Integrated Nutrition and Mortality Smart Survey Report

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

INTEGRATED NUTRITION AND MORTALITY SMART SURVEY REPORT

HUDUR TOWN, BAKOOL REGION, SOMALIA

OCTOBER 2020

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

ACKNOWLEDGEMENTS

Action against Hunger (AAH), would like to acknowledge all the support provided during the preparation, training and field activities of the survey, which includes but not limited to: ➢ Technical and logistical supports provided by Hudur Municipality and the Ministry of Health in South West state of Somalia, facilitations during the training and field work. ➢ We would like to acknowledge the roles of the assessment teams including the team leaders, enumerators and community field guides and all the parents/caregivers who provided valuable information to the survey team, and participated the assessment. ➢ Assessment Information Management Working Group (AIMWG) members for the technical input and validation. ➢ Appreciation also goes to SIDA/DFID, for the generous financial support to conduct this nutrition and mortality survey.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

TABLE OF CONTENTS

Contents ACKNOWLEDGEMENTS ...... II

TABLE OF CONTENTS ...... III

Contents ...... III

LIST OF TABLES ...... V

LIST FIGURES ...... VI

ACRONYMS AND ABBREVIATIONS ...... VII

EXUCUTIVE SUMMARY...... IX

1. INTRODUCTION AND SURVEY OBJECTIVES ...... 1

1.1. Background ...... 1

1.2. Justifications ...... 1

1.3. Objectives...... 2

1.3.1. Overall objective: ...... 2

2. METHODOLOGY ...... 3

2.1 Survey Design ...... 3

2.2 Study Population ...... 3

2.3. Geographic target area and population group ...... 3

2.4. Sample size calculation ...... 3

2.5. Cluster Sampling Strategy...... 4

2.6 Variables collected ...... 6

2.7 Data Managements ...... 7

2.7.1 Survey Teams ...... 7

2.7.2: Quality Assurance ...... 7

2.7.4: Data Analysis and Reporting ...... 8

3. RESULT ...... 9

3.1 Planned versus the actual ...... 9

3.2 Demographic Characteristics ...... 9 III

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.3 Education Level ...... 10

3.4 Anthropometric results (based on WHO standards 2006): ...... 10

3.4.1 Acute Malnutrition among 6 – 59 months children, based on WHZ ...... 10

3.4.2. Distribution of age and sex of sample ...... 11

3.4.3. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ...... 11

3.4.5. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema ...... 12

3.4.6. Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex ...... 13

Table 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema ...... 14

3.4.7. Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema ...... 14

3.4.8.Prevalence of combined GAM and SAM based on WHZ and MUAC cut off's (and/or oedema) and by sex* ...... 15

3.4 Mortality results (retrospective over 93 days prior to interview) ...... 16

3.5 Children’s morbidity ...... 16

3.6. Health Seeking Behiviours ...... 17

3.7 Vaccination Results ...... 18

3.8 Program coverage ...... 18

3.9 Vitamin A Supplementations and Deworming...... 19

3.10. Maternal Malnutrition ...... 19

3.10.1. Physical Status for Mothers ...... 19

3.10.2. Maternal nutrition and Multiple Micronutrient supplementations...... 20

3.11. Dietary diversity and CSI ...... 20

3.12. Water Sanitation and Hygiene (WASH) ...... 21

4. DISCUSSIONS ...... 22

4.1 Nutritional status ...... 22

4.2 Mortality ...... 22

4.3 Causes of malnutrition ...... 22

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

5. CONCLUSIONS ...... 23

6. RECOMMENDATIONS AND PRIORITIES ...... 1

6. REFERENCES ...... 1

7. ANNEXES ...... 2

7.1. LIST OF SELECTED CLUSTERS ...... 2

7.2. Plausibility check for: Hudur Survey Oct. 2020.as ...... 4

7.3. STANDARDIZATION TEST (Evaluation of Enumerators) ...... 5

LIST OF TABLES Table 1: Summery Findings ...... XI

Table 2: Summary Recommendation ...... XIII

Table 3: Sample Size Calculations ...... 4

Table 4: Calculation for number of households per team per day ...... 5

Table 5: Survey plan and Results ...... 9

Table 6: level of Education for Caregivers ...... 10

Table 7: Distribution of age and sex of sample ...... 11

Table 8: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex ...... 11

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema 12

Table 10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores ...... 13

Table 11: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex ...... 13

Table 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema ...... 14

Table 13 : Prevalence of combined GAM and SAM based on WHZ and MUAC cut off's (and/or oedema) and by sex* ...... 15

Table 14: Detailed numbers for combined GAM and SAM ...... 15

Table 15: Mean z-scores, Design Effects and excluded subjects ...... 16

Table 16: Mortality rates ...... 16

Table 17: Prevalence of reported illness in children in the two weeks prior to interview (n= 228) ...... 16 V

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Table 18: Symptom breakdown in the children in the two weeks prior to interview (n=228) ...... 17

Table 19: Vaccination coverage: BCG for 6-59 months and measles for 9-59 months ...... 18

Table 20: Children registered in Therapeutic and Supplementary Feeding Centers ...... 18

Table 21: Vitamin A Supplementations and Deworming ...... 19

Table 22: Physical Status for Mothers ...... 19

Table 23: Maternal nutrition and Multiple Micronutrient supplementations ...... 20

Table 24: WASH indicators ...... 21

Table 25: Recommendations ...... 1

LIST FIGURES Figure 1: Population age and sex pyramid ...... 9

Figure 2: Weight for Height Z - score ...... 12

Figure 3: Proportion Malnutrition by age group accoding to MUAC ...... 14

Figure 4: Child Illnesses Reported ...... 16

Figure 5: Health Seeking Behaviors...... 17

Figure 6: Household Dietary Diversity ...... 20

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

ACRONYMS AND ABBREVIATIONS

AIMWG Assessment and Information Management Working Group ARI Acute Respiratory Infections ACF Action Contre Lafaim AWD Acute Watery Diarrhea BCG Bacillus Calmette-Goerrin CDR Crude Death Rate DEFF Design Effect DFID Department of Foreign International Development ENA Emergency Nutrition Assessment EPI Expended Program on Immunization FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition HAZ Height for Age Z – Scores HDDS Household Dietary Diversity Scores HH Household IDP Internally Displaced Persons IPC Integrated Phase Classifications IYCF Infant and Young Child Feeding MM Millimeter MOH Ministry of Health MUAC Mid Upper Arm Circumference ODK Open Data Kit OTP Outpatient Therapeutic Program PPS Probability Proportionate to Size rCSI Reduced Coping Strategies Index SAM Severe Acute Malnutrition SD Standard deviation SIDA Swedish International Development Agency SMART Standardized Methods of Assessment in Relief and Transitions SRCS Somali Red Crescent Society TSFP Target Supplementary Feeding Program U5DR Under Five Death Rates UNICEF United Nations Children’s Fund WASH Water Sanitation and Hygiene VII

