Ye 27 August- 9 September 2015

Nutrition and Mortality Survey in

Lowland and Mountainous Ecological Zones Hajjah Governorate, Yemen Yemen

27 August- 9 September 2015

Ministry of Public Health and Population Hajjah Governorate Health Office United Nations Children’s Fund (UNICEF)

Nutrition and Mortality Survey Report Lowland and Mountainous Ecological Zones Hajjah Governorate, Yemen

Conducted 27 August- 9 September 2015

ACKNOWLEDGEMENTS

The Yemen Ministry of Public Health and Population (MoPHP)/ Hodeidah Governorate Public Health and Population Office, in collaboration with UNICEF Yemen Country Office and UNICEF Hodeidah 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 was provided by Taiz GHO and field supervisors were provided by the central MoPHP and Amran and Dhamar GHOs. Survey enumerators, team leaders and data entry team were provided by GHO of Hajjah. The data analysis and report writing were made by two FMF consultants. UNICEF YCO provided the overall technical assistance especially on sampling, questionnaire and the guideline. The Hodeidah Governorate Public Health and Population over saw the political and logistical arrangements for the survey, ensuring its smooth operation. The Nutrition survey was supported financially by UNICEF under a grant from the UK Department for International Development (DfID); 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. UNICEF and MoPHP also express their sincere appreciation to the entire assessment 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.

List of acronyms

ARI Acute Respiratory Infection

WFP-CFSS World food programme- Comprehensive Food Security Survey

CI Confidence Interval

CMAM Community Management of Acute Malnutrition

CSO Central Statistical Organization

DHS Demographic Health Survey

ENA Emergency Nutrition Assessment

FHS Family Health Survey

GAM Global Acute Malnutrition

HAZ Height for age z-score

HDD Household diet diversity

IPC Integrated food security phase calcification

IYCF Infant and Young Child Feeding

MAM Moderate Acute Malnutrition

MDD Minimum Dietary Diversity

MoPHP Ministry of Public Health and Population

MUAC Mid-Upper Arm Circumference

OTP Out-patient Therapeutic Programme

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring and Assessment of Relief and Transitions

U5 Under-five

UNICEF United Nations Children’s Fund

WAZ Weight for Age z-scores

WHZ Weight for Height z-scores

Table of contents:

Executive summary...... 1 Introduction / background: ...... 4 Assessment objectives:...... 5 Methodology ...... 6 Sampling Design and Sample Size Determination ...... 6 Sampling Procedure...... 8 Survey Population and Data Collection Process ...... 10 Measurement Standardization and Quality Control ...... 11 Data Entry and Analysis ...... 11 Data Entry Verification and Cleaning ...... 12 Results ...... 13 Household Characteristics of Study Population: ...... 13 Morbidity, Immunization Status of the U5 children:...... 16 Infant and young child feeding (IYCF) practices: ...... 17 Nutrition Status ...... 19 Mortality: ...... 23 Discussion and variable association ...... 24 Levels of Malnutrition: ...... 24 Child Feeding, Vitamin A Supplementation and Malnutrition Levels : ...... 26 Morbidity and Malnutrition Levels: ...... 27 Nutrition Status and Food consumption based on household dietary diversity ...... 27 Water and sanitation with Nutrition situation: ...... 28 Recommendations: ...... 28 Annexes ...... 30 Annex 1: Hajjah Governorate Nutrition Survey Questionnaire, 27 Aug- 9 September 2015 ...... 31 Annex 2: Hajjah Governorate Mortality Survey Questionnaire, 27 Aug- 9 September 2015 ...... 40 Annex 3: Hajjah Governorate Nutrition Survey Team, 27 Aug-9 September 2015 ...... 41 Annex 4: job descriptions for Survey Teams (Extracted from SMART Training Materials) ...... 43 Annex 5: Hajjah Lowland assessment Quality Checks ...... 46 Annex 6: Hajjah Mountainous assessment Quality Checks ...... 47 Annex 7: Tables of Weighted Finding of Nutritional Status ...... 48

Executive summary

Between 27 August and 9 September 2015, MoPHP and UNICEF conducted two nutrition surveys using the Standardized Monitoring and Assessment for Relief and Transition (SMART) methodology covering the two main ecological zones, Mountainous and Lowland of Hajja Governorate in Yemen to establish and monitor the levels of acute malnutrition, stunting and underweight among children aged 6-59 months in the different livelihood/ ecological zones, identify some of the factors associated with malnutrition, and inform on the appropriate responses.

Using a two-stage Probability Proportionate to Population Size (PPS) sampling methodology, 30 clusters in Lowland and 30 clusters in Mountainous ecological zones were randomly selected for both anthropometric and mortality assessments. A minimum of 15 households per cluster in the Lowland and Mountainous Ecological Zones were randomly selected and assessed. A total of 502 households in Lowland and 497 in Mountains were surveyed, covering a total of 580 and 630 children aged 6-59 months respectively.

Results indicate that the nutrition situation differs in the two zones as shown in table (1) below. The Global Acute Malnutrition (GAM) rate was 20.9 per cent (95% CI: 16.8 – 25.8), with Severe Acute Malnutrition (SAM) 3.8 per cent (95% CI: 2.1 – 6.9) in Lowland Ecological Zone. GAM and SAM rates in the Mountainous Ecological Zone were 9.9 per cent (95% CI: 7.4 – 13.2) and 0.8 per cent (95% CI: 0.3 – 2.2), respectively. These rates indicate that the nutrition situation in the Mountainous zone is poor (<10 per cent), while in the Lowland it is critical (>15 per cent), according to WHO categorization.

Stunting rates in the Lowland Zone and Mountainous Zone are 53.0 per cent (95% CI: 46.4 – 59.4) and 58.1 per cent (95% CI: 52.4 – 63.6) respectively with severe stunting of 17.2 per cent (95% CI: 12.5 – 23.2) and 22.9 per cent (95% CI: 18.3 – 28.2) respectively. These rates are exceed the critical levels of 40 per cent; thus the stunting rates are of great concern.

Underweight rate in the Lowlands Zone is 50.1 per cent (95% CI: 45.2 - 55.0), with severe underweight of 13.2 per cent (95% CI: 10.2 - 16.9) while the underweight and severe underweight rates in the Mountainous Zone are 41.5 per cent (95% CI: 35.9 - 47.4) and 11.1 per cent (95% CI: 8.3 - 14.8), respectively. These rates are above the critical levels of 30 per cent, as per WHO categorization.

The two main sources of drinking water in the Lowland Zone were protected open wells (29.9 per cent) and unprotected open wells (24.3 per cent) while in the Mountainous Zone they were unprotected surface water (24.9 per cent) and water tanker (19.9 per cent).

High prevalence of diarrhoea, Acute Respiratory Infection (ARI) and fever as reported 2 weeks before the survey (table 1 ) below . Vitamin A coverage was lower than the Sphere Standards recommendation of 95 per cent coverage (Lowland Zone – 68.2 per cent; Mountains – 75.1 per cent).

Exclusive breastfeeding under 6 months was 34.2 per cent in Lowland zone and 28.8 per cent in Mountainous zone. Continued breast feeding at one year in Lowland zone was 79.1 percent and dropped at two years to level of 45 per cent while in Mountainous zone, continued breast feeding at one year was 87.9 per cent and become 60 per cent at two years . Around 17 per cent of 6-23 children in Lowland zone are on proper diet diversity while that was 13.3 percent in Mountainous zone.

There are statistically significant relationships between malnutrition and child feeding practices, diarrhoea and fever, the cleanliness of drinking water storage, and human waste disposal practices (type of latrines in use). This implies that these factors may be contributing to the poor nutrition situation in Hajja, hence the need to address them in the intervention package.

Specific recommendations include:

Immediate Interventions:

- Strengthen and expanding CMAM services to reach all the existed health facilities and outreach services, especially in the low lands. - to promote appropriate IYCF practices (exclusive and sustained breastfeeding for 2 years and promotion of appropriate complementary feeding practices for children aged 6 to 24 months) along with micronutrient supplementations. - Accelerate the integration of IYCF counseling into all CMAM services delivered by both fixed and mobile clinics. - Intensive social mobilisation campaigns on improving maternal nutrition, IYCF feeding and caring practices through behavior change / communication interventions mainly in the following areas; exclusive breast-feeding for first six months of life, timely introduction of complementary food and continue breastfeeding up to two years, along with Vitamin A supplementation, micronutrient supplements to mothers and their children, and dietary diversity, appropriate child care, and promotion of safe sanitation and hygienic practices, diarrhoea prevention measures and appropriate management of ARI among young children

Medium Term Interventions:

 Scaling up implementation of the national nutrition strategy and related action to address the high level of malnutrition in line with the lifecycle approach along with promotion of maternal nutrition.  Continued support for longer term water development and sanitation programmes throughout the Governorate, with community mobilization activities to promote safe sanitation and hygienic practices.  Enhance the livelihood patterns through introduction of projects that promote the household income such as food voucher and income generation projects that suit their situation.  In depth investigation to find out why, there is high prevalence of wasting among the lowland children compared with their counter part in high land 20.9% to 9.9% as mentioned above.

