Maternal and Young Child Feeding, WASH and Child Protection KAP Survey Report: Jere, Konduga, Mafa, and MMC

Table of Content

List of Acronyms 3 Executive Summary 5 1. Introduction 10 1.1 Background/Rationale 10 1.2 Aim and Specific Objectives 11 2. Methodology 12 2.1 Study location and Population 12 2.2 Core Indicators 13 2.3 Quantitative Approach 14 2.3.1 Sampling Design 14 4.0 Results and Discussion 18 4.1 Demographic Characteristics 18 4.2 Infant and Young Child Feeding (IYCF) 19 4.2.2 IYCF Core Indicators 20 4.2.3 IYCF Optional Indicators 25 4.3 Child Health 26 4.4 Mothers/Caretakers Knowledge of IYCF and Hygiene 29 4.5 Maternal Nutrition and Health 31 4.6 Maternal Hygiene 31 4.7 Water, Sanitation & Hygiene (WASH) 32 4.8 Child Protection 35 4.9 Covid-19 Awareness 37 Figure 8: Mode of Transmission of COVID-19 38 5. Conclusion 39 5.1 Recommendation 40 Annex 1-IYCF Results 44 Annex 2-Cluster Distribution 46 Annex 2-References 48

List of Acronyms

AOGs Armed Organized Groups

CH Cadre Harmonizé

CJTF Civilian Joint Task Force

CNMs Community Nutrition Mobilizers

CP Child Protection

DTM Displacement Tracking Matrix

EBF Exclusive Breastfeeding

ENA Emergency Nutrition Assessment

EPI Expanded Programme on Immunization

FGD Focus Group Discussion

FGDs Focus Group Discussions

HH Household

HHs Households

IDIs In-Depth Interviews

IDP Internally Displaced Person

IDPs Internally Displaced Persons

IOM International Organization for Migration

IYCF Infant and Young Children Feeding

IYCF-E Infant and Young Children Feeding in Emergency

KAP Knowledge Attitude and Practice

KIIs Key Informants Interviews

LGA Local Government Area

LGAs Local Government Areas

MDD Minimum Dietary Diversity

MLoS Master List of Settlements

MMC Maiduguri Metropolitan Council

MNCH Maternal, Newborn and Child Health

MSG Mother Support Group

MTMSG Mother-to-Mother Support Group

NFSS Nutrition and Food Security Surveillance

NGO Non-Government Organisation

NNHS National Nutrition and Health Survey

ODK Open Data Kit

OFDA Office of U.S. Foreign Disaster Assistance

ORS Oral Rehydration Solution

PHCs Primary Health Centres

SAM Severe Acute Malnutrition

SCI Save The Children International

SMART Standardized Monitoring and Assessment of Relief and Transitions

TSFP Targeted Supplementary Feeding Programme

UNICEF United Nations International Children's Emergency Fund

VAD Vitamin A Deficiency

VTS Vaccination Tracking System

WASH Water Sanitation and Hygiene

WHO World Health Organisation

Executive Summary

Borno state is in northeast Nigeria with a geographic area of 57,799 km2 and a population of approximately 4.9 million. Since 2009 the state has been experiencing armed conflict which has led to displacement of about 1 million people. Although the crisis is not at its 2012 peak, Borno state still has about 1,439,953 internally displaced persons (IOM DTM round 26) and at least 35% of the resident households in Borno State have an IDP or returnee in household. In Borno state, as in overall Northern Nigeria, IYCF practices were extremely poor prior to the conflict and the challenges to exclusive breastfeeding and optimal IYCF- E practices faced due to displacement and strain from the conflict are significantly contributing to malnutrition in children under two years. In addition to making treatment available for children under five with SAM, there is an urgent need to prevent and reduce malnutrition through a multi-sectoral approach. This approach includes improving IYCF practices, improving water quality, improving sanitation and hygiene practices and ensuring that children are well protected and have access to various health, WASH, nutrition and child protection services in target communities. To better inform SCI interventions in Borno state, this assessment was conducted to understand the prevailing Knowledge, Attitudes and Practices around Maternal Infant and Young Child Feeding, WASH and Child Protection (CP) in communities, in four Local Government Areas (LGAs)—Jere, Konduga, Magumeri and Kaga Local Government Areas (LGA). The study employed a mixed-survey design, which included both quantitative and qualitative data collection methods. For the quantitative component, cluster sampling design as recommended by CARE IYCF guideline is used and the 10 primary IYCF indicators are the principal indicators of study. Other maternal nutrition, WASH, Child Protection and Covid-19 indicators were included in the structure qualitative tool administered using koBo. The qualitative data collection used paper questionnaires administered through focus group discussions (FGDs) and key informant interviews (KIIs). A total of 2138 caregivers of children under 2 years from 3031 households were sampled for the quantitative data collection while the qualitative component, 12 FGDs and 12 stakeholder interviews were conducted. Data collection began on 18 July and ended on 26 July after 4 days of training plus piloting.

Summary of Findings The table 1 below presents a summary of key findings from the survey disaggregated by Local Government Areas (LGAs). Some of the primary findings presented includes; Core IYCF indicators, hand washing practices and MSG attendance. Please note that only the overall findings are representative as sampling for IYCF was estimated to be representative ate the domain level (combining all 4 LGAs). Therefore, disaggregated finding are merely indicative therefore should be interpreted with caution. See Annex 1 for full results and disaggregation by gender.

Table 1: Summary of survey findings Indicator LGAs (lower and upper bound) Jere Konduga Mafa MMC Overall

85.1% 90.3% 80.8% 82% Initiation to breastfeeding 79.9% (77.0% - 82.6 (79.6% - (86.0%- (77.9% - (80.3% - %) (Birth) (0-23) (n=2127) 89.6%) 93.6%) 83.5%) 83.7%)

63% 67.3% 76.7% 66.1% Exclusive breastfeeding (0-5) 56.4% (47.6% - (48.6% - (54.2% - (68.8% - (61.0% - 64.8%) (n=348) 75.9%) 78.5%) 83.7%) 70.9%)

86.1% 88.4% 89.4% 90.3% Continued Breastfeeding (12- 92.4% (88.0%- (72.2% - (76.4%- (83.9%- (87.2%- 95.6%) 15) (n=424) 94.5%) 95.4%) 93.4%) 92.9%)

81.1% 40% 54% 64.6% Introduction to Semi 69.5% (59.3%- (66.4% - (22.7% - (49.7% - (58.5% - 77.8%) Solid/Solid Food (6-8 ) (n=246) 91.1%) 59.34%) 69.7%) 70.4%)

25.6% 33.7% 22.1% 26.4% Minimum Dietary Diversity (6- 28.4% (21.8% - (14.0% - (21.1% - (16.2% - (22.1% - 36.4%) 23)(n=1779) 42.8%) 50.8%) 29.5%) 31.2%)

33% 32.7% 33% 32.8% Minimum Meal Frequency (6- 32.7% (29.4% - (26.3% - (26.5% - (29.5% - (30.7% - 36.2%) 23) (n=1779) 40.1%) 39.3%) 36.6%) 35.0%)

15.3% 20% 13.1% 15.3% Minimum Acceptable Diet (6- 15.9% (13.4% - (10.6% - (15.0% - (10.7% - (13.7% - 18.7%) 23)(n=1779) 21.2%) 25.9%) 15.8%) 17.0%)

9.1% 14.2% 9.9% 8.8% Consumption of Iron (6-23 ) 6.2% (4.6% - 8.1%) (5.5% - (9.9% - (7.8% - (7.5% - rich foods(n=1779) 14.0%) 19.4%) 12.3%) 10.2%)

87.8% 91.2% 92.9% 92.3% 93.3% (91.5% - (83.1% - (87.2% - (91.0% - (91.3% - Ever breastfed (0-23)(n=2127) 94.9%) 91.6%) 94.2%) 94.6%) 93.4%)

17.9% 40% 24.% 31.5% Continued Breastfeeding (20- 36.6% (30.2% - (7.2% - (27.8% - (18.9% - (27.3% - 43.3%) 23) (n=460) 34.8%) 53.2%) 31.7%) 35.8%)

Minimum dietary diversity – 32.50% 37.80% 39.40% 31.40% 34% Women(n=1913)

Caregiver who are member of MSG that have at least 3 60.10% 65.22% 85.60% 69.23% 67.90% critical IYCF knowledge (n=1913) Care givers that know critical handwashing times (3- 70.20% 78.70% 89.36% 75.10% 75.30% 5) (n=735)

. Overall results from this survey shows that the practice of exclusive breastfeeding in the survey area (66%) is slightly higher than baseline (62.7%) conducted by SCI in the 2019 but significantly higher than NFSS 8 2019 estimate (45.3%). It is important to note that this survey and the baseline covered only SCI programme areas while the NFSS covered the entire LGA, the EBF results however, indicates an improvement in mothers breastfeeding practices. Earlier initiation to breastfeeding practice (82%) is slightly higher than the baseline estimate (79.2%) but continued breastfeeding at 1-year practice is significantly lower (90%) when compared to the baseline (99%). Introduction of solid, semi-solid or soft food practice is in line with Nigeria National Nutrition and Health Survey. Overall, child breast feeding indicators seem to be in line or showing better results than the baseline and other nutrition surveys, however, breastfeeding practices is still poor as about 7% of assessed children were not breastfeed and SDG targets for EBF has not been achieved. In line with the baseline, MMF, MMD and MAD results in the survey area are really poor which according to FGDs is mainly caused by of lack of resources to buy nutritious food in the right quantity. This poor food intake by children 0-23 months in the households signals a broader issues of household food insecurity as a lot of households have been affected by the conflict which have disrupted their means of livelihood. In general women in the survey area had a decent knowledge of IYCF but lack of resources and cultural barriers continue to hinder full adoption of good IYCF practices. A large proportion of women of reproductive age (15 - 49 years) did not consume the required 5 out of the 10 food groups categories required to meet the minimum dietary diversity which has an effect on breastfeeding and then the baby's health. The study also shows that mothers who are part of MSG have more robust IYCF knowledge and are more able to practice them. Most of the surveyed communities do have access to improved water but a lot still face problems of long travel distance, queuing time and inadequate collection and storage containers. The majority of respondent reported being aware of child protection and could identify a lot of child protection issues, however a lot of the issues mentioned revolved around child’s needs and access to services and not so much on social and

emotional related child issues this could be heavily influenced by social norms as some child protection issues were described as “normal”. Communities in the survey area rely heavily on community mechanisms for reporting and dealing with child protection issues. Communities seemed fairly knowledgeable on how Covid-19 is spread and can be prevented, however, there is a need to improve personal hygiene and handwashing practices in the community.