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

WAZ Weight for Age Z –Scores WFP World Food Program WHO World Health Organization WHZ Weight for Height Z- Scores

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EXECUTIVE SUMMARY

Action Against Hunger (ACF) has been implementing key humanitarian interventions in Somalia during the last three decades, with key activities that includes health, nutrition, WASH and food security and livelihood. Hudur district is among the project areas of ACF, providing different services that include integrated health and nutrition services through health centers, mobile teams and stabilization center. ACF has also additional activities on food security/livelihood and WASH including conditional/unconditional cash transfers, hygiene promotions, provision of hygiene kits, and construction of latrines, water chlorination, barked constructions and household water treatments (using aqua tabs) The other humanitarian organizations implementing programs in the district include Somali Red Crescent Society (SRCS), SOS Children’s village and MARDO. Action Against Hunger conducted SMART nutrition survey in October 2020 to assess the nutrition status among children 6 – 59 months, as well as, the women in child bearing age (15 – 49) among other indicators. Two stage cluster sampling methodology was employed, where in the first stage a total of 40 clusters were sampled, using ENA for SMART software January 2020, with probability proportionate to size (PPS). The second stage involved selection of 600 households using simple random sampling method. During the assessment, anthropometric measurement was taken for 861 children. The findings indicated a Global Acute Malnutrition (GAM) of 16.4% (13.6 – 19.5) and Severe Acute Malnutrition (SAM) at 5.8% (4.4 – 7.7) indicating very high/critical nutrition situation and showing very significant deteriorations(P Value <0.001) from the moderate/alert nutrition status of 8.7% (6.3 – 11.7) reported in 2019 SMART survey. Retrospective death rate also showed an acceptable level CDR of 0.50 (0.29 – 0.83)/10,000/day and U5DR of 0.36 (0.11 – 1.12)/10,000/day which was below the international thresholds (<1 deaths /10,000/day1 The survey findings further indicated 25.1% of children reported illness two weeks prior the assessment, mostly Acute Water Diarrhea (46.7%) and acute respiratory infections (34.2%). The prevalence of health intervention indicators - measles and BCG immunization coverage were (63.7%) and (91.0%) respectively, compared to BCG coverage (85.3%) and measles (83.7%) results in 2019, both were below the recommended Sphere coverage (>95%) , while vitamin A supplementation was much lower, as only 49.7% had received Vitamin A during the past six months.

1 IPC Global partner, 2010, The Integrated Phase Classification Technical Manual

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

In conclusion, the nutrition status among Hudur district children has deteriorated from alert to critical, this could be attributed to by the high morbidity level (AWD and ARI), while the majority of households (>95%) reported high or moderate coping strategies during the past seven days.

Although most of households had latrines, access to safe drinking water was low which can be among the attributing factors of high AWD cases and led to increased malnutrition

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Hudur urban and IDPs SMART nutrition Survey - Preliminary results

Table 1: Summery Findings Total children 861 Boys = 419, Girls = 442

# Indicators Number % (CI)

Plausibility Scores 19%

1 Prevalence of Global Acute Malnutrition (All) 141 16.4% (13.6 – 19.5) Boys 70 16.7% (13.5 – 20.5) Girls 71 16.1% (12.8 – 20.0)

2 Prevalence of Severe Acute Malnutrition (All) 50 5.8% (4.4 – 7.7) Boys 21 5.0% (3.4 – 7.4) Girls 29 6.6% (4.4 – 9.8)

3 Oedema 0 0%

4 Design Effect 1.94

5 Prevalence of GAM MUAC (All) 127 14.4% (11.0 – 18.8) Boys 88 11.4% (7.6 – 16.9) Girls 87 17.3% (12.8 – 2.8)

6 Prevalence of SAM MUAC (All) 48 5.5% (3.8 - .8) Boys 22 4.7% (2.7 – 7.9) Girls 25 6.2% (4.0 – 9.5)

7 Prevalence of Stunting (All) 148 17.4% (13.3 – 2.3) Boys 83 20.1% (15.3 – 26.1) Girls 65 14.8% (10.4 – 20.5)

8 Severe Stunting (All) 45 5.3% (3.5 – 8.0) Boys 29 7.0% (4.5 – 11.0) Girls 16 3.6% (1.8 – 7.3)

9 Prevalence of Underweight (All) 175 20.1% (16.4 – 24.5)

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Boys 88 20.9% (16.6– 26.0) Girls 87 19.4% (14.4 – 25.6)

10 Severe Underweight (All) 47 5.5% (3.8 – 7.8) Boys 22 4.7% (2.7 – 7.9) Girls 25 6.2% (4.0 – 9.5)

11 Death Rates

12 Crude Death Rate/10,000/day 13 0.50 (0.29 – 0.83)

13 Under five Death Rates/10,000/day 3 0.36 (0.11 – 1.12 )

14 Design Effect 1.0

15 Morbidities

16 Child Illness prior two weeks (All) 228 25.1% (15.7 – 34.5) 17 Immunization Coverages

18 BCG vaccination (with scars) 578 63.7% (50.8-7.5) Measles Vaccination 826 91.0% (86.5 – 95.6) Polio vaccination 846 93.5%(88.9 - 97.6)

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Table 2: Summary Recommendation

No. Key Findings Recommendations By WHO. 1. High prevalence of acute Malnutrition Continuation of the Ongoing management of Severe and Ministry of Health, at 16.4% (13.6 – 19.5 95% CI) with high moderate acute malnutrition (OTP, SC and TSFPs) as well as Action Against Hunger severe acute malnutrition 5.8% (4.4 – treatment /management of communicable diseases (especially and other partners 7.7 95% CI) AWD and ARI)

2 Low immunization and Demand generation activities to increase utilization of Ministry of Health, supplementation coverage. health/immunization services to improve immunization, Action Against Hunger Immunization coverages are below the Deworming and vitamin supplementation coverages. and other partners international standards (sphere >95%); Such activities include: Mass campaign, scaling up using CHWs, Very low vitamin A supplementations Improve on documentation of immunization and 49.7% (40.4 – 58.9) supplementation Deworming: 57.8% (70.5) 3 Limited access to safe drinking water Improve the access to safe drinking water through construction of Ministry of Health and and the need for improved WASH protected water sources. Action Against Hunger practices and other partners Access to safe drinking water: 18.4% Social mobilization activities on safe drinking water, provision of (7.5 – 29.4) aqua tabs etc.

4 High proportion of the population are Address short term food insecurity issue with programs like Ministries of planning still practicing high-reduced coping Like cash voucher or cash for work, as well as a long term plan on and agriculture, Action strategies. chronic food insecurity. Against Hunger and 59.7% of households employing high other partners coping strategies.

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1. INTRODUCTION AND SURVEY OBJECTIVES

1.1. Background

Action Against Hunger has been a key humanitarian actor in Somalia since May 1992 providing an array of services in Nutrition, Health, Food Security and Livelihood, Water Sanitation and Hygiene across 3 Regions; Bakool, Nugal and Banaadir . The Health and Nutrition program focuses primarily on prevention and treatment of Acute Malnutrition through static and mobile therapeutic centers and Stabilization Centers as well as primary health care services through maternal and child health centers and mobile outreach teams. Action against Hunger also co- leads the Nutrition Cluster Assessment and Information Management Working Group.

