Republic of Yemen Ministry of Public Health and Population

Nutrition and Mortality Survey Report Socotra Governorate, Yemen 28 March to 4 April 2018

Acknowledgements The Yemen Ministry of Public Health and Population (MoPHP)/Socotra Governorate Public Health and Population Office, in collaboration with UNICEF Yemen Country Office and UNICEF Aden Zone, acknowledge the contribution of the various stakeholders in this survey. The UNICEF Yemen Country Office provided technical support, employing SMART methodology. The Survey Manager and his assistants, supervisors were provided by Socotra, Adh Dhale, Al-Baidha, Hadhramout, Lahj, and Abyan GHOs and the central MoPHP in Aden. Survey enumerators and team leaders were provided by GHO of Socotra. Data entry team were provided by GHOs of Socotra and the head of data entry was provided by Lahj GHO. The protocol was finalised by Socotra GHO with technical support of UNICEF YCO. UNICEF YCO provided technical assistance especially that related to daily quality check, data analysis and report writing were made by UNICEF YCO. Socotra Governorate Public Health and Population Office over saw the political and logistical arrangements for the survey, ensuring its smooth operation. The survey was supported financially by UNICEF under a grant from the USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA); this support is greatly appreciated. The contribution of local authorities in ensuring the survey teams’ security during fieldwork and in providing office facilities is gratefully appreciated. The data could not have been obtained without the co-operation and support of the communities assessed, especially the mothers and caretakers who took time off from their busy schedules to respond to the interviewers. Their involvement and cooperation is highly appreciated. MoPHP and UNICEF also express their sincere appreciation to the entire survey team for the high level of commitment and diligence demonstrated during all stages of the assessment to ensure high quality of data collected, and the successful accomplishment of the exercise.

Content Acknowledgements ...... 1 Content ...... 2 Introduction ...... Error! Bookmark not defined. Assessment objectives ...... Error! Bookmark not defined. Methodology ...... Error! Bookmark not defined. Study and sampling design ...... 9 Sampling Procedure (The second stage) ...... 10 Survey Population and Data Collection Process ...... 10 Measurement Standardization and Quality Control ...... 11 Data Entry and Analysis ...... 12 Results and discussion ...... 14 The survey sample ...... 14 Background indicators ...... 15 Household income situation ...... 16 Water, sanitation and hygiene ...... 17 Child Nutrition ...... 19 Acute malnutrition by WHZ ...... 20 Acute malnutrition by MUAC ...... 21 Underweight ...... 23 Stunting ...... 25 Mean z scores, design effects and flags ...... 26 Change in Nutrition status between 2012 and 2017 ...... Error! Bookmark not defined. IYCF practices ...... 27 Child morbidity ...... 28 Vitamin A supplementation and child vaccination ...... 28 Women nutrition ...... 29 Mortality ...... 29 Associations of the nutritional status ...... 30 Acute malnutrition ...... 31

Underweight ...... 32 Stunting ...... 33 Child nutrition in related to mother nutrition ...... 34 Recommendations ...... 34 Global, moderate and severe acute malnutrition prevalence used for caseload calculation ...... 34 References ...... 35 Annexes ...... 36 Annex 1: Ibb March-April 2017 Nutrition Survey Questionnaire ...... 36 Annex 3: Calendar of events ...... 53 Annex 4: Age determination job aid ...... Error! Bookmark not defined. Annex 5: Ibb March-April 2017 Survey Plausibility Check ...... 59 Annex 6: Ibb Nutrition Survey Standardization Test Report for Evaluation of Teams ...... 60 Annex 7: Clusters for Ibb March-April 2017 Nutrition Survey ...... 64 Annex 8: Tables of Weighted Levels of Anthropometrical Indicators ... Error! Bookmark not defined. Annex 9: Decision Tree for Household Selection (SMART Sampling Guideline, June 2012) ...... Error! Bookmark not defined.

Introduction Introduction: Socotra in general: Figure 1. Socotra Governorate Map Socotra is an archipelago of six islands located in the Arabian Sea, the largest island of which is also known as Socotra. The territory is part of Yemen, and had long been a subdivision of the Aden Governorate. In 2004, it administratively became part of Hadhramaut Governorate, which is much closer to the island than Aden. In 2013, the Archipelago became the 22nd Yemeni governorate called Socotra Governorate. The island of Socotra constitutes around 95% of the area of the Socotra Archipelago. It lies 380 kilometers (240 mil) south of the Arabian Peninsula. The island is very isolated, home to a high number of endemic species; up to a third of its plant life is endemic. It has been described as "the most alien-looking place on Earth." The island measures 132 kilometers (82 mil) in length and 49.7 kilometers (30.9 mi) in width. The Governorate is calm and there is no conflict in progress.

Geography and Climate: The main island has three geographical terrains: the narrow coastal plains, a limestone plateau permeated with karstic caves, and the Haghier Mountains. The mountains rise to 1,503 metres (4,931 ft.). The island is about 125 kilometres (78 mil) long and 45 kilometres (28 mil) north to south.

The climate of Socotra is classified in the Köppen climate classification as BWh and BSh, meaning a tropical desert climate and semi-desert climate with a mean annual temperature over 25 °C or 77 °F. Yearly rainfall is light to medium and rare heavy, but is fairly spread throughout the year. Due to orographic lift provided by the interior mountains, especially during the northeast monsoon from October to December, the highest inland areas can average as much as 800 millimetres (31.50 in) per year and receive over 250 millimetres (9.84 in) per month in November or December.[29] The southwest monsoon season from June to September brings strong winds and high seas. For many centuries, the sailors of Gujarat called the maritime route near Socotra as “Sikotro Sinh”, meaning the lion of Socotra that constantly roars—referring to the high seas near Socotra.

In an extremely unusual occurrence, the whole Socotra received more than 410 millimetres (16.14 in) of rain from Cyclone Chapala in early November and a week later Meige cyclone 2015.

UNESCO recognition The island was recognised by the United Nations Educational, Scientific and Cultural Organization (UNESCO) as a world natural heritage site in July 2008. The European Union has supported such a move, calling on both UNESCO and International Organization of Protecting Environment to classify the archipelago among the environmental heritages.

Economy The primary occupations of the people of Socotra have traditionally been fishing, animal husbandry, and the cultivation of dates. Some residents raise cattle and goats. The chief export products of the island are dates, ghee, and fish.

Transportation Long monsoons made the archipelago unreachable from June to September each year. However, in July 1999, Socotra's new airport opened to the outside world year round. There is currently irregular service to seiyon via Yemenia Airways because of the current circumstances and the state of war in Yemen.

History of the intervention of UN organizations in Socotra At the end of the 1990s, a United Nations Development Program was launched with the aim of providing a close survey of the island of Socotra. The project called Socotra Governance and Biodiversity Project.

At the end of 2016 UNICEF joined Socotra through its partner HAD in health and nutrition project, which works to combat severe acute malnutrition, as well as strengthening the health

system through work in 7 permanent health centres, 3 mobile clinics, and 175 CHVs. This project lasted February 2018 with promises to continue and expand.

The World Food Program (WFP) has already worked in Socotra through the Health and Population Office, but has been suspended from the beginning of 2017 for unknown reasons

Background on the timing of the survey: The months March, April and May is the warmest months which the sea is stable and easy to enter and exit Socotra cross the sea and its season of no rain or wind. Sale and stability of livestock herdsmen also because it is a period in which these cattle can be sold because it is not a breeding period.

Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Socotra Governorate and key determinants

Specific Objectives: • To assess levels of acute malnutrition by WHZ criteria among children aged 6 to 59 months in Socotra Governorate. • To assess levels of acute malnutrition by MUAC criteria among children aged 6 to 59 months in Socotra Governorate. • To determine the combined acute malnutrition in children aged 6 to 59 months in Socotra Governorate. • To assess levels of stunting among children aged 6 to 59 months in Socotra Governorate. • To assess levels of underweight among children aged 0 to 59 months in Socotra Governorate • To assess the routine polio vaccination coverage among children aged 3 to 59 months, measles vaccination coverage among children aged 9 to 59 months and vitamin A supplementation coverage within the last 6 months prior to survey among children aged 6 to 59 months in Socotra Governorate. • To assess the level of acute malnutrition among women at child bearing age (15 to 49 years) in Socotra Governorate. • To assess the food consumption scoring (FCS) in past 7 days in Socotra Governorate. • To assess the mean coping strategy index (CSI) of households in Socotra Governorate. • To assess the household practice of a set of stress, crisis and emergency coping strategies in Socotra Governorate. • To assess the household head losing of income sources in Socotra Governorate due to the current conflict crisis. • To assess the monthly household expenditure of households in Socotra Governorate. • To assess the education level of household caregivers in Socotra Governorate. • To assess the main household drinking water source, the quality classification of the water sources and the cleanness of drinking water storage in Socotra Governorate.

