -3 SD ≥-3 SD - <- 2 SD ≥ -2 SD N % N % N % N % 06-17 169 3 1.8% 30 17.8% 136 80.5% 0 0.0% 18-29 208 2 1.0% 15 7.2% 191 91.8% 0 0.0% 30-41 108 1 0.9% 8 7.4% 99 91.7% 0 0.0% 42-53 132 0 0.0% 14 10.6% 118 89.4% 0 0.0% 54-59 171 3 1.8% 30 17.5% 138 80.7% 0 0.0% TOTAL 788 9 1.1% 97 12.3% 682 86.5% 0 0.0%

Table 5 Weight for Height vs. Oedema in Z-score

< -2 SD ≥ -2 SD

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0% Oedema Marasmus No malnutrition NO 106 13.5% 682 86.5%

No case of kwashiorkor was found in the sample. All the cases of malnutrition are of marasmic type. 17

Figure 2 Z-scores distribution Weight-for-Height, Nimni payam

Weight for Height Z-score distribution, Nimni payam, November, 2005

e 15 Reference Sex Combined

Percentag 10

0 -5 -4 -3 -2 -1 0 1 2 3 4 5 Z-score

There is noticeable displacement of the sample curve to the left side of the reference curve. The mean Z- Scores of the sample, – 0.95, indicates a slightly under-nourished population. The standard deviation is equal to 0.97, which is in the range of 0.80–1.20. Therefore, the sample can be estimated as representative of the assessed population.

Table 6 Global and Severe Acute Malnutrition by Age Group in Z-scores 6-59 months (n = 788) 6-29 months (n =377) Global acute malnutrition 13.5 % (10.3%-17.4%) 13.3% (8.8%-19.3%) Severe acute malnutrition 1.1 % (0.4%-3.0%) 1.3% (0.2%-4.6%)

The results of the analysis of malnutrition rates by age group in Z-score do not show any statistical difference between the malnutrition rates observed among the children of ages 6-29 months and 30-59 months (p > 0.05, Chi square test= 0.02). Children of all age groups present the same risk of being malnourished.

Table 7 Nutritional Status in Z-scores by gender

Boys Girls Nutritional status Definition N % N % Weight for Height < -3 SD or Severe malnutrition 5 1.3% 4 1.0% oedema Moderate malnutrition -3 SD ≤ Weight for Height < -2 SD 48 12.4% 49 12.2% Normal Weight for Height ≥ -2 SD 333 86.3% 349 86.8% TOTAL 386 49.0% 402 51.0%

There is no statistical significance in the difference of figures observed between boys and girls (p>0.05, Chi square test= 0.05). According to the results, both boys and girls present the same risk of being malnourished. 18

¾ Distribution of Malnutrition in Percentage of the Median for Children 6-59 months of age Acute malnutrition rates expressed in percentage of the median are useful in the coverage targeting nutritional treatment programs, and are used in its admission and exit criteria.

The distribution of acute malnutrition in percentage of the median reveals a global acute malnutrition rate of 7.1%. 0.1% of the children were severely malnourished while 7.0% were moderately malnourished.

Table 8 Weight/Height: Distribution by Age in percentage of median

Severe Moderate No AGE malnutrition malnutrition malnutrition Total (In months) < 70% ≥ 70% & <80% ≥ 80% Oedema N % N % N % N % 06-17 169 0 0.0 24 14.2 145 85.8 0 0.0 18-29 208 1 0.5 9 4.3 198 95.2 0 0.0 30-41 108 0 0.0 5 4.6 103 95.4 0 0.0 42-53 132 0 0.0 6 4.5 126 95.5 0 0.0 54-59 171 0 0.0 11 6.4 160 93.6 0 0.0 TOTAL 788 1 0.1 55 7.0 732 92.9 0 0.0

Table 9 Weight for Height vs. oedema in percentage of median < -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0% Oedema Marasmus No malnutrition NO 56 7.1% 732 92.9%

No case of kwashiorkor was found in the sample.

