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Smart - Nutrition and Mortality Survey SMART - NUTRITION AND MORTALITY SURVEY FINAL REPORT Kaga, Konduga, Magumeri, and Jere LGAs Borno State, Nigeria July 2019 Save the Children International Acknowledgements Save the Children International (SCI) would like to acknowledge the important contribution of the following towards the success of the survey: SCI staff and management in the MEAL and nutrition sections for the leadership, guidance and oversight. SCI administration and security units who provided logistical support through vehicles and security arrangements. The survey teams who worked tirelessly during training and data collection. The community leaders who allowed the survey teams to work without hindrance. Mothers, caregivers, fathers and children who graciously took part in the survey. 2 Table of contents Acknowledgements……………………………………………………………………………2 Executive summary……………………………….………………………..…………...….…..7 1. Introduction……………..…………………………..…..…………...……….…….....14 1.1 Background………………………………………………….……………………………14 1.2 Survey Justification………………………………………………………………………..15 1.3 Survey Objectives…………………………………………………………………..…….16 2. Methodology…….……………………….……………………………….….…..........17 2.1 Survey design…….…………………………………………….……….….….………......17 2.2 Sample size determination…….….………………………………….….…….…......…....17 2.3 Survey target population…………………………………….…………………….….......13 2.4 Sampling procedure….………………………....…...................................................................14 2.4.1 Selecting clusters……………………………………………………………………….18 2.4.2 Selecting households and children…………………………………………………...…18 2.5 Survey implementation……….……………………………………………………...…....18 2.5.1 Questionnaire and training……………………………………………………………..18 2.5.2 Data collection and supervision……………………………………………………..….19 2.5.3 Data cleaning and analysis…………………………………………………………...….19 2.5.4 Data collection tools…………………………………………………………………....19 2.5.5 Case definitions, inclusion criteria and classification…………………………………...20 2.6 Limitations…………………………………………………………………………….......21 2.7 Classification of malnutrition……………………………………………………………..21 3. Results…….…………………….………………………………………..……....…....23 3.1 Household characteristics and demographics………….…………………….……..…..24 3.1.1 Response rates……………………………………………………………………….....24 3.1.2 Data quality…………………………………………………………………………..…24 3.1.3 Age and sex ratio in children 6-59 months…………………………….………..……..24 3.2 Anthropometric results (based on WHO standards 2006)……...….. ……………......25 3.3 Mortality results………………………………………………………………………...31 3.4 Children’s morbidity …………………………………………………………………..31 3.5 Measles vaccination and Vitamin A supplementation ………..………………………..32 3.6 Infant and young child feeding (IYCF)……………………………………………….....33 3.7 Women of reproductive age……………………………………………….………......34 4. Discussion………………….…………………..…………………………...….….…..36 5. Conclusion ………………………………………………………………………...…37 6. Recommendations……………………………………………………………………37 Annex 1 List of individuals who participated in the survey………………………………….39 Annex 2 Assigned clusters………………………………………………………...……….....40 Annex 3 Survey questionnaire…………………………………………………….…………41 Annex 4 Standardisation test report………………………………………….….………… 45 Annex 5 Survey local calendar of events………………………………………...…………. 48 Annex 6 Plausibility report for anthropometry………………………………………….…..51 3 List of tables Table 1 Child Health, Nutrition and Morbidity…………………….…………………………9 Table 2 Infant and Young Child Feeding……………………………….……………………..10 Table 3 Women of reproductive age (15-49 years) ………………………..……………….10 Table 4 Mortality……………………………………………………...…………………...…10 Table 5 Sample size calculation………………………………………….………………...…17 Table 6 Classification of malnutrition using WHO 2006 Growth Standards………….……21 Table 7 Classification of public health significance for children under 5 years of age………22 Table 8 MUAC cut-off’s for women of reproductive age………………………..……….…23 Table 9 Minimum dietary diversity for women (MDD-W) ……………...……………….…23 Table 10 Survey response rates………………..……………………………………….……24 Table 11 Overall survey data quality…………………………………..…………….…….…24 Table 12 Distribution of age and sex of sample…………………………….………..………25 Table 13 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex……………..………………………………………………………....…25 Table 14 Prevalence of acute malnutrition disaggregated by LGA……………..………...….26 Table 15 Weighted prevalence of global acute malnutrition………………………………...26 Table 16: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema……………………………………………………………………………….26 Table 17: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex…………………………………………………………………………..…………….27 Table 18 Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema…………………………………………………………………………………….