Table 1: Summary of Nutrition Survey in Hajjah Governorate, 2015 Mountains Lowland Indicator N % 95% CI N % 95% CI Child Malnutrition Total number of households assessed for children 502/504 99.6 497/ 501 99.4 Mean household size 7.3 8.2 Total number of children assessed (6-60 months) 640/ 640 100% 704/ 704 100% Number of children less than 6 months 60/ 640 9.3 74/ 704 10.5 Child sex of U5 children Males (boys) 322 50.3 334 47.4 Females (girls) 318 49.7 370 52.6 Global acute malnutrition (WHZ<-2 z-score or 120 20.9 16.8 - 25.8 9.9 oedema) 62 7.4 - 13.2

Moderate acute Malnutrition (-2 >z-score >=-3, 98 17.1 13.8 - 20.9 57 9.1 6.7 - 12.3 no oedema) Severe acute Malnutrition (WHZ<-3 z score or 22 3.8 2.1 - 6.9 5 0.8 0.3 - 2.2 oedema) Oedema 0 0.0 0.0- 0.0 0 0.0 0.0-0.0 Chronic malnutrition (H/A<-2 z score) 305 53.0 46.4 - 59.4 363 58.1 52.4 - 63.6 Moderate chronic Malnutrition(-2 >z-score >=-3( 206 35.8 31.7 - 40.0 220 35.2 31.3 - 39.3 Severe chronic Malnutrition (H/A<-3 Z score) 99 17.2 12.5 - 23.2 143 22.9 18.3 - 28.2 Underweight prevalence (W/A<-2 Z score) 289 50.1 45.2 - 55.0 261 41.5 35.9 - 47.4 Moderate underweight(-2 >z-score >=-3( 213 36.9 32.3 - 41.8 191 30.4 26.3 - 34.8 Severe underweight (W/A<-3 z score) 76 13.2 10.2 - 16.9 70 11.1 8.3 - 14.8 Child Morbidity Children reported with suspected measles within 35 5.5 3.7 - 7.3 76 10.8 8.5 -13.1 one month prior to assessment Children reported with diarrhoea in 2 weeks 317 49.9 46.0 - 53.8 337 48.1 44.4 - 51.8 prior to assessment Children reported with ARI within 2 weeks prior 197 30.9 27.3 - 34.5 271 38.8 35.2 - 42.4 to assessment Children reported with fever in 2 weeks prior to 35 5.5 3.7 - 7.3 76 10.8 8.5 -13.1 assessment Immunization and Supplementation Status Children aged 9 – 59 months immunised against measles 443 82.2 79.0 - 85.4 503 84.1 81.2 - 87.0 Confirmed by vaccination cards 213 39.5 35.4 - 43.6 191 31.9 28.2 - 35.7 Confirmed by recall 230 42.7 38.5 - 46.9 312 52.2 48.2 - 56.2 Children who have received 3 doses of polio vaccine 413 71.6 67.9 - 75.3 467 75.2 71.8 - 78.6 Children reported to have received vitamin A 395 68.2 64.4 - 72.0 465 75.1 71.7 - 78.5 supplementation in last 6 months Child Feeding Exclusive breastfeeding under 6 months 25 34.2 23.4 - 45.1 17 28.8 17.3 - 40.4 Continued breast feeding at one year 34 79.1 66.9 - 91.2 51 87.9 79.6 - 96.3 Continued breast feeding at two years 18 45.0 29.6 - 60.4 33 60.0 47.1 - 73.0 Minimum diversity diet at 6-23 months 31 16.8 11.4 - 22.3 29 13.3 8.8 - 17.8 Mortality 0-5 Death Rate (U5DR) as deaths/10,000/ day 0.0 0.0-0.0 0.0 0.0-0.0 Crude Death Rate (CDR) as deaths/10,000/ day 0.17 0.09- 0.33 0.30 0.17- 0.53

Introduction / background:

The Governorate of Hajjah is located 120 km north west of Sana'a (capital city of Republic of Yemen). With an area of 8,228 square kilometers and divided into 31 districts. Hajjah is bordered by Saudi Arabia and Sa’ada Governorate in the north, Amran Governorate in the east, Mahweet and Hodeida Governorates in the south, and the Red Sea with part of Hodeida coastal area in the west. Abs district is the largest in terms of area, while Wadharah district is the smallest. Hajjah is inhabited with estimated total population of 1,959,000 1 . which represents 7.5% of the country’s population. Hajjah is ranked as the fifth largest Governorate in population size and Abs remains also the most populated district with about 166,477 people. Hajja Governorate is contains of two ecological zones, mountainous chains such as Alsharafain and Hajoor mountainous chain, Kuhlan mountainous chain and Washha mountainous chain that mainly located at the east of the Governorate, and lowland that extend from the foothills of the mountains into the western end of the Governorate. The majority of the population settled in mountainous areas while some of the population residing in the plains and coastal areas. Some of the settled farmers inhabited the sides of valleys where there are good agricultural land and water resources. Hajjah Governorate has diverse agro ecological climate and landscape. Agricultural lands are limited in the eastern part of the Governorate compared to the extensive cultivable land in the west. Agriculture and grazing are the main activities of the people in this Governorate. Whereas Qat is grown in the mountain areas, farmers in the plain lands between the mountains and the Saudi Arabian border in the north (Tihama) concentrate on fruit and vegetable. The location of the Governorate at the red sea to the west allows some part of the population of the coastal district to make income through fishing. Agriculture and livestock are the main two sources of food and income. Since 2009, Hajja was affected by the conflict in the neighbor Governorate, Sa’ada during the 6th war between the government and Houthies group during while thousands of IDPs left their homelands in Sa’ada to stay in many settlements in Hajja and Amran Governorates. In 2012, new conflict raised within some of Hajja districts between tribes living in these districts and Houthies groups which was resulted in new internally displacement to other districts within Hajjah Governorate.

1 Source: CSO, projection 2014. 4

Current situation: Airstrikes since end of March 2015 forced people to leave their villages to safer places within the Governorate causing farms to be abandoned; In addition to existing IDPs of the six internal wars, a large number of newly displaced population are present in the Governorate. The humanitarian conditions and human sufferings continued to worsen in various parts of the Governorate, especially in areas affected by multiple airstrikes and ground conflict and displacement. Shortage and high price of fuel and security constraints and destruction/disruption of the markets and transportation infrastructure is affecting the transportation of food stuffs, other essentials, including agriculture products and livestock. The conflict has a severe impact on household access to food. Livelihood disruptions, price increases and loss of incomes and sources are further straining the already low levels of household resources, and this is greatly reducing access to food for most of households in the Governorate that is battling with poverty, drought and malnutrition, these effects of the conflict will further reduce their resilience and ability to recover2.

Assessment objectives: The overall objective of the survey was to establish the nutrition situation in Hajjah Mountainous and Lowland, determine some of the factors influencing malnutrition. Specific objectives were: 1. To estimate the level of acute malnutrition (wasting), stunting and underweight among children aged 6-59 months in Hajjah Mountainous and Lowland. 2. To identify health and nutrition underlying causes for malnutrition with a particular focus on IYCF practices for initiating corrective actions in Hajjah Mountainous and Lowland. 3. To estimate the prevalence of some common diseases (suspected measles, diarrhoea, fever and ARI) in Hajjah Mountainous and Lowland. 4. To estimate the measles and polio vaccination and vitamin A supplementation coverage among children in Hajjah Mountainous and Lowland. 5. To assess distribution of baby milk gifts in Hajjah Mountainous and Lowland. 6. To assess the level of food consumption based on the Household dietary diversity scoring in Hajjah Mountainous and Lowland. 7. To assess effect of the primary source of income for household head on nutritional status in Hajjah Mountainous and Lowland. 8. To assess situation of income losing during crisis among household heads in Hajjah Mountainous and Lowland. 9. To estimate the crude and under-five mortality rates in Hajjah Mountainous and Lowland.

