Nutritional Anthropometric Survey Final Report Idp

NUTRITIONAL ANTHROPOMETRIC SURVEY

FINAL REPORT

IDP CAMPS AND RESETTLEMENT AREAS OF GULU & AMURU DISTRICTS, NORTHERN UGANDA

MAY 2007

Funded by:

ACKNOWLEDGMENTS

We would like to extend our appreciation to the Gulu & Amuru District Director of Health Services for fully supporting the nutrition survey and involving two of their staff in the survey.

We would like to thank all of the AAH management team for their assistance in preparing and conducting the survey. Without the support of logistics and administration at both capital and base levels, the survey would not have been possible. We further appreciate the management team members that took the time to participate in the survey. The involvement of AAH-Canada further broadened our understanding of the SMART methodology and was warmly welcomed.

We appreciate all of the team members from the office and field that spent two long weeks conducting the survey. Their dedication and hard work helped ensure the accuracy and reliability of the data. Further thanks to all of the drivers that ensured the teams’ safe delivery to and from the field.

Special thanks are extended to all of the camp and village leaders that welcomed and willingly assisted the teams in their home communities. Without their support and sensitization to the community, finding the houses and finding families at home would have been impossible. Finally, we offer much thanks to the individual families that patiently allowed us to weigh and measure their children and provided vital information for the survey.

Table of content

I EXECUTIVE SUMMARY ...... 4 II INTRODUCTION ...... 8 III OBJECTIVES ...... 9 IV METHODOLOGY...... 10 IV.1 Type of Survey and Sample Size ...... 10 IV.2 Data Collection ...... 10 IV.3 Indicators, Guidelines, and Formula’s Used ...... 11 IV.3.1 Acute Malnutrition ...... 11 IV.3.2 Mortality ...... 12 IV.4 Field Work ...... 12 IV.5 Data Analysis...... 12 V RESULTS OF THE ANTHROPOMETRIC SURVEY ...... 12 V.1 Anthropometry ...... 12 V.1.1 Distribution by Age and Sex...... 13 V.1.2 Anthropometric Analysis ...... 13 V.2 Measles Vaccination Coverage...... 15 V.3 Household Status and composition...... 16 VI RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ...... 16 VII DISCUSSION ...... 17 VIII RECOMMENDATIONS...... 18 IX APPENDIX...... 19 IX.1 Sample Size and Cluster Determination ...... 19 IX.2 Anthropometric survey questionnaire ...... 20 IX.3 Household enumeration data collection form for a death rate calculation survey (one sheet/household) ...... 21 IX.4 Calendar of events in AMURU & GULU districts...... 22

I EXECUTIVE SUMMARY

Lying 332 km from the national capital Kampala, Gulu district has traditionally been widely acknowledged as the regional capital of the northern region. Up to May 2006, Amuru was part of Gulu District but has then been upgraded as an entire District. The 2 districts cover an area of 11,732 sq km, comprised of open water and swamps (180 km²), arable land (10,301 km²), national parks and games reserves (982 km²) and forest coverage (371 km²).

Security and displacement The war in Northern Uganda has been ongoing for twenty years. Initially rooted in a popular rebellion against President Yoweri Museveni’s National Resistance Movement (NRM) government, the conflict has since been transformed by Joseph Kony’s Lord’s Resistance Army (LRA) into a brutally violent war in which civilians in the northern districts are the main victims. Approximately 1.9 million people have been internally displaced. The Acholi region of Uganda (Kitgum, Pader, and Gulu Districts) has seen an increase in the intensity of insurgency since 1996. This has resulted in people’s displacement, spontaneously or under the direction of the Government, into camps protected by the Uganda People’s Defense Forces (UPDF).

The conflict in Northern Uganda is often referred to as the forgotten war. Funding for relief and development activities has never been proportional to the needs. However, in the last two to three years, an increase in international attention has been followed by an increase in the amount of international funds designated to humanitarian projects in Northern Uganda war affected districts. Besides funding, the peace talk on going since August 2006 led to a significant improvement of the security situation. This improvement of security conditions motivated the beginning of a returning process for IDP’s to their villages of origin, improving their access to land for gardening. However, people showed still traumatize by the war and most of them still feared to return back where the government army (UPDF) can not provide them security.

Weather Amuru & Gulu districts climate consists in wet and dry seasons. The average rainfall received is 1,500 mm per annum with a monthly rainfall average varying between 14 mm in January and 230 mm in August. The wet season extends from April to October with peaks in May, August and October. The dry season starts in November and lasts up to March.

Population The district has a population of 479,496 according to the 2002 population census. Gulu is a multi-ethnic district although some 85 percent of the people are from the Acholi ethnic group. Other ethnic groups represented are the Langi, Madi and Alur. The main languages spoken are Luo, English, Swahili, Madi, Lugbara, Luganda, Acholi and Kinubi.

