FINAL REPORT

NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LOCAL GOVERNMENT, BORNO STATE NIGERIA

Conducted by Mercy Corps December 2020

1 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA ACKNOWLEDGEMENT This survey was commissioned by Mercy Corps with financial support from USAID - Food for Peace. Mercy Corps wishes to express gratitude and appreciation to the following individuals and organizations for their contribution to the survey process. ▪ Damboa Local Government communities, especially the individuals that reside in the households that participated in this survey, thank you for allowing the survey team to collect valuable information including measuring your children.

▪ The Northeast Nigeria Nutrition in Emergency Sector Coordination team, especially the Information Management Technical Working Group (IMTWG) members for their technical and logistical support accorded during survey preparation and validation of survey protocol and findings. Special thanks to Mr. Simon Karanja (Nutrition Sector Coordinator), Adamu Yerima (IMTWG Co-chair) and Dr. Narendra Patil (ACF – SMART manager). ▪ We express our gratitude to the National Bureau of Statistics (NBS) and Borno State Primary Health Care Development Agencies (SPHCDA) for the cooperation and authorization to carry-out the survey. Special thanks to Damboa Local Government Primary Health Care team (PHC Coordinator – Alhaji Ali Fintiri and the Nutrition Focal Person-Hajia Zainab) and community leaders and other stakeholders for their support in several capacities including guidance, coordination, general supervision and participation.

▪ We also appreciate the Mercy Corps team in Damboa and Maiduguri Field Offices, especially Eric Ssebunnya (Nutrition Advisor), Bemshima Abako (Senior Programme Officer Nutrition), Murtala Musa (Field Manager), Maxwell Samaila (Program Manager), David Okutu and Charles Okoro (M & E team), Abdullahi Shittu and other members for their technical advice, internal coordination, security guidance and support.

▪ Lastly, many thanks to the survey consultant Dr. Ibraheem ADEBAYO and his team for providing overall leadership and technical support. We are grateful to all the data collection team – the field enumerators, supervisors, field guides, and community nutrition promoters (from mercy corps) for their dedication and commitment throughout the data collection period. We specially acknowledge Tobi Olayemi – one of the supervisors of the data collection team, who passed away at her home 2 days after field work following a brief illness, may her soul rest in perfect peace.

2 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA TABLE OF CONTENTS Contents TABLE OF CONTENTS iii TABLES AND FIGURES iv LIST OF TABLES iv LIST OF FIGURES v LIST OF ACRONYMS v EXECUTIVE SUMMARY vii CHAPTER ONE 11 BACKGROUND INFORMATION 11 1.1 General objective of the Survey: 2 1.2 Specific objectives: 2 1.3 Justification of the survey 2 CHAPTER TWO 3 METHODOLOGY 3 2.1 Survey Area and Period 3 2.2 Survey Design 3 2.3 Target Populations 3 2.4 Sample Size 3 2.5 Ethics 4 2.6 SMART Survey Training and Data Collection 5 2.7 COVID-19 Personal Prevention Strategy and Prevention of Community Transmission 5 CHAPTER THREE 6 THE RESULTS 6 Data Quality – Plausibility Checks 6 Damboa SMART Nutrition Survey Coverage 7 3.1. Households 7

3 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA 3.2. Anthropometric Results for Children aged 6 – 59 months 11 3.3. Morbidity Status in the past 2 weeks prior to survey 16 3.4. Health Seeking behavior 17 3.5. Mortality 17 3.6. Measles Vaccination, and Vitamin A Supplementation 18 3.7. Infant and Young Child Feeding Practices including MDD-C, MAD 19 3.8. Maternal Nutrition Status, Dietary Practices and Perception of Importance of EBF 20 3.9. Water Sanitation and Hygiene Practices 22 CHAPTER FOUR 27 CONCLUSIONS AND RECOMMENDATIONS 27 Challenges and Limitations 28 ANNEXES 29

4 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA TABLES AND FIGURES LIST OF TABLES Table 1: Sample size estimation 14 Table 2: Summary of data quality plausibility test result 16 Table 3: Sample size coverage – planned and actual 17 Table 4: Socioeconomic characteristics of households in Damboa LGA 17 Table 5: Sources of food for the Households in Damboa LGA 18 Table 6: Households’ beneficiaries from Mercy Corps Food Basket and Food Vouchers Programme 19 Table 7: Food Composition Score of the Surveyed Households and Coping Mechanism 20 Table 8: Acute Malnutrition by Weight for Height Z-score (WHZ) for Children aged 6-59 months (WHO standard 2006) 22 Table 9: Acute Malnutrition by Mid-Upper Arm Circumference (MUAC) – WHO standard 2006 23 Table 10: Prevalence of Stunting – Height-for-Age Z-score (HAZ), WHO Standard 2006 24 Table 11: Prevalence of Underweight – Weight-for-Age Z-score (WAZ), WHO Standard 2006 25 Table 12: Morbidity Rate and Prevalence of Diarrhea and Treatment, Insecticide Treated Net Usage and Fever and ARI Prevalence 26 Table 13: Health Seeking Behavior among Caretakers of Children aged 6-59 months 26 Table 14: Retrospective estimation of Crude mortality rates and Under-5 mortality rates (recall period = 135 days) 27 Table 15: Measles vaccination, Vitamin A Supplementation and MNP 28 Table 16: Infant and Young Child Feeding Practices among Children aged 0 – 23 months 29 Table 17: Maternal Nutrition Status WCBA aged 15 – 49 years 30 Table 18: Women of Childbearing Age Feeding Practices: MDD-W, Women Perception of Importance of Exclusive Breastfeeding 30 Table 19: Households’ Report of Water Impurities and Types of Impurities 32 Table 20: Water Treatment Methods Usage 33 Table 21: Handwashing Station Availability within the Households 33

5 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA LIST OF FIGURES Figure 1: Distribution of Weight-for-Height in Z-score compared to WHO Standards (2006), SMART Flagged (n=4) 22 Figure 2: Cumulative Distribution of MUAC by gender 23 Figure 3: Distribution of Height-for-Age in Z-score compared to WHO Standards (2006); SMART flagged; n=18 24 Figure 4: Distribution of Weight-for-Age Z-score compared to WHO Standards 2006, SMART Flagged n=10 25 Figure 5: Population Pyramid of Damboa LGA & Mercy Corps Programme Communities in Damboa LGA 28 Figure 6: Main Source of Drinking Water at Damboa LGA and at Mercy Corps Programme Communities 32 Figure 7: Distance walked by members of the households to the primary source of drinking water 32 Figure 8: Types of Toilet Facilities available within the households 34 Figure 9: Households with Animal Feces in Domestic Space 35

LIST OF ACRONYMS ANC Antenatal Care

6 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CMAM Community-based Management of Acute Malnutrition CP Child Protection D-LGA Damboa Accessible Areas Local Government EA Enumeration Areas ECD Early Childhood Development ENA Emergency Nutrition Assessment EU European Union EC European Commission FSL Food Security and Livelihoods GAM Global Acute Malnutrition HAZ Height-for-Age Z-score HH Households HHH Households Head IDP Internally Displaced Persons ITN Insecticide Treated Net IYCF Infant and Young Child Feeding LGA Local Government Area MCPC Mercy Corps Programme Communities MNCHW Maternal Neonatal and Child Health Week NBS National Bureau of Statistics Nb Number NPopC National Population Commission PLW Pregnant and Lactating Women SMART Standard Monitoring and Assessment of Relief and Transitions UNICEF United Nations Children Funds USAID United State Agency for International Development WASH Water Sanitation and Hygiene WCBA Women of Childbearing Age

7 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA WAZ Weight-for-Age Z-score WFP World Food Programme WHZ Weight-for-Height Z-score WHO World Health Organization

EXECUTIVE SUMMARY Data collection for the Nutrition and Retrospective mortality survey was conducted by Mercy Corps from 12th December – 15th December 2020 in Damboa Local Government accessible areas. Damboa LGA in Borno State of Nigeria was one the highly affected

8 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA areas by the Boko Haram insurgencies, which has been ongoing for some years in the Northeastern part of Nigeria. The insurgencies have resulted in widespread forced displacement, violation of international human rights law, severe protection concerns and a growing food and nutrition crisis. Mercy Corps with support from USAID Food for Peace (FFP) is implementing a humanitarian assistance program to increase access to food and mitigate the need for harmful negative coping mechanisms. The survey aimed to assess the current prevalence of acute malnutrition among children aged 6-59 months and mortality among the general population in Damboa LGA. The specific objectives of this survey include: estimation of the prevalence of wasting, stunting and underweight among children 6 to 59 months of age and women 15-49 years old in Damboa LGA accessible areas; assessment of the coverage of measles vaccination, vitamin-A supplementation and health seeking behavior among the caretakers of children aged 6-59 months; determination of the prevalence of morbidity - child illness (diarrhea, fever and cough-ARI) and mortality; provide information on infant and young child feeding practices, food consumption and coping mechanisms, and water, sanitation and hygiene practices.

