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Grand Gedeh County

FOOD SECURITY AND NUTRITION SURVEY

TABLE OF CONTENTS

3 Acknowledgement

3 Executive Summary

4 Background and Introduction

Economy of Grand Gedeh County Survey justification Objectives and methodology

7 Part I—Community Level Findings

Demographic information Land and resource access Education services Community perception of needs

10 Part II—Household Level Findings

Household Demography Household Circumstances Housing Assets ownership Agriculture Sources of Incomes Household Expenditures Frequency of food consumption Food aid Shocks and coping strategies

17 Part III—Nutrition and Health

Child nutritional status Health services HIV/AIDS knowledge

26 Part IV—Household Food Security and Consumption Typologies

Classification by Food consumption Description of the consumption groups

30 Recommendations

31 Appendices

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ACKNOWLEDGEMENT households were assessed. Food security, nutrition, mortality and other health indicators were collected WFP Liberia sponsored the Grand Gedeh County during the assessment. Food Security and Nutrition Survey in March 2005. WFP wishes to acknowledge the assistance provided The assessment indicates unstable food security by Government counterparts, NGOs and UN sister situation in the county. The survey reveals that some agencies. In particular, WFP is grateful to LRRRC and populations are not attaining adequate food ICRC in providing basic statistics and population consumption levels; characterized by low food figures, which were crucial for the development of the diversity, high proportion (over 60%) of household sampling frame and cluster identification. UNICEF’s expenditure used for food purchases at the expense support in the training of enumerators and supervision of other basic needs, low frequency of daily food of the whole exercise is also appreciated. UNHCR intake, low household asset holdings (mainly limited to Zwedru office seconded a vehicle and senior officer utensils and other relatively less valued household for supervision during the exercise. Their gesture is goods) and unreliable income sources. Agricultural highly acknowledged. The participation in production is still limited with over 80% of food items enumeration and supervisory assistance provided by sourced through markets. the Ministry of Planning and Economic Affairs (MPEA) and Ministry of Health and Social Welfare (MOH & SW) Although the communities are resettling in their through the County Health Team (CHT) is highly appreciated. villages, seeds and farming tools are not readily available nor do they have the capacity to purchase The contribution from the SC-UK which seconded the required farm tools. They will still heavily rely on their staff to assist with the data collection was external support to undertake farming activities. extremely helpful. The Humanitarian Information Centre (HIC) provided the much needed basic Generally, the communities have limited capacity to statistics on population data and maps. Various respond to problems afflicting them. For example, organizations including UNHCR, FAO, SC-UK and their capacity to construct schools, health facilities, others participated in the planning process and provided useful comments that were valuable in and involvement in constructive farming endeavours is carrying out the exercise. WFP is grateful for the constrained by high poverty levels. This makes them members of households, key informants and heads of extremely vulnerable to negative affects of shocks. community groups who rendered their time and Results indicate that while 50% of the households had provided the crucial information on livelihoods in experienced some shock ((in food or income access) Grand Gedeh County. over the previous 12 months, a significant proportion (10-20%) did not have enough mechanisms to absorb Finally, WFP is grateful to all who contributed in the negative impacts. various forms for the success of this survey including leadership of Grand Gedeh County, and county health Team. The nutrition survey results indicate a global acute malnutrition of 4.5% and severe acute malnutrition was 0.7%. The survey confirms high stunting levels EXECUTIVE SUMMARY (40%) with severe stunting (17%) observed in Liberia. Underweight is also high at 25%. Crude Mortality

Rate (CMR) is 1.27 deaths per 10,000 per day while WFP in collaboration with MOH & SW, UNICEF, and Under-Five Mortality Rate (U5MR) is extremely high at UNHCR conducted a food security and nutrition 3.34 deaths per 10,000 per day. The high Under Five survey in Grand Gedeh County from March 3-11, Mortality requires urgent follow up. Main causes of 2005. The survey provides baseline information on deaths among under-five year old children are the key food security and nutrition indicators and malaria, diarrhoeal diseases and acute respiratory possible causes of vulnerability in the County. The infections. Inadequate provision of health care results will facilitate the review of the already existing services, unsafe water and poor child feeding programmes and guide the planning and appropriate practices remain major issues of concern. Nearly targeting of future food assistance in Grand Gedeh three-quarters of the surveyed children were County and in Liberia in general. introduced to solid foods either too early or too late while only less than 4% continue to breastfeed up to The survey utilized both quantitative and qualitative the recommended age of two years. This signals information collected at both household and inadequate feeding practices. Teen-age pregnancies/ community levels. A two-stage cluster sampling mothers are reported to be the norm. High incidences methodology was used in which 30 communities were of malaria, diarrhoea and respiratory infections are randomly selected. In each community, at least 25 also reported while less than one-sixth of the mothers Page 3 of 51 sleep under mosquito nets with their young children. atmosphere of free movement in the County. In Assessment of HIV/AIDS awareness reveals appalling February 2005, Grand Gedeh was declared one of the statistics characterized by high levels of ignorance thirteen counties ready for resettlement in Liberia. about the pandemic, stigmatization, and discrimination. Less than one-fifth of the assessed Since the last population census of 1984, no other household have appropriate knowledge on the census has been conducted. However, population spread, prevention and care for the pandemic despite estimates by the National Seed and Tools Committee the reported cases of sexually transmitted infections in 1999 put the figure of Grand Gedeh County at (mainly gonorrhoea) amongst the residents 100,652 inhabitants. Majority were thought to reside in Tchien (52,060 people) while the population figures The survey reveals low enrolment of children in for Gbarzon and Konobo Districts were estimated at schools mainly due to inadequate equipment, long 24, 368 and 24, 224 respectively. However, like any distances, or lack of facility. Health service provision other remote county in Liberia, Grand Gedeh is far from adequate in the county. The communities experienced a net outflow of its residents during the heavily rely on sourcing basic food items from far wars of 1990s to 2003. The wars resulted into heavy markets in the neighbouring countries. losses including destruction of property and loss of life.

The report recommends the following actions as a Currently, it is estimated that about 28,587 people are priority in the county: urgent follow up on the high expected to be resettled in the county. This under-five mortality in the county; rehabilitation of population is still scattered in various camps in and outside Liberia, but mainly in camps around Monrovia. basic infrastructures such as schools and skills The county is also a home to some Internally training facilities; health service provision especially Displaced Persons (IDPs) and returnees, refugees urgent in remote parts of Tchien District; improvement and Third Country Nationals (TCNs) from Cote D’ Ivoire. in sanitation situation through construction of latrines and education, etc. Other recommendations include initiation of income generating activities especially Economy of Grand Gedeh County those involving women and the youth; focusing on education of girls to control teen-age motherhood; For a long time, the economy of Grand Gedeh County provision of agricultural tools and equipment; depended on timber production. However, following intensification of health and nutrition education mainly the imposition of UN sanctions on timber exports from focusing on primary health care and child feeding Liberia, timber production has somehow dwindled. practices and concerted HIV/AIDS awareness There is however an ongoing illegal indiscriminate campaigns in the county. felling of trees and subsequent black market sales as witnessed by the continued presence of trucks loaded with woods and timbers seen crossing though the BACKGROUND AND INTRODUCTION Guinean borders via Nimba County.

Grand Gedeh County is situated in the south-eastern Before 1990, residents of Grand Gedeh were also part of the Country and is bordered to the east by actively involved in large scale cash crop production Cote D’Ivoire. The county is enclosed by River Gee (mainly coffee and cocoa) as well as food crop and Sinoe counties to the South, and Nimba County production (mainly rice farming but also cassava and to the Northwest. The county has three districts, vegetables). Cash crop production offered the local namely: Gbarzon, Konobo and Tchien. River gee was residents income for purchase of other commodities however, part of Grand Gedeh until the year 2000. while food crops were mainly consumed locally. The residents were in most cases meeting their The county remained under the control of MODEL consumption needs through the local produce with rebels until the end of 2003. Security improved in the some surplus for exchange with other commodities County in 2004 following the deployment of UN from other counties and neighbouring countries. Crop peacekeeping Forces under UN Mission for Liberia production has been highly labour intensive (UNMIL) in September 2003 to restore order in the preoccupying the local farmers thus serving as their country. The Un Forces deployed in Grand Gedeh in primary source of livelihood. Ample rainfall and fertile late 2003/early 2004 ended the manning of road soil has been conducive for such production. Other checkpoints by combatants thereby allowing sources of food included palm oil sales, fishing and humanitarian organizations to deliver the much bush animal hunting. Grand Gedeh was known for needed humanitarian assistance to the remote areas. production of “bush foods”. Mining of natural Both the MODEL and the Government ex-combatants resources also supplemented the income sources of were disarmed and demobilized, culminating into an the population. Gold mining was common in the county. Page 4 of 51

However, since the war, minimal crop production is Nutrition: taking place. The residents are yet to resume active ƒ To estimate prevalence of acute malnutrition in crop production and largely remain net importers of children less than five years of age food commodities. In addition, income from timber ƒ To estimate a two-week cummulative morbidity production and gold mining has significantly reduced. rate in children less than five years of age ƒ To estimate Crude and under five mortality rates and causes of death over the past 6 months Survey justification ƒ To determine coverage of measles vaccination among children 6 – 59 months of age Grand Gedeh is regarded as one of the remotest ƒ To estimate coverage of Vitamin A supplementation counties in Liberia. The county had relatively limited in children less than 5 years of age humanitarian operations at the end of 2003 and 2004 ƒ To determine the prevalence of appropriate Infant as most agencies still feared the uncertain security and child feeding practices (introduction of situation. It is now that the county is opening up for complementary feeding). humanitarian operations albeit at a slow pace mainly due to extremely poor infrastructural network and Survey design limited data to guide interventions. Some remote areas A two-stage cluster sampling methodology was of the county are still less accessible due to poor road utilized in which 30 clusters were randomly selected conditions. There is still limited information existing on and 25 households surveyed in each cluster using the food security and nutrition situation in the county. general household/food security questionnaire. The 25 households plus an additional 5 (for a total of 30 Furthermore, in February 2005, Grand Gedeh County households) were assessed for mortality. was finally declared ready for the return and resettlement of refugees and IDPs. This brought to Qualitative and quantitative information were collected bear increased pressure and a sense of urgency to at community and household levels respectively. The provide concrete baseline information to guide community level data was collected through focus resettlement activities. As part of WFP operations, the group discussions with knowledgeable informants in vulnerability and nutrition assessment will provide the survey areas (both men and women together) in baseline data on food security, health and nutrition order to allow better understanding of opportunities situation in the county. The information will assist in and constraints to access basic services in the the planning and proper targeting of aid interventions communities. Food security, maternal and child health and allow proper impact assessment in the future. and nutrition data were collected at the household Various Partners in Nutrition and Food Security were level. The WFP Nutrition and Vulnerability Analysis involved including MOH, UNICEF, SC-UK and UNHCR. and Mapping (VAM) Units of Liberia designed the assessment methodology and tools and analyzed and wrote the survey report. Objectives and methodology Sampling Frame The survey provides baseline information on key food Population statistics are lacking for Grand Gedeh security and nutrition indicators and possible causes County. However a list of villages/towns with their of vulnerability in Grand Gedeh County. The results corresponding population estimates obtained from will facilitate review of already existing programmes LRRRC and ICRC was used as a basis for sampling and guide the planning and appropriate targeting of of communities/villages. future food assistance in Grand Gedeh County. Cluster Selection Specific objectives Counties in Liberia are divided into districts, clans and Food security and vulnerability: villages. Villages/communities were the smallest ƒ To determine the underlying food security sampling units used for selection of clusters. A list of situation in the county; villages and their corresponding population estimates ƒ To identify coping mechanisms available to the was obtained from the LRRRC and ICRC. A sampling population in the county; frame was established using the list of ƒ To assess peoples’ access to basic social services; villages/communities with their corresponding ƒ To identify the characteristics of vulnerable groups; population and household numbers. Cluster selection ƒ To determine the levels of vulnerability of the from each village/community was on a probability households. proportional to its population size giving equal chance of selection for each village. The cummulative size Page 5 of 51

(CUMM SIZE) of the estimated population was adjacent village on the left of the original village was 127,753 and divided by 30 to derive the Sampling used. Interval (SI) of 4,158. After calculating the Sampling Interval (SI) by dividing total population by 30, a When the team encountered a large village, the random number between 1 and the SI was drawn from village leader was asked to help in dividing the village a random number table to identify the first cluster. The into small segments. A list of segments was randomly selected number generated to select the first constructed containing the number of households. cluster was 448. The subsequent clusters were Similar to the first stage of sampling, the segment was selected by adding the sampling interval to the number selected with probability proportional to size. The total that identified the previous cluster. The sum and SI number of households in the selected segment was were added each time to select a new cluster. The noted to calculate the sampling interval and therefore sampling frame is shown in the table in appendices. the same procedure as described above was applied.

Microsoft Excel software was utilized to select the Sample sizes for Food security, Nutrition and sample. See annex showing the sampling frame. Mortality assessments Different sample sizes were selected depending on Household Selection the questionnaire administered although using the In the second stage of sampling, improved cluster same methodology. For the general household survey methodology was used. Household selection questionnaire (food security), 25 households were within a selected cluster employed systematic random assessed in each cluster. However, for mortality sampling, rather than the usual EPI methodology that survey, additional 5 households were included using entails identifying the center of the cluster and the same household sampling interval to reach a selecting a direction by spinning a bottle on the target of 30 households in a cluster. It is notable that ground. A systematic random sampling yields a more mortality assessment did not depend on presence of representative sample of households as all an under-five year old child in household but rather, households have equal chance of selection. only on the household sampling interval. On the other hand, the child anthropometry questionnaire largely On arrival to a village, a village leader was contacted depended on the presence and number of under-fives and asked to provide the total number of households in the various households visited for mortality or food in the village including new arrivals. The total number security interview. Only households with under-fives of households in the selected village was used to were assessed for anthropometry. Thus in a case calculate the sampling interval by dividing the total where a household had an under-five, all the three number of households by the number of households questionnaires were administered. Accordingly, 750 desired, in this case 30. Based on the sampling households were assessed for the general household interval, every nth household was selected and profile questionnaire, 900 households for mortality interviewed. A departure number was randomly assessment and 627 households for child selected and adding it to the interval to determine anthropometry. each household to be visited for administration of both the household questionnaire and measurement of Questionnaires children in case an under-five was present in that The survey data was collected through community household. The survey team started at the furthest and household interviews. The community point of the village and worked their way through to questionnaire is composed of the following indicators: the opposite end of the village. demographic information, economic, infrastructure, agriculture, education, health, markets, community If household members were not at home, a neighbor organizations and community priorities while the was consulted regarding the whereabouts of the household questionnaire is composed of the following household. If the members had departed permanently indicators; household demographics, household or would not return before the survey team had to circumstances and movements, housing, household leave the village, the household was skipped and and animal assets, agriculture, sources of income, replaced. The team supervisor made note of any household expenditures, food consumption, food aid, households replaced on the cluster control form. If Household risks and maternal health and nutrition. household members were expected to return, the The household questionnaire was used together with team visited the house before declaring absent and anthropometry and mortality questionnaire to collect replacing it. If the village fails to have enough household information. households with children meeting the criteria the