2 Acute food insecurity analysis of Hajjah. May 2015

Methodology

Sampling Design and Sample Size Determination Hajjah Governorate is composed from 31 districts located in two ecological zones, Mountains that is mainly the eastern part of the Governorate and Lowland in the north and west. The Governorate for the survey purpose has been divided into the two ecological zones. Two cross-sectional cluster survey were conducted between 29th August and 7th September 2015 in the two ecological zones of Hajjah Governorate where each zone was considered as independent survey stratum. 8 districts were put in the Lowland stratum; they are Bakeel AlMeer, Haradh, Mustaba, Hayran, Midi, Abs, Aslam, and Bani Qais AlTawr. 14 districts were put in the Mountainous stratum; they are Najra, AlMahabesha, Qarah, AlMaghraba, Shares, Aflah AlSham, Kohlan AlSharaf, AlJameema, AlMoftah, AlShahel, Kohlan Afar, Hajjah City, Bani AlA'waam, and Wadhra. The rest 9 districts shared the two strata as the following: - Qufl Shammar District, all ozlas were put in the in Mountainous stratum except the ozla of AlMekhlaf that was put in Lowland stratum. - Mabyan District, all ozlas were put in the in Mountainous stratum except the ozla of AlA’dbea’a that was put in Lowland stratum. - Hajjah District, all ozlas were put in the in Mountainous stratum except the ozla of Khawlan that was put in Lowland stratum. - AlShaghadera District, all ozlas were put in the in Mountainous stratum except the ozla of Qalat Hameed that was put in Lowland stratum. - Kushar District, all ozlas were put in the in Mountainous stratum except the ozla of A’ahem was put in Lowland stratum. - Washha District, ozlas of Bani Rezq, Bani Hani, and Bani Sa’ad were put in Lowland stratum while Dhaein ozla was put in Mountainous stratum. - Aflah AlYaman District, all ozlas were put in the in Lowland stratum except the ozla of Jayah that was put in Mountainous stratum. - Khairan AlMoharraq District, all ozlas were put in the in Lowland stratum except the ozla of Bani Hamla that was put in Mountainous stratum. - Kuaidena District, all ozlas were put in the in Lowland stratum except the ozla of Kuaidena that was put in Mountainous stratum. Hajjah is among Governorates that is heavily affected by the current conflict. The three districts of Bakeel AlMeer, Haradh, and Midi which are located at the south to the Yemen-Saudi boarders were inaccessible so that these district were removed from the sample frame before selection of clusters. Other excluded areas for security reasons are Arshan in Mabyan District, A’ahem, Al-abaisa and Bani E’rgash in Kushar District, and finally Al-Dhahra Al-Sofla, Al-Dawra. Khafesh, AlQasaba, al-Sarba and Al-Shate in AlJameema District. - Because of the military operations at the Yemen-Saudi boarders and the airstrikes, large displacement has taken place mainly from the above mentioned three boarder districts and other affected districts in Sa’ada Governorate. Districts of Washa, Aslam Abs, Hayran, Mustaba, Najra and Khairan AlMoharraq are the highest districts host those IDPs.

Because of this displacement, the selection of clusters was through three stages. In the first stage, the current distribution of population in the all districts for each stratum as prepared by the GHO office after consulting the local authorities has been used to identify the number of clusters per each district in each stratum using the Proportionate to Population Size (PPS) approach. The second stage was to select cluster sites for each district in each stratum independently using the same PPS approach. For each stratum, 30 core clusters and 4 reserve clusters were randomly selected for both anthropometric and mortality assessments. Report and dataset of nutrition survey conducted in Hajjah in 2014 were visited for sifting values of parameters that have been used for calculating of sample size as shown in table (2) below.

Table 2 a. Parameters used in the Sample Size Determination for Hajjah Mountains Anthropometry Mortality Number of clusters 30 Number of clusters 30 Probability 0.05 Probability 0.05 T 2.045 T 2.045 Expected prevalence (p) 9.2 Estimated crude death rate (CDR) per 10000/day 0.23 Relative desired precision (d) 3.5 Relative desired precision (d) per 10000/day 0.2 Design Effect (DEFF) 2 Design Effect (DEFF) 1.5 n (children 6 – 59 months) 570 Recall period in days (RP) 150 Average household size 8.2 n (population) 2405 % of U5 in population 18.6 Average household size 8.2 Proportion of 6 - 59 months in U5 0.90 % Non response 3 population % Non response 3 n (households) 428 n (households) 302 Households per cluster 15 Households per cluster 11

Table 2 b. Parameters used in the Sample Size Determination for Hajjah Lowland Anthropometry Mortality Number of clusters 30 Number of clusters 30 Probability 0.05 Probability 0.05 T 2.045 T 2.045 Expected prevalence (p) 18.9 Estimated crude death rate (CDR) per 10000/day 0.15 Relative desired precision (d) 3.5 Relative desired precision (d) per 10000/day 0.2 Design Effect (DEFF) 2 Design Effect (DEFF) 1.5 n (children 6 – 59 months) 531 Recall period in days (RP) 150 Average household size 7.1 n (population) 1569 % of U5 in population 19.7 Average household size 7.1 Proportion of 6 - 59 months in U5 0.90 % Non response 3 population % Non response 3 n (households) 433 n (households) 228 Households per cluster 15 Households per cluster 8

Calculation of sample size was using ENA for SMART ENA software The number of households decided per both household questionnaire including anthropometry and for mortality in both strata is 15 which is the number that is calculated for anthropometry as shown in the table (2) above. Sampling Procedure As mentioned above, there was a large displacement in the Governorate due to the armed conflict, so that, the first stage was the identification of cluster numbers per district in each stratum based on the most accepted population distribution. PPS was followed for this process Table (3) below shows the distribution of clusters per districts. In the second stage, cluster sites were selected randomly from each district independently using the same PPS approach. The process is repeated for each district using a different random number and confidence interval.

Table 3 a: Number of clusters in districts of Hajjah Mountains Estimated Number of core Number of District population clusters reverse Najra 62850 1 clusters1 AlMahabesha 70176 1 Qarah 42711 1 AlMaghraba 88214 2 Shares 21908 1 Aflah AlSham 73744 2 Kohlan AlSharaf 61451 1 AlJameema 36994 2 AlMoftah 44864 1 AlShahel 46183 0 2 Kohlan Afar 57484 1 Hajjah City 84101 3 Bani AlA'waam 73425 2 1 Wadhra 17227 0 Qufl Shammar 47908 2 Mabyan 59759 2 Hajjah 27391 1 AlShaghadera 51970 1 Kushar 72077 2 Washha 53632 1 Aflah AlYaman 25832 1 Khairan AlMoharraq 19998 1 Kuaidena 14911 1 Total 1154720 30 4

Table 3 b: Number of clusters in districts of Hajjah Lowland Estimated Number of Number of District population core clusters reverse clusters Mustaba 72888 2 1 Hayran 43705 1 1 Abs 227168 9 Aslam 91378 2 2 Bani Qais AlTawr 76145 4 Qufl Shammar 20439 1 Mabyan 11837 0 Hajjah 13753 1 AlShaghadera 19865 1 Washha 60985 2 Aflah AlYaman 31095 1 Khairan AlMoharraq 91453 3 Kuaidena 84691 3 Total 845402 30 4

All the core and reserve clusters randomly selected from the sampling frame were accessible and were assessed. Upon reaching the cluster/ villages, the survey teams, with the help of an elder or a zone guide requested their permission to assess the areas. The purpose of the survey was explained and the process of random selection of a representative sample from the cluster was also elaborated. Once granted permission to continue with the survey, the team head started the process of the random selection the sampled households by identification of the borders of the cluster, the centre, and important landmarks. The team head is one who should decide about the appropriate method to randomly select household as per a standard decision tree he has trained on. The first and the best option is look (or do) an updated list of households and then randomly select them from that list either in systematic or simple manner. Segmentation of the large cluster and listing of households in one randomly selected segment before doing the random selection of household from that list is the second appropriate method. The last option in that decision tree which is used in the difficult clusters is the modified EPI random walking method. The Modified EPI methodology involved identifying the centre of the cluster or the segment, where they had to spin a pen to randomly select the direction to take to the edge/periphery of the Figure (2): The modified EPI method used for cluster. The team walked to the edge of the cluster. selection of households From the edge of the cluster, the team had to spin the pen again aiming to randomly get a direction to follow to the other extreme edge of the cluster. In case the pen pointed towards outside of the cluster boarders, the teams were to spin the pen multiple times till the pen pointed to any of the directions towards the cluster. Once a new direction was obtained, the team counted all the households along the randomly selected direction, gave each household a number, and then randomly selected 9

the first household to be interviewed from the numbered households (for example, household number 7 in the households numbered 1 to 10, in the figure (2)). Same direction was followed to select the subsequent household for interview, going for next nearest household on the right side and following the selected direction, until the required minimum number of households and children had been assessed (Ref: Figure (2) indicating the household selection process– Figure adopted from the SMART Methodology Guideline). In case the team assessed all households to the edge of the cluster and did not reach the required number of households, the team would repeat the process again i.e. start from the cluster centre to randomly select another direction, then walk to the edge, then spin the pen again and count the households to the edge of the cluster. Then randomly pick the first household for interview, and then go the next nearest household, to the right hand side, till the required number of households were interviewed. In case of absence of members or children of the randomly selected house during the interview time, an appointment was made by the survey team to return back before leaving the cluster.