This survey followed a Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. A cross-sectional sample survey with two stage sampling design (cluster and systematic random sampling methods) was employed to undertake the survey. Sample size was calculated to be representative of Damboa LGA. However, the security situation reduced access and certain wards were excluded. The data was collected using CAPI-galaxy tablets already configured with the survey questionnaire adapted from NNHS and NFSS, through ODK-ONA enabled remote server. The nutrition status and mortality rate were analyzed using ENA for SMART software updated version 2020. Other indicators: Households characteristics, IYCF, Women’s Nutrition indicators, and WASH were analyzed using STATA vs 14. The nutritional status of children was analyzed using WHO 2006 Child Growth Standards and SMART flags (-3/+3 SD) were excluded from the observed survey mean. The cut- off of <-2 SD was used to determine GAM, stunting and underweight using weight-for- height (WHZ), height-for-age (HAZ), and weight-for-age (WAZ), respectively. MUAC was also used to assess acute malnutrition among children 6-59 months and women of reproductive age, using cut-offs of 125cm and 190cm respectively. Data were collected from a total of 615 households, including 580 children aged 6-59 months and 626 women of childbearing age (15-49 years) in 31 randomly selected clusters.

Shown below are the Results / key findings: Nutrition Characteristics Damboa LGA Accessible Areas; % (95% CI) GAM rate based on WHZ 5.9% (4.2-8.3) SAM based on WHZ 1.2% (0.2-2.7) GAM based on MUAC 2.2% (1.3-3.9)

9 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Prevalence of Edema 0.0% Stunting rate HAZ 36.8% (31.9-42.1) Underweight rate WAZ 17.2 (13.6-21.6) Child Illness Rate 2 weeks prior survey 25.5% (22.1-29.2) Prevalence of Diarrhea 10.3% (8.1-13.1) Prevalence of Fever 11.2% (8.9-14.1) Prevalence of Cough (ARI) 12.2% (9.8-15.2) Crude Mortality Rate (per 10,000/day) 1.2 Under-Five Mortality Rate (per 10,000/day): 0-4years age 2.6 Measles vaccination for children aged 9-23months (with Vacc 81.2% (69.6-93,7) Card and Recall only) Vitamin A received for children aged 6-59months in the last 6 67.6% (63.7-71.3) months (recall) Deworming of children aged 12-59months received in the last 60.9% (56.6-65.0) 6 months Severe malnutrition among Women of Childbearing Age on 2.0% (1.1-3.3) MUAC (<19.0cm) Moderate undernutrition among WCBA on MUAC (19.0cm – 19.5% (16.6-22.8) 23.0cm) Minimum Dietary Diversity for Women (MDD-W) 49.5% (45.6-53.4) Consumption of Iron-rich Food among WCBA 65.2% (61.3-68.8) Consumption of Vitamin-A rich Food 34.3% (30.7-38.2) Ever Breastfed children 0-23 months 77.8% (72.5-82.4) Initiated Breastfeeding of Children 0-23 months old within 1 65.0% (58.3-71.1) hour Exclusive Breastfeeding of Infants less than 6 months 63.8% (50.4-75.4) Complementary Food Introduction to children 6-8 months 66.7% (47.2-81.7) Minimum Dietary Diversity for Children aged 6-23 months 25.5% (19.0-33.3) Minimum Meal Frequency (MMF) 53.2% (44.3-62.0) Minimum Acceptable Diet (MAD) 14.3% (9.4-21.2) Consumption of Iron-rich Food 24.1% (17.8-31.9)

10 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Food Consumption Score 0-21 (Poor) 19.0% (16.1-22.3) 21.5-35 (Borderline 45.4% (41.5-49.3) Coping Mechanism Consumption of low-quality food 55.0% (51.0-58.9) Consumption of fewer food items 32.7% (29.1-36.5) Main Source of Drinking Water Public Tap/ Piped Water/ Borehole 84.0% (80.8-86.6) Protected dug well 5.0% (3.6-7.1) Water Trucking/Water vendor 7.2% (5.4-9.5) Toilet facilities available in the households Flush/Pour flush toilet/VIP/Simple Pit with woods as slab 76.9% Pit latrine no slab/open pit/none 23.1%

Conclusion and Recommendations The estimated level of GAM in Damboa LGA was 5.9% (CI: 4.2-8.3%) which falls within the category of medium threshold according to the WHO1 classification of acute malnutrition. The SAM level was 1.2% (CI: 0.2-2.7) and warrants close attention in such a sensitive environment, susceptible to food security shocks. Borderline and poor food consumption scores were 45.4% and 9.0% respectively.

The GAM rate in Damboa according to this survey is relatively low in comparison with Borno State where the estimated GAM level varied from 16.0% in the NDHS 2018/19 survey2 to 10.6% in the NNHS 20183 and 8.1% in the NFSS 2019. Nevertheless, GAM is still within the medium threshold and given the relatively high borderline and poor food consumption scores (FCS of over 50%), a small shock to food security could have a significant impact on the nutritional status of the children. Close monitoring is therefore required with rapid intervention in case of serious decline. The stunting estimate of 36.8% (CI: 31.9-42.1%) in this survey remains very high, indicating a need for continued effort to address the underlying and root drivers of chronic malnutrition, including understanding and overcoming contextualized barriers to optimal IYCF practices.

1 WHO 2006

2 NDHS 2018/19

3 NNHS 2018

11 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA The under-five mortality rate (2.6 per 10,000/day) is high according to Sphere criteria (<2.0 per 10,000/day) and a minority of caregivers eschew formal health services, instead patronizing traditional healers (18.8%) or not seeking treatment at all (8.0%). Improved community outreach and a strengthened referral system will be critical in the drive to improve future rates of child survival. The nutritional status of women is sub- optimal and warrants more targeted interventions including efforts to include uptake of micronutrient supplementation, improve dietary diversity and reduce workload (and hence high calorie expenditure). On the other hand, generally the WASH situation is good, with over 80% having access to safe drinking water and 77% having safe toilet facilities in their households. Efforts are nonetheless still required in order to improve and sustain WASH indicators.

Following these, it is recommended that active case findings of SAM and also MAM should be intensified by Mercy Corps and other partners, at community level through the existing community nutrition promoters and increase their coverage to involve all the accessible areas of Damboa LGA. In addition, CMAM activities should be strengthened through improved monitoring and supervision of CMAM centers and strengthening of the referral system. Increasing the coverage of food security programs to include other accessible areas not yet covered would further improve the food security situation in Damboa LGA. Community health and nutrition promotion activities should be intensified to reach throughout the LGA. Formation of WASH committees around water points to ensure sustenance of safe drinking water access is recommended, coupled with intensification of the open defecation free campaign.

12 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA 13 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA 14 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CHAPTER ONE BACKGROUND INFORMATION Damboa is one of the 27 local governments in Borno – a State that has been experiencing years of insurgency which has resulted in widespread forced displacement, severe protection concerns and a growing food and nutrition crisis. The vast majority of these displacements are within Borno State with about 1.4 million recorded internally displaced people (IDPs). In large part, this uprising has had devastating repercussions on livelihoods with heavy impacts on the host communities and the returnees. Borno State according to National Nutrition Survey (NNHS) 2018, Borno State has a GAM (WHZ) estimate of 10.6% (8.1-13.7) and stunting estimate of 37.3% (32.1-42.7). As of March 2019, the majority of IDPs are clustered in the urban areas of Borno State such as Maiduguri and other local government areas (LGAs) such as Damboa. Over 60% of households in Damboa LGA have access to less than half a hectare of agricultural land with less than 30% of households being able to cultivate land in the last planting season.