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Part I. COMMUNITY LEVEL FINDINGS However, the communities currently indicate that forest products, wild animals and collection of wild Demographic information palm nuts are the leading income generation activities in Gbarzon and Tchien Districts while forest products, mining (gold) and palm nuts collection are the major Population movements and displacements income activities in Konobo District. Fishing is also reported in Konobo and Gbarzon Districts. Thus, land, In the qualitative research, communities were asked forests, minerals and animals remain the prime about population movements/displacements since the natural resources in Grand Gedeh County. year 2000. Access to markets Compared to other counties like Lofa, Bomi, cape Mount etc in which over three quarters of the From the qualitative responses, most of the population had moved during the said period, only permanent food markets are outside the communities less than a half of the population had moved in Grand leading to difficult accessibility especially during the Gedeh County. This underscores the relatively lower rainy seasons. Majority of the communities in impact of the 2000s wars in the county as compared Gbarzon and Konobo districts have to walk for at least to counties situated to the west of Liberia. The a half-day to reach the nearest permanent food response was also similar in all the three districts with market. However, Tchien District is relatively the communities concurring that less than a half had adequately served with market centres and moved out. populations can manage to walk back and forth for food purchases. However, the respondents reveal that there were some displacements recorded in the county during the There are public as well as private vehicles available said period. The communities indicate that there is at in all of the districts for communities that are very far least 15%, 11% and 18% displaced persons currently from the permanent food markets. Such transport is in Gbarzon, Konobo, and Tchien Districts respectively. not regular in some places especially during rainy These internally displaced populations relocated to seasons. Transport cost is normally high for the poor areas within the county that were regarded as households. Transportation cost per person in either relatively more secure during the war. public or private transport averages LD$100-200 LD in all districts. Transporting a 50-kilogram bag of rice The communities further revealed that at least a half normally costs LD$60-150 on either public or private of those displaced from the county at the peak of war vehicle during the dry season. However, the cost is have already returned. In some districts like Tchien, it normally hiked during the rainy season to LD $100 – is estimated that up to 80% of the population 250 per bag of rice in Gbarzon and some villages of displaced from the county are already back. Majority Tchien District respectively. of the returnees have come spontaneously without undergoing the formal repatriation or resettlement Transporting a 50 kilogram bag of rice on foot costs procedure. LD$60 – 130 during the dry season and goes up to LD$70-150 during the rainy season. For the displaced populations still residing in Grand Gedeh, the fear of insecurity and damaged homes Transport is therefore a major drain on the purchasing were the most common reasons cited by the power of local residents considering that majority have communities as preventing their return. Other factors to rely on them for sourcing of commodities. hindering return specifically mentioned by IDPs in Konobo District were shortage of food in the returnee areas and lengthy repatriation process. Education services

Land and resource access Functioning School facilities

Natural resources From the community responses and confirmed by the County Education Office, there were 46, 38, 24 schools in Tchien, Gbarzon and Konobo Districts Prior to the war, agricultural production was the major respectively by 1990. A number of these educational source of livelihood for majority of the inhabitants of facilities were destroyed during the wars. Currently, Grand Gedeh County. The fertile agricultural land and there are 37, 31 and 15 schools in Tchien, Gbarzon, its vastness provided adequate natural resource for and Konobo Districts respectively. Most of these exploitation. schools operate at the primary level. The communities confirm that nearly eight of the ten Page 7 of 51 schools have been rehabilitated and re-opened in the sometimes, according to members of these county. English remains the main language of communities, run out of drugs. instruction in all of the schools. Water and sanitation-A large proportion of the Of the functional schools, WFP is currently providing assessed population does not have access to safe food rations to 28, 19 and 10 schools in Tchien, drinking water as most of the hand pumps were Gbarzon and Konobo Districts respectively. WFP destroyed during the wars. These pumps are yet to reveals that over 15,000 children received the WFP be rehabilitated. The functional hand pumps are ration in the month of February 2005 in Grand Gedeh insufficient to serve the communities especially during County. the dry season. Communities end up fetching water from unsafe sources like open wells and rivers. Use School enrolment and attendance of latrines is extremely low. The communities appear to recognise the importance of using latrines. Communities were asked to estimate the proportion of However, they cite need for assistance with boys and girls of primary school age (ages 6-14 construction materials. years) currently enrolled and attending schools. Rehabilitation of educational facilities, including skills Communities indicate that at least 50% of the children training–Although schools have been re-opened in the are already enrolled in schools. Enrolment is slightly county, the distribution is extremely inadequate. lower in Konobo as compared to areas districts in Children have to travel far distances to reach the Grand Gedeh County. Inaccessibility accounts for low nearest school. For example, it is mentioned that enrolments in Konobo District. most schools in Tchien District are concentrated around Zwedru city. The schools do not have enough Schooling problems learning materials; neither do they have enough qualified teachers. Thus, equipping existing schools Community members unable to send their children to with both manpower and other learning materials, in school cite lack of school fees, doing other work at addition to opening up more schools to serve remote home, no food, far distance from school, damaged areas, should be a priority. structures and no school in the locality as the major hindrances. There is also a large number of young ex-combatants who missed formal education due to wars. This group requires skills development. They require artisan Community perception of needs training institutions.

Development priorities Agriculture rehabilitation–Residents of Grand Gedeh In the focus group discussions, communities were are willing to be actively involved in agricultural asked to identify their immediate development production. However, they report inadequate or priorities. The three districts of Grand Gedeh County absence of seeds and tools. This so far limits their reported generally similar development priorities. By production capacity. ranking the priorities, the following were identified: Construction of shelters–Some of the shelters are Construction of Health facilities/provision of health partly damaged and are in deplorable condition. services – From the briefings, only a fraction of the Communities report leaking roofs. They indicate that Grand Gedeh population had easy access to the situation would be worse when it starts raining. functional health facilities. Most communities (over The residents need support to construct habitable three-quarters) in Tchien District do not have shelters. functional health facility within the vicinity and have to travel to Zwedru to seek medication or alternatively Community organizations wait for mobile clinics to come. It was not different for Gbarzon District where only 40% of the communities A number of organizations or groups have been reported functional health facility in the vicinity. In initiated in the communities. There are 10 local some of these communities, people have to walk at organizations in Tchien District, more than 15 in least five hours to access health services to the Gbarzon and just around 10 in Konobo district. nearest health facilities. The functional facilities are also reported to be ill equipped with observation of The organizations in both Tchien and Gbarzon drug shortages occasioned by the huge attendance of Districts undertake reconstruction of schools, patients. For example, in Tchien district, both reconstruction and maintenance of health facilities, residents of Gaye and Jarwodee Towns seek health maintenance of roads and rehabilitation of farms while services in Zleh Town or Polar Town clinics which those in Konobo district undertake rehabilitation of Page 8 of 51 farms, water and health facilities. These organizations are mainly supported by INGOs and UN agencies working in the county.

External organizations

Nearly all UN organizations are actively involved in supporting local structures within the county. A number of INGOs such as MERLIN, MSF, SC-UK, GTZ and ICRC are also involved in supporting activities in the county.

MSF runs the only referral hospital in the county, in addition to supporting a clinic in Zia town. Merlin supports 9Primary Health Care clinics in the county in addition to running mobile clinics in remote parts of the county. Save the Children UK is involved in provision of tools and seeds and the general food security activities. They are supported by GTZ and UNHCR. UNHCR is actively involved in repatriation activities in addition to supporting agriculture, capacity building, supporting rehabilitation of health facilities and schools.

WFP uses its food support to revive schools by giving both the girl child and other school going children hot lunches to sustain them in class, supports agricultural initiatives and road rehabilitation through food for work activities, provides resettled population with food, and supports clinics and hospitals, among other activities.

ICRC is involved in tracing and re-unification activities, supports agriculture, including fish pond projects.

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PART II. HOUSEHOLD LEVEL FINDINGS Household Circumstances

Household Demography Household status and movements

Household composition Returnees are almost half (48%) of the population in the county. Displaced populations only account for 8% The average size of households in the county is 7 of the households. The finding tallies with community people. Adults represent more than one-half of contention that at least a half of those who moved out household members. Females are slightly more than during the war have returned. Gbarzon District males. The average age of the household heads is 40 reported the highest proportion (66%) of returnee years. Females head at about 39% of the households households, followed by Konobo (40%) and Tchien in the county with the proportion slightly higher in (39%). However, Tchien has the highest proportion of Tchien District (at 43%). Children under 5 years old IDP households (12%) followed by Gbarzon (9%) and constitute 24% while proportion of boys attending Konobo (4%). A significant proportion of returnees are school is slightly higher than girls. The breakdown of from Cote D’Ivoire although some returnees are from the household demographic composition is presented counties within Liberia, mainly Montserrado, River on the table below. Gee and Rivercess while some few are from Guinea and Sierra Leone. The proportion of returnees from Table1: Household demographic composition by Cote D’Ivoire varied across the Districts. About 59% District. of returnee households in Gbarzon moved from Cote d’Ivoire while only 35% and 32% of returnees in Propor- Konobo and Tchien respectively are from Cote Propor- tion of D’Ivoire. Propor- tion of female Ave. age tion male children Propor- of house- The returnee population mainly came back prior to Under children in tion of Proportion hold Districts 5 years in school school adults of females heads 2000. Only 12% returned after 2004 implying that the last wars might not have resulted to massive Gbarzon 24 78 88 52 53 41 population movements. Konobo 26 70 67 51 51 39 Tchien 23 81 77 51 52 41 Reason preventing return to place of origin

Professions of household heads For the displaced populations in the county, insecurity is cited as the primary reason stopping them from Distribution of professions of households returning to the original places. Significantly higher proportion (68%) of displaced residents in Gbarzon Profession Total Proportion at District level District cited insecurity while only about a third of them Gbarzon Konobo Tchien mentioned insecurity in the other districts. Other Farmer/Gardener 67.2% 70.6% 53.6% 64.3% reasons cited for not returning include not enough Casual labourer 9.2% 1.5% 8.0% 6.0% resources in the returnee areas, not jobs in expected areas of return while some also report that their lands Trader/Seller 8.4% 9.2% 12.5% 9.9% back in the areas of origin are already occupied. It is Carpenter 1.2% 0.4% 2.7% 1.3% noted that some of the displaced populations are Teacher 4.0% 1.5% 4.0% 3.1% refugees from Cote D’Ivoire where insecurity is still a Other: (Blacksmith, major challenge. 8.4% 10.3% 16.5% 13.3% Tailor/Seamstress) Nothing 0.4% 3.3% 0.9% 1.6% Disability amongst the population

The main profession of households in the county is The households were asked if any of their members farming. Other professions mentioned are: are disabled. 15% of the households report that at trade/selling and casual labour (especially in Gbarzon least a member of their family is disabled. and Tchein Districts). The table below summarizes Lameness/polio, injury and blindness are the the professions of households by District. Some 3% of commonest forms of disabilities in the households. the households in Konobo District report doing nothing Amputees are also mentioned in the county. There to earn their livelihood. It is notable that professions was no variation in the number of disabilities across are more varied in Tchien District than others possibly the districts. due to the presence of a large city hosting populations of different professions.

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Housing Cooking fuel

Duration of stay in current dwelling Firewood is the most important source of cooking fuel for the majority of households. Another important Responses on the duration of stay in current dwellings source of cooking fuel is charcoal followed by fuel oil - were categorized as follows: Stay of up to 1 year; 2 -5 extracts from palm nuts The chart shows variations in years; 6 -20 years, and over 20 years of stay in monthly expenses on cooking fuel across the districts. current dwelling. Only 15% have stayed in their Tchien records the highest (12%) amount of current dwellings only for up to one year. Some 38% expenditure on charcoal. The district hosts Zwedru have stayed in their current dwellings for a period 2-5 city where charcoal is the main cooking fuel. years. The rest have stayed for 5 or more years in Household Monthly Cooking Fuel Expenditure their current dwellings. Gbarzon has the highest (18%) proportion of those who have stayed in their 100 2 current dwellings for more than 20 years as compared 90 to other districts with proportions less than 5%. The 80 70 response has implications of community requirements 60 for housing. Since the majority has stayed for several 50 1 years, poor housing can be more attributed to poverty 40 $/household $/household 30 than to wars although the later also had impacts. 20

expenditure in-Liberian in-Liberian expenditure 10 0 0 expenditure in USD- /household USD- in expenditure Persons sleeping in a house Gbarzon Konobo Tchien

Most dwellings are generally overcrowded with Liberian $ USD majority hosting 5 or more persons. About 14% report that more than 10 persons sleep in one room. Assets ownership Overcrowding in a room can be a major healthy risk to the residents. This observation is more in Tchien Ownership of assets has been categorized into five, District, probably due to its large urban population. as follows: Households with up to 2 assets, those with Airborne infections, like tuberculosis, are easily 3- 4 assets, a group with 5 - 6 assets, those who own spread in such environments. 7 -8 assets and those with 9 or more assets. Most (39%) households own 5-6 assets while only 11% of Condition of dwellings households own 9 or more assets.

Most (about 90%) residents report that their shelters Assets Ownership are not in good condition and require either 9 or more Gbarzon Konobo Tchien rehabilitation (81%) or complete re-construction (8%). This could be attributed to high poverty levels. Only 11% are satisfied with the condition of their current shelters. 7 t o 8

Lighting 5 t o 6

The primary source of lighting is kerosene lamps. 3 to 4 Kerosene is sourced from neighbouring Cote D’ Ivoire. Oil lamps are also common. Oil is extracted from palm nuts 0 to 2 through local processing. Households spend an 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% equivalent of US$ 5 per month on lighting. The breakdown % of household of lighting expenses is presented on the chart. It is noted that most of these assets are non- Household Monthly lighting Expenditure productive types with few productive assets, only

300 6 limited to farm tools like cutlass/axe and hoe. The 250 5 population in Grand Gedeh seems better off 200 4 compared to Lofa in terms of asset ownership where 150 3 majority had less than 5 assets. 100 2 /household $/household $/household 50 1 Variations were observed in asset ownership across

0 0 USD- in expenditure districts with Tchien recording the highest (15%) of expenditure in Liberian Liberian in expenditure Gbarzon Konobo Tchien those with 9 or more assets while only 7% of households in Gbarzon District owned as much. Liberian $ USD Page 11 of 51

Agriculture Sale of field crops is significant in all districts although slightly more in Gbarzon and Tchien. Agricultural Access to agriculture wage labour on the other hand is more in Gbarzon and Konobo Districts while petty trade/small business Access to land for agricultural production is not a and salaries/jobs appears to be mainly in Tchien problem in the county. However, some households District. Bush meat collection and palm oil sales are reported limited access to land, with the highest mainly reported in Konobo District. proportion (28%) recorded in Tchien. Residents of cities seem to have problems with accessibility to land While sale of field crops is reported as a primary than those in villages. Although land accessibility is source of income in all districts, secondary sources of not a major issue, few households own farm plots. income varied from cash crop sales and bush meat Most families are not fully involved in agricultural production in Konobo District to casual work in Tchien cultivation. The proportion (44%) of households not District. cultivating farm plots is higher in Tchien District followed by Konobo at 33%. In Konobo District, only In all districts, adults are the primary activists in 20% of the households do not own or cultivate farm sourcing income, whether primary or secondary. plots. Most of the agricultural land is owned by the However, children are also involved in income residents. However some 13% and 8% are squatting activities, participating in 18% of the income and renting respectively in Tchien District. However, generating activities. the proportion of squatters and those renting are lower (less than 5%) in both Konobo and Gbarzon Districts. Household Expenditures