• To assess the household latrine type and the quality classification of sanitation facilities in Socotra Governorate. • To assess the practice of hand washing with water and soap (or soap alternatives) by household care giver after toilet and before the meal in Socotra Governorate. • To assess the crude and under-five mortality rates in Socotra Governorate using the recall period of 118 days. • To assess the prevalence of exclusive breastfeeding among under six months, breastfeeding continuation at 1 and 2 years, children aged 6 to 23 months with proper complementary feeding practices in Western Highlands and Eastern Highlands of Ibb Governorate. • To assess the prevalence of exclusive breastfeeding among under six months, breastfeeding continuation at 1 and 2 years, children aged 6 to 23 months with proper complementary feeding practices in Socotra Governorate.

Methodology The Governorate of Socotra was assessed as one strata. That includes 2 districts namely Hadibo and Qalansia. Between 28 March and 3 April 2018 and after a week of training and logistic preparation , a total of 588 households in Socotra Governorate were visited for the survey with absence rate of 2.6% and no refusal. The two small islands of Samha and Abdulkouri were excluded before selection of clusters, because of transportation difficulties. The population of these two islands represents 2% of the Governorate population.

There was no IDP settlements in the Governorate.

Sample size and sampling design The following assumptions (based on the given context) were used to calculate the sample size in number of children, which were then converted into number of households to survey. All calculations were made using ENA Software for SMART (July 9 2015 version).

Parameters for Anthropometry Value

Estimated Prevalence of GAM (%) 14.6%

± Desired precision 3.5%

Design Effect 1.5

Children to be included 638

Average HH Size 7

% Children under-5 18.4%

% Non-response Households 3 %

Households to be included 568

Parameters for Mortality Value

Estimated Death Rate /10,000/day 0.5

± Desired precision /10,000/day 0.3

Design Effect (if applicable) 1.5

Recall Period in days 118

Population to be included 2953

Average HH Size 7

% Non-response Households 3 %

Households to be included 435

The sample size calculated was higher in anthropometry than in mortality. The highest calculated sample sizes for households were 568. With these numbers of households, the expected numbers of under-five children are 638 children in the survey.

The survey has taken place in 42 clusters. These clusters were selected following Probability Proportional to Size (PPS) approach in the presence of the Deputy Governor Socotra and the Deputy Director of the Health and Population Office in the governorate. The number of households per cluster was as planned 14 households. Primary sampling units in the sampling frames are villages in rural settings and Haras in cities as previously presented in the survey protocol. The selection of households at the cluster level followed the SRS method after households listing. Segmentation was considered for large clusters in Hadibo Haras of 26 September (4 clusters), 14 October (2 clusters), and Mezaghabehen (3 clusters) and in Qalansia town (2 clusters). The selection of sample segments was made randomly using PPS.

The most updated list of villages was used as the frame (update of the Relief Committee in the Governorate 2015) after excluding islands of Samha and Abdulkouri. Many small scattered villages near to each other were merged into one cluster before PPS selection was used to assign clusters.

Sampling Procedure (The second stage) The selection of households at the cluster level was made following the decision tree mentioned in SMART sampling guideline of June 2012 (Annex 9). For 42 clusters, listing of households was made by team heads and villagers then the target number of households were randomly selected using SRS approach. The SRS was also followed but after segmentation. For the purpose of listing, the survey operation room in Hadibo was providing teams in daily basis with special forms called “Sample listing and selection form” as well as numbering strips that used by teams to complete selection process. At the end of the day, these forms together with the daily cluster reports and filled questionnaire were submitted to the survey manager at the survey operation room in Hadibo city. The EPI random walking methods was not used in this survey.

Survey Population and Data Collection Process The survey population consisted of: 1) anthropometry: children aged 6 to 59, 2) mortality: all people that have lived at the household (currently residing, left, born or died) over a recall

period started from day of killing the previous Yemeni President Ali Abdullah Saleh; 3) IYCF: children 0-24 months; 4) morbidity: children 0-59 months. Age estimation was based on birth or immunization card details and/or supported with events calendar that includes governorate specific events and national events that are widely known (Annex 3: Events Calendar and Annex 4: Age determination job aid).

Six field teams and three data entry persons (Annex 2: March-April 2018 Socotra Governorate Nutrition Survey Team) were trained for 7 days by the survey manager and the survey field supervisors. The training consisted of anthropometry, filling of questionnaire, and the field procedures following by rigorous standardization exercise (Annex 6: March-April 2018 Socotra Governorate Nutrition Survey Standardization Test Report) and field test before commencing the data collection phase. Out of the 6 trained teams, then the teams were selected to complete the data collection over a 7 days period.

Selected households were given a brief overview of the survey and invited to participate. Verbal consent to participate was obtained after the household participant heard the survey overview from the survey team. After consent was given, the survey teams assisted a member from each selected household to complete a questionnaire comprising of 1) background demographics; 2) gender of household head, 3) gender, education and marital status of household caretaker; 4) information on household income and expenditure; 5) WASH indicators; 6) household food consumption and coping strategies; 7) marital status, physiological status and MUAC of woman at child bearing age; 8) child vaccination and vitamin A supplementation; 9) child anthropometry; 10) child morbidity; 11) IYCF practices; and 12) crude and under-fives mortality. (Annex 1: March-April 2018 Socotra Governorate Nutrition Survey Questionnaire).

Retrospective mortality data were collected from all randomly selected households, irrespective of presence or absence of children aged 6-59 months. A recall was calculated from the day of killing the pervious Yemeni president Ali Abdullah Saleh 118 days.

Measurement Standardization and Quality Control The survey teams has undergone to a concentrated practical training prior to the survey covering all areas related to the field work including standardisation test of the enumerators. Data quality was ensured through (i) monitoring of fieldwork by field technical supervisors; (ii) crosschecking of filled questionnaires on a daily basis, recording of observations and daily de- briefing and discussion; (iii) confirmation of measles, severe malnutrition especially oedema cases and death cases by supervisors; (iv) daily entry of anthropometric data; (v) doing the plausibility check in daily basis for the overall quality scoring and identification each team quality using 10 scoring criteria (statistical tests), plus ensuring each team was given feedback on the quality of previous day’s data before the start of a new day; (v) daily equipment

calibration, (vi) additional check done at the data entry level to enable entry only of relevant possible responses and measurements which was assisted by the auto check sheet that was specially designed for the data entry; and (vii) continuous reinforcement of good practices. For a quality concerns two clusters in the Western Highlands were revisited by the teams under supervision making sure that process of sampling, measurement and filling the questionnaire was completed properly.

Clear job descriptions were provided to field teams during the training and before commencing the data collection in order to ensuring appropriate guidance in completing the assigned tasks. Field team head was reviewing the filed questionnaires and verify the accuracy of the details before the team was leaving the cluster site, thus minimizing possibility of incomplete data (missing variables) and outlier data. The overall plausibility scores were 10% (-) (Annex 5: Assessment Plausibility Check Report)

Data Entry and Analysis The data in the filled questionnaires and mortality forms were entered into an Excel spread sheet created for the purpose of this survey. The spreadsheet contained all required self-check formulas as well as converting dates from Hijri to Gregorian. The verification of data entry was made by randomly selection of 10% of records (households), dataset was considered verified since more than 95% of the selected records approved an accurate data entry work.

The anthropometrical data then were copied to ENA for SMART for interpretation to z scores as well as creation of the final plausibility check report and results of nutritional anthropometry status tables and curves. Similarly, the data of mortality were transferred to ENA for the analysis purposes and getting out the final death results with population pyramid.

Household variables and the remaining child-related variables (vaccination, vitamin A supplementation, feeding practices and morbidity) were analysed using Epi Info(TM) 3.5.3. The anthropometry indices (z-scores) for Weight for Height (wasting), Height for Age (stunting) and Weight for Age (underweight) were generated and compared with WHO 2006 Growth Standards. Children/cases with extreme z-score values were flagged and investigated and appropriately excluded in the final analysis if deviating from the observed mean (SMART flags).