Survey Population and Data Collection Process The survey population for the anthropometry is children aged 6 months to less than 60 months, while population for the mortality assessment is everyone living in the household including those joined or lift the household and also those porn or died within the recall period. All ages are rounded down to the nearest year The activities undertaken in the entire survey period are summarised in Table 4, below. As Hajjah Governorate has already a qualified SMART survey field teams participated in SMART and non-SMART surveys in the past, the survey manager has planned for only two days refresher training focusing on anthropometry, filling of questionnaire, and the field procedures before commencing the data collection phase. The data collection was completed in five days by seven teams (Ref: Annex 3: Hajjah Nutrition Survey Team). Quantitative data were collected by means of a household questionnaire for nutrition survey and a mortality survey question, adopted from the SMART Methodology guidelines (Ref: Annex 1: Hajjah Nutrition Survey Questionnaire and Annex 2: Hajjah Mortality Form). Although all under five children were involved in the survey for questions related to morbidity, only children aged 6 to less than 5 years were included in the measurement of height, weight and MUAC and questions related to vaccination and vitamin A supplementation, while children aged 0 to 24 months were included for questions related to IYCF practices. The age estimation was based on birth or immunization card details and/or supported with events calendar and date conversion tables based on the Islamic Calendar. Using agriculture seasons as well as national and local events are among methods used for age estimation. Retrospective mortality data were collected from all randomly selected households, irrespective of presence or absence of children aged 6-59 months. A recall period of 150 days prior to the survey was used.

Table 4: Chronology of Activities in the Hajjah Nutrition Survey

Action Period

Preparation: Contacting local authority, survey team identification, training material preparation 20-26 August 2015

Refresher training of survey teams 26 – 27 August 2015

Data collection and data entry 29 Aug – 7 Sep 2015

Data cleaning and analysis (row table and slides) 9-15 September 2015

Preparing the first report (report of findings) 16-21 September 2015

Receiving comments 22-26 September 2015

Finalizing and circulating the final report 27-29 September 2015

Measurement Standardization and Quality Control The six teams participated in this survey have already been included in a rigorous standardisation tests during the training of surveys done in past years. As mentioned above, for this survey only short refresher training organized but not including a repeating of standardization exercise. Beside training, 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; (vii) continuous reinforcement of good practices. Clear job descriptions were provided to the teams before commencing the data collection to ensure appropriate guidance in delivering the assigned tasks (Annex 4: Survey Team Job Description). Field team head had to review the questionnaire and verify the accuracy of the details before the teams leave a household, thus minimizing possibility of incomplete data (missing variables) and outliers.

Data Entry and Analysis The data in the filled questionnaires and mortality forms were entered to an Excel sheets that were formulated for the purpose of the survey supported with all required self-check formulas as well as converting dates from Hijri to Gregorian. 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. The remaining household variables and child-related variables (feeding practices and morbidity) were analysed using SPSS. Running and tabulation of all variable frequencies was carried out as part of data cleaning. The nutrition 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). The classification used for wasting levels was a follows: W/H < -3 Z-Scores or oedema = Severe acute malnutrition W/H  -3 Z-Scores to < -2 Z-Scores = Moderate acute malnutrition W/H < -2 Z-score or oedema = Global/total acute malnutrition W/H  -2Z-Scores = Normal The classification used for Stunting levels was a follows: H/A < -3 Z-Scores = Severe stunting H/A  -3 Z-Scores to < -2 Z-Scores = Moderate stunting H/A < -2 Z-score = Stunting Prevalence rates H/A  -2Z-Scores = Normal The classification used for Underweight levels was a follows: W/A < -3 Z-Scores = Severe Underweight W/A  -3 Z-Scores to < -2 Z-Scores = Moderate underweight W/A < -2 Z-score = Underweight Prevalence Rates W/A  -2Z-Scores = Normal Frequencies and cross-tabulations were used to give per centages, means and standard deviations in the descriptive analysis and presentation of general household and child characteristics.

Data Entry Verification and Cleaning Four team members shared the work of data entry, and then each member would review the work done by another colleague before merging the data on a daily basis. About 10 per cent of the entered questionnaires were randomly drawn using the Random Number table of ENA software. These drawn questionnaires were revised for accuracy of entry in the electronic database. The quality of data entry was accepted if accuracy was not less than 95 per cent. The uniqueness of IDs of both household questionnaire and mortality sheet was also reviewed for any repeating during data entry. For anthropometry data, all flagged records were also reviewed by means of revisiting original questionnaires.

Results

Household Characteristics of Study Population: As shown in table (5) below, majority of surveyed households were residents (91.2 per cent in Lowlands and 95.6 percent in Mountains ). The gender of household head is largely male for both lowland and Mountainous zones (96 per cent & 97 percent respectively ). The main income source for household’s heads in both zones is causal work that was found in about almost half of households in Lowland Zone and in about one third of households in Mountainous Zone. Own a small scale business and working in farms represents the second main income source for households in Lowland and Mountainous zones respectively, as shown in table (5). During the last 4 months, 41.6 per cent of household’s heads have partially lost their income in Lowlands comparing to 46 percent in Mountainous zone and 36.0 per cent have totally lost their income in Lowlands comparing to 12.2 percent in Mountainous zone. Regarding drinking water, the “ protected open well ” was the main sources for 30 per cent of households in Lowlands and it was “ unprotected surface water” for 25 percent of households in Mountainous zone (figure 3). Among those who are not use bottled water for drinking, only 9.7 per cent do treating drinking water in Lowlands and 15.9 percent in Mountains , mainly by filtering. About 70.7 per cent of the households in Mountains store drinking water in clean containers while in Lowlands only 43.6 percent. As shown in table (5), 48.1 per cent of households in Lowland Zone reported defecation in open in compare to 29.2 per cent in Mountainous Zone, while the main household latrine type for households in Mountainous and Lowland Zones is flush or pour flush latrine ( 39.9 percent and 33.5 percent respectively). The assessment of food consumption level in the two zones has been made using the 12 food groups HDDS and classified using the new IPC criteria3. It was found that around 85 per cent of households in Mountains and 81 per cent in Lowland zone are classified as normal or stressed with HDDS between 5 and 12 in compare to 3 percent and 2.6 percent in the two zones respectively which classified as emergency or catastrophe with HDDS between 0 and 2.

3 Household food consumption indicator study: summary recommendations for the integrated food security phase classification acute reference table for house hold group classification. This summary brief was prepared by L.Glaeser (FANTA) , C. Hillbruner (FEWS NET), A. Mathiessen (WFP Vulnerability Analysis and Mapping [VAM]), and L. Olivera (IPC Global Support Unit [GSU]. 2015 13

Figure (3): Main drinking water source for households in Hajjah Lowlands and Mountainains (%) Water from protected open well 30 28 Water from unprotected open well 26 Water tanker 24 22 Unprotected surface water (Wadi, 20 springs, etc.) 18 House connected piped water 16 Bottled water 14 12 House connected yard piped water 10 8 Water from covered rainwater 6 harvesting tank Water from uncovered rainwater 4 harvesting tank 2 Water from protected spring 0 Mountains Lowlands Other

Table 5 : Household Characteristics Mountainous Lowland N % N % Total Households 497/501 99.0 502/504 99.6 Household size (Mean): 8.2 7.3 Mean No of children Under-fives 1.4 1.3 Mean No of children under 6 months 0.1 0.1 Sex of Household Head: Male 483 97.2 480 95.6 Female 14 2.8 22 4.4 Residence Rural 425 85.5 446 88.8 Urban 72 14.5 56 11.2 HH Resident or IDPs Resident 475 95.6 458 91.2 IDP 22 4.4 44 8.8 Presence of IDPs families in resident HH 17 3.6 20 4.4 Main Source of Income: Casual worker 166 33.4 247 49.2 Farmer working in his farm. 135 27.2 42 8.4 Own a small scale business 36 7.2 88 17.5 Public / mix sector employee 87 17.5 34 6.8 Remittances 0 0.0 39 7.8 In security or military forces 29 5.8 13 2.6 Donations 0 0.0 18 3.6 Own a medium scale business 6 1.2 3 0.6 Large private sector employee 5 1.0 3 0.6 Medium or small private sector employee 5 1.0 2 0.4 Social insurance 6 1.2 2 0.4 Casual worker 22 4.4 11 2.2 Other 166 33.4 247 49.2 During the last 4 months, was the income of head of household affected? Ordinary income has not been lost 206 41.8 112 22.4 Income has partially been lost 227 46.0 208 41.6 Income has totally been lost 60 12.2 180 36.0 Household latrine type Defecation in open ( in fields, etc.) 145 29.2 240 48.1 Flush/pour flush latrine 198 39.9 167 33.5 Open pit latrine 123 24.8 41 8.2 Simple covered pit latrine 27 5.4 49 9.8 Other 3 0.6 2 0.4 Food consumption based on household dietary diversity Normal or stressed 420 84.8 404 80.8 Crisis 60 12.1 83 16.6 Emergency or catastrophe 15 3 13 2.6 Distribution of baby milk gifts 20 4 11 2.2

Morbidity, Immunization Status of the U5 children: High prevalence of common diseases was recorded in both the Lowland and Mountainous ecological zones, as reflected in table 6 , below. During the two weeks prior to the survey, recorded prevalence of diarrhoea among children was 49.9 per cent and 48.1 per cent in the Lowland Zone and Mountainous Zone, respectively. The prevalence of ARI as described by coughing or breathing difficulty and the prevalence of fever two weeks prior to the survey were 30.9 per cent and 56.8 per cent respectively in Lowland Zone and 38.8 per cent and 62 per cent in Mountainous Zone respectively. Suspected measles during the last month was 5.5 per cent in Lowland Zone and 10.8 per cent in Mountainous Zone.