Main Crops and plots cultivated Proportion of food expenditure is high in all the districts, with a county average food expenditure of A variety of crops are grown in the county. However, 62%. Cereals (rice and bulgur wheat) account for a rice is the most important crop grown in the districts, greater proportion of the expenditure on food. followed by cassava. Other crops grown in the county Respondents report frequent rice price fluctuations in include plantains/bananas, vegetables and other the market depending on availability and type. Other tubers, particularly eddoes and sweet potatoes. household expenditures are on commodities or Nearly all (98%) of farming households in Konobo services such as clothing, education, medical grow rice, while some 50% double with cultivation of expenses, transportation, debt payment, and social cassava. In Tchien and Gbarzon, about three- expenses. quarters of farming households grow rice. Some 59% and 39% of farming households double with Household expenditure in Gbarzon District cultivation of cassava in Gbarzon and Tchien Districts respectively. In addition to the above crops, about Household Expenditure Gbarzon District Social Other Rice 21% of the farming households cultivate 5% 6% 34% plantains/bananas and vegetables. Only 17% of the Clothing Cassava, 4% Potatoes farming households cultivate sweet potatoes. 6% Palm oil Education 5% 8% Food 59% Meat, fish, debt poultry 6% Sources of Incomes 3% Bulgur wheat Transportation 3% 13% The main income sources reported in the county are: Medical Other food 2% Sale of field crops (23%); small business; agriculture 5% wage labour (10%); small business (10%); casual labour (9%); sale of palm oil (9%); sale of bush meat (8%); and salaries/Government jobs and petty trade Over a half of the total household expenditure is used (both 5%). Other insignificant income sources include on food items. Again, rice accounts for 57% of sale of fish, sale of cash crops, skilled labour and expenditure on food. Compared to other districts, remittances. Gbarzon has the lowest proportion (59%) of expenditure on food. The district, however, has the All assessed households indicate at least a source of highest proportion (13%) of expenditure on income. However, only 39% of the households transportation when compared to other districts. The indicate that they have at least two income sources. district also has the highest proportion (3%) of debt Three or more income sources are not common in the settlement. The district also incurs expenditure on county, being reported by only 18% of the other non-food items like education, clothing, households. medicine, payment of debts, beer, cigarettes etc. Page 12 of 51

Household expenditure in Konobo District is different since nearly a half of the population are This district does not report payment of debts. returnees, some of whom resettled recently and are However, it has the highest proportion (65%) of food still consuming the resettlement food package, expenditures. Expenditure on cereals account for consisting of mainly bulgur wheat as the cereal item. about 45% of total spending on food, more than the However, as shown on the chart, Gbarzon District has combined expense on meat, oil, and tubers. the highest proportion of those consuming rice more often. Household Expenditure Konobo District Food Frequency Rice Ot her Rice 8% 29%

Social 80% 2% Cassava, Potatoes 5% 70% Gbarzon Clothing 60% 4% Palm oil 50% Food 10 % Konobo Educat ion 65% 40% 11% Meat, fish, poultry 13% 30% debt Tchien % of households 0% 20% B ulgur wheat 10% Transp ort at ion 1% 7% 0% Never Rarly (1 to 2 sometime (3 to 4 often (5 to 6 every day Medical Other food days) days) days) 4% 6%

Consumption of Bulgur wheat Education is also major expenditure in the district accounting for one-tenth of the total expenses. Other Consumption of bulgur wheat is more frequent in major expenditures by households include Gbarzon and Tchien Districts. These two districts transportation, clothing and medical bills. have got relatively high proportions of returnee and IDP households who receive/have been receiving Household expenditure in Tchien District WFP food rations. About 31% and 23% of households in Gbarzon and Tchien Districts Household Expenditure Tchien District respectively ate bulgur wheat at least more than twice Other Rice a week as compared to only 8% consuming bulgur 7% Social 28% wheat at the same frequency in Konobo District. 1% Cassava, Some 18% and 12% respectively consume bulgur Clothing Potatoes 4% wheat at least four times in a week in Gbarzon and 7% Food Palm oil Tchien Districts. It is notable that bulgur wheat can Educ at i on 64% 9% 10 % only be received through the WFP food support. Meat , f ish, debt poultry 10% 2% Consumption of maize meal Bulgur Transportat ion wheat 6% 3% Medical Other f ood Consumption of maize meal is generally uncommon. 4% 9% The majority (94%) of households report that they have never eaten maize meal. Only 6% of the households have eaten maize meal in the week prior Households devote over a third of their expenditure on to the survey. They only report occasional food. The combined expenditures on education, consumption of maize meal. clothing, transportation and medical treatment is only about a quarter of total household expenditure. Other Consumption of Cassava expenditures reported in the district include debt resettlement, and other social activities (susu clubs, Food Frequency Cassave smoking, taking of alcohol and the like).

50% 45% Gbarzon 40% Frequency of food consumption 35% 30% Konobo 25% Frequency of rice consumption 20% 15% Tchien Rice is the staple cereal commodity in Grand Gedeh % of households 10% County. With the exception Gbarzon, at least three- 5% quarters of households in the other districts consume 0% Never Rarly (1 to 2 sometime (3 to often (5 to 6 every day rice on daily basis. However, the situation in Gbarzon days) 4 days) days) Page 13 of 51

Cassava is the second most popular cereal Consumption of fish commodity in people’s diet. However, only few report Fish is the second most important source of protein consumption of cassava, mainly 1-4 times in a week. for the people in Grand Gedeh. As shown in the chart, Only about 5-10% of the households consume significant proportions of households report daily fish cassava on daily basis. Generally, consumption of intake in Tchien and Konobo as compared Gbarzon cassava is even much lower in Tchien when District. Fish has a wider consumption with most compared to other districts. families consuming it at least once in the week preceding the assessment. However, there is also a high proportion (15-25% across the districts) of those Consumption of Meat reporting no in take of fish in the week preceding the assessment.

Food Frequency Meat (Bush Meat) Food Frequency Fish

50% Gbarzon 50% 45% 45% Gbarzon 40% 40% 35% 35% 30% 30% Konobo Konobo 25% 25% 20% 20% 15% Tchien 15% % of households

% of households of % 10% 10% 5% 5% Tchi en 0% 0% Never Rarly (1 to 2 sometime (3 to 4 often (5 to 6 every day Never Rarl y (1 to 2 days) someti me (3 to 4 days) often (5 to 6 days) every day days) days) days)

Consumption of Vegetables and fruits Grand Gedeh County is popular with “bush meat”. As was reported in previous findings, about one-tenth of Food Frequency Vegetable the Grand Gedeh residents earn their livelihood through hunting and gathering. Some of this meat is 50% 45% supplied to other markets including Monrovia. Bush Gbarzon 40% meat is the most popular source of protein in all the 35% districts. The commodity is cheaper compared to 30% Konobo other protein sources. A significant proportion of the 25% 20% Grand Gedeh residents consume the commodity at 15% Tchien % of households of % least once in a day. Bush meat is commonest in 10% Konobo than other districts, possibly due to its relative 5% 0% remoteness and less frequent in Gbarzon District Never Rarly (1 to 2 sometime (3 to 4 often (5 to 6 every day where over half of the households rarely or never days) days) days) consumed meat in the week preceding the survey. Meat from domestic animals - cattle and goat - is also Households mainly report infrequent intake of consumed, albeit in smaller amounts vegetables in their diet with some 45% reporting none intake of vegetables in Konobo District in the week Consumption of Pulses prior to the survey. Daily intake of vegetables is Consumption of pulses is also uncommon in the reported by only between 3 and 10% of households in county, explained possibly by the product’s the districts. Tchien fairs relatively better in vegetable unavailability and relatively high cost. Over three- consumption when compared to other districts. This quarters of the respondents did not consume pulses in could be associated with the relatively enlightened the week prior to the assessment with those who residents of urban centres in the district. reported consumption, only indicating eating the product occasionally. Consumption of fruits is not common with some two- thirds of the surveyed households reporting no intake In comparison, Konobo recorded the lowest proportion of the commodity in the week before the assessment. of those managing to eat pulses. Districts like Tchien People rarely consume fruits despite its vastness in and Gbarzon have comparatively better access to the forests. markets thus managing to purchase the commodity once in a while.

Page 14 of 51

Consumption of poultry Food aid

People rarely eat chicken; neither do they consume The households were asked if any of their members eggs, in Grand Gedeh County. The proportion of had received food aid through any of the WFP feeding poultry consumption in week preceding the programmes. Over a third (34%) of the households assessment ranges between 1-9% for those who report at least a member of the family had receiving rarely manage to consume either eggs or chicken. WFP ration within the month preceding the The same observation was noted in Lofa County. assessment. While 53% of the households reported a Less than 1% consumes poultry frequently (at least member receiving food aid in Tchien, the proportion four times). was 42% and 10% respectively in Gbarzon and Konobo Districts respectively. About 90-99% of the Consumption of oil free food rations were mainly provided through the

Food Frequency Palm Oil emergency school feeding in the county. Konobo has less operational schools than the other districts.

50%

45% Gbarzon Shocks and coping strategies 40%

35%

30% Konobo The assessment sought to know the perceived levels 25% of vulnerability to food insecurity occasioned by any 20% shock and/or problem experienced in the previous one

% of households % Tchien 15% year. 10%

5%

0% The residents of Grand Gedeh report improved Never Rarly (1 to 2 sometime (3 to often (5 to 6 every day days) 4 days) days) security situation in the 12 months preceding the assessment.

Palm oil intake is reportedly frequent in all districts. Thus, household mainly reported natural and external Only a small group of households report that they had shocks in the last 12 months. The commonly never eaten the commodity. Less than 10% of the mentioned shocks were: Sudden price fluctuations Grand Gedeh residents report no intake of oil in (especially prices of rice frequently changing); the week prior to the assessment. It is notable irregular rains (more than normal or too much) leading that oil is normally used to prepare most meals. It to floods; high winds/storms; and unusually high level is only in extreme circumstances of that of crop pests & disease. About a half of the households prepare foods with no oil. While palm households experienced one shock or another in the oil remains the major type of oil used by residents, year preceding the assessment. some households also reported consumption of vegetable oil in the week preceding the survey. Households typically respond to these shocks Vegetable oil is distributed by WFP ration and some through: Reduction in the quality/quantity of diet; households might have benefited through free food seeking assistance from community members; distributions. begging; additional wage labour; and decreased

expenditures on essential commodities. Reduction in Consumption of Sugar, Milk and Bread food quantity and quality appear to be the most

common strategy applied by of the households except At least 8% of the households report daily intake of in Tchien District where begging is reported as sugar. However, nearly three-quarters of the surveyed common. Begging is normally rampant in urban set- households did not eat sugar in the week preceding ups than rural villages. Zwedru, the largest town in the survey. Grand Gedeh is situated in Tchien, offering home to Some 2% of the households report daily consumption most beggers. Some 10-15% reported no particular of milk in the week before the survey. However, coping strategy. overwhelming majority (9%) had not taken milk in the same week. In the event of failure in the above coping strategies,

household resort to credit, going without meals for Although bread is a non-staple commodity, some 35% some days, spending savings or investment of the households reported at least some consumption (withdrawing from susu clubs, selling productive of the commodity in the week before the survey. This assets), sending children to work for money/food; or proportion is higher than the observation in Lofa that moving entire family to new locations. indicated at least some intake by only 25% of the households. Page 15 of 51

Most households would use more than one coping strategy in the event of a shock. However, only 25- 35% of the households have up to three coping strategies. In Gbarzon, majority (56%) use the primary coping strategy, the highest proportion observed for those using a single coping strategy. On the other hand, Konobo has the highest proportion (33%) of those using up to two coping strategies and Tchien recorded the highest proportion (20%)of those employing up to three coping strategies.

In addition to the shocks mentioned above, households also experienced varied problems in the year preceding the assessment. Problems mentioned were: Serious illness of a working and/or other member of household; death of a working and/or other household member; and theft and/or violence.

Page 16 of 51

PART III. NUTRITION AND HEALTH As presented in the table above, acute malnutrition was significantly higher amongst the younger age group (6-29 months) than among children aged 30-59 Child nutritional status months. The age bracket 6-29 months is normally associated with introduction of complementary and The survey team randomly surveyed 900 households weaning foods. It is at this age when children are for mortality and anthropometric measurements in the more prone to common childhood diseases mainly 30 randomly selected communities in Grand Gedeh resulting from poor feeding practices (unhygienic County. Of these households, 627 had children aged preparation of foods, use of unclean water, 6-59 months thus qualifying for anthropometric introduction to family foods which are in most cases assessment. Nine hundred and thirty six (936) inappropriate for the digestive system of the young children aged 6-59 months were assessed. However, etc.). The finding confirms survey results elsewhere 20 children were dropped at analysis mainly due to in Liberia (WFP Surveys in Montserrado, Lofa, Nimba incomplete records and/or extreme measurements. Of and Bomi counties) that reveals higher levels of acute the 916 children analysed, 50.2% were boys giving an malnutrition amongst the younger age group (6-29 overall ration of boys to girls at 0.99, a finding within months). the recommended range of 0.9 – 1.1. There was no sex bias in the selection of children (see graph on Prevalence of Acute Malnutrition based on weight-for-height z- distribution of children). The distribution of the scores and/or Oedema Grand Gedeh County, March 2005 6-59 months 6-29 months 30-59 months surveyed children was normal for children aged 6-59 n = 916 n = 490 n=426 months in developing countries. Prevalence of No. = 41 No. =36 No. = 5 GAM % = 4.5 % = 7.3 % = 1.2 Distribution of children Aged 6- 59 months by gender, Grand (<-2 z-scores 95% C.I (3.3 95% C.I (5.3 95% CI (0.4 - 2.9) Gedeh County March 2005 WFH and/or – 6.1) – 10.1) Female Male Total children oedema) No. % No. % No. % Prevalence of No. = 6 No. = 4 No. =2 6 –17 110 46.2 128 53.8 238 26 SAM % = 0.7 % = 0.8 % =0.5 months (<-3 z-scores 95% C.I (0.3 - 95% C.I (0.3 95% CI (0.1 –1.9) 18 –29 123 48.8 129 51.2 252 27.5 WFH and/or 1.5) –2.2) months oedema) 30 –41 113 54.6 94 45.4 207 22.6 months Relatively poor child feeding practices and inadequate 42 –53 73 50.3 72 49.7 145 15.8 months hygiene behaviour has been associated with the 54 –59 37 50 37 50 74 8.1 observed higher malnutrition among younger children. months The population in Grand Gedeh mainly fetch their Total 456 49.8 460 50.2 916 100 water from unprotected sources, mainly from rivers. Water is hardly boiled or treated even for the younger children. Rice is the main food provided to younger Acute Malnutrition children. It is in most cases prepared as a family dish which may not be appropriate for the younger Global Acute Malnutrition (Weight/Height <-2 z-scores children. As presented in the table above, there was and/or oedema) was relatively low at 4.5% (95%CI 3.3 no significant variation in the prevalence of acute – 6.1) while severe wasting was 0.7% (95% CI 0.3- 1.5). Four oedema cases were noted. As shown on the chart below, this level of malnutrition is within Prevalence of Acute Malnutrition by Gender based acceptable levels and almost equals the reference on Weight For Height z-score and or oedema, population statistics. Gender Severe Acute Global Acute Malnutrition Malnutrition (<-3 z- (<-2 z-score and/or Weight for Height Z-score score and/or oedema oedema) Males No.= 2 No. =24 N=460 %= 0.4 %= 5.2 25 95% CI (0.1 –1.7) 95% CI= (3.4 – 7.8) % popn. Reference 20 Female No.= 4 No. =17 Sex Combined N=456 %= 0.9 %= 3.7 Boys 95% CI (0.3 –2.4) 95% CI= (2.3 - 6.0) 15 Girls 10 malnutrition across gender.

