1

South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OF AGE

FINAL REPORT

KAJOKEJI COUNTY, EASTERN EQUATORIA

June 21st – July 8th, 2005

Joyce Mukiri - Nutritionist Deborah Morris - Nutrition Survey Program Officer (ACF-USA) 2

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

OFDA for funding the survey,

Sudan Relief and Rehabilitation Commission (SRRC), both in Lokichoggio and Kajokeji County and county health department for facilitating the work in the field,

The local survey teams for working tirelessly,

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

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

.I.1. CONTEXT ...... 5 .I.2. OBJECTIVES ...... 5 .I.3. METHODOLOGY ...... 5 .I.4. RESULTS OF THE ANTHROPOMETRIC SURVEY...... 6 .I.5. DISCUSSION ...... 7 .II. INTRODUCTION ...... 8

.III. METHODOLOGY ...... 8

.III.1. TYPE OF SURVEY AND SAMPLE SIZE ...... 8 .III.2. SAMPLING METHODOLOGY ...... 9 .III.3. DATA COLLECTION ...... 9 .III.4. INDICATORS, GUIDELINES, AND FORMULA’S USED...... 9 .III.4.1. Acute Malnutrition...... 9 .III.4.2. Mortality...... 10 .III.5. FIELD WORK ...... 10 .III.6. DATA ANALYSIS...... 11 .IV. RESULTS OF QUALITATIVE ASSESSMENT ...... 11

.IV.1. INTERNALLY DISPLACED PERSONS (IDP’S) AND RETURNEE’S POPULATION ...... 11 .IV.2. FOOD SECURITY...... 11 .IV.3. FEEDING AND CHILD CARE PRACTICES ...... 12 .IV.4. HEALTH ...... 12 .IV.5. WATER AND SANITATION...... 13 .IV.6. EDUCATION...... 13 .IV.7. AGENCIES INTERVENING IN THE AREA...... 13 .V. RESULTS OF ANTHROPOMETRIC SURVEYS...... 14

.V.1. DISTRIBUTION BY AGE AND SEX ...... 14 .V.2. ANTHROPOMETRIC ANALYSIS ...... 15 .V.2.1. Acute Malnutrition ...... 15 .V.2.2. Risk of mortality: Children’s MUAC...... 18 .V.3. MEASLES VACCINATION COVERAGE...... 18 .V.4. HOUSEHOLD STATUS...... 19 .V.5. COMPOSITION OF THE HOUSEHOLDS...... 19 .VI. RESULTS OF RETROSPECTIVE MORTALITY SURVEY...... 19

.VI.1. MORTALITY RATE...... 19 .VI.2. CAUSES OF MORTALITY ...... 20 .VII. CONCLUSION...... 20

.VIII. APPENDIX...... 22

.VIII.1. NUTRITIONAL SURVEY, BOMA SELECTION, KAJOKEJI, JUNE 2005 ...... 22 .VIII.2. WATER SOURCES IN KAJOKEJI COUNTY...... 24 .VIII.3. ANTHROPOMETRIC SURVEY QUESTIONNAIRE ...... 25 .VIII.4. CALENDAR OF EVENTS, KAJOKEJI COUNTY- JUNE, 2005...... 26 .VIII.5. MORTALITY SURVEY QUESTIONNAIRE...... 27 .VIII.6. ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN 6 MONTHS...... 28 4

LIST OF TABLES

TABLE 1 ANTHROPOMETRIC, MORTALITY AND MEASLES COVERAGE RESULTS ...... 6 TABLE 2 DISTRIBUTION OF PRIMARY SCHOOLS, NUMBER OF PUPILS AND TEACHERS IN THE COUNTY ...... 13 TABLE 3 ORGANIZATIONS INTERVENING IN KAJOKEJI COUNTY ...... 13 TABLE 4 DISTRIBUTION OF THE SAMPLE BY AGE AND SEX...... 14 TABLE 5 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORES ...... 15 TABLE 6 WEIGHT FOR HEIGHT VS. OEDEMA IN Z-SCORE...... 15 TABLE 7 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN Z-SCORES ...... 16 TABLE 8 NUTRITIONAL STATUS IN Z-SCORES BY GENDER ...... 16 TABLE 9 WEIGHT/HEIGHT: DISTRIBUTION BY AGE IN PERCENTAGE OF MEDIAN...... 16 TABLE 10 WEIGHT FOR HEIGHT VS. OEDEMA IN PERCENTAGE OF MEDIAN...... 17 TABLE 11 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN PERCENTAGE OF MEDIAN...... 17 TABLE 12 AGE DISTRIBUTION OF THE UNDER 6 MONTHS ...... 17 TABLE 13 FEEDING PRACTICES ...... 17 TABLE 14 NUTRITIONAL STATUS BY MUAC ...... 18 TABLE 15 HOUSEHOLD STATUS ...... 19 TABLE 16 HOUSEHOLD COMPOSITION...... 19 TABLE 17 CAUSES OF DEATH ...... 20

LIST OF FIGURES

FIGURE 1 DISTRIBUTION OF THE SAMPLE BY AGE AND SEX, KAJOKEJI COUNTY...... 14 FIGURE 2 Z-SCORES DISTRIBUTION WEIGHT-FOR-HEIGHT, KAJOKEJI COUNTY ...... 15 5

.I. EXECUTIVE SUMMARY

.I.1. Context

Kajokeji County is situated on the western side of the Eastern Equatoria region. It borders the Moyo district of Uganda to the south, the river Nile to the east, the Yumbe district of Uganda to the south-west, the Lainya County to the west, and the Juba County to the north. The county is made up of five payams namely Kangapo1, Kangapo2, Lire, Ngepo and Liwolo, which are further subdivided into bomas. Topographically, most parts are made of sandy soil, while others have a mixture of loamy and clay soils; the area is also characterised by green vegetation with gentle slopes and valleys. Rivers Nile and Kaya offer good fishing opportunities, and grazing areas for the cattle while seasonal streams also exist.