Hudur is one of the districts in Bakool region, and is where the regional administration of Bakool sits in Southern Somalia. Majority of the population are agro pastorals and urban (In Hudur town) but during the recent years, there has been a significant number of migrations who moved from the other districts of the region due to insecurity. ACF runs key life saving health and nutrition services in Hudur, including OTP and SC programs for the town and the surrounding villages. During the drought, ACF up scaled nutrition program including introduction of TSFP to address and treat Severe and moderate acute malnutrition The survey was planned as a follow up to establish the nutrition situation after the massive interventions. This survey focused on both urban and IDP populations of Hudur town.

1.2. Justification

The recurrent droughts of last decade had resulted in loss of productive assets and increased household food insecurity throughout Somalia, and Bakool region is among the most affected areas, where beside the climatic shocks, conflict has worsened the situation due to limitation of road accessibilities to main markets, thus affecting the food prices and the overall livelihood status. ACF conducted SMART nutrition surveys in 2015 (10.1% (CI: 7.4 – 13.7), 2017 (13.4% (CI; 10.4 - 17.2) and 2019 8.7% (6.3 – 11.7). The October 2020 SMART survey was planned to assess the current nutrition status, compared to the previously conducted surveys and further understand the challenges and the intervention gaps that need further improvement and to provide the relevant recommendations. The study area in this survey was Hudur town for urban and IDP populations.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

1.3. Objectives

1.3.1. Overall objective:

To assess acute malnutrition rates amongst children 6-59 months and retrospective mortality rates amongst the population.

1.2.2. Specific objectives

1. To estimate the prevalence of acute malnutrition amongst children aged 6-59 months. 2. To assess the retrospective crude and under five mortality rates in the selected locations. 3. To assess the coverage of vitamin A supplementation amongst children aged 6-59 months. 4. To assess measles immunization coverage amongst children aged 9-59 months. 5. To assess the coverage of immunization of polio and BCG amongst children aged 6-59 months 6. To estimate the prevalence of common child illnesses in the target locations amongst children under 5 years two weeks prior to the survey. 7. To assess water, sanitation and hygiene practices at the household level. 8. To estimate levels of key food security and livelihood indicators of HDDS2, and CSI3.

2HDDS: Household Dietary Diversity Score 3 CSI: Coping Strategy Index 2

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

2. METHODOLOGY

2.1 Survey Design

The survey applied a two stage cluster sampling with the clusters being selected using the probability proportionate to population size (PPS) as different sections of the town were constituting the sampling frame.

2.2 Study Population

The target populations for the survey were children aged 6 – 59 months for the anthropometric component, and women of reproductive age between 15 – 49 years for the maternal health indicators.

2.3. Geographic target area and population group

The geographical coverage of the survey was limited to Hudur town populations, where the primary respondents for the survey were mothers and/or care takers of children under five years for both household and child questionnaire.

2.4. Sample size calculation

The sample size for the assessment was calculated on the basis of the key parameters for the primary outcomes (mortality and GAM) only in line with current SMART guidance, number of villages that were not accessible due to security were excluded from the sampling. The tables below represent the sample size calculations for both the anthropometric and mortality components. Emergency Nutrition Assessment (ENA) software; 20th January, 2020 version was used (see table 3 for sample size calculations)

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Table 3: Sample Size Calculations

Hudur Anthropometric and Mortality Sample Size Calculation Description of the population Total number of people residing in Hudur Approximately 1017204 town & accessible villages. Type of population Urban, rural and IDP communities Parameters for Anthropometry Value Assumptions based on context Estimated Prevalence of GAM (%) 8.7 Point estimate of SMART Survey of October 2019 used. Secondary data review indicates no major changes in context. ± Desired Precision 3.3 Precision determined by objectives of this assessment attributed to multi-indicators Design Effect (if applicable) 1.90 As per October 2019 results Children to be included 580 As calculated from ENA Average HH Size 5.5 SMART Survey October 2019 % Children under- 5 20 SMART Survey October 2019/WHO polio estimates % Non-response Households 2 Experience during the October 2019 SMART Survey/to cater for unforeseen circumstances Households to be included 597 As calculated from ENA Parameters for Mortality Value Assumptions based on context Estimated Death Rate/ 10,000/day 0.39 October 2019 SMART Survey results ± Desired Precision /10,000/day 0.33 SMART guidelines with death rate < 0.5; Design Effect (if applicable) 1.44 October 2019 survey result Recall Period in Days 93 Population to be included 2690 As calculated from ENA Average HH size 5.5 SMART Survey October 2019 % Non-response Households 2 Experience during the October 2019 SMART Survey/to cater for unforeseen circumstances Households to be included 499 As calculated from ENA

**Higher household numbers from Anthropometric component of 597 was used in cluster assignment.

2.5. Cluster Sampling Strategy.

A two-stage cluster sampling was employed.

2.5.1 Stage one: Entails cluster selection. An updated sampling frame (list sections in the study location) have been developed based on secondary data and updated with the assistance of local authority, this along respective population estimates was entered into ENA for SMART software 9th July 2015 version on the planning tab. Clusters were then assigned by study location. All the planned clusters and households were covered and there was no non-accessible clusters.

4 Source: WHO Polio population, and updated with key informants in Hudur

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

The number of clusters assigned were based on the number of households a team can visit in a day as per calculations in the table below (see table 4 on households per team).

Table 4: Calculation for number of households per team per day

Departure from Office 7:00 AM a. Daily morning Briefings 30 minutes b. Travel to clusters 15 minutes c. Introduction and HH list development 45 minutes d. Lunch break 30 minutes e. Travel back to base 15 minutes Total time taken 135 minutes Arrival back to Base 5:00 PM Total Available time in a day 10 hrs (600 minutes) Available time for work 600 - 135 minutes= 465minutes Time taken to complete one 31 minutes questionnaire/moving from one HH to another

The calculations above have been based on as an average. Based on this, the number of HH that the team can comfortable visit in a day was calculated as: 465 (min) / 31 (min) = 15 HH/per day5

This will translate to the following clusters; 597/15=39.8 approx. 40 clusters Hudur Total number of HH based on sample size calculation 597 Total number of HH to be assessed per day per team6 15

Clusters Needed 39.8

Rounded UP (Clusters) 40 Rounded UP(Households) 600

2.5.2. Stage two: Selection of households

• Definition of household for the survey: On arrival in the selected clusters, the team leader met with the village/section elders . The team introduced themselves, explaining the survey objectives as well as expectations from the elders. A household was defined as number of people living together and sharing a common cooking pot. Polygamous families was defined based on the same

5 There are chance of slight variation on cluster locations and if necessary, adjustments will be done without any changes in the sample size

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

criter, if each wife has her own pot, even if living in the same compound, this was treated as different households.

