Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Republic of Yemen
Ministry of Public Health and Population
Report on the Nutritional Status and Mortality Survey Mareb Governorate, Yemen
From 22 July to 6 August 2018
1 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Acknowledgement
The Ministry of Public Health and Population in Yemen, represented by the Public Health and Population Office in the Mareb governorate and in cooperation with the UNICEF country office in Yemen and the UNICEF branch in Sana’a, acknowledges the contribution of different stakeholders in this survey.
The UNICEF country office in Yemen provided technical support, using the SMART methodology, while the survey manager and his assistants from the Ministry of Public Health and Population and the Public Health and Population Offices in Taiz, Mahwit, Hudaydah, and Al Jawf were also relied on. The surveyors and team heads were provided by the Public Health and Population Office in the Mareb governorate. The data entry team was provided by the Public Health and Population Office in Mareb.
The final touches on the survey protocol were put in place by the Nutrition Department in the Ministry of Public Health and Population with technical support from UNICEF and the SMART Technical Committee. UNICEF provided technical assistance, especially with regards to daily quality checks, data analysis, and report writing.
The Public Health and Population Office in the Mareb governorate was informed of the organizational and logistical arrangements for the survey in order to ensure that the process went along smoothly. UNICEF provided funding to the nutrition survey within the scope of a grant from the United Nations Central Emergency Response Fund (UNICEF YCO), and this support is greatly appreciated. The contributions of the local authorities in ensuring the security of the survey teams during their field working, and in facilitating their work, is also appreciated.
It would not have been possible to get this data without the cooperation and support of the communities that were assessed, especially the mothers and caregivers who responded to the interviews. Their participation and cooperation are greatly appreciated. The Ministry of Public Health and Population and UNICEF express their thanks and appreciation to the survey team for their high level of commitment and effort during all of the stages of the assessment to ensure the high quality of the data that was collected and that this process is successful.
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Table of Contents Acknowledgement ...... 2 Table of Contents ...... 3 Index of Tables ...... 5 List of English Abbreviations and Their Definitions – Mareb Survey – July to August 2018 ...... 7 Introduction ...... 8 Survey Objectives ...... 10 SMART Methodology ...... 12 Sample Size ...... 12 Sample Frame Description ...... 14 Survey Community and Data Collection Procedures...... 15 Monitoring Measurements and Quality Control ...... 16 Data Entry and Analysis ...... 17 Results and Discussion ...... 21 Household Characteristics ...... 21 Household Income Status ...... 22 Water, Sanitation, and Hygiene ...... 23 Household Food Security ...... 25 Average Coping Strategies and Food Consumption ...... 25 Child Nutrition ...... 26 Severe Malnutrition – Wasting – WHZ Indicator ...... 26 Severe Malnutrition by Mid-Upper Arm Circumference (MUAC) ...... 28 Chronic Acute Malnutrition (Underweight) – WAZ Indicator ...... 29 Chronic Malnutrition (Stunting) – HAZ Indicator ...... 31 Standard Deviations of the Mean, the Effect of the Design, and Outliers (Extremes) ...... 33 Infant and Young Children Feeding (IYCF) ...... 34 Child Morbidity ...... 34 Vitamin A Supplements and Child Vaccination ...... 35 Nutrition of Women of Reproductive Age (15 to 49 years old) ...... 35 Mortality Rate ...... 36 Nutritional Status Factors ...... 37 Child Nutrition and Its Relationship to the Mother’s Nutrition ...... 41 Conclusions and Recommendations ...... 44 The Prevalence of Global, Moderate, and Severe Acute Malnutrition Used in the Calculation of Cases ...... 46 References ...... 47 Annexes ...... 48
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Annex 1: Malnutrition Survey Questionnaire – Mareb Governorate – July – August 2018 ...... 48 Annex 2: Nutrition Survey Team – Mareb Governorate – July – August 2018 ...... 73 Annex 3: Table to determine the ages of children using the Gregorian and Hijri calendars – Mareb Governorate – July 2018 ...... 74 Annex 4(A): Plausibility Check for the Mareb City Zone – July – August 2018 ...... 77 Annex 4(B): Plausibility Check for the Rural Mareb Zone – July – August 2018 ...... 79 Annex 5: Report on the Child Measurement Session to Evaluate the in the Mareb Survey – July – August 2018 ...... 81 Annex 6(A): The Clusters Chosen for The Nutrition and Mortality Survey – Mareb City – July – August 2018 ...... 85 Annex 6(B): The Clusters Chosen for The Nutrition and Mortality Survey – Rural Mareb – July – August 2018 ...... 87 Annex 7(A) – Weighted Levels of Malnutrition (Stunting) in Both the Mareb City and Rural Mareb Zones ...... 89 Annex 7(B) – Weighted Levels of Malnutrition (Underweight) in Both the Mareb City and Rural Mareb Zones ...... 91 Annex 7(C) – Weighted Levels of Acute Malnutrition (Wasting) by Weight for Height in Both the Mareb City and Rural Mareb Zones ...... 93 Annex 7(D) – Weighted Levels of Acute Malnutrition (MUAC) in Both the Mareb City and Rural Mareb Zones ...... 95 Annex 8 – Sample Removal Decision Tree – Mareb Survey – July - August 2018 ...... 97
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Index of Tables Table 1 - List of English Abbreviations and Their Definitions ...... 7 Table 2 – The Division of the Mareb Governorate into Two Parts (Mareb City and Rural Mareb) ...... 9 Table 3 - Sample of Children and Households in the First zone of the Survey Area (Mareb City) ...... 13 Table 4 – Population Sample Need to be Included in the First Zone of the Survey (Mareb City) ...... 13 Table 5 – Sample of Children and Households in the Second Part of the Survey Area (Rural Mareb) ..... 13 Table 6 - Population Sample Need to be Included in the Second Part of the Survey (Rural Mareb) ...... 14 Table 7 - Households, Children, and Women in both the Mareb City and Rural Mareb Zones of the Survey ...... 21 Table 8 - Basic Data on Heads of Household and the Marital Status and Education of the Household Caregivers in Both the Mareb City and Rural Mareb Zones ...... 22 Table 9 - The Effect of the Crisis on Household Income ...... 22 Table 10 – Median Monthly Spending of Households in YER Classified by Coping Strategies in Both the Mareb City and Rural Mareb Zones ...... 23 Table 11 - Water and Environmental Sanitation for Both the Mareb City and Rural Mareb Zones of the Survey ...... 23 Table 12 - Categorizing Food Consumption ...... 25 Table 13 - Averages for Coping Strategies ...... 25 Table 14 - Prevalence of Acute Malnutrition Based on Weight for Height (and/or Oedema) by Gender Among Children from 6 to 59 months old in Mareb City...... 26 Table 15 - Prevalence of Acute Malnutrition Based on Weight for Height (and/or Oedema) by Gender Among Children from 6 to 59 months old in Rural Mareb...... 26 Table 16 - Prevalence of Acute Malnutrition by Age Group, Based on the Weight for Height Indicator (and/or Oedema) Among Children between 6 and 59 Months Old in the Mareb City Zone ...... 28 Table 17 - Prevalence of Acute Malnutrition by Age Group, Based on the Weight for Height Indicator (and/or Oedema) Among Children between 6 and 59 Months Old in the Rural Mareb Zone ...... 28 Table 18 - Prevalence of Acute Malnutrition Based on MUAC Measurement (and/or Oedema) Based on Gender Among Children between 6 and 59 Months Old in the Mareb City Zone ...... 28 Table 19 - Prevalence of Acute Malnutrition Based on MUAC Measurement (and/or Oedema) Based on Gender Among Children between 6 and 59 Months Old in the Rural Mareb Zone ...... 29 Table 20 - Prevalence of Acute Malnutrition by Age Group Based on MUAC Measurement and/or Oedema Among Children between 6 and 59 Months Old in the Mareb City Zone ...... 29 Table 21 - Prevalence of Acute Malnutrition by Age Group Based on MUAC Measurement and/or Oedema Among Children between 6 and 59 Months Old in the Mareb City Zone ...... 29 Table 22 - The Spread of Underweight Based on Standard Deviation of Weight for Age and by Gender of Children from 0 to 59 Months of Age in the Mareb City Zone ...... 29 Table 23 - The Spread of Underweight Based on Standard Deviation of Weight for Age and by Gender of Children from 0 to 59 Months of Age in the Rural Mareb Zone ...... 30 Table 24 - Prevalence of Underweight by Age Group Based on the Standard Deviation in Weight for Age Among Children between 0 and 59 months Old in the Mareb City Zone ...... 31 Table 25 - Prevalence of Underweight by Age Group Based on the Standard Deviation in Weight for Age Among Children between 0 and 59 months Old in the Rural Mareb Zone ...... 31 Table 26 – Prevalence of Stunting Based on Standard Deviation of Height for Age by Gender Among Children Between 6 and 59 Months Old in the Mareb City Zone ...... 31 Table 27 – Prevalence of Stunting Based on Standard Deviation of Height for Age by Gender Among Children Between 6 and 59 Months Old in the Rural Mareb Zone ...... 31 Table 28 – Prevalence of Stunting by Age Based on Standard Deviation for the Height for Age Indicator Among Children from 6 to 59 Months Old in Mareb City Zone ...... 32 Table 29 – Prevalence of Stunting by Age Based on Standard Deviation for the Height for Age Indicator Among Children from 6 to 59 Months Old in Rural Mareb Zone ...... 33
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Table 30 – Standard Deviations from the Mean, and Design Effects in Mareb City ...... 33 Table 31 – Standard Deviations from the Mean, and Design Effects in Rural Mareb ...... 33 Table 32 – Infant and Young Child Feeding Indicators ...... 34 Table 33 – Morbidity of Children Under Five Years of Age Within the Two Weeks Before the Day of the Survey in Both zones of the Survey Area ...... 34 Table 34 – Vitamin A Supplements and Child Vaccination in Both the Mareb City and Rural Mareb Zones ...... 35 Table 35 – Acute Malnutrition Among Women in Reproductive Age in the Mareb City and Rural Mareb Zones ...... 35 Table 36 – Mortality Rates in the Al Jawf Governorate During the 144 Days Before the Survey ...... 36 Table 37 – Factors of Acute Malnutrition (Weight for Height) In Both zones of the Survey Area ...... 37 Table 38 – Factors of Acute Malnutrition (MUAC) ...... 38 Table 39 - Underweight Factors (Chronic Acute) for Both zones of the Survey ...... 39 Table 40 - Stunting Factors for Both zones of the Survey Area ...... 40 Table 41 - Summary of the Factors Associated with the Different Forms of Malnutrition with the Different Determinants Included in the Survey in Both zones ...... 41 Table 42 - Relationship Between Malnutrition in the Mother and Child in the Mareb City Zone ...... 42 Table 43 - Relationship Between Malnutrition in the Mother and Child in the Rural Mareb Zone ...... 42 Table 44 - Mixed Acute Malnutrition (Based on WHZ and MUAC) for Planning in Both zones (Mareb City and Rural Mareb) ...... 46
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List of English Abbreviations and Their Definitions – Mareb Survey – July to August 2018
Table 1 - List of English Abbreviations and Their Definitions Abbreviation Meaning BF Breastfeeding CDR Crude Death Rate CI Confidence Interval CSI Coping Strategy Index CSO Central Statistics Office DEFF Design Effect DF Degree of Freedom DHS International Health & Demographic Survey EFSNA Emergency Food Security and Nutrition Assessment ENA for Emergency Nutrition Assessment for Standardized SMART Monitoring & Assessment of Relief & Transitions FCS Food Consumption Score GAM Global Acute Malnutrition GHO General Health Office HAZ Height for Age Z-Score HDDS Household Dietary Diversity Score HH Household IYCF Infant and Young Children Feeding MAD Minimum Acceptable Diet MAM Moderate Acute Malnutrition MDD Minimum Dietary Diversity MMF Minimum Meal Frequency MoPHP Ministry of Public Health and Population MUAC Mid-Upper Arm Circumference SAM Severe Acute Malnutrition SD Standard Deviation U5MR Under Five Mortality Rate UNICEF United Nations Children's Emergency Fund WASH Water, Sanitation and Hygiene WAZ Weight for Age Z-Score WFP World Food Program WHZ Weight for Height Z-Score
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Introduction
The Mareb governorate is located around 173 km northeast of the capital, Sana’a (See Figure 1). The population of the governorate makes up 1.2% of the total population of the country, and it has 14 districts. The city of Mareb is the capital of the governorate. Agriculture is the main activity of the people of the governorate, and the governorate is in third place among the governorates in the country in agriculture (it produces 7.6% of the crops in the country), coming in after Hudaydah and Sana’a. The most important crops are fruits, grains, and vegetables. There are some minerals in the governorate, the most important are granite, scoria, rock salt, gypsum, marble, and zinc. The Mareb governorate was the first Yemeni governorate where oil was discovered, and it started production in 1986. Among the most important tourist landmarks are the Old Mareb Dam, the Temple of the Sun, and the Throne of Bilqis. The most important cities in the governorate are Sirwah and Harib.
Figure 1 - Map of the Republic of Yemen with the Mareb Governorate Highlighted
The Mareb governorate is bordered by Al Jawf to the north, Shabwa and Al Baydha to the south, Hadramawt and Shabwa to the east, and Sana’a to the west (see Figure 2).
The governorate has an area of around 17,405 km2 and is divided into 14 districts. The Mareb district is the largest district in the governorate.
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Figure 2 - Map of the Mareb Governorate
No SMART survey has been conducted in the governorate before. The Results of the Comprehensive Food Security Survey (CFSS) in 2014 showed that the level of global acute malnutrition was 1.5%, while the most recent results from the Emergency Food Security and Nutrition Assessment (EFSNA) in November 2016 show that the level of global acute malnutrition is 8.1%, with severe acute malnutrition at 1% and acute malnutrition at 7.1%. It should be noted that the EFSNA in 2016 was only carried out in 4 districts, and this rate is expected due to the current situation.
The governorate was divided into two zones as a result of the population and living standards change in the Mareb governorate, especially in Mareb City. The city of Mareb was kept as a separate zone in the survey, including the IDPs, hosts, and residents. The second zone of the governorate is made up of the rest of the districts (rural Mareb), and the following table (Table 2) shows the division of the governorate into two parts, Mareb City and rural Mareb, as follows:
Table 2 – The Division of the Mareb Governorate into Two Parts (Mareb City and Rural Mareb)
Total Population (Residents and IDPs) District # of Males # of Females Total
First Part (Mareb City) 11,240
Mareb City 26,332 26,332 52,664
IDPs 59,736
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Second Part (Rural Mareb) 289,292
Bidbadah 18,090 11,869 29,959
Harib Al Qaramish 5,935 5,392 11,327
Sirwah 14,099 12,683 26,782
Jabal Murad 7,535 6,690 14,225
Rahabah 5,439 4,949 10,388
Mahliyah 6,575 6,193 12,768
Al Abdiyah 9,465 8,551 18,016
Harib 24,411 22,310 46,721
Al Jubah 15,366 13,851 29,217
Mareb Al Wadi 29,023 26,006 55,029
Raghwan 3,378 2,541 5,919
Majzar 7,669 6,787 14,456
Medghal Al Jid’an 7,782 6,793 14,575
Source: Data taken from OCHA, including the IDP figures Survey Objectives
Assessing the current nutritional situation, total mortality, and mortality of children under 5 years old in the Mareb governorate and looking for the relationship between the nutritional situation with health indicators and health and nutritional practices.
The special objectives of the survey are as follows:
Estimating the prevalence rate of acute malnutrition (wasting) and chronic malnutrition (stunting) and underweight among children between 6 and 59 months of age in both zones, Mareb City and rural Mareb, in the Mareb governorate
Estimating the prevalence rate of exclusive breastfeeding between children from 0 to 6 months old, continuing breastfeeding until the age of 1 year and 2 years, and the practice of sound supplementary feeding among children from 6 to 23 months of age in both zones, Mareb City and rural Mareb, in the Mareb governorate
Targeting children between 0 and 6 months of age with weights in both zones, Mareb City and rural Mareb, in the Mareb governorate
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Estimating child morbidity by determining the prevalence rate of diarrhea, respiratory infections, and fever in both zones, Mareb City and rural Mareb, in the Mareb governorate
Estimating the coverage of vaccines for the third dose of the polio vaccine and the third dose of the pentavalent vaccine among children from 6 to 59 months of age, the coverage of vaccines for measles among children from 9 to 59 months of age, the coverage of supplementary Vitamin A during the 6 months before the survey among children from 6 to 59 months old in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Estimating the prevalence rate of severe acute malnutrition (wasting) among women of reproductive age (between 15 and 49 years old) in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Estimating the rate of food consumption in the 7 days before the survey in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Estimating the coping strategies index of the households in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Assessing the households’ use of a number of intensive coping strategies, during the emergency crisis, in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Estimating the percentage of heads of households that have lost their means of incomes as a result of the crisis and the current conflict in Yemen.
Estimating the average monthly expenditures of households in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Assessing the educational level of household caregivers in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Assessing the main source of drinking water for households and assessing the quality of the water source and the cleanliness of water storage areas in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Assessing the types of household latrines and classifying the quality of the sewage facilities used in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Assessing the practices of household caregivers in washing hands with water and soap (or soap alternatives) after defecating and before eating in both zones, Mareb City and rural Mareb, in the Mareb governorate.