Mainly agro-pastoralists, the population of the county is estimated at 53,669 (SRRC records). They are predominantly of the Kuku ethnic group consisting of Bare speakers, which include the Bare, Kakwe, Mundari, Nyambara and Kajulu. Internally displaced persons fleeing from neighbouring counties such as Juba are housed in camps along Bamure, Kerwa, Limi and Mangalatore where ethnic groups such as the Dinka, Lotuko, Lokoro, Acholi, Madi and Nuer reside.

The health sector is supported by the following non-government organizations: Médecins Sans Frontières- Switzerland (MSF-CH) manages the referral hospital for the county, while the American Refugee Committee (ARC) International and the Sudan Health Association operate Primary Health Care Centres (PHCC’s) and Units (PHCU’s) in the different payams. Trans-cultural Psychosocial Organisation (TPO) offers psychosocial and mental health services, while the Kajokeji Aids Programme (KAP) is a community based organization dealing with HIV/AIDS awareness and campaign.

There are 82 boreholes distributed evenly throughout the area which are the source of water for majority of the population; during the wet season, shallow wells and streams become more common points for collecting water.

Several other humanitarian agencies are present, providing programs on Food Security (NPA), veterinary health care (NPA), and education (Comboni Missionary, Jesuit Relief Services, and Humanitarian Assistance for South Sudan). Due to prevailing peace in the area, Kajokeji enjoy unimpeded access to both internal and external markets in Uganda with the main medium of trade being cash. For the same reason, there has been a reported influx of returnees from Uganda into Kajokeji during the year. With the potential threat in terms of food security for the community, and since no nutritional data has ever been collected in this county, a nutritional survey was carried out in the location on June 2005 by ACF-USA in collaboration with ARC International.

.I.2. Objectives

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

.I.3. Methodology

A two-stage cluster survey methodology was applied. The 30 by 30 cluster methodology was used, that ideally would contain 900 children. This sample size was taken to provide the estimates of the prevalence of malnutrition with a 95 % confidence interval. 6

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

A retrospective mortality survey (over the past three months) was also conducted at the same time as the anthropometric survey. Focus group discussions and observations were also carried out to capture food security and health information.

.I.4. Results of the Anthropometric Survey

Table 1 Anthropometric, mortality and measles coverage results

AGE INDICATOR RESULTS GROUP Global Acute Malnutrition: W/H< -2 z and/or oedema 8.3% [6.0%-11.4%] Z-score Severe Acute Malnutrition: W/H < -3 z and/or 1.5% [0.6%-3.3%] 6-59 months oedema (n = 915) Global Acute Malnutrition: W/H < 80% and/or 4.8% [3.1%-7.4%] oedema % Median Severe Acute Malnutrition: W/H < 70% and/or 0.8% [0.2%-2.2%] oedema 12.4% [8.5%- Global Acute Malnutrition: W/H < -2 z and/or oedema 17.7%] Z-score Severe Acute Malnutrition: W/H < -3 z and/or 2.2% [0.8%-5.4%] 6-29 months oedema (n = 451) Global Acute Malnutrition: W/H <80% and/or oedema 6.9% [4.0%-11.3%] % Median Severe Acute Malnutrition: W/H <70% and/or 1.1% [0.2%-3.9%] oedema Severe Acute Malnutrition: W/H < -3 Z-score and/or 0.0 % oedema Z-score Global Acute Malnutrition: W/H < -2 Z-score and/or < 6 months 0.0 % oedema (n = 61) Severe Acute Malnutrition: W/H < 70% and/or 0.0 % oedema % Median Global Acute Malnutrition: W/H <80% and/or oedema 0.0 % Crude retrospective mortality (last three months) 0.25/10,000/day Percentage of under five years among the deaths 66.7% By card 2.1% According to caretaker1 8.4% Measles immunization coverage Not immunized 89.5% Total 100%

1 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker 7

.I.5. Discussion

The results of the nutrition survey displayed an 8.3% rate of Global Acute Malnutrition (GAM) and 1.5% of Severe Acute Malnutrition (SAM) expressed in Z-scores. These rates are below the nutritional emergency threshold for south Sudan, and is one of the lowest rates seen in any ACF-USA surveys in the past. The crude mortality rate is also within a non-critical level of 0.25/10,000 per day.

Kajokeji has an agricultural based economy, and the general population has been largely self-sufficient in food production since 2001, with much support obtained from humanitarian agencies. Food has been adequate among host communities as past harvests were sufficient and consistent, improved by distributed rains experienced in the county. Diversified food is available and accessible both internally and externally, and is utilized by families. The crops grown in the area are sorghum, maize, simsim, okra, groundnuts, cassava, pigeon peas, beans and cowpeas. The area has two cropping seasons, from April to May and from July to September. Fish also contributes significantly to the household food security, particularly for the populations living along River Nile (available throughout the year) and River Kaya (during the rainy months of March to May and November to December). In an average year, approximately 25kgs of fish per day are caught, making up 25% contribution to the annual food basket2; some are also being sold in exchange for or to purchase household items. Likewise, even within the lower socio-economic class that comprises of majority of the population, livestock ownership is common. At present, there are 63,000 heads of cattle in the county with each cow producing an average of 1 litre of milk a day. Meanwhile, significant amount of trade takes place between the local residents and IDP’s, as well as cross-border trade with the populations of larger towns such as Moyo and Adjumani in Northern Uganda.