5 As indicated in the table, Konobo has slightly higher 0 prevalence of acute malnutrition. However, the -6 -4 -2 0 2 4 6 difference is not statistically significant (P- -5 value=0.291). Page 17 of 51

Prevalence of chronic malnutrition/stunting (HFA) by z-score The graph above presents the distribution of chronic across the Districts of Grand Gedeh County, March 2005 malnutrition as compared to the distribution exhibited Severe Moderate Overall >=-2 z- Total by the reference population. It shows a significant stunting stunting stunting core HFA shift of the nutritional status of children to the negative (not stunted) side indicating worse malnutrition levels as marked by Gbarzon 61 70 131 181 312 stunting levels. Significantly high proportions (over (19.6%) (22.4%) (42.0%) (58.0%) (34.1%) 60%) of children are distributed outside the reference Konobo 48 82 130 181 311 normal distribution curve. Stunting not only has (15.4%) (26.4%) (41.8%) (58.2%) (34.0%) Tchien 41 68 109 184 293 implication on survival levels, but also a negative (14.0%) (23.2%) (37.2%) (62.8%) (32.0%) implication on productivity. Total 150 220 370 546 916 (16.4%) (24.0%) (40.4%) (59.6%) The high proportions of stunting could mean that children suffered repeated episodes of wasting at Stunting/Chronic Malnutrition younger ages, an observation that correlates well to the relatively higher levels of wasting among children Fourty percent of children surveyed in Grand Gedeh aged 6-29 months. Chronic malnutrition portrays County were stunted (too short for their age) with longer-term socio-economic problems including poor nearly one of every six (16.4%) children severely feeding practices, consumption of unsafe water, stunted (see table below). unsanitary environment and common childhood illnesses. Chronic malnutrition levels correlate highly Prevalence of Chronic Malnutrition/Stunting based on Height- with poverty levels. In sub-Saharan Africa the for-Age z-scores, March 2005 malnutrition levels over 30% correlate with poverty 6-59 6-29 30-59 months months months n=426 levels in the region. Liberia has high poverty levels, n = 916 n = 490 unsanitary conditions (low usage of toilets and poor Prevalence of No. = 370 No. = 175 No. = 195 waste disposal) and high illiteracy levels. Addressing Stunting % = 40.4 % = 35.7 % = 45.8 chronic malnutrition requires concerted efforts from all (<-2 z-scores 95% C.I 95% C.I 95% CI (41.0- HFA (20.9- (31.5-40.2) 50.6) stakeholders to correct these serious underlying 26.4) problems. It is well documented that stunted children Prevalence of No. = 150 No. = 61 No. = 89 will never attain their optimal learning capacities. Severe Stunting % = 16.4 % = 12.4 % = 20.9 As shown on the table, stunting levels were generally (<-3 z-scores 95% C.I 95% C.I 95% C.I (17.2 – HFA (14.1– (9.7 –15.8) 25.1) high across all the districts in Grand Gedeh County. 19.0) Under-Weight or Weight for Age This confirms results from previous nutrition survey in As shown on the table below, about one-quarter of the Liberia that have consistently shown similarly higher surveyed children were underweight (a combination of levels of stunting with the national average reported at both wasting and stunting) with about 6% of the 39% (Liberia National Nutrition Survey 2000). The Bomi children severely underweight. The finding is almost and Cape Mount Nutrition survey had also indicated high similar to those of previous surveys in Liberia as well levels of stunting (44% with a 95% CI40.1- 48). as national figure of about 27% (DHS 2000).

As expected, chronic malnutrition was significantly Prevalence of Underweight based on weight-for-Age z-scores, March 2005 higher among children aged 30-59 months than the 6-59 6-29 30-59 younger children. Chronic malnutrition is cumulative and months months months would normally be manifested after two years of age. n = 916 n = 490 n=426 It results from repeated episodes of disease infections Prevalence of No. = 216 No. = 137 No. = 79 and or repeated occurrences of acute food insecurity. underweight % = 23.6 % = 28 % = 18.5 (<-2 z-scores WFA 95% C.I 95% C.I 95% CI (15- and/or oedema) (20.9-26.5) (24.1-32.2) 22.6) Height For Age Z-score (stunting) 25 Prevalence of No. = 55 No. = 37 No. = 18 % population Severe underweight % = 6.0 % = 7.6 % = 4.2 20 (<-3 z-scores WFA 95% C.I 95% C.I (5.4 95% C.I and/or oedema) (4.6-7.8) –10.4) (2.6-6.7) Reference 15 Sex Combined Boys The graph shows the distribution of underweight as Girls 10 compared to the standard distribution of a reference population. As is depicted, the graph has shifted to 5 the left signalling a negative shift in the nutritional status of the population in Grand Gedeh. 0 Underweight portrays the overall growth of the child. It -6 -4 -2 0 2 46 is normally recommended for use in Growth -5 Page 18 of 51

Weight for Age Z-score 25 % population. and general maintenance to all the other health 20 Reference facilities in the county. MERLIN is also providing Sex Combined ambulance services in the entire county especially in 15 Boys areas where there is no health facility. Health services Girls 10 are free of charge in all the health facilities.

5 Qualitative findings also reveal that malaria and

0 diarrhea are the main sicknesses affecting both -6 -4 -2 0 2 46 children and adults in the three districts. Furthermore, -5 children are suffering from cold/ cough, while adults suffer from STIs (mainly gonorrhea). Majority (70%) of Monitoring. Higher rates of underweight are a the community members seek medical assistance from national concern as it signifies general poor growth of health centers. However, some communities resort to the children which if not corrected, eventually has a heavy negative toll on the economy. A malnourished either seeking treatment from traditional healers or child is more likely to suffer more episodes of common using self – prescribed medications from drug stores. child illness, which is not only an economic drain but also has implications of child survival. Water sources

Health services Majority of the residents of Grand Gedeh County indicate use of boreholes with hand pumps as their primary source of drinking water. About three- Access to health care quarters (78%) of households in Tchien, 70% Konobo and 53% in Gbarzon Districts respectively source There were only 10 health facilities and one referral their drinking water from hand pumps. hospital (Martha Tubman Memorial hospital) in the County by 1990. Gbarzon District had four health However, some households fetch drinking water from facilities and Konobo, three, while Tchien District had ponds, streams or rivers. These sources rank as the four health facilities. Most of these health facilities were second most important in the county. The sources subsequently destroyed during the war. However, majority are more common; Gbarzon District reporting usage of them have since been renovated with the help of by a quarter of the surveyed households, followed by UNHCR in collaboration with international medical Konobo District at 17% while only 6% of the households organizations (mainly MERLIN and MSF-Belgium). in Tchien District report usage of the sources.

Currently there are three health centres in Gbarzon, There is also a significant proportion of the population three in Konobo and five health centres in Tchien sourcing drinking water from wells. The proportion is District. While most of the previous facilities were 21%, 15% and 12% respectively in Gbarzon, Tchien renovated, few new facilities have been constructed in and Konobo Districts. areas where none existed before. However, group discussions with the inhabitants reveal that only a small On the whole, some residents, nearly half (47%) of Gbarzon, proportion of the Grand Gedeh residents have good 30% of Konobo and 22% of Tchien Districts respectively, draw water from unprotected sources. This shows a high access to functional health facilities. In Gbarzon proportion of people consuming unsafe water. District, the community indicated that only 40% have

easy access while only 60% of population in Konobo Sanitation District and a paltry 10% in Tchien District have easy access to functional health facilities. In some parts of A high proportion (83%) of the households visits Tchien District, populations have to walk long distances bushes for toiletry. Only some one-tenth of the to reach the nearest health facility, especially on days households visit traditional pit latrines for toiletry while when mobile services are not available. some other 5% of the households visit open pits. The use of VIP latrines is extremely rare with Konobo and The Martha Tubman Memorial hospital and Ziah Clinic Tchien districts recording a similar proportion of only are operated by MSF-Belgium. MSF-Belgium also 2% of the households. The VIP latrines are only implements supplementary feeding programme at the found in major urban centres within the county Marter Tulman Memorial Hospital with support from especially in Zwedru. These facilities are usually WFP. The hospital, located in Zwedru city, Tchien constructed by NGOs. District, still remains the only referral health facility in the county. MERLIN is providing drugs, incentives There are no significant differences in access to toilet facilities across the districts. While 88% of the Page 19 of 51 households in Gbarzon visit bushes for toiletry, the the reportedly immunized children. Tchein District had proportion is 85% and 74% respectively for Konobo the lowest coverage of measles vaccination at only and Tchien Districts. 65% compared to Gbarzon District which reported coverage of about 80%. Morbidity M easles immuniation and V itamin A supplementation in Over a half (52%) of the surveyed children had Grand Gedeh Count y, M arch 0 5 10 0 measles vaccine developed a symptom of sicknesses in the two weeks Verified by card 90 prior to the survey. As presented in the table below, never immunised the commonest symptom of sickness experienced by 80 Immunized in last 6 months children is fever followed by diarrhea, malaria, and 70 Received Vit-A supplement coughing in that order. The survey could verify the 60 reported malaria cases. However, the high incidences of 50 fever could signal other diseases like malaria, ARI etc. 40

Seventeen children were suspected by the respondents 30 to have had measles in the previous two weeks. 20

10 About 56% of the mothers had suffered from either 0 fever or diarrhea in the two weeks prior to the survey Gbarzon Konobo Tchien G. Gedeh County with about one-sixth of the interviewed mothers indicating that they suffered from both the two disease symptoms. As for the adult mothers, fever was again The coverage of Vitamin A supplementation in the 6 the commonest sign of sickness (49%). Diarrhoea was months prior to the survey was 94.5%. NIDs carried also common with nearly a quarter of the respondents out in 2004 were accompanied by administration of reporting diarrhoea in the two weeks prior to the Vitamin A supplements. This explains the relatively survey. The result underscores the glaring statistics higher Vitamin A supplementation coverage. of worrisome disease burden. According to MOH monthly epidemiological statistics (1993-2003), at least Tchien District reported a lower coverage of vitamin A 3.5% of the outpatient morbidity consultations result in supplementation than the other districts. Conversely, hospital admission with a current inpatient death rate at Tchien is relatively more accessible than the other 67 per 1000 admissions. The statistics showed that on districts of Grand Gedeh. Thus, reasons for the average, there were 1.5 million morbidity cases seen relatively low coverage for both measles immunization each year at health facilities in Liberia. This makes and Vitamin A supplementation can not be adequately Liberia to be a generally “sick ling population”. Further explained. A clear understanding of the reasons for to the previously high disease caseload, the such observation will be useful for the planning future prevalence of HIV/AIDS is reported to be on the exercises. increase all over Liberia. The current national HIV/AIDS prevalence is estimated at 8-12% (NACP 2004). This could have a heavy toll on the morbidity trend thereby worsening morbidity caseload in Liberia.

Measles Immunization and Vitamin A supplementation Coverage

Immunization of children is important for boosting their immune system. Fully immunized children are less susceptible to common childhood infections and are better equipped to fight off the illnesses than children who are not immunized. Measles vaccine is normally administered to children at the age of six months or when they are suspected to have suffered episodes of infections that might have altered their reserve systems. Overall, 71.6% of the eligible children (9-59 months) had received the measles vaccine. The survey reveals that only about a third (35%) of the children received the measles vaccine in the six months prior to the survey. Verified immunization was even much lower at only about a quarter (24.7%) of Page 20 of 51

Mortality high mortality levels among under-fives should be a cause for concern in the county. This collaborates Retrospective mortality data was collected utilizing with the high morbidity levels. Diarrhea (30%), acute ACF’s methodology as outlined in their book titled, respiratory infections (14.4%) and fever (110.4%) Assessment and Treatment of Malnutrition in were the main causes of death among under-fives. Emergencies. The time period for collecting the data Respondents could not state the causes for a high was about 184 days, i.e., September 1, 2004 through proportion of deaths, a further indication of inadequate the time of the survey. A total of 898 households use of diagnostic tests. were visited in randomly selected 30 clusters. The total number of household members was 6,360 with To interpret crude and <5 mortality, thresholds have the under-five year population of 1,394. been established. The emergency threshold for CMR is 0.9/10,000 per day for Sub-Saharan Africa; greater Symptoms of illness at death than 0.9/10,000 per day indicates an emergency2. 100

90 For under-five year olds, the emergency threshold for 80 mortality rates is 2.3/ 10,000 per day in Sub-Saharan 70 <5years Africa; greater than 2.3/10,000 per day indicates an 60

n

o >5years emergency3. i

t

r 50

o

p

o r 40

P 30 Access to health and child care practices by 20 mothers during pregnancy and lactation 10 0 Diarrhoea ARI Fever Malnutrition Measles War- Unknown Others Information on mother and child care practices was related disease injuries elicited from 750 families randomly selected in 30 clusters.