Damboa Local Government (LGA) is one of the LGAs hosting Internally Displaced Persons (IDPs). Damboa is located in the southern part of Borno State with an estimated population of 166,000 (2019 estimate) and landmass of 6,219km2; 87km by road from Maiduguri4. More than half of this population are currently internally displaced persons (IDP). There has been a steady increase of food insecurity among the displaced population with those living among the host community reporting a higher proportion of food insecurity than those living in the IDP camps. Consequently, the nutrition situation in Damboa has become dire. A survey conducted in 2019 showed that the Global Acute Malnutrition by WHZ (GAM) among under-five children was 9.0% (6.8-11.8) and by MUAC 10.8% (7.4-13.8), with a stunting estimate of 48.8%.

Mercy Corps with support from USAID Food for Peace FFP is implementing a humanitarian assistance program to increase access to food and mitigate the need for harmful negative coping mechanisms. The program aims to enable conflict-affected households in Damboa (94,584 people from 13,512 Households) to meet essential food needs. Using a multi-pronged approach that engages multiple market systems to address immediate food security needs and promotion of sustainable and resilient populations. To comple ment the food assistance, the program integrates nutrition interventions to improve availability, access, and consumption of diversified nutritious diets through immediate and sustained approaches, including provision of fresh food vouchers to approximately 5,000 households and piloting backyard gardening and poultry production among 945 households. Building on previous programs to further address the causes of malnutrition, the program supports a multi-pronged approach to increase community awareness and social behavior change (SBC) for improved

4 OCHA 2019. Fact Sheet: Damboa Local Government Area. Borno State, North-east Nigeria. Last updated December 2019. Assessed from Relief Web: https://reliefweb.int/report/nigeria/fact-sheet-damboa-local-government-area-borno-state-north-east- nigeria-last-updated.

1 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA nutritional status and health seeking behavior for Community Management of Acute Malnutrition services (CMAM).

Damboa LGA has 10 wards, though initially overrun by the insurgent but some of it are currently accessible, having large proportion of internally displaced persons settlements. At the time of this survey, only three wards were deemed accessible which houses about 108 communities out of which 8 communities were covered by Mercy Corps Programme intervention.

1.1 General objective of the Survey: To assess the current prevalence of acute malnutrition among 6-59 months old and mortality among the general population and children 6-59 months in Damboa LGA, Borno State, Nigeria. 1.2 Specific objectives: ● To estimate the prevalence of acute malnutrition (wasting and edema) among children aged 6-59months ● To determine the prevalence of chronic malnutrition and underweight among children aged 6-59 months of age ● To estimate the coverage of measles vaccinations, vitamin A supplementation and health seeking behavior among caretakers of children aged 6-59 months ● To assess the prevalence of diarrhea and use of ORS, Zinc among children under-five years, two weeks preceding the survey ● To retrospectively estimate the levels of crude mortality rates and under-five mortality rates in a specific time period (135 days) ● To assess the maternal malnutrition among the mothers of children surveyed ● To determine Infant and young child feeding practices (IYCF) indicators in the survey area for the age group of 0-23 months old children ● To determine water, sanitation, and hygiene practices of the survey population ● To assess the current food consumption score and coping strategy situation of the surveyed population.

1.3 Justification of the survey To investigate and determine up-to-date nutrition, mortality, IYCF data, Food Security and Livelihoods (FSL) and WASH situation data specific to these surveyed areas and to inform better future programming with evidence based specific information to the areas of intervention of Mercy Corps – an implementing partner of the Nutrition Cluster and Ministry of Health in Damboa.

2 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CHAPTER TWO METHODOLOGY 2.1 Survey Area and Period The nutrition and retrospective mortality survey covered only accessible communities in Damboa Local Government Area (LGA) of Borno State and was conducted from 12th December to 15th December 2020. Based on the security assessment pre-survey exercise, with consultations with the LGA stakeholders (Primary Healthcare Coordinator, Nutrition focal Person, Community Leaders and the Security Personnel), the UNICEF surveillance team, and the Mercy Corps team, only 108 communities were deemed accessible (thus forming the sampling frame), others were inaccessible due to insurgencies.

2.2 Survey Design The survey was designed as a cross-sectional survey using two-stage sampling methodology. The first stage cluster sampling was made out of the accessible settlements sampling frame using updated WHO immunization plus day settlements data. Population proportional to size cluster sampling was applied using ENA software. 31 clusters were selected which connotes 620 households calculated by ENA-for SMART software. The second stage used systematic random sampling to select households within the selected clusters. Twenty households were selected per cluster.

Out of 31 clusters, six (translating into 120 HHs) fell within the Mercy Corps Programme Communities, referred to as the Mercy Corps Program Accessible Areas in this report.

2.3 Target Populations The target population were children under 5 years of age, women of childbearing age (WCBA); 15-49 years, and male and female heads of household.

2.4 Sample Size An updated Emergency Nutrition Assessment (ENA) software January 2020 version, was used for sample size calculation.

Table 1: Sample size estimation Parameter Value Source/Assumptions

Damboa

3 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Upper limit of the 11.8% In the previous Nutrition SMART survey Estimated Prevalence 2019 (FHI360), the upper limit of the o f G l o b a l A c u t e prevalence of GAM in Damboa was 11.8%. Malnutrition (GAM) in To be on the safe side, the upper limit of % the range was used as the prevalence. +/- Desired Precision ±3.5 % Since the GAM prevalence is higher than 10%, a precision of +/-3.5% was chosen. Design Effect (DEFF) 1.50 This was set based on previous SMART survey in Damboa by FH360 Children to be 533 Based on the formula above computed included using ENA

Average Household 5.0 Based on the previous SMART survey Size Finding by FHI360 in 2019 % Children under-5 20.0 Based on previous SMART survey estimate in 2019 % N o n - r e s p o n s e 3.0 Based on previous survey estimate households Households to be 610 Based on the formula above computed included (according using ENA to ENA) Prevalence of Crude 0.4 Based on estimate from previous survey – Mortality Rate FHI 360 in 2019 +/- Desired Precision 0.3 Based on estimate from previous SMART survey 2019 by FHI360 Design Effect (DEFF) 1.5 This was set based on previous survey 2019 Recall Period (in 135 From the Salah (Eid-il-Kabir day – July 31st days) 2020) the restriction of COVID-19 lockdown was partially lifted Population to be 2065 Based on the formula above computed included using ENA Average Household 5.0 Based on the previous SMART survey Size estimate 2019 % N o n - r e s p o n s e 3.0 Based on the previous SMART survey households estimate

4 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Households to be 426 Based on the formula above computed included using ENA

2.5 Ethics The protocol for the survey was presented for validation to the Nutrition Cluster – Information Management Working Group (IMWG) and was validated on 7th December 2020. The preliminary results (draft report) were validated on 11th January 2021 by the same body.

2.6 SMART Survey Training and Data Collection A 4-day training for enumerators and supervisors was conducted from 7th to 10th December 2020, and was facilitated by the SMART survey Consultant, alongside experienced trainers and representatives from Mercy Corps. In the 4 day training, a full day was dedicated to the standardization test for enumerators and another 1 day for field testing at Meri settlement camp; Maiduguri. Results of the pre-test, post-test, standardization test and observations from the field test were used for the final selection of the 20 enumerators and 5 supervisors involved in the SMART survey data collection.

Data collection took place over a period of 5 days inclusive of 2 days of travelling from Maiduguri to Damboa. The SMART survey consultant was responsible for the overall coordination of the enumerators with security, supervision and technical support from the Mercy Corps team in Damboa. Prior to the start of data collection, the Nutrition Cluster, the State Nutrition and Borno State Primary Healthcare Development Agency, the Local government executives, the security operatives and the community leaders were informed about the survey to facilitate ease of access into the communities and camps. Each team had its own vehicle with a driver attached. Systematic random sampling was the second stage sampling method used to select 20 households. Upon arrival in the selected clusters, an updated list of the households in the clusters were obtained from the community leader/camp managers and with the help of the local guides, household listings were conducted (and/or segmentation into units were conducted), thereafter, sampling interval were determined and the households selected were numbered with chalks, whereupon data collection started.

2.7 COVID-19 Personal Prevention Strategy and Prevention of Community Transmission Presidential Task Force (PTF), Nigeria Center for Diseases Control (NCDC) and WHO’s COVID-19 Prevention Strategies Guidelines, coupled with UNICEF and National Bureau of Statistics (NBS) COVID-19 guidelines on the prevention of transmission COVID-19 was applied throughout the period of SMART training and during the fieldwork exercise. Wearing of face shields and face masks were made compulsory for the trainees and for all the enumerators in the field. Disinfecting wipes were frequently used by the trainees to intermittently clean the weighing scale and height board during the standardization test, and during the fieldwork to clean the measuring equipment after each session of data collection and anthropometric measurement of the women and children.