• Household selection techniques: The standard definition of a HH was shared with the teams to aid in developing the HH listing within the cluster, 15 HHs were then randomly selected from the complete list of HHs, using the random number tables or the random number generator in Smart phones. Then the survey team visited these HHs. The field guide/head of the section and the elders supported the teams in updating the list of households. Some of the sections had already updated list of households. Where there is no updated list, teams developed new list, with the support of local municipality and elders.

For clusters with more than 250HHs, segmentation was used to select one portion of the cluster that will represent the cluster. This was done using probability proportion to size (PPS). A segment was selected randomly, using simple random sampling. In the selected segment, the process of HH selection followed the same process done in each cluster for selection of the 15 HH.

In all selected households, children 6 to 59 months (based on immunization card or calendar of events) were included in the anthropometric survey. In HHs without children 6-59 months, other variables (mortality, FS,) were collected. All children in the age range of 6-59 months were included in the anthropometric, immunization and health components. However, only children 9-59 months were assessed for measles immunization coverage, as per WHO guidelines and immunization schedule.

2.6 Variables collected

Age: the age of the child will be recorded based on a combination of child health cards and mothers’/caretakers’ recall of the child’s birth date, using calendar of events for Hudur town that was developed in collaboration with the survey teams. Sex: The gender of the child whether a male or female were recorded Bilateral Edema: normal thumb pressure was applied on the top part of both feet for 3 seconds Weight: Children were weighed when wearing minimal or light clothing. Weight will be taken using Electronic scales, reading the nearest 0.1 Length/Height: children were measured bareheaded and barefooted using wooden UNICEF height boards with a precision of 0.1cm. Children under the age of two years were measured while lying down and those over two years while standing upright. Mid Upper Arm Circumference (MUAC): MUAC of children were taken at the midpoint of the upper left arm using a MUAC tape and the nearest 0.1cm was recorded. Retrospective Morbidity of Children: Based on mother’s recall was conducted for all children (6-59 months) to assess the prevalence of common diseases, 2 weeks recall period was taken for Diarrhea, fever and pneumonia, while the recall period for the measles was based on last 30 days.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Vaccination Status and Coverage: For all children 6-59 months, information on Oral polio Vaccine and measles vaccination were collected using the recall from caregivers. Vitamin A supplementation status: For all children aged 6-59 months, information on Vitamin A supplementation were collected based on mother/caregiver’s recall again. Information on whether the child had received supplementation in the last 6 months was collected. Vitamin A capsule samples were shown to the mothers to support in recall. Household water source: This indicator is aimed to understand the main water source of the households and whether they get from protected or unprotected source. Sanitation: Information on household accessibility to a toilet/latrine and the type of the latrine they use.

2.7 Data Managements

2.7.1 Survey Teams

• Number of Teams: Action Against Hunger as the lead in the survey oversaw the actual field level implementation of the survey from final review of protocol, enumerator selection, training, data collection, supervision, analysis and reporting. ACF had also worked closely with 6 teams comprising of one (1) team leader, two (2) measurers and a village guide. All the enumerators and team leaders were selected on competitive process after the advertisement to ensure fair selection of survey teams and get experienced and competitive members

• .Data entry procedures: Data was collected on mobile platform (Open Data Kit) to allow direct entry and submission to central repository online. The survey used ODK (Android application) for data collection and ONA (online platform) as the repository for the data. Entire survey questionnaire were uploaded; Cluster control form was also used. • Daily plausibility check was done and briefing and feedback provided to the teams before they left for field data collection.

2.7.2: Quality Assurance

The following measures were put in place by Action Against Hunger to ensure good quality work.

1. Oversaw the work of the survey process to ensure adherence to protocol and standards of quality survey implementation include: 7

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

a. Ensure that training of survey teams are done using standardised material. b. Undertook standardisation test as part of the training; taking appropriate steps thereafter based on performance of the survey teams. c. Appropriate calibration of survey equipment. d. Daily debriefing with the teams giving feedback geared at improving the quality of the measurements and congratulate the teams for job well done e. Plausibility checks undertaken daily as data streams in. f. An updated calendar of events has been used to estimate the ages of children; when documented proof of age is lacking

2.7.4: Data Analysis and Reporting The survey data was analysed using ENA for SMART software 20th January 2020 version. This was used for both the anthropometric and mortality components. Additional data captured during the survey, such as food security, immunization and morbidity were analysed using EPI Info. Statistical methods consisted of point prevalence calculations for each of the variables disaggregated by sex.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3. RESULT

3.1 Planned versus the actual A total of 600 households were assessed, comprising a population of 2818 and 861 children under 5 years. The findings further showed an average household size of 4.7 and sex ratio of 0.97 with 49.3% being male while 50.7% were female. This is showing an equal distribution of male and female and table 5 below shows planned versus the actual variables:

Table 5: Survey plan and Results

Parameters for Anthropometry Planned Results Proportion Estimated Prevalence of GAM (%) 8.7 16.4 Design Effect (if applicable) 1.94 1.33

Children to be included 580 861 148%

Average HH Size 5.5 4.7 Number of Clusters 40 40 100% % Children under- 5 20 30% Households to be included 600 601 100%

Estimated Death Rate/ 10,000/day 0.39 0.50 Population to be included 2690 2818 104.7%

3.2 Demographic Characteristics

Figure 1: Population age and sex pyramid

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.3 Education Level The survey findings indicated a very low literacy level among care-givers with 41.6% (250 out of 600) who never went to school, while 32.7% went to Koranic school, 20.7% attended primary school and only 3.5% attended secondary school as shown in table 6 below.

Table 6: level of Education for Caregivers

SN Education Level Number Proportion (95% CI) 1 Didn't go to school 250 41.6% (28.4 – 54.7)

2 Religious & Koranic school 197 32.7% (22.6 – 42.9)

3 Primary school 125 20.7% (11.3 – 30.2)

4 Secondary school 21 3.5% (1.6 – 5.3)

5 Technical School 5 0.8% (0.1 – 1.5)

6 Higher Education 1 0.1% (0.0 – 0.5)

7 Don’t Know 2 0.3% (0.1 – 0.8)

Total 601 100%

3.4 Anthropometric results (based on WHO standards 2006):

Global acute malnutrition is defined as <-2 z scores weight-for-height and/or oedema, while severe acute malnutrition is defined as <-3z scores weight-for-height and/or oedema) Exclusion of z-scores from Observed mean SMART flags: WHZ -3 to 3; HAZ -3 to 3; WAZ -3 to 3

3.4.1 Acute Malnutrition among 6 – 59 months children, based on WHZ

Based on the survey result, the global acute malnutrition (<-2 WHZ scores and/or oedema) is showing 16.4% (13.6 – 19.5) and Severe acute malnutrition of 5.8% (4.4 – 7.7) (<-3 WHZ scores and/or oedema). Based on WHO and IPC thresholds this indicates a very high/critical nutrition status and is a deterioration from the moderate/alert nutrition situation- GAM of 8.7% (6.3 – 11.7)7 and SAM of 1.0%, recorded in October 2019 SMART survey, with statistically very significant deterioration (P Value <0.001). See table 8 below on prevalence of acute malnutrition.