As shown in table (6), the coverage for the third dose of polio vaccination is low with a proportion of 71.6 per cent in Lowland and 75.2 per cent in Mountainous Zone. Eighty two per cent of children aged 9 months to below 60 months vaccinated for measles in Lowland and that was 84 percent in Mountainous Zone . During the previous six months, only around 68.2 per cent and 75.1 per cent of the children had received vitamin A supplement in Lowland and Mountainous Zone respectively . The above immunization coverage and vitamin A supplementation coverage are lower than the Sphere Standards recommended 95 per cent coverage.

Table 6 : Morbidity and Immunization Mountainous Lowland N % N % Morbidity: Proportion of children with diarrhoea within 2 weeks prior to 337 48.1 317 49.9 assessment Proportion of children with ARI within two weeks prior to assessment 271 38.8 197 30.9 Proportion of children with fever within two weeks prior to 435 62.0 362 56.8 assessment Suspected measles within one month prior to assessment 76 10.8 35 5.5 Immunization: Children (9-59 months) immunised against measles Total 503 84.1 443 82.2 Confirmed by vaccination cards 191 31.9 213 39.5 Confirmed by recall 312 52.2 230 42.7 Children who have ever received routine polio 3 vaccine 467 75.2 413 71.6 Supplementation: Children who received vitamin A supplementation in last 6 months 465 75.1 395 68.2

Infant and young child feeding (IYCF) practices:

Exclusive breastfeeding:

The overall prevalence of exclusive breastfeeding among children aged below 6 months in Lowland was 29 per cent and it was that in Mountainous 34.2 percent. Figure (4) below shows prevalence of exclusive breastfeeding among girls and boys in both Lowland and Mountainous zones.

Fig.(4 ): Prevalenc of exlusive breastfeeding by gender in Lowlands and Mountains

40% 35% 30% 39.4% 37.5% Girls 25% 30.3% Boys 20% 15% 15.4% 10% 5% 0% Lowlands Mountains

Continued breast feeding at one year:

The overall prevalence of continued breast feeding at one year was 88 per cent in Lowlands and 79 per cent in Mountains. Figure (5) below shows continued breast feeding at one year among boys and girls in Lowlands and Mountains.

Fig. (5): Prevalenc of continued breastfeeding at one year by gender in Lowlands and Mountains

90%

87.5% 85% 88.5% Girls

80% Boys

81.3% 75% 77.8%

70% Lowlands Mountains

Continued breast feeding at two years:

The overall prevalence of continued breast feeding at two year was 60 per cent in Lowlands and it was 45 per cent in Mountains. Figure (6) below shows continued breast feeding at two years among boys and girls in Lowlands and Mountains.

Fig.(6): Prevalenc of comtinued breastfeeding at two year by gender in Lowlands and Mountains

80% 70% 71.0% 60% Girls 50% Boys 40% 56.3% 30% 45.8% 20% 37.5% 10% 0% Lowlands Mountains

Minimum diversity diet (MMD) in 6 – 23 months children

The minimum dietary diversity score was calculated as the proportion of children 6-23 months of age who received foods from four or more out of the seven food groups4 during the previous day. Only 13.3 per cent and 16.8 per cent of children aged 6-23 months are on proper diversified/ complementary feeding in Lowlands and Mountains respectively . Figure (7) shows good minimum dietary diversity among boys and girls in Lowlands and Mountains.

Fig.(7): Prevalenc of good MDD by gender in Lowlands and Mountains

25%

20% Boys 15% 22.2% Girls 12.6% 10% 13.8% 11.7% 5%

0% Lowlands Mountains

4 The seven food groups used are: (Grain, roots, tubers), (Legumes and nuts), Dairy products (milk, yogurt, cheese), Flesh foods (meat, fish poultry and liver/organ meats), eggs, Vitamin-A rich fruits and vegetables and Other fruits and vegetables.

Characteristics of the children assessed

Table 7: Lowland zone: Age and Sex distribution Boys Girls Total Ratio Generally there were equal numbers of boys and girls assessed in the two AGE (mo) no. % no. % no. % Boy: girl surveys, implying representativeness 6-11 36 45.0 44 55.0 80 13.8 0.8 of the sample collected during the 12-23 61 42.7 82 57.3 143 24.7 0.7 survey, as shown in Tables 7 & 8. 24-35 69 57.5 51 42.5 120 20.7 1.4 The age ratios of 6-29 months to 30-59 36-47 61 49.6 62 50.4 123 21.2 1.0 months are 0.73 & 0.93 in 48-59 61 53.5 53 46.5 114 19.7 1.2 Mountainous and Lowland zones Total 288 49.7 292 50.3 580 100.0 1.0 respectively. However, significant Table 8: Mountainous zone: Age and Sex distribution difference was found in the overall Boys Girls Total Ratio sex/age distribution in the AGE (mo) no. % no. % no. % Boy: girl Mountainous Zone (p<0.05).

6-11 28 50.0 28 50.0 56 8.9 1.0 12-23 64 48.1 69 51.9 133 21.1 0.9

24-35 80 53.0 71 47.0 151 24.0 1.1 36-47 69 43.4 90 56.6 159 25.2 0.8 48-59 60 45.8 71 54.2 131 20.8 0.8 Total 301 47.8 329 52.2 630 100.0 0.9

Nutrition Status Below is a summary of the anthropometry results. Data quality was validated using the Plausibility check tool of ENA for SMART software. The overall scoring of the plausibility check of the surveys data is 1 for Lowland data and 7 for Mountainous data which is categorized as excellent (Ref: Annexes 5 and 6 for the Assessment Quality Check).

Acute Malnutrition Though there is an overall shift to the left of the study population when compared with the reference population, as per the graphs shown (implying presence of malnutrition), there is a clear difference in nutrition vulnerability between the two zones, based on global acute malnutrition rates. The interpretation was made based on the 2006 WHO Growth Standards.

The level of wasting with oedema – also known as global acute malnutrition (GAM) – found in Mountainous Zone is 9.9 per cent, which classifies as “poor‟ as per the WHO categorization of the severity, while in the Lowland Zone, the GAM rate is 20.9 per cent, which is “critical‟ according to the WHO categorization, as shown in Tables 9 & 10 (including the confidence intervals). Sever wasting is 3.8 per cent & 0.8 per cent for Lowland & Mountainous zones. There no single oedema case identified in the two zones.

Table 9: Hajjah Lowland zone: Acute Malnutrition (Wasting) Rate All Boys Girls n = 574 n = 284 n = 290 Prevalence of global malnutrition (120) 20.9% (66) 23.2% (54) 18.6% (<-2 z-score and/or oedema) (95% CI: 16.8 - 25.8) (95% CI: 17.6 - 30.0) (95% CI: 14.2 - 24.0) Prevalence of moderate malnutrition (98) 17.1 % (55) 19.4 % (43) 14.8 % (<-2 z-score and >=-3 z-score (95% CI: 13.8 - 20.9) (95% CI: 14.5 - 25.4) (95% CI: 11.3 - 19.2) Prevalence of severe malnutrition (22) 3.8 (11) 3.9 % (11) 3.8 % (<-3 z-score and/or oedema) (95% CI: 2.1 - 6.9) (95% CI: 1.7 - 8.7) (95% CI: 1.9 - 7.4) The prevalence of oedema is 0.0 per cent

Table 10: Hajjah Mountainous zone: Acute Malnutrition (Wasting) Rate All Boys Girls n = 625 n = 298 n = 327 Prevalence of global malnutrition (62) 9.9 % (33) 11.1 % (29) 8.9 % (<-2 z-score and/or oedema) (95% CI: 7.4 - 13.2) (95% CI: 7.3 - 16.4) (95% CI: 6.2 - 12.5) Prevalence of moderate malnutrition (57) 9.1 % (30) 10.1 % (27) 8.3 % (<-2 z-score and >=-3 z-score (95% CI: 6.7 - 12.3) (95% CI: 6.4 - 15.4) (95% CI: 5.7 - 11.9) Prevalence of severe malnutrition (5) 0.8 % (3) 1.0 % (2) 0.6 % (<-3 z-score and/or oedema) (95% CI: 0.3 - 2.2) (95% CI: 0.3 - 3.1) (95% CI: 0.1 - 2.5) The prevalence of oedema is 0.0 per cent

Chronic Malnutrition Rates:

There is also an overall shift to the left of the study population deviating from the reference population.

Stunting prevalence as shown in table 11 & 12 is 53.0 per cent & 58.1 per cent in Lowland & Mountainous Zone respectively. The prevalence of severe stunting is 17.2 per cent in Lowland Zone and 22.9 per cent in Mountainous Zone. The statistical details of the stunting rates are as shown in the tables 11 & 12 below. These stunting levels exceed the 40 per cent threshold for critical levels according to WHO (2000), hence the situation is of great concern.