5 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Communities and households were sensitized about the COVID-19 pandemic and preventive measures, and a distance of 2 meters was maintained between the enumerators and respondents. The data collectors were fully gloved and masked during the data collections. During the briefing in the field every morning, temperature checks were conducted using a handheld thermometer, and in the evening upon returning from the field, to screen for suspected cases of COVID-19. Throughout the course of the training and data collection in the field, no suspected cases of COVID-19 were detected or reported among the data collection team.

Challenges and Limitations A critical challenge experienced by the survey team was accessing Damboa by road from Maiduguri – which was made difficult by prevailing insecurity and multiple security checkpoints. It took almost two days for the team to travel by road to Damboa, and the team had to sleep at Gwoza before proceeding on the second day.

The most significant limitations to Damboa SMART nutrition survey was the insecurity which limited the survey clusters to only the accessible areas of the local government – out of the ten wards in Damboa LGA, only three wards were deemed to be accessible by the local government officials and the security personnel. This means that the clusters selected for this survey had a limited coverage – mainly the township and IDP camps, and very few villages. Field survey staff (data collection team) were only able to access a set of wards that were considered to be safe and secured to allow proper data collection. This limited the extent of the survey in assessing the nutrition situation in most remote areas of Damboa LGA.

6 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CHAPTER THREE THE RESULTS Data Quality – Plausibility Checks ENA for SMART application software was used to assess the quality of the anthropometric measurements. SMART flags (as recommended by the SMART methodology) were used to exclude from the analysis any extreme values that likely resulted from incorrect measurements. SMART flags exclude anthropometric indices that deviate from the observed mean: -3 to +3 for Weight-for-Height Z-score (WHZ), -3 to +3 for Height-for-Age Z-score (HAZ), and -3 to +3 for Weight-for-Age Z-score (WAZ).

Using the anthropometric data as the proxy, the overall data quality was excellent. Analysis of the SMART quality parameters as shown in Table 2 below shows that the plausibility test result for the survey was 0.0%, and the mean +/- standard deviation for WHZ falls within the excellent range; (-0.37±1.06). The flagged data was within the excellent range (0.70%), and age and gender ratio were as expected for the survey. There was no significant digit preference for weight, height and MUAC measurements in the entire dataset.

Table 2: Summary of data quality plausibility test result Sex Age Digit Preference Rati Ratio (Score) SD WHZ Pois Flag o 6-23/ (Standar Skew Kurto on Sco Sta LGA ged (M: 30-59 d ness sis WHZ re te Weig MUA p- Data F) p- (p- Height Deviatio WHZ WHZ % valu value ht C n) valu e ) e

Bor Damb 0.70 p=0. p=0.1 p=0. 0.0 5 6 3 1.06 0.03 -0.05 no oa % 115 44 565 %

7 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA 10-1 >25: Scor 0-9: 4: 15-24: Probl e: Excell Goo Accept emati (%) ent d able c

Survey Coverage One-hundred percent of the planned clusters with 99.2% of the planned 620 households (HHs) were interviewed for the survey. Target groups in the households were household heads, children aged 6-59 months, and women of childbearing age group (15-49 years). Overall, 615 household heads (HHH) with 626 women (WCBA) were interviewed, and information about 580 under-five children were collected through their mothers or caregivers, with their anthropometric measurement.

Table 3: Sample size coverage – planned and actual Numbe Number of r of Population to Number of Number of Children Wome be included Clusters Households aged 6-59 n aged Surve for Mortality Stat months 15-49 y e years LGA Survey Survey Survey Survey Plann Plann Plann Plann Survey ed n ed n ed ed n ed ed ed ed ed (n) (%) (%) n (%) (%)

615 Bor Damb 31 580 2669 31 620 (99.2% 533 2065 626 no oa (100%) (109%) (129%) )

3.1. Households Characteristics, Sources of Food, and Food Security For the purpose of this survey, a household was defined as “a person or a group of persons, related or unrelated, who live together and share a common pot- source of food; and recognized a person as the household head”. Majority of the household’s head interviewed were men; 77% in Damboa LGA (D-LGA) with mean age of 48 years. Most of the households surveyed were in the township 73%. In D-LGA, setting of the households surveyed was 61% formal IDP camp and 38% host communities. Most households surveyed had no formal education at all in D-LGA (71%). Among educated households’ heads in the survey, Arabic and Quranic schooling is the most common form of education: D-LGA (13.8%).

Table 4: Socioeconomic characteristics of households in Damboa LGA Socio-demographics Characteristics of Households at the Surveyed Clusters in Damboa LGA

8 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA DAMBOA (All Accessible Clusters - Characteristics Nb Areas) - D-LGA; %CI

Gender of Household's Head 615 (HHH) Female 23.0(19.8-26.4) Male 77.1(73.6-80.2) Mean Age of the Household 615 47.9(46.7-49.0) head (Age in years) Mean Household Sizes 615 4.7(4.4-4.9) Mean Number of Children of 615 1.1(1.0-1.2) Children in Household (HH) Mean Number of Women in HH 615 1.0(0.9-1.1) Type of Settlement 615 Village 27.2(23.9-30.9) Town 72.8(69.1-76.1) Type of Setting 615 Formal Camp 60.6(56.7-64.4) Informal Camp 1.3(0.6-2.6) Host Community 38.1(34.3-42.0) Highest Level of Education 615 completed by Household Head None 70.6(66.8-74.0) Primary School 10.4(8.2-13.1) Secondary School 4.4(3.0-6.3) Tertiary 0.8(0.3-2.0) Others (Arabic/Quranic & 13.8(11.3-16.8) Vocational) History of Migration 615 IDP 63.1(59.2-66.8) Returnee 6.8(5.1-9.1) Host Community 30.1(26.6-33.8)

9 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Others (seasonal migrant) 0

Sources of Food The survey’s findings as shown in Table 5 revealed “food/cash assistance from NGO”, “market (purchased with cash” and “farming/livestock rearing” were the main sources of food for the surveyed households in Damboa LGA. The survey found that 8.1% of the households have women who were recipients of the food baskets in Damboa LGA accessible areas.

Table 5: Sources of food for the Households in Damboa LGA

Household Sources of Food

DAMBOA (All Accessible Clusters - Characteristics Nb Areas) - D-LGA Test of Gender Diff; Male Female 615 ALL: %CI p at 95%CI HHH: % HHH: % Own Production (Farming and 43.6(39.7-47.5) 45.6 36.9 0.07 Livestock) Food/Cash Assistance from 62.0(58.0-65.7) 58.7 73.1 0.00 NGO Market (purchase 54.8(50.8-58.70 61.8 31.2 0.00 with Cash) Market (purchase 5.9(4.2-8.0) 6.3 4.3 0.36 on credit) Beg for food 4.2(2.9-6.1) 2.5 10.0 0.00 Exchange labor or item-assets for 5.5(4.0-7.6) 5.5 5.8 0.93 food Gift (food) from family, relatives or 13.3(10.9-16.3) 11.4 19.9 0.01 friends Unknown 0.3(0-1.3) 0.2 0.7 0.36

Food Security and Coping Mechanisms The Food Consumption Score (FCS) is a composite indicator that measures dietary diversity, food frequency and the relative nutritional importance of food groups based on

10 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA a 7-day recall of food consumed at household level. The FCS is estimated by grouping food items into these 8 food categories: main staples; pulses; vegetables; fruits, meat/ fish; milk; sugar; and oil. The consumption frequencies of food items are then summed within the same food group and each value of the food group multiplied by its weight – main staples (2.0); pulses (3.0); vegetables (1.0); fruits (1.0); meat/fish (4.0); milk (4); sugar (0.5), and oil (0.5). Thereafter, weighted food group scores are summed to obtain the FCS. Using the FCS as illustrated in Table 7, 45.4% of all households were found to be in borderline status, while 19.0% were in poor status. Less than 40.0% in the surveyed areas in Damboa were found to have acceptable FCS scores. Male headed households had more acceptable FCS than female headed households.

