Christian Mission Aid CMA

South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER 5 YEARS OLD ATHOC: BAIDIT AND JALLE PAYAMS, SOUTH BOR COUNTY, UPPERNILE REGION

June 14th – June 30th, 2005

Joy Kiruntimi– Nutritionist Edward Kutondo – Nutritionist Santino Gatkuoth – Programme Officer (ACF-USA) Jennifer Karanja- Nurse (CMA) 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 at Lokichoggio and field level for facilitating the work in the field.

• The local survey teams for working tirelessly in the hostile environment.

• Last but not least, thanks to the local community, particularly mothers/caretakers, for their co- operation. 3

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

.I.1. CONTEXT ...... 5 .I.2. JUSTIFICATION ...... 5 .I.3. OBJECTIVES ...... 6 .I.4. METHODOLOGY ...... 6 .I.5. RESULTS OF THE ANTHROPOMETRICS SURVEY ...... 7 .I.6. DISCUSSION ...... 7 .I.7. RECOMMENDATIONS...... 8 .I.7.1. Programmatic ...... 8 .I.7.2. On Methodology...... 8 .II. INTRODUCTION ...... 8

.III. OBJECTIVES ...... 9

.IV. METHODOLOGY...... 9

.IV.1. TYPE OF SURVEY AND SAMPLE SIZE ...... 9 .IV.2. SAMPLING METHODOLOGY...... 9 .IV.3. DATA COLLECTION ...... 10 .IV.4. INDICATORS, GUIDELINES, AND FORMULAS USED...... 10 .IV.4.1. Acute Malnutrition...... 10 .IV.5. FIELD WORK ...... 11 .IV.6. CONSTRAINTS ...... 11 .IV.7. DATA ANALYSIS ...... 11 .V. RESULTS OF THE QUALITATIVE ASSESSMENT...... 11

.V.1. INTERNALLY DISPLACED PERSONS (IDP’S) AND RETURNEES POPULATION ...... 11 .V.2. FOOD SECURITY ...... 11 .V.3. HEALTH...... 12 .V.4. WATER AND SANITATION ...... 13 .V.5. MOTHER AND CHILDCARE PRACTISES...... 13 .V.6. ACTIONS TAKEN BY NGO’S AND OTHER PARTNERS ...... 13 .VI. RESULTS OF THE ANTHROPOMETRICS SURVEY...... 14

.VI.1. DISTRIBUTION BY AGE AND SEX...... 14 .VI.2. ANTHROPOMETRIC ANALYSIS...... 15 .VI.2.1. Acute Malnutrition for Children 6-59 months of Age ...... 15 ¾ DISTRIBUTION OF MALNUTRITION IN PERCENTAGE OF THE MEDIAN ...... 17 .VI.2.2. Nutritional Status of Children below 6 months...... 18 .VI.2.3. Risk to Mortality: Children’s MUAC...... 19 .VI.3. MEASLES VACCINATION COVERAGE...... 19 .VI.4. HOUSEHOLD STATUS...... 20 .VI.5. COMPOSITION OF HOUSEHOLDS ...... 20 .VII. CONCLUSION...... 20

.VIII. RECOMMENDATIONS...... 21

.IX. APPENDIX...... 22

.IX.1. SAMPLE SIZE AND CLUSTER DETERMINATION ...... 22 .IX.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE ...... 24 .IX.3. RETROSPECTIVE MORTALITY SURVEY QUESTIONNAIRE ...... 25 .IX.4. CALENDAR OF EVENTS IN ATHOC: JALLE II AND BAIDIT PAYAMS...... 26 .IX.5. ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN 6 MONTHS ...... 28 .IX.6. PADAK MARKET COMMODITY PRICES ...... 29 4

LIST OF TABLES TABLE 1 RESULTS OF THE ANTHROPOMETRICS SURVEY...... 7 TABLE 2 AGENCIES INTERVENTION IN ATHOC: JALLE 2 AND BAIDIT PAYAMS...... 13 TABLE 3 DISTRIBUTION BY AGE AND SEX...... 14 TABLE 4 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORE ...... 15 TABLE 5 WEIGHT/HEIGHT VS. OEDEMA...... 15 TABLE 6 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN Z-SCORE ...... 16 TABLE 7 NUTRITIONAL STATUS BY SEX IN Z-SCORE...... 17 TABLE 8 DISTRIBUTION OF WEIGHT/HEIGHT BY AGE IN PERCENTAGE OF THE MEDIAN...... 17 TABLE 9 WEIGHT FOR HEIGHT VS OEDEMA ...... 17 TABLE 10 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN PERCENTAGE OF THE MEDIAN ...... 17 TABLE 11 NUTRITIONAL STATUS BY SEX IN PERCENTAGE OF MEDIAN...... 18 TABLE 12 AGE DISTRIBUTION OF THE UNDER 6 MONTHS...... 18 TABLE 13 FEEDING PRACTICES ...... 19 TABLE 14 MUAC DISTRIBUTION ...... 19 TABLE 15 MEASLES VACCINATION COVERAGE ...... 19 TABLE 16 HOUSEHOLD STATUS ...... 20 TABLE 17 HOUSEHOLD COMPOSITION ...... 20 TABLE 18 GAM AND SAM RATES ...... 20

LIST OF FIGURES FIGURE 1 DISTRIBUTION BY AGE AND SEX ...... 14 FIGURE 2 WEIGHT FOR HEIGHT IN Z-SCORE DISTRIBUTION, ATHOC, 2005 ...... 16 5

.I. EXECUTIVE SUMMARY

.I.1. Context

Athoc: Baidit and Jalle II Payams are located in South Bor County in the Jonglei Upper Nile Region. The County comprises of six payams namely: Jalle, Baidit, Makuach, Anyidi, Kolnyang and Bor town. The river Mabor Gol cuts across the county and provides grazing areas, water and fishing points. The Nile River on the eastern side of the County offers good fishing opportunities and grazing areas for cattle. The area is generally flat and made of black cotton and sandy soils. The inhabitants belong to the Dinka Bor clan.