In Epi Info, frequencies and cross-tabulations were used to give percentages, means and standard deviations in the descriptive analysis and presentation of general household and child characteristics. Significances was defined as (P<0.05).

The classification the nutritional status using the above indices as well as MUAC was made following the WHO classification (WHO 2006) and (WHO 2013). For acute malnutrition,

additional calculation was made for programmatic purposes that showing the prevalence of GAM and SAM combining the respective cut-off thresholds of WHZ and MUAC considering the presence of bilateral biting oedema.

For IYCF indicators related to breast feeding and complementary feeding, the WHO guidelines on assessing infant and young child feeding practices were used (WHO 2008).

For the calculation of the value for Minimum Dietary Diversity (MDD), a 7 food group score variable was created. The 7 foods groups used for calculation are 1) grains, roots and tubers; 2) legumes and nuts; 3) dairy products (milk, yogurt, cheese); 4) flesh foods (meat, fish, poultry and liver/organ meats); 5) eggs; 6) vitamin-A rich fruits and vegetables; 7) other fruits and vegetables. Another indicator is the Minimum meal frequency (MMF) which is measuring the child consumption for solid, semi-solid, or soft foods. Minimum acceptable diet (MAD) is combining both MDD and MMF. The methods and analysis for the MDD, MMF and MAD were based as recommended by the WHO (WHO 2008).

The classification of MUAC of Women was made based on the global one.. Woman is considered severely wasted if her MUAC is below 18.5 cm, and moderately wasted if her MUAC is equal or more than 18.5 cm and below 21.0 cm, however, if the women is either pregnant or lactating mother, she is considered moderately wasted if her MUAC is equal or more than 18.5 cm and below 23.0 cm. Above that, MUAC reading is considered normal.

For sources of drink water indicators, the sources listed in the classification were classified to improved and unimproved sources. Improver drinking water sources are: 1) House connected piped water; 2) Artesian well; 3) protected well; 4) Protected spring; and 5) Protected rainwater harvesting. Unimproved sources are: 1) Public tap/ Community point/ Sabeel; 2) Unprotected well; 3) Unprotected spring; 4) Bottled water; 5) Unprotected surface water (Wadi, springs, etc.); 6) Unprotected rainwater harvesting; 7) Water tanker; and 8) any other unclassified sources other those mentioned above.

Sanitation was also classified as improved and unimproved based on the type of latrine. Improved latrines are 1) Flush to piped sewer system; 2) Flush to septic tank; 3) Flush to pit latrine; 4) Ventilated improved pit latrine; 5) Pit latrine with slab; and 6) Composting toilet. Unimproved latrines include 1) Flush to open drain; 2) Flush to DK where; 3) Pit latrine without slab/ open pit; 4) Bucket; 5) Hanging latrine; 6) Defecation in open (in fields, etc.) and 7) any other unclassified sources than those previously mentioned.

Food consumption scores (FCS) were calculated based on the consumption during the last 7 days from the 8 food groups following WFP guidelines. The classification of FCS is not made following the global WFP one but based on the WFP Yemen way as the following:

- Below of equal to 28: Poor food consumption - Above 28 to 42: Border line food consumption - Above 42: Acceptable food consumption

The coping strategy index CSI scoring was done following WFP guidelines. It made depending on practicing of a list of 11 coping strategies. Another extended list of coping strategies in this survey was used to determine households who are practicing no coping strategies, stress coping strategies, crisis coping strategies and emergency coping strategies during the last 30 days as shown below:

Stress coping strategies: Selling households assets/belongings (furniture, jewellery, clothes, etc.) Buying food by credit or pawning Spending from saving Borrowing money Crisis coping strategies: Selling of production assets or transport means (sewing machine, car or motorcycle, etc.) Consuming the stock of seeds that is reserved for the coming season Withdraw children out of school Reduce spending on education and health (including drugs) Emergency coping strategies: Selling the house or land Begging Selling the last female of cattle the household has

Results and discussion The survey sample

A total of 588 households were targeted by the survey field teams in Socotra Governorate were visited for the survey with absence rate of 2.6% and no refusal shown in Table 3. Data were collected from a total number of 571 households including 684 children and 987 women.

Table 3. Sampled households, children and women in the two survey layers

Socotra

Households visited 588

Absence 15 (2.6%)

Refusal 0 (0.00%)

Households with completed questionnaires 571 (97.1%)

Households with below 5 years children 378 (66.2%)

Households with below 6 months children 73 (12.8%)

Households with 15 to 49 women 522 (91.4%)

Under 5 years children 684

Under 6 months children 78

6 to 59 months children 606

15 to 49 women 987

Average household size 8.37

The number of households visited was 3% more than the planned.

Household characteristics Background indicators Man was found a head of the household in 95.8 % of, while woman was found the main household caretaker in 95.1% of households. 88 % of household heads were found married.

Illiteracy was found high among household caretakers who are women in majority. 60.2% of caretakers were found illiterate more in some clusters than others e.g. (Cluster number 12 the illiteracy of household caretakers was 100%), while those of basic education and beyond (secondary education and higher) are only 18.5%. Details are in table 4

Table 4. Background data on household head and household caretaker

Background indicator N % (95% CI) The gender of household head Man 546 95.8 (93.8 - 97.2) Woman 24 4.2 (2.8 - 6.2)

Background indicator N % (95% CI) The gender of household caretaker Woman 543 95.1 (93 - 96.6) Man 28 4.9 (3.4 - 7.0) Marital status of household head Married 505 88.4 (85.6 - 90.8) Widow 39 6.8 (5.0 - 9.2) Divorced 14 2.5 (1.5 - 4.1) Single 13 2.3 (1.3 - 3.9) Education level of household caretaker Illiterate 344 60.2 (56.2 - 64.2) Can read and write 122 21.4 (18.2 - 24.9) Basic education 33 5.8 (4.1 - 8.0) Secondary education 58 10.2 (7.9 - 12.9) Higher education (university, college or institute) 14 2.5 (1.5 - 4.1)

Household income situation As seen in table 5, around 85.1% of households in reported no impact on their income sources during the current crisis (since March 2015). Only 13.5% of households reported an impact on their income source. These levels are much lower than that seen in Ibb Governorate April 2017 (86.4%)also less than Shabwa Governorate in January 2017 (around 25%) as well as that reported in Adh Dhale’ Governorate in August 2016 (around 65%). There is no information to compare with the neighbour governorates of Al-Mahrah and Hadhramout.

Table 5. Crisis effect on the household income

Indicator N % (95% CI)

The impact on household income There is no impact on the household income 484 85.1 (81.9 - 87.8) There is impact on the household income 77 13.5 (11.0 - 16.6)

The respondent does not know 8 1.4 (0.7 - 2.7)

Median monthly expenditure for household as shown in table 6 is 60,000 Yemeni Riyals which is equal to an amount of USD 123 (as per the YER exchange rate during the month of the survey). Higher expenditure in the survey area was found in households with no coping strategies. The median expenditures in Socotra was found equal to that found in Shabwa (50,000 to 60,000 Yemeni Riyals) in January 2017,(*The average rate of 1 USD in March/April 2017 is YR 350 in parallel market).

Table 6. Median monthly household expenditure in Yemeni Riyals distributed based on type of coping strategies: Median Income median (±SD) Monthly expenditure in YR (n=568) 60,000 (36,414) Monthly expenditure means based on category of coping strategy (in 30 days) No coping strategy (n=447) 60,000 (31,698) Stress coping strategy (n=109) 60,000 (51,948) Crisis coping strategy (n=10 60,000 (32,128) Emergency coping strategy (n=2) 45,000 (21213)

Water, sanitation and hygiene As shown in table 7, household connected piped water is the main drinking water source found slightly higher than half of households especially for those of Hadibo and Qalansia towns. Unprotected wells, unprotected surface water, unprotected rainwater harvesting and unprotected spring is the main drinking water source for almost quarter of the island's households.

Using of improved drinking water sources by households was significantly higher (60.8%) than unimproved (39.2%). However, treatment of water before drinking was found very low (8.4%). Storage of drinking water was found clean in about 3 out of 5 households.

Flush toilet to septic tank type used by over 65.6% of households, however the defecation in open drain is also highly practiced (28.6%). On the other hand, using of flush to sewer system is almost absent. In total, households use improved latrine is higher (69.4%) than Unimproved (30.6%).

The practice of hand washing with water and soap practiced by household caretakers was mentioned as after the toilet by (28.2%), and near to it as before meal by (29.1%).

Table 7. Water, sanitation and hygiene indicators

WASH indicators N % (95% CI) The main household drinking water main source House connected piped water 328 57.4 (53.4 - 61.4) unprotected rainwater harvesting 56 9.8 (7.6 - 12.5) Unprotected spring 47 8.2 (6.3 - 10.8) Water tanker 38 6.7 (4.9 - 9.0) Public tap/ Community point/ Sabeel 35 6.1 (4.4 - 8.4) Unprotected surface water (Wadi,, etc.) and unprotected 34 6.0 (4.3 - 8.2) wells Protected rainwater harvesting and Protected well 18 3.15 (2.0 - 5.0) Other 15 2.6 (1.6 - 4.3) Category of the main household drinking water main source Improved 347 60.8 (56.7 - 64.7) Unimproved 224 39.2 (35.3 - 43.3) Treatment of water before drinking (n=570) 48 8.4 (6.4 - 11.0) Clean drinking water storage (n=571) 330 57.8 (53.7 - 61.8) The main facility for defecation Flush to septic tank 373 65.6 (61.6 - 69.3) Defecation in open (in fields, etc.) 163 28.6 (25.1 - 32.5) Pit latrine with slab 17 3.0 (1.9 - 4.7) Flush to open drain 8 1.4 (0.7 - 2.7) Flush to DK where 3 0.5 (0.2 - 1.5) Flush to pit latrine 3 0.5 (0.2 - 1.5) Flush to piped sewer system 1 0.2 (0.0 - 1.0) Ventilated improved pit latrine 1 0.2 (0.0 - 1.0) The type of the latrine Improved 395 69.4 (65.5 - 73.1) Unimproved 174 30.6 (26.9 - 34.5) Hand washing practice by household caretaker After the toilet (n=571) 161 28.2 (24.7 - 32.0) Before meal (n=570) 166 29.1 (25.5 - 33.0)

Household food security Food consumption scoring (FCS) was calculated based on the food consumption of 8 groups during the last 7 days and classified using the WFP (Yemen) classification. As shown in table 8 below, 57.6% were classified acceptable to food consumption. Food insecurity (borderline and poor) was found in 42.4% of households, half of them are severely food insecure.

Table 8: Food consumption classification

Food consumption classification N % (95% CI)

Household food consumption (WFP Yemen classification) Acceptable 326 57.6 (53.5 - 61.6) Borderline 123 21.7 (18.5 - 25.3) Poor 117 20.7 (17.5 - 24.2)

Coping strategies were measured using the full coping strategy index (CSI). The mean scores in the Governorate were found as 0.282. The average CSI for those have not practiced coping strategies during the last 30 days was 0.114, while among those reported practicing stress coping strategies with mean CSI of 0.928 as seen in table 9.

Table 9. Means of CSI

Coping Strategy Index (CSI) Mean (±SD)

Coping strategy index (CSI) in 7 days (n=567) 0.282 (2.07) CSI means based on category of coping strategy (in 30 days) No coping strategy (n=446) 0.114 (1.07) Stress coping strategy (n=111) 0.928 (4.07) Crisis coping strategy (n=8) 0.750 (2.12) Emergency coping strategy (n=2) 0.000 (0.00) CSI means based on food consumption (WFP Yemen classification) Acceptable (n=324) 0.275 (2.31) borderline (n=123) 0.350 (1.90) Poor (n=116) 0.241 (1.51)

Child Nutrition

Acute malnutrition by WHZ Figure 2. The survey children WHZ scores The survey showed a prevalence of global distribution vs the reference population acute malnutrition (GAM) - as defined by WHZ in Socotra Governorate. - of 9.6 %. Boys show higher GAM rates than girls, but the difference is not statistically significant. Severe acute malnutrition (SAM) prevalence has been found as 1.0% (tables 10). No single oedema case was reported. Graphs in figure 2 shows shift to the left of the survey population when compared to the reference population, which is implying a presence of malnutrition above the reference one. This GAM level is classified as ‘poor’ as per the WHO categorization of wasting severity. There is no previous SMART Nutrition Survey conducted in Socotra, therefore, levels of GAM and SAM found by this survey cannot be compared by previous ones obtained by similar assessment methodology. The CFSS conducted in April 2014 includes anthropometrical measurements that shows GAM and SAM levels of 12.1% and 3.0% respectively. Table 10. Prevalence of acute malnutrition based on weight-for-height z-scores in children aged 6 to 59 months (and/or oedema) and by sex in Socotra Governorate All Boys Girls

n = 581 n = 308 n = 273

(33) 10.7 % Prevalence of global (56) 9.6 % (23) 8.4 % (7.7 - 14.6 95% malnutrition (6.9 - 13.4 95% C.I.) (4.9 - 14.1 95% C.I.) C.I.)

(29) 9.4 % Prevalence of moderate (50) 8.6 % (21) 7.7 % (6.6 - 13.3 95% malnutrition (6.0 - 12.1 95% C.I.) (4.6 - 12.7 95% C.I.) C.I.)

Prevalence of severe (6) 1.0 % (4) 1.3 % (2) 0.7 % malnutrition (0.4 - 2.5 95% C.I.) (0.5 - 3.3 95% C.I.) (0.2 - 3.0 95% C.I.)

The prevalence of oedema is 0.0 %

Table 11. Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema in in Socotra Governorate Severe Moderate Wasting Age (mo.) Total no. wasting wasting No. % No. % No. %

6-23 210 2 1.0 14 6.7 16 7.6

24-59 371 4 1.1 36 9.7 40 10.8

Total 581 6 1.0 50 8.6 56 9.6

X2=0.000*, X2=1.540, df=1, Statistical test df=1, P=1.000 P=0.215

* Corrected (Yates) Tables 11 show that GAM (by WHZ-score criteria) in the survey zones is higher in older children (24– 59 months) than in younger group aged 6 to 24 months. The difference was not statistically significant. GAM level in Socotra is found lower than those found by previous surveys in coastal zones of Lahj, Abyan and Aden Governorates Acute malnutrition by MUAC Acute malnutrition defined by MUAC is shown in table12. The prevalence of MUAC below 12.5 cm (GAM by MUAC) was 3.9% while prevalence of MUAC below 11.5 cm (SAM by MUAC) was found as 0.3%.. GAM by MUAC was found higher in girls than in boys, but the difference is not statistically significant. Tables 13 show that GAM prevalence by MUAC were higher in young children (6 – 23 months) (8.3%) than in older children aged 24 to 59 months (1.3%). The difference is significance.

Table 12. Prevalence of acute malnutrition based on MUAC cut off's in children aged 6 to 59 months (and/or oedema) and by sex in in Socotra Governorate

All Boys Girls

n = 597 n = 318 n = 279

Prevalence of global (23) 3.9 % (8) 2.5 % (15) 5.4 % malnutrition (2.0 - 7.2 95% C.I.) (1.1 - 5.6 95% C.I.) (2.7 - 10.5 95% C.I.)

Prevalence of moderate (21) 3.5 % (7) 2.2 % (14) 5.0 % malnutrition (1.9 - 6.4 95% C.I.) (1.0 - 4.9 95% C.I.) (2.5 - 9.8 95% C.I.)

Prevalence of severe (2) 0.3 % (1) 0.3 % (1) 0.4 % malnutrition (0.0 - 2.4 95% C.I.) (0.0 - 2.2 95% C.I.) (0.0 - 2.6 95% C.I.)

The prevalence of oedema is 0.0 % Table 13. Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema in Socotra Governorate Moderate Severe wasting Wasting Age Total wasting (mo) no. No. % No. % No. %

6-23 216 2 0.9 16 7.4 18 8.3

24-59 381 0 0.0 5 1.3 5 1.3

Total 597 2 0.3 21 3.5 23 6.3

X2=1.310*, df=1, Statistical test X2=18.345, df=1, P=0.000 P=0.252

* Corrected (Yates)

Underweight Figure 3. The survey children WAZ scores The survey has shown an underweight distribution vs the reference population in the Socotra governorate. prevalence of 33.6%, while severe underweight was found as 8.7% (Tables 14). Equal underweight levels were found in boys and girls (33.7% and 33.5% respectively). Severe underweight levels were found higher in boys than in girls, however, differences are statistically insignificant. With these levels of underweight that exceed 30%, Socotra is classified as a governorate with ‘critical prevalence’ underweight according to the WHO categorization of the public health significance of underweight. These levels of underweight and severe underweight in Socotra Governorate are found similar to those found by CFSS 2014 (32.4% for underweight and 8.8% for severe underweight). Table 14. Prevalence of underweight based on weight-for-age z-scores by sex in children aged 0 to 59 months in Socotra Governorate All Boys Girls

n = 663 n = 347 n = 316

(106) 33.5 % Prevalence of (223) 33.6 % (117) 33.7 % (28.1 - 39.4 95% underweight (29.3 - 38.3 95% C.I.) (28.0 - 39.9 95% C.I.) C.I.)