The prevailing peace scenario have allowed the return of Sudanese people to Kajokeji who were previously exiled in Mijale, Mungula or Muaj in Uganda; SRRC estimate that 66,655 returnees have arrived in the location between March and June, 2005. Additionally, 25,852 IDP’s who have fled from neighbouring counties (mainly Juba) with insecurity are also recorded. They are being assisted by several humanitarian agencies to have increased and sustained access to food.

Health care is widely available and accessible with several facilities dispersed within the County that altogether has curative, diagnostic and preventive service capacities. There is an ample workforce of trained and effective community-based workers. The Expanded Program on Immunization is implemented and the coverage is reasonably good. More importantly, growth monitoring, with the capacity to detect referable cases, is being employed in the health facilities.

All these are complemented by a general positive health-seeking attitude and practices of the communities of Kajokeji, especially in ensuring adequate nutrition for the family, in using safe water and in improving the sanitary conditions in the location. According to the ARC that implements water and sanitation activities, 41% of the population are using latrines and 27% more are having latrines constructed. Also, a big group of locally hired and trained hygiene promoters simultaneously carry out sensitization workshops on basic hygiene and sanitation.

An educational system is relatively established in the county, with support agencies delivering primary to tertiary levels of instruction. There are a reasonable number of enrolees who are tutored by several trained and untrained teachers.

The recommendation brought forward by ACF-USA at this point is to continue, sustain and enhance the impact potential of the different programs and services being implemented by the different agencies in Kajokeji– especially the growth/nutritional monitoring that has already been initiated. 8

.II. INTRODUCTION

Kajokeji County is situated on the western side of Eastern Equatoria region and borders the Moyo district of Uganda to the south, the river Nile to the east, the Yumbe district of Uganda to the south-west, the Lainya County to the west and the Juba County to the north. The county is made up of five payams namely Kangapo1, Kangapo2, Lire, Ngepo and Liwolo, which are further subdivided into bomas. Topographically, most parts are made of sandy soil while others have a mixture of loamy and clay soils; the area is also characterised by green vegetation with gentle slopes and valleys. The rivers Nile and Kaya offer good fishing opportunities and grazing areas for the cattle while seasonal streams also exist.

Mainly agro-pastoralists, the population of the county is estimated at 53,669 (SRRC records). They are predominantly of the Kuku ethnic group consisting of Bare speakers which include the Bare, Kakwe, Mundari, Nyambara and Kajulu. Internally displaced persons fleeing from neighbouring counties such as Juba are housed in camps along Bamure, Kerwa, Limi and Mangalatore where ethnic groups such as the Dinka, Lotuko, Lokoro, Acholi, Madi and Nuer reside.

The county has been enjoying stable peace and security for many years. Although many areas are known to be mined, no incident has occurred in the recent past.

Due to prevailing peace in the area, Kajokeji enjoys unimpeded access to both internal and external markets in Uganda with the main medium of trade being cash. For the same reason, there has been a reported influx of returnees from Uganda (as well as Juba) into Kajokeji during the year; the host community provides food for these returnees. With the potential threat in terms of food security for the community, and since no nutritional data has ever been collected in this county, a nutritional survey was carried out in the location on June 2005 by ACF-USA in collaboration with ARC International.

.III. METHODOLOGY

The survey was conducted from 21st June to 8th July 2005 in Kajokeji County, Eastern Equatoria. According to SRRC, population figures were estimated at 173,376 persons; the number of children under five years was estimated at 34,677 (20% of the entire population).

.III.1. Type of Survey and Sample Size

A two-stage cluster sampling survey was applied. The 30 by 30 cluster methodology was used, that require a minimum of 900 children. This sample size was taken to provide the estimates of the prevalence of malnutrition with a 95 % confidence interval.

A retrospective mortality survey (over the past three months) was also conducted, alongside the anthropometric survey. Focus group discussions and observations were also done to capture food security and health information. 9

.III.2. Sampling Methodology

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

.III.3. Data Collection

During the anthropometric survey, for each selected child 6 to 59 months of age, the following information was recorded (See appendix 3 for the anthropometric questionnaire): • Age: recorded with the help of a local calendar of events (See appendix 4 for the calendar of events) • Gender: male or female • Weight: children were weighed without clothes, with a SALTER weighing scale of 25kg (precision of 100g). • Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm were measured lying down, while those greater than or equal to 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.

During the retrospective mortality survey, in all the visited households– including where there were no children less than five years of age– the teams asked for the number of household members alive per age group, the number of people present within the recall period, the number of deaths and births over the last three months and if any, the presumed cause of death, and the number of persons who left or arrived in the last three months (See appendix 5 for the mortality questionnaire).

.III.4. Indicators, Guidelines, and Formula’s Used

.III.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 NCHS2 references. WFH indices were expressed both in Z-scores and percentage of the median. The expression in Z-scores has true statistical meaning and allows inter-study comparison. The percentage of the median, on the other hand, is commonly used to identify eligible children for feeding programs.