The County faced the last insecurity incident in 2000 when the militia group made aerial bombardments in Anyidi, Makuach and Jalle payams; unspecified number of people was injured and properties were destroyed during the incident. During the recent years, apart from sporadic cattle raids in the location, security has been relatively stable.

The NGO’s operating in the location are: CMA, WHO, FAO, CRS, Southern Sudan Agricultural revitalization Program (SARP), Penykou Agency for Relief and Development (PARAD), WFP and CARE. CMA operates six Primary Health Care Units (PHCUs) and one Primary Health Care Center (PHCC) that provides in-patient services and tuberculosis clinic. The PHCU’s are located in Tong, Makol cuei, Akuei Deng, Apoor, Mathiang, and Kolmarek. There are three non-functional PHCUs located in Kuei, Yolmuchel and Jalle II. CRS, FAO and SARP provide capacity building in fishing. WFP provides relief food; the last distribution was done in April 2005. WHO provides polio vaccinations services. CARE and PARAD implement water project, while GTZ is implementing road rehabilitation and dyke construction projects supported by WFP.

Households have access to potable water from borehole facilities; however, in some locations, households get their water from unsafe sources, such as swamps and rivers. A few latrines were observed mainly in church, local authority and health centre compounds. Waste disposal in both payams is poor.

Majority of families seek medical attention from local traditional healers first and only consult at the PHCC/U when the condition is severe. Hygiene and sanitary practices are generally poor in the community; there is high prevalence of diarrhoeal diseases as reported by CMA.

.I.2. Justification

ACF-USA conducted a nutritional survey in Padak in May 2002 which revealed GAM and SAM rates of 37.7% and 6.6%, respectively. In March 2003, the nutrition survey by TEARFUND showed malnutrition rates of 20.8% GAM and 2.4% SAM. The ANA report 2004/5 indicates that food security in Bor will be relatively stable due to market access, fishing opportunities, and enhanced income. However, poor households are likely to experience food deficits due to declined household production and low purchasing power.

In May this year, CMA reported 17 cases of severe malnutrition in its PHCC and raised this concern with ACF- USA; consequently, a nutritional survey was carried out. 6

.I.3. 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.

.I.4. Methodology

A two-stage 30 by 30 cluster survey methodology was applied. This sample size was taken to provide the estimates of the prevalence of malnutrition with a 95 % confidence interval. This sampling frame covered all villages falling within Baidit and Jalle II payams. In each cluster, households were randomly selected and surveyed. All the children 6 to 59 months of age belonging to the same family, defined as a woman and her children, were included in the survey.

Data collected during the survey included the following variables: - For the children: age, sex, height, weight, oedema, MUAC, measles vaccination. - Qualitative information to capture food security situation, child care practices, nutrition, and health and sanitation situation were collected through focus group discussions, individual interviews and observation method. 7

- Results of the Anthropometrics Survey Table 1 Results of the Anthropometrics Survey

AGE GROUP INDICATOR RESULTS Global Acute Malnutrition: W/H< -2 z and/or 39.3% [34.7%-44.1%] oedema Z-score Severe Acute Malnutrition: W/H < -3 z and/or 5.9% [4.0%-8.6%] oedema 6-59 months Global Acute Malnutrition: W/H < 80% and/or (n = 916) 27.7% [23.6%-32.2%] % oedema Median Severe Acute Malnutrition: W/H < 70% and/or 1.5% [0.6%-3.3%] oedema Global Acute Malnutrition: W/H < -2 z and/or 39.4% [33.2%-46.0%] oedema Z-score Severe Acute Malnutrition: W/H < -3 z and/or 8.1% [5.1%-12.5%] oedema 6-29 months Global Acute Malnutrition: W/H <80% and/or 29.7% [24.0%-36.0%] (n = 492) % oedema Median Severe Acute Malnutrition: W/H <70% and/or 2.8 % [1.2%-6.1%] oedema Severe Acute Malnutrition:W/H<-3 z and/or 0.0% oedema Z-Score Global Acute Malnutrition: W/H < -2 z and/or < 6 months 6.0% oedema (n = 67) Severe Acute Malnutrition: W/H < 70% and/or 1.5% % oedema Median Global Acute Malnutrition: W/H <80% and/or 3.0% oedema By card 32.3% Measles immunization According to caretaker1 40.8 % coverage Not immunized 26.9% Total 100.0%

.I.5. Discussion

The analysis of the anthropometric data of children 6 to 59 months of age show the following rates of malnutrition: Global Acute Malnutrition (GAM) 39.3% and Severe Acute Malnutrition (SAM) of 5.9% expressed in Z-scores. These rates are above emergency thresholds of 15% GAM and 4% SAM as defined by WHO2.