Recommendations ━ Because of the significantly high rate of children not breastfeed. It is critical that maternity facilities and health centers supported by SCI are able to provide breastmilk for sick born, separated children and children who have lost their mothers as a result of death during child birth or conflict. ━ As a result of Covid, MSG meetings and house to house visit are not as frequent as needed. Mediums like radio, health facility and community leaders should be used in raising awareness of child breastfeeding in the community. Also to be packaged in the sensitization message is the awareness on breastfeeding from birth through two years’ age and why this is important for a child. ━ SCI should support the implementation of the ten steps to successful breastfeeding developed by UNICEF and WHO in all supported health facilities if that is not already been done. ━ SCI should work to strengthen the link between health facilities and communities to ensure continued support for breastfeeding and this should be continuously tracked and monitored to see improvement in breastfeeding practices. ━ Since iron rich foods like liver, red meats, eggs and fish, are not widely available or affordable, SCI support the distribution of fortified food to children and iron/folate supplement for pregnant mothers. ━ A lot of women cannot afford a nutritious diet and struggle to meet their full dietary requirement especially during pregnancy and breastfeeding so SCI can support these women through conditional cash transfer programme for PLW, integrated with food diversification programme to teach women how to utilize home yard/garden to provide nutritious food their family and a behavioral change campaign around consumption of nutritious food. ━ Caregivers need to be encouraged and motivated to join MSG. This can be done through sensitization campaigns using existing community structure (gate keepers), discussions with mothers to understand barriers to participating in MSG and further incorporation of livelihood activities into the MSG design Findings from the survey show a significant proportion of women are not part of MSG, we therefore recommend a scale up of MSG so more women can have access. ━ Community child protection mechanisms need to be reinforced and realigned with the national child protection laws as the majority of beneficiaries including some community leaders did not

know national child protection laws. Further research is required to properly understand these community systems and how it can be aligned to the national child protection response. ━ A significant proportion of respondents believed boys should be prioritized over girls in terms of going to school, and children with disability don’t need to go to schools. This perception, coupled with the fact that 27% of beneficiaries reported have difficulty with atleast one function (using WGS), it is critical that SCI programmes are designed to include vulnerable groups (young girls and disabled children) and there is a need for serious community sensitization around issues of gender and disability. ━ From FGDs with fathers, a reoccurring theme was that fathers understood their role in the family to be that of a provider and protector and nothing more. Because of this perception, father are not getting very involved in their children’s nutrition. Therefore, a sustained scale up of child nutrition and awareness campaigns specifically targeting fathers which could also be organized through the community structure. We recommend bolstering the father support group programme. ━ In light of Covid-19, personal hygiene and handwashing messages should be increased. SCI staffs should deliver hand washing and Covid-19 messages at every point of contact with beneficiaries and the community. This should be implemented throughout all the stages of implementation and by every staff in the organization.

━ Finally, SCI should consider a multi-sectoral approach that address all the sectoral needs of children, mothers and households. Further research would be needed to fully understand the needs of community in other to design an effective approach.

1. Introduction

1.1 Background/Rationale Since 2009, the Boko Haram driven crisis (herein, Armed Opposition Groups [AOGs]) has crippled north eastern Nigeria, events from 2019 have led to an upsurge in the number of people that require humanitarian assistance. From 2017 to 2019, the number of people in need of urgent assistance reduced from 8.5 million to 7.1 million. Increased attacks by Non-State Armed Groups (NSAGs) against civilians, compounded by the effects of climate change, natural hazards and disease outbreaks, exacerbated the needs of the population already afflicted by more than ten years of protracted crisis. Millions of people have been plunged into further vulnerability and 7.9 million are now in need of life-saving aid in 2020 – 800,000 more people than in 2019[1]. Violations and abuse of international humanitarian and human rights law remain pervasive. Non-state armed groups are increasingly setting up illegal checkpoints on main supply routes directly targeting civilians. This condemnable practice has disastrous consequences for civilians and humanitarians, hindering freedom of movement and heightening protection risks. Save the Children has been working in Nigeria since 2001. The early focus was on getting children actively involved in shaping the decisions that affect their lives. Today, SCI is working in 20 states focusing on child survival, education and protecting children in both development and humanitarian contexts. The humanitarian response started in 2014 with Save the Children among one of the first responders to the conflict. The ongoing conflict in the North East continues to increase population displacements, poor sanitation, hygiene, poor access to safe water supplies, restrict income-generating opportunities, limit trade flows and escalate food prices. As a result of the reduced food availability and access, local and IDP populations in worst-affected areas of Borno, Yobe and Adamawa states continue to experience food gaps, in line with crisis (IPC Phase 4) acute food insecurity, with an estimated 4.6M people in Phase 3-5 (Cadre Harmonizé (CH) Analysis). In Borno state, as in overall Northern Nigeria, IYCF practices were extremely poor prior to the conflict and the challenges to exclusive breastfeeding and optimal IYCF-E practices faced due to displacement and strain from the conflict are significantly contributing to malnutrition in children under two years. In addition to making treatment available for children under five with SAM, there is an urgent need to prevent and reduce malnutrition through a multi-sectoral approach. This approach includes improving IYCF practices, improving water quality, improving sanitation and hygiene practices and ensuring that children are well protected and have access to various services in target communities.

To better inform SCI interventions in Borno state, this assessment was conducted to understand the prevailing Knowledge, Attitudes and Practices around Maternal Infant and Young Child Feeding, WASH and Child Protection (CP) in communities, in four Local Government Areas (LGAs)—Jere, Konduga, Magumeri and Kaga Local Government Areas (LGA).

1.2 Aim and Specific Objectives The general objectives of this survey is to determine knowledge, attitude and practice (KAP) of IYCF practices, risks associated with practices pertaining to water, sanitation and child protection for children and their families affected by conflict in targeted LGAs in Borno state, Nigeria. ━ Determine knowledge, attitudes and practices on Maternal Infant and Young Child nutrition in the targeted LGAs ━ Identify key actors of change and/or influential community leaders and recommend approaches to include them in programme designs. ━ Provide additional qualitative information on the choice of practices/ behaviours (through focus group discussions, Key Informant Interview, transect walks etc) ━ Determine community knowledge and awareness on existing nutrition interventions. ━ Determine the attitude and practice of households on water treatment and storage ━ Determine the knowledge and awareness of households on diarrheal and other water borne diseases. ━ Determine the community knowledge on hand washing and hygiene practice ━ Determine the level of knowledge of parent and caregiver on child protection practices ━ Determine the knowledge of parents and caregivers on availability of services for children and organizations that cater for children right within their community. ━ Recommend key simple, practical and achievable interventions that will address the identified issues to ensure appropriate practices.

2. Methodology

This survey adopted a combination of qualitative and quantitative approach. For the quantitative component, a representative household survey powered by IYCF indicators was conducted and was followed up by qualitative data collection; in depth interviews with traditional leaders, health facility in- charge, lead mothers, lead fathers and local nutrition focal points. Focus group discussions were conducted with caregivers of children, members of mother to mother support group (MTMSG), members of father to father support groups and community nutrition mobilizers (CNMs).

2.1 Study location and Population The survey was conducted in four targeted LGAs (Jere, Konduga, Mafa, & Maiduguri) in Borno State, these are the locations where SCI OFDA or FFP funded interventions are being implemented. The survey covered all accessible settlements in the targeted LGA. Based on the context of the humanitarian situation in Borno, the population group considered for the household’s survey are the following;

━ Host community: This group of the population are either returnees or host communities. Population estimates from the Polio Vaccination Tracking System (VTS) [2] were used to estimate the population of this group. ━ Internal Displaced Persons (IDPs): This group of the population includes all aborigines and settlers that are confined to defined IDPs camps or live in host communities. IDP population in the survey area was obtained from IOM DTM [3].

Vaccination Tracking System population estimate is filtered through the Borno polio master list of settlement (MLoS), the process generates a list of accessible settlements along with their respective population estimates, combining this with IOM DTM data the population of the surveyed area is estimated as follows;

Then the population of children aged 0-23 months living in the survey area is estimated by multiplying the total population of the area by 0.08 (studies show that children aged 0-23 months are about 8% of the population in the southern hemisphere. [4]

2.2 Core Indicators

Table 2: Primary Indicator for the Study

SN INDICATOR INDICATOR MEASURE Proportion of children 0-23 months who were put to the breast 1 Inititiaon of breastfeeding (Birth) within one hour. Proportion of infant 0-5 months of age who were fed exclusively 2 Exclusive breastfeeding (< 6 months) with breast milk in the past 24 hours prior to time of survey[1] Introduction of solid, semi-solid or soft Proportion of infants 6-8 months who received at least one solid, 3 foods (6-8 months) semi-solid or soft foods in the 24 hours prior to time of survey Proportion of children 12-15 months old who are fed breast milk in the past 24 hours prior to time of survey

Continued breastfeeding up to 1 year and Continued breastfeeding at 2 years of age (when children are 4 2 years 20-23 months)

Proportion of children 6-23 months who received food from 4 or more of the 7 food groups in the past 24 hours prior to time 5 Minimum dietary diversity of survey[2] Proportion of breastfed and non-breastfed children 6-23 months of age who receive solid, semi-solid or soft foods the minimum 6 Minimum meal frequency number of times or more, during the previous day[3]. Proportion of children 6-23 months of age who had at least the minimum dietary diversity and minimum meal frequency in the 7 Minimum acceptable diet past 24 hours prior to time of survey Proportion of children 6-23 months old who receive an iron rich Consumption of iron-rich or iron-fortified or iron-fortified food that is specially designed for infants and 8 foods young children or that is fortified in the home Proportion of children 6-23 months who were fed with a bottle 9 Bottle feeding over the 24 hours prior to time of survey Percentage of caregivers of children under 2 years who take part of support groups who are able to cite at least 3 IYCF best 10 IYCF knowledge practices Percentage of reproductive age women (15-49) that consume at 11 Minimum dietary diversity - Women least 5 out of the 10 food groups. community water treatment and storage knowledge attitude and 12 Water treatment and storage practice

13 Hand Washing hygiene Community hand washing hygiene practice Community and caregiver knowledge of child protection 14 Child protection knowledge knowledge

15 Awareness of child services Community awareness of child related services

2.3 Quantitative Approach

2.3.1 Sampling Design The survey adopted the WHO cluster sampling model [5] for vaccination which can be applied to a KAP survey as recommended by ACF lessons learnt in KAP survey report [6]. Villages in the study area were considered as primary sampling units and in order to estimate the effective sample size, an estimate of the percentage of mothers practicing each of the IYCF indicators from a sector wide KAP protocol [7] for the study area is used. Jere, Mafa, Konduga and Maiduguri are grouped into domain and using a 95% confidence interval, 5%. The EBF indicator had the highest sample size estimate (492). In order to achieve representation for all sub age groups within the 0-23 months cohort, CARE IYCF guide 2010 recommends multiplying the indicator with the largest sample size (in this case exclusive breastfeeding under 6 months with 492) by 4. This ensures that a representative sample was collected at all groups (0-5, 6-11, 12-17 and 18-23 months), therefore ensuring all indicators were representative. The result of the multiplication was 1968 which means 1968 children between 0-23 months were sampled across all LGA. All 1968 children within the 4 age groups (0-5, 6-11, 12-17 and 18-23 months), were sampled in one household survey containing questions on all of the indicators

2.3.3 Household Selection

Using the demographic parameter of the survey area, the sample size for children between 0-23 months) was to be reached in 3030 households (see table 3 below). 101 clusters were selected after putting into account a) time of travel b) community entry and briefings c) time spent in filling a questionnaire and taking anthropometric measurements and d) time required for household listing. Clusters were selected using probability proportional to size method on ENA for SMART. Each cluster contained not more than 150-250 households (see SMART Manual), for settlement/villages/camps that have a higher population, segments of the entire population were generated and one/more segments was randomly selected to represent the cluster/clusters as required. See Annex 2 for cluster distribution.

Table 3: Quantitative sample size

Number of households to Number of LGA Children 0-23 months to sample Visit clusters LGA

5 1968 3030 101 5

“All persons who slept in the house the day before, shared the same meal and who recognize the authority of a head of household” is the household definition adopted by this survey. Household listing was done in each cluster then households were randomly selected in each cluster using a random number generating android app. For settlements with more than 250HH that settlement was segmented. For mothers with more than one child who are 0-23 months old, all children were administered the questionnaire. In a case of multiple births (for example, twins and triplets), all age-eligible children in the family were interviewed

2.4 Qualitative Survey

Two types of qualitative data were collected in the survey area 1) in depth interviews (IDIs) with key informants and 2) Focus group discussion (FGDs) with community stakeholders. IDIs and FGDs were conducted in selected communities in all LGAs, one of each respondent group below were interviewed per LGA bringing the total number of qualitative samples to 32. To better understand the role played by different stakeholders, IDIs were conducted with traditional and religious leaders, health facility in-charge and lead mothers,. One of this group was selected from each LGA, because of the homogeneity of population within the LGA, similarity of needs and barriers and similarity of programme implementation within the LGAs. Also, because of Covid-19 person to person contact needed to be minimised therefore sampling was rationalised.