Estimating the total mortality rates and the mortality rate of children under five years old in both zones, Mareb City and rural Mareb, in the Mareb governorate since the night of 15 Sha’ban 1439 Hijri, or 1 May 2018.
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SMART Methodology
As a result of there being noticeable changes in Mareb City in the past few years, in people’s lives and living conditions, the Mareb governorate was divided into two zones for the survey. The first zone is Mareb City, and it includes the Mareb City district, while the second zone is rural Mareb and includes the remaining 13 districts in the governorate. The data was collected between July 22nd and August 2nd in the Rural Mareb Zone, or for 7 work days, and between July 29th and August 6th, 2018, in the Mareb City Zone, or for 8 work days. 427 households were visited in the Mareb City Zone, where there were no households that were absent and two households refused, while 424 households were visited in the Rural Mareb Zone, where there were no households that were absent, and two households also refused. In the Rural Mareb Zone, 6 villages in the Al Abidah district were removed because of the difficulty getting to them, in addition to the areas that were removed from the sample as a result of the conflict. The villages that were removed for the conflict included 27 villages in the Sirwah district, 11 villages in the Mahliyah district, 4 villages in the Medghal district, and two villages in the Majzar district. As for the Mareb City Zone, 4 villages were removed (Al Khasf, Al Hadi, Al Rumailah, and Al Faw), and they were included in the pretest.
Figure 3 – Map of the Mareb Governorate with both the Mareb City and Rural Mareb Zones
Sample Size
The following assumptions (based on a particular context) were used to calculate the size of the sample in number of children. After that, it was changed to number of households in the survey. All calculations were carried out by the ENA software for SMART (version released July 9th, 2015) as is shown in tables 3, 4, 5, and 6.
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Table 3 - Sample of Children and Households in the First zone of the Survey Area (Mareb City) Determinants of Anthropometric Context-Based Assumptions (References Value Measurements Used) Based on the Emergency Food Security and Expected spread of global acute malnutrition 8.1% Nutrition Assessment in 2016 According to SMART methodology Required accuracy 3% estimates According to SMART methodology Design effect 1.5 estimates Children required for survey 519 Average household size 8 Central Statistical Organization Estimates from the National Expanded Percentage of children under 5 years old 18% Program on Immunization Percentage of rejecting households According to SMART methodology 3% (unresponsive) estimates Households required for survey 413
Table 4 – Population Sample Need to be Included in the First Zone of the Survey (Mareb City) Context-Based Assumptions (References Mortality Determinants Value Used) Emergency Food Security and Nutrition Expected mortality rate (10,000 per day) 0.56 Assessment in November 2016 According to SMART methodology Accuracy required (10,000 per day) 0.3 estimates According to SMART methodology Design effect 1.5 estimates Recall period (in days) 93 Middle of Sha’baniyah Population included in the survey 4197 Average household size 8 Central Statistical Organization Percentage of refusing households According to SMART methodology 3% (unresponsive) estimates Households required for survey 529
Table 5 – Sample of Children and Households in the Second Part of the Survey Area (Rural Mareb) Determinants of Anthropometric Context-Based Assumptions (References Value Measurements Used) Based on the Emergency Food Security and Expected spread of global acute malnutrition 8.1% Nutrition Assessment in 2016 According to SMART methodology Required accuracy 3% estimates According to SMART methodology Design effect 1.5 estimates
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Children required for survey 519 Average household size 8 Central Statistical Organization Estimates from the National Expanded Percentage of children under 5 years old 18% Program on Immunization Percentage of rejecting households According to SMART methodology 3% (unresponsive) estimates Households required for survey 413
Table 6 - Population Sample Need to be Included in the Second Part of the Survey (Rural Mareb) Context-Based Assumptions (References Mortality Determinants Value Used) Emergency Food Security and Nutrition Expected mortality rate (10,000 per day) 0.56 Assessment in November 2016 According to SMART methodology Accuracy required (10,000 per day) 0.3 estimates According to SMART methodology Design effect 1.5 estimates Recall period (in days) 88 Middle of Sha’baniyah Population included in the survey 3903 Average household size 8 Central Statistical Organization Percentage of refusing households According to SMART methodology 3% (unresponsive) estimates Households required for survey 572
Note: The prevalence rate (8.1%) was taken from the results of the Emergency Food Security and Nutrition Assessment, as was the mortality rate (0.56) for both zones of the survey area.
The day of 15 Sha’ban 1439 Hijri, or 1 May 2018, was used as the recall day because it is a religious holiday that is important and easy to remember.
Looking at the calculations in the tables above, the size of the sample that was calculated for the anthropometric measurements for this survey was 413 households for both zones of the survey area for both the anthropometric measurements and the other indicators. Sample Frame Description
The most recent list of villages and blocks was used as the framework for the survey after the removal of the areas that are difficult to reach and the ones that have an ongoing conflict. These areas were determined by the Health Office in the Mareb governorate, the local council in the governorate, and the office of the Central Statistical Organization. The sampling frame was updated based on the presence of IDPs in the host communities before the clusters were chosen. A cluster in this survey is a village in the rural areas and a block in an urban area. In this survey, 30 clusters were chosen in each area based on the ENA software. There are 14 households chosen in each cluster.
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There are four field teams for the Mareb City Zone, and five field teams working in the Rural Mareb Zone. The survey was carried out over a period of around one week for each zone of the survey area. The training was carried out during the period from 14-19/07/2018. After that, the data is collected in the Mareb City Zone during the period from 29 July to 6 August 2018, while the data was collected in the rural zone of Mareb during the week from 22 July to 2 August 2018.
Sample Collection Procedures (Second Stage)
Division or Partition: The recommended scope is between 80 to 120 households for each village (blocks in the urban areas), and this is the maximum number of households for each village in order to ensure that the sample represents the targeted clusters.
The households were chosen at the group level after the decision tree mentioned in the Sampling Methods and Sample Size Calculation for the SMART Methodology, June 2012 (Appendix 8). The heads of the teams and the community leaders determined the targeted households and choose, using simple random samples, the households for all of the clusters that were studied. The operations room of the survey in Mareb would provide the survey teams with supplies, a list of the households, and random numbers on a daily basis. At the end of the day, these models would be submitted to the operations room, along with the forms that were filled out and the daily cluster report. Random walk sampling used for vaccination (EPI) was not used in this survey.
Rural Areas:
In areas where the number of households is 80 or less, a list was made with these households with the assistance of influential individuals in the village, then a random simple sample was implemented.
If there are mahallahs, the large independent mahallahs are divided, while small neighboring mahallahs are merged together, and they are approximated proportionally.
Urban Areas:
Each block that was chosen was divided into residential sub-blocks, and each one of the sub-blocks that were chosen randomly was the cluster.
The supervisors made the divisions for the urban areas before the teams went out to collect the data. This process included creating maps of the buildings in the sub-blocks, and the cumulative number of households was applied. Survey Community and Data Collection Procedures
The survey community is made up of the following:
1) Anthropometric measurements: Children from 6 months to 59 months old 2) Mortality rate: All individuals who lived in the household (currently live in the household or have left or were born or died) during the period starting on Sha’ban 15th, 1439 or May 1st, 2018. 3) Natural breastfeeding: Children from 0 to 24 months 4) Morbidity: Children from 0 to 59 months
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Estimating the age depends on details from the birth certificate or vaccination cards, and/or supported by the events list that includes events that happened in the governorate and well-known national events. (Annex 3: Table to Determine Children’s Age)
Five field teams were trained, as were four data enterers and the head of the operations room (Annex 2: Nutrition Survey Team in the Mareb governorate, August 2018). They were trained for 6 days by the survey manager and the survey field supervisors. The training included anthropometric measurements, filling out the questionnaires, and the following field procedures after strict normative training (Annex 5: Standardization Test Report for the Nutrition Survey in the Mareb governorate, July to August 2018) and the field test was implemented before beginning the data-collection stage began. The five teams that were trained were chosen to complete the data-collection process over the course of the work days of the survey.
The households that were chosen were given a brief introduction to the survey and called to participate. Their verbal agreement to participate was gotten from the participants after they got a general overview of the survey from the survey team. After their agreement was gotten, a single member of each family helped the survey team complete the questionnaire, which includes: 1) demographic characteristics, 2) gender of the head of household, 3) gender, education, and marital status of the members of the household, 4) information on household spending and income, 5) water and sanitation indicators, 6) food consumption of households and coping strategies, 7) social status, physiological status, and MUAC for women of reproductive age, 8) child vaccinations and vitamin A supplements, 9) anthropometric measurements for children, 10) infant morbidity, 11) natural breastfeeding practices, and 12) mortality of children under the age of 5 years. (Annex 1: Questionnaire for the Nutrition Survey in the Mareb governorate, July to August 2018)
The mortality data was collected retroactively from all of the randomly selected households, regardless of whether there were children between 6 and 59 months of age. The recall period was from Sha’ban 15th ,1439 Hijri (Sha’baniyah), or May 1st, 2018, meaning 95 days for the Mareb City survey zone and 88 days for the Rural Mareb Zone. Monitoring Measurements and Quality Control
The survey teams got practical and focused training before the survey, and this training covered all of the fields relating to the field work, including testing the measurements of the surveyors. Controlling the quality of the data was done through the following:
(1) Having the field work monitored by central and specialized supervisors (2) Conducting a review of the questionnaires that have been filled out with data, recording any comments on them, extracting the information, and discussing the results (3) Having the supervisors confirm cases of measles and acute malnutrition, especially cases of oedema and death (4) Entering the anthropometric data (body measurements) into the computer on a daily basis (5) Presenting the reasonableness check on a daily basis to determine the comprehensive quality and evaluate each team using 10 criteria for evaluation (statistical tests), in addition to ensuring that each team is given feedback on the type of data during the nightly meetings (6) Calibrating the scales and completing the daily review checklist before the teams go out into the field
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(7) Carrying out additional reviews and confirming the data to ensure that they are sound, reasonable, and consistent, and recording any comments in the field for review for the data enterers (8) Strengthening and building the capacity of team heads through participation and supervision of the method that the sample is taken by the central supervisors, and giving the surveyors feedback on information missing from the questionnaires after ensuring that they were completed correctly (9) Providing clear job descriptions with the tasks of the teams working out in the field during the training and before the data collection process starts in order to ensure that the teams carry out the functions that they are tasked with (10) Having the head of the field team carry out field reviews of the completed questionnaires and ensure that the data is complete, and then sign the forms before the team leaves the cluster, which will decrease the possibility of there being incomplete forms (missing variables) and the external data (cover). The total level of the reasonableness test was 5% in the Mareb City Zone and 2% in the Rural Mareb Zone (Annex 4: Report on the Reasonableness Check). Data Entry and Analysis
The data on the household forms (Form 1) and deaths (Form 2) were entered into a Microsoft Excel sheet that was made specifically for this survey. This sheet includes all of the required helping formulas and also converts the dates from Hijri to Gregorian.
The data entry process was confirmed through a random selection of 10% of the questionnaires (households), and the data that was entered was considered correct after they were checked and more than 95% of the selected records had accurate information.
The anthropometric measurements were copied to the ENA for SMART program to calculate the standard deviation, as well as to create a report on the final reasonableness check, the results of the nutritional and anthropometric condition, and the curves relating to acute malnutrition (wasting), chronic malnutrition (stunting), and acute chronic malnutrition (underweight), as well as MUAC. The mortality data was moved to the ENA program for analysis and to come up with the crude mortality indicators with the population pyramid.
The variables relating to household characteristics and the variables relating to children (vaccinations, vitamin A supplements, nutritional practices, and morbidity) were analyzed using EPI Info (commercial version) 3.5.4.
The indicators of anthropometric measurements (standard deviation) for weight for height (wasting), height for age (stunting), and weight for age (underweight) were analyzed and compared with the development criteria of the World Health Organization in 2006.
The children with extreme cases (extremes) from the standard deviation were reported and removed, as suitable, in the final analysis if the deviation from the mean was noticeable in the information from EPI Info.
Iterations and pivot tables were used to give percentage, averages, and standard deviations in the descriptive analysis and the presentation of the general characteristics of households and children. Statistical significance was defined as probability value being less than 0.05 (P < 0.05).
17 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
The nutritional status was described using the indicators mentioned above, as well as the mid-upper arm circumference indicator (MUAC), in accordance with the classification of the World Health Organization (World Health Organization 2006 and World Health Organization 2013). With regards to acute malnutrition, another calculation was carried out with the purpose of showing the Prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM), which combine the thresholds of the weight for height (WHZ) and MUAC while taking into account there being a bilateral oedema (legs and feet).
With regards to the infant and young child feeding indicators relating to natural breastfeeding and supplementary feeding, the guidelines of the World Health Organization were used to evaluate feeding practices of infants and young children (World Health Organization 2008).
The exclusive natural breastfeeding indicators for children under 6 months of age who only feed on their mother’s breastmilk, and continuing natural breastfeeding to one year old, were measured through natural breastfeed for children between 12 and 15 months old and up to 2 years for children between 20 and 23 months old.
In order to calculate the minimum dietary diversity (MDD), 7 food groups were used, and they are:
1) Grains, roots, and tubers 2) Legumes and nuts 3) Dairy products (milk, yogurt, etc.) 4) Meat (cow, goat, fish, chicken, and liver/kidneys) 5) Eggs 6) Vitamins – fruits and vegetables that are rich in Vitamin A 7) Other fruits and vegetables
The children’s meals must include at least four of these food groups to measure MDD.
Another indicator is also used, and it is minimum meal frequency (MMF), which measures the children’s consumption of solid, semi-sold, and soft (liquid) supplementary foods to measure the best practices of feeding breastfeeding children. The number recommended differs by age, and it is as follows:
It is two meals for children between 6 and 8 months of age who are breastfed
Three meals for children between 9 and 23 months of age who are breastfed
Four meals for children between 6 and 23 months of age who are not breastfed
The minimum acceptable diet indicator (MAD) is the sum of the minimum diet diversity indicator (MDD) and the minimum meal frequency indicator (MMF). The methods and analysis for the three indicators (MAD, MMF, and MDD) were based on the recommendations of the World Health Organization (2008).
The MUAC for women in reproductive age (15 to 49 years old) was not classified based on the international classification, but based on what is used by the World Food Program in Yemen (CFSS 2011 & CFSS 2014), as follows:
Women are considered to have extreme wasting if their MUAC is less than 21.3 cm.
18 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Women are considered to have moderate wasting if their MUAC is more than 21.3 cm and less than 22.2 cm.
Women are considered to be normal if their MUAC is not less than 22.2 cm.
With regards to the sources of the drinking water indicators, the sources that were included in the classification were classified as improved sources or sources that have not been improved. The water sources that are suitable for drinking (improved) are the following:
1) Water project that is linked to the home via water pipes 2) Artesian well 3) Protected well 4) Protected spring 5) Protected rain water collection
The sources of water that are not improved are:
1) Public faucet / communal water point / public water 2) Unprotected wells 3) Unprotected springs 4) Water filled from bottles (treated) 5) Surface water (table, runoff, irrigation channels, valleys, fountains, or others) 6) Unprotected rain water collection (water cisterns, ponds) 7) Water trucks or other water transportation vehicles 8) Any other sources that are not classified and were not mentioned above
Sanitation facilities were classified based on the types of latrines and whether they were improved or not improved.
Improved latrines are:
1) Latrines that drain into a sanitation system through pipes 2) Latrines that drain into a sewage tank 3) Latrines that drain into latrine pits 4) Latrine holes that are improved and ventilated 5) Latrine hole with boards 6) Composting latrines
Latrines that are not improved include:
1) Latrines that drain out into the open 2) Latrines that drain into unknown locations 3) Latrine holes without boards / not covered 4) Buckets 5) Hanging latrines 6) Defecating in the open (out in the fields, for example) 7) Any other sources that are not classified and were not mentioned above
19 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
The level of food consumption in the 7 days before the survey were calculated from the 8 food groups that are in accordance with the guidelines and manual of the World Food Program. The classification of the levels of food consumption were not in accordance with the global food classification of the World Food Program but were based on a special method for Yemen. This method is as follows:
- Less than 28: weak food consumption - From 28 to 42: minimal food consumption - More than 42: acceptable food consumption
The coping strategies indicator was used in accordance with the guidelines of the World Food Program, which is based on a list of 11 coping strategies. Another expanded list of coping strategies was used for this survey to determine the households that do not use any coping strategies.
Severe coping strategies:
Selling household assets / property (furniture, jewelry, clothes, etc.) Buying food on credit or by pawning property Spending savings Borrowing money
Coping strategies during the crisis:
Selling productive assets or means of transportation (sewing machine, car, motorcycle, etc.) Using grains that were stored for the coming season Taking children out of school Decreasing spending on education and healthcare (including medicine)
Emergency coping strategies:
Selling house or land Begging Selling the last of the furniture in the household
20 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Results and Discussion
Survey Sample:
The survey field teams targeted 427 households in the Mareb City Zone and 424 households in the Rural Mareb Zone, for a total of 851 households in both zones, as is clarified in Table 7. There were less than 1% absences and refusals in both the Mareb City and Rural Mareb Zones. Data was collected from a total of 425 households, including 565 children under five years of age and 813 women in reproductive age in the Mareb City Zone, and from a total of 424 households, including 634 children under five years of age and 978 women in reproductive age in the Mareb rural Zone.