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

2 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 10

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

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

.III.4.2. Mortality

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

The formulas are as follows:

Death Rate (DR) = n / [((n+M1) + M2) / 2] Where n = number of deaths within a given period M1 = number of persons alive over a given period M2 = number of persons alive at the time of the survey

Crude Mortality Rate (CMR) = (DR x 10,000) / number of days in the period. The period corresponds to 3 months (90 days) preceding the survey.

Therefore, CMR = (DR x 10,000) /90. It is expressed per 10,000-people / day.

The thresholds are defined as follows3:

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

The proportion of deaths within the past three months among the under five years old is also calculated.

.III.5. Field Work

All the surveyors participating in the survey underwent a three-day training, which included a pilot survey. Six teams of three surveyors each executed the fieldwork. ACF-USA and ARC International staff supervised all the teams in the bomas. As vehicles were available for the team during the survey, access to all the bomas was possible and the sampling frame included the entire county.

The survey, including the training and travelling days, lasted for a period of 18 days.

3 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95. 11

.III.6. Data Analysis

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

.IV. RESULTS OF QUALITATIVE ASSESSMENT

.IV.1. Internally Displaced Persons (IDP’s) and Returnee’s Population

As a result of the comprehensive peace agreement signed in January, Sudanese people who have previously exiled in Mijale, Mungula or Muaj in Uganda have been returning to Kajokeji; SRRC estimate that 66,655 returnees have arrived in the location between March and June, 2005. Additionally, 25,852 IDP’s who have fled from neighbouring counties (mainly Juba) with insecurity are recorded in the county.

.IV.2. Food Security

Kajokeji is largely an agricultural based economy, and self-sufficient in food production. The local residents moved from dependence on food aid in 1997 to self-sufficiency in food production in the year 2001, largely attributed to the assistance of NGO’s and prevailing peace in the county. The community is mainly agro- pastoralists with crop farming being the main livelihood; crops grown in the area are sorghum, maize, simsim, okra, groundnuts, cassava, pigeon peas, beans and cowpeas. The area has two cropping seasons, from April to May and from July to September.

The community’s diet mainly consists of sorghum and cassava. Cowpeas leaves, okra, amarantha and mushrooms accompany the sorghum/cassava diet depending on their availability. During the “hunger gap” period between April and May, the community depends on lulu oil seed and mangoes. In a normal year, wild food contribution to the diet is minimal except for mangoes, dodo and lulu. In a bad year, wild foods are used extensively especially limut and dobe. The contribution of wild foods to the household food basket in a normal year is 30-90kilograms per household, making up between 9%-10% of the annual household food needs4.

Food has been adequate among host communities, and report that the past harvests were good as a result of reasonable rains experienced in the county. On the other hand, there was marked difference with the food availability for the IDP’s and returnees noted. The returnees are dependent on food aid and cultivate an average plot size of one feddan, NPA augments by providing food (cereals, pulses, salt and oil) on a monthly basis to the returnee and IDP population, while UNHCR supplies survival kits. Kajokeji is not covered by WFP for food aid.

Fish contributes significantly to the household food security, particularly for the populations living along the Nile and Kaya rivers. Fishing in the Nile is done throughout the year, whereas in the Kaya rivers during the rainy months of March to May and November to December. In an average year, approximately 25kgs of fish per day are caught, making up 25% contribution to the annual food basket. Apart from being included in the household diet, fish is also sold in exchange for or to purchase household items.

Livestock kept by the community include cattle, sheep, goat, pigeons, rabbits, turkey 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. At the time of the survey, the community reported that there was enough pasture for livestock. Cattle are not moved to graze far from homesteads during the dry season; instead they graze along the seasonal streams. At present, there are 63,000 heads of cattle in the county which each cow producing an average of 1 litre of milk a day. The average number of cattle per household is 100-1,000

4 Starbase, Kajokeji report, version 2, 2004. 12 cows for the rich; 20-100 cows for middle class; 1-5 cows for the poor. Majority of households in the community falls under the latter classification.

Employing a cost-recovery strategy, NPA provides veterinary interventions for the County. It has trained 49 community animal health workers on livestock and poultry disease control through vaccination and treatment of livestock diseases, as well as by sensitizing the community on the importance of these services. The common livestock diseases reported by the County veterinary doctor include: black water disease, trypanosomiasis, contagious bovine plural pneumonia, east-coast fever and worms.

Furthermore, a significant amount of trade takes place between the local residents and IDP’s, as well as cross- border trade with the populations of larger towns such as Moyo and Adjumani in Northern Uganda, increasing access to diversified food products.

.IV.3. Feeding and Child Care practices

Interviewed mothers revealed that most children are weaned early at the age of four months with dodo soup, fish and sorghum/millet porridge. Cow’s milk was not always available especially among households that do not keep cattle. Additionally by expected norms, women, even when lactating, are responsible for most of the household chores, compromising the time and care for their infants, and consequently affecting the nutritional condition of the children. All household members consume two meals per day regardless of age.

.IV.4. Health

The county has one hospital operated by MSF-CH, and primary health care facilities (29 PHCU’s and 4 PHCC’s) distributed in different payams managed by either ARC International or SUHA. Comboni missionary are also running a dispensary offering curative services in Kangaroo2 payam. The PHCU’s have both In-Patient and Out- Patient departments, and offer both curative as well as preventive services. Preventive services provided include the distribution of condoms, EPI, antenatal and health education services.