7 Action Against Hunger, 2017, SMART nutrition survey for Hudur Urban and IDP populations

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.4.2. Distribution of age and sex of sample

452 girls (51.4%) and 428 boys (48.6%) were screened with sex ratio of 0.9 and generaly slightly higher proportion of children 6 to 29 months was observed, with age ratio of 1.17.

3.4.2. Distribution of age and sex of sample

Table 7: Distribution of age and sex of sample

Boys Girls Total Ratio

AGE (mo) no. % no. % no. % Boy:girl

6-17 113 47.7 124 52.3 237 26.9 0.9

18-29 115 48.3 123 51.7 238 27.0 0.9

30-41 75 47.2 84 52.8 159 18.1 0.9

42-53 84 51.5 79 48.5 163 18.5 1.1

54-59 41 49.4 42 50.6 83 9.4 1.0

Total 428 48.6 452 51.4 880 100.0 0.9

3.4.3. Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex 861 children were screened - 419 were boys with GAM of 16.7%, while 442 screened girls had GAM of 16.1%, and in generally there is no major variations for boys and girls with regards to malnutrition based on WHZ. Table 8 is showing the prevalence of malnurition by sex based on weight for height z scores.

Table 8: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or Oedema) and by sex

All Boys Girls

n = 861 n = 419 n = 442

Prevalence of global malnutrition (141) 16.4 % (70) 16.7 % (71) 16.1 %

(<-2 z-score and/or oedema) (13.6 - 19.5 95% (13.5 - 20.5 (12.8 - 20.0 95% C.I.) C.I.) 95% C.I.)

Prevalence of moderate malnutrition (91) 10.6 % (49) 11.7 % (42) 9.5 %

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

(<-2 z-score and >=-3 z-score, no (8.6 - 12.9 95% C.I.) (9.3 - 14.6 95% (7.2 - 12.4 95% C.I.) oedema) C.I.)

Prevalence of severe malnutrition (50) 5.8 % (21) 5.0 % (29) 6.6 %

(<-3 z-score and/or oedema) (4.4 - 7.7 95% C.I.) (3.4 - 7.4 95% (4.4 - 9.8 95% C.I.) C.I.)

The prevalence of oedema is 0.0 %

Figure 2: Weight for Height Z - score

Figure : The normal disribution curve on Weigt for Height Z Scores is skewed to the left and this is because of the high malnutrition levels. 3.4.5. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or Oedema

The youngest age groups of 6 – 17 months have shown the highest malnutriton levels (both severe ad moderate) and half of all the SAM cases are from this age group. Although there were no IYCF indicators collected due to larger sample size needed ,the reason for higher malnutrition in younger children may relate to feeding practices, especially breast feeding and complementary feeding. Table 9 is showing the prevalence of malnutrition by age group based on WHZ.

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or Oedema

Severe wasting Moderate Normal Oedema wasting (<-3 z-score) (> = -2 z score) (>= -3 and <-2 z- score )

Age Total No. % No. % No. % No. % (mo) no.

6-17 226 26 11.5 26 11.5 174 77.0 0 0.0

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

18-29 234 7 3.0 23 9.8 204 87.2 0 0.0

30-41 156 5 3.2 21 13.5 130 83.3 0 0.0

42-53 163 10 6.1 14 8.6 139 85.3 0 0.0

54-59 82 2 2.4 7 8.5 73 89.0 0 0.0

Total 861 50 5.8 91 10.6 720 83.6 0 0.0

Table 10: Distribution of acute malnutrition and Oedema based on weight-for-height z-scores

<-3 z-score >=-3 z-score

Oedema present Marasmic kwashiorkor. 0(0.0 %) Kwashiorkor. 0(0.0 %)

Oedema absent MarasmicNo. 65 ( 7.4 %) Not severely malnourished. 815

(92.6 %) 3.4.6. Prevalence of acute malnutrition based on MUAC cut offs (and/or Oedema) and by sex

Prevalence of Global Acute Malnutrition based on MAUC (<125mm) was 14.4 (11.0 – 18.8 9% C.I) percent and girls are more malnourished (17.3%) than boys (11.4%), and again girls have higher proportion of severe (6.2%) cases than boys (4.7%).

The overall MUAC result is showing deterioration from the GAM MAUC (9.0%), and the SAM MUAC (5.5%) recorded in 2019 nutrition assessment. Table 11 below is showing the prevalence of acute malnutrition based on MUAC.

Table 11: Prevalence of acute malnutrition based on MUAC cut offs (and/or Oedema) and by sex

All Boys Girls

n = 880 n = 428 n = 452

Prevalence of global malnutrition (127) 14.4 % (49) 11.4 % (78) 17.3 %

(< 125 mm and/or oedema) (11.0 - 18.8 95% C.I.) (7.6 - 16.9 95% C.I.) (12.8 - 22.8 95% C.I.)

Prevalence of moderate malnutrition (79) 9.0 % (29) 6.8 % (50) 11.1 %

(< 125 mm and >= 115 mm, no (6.6 - 12.1 95% C.I.) (4.4 - 10.4 95% C.I.) (7.8 - 15.4 95% C.I.) oedema)

Prevalence of severe malnutrition (48) 5.5 % (20) 4.7 % (28) 6.2 %

(< 115 mm and/or oedema) (3.8 - 7.8 95% C.I.) (2.7 - 7.9 95% C.I.) (4.0 - 9.5 95% C.I.)

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

The younger children of 6 – 17 months are more affected by both moderate (17.7%) and severe (15.2%) wasting, based on MUAC <125mm and 115mm results followed by the second younger group of 18 – 29 months and this may relate to IYCF practices and needs further study and understading Severe wasting Moderate Normal Oedema wasting (< 115 mm) (> = 125 mm ) (>= 115 mm and < 125 mm)

Age (mo) Total No. % No. % No. % No. % no.

6-17 237 36 15.2 42 17.7 159 67.1 0 0.0

18-29 238 9 3.8 26 10.9 203 85.3 0 0.0

30-41 159 2 1.3 4 2.5 153 96.2 0 0.0

42-53 163 0 0.0 6 3.7 157 96.3 0 0.0

54-59 83 1 1.2 1 1.2 81 97.6 0 0.0

Total 880 48 5.5 79 9.0 753 85.6 0 0.0

All the identified malnourished children using MUAC were transfered to the feeding centers. Table 12 above is showing the prevalence of acute malnutrition by age, based on MUAC. Table 12: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or Oedema

3.4.7. Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema Same as WHZ younger children of 6 – 17 months have the highest severe malnutrition on MUAC <115mm and moderate malnutriton based on MUAC >=115mm and <125 mm, followed by the second age group of 18 – 29 months. Figure 2 is showing acute malnutrtion by age group based on MUAC.