The crude mortality rate (CMR) was 1.27 deaths per Results from the interviews indicate that women start 10,000 people per day. The under 5 years of age giving birth at a very young age averaging only 17 mortality rate (U5MR) was 3.34 deaths per 10,000 years with a range of 13 - 45 years. A significant under five population per day. The CMR is less than majority (about 82%) of the mothers indicate that they the threshold1 of 2 deaths per 10,000 population per first delivered before their 20th birthday. The finding day that characterizes emergency. However, the signals sexual debut among women at a very tender CMR is higher than the average in Sub-Saharan age. This collaborates with the high levels of illiteracy Africa of 0.9/10,000 per day. Previous results had (over 70%) amongst the population with women being indicated a generally “sickling population”. Life the most affected. The statistics reveal a glaring expectancy is only at 47.7 years (DHS 2000) while problem of teen-age pregnancies and mothers. WHO 1998 State of the World Report indicated that About a half (49%) of the mothers were either 80% of Liberians die before their 50th birthday. Most pregnant or lactating at the time of the survey. Some deaths among adults were attributed to fever - a one-tenth of the mothers confirmed pregnancy while possible symptom of malaria - (24%), respiratory some 2% were unsure of pregnancy at the time of the infections (24%), and unknown causes, signaling survey. On average, mothers report having been inadequate utilization of diagnostic health services, pregnant at least 5.4 times (with a range of 1-16 either due to their absence or to the population’s lack pregnancies) while they only have an average of 3.8 of understanding of their importance. Deaths live children at the time of interview. Some mothers occasioned by war related injuries were also reported report up to 13 children although majority (65%) have in 12% of the cases. Measles was not mentioned as between 2 and 5 children. This indicates a generally a cause of death amongst the population aged more high fertility rate among the survey households but than 5 years. also with high child mortality rates. This corroborates the mortality assessment which showed heightened The U5MR was greater than the threshold of 2.3 mortality rates among the under-five year old children. deaths/ 10,000 population per day that characterizes The high fertility coupled with high under-five deaths is emergency in most Sub-Saharan Africa settings. The

2 The Sphere Project: Humanitarian Charter and Minimum 1 The threshold chosen for the interpretation of the mortality rate (Moren, Standards in Disaster Response, Oxfam Publishing, second 1995) as cited by ACF, assessment and treatment of malnutrition in edition, 2004. emergency situations 3 The Sphere Project: Humanitarian Charter and Minimum Total population: alert cut-off = 1/10,000 people/day, emergency: 2/10,000 people/day Standards in Disaster Response, Oxfam Publishing, second Children <5 years = alert cut-off = 2/10,000 children/day, emergency = edition, 2004. 4/10,000 people/day Page 21 of 51 a common observation especially in populations with About two-thirds of the respondents use soap to wash high illiteracy levels and undeveloped health system. their hands after toiletry. However, some 35% do not Qualitative findings also indicate poor child spacing wash their hands or use only water to clean their with a number of women reporting two births in less hands after toiletry, an observation that could signal than two years. The date of first birth and level of either poor knowledge on the hygiene issues or education among women is highly correlated to absolute poverty that makes it unaffordable for number of children a woman bears in her lifetime. mothers to use detergents. As the primary caretakers Lower literacy levels would normally be associated of the young children, there is high risk of transmitting with high numbers of births. The above findings germs from unclean hands to the child if mothers do confirm similar observations in Liberia (WFP nutrition not disinfect their hands after toiletry or any other surveys, 2004 and DHS 2000). contact with germs. Furthermore, unclean hands would normally lead to rapid spread of infectious Care for women during pregnancy and lactation diseases such diarrhoeal infections. Characteristic Outcome No. & proportion Ever received iron-folate Yes 44 (67.7%) tablet during current Infant feeding practices pregnancy? Vitamin A Yes 208 (27.7%) WHO Breast Feeding and complementary Feeding supplementation after Indicators in children 6-24 months of age, Grand Gedeh delivery Slept under mosquito Yes 124 (16.5%) County, March, 2005 (n=397) net with child Indicators Total No % Do you wash hand after No 75 (10.0%) Timely Complementary feeding n=365 96 26.3% visiting toilet? Use water only 187 (24.9%) with solid foods started at 6-9 Using soap and water 488 (65.1%) months Introduced to solid foods before n=365 180 49.3% At the time of survey, majority (69%) of the pregnant 6 months women were 5-9 months’ pregnant. Of these Introduced to solid foods after 9 N=365 89 24.4% mothers, nearly two-thirds had received iron-folate months tablets. Majority get these prescriptions from health Proportion of children aged 6-24 n=397 271 68.3% workers. This could be an indication of the widely months currently breastfeeding believed high prevalence of anaemia amongst the Continued breast feeding n=262 140 53.4% beyond 1 year mothers. It is also a positive signal that the necessary Continued breast feeding n=515 17 3.3% precautions and health advice is sought during beyond 2 years (>24 months) pregnancy. However, only about one-third were Average age of introducing 8.4 months (SD 7.2) taking the recommended dosage of one tablet per solid foods day, with the majority either just consuming the tablet Average age of introducing 2.98 months (SD=3.1) once in a while, or a few over-dosing themselves. liquids Overdose can be a major health risk in pregnancy. Average age of stopping 17.4 months (SD=4.9) breastfeeding Of the respondents, only 28% of the mothers indicate Frequency of feeding in a day 1-2 times------203 (51.1%) having received Vitamin A supplementation after the for children aged 6-24 months >3 times------194 (48.9%) birth of their last born. Considering the high Infant feeding practices are determinants of the health prevalence of Vitamin A deficiencies, the and nutritional status of a child. WHO recommends supplementation coverage was extremely low. This that an infant should be exclusively breast fed for the finding is a big contrast to the high coverage (about first 4 to 6 months of age and complementary food 95%) of Vitamin A supplementation among the under- should be introduced progressively thereafter. fives. However, the observation is no different from other findings in Liberia that show similarly lower Overall, 53% of children aged below two years were Vitamin A supplementation coverage among mothers. breast fed beyond their first birthday. The proportion drops further with only 3% breastfeeding until their Only 16.5% of the pregnant/lactating mothers slept second birthday. Only about two-thirds of the children under mosquito net the night prior to the survey. aged 6-24 months were breastfeeding at the time of Malaria is one of the leading causes of death among survey, implying that significantly more children were under-fives and even adults in Liberia. The disease not breastfeeding. While majority (97%) of the also has far reaching consequences on the life of children aged 6-12 months were still breastfeeding, unborn baby if the pregnant mother develops malaria. only about a half of the children aged 13-24 months There are increased chances of the mother becoming continue breast feed. WHO recommends breast anaemic- which could complicate delivery of the child feeding up to the age of two years. Findings from - aborting the pregnancy or having a preterm delivery. other surveys conducted in Liberia reveal an almost

Page 22 of 51 universal breastfeeding by mothers. However, also reveal that the population would not bother going continued breastfeeding beyond one year is for HIV tests as long as they look healthy noting that remarkably low. Qualitative findings indicate that by or the results is not necessary as HIV/AIDS cases are immediately after the first birthday of most children, only seen in the spectrum of succumbing to death or their mothers are already pregnant; at times leading to looking remarkably sick ling. Of those who know that abrupt stoppage of breastfeeding especially, among HIV/AIDS exists, almost 40% either refuse or do not the teen-age mothers. The mean age of stopping know that it is possible for a healthy looking person to breastfeeding was however, about 17 months with an have the virus that causes AIDS. equally large variance. This indicates that while most children were only breastfed up to one year, there HIV and Mother to Child Transmission were few extreme cases where breastfeeding continued even beyond 24 months. General knowledge on the virus and Mother to child transmission 80 Yes Only about a quarter (26%) of the surveyed children were complemented with solid foods at the right age 70 No/Do not know of 6-9 months. Significantly more (74%) children were 60 either introduced to solid foods at an early age or far 50 beyond the recommended upper ceiling of 9 months. 40

Majority of these children were mainly introduced to Proportion 30 solid foods before their sixth month of life. The 20 average age of introducing solid foods in a child’s diet 10 is 8 months while fluids are introduced much earlier 0 HIV is Anybody can MTCT Transmission (about 3 months), but with majority of the children preventable have HIV possible via taking their fluids before one month. Fluids, if not Breastfeeding treated/prepared well could be a major avenue for transmitting germs to the infants. On transmission and prevention, knowledge varied depending on the mode of transmission. Of the Frequency of consumption for adults respondents (those who acknowledge the existence of the disease), about two-thirds (61.4%) correctly Majority (over 85%) of the households eat only 1-2 acknowledge that the virus can be transmitted from times in a day. Some 15-30% can only manage to eat mother to the child. However, as shown on the chart, once in a day. The normal Liberian eating pattern is some 23% said that such transmission is not possible two or more meals in day. Except for households in while one-sixth of the respondents indicate that they Tchien, all the other districts report that less than 12% do not know whether mother to child transmission of are able to consume two or more meals in day. the virus is possible. Again, of the respondents, some 27% do no know that the virus can be HIV/AIDS knowledge transmitted through breastfeeding. However, 72% of the respondents indicate that transmission through Mothers were asked about their knowledge of the breast-feeding is possible. However, it is not clear HIV/AIDS pandemic. Respondents were expected to whether those who indicate knowledge of indicate their knowledge or lack of knowledge on the transmission through breastfeeding may opt to use transmission, prevention, control and recognition of alternatives to breast milk or not. HIV/AIDS. About two-thirds (66%) of the interviewed mothers indicate that they have heard of HIV/AIDS. HIV and Sexuality Some 34% have never heard of the disease. This reveals a considerably low awareness on the Knowledge on HIV/AIDS with regard to sexuality was existence of the pandemic despite its high prevalence not only poor but also response was not forthcoming in Liberia (at 8-12%). with less than 50% responding to the questions. Sexuality is regarded sacred and not openly On the control and prevention of the infection, about discussed in most African cultures. Populations are three-quarters (72%) acknowledge that there are normally shy to discuss sexuality especially with steps people could take to prevent themselves from strangers. As indicated on the chart, majority (77%) contracting the virus. The remaining 28% indicate of the respondents, however, believe that one can that either nothing can be done or simply that they do protect herself/himself from the virus by having sex not know whether something can be done to prevent with only one uninfected and faithful partner. themselves from the virus. The revelations Amongst the respondents, the usage of condoms is underscore the limited knowledge people have about trusted by three-quarters (75%) as a preventive the virus. Qualitative findings, elsewhere in Liberia measure against infection by the virus, if properly and Page 23 of 51 routinely used each time a person has sex. However, Extent of discrimination for HIV/AIDS victims & some beliefs it is not clear whether the respondents would use 80 condom for their own protection. 70 Agee Knowledge of HIV/AIDS and Sexuality 60 Disagree 80 Agree Indifferent 50 70 Do not agree 40 60 proportion 50 30

40 20 30 10 20 0 10 Purchase Allowing Sharing Transmission Transmission 0 from teaching meals through through A bst inence Condo m use Fait hf ullness shopkeeper witchcraft mosquito bite

Wrong beliefs on the transmission of the virus are also On the other hand, abstinence ranks lowly (only 59% widespread in the society. Some 35% of the of the respondents agree with its application) as a respondents wrongly believe that the HIV/AIDS virus preventative measure against the virus, if one is not can be transmitted through mosquito bites and a already infected. A high proportion (41%) of further 16% do not know whether such transmission is respondents either flatly reject that abstinence is possible. Additionally, some 12% of the respondents important for prevention of HIV infection or are also indicate that witchcraft can also transmit the indifferent about it. This reveals that advocacy for virus. However, at least three-quarters do not believe abstinence as a control measure against the virus is on witchcraft as a cause of HIV/AIDS. unlikely to succeed in an environment when few believe in abstinence, more so with the responses Overall rating of knowledge on HIV/AIDS coming from women. On a scale of 0-12, responses were rated based on HIV and Social Discrimination correct responses on their knowledge on HIV/AIDS Discrimination towards people living with HIV/AIDS, transmission, prevention and control. This was aimed stigmatization coupled with inadequate knowledge on at providing an overall picture of knowledge on the the HIV virus remains an issue in Liberia, a revelation pandemic. Thus, respondents that correctly answered corroborated with findings from other surveys 10-12 questions relating to knowledge on the conducted in the country. As indicated on the graph pandemic were rated as having good/satisfactory below, less than a half (39%) of the respondents knowledge, 6-9 correct responses signified average or indicate that they will allow an active healthy looking some knowledge, 2-5 correct responses denoted poor teacher to continue discharging his/her duties in class knowledge while respondents with no correct answer if they discover that he/she has the HIV/AIDS virus. or just one correct answer were classified as having Majority of the respondents (52%) would not allow complete lack of knowledge. One correct answer, him/her to continue teaching while a further 9% are which in this case was only 2% was regarded as a indifferent to such situations. The same treatment will “chance” response and therefore amounted to no be given to a healthy looking HIV infected shopkeeper better than lack on knowledge. whose goods will not be bought by 71% of the Overall knowledge on transmission and control respondents. Only 29% would continue buying goods of HIV/AIDS pandemic Good knowledge from such a shopkeeper. About one-fifth (21%) 18% complete lack of knowledge believe that sharing meals with HIV-infected persons 10% Poor knowledge can lead to transmission of the virus and would 23% probably avoid sharing meals with somebody infected with the virus. These are worrying statistics of discrimination. It signals that HIV infected persons will not be treated humanely, neither will they be allowed to freely continue with earning their livelihoods. Such societal discrimination would lead to faster deaths of the infected as their options become limited. Fighting Average knowledge the virus would remain a major challenge in such 49% extremely hostile environments.

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A significant proportion (49%) of the respondents only had minimal/average knowledge on the pandemic. As presented on the graph, only 18% of the respondents had satisfactory/good knowledge on the pandemic, while some 23% has extremely poor knowledge. At least one-tenth of the respondents completely lacked any knowledge on the virus much as they acknowledge its existence. None or only one of their responses to questions on the pre-requisite knowledge of transmission/control was correct.

The findings above corroborates to initial findings by WFP and other agencies that indicated high levels of ignorance about the pandemic as well as stigmatization, and even discrimination. For example, “WFP Needs Assessment on HIV/AIDS in Liberia- March 2004” revealed glaring gaps in HIV/AIDS knowledge with limited protective steps to the infection despite the high sexual activities amongst the Liberian population. A WFP VAM assessment in Bong and Margibi Counties, May 2004 also indicated gaps in knowledge as well high degree of social discrimination where over 40% indicated that an asymptomatic should not be allowed to teach.

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PART IV. HOUSEHOLD FOOD SECURITY As shown on the chart, food consumption levels AND CONSUMPTION TYPOLOGIES appear better in Tchien as compared to other districts with majority (two-thirds) reporting either fairly good or satisfactory/good consumption. On the other hand, Household food consumption classifications are Konobo reports the worst food consumption pattern based on the frequency of consumption for the with more than three-quarters of the households individual food items, and dietary diversity in the week reporting extremely poor or simply poor (diversity and prior to the survey. frequency) intake of food in the week prior to the survey. Only 40% of the households in Gbarzon Classification by Food consumption manage some fairly good or adequate consumption (diversity and frequency). In the analysis, the individual food items reportedly consumed by the households were classified into seven food groups: cereals; legumes and oilseeds; Description of the consumption groups tubers and roots; vegetables and fruits; animal

products; oils and fats and sugar. The criteria for Very Poor food consumption group qualifying the food consumption are as follows: Rare Some Never Often Always (1- -times • Very poor food consumption: when a (5-6) (7) household hardly manages daily consumption of 2) (3-4) the staple food or when their diet is based largely Rice Maize, Cereals on cereals. bulgur • Poor food consumption: when a household has Bread daily intake of cereals but also frequently eats one Legumes Groundnuts

or more food items from other food groups. & oilseeds beans Tubers Cassava/

• Fairly good food consumption: when a and roots Potatoes household has daily intake of foods from at least 3 Vegetables Veget-

food groups (cereals included) in addition to and fruits ables frequent intake of items from 2 or more food Fruits groups (mainly from oils, animal products, or Animal Fish vegetables/fruits). products Bush meat Chicken, • Good food consumption: when a household has beef, daily intake of at least four food groups and Eggs/

frequently integrate their diet with items belonging Milk to other two food groups. In particular, households Oils and Palm and having daily access to cereals, oil, vegetables and fats veg. oil, fats animal products plus frequent access to legumes Sugar Sweets,

and sugar have been included into this cluster. sugar

Food consumption classification at district level Thirty-nine percent of households in this cluster are headed by women. The group mainly consume rice, Food Consumtion staple cereal in addition to frequent intake of oil/fats. Meat products (mainly bush meat) is only eaten once 60% 57%

55% in a while. The group reports no intake of pulses in 48% 48% Very Poor Food the week prior to the survey. Vegetables and fruits, 50% Consumpt ion 45% presumed relatively cheap in Liberia, is either not

40% Poor Food consumed or are rare in the group’s diet. 35% 32% Consumpt ion 29% 30% Food sources 22% 25% Fairly Good Food 20% Consumpt ion 14 % 15% Food consumed in these households are mainly 12 % % household of 15% 10 % sourced through purchases. Own production 10% 7% 5% Good Food Consumpt ion accounts for only 21% of the group’s food source. 5% Some 3% of the households depend on free food 0% Gbar zon Konobo Tchi en distribution.

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Some Rare Household Income Never time Often Always ly s (5-6) (7) Main Income activity for Poor Food Consumption (1-2) (3-4)

Other Rice Agricult ural wage labour Maize, Cereals Sale of bush meat bulgur

sale palm oil Bread salary/ Government job Legumes Ground

Petty trade & nuts,

Casual labour oilseeds beans Tubers Cassava/ Skilled labour and roots Potatoes Sales of cash crops Veget- Veget-

Small business ables ables Sales of f ield crops and fruits Fruits 0% 5% 10% 15% 20% 25% Animal Fish products Chicken, The very poor food consumption households earn beef,

their income mainly from sale of field crops, sale of bush palm oil, agriculture wage labour and casual labour. meat Eggs/Mi Other income activities as shown in the chart, constitute insignificant income source. lk Oils and Palm fats and

Household Expenditure veg. oil, fats Sugar Sweets, About two-thirds of this group’s expenditure is sugar dedicated to food purchase, with over 50% and some 13% of the food expenditure used for sourcing rice and other cereals respectively. Only 38% is the Forty percent of these households are headed by expenditure on food is used to purchase other food women. items like fish, oil etc. The group is either unable to pay debts or are simply not indebted, thus no The group consumes rice (staple cereal) on daily expenditure. basis in addition to regular oils/fats and animal products, mainly meats though with significant intake Household Expenditure Very poor Food consumption Rice 31% of fish. Unlike the very poor consumption group, Food Other these households manage some intake of pulses and 61% 7% vegetables. Social Cassava, 3% Potatoes 6% Clothing 4% Food sources Oil 7% Education Like the very poor consumption category, majority 10% Fish 10% (77%) of these households source their foods through debt 0% the markets, with some 3% reporting food aid

Transportation Bulgur/maize 9% 2% Household Income

Medical Other food 5% M ain Income activity for Very P oor Food Consumption 6%

Ot her

Asset ownership Agricult ural wage labour

Sale of bush meat Seventy-six percent of this group own six or less sale palm oil assets, mainly consisting of non-productive household assets like kitchen utensils, beddings etc. Less than a Casual labour quarter report 7 or more assets, which would normally Skilled labour include some cheap productive asset e.g. hoe. Sales of cash crops Small business Poor food consumption Group Sales of f ield crops 0% 5% 10% 15% 20% 25% 30%

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Like the very poor consumption group, this category of Food sources households also generate their income mainly from sale of field crops, agriculture wage labour, sale of As indicated earlier, the group manages to eat palm oil, sale of bush meat and casual labour. commodities like sugar and pulses that are mainly sourced through purchase. They report that 87% of Household Expenditure their foods are sourced through purchases from markets. The poor consumption households also expend nearly two-thirds of their budgets on food. Expenses on rice Household income as a proportion of overall expenditure on food is Most income activities appear to be similar to those of slightly lower (47%) than that of the very poor previous consumption groups (i.e. sale of field crops, consumption group. The proportion of expenditure on non-cereal foods (as proportion of total food M ain Income activity for fairly good Food Consumption expenditure) is about 40%, higher than that of the very Other poor category that records only less than 25%. Agricult ural wage labour

Sale of bush meat

Household assets sale palm oil

salary/ Government job In this category, at least some 31% own 7 or more Pett y t rade assets. This is higher than that of the very poor Casual labour consumption group where only 23% of the households Skilled labour reported 7 or more assets. Only 27% report owning Small business less than 5 assets, unlike the very poor group where Sales of field crops 42% reported owning less than 5assets. However, 0% 5% 10% 15% 20 % 25% like the very poor consumption group, these category mainly own non-productive assets with some limited agriculture wage labour, casual labour and sale of cheap productive assets (hoe, and cutlasses) bush meat). However, this group additionally reports significant incomes from small business, petty trade Fairly good food consumption group and salaries.

Both rice and oils/fats are consumed on daily basis by Household Expenditure this group. There is also regular intake of animal Like the previous consumption categories, this group products (bush meat and fish) and fairly good intake spends two-thirds of their expenditure on food of vegetables-at least three times in a week. commodities. However, the purchase of food is more Consumption of legumes and roots/tubers are also diverse although rice still takes the greatest reported. The group is normally able to eat food items proportion. The group reports some expenditure on from virtually all the seven food groups at least once debts, which could be a sign of the capacity to offset in a week unlike the previous consumption groups. some external burdens. Intake of sugar is also reported. Household assets Women head 35% of Some these households, and Never Rarely OftenAlways Household Expendit ure Fairly good Food consumptRice ion times 31% men head the rest of (1-2) (5-6) (7) Other (3-4) Food them. 6% Soc i al 64% Cassava,

Rice Potatoes Cl othing2% Maize, 5% Cereals 5% bulgur Oi l 8% Bread Educati on Legumes Groundnuts, 10% Fi sh & oilseeds beans 10% Tubers Cassava/ debt

and roots Potatoes 2% Bul gur / maize Vegetables Veget- 3% T r anspor tation and fruits ables 8% Medical

Fruits 3% Other f ood Animal 7% Fish products Chicken, beef, bush meat Less than 20% of the households in this group own Eggs/Milk less than 5 assets, substantially lower than that of Oils and Palm and previous groups. The proportion of those owning fats veg. oil, more than 7 household assets is also 42%, again fats Sugar Sweets,

sugar Page 28 of 51

higher compared to previous consumption categories. Main Income act ivit y f or good Food Consumpt ion However, no significant productive asset is reported, just as in the previous consumption categories. sal e of pr epar ed f ood

Good food consumption group Sal e of bush meat

Remittances Proportion of female-headed households is almost similar to those reported in other consumption groups, Petty tr ade

at 38%. Skilled labour

Sales of f ield cr ops Some Never Rarely Often Always times 0% 5% 10% 15% 20% 25% (1-2) (5-6) (7) (3-4) Rice Maize, significant here than all the previous consumption Cereals bulgur categories. Bread Legumes Household Expenditure & Groundnuts, oilseeds beans Tubers Cassava/ Household Expenditure good Food and roots Potatoes Veget- Veget- Ot her consumption Ri ce ables and ables Soc i al 7% Food 28% fruits 2% 59% Cassava, Fruits Potatoes Animal Cl othi ng 4% Fish products 9% Oi l Chicken, 8% beef, bush Educati on Fi sh meat 9% 10%

Eggs/Milk debt Oils and Palm and 3% Bul gur / maize fats veg. oil, 2% fats Transportation Sugar Sweets, 9% Medical Other f ood sugar 3% 6% The proportion of expenditure is still high although The group manages to consume not only at least a less than 60% unlike in the previous consumption commodity from the seven food groups but also all groups. The group’s expenditure on food is also more food items reported in the county at least once in a varied as compared to previous groups. week. Cereals, animal products and oils/fats are eaten virtually everyday by this group. In addition, the Household assets group reports regular (at least three times in a week) intake of vegetables, roots and tubers and sugars. The group reports the highest proportion of Intake of pulses just like intake of varied cereals and households with 7 or more assets, at 52%. Only 17% poultry is reported at least 1-2 times in a week. of the households report owning less than 5 assets in this category. However, productive assets are limited Food sources to only farm implements. Like the fairly good consumption group, households in this category source a significantly high proportion (86%) of their foods though market purchases. The group minimally relies on food aid (only 1%) unlike other categories where at least 2% get food though free food aid.

Household income

Like the previous consumption groups, households in this category are mainly engaged in sale of field crops, small business, agriculture wage labour, skilled labour and sale of bush meat as income activities. However, small business and skilled labour are more

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RECOMMENDATIONS • Urgently conduct a verification and causal analysis of the high under-five mortality rates Food access observed in the county and recommend ways of reversing the trend. Food is mainly sourced through the market. However, • Initiate programmes that address the long-term Grand Gedeh is deemed capable of self-reliance on effects of malnutrition. Programmes that ensure crop production. Agricultural support through provision of basic health care, promote adequate provision of seeds and tools is urgently required to childcare practices, promote uptake of MCH increase productivity. services (immunization, treatment of diseases, growth monitoring promotion, family planning Income access promotion etc) and adequate planning/production of appropriate meals need to be encouraged. The communities report limited income sources. • Hygiene promotion through construction of Income opportunities are not only minimal but also latrines should be encouraged. INGOs should be provides less than the household requirements. Thus, actively involved in promoting awareness on the most households tend to only afford purchase of food dangers of inadequate sanitation facilities. at the expense of other essential commodities and • Hand pumps are inadequate, leading to high services. Income generating opportunities need to be consumption of unsafe water. Rehabilitation of enhanced in the county. boreholes should be ensured.

Education access HIV/AIDS

• Most schools lack essential learning materials. • Need for community sensitization on HIV-AIDS Teachers also lack motivation due to issues to equip the community with the right inadequate/irregular incentives. There is need to knowledge on prevention, control and improve the functional facilities to provide management of the virus in the community essential learning environment. • Concerted efforts should be directed at educating • Some communities have to walk several miles to the community about HIV/AIDS transmission and reach the nearest facility. Equitable distribution of prevention to control the existing discrimination of learning facilities should be ensured in the county. the victims. • Skills training is urgently required especially to cater for the large youthful population who served Shelter/infrastructure as combatants during the wars. • There is need to increase girls’ enrolment to The resettling communities need assistance to afford schools to delay sexual debuts and the high levels some shelter. Most communities have started of teen-age pregnancies and mothers in the rehabilitating and reconstructing their houses. They county. Improvement of literacy levels, especially can be encouraged through provision of construction targeting mothers, could also be instituted. The materials. Most shelters in the communities are in adult literacy lessons could also include basic deplorable state and would be become a major health home economics lessons. risk when heavy rains start.

Health, water, sanitation and Nutrition

• Construct/open up health facilities in the remote parts of the county which are otherwise not adequately served. • Ensure adequate supply of drugs and other medical supplies in the functional health facilities to avoid shortages commonly witnessed. • Improve access to basic treatment for common childhood illnesses such as diarrhoea, malaria, and Respiratory infections • Provide education on appropriate child feeding and caring practices to address the inadequate feeding patterns, especially amongst the under- fives and encourage compliance.

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APPENDICES expressed as a z-score with children falling below – 2z-scores regarded as underweight and those below – Appendix 1: Interpretation of Nutrition data 3 z-scores as severely underweight.

Definitions: The prevalence of acute malnutrition is Interpretation of Malnutrition Rates presented using z-scores. However, percent of The West African region has an estimated prevalence median is usually used for screening and admission to of global acute malnutrition of 10.3% 5 . In sub- feeding programs. Therefore to estimate expected Sahara Africa, rates of wasting or Global acute number of beneficiaries for feeding programs, the malnutrition6 (GAM) are usually within the range of 5- prevalence of acute malnutrition is also presented as 9 %. In the nationwide nutrition survey conducted in percent of median. Liberia in 1999-2000, the prevalence of GAM for Monrovia was reported as 5.5%. Nutrition surveys Weight for Height: Measures wasting or acute (November 2003) in the IDP camps outside of malnutrition. This is the weight of a child compared Monrovia reported GAM rates of 3.4% to 7.8%. The with height of reference children of the same height GAM rate reported in a nutrition survey conducted in and sex. For simplicity this is expressed in z-scores. March 2003 in Bomi and Cape Mount Counties was It is the most reliable indicator for acute malnutrition in 4.1%. Wasting was estimated at 6.9% (5.4 – 8.4) for children. the survey in Monrovia and environments (August 2004). All children with oedema were automatically considered severely malnourished. In contrast, stunting or chronic malnutrition and underweight are high in Liberia, 39% and 26% ƒ Global Acute Malnutrition (GAM): respectively7. Chronic malnutrition is estimated at 32.9% <-2 z-score weight-for-height and/or oedema and underweight at 27.1% for the West African region8. WFP’s VAM surveys in Monrovia (June, September 2003) ƒ Severe Acute Malnutrition (SAM): and Bong Counties (February 2004) reported a similar <-3 z-score weight-for-height and/or oedema pattern of malnutrition results, i.e. low levels of GAM but high levels of underweight and chronic malnutrition. ƒ Global Acute Malnutrition (GAM): <80% median weight-for-height and/or oedema

ƒ Severe Acute Malnutrition (SAM): <70% median weight-for-height and/or oedema

Height/Age 4 : Measures stunting or chronic malnutrition. This is the height of a child compared with reference children of the same age and sex. A child with a low height for age is termed as stunted. This is caused by an extended period or repeated episodes of inadequate diet, illness or both, which slows the rate of growth. The height for age index of a child is expressed as a z-score. As in wasting, children falling below –2 z-scores are considered stunted and those falling below –3 z-scores, severely stunted.

Weight/Age: Measures underweight in children: This index expresses the weight of a child in relation to his age, and compares him/her to reference children of the same age and sex. A child with a low weight for age is termed as underweight. However, this index does not allow the differentiation between children of the same weight and age, one being tall and thin 55th Report on the World Nutrition Situation, United Nations, (wasted) and the other being shorter (stunted), but not Standing Committee on Nutrition, March 2004, Annex 4. wasted. The weight for age index of a child is 6 GAM is weight for height measurement below –2 z-scores and/or oedema. It is a measure of acute malnutrition 4 Stunting is more common in older children because there has 7 Liberia National Nutrition Survey, 1999-2000, UNICEF. been a longer period of slow height growth (FAO, 1990). 8 Ibid, 7. Page 31 of 51

Appendix 1 Map

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Appendix 2 Towns Population Cumulative of the Clusters Number of households to estimated population interview per area DISTRICTS Bah 180 180 GBARZON Blouwn 230 410 B’Hai Tarway 372 782 1 25 Borkor 1260 2042 Toe 4500 6542 2 25 Goiyeazon 148 6690 Niako 310 7000 B’hai-Jorzon 1305 8305 Senewein 3400 11705 3 25 Dougee 3786 15491 4 25 Tian 2142 17633 5 25 Zleh 8440 26073 6, 7 50 Toweh 98 26171 Pouh 3180 29351 Gaye 578 29929 8 25 Polar 3408 33337 Salaken 374 33711 Jarwondee 4663 38374 9, 10 50 Tchslar 348 38722 Zuwayah 467 39189 Kpaker 279 39468 Dalaley 1804 41272 Tekadee 167 41439 Barkor 84 41523 Kurgbo 210 41733 Boundary 1000 42733 11 25 KONOBO Sennedur 400 43133 Barlo 250 43383 Tuglor 350 43733 Yealee 85 43818 Wulue 1100 44918 Varglor 450 45368 Dweh #1 700 46068 Ziah 7800 53868 12, 13, 14 75 Banglor 575 54443 Dowelh 330 54773 Wrabo 525 55298 15 25 Karwoe 175 55473 Glay 450 55923 Gbolue 75 55998 Gleeglor 150 56148 Druglor 450 56598 Dehjallah 100 56698 Duwen 150 56848 Barwu 450 57298 Peah 500 57798 Druwar 331 58129 Baio 482 58611 Tarloken 771 59382 16 25 Koltedee 880 60262 Garlio 150 60412 Yeah 71 60483 Whilyboe 221 60704 Say-you-woe 333 61037 Barlaken 383 61420 Nyengba 278 61698 Tuwarbo Dehjallah 200 61898 Coinyee 110 62008 Flahn 189 62197 Gbarwu 321 62518 Karwleleh 750 63268 17 25 Duo 680 63948 John David 4225 68173 18 25 Panrwon 575 68748 Tiamah 1200 69948 Boley 110 70058

Grand Gedeh April 05

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Penneken 2200 72258 19 25 Geebloe 725 72983 Dweh 300 73283 Jarwondee 4200 77483 20 25 Seoh Village 60 77543 New 150 77693 Walagbarleh 160 77853 Wologbarleh 70 77923 Slogbarleh 61 77984 Gorbogar 300 78284 TCHIEN Gborlue 275 78559 Pennue 154 78713 Kumah 775 79488 Zabay 576 80064 21 25 Gbarbo 225 80289 Jayboe 135 80424 Pelezon 120 80544 Jarba 506 81050 Pollah 102 81152 Barway 115 81267 Youbor 125 81392 Krah 75 81467 Manyea 134 81601 Beezon 225 81826 Toffoi 575 82401 Jellue #1 75 82476 Gbaryoubo 475 82951 Zeon 54 83005 Gleplay 304 83309 Beh 425 83734 Kpah 180 83914 Compound 192 84106 22 25 Sinkor 70 84176 Julutuzon 126 84302 Vlayee 215 84517 Toegbahe 561 85078

Glokpada 51 85129 Boduoe 163 85292 Boe 201 85493 Geeyeah 62 85555 Jellue#2 116 85671 Zai 590 86261 Sawaken 39 86300 Tuzon 763 87063 Solo 236 87299 Boleken 598 87897 Garley #1 125 88022 Garley #2 161 88183 Fanksay 168 88351 23 25 Gweniebo 78 88429 Ganbo 63 88492 Dolowelzon 52 88544 Tojilah 243 88787 Cheadyville 25 88812 Bawadee 341 89153 Janzon 1214 90367 Diah 105 90472 Dwuyee 28 90500 Pouh 313 90813 Boe 159 90972 Gwien 671 91643 Zone #1 3690 95333 24 25 Zwedru City Zone #2 4305 99638 25 25 Zone #3 4900 104538 26 25 Zone #4 4225 108763 27 25 Zone #5 3075 111838 28 25 Zone #6 4500 116338 29 25 Zone #7 3475 119813 30 25 Zone #8 1385 121198 Zone #9 3555 124753 TOTAL 4158.433333 GrandSampling Gedeh Interval April 05 4158 Starting random number is 448 Page 34 of 51

Appendix 3 (Household questionnaire)

A: QUESTIONNAIRE IDENTIFICATION: A.1: Date of interview A.2: Interviewer ID A.3: County name

A.4: County code A.5: District name A.6: District code

A.7: Cluster Code A.8: Clan name A.9: Clan code

A.10: Town /village name A.11: Town /village code A.12: Household ID:

A.13: Name of Respondent ______

A.14: Checking of Questionnaire: Supervisor / Team leader’s signature ______A.15: Date checked: |__|__| |__|__| 2005

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Section 1 – Household Demography

1.1 – Sex of household head

Male = 1 Female = 2

1.2 – Age of HH head (in years)

|__|__| years

1.3 – What is the main occupation of this household head?

1 = Carpenter 2 = Teacher 3= Taylor /Seamstress 4 = Blacksmith 5 = Farmer / Gardener 6 = Casual labourer 7 = Trader / seller 8 = Fisherman 9 = Other (specify) ______10 = nothing

1.4 – Total number of persons in household

Males 0-5 years |__| Males 6-14 years |__|

Males 15-59 years |__| Males 60+ years |__|

Females 0-5 years |__| Females 6-14 years |__|

Females 15-59 years |__| Females 60+ years |__|

1.5 - How many children do you have currently enrolled and attending school?

Male |__|__| Female |__|__|

Grand Gedeh April 05 Page 36 of 51

Section 2 – Household Circumstances Please use the codes below to complete the following 2.5 Are any members of your households currently 1 = Piped into dwelling, yard or plot questions. living else where? If so where exactly are they? 2 = borehole with pump 3 = Protected dug /well covered Liberia county and other countries codes 1 = IDP camp 4 = Rain water 2 = Another town 5 = Unprotected /well not covered 1 = Bong 7 = Grand Kru 13 = Rivercess 3 = Another house within the village/town 6 = Pond, river or stream 2 = Bomi 8 = Lofa 14 = Sinoe 4 = Other County/country |__|__| 7 = Tanker (If other pleases use the codes above listed) 8 = Other (specify)______3 = Gbarpolu 9 = Margibi 15 = River Gee

4 = Maryland 10 = Nimba 16= SIL 2.6 – Are any members of this household disabled? 3.5 - What kind of toilet facility does your household 5 = Grand 11 = Cape 17= Guinea YES……………1 NO…………2 use? Bassa Mount 1 = NGO build latrine 6 = Grand 12 = 18=COT If so, what kind of disability? (Circle all that apply) 2 = Traditional pit latrine Gedeh Montserrado 3 = Open pit 19=other counties 1 = Amputee 4 = bush / open space 2 = Blindness 5 = Flush toilet 3 = Mental illness 6 = Other (specify)______2.1 – What is the status of your household? (Circle 4 = deaf/mute only one option) 5 = lame – polio /injury 1 = displaced household 6 = chronic illness (eg. TB) 3.6 – What is the main source of lighting for this house? 2 = returnee household 7 = Other (specify) ______3 = host household 1 = Generator 2 = Oil lamp 2.2 – Where is your household coming from? (Use Section 3 - Housing 3 = Kerosene lamp the above codes) 4 = Candle |__|__| 3.1 – How many years has your household been 5 = Firewood living in this dwelling? 6 = Other (specify) ______2.3 – When did your household move to this current 7 = None settlement? (Record year) Years |__|__|

|__|__|__|__| 3.2 – How many people usually sleep in this house? 3.7 – How much do you spend for lighting per month? People |__|__| 2.4 -What main problems prevent you or have |__|__|__|__| LD$ prevented you from returning? 3.3 – How would you classify the physical condition (Circle all that apply) of this dwelling?

1 = Insecurity 1 = Good 2 = No land in place of origin 2 = acceptable 3 = Land in place of origin occupied by others 3 = partly damaged 4 = Cannot find work/earn enough money there 4 = Needs improvement 5 = Roads/bridges/infrastructure destroyed 5 = Other______6 = Don’t have enough resources to return 7 = Nothing existing to return to 8 = Other (specify) ______3.4 - What is the main source of drinking water for your household?

Section 5 - Agriculture 3.8 - What is the main source of cooking fuel for this 4.2 – Does your family own livestock? household? Land access codes YES……………1 NO…………2 (If no skip to 4.7) 2 = Own 1 = rent 3= Sharecropping 1 = Firewood / bush land 2 = Charcoal 6 = Squat by 3 = fuel oil 4.3 - How many poultry does your family own? 4 = Lend by 5 = Inherited permission 4 = Kerosene Govt 5 = Generator Poultry |__|__| (chickens/ducks) 7 = Other 6 = Gas (specify)_____ 7 = Other (specify) ______4.4 - How many goats does your family own? __

Goats |__|__| Production codes 3.9 – How much do you spend for cooking fuel per 3= potatoes / month? 4.5 - How many sheep does your family own? 1 = Rice 2 = Cassava eddoes

|__|__|__|__| LD$ Sheep |__|__| 4 = Maize 5 = other 6 = Plantain / (corn) vegetables banana 4.6 - How many cows does your family own? 8 = Kola 7 = other fruits 9 = Rubber Section 4 – Household & animal assets nuts Cows |__|__| 11= 12 = Other 8 = peanuts 4.1 - Does your family own any of the following coconuts (specify)______household items/productive assets? (Circle all that 4.7 - Do you have access to credit? apply) 5.1: Do you have access to Agriculture land? 4.1.1 = Bed YES……………1 NO…………2 (If no skip to 4.9)

4.1.2 = Table YES……………1 NO…………2 (if no skip to section 6)

4.1.3 = Chair 4.8 – From whom do you usually credit? (Circle all that apply) 4.1.4 = Mattress 5.2a: Do you have a farm plot? 1 = relatives / friends 4.1.5 = Cutlass / axe 2 = charities / NGOs YES……………1 NO…………2 (If no Skip to 5.3a) 3 = local lender / Susu club 4.1.6 = hoe / digger 4 = Church / Mosque 4.1.7 = Coal pot 5 = Anybody 6 = other (specify) ______4.1.8 = Bucket / tub 5.2b: How did you or members of your household acquire this land? (See Land Access codes) 4.1.9 = Wheel barrel 4.9– Does your family have cash savings?

4.1.8 = Radio / Tape 5.2b1 |__| 5.2b2 |__| YES……………1 NO…………2 4.1.11 = Cooking utensils 4.10 – Do you lend out cash or kind to other 4.1.12 = Mobile phone 5.2c: What do you produce in this farm plot? (See people? Production codes) 4.1.13 = Generator YES……………1 NO…………2 4.1.14 = Other (specify)______5.2c1 |__| 5.2c2 |__| 5.2c3 |__|

5.3a: Do you have a vegetable plot / garden? 5.5a: Do you use fertilizers? (Circle one)

YES……………1 NO…………2 YES……………1 NO…………2 If no (Skip to 5.6a)

5.3b: How did you or members of your household acquire this garden plot? (See Land Access codes) 5.5b: For your farming /garden, what is the main source of fertilizer? (Circle one) 5.3b1 |__| 5.3b2 |__| 1 = purchase 2 = Borrow 5.3c: What do you produce in this garden? (See 3 = Government Production codes) 4 = NGOs/INGOs

5 = credit 5.3c1 |__| 5.3c2 |__| 5.3c3 |__| 6 = gift

5.4: For your farming /garden, what is the main 5.6a: Do you use pesticides / herbicides? (Circle source of seeds? (Circle all that apply) one) 1 = purchase YES……………1 NO…………2 2 = own stock If no (Skip to 6.1)

3 = Government

4 = borrowed 5.6b: For your farming /garden, what is the main 5 = NGOs/INGOs source of pesticides / herbicides? 6 = no seed required (orchards) 1 = purchase 2 = borrow 7 = credit 8 = gift 3 = Government 4 = purchase and own stock 5 = NGOs/INGOs

6 = credit 7= gift

6.3: What is your second most important income Section 6 – Sources of income activity? |__|__| Using the following codes, please complete the following questions: Section 7 – Household expenditures – IN PAST MONTH Income activity codes 1 = Sales of 2 = Small 6.4: Who participates in this activity? |__| Total expenditure 3 = Mining Expenditure activities – in past MONTH field crops business (in LD) 7.1 – Rice 4 = Sales of 5= Skilled 6 = casual 6.5: What is your third most important income cash crops labour labour activity? |__|__| 7.2 – cassava, Potatoes 8 = Salary 9 = 7.3 – Palm oil 7 = Petty trade /Government Remittances job 6.6: Who participates in this activity? |__| 7.4 - Vegetable oil

10 = Sale palm 11 = sale of 12 = Sale of 7.5 – Meat, fish, poultry oil bush meat fish 6.7: What is your fourth most important income 7.6 – maize meal 13 = 14 = Firewood 15 =Sales of activity? |__|__| Agricultural 7.7 – Bulgur wheat /charcoal sales prepared foods wage labour 7.8 – Pulses (Beans, lentils) 17 =Sales of 18 = Sales of 16 = Sales of 6.8: Who participates in this activity? |__| 7.9 – Other food (fruits, vegetables, salt, livestock orchard livestock Sugar) products products 7.10 – Food & drinks consumed outside the 20 = Sale of 6.9: Using proportional piling or ‘divide the pie’ 19 = 21 = Other home productive methods, please estimate the relative contribution to Handicrafts Gov’t benefits 7.11 – Alcohol & tobacco assets total income of each activity and record below. 24 = Other 7.12 – Payment for medical services (specify)_____ 22 = Borrowing 23 = Begging 7.13 – Medical items and drugs __ 6.9: 1 - % Most important income (Q6.1) ______7.14 – Transportation, fuel (vehicle) Participant codes 7.15 – Fines or debt repayments 1 = men only 4 = adults only 7 = everybody 6.9: 2 - % Second income (Q6.3) 7.16– Education/school fees 2 = women 5 = women & ______only children 7.17– Clothing/shoes

3 = children 6 = men & 7.18– Soaps / Detergents / HH items only children 6.9: 3 - % Third income (Q6.5) ______7.19- Celebrations/social events

7.20 Other/miscellaneous THROUGHOUT THE YEAR……… 6.9: 4 - % Fourth income (Q6.7) 6.1: What is your household’s main income activity? ______|__|__| = 80%

6.2: Who participates in this activity? |__| Note: If less than four sources are named, please put ‘0’ in the empty spaces above.

Section 8 – Food Consumption Food source codes: 9.3e – CSB Yesterday, how many meals did the……..in this house 1 = Purchase 3 = Remittances 2 = Borrowed |__|__|.|__| eat? 4 = Own 5 = Received 6 = Exchange

production as gift services 8.1 - Adults 8.2 - Children 9 = Other 7 = Traded 9.4 – Did you sell any of the food aid received 8 = Food aid (specify) I would like to ask you about all the different goods foods that your household members have eaten last month? in the last 7 days. Could you please tell me how many days in the past week your household has YES……………1 NO…………2 eaten the following foods? Section 9 – Food aid DAYS Sources of eaten in 9.1 – Has any member of your household Food item food (see 9.5 – If so, how much of each? past week received codes below) (0-7 days) food aid in the past month? 9.5a – Bulgur wheat

8.3a – Rice YES……………1 NO…………2 |__|__|__|.|__| 8.3b – wheat (Bulgur) 9.5b –Maize meal

8.3c - maize meal 9.2 – If so, through which programme is the |__|__|.|__| food aid received? 9.5c – vegetable oil 8.3d – Cassava (tubers) 8.3e – Vegetables 1 = General food ration |__|__|.|__|

(including leaves) 2 = School feeding 8.3f - Beans (Pulses) 3 = Supplementary feeding 9.5d – pulses/beans 8.3g - Fish – fresh or |__|__|.|__| dry 4 = Food for work 8.3h - Meat (bush 9.5e – CSB

/imported) 9.3 – How many kilograms of each of the |__|__|.|__| 8.3i – Poultry (chicken / following commodities has your household duck) received in the past month?

8.3j - Vegetable oil 9.3a – Bulgur wheat 8.3k- Palm oil |__|__|__|.|__| 8.3l - Eggs 9.3b –Maize meal 8.3m - Milk (liquid or |__|__|.|__| powder) 9.3c – vegetable oil 8.3n – Bread 8.3o – Fruits (banana, |__|__|.|__| orange 9.3d – pulses/beans 8.3p – Sweet, sugar |__|__|.|__|

Section 10 – Household Risks In the last 12 months has the What did the household do to compensate or What did the household do to compensate or HH member been negatively resolve this problem. In the last 12 months has the resolve it? HH been negatively affected by Primary Secondary Tertiary any of the following (shock)? Primary Secondary Tertiary strategy strategy strategy strategy strategy strategy 10.4. 10.4a 10.4b 10.4c 10.1. 101a 101b 101c 10.5. 10.5a 10.5b 10.5c 10.2. 102a 102b 102c 10.6. 10.6a 10.6b 10.6c 10.3. 103a 103b 103c 1. Loss of employment 1. Reduced quality/quantity of diet 1. Reduced quality/quantity of diet for a household member 2. Skip a day without eating 2. Skip a day without eating 2. Reduced salary of a 3. Decreased expenditures 3. Decreased expenditures 1. Insecurity/violence household member\ 4. Increased collection and sale of natural 4. Increased collection and sale of natural resources 2. Sudden price fluctuations resources 3. Serious illness or

accident of working 5. Sold furniture or other HH assets 3. High winds/storms 5. Sold furniture or other HH assets household member 6. Sold income generating equipment or 4. Irregular rains 6. Sold income generating equipment or assets 4. Serious illness of assets

7. Sold female reproductive livestock other household 7. Sold female reproductive livestock 5. Floods member 8. Additional wage labour 8. Additional wage labour 6. Unusually high level of

crop pests & disease 5. Death of a working 9. Loans from family/friends 9. Loans from family/friends household member 10. Loans from moneylender/trader 10. Loans from moneylender/trader 7. Unusually high level of livestock diseases 11. Purchased food on credit 6. Death of other 11. Purchased food on credit 8. Unusually high level of 12. pond household items to others household member 12. pond household items to others human disease 13. Received help from others in community 7. Theft and/or 13. Received help from others in 9. Erosion 14. Worked on relief programs from violence community Government, NGO or UN 14. Worked on relief programs from Government, NGO or UN 10. Restricted access to 15. Spent savings or investments markets 16. Out-migrated to look for work 15. Spent savings or investments 16. Out-migrated to look for work 17. Entire family moved to new location 18. Sent children to work for money or food 17. Entire family moved to new location 19. Marry off young daughters (< 13 years) 18. Sent children to work for money or food 20. Begging 19. Marry off young daughters (< 13 years)

20. Begging 21. Other______21. Other______22. Did not do anything 22. Did not do anything

Section 11 – Maternal Health and Nutrition 11.6b – Fever? 1 = YES 2 = NO

Mother’s name______Age |__|__| 11.7 – Last night, did you sleep under a mosquito net? Note: If more than one mother in household, please select according to 1 = YES 2 = NO following preferences: 1. Mother with child(ren) under 5 years of age. 2. Mother with most child(ren) under 5 years of age. 11.8 – After visiting the toilet, what do you use to wash your hands? 3. If none with young children, then mother 15-49 years of age. 1 = water only, 2 = local soap & water, 3 = washing soap & water, 4 = 4. If more than one mother but no children < 5years, then select nothing most senior mother for interview.

11.1 – Are you currently pregnant or breastfeeding? (Circle one) Now I would like to talk to you about a serious illness, in particular, 1 = pregnant 2 = breastfeeding 3 = neither 4 = both 5 = don’t about HIV and AIDS. know

11.2 – If pregnant, how many months pregnant? |__| 11.9 – Have you ever heard of the virus HIV or an illness called AIDS?

YES………………1 NO………………2 (if no end the interview)

11.3a – If pregnant, did you receive iron-folate tablets (pink/reddish tablets) from the WCD, SVA, FAB, SUB or maternity clinic? 11.10 – Is there anything a person can do to avoid getting HIV, the virus that causes AIDS? 1 = YES 2 = NO (skip to 11.4a) YES………1 NO………2 (skip to 11.16) Don’t Know…9 (skip to 11.16) 11.3b – If so, how many tablets have you taken in the past 7 days? |__| Now I will read some questions about how people can protect themselves from the AIDS virus. These questions include issues related to sexuality 11.4a – How many times have you been pregnant? |__|__| which some people might find difficult to answer. However, your answers are very important to help understand the needs of people in Liberia. Again, this information is all completely private and anonymous. Please 11.4b – How many children do you have now? |__|__| answer YES or NO to each question.

11.4c – How old were you with your first delivery? |__|__| 11.11 – Can people protect themselves from getting infected with the AIDS virus by having one uninfected sex partner who also has no other partners? 11.5 – After the birth of your last child, did you receive a vitamin A capsule? YES…………1 NO…………2 Don’t know………..9 1 = YES 2 = NO 11.12 – Do you think a person can get infected with the AIDS virus In the past 2 weeks have you been ill with: through witchcraft? 11.6a – Diarrhoea? 1 = YES 2 = NO YES…………1 NO…………2 Don’t know………..9

11.21– If you knew that a shopkeeper or food seller had AIDS or the virus 11.13 – Can people protect themselves from the AIDS virus by using a that causes it, would you buy food from that person? condom correctly every time they have sex? YES…………1 NO…………2 YES…………1 NO…………2 Don’t know………..9

11.14 – Can a person get AIDS from mosquito bites?

YES…………1 NO…………2 Don’t know………..9

11.15 – Can people protect themselves from getting infected with the

AIDS virus by not having sex at all?

YES…………1 NO…………2 Don’t know………..9

11.16 – Is it possible for a healthy-looking person to have the AIDS virus? YES…………1 NO…………2 Don’t know………..9

11.17 – Can the AIDS virus be transmitted from a mother to a child? YES…………1 NO…………2 Don’t know………..9

11.18 – Can the AIDS virus be transmitted from a mother to a child through breast milk?

YES…………1 NO…………2 Don’t know………..9

11.19 – Can a person can get AIDS by sharing a meal with someone who is infected? YES…………1 NO…………2 Don’t know………..9

11.20 – If a teacher has the AIDS virus but is not sick, should he or she be allowed to continue teaching in school? YES…………1 NO…………2 Don’t know………..9

APPENDIX 3 (COMMUNITY QUESTIONNAIRE) A: QUESTIONNAIRE IDENTIFICATION:

A.1: Date of interview A.2: Interviewer ID A.3: County name

A.4: County code A.5: District name A.6: District code

A.7: Cluster Code A.8: Clan name A.9: Clan code

A.10: Town /village name A.11: Town /village code

A.12: Y-coordinate (latitude) ______A.13: X-coordinate (longitude) ______

Section 1: Demographic Information 1.7 - How many original inhabitants have returned to this community? 1.0 - Number of people living in this community? |__|__|__|__|__| 1 = All 1.1 - Number of people who live in this community before? |__|__|__|__|__| 2 = Less than half 3 = More than half 1.2 - Number of dwellings/houses in this village? |__|__|__|__| 4 = None

1.3 - Number of households in this village? |__|__|__|__| 1.8 – What are the main reasons stopping people from returning to this community? (circle all that apply)

1.4 - Since 2000 (that is, 5 years ago), have people moved away from your community? (Circle answer) 1 = Fear of insecurity 1 = Less than half moved 2 = Homes are damaged 2 = More than half moved 3 = Land occupied by others 3 = Everyone moved 4 = No food 5 = Do not want to return 4 = No one moved 6 = Other (specify) ______

1.5– Are there displaced people living in this community?

YES………………..1 NO………………..2 (If no skip to 1.7)

Section 2 – Economy

1.6 – How many displaced people are in the total population of this community?

______%

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2.1 - What are the three most important natural resources for income generation 3.2b - What are the main sources of credit for people in this community? for the people in this community? (Check in order of importance) (Circle all that apply)

1 = Bank/Credit union 2 = relatives / friends Resources Rank 3 = Charities / NGOs 4 = Local lender – loan account 1st 2nd 3rd 5 = Other (specify) ______None

Forest / forest products

Mines (Iron ore, gold, Section 4 – Agriculture diamond) Wild plants /herbs Palm nuts / bamboo 4.1 - How much money Wild animals (in LD) does an 4.4.1 4.4.3 4.4.4 4.4.2 agricultural laborer earn CLEARIN WEEDIN HARVESTI Fish / sea mammals PLANTING for a day’s work? G G NG Other (specify)

______a – Amount for a MAN Section 3 – Infrastructure b – Amount for a WOMAN 3.1a - Is the road that comes to this community (or passes by it) impassable by vehicle during certain times of the year? (Circle answer) c – Amount for a CHILD

YES………………..1 NO………………..2 (skip to 3.2a)

3.1b - During which months is the road usually impassable?

From |__|__| to |__| __| (see codes below)

1 = January 2 = February 3 = March

4 = April 5 = May 6 = June 7 = July 8 = August 9 = September 10 = October 11 = November 12 = December

3.2a - Do people in this community have access to credit? (Circle answer) YES………………..1 NO………………..2

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Section 5 – Education 6 = None 5.2c What are the reasons for boys not attending school? 5.1 Are there schools open in this community?

YES………………..1 NO………………..2 Reason % boys (if yes fill the bellow table, if no skip to 5.2a) 1 = No school fees A 2 = School damage B Name of Kind Status Ownership Physical Functional 3 = No food C School Condition Condition 4 = The distance is far D 5 = Doing other home work E 5.1a. 6 = No school in the area F 5.1b. 7 = Other______G 5.1c. 5.1d. 5.1e. 5.2d About what proportion of the girls of primary school age are enrolled and attending? School Codes physical and function conditions also apply for Health center 1 = Almost all of the boys 2 = More than half, but not all Kind Status Ownership Physical Functional 3 = Half of the 4 = Less than half 1=Engli 1=Seconda 1=Gov’t 1=Good 1= Good 5 = Only a few boys sh ry 6 = None 2=Arab 2=Primary 2=Private 2=Average 2=Ave. with some ic problems 5.2e What are the reasons for girls not attending school?

3=Fren 3=Literacy 3=NGO 3=Bad 3=Irregular Reason % boys ch Program

1 = No school fees A 4=Community 4=Unaccep 4=Mostly not table functioning 2 = School damage B 3 = No food C 4 = The distance is far D

5.2a Are children in this community attending school in another community? 5 = Doing other home work E

6 = No school in the area F

YES………………..1 NO………………..2 (skip to 5.2c) 7 = Other______G

5.2b About what proportion of the boys of primary school age are enrolled and attending?

1 = Almost all of the boys 2 = More than half, but not all 3 = Half of the 4 = Less than half 5 = Only a few boys

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Section 6 – Health

6.1 Is there any health center in this community? YES………………..1 NO………………..2

Clinic/Health Center Fees for clinic in LD$ Availability of drugs 1= Less $10.00 (1 = yes; 2 = No) 2= 10.00-$30.00 3= 30.00-$50.00 4= Above $50.00

6.2 What are the three main sickness affecting children in Illness for children this community? 1 = Malaria/fever 2 = Cold/cough 6.2a |__| 6.2b |__| 6.2c |__| 3 = Measles

4 = Diarrhea

5 = Tuberculoses

6 = Skin disease

7=Other______6.3 What are the three main sickness affecting adult in Illness for adult this community? 1 = Malaria 2 = Cold/cough 6.3a|__| 6.3b |__| 6.3c |__| 3 = STDs/infections 4 = Diarrhea 5 = Tuberculoses 6 = Skin disease 7=Other______7.4 Where do people in this community go for treatment when Facility % Pop they are sick? a 1 = Health Center/clinic

b 2 = Traditional healer

c 3 = Drug Store

4 = d Other______Section 7 - Markets 7.1 - Transportation and costs to markets

Means of 7.1.1 - What is the time 7.1.2 - 7.1.3 - What is the 7.1.4 - What is 7.1.5 - What is transport taken to get to the nearest What is the frequency of vehicle the cost the cost permanent food market? cost transport to the (in LD) (in LD) (in LD) nearest permanent of transporting of transporting 1 = In the community of return food market? 50 kg rice bag 50 kg rice bag transport to from the from the 2 = Less than ¼ day the 1 = Daily permanent food permanent food 3 = ¼ to ½ day permanent 2 = Once per week market to the market to the 4 = ½ day to 1 day food 3 = Once per month community in community in market? 4 = Once per season the dry season? the rain season? 5 = More than 1 day 5 = 5. Never 6 = Transport type does (excluding the (excluding the not exist cost of the rice) cost of the rice) Foot 7.1.1a 7.1.2a 7.1.4a 7.1.5a

Public 7.1.1b 7.1.2b 7.1.3b 7.1.4b 7.1.5b transport Private 7.1.1c 7.1.2c 7.1.3c 7.1.4c 7.1.5c vehicle

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Section 8– Community organizations

8.1 Are there community groups, organization (NGOs) or structures existing in this community? |______|

YES………………..1 NO………………..2 (skip to 9.1)

8.2 - What four major community development projects exist in this community? (circle the main three) 1 = No community development projects 2 = Construction of school building 3 = Construction/maintenance of health facility 4 = Provision of drinking water 5 = Provision of irrigation water 6 = Construction of Community Centre 7 = Construction of Community Farm 8 = Construction of Community Market 9 = Construction/maintenance of Roads 10 = Other (specify)

8.3 What are the main community organizations that exist in this community, such as women’s groups, farmer’s co-operatives, credit organizations? If so, please name and describe their activities.

Community organizations Type of project or activity 1. 2. 3. 4.

8.4 Are there any external agencies such as NGOs, Church Groups or Government agencies that are supporting activities in this community? If so, please name and describe their activities.

Community organizations Type of project or activity 1. 2. 3. 4.

Section 9– Community priorities

9.1 – What are the three immediate priorities for people in this community?

(a) ______|__|__|

(b) ______|__|__|

(c) ______|__|__|

9.2 – What are the three long-term priorities for people in this community?

(a) ______|__|__|

(b) ______|__|__|

(c) ______|__|__|

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APPENDIX6 Zone/Community # _____ Cluster/ # ___ CHILD DATA COLLECTION FORM h child DOB Sex Oedema Weight Heigh Registered in measles Vitamin Illness- last 2 Is the if no to # of Times Age of child in h # (m/d/y) or (m/ (Y/N) (Kg) t SFP/TFC vaccine A last 6 weeks [no or child breastfeed a day feed months when # age in F) 0 .1 kg (cm) [no, Yes; SFP (1-7; months 1 = Diarrhea; 2 = breastfe ing, at child Fluids + Foods months 0.1cm (Wet/Dry/both see (y/N) ARI; 3 = Malaria; 4 eding what age Breast starte or TFC] below) = fever; 5= now in months d Measles; 6= other [Yes, did you no; stop?] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Measles vaccination- 1 = past 2 months by card; 2 = past 2 months by recall; 3 = past 4-6 months by card; 4 = past 4-6 months by recall; 5 = before the past 6 months by card; 6 = before the last 6 by recall; 7 = never received vaccine

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APPENDIX7 Cluster #______MORTALITY DATA COLLECTION FORM HH # Live Births Number and Date of live births That died total people total under total deaths No. deaths of > No. deaths of < causes of causes of No. to the Mother in hh 5 after 5 after 5 after death in death in > in hh September 1, September 1, September 1, <5 5 04 04 04 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Key for cause of death: 1 = diarrhea, 2 = ARI, 3 = fever, 4 = measles, 5 = malnutrition, 6 = accident, 7 = war related, stray bullet, etc., 8= unknown, 9 = other

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