Infrastructure Gulu can be accessed by road and air. The national railway line also extends to the district although it is not actually functional. The district has a 415 km feeder road network and a 600 km community road network Mobile Telephones Network (MTN) and Uganda telecom networks are covering the districts. Gulu district has four main hospitals and five health sub-districts (HSD). The hospitals are Anaka District Hospital, Gulu Referral Hospital, St. Mary’s Lacor Hospital (Missionary founded) and a private independent Hospital. Agriculture remains the major economic activity in Gulu district. Over 90 percent of the population in the district engages and benefits from agriculture activities. Agriculture contributes 45 percent of the Gross Domestic Product (GDP). Some 10,301 km² are cultivated but insecurity has rendered big chunks of the district no-go areas. Among the cash crops grown are rice, tobacco, cotton, groundnuts, sun flowers and sesame. The staple foods are finger millet, sorghum, cassava, sweet potatoes, pigeon peas, beans, cowpeas, bananas, soy beans and maize.

Objectives of the survey A nutritional survey was conducted in Gulu & Amuru districts in April 2007.

• To evaluate the nutritional status of children aged 6 to 59 months. • To estimate the measles immunization coverage of children aged 9 to 59 months. • To estimate the crude mortality rate through a retrospective survey.

Methodology In order to be able to compare 2007 nutritional data with those collected during the last years surveys, and as it appeared that nutritional status of the people in Gulu and Amuru districts could be assumed equivalent, the survey was conducted jointly for both districts. Targeted population remained the IDP’s, as considered as the most vulnerable. Compared with 2006 survey, transit and resettlement camps and villages of return were included in the survey in order to follow the population in its returning process.

The Smart methodology was applied for the calculation of the sample size: 32 cluster of 22 children. The sampling frame covered all accessible IDP camps, including resettlement and transit camps and villages. In each cluster, households were randomly selected and surveyed using the EPI method. All the children aged between 6 and 59 months of the same family, defined as all inhabitants using the same cooking pot, were included in the survey. A retrospective mortality survey over the period from January 1st up to the date of the survey (3 months and half) was undertaken alongside the anthropometric survey, using SMART methodology.

Nutrition and mortality data were analyzed using Nutrisurvey version December 2006 software.

Summary of the findings

As a transition to a complete return from camps, authorities organized several resettlement and transit camps in Gulu and Amuru districts, An average of 25% of the population had already returned or joined transit camps in both Gulu & Amuru while in Lira over 79% is no longer in the displaced camps in March 2007. In Gulu and Amuru most people in transit or returning process were still linked with some humanitarian assistance provided in the camps (as access to health facilities, education, and access to clean water is questionable in villages, returning areas and transit camps).

Results of the survey

Table 1: Results for Gulu & Amuru Districts

Index INDICATOR RESULTS (n =763) Global Acute Malnutrition 3.1 % W/H< -2 z and/or oedema [1.8% - 4.5%] Z-scores Severe Acute Malnutrition 0.4 % NCHS W/H < -3 z and/or oedema [0.0% - 0.8%] Global Acute Malnutrition 2.1 % W/H < 80% and/or oedema [1.0% - 3.2%] % Median Severe Acute Malnutrition 0.0% W/H < 70% and/or oedema [0.0%-0.2%] Global Acute Malnutrition 3.5 % W/H< -2 z and/or oedema [2.1% - 5.0%] Z-scores Severe Acute Malnutrition 0.8 % W/H < -3 z and/or oedema [0.2% - 1.4%] WHO Global Acute Malnutrition 1.0 % W/H < 80% and/or oedema [0.3% - 1.8%] % Median Severe Acute Malnutrition 0.0% W/H < 70% and/or oedema [0.0%-0.2%]

Total crude retrospective mortality (last 3.5 months) /10,000/day 0.30 [0.11-0.48] Under five crude retrospective mortality /10,000/day 0.20 [0.00-0.43]

Measles immunization coverage on By card 47.8% children >=9 months old According to caretaker1 41.4% (n= 739) Not immunized 10.8%

Table 2: Nutritional Surveys – Gulu/Amuru Districts - Main results since 2003 May 2003 June 2004 June 2005 June 2006 April 2007 (n=900) (n=1072) (n=976) (n=934) (n=763) Global Acute Malnutrition 6.7% 4.6% 4.1% 4.3% 3.1% (W/H <-2 Z-scores2 and/or (4.6% - 9.5%)3 (3.0% - 6.8%) (2.6% - 6.4%) (2.7% - 6.7%) (1.8% - 4.5%) oedema) Severe Acute Malnutrition 1.3% 0.8% 1.2% 0.3% 0.4% (W/H <-3 Z-scores and/or oedema) (0.7% - 2.4%) (0.3% - 2.2%) (0.5% - 2.8%) (0.0% - 1.5%) (0.0% - 0.8%) Measles vaccination coverage: Confirmed by Card 38.3% 47% 83.1% 63.9% 47.8% Not conformed by Card 61.7% 53% 16.0% 32.8% 41.4%