(81) 25.6 % Prevalence of (165) 24.9 % (84) 24.2 % moderate (20.5 - 31.5 95% (21.2 - 28.9 95% C.I.) (19.4 - 29.7 95% C.I.) underweight C.I.)

Prevalence of severe (58) 8.7 % (33) 9.5 % (25) 7.9 % underweight (6.4 - 11.8 95% C.I.) (7.0 - 12.9 95% C.I.) (5.2 - 11.9 95% C.I.)

In the survey, table 15 shows that underweight is higher in children aged 24 to 59 months (43.3%) than in children aged 6 to 23 months (22%) which in turn higher than that in children aged 0-5 months (17.1%). Severe underweight was found higher in children aged 24 months and above than smaller children. Either of underweight or severe underweight, levels in children aged 24 months and above are significantly higher than smaller group..

Table 15. Prevalence of underweight by age, based on weight-for-age z-scores in Socotra Governorate Severe Moderate Underweight Age (mo.) Total no. underweight underweight No. % No. % No. %

0-5 70 4 5.7 8 11.4 12 17.1

6-23 214 12 5.6 35 16.4 47 22.0

24-59 379 42 11.1 122 32.2 164 43.3

Total 663 58 8.8 165 24.9 223 33.6

X2=6.037, df=2, X2=37.359, Statistical test P=0.048 df=2, P=0.000

Stunting Figure 4. The survey children HAZ scores The stunting was found prevalent in half of distribution vs the reference population in Governorate children with 49.5%, while severe Socotra Governorate. stunting were found in 14.7%of survey children aged 6 – 59 months (Tables 16). Boyes show approximately equal levels as girls (49% and 50% respectively). With these levels of stunting that exceed 40%, Socotra is classified as a governorate with ‘critical high prevalence’ stunting according to the WHO categorization of public health significance of stunting. Stunting levels shown by this survey is higher than that shown by CFSS 2014 (40%) but has shown almost similar severe stunting as that of the CFSS 2014 (14.3%).

Table 16. Prevalence of stunting based on height-for-age z-scores and by sex in children aged 6 to 59 months in Socotra Governorate

All Boys Girls

n = 584 n = 312 n = 272

Prevalence of (289) 49.5 % (153) 49.0 % (136) 50.0 % stunting (44.2 - 54.8 95% C.I.) (42.8 - 55.3 95% C.I.) (43.5 - 56.5 95% C.I.)

Prevalence of (203) 34.8 % (104) 33.3 % (99) 36.4 % moderate stunting (30.3 - 39.5 95% C.I.) (28.2 - 38.9 95% C.I.) (29.9 - 43.4 95% C.I.)

Prevalence of (86) 14.7 % (49) 15.7 % (37) 13.6 % severe stunting (11.3 - 18.9 95% C.I.) (11.6 - 21.0 95% C.I.) (9.8 - 18.5 95% C.I.)

Tables 17 show higher stunting and severe stunting levels in children aged 24 to 59 months (53.7% and 17% respectively) than in children aged 6 to 23 months (41.8% and 10.6% respectively). Difference are significant.

Table 17. Prevalence of stunting by age based on height-for-age z-scores in Socotra Governorate Severe Moderate Stunting Age (mo.) Total no. stunting stunting No. % No. % No. %

6-23 208 22 10.6 65 31.3 87 41.8

24-59 376 64 17.0 138 36.7 202 53.7

Total 584 86 14.7 203 34.8 289 49.5

X2=4.429, X2=7.582, df=1, Statistical test df=1, P=0.035 P=0.006

Mean z scores, design effects and flags Table 18 shows mean z scores of different anthropometry indices with SDs of above 1 except for WFH that below 1. In general, no SDs is below 0.85 or above 1.2.Design effect was higher than 1.5 for WFH and HFA while it is 1.5 for WFA.

Table 18. Mean z-scores, Design Effects and excluded subjects z-scores z-scores Mean z- Design Effect Indicator n not out of scores ± SD (z-score < -2) available* range Children aged 6 to 59 months Weight-for- 581 -0.86±0.92 1.69 8 16 Height Height-for-Age 584 -1.97±1.03 1.62 7 14 Children aged 0 to 59 months Weight-for-Age 663 -1.60±1.00 1.50 8 11

* contains for WHZ and WAZ the children with oedema.

IYCF practices Among all children aged 0 to 23 months, 73.2% who have been breastfed either exclusively or partially in the previous day to the survey. Exclusive breastfeeding level in Socotra survey is very close to the national average (10.3% as per DHS 2013) as shown in the table 19. Continuation of breast of breastfeeding at one year is slightly above 70%, but that level is reduced to the half for children continue the breastfeeding at two years. Young child feeding practices have also been found as inappropriate. Although half of children both breastfed and non-breastfed aged 6 to 23 months were found to receive the age appropriate number of meals, only 19.4% of children at this age group are receiving the accepted diversified diets (composed of 4 food groups or more). Levels of minimum acceptable diet are too low as 9.6%. Table 19. IYCF indicators Socotra governorate Indicator N % (95% CI)

Breastfed yesterday (n=269) 197 73.2 (67.5 - 78.4)

Exclusive breastfeeding (n=61) 7 11.5 (4.7 - 22.2)

Continued breastfeeding at 1 year (n=34) 24 70.6 (52.5 - 84.9)

Continued breastfeeding at 2 years (n=54) 20 37.0 (24.3 - 51.3)

Minimum dietary diversity (n=206) 40 19.4 (14.2 - 25.5)

Indicator N % (95% CI)

Minimum meal frequency (n=165) 84 50.9 (43.0 - 58.8)

Minimum acceptable diet (n=146) 14 9.6 (5.3 - 15.6)

Child morbidity Table 20 shows the prevalence of diarrhoea, ARI and fever within two weeks preceding the survey. Diarrhoea level was found as 12.2% which is too lower when compare with the levels that found in Ibb 2017 or Hodeida and Taiz in March and May 2013. ARI levels were found as (25.9%) that means one quarter of the children are affected by ARI. Higher levels of fever were found (25.1%), approximately same result as ARTI. Table 20. Child morbidity within the last two weeks prior to the survey

Indicator N % (95% CI) Diarrhea (n=639) 78 12.2 (9.9 – 15.0) Acute respiratory infection (n=642) 166 25.9 (22.6 - 29.4) Fever (n=642) 161 25.1 (21.9 - 28.6) Vitamin A supplementation and child vaccination The last national polio campaign that included vitamin A supplementation to children aged 6 to 59 months was in November 2017, however the quantity of vitamin A capsules during that campaign was too small which was distributed only to cover limited villages, the coverage of vitamin A supplementation within the last 6 months was found below (31.1%) as shown in table 21 which is lower than Sphere Standards. The routine polio vaccination (dose 3) was found 99.3% while measles vaccination were found 98.5%. Prevalence of above 80% of vaccination answers below were made based on available vaccination cards. Such prevalence is relatively high that is very rare to find in other governorates in the country. Table 21. Vitamin A supplementation and child vaccination

Indicator N % (95% CI) Vitamin A supplementation within the last 6 months 178 31.1 (27.4 – 35.0) (for children aged 96 to 59 months) (n=573) Routine polio vaccination (by card) among children 476 83.5 (80.2 - 86.3) aged 3 months and above (n=570) Routine polio vaccination (by recall) among children 90 15.8 (13.0 – 19.0) aged 3 months and above (n=570) Routine polio vaccination (by card and recall) among 566 99.3 (98.2 - 99.7) children aged 3 months and above (n=570)

Indicator N % (95% CI) Measles vaccination (by card) among children aged 9 440 82.1 (78.6 - 85.1) months and above (n=536) Measles vaccination (by recall) among children aged 9 88 16.4 (13.5 - 19.8) months and above (n=536) Measles vaccination (by card and recall) among 528 98.5 (97.1 - 99.2) children aged 9 months and above (n=536)

Women nutrition Using the Sphere Project definition of acute malnutrition in adults using MUAC, table 22 shows a global acute malnutrition of almost 17% in all women at child bearing age (15 to 49 years). Pregnant mothers are the most affected groups with GAM levels of around 32%..