Table 11: Hajjah Lowland zone: Chronic Malnutrition (Stunting) Rate All Boys Girls n = 576 n = 285 n = 291 Prevalence of stunting(<-2 z-score ) (305) 53.0 % (148) 51.9 % (157) 54.0 % (95% CI: 46.4 - 59.4) (95% CI: 42.5 - 61.2) (95% CI: 47.4 - 60.4) Prevalence of moderate stunting (206) 35.8 % (95) 33.3 % (111) 38.1 % (<-2 z-score and >=-3 z-score) (95% CI: 31.7 - 40.0) (95% CI: 28.1 - 39.0) (95% CI: 32.5 - 44.1) Prevalence of severe stunting (99) 17.2 % (53) 18.6 % (46) 15.8 % (<-3 z-score) (95% CI: 12.5 – 23.2) (95% CI: 12.6 - 26.7) (95% CI: 11.3 - 21.6)

Table 12: Hajjah Mountainous zone: Chronic Malnutrition (Stunting) Rate All Boys Girls n = 625 n = 299 n = 326 Prevalence of stunting(<-2 z-score ) (363) 58.1 % (187) 62.5 % (176) 54 % (95% CI: 52.4 – 63.6) (95% CI: 55.8 – 68.9) (95% CI: 46.9 – 60.9)

Prevalence of moderate stunting (220) 35.2 % (105) 35.1 % (115) 35.3 % (<-2 z-score and >=-3 z-score) (95% CI: 31.3 - 39.3) (95% CI: 29.6 – 41.1) (95% CI: 30.3 -40.6) Prevalence of severe stunting (143) 22.9 % (82) 27.4 % (61) 18.7 % (<-3 z-score) (95% CI: 18.3 – 28.2) (95% CI: 21.8 – 33.8) (95% CI: 13.9 – 24.7)

Underweight Rates:

Underweight prevalence is shown in tables 13 & 14. The rate is 50.1 per cent in the Lowland Zone and 41.5 per cent in the Mountainous Zone. The prevalence of severe underweight is 13.2per cent and 11.1 per cent in Lowland Zone and Mountainous Zone, respectively. An overall shift of the study population is shown in the graphs, reflecting the overall deviation of the study population from the reference population, implying presence of widespread malnutrition. The statistical details of the underweight prevalence are shown in the tables 13 & 14 below. The above underweight rate is exceed the WHO (2000) critical levels of 30 per cent and above which is classified as ‘Critical’ as per the WHO (2000( categorization.

Table 13: Hajjah Lowland zone: Underweight Rate All Boys Girls n = 577 n = 286 n = 291 Prevalence of stunting (<-2 z-score ) (289) 50.1 % (146) 51.0 % (143) 49.1 % (95% CI: 45.2 - 55.0) (95% CI: 43.4 - 58.7) (95% CI: 45.3 - 53.0) Prevalence of moderate stunting (213) 36.9 % (105) 36.7 % (108) 37.1 % (<-2 z-score and >=-3 z-score) (95% CI: 32.3 - 41.8) (95% CI: 30.4 - 43.6) (95% CI: 32.0 - 42.6) Prevalence of severe stunting (76) 13.2 % (41) 14.3 % (35) 12.0 % (<-3 z-score) (95% CI: 10.2 - 16.9) (95% CI: 10.7 - 19.0) (95% CI: 7.9 - 17.9)

Table 14: Hajjah Mountainous zone: Underweight Rate All Boys Girls n = 629 n = 300 n = 329 Prevalence of stunting(<-2 z-score ) (261) 41.5 % (134) 44.7 % (127) 38.6 % (95% CI: 35.9 - 47.4) (95% CI: 38.0 – 51.5) (95% CI: 32.1 – 45.6) Prevalence of moderate stunting (191) 30.4 % (101) 33.7 % (90) 27.4 % (<-2 z-score and >=-3 z-score) (95% CI: 26.3 – 34.8) (95% CI: 27.8 - 40.1) (95% CI: 22.0 – 33.4) Prevalence of severe stunting (70) 11.1 % (33) 11.0 % (37) 11.2 % (<-3 z-score) (95% CI: 8.3 – 14.8) (95% CI: 7.4 – 16.1) (95% CI: 8.0 – 15.5)

Mortality:

Table 15: Mortality data The crude death rate in Lowland Mountainous Lowland Zone is 0.17 per 10,000 per day, U5 Total U5 Total while it is 0.30 per 10,000 per day in Mountainous Zone. Total HHs surveyed 480 480 478 478 Total Population assessed in HHs 551.5 3860 483 3441 The rate is higher among females Number who joined the HHs 66 550 41 362 than males in Mountainous Zone (0.37 and 0.24 respectively) while Number who left the HHs 65 532 35 287 it is 0.18 & 0.15 for females & Number of births 0 0 0 0 males respectively in Lowland Number of deaths 0 13 0 7 Zone. Mortality rate (per 10,000 per day) The under-five death rate is 0.00 Under-five 0.00 0.00 per 10,000 per day for both strata Crude 0.30 0.17 which can be reported as below 0.1 per 10,000 per day.

Population Pyramid: Information about household members during the previous 135 days was collected. The resulting population pyramid for each zone is shown here.

Discussion and variable association

Levels of Malnutrition: Levels of different types of malnutrition in Hajjah Governorate for both strata are summarized in figures (8a), (8b) below. Fig.(8 a): Prevalence of diffrent types of malnutrition The level of GAM in Lowland among U5 children -Lowland zone of Hajjah-2015 Zone is high statistically 60% 53.0% different from that in 50.1% Mountainous Zone (X2: 28.05 , 50% P < 0. 1, df 1). It was classified as “poor‟ (20.9 per cent) in the 40% 35.8% 36.9% Lowland and as “critical‟ ( 9.2 Severe+Moderate per cent) in Mountainous 30% Moderate Zones. According to WHO 20.9% Severe categorization, GAM rates of 20% 17.1% 17.2% less than 5 per cent are 13.2% acceptable, GAM rates between 10% 3.8% 5 - 9.9 per cent indicate the situation is poor, GAM rates 0% between 10-14.9 per cent are Wasting Stunting Underweight serious, while GAM rates of 15 per cent and above are critical and indicate an emergency Fig.(8 b): Prevalence of diffrent types of malnutrition situation. MAM in Lowland among U5 children -Mountinous zone of Hajjah-2015 Zone (17.1 per cent) is high 58.1% statistically different from that 60% in Mountainous (9.1 per cent). SAM is higher in Lowland Zone 50% 41.5% than Mountainous ( 3.8 per cent 40% & 0.8 respectively) without 35.2% Severe+Moderate significant differences. The 30.4% Moderate 30% results above indicate an 22.9% Severe emergency nutrition situation in 20% the Lowland Zone based on the 11.1% 9.2% 9.1% acute malnutrition levels, hence 10% a need for emergency response 0.8% to avert excess mortality due to 0% malnutrition. Wasting Stunting Underweight

Levels of stunting and underweight found in this survey for both zones as Figures (8 a),(8 b) show, are above the WHO “critical‟ levels thresholds of 40 per cent and 30 per cent respectively. No significant different is noted in stunting between the two zones while there is significant different in underweight (X2: 8.96 , P< 0.01, df 1).

The significant differences between rural and urban were not reported except for stunting in Mountainous zone that was higher in rural than in urban (X2: 8.3, P<0.05, df 1).

No significant differences were found in wasting and underweight between boys and girls, however, boys are found with higher stunting (X2: 4.7, P<0.05, df 1) and severe stunting (X2: 6.7, P<0.05, df 1) than girls, that is seen in Mountainous Zone. GAM is noted higher among children aged 6 and less than 12 months than older group in two zones.

There is no significant difference among age categories in prevalence of both global and severe underweight, global and severe wasting for both zones. Underweight and severe underweight are highest in age group of 24 to 35 months with 47.7 per cent and 14.6 per cent respectively in Mountainous zone, while Underweight in Lowland zone is highest in age group of 6 to 11 months with 55.7 per cent and severe underweight is highest in age group of 24 to 35 months with 18.3 per cent. wasting is highest among those aged 6 to 11 months in Mountainous and Lowland zones with 24.7 per cent and 12.5 percent respectively. stunting is significantly highest among those aged 24 to 35 months in Mountainous zone with 67.5 per cent and is significantly highest among those aged 12 to 23 months per cent in Lowland zone while sever stunting is significantly highest among those aged 24 to 35 months in both Mountainous and Lowland zones with 30.5 per cent and 24.2 per cent respectively.