The hospital is located in Mundari and serves as the referral facility for the PHCC/U’s; EPI and antenatal services are also offered. 5 midwives, 2 TBA’s and 4 community health workers make-up the local staff in the hospital. MSC-CH also carries out regular outreach activities for nutrition, sleeping sickness and TB. Trained community health educators also deliver community outreach services on health education.

The PHCC’s run by ARC International are managed by a clinical officer and a medical assistant while the units are managed by CHW’s. Trained TBA’s and MCH workers provide antenatal, normal delivery and postnatal health care. The PHCC’s also have the capacity for obstetric emergency care, but complicated cases may be referred to the Mundari hospital. Growth monitoring is likewise being carried out in the centers, and where necessary, referrals to the hospital are made. Community health educators (n=42) do active case finding at the household level for individuals needing referral and prompt medical attention. Additionally, ARC implements guinea worm and OV prevention programs that are supported by Carter Centre and Christofel Blinden Mission.

SUHA has employed 22 trained CHW’s who carry out hygiene promotion activities at the household level. There are 2 TBA’s in each health unit and a mobile team of 7 people operating mobile EPI clinics.

Morbidity reports in the health facilities in the County indicate that malaria, upper respiratory tract infections, diarrhoea and intestinal worms as most prevalent diseases in the County. The same information has been documented by the Starbase report, 2004. Other leading causes of morbidity are TB, sleeping sickness, onchocerciasis (OV), STI’s, anaemia, abortions and chronic liver disease. 13

.IV.5. Water and Sanitation

There are 82 functioning boreholes in the county, serving as source of potable water to majority of the population. In some payams, such as Liwolo, access is lower and water is instead sourced from streams. During the wet season, shallow wells and streams become more common water points (refer to Appendix 2 for water sources in the county). ARC has employed and trained 2 technicians and 1 supervisor in each payam who maintains the boreholes. ARC reports that 41% of the population are using latrine while 27% of the latrines are under construction and 14% are filled up. It was noted that sanitary facilities are uncommon in schools and construction is limited to classrooms, however ARC has initiated installations of latrines in these structures. There are 47 hygiene promoters in the whole county trained by ARC who carry out sensitization workshops on basic hygiene education including latrines use.

.IV.6. Education

There are 60 primary schools in the county (offering levels 1-5 education and a few up to level 7), 8 secondary schools (up to senior 4 level) and 2 tertiary colleges. These are supported by several agencies on varying degrees: JRS in collaboration with UNHCR on primary and secondary education; HASS on primary, secondary and tertiary levels; and Comboni missionary on primary and secondary schools in Kangapo2 payam. The total number of pupils enrolled at the primary level is 13,363, with 228 trained and 274 untrained teachers/educators. In secondary schools, the total enrolees are 1,751 having 119 teachers (65 are trained and 54 are untrained).

Table 2 Distribution of primary schools, number of pupils and teachers in the county Payam Number of Number of Number of Number of Number of primary boys girls trained untrained schools teachers teachers Liwolo 18 2,058 1,641 62 70 Kangapo 2 19 2,883 2,799 91 69 Lire 9 1,100 1,070 30 34 Kangapo 1 10 981 270 39 91 Ngepo 4 334 227 6 10

.IV.7. Agencies Intervening in the Area

Various agencies implement programs on health, water, education and food security in Kajokeji, outlined below.

Table 3 Organizations intervening in Kajokeji County Agency Activities ARC International • Health: 3 PHCC’s and 18 PHCU’s NPA • Food security and veterinary services SUHA • Health: 1 PHCC and 11 PHCU’s MSF-CH • Health: Running a referral hospital Comboni • Education and pastoral work activities Missionary • Funds ARC, JRS, SUHA and HASS who in turn implement different activities in the UNHCR county JRS • Supports education in the county HASS • Supports education and planning to start health activities soon TPO • Offers psychosocial and mental health services to people traumatized by war KAP • Involved with HIV/AIDS awareness and campaign activities 14

.V. RESULTS OF ANTHROPOMETRIC SURVEYS

A total of 925 children were measured. Due to aberrant data in some records, only the results in 915 records were included in the analysis.

.V.1. Distribution by Age and Sex

Table 4 Distribution of the sample by age and sex

AGE BOYS GIRLS TOTAL Sex (In months) N % N % N % Ratio 06 – 17 125 47.5% 138 52.5% 263 28.7% 0.91 18 – 29 84 44.7% 104 55.3% 188 20.5% 0.81 30 – 41 89 47.1% 100 52.9% 189 20.7% 0.89 42 – 53 101 55.8% 80 44.2% 181 19.8% 1.26 54 – 59 47 50.0% 47 50.0% 94 10.3% 1.00 Total 446 48.7% 469 51.3% 915 100% 0.95

The distribution of the sample by gender shows that girls are slightly more than boys. However, the sex ratio, which is 0.95, indicates a random selection of the sample.

Figure 1 Distribution of the sample by age and sex, Kajokeji County

Distribution by age and sex, July 2005

54-59

42-53 h

30-41 Boys Girls Age in mont in Age

18-29

06-17

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

The results show a slight imbalance in age distribution having over representation of age group 42-53 months. This may be attributed to ages approximated by parents (caretakers) who 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

.V.2. Anthropometric Analysis

.V.2.1. Acute Malnutrition

¾ Distribution of malnutrition in Z-scores for children aged 6 to 59 months The distribution of acute malnutrition in Z-scores shows that the global acute malnutrition is equal to 8.3% with 1.5% of the children being severely malnourished and 6.8% moderately malnourished. One case of oedema– Kwashiorkor was found in the sample.