Table 22. Acute malnutrition among women at child bearing age Global acute Severe acute Indicator malnutrition malnutrition N (%) (95% CI) N (%) (95% CI) Women at child bearing age (15 158 (16.9) (14.6 - 19.4) 12 (1.3) (0.7 - 2.2) – 49 years) Lactating mothers 39 (18.8) (13.8 - 24.8) 2 (1.0) (0.1 - 3.5) Pregnant women 34 (31.8) (23.1 - 41.5) 0 (0.0) (0.0 - 3.4) Neither lactating nor pregnant 82 (13.7) (11.2 - 16.7) 10 (1.7) (0.9 - 3.1)

Mortality Using a recall period of 118 days, the crude death rates found are (0.12%) (95% CI 0.06 – 0.24) per 10,000 per day. Under-five death rates were found as 0.24 (95% CI 0.06 – 0.98) per 10,000 per day. Details are in table 23. Table 23. Death rates in the Socotra Governorate 118 day prior to the survey Death Rate (95% Design Effect CI) Overall (CDR) 0.12 (0.06-0.24) 1

Sex Male 0.17 (0.07-0.39) 1 Female 0.07 (0.02-0.29) 1 Years 0 – 4 yrs. (U5DR) 0.24 (0.06-0.97) 1 5 – 11 yrs. 0.00 (0.00-0.00) 1 12 – 17 yrs. 0.00 (0.00-0.00) 1 18-49 yrs. 0.19 (0.07-0.49) 1 50-64 yrs. 0.00 (0.00-0.00) 1 65-120 yrs. 0.61 (0.08-4.52) 1

Figure 7. Population pyramids in Socotra Governorate

Further demographic information obtained by the demographic sheet used in the survey mainly to assess death rates are shown in the table xxx. Table xx. Demographic information obtained for a recall period of 118 dats (From 4/12/2017 to 4/4/2018)

Total number of HHs 572

Total number of HHs with children under 389 five Average household size 8.4 Mid Interval Population Size 4808.5 Number of Clusters 42 Percentage of children under five 15.7 Birth Rate 0.14 In-migration Rate (Joined) 8.20 Out-migration Rate (Left) 6.33 Associations of the nutritional status Acute malnutrition In Socotra governorate, acute malnutrition (when defined using WHZ) was found associated with existence of diarrhoea (P<0.01). Acute malnutrition (by WHZ), among children who suffering fever 2 weaks prior to the survey (P<0.05) as shown in table 24. The acute malnutrition (as defined by MUAC cut offs) was found associated with diarrhoea among children two weeks prior to the survey (P<0.01), and acute malnutrition in association to drinking source water is (p<0.01) as shown in table 25. The Socotra governorate, acute malnutrition (by using either WHZ or MUAC) was found associated with diarrhoea (p<0.001), ARI (p<0.05) and fever found (p<0.05) ) as shown in table 26.

Table 24. Associations of acute malnutrition (by WHZ) Acute malnutrition Indicator (by WHZ) Statistical test

N % Diarrhea (n=560)

Yes (n=69) 14 20.3 X2=9.258, df=1, P=0.002

No (n=491) 42 8.6

Fever (n=563)

Yes (n=149) 22 14.8 X2=5.252, df=1, P=0.022

No (n=414) 34 8.2

Table 25. Associations of acute malnutrition (by MUAC)

Acute malnutrition Indicator (by MUAC) Statistical test N %

Diarrhea (n=575) X2=9.992*, df=1, Yes (n=71) 8 11.3 P=0.002 No (n=504) 14 2.8 Drinking water source type (n=597) X2=8.346, df=1, P=0.004 Improved (n=331) 6 1.8 Unimproved (n=266) 17 6.4 * Yates' chi-square Table 26. Associations of acute malnutrition (by either WHZ or MUAC) Acute malnutrition Indicator (by MUAC) Statistical test N % Diarrhoea (n=576) X2=14.831, df=1, Yes (n=71) 18 25.4 P=0.000 No (n=505) 49 9.7 ARI (n=579) Yes (n=151) 25 16.6 X2=4.960, df=1, P=0.026 No (n=428) 42 9.8 Fever (n=579) Yes (n=152) 25 16.5 X2=4.788, df=1, P=0.029 No (n=427) 42 9.8

Underweight In Socotra governorate, underweight was significantly associated with WASH and food consumption. Higher levels of underweight were found in children from households those use unimproved drinking water sources (P<0.05) and those use the unimproved Type of sanitation (P<0.05). Underweight was also found higher in children where household poor Food consumption category (P<0.05) as presented in tables 27. Table 27. Associations of underweight

Underweight Indicator Statistical test N % Drinking water source type X2=6.562, df=1, P=0.011 (n=663)

Underweight Indicator Statistical test N % Improved (n=373) 110 29.5 Unimproved (n=290) 113 39.0 Type of sanitation (n=663) Improved (n=460) 142 30.9 X2=5.779, df=1, P=0.017 Unimproved (n=200) 81 40.5 Food consumption category (n=663) Acceptable (n=380) 110 29.0 X2=8.451, df=2, P=0.015 borderline (n=151) 57 37.8 Poor (n=125) 52 41.6

Stunting In Socotra governorate, stunting was associated with WASH. Lower stunting levels is associated with using of improved drinking water sources and higher with using of unimproved drinking water (P<0.05), Details are shown in tables 28. Table 28. Associations of stunting

Stunting Indicator Statistical test N % Drinking water source type (n=584) X2=3.885, df=1, Improved (n=325) 149 45.9 P=0.049 Unimproved (n=259) 140 54.1

As a summary of all associations explained above, table 29 presents all determinants and background factors related to household, household caretaker and child and the type of association (if existed) either negative or positive. Table 29. Summary of associations of different malnutrition forms with different determinants included in the survey GAM (by GAM (by GAM (by Determinants WHZ or Underweight Stunting WHZ) MUAC) MUAC) Diarrhea + + + ○ ○ ARI ○ ○ + ○ ○ Fever + ○ + ○ ○

GAM (by GAM (by GAM (by Determinants WHZ or Underweight Stunting WHZ) MUAC) MUAC) Using improved drinking water ○ ○ ○ - ○ source type Using improved - ○ ○ - - latrine type Food insecurity ○ ○ ○ - ○ (using FCS)

Child nutrition in related to mother nutrition No significant association was found between mother acute malnutrition status and any type of malnutrition in children

التوصيات Recommendations

Global, moderate and severe acute malnutrition prevalence used for caseload calculation For CMAM programme planning purposes, the child is considered acutely malnourished in case at least one of the three criteria is existed, the first one is the WHZ below -2, the second is the existence of oedema, and the third is the child mid-upper arm circumference (MUAC) is below 125 mm. Similarly for severely acute malnutrition (SAM), the child is considered SAM if his WHZ is below -3, and/or the oedema is existed, and the third is the child MUAC is below 115 mm. Such analysis is crucial for calculation of caseload and for programme planning purposes. Table 32 shows combined acute malnutrition figures at the zone level as well the weighted ones for the governorate level. Table 32. Combined acute malnutrition (based on WHZ and MUAC) for CMAM Planning purposes 95% Conf N % Limits Lower Upper Socotra (n = 682) Moderate 61 8.9% 7.0% 11.3%

95% Conf N % Limits Lower Upper Severe 7 1.0% 0.5% 2.1% Moderate and Severe 68 10.0% 7.9% 12.5%

المراجع References

Annexes Annex 1: Socotra March-April 2017 Nutrition Survey Questionnaire

Annex 2: Socotra March-April 2018 Nutrition Survey Team Annex 3: Calendar of events