Fig.(9): Trends of malnutrition in Hajjah governorate (2011-2015) 65% 61.3% 60% 58.1% 55.5% 53.0% 55% 53.2% 48.8% 50% 44.1% 50.1% 45% 38.0% 47.3% 47.0% 40% 45.5% 42.9% 37.9% 41.5% 35% 35.6% 30% Wasting 25% 21.6% 20% 19.8% 20.9% Stunting 15% 14.9% Underweight 15.3% 10% 9.2% 5% 9.3% 9.9% 0%

As figure (9) shown, the levels of GAM of 21.6 per cent , 19.8 per cent and 20.9 per cent in Lowland zone for the previous SMART surveys in 2012, 2014 and 2015 respectively are higher than the national one of 2014 (16.3 per cent ) and higher than those found in two surveys 2011 and 2014 conducted by WFP-CFSS ( 14.9 per cent and 15.3 percent respectively ), while levels of GAM (9.3 per cent, 9.2 per cent and 9.9 per cent) in Mountainous zone for all those SMART surveys in 2012, 2014 and 2015 respectively are lower than the national one and WFP- CFSS surveys. The stunting rates for Lowland & Mountainous Zones (53 per cent & 58 per cent respectively) are higher than the estimated national stunting levels of 46.5 per cent and than that estimated by WFP- CSS in 2014 (38 percent) but close to which found in 2011 by WFP-CSS ( 55.5 percent). The underweight prevalence in Hajja Governorate as shown by findings of the WFP-CFSS 2014 survey is 35.6 per cent and by national one 2014 (39 per cent ) that are lower than prevalence of Lowland & Mountainous Zones ( 50.1 per cent & 41.5 per cent respectively).

Child Feeding, Vitamin A Supplementation and Malnutrition Levels : Exclusive breastfeeding was found in Lowland & Mountainous zones are 28.8 per cent & 34.2 respectively which is higher than national level of DHS with level of 10.3 per cent but these rates are still low as WHO defined that rate of EBF should be 50 per cent up to 89 per cent to be classified as a practice of “good” level.5 The continued breastfeeding at one year in Lowland zone was found as 87.9 per cent that dropped to 60 per cent at two years and continued breastfeeding at one year in Mountainous 79 percent which dropped to 45 percent at two years. Continuation of the breastfeeding gradually declined with age, however, continued breast feeding at both one year and two years in Lowland are higher than the national ones (71.2 per cent and 45.3 per cent respectively as per the DHS 2014). Survey results show no significant association of continuation of breastfeeding with malnutrition levels.

There was no significant association between Minimum diversity diet and malnutrition in both zones except with underweight in Lowland (X2: 7.9, P<0.01, df 1).

It is notable that the vitamin A coverage in the two zones (supplementation 6 months prior to the survey) was lower than the recommended 95 per cent coverage Sphere Standards. There is no effect was found for vitamin A supplementation during the last 6 months on stunting, underweight and wasting prevalence in Lowland while in Mountainous zone wasting prevalence was significant higher among children who have not receive vitamin A supplementation ( 14.5 per cent) than who have received (8.7 per cent), (X2: 4.3, P<0.05, df 1).

Suboptimal infant and child feeding and low vitamin A supplementation seem to negatively affect the nutrition well-being of Hajjah population.

5 WHO. Infant and young child feeding. A tool for assessing national practices, policies and programmes. Geneva. 2003 26

Morbidity and Malnutrition Levels:

The disease prevalence was recorded as being high in the Governorate. In the Lowland Zone the survey found diarrhoea - 49.9 per cent, ARI – 30.9 per cent, fever – 56.8 per cent. Higher prevalence was recorded in the Mountainous Zone: diarrhoea – 48.1 per cent, ARI - 38.8 per cent, and Fever – 62 per cent.

The relationship between diarrhoea and malnutrition is bidirectional: diarrhoea leads to malnutrition while malnutrition aggravates the course of diarrhoea. On the one hand, severe and prolonged episodes of diarrhoea cause malnutrition in individual patients; on the other hand, malnourished children are more likely to develop complications with diarrhoea6. This survey shows no statistical significant effect was observed for diarrhoea two weeks prior to the survey on the prevalence of global wasting and stunting. The effect for diarrhoea two weeks prior to the survey was found on underweight in lowland & Mountainous zones. (X2: 4.2, P<0.05, df 1, X2: 5.1, P<0.05, df 1 respectively) and on severe stunting in Lowland (X2: 5.03, P<0.05, df 1). In Mountainous zone diarrhoea was significant effect on severe wasting (X2: 8.03, P<0.01, df 1) and on severe underweight (X2: 10.9, P<0.01, df 1).

No significant difference was found in stunting, underweight or wasting between those who had and those who had not had ARI (cough or breathing difficulty) two weeks prior to the survey in Lowland and Mountainous zones. The only effect of ARI was found on global stunting (X2: 9.1, P<0.01, df 1)and on severe stunting in Lowland (X2: 5.4, P<0.05, df 1). However, the high prevalence of fever was found linked to higher rates of stunting in Lowland (X2: 3.7, P<0.05, df 1) and was found linked to higher rates of underweight in Mountainous zone (X2: 7.8, P<0.01, df 1).

Overall, a relationship was identified between illness and malnutrition, calling for appropriate and adequate health service provision in order to address the malnutrition. Nutrition Status and Food consumption based on household dietary diversity

Severe wasting was found to be lower among children from households with normal food consumption in Lowland (X2: 6.9, P<0.05, df 2) and in Mountainous zone (X2: 9.2, P<0.05, df 2). Similarly, lower underweight (X2: 8.5, P<0.05, df 2) and severe stunting (X2: 6.3, P<0.05, df 2) among children from households with normal food consumption in Lowland zone.

6 Nel ED. Diarrhoea and malnutrition. South Africa J Clin Nutr 2010; 23(1). 2010. 27

Water and sanitation with Nutrition situation:

There are only a significant association has been found between SAM, severe stunting and severe underweight with the clean storage of drinking water in Lowland zone. Table 16 shows Statistical significant . Table (16): Malnutrition and cleanness of drinking water storage in Lowland Indicator Yes No Statistical significance N % N % Severe Underweight 24 9.6 51 15.7 X2:4.76 , P- value = 0.029, df1 Severe Stunting 34 13.5 64 19.8 X2:3.92 , P- value = 0.048, df1 Severe acute malnutrition 4 1.6 18 5.6 X2:6.06 , P- value = 0.014, df1

The different types of latrines in two zones seemed to have no significant association with nutrition situation except for severe acute malnutrition in Lowland zone, there was a significant association between SAM and defecation in open (X2: 4.37, P< 0.05, df1).

Recommendations:

Although mortality is still low, the critical levels of stunting and underweight in all ecological zones and the critical GAM levels in the Lowlands requires an urgent intervention to address the situation a cross the governorate. The existence of multi-sectoral aggravating factors like poor feeding practices, high prevalence of communicable diseases, insufficient coverage of essential health services like immunization and micronutrient supplementation. The need to deliver an integrate package of services to mothers and their children is very important not only to address the high wasting level but also to address the high level of stunting and other development indicators.

Below are the main immediate and medium-term recommendations:

Immediate Interventions:

diversity, appropriate child care, and promotion of safe sanitation and hygienic practices, diarrhoea prevention measures and appropriate management of ARI among young children

Medium Term Interventions:

Annexes

Annex 1: Hajjah Governorate Nutrition Survey Questionnaire, 27 Aug- 9 September 2015

الجمهورية اليمنية وزارة الصحة العامة والسكان مكتب الصحة العامة والسكان بمحافظة الحديدة مسح الحالة التغذوية والوفيات في محافظة حجة، سبتمبر 5102

استبيان األسرة )نموذج 0(

أوالً. يتم الشرح للساكنين في المسكن )البالغين منهم( عن المسح والتعريف بالجهة القائمة عليه واألشخاص العاملين فيه )أعضاء الفريق(، ثم بعد ذلك الحصول على الموافقة الشفهية منهم. 1. نعم

2. ال انتقل إلى

الموافقة النهاية

هل األسرة مقيمة أم في حال األسرة المقيمة. هل تقيم معكم أسرة أو اسر نازحة؟ نازحة؟ 1. نعم في حال وجود أسرة نازحة تعيش مع أسرة مقيمة فينبغي تعبئة بيانات 1. مقيمة. األسرتين في استبيانين منفصلين عدا استمارة الوفيات فيجب ان تكون 2. نازحة 2. ال استمارة واحدة لألسرتين، وترفق مع استبيان األسرة المقيمة.

لمديرية العزلة القرية/ الحارة

يوم شهر سنـــــــــة تاريخ المقابلة 2 Ø 1 5 Ø 8

اسم رب األسرة:

فريق االسم التوقيع

األسرة واألنثروبومتري المسح رقم ...... الوفيات رئيس الفريق

بين فيما إذا كان هناك: 1. غياب األسرة عند الزيارة األولى ويتطلب األمر زيارة ثانية 2. غياب طفل عند الزيارة األولى ويتطلب األمر زيارة ثانية* * عند غياب الطفل، تستكمل كل بياناته عدا القياسات األنثروبومترية واألوديما حيث تستكمل عند حضوره.

مالحظة: البيانات في الغالف هي لالستخدام الميداني واإلداري من قبل أعضاء الفريق.