Table 5 Weight for Height Distribution by age in Z-scores

Severe Moderate No AGE Oedema Malnutrition malnutrition malnutrition (in Total months) < -3 SD ≥-3 SD - <- 2 ≥ -2 SD N % SD N % 06-17 263 8 3.0% 36 13.7% 219 83.3% 0 0.0% 18-29 188 2 1.1% 10 5.3% 176 93.6% 0 0.0% 30-41 189 3 1.6% 3 1.6% 183 96.8% 0 0.0% 42-53 181 0 0.0% 4 2.2% 176 97.2% 1 0.6% 54-59 94 0 0.0% 9 9.6% 85 90.4% 0 0.0% TOTAL 915 13 1.4% 62 6.8% 839 91.7% 1 0.1%

Table 6 Weight for Height vs. oedema in Z-score

< -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 1 0.1% Oedema Marasmus No malnutrition NO 75 8.2% 839 91.7%

One case of oedema – Kwashiorkor was found in the sample. All the other cases of malnutrition are of the marasmic type.

Figure 2 Z-scores distribution Weight-for-Height, Kajokeji County

Weight for Height Z-score distribution, Kajo Keji County

25

20

15 g

Reference 10 Sex Combined Percenta

5

0 -5 -4 -3 -2 -1 0 1 2 3 4 5

-5 Z-score 16

There is minimal displacement of the sample curve to the left side of the reference curve. The mean Z-Scores of the sample, –0.56, indicates a slightly under-nourished population. The standard deviation is equal to 1.02, which is in the range of 0.80–1.20. Therefore, the sample can be estimated at representative of the assessed population

Table 7 Global and Severe Acute Malnutrition by Age Group in Z-scores

6-59 months (n = 915) 6-29 months (n =451) Global acute malnutrition 8.3% [6.0-11.4%] 12.4% [8.5-17.7%] Severe acute malnutrition 1.5% [0.6-3.3%] 2.2% [0.8-5.4%]

Statistically, there is a significant difference between the malnutrition rates observed among the children 6-29 months of age, and the children 30-59 months of age (p < 0.05, Chi square test). Children 6-29 months of age present 2.88 [1.76

Table 8 Nutritional Status in Z-scores by gender

Boys Girls Nutritional status Definition N % N % Weight for Height < -3 SD or Severe malnutrition 9 2.0 5 1.1 oedema Moderate -3 SD ≤ Weight for Height < -2 SD 33 7.4 29 6.2 malnutrition Normal Weight for Height ≥ -2 SD 404 90.6 435 92.8 TOTAL 446 100% 469 100%

The difference of figures observed between boys and girls is not statistically significant (p>0.05, Chi square test).

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

The distribution of acute malnutrition in percentage of the median reveals a global acute malnutrition rate of 4.8% - 0.8% of the children were severely malnourished while 4.0% were moderately malnourished.

Table 9 Weight/Height: Distribution by Age in percentage of median

Severe Moderate No malnutrition malnutrition malnutrition Oedema AGE Total (In months) < 70% ≥ 70% & < 80% ≥ 80% N % N % N % N % 06-17 263 4 1.5% 21 8.0% 238 90.5% 0 0.0% 18-29 188 1 0.5% 5 2.7% 182 96.8% 0 0.0% 30-41 189 1 0.5% 5 2.6% 183 96.8% 0 0.0% 42-53 181 0 0.0% 2 1.1% 178 98.3% 1 0.6% 54-59 94 0 0.0% 4 4.3% 90 95.7% 0 0.0% TOTAL 915 6 0.7% 37 4.0% 871 95.2% 1 0.1% 17

Table 10 Weight for Height vs. oedema in percentage of median < -2 SD ≥ -2 SD Marasmus/Kwashiorkor Kwashiorkor YES 0 0.0% 1 0.1% Oedema Marasmus No malnutrition NO 43 4.7% 871 95.2%

One case of oedema – Kwashiorkor was found in the sample.

Table 11 Global and Severe Acute Malnutrition by Age Group in Percentage of Median

6-59 months (n = 915) 6-29 months (n = 492) Acute global malnutrition 4.8% [3.1%-7.4%] 6.9% [4.0%-11.3%] Severe acute malnutrition 0.8% [0.2%-2.2%] 1.1% [0.2%-3.9%]

According to the weight for height in percentage of the median, there is a significant difference in the nutritional status between the age groups 6-29 months and 30-59 months (p<0.05) with a relative risk of 2.45 (1.30

¾ Nutritional Status of the Children Below 6 months of age 88 children below six months of age, present in the households at the time of the survey, were measured in order to determine their nutritional status. 41 (46.6%) were boys and 47 (53.4%) were girls.

Table 12 Age Distribution of the Under 6 months Age in month N % 0 - - 1 34 38.6% 2 8 9.1% 3 16 18.2% 4 11 12.5% 5 19 21.6% Total 88 100%

There was no acute malnutrition recorded among the children measured that were less than 6 months old.

¾ Feeding Practices More than half 75 (85.2%) of the mothers who had children less than six months old, breastfed exclusively while only 13 (14.8%) had begun weaning. The weaning food was mainly cow milk and porridge.

Table 13 Feeding practices Feeding practices Frequency Percentage Exclusive breastfeeding 75 85.2% Mixed feeding (breast milk and weaning 13 14.8% food) Total 88 100% 18

.V.2.2. Risk of mortality: Children’s MUAC

As MUAC overestimates the level of under nutrition in children less than one year old, the analysis refers only to children having height equal to or greater than 75 cm. A total of 617 children have been included in the analysis.