The malnutrition revealed in the region can be linked to food insecurity among the poor households, poor health seeking practices, and poor hygiene and sanitation.

The community harvested little food and food stocks have been depleted. Poor households were also not able to purchase food commodities sold in the local market due to high prices. There is very low attendance in the PHCU’s. Most people seek medical attention at health facilities when the disease is at an advanced stage; in this case, the disease will have already compromised the health and nutritional status of the patient. Hygiene and sanitary practices are generally poor in the community, increasing risk of exposure to pathogens. There are

1 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker 2 WHO classification of wasting prevalence in populations, 2000. 8 high incidences of malaria and diarrhoeal diseases. The combined effect of disease and low food intake rapidly deteriorated the nutritional status especially among the under 5 year olds.

A retrospective mortality survey has been implemented alongside the nutritional survey. Unfortunately, the data collected was not satisfying, and can be attributed to the methodology that was used. As a result, this indicator is reported in this the present survey.

.I.6. Recommendations

.I.6.1. Programmatic

• A therapeutic feeding program should be immediately implemented to cover the South Bor County, to treat and reduce the risk of mortality among the severely malnourished children. Co-ordination with and among humanitarian agencies on ground should be initiated; technical support should be offered by ACF-USA.

• Deeper analysis of the health situation should be undertaken by CMA, while enhancing the coverage of its primary health care services in the area, ensuring increased access and utilization by the population. The PHCU’s in Kuei, Yolmuchel and Jalle II should be re-established.

• Further assessment and monitoring of the food security situation should be carried out; meanwhile, general food aid must be promptly delivered by WFP. Existing food security programs and initiatives should be continued while further developing its impact potentials.

• Capable agencies should support South Bor with projects to increase safe water sources (such as borehole installation) and basic sanitary facilities.

.I.6.2. On Methodology

• To implement in the future surveys the SMART methodology for the collection of data and the analysis of the retrospective mortality rate.

.II. INTRODUCTION

Baidit and Jalle II Payams are located in South Bor County in the Jonglei Upper Nile Region. The County comprises of six payams namely: Jalle, Baidit, Makuach, Anyidi, Kolnyang and Bor town. The river Mabor Gol cuts across the county and provides grazing areas, water and fishing points. The Nile River in the eastern side of the County offers good fishing opportunities and grazing areas for cattle. The area is generally flat and made of black cotton and sandy soils. The inhabitants belong to Dinka Bor clan.

Several NGO’s are operating in South Bor, covering programs such as primary health care, food security, water and sanitation, fisheries, livestock health, and road rehabilitation/construction, among others 9

In May 2002, ACF-USA conducted a nutritional survey in Padak, which revealed GAM and SAM rates of 37.7% and 6.6%, respectively. Again in March 2003, the nutritional survey by TEARFUND showed persistently high malnutrition rates of 20.8% GAM and 2.4% SAM. By the end of the 2004, assessment reports (ANA and STARBASE), indicated that food security in Bor will be relatively stable due to market access, fishing opportunities and enhanced income. However, poor households are likely to experience food deficits due to declined household production and low purchasing power. A 15- 20% food deficit was projected in 2005, and the most affected would be the small-scale crop farming households.

In the month of May alone, CMA reported 17 cases of severe malnutrition in its PHCC and raised this concern with ACF-USA. Consequently, a nutritional survey was carried out to determine the current nutritional situation in the area.

.III. 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.

.IV. METHODOLOGY

The survey was conducted in Athoc: Baidit and Jalle II Payams of South Bor County in the Jonglei Upper Nile region, from 14th - 30th June 2005.

.IV.1. Type of Survey and Sample Size

The target population of the survey was children 6-59 months of age.

The total population of the 30 accessible villages in Baidit/Jalle II payams was estimated at 41,728, giving a target population of 8,345 children (calculated as 20% of the total population). A two-stage cluster sampling methodology was used, composed of 30 clusters of at least 30 children in each cluster.

Qualitative information to capture food security, childcare practices, nutrition, and health and sanitation situation was collected through focus group discussion, individual interview and observation methods.

.IV.2. Sampling Methodology

A two-stage cluster sampling was used: • At the first stage, 30 clusters were randomly selected. Using a random draw, villages were chosen from a list of accessible villages and the clusters assigned accordingly. (See appendix 1 for village list and estimated population). The probability of selection was proportional to the village population size. Each cluster included a minimum of 30 children. 10

• At the second stage, i.e. the selection of the households within each cluster, the standard WHO 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 included in the households encountered in that direction were measured.

.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 anthropometric questionnaire): • Age: recorded with the help of a local calendar of events (See appendix 4 for calendar of events) • Gender: male or female • Weight: children were weighed without clothes, with a SALTER balance of 25kg (precision of 100g). • Height: children were measured on a measuring board (precision of 0.1 cm). Children less than 85cm were measured lying down, while those greater than or equal to 85cm 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, or displaced.

.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 NCHS3 references. WFH indices were expressed both in Z-score and percentage of the median. The expression in Z-score has true statistical meaning and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs.

Guidelines for the results in Z-score: • 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.

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

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.5. Field Work

Four teams of three surveyors each executed the fieldwork. All the surveyors participating in the survey underwent a 3-day training, which included a pilot survey. ACF-USA and CMA staff supervised all the teams in the villages. The survey (including training) lasted for a period of 17 days.

.IV.6. Constraints

A retrospective mortality survey was implemented alongside the nutritional survey. The standard methodology was applied: all the households selected by the sampling methodology, event those without eligible children for the nutritional survey, were asked questions regarding their current composition, and the demographic movement that occurred within the past 3 months (the questionnaire is in appendix 3). Unfortunately, the information collected was not satisfactory, and the data was not validated. The retrospective mortality rate is absent in the present report.

.IV.7. Data Analysis

Data processing and analysis were carried out using EPI-INFO 5.0 software and EPINUT 2.2 program.

.V. RESULTS OF THE QUALITATIVE ASSESSMENT

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

According to SRRC, a total number of 5,077 returnees were reported to have arrived in the Jalle and Baidit payams by December 2004. The returnees were coming from Khartoum, Western Equatoria State, Uganda and Kenya as a result of the peace agreement signed in December 2004. CRS assists 1,116 returnees.

.V.2. Food Security

The community of Baidit and Jalle II are mainly agro-pastoralists and crop farming is the main livelihood. Crops grown in the area are: sorghum, maize, simsim, okra, groundnut and cowpeas. The cropping season is between May and October for maize while for sorghum it is between May and September. Maize is cultivated on lowlands while sorghum on highlands. A household cultivates an average of 4 feddans, although the amount of 12 land cultivated depends on available farm labour and tools. Most households have few malodas, pangas and sickles; this limits the amount of land that can be cultivated. Returnees have introduced Jembes, which resident communities have been receptive to.

For most of the year, the Dinka Bor diet consists of sorghum, fish, goat meat and milk. Maize is consumed to a limited extent. Milk is added to the sorghum/maize diet depending on its availability. Fish and goat meat are served as stews. During the “hunger gap” period, the community depends on wild leaves, lalop, water lily, barter trading in which goats and grass are exchanged for grains, as well as from WFP relief food. Sale of firewood to NGO’s and food for work are also practised.

Food stocks were not observed in most of the visited households during the time of survey. According to the community, the last harvest in October/ November 2004 was poor as compared to 2003 harvest due to late rains, heavy wind and attack from birds. This concurs with STARBASE 2004 report, which estimated that poor households in Bor were to experience a 15- 20% food deficit. The most affected are the pure small-scale crop farming households. The community reported that the maize harvested last October had been exhausted by the time of survey and they are now surviving on the little sorghum harvested in November 2004 and on wild food. The last WFP distribution was done in April 2005. The total number of beneficiaries was 13,758 with 50% rations provided for residents and 100% rations for returnees; this was estimated to last for 44 and 30 days, respectively. The food consisted of cereals 152.35 mt, pulses 17.25mt, CSB 10.9 mt, oil 10.719 mt and salt 1.5 mt. Each returnee household received; cereals 81kg, pulses 9kg, CSB 9kg, oil 5.4kg and salt 0.92 kg. Each resident household received; cereals 60kg, pulses 7kg, CSB 3kg, oil 4.35kg and salt 0.53kg. These have been exhausted.

The rivers Magol Bior and Nile provide fishing opportunities, although access is limited due to lack of appropriate fishing gear, canoes, and presence of crocodiles and hippos. FAO and CRS through SARP are currently implementing a capacity building project in fishing. FAO provides training in fishing methods and processing, in boat construction and marketing. In fish processing, FAO has introduced smoked fish, sun dried salty fish and wet salty fish although low access to salt hinders local fishermen from gaining from this program fully. Five shops along the Nile River have been established where fish and fishing equipment such as twines are sold on cost recovery basis. SARP offers training in technical, business skills and is overseeing the construction of fishing school.

Livestock kept by the community include cattle, sheep, goat, and chicken. Cattle are kept as a source of milk, for trading purposes and payment of dowry. On special occasions, cattle, goat and sheep are slaughtered to provide meat. Milk produced by cow is 2 litres per day during the rainy season and 0.5 litres per day during the dry season. The cattle are usually moved to the cattle camps between the month of May and November. At present, little livestock is kept by households due to massive cattle raids from 1991 to 1994 and sporadically to this time. The average number of cattle per household is 60-300 for the rich, 5-15 for the middle class and 0-4 for the poor; majority of the community is in the middle class. CARE supports veterinary services in the area through SRRC on a cost recovery basis.

.V.3. Health

CMA operates 6 Primary Health Care Units (PHCU’s), one Primary Health Care Centre (PHCC) and a tuberculosis clinic. The PHCU’s are located in Tong, Makol cuei, Akuei Deng, Apoor, Mathiang, and Kolmarek, while there are three non-functional PHCUs located in Kuei, Yolmuchel and Jalle II. The services are managed by an expatriate Doctor and 3 Nurses together with 15 community health workers (CHW’s), 1 medical assistant, 2 Nurses, 2 Laboratory assistants, 2 Pharmacy assistants and 36 support staff. MEDAIR, which used to operate in the location, trained all technical local staff. 60 Trained birth Attendants assist in the maternal child health care while 4 other community health promoters deliver health education to the community.

Morbidity reports in the PHCC indicate that malaria, diarrhoea and respiratory infections are the leading causes of consultations. Other reported diseases are skin diseases, malnutrition, intestinal parasites and eye infections. Screening for TB cases is carried out at the centers, and positive cases are referred for treatment in the TB clinic in Baidit. Other services provided are regular EPI (measles, polio, BCG, and DPT) and maternal child health care. 13

The health seeking practice of the community is still poor. People tend to first seek health care from traditional healers before going to the PHCU’s. When recovery in the health unit is not immediate, patients are usually reluctant to continue with medication.

.V.4. Water and Sanitation

Potable water is accessed from the 125 borehole facilities present in the Athoc Payam, installed by UNICEF, CARE and Pride Africa; CARE is in the process of handing over the water project to PARAD. However, in some locations, households still depend on water from swamps, pools and rivers due to the inaccessibility to boreholes. Boiling of drinking water is generally not practiced, and the families interviewed stated that boiling changes the taste of the water. Few latrines were observed mainly in the church, local authority and health centre compounds and there is general non-acceptance of using latrines among the population; for the majority, open defecation is practiced.

.V.5. Mother and Childcare Practises

Most mothers report to be exclusively breastfeeding infants in their first 6-12 months; the belief that early weaning causes children to wet while sleeping at night is common. The infants are breastfed on demand while the rest of the children are fed three meals per day comprising of milk, porridge, fish and sorghum. Hygiene during breastfeeding and food preparation was observed to be poor. The quantity and quality of food served to children during hunger gap is low with priority given to the husband and visitors followed by children and elders.

.V.6. Actions Taken by NGO’s and other Partners

The following table summarizes NGO activities in the area:

Table 2 Agencies intervention in Athoc: Jalle 2 and Baidit Payams Agency Activities

WFP • Targeted Food Aid distribution and monitoring

CMA • Offers health services in the location

WHO • Polio vaccination

FAO, CRS and • Capacity building in fishing. SARP • Veterinary support through SRRC, Borehole drilling, seed distribution and CARE farmer training. Handing over water project to PARAD and Agriculture to CRS. GTZ • Road rehabilitation and dyke construction. 14

.VI. RESULTS OF THE ANTHROPOMETRICS SURVEY

.VI.1. Distribution by Age and Sex

916 children have been measured during the survey.

Table 3 Distribution by Age and Sex AGE Sex BOYS GIRLS TOTAL (In months) Ratio N % N % N % 06 – 17 125 43.9 160 56.1 285 31.1 0.78 18 – 29 108 52.2 99 47.8 207 22.6 1.09 30 – 41 96 52.7 86 47.3 182 19.9 1.12 42 – 53 70 53.0 62 47.0 132 14.4 1.13 54 – 59 44 40.0 66 60.0 110 12.0 0.67 Total 443 48.4% 473 51.6% 916 100% 0.94

The overall sex ratio of 0.94 allows the validation of the sample selection, since it lies within the accepted benchmark range of 0.80 - 1.20.

Figure 1 Distribution by Age and Sex

Figure 1: Distribution by age and sex, Athoc payams, 2005

54-59

42-53 t

30-41 Boys Girls Age in in Age mon

18-29

06-17

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

There is a slight over representation of the 6-17 months and under representation of 42-53 months age groups. This can be attributed to ages given by parents (caretakers) during the survey being approximate and 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. 15

.VI.2. Anthropometric Analysis

.VI.2.1. Acute Malnutrition for Children 6-59 months of Age

¾ Distribution of Malnutrition in Z-Scores Table 4 Weight for Height distribution by age in Z-score

AGE < -3 SD ≥ -3 SD & < - 2 SD ≥ -2 SD Oedema (In months) N N % N % N % N % 06-17 285 30 10.5 98 34.4 157 55.1 0 0.0 18-29 207 10 4.8 56 27.1 141 68.1 0 0.0 30-41 182 3 1.6 64 35.2 115 63.2 0 0.0 42-53 132 5 3.8 51 38.6 76 57.6 0 0.0 54-59 110 6 5.5 37 33.6 67 60.9 0 0.0 TOTAL 916 54 5.9% 306 33.4% 556 60.7% 0 0.0

Table 5 Weight/Height vs. Oedema

< -2 SD ≥ -2 SD

Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0 Oedema Marasmus No malnutrition NO 360 39.3% 556 60.7%

No case of kwashiorkor was found in the sample. 16

Figure 2 Weight for Height in Z-Score Distribution, Athoc, 2005

Figure 2. Weight for Height Z - score distribution, Athoc, 2005.

3 0

2 5

2 Percentag0 e

Referenc 1 Sexe 5 Combined

1 0

0 - - - - - 012345 5 4 3 2 1 Z - Score

There is a significant displacement of the sample curve to the left of the reference curve, indicating a poorer nutritional situation in this population than in the reference one. The mean Z-score of the sample is –1.76. The standard deviation of the curve, equal to 0.90, lies within the accepted benchmarks (0.80 – 1.20): it shows that the sample is representative of the population.

Table 6 Global and Severe Acute Malnutrition by age group in Z-score

6-59 months (n = 916) 6-29 months (n =492) Global acute malnutrition 39.3% [34.7%- 44.1%] 39.4% [33.2%- 46.0%] Severe acute malnutrition 5.9% (4.0%- 8.6%] 8.1% [5.1% -12.5%]

Statistical comparative analysis of malnutrition rates for children 6-29 months and 30-59 months of age indicate that there is no significant difference (p>0.05) between the two age groups. The 6-29 and 30-59 months age groups have equal chances of being malnourished. 17

Table 7 Nutritional Status by Sex in Z-score Boys Girls Nutritional status Definition N % N % Weight for Height < -3 and/or Severe malnutrition 32 7.2 22 4.7 oedema Moderate malnutrition -3 ≤ W/H < -2 and no oedema 156 35.2 150 31.7 Normal -2 ≤ W/H and no oedema 255 57.6 301 63.6 TOTAL 443 48.4% 473 51.6%

The statistical analysis shows that there is no significant difference in the prevalence of malnutrition between boys and girls (p>0.05). Both boys and girls present equal chances of becoming malnourished.

¾ Distribution of Malnutrition in Percentage of the Median

Cut-offs for acute malnutrition expressed in percentage of the median are commonly used in determining admission criteria in feeding centres.

Table 8 Distribution of Weight/Height by age in percentage of the median

AGE < 70% ≥ 70% & < 80% ≥ 80% Oedema (In months) N N % N % N % N % 06-17 285 13 4.6 87 30.5 185 64.9 0 0.0 18-29 207 1 0.5 45 21.7 161 77.8 0 0.0 30-41 182 0 0.0 42 23.1 140 76.9 0 0.0 42-53 132 0 0.0 38 28.8 94 71.2 0 0.0 54-59 110 0 0.0 28 25.5 82 74.5 0 0.0 TOTAL 916 14 1.5% 240 26.2% 662 72.3% 0 0.0%

Table 9 Weight for height vs oedema < -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 0 0.0% Oedema Marasmus No malnutrition NO 254 27.7% 662 72.3%

Table 10 Global and Severe Acute Malnutrition by age group in percentage of the median

6-59 months (n = 916) 6-29 months (n = 492)

Acute global malnutrition 27.7% [23.6%-32.2%] 29.7% [24.0%-36.0%] Global and Severe Acute Malnutrition by age group in 1.5% [0.6%-3.3%] 2.8% [1.2%-6.1%] percentage of the median

Statistical comparative analysis of malnutrition rates for children aged 6-29 months and 30-59 months indicate that there is no significant difference (p>0.05). 18

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 5 1.1 9 1.9

Moderate malnutrition 70% ≤ Weight for Height < 80% 123 27.8 117 24.7

Normal Weight for Height ≥80% 315 71.1 347 73.4

TOTAL 443 48.4 473 51.6

The statistical analysis shows also, as previously, that there is no significant difference in the prevalence of malnutrition between boys and girls (p>0.05). Both boys and girls present equal chances of becoming malnourished.

.VI.2.2. Nutritional Status of Children below 6 months

83 children aged below 6 months, present in the households at the time of the survey were measured in order to determine their nutritional status. Among the under 6 months old, 51.8% (43) were boys and 48.2 % (40) were girls.

Table 12 Age distribution of the under 6 months Age in month N % 0 - - 1 12 14.5 2 18 21.7 3 17 20.5 4 24 28.9 5 12 14.5 Total 83 100

In the Z-score and percentage of median the analysis of the 83 children, only 67 children were included (some caretakers did not accept their infants to be measured).

According to the Weight for Height index in Z-score, there were no severely malnourished infants, 4 (6.0%) were moderately malnourished, and 63 (94.0%) had good nutritional status. By Weight for Height index in percentage of the median out of the 67 children, 1(1.5%) infant was severely malnourished, 1(1.5%) moderately malnourished and 65 (97.0%) had good nutritional status.

¾ Feeding Practices Breast milk was part of the diet of all infants. 86.7 % of the mothers interviewed practiced exclusive breastfeeding for their infants, while 13.3% had begun weaning before the child reaches 6 months old. Weaning food was usually composed of sorghum porridge and cow milk when available. 19

Table 13 Feeding practices Feeding practices Frequency Percentage Exclusive breastfeeding 72 86.7% Mixed feeding (breast milk and weaning food) 11 13.3% Total 83 100%

.VI.2.3. Risk to Mortality: Children’s MUAC

As MUAC overestimates the level of under nutrition in children less than 1 year old, the analysis refers only to children having height equal to or greater than 75cm.

Table 14 MUAC distribution

Total 75 to 90 cm 90 to 115 cm height height Criteria Nutritional status

N % N % N %

<110 mm Severe malnutrition 5 0.7 5 1.8 0 0.0

110>=MUAC<120mm Moderate malnutrition 50 7.0 35 12.5 15 3.5

120 >=MUAC<135 mm At risk of malnutrition 276 38.7 128 45.7 148 34.1

MUAC>=135 No malnutrition 383 53.6 112 40.0 271 62.4

TOTAL 714 100 280 39.2 434 60.8

According to the MUAC measurement, 0.7 % of the children are severely malnourished, and therefore, at high risk of mortality, 7.0% are moderately malnourished and could easily slip into the severely malnourished group. 38.7% are at risk to malnutrition.

.VI.3. Measles Vaccination Coverage

Measles vaccination is administered from the age of 9 months. Children 9-59 months of age were included in the analysis. A total of 844 children were included in the analysis.

Table 15 Measles vaccination coverage

Measles vaccination N %

Proved by Card 273 32.3 According to the mother/caretaker 344 40.8 Not immunized 227 26.9 Total 844 100

Only 32.3% of the children were vaccinated against measles as proved by the card, and 40.8% were vaccinated according to the mothers or caretakers. By then, at least 26.9% of the children were not immunized. 20

.VI.4. Household Status

Table 16 Household Status

Status N % Residents 589 98.5 Internally Displaced 4 0.7 Temporary Residents (on 5 0.8 transit) Total 598 100

The larger proportion of the surveyed families were residents 589 (98.5%), while 4 (0.7%) were internally displaced. 5 (0.8%) of the households were temporarily residing in the location. There was minimal movement of the population during the time of the survey.

.VI.5. Composition of Households

Table 17 Household Composition

Age group N %

0 to 59 months 999 29.6

Adults 2376 70.4

Total 3375 100.0

598 households were visited during the survey. The mean number of under 5 year olds per household is 1.61 (SD: 0.73) and the mean number of over 5 year olds per household is 3.84 (SD: 2.02).

.VII. CONCLUSION

The nutritional survey was undertaken in 2 of 5 payams of the South Bor County, sampling 916 children 6-59 months of age. The analysis of the anthropometrics data showed that 39.3% of the children are acutely malnourished, 5.9% of which are in the severe form. Among children 6-29 months of age, the GAM rate is 39.4% while SAM is 8.1%. These rates are far above the critical threshold of 15% and 4%, respectively, and are the highest obtained from a nutritional survey in South Sudan in the most recent years:

Table 18 GAM and SAM Rates May 2002 March 2003 June 2005 37.7% 20.8% 39.3% Global acute Malnutrition (33.1% - 42.4%) (N/A) (34.7% - 44.1%) 6.6% 2.4% 5.9% Severe Acute Malnutrition (4.5% - 9.4%) (N/A) (4.0% - 8.6%)

The most relevant factors seen to have contributed to the current nutritional state among the under 5 years of age population are the low access to food and to health services.

The long dry spell and erratic rains of 2004 widely affected farming produce in many parts of the Upper Nile region did not spare this area. Worsened by crops destruction from pests and strong winds, the households interviewed reported minimal harvest of maize in October, which has been exhausted by the 1st quarter of this year. During the time of survey, majority of the communities have been depending on limited sorghum stocks from the November harvest, and on wild foods. The Rivers Magol Bior and Nile are a source of fish, however, access is constrained by lack of tools and means for fishing – NGO’s such as FAO and CRS deliver programs and activities related to fishing, but its full potential is yet to be realized. Similarly, milk or meat from livestock is meager, with majority of families owning maximum of 15 cattle to none. Moreover, although no significant movement was observed during the time of survey, more than 5000 returnees were recorded in December 2004, accordingly depleting the available food among the host families even more. WFP last carried out general food distribution in April, providing 50% ration for resident households and 100% ration for returnees; these have lasted for only a month.

Health records show rising incidence of these conditions in the current period, but utilization of health services from the existing primary health care facilities is not practiced among the majority of the households surveyed. The health-seeking practices, especially on drinking safe water, hygiene and sanitation are unimproved.

A retrospective mortality survey has been implemented alongside the nutritional survey. Unfortunately, the data collected were not satisfying, which can be attributed to the methodology that was used. As a result, this indicator is reported in this the present survey.

.VIII. RECOMMENDATIONS

ACF-USA recommends the following:

Programmatic recommendations:

• A therapeutic feeding program should be immediately implemented to cover South Bor County, to treat and reduce the risk of mortality among the severely malnourished children. Co-ordination with and among humanitarian agencies on ground should be initiated; technical support should be offered by ACF-USA.

• Deeper analysis of the health situation should be undertaken by CMA while enhancing the coverage of its primary health care services in the area, ensuring increased access and utilization by the population. The PHCU’s in Kuei, Yolmuchel and Jalle II should be re-established.

• Capable agencies should support South Bor with projects to increase safe water source (such as borehole installation) and basic sanitary facilities.

Methodological recommendation:

• To implement in the future surveys the SMART methodology for the collection of data and the analysis of the retrospective mortality rate. 22

.IX. APPENDIX

.IX.1. Sample Size and Cluster Determination

Villages Distance from CMA Estimated Target Cumulative target Attributed numbers Cluster Number of COMPOUND population population population clusters Jalle II 2hrs 3302 660 164 1- 660 1, 2 2 Makuach 1.5hrs 3538 708 1368 661- 1368 3, 4, 5 3 Akuei Deng 4hrs 1060 212 1580 1369- 1580 6 1 Liliir 4.5hrs 1188 238 1818 1581- 1818 Akoi- Rial 4.25hrs 2093 419 2237 1819- 2237 7, 8 2 Pamuom 3.25hrs 1138 228 2465 2238- 2465 9 1 Maluak 3hrs 1224 245 2710 2466- 2710 10 1 Mathiang 2hrs 1203 241 2951 2711- 2951 11 1 Thontok 2.25hrs 1021 204 3155 2952- 3155 Gameth 2.5hrs 1700 340 3495 3156- 3495 12 1 Thoi – Bek 2.5hrs 1080 216 3711 3496- 3711 13 1 Anya 1.75hrs 1252 250 3961 3712- 3961 14 1 Kurkuot 1.5hrs 1280 256 4217 3962- 4217 15 1 Wut – cuei 1.25hrs 1080 216 4433 4218- 4433 16 1 Awuolthou 2hrs 1060 212 4645 4434- 4645 17 2 Ayen 1hr 1230 246 4891 4646- 4891 18 1 Cholanyang 0.75hrs 1135 227 5118 4892- 5118 Lual leek 0.25hrs 2100 420 5538 5119- 5538 19, 20 2 Apoor 0.75hrs 1235 247 5785 5539- 5785 21 1 Pakeer 0.75hrs 2115 423 6208 5786- 6208 22 1 Magok 0.75hrs 2012 402 6610 6209- 6610 23, 24 2 Ayuira 1hr 1000 200 6810 6611- 6810 Pagook 1.5hrs 1012 202 7012 6811- 7012 25 1 Bongor 2hrs 1001 200 7212 7013- 7212 26 1 Makol 3hrs 1201 240 7452 7213- 7452 27 1 Chol Agoot 3.5hrs 1050 210 7662 7453- 7662 Pabeu 2.5hrs 1150 230 7892 7663- 7892 28 1 Panomahooth 2hrs 1010 202 8094 7893- 8094 29 1 Pachalou 2.25hrs 707 141 8235 8095- 8235 30 1 Malualbiol 2.5hrs 551 110 8345 8236- 8345 Total 41728 8345 30 23

The sampling interval is equal to target population divided by number of clusters i.e. 8345/30 =278. Villages included in the clusters are shown in the table above. The random number drawn between 1 and 52 was 165.

The target population was greater than 4,500 hence the sample size was 900 children. A total of 916 children were included in the survey.

The number of children included in each cluster is sampling size/ number of clusters, which was 900/30 = 30. 24

.IX.2. Anthropometric Survey Questionnaire

DATE CLUSTER No: VILLAGE: TEAM No: Tribe Statu Sex Sittin Oedem MUAC Age Measles Family s Weight Heigh g a Y/N mm N°. C/M/N N°. (1) Kg t Heigh Mths (3) M/F cm t cm (2) 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…). (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

.IX.3. Retrospective Mortality Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No:

Number Number NUMBER Number of Number of of < 5 TRIBE of < 5 of >= 5 dead >=5 people alive in Family years CAUSE CAUSE Years years years in the last 3 N°. dead in (2) (3) (1) alive alive the last 3 months** last 3 today today months months 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

(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family…). (2) Tribe: Nuer, Dinka, Shilluk. Murle. Cause: Diarrhoea (watery diarrhoea), 2=Bloody diarrhoea (Dysentery), 3=Measles, 4=Malaria, 5= TB, 6=Pneumonia, 7=Malnutrition, 8= Kala-Azar, 9=Accident (gunshot, snakebite…), 10=other (write presumed cause of death). 26

.IX.4. Calendar of Events in Athoc: Jalle II and Baidit Payams

MONTHS SEASONS 2000 2001 2002 2003 2004 2005 Christmas 53 41 29 17 5 JANUARY /celebrations Bombing stops GTZ arrival in PEITOK continue. Padak Winnow and store sorghum.

52 40 28 16 Construction of FEBRUARY Opening of new tukuls. PEIROU airstrip 51 39 27 15 Clearance of MARCH TEARFUND land. PEIDIAK nutrition survey 50 38 26 14 2 Land clearance APRIL and cultivation. PEI NGUAN Start of rain and 49 37 25 13 1 MAY planting of Returnees Drought PEI DHIEC maize and arrived in Athoc sorghum. JUNE 48 36 24 12 PEI DHETEM Weeding Flooding John Garang visit

JULY 59 47 35 23 11 PEI DHOROU Weeding Drought Flooding AUGUST Scare birds 58 46 34 22 10 PEI BET from attacking Birds destroy sorghum. crops Eating of green maize. SEPTEMBER 57 45 33 21 9 PEI Harvest sorghum. Little Good yield of Poisonous fish Torit captured by Flooding DHONGUAN crops SPLM rain. 27

OCTOBER 56 44 32 20 8 PEI THEIR Harvest maize. Recultivate.Hea vy rain. Torit recaptured by GOS NOVEMBER 55 43 31 19 7 PEI Dry and store THIERUTOK cereals. End of Peace heavy rain. agreement signed in Machakos Christmas, 54 18 6 DECEMBER repair tukuls End of PEI THIE and marriage TEARFUND ceremonies. feeding project 28

.IX.5. Anthropometric Survey Questionnaire for Children Less than 6 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 beast feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food =3. 29

.IX.6. Padak Market Commodity Prices

Commodity Quantity Price in Sudanese Dinar(SD) Sorghum 2kg 400.00 Beans 0.5kg 225.00 Maize 50kg 4200.00 Milk 1litre 225.00 Sugar 1kg 600.00 Salt 0.25kg 50.00 Cooking oil 1 litre 600.00 Onions 3 pieces 100.00 Soda 0.5 litre 300.00 Fish(dry) Small size 100.00 Fish(fresh) Small size 84.00 Beef 1kg 300.00 Bar soap 1 piece 50.00 Omo 0.25kg 90.00

Exchange rates: 1 Kshs = 3 SD, 1 US $ = 210 SD