Table 4: Qualitative sample size

Key Informant Interviews (KII) Number Focus Group Discussion (FGD) Number

Traditional and Religious leaders 4 Households including Mothers of under 2 years Children 4 Health facility In-charge 4 Households including Fathers of under 2 years Children 4 Lead Mother 4 Member of MTMSG 4 Total 16 Total 16

2.5 Field Data Collection

Field data collection ran concurrently across all 4 LGAs for a duration of 10 days. The survey teams were assessed during the training and continually throughout the data collection period. Teams with consistent high- quality data were retained, while any team found wanting as regards data quality, were dropped. Enumerator training was conducted from 13 to 17th of July 2020. The training covered the following thematic areas; overview of the survey and its objectives and introduction to KAP methods, Interview and general communication skills, questionnaires simulation, sampling, estimation of age in months and validation using

the calendar of local events, community entry and COVID-19 Awareness and Sensitization. Quantitative data collection was conducted using ODK mobile data collection platform and data uploaded to/ downloaded from a dedicated KoBo server. Data was cleaned daily and reviewed for daily briefings and quality checks (QC) will be done. Following data collection, final data processing and cleaning was conducted.

2.6 Data management

Participants were asked for consent to participate and all information was handled with confidentiality and in line with SCI’ data protection protocol. Data checking and validation for completeness and consistency was carried out on a daily basis, based on the uploaded entries to KoBo Collect from phones. Data that was deemed inconsistent were highlighted and shared with the relevant coordination team for rectification. Quality control was ensured on a daily basis, with corrections being carried out immediately.

Quantitative data was processed and cleaned on excel and Following the completion of field data collection, data was analysed using R version 3.6.2. while qualitative data was translated and analysed on Nvivo.

3.Ethical Considerations and Approval

3.1 Confidentiality

For all the study components (interview and FGD), no personal identifiers such as name, address, telephone and hospital identification number were documented on the study tools. There is no way to link a specific questionnaire to a specific respondent. During the Household survey, the respondent and the enumerators sort a comfortable place or corner in the house to ensure privacy during the question and answer sessions. A high level of confidentiality and security was strictly adhered to in handling the data from the study.

3.2 Informed Consent

Informed Consent was obtained from all respondents and FGD participants. Only respondents or participants who voluntarily accepted to be part of the survey participated in the HH interview and FGD. For Only participants 18 and above participated in this study.

3.3 COVID-19 Considerations

Enumerators Training

━ Facilitators and Enumerators used facemask all through

━ Hand washing facility/ hand sanitizers were available ━ Venue of training was well ventilated and seats were arranged to maintain physical distance of at least 2 metres ━ COVID-19 sensitization and awareness formed part of the enumerators training

During Data collection

━ Physical distance of at least 2 meters from respondent ━ All enumerators use facemask during data collection and are provided with hand sanitizers ━ FDGs participants limited to not more than 6 persons ━ Face mask were provided for all FGD participants and physical distancing maintained ━ 3 enumerators are transported per vehicle to ensure physical distancing ━ Data collection devices (i.e phones) are decontaminated daily (before and after field visits

3.4 Limitations

The following are thus the challenges and limitations of the survey;

━ Representativeness of the survey finding is limited to only accessible settlements and in targeted locations, due to the current security challenges. ━ The study focuses on areas where SCI in implementing nutrition and child related programmes so caution should be taken when adopting finding for other purposes or generalizing across the entire area. ━ Results for IYCF indicators are representative at the domain level (Jere, Konduga, Mafa and MMC). LGA level results are not representative but merely indicative so should be interpreted with caution. ━ There is an inherent susceptibility for subjective biases and recall.

4.0 Results and Discussion

4.1 Demographic Characteristics

Table 5: Response Rate

Category Targeted Achieved Response Rate LGAs 5 4 80% Cluster 101 103 101%

5 LGAs (Jere, Konduga, Mafa, Magumeri and MMC) were targeted for this assessment with a total of 101 clusters. Due to the prevailing insecurity challenges around the Magumeri environs, the LGA was dropped as part of this KAP assessment and its clusters were redistributed to the other 4 LGAs.

Table 6: Socio-Demographic Characteristics Jere Konduga Mafa MMC Overall(%) Characteristics (n=1990) n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%)

Gender of the Head of Female 24.3% 15.3% 26% 19.2% 21.7% Household Male 75.7% 84.7% 74% 80.8% 78.3% 54.4% koranic 60.3% 57% 55.5% 14.6% none 51.3% 20.6% 11% 10.5% 14.6% secondary 18% 9.6% 17% 16.5% Highest form of education primary 13.6% 7.7% 10% 8.2% 8.7% achieved tertiary 9.1%8.1% 1.9% 6% 9.3% 7.6% 25.9% 3.3% agriculture 31.4% 47.9% 17.1% 16.7% aid_assistance 3.9% 2.4% 1.6% 3.4% 0.3% begging 0.1% 0.5% 0.0% 0.4% 24.1% casual_labor 19.3% 16.8% 30.5% 29.3% 0.9% hunting 0.9% 3.8% 0.4% 0.1% 3.5% no_income 4.8% 1.4% 1.2% 3.4% 12.7% other 12.5% 9.1% 18.7% 11.9% 25.1% petty_trade 21.7% 12% 25.6% 32.4% Selling_charcoal 2.3% 2.4% 3.3% 0.8% 1.9% HH_income selling_fireword 3.3% 3.8% 1.6% 1.6% 2.5% No 72.9% 71.3% 67.5% 75.0% 72.9% Caregivers with Disability Yes 27.1% 28.7% 32.5% 25.0% 27.1%

Washington Group question sets on disability are used to identify respondents with disability.

Respondents report having “some difficulty”, “a lot of difficulty” or “cannot do it at all” when asked whether they have difficulty performing basic universal activities (walking, seeing, hearing, cognition, self-care and communication) are categories as disabled. From the analysis, 27.1% of caregivers reported having some form of difficulty with certain universal activities/function.

Averagely the gender distribution of head of households is 78.3% males and 21.7% were females (n=1990). The gender distribution ratio for heads of HH across the 4 LGAs follows the same pattern of 7:3, this is consistent with the patriarchal nature of Northern Nigeria.

The highest form of education achieved by heads of HHs across the survey areas is Koranic education at 54.4%, 14.6% had acquired secondary education and the same proportion (14.6%) do not have any form of formal education. Konduga LGA recorded the highest proportion of persons with no any form of formal education at 20.6%. More so the most common source of income for households are Agricultural activities, petty trade and casual labor at 25.9%, 25.1% and 24.1% respectively. 4.2 Infant and Young Child Feeding (IYCF)

Poor Infant and Young Child Feeding (IYCF) practices can be detrimental to the health and nutritional status of children, which consequently has a direct effect on their mental and physical development. Breastfeeding also has an impact on the health status of mothers, the period of postpartum fertility and, hence, the length of birth interval and the fertility levels [8]. Infants should be breastfed within one hour of birth, exclusively breastfed (EBF) for the first six months of life and then continue to be breastfed at least up to two years with age-appropriate, nutritionally adequate and safe complementary foods.

Table 7: Distribution of Children (0-36 Months) Jere Konduga Mafa MMC Overall(%)

Characteristics n=858 n=224 n=260 n=786 (n=2138) (Freq./%) (Freq./%) (Freq./%) (Freq./%) (Freq./%)

Age Distribution for Children 0-5 months 126(14.7%) 46(20.5%) 55(21.2%) 121(38.3%) 348(16.3%) (0- 6-11 months 190(22.1%) 69(30.1%) 57(22%) 202(25%) 518(24.2%) 23Months) 12-23 months 542(63.2%) 109(49%) 148(56.9%) 473(59.4%) 1272(59.5%) Female 399(46.5%) 99(44.2%) 112(43.8%) 395(49.6%) 1005(47%) Sex of Child Male 459(53.5%) 125(55.8%) 148(56.9%) 401(50.1%) 1133(53%)

4.2.2 IYCF Core Indicators

Table 8: Early Initiation, Exclusive, Continued breastfeeding and Complementary Feeding

Early initiation of breastfeeding (0-23 Months) Indicators Continued Introduction to Semi Early Initiation of Exclusive LGAs Breastfeeding (12- Solid/Solid Food (6-8 Breastfeeding (0-24) breastfeeding (0-5) 15) ) (n=2127) (n=348) (n=424) (n=246) Jere 79.9% (77.0% - 82.6%) 56.4% (47.6% - 64.8%) 92.4% (88.0%- 95.6%) 69.5% (59.3%-77.8%) Konduga 85.1% (79.6% - 89.6%) 63% (48.6% - 75.9%) 86.1% (72.2% - 94.5%) 81.1% (66.4% - 91.1%) Mafa 90.3% (86.0%- 93.6%) 67.3% (54.2% - 78.5%) 88.4% (76.4%-95.4%) 40% (22.7% - 59.34%) MMC 80.8% (77.9% - 83.5%) 76.7% (68.8% - 83.7%) 89.4% (83.9%-93.4%) 54% (49.7% - 69.7%) 66.1% (61.0% - 90.3% (87.2%- 64.6% (58.5% - Overall 82% (80.3% - 83.7%) 70.9%) 92.9%) 70.4%)

According to WHO [9] “Provision of mother’s breast milk to infants within one hour of birth is referred to as “early initiation of breastfeeding” and ensures that the infant receives the colostrum, or “first milk”, which is rich in protective factors. Current evidence indicates that skin-to-skin contact between mother and infant shortly after birth helps to initiate early breastfeeding and increases the likelihood of exclusive breastfeeding for one to four months of life as well as the overall duration of breastfeeding. Infants placed in early skin-to-skin contact with their mother also appear to interact more with their mothers and cry less”

Early initiation of breastfeeding enhances the release of oxytocin, this aids in the contraction of the uterus (womb) and reduces risk of post-partum haemorrhage (blood loss of 500 ml or more within 24 hours after birth) after birth in women. Additionally, the milk produced by the mother during the first 2-3 days of birth (colostrums) contains large quantity antibodies and essential nutrients for newborns. Therefore, it is of utmost importance to feed newborns with colostrum within the first hour of birth and that they continue to be exclusively breastfed for 6 months. Table 7 above shows that, across the 4 LGAs targeted for the survey, 82% of infants-initiated breastfeeding within the first hour of life. (n=1964) of children (0-24 month). Comparatively, according to the Nutrition & Food Security Surveillance (NFSS): Northeast Nigeria-emergence survey report, 2019[9] , the proportion

of mothers that initiated early breastfeeding (within one hour of birth) in MMC & Jere and Central Borno domains is 53.7%(n=246) and 49.2% (n=240) respectively, while the proportion of mothers that initiated breastfeeding within the first 24 hours of birth is 34.6% and 31.7% for the two domains respectively

Knowledge and Attitude

Table 9: Knowledge of Early Initiation of breastfeeding

Jere Konduga Mafa MMC AVE.(%) Characteristics (n=1990) n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%) Breast milk 755(95.1%) 202(97.1%) 240(98.1%) 728(98.1%) 1925(96.7%) Don't Know 20(3.0%) 1(0.5%) 4(2.0%) 5(1.1%) 30(1.5%) Baby_milk 11(1.4%) 3(1.4%) 0(0.0%) 2(0.3%) 16 (0.8%) Water 5(1.0%) 2(1.1%) 0(0.0%) 4(0.5%) 11(0.6%) What is the first food a Holy_water 2(0.3%) 1(0.5%) 0(0.0%) 2(0.3%) 5(0.3%) newborn baby should Date_fruit 1(0.1%) 0(0.0%) 2(1.0%) 0(0.0%) 3(0.2%) receive?