…28 Table 19 Prevalence of underweight based on weight-for-age z-scores by sex………….….28 Table 20 Prevalence of underweight by age, based on weight-for-age z-scores…………….29 Table 21 Prevalence of stunting based on height-for-age z-scores and by sex………...……29 Table 22 Prevalence of stunting by age based on height-for-age z-scores……………….….30 Table 23 Mean z-scores, Design Effects and excluded subjects…………………………..…31 Table 24 Mortality rates, Borno SMART Survey, July 2019…………………………………31 Table 25 Prevalence of reported illness in children in the two weeks prior to interview (n=590)………………………………………………………………………………….……31 Table 26 Measles vaccination and Vitamin A supplementation vaccination coverage……….33 Table 27 Infant and Young Child Feeding results……………………………………….……33 4 List of figures Figure 1 Trend of SAM admissions in SCI operational areas of Borno state, June 2018-July 2019…………………………………………………………………………..15 Figure 2: Weight-for-Height z-scores………………………………..………………..……...27 Figure 3: Height-for-age z-scores……….……………………….………………….….……..30 Figure 4: Proportion of children who sought treatment for illness….…….…………….…..32 Figure 5: Health-seeking behaviour…………………………………………………………..32 Figure 6: Complementary feeding for children 6-23 months..…….……………………...….34 Figure 7: Minimum dietary diversity for women 15-49 years…………….………………….34 Figure 8: Dietary diversity for women 15-49 years……………………………….……....….35 Figure 9: Proportion of malnutrition by pregnancy and lactation status…………………….35 5 List of acronyms ARI A-cute Respiratory Infection CI- Confidence Interval ENA- Emergency Nutrition Assessment FAO- Food and Agricultural Organisation GAM- Global Acute Malnutrition HAZ- Height-for-age z-score IYCF- Infant and young child feeding IPC- Integrated phase classification LGA- Local government area MAM- Moderate acute malnutrition MDD-W Minimum dietary diversity for women MUAC Mid upper arm circumference NBS National Bureau of Statistics OTP Outpatient therapeutic care programme PPS Probability proportional to size SAM- Severe acute malnutrition SCI- Save the Children International SFP- Supplementary feeding programme SMART- Standardised Monitoring and Assessment for Relief and Transitions UNICEF- United Nations Children’s Fund WAZ- Weight-for-age z-score WHO- World Health Organisation WHZ- Weight-for-height z-score 6 Executive Summary Introduction Given the prevailing acute food security situation and high malnutrition prevalence observed in the previous survey, it is necessary to update the nutrition and mortality indicators by determining the prevalence of acute malnutrition and mortality as well as to investigate factors related to malnutrition. According to the 2018 SMART Nutrition and Mortality Survey conducted in Kaga, Jere, Konduga and Magumeri LGAs in Borno State, the prevalence of global acute malnutrition (GAM) was 15.7% (12.2-20.0, 95% C.I), with a severe acute malnutrition (SAM) prevalence of 4.2% (2.9-6.1, 95% C.I). The crude death rate was 0.79 deaths per 10,000 per day (0.52-1.20, 95% C.I), with an under 5 death rate of 1.60 deaths per 10,000 per day (0.83-3.07, 95% C.I). However, due to the persistent on-going conflicts in the areas, it is necessary to also continue monitoring the mortality trends, and as such, this survey will also measure the mortality rates. The overall objective of the survey was to determine the magnitude and severity of malnutrition and retrospective mortality rates amongst the population in the accessible communities of the 4 LGAs (Kaga, Jere, Konduga and Magumeri) in Borno State within the areas in which Save the Children is operational. Specific objectives To determine prevalence of Malnutrition (acute malnutrition, chronic malnutrition and underweight) among children 6-59 months in the target population in the accessible communities of the 4 LGAs. To assess retrospective morbidity among children under 5 in the target population in the 4 LGAs. To assess retrospective mortality (Crude Mortality and U5 Mortality rates) over 3 months’ recall period among target populations in the 4 LGAs. To estimate measles vaccination coverage of children 9-59 months and Vitamin A supplementation coverage of children 6-59 months in the target population in the 4 LGAs. To assess IYCF practices among the households with children under two years of age in the target population in the 4 LGAs. To estimate the prevalence of malnutrition in women of reproductive age (15-49 years) in the target population in the 4 LGAs. To establish recommendations on actions to address identified gaps, to support planning, advocacy, decision making and monitoring in the 4 LGAs. Methodology The Standardized Methodology for Assessment in Relief and Transitions (SMART) which applies a two-stage cluster sampling
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