العمر العمر العمر العمر الشهر العمر المقر العمر المقر الشهر المقر المقر الهجر 1434 المقرب 1435 ب 1436 المقرب 1437 1438 ب 1439 الهجر ب ب ي )شهر( )شهر )شهر( )شهر ي )شهر( )شهر( ) ) ذكرى ذكرى ثورة 26 ثورة 14 عاشوراء عاشورا سبتمبر أكتوبر في 10 ء 10 في 6 1 محرم محرم محرم محرم عاشوراء عيد عاشور ذكرى عاشوراء 10 محرم محرم 49.4 الجالء 39.0 اء 10 28.3 17.2 ثورة 5.8 10 محرم االعصار 30 محرم 14 محرم شباال على نوفمبر أكتوبر ذكرى سقطرى في 27 في 13 ثورة 14 والسواحل محرم محرم أكتوبر الشرقية في 24 23 محرم محرم عيد عيد الجالء الجالء 30 صفر 48.5 38.1 27.4 30 16.3 4.8 صفر نوفمبر نوفمبر في في 8 18 صفر صفر المولد النبوي عيد يوم 12 الجالء ربيع أول 30 عيد المولد نوفمبر الجالء المولد النبوي المولد في 1 30 النبوي ربيع يوم النبوي يوم ربيع نوفمبر ربيع 47.7 يوم 12 37.3 26.5 15.4 3.9 12 12 ربيع أول في 12 أول ربيع أول ربيع أول المولد ربيع أول أول أول النبوي مقتل يوم 12 علي ربيع عبدهللا أول صالح يوم 16 ربيع أول ربيع ربيع 2.9 14.4 25.6 36.4 46.8 ثاني ثاني خروج أحداث نهاية جماد جمادي عبدربه يناير 60.0 التقويم 46.0 35.5 24.7 13.5 1.9 ي منصو 2018 أول 15 ر الى في عدن أول

ربيع عدن 3 يوم 12 أول جمادي جمادي أول أول

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ذكرى عيد عيد ثورة 26 األضح األضح سبتمبر عيد ى 10 ى 10 في 2 ذي األضحى ذو ذو الحجة 10 ذو عيد الحجة الحجة عيد الحجة األضح ذو األضحى ذكرى ذو 50.2 ذكرى 39.9 29.2 18.2 ذكرى 6.8 ى 10 10 ذو ثورة الحجة ثورة ثورة 26 الحجة الحجة 26 ذو 14 سبتمبر في ذكرى سبتمبر الحجة أكتوبر 24 ذي ثورة 14 في 13 في 10 الحجة أكتوبر ذي ذو في 20 الحجة الحجة ذو الحجة

العمر العمر العمر العمر الشهر العمر المقر العمر المقر الشهر المقر المقر الميالد 2013 المقرب 2014 ب 2015 المقرب 2016 2017 ب 2018 الميالد ب ب ي )شهر( )شهر )شهر( )شهر ي )شهر( )شهر( ) ) أحداث المولد المولد يناير النبوي النبوي 2018

يوم 13 يوم 2 في عدن موسم موسم يناير 62 50 يناير 38 يناير 26 14 2 يوم 28 يناير تلقيح تلقيح موسم موسم يناير النخيل النخيل تلقيح تلقيح موسم النخيل النخيل تلقيح النخيل خروج عبدربه منصو فبراير 61 49 37 ر الى 25 13 1 فبراير عدن 21 فبراير

16مار بداية س وفاة نهاية قصف محافظ التقويم التحال سقطرى 27 ف 26 بن مارس موسم موسم موسم مارس - 0 حمدون - مارس 60 موسم 48 اصطياد 36 24 اصطياد 12 اصطياد مارس موسم 1 بداية اصطي الشروخ الشروخ الشروخ اصطي المسح اد اد 28 الشرو الشرو مارس خ خ موسم اصطياد الشروخ

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العمر العمر العمر العمر الشهر العمر المقر العمر المقر الشهر المقر المقر الميالد 2013 المقرب 2014 ب 2015 المقرب 2016 2017 ب 2018 الميالد ب ب ي )شهر( )شهر )شهر( )شهر ي )شهر( )شهر( ) ) بداية عيد عيد رمض الفطر الفطر عيد الفطر

ان 8 28 17 6 يوليو موسم يوليو 56 يوليو 44 يوليو 32 يوليو 20 موسم 8 يوليو حصاد موسم موسم موسم حصاد التمور حصاد حصاد حصاد التمور التمور التمور التمور عيد الفطر أغسط أغسط 7 19 31 43 7 55 س أغسط س س

عيد األضح ى 1 سبتمبر دخول عيد بداية الحوثيين األضح السنة عيد ذكرى صنعاء ى 23 الهجرية األضحى ثورة 21 سبتمبر 1439 12 26 سبتمبر ذكرى في 21 سبتمبر سبتمبر ذكرى ثورة سبتمبر ذكرى 20س ثورة 26 ذكرى سبتمبر 54 42 30 18 ثورة 26 6 سبتمبر بتمبر 26 سبتمبر ثورة سبتمبر بدء سبتمبر 20س 26 20سبتمبر موسم 20سبت بتمبر سبتمبر بدء موسم فتوح مبر بدء بدء عاشورا فتوح البحر موسم موسم ء 30 البحر فتوح فتوح سبتمبر البحر البحر 20سبتم بر بدء موسم فتوح البحر

العمر العمر العمر العمر العمر الشهر العمر المقر المقر الشهر المقر المقر المقر الميالد 2013 المقرب 2014 ب 2015 2016 2017 ب 2018 الميالد ب ب ب ي )شهر( )شهر )شهر ي )شهر( )شهر( )شهر( ) )

عيد األضحى ذكرى بداية 4 ذكرى ثورة 14 السنة أكتوبر ثورة أكتوبر الهجرية ذكرى 14 بداية 1438 ثورة ذكرى أكتوبر السنة في 2 14 ثورة عيد الهجرية أكتوبر أكتوبر 14 األضح 1437 عاشوراء أكتوبر 53 41 بداية 29 17 5 أكتوبر أكتوبر ى 14 في 14 11 السنة بدء أكتوبر أكتوبر أكتوبر الهجرية موسم بدء عاشوراء ذكرى 1436 االمطار موسم 23 ثورة 14 في 24 االمطا أكتوبر أكتوبر أكتوبر ر بدء موسم بدء موسم بدء االمطار االمطار موسم االمطار 1نوفمبر اعصار بداية عيد شباال السنة الجالء على الهجر 30 سقطرى ية نوفمبر عاشوراء والسواح 1435 المولد 2 ل في 4 عيد النبوي نوفمبر الشرقية نوفمبر الجالء يوم 30 نوفمبر 52 40 عيد 28 8نوفمبر 16 4 نوفمبر عاشور 30 نوفمبر الجالء اعصار اء 13 نوفمبر 1نوف 30 ميج على نوفمبر مبر نوفمبر سقطرى عيد 2017 5 نوفمبر الجالء مهرجان عيد 30 سقطرى الجالء نوفمبر الثقافي 30 نوفمبر المولد النبوي يوم 11 ديسمبر مقتل 2ديسمبر المولد علي غرق النبوي عبدهللا ديسمبر 51 39 27 15 سفينة 3 ديسمبر يوم 23 صالح على ديسمبر يوم 4 متنها 60 ديسمبر راكب من ابناء سقطرى ووفاتهم

Annex 5: Socotra March-April 2018 Survey Plausibility Check

Annex 6: Socotra Nutrition Survey Standardization Test Report for Evaluation of Teams Supervisor Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.9 110 110 18.3 18.3 15.9 15.9 102.5 102.5 15.9 15.9 14.6 14.6 103.9 103.9 14.5 14.5 16 16 102.1 102.1 16.4 16.4 15.3 15.3 101 101 16.4 16.4 14.5 14.5 99.6 99.6 14.7 14.7 17.5 17.5 108.8 108.8 16.7 16.7 14.1 14.1 98.3 98.3 15 15 16.7 16.7 106.9 106.9 15.7 15.7 16.9 16.9 108.9 108.9 16 16 Enumerator 1 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 19 18.8 108.8 107.4 17.9 17.8 15.8 15.4 99.2 96.7 16.5 16.5 14.6 14.3 103.2 101.4 14.6 15.1 15.8 15.8 101.4 100.6 16.4 17.5 15.3 15.2 79.2 99.2 19.4 16.5 14.3 14.3 99.2 99.3 15.2 14.3 15.2 17.5 107.8 107.3 16.8 16.5 14.1 14 97.8 76.6 5.6 15.1 16.5 17.1 104.9 107.6 15.4 17.4 16.9 17.1 170.8 107.6 16.6 17.4