Table 7: Food Composition Score of the Surveyed Households and Coping Mechanism Food Security - Food Composition Score and Coping Mechanism

Characteristics Nb DAMBOA (All Accessible Clusters - Test HH Areas) - D-LGA Gender Diff at 95%CI Food Consumption 615 ALL: %CI Male Female Damboa Score HHH: % HHH: % 0 - 21 (Poor) 19.0(16.1-22.3) 16.5 26.2 0.00 21.5 - 35 (Borderline) 45.4(41.5-49.3) 44.3 49.7 >35 (Acceptable) 35.7(32.0-39.5) 39.2 24.1 Food Insecurity 615 Worry about food 61.3(57.4-65.1) 60.8 63.1 0.77 Unable to eat 67.6(63.8-71.2) 67.5 68.1 0.74 preferred food Eat a few kinds of 68.1(64.3-71.7) 66.9 72.3 0.22 foods Eat food that one does 67.6(63.8-71.2) 65.2 75.9 0.02 not want to eat Eat smaller meal 74.3(70.7-77.6) 71.3 83.0 0.03 because of scarcity Eat fewer meals in a 65.5(61.7-69.2) 62.5 75.9 0.01 day No food of any kind in 41.0(37.1-45.0) 39.5 46.1 0.33 the households Go to sleep hungry 29.4(26.0-33.2) 27.9 34.8 0.25

11 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Go a whole day or 24.9(21.6-28.5) 24.3 27.0 0.52 night without eating Coping Mechanism 615 Consumption of low- 55.0(51.0-58.9) 56.1 55.0 0.27 quality foods Consumption of fewer 32.7(29.1-36.5) 33.1 32.7 food items Sale or mortgage of 1.1(0.5-2.4) 1.1 1.1 assets for food Borrowed food 4.9(3.4-6.9) 4.6 4.9 Borrowed money to 4.0(2.6-5.8) 3.2 4.0 buy food Others 2.4(1.5-4.0) 2.0 2.4

Most surveyed households reported having to resort to some coping strategies to manage the limited food and resources at their disposal. The Coping Strategies Index (CSI) measures people’s behavioral response to food insecurity. The commonest type of coping strategies predominantly being used by the households in this survey as shown in Table 7 include – consumption of lower-quality foods (55.0%); consumption of fewer food items (32.7%) and borrowed food/borrowed money to buy food (8.9%).

3.2. Anthropometric Results for Children aged 6 – 59 months Prevalence of Wasting – Acute Malnutrition (WHZ; MUAC) Global Acute Malnutrition (GAM) according to weight-for-height (WHZ) in the surveyed areas of Damboa LGA was 5.9% (95% CI: 4.2-8.3) and severe acute malnutrition was 1.2% (95% CI: 0.5-2.7) as shown in Table 8. Compared with the national estimate of 7.0% in the National Nutrition and Health Survey NNHS 2018, this finding appears comparatively low, and is much lower than the Borno GAM estimate of 10.6% in the same 2018 survey5.

5 Nigeria National Nutrition and Health Survey NNHS 2018.

12 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA

Figure 1: Distribution of Weight-for-Height in Z-score compared to WHO Standards (2006), SMART Flagged (n=4)

The above figure 1 shows the survey distribution of weight-for-height (in red) follows close to Gaussian distribution curve (in green). The mean weight-for-height Z-score was -0.37 with a standard deviation (SD) of +/-1.06. A SD which is between 0.9-1.1 reflects that the data of weight and height is of excellent quality.

Table 8: Acute Malnutrition by Weight for Height Z-score (WHZ) for Children aged 6-59 months (WHO standard 2006) Prevalence of Acute Malnutrition by Weight-for-Height-Z-score (WHZ) Children aged 6-59 months WHO Standard DAMBOA (All Accessible Clusters - Areas) -D-LGA Girls %CI; All %CI; n=576 Boys %CI; n=269 n=307 GAM (WHZ<-2SD) 5.9 6.3 5.5 CI 4.2-8.3 4.1-9.7 3.5-8.7 MAM (WHZ>=-3SD - <-2 SD) 4.7 4.8 4.6 CI 3.2-6.9 2.8-8.2 2.8-7.3 SAM (WHZ<-3SD) 1.2 1.5 1.0 CI 0.5-2.7 0.4-4.9 0.3-3.0

13 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA GAM estimate according to MUAC (Table 9) was 2.2% (1.3-3.9) with SAM of 0.2% (0.0-1.3). GAM and SAM prevalence calculated by MUAC was lower than the prevalence obtained from WHZ.

Figure 2: Cumulative Distribution of MUAC by gender

According to the WHO cut-off for prevalence of wasting, GAM by WHZ was considered to be medium which requires close monitoring. However, MUAC, which is generally considered to be highly sensitive for predicting mortality, was low. While WHZ is generally used as the base measure for GAM in surveys, it is worth mentioning that there is no effective gold standard for global acute malnutrition. Recent evidence has suggested that GAM measured by WHZ and by MUAC actually identify acute malnutrition in different child populations6, therefore it is imperative to use both methods as independent admission and discharge criteria for CMAM programming. Less than 30% of children identified by either of the methods overlap with the other6.

Table 9: Acute Malnutrition by Mid-Upper Arm Circumference (MUAC) – WHO standard 2006 Prevalence of Acute Malnutrition by Mid-Upper Arm Circumference (MUAC); Children aged 6-59 months WHO Standard DAMBOA (All Accessible Clusters - Areas) Boys %CI; Girls %CI; All %CI; n=580 n=271 n=309

6 Oleg Bilukha and Eva Leidman 2018. Concordance between estimates of wasting measured by weight-for-height and by mid- upper arm circumference for classification of severity of nutrition crisis: analysis of population-representative surveys from humanitarian settings. BMC Nutrition. https://doi.org/10.1186/s40795-018-0232-0.

14 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA GAM (MUAC<125mm) 2.2 1.8 2.6 CI 1.3-3.9 0.7-4.8 1.1-5.8 MAM (MUAC>=115mm - <125mm) 2.1 1.8 2.3 CI 1.2-3.6 0.7-4.8 1.0-5.0 SAM (MUAC<115mm) 0.2 0 0.3 CI 0.0-1.3 0.0-0.0 0.0-2.4

Prevalence of Stunting (Chronic Malnutrition); HAZ Stunting is a reference to the cumulative effect of long-term under-nutrition. The overall stunting rate among children aged 6 – 59 months in this survey was 36.8% (95% CI: 31.9-42.1) with severe stunting estimate of 12.6% (95% CI: 9.9-15.9) as shown in Table 10. This was considered according to WHO stunting threshold classification to be very high however not yet at the critical threshold (>40%).

Figure 3: Distribution of Height-for-Age in Z-score compared to WHO Standards (2006); SMART flagged; n=18

Table 10: Prevalence of Stunting – Height-for-Age Z-score (HAZ), WHO Standard 2006 Prevalence of Chronic Malnutrition (Stunting) by Height-for-Age-Z-score (HAZ) WHO Standard DAMBOA (All Accessible Clusters - Areas) Boys %CI; Girls %CI; All %CI; n=562 n=256 n=306 Global Stunting (HAZ<-2SD) 36.8 39.8 34.3

15 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CI 31.9-42.1 33.7-46.3 27.7-41.6 Moderate Stunting (HAZ>=-3SD - 24.2 25.0 23.5 <-2 SD) CI 20.9-27.8 20.0-30.8 18.6-29.3 Severe Stunting (HAZ<-3SD) 12.6 14.8 10.8 CI 9.9-15.9 11.2-19.5 7.7-15.0

Stunting or chronic malnutrition generally occurs due to poor nutrition during pregnancy and within the first two years of life, in combination with persistent and frequent infections. Its effect is largely irreversible after 2 years. As shown in Table 10, approximately one in every three children aged 6-59 months were found to be stunted in Damboa LGA, with similar results in Mercy Corps Programme communities (38%). The survey estimate is comparable to the national stunting estimate for 0-59 months (32.0%) and the prevalence for Borno (37.2%) in the National Nutrition and Health Survey (NNHS) of 20187.

Prevalence of Underweight (WAZ) Underweight status reflects the current and past nutritional status of the population. It is a standard measure of both acute malnutrition and stunting which is very useful in the monitoring of child growth. In this survey, the underweight estimate was 17.2% (95% CI: 13.6-21.6) with severe underweight of 3.0% (1.6-5.4) as shown in Table 11 below.