96.7% (n=1990) of mothers know that the first food a newborn baby should be given is breast milk, while 1.8% of them made reference to baby milk, date fruit, holy water and water and 1.5% said they don't know. This indicates that a large proportion of mothers in the study area have good knowledge of early initiation of breastfeeding, this corroborates findings from FGDs. FGDs participants in the Gonari community of Konduga LGA all agreed that most women in the community put the child to breast immediately after the child is born and this theme continued throughout the other FGDs. They said “it creates good attachment of child to the mother”

Exclusive Breastfeeding (EBF) (0-5 Months)

Exclusive breastfeeding (EBF) refers to feeding infants with only breast milk and nothing else. Specifically this connotes no other food or drink, not even water, except breast milk for the first 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines). UNICEF and WHO recommend that children be exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life, since breast milk contains all the nutrients needed. Apart from being nutritionally inadequate, substitutes – such as formula, other kinds of milk, and/or porridge – can be contaminated, exposing infants to the risk of illness, thus increasing their risk of mortality. A total of 66.1% f mothers of

children 0-5 months reported exclusively breastfeeding their infants (table 8) across all LGAs. No significant difference was observed between male and female children. The 2019 NFSS report, indicated 45.3% and 37.5% (n=64) of children 0-5 months were exclusively breastfed in MMC & Jere and Borno Central domains respectively. FGDs revealed that the reasons why some women do not exclusively breastfeed their babies is because of lack of food for the mother which makes it hard to produce breast milk. Also, FGDs participants reported that breast milk is perceived as inadequate so a child may become dehydrated due to hot weather. FGD findings also indicated that psychological and physical stress due to displacement from their villages and life in IDP camps with little or no source of livelihood interlaced with insecurity is also a contributing factor to why some women don't practice exclusive breastfeeding.

Knowledge and Attitude Table 10: Knowledge and Attitude of EBF

Jere Konduga Mafa MMC Overal(%) Characteristics (n=1990) n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%)

41(2.1%) Have you heard Don't Know 20(3.0%) 0(0%) 7(3.1%) 14(2.1%) 154(8.0%) about exclusive No 91(11.5%) 17(8.1%) 11(4.5%) 35(5.0%) breastfeeding? Yes 683(86.0%) 192(92.1%) 228(93.1%) 692(93.4%) 1795(90.2%)

How long should a 120(6%) baby receive 3_months 59(7.4%) 12(6.0%) 11(4.5%) 38(5.1%) 1659(83.4%) nothing more than 6_months 628(79.1%) 165(79.1%) 221(90.0%) 645(87.0%) breastmilk? more_6_months 107(13.5%) 32(15.3%) 14(6.1%) 58(8.0%) 211(11.0%)

What are the 92(12.1%) 7(3.4%) 17(7.0%) 54(7.3%) 170(9.0%) benefits for a baby Don't Know 1303(66.0%) if he or she receives He/she grows healthily 488(61.5%) 149(71.3%) 160(65.0%) 506(68.3%) 23(1.2%) only breastmilk Protection against obesity and chronic 12(2.0%) 4(2.0%) 1(0.4%) 6(1.0%) during the first six Protection against other diseases. 149(19.1) 44(21.1%) 39(16.1%) 136(18.4%) 368(19.0%) months of life? Protection from diarrhoea and other infections 53(7.1%) 52.4%) 29(12.1%) 395.3%) 126(6.3%)

Analysis from the table 9 above indicates that 90.2% of mothers across the targeted LGAs for the assessment confirmed they have heard of exclusive breastfeeding and 83.4% are aware of the duration for exclusive breastfeeding. 66% of mothers are aware of the benefits of exclusive breastfeeding. Across all the FGDs conducted, caregivers all agreed that breastfeeding a child is good because it helps the child grow, improves child intelligence and prevents sickness. One FGDs participant said that exclusive

breastfeeding especially is good the child so that “Diseases a mother takes in through water would not affect the child”

Continued Breastfeeding up to 2 years of age Beside EBF until six months, optimal breastfeeding practices involve continued breastfeeding up to at least 24 months of age along with appropriate complementary feeding. Findings from this survey (table 4) indicates that 90.3% (n=424) children still breastfed up to 1 year When disaggregated by LGA, the proportion of children 12-15 month still being breastfed is at 92.4 %, 86.1%,88.4% and 89.4% in Jere, Konduga, Mafa, and MMC respectively. From the NFSS report, continued breastfeeding for children 12- 15 months is 84.8% and 84.4% for MMC & Jere and the Borno Central domain respectively.

Knowledge and Attitude Table 11: Knowledge of Continued Breastfeeding

Jere Konduga Mafa MMC Overall (%) Characteristics (n=1990) n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%)

12-23 months 392(49.4%) 120(57.4%) 130(53.1%) 363(49.1%) 1005(51%) Until what age is it 24 & Above 173(22.1%) 43(21.1%) 57(23.2%) 186(25.1) 459(23.1%) recommended that a 6-11months 151(19.0%) 36(17.2%) 27(11.1%) 98(13.2%) 312(16.0%) mother continues Don't know 33(4.2%) 5(2.4%) 10(4.1%) 14(2.1%) 62(3.1%) breastfeeding? Less than 6months 45(6.1%) 5(2.4%) 229.0%) 8011.0%) 152(8.0%)

51% (n=1990) of mothers and caregivers have knowledge on the duration for continued breastfeeding (12- 23 months) All FGDs participants across all of the FGDs conducted choose between 12-24 months as the ideal age to stop breastfeeding a child. There are cultural and religious reasons around this choice as one of the FGD participants says; “In Islam we are supposed to breastfed until 21 months, while culturally is until 17 months, both are going hand in hand but the difference is 4 months”

Minimum Dietary Diversity (MDD) (6-23 Months) Dietary diversity refers to nutrient adequacy (basic nutrients needed in terms of macro and micro nutrients) and to diet variety/balance, these are two of the main components of diet quality. For children aged 6 to 23 months, it means feeding on food from at least four out of the seven food groups. The cut-off at “at least 5 of the 8 food groups” is generally associated with better quality of diets.

Overall, as shown in table 12, 26% (n=1779) of children aged 6-23 months consumed 4 or more food

groups; Minimum dietary diversity is at 28.4%, 25.6%, 33.7% and 22.1% in Jere, Konduga, Mafa and MMC. From the NFSS report MDD is at 8.8% and 4.2% for the MMC & Jere and the Borno central domain.

Minimum Meal Frequency (6-23 Months) Minimum meal frequency is the proportion of breastfed and non-breastfed children aged 6 to 23 months who received solid, semi-solid, soft foods or milk feeds the minimum number of times or more during the previous day. These minimum feeding frequencies are based on the energy needs estimated from age- specific total daily energy requirements. To be considered acceptable, breastfed infants aged 6-8 months should be fed meals of complementary foods two to three times per day, with one to two snacks as desired; breastfed children aged 9-23 months should be fed meals three to four times per day, with one to two snacks. Non-breastfed children should be fed the seven food groups used to calculate this indicator are: grains, roots and tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin A rich fruit and vegetables; other fruits and vegetables [15]

The result from the survey is shown in table 12, only 26.4% (n=469) of children 6-23 months were fed the recommended number of times during the 24 hours preceding the interview; disaggregated by LGAs is 28.4%, 25.6%, 33.7% and 22.1% for Jere, Konduga Mafa and MMC respectively. 3 out of 8 FDGs participants

Minimum Acceptable Diet (6-23 Months) Minimum acceptable diet indicator combines standards of dietary diversity and feeding frequency by breastfeeding status for children 6-23 months of age. For breastfed children it means considering only those children aged 6 to 23 months who have received both the minimum dietary diversity and the minimum meal frequency in the last 24 hours.

Table 12 shows that overall, only 15.3% (n=272) of children aged 6-23 months (breastfed and non- breastfed) received the minimum acceptable diet during the previous day, reflecting generally poor IYCF practices. Consumption of Iron-rich or Iron Fortified Foods (6-23 Months) Micronutrient deficiency is a major contributor to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. Iron is essential for red blood cell formation and cognitive development, and low iron intake can contribute to anaemia[1⁶]. Iron requirements are greatest at age 6-23 months, when growth is extremely rapid. Findings from this survey (Table 12) show that overall, 8.8% (n=1779) of children 6-23 months consumed iron rich food or iron fortified food in the 24 hours prior to the survey. Among the LGAs, the proportion of children 6 to 23 months who consumed iron ranges from 14.2% in Mafa to 6.2% in Jere.

Table 12: Minimum dietary diversity, Minimum Meal Frequency, Minimum Acceptable Diet & Consumption of Iron rich foods Indicators Minimum Dietary Minimum Meal Minimum Acceptable Consumption of Iron LGAs Diversity (6-23) Frequency (6-23) Diet (6-23) (6-23 ) (n=1779) (n=1779) (n=1779) (n=1779) Jere 28.4% (21.8% - 36.4%) 32.7% (29.4% - 36.2%) 15.9% (13.4% - 18.7%) 6.2% (4.6% - 8.1%) Konduga 25.6% (14.0% - 42.8%) 33% (26.3% -40.1%) 15.3% (10.6% - 21.2%) 9.1% (5.5% - 14.0%) Mafa 33.7% (21.1% - 50.8%) 32.7% (26.5% - 39.3%) 20% (15.0% - 25.9%) 14.2% (9.9% - 19.4%) MMC 22.1% (16.2% - 29.5%) 33% (29.5% - 36.6%) 13.1% (10.7% - 15.8%) 9.9% (7.8% - 12.3%) 26.4% (22.1% - 32.8% (30.7% - 15.3% (13.7% - Overall 8.8% (7.5% - 10.2%) 31.2%) 35.0%) 17.0%)

4.2.3 IYCF Optional Indicators

Table 13: Children ever breastfed, Continued BF at 2yrs Indicators Continued Breastfeeding (20-23 LGAs Children ever breastfed (0-23) months( (n=2127) (n=461) Jere 93.3% (91.5% - 94.9%) 36.6% (30.2% - 43.3%) Konduga 87.8% (83.1% - 91.6%) 17.9% (7.2% - 34.8%) Mafa 91.2% (87.2% - 94.2%) 40% (27.8% - 53.2%) MMC 92.9% (91.0% - 94.6%) 24.% (18.9% - 31.7%) Overall 92.3% (91.3% - 93.4%) 31.5% (27.3% - 35.8%)

Children Ever Breastfed This indicator refers to those infants, aged 0-23 months, who have been put to breast, even if only once. The results show that the awareness and practice of breastfeeding is a common practice within the surveyed LGAs, with 92.3% (n=2127) of children ever breastfed (table 13). NNHS 2018 survey report [10] children ever breastfed as 97% of in Borno and in the same year a UNICEF report on breastfeeding[11] estimated this to be 95% of children in Nigeria. Although this surveys’ estimate is significantly lower than the NNHS and UNICEF estimates, it still falls within the lower bound of the UNICEF estimate, further research is needed to validate this finding.

on bresa. Disaggregated data although not representative shows that the highest percentage of children ever breastfed to be (93.3 %) in Jere and the lowest being Konduga (87.8%).

4.3 Child Health Vitamin A Supplement Coverage Improving the vitamin A status of deficient children through supplementation enhances their resistance to disease and can reduce mortality from all causes by approximately 23 per cent. High supplementation coverage is therefore critical, not only to eliminating vitamin A deficiency as a public-health problem, but also as a central element of the child survival agenda [11]. Figure 1: Vita A supplementation by LGAs

In Africa, Vitamin A deficiency (VAD) alone is responsible for almost 6% of child deaths under the age of 5 years. survey results show that only about 54% of the children aged between 6 to 59 months received Vitamin A supplement in the 6 months prior to the survey (N.B - caregivers where not asked to show vaccination cards). This implies that about 45% of children in the 4 LGAs that did not receive the supplement, may be growing up with VAD.

Deworming Treatment Coverage

Soil-transmitted helminth infections are among the most common infections in humans, caused by a group of parasites commonly referred to as worms, including roundworms, whipworms and hookworms. Preventive chemotherapy (deworming), using annual or biannual single-dose albendazole (400 mg) or

mebendazole (500 mg)b is recommended by WHO as a public health intervention for all young children 12–23 months of age, preschool children 1–4 years of age, and school-age children 5–12 years of age[12].