Table 14 Nutritional Status by MUAC

Total 75 – 90 cm ≥ 90 cm height Criteria Nutritional status N % N % N % < 110 mm 0 0.0 0 0.0 110 mm ≥ MUAC < 120 mm Moderate malnutrition 2 120 mm ≥ MUAC < 135 mm At risk of malnutrition 56 MUAC ≥ 135 mm No malnutrition 634 TOTAL 692 100 336 48.6 356 51.4

By MUAC measurements, 91.6% showed good nutritional status while 0.3% was moderately malnourished and 8.1% were at risk. Moderate malnutrition was mostly seen among children within the 75-90cm height or 1-3 years age bracket.

.V.3. Measles Vaccination Coverage

Measles vaccination for the regular EPI is administered to children aged 9 months; therefore only the children aged 9-59 months (849 children) were included in this analysis.

Measles Vaccination N %

According to the EPI card 350 41.2

According to the caretaker 358 42.2

Not immunized 141 16.6

Total 849 100

Measles vaccination of 41% of the children was confirmed by the presence of EPI cards, while caretakers affirm vaccination in the other 42% of the children, although no card was produced. 19

.V.4. Household Status

The information on the residential status was collected from 575 caretakers during the anthropometric survey.

Table 15 Household Status

Status N %

Residents 533 92.7

Returnees 34 5.9

Temporarily residents 8 1.4

Total 575 100

The larger proportion of the surveyed families was residents 533 (92.7%) while 34 (5.9%) were returnees. 8 (1.4%) of the households were temporarily residing in the location.

.V.5. Composition of the Households

Table 16 Household composition Age group N % 0 to 59 months 1074 27.2 Adults 2881 72.8 Total 3955 100.0

Six hundred and twenty households were visited during the survey. The mean number of under 5 year of age per household was 1.73 (SD: 0.76), whereas, that of the above 5 years of age per household was 4.63 (SD: 2.28).

.VI. RESULTS OF RETROSPECTIVE MORTALITY SURVEY

.VI.1. Mortality Rate

The crude mortality was calculated from the figures collected from all the visited households, regardless of whether there were children under 5 years of age. The day of the survey, a total of 3955 people were found in the assessed households. Among them, there were 1,074 children under 5 years old alive (27.2% of the total population), as well as 2,881 above 5 years.

At the beginning of the recall period, there were 3,956 people in the assessed households, 1034 children below 5 years of age and 2922 above 5 years of age. Over the three months preceding the survey, the following demographic changes were observed: • 43 births 20

• 128 persons had arrived in the location • And 163 people had left the location in the same period • 9 deaths, 6 (66.7%) of which were below five years old.

Death Rate (DR) = 9/ [((9+3956) +3955)/2] = 0.0022727 Crude Mortality Rate (CMR) = [0.0022727 x 10,000]/90 people/day = 0.25

According to the above formula, the crude mortality rate is 0.25/10,000 per day.

.VI.2. Causes of Mortality

The main presumed cause of death5 among the children under five years old was malaria (three cases).

Table 17 Causes of death Under five Above five Cause of Death N % N % Watery diarrhea 1 16.7% - - Malaria 3 50.0% - - Others* 2 33.3% 3 100.0% Total 6 100.0% 3 100.0%

2 cases- anaemia; 1 case- neonatal infection; 1 case- sleeping sickness; 1 case- liver problem

.VII. CONCLUSION

The nutritional survey was undertaken in all the five payams of Kajokeji County, sampling 915 children ages 6- 59 months. The analysis of the anthropometrics data showed that 8.3% of the children are acutely malnourished, 1.5% of which are in the severe form. Among children 6-29 months of age, the GAM rate is 12.4% while SAM is 1.5%. These rates are one of the lowest detected throughout nutritional surveys in any part of south Sudan by ACF-USA.

The balance of several factors such as availability and access to food, water, livelihood, health services, and general hygiene and sanitation have parallel effect to a population’s nutritional status. These factors are controlled in Kajokeji at the present time.

Kajokeji has an agricultural based economy and the general population has been largely self-sufficient in food production. Past harvests were sufficient and consistent, improved by distributed rains experienced in the county. Diversified food is available and accessible both internally and externally, and families utilize them. Returnees and IDP’s are likewise assisted by several humanitarian agencies to have increased and sustained access to food.

Health care is widely available and accessible with several facilities dispersed within the County that altogether have curative, diagnostic and preventive service capacities. There is an ample workforce of trained and effective community-based workers. EPI is implemented, and the coverage is reasonably good. More importantly, growth monitoring, with the capacity to detect referable cases, is being employed in the health facilities. All these are

5 As mentioned by the community. 21 complemented by a general positive health-seeking attitude and practices of the communities of Kajokeji, especially in ensuring adequate nutrition for the family, in using safe water and in improving the sanitary conditions in the location.