Figure 4: Distribution of Weight-for-Age Z-score compared to WHO Standards 2006, SMART Flagged n=10

7 Nigeria National Nutrition and Health Survey NNHS 2018.

16 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Table 11: Prevalence of Underweight – Weight-for-Age Z-score (WAZ), WHO Standard 2006 Prevalence of Underweight by Weight-for-Age-Z-score (WAZ) WHO Standard DAMBOA (All Accessible Clusters - Areas) Boys %CI; Girls %CI; All %CI; n=570 n=263 n=307 Global Underweight (WAZ<-2SD) 17.2 17.1 17.3 CI 13.6-21.6 12.6-22.9 12.0-24.2 Moderate Underweight 14.2 13.3 15.0 (WAZ>=-3SD - <-2 SD) CI 10.9-18.3 9.1-19.0 10.3-21.3 Severe Underweight (WAZ<-3SD) 3.0 3.8 2.3 CI 1.6-5.4 1.7-8.1 1.1-4.7

Comparing the survey finding with national global underweight estimates based on NNHS 2018, the global underweight estimate for Damboa was comparably similar to the national estimate of 19.9%, however lower than Borno’s estimate of 27.2%.

3.3. Morbidity Status in the past 2 weeks prior to survey Presence of disease results in lowered immunity and susceptibility to loss of nutrients which in turn worsens the nutritional status of the children. There was mild incidence of illness (considering these three mortality-associated diseases among children: Diarrhea, Malaria-Fever and Acute Respiratory Infection – ARI) 2 weeks prior to this survey with a morbidity estimate of 25.5%, diarrhea incidence of 10.3% with moderate usage of ORS (61.7%) and Zinc (40.0%) in the management of diarrhea cases in this population. Over fifty-percent of children aged 6-59 months slept under insecticide treated nets (ITN). Incidence of malaria-fever and cough (ARI) among children aged 6-59 months 2 weeks prior to this survey was 11.2% and 12.2% respectively.

Table 12: Morbidity Rate and Prevalence of Diarrhea and Treatment, Insecticide Treated Net Usage and Fever and ARI Prevalence Retrospective Morbidity Patterns among 6-59 months Test of DAMBOA (All Accessible Gender Diff Nb Clusters - Areas) at 95% CI (p) Boys Girls All %CI % %

17 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Morbidity- Child reported ill 580 25.5 23.0 27.6 0.21 2 weeks prior to the survey CI 22.1-29.2 Prevalence of Diarrhea in 580 10.3 9.2 11.3 0.04 the past two weeks CI 8.1-13.1 Were given ORS during 61.7 (48.5-73.3) 60.0 62.9 0.82 diarrhea episode 60 Were given Zinc tablets 60 40.0(28.1-53.2) 32.0 45.7 0.35 Were given both Zinc tablets 33.3(22.3-46.5) 28.0 37.1 0.46 and ORS together 60 Children who slept under mosquitoes Net previous 56.7 54.6 58.6 0.34 night 580 52.6-60.7 Prevalence of Fever in the 11.2 10.7 11.7 0.93 past two weeks 580 CI 8.9-14.1 Prevalence of Cough (ARI) 580 0.72 in the past two weeks 12.2 11.1 13.3 CI 9.8-15.2 3.4. Health Seeking behavior Most care giver respondents sought health care from four primary sources: NGO/ Faith Based organization (69.5%); Government Clinics (28.6%); Chemist shop (19.0%) and Traditional healer (18.8%). Only about 8.0% did not seek out healthcare at all. Noteworthy was the prevalence of those that sought health care from traditional healers and local medicine sellers – who might not be getting the optimal care required.

Table 13: Health Seeking Behavior among Caretakers of Children aged 6-59 months Health Seeking Behaviour among the Caregivers of Children aged of 6-59 months Test of DAMBOA (All Accessible Nb Gender Clusters - Areas) Diff ALL %CI Male Female 580 P at 95%CI n=580 HHH % HHH %

18 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Traditional Healer 18.8 17.9 26.7 0.10 CI 15.8-22.2 Private Clinic 0.7 0.6 1.7 0.33 CI 0.3-1.8 Chemist Shops/Pharmacy 19.0 19.2 16.7 0.63 CI 16.0-22.4 Government Clinic 28.6 30.2 15.0 0.01 CI 25.1-32.4 NGO Facility/FBO Clinic 69.5 68.5 78.3 0.12 CI 65.6-73.1 Local Medicine seller 5.3 5.8 1.7 0.18 CI 3.8-7.5 No treatment Sought 7.8 7.7 8.3 0.86 CI 5.8-10.2

3.5. Mortality8 Mortality rate measures the risk of dying during the time period by collecting retrospective data on deaths from all causes that occurred within the households during a specified time period of recall. In this survey, the recall period was set at 135 days from the day of Eid-il-Kabir – the most popular date in the survey region – July 31st 2020. Crude mortality rate (CMR) captures death among everyone in the target population while under-five mortality rate (U5MR) measures the death rate among children aged 0-4 years. Table 14 shows that CMR estimate was 1.2 per 10,000/day and U5MR of 2.6 per 10,000/day which is above the critical level of 2 and requires close monitoring as well as strategies to improve the health seeking behavior of the population. Noteworthy was the serious level of under-five mortality rate in this survey. An overestimation of U-5MR could have happened due to the longer recall period used (135 days). Other factors that might have accounted for this includes high level of patronage of traditional healers among the surveyed population, and caregivers not seeking for care at all when a child fall sick (Table 13 above), where death might occur at households’ level without being reported.

8 Threshold for Crude Mortality Rate: <1/10,000/day – Acceptable; >1 & <=2/10,000/day – Serious/Emergency; >2 & <5/10,000/day – Out of control; >5/10,000 – Major Catastrophe (WHO 2006 classification). Thresholds for Under-5 Mortality rate: <2/10,000/day – Acceptable; >2 & <=4/10,000/day – Serious/Emergency; >4/10,000/day – Out of control; >10/10,000/day – Major Catastrophe (WHO 2006 classification)

19 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Table 14: Retrospective estimation of Crude mortality rates and Under-5 mortality rates (recall period = 135 days) Crude Mortality Rate and Under-Five Mortality Rate DAMBOA (All Accessible Clusters - Areas) per 10,000/day HH Nb 615 Total Nb of HH with Under-5 Children 430 In-Migration (Joined) 0.2 Out-migration (Left) 1.2 Crude Death Rate; per 10,000/day 1.2 (0.7-1.8) Under-5 Mortality Rate (0-4years); per 10,000/day 2.6 (1.5-4.5) Causes of Death Unknown; % 7.0% Trauma; % 2.3% Illness; % 90.7%

Figure 5: Population Pyramid of Damboa LGA

3.6. Measles Vaccination, and Vitamin A Supplementation Vaccination against diseases of public health significance prevent and reduce child mortality. In this survey; over 80.0% (95% CI: 69.6-93.7) of children aged 9-23 months have had a measles vaccination and approximately 68.0% of children aged 6-59

20 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA months have had Vitamin A supplementation. Only 17.5% of children aged 6-23 months have received micronutrient powder in the past 6 months, whereas over 60% of children aged 12-59 months have had deworming tablets in the past 6 months.

Table 15: Measles vaccination, Vitamin A Supplementation and MNP…. Coverage of Measles vaccination, Vitamin Supplementation, MNP Supplementation and Deworming

Test of DAMBOA (All Accessible Gender Characteristics Nb Clusters - Areas) Diff at 95% CI (p)

Measles Vaccination (9-23 170 All %CI Boys % Girls % months) With Vaccination Card 12.4(8.2-18.3) 9.2 14.9 0.37 Without Vaccination Card 68.8(61.4-75.4) 71.1 67.0 Vitamin A Supplementation (6-59 580 67.6 67.5 67.6 0.95 months)

CI 63.7-71.3

Micronutrient Powder 200 17.5(12.8-23.5) 17.2 17.7 0.68 MNP for 6-23 months CI Deworming Tablet (12-59 514 60.9(56.6-65.0) 60.2 61.3 0.95 months

3.7. Infant and Young Child Feeding Practices including MDD-C, MAD, Poor feeding practices can adversely impact the health and nutritional status of children and consequently affect cognitive and physical development during the 1000 days critical window of opportunity from conception to 2 years of age. Ideally, a young child should be put to the breast within one hour of birth (i.e. - early initiation of breastfeeding), exclusively breastfed (EBF) for the first six months of life and continue breastfeeding up to two years with age-appropriate nutritionally adequate and safe complementary food. In this survey, early initiation of breastfeeding was estimated at 65%; and exclusive breastfeeding rate approximately 64% as illustrated in Table 11 below. Proportion of

21 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA children aged 6-23 months who achieved minimum dietary diversity (MDD-C9) and minimum acceptable diet (MAD) were 25.5% and 14.3% respectively. Food groups mostly consumed include cereal and legumes with less animal-based proteins food groups consumed. Table 16: Infant and Young Child Feeding Practices among Children aged 0 – 23 months Infant and Young Child Feeding Practices