Figure 2: Deworming treatment coverage by LGA

Using the 6 months recall period, findings from this study presents the coverage of deworming treatment at 42% (n=1272), while Mafa LGA has the highest deworming coverage Konduga LGA at 55.4% reported the least coverage at 32.1%(N.B - caregivers where not asked to show vaccination cards).

Measles Vaccination Coverage

Measles is a highly contagious viral respiratory tract infection known to be an important cause of death and acute malnutrition among young children particularly in emergency contexts wherein 1 to 5 percent of children with measles may die from complications of the disease [13]. Measles vaccination is one of the immunizations provided as part of the Nigerian Expanded Programme on Immunization (EPI), a program initiated in 1979. A child is considered adequately immunized against measles after receiving only one dose of vaccine (around 9 months of age). Currently, a second dose of measles vaccination has been introduced in Nigeria with implementation staggered and expected to cover the whole country by the end 2020.

Figure 3: Meals coverage by LGA 27

Mothers/caregivers of children above 9 months of age were asked to present vaccination cards to enumerators to confirm measles vaccination status of the child, measles is refered to in the local Hausa languge as “cutar kyanda”. If the child had no vaccination card, the respondents were asked to recall if the vaccine was given to the child. Overall, measles vaccination coverage among children 12-59 months as determined by observation of vaccination card or maternal recall was 85.1% (1544).

Diarrhea Mothers (or caregiver) were asked whether any of their children under five had an illness at any time during the preceding two weeks. 49.9% (n=2137) of respondents reported their children had an illness within the recall period, the distribution across LGAs is thus 49.3%, 48.2%, 48.5% and 51.5% in Jere, Konduga, Mafa and MMC respectively. 69.1%(n=1066) of respondents reported diarrhea as the ailment that the children suffered from (Fig 4). Mafa recorded the highest prevalence of diarrhea at 77% while Jere recorded the lowest prevalence at 67.5%. 36.2% of respondents indicated they sought treatment for their children that suffered from diarrhea at a hospital, 24.9%,11.7% and 6.3% from Pharmacy/Dispensary, PHCs and community health workers respectively. 55.3% of the mothers/caregivers indicated they sort treatment immediately, 31.9% within 48 hours and 12.8% after 48 hours.

Figure 4: Diarrhea prevalence

4.4 Mothers/Caretakers Knowledge of IYCF and Hygiene

Figure 5: caregivers IYCF knowledge (MSG vs none MSG members) by LGAs

Questions in table 15 below were asked to caregivers to further uncover other attitudes and practices towards feeding their child(ren). Overall, a majority of caregivers reported cleaning utensils before feeding a child (98%), washing the child’s hands before feeding them (97%) and covering the child's food after cooking (97%). It is interesting to see that 32% of caregivers force their children to eat and 15% do not reheat leftover meals before feeding their child(ren). Table 15: IYCF Hygiene

Respon LGA Question se Jere Konduga Mafa MMC Overall

no 3.15% 0.96% 0.81% 2.43% 2.40% Do you clean utensils before feeding a child? i.e Child (ren) under 24 months yes 96.73% 99.04% 99.19% 97.57% 97.60%

no 3.27% 0.48% 0.81% 3.24% 2.70%

Do you wash the hands of children before feeding? yes 96.35% 99.52% 99.19% 96.76% 97.20%

no 2.64% 0.48% 3.25% 3.10% 2.70%

Do you cover your child’s food after cooking? yes 97.23% 99.52% 96.75% 96.90% 97.30%

no 17.51% 25.36% 10.57% 9.58% 14.50%

Do you reheat leftover food before serving your child? yes 81.74% 74.64% 89.43% 90.42% 85.20%

no 68.14% 76.56% 58.13% 69.64% 68.30%

Do you force your child(ren) to eat? yes 31.49% 23.44% 41.87% 30.23% 31.50%

no 23.30% 28.71% 16.26% 19.16% 21.50% Do you support your child while they are eating (like talking to them)? yes 76.32% 71.29% 83.74% 80.84% 78.40%

4.5 Maternal Nutrition and Health Maternal nutrition focuses on women as mothers, on their nutritional status as it relates to the bearing and nurturing of children. Overall only 17% of women surveyed were enrolled in a State or NGO funded nutrition program i.e targeted supplementary feeding programme (TSFP), the disaggregated results are similar across all 4 LGAs. Women of reproductive age (15 - 49 years) were asked to list all of the food items they ate in the previous day and their responses were placed within the 10-food group category to assess the proportion of women that met the minimum dietary diversity (MDD-W) in the survey area. The results showed that overall, only 34% (667) of assessed women met MDD criteria of consuming 5 or more food groups in the previous day or night and there were no significant difference between LGAs; Jere 32% (258), Konduga 38% (79), Mafa 39% (97) and Maiduguri 32% (233).

4.6 Maternal Hygiene

96% of surveyed women reported washing hands with a cleaning agent the last time they washed their hands and of this proportion, 86% used soap while 6% ash this result is consistent across the 4 assessed LGAs. Enumerators asked women who reported using soap if they could see the soap and overall, only 19% of women could not provide the soap, the result is slightly higher in Konduga 23% and Mafa 25%.

Figure 6: caregivers knowledge on critical handwashing times by LGAs

Knowledge of 3-5 critical hand washing times was high amongst caregivers, however, Jere LGA had the lowest proportion 70%. Overall, the most practiced hand washing was ‘before eating’ 87%, ‘after defecating’ 79%, ‘before preparing food’ 68%, ‘before feeding child’ 60% and ‘after cleaning a baby’s bottom’ 51%. Caregivers were asked where they went to the last time they defecated and an overwhelming majority 83.5% used a latrine while 12% reported digging a hole to defecate, 3% reported open defecation and a very small proportion (0.2%) reported defecating in a river.

4.7 Water, Sanitation & Hygiene (WASH)

Access to water supply and sanitation facilities has considerable health and economic importance to both households and individuals. Lack of access to safe drinking water and inadequate disposal of human excreta are associated with a range of diseases, including diarrhea, schistosomiasis and intestinal helminths [16] 32

4.7.1 Water

Table 16: Water Indicators

Jere Konduga Mafa MMC AVE.(%) Characteristics (n=1990) n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%)

1245(63.0%) 9(1.0%) borehole 495(62.3% 155(74.2%) 151(61.4%) 444(60.0%) 147(7.4%) bottled_sachet 0(0.0%) 0(0.0%) 8(3.3%) 1(0.1%) 1(0.1%) handpump 76(10.1%) 19(9.1%) 6(2.4%) 46(6.2%) 26(1.3%) What is the main open_rainwater 0(0.0%) 0(0.0%) 0(0.0%) 1(0.1%) source of water open_well 14(2.1%) 4(2.0%) 0(0.0%) 8(1.1) 15(1.0%) used by your piped_dwelling 9(1.1%) 0(0.0%) 1(0.4%) 5(1.1%) 1(0.1%) household for protected_spring 1(0.1%) 0(0.0%) 0(0.0%) 0(0.0%) 83(4.2%) drinking? public_tap 50(6.3%) 10(5.1%) 8(3.3%) 15(2.2%) 64(3.2%) sealed_well 26(3.3%) 0(0.0%) 0(0.0%) 38(5.1%) 1(0.1%) spring 0(0.0%) 1(0.5%) 0(0.0%) 0(0.0%) 10(1.0%) surface_water 1(0.1%) 8(4.0%) 0(0.0%) 1(0.1%) water_truck 4(1.0%) 0(0.0%) 0(0.0%) 32(4.3%) 36(1.8%) water_vendor 118(15.1%) 12(6.0%) 72(29.3%) 150(20.2%) 352(18.0%) Does your household treat water to make it N0 483(61.0%) 158(76.0%) 139(57.0%) 464(63.0%) 1244(63.0%) safer to drink? Yes 311(39.2) 51(24.4%) 107(44.0%) 277(37.4%) 746(38.0%) 107(15.2%) 33(5.0%) aquatabs_tablets 51(18.0%) 0(0.0%) 1716.1%) 39(15.3%) boil 3(1.0%) 1(2.0%) 8(7.5%) 21(8.2%) 14(2.0%) disinfection_product 7(2.4%) 1(2.0%) 22.1%) 4(2.1%) 2(0.3%) How do you treat dnk 1(0.3%) 0(0.0%) 0(0.0%) 1(0.4%) 36(5.1%) the water? expose_sunlight 12(4.1%) 11(22.5%) 4(4.0%) 9(4.0%) 268(38.2) filter_it 114(39.2%) 4(8.2%) 52(49.0%) 98(38.4%) 65(9.3%) liquid_clorine 26(9.0%) 8(16.3%) 6(6.0%) 25(10.0%) 24(3.4%) powder_clorine 13(4.5%) 0(0.0%) 0(0.0%) 11(4.3%) stand_settle 63(22.1%) 2449.1%) 17(16.1%) 46(18.0%) 150(21.4%) watermaker 1(0.3%) 0(0.0%) 1(1.0%) 1(0.4%) 3(0.4%)

Access to Improved Water Source Access to an improved water source refers to the percentage of the population using improved drinking water source. The improved drinking water source includes piped water on premises (piped household water connection located inside the user’s dwelling, plot or yard), and other improved drinking water sources

(public taps on standpipes, tube wells or boreholes, protected dug wells, protected springs, and rainwater collection) Overall, 97.6% (n=1990) of HHs within the LGAs of this study have access to improved water sources for drinking and HHs chores. This finding meets the global WHO standard (emergency) for access to improved water sources, which is pegged at ≥ 70[18]. This finding is also in pari passu with that of REACH, which reported about 75% [19] of surveyed households with access to improved water sources. Treatment of Drinking Water 39% of HHs reported, they treat their drinking water while 61% of the HHs reported `no treatment`. The use of Filter is the most common medium of water treatment cited by 39.2%%, followed by Sand settle cited by 22.1% , 18% reported the use of aquatabs tablets, 9% cited liquid chlorine, and 4,5% powder chlorine.

Challenges in Accessing Water point

Table 17: Access to Water points

Jere Konduga Mafa MMC AVE.(%) Characteristics (n=1990)

n=794 n=209 n=246 n=741 (Freq.%) (Freq.%) (Freq.%) (Freq.%)

No problem Long distance to water point 412(52.1%) 97(46.4%) 103(42.1%) 377(51.1%) 989(50.0%) Long queue time at water point 179(23.0%) 68(33.0%) 87(35.4%) 200(27.1%) 534(27.0%) Water Point is not safe in general (insecurity, harassment, physical violence, 246(31.1%) 79(38.0%) 100(41.1%) 215(29.0%) 640(32.2%) What are kidnapping) 4(1.0%) 8(4.0%) 2(1.0%) 9(1.2%) 23(1.2%) the Water point is not safe for women (risk of sexual harassment or attack) 3(0.4%) 1(0.5%) 1(0.4%) 2(0.3%) 7(0.4%) problems Waterpoint is not safe due to presence of explosive hazards 20 (3%) 1(0.5%) 1(0.4%) 5(1.1%) 9(1.0%) your Water point is too expensive 60(8.1%) 13(6.2%) 26(11.1%) 51(7.1%) 150(8.0%) household Water point is dirty 24(3.0%) 6(3.1%) 1(0.4%) 18(2.4%) 49(2.5%) has with Water point is not easy to operate 39(5.0%) 1(0.5%) 4(2.0%) 10(1.4%) 54(3.1%) collecting Water is not functional/needs fixing 14(2.1%) 16(8.1%) 4(2.0%) 33(4.5%) 67(3.4%) water? Water point gives bad quality water 10(1.3%) 0(0.0%) 6(2.4%) 7(1.0%) 23(1,2%) Other 6(1.1%) 0(0.0%) 6(2.4%) 6(1.0%) 18(1.0%) No response 6(1.1%) 1(0.5%) 0(0.0%) 1(0.1%) 8(0.4%) Don’t know 6(1.1%) 0(0.0%) 2(0.81%) 4(1.0%) 12(1.0%) How long does it take to collect water from 15-30 Minutes 190(24.2%) 40(19.3%) 56(23.3%) 186(25.4%) 472(24.1%) your main 1-2 Hours 56(7.1%) 14(7.1%) 12(5.0%) 41(6.0%) 123(6.3%) water 30 Minutes-1hour 96(2.2%) 32(15.5%) 41(17.1%) 71(10.0%) 240(12.2%) source, Don't Know 8(1.0%) 1(0.5%) 11(5.1%) 18(2.5%) 38(2.0%) including Greater than 2 hours 20(3.1%) 7(3.4%) 13(5.4%) 23(3.2%) 63(3.2%) traveling Less than 15 Minutes 297(38.1%) 100(48.3%) 84(35.0%) 252(34.5%) 733(37.4%) back and No Travel 113(14.4%) 13(6.3%) 21(9.0%) 137(19.0%) 284(15.0%) forth and other 4(1.0%) 0(0.0%) 2(1.0%) 3(0.4%) 9(1.0%) 34

queuing time?