Figure 3: Proportion Malnutrition by age group according to MUAC

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.4.8.Prevalence of combined GAM and SAM based on WHZ and MUAC cut off's (and/or oedema) and by sex* Prevalence of combined GAM on WHZ and MUAC (WHZ <-2/or MUAC <125) is showing 21.1% (18.1 – 25.6 95% C.I.), with girls higher slightly than boys and the combined severe cases (WHZ <-3 and/or MUAC <115mm) are also very high (8.0%). Table 13 is showing combined prevalence of GAM and SAM based on WHZ and MUAC.

Table 13 : Prevalence of combined GAM and SAM based on WHZ and MUAC cut off's (and/or oedema) and by sex*

All Boys Girls

n = 880 n = 428 n = 452

Prevalence of combined GAM (190) 21.6 % (87) 20.3 % (103) 22.8 %

(WHZ <-2 and/or MUAC < 125 mm (18.1 - 25.6 (16.2 - 25.2 (18.3 - 28.0 and/or oedema) 95% C.I.) 95% C.I.) 95% C.I.)

Prevalence of combined SAM (70) 8.0 % (30) 7.0 % (40) 8.8 %

(WHZ < -3 and/or MUAC < 115 mm (5.9 - 10.6 (4.6 - 10.5 (6.0 - 12.9 and/or oedema 95% C.I.) 95% C.I.) 95% C.I.)

*With SMART or WHO flags a missing MUAC/WHZ or not plausible WHZ value is considered as normal when the other value is available

Table 14: Detailed numbers for combined GAM and SAM

GAM SAM

no. % no. %

MUAC 49 5.6 20 2.3

WHZ 63 7.2 22 2.5

Both 78 8.9 28 3.2

Edema 0 0.0 0 0.0

Total 190 21.6 70 8.0

Total population: 880

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Table 15: Mean z-scores, Design Effects and excluded subjects

Indicator n Mean z- Design Effect z-scores not z-scores out scores ± SD (z-score < -2) available* of range

Weight-for-Height 861 -0.89±1.15 1.33 0 19

Weight-for-Age 870 -1.20±1.00 2.18 0 10

Height-for-Age 852 -1.03±1.06 2.90 0 28

3.4 Mortality results (retrospective over 93 days prior to interview) Both CDR and U5DR are low and are in line with the results reported by FSNAU in Gu’ 2019 for most of areas in Somalia. This result is also showing an improvement compared to 2017 ACF SMART survey in Hudur town where CRD and U5DR of 0.7 and 1.34/10,000/day were reported respectively.

Table 16: Mortality rates

CDR (total deaths/10,000 people / day): 0.50 (95% CI 0.29 – 0.83)) U5DR (deaths in children under five/10,000 children under five / day): 0.39 (95% CI 0.11 – 1.12)

3.5 Children’s morbidity Table 17: Prevalence of reported illness in children in the two weeks prior to interview (n= 228)

Condition # 6-59 months

Prevalence of reported 228 25.1% (95% C.I 15.7 – 34.5) illness

Figure 4: Child Illnesses Reported

Child morbidities reported during the past two weeks prior to the survey was 25.1%, which is indicating a deterioration from the 9.7% morbidity level reported in 2019 nutrition survey. Scaled up health interventions are currently going on in Hudur town, where people have improved access to health care services, as number of health facilities are currently working in Hudur managed by ACF and other organizations. Increased morbidity level can be among the factors contributed to the worsened nutrition situation in Hudur district as well as road blockages that 16

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN limit entry of commodities in the district. Table 18 is showing prevalence of illness among under five children

Table 18: Symptom breakdown in the children in the two weeks prior to interview (n=228)

Disease # 6-59 months

Cough 78 342% (95% C.I 20.7 – 47.6)

Diarrhoea 93 40.7% (95% C.I. 28.9 – 52.6)

Fever 20 8.7% (95% C.I. 4.7 – 12.8)

Measles 1 0.4% (95% C.I. 0.0 – 1.2)

Blood stool 8 3.5% (95% C.I. 0.3 – 6.6)

Stomach ache 20 8.7% (95% C.I. 3.2 – 14.2)

Eye infections 49 21.5% (95% C.I. 13.5 – 29.4)

Skin Infection 31 13.6 % (95% C.I. 4.9 – 22.2)

Others 3 1.3% (95% C.I. 0.0 – 2.9)

3.6. Health Seeking Behiviours Figure 5: Health Seeking Behaviors

Majority of caregivers reported that they go to public health facilities 86.8% (78.3– 95.2), fewer numbers use private pharmacy 0.8 % (0.0 – 2.1) or traditional healers 3.5% (0.5 – 9.6) ,while others reported that they did not take the child anywhere 8.3% (1.5 – 15.1) (see figure 5 on health seeking behaviour)

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.7 Vaccination Results BCG coverage is showing 63.7 percent (based on BCG scars), this is lower than 2019 results where 83.7% of BCG coverage was reported8. In 2020 SMART survey accessible rural villages of Hudur district were included, while 2019 only urban and IDP settlements were covered. For measles immunization coverages 19.4% of the children had immunization cards, while the combination of the card and mothers recall showed 91.0%. This shows that measles immunization coverage has slightly increased from 85.3% results in October 2020, but is still below the sphere standard of >95%9. Table 19 is showing immunization coverages among 6 – 59 months children.

Table 19: Vaccination coverage: BCG for 6-59 months and measles for 9-59 months

BCG Measles Measles n= 750 (with card) (with card or confirmation from n= 359 mother) n= 764 YES (No. 750) 83.7% (No= 176.) 19.4% (No= 826) 91.0% (95% C.I. 73.0 – 94.5) (95% C.I. 9.7 – 29.0) (95% C.I 86.5 – 95.6)

3.8 Program coverage Few children were in programs among the assessed group, as 6.7% were in supplementary feeding programs and 4.7% in therapeutic feeding program, indicating that the severe children in nutrition program are higher than last year (0.6%), and this is likely due to deteriorated nutrition status. Table 20 is showing program coverages.

Table 20: Children registered in Therapeutic and Supplementary Feeding Centers

Programme type Supplementary feeding programme coverage 6.7% (n=61) (95% C.I. 4.3 – 9.1) Therapeutic feeding programme coverage 4.7% (n=43) (95% C.I. 2.7 – 6.7)

8 Action against Hunger, 2017, Integrated SMART Survey Report in Hudur district.

9 The sphere hand book, 2018, humanitarian charter and minimum standard in humanitarian response

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.9 Vitamin A Supplementations and Deworming Vitamin A is essential to support rapid growth and to help combat infections. Inadequate intake of vitamin A may lead to vitamin A deficiency, which can cause visual impairment in the form of night blindness and may increase the risk of illness and death10. Based on the survey result, majority of the children did not receive recent vitamin supplementation with only 49.7% received supplementation during the past 6 months, which is almost similar to the 47.1% reported in 2019. Proportion of children who received deworming was 57.8%, which is a key public health intervention for children 12 to 23 months11. There is no significant change from the 59.7% recorded in 2019 SMART survey in Hudur. Table 21 is showing Vitamin A supplementation and deworming coverages. Table 21: Vitamin A Supplementations and Deworming SN Vitamin A & Deworming Number Proportion (95% CI) 1 Vitamin A supplementations during 180 49.7% (40.4 – 58.9) last 6 months 2 Deworming 140 57.8% (45.2 – 70.2)

3.10. Maternal Malnutrition

Regarding the physical status of mothers, around one third of mothers (33.1%), were non- pregnant none lactating during the assessment, while more than half of them were lactating (51.2%). Table 26 is showing the physical status of assessed mothers.