DAMBOA (All Accessible Characteristics Nb Clusters - Areas)

Children aged 0-23 months %CI Ever Breastfed 275 77.8(72.5-82.4) Still Breastfeeding 214 87.4(82.2-91.2) Early Initiation of Breastfeeding 214 Within 1 hour of Birth 65.0(58.3-71.1) Within 1 day of Birth 32.2(26.3-38.8) Exclusive Breastfeeding 58 63.8(50.4-75.4) Predominant Breastfeeding 58 77.6(64.7-86.7) Complementary Food Introduction 30 66.7(47.2-81.7) Mean of Food Groups Consumed 145 2.6(2.3-2.8) Minimum Dietary Diversity; MDD-C (6-23 145 25.5(19.0-33.3) months) Minimum Meal Frequency (MMF) 124 53.2(44.3-62.0) Minimum Acceptable Diet (MAD) 140 14.3(9.4-21.2) Consumption of Iron Rich Food 145 24.1(17.8-31.9)

3.8. Maternal Nutrition Status, Dietary Practices and Perception of Importance of EBF The nutritional status of women of childbearing age 15-49 years was assessed using mid-upper arm circumference (MUAC). MUAC can be used as an indicator of maternal

9 Minimum Dietary Diversity for Children aged 6-23 months (MDD-C) score is a population-level indicator designed by WHO to assess diet diversity as part of infant and young child feeding practices (IYCF) among children aged 6-23 months. This indicator is one of the eight IYCF indicators developed to provide simple, valid, and reliable metrics for assessing IYCF practices at the population level. MDD-C estimates the proportion of children aged 6-23 months who received at least 4 food groups among the 7 groups of foods in the previous 24-hours namely: 1. Grains, roots and tuber; 2. Legumes and nuts; 3. Dairy products – milk and milk products; 4. Flesh foods – beef/fish; 5. Eggs; 6. Vitamin A rich fruits and vegetables; 7. Other fruits and vegetables.

22 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA nutritional status because of its close association with maternal weight. For the analysis, the convention used by the Nutrition sector in Nigeria was followed – women with MUAC<19.0 cm were considered to be severely acutely malnourished; and those with MUAC between 19.0 cm and 23.0 cm classified as moderately acutely malnourished, with those greater than 23.0 cm categorized as normal.

In this survey, 2.0% of sampled WCBA were found to be severely acutely malnourished as shown in Table 17.

Table 17: Maternal Nutrition Status WCBA aged 15 – 49 years using Nigeria Nutrition sector classification (MUAC<19.0 cm = severe acute malnutrition, MUAC>=19.0 cm & <=23.0 cm = Moderate Acute Malnutrition, MUAC>23.0 cm = Normal) Prevalence of Acute Malnutrition by Mid-Upper Arm Circumference (MUAC) among Women of Child Bearing Age; 15 - 49 years old DAMBOA (All Accessible Clusters - Areas) Nb ALL: %CI Mothers, 15-24 25-49 (626) n=170: %CI YEARS, YEARS, n=198: n=428: %CI %CI SAM (MUAC<19.0 cm) 2.0(1.1-3.3) 0.0 3.0(1.4-6.6 1.4(0.6-3.1) ) MAM (MUAC>=19.0 cm - 19.5(16.6-22.8 11.8(7.7-17.6) 39.9(33.3- 10.0(7.5-13 <=23.0 cm) ) 47.0) .3) Normal (MUAC>23.0 cm) 78.6(75.2-81.4 88.2(82.4-92.3) 57.1(50.0- 88.6(85.2-9 ) 63.8) 1.2)

Women of Childbearing Age , and particularly those who are pregnant or breastfeeding, require nutrient dense food. However, in some settings, women may be in a disadvantaged position in terms of intra-household sharing of nutrient dense foods especially in a dominant patriarchal system. Improving dietary diversity and access to micronutrient supplements are strategies that can be employed to improve the nutritional status of women and prevent macro-nutrient (acute malnutrition) and micro-nutrient deficiencies – especially Iron/folate and Vitamin A.

The Minimum Dietary Diversity for Women (MDD-W10) is a dichotomous indicator that shows whether or not women aged 15-49 years have consumed at least five out of ten food groups the previous day and night using 24-hour recall. The mean number of food

10 Minimum Dietary Diversity – Women: is defined as receiving foods from at least 5 of 10 food groups. The ten food groups are: 1. Grains, white roots and tubers, and plantain; 2. Pulses (beans, peas, and lentils); 3. Nuts and Seeds; 4. Dairy; 5. Meat, Poultry and fish; 6. Eggs; 7. Dark green leafy vegetables, 8. Other Vitamin A-rich fruits and vegetables, 9. Other vegetables, and 10. Other fruits.

23 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA groups consumed by women in this survey was below 5 and the proportion of women that achieved minimum dietary diversity was about 50%. Additionally, sixty-five percent of them reported consuming foods rich in Iron and less than 40% reported consuming Vitamin A rich food in the previous 24-hours, as shown in table 18.

57.7% of women of childbearing age in Damboa LGA perceived that exclusive breastfeeding for the newborn was very important while 20% perceived it as not important.

Table 18: Women of Childbearing Age Feeding Practices: MDD-W, Women Perception of Importance of Exclusive Breastfeeding Women of Child Bearing Age; WCBA; (15-49 years) Feeding Practices, and Perception of Importance of Exclusive Breastfeeding among WCBA

DAMBOA (All Characteristics Nb Accessible Clusters - Areas) %CI

WCBA 626 Mean Number of Food Groups Consumed by 3.8(3.6-4.1) Women Women meeting Minimum Dietary Diversity (MDD- 626 49.5(45.6-53.4) W) Women Consuming Iron-rich Food 626 65.2(61.3-68.8) Women consuming Vitamin-A rich Food 626 34.3(30.7-38.2) Women Perception of Importance of Exclusive 626 Breastfeeding (15-49years) Very Important 57.7(53.7-61.5) Slightly Important 22.4(19.3-25.8) Not Important 16.0(13.3-19.1) Not Important at all 4.0(2.7-5.8)

3.9. Water Sanitation and Hygiene Practices According to WHO11, about fifty-percent of malnutrition is associated with repeated diarrhea and frequent intestinal infections due to inadequate and unsafe drinking water, poor sanitation and hygiene practices.

11 WHO 2008. Safer water, better health: Costs, benefits and sustainability of interventions to protect and promote health. Geneva.

24 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Primary Source of Drinking Water in the Households; The common primary source of drinking water in the surveyed areas of Damboa as illustrated in Figure 6, was public tap/piped water and borehole (84.0%) followed by water trucking and water vendors (7.2%) who usually fetch their water from the borehole. Some three-percent of the surveyed households still got their drinking water from the unprotected dug well. In the surveyed areas, more than 80% of households reported that their access to drinking water was safe.

Main Source of Drinking Water in Damboa LGA

Water Trucking/ Water Vendor 7.2 Unprotected Dug Well 3.1

Unprotected Spring 0.1 Rainwater (Stored in a Container until used) 0.3

Protected Spring 0.3

Protected Dug Well 5 Drinking Water Source DrinkingWater Public Tap/Piped Water/ Borehole 84 0 22.5 45 67.5 90 Proportion of Households % DAMBOA (All Accessible Clusters - Areas) % Figure 6: Main Source of Drinking Water at Damboa LGA

Distance Walked to Primary Source of Drinking Water In this survey, less than 10% of the households in Damboa walked more than 30 minutes to their primary source of drinking water.

25 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA

Figure 7: Distance walked by members of the households to the primary source of drinking water

Properties of Water, Impurities and Water Treatment Methods Households were asked if they felt the water from their primary source of drinking water had impurities which makes the water unsafe to drink. About 5% of the respondents in Damboa LGA reported the water had one form of impurity or the other as shown in Table 19.

Table 19: Households’ Report of Water Impurities and Types of Impurities Households' Report of Water Impurities and Types DAMBOA (All Accessible Water Impurities Nb Clusters - Areas) %CI Water impurities prevalence in Drinking Water 615 5.4 (3.8-7.5) Type of Impurities Reported 33 Bad Odor 27.3(14.3-45.7) Unclean/Dirty/Muddy Water 15.2(6.1-33.8) Bad Taste 39.4(23.7-57.6) Other Unknown 18.2(8.0-36.1)

As revealed in Table 20, approximately 27% of households reported using at least one method of water treatments in Damboa LGA, with common methods of water treatment being “adding bleach or chlorine” and the use of “Alum”.