50% (n=1990) of respondents cited they do not face any challenge or face any problem in accessing water for household use. 32.2% cited Long queue time at water point, and 27% cited Long distance to water point as challenges in accessing water.

Moreso, 37.4% of respondents reported it takes them less than 15 minutes to access water, 24.1% within 15-30 minutes, 15% need not travel to access water, and 12.2% have to travel 30 minutes to 1 hour to access water for household use.

4.8 Child Protection Save the Children defines child protection as measures and structures to prevent and respond to abuse, neglect, exploitation and violence affecting children. Child protection means safeguarding children from harm which includes violence, abuse, exploitation and neglect. 79% of respondents reported knowing about child protection issues in their community and when asked to list some of the situations that put children in danger in their community, basic needs not met (67%) and No access to school or to health care (29%) were the most frequently mentioned (see table 18 below), also there was no significant difference across LGAs.

Table 18: Child Protection Issues Child Protection Issues Percentage Basic needs not met (food, shelter, clothing) 67% No access to school or to health care 29% Domestic violence 9% Children living in the streets 8% Harmful child labour 8% Peer Pressure 8% Abuse and exploitation of children 6% Abandonment by parent or guardian 4% Teenage pregnancy 3% Corporal Discipline 2% Drugs or liquor 2%

Giving children to other people 2% Unsafe migration (e.g., child goes away to work) 1% Child Soldiers 1%

Less than a third of the overall sampled household (29%) did not know of any law in Nigeria about care and safety of children. 41% of households reported having a place in the community where children can go if they are abused (physical, sexual, psychological etc) or if they run away from home. An overwhelming 87% reported that the community leader's house was that place, followed by social worker and NGO (19%) and a community members house (14%).

Overall, 73% of respondents said they do report when they see or hear of children experiencing abuse at home or in the community and 25% would confront the perpetrators, 14% would comfort the child while 8% would not report

Table 19: Report of Child Protection Issues

Jere Konduga Mafa MMC Average Report 69% 81% 82% 73% 73%

Confront the perpetrator 25% 18% 28% 26% 25% Comfort the child 15% 7% 18% 14% 14% Keep quiet/do nothing 10% 6% 10% 7% 8%

Of the proportion of household that do report cases of child abuse, 70% report to bulama (community leader) and 12% family member. Other reporting channels mentioned by respondents include Police/Army/CJTF (8%) and NGO staff (4%). For the 10% of respondent that do not report cases of child abuse, the main reasons for their silence include; dont know where to report (64%), fear of retaliation (14%), none of my business (13%) and no action is likely to be taken (11%). 57% of respondents heard about NGO/Government agencies providing child services in their community.

There is accumulating evidence that community perception of what constitutes child protection plays an important role in communities’ response and action in cases of child abuse. Respondents were provided with a list of comments regarding perception of what constitutes a protection issue and asked whether they agree or disagree (Table 19).

Table 20; Child protection KAP Question Agree Disagree It is justified to beat children for discipline and correction 55% 45% Children with disabilities or special needs should not go to school 30% 69% Girls under 18 years should be given out to marriage 30% 69% 36

Girls should be forced to marry partners chosen for them by their parents or families 8% 92% It is sometimes justified for parents to send children to hawk on the streets 18% 81% Boys should be sent to school in preference to girls 19% 79%

From the table 20 above it is clear that most respondents (55%) approve of beating children for discipline and correction. Although most respondents (92%) did not agree that a girl should be forced into marriage, 30% of respondents agreed that a girl under the age of 18 should be given out to marriage. In terms of education, 19% of respondents think boys should be sent to school in preference of girls and a worrying 30% of respondents feel children with disabilities or special needs should not go to school. FGDs participants say marriage of girls under 18 is common and once parents feel a girl is ready, they can give her out to marriage notwithstanding her age.

4.9 Covid-19 Awareness

Respondents awareness on covid-19 risks and mitigation to protect their household and communities. When respondents were asked if they knew of any measures to prevent themselves and those around them from getting sick from Coronavirus, the majority (80%) of respondents reported constant hand washing, and keeping a safe distance from others (66%). disaggregation of the data showed no significant difference between LGAs.

Figure 7: Awareness on covid-19 risks and mitigation

Respondents were asked if they know how covid-19 is spread and as in figure below 71% of respondents reported direct contact with infected people, 50% reported droplets from infected people and touching 37

contaminated objects or surfaces (43%). It's worth noting that 13% of respondents did not know how Covid- 19 is transmitted. In case they become sick with covid type symptoms, 67% of respondents said they would go to a hospital while 20% would call health authorities. Went asked about their source of information on covid 86% said they got information from the radio while 20% and 19% received corona information from family members and friends respectively.

Figure 8: Mode of Transmission of COVID-19

5. Conclusion Good maternal nutrition can help ensure children are healthy from birth and when women are informed, empowered and supported to breastfeed, the benefits extend beyond their children, to themselves and to society as a whole. Overall results from this survey shows that the practice of exclusive breastfeeding in the survey area (66%) is slightly higher than baseline (62.7%) conducted by SCI in the 2019 but significantly higher than NFSS 8 2019 estimate (45.3%). It is important to note that this survey and the baseline covered only SCI programme areas while the NFSS covered the entire LGA, the EBF results however, indicates an improvement in mothers breastfeeding practices. Earlier initiation to breastfeeding practice (82%) is slightly higher than the baseline estimate (79.2%) but continued breastfeeding at 1-year practice is significantly lower (90%) when compared to the baseline (99%). Introduction of solid, semi- solid or soft food practice is in line with Nigeria National Nutrition and Health Survey. Overall, child breast feeding indicators seem to be in line or showing better results than the baseline and other nutrition surveys, however, breastfeeding practices is still poor as about 7% of assessed children were not breastfeed and SDG targets for EBF has not been achieved. Malnutrition remains the leading cause of poor health, wasting and stunting in children, even less visible is hidden hunger which is as a result of deficiencies in vitamins and other essential nutrients. In line with the baseline, MMF, MMD and MAD results in the survey area are really poor which according to FGDs is mainly caused by of lack of resources to buy nutritious food in the right quantity. This poor food intake by children 0-23 months in the households signals a broader issues of household food insecurity as a lot of households have been affected by the conflict which have disrupted their means of livelihood. To buttress this, a large proportion of women of reproductive age women (15 - 49 years) did not consume the required 5 out of the 10 food groups categories required to meet the minimum dietary diversity which means women are physically unable to exclusively breastfeed on continue breastfeeding their children for long. The survey shows a significant difference in general IYCF knowledge between caregivers who are part of MSG and mothers who are not, as mothers who are part of MSG have more robust IYCF knowledge and are more able to practice them. Most of the surveyed communities do have access to improved water but a lot still face problems of long distance and queuing time. FGDs participants complained of not having adequate containers for collecting and storing water. And although most caregivers reported using latrine,

a small proportion still continue to practice open defecation (defecating in bushes and rivers) and most caregivers know about the critical hand washing times and handwashing with soap. The majority of respondent reported being aware of child protection and could identify child protection issues, however a lot of the issues mentioned revolved around child’s needs and access to services and not a lot of social and emotional related child issues were mentioned, this maybe because of cultural norms as some of this issues were seen as normal (child beating, early marriage etc). A high proportion of respondents said they do report cases of child abuse to community leaders and identify the community leaders house as the safe haven for children suffering abuse in the community. This implies a heavy reliance on community structure to deal with child protection cases and the fact that only a few respondents know about any laws that protect the right of children further enhance the reliance and use of community mechanism and authority in dealing with child protection issues as most community members may not be aware of other referral channels. Finally, the communities seem to have fairly good knowledge on how Covid-19 is spread and can be prevented. The main source of covid-19 information in the community is mainly from the radio and then from family and friends in that order.

5.1 Recommendation

━ The fact that ever breastfeeding rates are low, suggests that women are not being provided with sufficient information and support. This are areas that requires urgent attention. It is important that increase awareness of the important of child breastfeeding is bolstered. Because of the current Covid pandemic, MSG meetings and house to house visit are not as frequent. Mediums like radio, health facility and community leaders to should be used in raising awareness of child breastfeeding. It is also critical that maternity facilities are able to provide breastmilk for sick born, separated children and children who have lost their mothers as a result of death during child birth or conflict. ━ Also to be packaged in the sensitization message above is the awareness on breastfeeding from birth through two years’ age and why this is important for a child. ━ SCI should support the implementation of the ten steps to successful breastfeeding developed by UNICEF and WHO in all supported health facilities ━ SCI should also work to strengthen the link between health facilities and communities to ensure continued support for breastfeeding and this should be continues tracked and monitored to see improvement in breastfeeding practices. ━ Since iron rich foods like liver, red meats, eggs and fish, are not widely available or affordable, SCI support the distribution of fortified food to children and iron/folate supplement for pregnant mothers. 40

━ Although a lot of women cannot afford a nutritious diet and struggle to meet their full dietary requirement especially during pregnancy and breastfeeding, SCI can support these women through conditional cash transfer programme for PLW integrated with food diversification programme to teach women how to utilize home yard/garden to provide nutritious food the family and a behavioral change campaign around consumption of nutritious food. ━ It is evident from the survey that women who were part of an MSG had significantly better IYCF knowledge which has the potential to better the nutrition and health outcome of the child. Community sensitization on the benefits of being part of MSG needs to be improved. Caregivers need to be encouraged and motivated to join MSG. This can be done through sensitization campaigns using existing community structure (gate keepers), discussions with mothers to understand barriers to participating in MSG and further incorporation of livelihood activities into the MSG design. Consideration should also be given to house to house visits by MSG volunteers in areas where MSG are currently not very active. ━ From the survey it is clear that the communities rely heavily on community mechanism to deal with child protection issues, this creates both a problem and an opportunity as on the one hand heavy reliance on community mechanism may mean that lots of child protection issues would continue undedicated because of cultural norms but on the other hand it creates an opportunity to design and implement a thoroughly community led child protection strategy. Community child protection mechanisms need to be reinforced and realigned with the national child protection laws. Further research is required to properly understand these community systems and how it can be aligned to the national child protection response. ━ A significant proportion of the surveyed community think children with disability should not go to school and that it is preferable to send a boy rather than a girl to school. This community perception hinders the achievement of gender and disability inclusive education. This perception, coupled with the fact that 27% of beneficiaries reported have difficulty with atleast one function (using WGS), it is critical that SCI programmes are designed to include vulnerable groups (young girls and disabled children) and there is a need for serious community sensitization around issues of gender and disability. ━ From FGDs with fathers, a reoccurring theme was that fathers understood their role in the family to be that of a provider and protector and nothing more. Because of this perception, father are not getting very involved in their children’s nutrition. Therefore, a sustained scale up of child nutrition and awareness campaigns specifically targeting fathers which could also be organized through the community structure. We recommend bolstering the father support group programme.