The recommendation brought forward by ACF-USA at this point is to continue, sustain and enhance the impact potential of the different programs and services being implemented by the different agencies in Kajokeji– especially the growth/nutritional monitoring that has already been initiated. 22

.VIII. APPENDIX

.VIII.1. Nutritional Survey, Boma Selection, Kajokeji, June 2005

Bomas Estimated Target population Cumulative target Attributed numbers Cluster Distances from population population Wurta Leikor 4,624 925 925 1-925 1, 24km Limi 5,503 1,101 2,026 926-2,026 2, 30km Moijo 1,656 331 2,357 2,027-2,357 65km Kigwo 2,597 519 2,876 2,358-2,876 34km Pomoju 2,956 591 3,467 2,877-3,467 3, 27km Litoba 2,638 528 3,995 3,468-3,995 30km Sera jale 3,800 760 4,755 3,996-4,755 4, 28km Kiri 7,639 1,528 6,283 4,756-6,283 5, 17km Wudu 10,983 2,197 8,480 6,284-8,480 6, 7 23km Logili 4,888 978 9,458 8,481-9,458 8, 20km Logu 6,052 1,210 10,668 9,459-10,668 9, 15km Kinyiba 7,230 1,446 12,114 10,669-12,114 10, 18km Jalimo 11,593 2,319 14,433 12,115-14,433 11, 12 12km Bori 13,024 2,605 17,038 14,434-17,038 13, 14, 15 12km Romoggi 3,009 602 17,640 17,039-17,640 38km Mekir 3,795 759 18,399 17,641-18,399 16, 50km Likamorok 2,731 546 18,945 18,400-18,945 55km Longira 4,574 915 19,860 18,946-19,860 17, 46km Kudaji 1,301 260 20,120 19,861-20,120 58km Mere 5,201 1,040 21,160 20,121-21,160 18, 30km Kansuk 4,113 823 21,983 21,161-21,983 19, 56km Rodo 3,384 677 22,660 21,984-22,660 20, 65km Lori 3,771 754 23,414 22,661-23,414 78km Gederu 2,645 529 23,943 23,415-23,943 21, 72km Sokare 8,406 1,681 25,624 23,944-25,624 22, 19km 23

Kendiri 9,288 1,858 27,482 25,625-27,482 23, 24 36km Mangalatore 9,631 1,926 29,408 27,483-29,408 25, 20km Kerwa 9,230 1,846 31,254 29,409-31,254 26, 27 39km Kala 8,571 1,714 32,968 31,255-32,968 28, 80km Ajio 8,543 1,709 34,677 32,969-34,677 29, 30 65km TOTAL 173,376 34,677

Sampling interval was calculated by dividing the Target population with number of clusters i.e. 34,677/30 =1,155.9, which was rounded off to 1,155. Bomas included in the clusters are shown in the figure above. The random number drawn between 1 and 1,155 was 707.

The number of children to be included in each cluster is Sampling size/ Number of clusters = 900/30 = 30.

Due to inaccessibility, three clusters from Kala and Ajio bomas were shifted to 3 different bomas: Mangalatore, Mere and Kiri. 24

.VIII.2. Water Sources in Kajokeji County

Lire Nyepo Liwolo Kangapo1 Kangapo2 Total

Functional bore holes 24 11 9 9 29 82

Low yield bore holes 5 3 4 2 5 19

Non-functional boreholes 2 8 12 2 0 24

Bore holes filled with stones 5 0 0 0 0 5

Functional shallow wells 13 2 6 3 4 28 throughout the year Seasonal shallow wells 14 2 11 10 16 53

Non-functional shallow wells 3 0 0 3 7 13

Functional springs 1 0 0 0 0 1

Total 67 26 42 29 61 225 25

.VIII.3. Anthropometric Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No: Age Sitting Measles Statu Gender Weight Height Oedema MUAC N°. Famil Height C/M/N s M/F Kg Cm Y/N mm y N°. Mths Cm(2) (3) (1) 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 26

.VIII.4. Calendar of Events, Kajokeji County- June, 2005

MONTHS SEASONS 2000 2001 2002 2003 2004 2005 53 41 29 17 5 Harvesting sorghum JANUARY and hunting Yapa to Geleng 52 40 28 16 4 FEBRUARY Building and land Transfer of sleeping Yapa to murek preparation sickness centre from Kiri to Mundari Land preparation 51 39 27 15 3 MARCH continues. Millet Principal of Lomin Yapa to musala planting and honey secondary school shot harvesting dead by LRA 50 38 26 14 2 Mango season; APRIL Repatriation of planting of maize Yapa to engwan returnees to the and sorghum county Weeding; planting 49 37 25 13 1 MAY beans and sweet Yapa to mukanai potatoes Hunger gap; 48 36 24 12 JUNE Preparing land for Yapa bukiyan second season sorghum 59 47 35 23 11 JULY Talking trees were Yapa to buryo discovered in Sokari First harvest of maize boma and ground nuts A felled tree stands on its own in Liwolo payam 58 46 34 22 10 Women concern AUGUST Second planting of Yapa to budok organization simsim and ground suspended from nuts carrying out any activities in the county 57 45 33 21 9 SEPTEMBER Planting cowpeas Yapa to buyan

Planting of 56 44 32 20 8 OCTOBER cowpeas continues; Rain maker Godi dies Yellow fever and Yapa to puwok harvesting of second measles campaign season maize Second season 55 43 31 19 7 NOVEMBER harvesting of simsim Yapa to puwogeley and ground nuts Cutting grass for 54 42 30 18 6 DECEMBER renovating tukuls in Yapa to puwomurek January; marriages 27

.VIII.5. Mortality Survey Questionnaire

DATE: CLUSTER No: VILLAGE: TEAM No:

Today 3 months ago Deaths Nb Nb Migrants Status Nb of < 5 Nb of >= Nb of < 5 Nb of Nb Cause Age Births arrived left in (1) Family Years 5 years years >= 5 (2) in the the N°. alive alive alive years period period alive 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) Cause:1= 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) 28

.VIII.6. 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 breast-feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive