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MSF HEALTH SURVEILLANCE PROGRAMME EAST DARAA, SYRIA FIRST FOLLOW-UP ASSESSMENT Centre for the Advancement of Humanitarian Medicine May 2017 © MSF Old lady from Daraa being interviewed by MSF teams. MSF Middle East Unit Centre for the Advancement of Humanitarian Medicine Health Surveillance Programme Building No. 12 Jordan Tower Building; 5th Floor Abdul Hameed Shoman Street Al-Shemsani Amman, Jordan P.O. Box: 942212 MSF Headquarters Médecins Sans Frontières/Médicos Sin Fronteras Nou de la Rambla, 26 08001 Barcelona, Spain Tel: +34 933 046 100 Fax: +34 933 046 102 www.msf.es EAST DARAA, SYRIA, FIRST FOLLOW-UP ASSESSMENT TABLE OF CONTENTS 04 About the crisis 06 Study objectives 06 Primary assessment components 06 Secondary assessment components 07 Methodology 08 Inclusion and exclusion criteria 08 Survey instrument 08 Data cleaning 08 Data analysis 09 Results 09 Household demographics 10 Displacement 10 Living conditions 11 Food access 12 Mortality 12 Chronic diseases burden 13 Healthcare-seeking behaviour 16 Predictive analysis 16 Mental health 16 Immunisation BCG Hepatitis B Pentavalent Vaccine Measles OPV 21 Sexual and reproductive health 22 Summary and recommendations 24 Study limitations 25 Contact information 26 References 3 MSF HEALTH SURVEILLANCE PROGRAMME ABOUT THE CRISIS Figure 1. Syrian Civil War: terrotorial control map as of July 22, 2017 As the Syria crisis enters its seventh year, people Over half of the population, many of whom have been continue to suffer the consequences of a conflict that displaced multiple times, have been forced from their has caused destruction and devastation with complete homes. This conflict has affected adults and children disregard for human life. The United Nations Office for alike, exposing them to grave protection threats. the Coordination of Humanitarian Affairs (UNOCHA) Children and young people comprise more than half estimates that 13.5 million people require humanitarian of the displaced communities, as well as half of those assistance, 4.6 million of whom are trapped in hard-to in general need of humanitarian assistance. reach and besieged areas. 4 EAST DARAA, SYRIA, FIRST FOLLOW-UP ASSESSMENT © MSF There are currently 13 besieged locations across Syria where people are trapped. Humanitarian groups do not have sustainable access to these areas, and people are being denied the most basic rights, including freedom of movement and access to adequate food, water and healthcare. This is paralleled by a complicated political landscape where neighbouring countries have restricted the admission of people fleeing Syria. This has left hundreds of thousands of people stranded on their borders in deplorable conditions and exposed to a range of life-threatening needs. In the absence of a political solution to the conflict, intense and widespread hostilities are likely to persist © MSF in some parts of the country throughout 2017. http://www.unocha.org/syrian-arab-republic/ syria-country-profile/about-crisis Normal roads in towns in east Daraa. 5 MSF HEALTH SURVEILLANCE PROGRAMME STUDY OBJECTIVES The objectives of the Eastern Daraa First Follow-up 7. What is the current use and sources of medication Assessment, conducted in all study settings with the used among this population? participation of all respondents, aimed to answer 8. What is the prevalence of chronic medical conditions the following questions. among the population in this region? 9. What are the gaps in medical coverage among those PRIMARY ASSESSMENT COMPONENTS who have been diagnosed with chronic medical 1. What are the critical health needs of the people conditions in this area? currently living in eastern Daraa? 10. What type and amount of medical services are 2. What is the current quality of life of those living available for the population in this region? in the area of interest? 11. What is the health services utilisation behaviour and 3. How do the follow-up findings compare to the rate of use for this population? baseline findings? 12. Are health service utilisation behaviours related to recent population displacement? SECONDARY ASSESSMENT COMPONENTS 13. What is the immunisation coverage, incidence of 1. What is the demographic profile of households diarrhoeal disease, and prevalence of respiratory currently living in eastern Daraa governorate? infection among children under the age of five among 2. What are the medical service access issues and those displaced in this area? concerns among the overall population in this region? 14. What reproductive health and family planning 3. What is the crude mortality rate among this services are used by women of 15-49 years of age population? in this area? 4. What are the general morbidities and prevalence 15. What is the current situation among this population of these morbidities among this population? related to shelter and sanitation? 