━ There is a need to increase awareness on hand washing, the danger of drinking water from unsafe water sources and open defecation which are the root causes of many diarrheal and water-borne diseases. In light of Covid, these personal hygiene messages are even more critical. SCI staffs should deliver hand washing and Covid-19 messages at every point of contact with beneficiaries and the community. This should be implemented throughout all the stages of implementation and by every staff in the organization.

━ Community child protection mechanisms need to be reinforced and realigned with the national child protection laws as the majority of beneficiaries including some community leaders did not know national child protection laws. Further research is required to properly understand these community systems and how it can be aligned to the national child protection response. ━ Finally, SCI should consider a multi-sectoral approach that address all the sectoral needs of children, mothers and households. Further research would be needed to fully understand the needs of community in other to design an effective approach.

━

Annex 1-IYCF Results

lga jere95.0% 95.0% konduga95.0% 95.0% mafa95.0% 95.0% mmc95.0% 95.0% overall95.0% 95.0% Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Column CL for CL for Column CL for CL for Column CL for CL for Column CL for CL for Column CL for CL for Count N % Column Column Count N % Column Column Count N % Column Column Count N % Column Column Count N % Column Column immediat 637 79.9% 77.0% 82.6% 166 85.1% 79.6% 89.6% 214 90.3% 86.0% 93.6% 594 80.8% 77.9% 83.5% 1611 82.0% 80.3% 83.7% e after_first 115 14.4% 12.1% 17.0% 21 10.8% 7.0% 15.7% 14 5.9% 3.4% 9.5% 105 14.3% 11.9% 17.0% 255 13.0% 11.6% 14.5% _hr_first_ Initiation to 24_hr breastfeeding after_24_ 35 4.4% 3.1% 6.0% 7 3.6% 1.6% 6.9% 8 3.4% 1.6% 6.3% 32 4.4% 3.1% 6.0% 82 4.2% 3.4% 5.1% hrs no_respo 10 1.3% 0.6% 2.2% 1 0.5% 0.1% 2.4% 1 0.4% 0.0% 2.0% 4 0.5% 0.2% 1.3% 16 0.8% 0.5% 1.3% nse no 659 91.0% 88.8% 92.9% 163 93.1% 88.7% 96.2% 188 91.7% 87.3% 94.9% 625 93.3% 91.2% 95.0% 1635 92.2% 90.8% 93.3% yes 64 8.8% 6.9% 11.1% 12 6.9% 3.8% 11.3% 16 7.8% 4.7% 12.1% 43 6.4% 4.7% 8.5% 135 7.6% 6.4% 8.9% Bottle feeding no_respo 1 0.1% 0.0% 0.6% 1 0.1% 0.0% 0.7% 2 0.1% 0.0% 0.4% nse don't_kno 1 0.5% 0.1% 2.3% 1 0.1% 0.0% 0.7% 2 0.1% 0.0% 0.4% w Eclusive no 783 91.7% 89.7% 93.4% 193 86.9% 82.0% 90.9% 223 85.8% 81.1% 89.6% 698 88.2% 85.9% 90.3% 1897 89.2% 87.8% 90.5% breasfeeding yes 71 8.3% 6.6% 10.3% 29 13.1% 9.1% 18.0% 37 14.2% 10.4% 18.9% 93 11.8% 9.7% 14.1% 230 10.8% 9.5% 12.2% no 57 6.7% 5.1% 8.5% 27 12.2% 8.4% 16.9% 23 8.8% 5.8% 12.8% 56 7.1% 5.4% 9.0% 163 7.7% 6.6% 8.9% Ever breastfed yes 797 93.3% 91.5% 94.9% 195 87.8% 83.1% 91.6% 237 91.2% 87.2% 94.2% 735 92.9% 91.0% 94.6% 1964 92.3% 91.1% 93.4% Continued no 14 7.6% 4.4% 12.0% 5 13.9% 5.5% 27.8% 5 11.6% 4.6% 23.6% 17 10.6% 6.6% 16.1% 41 9.7% 7.1% 12.8% Breastfeeding 171 92.4% 88.0% 95.6% 31 86.1% 72.2% 94.5% 38 88.4% 76.4% 95.4% 143 89.4% 83.9% 93.4% 383 90.3% 87.2% 92.9% (12-15) yes Continued no 130 63.4% 56.7% 69.8% 23 82.1% 65.2% 92.8% 33 60.0% 46.8% 72.2% 130 75.1% 68.3% 81.1% 316 68.5% 64.2% 72.7% Breastfeeding 75 36.6% 30.2% 43.3% 5 17.9% 7.2% 34.8% 22 40.0% 27.8% 53.2% 43 24.9% 18.9% 31.7% 145 31.5% 27.3% 35.8% (20-23) yes Introduction to no 29 30.9% 22.2% 40.7% 7 18.9% 8.9% 33.6% 15 60.0% 40.6% 77.3% 36 40.0% 30.3% 50.3% 87 35.4% 29.6% 41.5% Semi Solid/Solid 65 69.1% 59.3% 77.8% 30 81.1% 66.4% 91.1% 10 40.0% 22.7% 59.4% 54 60.0% 49.7% 69.7% 159 64.6% 58.5% 70.4% Food (6-8 ) yes 0 72 9.9% 7.9% 12.2% 15 8.5% 5.1% 13.3% 28 13.7% 9.5% 18.9% 97 14.5% 12.0% 17.3% 212 11.9% 10.5% 13.5% 1 178 24.5% 21.4% 27.7% 52 29.5% 23.2% 36.6% 42 20.5% 15.4% 26.4% 187 27.9% 24.6% 31.4% 459 25.8% 23.8% 27.9% 2 165 22.7% 19.7% 25.8% 36 20.5% 15.0% 26.9% 34 16.6% 12.0% 22.1% 137 20.4% 17.5% 23.6% 372 20.9% 19.1% 22.8% 106 14.6% 12.1% 17.3% 28 15.9% 11.1% 21.8% 32 15.6% 11.1% 21.0% 101 15.1% 12.5% 17.9% 267 15.0% 13.4% 16.7% Minimum 3 Dietary 4 82 11.26% 9.12% 13.71% 14.00 7.95% 4.63% 12.64% 25.00 12.20% 8.25% 17.20% 68.00 10.15% 8.03% 12.61% 189.00 10.62% 9.26% 12.12% Diversity 5 57 7.83% 6.04% 9.95% 14.00 7.95% 4.63% 12.64% 23.00 11.22% 7.45% 16.08% 33.00 4.93% 3.48% 6.76% 127.00 7.14% 6.01% 8.41% 6 34 4.67% 3.31% 6.39% 9.00 5.11% 2.56% 9.12% 12.00 5.85% 3.24% 9.70% 33.00 4.93% 3.48% 6.76% 88.00 4.95% 4.01% 6.03% 7 34 4.67% 3.31% 6.39% 8.00 4.55% 2.17% 8.39% 9.00 4.39% 2.19% 7.86% 14.00 2.09% 1.20% 3.39% 65.00 3.65% 2.86% 4.60% MMD 207 28.4% 21.8% 36.4% 45 25.6% 14.0% 42.8% 69.00 33.7% 21.1% 50.8% 148.00 22.1% 16.2% 29.5% 469.00 26.4% 22.1% 31.2%

Minimum Meal no 490 67.3% 63.8% 70.6% 118 67.0% 59.9% 73.7% 138 67.3% 60.7% 73.5% 449 67.0% 63.4% 70.5% 1195 67.2% 65.0% 69.3% Frequency yes 238 32.7% 29.4% 36.2% 58 33.0% 26.3% 40.1% 67 32.7% 26.5% 39.3% 221 33.0% 29.5% 36.6% 584 32.8% 30.7% 35.0% Minimum no 612 84.1% 81.3% 86.6% 149 84.7% 78.8% 89.4% 164 80.0% 74.1% 85.0% 582 86.9% 84.2% 89.3% 1507 84.7% 83.0% 86.3% Acceptable Diet yes 116 15.9% 13.4% 18.7% 27 15.3% 10.6% 21.2% 41 20.0% 15.0% 25.9% 88 13.1% 10.7% 15.8% 272 15.3% 13.7% 17.0%

Consumption of no 683 93.8% 91.9% 95.4% 160 90.9% 86.0% 94.5% 176 85.9% 80.6% 90.1% 604 90.1% 87.7% 92.2% 1623 91.2% 89.8% 92.5% Iron yes 45 6.2% 4.6% 8.1% 16 9.1% 5.5% 14.0% 29 14.1% 9.9% 19.4% 66 9.9% 7.8% 12.3% 156 8.8% 7.5% 10.2%

lga

jere konduga mafa mmc female male female male female male female male

95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for CL for Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Colum Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % Count n N % n N % n N % yes 306 82.0% 77.9% 85.7% 331 78.1% 73.9% 81.8% 81 91.0% 83.8% 95.7% 85 80.2% 71.8% 86.9% 89 89.9% 82.8% 94.7% 125 90.6% 84.9% 94.6% 298 81.4% 77.2% 85.1% 296 80.2% 75.9% 84.0% Initiation 2 43 11.5% 8.6% 15.1% 72 17.0% 13.6% 20.8% 5 5.6% 2.2% 11.9% 16 15.1% 9.3% 22.8% 7 7.1% 3.2% 13.4% 7 5.1% 2.3% 9.7% 52 14.2% 10.9% 18.1% 53 14.4% 11.1% 18.2% to breastfee 3 17 4.6% 2.8% 7.0% 18 4.2% 2.6% 6.5% 3 3.4% 1.0% 8.7% 4 3.8% 1.3% 8.7% 3 3.0% 0.9% 7.9% 5 3.6% 1.4% 7.8% 15 4.1% 2.4% 6.5% 17 4.6% 2.8% 7.1% ding dont't_know 7 1.9% 0.8% 3.6% 3 0.7% 0.2% 1.9% 1 0.9% 0.1% 4.3% 1 0.7% 0.1% 3.3% 1 0.3% 0.0% 1.3% 3 0.8% 0.2% 2.2%

no 303 90.4% 87.0% 93.2% 356 91.5% 88.4% 94.0% 73 97.3% 91.7% 99.4% 90 90.0% 83.0% 94.7% 84 90.3% 83.1% 95.1% 104 92.9% 87.0% 96.6% 312 95.7% 93.1% 97.5% 313 91.0% 87.6% 93.7% yes 31 9.3% 6.5% 12.7% 33 8.5% 6.0% 11.6% 2 2.7% 0.6% 8.3% 10 10.0% 5.3% 17.0% 8 8.6% 4.2% 15.6% 8 7.1% 3.4% 13.0% 14 4.3% 2.5% 6.9% 29 8.4% 5.8% 11.7% Bottle feeding dont't_know 1 0.3% 0.0% 1.4% 1 0.3% 0.0% 1.4%

no_response 1 1.1% 0.1% 4.9% 1 0.3% 0.0% 1.4%

Eclusive no 358 90.2% 87.0% 92.8% 425 93.0% 90.4% 95.1% 84 85.7% 77.8% 91.6% 109 87.9% 81.3% 92.8% 100 89.3% 82.6% 94.0% 123 83.1% 76.5% 88.5% 338 86.0% 82.3% 89.2% 360 90.5% 87.3% 93.0% breasfee yes 39 9.8% 7.2% 13.0% 32 7.0% 4.9% 9.6% 14 14.3% 8.4% 22.2% 15 12.1% 7.2% 18.7% 12 10.7% 6.0% 17.4% 25 16.9% 11.5% 23.5% 55 14.0% 10.8% 17.7% 38 9.5% 7.0% 12.7% ding no 24 6.0% 4.0% 8.7% 33 7.2% 5.1% 9.9% 9 9.2% 4.6% 16.1% 18 14.5% 9.2% 21.5% 13 11.6% 6.7% 18.5% 10 6.8% 3.5% 11.7% 27 6.9% 4.7% 9.7% 29 7.3% 5.0% 10.2% Ever breastfed yes 373 94.0% 91.3% 96.0% 424 92.8% 90.1% 94.9% 89 90.8% 83.9% 95.4% 106 85.5% 78.5% 90.8% 99 88.4% 81.5% 93.3% 138 93.2% 88.3% 96.5% 366 93.1% 90.3% 95.3% 369 92.7% 89.8% 95.0%