Table 10 Global and Severe Acute Malnutrition by Age Group in Percentage of Median

6-59 months (n = 788) 6-29 months (n = 400)

Acute global malnutrition 7.1% (4.8%-10.3%) 9.0% (5.4%-14.4%)

Severe acute malnutrition 0.1% (0.0%-1.4%) 0.3% (0.0%-2.9%)

According to the weight for height in percentage of median, there is a significant difference in the nutritional status between the age groups 6-29 months and 30-59 months (p<0.05) with a relative risk of 1.68 (1.00

Table 11 Nutritional status by sex in percentage of median

Boys Girls Nutritional status Definition N % N %

Severe malnutrition Weight for Height < 70% or oedema 1 0.3% 0 0.0%

Moderate 70% Weight for Height < 80% 26 6.7% 29 7.2% malnutrition ≤

Normal Weight for Height ≥80% 359 93.0% 373 92.8%

TOTAL 386 49.0% 402 51.0%

Statistical analysis of the nutritional status by gender in percentage of median does not show any significant difference in the prevalence of malnutrition between boys and girls (Chi square=0.01, p>0.05). Both have equal chances of being malnourished.

¾ Nutritional Status of Children below 6 months 63 children below 6 months of age, present in the households at the time of the survey, were measured in order to determine their nutritional status. 29 (46.0%) were boys and 34 (54.0%) were girls.

Table 12 Age distribution of the under six months Age in months N % 0 - - 1 18 28.6% 2 7 11.1% 3 10 15.9% 4 10 15.9% 5 18 28.6% Total 63 100%

In both the Z-score and percentage of the median analysis of the 63 children, only 48 children were included. This was because some caretakers did not accept their infants to be taken the weight and height measurements.

According to the Weight for Height index in Z-score, there were no severe cases of malnutrition but 2 (4.2%) were moderately malnourished while 46 (95.8%) were of good nutritional status. On the other hand, analysis in percentage of median revealed that 1 (2.1%) of the infants was severely malnourished, 2 (4.2%) had moderate malnutrition and 45 (93.8%) of the infants were having a good nutritional status.

¾ Feeding Practises Most of the mothers who had children less than six months practiced mixed feeding 38 (60.3%) while 24 (38.1%) breastfed exclusively. 1 (1.6%) mother had begun to wean her child exclusively. The weaning food was mainly composed of cow milk, walwal, kisra with fish soup and maize porridge.

Table 13 Feeding practices Feeding practices Frequency Percentage Exclusive breastfeeding 24 38.1 Mixed feeding (breast milk and weaning food) 38 60.3 Exclusive weaning 1 1.6 Total 63 100 20

.VI.2.2. Risk of Mortality: Children’s MUAC

As MUAC overestimates the level of under nutrition in children less than one year old, the analysis refers only to children having height equal to or greater than 75cm. A total of 656 children have been included in this analysis.

Table 14 Nutritional Status by MUAC.

Total 75 – 90 cm ≥ 90 cm height Criteria Nutritional status N % N % N % < 110 mm 0 0.0% 0 0.0% 0 0.0% 110 mm ≥ MUAC < 120 mm Moderate malnutrition 6 0.9% 6 2.4% 0 0.0% 120 mm ≥ MUAC < 125 mm High risk of malnutrition 5 0.8% 4 1.6% 1 0.2% 125 mm ≥ MUAC < 135 mm Risk of malnutrition 69 10.5% 29 11.7% 40 9.8% MUAC ≥ 135 mm No malnutrition 576 87.8% 209 84.3% 367 90.0% TOTAL 656 100.0% 248 100.0% 408 100.0%

By MUAC measurements, 87.8% showed good nutritional status,while only 0.9% children were moderately malnourished and 11.3% at risk. According to this indicator, no children were severely malnourished.

.VI.3. Measles Vaccination Coverage

Measles vaccination for the regular EPI is administered to children 9 monthhs of age; therefore only the children 9-59 months of age (750 children) were included in this analysis.

Table 15 Measles vaccination coverage

Measles Vaccination N %

EPI card 7 0.9%

According to the caretaker 197 26.3%

Not immunized 546 72.8%

Total 750 100.0%

Measles coverage in this location was very low as revealed by the results. Majority of the children (72.8%) had not received measles vaccination according to the caretakers. Only 0.9% of the children had received the vaccination as confirmed by presence of EPI cards, while caretakers affirm vaccination in the other 26.3% of the children, although no card was produced. 21

.VI.4. Household Status

The information on the residential status was collected from 375 caretakers during the anthropometric survey.

Table 16 Household Status

Status N %

Residents 365 97.3%

Internally displaced persons 6 1.6%

Temporarily residents 4 1.1%

Total 375 100.0%

The larger proportion of the surveyed families were residents 365 (97.3%), while 6 (1.6%) were Internally Displaced Persons. 4 (1.1%) of the households were temporarily residing in the location. The results revealed minimal movement of the population during the preceding three months prior to the survey.

.VI.5. Composition of the Household

Table 17 Household Composition

Age group N %

0 to 59 months 828 40.8% Adults 1,201 59.2%

Total 2,029 100.0%

391 households were visited during the survey. The mean number of children under 5 years of age per household is 2.1 and the mean number of the over five per household is 3.1.

.VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

.VII.1. Mortality Rate

The crude mortality was calculated from the figures collected from all visited households, regardless of whether there were children under the age of 5 years.

During the survey, a total of 2,029 people were found in the assessed households. Among them were 828 (40.8%) children below the age of 5 years, and 1,201 (59.2%) people above the age of 5 years.

Over the three months preceding the survey, the following demographic changes were observed: • 31 births • 78 persons had arrived in the location 22

• 114 people had left the location in the same period • 8 deaths with two being recorded among children below the age five years old.

Crude Mortality Rate (CMR) = 0.44 [0.02-0.89] /10,000/day Under five Crude Mortality Rate = 0.27 [0.0-0.67] /10,000/day

.VIII. CONCLUSION

There has been a marked improvement on security situation in the location since the signing of CPA in January, 2005. This has seen progressive repatriation of cattle that had been hidden during the time of war, which has ensured that cow milk is available and accessible to most households. This might have boosted the nutritional status of the small infants considering that it is a major weaning food in the community. The community is also able to access the markets of GoS controlled towns of Bentiu and Malakal. As a result, diversified food is available and accessible. Fish is a major component of the household diet, and hence contributes to the household food security, especially of the poor socio-economic group. Dry fish is also sold in exchange for or to purchase non-food items from the external markets. Additionally, WFP and NPA are currently cushioning the most vulnerable people in the community from food insecurity through food rations.

.IX. RECOMMENDATIONS

Although the results do not indicate critical nutritional status among the population in the payam, any slight deterioration of the situation would compromise this, and hence several factors need to be enhanced and maintained. ACF-USA recommends the following:

• Agencies concerned with water and sanitation activities having the capacity to intervene to consider increasing access to safe water and latrine facilities, and in addition offer education on the importance of the same.

.X.1. List of Villages and Clusters

Villages Estimated Total Target Cumulative Number Clusters No. of Estimated Population population (20% Frequency Assigned Clusters distances from of the entire per village SRRC population) compound Thakleak 432 86 86 1 – 86 1, 2 2 3hrs Dogeal 647 129 215 87 – 215 3, 4, 5, 6 4 2hrs Tharkuer 810 162 377 216 – 377 7, 8, 9, 10 4 2hrs 30mins Nyebuor 710 142 519 378 – 519 11, 12, 13, 14 4 2hrs Kak 370 74 593 520 – 593 15 1 1hrs 30mins Keac 380 76 669 594 - 669 16, 17 2 1hrs Wanglieth 500 100 769 670 - 769 18, 19, 20 3 4hrs Momkuan 550 110 879 770 - 879 21, 22, 23 3 4hrs Bil 500 100 979 880 - 979 24, 25 2 3hrs Nimni 500 100 1079 980 - 1079 26, 27, 28 3 Burbur 500 100 1179 1080 - 1179 29, 30 2 4hrs

Due to the population figures that were less than 4,500 but more than 1,000, the formula had to be revised to give 22 children per cluster instead of the usual 30 children in a cluster. Sampling interval was calculated by dividing the Target population with number of clusters i.e. 1,179/30 =39.3, which was rounded off to 39. Villages included in the survey are shown in the table above. The random number drawn between 1 and 39 was 12.

The number of children to be included in each cluster is Sampling size/ Number of clusters = 651/30 = 21.7 rounded up to 22.

Due to inaccessibility, two clusters from Bil village were shifted and covered in a different place. 24

.X.2. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No: Sitting Measles Family Status Age Sex Weight Height Oedema N°. Height MUAC C/M/N N°. (1) Mths M/F Kg Cm Y/N Cm(2) mm (3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family…), 4=Returnee (2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research. (3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles. 25

.X.3. Calendar of events in Nimni Payam – October, 2005

MONTHS SEASONS 2000 2001 2002 2003 2004 2005

57 45 33 21 9 JANUARY Movement to Comprehensive Tiop tot cattle camps SPDF CDR James Fighting between Leek peace agreement Liah defect to SPLA and Bul community is signed. 56 44 32 20 8 FEBRUARY Renovation of CDR Gatluac CDR Dor arrests Fighting between CDR Peat houses defect from SPDF supporters of CDR Dor and CDR Liah to SPLA Liah Groups. 55 43 31 19 7 Digging wells and MARCH GOS bombs Nimni Fighting between Fighting between thrushing Duong’ church killing 5 GoS and SPLA/M groups of CDR Liah CDR Dor group raided sorghum. people and CDR Dor. cattle in Rier village . 54 42 30 18 6 APRIL Identifying and Fighting between Guok clearing land. Nhialdiu is captured the two groups CDR Dor raided cattle by GOS from SPLA/M continues. in Jieth village. 53 41 29 17 5 Preparing land for MAY SPLA recaptures SPDF attacked by SPLA planting Duat Nhialdiu from GoS in Rupkoana town. 52 40 28 16 4 Cultivation of Nhialdiu is SPDF reiterates by JUNE maize and Kurnyuot recaptured back the attacking SPLA in Nimni sorghum. second time by GoS village. 51 39 27 15 3 Weeding JULY Cattle raided by activities. Payiene CDR Matip 50 38 26 14 2 AUGUST Continuation of Recruitment of Ter weeding. army by CDR SPDF attacks SPLA the Matip second time in Nimni. 49 37 25 13 1 SEPTEMBER Consumption of SPLA hits back at SPDF green maize in Thoar village and Thor raids cattle. 48 36 24 12 OCTOBER Harvesting of Kur sorghum and its Shelling of Bentiu SPLA ambushes SPDF consumption by CDR Peter Fighting between truck in Kilo 30 and Kilo Gatdet of SPLA SPLA and SPDF 20. Stocking of 59 47 35 23 11 NOVEMBER sorghum and Fighting between Labur Maize SPLA and SPDF 26

DECEMBER 58 46 34 22 10 Christmas Tiop Dit celebrations .X.4. Mortality survey questionnaire (Cluster enumeration data collection form).

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

Current HH Past HH members Current HH members who who left during Births Deaths N Member arrived during recall recall during during recall (exclude births) (exclude deaths) recall Total < 5 Total <5 Total < 5 Total < 5

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 28

.X.5. Mortality survey questionnaire form (Household enumeration data collection form for a death rate calculation survey).

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

1 2 3 4 5 6 7

ID HH member Present now Present at beginning of recall (include those not present now and indicate which members were not present at the start of the recall period ) Sex Date of birth/or age in years Born during recall period? Died during the recall period

3 29

8 30

13 31

18 32

Tally (these data are entered into Nutrisurvey for each household):

Current HH members – total

Current HH members - < 5

Current HH members who arrived during recall (exclude births)

Current HH members who arrived during recall - <5

Past HH members who left during recall (exclude deaths)

Past HH members who left during recall - < 5

Births during recall 33

Total deaths

Deaths < 5 34

.X.6. Anthropometric Survey questionnaire for children less than six months

DATE: CLUSTER No: VILLAGE: TEAM No: Family Age Sex Weight Height Feeding practices* N°. N°. Mths M/F Kg Cm 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

* Exclusive breast-feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food =3.