5. What proportion of overall population mortality 16. What are the current issues among this population and morbidity is related to the current conflict related to non-food items, including summer cooling in the region? supplies, bedding? 6. What are the recent healthcare-seeking behaviours 17. What are the current and future plans of the of the overall population in the eastern Daraa population in this area in terms of income generation governorate area? and if applicable, ‘home region’ repatriation? 6 EAST DARAA, SYRIA, FIRST FOLLOW-UP ASSESSMENT METHODOLOGY The area of interest comprises the cities, towns, and locations, trained data collectors proceeded to collect villages of Smaqiyat, Simej, Smad, Busra Esh-Sham, data until the target sample size was reached. Jemrine, Moraba, Nada, Abu Katuleh, Mataeiyeh, Ghasm, Sahwa, Jizeh, Mscifra, Karak, Um Walad, Rikhim, The target sample size was a minimum of 3,500 eastern Maliha, western Maliha, Hrak, Nasib, Tiba, Um individuals, from at least 600 households dispersed Elmayathen, Kahil, Sayda, western Gharyeh and eastern throughout 26 small communities. Within each Gharyeh. The total population in this catchment area is household that met the inclusion criteria, a pre-tested, estimated to be approximately 200,000 people, including standardised, comprehensive questionnaire was internally displaced people (IDPs), according to local administered to all persons who met the ‘household government estimates. The sampling strategy used definition’ (see below). Dharma Mobile™ software was was a multi-stage cluster sampling design. Since the used for data collection, storage, and some automated sampling frame was very large, two clusters (labelled as analytic. Data collectors used MSF- provided mobile Red and Green) of equal size were initially selected to data collection devices (iOS tablets, mini iPads) for represent the different social demographics of the area. all collection activities. Access to the MSF Health Within each cluster we then conducted a systematic Surveillance Program (HSP) web portal is available random sampling of every sixth dwelling. At all selected internally for authorised MSF staff. Figure 2. Assessed towns and cities in east Daraa 7 MSF HEALTH SURVEILLANCE PROGRAMME © MSF INCLUSION AND EXCLUSION CRITERIA All persons living in the area of interest were included as participants in the East Daraa Follow-up Assessment, regardless of the period of time they had been living in the current location. Syrians, Iraqis, Palestinians and people of other nationalities who were living in the study locations were all included as participants. There were no exclusions related to gender, age, sex, ethnicity or socioeconomic reasons. Inclusion: All participants from selected dwellings who met the ‘household’ definition as described below. Exclusion: Any members of selected dwellings who did not meet the ‘household’ definition as stated below. MSF teams during households’ visits. Household: PPrimary family members living in the same dwelling for at least one month prior to interview. In addition, any individual living and eating with primary DATA CLEANING family members for at least one month prior to interview The data was extracted from Dharma platform in a were included. csv format. It was then converted to an xls format and imported to Stata 13 MP. The total count amounted to SURVEY INSTRUMENT 5,166 entries representing a stacking of household and A standardised questionnaire was used for the MSF-HSP: individual level data. The two datasets were separated Eastern Daraa Follow-up Assessment. This instrument based on a unique pattern at household level. The has been used by MSF’s Operating Centre Geneva household level dataset was merged under the individual (OCG) and Operating Centre Barcelona-Athens (OCBA) dataset facilitating the use of the household identifier sections since 2014, and was designed and implemented as a cluster variable to adjust for random effects in originally by researchers with the World Health multilevel modelling. Multiple choice variables were Organization (WHO) in Iraq. Additional reproductive split into categorical binary variables for bivariate and health questions were incorporated from Knowledge, multivariate analyses. Using household identifiers, Practices, & Coverage surveys (USAID-sponsored individual-level variables were recoded numerically and Maternal and Child Health Integrated Program (MCHIP) collapsed to a household level using the summation assessments). All addendums/additional questions were function when needed for cross-tabulations and first vetted by the MSF OCBA regional medical advisor advanced analyses at household level. and HSP project manager
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