Continue no 7 8.2% 3.8% 15.5% 7 7.0% 3.2% 13.3% 2 14.3% 3.1% 38.5% 3 13.6% 4.0% 32.1% 3 14.3% 4.2% 33.4% 2 9.1% 1.9% 26.1% 7 9.3% 4.3% 17.5% 10 11.8% 6.2% 19.9% d yes 78 91.8% 84.5% 96.2% 93 93.0% 86.7% 96.8% 12 85.7% 61.5% 96.9% 19 86.4% 67.9% 96.0% 18 85.7% 66.6% 95.8% 20 90.9% 73.9% 98.1% 68 90.7% 82.5% 95.7% 75 88.2% 80.1% 93.8% Breastfee Continue no 51 58.6% 48.1% 68.5% 79 66.9% 58.1% 74.9% 12 92.3% 69.3% 99.2% 11 73.3% 48.3% 90.3% 12 60.0% 38.4% 78.9% 21 60.0% 43.5% 74.9% 59 73.8% 63.4% 82.4% 71 76.3% 67.0% 84.1% d yes 36 41.4% 31.5% 51.9% 39 33.1% 25.1% 41.9% 1 7.7% 0.8% 30.7% 4 26.7% 9.7% 51.7% 8 40.0% 21.1% 61.6% 14 40.0% 25.1% 56.5% 21 26.3% 17.6% 36.6% 22 23.7% 15.9% 33.0% Breastfee Introducti no 15 27.8% 17.2% 40.7% 14 35.0% 21.7% 50.4% 3 16.7% 4.9% 38.1% 4 21.1% 7.6% 42.6% 7 58.3% 31.2% 82.0% 8 61.5% 35.0% 83.5% 14 33.3% 20.6% 48.3% 22 45.8% 32.3% 59.8% on to yes 39 72.2% 59.3% 82.8% 26 65.0% 49.6% 78.3% 15 83.3% 61.9% 95.1% 15 78.9% 57.4% 92.4% 5 41.7% 18.0% 68.8% 5 38.5% 16.5% 65.0% 28 66.7% 51.7% 79.4% 26 54.2% 40.2% 67.7% Semi Minimum 0 35 10.4% 7.5% 14.0% 37 9.5% 6.9% 12.7% 8 10.7% 5.2% 19.1% 7 6.9% 3.2% 13.1% 15 16.1% 9.7% 24.6% 13 11.6% 6.7% 18.5% 47 14.4% 10.9% 18.5% 50 14.5% 11.1% 18.6% Dietary 1 95 28.2% 23.6% 33.2% 83 21.2% 17.4% 25.5% 19 25.3% 16.6% 36.0% 33 32.7% 24.1% 42.2% 21 22.6% 15.0% 31.8% 21 18.8% 12.4% 26.7% 97 29.8% 25.0% 34.9% 90 26.2% 21.7% 31.0% Diversity 2 68 20.2% 16.2% 24.7% 97 24.8% 20.7% 29.3% 18 24.0% 15.4% 34.5% 18 17.8% 11.3% 26.1% 20 21.5% 14.1% 30.6% 14 12.5% 7.3% 19.6% 70 21.5% 17.3% 26.2% 67 19.5% 15.6% 23.9%

3 50 14.8% 11.3% 18.9% 56 14.3% 11.1% 18.1% 9 12.0% 6.1% 20.8% 19 18.8% 12.1% 27.3% 10 10.8% 5.7% 18.2% 22 19.6% 13.1% 27.7% 54 16.6% 12.8% 20.9% 47 13.7% 10.3% 17.6% 4 39 11.6% 8.5% 15.3% 43 11.0% 8.2% 14.4% 7 9.3% 4.3% 17.5% 7 6.9% 3.2% 13.1% 10 10.8% 5.7% 18.2% 15 13.4% 8.0% 20.6% 29 8.9% 6.2% 12.4% 39 11.3% 8.3% 15.0%

5 26 7.7% 5.2% 10.9% 31 7.9% 5.6% 10.9% 7 9.3% 4.3% 17.5% 7 6.9% 3.2% 13.1% 11 11.8% 6.4% 19.5% 12 10.7% 6.0% 17.4% 12 3.7% 2.0% 6.1% 21 6.1% 3.9% 9.0%

6 16 4.7% 2.9% 7.4% 18 4.6% 2.9% 7.0% 4 5.3% 1.8% 12.2% 5 5.0% 1.9% 10.5% 3 3.2% 0.9% 8.4% 9 8.0% 4.1% 14.2% 12 3.7% 2.0% 6.1% 21 6.1% 3.9% 9.0%

7 8 2.4% 1.1% 4.4% 26 6.6% 4.5% 9.4% 3 4.0% 1.1% 10.3% 5 5.0% 1.9% 10.5% 3 3.2% 0.9% 8.4% 6 5.4% 2.3% 10.7% 5 1.5% 0.6% 3.3% 9 2.6% 1.3% 4.7%

Minimum no 236 70.0% 65.0% 74.7% 254 65.0% 60.1% 69.6% 52 69.3% 58.3% 78.9% 66 65.3% 55.7% 74.1% 69 74.2% 64.7% 82.3% 69 61.6% 52.4% 70.2% 216 66.3% 61.0% 71.2% 233 67.7% 62.7% 72.5% Meal yes 101 30.0% 25.3% 35.0% 137 35.0% 30.4% 39.9% 23 30.7% 21.1% 41.7% 35 34.7% 25.9% 44.3% 24 25.8% 17.7% 35.3% 43 38.4% 29.8% 47.6% 110 33.7% 28.8% 39.0% 111 32.3% 27.5% 37.3% Frequenc Minimum no 290 86.1% 82.1% 89.4% 322 82.4% 78.3% 85.9% 64 85.3% 76.1% 91.9% 85 84.2% 76.1% 90.3% 79 84.9% 76.7% 91.1% 85 75.9% 67.4% 83.1% 296 90.8% 87.3% 93.6% 286 83.1% 78.9% 86.8% Acceptabl yes 47 13.9% 10.6% 17.9% 69 17.6% 14.1% 21.7% 11 14.7% 8.1% 23.9% 16 15.8% 9.7% 23.9% 14 15.1% 8.9% 23.3% 27 24.1% 16.9% 32.6% 30 9.2% 6.4% 12.7% 58 16.9% 13.2% 21.1% e Diet Consump no 319 94.7% 91.9% 96.7% 364 93.1% 90.3% 95.3% 68 90.7% 82.5% 95.7% 92 91.1% 84.4% 95.5% 86 92.5% 85.8% 96.6% 90 80.4% 72.3% 86.9% 298 91.4% 88.0% 94.1% 306 89.0% 85.3% 91.9% tion of yes 18 5.3% 3.3% 8.1% 27 6.9% 4.7% 9.7% 7 9.3% 4.3% 17.5% 9 8.9% 4.5% 15.6% 7 7.5% 3.4% 14.2% 22 19.6% 13.1% 27.7% 28 8.6% 5.9% 12.0% 38 11.0% 8.1% 14.7% Iron 45

Annex 2-Cluster Distribution

Household Lga Ward Kanguri Population Sampled Clusters Jere Dusuman Bashetti 580 1 Jere Dusuman BOSAP Quarters 121 2 Jere Dusuman Musari 527 3 Jere Galtimari Mulai Bulabulin 82 4 Jere Galtimari Mulai Quarters 680 5,6 Jere Gongulong Bulabulin 851 7,8 Jere Gongulong Gongulong Bulamari Aliye 202 9 Jere Gongulong Gumsumeri 292 10 Jere Gongulong Modu Ajiri 555 11 Jere Gongulong Modu Ajiri Gana 196 12 Jere Khaddamari Basheti 293 13 Jere Old maiduguri Gwazari 320 99 Jere Old maiduguri El-yakub 410 RC Jere Old maiduguri Fariah block 741 RC,14 Jere Dala Lawanti Dala Kafe 183 15 Jere Dusuman Muna Ethiopia 330 16 Jere Dusuman Musari 986 17,18 Jere Mashamari Kantigoma 257 19 Jere Mashamari Goni Kachallari 1,112 20,21,22,96,97 Jere Galtimari Bulabulin Kusheri 60 23 Jere Galtimari Molai Juddumri 297 24 Jere Galtimari Molai Kura 266 25 Jere Galtimari Molai Quarters 870 RC,26

Jere Galtimari Molai Shuwari 2,279 27,28,29,30,31,32 Jere Galtimari Polo gwarri 2,364 33,34,35,36,37,38 Jere Mairi Mairi Kuwait 600 39 Jere Mairi Dalori 931 40,41 Jere Mairi Chabbal 530 42,43 Jere Mairi Dangalti (Usmanti) 620 44 Konduga Dalori Amarwa Bulamari 335 45 Konduga Dalori Amarwa Goniri 331 46 Konduga Dalori Kalari Abdule 268 47 Magumeri Ardoram Chingowa 86 48 Konduga Zarmari Gremari 500 49 Konduga Zarmari Shiwari bypass 500 50 Konduga Konduga Central Kiji Malari 62 51 Konduga Konduga Central Kofan Ruwa 543 52 Konduga Konduga Central Mandadari - 2 550 53,98, Konduga Konduga Central Yandadari Gana 121 54 Konduga Konduga Central Sabon Gari 1 750 55,56, Konduga Konduga Central Sabon Gari 2 328 57 Konduga Konduga Central Mainari 226 58 Mafa Tamsumgandua Kaleri 750 61,RC, 94, 95 Mafa Tamsumgandua Malakylari 1845 62,63,64,65 MMC Shehuri North Kawar Maila 890 66,67 MMC Shehuri North Gangamari 1300 68,69,70 MMC Bolori II Musari Dubai 430 RC MMC Bolori II Bolori II 650 71,72 MMC Bolori II Bolori 3 731 73,74 MMC Bolori II Bolori 8 802 75,RC MMC Bolori II Bulabulin Bolibe 442 76 MMC Bolori II Low Cost block 1130 77,78 47

MMC Bolori I Sabon Gari 641 79,80 MMC Bolori I Garba Buzu 641 81 MMC Maisandari Bintu Suga 400 82 MMC Maisandari Mudosullumri 244 RC MMC Maisandari Bulabulin Extension 1,878 83,84,85,86 MMC Maisandari Mega 226 87 MMC Maisandari Kabanti 544 RC MMC Maisandari Dala Dayeri 224 88 MMC Maisandari Dala Shuwari 421 89 MMC Bulabulin Bulabulin 1,964 90,91,92,93,RC

Annex 2-References

1. https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/docum ents/files/ocha_nga_humanitarian_response_plan_march2020.pdf

2. http://vts.eocng.org/population/LGA?s=&l=&gender=MF&from=0&to=100

3. https://displacement.iom.int/

4. CARE IYCF Guildline https://www.ennonline.net/attachments/987/final-iycf-guide-iycf-

practices.pdf

5. http://www.who.int/immunization/monitoring_surveillance/Vaccination_coverage_cluster_su

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10. https://fscluster.org/sites/default/files/documents/nfss_round_8_final_report_november_201

9.pdf

11. https://www.unicef.org/nigeria/media/2181/file/Nigeria-NNHS-2018.pdf

12. https://www.who.int/nutrition/topics/vad/en/

13. http://www10.who.int/entity/elena/titles/deworming/en/

14. World Health Organization (WHO). 2007. WHO Fact sheet N°286: Measles. Available at: http://www.who.int/mediacentre/factsheets/fs286/en/