Enumerator 2 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.5 108.2 108.1 18.2 17.1 15.9 16 101.6 101.2 15.7 15.5 14.3 14.3 102 102 14.2 14.2 15.9 15.9 102 102 16 16 15.3 15.3 98.1 98.1 16.1 16.1 14.3 14.3 90.2 100 14.5 19.5 17.7 17.4 107.2 107.9 16.1 15.4 14.1 14 96.8 97.1 14.5 14.6 16.6 16.6 105.9 106 15 15.5 17 17.1 108 108 15.6 15.4 Enumerator 3 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.9 108.8 109.1 18 17.5 15.8 15.7 101 101.3 16.2 15.6 14.5 14.5 103 103.2 14.7 14.3 15.9 15.7 102.8 101 17.3 16.4 15.2 15.3 97.3 98.4 15.8 16.2 14.3 14.2 100.2 100.2 14.7 14.7 17.5 17.1 107.5 107.5 16 16.4 14.1 14.1 97.4 97.7 14.9 15.6 16.6 16.6 106 106.1 15.5 15 16.9 17.1 108.4 108.3 16 15.8 Enumerator 4 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.8 104.4 108.3 17.7 18.6 15.7 15.8 100.9 101.2 16.4 16.4 14.3 14.5 103.4 103.3 14.6 14.6 15.9 15.8 102 102.7 16.4 16.5 15.3 15.2 100.2 99.1 16.2 16.9 14.4 14.4 99.6 100.2 15.1 15.1 17.4 17.4 107.3 107.4 16.6 16.4 14.2 14.1 97.6 97.3 15.3 15.9 16.6 16.7 106.3 106.5 15.4 15.6 16.9 17 107.9 108.3 16.2 16.4

Enumerator 5 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.6 108.8 108.4 108.2 17.4 17.4 15.7 15.7 99.1 101.3 16.5 15.2 14.3 14.3 103.2 103.3 14.5 14.4 15.8 15.9 101.6 102 16 16 15.4 15.3 99.2 99.2 16 16 14.4 14.3 102 51.2 15 14.5 17.5 17.4 107 108 16.5 16.3 14.2 14 97.4 98 14.6 15 16.6 16.4 110.6 106 15.5 15.2 19.9 17.1 107.1 108.7 16 15.4 Enumerator 6 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.8 108.4 109 18 18 15.7 15.8 100.5 101.3 16 16 14.5 14.4 103 102.7 15 14.6 15.8 15.8 102 102 16 15 15.3 15.2 99 100 16 16.4 14.4 14.3 99.9 100.2 15 14.5 17.4 17.4 106.5 107.3 17 16.5 14.1 15.2 105.4 98.5 18.4 15 16.5 16.5 106 105.5 15.4 15.2 16.9 17.1 108 108 16.7 16 Enumerator 7 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 18.9 18.8 108.2 107.9 18.2 18.4 15.7 15.8 99.3 104.4 16.4 15.5 14.3 14.5 10 102.3 14.5 14.4 15.8 15.7 101.6 101.5 16.5 16.6 15.3 15.3 97.5 99.4 16.2 16.2 14.3 14.4 99.6 99.6 14.5 14.4 17.5 17.4 107.5 107.4 16.9 16.5 14.1 14.1 98.1 94.4 15.6 14.5 16.6 16.6 106.6 106 16 14.7 16.9 17.1 108.4 108 16.5 16.3

Enumerator 8 Weight 1 Weight 2 Height 1 Height 2 MUAC1 Weight 1 19 18.8 109 108.6 18.4 19 15.7 15.7 101.3 101.3 16.1 15.7 14.3 14.4 103.3 103 14.3 14.3 15.7 15.8 101.3 101.6 16 15.7 15.3 15.2 100.1 99 16.2 15.3 14.4 14.3 99.3 100 14.5 14.4 17.5 17.4 106.2 107.3 16.4 17.5 14.2 14 99.1 97.5 14.3 14.2 16.6 19.9 107.2 106.1 15.5 16.6 16.9 17.1 108.3 108.3 16.2 16.9 Enumerator 9 Weight 1 Weight 2 Height 1 Height 2 MUAC1 Weight 1 18.9 18.8 108.4 108.3 17.7 18.9 15.9 15.9 101.7 100.5 16 15.9 14.4 14.3 102.8 102.7 14.5 14.4 15.8 15.8 101.3 101.8 16.3 15.8 15.3 15.2 98.9 98.4 16.3 15.3 14.3 14.2 98.9 99.4 14.7 14.3 17.4 17.4 107.5 107.4 16.4 17.4 14 13.9 97.4 97.2 15 14 16.6 16.5 106.6 105.6 15.3 16.6 16.9 17.1 108.3 108 16 16.9 Enumerator 10 Weight 1 Weight 2 Height 1 Height 2 MUAC1 MUAC2 19 18.9 109.7 107.9 18 18.2 15.7 15.9 101.4 101.6 15.7 16 14.3 14.4 103.2 102.3 14.3 14.6 15.8 15.8 102.2 101.7 16.6 16.5 15.3 15.2 98.8 99 16 14.6 14.3 14.3 100.5 99.7 14.9 16.6 17.4 17.7 107.6 107.3 16.6 14.6 14.1 14 97.1 97.4 14.7 15.6 16.5 16.7 106.3 106.3 15.5 15.6 16.9 17.1 108.4 108.3 16.1 15.8

Annex 7: Clusters for Socotra March-April 2018 Nutrition Survey عـــدد رقـــم اسم العنقود رقم العنقود المنطقة المشرف الــيـــــوم الســكان الفـريق الساحل ديحمض 1225 1 6 ابراهيم الهادي 28/3/2018 الغربي الساحل زعلوتي 686 2 5 جالل 28/3/2018 الغربي الساحل غبه 1015 3 2 هيثم 28/3/2018 الغربي الساحل ارسيموه 210 4 4 محفوظ 28/3/2018 الغربي الساحل قاضب 1561 32 3 كمال 28/3/2018 الغربي الساحل نوجهر 868 33 1 فهد 28/3/2018 الغربي االتجاه دبنه 357 8 6 جالل 29/3/2018 الشرقي تمره وعداهن 217 34 حالة 5 محفوظ 29/3/2018 عرريهن 364 35 حالة 4 كمال 29/3/2018 ابسر 245 38 شاتا 3 هيثم 29/3/2018 روكب 886 40 2 فهد 29/3/2018 حماره وجومهر 210 39 شاتا 1 ابراهيم 29/3/2018 موقهر ومعبهر 161 10 قعرة 3 فهد 30/3/2018 زاحق 1421 16 نوجد 5 كمال 30/3/2018 حلمه 994 17 نوجد 6 محفوظ 30/3/2018 محطه 350 18 نوجد 2 ابراهيم 30/3/2018 ستاروه 1736 19 نوجد 4 هيثم 30/3/2018 دعصرهو)كزه( 280 23 نوجد 1 جالل 30/3/2018 كدحه 294 9 قرب حديبو 3 ابراهيم 31/3/2018 مصاقبهن 5824 5,6,7 حديبو 1,4,5 محفوظ,فهد,هيثم 31/3/2018 قلنسية 3661 41,42 قلنسية 2,6 جالل,كمال 31/3/2018 باقحيف 133 11 قبهتن 4 ابراهيم 1/4/2018 دروحح 168 12 دكشن 1 كمال 1/4/2018 جشرهن وغاديهن 112 13 شوعب 2 محفوظ 1/4/2018 غارانومشرب 133 14 عمدهن 5 فهد 1/4/2018 ودبلسهن شعررهن وقفقافة 84 36 ديكسم 3 جالل 1/4/2018 مصابع 140 37 ديكسم 6 هيثم 1/4/2018 دحمرهو واراروه 161 15 طيدع 4 جالل 2/4/2018 طوقق 210 20 مومي 1 هيثم 2/4/2018 سيهون جبئه قصصهن حلونه 322 21 مومي 5 ابراهيم 2/4/2018 شصهر شبنهو 133 22 مومي 2 كمال 2/4/2018 حي السالم 140 24 جؤه 6 فهد 2/4/2018 برقه وايهيل 224 25 جؤه 3 محفوظ 2/4/2018

حديبوه 26سبتمبر 7238 28,29,30,31 1,2,3,4 هيثم , فهد , كمال , محفوظ 3/4/2018 حديبو 14 اكتوبر 6986 26,27 5,6 جالل, ابراهيم 2/4/2018 كزماعه RC 399 معنفوه RC 903 حامره RC 238 بدهوله RC 2800 حديبوه 14كتوبر RC,26,27 6986