3.10.1. Physical Status for Mothers

Table 22: Physical Status for Mothers SN Physical Status Number Proportion 1 Non Pregnant/non lactating 123 23.0% (17.7 – 28.4)) 2 Lactating 281 52.7% (47.1 – 58.3) 3 Pregnant 129 24.2% (18.6 – 29.7)

10 WHO, 2011, Guideline: Vitamin A supplementation for infants 1–5 months of age. Geneva, World Health Organization.

11 WHO, https://www.who.int/elena/titles/deworming/en/

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.10.2. Maternal nutrition and Multiple Micronutrient supplementations. Malnutrition among pregnant and lactating mothers was not high, as 2.3 percent of MUAC <21.0cm, have been reported but 17.2% of pregnant and lactating mothers were at risk (MUAC <23.0cm). Table 23 is showing prevalence of maternal malnutrition based on MUAC <21.0cm and <23.0cm

Table 23: Maternal nutrition and Multiple Micronutrient supplementations

Indicators Status Number Proportion (CI) Maternal Malnutrition N= MAUC <21.0cm 8 2.3% (0.4 – 4.2) MUAC <23.0cm 24 6.9% (3.7 – 10.1)

3.11. Dietary diversity and CSI

Majority of the assessed households (99.6%), during the survey reported that they have consumed ≥4 food groups but most of the households were practicing either high (≥10) reduced coping strategies (59.7%), or medium (36.9%) rCSI (4 - 9)12. This shows that vulnerabilities of the population in generally high.

Figure 6: Household Dietary Diversity

12 WFP, 2012,calculation of household food security outcome indicators, Afghanistan

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

3.12. Water Sanitation and Hygiene (WASH)

Access to safe source of drinking water is low (18.4%), and the majority of households were getting water from open shallow wells, which is a non-protected source but higher than October 2019 results (9.6%). However, most of the households have their own latrines (81.0%) with no major differences from 2019 results (82.5%), and majority of families practice handwashing activities before eating the food (96.9%) while 77.8% wash their hands after the toilet and fewer proportions of 47.4% and 62.0% practice after taking the child to the toilet and before cooking respectively. Table 24 is showing the status of WASH indicators

Table 24: WASH indicators

SN Indicators Number Proportion (95% CI) 1 Access to safe drinking water sources 56 18.4% (7.5 – 29.4) 2 Use of HH latrine 487 81.0% (70.9 – 91.1) 3 Hand washing after taking children to the 231 47.4% (32.6 – 62.2) toilet 4 Hand washing after the toilet 379 77.8% (66.9 – 88.7) 5 Hand washings before cooking 302 62.0% (46.6 – 77.3) 6 Hand washings before eating 472 96.9% (94.9 – 98.8)

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

4. DISCUSSIONS

4.1 Nutritional status

During the assessment 861 children of 6 – 59 months were assessed, with 419 (48.7%) boys and 442 (51.3%) girls and girls were slightly higher than the boys Prevalence of Global Acute Malnutrition (GAM) is showing 16.4% (13.6 – 19.5), with Severe Acute Malnutrition (SAM) rate of 5.8% (4.4 – 7.7) and the current nutrition situation is showing a very high/critical situation based on the international thresholds (≥ 15%), and deteriorated from the moderate/alert level GAM of 8.7% reported in 2019 SMART survey in Hudur. This could be due to high morbidity level (25.1%), deteriorated food security indicators compared to 2019 survey, as well as, other key indicators like low coverages of vitamin A supplementation and deworming, additionally, majority of households are accessing water from none protected source.

Morbidity level of 25.1%, was recorded, most common illnesses reported were acute respiratory infection and acute water diarrhoea .There was a significant increase in the number of children reporting illness two weeks prior to the assessment, compared to 2019 (8.7%).This can be among the major factors aggravating the nutrition status. Additionally, majority of households are accessing water from unprotected (81.6%) source, which is likely an influence to the increase of morbidities

4.2 Mortality

Crude and under five death rates are within the acceptable ranges. Current CDR of 0.50 and U5DR of 0.36 are showing slightly higher from the last assessment in 2019 (CRD 0.39) and the main cause of death were due to Illnesses and trauma/accident.

4.3 Causes of malnutrition Nutrition situation has deteriorated as there are some risk factors, which can contribute and likely affected negatively the nutrition status of children 6-59 months .They includes: • Majority of households are accessing water from unprotected (81.6%) source, and there is a likelihood that this has an influence to the increased disease trends, especially waterborne diseases (AWD). • Presence of high proportion of IDPs, who migrated from the other districts of the region, due to conflict, with limited assets and job opportunities .There are possibilities of increased IDP numbers as far as the conflict is still there. • There are road blockages from all directions which has negatively affected the business activities and the overall transport services. 22

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

• Vitamin A supplementation (49.7%) is also much lower than the recommended coverages, while the measles immunization coverage is also far below the sphere standard of >95%. • Another concern that can have an impact to the nutrition status of children is the low literacy rate of caregivers, as more than 40% of care givers did not go to school. • Nearly 60% of household reported that they have adapted high-reduced coping strategies. This indicates alarming food security situation.

5. CONCLUSIONS

The current nutrition situation in Hudur town is indicating deterioration from the alert results in 2019 to very high/critical situation in 2020. Factors contributed to the worsened situation might include: increased morbidities as well as vulnerabilities among population due to road blockages, displacements and the general chronic food insecurity. Therefore, continuation and further scaling of interventions are very crucial to prevent further deterioration of the situation.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

6. RECOMMENDATIONS AND PRIORITIES

To address the high malnutrition levels among children under five, continuation of current ongoing humanitarian interventions are very crucial and the following recommendations have been put forward to complement the on-going interventions.

Table 25: Recommendations Findings Descriptions Recommendations Critical Acute malnutrition and high GAM 16.4% (113.6– 19.5) • Continue the Ongoing management of Severe prevalence of Underweight SAM 5.8% (4.4 – 7.7) and moderate acute malnutrition (OTP, SC and MUAC <125mm 14.4% (11.0 – 11.8) TSFPs). • Treatment/management of communicable diseases (especially AWD, Fever and ARI). Low health service coverages BCG coverage (61.3%) • Demand generation to increase utilization of Immunization coverages are below the Vitamin A supplementations (49.7%) health/immunization services. international standards (sphere >95%). • Conduct immunization outreach and mobile Very low vitamin A supplementations Deworming 57.8% activities to reach areas with no access to Deworming health services Limited access to safe drinking water and • Access to safe drinking water • Improve the access to safe drinking water the need for improved WASH practices (18.4%) through availing protected water sources • Hygiene promotion. High proportion of the population are still High rCSI (59.7%) • Food Security interventions (like cash voucher practicing high-reduced coping strategies. or cash for work).