The results of the last 3 annually surveys show a general slight improvement in the prevalence of Global Acute Malnutrition, as compared to the rates found in the previous years:

Rates of malnutrition have notably decreased. Immunization rates are acceptable as well, showing a good coverage for the prevention of outbreaks, and also reveal an acceptable level in health access. Many mothers couldn’t provide EPI cards as most of the time they were burnt or lost. Acute malnutrition in the surveyed areas is of low magnitude and low intensity, which makes the population slightly vulnerable to potential shocks.

The current nutritional situation in Gulu and Amuru districts can be explained by the following factors:

Health Access and Water and Sanitation: Gulu and Amuru districts have good coverage of health facilities compared with other affected districts in Northern Uganda. Access to water improved although sanitation remains a concern (poor hygiene conditions in most camps and high level of promiscuity…). Such a situation could still lead to high incidence in some communicable diseases within the camps. Both districts have good number of facilities and health workers in the mains camps (with the exception of transit camps and villages), and IDP’s developed copying mechanisms in order to access health services (as moving to the main camps to access them). It has been noticed that in most cases the distance from return or transit areas to the main camps were from 1 to 20 km.

Food Security: The improvement of the security situation helped ensuring people a better access to lands. Relief organizations as ACF, CICR, etc., provided seeds to support cultivation activities. General food distributions (GFD) from WFP were still ongoing. Following the improvement of the situation, World Vision and Save the Children phased out from their nutritional programs end 2006 and beginning 2007.

Nutrition and Health Education: Nutritional and health education messages are commonly provided among mothers who attend nutritional programs and at lower level in communities: proper breastfeeding and weaning practices, well balanced diets, food safety, etc. However, to strengthen nutritional education and hygienic promotion is still needed for the entire population of Gulu and Amuru districts.

1 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker. 2 NCHS reference. 3 Confidence interval at 95%

Recommendations

In order to improve and sustain the nutrition status of the surveyed communities, ACF recommends the following:

Health and nutrition: Integration of nutritional curative activities in the existing health facilities to ensure sustainability Capacity building of the MoH structures (DDHS, health facilities) on the management of acute malnutrition (identification of cases and treatment of severely malnourished children). Rehabilitation of health facilities in returning areas and villages. Conduction of EPI campaigns whenever necessary in parallel with systematic routine immunization activities to ensure all children are vaccinated against childhood diseases. Increase the number of medical staff in health facilities as well as access to drugs and equipments.

Water and Sanitation: Increase the access to proper water by constructing/rehabilitating boreholes in transit and returning areas. Improve the quality of water in earth pans by introducing methods to filter water affordable and sustainable for the community. Continue with sanitation programs such as water protection and education.

Nutrition and health education: Strengthen nutrition education activities in the districts, focusing on the improvement of the quality of food prepared from locally available foods. Coordinate with Water & sanitation programs to provide hygiene promotion sessions to the communities. Continue with health promotion programs in communities to improve nutritional and hygienic practices.

Food Security: Establish food for work programs as only vulnerable people in communities would receive food distribution resulting with proper targeting. Device ways of enhancing food security for pastoralist communities especially improving grazing lands, establishing market for the livestock’s and improving crop cultivation especially along the rivers.

II INTRODUCTION

General sanitation is at poor level and people live in densely confined areas within the security of the camps. Access to safe water improved but remains lower than recommended by SPHERE standards (250 persons per water point); security situation regularly improved for the 2 last years. Access to land also improved and returning process started to villages and Parishes.

ACF intervention ACF-USA has been operational in Gulu/Amuru Districts since May 1997 through nutrition, food security and water & sanitation programs. ACF-USA currently supports 16 Supplementary Feeding Centers (SFC) integrated in Health facilities spread throughout the two districts, one Therapeutic Feeding Centre (TFC), in Gulu Municipality Hospital and 6 community-based therapeutic care centers (OTP centers). A home visiting program has been operational since October 2003, devoted to the active research of the acutely malnourished cases in the camps surrounding the nutritional centers. In parallel, Health facilities staffs have been trained in prevention and detection of acute malnutrition, and health/nutrition education is being provided at community level by health educators and Community Health Workers in 16 camps.

In 2006, attendance of each centre was as follow: ¾ SFC: around 10863 admissions ¾ Gulu TFC: around 534 admissions ¾ OTP centers: around 633 admissions

Humanitarian int