26 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Table 20: Water Treatment Methods Usage Water Treatment Methods

Nb DAMBOA (All Accessible Clusters - Areas) %CI Report of the use of at least one method of 615 26.5(23.2-30.1) water treatment Water Treatment Method Used 163 Boil 8.0(4.7-13.3) Add Bleach/ Chlorine 60.0(52.3-67.4) Strain through Cloth 7.4(4.2-12.6) Use water filter (ceramic/sand etc.) 0.6(0-4.3) Solar Disinfection 3.7(1.6-8.0) Let Water stand to settle 0.6(0-4.3) Alum 30.1(23.5-37.6) Unknown 9.8(5.6-14.8)

Sanitation and Hygiene Handwashing Observation of handwashing stations and availability of materials for handwashing within households represents a more reliable proxy for measuring handwashing behavior than asking individuals to report their own behavior12. This survey found (Table 21) that more than half of surveyed households (56%) did have hand washing stations at the time of survey; with about 65% of the households having no any handwashing materials available.

Table 21: Handwashing Station Availability within the Households Handwashing Station Observation

DAMBOA (All Accessible Nb Clusters - Areas) %CI

12 Pavani Ram 2013. Practical Guidance for Measuring Handwashing Behavior: 2013 Update. Global Scaling Up Handwashing. Water and Sanitation Program: Working Paper. University at Buffalo, New York, USA.

27 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA Households where handwashing station 615 56.0(52.0-59.8) observed Availability of Handwashing Materials Water available at handwashing station 344 19.8(15.9-24.3) Bar soap available 25.0(20.7-29.9) Detergent (Powder/Liquid) available 10.2(7.4-13.9) Liquid soap available 0.9(0.3-2.7) Ash/Mud/Sand available 15.4(12.0-19.6) None available 64.8(59.6-69.7)

Availability and Types of Toilet facilities in the Households As shown in the Figure 8 below, “ventilated improved pit latrine with slab” and “simple pit latrine with wooden slab” were the commonest toilet facilities at Damboa LGA households surveyed. Additionally, about 12% of households used pour flush toilet facilities. However, about 22% of households were using “open pit” toilet facilities in Damboa which is considered to be unsafe.

Toilet Facilities Available and Types in the Households

None Currently 0.7

Pit Latrine with no slab/ open pit 22.4

Simple Pit Latrine with Local Materials like Woods as a slab 21.6

Ventilated Improved Pit Latrine with Slab 43.4

11.9 Types of Toilet Availables Toilet of Types Flush or pour / flush toilet flushed

0 12.5 25 37.5 50 Proportion %

DAMBOA (All Accessible Clusters - Areas) -D-LGA % Figure 8: Types of Toilet Facilities available within the households

Environmental Fecal Contamination Animal feces in the households’ environment is one of the common external sources of infection for the children. About 13% of households in Damboa LGA were observed to have feces in their domestic space.

28 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA

Figure 9: Households with Animal Feces in Domestic Space

29 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA CHAPTER FOUR CONCLUSIONS AND RECOMMENDATIONS The surveyed areas of Damboa LGA appeared as a food stressed local government sensitive to food security shock, having acceptable food consumption scores of below 50% (FCS of 36%). Survey areas as shown in the results revealed that the households were of a low socio-economic status who depend heavily on food and cash gifts as a major source of food, and own farming and livestock production, with high borderline food insecurity. A little shock in terms of food security would likely have a significant impact on under-five nutritional status, their households and the women of childbearing age because of higher levels of borderline food consumption score (45%). Nutritional status of children in the surveyed areas of Damboa (GAM by WHZ of 5.9%) appeared to have improved compared to a survey conducted by FHI-360 one year ago in which the GAM estimate was 9.0%. However, care must be taken in interpreting this improvement because the accessible areas of Damboa surveyed might have changed from 1 year ago; some areas that were accessible then might no longer be accessible now. GAM is sensitive to emergency short- term interventions with nutrition specific strategies, which may also partially explain this reduction. INGOs such as Mercy Corps have been providing direct food assistance and food vouchers; in addition to support for home gardening and farming in these surveyed areas, while other INGOs have intervened with nutrition specific and sensitive interventions in most of IDP camps surveyed. Suffice to say that GAM is still within the medium-prevalence threshold according to WHO standards and this requires close monitoring.

Morbidity also appeared to have reduced in this survey with many households seeking health care from NGO/FBO clinics and from the government clinics. However, crude mortality and under-five mortality in this survey remains high – with most deaths attributed to illness (the possibility of over-estimation could also account for this because of a longer recall period – 135 days). Close monitoring of this index is highly recommended. Interventions aimed at increasing prompt health seeking behavior and strengthening referral systems should be encouraged and promoted by Mercy Corps and other humanitarian organizations situated in this LGA.

The nutritional status of women appeared sub-optimal in the surveyed areas with over 20% of women of childbearing age acutely malnourished (including approximately 2% severely malnourished) with low minimum dietary diversity. However, the perception of importance of exclusive breastfeeding was above average (50%) among the women of childbearing age. Further nutrition specific interventions targeting women of childbearing age are recommended.

The survey findings further revealed that about thirty-four percent of households were still exposed to poor sanitation practices using open pit latrines; further WASH intervention such as open defecation free strategies need to be intensified. In addition, WASH committees (WASHCOM) strategies should be adopted, where there is the existence of volunteer community WASH monitoring teams around the water points,

30 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA incentivized with performance-based cash transfer for WASH hardware maintenance for the sustenance of access to the safe drinking water.

Following the findings from this survey; the following recommendations are encouraged:

● Although, the nutrition status of children appears to be at the lower value of the medium threshold there is still a risk of deterioration due to suboptimal food security. Continued strengthening of active case finding of SAM and MAM is highly recommended with further training of the care givers on self-MUAC screening of their children (family-led MUAC screening approach).

● With many of the acutely malnourished children based on this survey finding were at moderate acute threshold (even though lower) , it is highly recommended for Mercy Corps and Other Nutrition partners in Damboa to further strengthen CMAM activities at the community level through monitoring and providing supportive supervision, and technical assistance to the CMAM centers, to ensure compliance to management protocol and full implementation.

● Considering the high level of borderline (and poor) food consumption score in this survey, it is highly recommended to increase the coverage of food security interventions to reach a wider target population, with a particular focus on improving the dietary diversity of children and their mothers. An effective monitoring system should be put in place to ensure that administered food vouchers are used accordingly.

● Efforts should be geared towards further integration of facility-based IYCF counselling and community-based IYCF support and promotion with strengthened referrals for complicated cases; This includes training, mentoring and supportive supervision of community nutrition promoters, health care workers, and CMAM providers.

● Formative research is recommended to better understand the opportunities and barriers to health seeking behavior. The use of contextually informed social and behavior change strategies to improve demand side factors (especially for malnutrition, childhood illnesses and maternal care) should then be employed alongside supply side improvements, including a strengthened health care referral system.

● Although access to safe drinking water appears moderately optimal in this survey, access to modern toilet facilities is rated mild. Hygiene awareness activities using contextually adapted behavioral change communication techniques continues to be important. Implementation of a monitoring dashboard for WASH committees’ scheme (WASHCOM) to improve and sensitize further on open defecation discouragement is recommended.

31 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA ● With finding of optimal access to safe drinking water in this survey, continuous maintenance of WASH facilities especially the boreholes in order to prevent deterioration of safe drinking water sources is encouraged. This can be done through establishment of a community monitoring volunteer system – WASH committee team around water points. Increase in the penetration of piped/ borehole water sources to the yet unreached areas in the LGA is also recommended.

● Continuous health promotion activities and the use of integrated approaches by the partners to increase vaccination uptake among the children under-five should be complemented and sustained.

32 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA ANNEXES

Annex 1: Plausibility Check Summary

DamboaFinalPlausi bility6-59months.rtf

Annex 2: Standardization Test Score

Damboa_SMART_St andardization.xlsx

Annex 3: List of the Clusters

Damboa accessible clusters_ClustersSelectedforSMARTSurvey.xlsx

Annex 4: List of the Field Staff (Enumerators, Supervisors)

List of Enumerators for DamboaSMARTSurvey.xlsx

Annex 5: Damboa SMART Nutrition Survey Questionnaire

main_damboa_ques tionnaire08122020.xls

33 NUTRITION AND RETROSPECTIVE MORTALITY SURVEY IN DAMBOA LGA