Table 7 - Households, Children, and Women in both the Mareb City and Rural Mareb Zones of the Survey Mareb City Resulting Survey Sample Rural Mareb Zone Zone Households visited 427 424 Households absent 0 (0.00%) 0 (0.00%) Households that refused 2 (0.5%) 2 (0.5%) Displaced households by themselves 118 (27.6%) 12 (2.8%) Displaced households with host households (residents) 6 (1.4%) 3 (0.7%) Households with complete questionnaires 425 (99.5%) 422 (995%) Households with children under 5 years of age 300 (70.3%) 304 (71.7%) Households with children under 6 months of age 69 (16.2%) 76 (17.9%) Households with a woman in reproductive age (15 to 49 years old) 418 (97.9%) 303 (71.5%) Number of children under 5 years old 565 634 Number of children under 6 months old 79 86 Number of children from 6 to 59 months old 486 548 Number of women in reproductive age (15 to 49 years old) 813 978 Average size of household 7.9 9.2
The number of households who were visited was about 3% more than the number of households that were planned in the anthropometric and nutrition indicators in both the Mareb City and Rural Mareb Zones of the survey, which is clarified in Table 7 above.
Household Characteristics
Definitions
A household is an individual or group of individuals who reside in a single house, apartment, residence, tent, etc. They share household characteristics, eat together, and it is not required that they have a separate kitchen for them. The head of the household is the male or female adult who is responsible for managing the affairs of the household. The household caregiver is the male or female adult who is responsible for taking care of the children in the household.
Background on the Indicators
The survey found, in Table 8, that that 98% of the households that were surveyed had male heads of households in the Mareb City Zone, while 97% had male heads of households in the Rural Mareb Zone. The survey found that the gender of the family caregiver was female in 99% of the households in the Mareb
21 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
City Zone, and 97.4% female in the Rural Mareb Zone. Around 94% of the household caregivers are married in the Mareb City Zone, while 85% of the caregivers are married in the Rural Mareb Zone.
The survey found that illiteracy is high among the household caregivers in both zones of the survey, with 45% in the Mareb City Zone and 69% in the Rural Mareb Zone of the household caregivers were illiterate, and they represent the vast majority of women, while the percentage of women who had a primary school education was between 5 and 10% in both zones, as detailed in Table 8.
Table 8 - Basic Data on Heads of Household and the Marital Status and Education of the Household Caregivers in Both the Mareb City and Rural Mareb Zones Mareb City Zone Rural Mareb Zone Background Indicators % (95% confidence % (95% confidence n n interval) interval) Gender of Head of Household Male 418 98 (97 – 99) 410 97.2 (95.1 – 98.4) Female 7 2 (1 – 3) 12 2.8 (1.6 – 4.9) Gender of Household Caregiver Male 422 99 (98 – 100) 411 97.4 (95.4 – 98.5) Female 3 1 (0 – 2) 11 2.6 (1.5 – 4.6) Marital Status of the Household
Caregiver Married 397 93.6 (90.9 – 95.6) 357 84.8 (81.1 – 87.9) Widowed 23 5.4 (3.6 – 8) 57 13.5 (10.6 – 17.1) Divorced 2 0.5 (0.1 – 1.7) 6 1.4 (0.7 – 3.1) Single 2 0.5 (0.1 – 1.7) 1 0.2 (0 – 1.3) Education of Household
Caregiver Illiterate 191 44.9 (40.3 – 49.7) 290 68.7 (64.1 – 73) Literate 103 24.2 (20.4 – 28.5) 70 16.6 (13.3 – 20.4) Primary School Education 43 10.1 (7.6 – 13.4) 22 5.2 (3.5 – 7.8) Secondary School Education 59 13.9 (10.9 – 17.5) 31 7.3 (5.2 – 10.2) Higher Education (University, 29 6.8 (4.8 – 9.6) 9 2.1 (1.1 – 4) College, or Institute)
Household Income Status
Looking at Table 9, you can see that around 50 to 55% of the households in both the Mareb City and Rural Mareb Zones of the survey did not have their normal income or salary affected, while around 45% of the households in the same two zones lost their sources of income, whether partially or totally, during the current crisis (since March 2015). These levels are low compared to the affect and loss of income in the Al Jawf governorate in April 2018, which was around 85%.
Table 9 - The Effect of the Crisis on Household Income Mareb City Zone Rural Mareb Zone Income Status Indicator % (95% confidence % (95% confidence n n interval) interval) Household Income Affected The normal income or salary was not 190 55 (50.2 – 59.6) 223 52.8 (48.1 – 57.6) affected (No) The income or salary was partially 233 44.8 (40.1 – 49.6) 193 45.8 (41 – 50.5) affected (Yes) The respondents do not know 1 0.2 (0.0 – 1.3) 6 1.4 (0.7 – 3.1)
22 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Monthly Spending
The median monthly spending, as is shown in Table 10, is only 49,000 YER in the Mareb City Zone, compared to 58,000 YER in the Rural Mareb Zone. Both of these medians in monthly spending in both zones of the Mareb governorate are higher than the median monthly spending in Al Jawf (from April 2018), which was 31,000 YER. The lowest median monthly spending relying on coping strategies was found among households that have emergency coping strategies in both zones, the Mareb City Zone and the Rural Mareb Zone.
Table 10 – Median Monthly Spending of Households in YER Classified by Coping Strategies in Both the Mareb City and Rural Mareb Zones Mareb City Zone Rural Mareb Zone Median Spending Median (± Standard Median Spending Median (± Standard Deviation) Deviation) Monthly spending in Monthly spending in a year in YER (n = 425) a year in YER (n = 49000 (56864) 58000 (55168) for the Mareb City Zone 418) for the Rural Mareb Zone Average monthly spending of Average monthly spending of households households based on based on dependence on coping strategies (in dependence on 30 days) coping strategies (in 30 days) No coping strategies No coping strategies (n = 210) 47500 (66575) 65000 (63875) (n = 215) Severe coping Severe coping strategies (n = 138) 50000 (47193) 56000 (41540) strategies (n = 128) Coping strategies Coping strategies during the crisis (n = 71) 51000 (39420) during the crisis (n = 56000 (49282) 52) Emergency coping Emergency coping strategies (n = 6) 37500 (72353) 50000 (30730) strategies (n = 23)
Water, Sanitation, and Hygiene
Table 11 shows that around half of the households in the Mareb City Zone depend on bottled water (Kawthar water), with around 47% of the households having this as their main source of water, followed by water trucks or water transportation vehicles with around 25% of the households, and artesian wells with around 16% of the households. This means that 79% of the sources of drinking water are not improved, and only 14% of the households treat their drinking water. Around 92% of the households store their drinking water in clean storage containers.
Table 11 - Water and Environmental Sanitation for Both the Mareb City and Rural Mareb Zones of the Survey Mareb City Zone Rural Mareb Zone Water and Environmental Sanitation % (95% confidence % (95% confidence Indicators n n interval) interval) Main Source of Drinking Water: Water project that brings water to the 10 2.4 (1.3 – 4.3) 53 12.6 (9.73 – 16.06) house (public or private) Public faucet, communal water point, or 5 1.2 (0.5 – 2.7) 11 2.6 (1.46 – 4.61) public water
23 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Artesian well 66 15.5 (12.4 – 19.3) 38 9 (6.63 – 12.12) Covered well 16 3.8 (2.3 – 6) 52 12.3 (9.52 – 15.8) Unprotected well 26 6.1 (4.2 – 8.8) 139 32.9 (28.63 - 37.56) Bottled water (mineral or Kawthar) 197 46.4 (41.7 - 51.1) 19 4.5 (2.9 - 6.92) Water trucks 105 24.7 (20.8 - 29.0) 108 26 (21.66 - 29.96) Unprotected rain water collection (valley 0 0 (0 - 0) 2 0.5 (0.13 - 1.71) or pond) Classification of Household Sources of
Drinking Water Improved 92 21.6 (18 - 25.8) 143 33.9 (29.53 - 38.53) Unimproved 333 78.4 (74.2 - 82) 279 66.1 (61.47 - 70.47) Treating the water before drinking it 31 13.7 (9.5 - 18.9) 38 9.5 (7 - 12.77) Cleanliness of the container used to store 389 91.7 (88.7 - 94) 359 85.27 (81.57 - 88.34) the water Sanitation Facilities (Defecation) Latrine – to public sewage 13 3.1 (1.8 - 5.2) 5 1.19 (0.51 - 2.75) Latrine – to a [septic tank] 340 80 (75.9 - 83.5) 265 62.95 (58.23 - 67.42) Latrine – to a latrine pit 16 3.8 (2.3 - 6) 5 1.19 (0.51 - 2.75) Latrine – out into the open 7 1.6 (0.8 - 3.4) 67 15.9 (12.73 - 19.71) Latrine – drains to an unknown location 1 0.2 (0 - 1.3) 1 0.24 (0.04 - 1.33) Ventilated and improved latrine hole 16 3.8 (2.3 - 6) 7 1.66 (0.81 - 3.39) Latrine hole with boards 20 4.7 (3.1 - 7.2) 10 2.38 (1.3 -4.32) Latrine whole without boards / uncovered 8 1.9 (1 - 3.7) 7 1.66 (0.81 - 3.39) Open defecation (out in the fields, for 4 0.9 (0.4 - 2.4) 54 12.83 (9.97 - 16.36) example) Type of Sanitation Improved 405 95.3 (92.8 - 96.9) 292 69.4 (64.8 - 73.57) Unimproved 20 4.7 (3.1 - 7.2) 129 30.6 (26.43 - 35.2) Caregiver Handwashing Practices After using the bathroom (n = 425) 140 9.32 (28.6 - 37.5) 122 29.26 (25.1 - 33.8) Before eating (n = 425) 204 48.0 (43.3 - 52.7) 193 45.84 (41.14 - 50.62)
On the other hand, Table 11 found, in the Rural Mareb Zone, that around a third of the households depend on uncovered wells for their water source, with 33% having it as their main source of drinking water, followed by water trucks with 26%, water sources that are connected to the house (public or private) and covered wells at similar percentages of around 12.5%, and artesian wells at 9%. A third of the households rely on improved sources of drinking water and two-thirds rely on unimproved sources of drinking water, while only around 10% of the households treat their drinking water. Around 85% of the households store their drinking water in clean containers.
Going back to the same table, Table 11, the survey found that the largest group in the Mareb City Zone use latrines into a septic tank, with 80% of the households using this method. As for defecation in the open, it was only used by 1.6% of the households, meaning that improved sanitation made up 95%. The survey also found that around half of the household caregivers wash their hands before eating, at 48%, while around a third of them stated that they wash their hands after using the bathroom at 33%.
In the Rural Mareb Zone, the highest percentage of households also use latrines that drain into septic tanks, but at around 63%. As for latrines that drain out into the open, 16% of the households used them, followed by open defecation with 13% of the households. This means that improved sanitation was used by 70% of the households, and it was found that around half of the caregivers washed their hands before eating (46%), while around a third of them said that they washed their hands after using the bathroom (30%).
24 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Household Food Security
Food consumption was calculated based on the consumption during the 7 days before the day of the survey for the eight food groups, and they were categorized using the thresholds of the World Food Program (Yemen). As show in Table 12 below, 80% in the Mareb City Zone and 76% in the Rural Mareb Zone had acceptable food security, while 16% in both zones were suffering from a lack of food security. We found that severe lack of food security was between 5 to 9% in both zones of the governorate.
Table 12 - Categorizing Food Consumption Mareb City Zone Rural Mareb Zone
Food Consumption Score Indicator % (95% confidence % (95% confidence n n interval) interval)
(Classification of the World Food Program in Yemen) Acceptable food consumption 334 79.7 (75.6 - 83.3) 313 75.6 (71.24 - 79.49) Minimum food consumption 66 15.8 (12.6 - 19.5) 64 15.46 (12.3 - 19.26) Weak food consumption 19 4.5 (2.9 - 7) 37 8.94 (6.55 - 12.08)
Average Coping Strategies and Food Consumption
Coping strategies were measured using the Coping Strategy Index (CSI), and the average CSI during the 7 days before the survey that the families resorted to was 2.55% in the Mareb City Zone and 1.97% in the Rural Mareb Zone. The highest average of coping strategies was among those that had practiced emergency coping strategies during the crisis, where the average was 39.16 in the Mareb City Zone, followed by those that used coping strategies during the crisis with an average of 5.50. The highest average in the Rural Mareb Zone was among those that use coping strategies during the crisis, where the average was 6.21, followed by those using emergency coping strategies, with an average of 4.22. This is all shown in Table 13.
Table 13 - Averages for Coping Strategies Mareb City Zone Rural Mareb Zone Coping Strategies Index (CSI) Average (± standard Average (± standard deviation) deviation) Coping strategies during the previous 7 days 2.55 (8.11) 1.97 (6.54) Average of groups of coping strategies during the previous 7 days Non-coping strategy 0.05 (0.46) 0.42 (4.94) Severe coping strategies 3.23 (6.52) 2.45 (5.05) Coping strategies during the crisis 5.50 (10.84) 6.21 (10.99) Emergency coping strategies 39.16 (27.02) 4.22 (8.31) Average food consumption (based on the classification of the World Food Program in Yemen) Acceptable food consumption 67.70 (15.88) 66.43 (16.91) Minimum food consumption 36.09 (4.30) 35.44 (4.04) Weak food consumption 23.68 (3.50) 22.54 (4.20)
Table 13 above also shows that the highest average food consumption is acceptable food consumption, which had an average of between 66 and 68% in both the Mareb City and Rural Mareb Zones, while the lack of food security was the lowest average rate, where it was around 23% in both the Mareb City and Rural Mareb Zones.
25 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Child Nutrition
Severe Malnutrition – Wasting – WHZ Indicator
The prevalence of global acute malnutrition (wasting), based on the weight for height indicator, was 10% in both of the zones (Mareb City and rural Mareb). It was 12% among the boys, higher than the 8% among girls, in both zones. The severe acute malnutrition was 1% in both zones, and there were no cases of oedema in the Mareb City area, while there was a single case of oedema in the rural Mareb area (Table 14 and Table 15).
Table 14 - Prevalence of Acute Malnutrition Based on Weight for Height (and/or Oedema) by Gender Among Children from 6 to 59 months old in Mareb City Boys Girls Total Acute Malnutrition n = 248 n = 237 n = 485
(30) 12.1 % (19) 8.0 % (49) 10.1 % The prevalence rate of severe acute malnutrition (SAM) (8.8 - 16.4 95% (5.4 - 11.8 95% (7.8 - 13.0 95% C.I.) C.I.) C.I.)
(26) 10.5 % (18) 7.6 % (44) 9.1 % The prevalence rate of moderate acute malnutrition (MAM) (7.5 - 14.4 95% (5.0 - 11.3 95% (6.9 - 11.8 95% C.I.) C.I.) C.I.)
(4) 1.6 % (1) 0.4 % (5) 1.0 % The prevalence rate of severe acute malnutrition (SAM) (0.6 - 4.0 95% C.I.) (0.1 - 3.0 95% C.I.) (0.5 - 2.3 95% C.I.)
The Prevalence of oedema = 0.0%
Table 15 - Prevalence of Acute Malnutrition Based on Weight for Height (and/or Oedema) by Gender Among Children from 6 to 59 months old in Rural Mareb Boys Girls Total Acute Malnutrition n = 248 n = 237 n = 485
(34) 12.3 % (20) 7.6 % (54) 10.0 % The prevalence rate of severe acute malnutrition (SAM) (8.6 - 17.2 95% (4.7 - 12.1 95% (7.4 - 13.3 95% C.I.) C.I.) C.I.)
(31) 11.2 % (17) 6.5 % (48) 8.9 % The prevalence rate of moderate acute malnutrition (MAM) (7.6 - 16.2 95% (4.0 - 10.2 95% (6.8 - 11.5 95% C.I.) C.I.) C.I.)
26 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
(3) 1.1 % (3) 1.1 % (6) 1.1 % The prevalence rate of severe acute malnutrition (SAM) (0.3 - 3.5 95% C.I.) (0.4 - 3.5 95% C.I.) (0.4 - 2.8 95% C.I.)
The Prevalence of oedema = 0.2%
Figure 4 shows the slope of the curve resulting from the natural slope to the left, which is smooth, compared to the reference curve in both zones. This shows that acute malnutrition is higher than the categorization of the World Health Organization by a standard deviation within 0.8 to 1.2 in the two parts.
Figure 4 – Distribution of Acute Malnutrition Based on the Weight for Height Indicator for Children Between 6 and 59 Months Compared to the Reference Curve for the Two Parts
These results can be compared to the results of nutrition surveys that used other methodologies, showing that this rate is higher than the global acute malnutrition rate for the Comprehensive Food Security Survey in 2014 and the Emergency Food Security and Nutrition Assessment (EFSNA) in December 2016, where the rates were 1.5% and 8.1% respectively, and severe acute malnutrition was 1% and acute malnutrition 7.1%. It should be noted that the EFSNA in 2016 was only conducted in four districts. Based on the classification of the World Health Organization, the current levels are considered ‘critical’. If we look closely at the results, they are on the edge of the scope from 10 to 14%, meaning that the situation might turn into ‘dangerous’.
The prevalence rate of global acute malnutrition (wasting) using the WHZ indicator among children younger than two years old (6 to 23 months old) is high compared to children between 24 and 59 months old in the Mareb City Zone, while the opposite was true in the Rural Mareb Zone. There, the prevalence rate between children under two years of age (6 to 23 months) was less than the rate for those between 24 and 59 months old. All of the differences between the prevalence rates based on age groups in both zones of the survey area did not have statistical significance, as is show in Tables 16 and 17.
27 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Table 16 - Prevalence of Acute Malnutrition by Age Group, Based on the Weight for Height Indicator (and/or Oedema) Among Children between 6 and 59 Months Old in the Mareb City Zone Severe Wasting (SAM) Moderate Wasting (MAM) Global Wasting (GAM) Age Group Total Number n % n % n %
6 to 23 months 185 4 2.16 20 10.81 24 12.97
24 to 59 months 300 1 0.33 24 8 25 8.33
Total 485 5 1.03 44 9.07 49 10.1
Chi-squared test X2 =2.17 , df =1, P= 0.140 X2 =2.23 , df =1, P= 0.135
Table 17 - Prevalence of Acute Malnutrition by Age Group, Based on the Weight for Height Indicator (and/or Oedema) Among Children between 6 and 59 Months Old in the Rural Mareb Zone Severe Wasting (SAM) Moderate Wasting (MAM) Global Wasting (GAM) Age Group Total Number n % n % n %
6 to 23 months 184 3 1.63 14 7.61 17 9.24
24 to 59 months 356 3 0.84 34 9.55 37 10.39
Total 540 6 1.11 48 8.89 54 10
Chi-squared test X2 =1.56 , df =1, P= 0693 X2 =0.07 , df =1, P= 0.785
Severe Malnutrition by Mid-Upper Arm Circumference (MUAC)
Looking at Tables 18 and 19, we find that the prevalence of global acute malnutrition (wasting) has reached, based on the mid-upper arm circumference measurement (MUAC) being less than 12.5 cm, 4 to 4.5% in both the Mareb City and the Rural Mareb Zones. The prevalence of severe acute malnutrition based on the MUAC measurement being less than 11.5 cm is 0.8 – 1.1% for both zones. The prevalence rate of global malnutrition among girls = 4.5 – 5.5% more than it is among the boys in the two parts, and the prevalence rate of SAM is higher among girls than it is among boys in the two parts.
Table 18 - Prevalence of Acute Malnutrition Based on MUAC Measurement (and/or Oedema) Based on Gender Among Children between 6 and 59 Months Old in the Mareb City Zone Boys Girls Total Acute Malnutrition (MUAC) n = 248 n = 237 n = 485 (9) 3.6 % (13) 5.5 % (22) 4.5 % The prevalence rate of global acute malnutrition (GAM) (2.8 - 10.4 95% (1.8 - 7.1 95% C.I.) (2.8 - 7.3 95% C.I.) C.I.) (8) 3.2 % (10) 4.2 % (18) 3.7 % The prevalence rate of moderate acute malnutrition (MAM) (1.6 - 6.3 95% C.I.) (2.1 - 8.4 95% C.I.) (2.3 - 6.0 95% C.I.) (1) 0.4 % (3) 1.3 % (4) 0.8 % The prevalence rate of severe acute malnutrition (SAM) (0.1 - 3.0 95% C.I.) (0.4 - 3.7 95% C.I.) (0.3 - 2.1 95% C.I.)
28 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Table 19 - Prevalence of Acute Malnutrition Based on MUAC Measurement (and/or Oedema) Based on Gender Among Children between 6 and 59 Months Old in the Rural Mareb Zone Boys Girls Total Acute Malnutrition (MUAC) n = 278 n = 264 n = 542 (10) 3.6 % (12) 4.5 % (22) 4.1 % The prevalence rate of global acute malnutrition (GAM) (1.2 - 10.3 95% (2.7 - 7.6 95% C.I.) (2.1 - 7.6 95% C.I.) C.I.) (8) 2.9 % (8) 3.0 % (16) 3.0 % The prevalence rate of moderate acute malnutrition (MAM) (1.0 - 8.2 95% C.I.) (1.5 - 6.0 95% C.I.) (1.5 - 5.7 95% C.I.) (2) 0.7 % (4) 1.5 % (6) 1.1 % The prevalence rate of severe acute malnutrition (SAM) (0.2 - 2.8 95% C.I.) (0.6 - 3.7 95% C.I.) (0.5 - 2.6 95% C.I.)
As Tables 20 and 21 shows, the prevalence rate of global acute malnutrition (wasting) based on a MUAC measurement of less than 12.5 cm by age group was 4 – 5% in both zones, while the prevalence rate of severe acute malnutrition based on a MUAC measurement of less than 11.5 cm by age group was 0.8 – 1.1% in both zones. The prevalence rate of global and severe acute malnutrition was high among the 6 to 23-month age group in both zones of the survey area compared to the rates for the 24 to 59-month age group, and this difference is statistically significant with a significance of less than 0.05.
Table 20 - Prevalence of Acute Malnutrition by Age Group Based on MUAC Measurement and/or Oedema Among Children between 6 and 59 Months Old in the Mareb City Zone Severe Acute Malnutrition Moderate Acute Malnutrition Global acute Malnutrition Age Group Total Number n % n % n % 6 to 23 months 185 4 2.16 18 9.7 22 11.89 24 to 59 months 300 0 0 0 0 0 0 Total 485 4 0.82 18 9.7 22 4.54 Chi-squared test X2 =4.16 , df =1, P= 0.041 X2 =34.67, df =1, P= 0.000
Table 21 - Prevalence of Acute Malnutrition by Age Group Based on MUAC Measurement and/or Oedema Among Children between 6 and 59 Months Old in the Mareb City Zone Severe Acute Malnutrition Moderate Acute Malnutrition Global acute Malnutrition Age Group Total Number n % n % n % 6 to 23 months 185 6 3.24 8 4.32 14 7.57 24 to 59 months 357 0 0 8 2.24 8 2.24 Total 542 6 1.11 16 2.95 22 4.06 Chi-squared test X2 =8.93 , df =1, P= 0.002 X2 =7. 56 , df =1, P= 0.005
Chronic Acute Malnutrition (Underweight) – WAZ Indicator
Look at Tables 22 and 23, we find that the prevalence rate of global chronic acute malnutrition (underweight) using the weight for age indicator is 28.6% in the Mareb City Zone and 22% in the Rural Mareb Zone. The prevalence rate of severe global chronic acute malnutrition using the weight for age indicator is 6.4% in the Mareb City Zone and 4.3% in the Rural Mareb Zone. It was found that the global and severe underweight rates were more prevalent in girls than in boys in the Mareb City Zone, while it was more prevalent in boys than in girls in the Rural Mareb Zone.
Table 22 - The Spread of Underweight Based on Standard Deviation of Weight for Age and by Gender of Children from 0 to 59 Months of Age in the Mareb City Zone Severe Chronic Malnutrition Boys Girls Total (Underweight) n = 289 n = 271 n = 560
29 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
(80) 27.7 % (80) 29.5 % (160) 28.6 % Prevalence Rate of Underweight (21.4 - 34.9 95% C.I.) (24.1 - 35.6 95% C.I.) (23.7 - 34.0 95% C.I.) (65) 22.5 % (59) 21.8 % (124) 22.1 % Prevalence Rate of Moderate Underweight (17.9 - 27.9 95% C.I.) (17.3 - 27.0 95% C.I.) (18.6 - 26.2 95% C.I.) (15) 5.2 % (21) 7.7 % (36) 6.4 % Prevalence Rate of Severe Underweight (2.8 - 9.3 95% C.I.) (5.0 - 11.8 95% C.I.) (4.1 - 9.9 95% C.I.)
Table 23 - The Spread of Underweight Based on Standard Deviation of Weight for Age and by Gender of Children from 0 to 59 Months of Age in the Rural Mareb Zone Severe Chronic Malnutrition Boys Girls Total (Underweight) n = 326 n = 298 n = 624 (84) 25.8 % (53) 17.8 % (137) 22.0 % Prevalence Rate of Underweight (20.7 - 31.5 95% C.I.) (12.7 - 24.3 95% C.I.) (17.8 - 26.7 95% C.I.) (67) 20.6 % (43) 14.4 % (110) 17.6 % Prevalence Rate of Moderate Underweight (15.9 - 26.2 95% C.I.) (10.1 - 20.2 95% C.I.) (13.9 - 22.1 95% C.I.) (17) 5.2 % (10) 3.4 % (27) 4.3 % Prevalence Rate of Severe Underweight (3.2 - 8.5 95% C.I.) (1.8 - 6.2 95% C.I.) (2.9 - 6.3 95% C.I.)
Figure 5 below shows that the slope of the curve resulting from the natural curve is a smooth curve to the left, which is shown by the reference curve of both zones of the survey area. This shows that chronic acute malnutrition (underweight) is higher than the classification of the World Health Organization with a standard deviation within the scope of 0.8 to 1.2 in both zones.
Figure 5 - Distribution of Underweight Curve Based on Weight for Age Among Children Compared to the Reference Curve in Both zones of the Survey Area
It is clear that this rate is higher than the severe acute malnutrition (underweight) with regards to the Emergency Food Security and Nutrition Assessment in December 2016, which was 2.7%.
Tables 24 and 25 show that the prevalence rate of global chronic acute malnutrition among children between 24 and 59 months of age is higher than the children in the other age groups in both zones of the survey area, while severe underweight among children in the 0 – 5 age group was higher compared to children in other age groups in both zones of the survey area. The differences were only statistically significant in the Mareb City Zone.
30 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Table 24 - Prevalence of Underweight by Age Group Based on the Standard Deviation in Weight for Age Among Children between 0 and 59 months Old in the Mareb City Zone Severe Underweight Moderate Underweight Global Underweight Age Group Total Number n % n % n % 0- 5 77 10 12.99 4 5.19 14 18.18 23-Jun 184 14 7.61 38 20.65 52 28.26 59-24 299 12 5.53 82 27.42 94 31.44 Total 560 36 6.43 124 22.14 160 28.57
Chi-squared test X2 =4.099, df =1, P= 0.042 X2 =2.290 , df =1, P= 0.130
Table 25 - Prevalence of Underweight by Age Group Based on the Standard Deviation in Weight for Age Among Children between 0 and 59 months Old in the Rural Mareb Zone Severe Underweight Moderate Underweight Global Underweight Age Group Total Number n % n % n % 0- 5 82 6 7.32 10 12.2 16 19.51 23-Jun 184 8 4.35 26 14.13 34 18.48 59-24 358 13 3.63 74 20.67 87 24.3 Total 624 27 4.33 110 17.63 137 21.96 Chi-squared test X2 =0.627 , df =1, P= 0.42 X2 =1.56 , df =1, P= 0.211
Chronic Malnutrition (Stunting) – HAZ Indicator
Looking at Tables 26 and 27, we find that the prevalence rate of chronic malnutrition (stunting) based on the indicator of height for age is 34% in the Mareb City Zone and 29.3% in the Rural Mareb Zone. Both of these rates are around 30% but less than 40% and based on the classification of the World Health Organization, these rates are considered critical. The survey also found that global stature deficiency is higher among boys than it is among girls in both zones of the survey area, while extreme stunting is higher among girls than it is among boys only in the Mareb City Zone.
Table 26 – Prevalence of Stunting Based on Standard Deviation of Height for Age by Gender Among Children Between 6 and 59 Months Old in the Mareb City Zone Boys Girls Total Chronic Malnutrition (Stunting) n = 246 n = 233 n = 479 (86) 35.0 % (80) 34.3 % (166) 34.7 % Prevalence rate of stunting (26.5 - 44.5 95% (28.3 - 41.0 95% (28.7 - 41.1 95% C.I.) C.I.) C.I.) (65) 26.4 % (55) 23.6 % (120) 25.1 % Prevalence rate of moderate (19.7 - 34.5 95% (17.8 - 30.6 95% (20.3 - 30.5 95% stunting C.I.) C.I.) C.I.) (21) 8.5 % (25) 10.7 % (46) 9.6 % Prevalence rate of severe (5.0 - 14.3 95% C.I.) (7.3 - 15.5 95% C.I.) (6.6 - 13.9 95% C.I.)
Table 27 – Prevalence of Stunting Based on Standard Deviation of Height for Age by Gender Among Children Between 6 and 59 Months Old in the Rural Mareb Zone Boys Girls Total Chronic Malnutrition (Stunting) n = 277 n = 263 n = 540
31 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
(87) 31.4% (71) 27.0% (158) 29.3% Prevalence rate of stunting (24.7 - 39.0 95% (21.4 - 33.4 95% (24.3 - 34.8 95% C.I.) C.I.) C.I.) (64) 23.1% (58) 22.1% (122) 22.6% Prevalence rate of moderate (18.0 - 29.1 95% (16.9 - 28.2 95% (18.3 - 27.5 95% stunting C.I.) C.I.) C.I.) (23) 8.3% (13) 4.9% (36) 6.7% Prevalence rate of severe (5.2 - 12.9 95% C.I.) (3.0 - 8.1 95% C.I.) (4.6 - 9.5 95% C.I.)
The figure below (Figure 6) shows the slope of the curve resulting from the natural curve to the left compared to the reference curve for both zones of the survey area, and the figure shows that chronic malnutrition (stunting) is higher than the classification of the World Health Organization by a standard deviation within the scope of 0.8 to 1.2 in both zones of the survey area.
Figure 6 - Distribution Curve of Stunting Based on Height for Age Among Children Between 6 and 59 Months of Age Compared to the Reference Curve for Both zones of the Survey Area
It shows that the rate of chronic malnutrition (extreme stunting) for the Mareb City Zone is higher than the rate of extreme stunting from the EFSNA in December 2016, which was 7.5%.
Tables 28 and 29 show that the prevalence rate of global chronic malnutrition (stunting) among children in the 24 to 59-month age group is higher than the prevalence rate among children in the 6 to 23-month age group in both zones of the survey area, and the difference was not statistically significant. The prevalence rate of extreme stunting among children in the 24 to 59-month age group was higher than the prevalence rate among children in the 6 to 23-month age group in the Mareb City Zone, while the prevalence rate of extreme stunting in the 6 to 23-month age group was higher in the Rural Mareb Zone, and the differences were not statistically significant.
Table 28 – Prevalence of Stunting by Age Based on Standard Deviation for the Height for Age Indicator Among Children from 6 to 59 Months Old in Mareb City Zone Severe Stunting Moderate Stunting Global Stunting Age Group Total Number n % n % n % 6 to 23 180 15 8.33 41 22.78 56 31.11 24 to 59 299 31 10.37 79 26.42 110 36.79 Total 479 46 9.6 120 25.05 166 34.66
32 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Chi-squared test X2 =0.327 , df =1, P= 0.567 X2 =1.358 , df =1, P= 0.243
Table 29 – Prevalence of Stunting by Age Based on Standard Deviation for the Height for Age Indicator Among Children from 6 to 59 Months Old in Rural Mareb Zone Severe Stunting Moderate Stunting Global Stunting Age Group Total Number n % n % n % 6 to 23 184 15 8.15 35 19.02 50 27.17 24 to 59 356 21 5.9 87 24.44 108 30.34 Total 540 36 6.67 122 22.59 158 29.26
Chi-squared test X2 =0.66 , df =1, P= 0.416 X2 =0.4435 , df =1, P= 0.505
Standard Deviations of the Mean, the Effect of the Design, and Outliers (Extremes)
Tables 30 and 31 show that the average deviation of the z-score for the anthropometric measurements is higher than 1, except for the weight for height indicator, which was lower than 1 in both zones of the survey area. In general, there were standard deviations lower than 0.80 or higher than 2, and the design effect was 1.98 for the height for age indicator, followed by the weight for age indicator at 1.75, the weight for height indicator at 1 for the Mareb City Zone. With regards to the Rural Mareb Zone, the design effect was 1.75 for the height for age indicator, followed by the weight for age indicator at 1.72, then the weight for height indicator at 1.16.
Table 30 – Standard Deviations from the Mean, and Design Effects in Mareb City Mareb City Indicator Mean z-scores ± Design Effect (z-score < z-scores not z-scores out of N SD -2) available range Children from 6 to 59 months of age Weight for height 485 -0.80±0.92 1 1 0 (WHZ) Height for age (HAZ) 479 -1.60±1.07 1.98 1 6 Children from 0 to 59 months of age Weight for age (WAZ) 560 -1.46±0.97 1.75 1 4
* Contains for WHZ and WAZ the children with oedema
Table 31 – Standard Deviations from the Mean, and Design Effects in Rural Mareb Rural Mareb Indicator Mean z-scores ± Design Effect (z-score < z-scores not z-scores out of N SD -2) available range Children from 6 to 59 months of age Weight for height 540 -0.77±0.94 1.16 7 2 (WHZ) Height for age (HAZ) 540 -1.44±1.02 1.75 6 2 Children from 0 to 59 months of age Weight for age (WAZ) 624 -1.28±0.96 1.72 6 4
* Contains for WHZ and WAZ the children with oedema
33 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Infant and Young Children Feeding (IYCF)
The survey showed that both breastfeeding and bottle feeding during the night before the survey was carried out was 67 to 68% among children younger than two years in both the Mareb City and Rural Mareb Zones, while exclusive breastfeeding for children less than 6 months old was 8.9% in the Mareb City Zone and 22.1% in the Rural Mareb Zone. This indicator is higher than the national indicator in the Rural Mareb Zone.
Around 1 out of every 2 children continues to breastfeed until their first year in both zones of the survey area, while around 1 out of 4 children continue to breastfeed until their second year in both zones.
There are practices that were classified as being optimal practices for feeding infants and young children considering that the child has eaten the recommended number of meals based on the classification of the World Health Organization in solid or semi-solid foods for children between 6 and 23 months of age who are breastfed or artificially fed and get solid or semi-solid foods.
It also shows that the practices of feeding young children are lower in the Mareb City Zone than they are in the Rural Mareb Zone. Despite the fact that half of the children who are breastfeed and are between 6 and 23 months of age have gotten an appropriate number of meals in both of the survey areas, only 36% of the children in this age group in the Mareb City Zone get acceptable diverse diets (made up of four food groups or more). As for the Rural Mareb Zone, the percentage of children goes up to around 50%. As for the minimum acceptable diet, it is low and is only around 27 to 29% in both zones, as is clarified in Table 32.
Table 32 – Infant and Young Child Feeding Indicators Mareb City Zone Rural Mareb Zone Indicator n (95% CI) % n (95% CI) % Breastfed yesterday 177 67 (61 - 72.7) 188 68.1 (62.3 - 73.6) Exclusively natural breastfeeding 7 8.9 (3.6 - 17.4) 19 22.1 (13.9 - 32.3) Continuing natural breastfeeding for first year 24 61.5 (44.6 - 76.6) 29 59.2 (44.2 - 73) Continuing natural breastfeeding until 2 years old 10 28.6 (14.6 - 46.3) 9 25 (12.1 - 42.2) Minimum dietary diversity (MDD) 93 36.5 (43.1 - 58) 97 52.2 (44.7 - 59.5) Minimum meal frequency (MMF) 107 58.2 (50.7 - 65.4) 100 53.8 (46.3 - 61.1) Minimum acceptable diet (MAD) 54 29.3 (22.9 - 36.5) 50 27 (20.8 - 34)
Child Morbidity
Table 33 shows that the most prevalent illnesses among children under the age of five are diarrhea, acute respiratory infections, and fever, and this data is for the two weeks before the day of the interview. The prevalence rate of fever is the highest, between 40 and 43% for both zones of the survey area. This rate is lower than the rate of fever from the EFSNA in December 2016, which was 54.6%. With regards to diarrhea, the rate was relatively high in the Mareb City Zone compared to the Rural Mareb Zone.
We found that the prevalence of acute respiratory infections was around 25% in both zones of the survey area, which is around 2.5 times less than the rate in the EFSNA in December 2016, which was 60.2%.
Table 33 – Morbidity of Children Under Five Years of Age Within the Two Weeks Before the Day of the Survey in Both zones of the Survey Area Mareb City Zone Rural Mareb Zone Indicator N % (95% C.I.) N % (95% C.I.)
34 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Diarrhea 172 30.55 (26.89 - 34.48) 154 24.44 (21.25 - 27.95) Acute respiratory infections 146 25.89 (22.44 - 29.66) 158 25.08 (21.85 - 28.61) Fever 245 43.44 (39.41 - 47.56) 247 39.39 (35.64 - 43.27)
Vitamin A Supplements and Child Vaccination
The survey was implemented at the same time as the implementation of a comprehensive integrated communication activity that gave Vitamin A to children between 6 and 59 months of age. The survey showed that the coverage of both types of Vitamin A during the six months before the implementation of the survey was between 10 and 22% for both zones of the survey area, as is shown in Table 34, which is much lower than the Sphere Standards. The table also shows that the routine vaccinations against polio (third dose) is around 70% in the both zones of the survey area, while the total vaccination against measles for children between 9 and 59 months of age was between 67 and 70% in both zones of the survey area. There is still 1 child who has a vaccination card from the two groups and was vaccinated for measles.
Table 34 – Vitamin A Supplements and Child Vaccination in Both the Mareb City and Rural Mareb Zones Mareb City Zone Rural Mareb Zone Indicator N % (95% C.I.) N % (95% C.I.) Vitamin A supplements during the previous six months (for children 19.18 (15.92 - 21.59 (18.33 - 93 117 between 6 and 59 months) 22.92) 25.24) Routine vaccinations for polio (from vaccination card) for children who 31.96 (27.96 - 35.85 (31.93 - 155 195 are 3 months and older 36.24) 39.96) Routine vaccinations for polio (from recall) for children who are 3 41.44 (37.14 - 34.74 (30.86 - 201 189 months and older 45.88) 38.84) Routine vaccinations for polio (from the vaccination card and recall) for 73.4 (69.3 - 70.59 (66.63 - 356 384 children who are 3 months and older 77.14) 74.26) Vaccination against measles (from vaccination card) for children who 28.92 (24.93 - 31.99 (28.13 - 131 167 are 9 months and older 33.26) 36.11) Vaccination against measles (from recall) for children who are 9 months 41.06 (36.62 - 34.48 (30.53 - 186 180 and older 45.65) 38.66) Vaccination against measles (from vaccination card and recall) for 69.98 (65.6 - 66.48 (62.32 - 317 347 children who are 9 months and older 74.02) 70.39)
Nutrition of Women of Reproductive Age (15 to 49 years old)
Table 35 shows that the MUAC indicator for women of reproductive age (15 to 49 years old) based on the classification of the World Food Program for Yemen shows that less than half of the women suffer from acute malnutrition (wasting) in both zones of the survey area. This means that 1 out of every 5 women suffer from acute malnutrition and this is distributed among the pregnant and nursing women at 21% and 16.7% respectively in the Mareb City Zone and 19.6% and 18.6% respectively in the Rural Mareb Zone. Severe acute malnutrition was 0.2% - 0.6% in both zones, and it is distributed among pregnant and nursing women at the 1.15% and 0.5%, respectively, in both zones of the survey area.
Table 35 – Acute Malnutrition Among Women in Reproductive Age in the Mareb City and Rural Mareb Zones Mareb City Zone Rural Mareb Zone Global Acute Severe Acute Global Acute Severe Acute Indicator Malnutrition Malnutrition Malnutrition Malnutrition N (%) N (%) N (%) N (%) (95% C.I.) (95% C.I.) (95% C.I.) (95% C.I.)
35 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Women in reproductive age 82 (10.2) 5 (0.62) 103 (10.7) 2 (0.2) (15 – 49) in general (8.3 - 12.5) (0.3 - 1.5) (8.9 - 12.8) (0.1 - 0.8) 29 (16.7) 2 (1.15) 34 (18.6) 1 (0.5) Breastfeeding mothers (11.5 - 23.1) (0.14 - 4.09) (13.2 - 25) (0 - 3) 22 (21) 0 (0) 22 (19.6) 0 (0) Pregnant women (13.6 - 30) (0 - 3.5) (12.7 - 28.2) (0 - 3.2) Not pregnant nor 31 (5.9) 3 (0.57) 47 (7.1) 1 (0.2) breastfeeding (4.2 - 8.3) (0.2 - 1.7) (5.4 - 9.4) (0 - 0.9)
Mortality Rate
The results of the study, which are clarified in Table 36, showed that the total crude mortality rate is 0.12 in the Mareb City Zone and 0.13 in the Rural Mareb Zone for every 10,000 people per day during the recall period (95 days in the Mareb City Zone and 88 days in the Rural Mareb Zone), while the number of children who died while less 5 years old was 0.38 in the Mareb City Zone and 0.0 in the Rural Mareb Zone for every 10,000 people per day.
Table 36 – Mortality Rates in the Al Jawf Governorate During the 144 Days Before the Survey Mareb City Zone Rural Mareb Zone
Mortality Rate (95% CI) Design Effect Mortality Rate (95% CI) Design Effect Crude Mortality Rate 0.12 (0.04-0.41) 1.43 0.14 (0.05-0.40) 1.3 Gender Male 0.11 (0.01-0.89) 2.02 0.23 (0.09-0.62) 1 Female 0.12 (0.03-0.50) 1 0.05 (0.01-0.42) 1 Age Groups 0 to 4 (less than five years old) 0.38 (0.09-1.60) 1.01 0.00 (0.00-0.00) 1 5 to 11 years old 0.00 (0.00-0.00) 1 0.00 (0.00-0.00) 1 12 to 17 years old 0.00 (0.00-0.00) 1 0.18 (0.02-1.40) 1 18 to 49 years old 0.07 (0.01-0.55) 1 0.00 (0.00-0.00) 1 50 to 64 years old 0.06 (0.08-4.45) 1 0.00 (0.00-0.00) 1 65 to 120 years old 0.00 (0.00-0.00) 1 3.55 (1.37-8.93) 1
Figure 7 below shows the population pyramid and relative distribution of individuals based on the five age groups. The data shows that the base of the pyramid is wide for the age groups under 20 years old, and there is a comparative similarity and symmetry between the genders in both zones.
Figure 7 - Population Pyramid in for the Survey Population in Both zones of the Survey Area
36 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Nutritional Status Factors
Acute Malnutrition Factors (Wasting)
Table 37(A) shows that there is an association between acute malnutrition (wasting) among children and them having respiratory infections, as the statistical significance was 0.02, which is less than 0.05 (p > 0.05). On the other hand, there is no statistically significant association between acute malnutrition (wasting) among children and them having diarrhea or fever, despite the fact that the number of children who have wasting and have diarrhea and fever is high and was between 18 to 25. There is also no statistically significant association between washing hands among the caregivers of the children after using the bathroom or before eating.
Table 37 also shows that there is an association between acute malnutrition (wasting) among children and emergency coping mechanisms for food consumption used by the household, where the statistical significance was 0.045, which is smaller than 0.05 (p > 0.05).
Table 37 – Factors of Acute Malnutrition (Weight for Height) In Both zones of the Survey Area (A) In the Mareb City Zone Acute malnutrition (wasting) Indicator Statistical Test Function N % Mareb City Zone Respiratory Infection (n = 484) Yes (n = 128) 20 15.63 X2=0.85, df=1, P=0.025 No (n = 356) 29 8.15 Diarrhea (n = 483) Yes (n = 150) 18 12 X2=0.73, df=1, P=0.39 No (n = 333) 30 9.01 Fever (n = 484) Yes (n = 217) 25 11.52 X2=0.588, df=1, P=0.443 No (n = 267) 24 8.99 Washing hands after using the bathroom (n = 485) Yes (n = 152) 10 6.58 X2=2.488, df=1, P=0.114 No (n = 333) 39 11.71
37 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Washing hands before eating (n = 485) Yes (n = 216) 23 10.65 X2=0.04, df=1, P=0.83 No (n = 269) 26 9.86 Coping Strategies CSType (n = 485) Coping strategies during the crisis (n = 91) 8 8.79 Emergency coping strategies (n = 8) 3 37.5 X2=4.005, df=1, P=0.045 Severe coping strategies (n = 150) 16 10.67 There are no coping strategies (n = 236) 22 9.32 (B) Rural Mareb Zone Educational level of the household caregiver (n = 540) Literate (n = 74) 2 2.7 Primary school education (n = 27) 4 14.81 X2=4.177, df=1, P=0.040 Secondary school education (n = 35) 3 8.57 Higher education (n = 9) 1 11.11 Illiterate (n = 395) 44 11.14
As table 37(B) above shows, in the Rural Mareb Zone of the survey, there is an association between acute malnutrition (wasting) among children and the educational level of the household caregiver, with a statistical significance of 0.04, which is less than 0.05 (p > 0.05). Despite the fact that the number of households that are illiterate and their children have wasting is high (44), there is no statistical significance.
It can be seen from Table 38(A) below that there is an association between acute malnutrition (wasting) using the MUAC indicator among children and them having diarrhea, where the statistical significance was 0.002, which is less than 0.05 (p > 0.05). On the other hand, there is no statistically significant association between acute malnutrition (wasting) using the MUAC indicator among children and them having respiratory infections and fever. The table below also shows that there is a statistically significant association between child caregivers washing hands after using the bathroom and acute malnutrition (wasting) using the MUAC indicator among children. There is also a statistically significant association between acute malnutrition (wasting) among children and the emergency coping strategies for food consumption that are used by the households, where the statistical significance is 0.0001, which is less than 0.05 (p > 0.05).
Table 38 – Factors of Acute Malnutrition (MUAC) (A) In the Mareb City Zone Acute malnutrition (wasting) Indicator Statistical Test Function N % Mareb City Zone Respiratory Infection (n = 484) Yes (n = 128) 9 7.03 X2=1.76, df=1, P=0.185 No (n = 356) 13 3.65 Diarrhea (n = 483) Yes (n = 150) 13 8.67 X2=8.309, df=1, P=0.003 No (n = 333) 8 2.4 Fever (n = 484) Yes (n = 217) 14 6.45 X2=2.545, df=1, P=0.110 No (n = 267) 8 3 Washing hands after using the bathroom (n = 485) Yes (n = 152) 1 0.66 X2=6.44, df=1, P=0.011 No (n = 333) 21 6.31 Washing hands before eating (n = 485) X2=0.32, df=1, P=0.568
38 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Yes (n = 216) 8 3.7 No (n = 269) 14 5.2 Classifying Food Consumption (n = 554) Acceptable food consumption (n = 457) 121 26.48 X2=4.145, df=1, P=0.037 Minimum food consumption (n = 75) 29 38.67 Weak food consumption (n = 22) 8 36.36 Five Spending Categories (n = 560) Lower (n = 209) 12 5.74 X2=3.990, df=1, P=0.045 Upper (n = 154) 2 1.3 Average (n = 122) 8 6.56 (B) Rural Mareb Zone (Acute malnutrition (wasting) using the MUAC indicator) Food Consumption Classification (n = 728) Acceptable food consumption (n = 496) 13 3.2 X2=4.002, df=1, P=0.045 Minimum food consumption (n = 79) 7 8.86 Weak food consumption (n = 51) 2 3.92 Educational level of the household caregiver (n = 542) Literate (n = 74) 0 0 Primary school education (n = 27) 0 0 X2=7.482, df=4, P=0.112 Secondary school education (n = 35) 3 8.57 Higher education (n = 9) 1 11.11 Illiterate (n = 397) 18 4.53
As table 38(B) above shows, acute malnutrition (wasting) among children based on the MUAC indicator is associated with the classification of food consumption in the family, as the statistical significance is less than 0.05, while there was no association with the educational level of the household caregiver, which had a statistical significance higher than 0.05.
Chronic Acute Malnutrition Factors (Underweight)
Table 39(A) below shows that there is a statistically significant relationship between the cases of underweight children in the Mareb City Zone and the factors that affect it, and they are respiratory infections, fever, the household caregiver not washing their hands after using the bathroom, coping strategies, and the five spending categories. The statistical significance was less than 0.05 (p > 0.05).
Table 39(B) below shows that there is a statistically significant relationship between the cases of underweight children in the Rural Mareb Zone and the factors that affect it, and they are type of latrine, coping strategies, classification of food consumption, and the educational level of the household caregiver. The statistical significance was less than 0.05 (p > 0.05).
Table 39 - Underweight Factors (Chronic Acute) for Both zones of the Survey (A) In the Mareb City Zone Underweight (Chronic Acute) Indicator Statistical Test Function N % Respiratory Infection (n = 559) Yes (n = 145) 55 37.63 X2=7.699, df=1, P=0.005 No (n = 414) 150 25.36 Fever (n = 559) Yes (n = 241) 82 34.02 X2=5.596, df=1, P=0.018 No (n = 318) 78 48.75 Washing hands after using the bathroom (n = 560) X2=4.040, df=1, P=0.044 Yes (n = 173) 39 22.54
39 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
No (n = 387) 121 31.27 Coping Strategies CSType (n = 485) Coping strategies during the crisis (n = 91) 8 8.79 Emergency coping strategies (n = 8) 3 37.5 X2=4.005, df=1, P=0.045 Severe coping strategies (n = 150) 16 10.67 There are no coping strategies (n = 236) 22 9.32 Five Spending Categories (n = 560) Lower (n = 230) 78 33.91 X2=7.100, df=2, P=0.028 Upper (n = 186) 41 22.04 Average (n = 144) 41 28.47 (B) Rural Mareb Zone (B) Rural Mareb Zone Indicator Underweight (Chronic Acute) Statistical Test Function N % Type of Latrine (n = 623) Improved (n = 408) 77 18.87 X2=5.567, df=1, P=0.018 Unimproved (n = 215) 59 27.44 Coping Strategies CSType (n = 624) Coping strategies during the crisis (n = 88) 23 26.14 Emergency coping strategies (n = 42) 3 7.14 X2=4.898, df=1, P=0.026 Severe coping strategies (n = 187) 39 20.86 There are no coping strategies (n = 307) 72 23.45 Classification of Food Consumption (n = 617) Acceptable food consumption (n = 496) 89 18.98 X2=10.81, df=2, P=0.0045 Minimum food consumption (n = 89) 25 28.09 Weak food consumption (n = 59) 21 35.59 Educational level of the household caregiver (n = 624) Literate (n = 82) 9 10.98 Primary school education (n = 32) 9 28.13 X2=5.188, df=1, P=0.022 Secondary school education (n = 42) 10 23.81 Higher education (n = 11) 3 27.27 Illiterate (n = 457) 106 23.19
Chronic Malnutrition Factors (Stunting)
Table 40(A) below shows that there is a statistically significant relationship between chronic malnutrition (stunting) among children in the Mareb City Zone and the following factors: the child’s caregiver washing their hands after using the bathroom, the type of latrine used, and the classification of their food consumption. The statistical significance was less than 0.05 (p > 0.05). Looking at table 40(B) you can see that there is only a statistically significant relationship between chronic malnutrition (stunting) among children in the Rural Mareb Zone and the five spending categories, where the statistical significance was less than 0.05 (p > 0.05).
Table 40 - Stunting Factors for Both zones of the Survey Area (A) Mareb City Zone (Stunting) Stunting Indicator Statistical Test Function N % Washing hands after using the bathroom (n = 479) Yes (n = 151) 40 26.49 X2=5.976, df=1, P=0.014 No (n = 328) 126 38.41 Type of household latrine (n = 479) X2=5.047, df=1, P=0.024 Improved (n = 448) 149 33.26
40 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Not improved (n = 31) 17 54.84 Classification of food consumption (n = 473) Acceptable food consumption (n = 391) 125 31.97 X2=9.3361, df=2, P=0.0094 Minimum food consumption (n = 64) 33 51.56 Weak food consumption (n = 18) 6 33.33 (B) Rural Mareb Zone (Stunting) Five spending categories (n = 533) Lower (n = 233) 69 29.61 X2=3.953, df=1, P=0.046 Upper (n = 151) 35 23.18 Average (n = 149) 51 34.23
Yates’ chi-square
Summary of Factors Associated with Forms of Malnutrition
Table 41 - Summary of the Factors Associated with the Different Forms of Malnutrition with the Different Determinants Included in the Survey in Both zones GAM GAM Determinants Underweight Stunting (by WHZ) (by MUAC) Mareb City Zone Diarrhea ○ + ○ ○ Fever ○ ○ + ○ Respiratory Infection + ○ + ○ Using improved sources of drinking water ○ ○ ○ ○ Using improved types of latrines ○ ○ ○ - Cleanliness of water storage containers ○ ○ ○ ○ Washing hands after using the bathroom ○ - - - Washing hands before eating ○ ○ ○ ○ Coping strategies + ○ + ○ Five spending categories ○ - - ○ Lack of food security ○ + ○ + (using FCS) Educational level of the household caregiver ○ ○ ○ ○ Rural Mareb Zone Diarrhea ○ ○ ○ ○ Fever ○ ○ ○ ○ Respiratory Infection ○ ○ ○ ○ Using improved sources of drinking water ○ ○ ○ ○ Using improved types of latrines ○ ○ - ○ Cleanliness of water storage containers ○ ○ ○ ○ Washing hands after using the bathroom ○ ○ ○ ○ Washing hands before eating ○ ○ ○ ○ Coping strategies ○ ○ + ○ Five spending categories ○ ○ ○ - Lack of food security ○ + + ○ (using FCS) Educational level of the household caregiver - ○ - ○
Child Nutrition and Its Relationship to the Mother’s Nutrition
Tables 42 and 43 show that the prevalence rates of acute malnutrition (wasting) reached 14.81% among children under the age of five whose mothers have acute malnutrition (wasting or too thin) in the Mareb
41 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
City Zone. These results are not statistically significant (p > 0.05). On the other hand, the prevalence rates of acute malnutrition (wasting) were 18.75% among children five years old, and this rate had a statistically significant association with wasting among their mothers who had acute malnutrition (too thin) in the Rural Mareb Zone.
The prevalence of underweight was in more than a third of children under five years old whose mothers had acute malnutrition in both zones of the survey area, and the relationship was statistically significant only in the Rural Mareb Zone. More than a third of children under five years old (around 39 - 40%) in both zones whose mothers had acute malnutrition had extreme stunting, and the relationship was not statistically significant.
Table 42 - Relationship Between Malnutrition in the Mother and Child in the Mareb City Zone Indicator N % Statistical Test Mareb City Acute Malnutrition (Stunting) by WHZ
Acute malnutrition (by WHZ) Wasting among mothers (n = 482) Wasting (n = 54) 8 14.81 X2=0.922*, df=1, P=0.336 Normal MUAC (n = 428) 41 9.58
Severe Acute Malnutrition (by WHZ)
Wasting among mothers (n = 482) Wasting (n = 54) 0 0 X2=0.007*, df=1, P=0.931 Normal MUAC (n = 428) 5 1.17 Underweight Wasting among mothers (n = 557) Wasting (n = 66) 24 36.36 X2=1.82, df=1, P=0.176 Normal MUAC (n = 491) 135 27.49 Severe Underweight Wasting among mothers (n = 557) Wasting (n = 66) 6 9.09 X2=0.433*, df=1, P=0.510 Normal MUAC (n = 491) 30 6.11 Stunting Wasting among mothers (n = 476) Wasting (n = 54) 21 38.89 X2=0.255, df=1, P=0.612 Normal MUAC (n = 422) 145 34.36 Severe Stunting Wasting among mothers (n = 476) Wasting (n = 54) 7 12.96 X2=0.392, df=1, P=0.530 Normal MUAC (n = 422) 39 9.24
Yates’ chi-square
Table 43 - Relationship Between Malnutrition in the Mother and Child in the Rural Mareb Zone Indicator N % Statistical Test Rural Mareb Acute Malnutrition (Stunting) by WHZ
Acute malnutrition (by WHZ) Wasting among mothers (n = 532) Wasting (n = 64) 12 18.75 X2=4.876*, df=1, P=0.027 Normal MUAC (n = 468) 42 8.97
42 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Severe Acute Malnutrition (by WHZ)
Wasting among mothers (n = 532) Wasting (n = 64) 0 0 X2=0.078*, df=1, P=0.779 Normal MUAC (n = 468) 6 1.28 Underweight Wasting among mothers (n = 615) Wasting (n = 83) 31 37.35 X2=12.94, df=1, P=0.0003 Normal MUAC (n = 532) 102 19.17 Severe Underweight Wasting among mothers (n = 615) Wasting (n = 83) 6 7.23 X2=1.614*, df=1, P=0.203 Normal MUAC (n = 532) 19 3.57 Stunting Wasting among mothers (n = 532) Wasting (n = 65) 26 40 X2=3.507, df=1, P=0.061 Normal MUAC (n = 467) 130 27.84 Severe Stunting Wasting among mothers (n = 532) Wasting (n = 65) 6 9.23 X2=0.530, df=1, P=0.466 Normal MUAC (n = 467) 28 6
Yates’ chi-square
43 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Conclusions and Recommendations
- The status of malnutrition in all of its forms in both zones of the survey area, compared to the criteria of the World Health Organization or with surveys in other neighboring governorates, is high, with the prevalence rate of global acute malnutrition higher than 10%, which is dangerous, high with 22 – 29% for underweight, and average to high with 29 – 35% for stunting. - The infant and young children feeding practices are weak with regards to exclusive breastfeeding, which is around 8.9 – 22.1% in both zones, and the minimum acceptable food consumption, which is around 27 – 29% in both zones. Vitamin A supplements during the previous six months are given to around one out of every five children, which means that it is still under the acceptable threshold for the Sphere criteria. On the other hand, high prevalence rates of diarrhea, respiratory infections, and fever were recorded among children who have malnutrition. - The survey found that the social and economic situation is weak, with illiteracy around 45% in the Mareb City Zone and 67% in the Rural Mareb Zone among the household caregivers (most of whom are women), while only 5 – 10% of them in both zones have gotten a primary education. More than 45% of the households in both zones of the survey area stated that they have either partially or completely lost their sources of income, and household spending is less than 3 USD a day for households, which have an average of 7 members. - The average use of improved water sources shows that there are still four out of every five households that use unimproved sources of water in the Mareb City Zone, and two out of every three households in the Rural Mareb Zone. The use of improved latrines makes up 95% of the households in the Mareb City Zone, while it makes up around 70% of the households in the Rural Mareb Zone. Open defecation is still used by around 13% of the households in the Rural Mareb Zone. The survey found that only one out of every three household caregivers wash their hands with water and soap after using the bathroom and around half before meals. - The survey found that the nutritional situation of children is linked to the use of sanitation and personal hygiene in both zones of the survey area, which includes the type of source of drinking water, latrines, and handwashing practices. The survey also found that the spread of diarrhea, fever, and respiratory infections were factors were catalysts for acute malnutrition and underweight in the Mareb City Zone. The survey found that spending, a lack of food security, coping strategies, and the education of household caregivers were linked to malnutrition, underweight, and/or stunting in both zones of the survey in general. - The survey found that acute malnutrition among women of reproductive age is 10% in both zones of the survey area (using the classification of the World Food Program for Yemen). Despite the fact that this rate is average based on international levels, a link has been found between malnutrition in mothers who have acute malnutrition or underweight and malnutrition in children in the Rural Mareb Zone.
With regards to these results and the general status of the country during the current crisis, the following recommendations can be made to be translated into suitable work points:
- Interventions are required in water, sanitation, and health hygiene, including the interventions that are carried out through C4D activities. This is needed to improve the use of improved latrines, improve the sources of drinking water, and raise awareness about handwashing practices so that they are done on a regular basis by the members of the households. - There must also be preventative activities for sexually transmitted infections and prevention of children’s illnesses, especially diarrhea.
44 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
- Among the poor, there must be interventions to deal with infant and young children feeding practices through intensive awareness-raising campaigns that target schools, women’s movements, and other social platforms. - There is a dire need to raise awareness in the local communities on the use of the available local foods to feed young children. - There is a need for support to ensure children are given Vitamin A supplements every six months with the goal of meeting the minimum levels used in the Sphere criteria. - There must be planning to create services to manage acute malnutrition for acute malnutrition using the rates of acute malnutrition together, as is shown in Table 44 below. - If there is no change in context, it is recommended that another survey be implemented in two years. This survey must be implemented either in July or in August. - There is no need to divide the survey area in the Mareb governorate into two zones in the future.
45 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
The Prevalence of Global, Moderate, and Severe Acute Malnutrition Used in the Calculation of Cases
For the purposes of planning for a CMAM program, a child is considered to have acute malnutrition if they meet at least one of three criteria. These criteria are:
1. That the weight for height indicator (WHZ) for the child be below -2 2. Oedema 3. That the mid-upper arm circumference (MUAC) measurement of the child is less than 125 mm
The same applies to severe acute malnutrition, with the following criteria:
1. That the WHZ for the child be below -3 2. And/or oedema 3. That the mid-upper arm circumference (MUAC) measurement of the child is less than 115 mm
This kind of analysis is crucial for the calculation of the number of cases and for planning the program. Table 44 below shows the figures for acute malnutrition for the Mareb City and Rural Mareb Zones, in addition to the weighted numbers for the Mareb governorate as a whole.
Table 44 - Mixed Acute Malnutrition (Based on WHZ and MUAC) for Planning in Both zones (Mareb City and Rural Mareb) (95% Confidence interval) N % Lower Upper Mareb City Zone (485) Moderate mixed malnutrition 49 10.10% 7.70% 13.10% (Not weighted) Severe mixed malnutrition 9 1.90% 1% 3.50% Global mixed malnutrition 58 12% 9.40% 15.10% Rural Mareb Zone (542) Moderate mixed malnutrition 53 9.80% 7.60% 12.60% (Not weighted) Severe mixed malnutrition 11 2% 1.10% 3.60% Global mixed malnutrition 64 11.80% 9.40% 14.80% In both zones of the Mareb governorate Moderate mixed malnutrition 103 9.90% 8.20% 11.80% (1052) (weighted) Severe mixed malnutrition 20 2% 1.30% 3% Global mixed malnutrition 124 11.80% 10% 13.90%
46 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
References
1. Action Against Hunger, Technical Advisory Group (2012), SMART, Sampling Methods and Sample Size Calculation for the SMART Methodology, Canada 2. World Health Organization (1995). Physical Status: The Use and Interpretation of Anthropometry. Report of a World Health Organization Expert Committee. WHO Technical Report Series 844. Geneva, World Health Organization 3. World Health Organization (2008). Indicators to Assess Nutrition Practices for Infants and Young Children, World Health Organization 4. World Health Organization (2010), NLIS Country Profile Indicators Interpretation Guide, World Health Organization, Geneva 5. World Health Organization (2013), Updates on the management of severe acute malnutrition in infants and children, World Health Organization, Geneva 6. World Health Organization Multi-Center Growth Reference Study Group (2006). World Health Organization Child Growth Standards: Methods and development Length/height-for-age, weight- for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and Development. World Health Organization, Geneva 7. World Health Organization, Water, Sanitation, Hygiene. http://www.who.int/water_sanitation_health/monitoring/jmp2012/key_terms/en. Accessed on 28/5/2016. 8. Food Security Analysis. (2009). Comprehensive Food Security & Vulnerability Analysis (CFSVA) Guidelines. United Nations World Food Program, Rome, Italy. 9. Maxwell, D. and Caldwell, R. (2008). The Coping Strategies Index: Field Methods Manual, Second Edition. Care, Inc. 10. OCHA’s website
47 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annexes
Annex 1: Malnutrition Survey Questionnaire – Mareb Governorate – July – August 2018 Questionnaire No: ______Republic of Yemen Ministry of Public Health and Population Office of the Ministry of Public Health and Population in the Mareb governorate Assessing the Nutritional Situation and Mortality in the Mareb governorate in July 2018 Household Questionnaire (Form 1)
First: Explain to the residents of the household (the adults) about the assessment, and introduce the entity that is carrying it out, as well as the individuals working on it (the team members), then get their verbal approval. 1. Yes Approval 2. No Move on to the next page
Is the household a resident If the household is a resident household: Does refugee household or a refugee household? households or a refugee household reside with you? 1. Residents 1. Yes If there is a refugee household that lives with 2. Refugees 2. No the resident household, the information for both households must be filled out in the questionnaire, separately, except for the mortality form, of which only one form is to be filled out for both households, and it is included with the resident household.
District Sub-District Village/Block
Household serial number Interview date Day Month Year according to sample
0 2 0 1 8
Household head name:
Team Name Signature Assessment Team Researcher 1 Number Researcher 2 + 3 ______Team Head Field Supervisor
The following data from Q. 1, household data and deaths, is copied to the cluster dump form.
48 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Number of Number of Number of Number of at Number of household children under 5 children under 6 childbearing age individuals in members years old months between 15 and mortality form 49 years
If the following apply: 1. If the household is absent during the first visit, and a second visit is needed. 2. If the woman is absent during the first visit, and a second visit is needed. 3. If the child is absent during the first visit, and a second visit is needed. * * If the child is absent, all of the information is filled out except for the anthropometric measurements and edema, which are completed when the child is present. Note: The data on the cover is for field and administrative use by the members of the team.
Questionnaire No: ______
To be filled out by the team head (used to enter data)
Interview date Day Month Year
0 2 0 1 8
Team #
Village / Neighborhood Code Sub-District Code
District Code Governorate Code
Assessment Print Number Cluster Number
Is the area (1) urban or (2) rural?
Household is absent after second visit (1 yes, or 2 no)
Approval (1 yes, or 2 no)
49 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
If no approval, move on to the next household.
Household Questionnaire Number
Resident household (1) or Refugee Household (2)
If it is a resident household, do they host a refugee household? (1 yes, or 2 no)
Refugee household serial
For Office Use
Name Day Month Year Signature
Data Enterer
Data Enterer
Reviewer
Notes:
2
50 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Questionnaire No: ______
Q 001: Information about the household (only those that are still alive and currently reside with the household)
Number Number of members of the household (only those that are still alive H001a and currently reside with the household)
Number Number of children under 5 years old (only those that are still alive H001b and currently reside with the household)
Number Number of children younger than 6 months old (only those that are H001c still alive and currently reside with the household)
Number Number of women between 15 and 49 years old (only those that are H001d still alive and currently reside with the household)
Q 002: Information about the gender of the household head (the person that is responsible for the household’s livelihood)
What is the gender of the head of the household?
H002 1. Male
2. Female
Q 003 – Q 005: Information about the household caregiver (the person that is responsible for taking care of the household, especially the children)
What is the gender of the household caregiver?
H003 1. Male
2. Female
51 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
What is the marital status of the household caregiver?
1. Married
2. Widow H004 3. Divorced
4. Separated
5. Single
What is the educational level of the household caregiver?
1. Illiterate
2. Literate
H005 3. Basic education
4. Secondary school education
5. Higher education (university, college, or institute)
Questionnaire No: ______
Q 006 – Q 007: Information about the household’s income and spending
Has the household’s income decreased during the past 12 months?
1. Yes H006 2. No
3. I do not know
What is the average spending (expenses) Spending (in riyals) for the household, in riyals?
H007 1. Daily spending 2. Weekly spending
3. Monthly spending
52 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Totals
Q 008 – Q 013: Information about water, sanitation, and hygiene.
What is the main source of drinking water in your house? (Choose one only) Go to
Water project that comes that brings water to the house (government 1 or private)
2 Public water pump / communal water source / public water
3 Artesian aquifer
4 Covered well
5 Unprotected well
H008 6 Covered spring 7 Unprotected spring
8 Treated water (mineral or treated) -> H010
9 Surface water table / stream / irrigation channels
10 Collecting covered rain water
11 Collected unprotected rain water (water cisterns / pond)
12 Water trucks or carts that transport water
13 Other: ______
Do you treat the water before drinking it? Go to
1 Yes H009a 2 No -> H010
3 I do not know -> H010
What is the main method of treatment that is used for drinking water?
H009b (Choose only one) 1 Boiling water before drinking it
53 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
2 Using chlorine
3 Filtering using a clean cloth
Using a ceramic or sand water filter, or a similar method (filter or 4 distill)
5 Leaving the water to settle so that the sediment settles.
6 Using alum
7 Other: ______
Note: Make sure that there are water storage areas for drinking water:
Is the container that is being used to store the water clean (free of algae)? H010 1 Yes (there is no algae)
2 No (there is algae)
Where do they answer the call of nature (defecate)? (Choose one of the
following): Verify the facilities and practices.
Latrines – They have water for cleaning (hose or bucket) that pours 1 into a public sewer system.
Latrines – They have water for cleaning (hose or bucket) that pours 2 into a septic tank.
Latrines – They have water for cleaning (hose or bucket) that pours 3 into a latrine hole.
H011 Latrines – They have water for cleaning (hose or bucket) that pours out 4 into the open.
Latrines – They have water for cleaning (hose or bucket) that pours 5 into an unknown location.
6 Improved and ventilated latrine hole.
7 Latrine hole with boards
8 Latrine hole without boards / is uncovered
9 Compost latrine
54 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
10 Bucket
11 Hanging latrine
12 Open defecation (in the fields, for example, etc.)
13 Other: ______
Questionnaire No: ______
H012a 1. Mentioned -> If the answer to question 1 was mentioned in the previous question. When do you wash your hands? (Record only when one or both of these situations are mentioned.) H012b What do you use to wash your hands? 2. If it was not mentioned, go to a. Just b. With water and c. Water question H013 with soap (piece of soap, with ashes / water liquid soap, dirt / powdered soap, pebbles / soap dough) leaves
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
A. After using the bathroom
B. Before eating
Q 013 – Q 015: Food consumption and coping strategies
Does the household eat any of the H013a H013b foods or food groups below? Has the household If the answer to the previous In the first column, the answer will eaten this in the question is yes, how many be yes or no (1 or 2). past 7 days? days did the household have H013 this food in the past 7 days? In the second column, the answer 1. Yes will be the number of days in the (The answer will be from 1 to last seven days. 2. No 7.) If no, move to the next choice.
55 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
A Wheat, bread, aseed, fattah, other grains (corn, thin corn, millet, barley), pastries, or any food made out of grains.
B Rice or macaroni
C Potatoes
D Vegetables (leafy vegetables, tomatoes, peppers, carrots, squash, etc.)
E Fruits (mangos, bananas, grapes, etc.)
F Meat (beef or goat meat), liver, kidneys, poultry
G Poultry
H Eggs
I Fish (fresh, dried, or canned)
J Legumes (beans, lentils, peas, kidney beans)
K Dairy products (milk, cheese, yogurt, etc.)
L Oils or fats (margarine, butter, vegetable oil, etc.)
M Sugar, sweets, honey, dried fruits (dates, raisins)
N Spices, tea, coffee
Questionnaire No: ______
During the past 7 days, has the Go to household not had enough food or money to buy the food that it needs? H014a 1 Yes
2 No -> H015
56 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
How many days, in the past 7 days, did the household have to do Number of days any of the following because it did not have enough food or money (Answer is from 0 to buy the food that it needs? to 7)
A Depending on lower quality or cheaper food.
B Borrowing food or depending on help from household and friends
C Lowering the amount of food that is served at the main meals
D Decreasing the meals of the adults in the household in order to secure food for the children H014b E Decreasing the number of daily meals
F Buying food on credit or by pawning items
G Collecting food from the brush or harvesting crops that are not ready for harvesting
H Using the seeds that are to be planted in the coming season
I Sending members of the household to eat elsewhere
J Sending members of the household to beg
K Spending a whole day without food.
Have any of the members of the household done any of the following 0. Never to deal with the scarcity of food in the previous 30 days? 1. Rarely Please fill out all of the fields as follows: 2. Sometimes (0) Never 3. Always (1) Rarely (once or twice in the past 30 days)
H015 (2) Sometimes (from 3 to 10 times in the past 30 days)
(3) Always (more than 10 times in the past 30 days)
A Selling the assets or holdings of the household (furniture, jewelry, clothes, etc.)
B Buying food on credit or by pawning items because cash is not available to buy it
57 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
C Spending savings
D Borrowing money
E Selling productive assets, or means of transportation (sewing machines, cars, bicycles, etc.)
F Using seeds stored for the next season
G Taking children out of school
H Selling homes or real estate
I Begging
J Selling the last remaining female livestock animals that they own
K Decreasing spending on education and healthcare (including medicine)
58 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Household Questionnaire No: ______
Q 016 – Q 020: MUAC of women in childbearing age (15 – 49 years old)
W016 W017 W018 W019 W020
Woman’s Woman’s Woman’s Marital Status: The woman is now: MUAC How much time did the Number First Name Age (in (cm) woman spend outside of the years) 1. Married 1. Pregnant house yesterday? 88.8 = 2. Widowed 2. Nursing refused
3. Divorced 3. Not 99.9 = pregnant or absent 4. Separated nursing 5. Single
6. If the answer is single (5), move to W019
H H M M 1 .
H H M M 2 .
H H M M 3 .
59 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
H H M M 4 .
H H M M 5 .
H H M M 6 .
H H M M 7 .
H H M M 8 .
H H M M 9 .
H H M M 10 .
Household Questionnaire No: ______
Q 021 – Q 023: Children’s ages (Document every child from 0 to 5 years old in the table below, starting from the oldest)
C021 C022 C023a C023b
60 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Child’s Child’s Child’s Number of woman (mother or Date of birth (Hijri or Child’s age What did the number first gender caregiver of the child, to be taken Gregorian) (in months) mother say name from the page with the women’s about the child’s 1 = male information) For children from 0 to 59 age? months old 2 = female
DD MM YYYY 1
DD MM YYYY 2
DD MM YYYY 3
DD MM YYYY 4
DD MM YYYY 5
DD MM YYYY 6
DD MM YYYY 7
61 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
DD MM YYYY 8
DD MM YYYY 9
DD MM YYYY 10
Household Questionnaire No: ______
Q 024 – Q 026: Anthropometric measurements of children between 6 and 59 months old in the household (leave blank for any children younger than 6 months)
C024 C025 C026
Child’s number (copied Child’s first name Child’s age Weight Height (centimeters MUAC (centimeters from the previous page) (from the previous (in months) (Kilograms and and millimeters) and millimeters) page) grams) (from 888.8 = refused 88.8 = refused previous 88.8 = refused page) 999.9 = absent 99.9 = absent 99.9 = absent
. . .
. . .
. . .
. . .
62 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
. . .
. . .
. . .
. . .
. . .
. . .
Household Questionnaire No: ______
Q 027 – Q 033: Edema, immunization, and morbidity among children between the ages of 0 and 59 months in the household (all of the children under 5 years old)
C027 C028 C029 C030 C031 C032 C033
For all children between 0 and 59 months For children 6 months old For children 9 and older months old and older
Child’s Child’s Child’s Edema Diarrhea* Coughing Fever Were they Has the child For children number first name age (in in both during the or difficulty in the given gotten the older than 9 (copied (from the months) feet past two breathing past vitamin A third dose of months, was the from the previous weeks in the past two during the the child given the previous page) (from 1 = Yes two weeks weeks past six pentavalent measles vaccine page) previous 1 = Yes months? vaccine (dose (dose in the left 2 = No page) 1 = Yes 1 = Yes (Show in the thigh)? hand)? 2 = No sample) 8 = 2 = No 2 = No Refused 1 = Yes
63 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
9 = 2 = No 1 = Yes, from 1 = Yes, from Absent the vaccination the vaccination 3 = Do not chart chart know 2 = Yes, from 2 = Yes, from memory memory
3 = Do not 3 = Do not know know
4 = Not 4 = Not vaccinated vaccinated
* Diarrhea: It is the increase in the number of watery diarrhea, more than usual
64 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Household Questionnaire No: ______
Q 034 – Q 035: Record the incidents of nursing children between 0 and 24 months old within the past 24 hours (leave blank for children older than 24 months)
Child’s Child’s Child’s C034 C035 number first name age (in (copied (from the months) Did the child Record the number of times that the child nursed yesterday (0 if the child did not from the previous nurse from nurse) previous page) (from their mother C035a C035b C035c C035d C035e page) previous (nursing or page) expressed If the answer to How many How many How How many milk) within the previous times did the times did the many times did the the past 24 question is yes, child have child drink any times did child have hours? how many times breastmilk in other kind of the child other food 1 = Yes did the child the last 24 milk, have that is solid, nurse, and how hours? powdered, yogurt or semi-solid, or 2 = No many times bottled, or fresh a yogurt soft (like were they given animal milk, in drink in bananas)? their mother’s the last 24 the past 24 If the answer milk, in the last hours? hours? is no, go to 24 hours? question C035b
65 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Household Questionnaire No: ______
Q 036: Record the feeding of children between the age of 0 and 24 months during the past 24 hours (leave blank for children older than 24 months)
Child’s Child’s Child’s C036 number first age (in (copied name months) Did the child eat any of the food groups below yesterday? (By yesterday, it means from the time the from the (from child woke up in the morning until they went to sleep at night) previous the (from Give the mother time to remember, and, when she finishes, list the items below. page) previous previous page) page) 1 = Yes / 2 = No / 3 = The mother does not know
C036a C036b C036c C036d C036e C036f C036g C036h C036i
Grains: Legumes: Vegetables Any other Any other Meat: Water, and fruits: fruits or foods or Aseedah, Any food Cheese with or Liver, vegetables drinks shabisah, made or ice Eggs Squash, without kidney, that were (other bread, from cream carrots, sugar heart, not than rice, beans, sweet mentioned children’s
66 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
macaroni, kidney or other potatoes, in the milk, or or any beans, organs yellow or previous any other other peas, orange part milk, food lentils, Any guava yogurt, made peanut beef or and from butter, or goat Any dark yogurt grains. any other meat, green drink.) legumes sheep leafy Tubers: meat, or vegetables poultry. White Mango or potatoes, Fresh, ripe or any canned, papaya other or dried tubers fish.
67 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Household Questionnaire No: ______
Assessing the Nutritional Situation and Deaths in Mareb governorate, 2018
Demographic Survey Form during the Period from 30 April 2018 (Form 2)
Assessment District: ______Block/Village: ______Date: ______Cluster Number: ______
Team Number: ______Household Questionnaire Number: ______Assessment Level: ______
Left the household Born on or after Died on or after Gender Joined the household Cause Place Age (in on or after the night the night of the the night of the # Name (Male or on or after the night of of of years) of the middle of middle of middle of Female) the middle of Sha’ban death death Sha’ban Sha’ban Sha’ban
Complete the list with the members of the household that currently reside with the household, then put a check mark (✓) for the household members that joined the household or were born after the night of the middle of Sha’ban.
1
2
3
4
5
6
7
8
9
68 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Continue on the next page
Household Questionnaire No: ______
69 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Joined the Left the household Born on or after the Died on or after Gender Cause Place Age (in household on or on or after the night anniversary the night the night of the # Name (Male or of of years) after the night of the of the middle of of the middle of middle of Female) death death middle of Sha’ban Sha’ban Sha’ban Sha’ban
Complete the list with individuals that left the household before the date of the visit, starting on or after the night of the middle of Sha’ban, then put a check mark (✓) for those that had joined the household or were born on or after the night of the middle of Sha’ban.
1 ✓
2
3
4
5
6
7
8
9
10
11
12
70 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Left the household on Born on or after Died on or after Gender Joined the household Cause Place Age (in or after the night of the night of the the night of the # Name (Male or on or after the night of of of years) the middle of middle of middle of Female) the middle of Sha’ban death death Sha’ban Sha’ban Sha’ban
Complete the list with individuals that died before the date of the visit, starting on or after the night of the middle of Sha’ban, then put a check mark (✓) for those that had joined the household or were born on or after the night of the middle of Sha’ban.
1 ✓
2
3
4
5
Has there been a pregnant woman in the household since the night of the 1. Yes If the answer is yes, how many pregnant middle of Sha’ban? women? 2. No
Causes of Death Codes
1 = Unknown 3 = Malnutrition
2 = Accident or injury 6 = Fever
3 = Diarrhea 7 = Other (specify):
4 = Problems breathing
71 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Places of Death Codes
1 = Current location
2 = While migrating
3 = In their last residence
4 = Other (specify):
72 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 2: Nutrition Survey Team – Mareb Governorate – July – August 2018 Team Mareb City Rural Mareb Task Number 1 Nayef Muhammad Al Qardhi Nayef Muhammad Al Qardhi 2 Ali Ahmad Al Dahmashi Ali Ahmad Al Dahmashi Ameen Hussein Nasser Al Ameen Hussein Nasser Al 3 Team Heads Qarda'i Qarda'i 4 Abdulrahman Ahmad Al Tafaf Abdulrahman Ahmad Al Tafaf 5 Ahmad Abdullah Al Rawqi Aishah Mubarak Al Musay Aishah Mubarak Al Musay 1 Fatimah Hadi Tuaiman Fatimah Hadi Tuaiman Latifah Abdrabboh Al Kharaz Latifah Abdrabboh Al Kharaz Bakheetah Hussein Al Iyal Bakheetah Hussein Al Iyal 2 Zahrah Musfir Al Bahri Zahrah Musfir Al Bahri Firjah Musid Al Khalasi Firjah Musid Al Khalasi Jamilah Ahmad Al Saba'i Jamilah Ahmad Al Saba'i 3 Zuhoor Abdulwali Al Faqih Zuhoor Abdulwali Al Faqih Researchers Salwa Ahmad Al Basis Salwa Ahmad Al Basis Badrah Abdulaziz Salamah Badrah Abdulaziz Salamah 4 Zamlah Fahd Dabash Zamlah Fahd Dabash Wadha Mubarak Abu Bakr Wadha Mubarak Abu Bakr Abeer Mahdi Ahmad Al Faqih 5 Ghadah Jamil Al Hakimi Fayezah Salem Al Ma'thoth Mareb City Rural Mareb Task Muhammad Taha Al Saqqaf Muhammad Taha Al Saqqaf Abdullah Khadim Al Aqzal Abdullah Khadim Al Aqzal Saleh Awadh Al Haimi Saleh Awadh Al Haimi Field Supervisors (Central) Saleh Ahmad Abbas Saleh Ahmad Abbas Ghailan Abdoh Al Sami'i Arqat Shamman (Manager of the Operations Room) Ammar Al Junaid Abdulwahid Aqlan Data Enterers Saleh Al Ja'mali Abdulaziz Al Sabri Data Analysis and Report Abdrabboh Al Rawhani / Ibrahim Al Shawkani / Abdulkareem Nasser Writing Adel Abdulmahmoud Muhammad Othman Survey Manager
73 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 3: Table to determine the ages of children using the Gregorian and Hijri calendars – Mareb Governorate – July 2018
Age in Years and Gregorian Years Hijri Years Age in Months Months Months Years 2018 2017 2016 2015 2014 2013 1439 1438 1437 1436 1435 1434
0 7 11
1 1 6 10
2 2 5 9
3 3 4 8
4 4 3 7
5 5 2 6
6 6 1 5
7 7 12 4
8 8 11 3
9 9 10 2
10 10 9 1
11 11 8 12
12 1 7 11
13 1 1 6 10
14 2 1 5 9
15 3 1 4 8
16 4 1 3 7
17 5 1 2 6
18 6 1 1 5
19 7 1 12 4
20 8 1 11 3
21 9 1 10 2
22 10 1 9 1
74 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
23 11 1 8 12
24 2 7 11
25 1 2 6 10
26 2 2 5 9
27 3 2 4 8
28 4 2 3 7
29 5 2 2 6
30 6 2 1 5
31 7 2 12 4
32 8 2 11 3
33 9 2 10 2
34 10 2 9 1
35 11 2 8 12
36 3 7 11
37 1 3 6 10
38 2 3 5 9
39 3 3 4 8
40 4 3 3 7
41 5 3 2 6
42 6 3 1 5
43 7 3 12 4
44 8 3 11 3
45 9 3 10 2
46 10 3 9 1
47 11 3 8 12
48 4 Month Gregorian 7 Month Hijri 11
49 1 4 1 January 6 1 Muharram 10
50 2 4 2 February 5 2 Safar 9
75 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
51 3 4 3 March 4 3 Rabi' I 3
52 4 4 4 April 3 4 Rabi' II 2
53 5 4 5 May 2 5 Jumada I 1
54 6 4 6 June 1 6 Jumada II 12
55 7 4 7 July 12 7 Rajab 11
56 8 4 8 August 11 8 Sha'ban 10
57 9 4 9 September 10 9 Ramadan 9
58 10 4 10 October 9 10 Shawwal 8
59 11 4 11 November 8 11 Dhul Qi'dah 7
60 5 12 December 7 12 Dhul Hijjah 6
Starting Date: Saturday, 21/7/2018 (8/11/1438 Hijri)
76 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 4(A): Plausibility Check for the Mareb City Zone – July – August 2018 Plausibility check for: Mareb City. July August 2018 Final Dataset.as
Standard/Reference used for z-score calculation: WHO standards 2006
(If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report are more for advanced users and can be skipped for a standard evaluation)
Overall data quality
Criteria Flags* Unit Excel. Good Accept Problematic Score
Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5
(% of out of range subjects) 0 5 10 20 0 (0.0 %)
Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.650)
Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.736)
Dig pref score - weight Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (3)
Dig pref score - height Incl # 0-7 8-12 13-20 > 20
0 2 4 10 2 (8)
Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (4)
Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20
77 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
. and or
. Excl SD >0.9 >0.85 >0.80 <=0.80
0 5 10 20 0 (0.92)
Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (-0.05)
Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 3 (0.52)
Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001
0 1 3 5 0 (p=0.478)
OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 5 %
The overall score of this survey is 5 %, this is excellent.
78 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 4(B): Plausibility Check for the Rural Mareb Zone – July – August 2018
Standard/Reference used for z-score calculation: WHO standards 2006
(If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report are more for advanced users and can be skipped for a standard evaluation)
Overall data quality
Criteria Flags* Unit Excel. Good Accept Problematic Score
Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5
(% of out of range subjects) 0 5 10 20 0 (0.4 %)
Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.550)
Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.946)
Dig pref score - weight Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (3)
Dig pref score - height Incl # 0-7 8-12 13-20 > 20
0 2 4 10 2 (12)
Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (6)
Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20
. and and and or
. Excl SD >0.9 >0.85 >0.80 <=0.80
79 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
0 5 10 20 0 (0.94)
Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (-0.03)
Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (-0.06)
Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001
0 1 3 5 0 (p=0.300)
OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 2 %
The overall score of this survey is 2 %, this is excellent.
80 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 5: Report on the Child Measurement Session to Evaluate the in the Mareb Survey – July – August 2018 Supervisor Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 13.2 13.0 98.3 98.6 141 143 10.9 10.9 88.2 88.2 142 144 8.8 8.7 79.1 79.2 139 134 9.3 9.3 80.9 80.8 147 144 12.8 12.8 92.0 92.0 154 154 13.4 13.5 96.6 96.8 145 143 15.3 15.4 94.4 93.7 177 170 10.5 10.5 84.4 83.6 136 135 8.7 8.7 72.3 73.0 143 144 10.0 10.1 84.3 84.2 134 134 Enumerator 1 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 13.3 13 98.2 98.8 141 142 10.6 10.9 88.2 87.6 138 139 8.5 8.7 78.3 79.7 137 134 9.2 9.4 81.5 80.9 146 143 12.4 12.7 92 91.7 152 158 13.4 13.5 96.5 95.8 146 143 15.3 15.4 94.5 94.3 164 170 10.5 10.5 84.6 83.6 135 135 8.6 8.6 72.2 73 143 142 10.1 10.1 84.3 84.2 129 132 Enumerator 2 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 13.2 13 98.8 98.5 142 143 10.9 10.8 88.2 88.4 140 139 8.4 8.7 78.7 78 139 139 9.3 9.3 80.7 80.4 148 144 12.8 12.8 92 92.1 154 153 13.4 13.5 98 96.6 145 147 15.3 15.3 84.2 93.5 169 168 10.5 10.6 84.4 83.6 134 135 7.9 8.6 72.2 73 143 143 9.9 10 84 84 134 134 Enumerator 3 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2
81 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
13.2 13.1 98.3 98.6 140 137 10.8 10.9 88.1 88.1 146 137 8.8 8.7 79.2 79.3 139 134 9.3 9.3 80.5 80.6 144 135 12.8 12.9 92.1 92.2 154 148 13.4 13.6 96.6 97.4 144 144 15.3 15.3 93.4 93.7 174 168 10.5 10.5 83.6 84.4 136 134 8.6 8.7 72.6 73 146 144 10 10.1 84.6 85 134 133 Enumerator 4 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 13.2 13.2 98.7 98.3 145 144 10.9 10.9 88 88 142 144 8.8 8.8 79.1 78.6 139 136 9.4 9.3 80.7 80.5 144 150 12.7 12.8 92 92 154 154 13.4 13.6 96.6 97 146 140 15.4 15.4 94.4 94 177 170 10.5 10.5 84.4 84.3 136 135 8.7 8.7 75.3 72.7 145 147 10 10.1 84.8 84.5 133 133 Enumerator 5 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 13.2 13 98 98.4 138 137 10.9 10.9 89 88.2 141 144 8.7 8.7 80.6 80.2 141 134 9.3 9.3 81.2 81 147 144 12.8 12.8 82 92 154 154 13.4 13.4 96 96.9 143 149 15.4 15.2 94.6 94.3 179 173 10.4 10.5 84.6 84 139 137 8.7 8.6 73.3 73.3 143 144 10 10 84.2 84.2 136 136 Enumerator 6 13.1 13 98.5 98.6 145 140 10.8 10.9 89.2 88.6 144 144 8.7 8.7 79 79 137 139 9.4 9.3 81.3 81 147 143 12.8 12.6 92 91.7 152 148
82 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
13.4 13.4 96.6 96.3 142 143 14.2 15.5 94 93.6 176 171 10.5 10.5 84.1 83.7 136 135 8.8 8.7 72 71.5 145 145 10 10.2 85 84.4 136 134
83 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Notes:
During the measurement test, the trainers were moving around and taking pictures and video clips so that they could show the participants the correct and incorrect ways of doing the things that they were doing. All of the figures that were written incorrectly by the participants were presented during this session to everyone in order to avoid these mistakes happening again. All of the figures were entered into the ENA. The training was divided exactly as it was written by the participants and the numbers that were written incorrectly were not corrected.
84 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 6(A): The Clusters Chosen for The Nutrition and Mortality Survey – Mareb City – July – August 2018 # District Sub-District Blocks The Clusters Chosen 1 Mareb City Al Ashraf Mareb Al Sad 1 2 Mareb City Al Ashraf Manin Al Ashraf 2 3 Mareb City Al Ashraf Manin Al Hadad 3 4 Mareb City Al Ashraf Al Jaboul 4 5 Mareb City Al Ashraf Al Mahtam 5 6 Mareb City Al Ashraf Al Rajw 6 7 Mareb City Al Ashraf Al Arsh 7 8 Mareb City Al Ashraf Jaw Al Abr 8 9 Mareb City Al Ashraf Mahatat Al Baqmah 9 10 Mareb City Al Ashraf Al Khayatin Street 10 11 Mareb City Al Ashraf Great Mosque 11 12 Mareb City Al Ashraf Hawsh Al Zira'ah 12 13 Mareb City Al Ashraf Northwestern Salam Neighborhood 13 14 Mareb City Al Ashraf Hussein Mijdi' Neighborhood 14 15 Mareb City Al Ashraf Western Al Sahn Neighborhood 15 16 Mareb City Al Jalal Kamb Al Zira'ah 16 17 Mareb City Al Jalal Gas Company Neighborhood 17 18 Mareb City Al Ashraf Al Safinah Neighborhood and areas to the north 18 19 Mareb City Al Ashraf Kamb Al Zira'ah and the surrounding areas 19 20 Mareb City Al Ashraf Bin Saud Neighborhood 20 21 Mareb City Al Ashraf Abu Naab Neighborhood 21 22 Mareb City Al Ashraf Gun Market and the surrounding farms 22 23 Mareb City Al Ashraf The neighborhood south of the Bilqees Park 23 24 Mareb City Al Ashraf Hayel Mosque 24 25 Mareb City Al Ashraf Judges Street Neighborhood 25 26 Mareb City Al Ashraf Hunt Park 26 27 Mareb City Al Ashraf Health Residences 27 28 Mareb City Al Ashraf Bilqees Hotel 28
85 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
29 Mareb City Al Ashraf Al Mahwa 29 30 Mareb City Al Ashraf Al Sunnah Mosque Neighborhood 30 Reserve Clusters 31 Mareb City Al Ashraf Al Saud RC 32 Mareb City Al Ashraf Al Qasr Neighborhood RC 33 Mareb City Al Ashraf Al Amtal RC 34 Mareb City Al Ashraf Manin Al Ashraf RC
86 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 6(B): The Clusters Chosen for The Nutrition and Mortality Survey – Rural Mareb – July – August 2018 # District Sub-District Blocks The Clusters Chosen 1 Al Jubah Al Jarshah Al Jarshah 1 2 Al Jubah Naja Al Maltah 2 3 Al Jubah Ya'rah Al Khathlah 3 4 Al Jubah Ya'rah Ya'rah 4 5 Al Abdiyah Al Ghanem Al Ghadi 5 6 Bidbadah Al Majza' Al Majza' 6 7 Bidbadah Ahl Ali Al Hanaya 7 8 Bidbadah Bani Shaker Al Makhlabah 8 9 Bidbadah Bani Ma'oud Al Awrat 9 10 Jabal Murad Jabal Murad Al Tarif 10 11 Jabal Murad Jabal Murad Al Ma'oud 11 12 Harib Al Abu Tuhaif Wadi Dhaba (Nomad bedouins) 12 13 Harib Al Ashraf Harib 13 14 Harib Al Ashraf Harib 14 15 Harib Al Qahaytah Al Salbah 15 16 Harib Jaradha Al Naysah 16 17 Rahabah Al Bushah Wadi Al Lab 17 18 Rahabah Rahabah Rahabat Al Kawlah 18 19 Raghwan Raghwan Lasahil 19 20 Mahliyah Al Amoud Al Taleb Kawlat Hadhah 20 21 Mareb Al Jalal Mareb City (Al Husun) 21 22 Mareb Al Rashid Munif Al Rakah 22 23 Mareb Al Rashid Munif Hadba' Al Suraihi 23 24 Mareb Al Shabwan Al Hani 24 25 Mareb Al Fijaih Lower Al Masil 25 26 Mareb Al Qaz'ah Al Hawi 26 27 Mareb Al Qaz'ah Hadba' Al Ashwan 27 28 Majzar Al Ashraf Husn Al Damar 28 29 Majzar Al Sahari Al Husun 29
87 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
30 Medghal Al Jid'an Medghal Al Jid'an Al Zabrah 30 Reserve Clusters 31 Al Jubah Al Jadidah Al Jadidah RC 32 Al Abdiyah Al Saidi Lower Khalilah RC 33 Harib Al Ashraf Al Ajruf RC 34 Mareb Al Rashid Munif Al Lamd RC
88 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 7(A) – Weighted Levels of Malnutrition (Stunting) in Both the Mareb City and Rural Mareb Zones
1: Stunting among children distributed per zone, residency place, gender, and age category 95% Conf Limits Stunting N % Lower Upper Moderate 67 25% 19.90% 30.60% Mareb City (n = 268) Severe 26 10% 6.40% 13.90% Moderate and Severe 93 35% 29% 41% Moderate 176 23% 20% 26% Rural Mareb (n = 777) Severe 52 7% 5% 9% Moderate and Severe 228 29% 26% 33% Moderate 114 22% 19% 26% Girls (n = 509) Severe 33 6% 5% 9% Moderate and Severe 147 29% 25% 33% Moderate 129 24% 21% 28% Boys (n = 536) Severe 44 8% 6% 11% Moderate and Severe 173 32% 29% 36% Moderate 18 15% 9% 23% 6 - below 12 months (n = 119) Severe 7 6% 2% 12% Moderate and Severe 25 21% 15% 30% Moderate 55 22% 17% 28% 12 - below 24 months (n = 246) Severe 23 9% 6% 14% Moderate and Severe 78 31% 26% 38% Moderate 56 26% 20% 32% 24 - below 36 months (n = 217) Severe 16 8% 4% 12% Moderate and Severe 72 34% 27% 40% Moderate 60 24% 19% 30% 36 - below 48 months (n = 251) Severe 15 6% 3% 10% Moderate and Severe 75 30% 24% 35% Moderate 54 26% 20% 32% 48 - below 60 months (n = 210) Severe 17 8% 5% 13%
89 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Moderate and Severe 71 34% 27% 40% Moderate 243 23% 21% 26% Mareb (n = 1045) Severe 78 7% 6% 9% Moderate and Severe 321 31% 28% 34%
90 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 7(B) – Weighted Levels of Malnutrition (Underweight) in Both the Mareb City and Rural Mareb Zones
2: Underweight among children distributed, gender, and age category 95% Conf Limits Underweight N % Lower Upper Moderate 69 22% 18% 27% Mareb City (n = 313) Severe 20 6% 4% 10% Moderate and Severe 89 28% 24% 34% Moderate 144 18% 16% 21% Rural Mareb (n = 780) Severe 30 4% 3% 5% Moderate and Severe 174 22% 20% 25% Moderate 92 17% 14% 21% Girls (n = 531) Severe 23 4% 3% 6% Moderate and Severe 115 21% 18% 25% Moderate 121 22% 18% 25% Boys (n = 562) Severe 27 5% 3% 7% Moderate and Severe 148 27% 23% 30% Moderate 2 5% 1% 16% 0- below 6 months (n = 43) Severe 6 13% 5% 28% Moderate and Severe 8 18% 8% 33% Moderate 21 17% 11% 25% 6 - below 12 months (n = 121) Severe 6 5% 2% 10% Moderate and Severe 27 22% 15% 31% Moderate 38 15% 11% 21% 12 - below 24 months (n = 246) Severe 13 5% 3% 9% Moderate and Severe 51 20% 16% 26% Moderate 51 23% 18% 29% 24 - below 36 months (n = 220) Severe 7 3% 1% 6% Moderate and Severe 58 26% 20% 32% Moderate 56 22% 17% 28% 36 - below 48 months (n = 251) Severe 6 3% 1% 5%
91 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Moderate and Severe 63 25% 20% 31% Moderate 46 22% 16% 28% 48 - below 60 months (n = 210) Severe 12 6% 3% 10% Moderate and Severe 58 28% 22% 34% Moderate 213 20% 17% 22% Mareb (n = 1094) Severe 50 5% 4% 6% Moderate and Severe 263 25% 22% 27%
92 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 7(C) – Weighted Levels of Acute Malnutrition (Wasting) by Weight for Height in Both the Mareb City and Rural Mareb Zones
3: Acute malnutrition (by WHZ) among children distributed, gender, and age category
95% Conf Limits Acute malnutrition (by WHZ) N % Lower Upper Moderate 25 9% 6% 13% Mareb City (n = 271) Severe 3 1% 0% 3% Moderate and Severe 28 10% 7% 14% Moderate 69 9% 7% 11% Rural Mareb (n = 777) Severe 9 1% 1% 2% Moderate and Severe 78 10% 8% 12% Moderate 35 7% 5% 9% Girls (n = 511) Severe 5 1% 0% 2% Moderate and Severe 40 8% 6% 10% Moderate 59 11% 9% 14% Boys (n = 537) Severe 7 1% 1% 3% Moderate and Severe 66 12% 10% 15% Moderate 14 12% 7% 19% 6 - below 12 months (n = 120) Severe 1 0% 0% 5% Moderate and Severe 15 12% 7% 20% Moderate 17 7% 4% 11% 12 - below 24 months (n = 247) Severe 6 2% 1% 5% Moderate and Severe 23 9% 6% 14% Moderate 19 9% 5% 13% 24 - below 36 months (n = 218) Severe 2 1% 0% 3% Moderate and Severe 21 10% 6% 14% Moderate 17 7% 4% 11% 36 - below 48 months (n = 251) Severe 1 1% 0% 2% Moderate and Severe 18 8% 4% 11% 48 - below 60 months (n = 210) Moderate 27 13% 9% 18%
93 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Severe 1 1% 0% 3% Moderate and Severe 28 14% 9% 19% Moderate 94 9% 7% 11% Mareb (n = 1049) Severe 11 1% 1% 2% Moderate and Severe 105 10% 8% 12%
94 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 7(D) – Weighted Levels of Acute Malnutrition (MUAC) in Both the Mareb City and Rural Mareb Zones
4: Acute malnutrition (by WHZ) among children distributed, gender, and age category 95% Conf Limits Acute malnutrition (by MUAC) N % Lower Upper Moderate 10 4% 2% 7% Mareb City (n = 271) Severe 2 1% 0% 3% Moderate and Severe 12 5% 2% 8% Moderate 23 3% 2% 4% Rural Mareb (n = 780) Severe 9 1% 1% 2% Moderate and Severe 32 4% 3% 6% Moderate 17 3% 2% 5% Girls (n = 512) Severe 7 1% 1% 3% Moderate and Severe 24 4% 3% 7% Moderate 16 3% 2% 5% Boys (n = 539) Severe 3 1% 0% 2% Moderate and Severe 19 4% 2% 6% Moderate 9 8% 3% 14% 6 - below 12 months (n = 122) Severe 6 5% 2% 10% Moderate and Severe 15 13% 7% 19% Moderate 12 5% 3% 8% 12 - below 24 months (n = 247) Severe 5 2% 1% 5% Moderate and Severe 17 7% 4% 11% Moderate 7 3% 1% 6% 24 - below 36 months (n = 219) Severe 0 0% 0% 2% Moderate and Severe 7 3% 1% 6% Moderate 1 1% 0% 2% 36 - below 48 months (n = 251) Severe 0 0% 0% 1% Moderate and Severe 1 1% 0% 2% Moderate 3 1% 0% 4% 48 - below 60 months (n = 210) Severe 0 0% 0% 2%
95 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Moderate and Severe 3 1% 0% 4% Moderate 33 3% 2% 4% Mareb (n = 1052) Severe 11 1% 1% 2% Moderate and Severe 44 4% 3% 6%
96 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Annex 8 – Sample Removal Decision Tree – Mareb Survey – July - August 2018
97 Nutritional Status and Mortality Survey – Mareb Governorate – July to August 2018
Mareb City Zone
34.70%
28.60%
10.10%
Chronic Malnutrition Chronic Acute Malnutrition Acute Malnutrition (Wasting) (Stunting) (Underweight)
Rural Mareb Zone
29.30%
22.00%
10.00%
Chronic Malnutrition Chronic Acute Malnutrition Acute Malnutrition (Wasting) (Stunting) (Underweight)
98