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

6. REFERENCES

1. IPC Global partner, 2010, The Integrated Phase Classification Technical Manual

2. WHO Polio population estimate, and updated with key informants in Hudur

3. Action against Hunger, 2019, Integrated SMART Survey Report in Hudur district.

4. The sphere hand book, 2018, humanitarian charter and minimum standard in humanitarian response

5. WHO, 2011, Guideline: Vitamin A supplementation for infants 1–5 months of age. Geneva, World Health Organization.

6. WHO, https://www.who.int/elena/titles/deworming/en/

7. WFP, 2012,calculation of household food security outcome indicators, Afghanistan

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

7. ANNEXES

7.1. LIST OF SELECTED CLUSTERS

Geographical unit Population size Assigned cluster

Sh. Aways 1 4300 1,2 Sh. Aways 2 2300 3 Sh. Aways 3 3400 4,5 Bulow 1 4152 6,RC Bulow 2 4152 7 Bulow 3 3696 8,9 Shiidle 1 3760 10,11 Shiidle 2 4240 12,13 Moragabey 1 4500 14,RC Moragabey 2 4500 RC,15 Horseed 1 5940 16,RC Horseed2 5060 17,18 Dondardir IDP 660 RC Hool Ade IDP 630 Lehelow IDP 1002 Garasweyne IDP 1302 19 Abal IDP 2340 20 Tieglow IDP 2568 21 Donfeylahow 900 22 Rabdhure IDPs 846 Weerow 1650 23 Fajer Bore 1944 24 lukuguurow 570 Cusbo Elo 1020 Tuboy 1692 25 Ilin 1272 26 Bakaaro 1362 Gomore 2700 27 Banjinay 1254 28 Mada Warabe 2796 29 Gabiney 2856 30 Faraq 1890 31

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Booran 1878 32 Waney 1260 33 Korey 2874 34 Goriyey 1182 Kulunta 1530 35 Madhowey 522 Kontomo 606 36 Tijeg 1812 Tawakal 1704 37 Shilow 1218 38 Urunbusle 822 Shidalow 1146 39 Gowaanow 1056 TegenTeegta 1278 40

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

7.2. Plausibility check for: Hudur Survey Oct. 2020.as 8 Overall data quality 9 10 Criteria Flags* Unit Excel. Good Accept Problematic Score 11 12 Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 13 (% of out of range subjects) 0 5 10 20 0 (2.2 %) 14 15 Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 16 (Significant chi square) 0 2 4 10 0 (p=0.418) 17 18 Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 19 (Significant chi square) 0 2 4 10 10 (p=0.000) 20 21 Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 22 0 2 4 10 0 (4) 23 24 Dig pref score - height Incl # 0-7 8-12 13-20 > 20 25 0 2 4 10 2 (11) 26 27 Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 28 0 2 4 10 0 (6) 29 30 Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 31 . and and and or 32 . Excl SD >0.9 >0.85 >0.80 <=0.80 33 0 5 10 20 5 (1.15) 34 35 Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 36 0 1 3 5 1 (-0.27) 37 38 Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 39 0 1 3 5 0 (-0.11) 40 41 Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 42 0 1 3 5 1 (p=0.049) 43 44 OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 19 % 45 46 The overall score of this survey is 19 %, this is acceptable.

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

7.3. STANDARDIZATION TEST (Evaluation of Enumerators)

Weight:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [W1-W2] [Enum.(W1+W2)- (Superv.(W1+W2)]

Supervisor 14617.00 5/3 Enumerator 1 25.03 OK 14401.50 OK 0/4 5/4 Enumerator 2 0.16 OK 14641.30 OK 9/1 3/7 Enumerator 3 1.95 OK 14594.00 OK 4/5 5/5 Enumerator 4 0.24 OK 14403.20 OK 0/7 8/1 Enumerator 5 6889.34 OK 1406.62 OK 4/4 6/3 Enumerator 6 0.34 OK 14328.90 OK 3/6 7/2 Enumerator 7 14577.80 OK 33.29 OK 4/6 7/2 Enumerator 8 14577.70 OK 33.40 OK 6/3 8/2 Enumerator 9 45.57 OK 14562.10 OK 4/4 5/4 Enumerator 10 0.09 OK 14569.10 OK 1/0 6/3 Enumerator 11 0.13 OK 14616.60 OK 2/0 4/5 Enumerator 12 0.01 OK 14473.60 OK 1/0 5/4

Height:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [H1-H2] [Enum.(H1+H2)- Superv.(H1+H2)]

Supervisor 11.52 6/3 Enumerator 1 14189.40 POOR 14324.40 POOR 4/2 3/6 Enumerator 2 18.00 OK 40.92 POOR 0/2 6/4 Enumerator 3 3638.03 POOR 3587.41 POOR 3/6 1/8 Enumerator 4 0.23 OK 17.51 OK 0/8 7/2 Enumerator 5 26.81 POOR 49.09 POOR 3/6 6/4 Enumerator 6 26.81 POOR 49.09 POOR 6/3 6/4 Enumerator 7 0.00 OK 180.64 POOR 0/0 7/3 Enumerator 8 0.09 OK 4937.45 POOR 1/0 5/5 Enumerator 9 17.77 OK 23344.60 POOR 2/1 1/9 Enumerator 10 0.35 OK 14.07 OK 4/5 4/6 Enumerator 11 17.32 OK 149.56 POOR 4/4 4/5 5

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN

Enumerator 12 0.00 OK 3475.16 POOR 0/0 3/6

MUAC:

Precision: Accuracy: No. +/- No. +/- Sum of Square Sum of Square Precision Accuracy [MUAC1-MUAC2] [Enum.(MUAC1+MUAC2)- Superv.(MUAC1+MUAC2]

Supervisor 1.10 0/3 Enumerator 1 0.13 OK 3.05 OK 2/3 4/5 Enumerator 2 0.00 OK 23.54 POOR 0/0 6/4 Enumerator 3 0.60 OK 8.20 POOR 4/5 9/1 Enumerator 4 6.48 POOR 27.34 POOR 10/0 8/1 Enumerator 5 1.55 OK 3.65 POOR 2/7 5/5 Enumerator 6 1.66 OK 1.98 OK 5/4 5/5 Enumerator 7 0.00 OK 2.02 OK 0/0 3/2 Enumerator 8 1.50 OK 68.36 POOR 0/4 8/2 Enumerator 9 22502.70 POOR 22837.30 POOR 6/4 8/2 Enumerator 10 1.26 OK 13.02 POOR 4/1 8/1 Enumerator 11 0.11 OK 2.75 OK 2/1 6/2 Enumerator 12 0.26 OK 14.70 POOR 1/1 8/1

ACF SMART NUTRITION AND MORTALITY SURVEY IN HUDUR TOWN