يملئ من قبل رئيس الفريق )تستخدم إلدخال البيانات( 31

غياب األسرة حتى بعد الزيارة الثانية )1 نعم ، 2 ال( الموافقة )1 نعم ، 2 ال(

رقم الفريق

رقم استبيان األسرة األسرة مقيمة )1( أم نازحة )2( في حال األسرة المقيمة، هل تأوي أسرة نازحة )1 نعم ، 2 ال(

تاريخ المقابلة ي ي ش ش س س س س 2 Ø 1 5 Ø 8

هل المنطقة حضرية )1( أم ريفية )2(

رمز القرية / الحارة رمز العزلة رمز المديرية رمز المحافظة رمز طبقة المسح رقم العنقود

------

العمل المكتبي االسم اليوم الشهر السنة التوقيع إدخال البيانات

المراجعة ترميز أخرى المالحظات ......

س 000: بيانات عن األسرة )األحياء فقط والذين يعيشون حاليا في األسرة(

العدد H001a عدد أفراد األسرة )األحياء فقط الذين يعيشون حاليا في األسرة تاريخ المسح(

عدد األطفال أقل من 5 سنوات )األحياء فقط الذين يعيشون حاليا في األسرة تاريخ العدد H001b المسح(

عدد األطفال أقل من 6 أشهر )األحياء فقط الذين يعيشون حاليا في األسرة تاريخ العدد H001c المسح(

س 000 – س 000: بيانات عن حال دخل األسرة

ما نوع رب األسرة

H002 1. ذكر

2. أنثى

ماهو العمل الرئيسي لرب األسرة؟ 1. موظف قطاع حكومي أو مختلط. 2. موظف في قطاع خاص كبير )مصانع وشركات كبيرة( 3. موظف في قطاع خاص متوسط أو صغير 4. موظف في قطاع ثالث )منظمات غير حكومية( 5. في األمن أو الجيش H003 6. عامل باألجر اليومي.

7. فالح يعمل في مزرعته/ صياد. 8. لديه عمل خاص صغير )بقاله صغيرة، بوفية، تاكسي، ...... ( 9. لديه عمل خاص متوسط )بيع جملة، بقالة كبيرة، معمل بالستيك، محطة 11. لديه مياه، عمل محطة خاص بترول كبير ....( )مالك المصانع والشركات الكبيرة والعقارات( 11. ضمان اجتماعي )معاشات التقاعد(. 12. أخرى: تذكر ......

خالل األربعة األشهر الماضية، هل تأثر دخل رب األسرة؟ 1. لم يفقد راتبه أو دخله المعتاد. H004 2. فقد جزء من راتبه أو دخله. 3. فقد كل راتبه أو دخله.

س 000– س 000: بيانات عن الماء واإلصحاح البيئي والنظافة

ماهو المصدر الرئيسي لمياه الشرب في منزلكم؟ )خيار واحد فقط( 1. أنابيب مياه موصلة إلى البيت. 2. أنابيب مياه موصلة إلى فناء البيت. 3. بئر مفتوحة غير محمية. 4. بئر مفتوحة محمية. 5. خزان مغطى لحصاد مياه األمطار. H005 6. خزان مفتوح لحصاد مياه األمطار. 7. سيارة نقل المياه )وايت ماء( 8. مياه صحية معبأة )حدة، شمالن، كوثر الخ( H007 9. مياه سطحية غير محمية )وادي، عين ماء جاري، الخ( 11. عين ماء محمية 11. أخرى: تذكر ......

هل تقومون بمعالجة الماء قبل الشرب؟ إنتقل إلى 1. نعم H006a 2. ال H007 3. ال أعرف H007

ما هي طريقة المعالجة الرئيسية المستخدمة لمياه الشرب )خيار واحد فقط( 1. غلي الماء قبل الشرب 2. استخدام الكلور 3. الترشيح عبر قماش نظيف H006b 4. استخدام مرشح سيراميك أو رمل أو ما شابه )فلتر أو قطارة( 5. ترك الماء ساكنا قبل الشرب لترسيب الشوائب. 6. استخدام الشب )شب الفؤاد( 7. أخرى:تذكر ......

للمالحظة:تحقق من توفر نقاط تخزين المياه لغرض الشرب: هل الوعاء الحاوي لمياه الشرب نظيف؟ H007 1. )عدم وجود نعم. طحالب يعني رقم 1 ووجود الطحالب يعني رقم 2( 2. ال.

أين تتم عملية قضاء الحاجة )التبرز(؟ )اختر فقرة من التالي(- تحقق من توفر المرافق والممارسات 1. مرحاض - يتوفر فيه صب الماء للتنظيف الذاتي )سيفون أو دلو(. 2. مرحاض - حفرة دون غطاء. H008 3. مرحاض - حفرة مغطاة بطريقة بسيطة )الجاف(. 4. قضاء الحاجة في العراء )في الحقول مثال، الخ.( 5. أخرى:تذكر ......

س :000 خاص بحالة االستلال الغذائي

خالل الـ 24 ساعة الماضية هل تم تناول أي من األغذية أو المجموعات الغذائية 1. نعم

أدناه. 2. ال

بر، خبز، عصيدة، فتة، حبوب أخرى )ذرة، ذرة رفيعة، دخن، شعير(، a. أرز، مكرونة، معجنات، أو أي منتجات مصنعة من الحبوب

.b بطاط

.c خضراوات )الخضراوات الورقية، الطماطم، الفلفل، جزر، دبا...... الخ(

.d فواكه )مانجو، عنب، ..... الخ(

.e لحم )بقري، غنمي(، ،كبده كالوي ، دواجن H009 .f بيض

.g أسماك )طازجة ومجففة ومعلبة(

.h فاصوليا، عدس، بازيليا، فول، .....

.i مشتقات الحليب )لبن، جبن، زبادي، حقين، .....(

.j زيوت/ دهون )سمن، زبدة، زيت نباتي، ....(

.k سكر، عسل، فواكه مجففة )تمر، زبيب(

.l بهارات، شاي، بن

س 000: هدايا من ألبان األطفال

خالل الثالثين اليوم الماضية، هل حدث وأن حصلتم على عبوات ألبان أطفال بشكل مجاني؟

H010 1. نعم

2. ال

س 000– س 000: حالة التحصين وتزويد فيتامين )أ( لألطفال في سن 6-00 شلراً في األسرة )يجب تدوين كل األطفال من عمر 0 إلى أقل من 0 سنوات في الجدول أدناه ابتداء باألصغر سنا( C015 C014 C013 C012b C012a C011 رقم االسم األول نوع الطفل تاريخ الميالد عمر الطفل )باألشهر( لألطفال بعمر 6 لألطفال بعمر لألطفال بعمر تسعة الطفل للطفل أشلر فأكثر 6 أشهر فأكثر أشهر فأكبر. هل تم 1= ذكر )بالهجري أو الميالدي( هل أخذ الطفل تطعيم الطفل ضد هل تم إعطاء الطفل جرعة لقاح الحصبة. )حقنة في اليد فيتامين )أ( خالل الستة 2 = أنثى لألطفال من بسن )1 إلى 59 شهر( الخماسي3/ اليسرى(؟ أشهر الماضية؟ الشلل3؟ )إظهار عينة( 1 = نعم من البطاقة. 1 = نعم 1 = نعم 2 = نعم بالتذكر. 2 = ال 2 = ال 3 = ال أعرف

3= ال أعرف 4 = لم يطعم 1. يوم شلر سنـــــة

2. يوم شلر سنـــــة

3. يوم شلر سنـــــة

4. يوم شلر سنـــــة

5. يوم شلر سنـــــة

6. يوم شلر سنـــــة

7. يوم شلر سنـــــة

ماذا قالت األم حول عمر الطفل:- الطفل رقم )1(: ...... الطفل رقم )2(:...... الطفل رقم )3(:...... الطفل رقم )4(:...... الطفل رقم )5(:...... الطفل رقم )6(:...... الطفل رقم )7(:......

س 006– س 000: القياسات الجسمانية لألطفال بين سن 6-00 شلر في األسرة )يتر فارغا لألطفال بسن أقل من 6 أشلر( C019 C018 C017 C016 رقم االسم عمر الطفل )باألشهر( الوزن )كيلو جرام( الطول )سم( التوذم (أوديما( في كال القدمين. قياس محيط الذراع الطفل األول 88.8 = رافض 888.8 = رافض 1 = نعم )سم()الميواك( )كما للطفل 99.9 = غائب 999.9 = غائب 2 = ال 88.8 = رافض سبق 8 = رافض 99.9 = غائب أعاله( 9 = غائب .1 . . . .2 . . . .3 . . . .4 . . . .5 . . . .6 . . . .7 . . .

س 000– س 003: مراضة األطفال بين سن 0-00 شلر في األسرة )كل األطفال تحت سن 0 سنوات(

C023 C022 C021 C020

رقم االسم األول للطفل عمر الطفل اإلسهال خالل سعال أو صعوبة في التنفس الحمى خالل االشتباه بالحصبة خالل الشهر الماضي )طفح جلدي + الطفل )باألشهر( األسبوعين الماضيين خالل األسبوعين الماضيين األسبوعين الماضيين حمى + )سعال أو التهاب حلق أو التهاب الملتحمة( )كما سبق 1 = نعم 1 = نعم 1 = نعم 1 = نعم أعاله( 2 = ال 2 = ال 2 = ال 2 = ال .1 .2 .3 .4 .5 .6 .7

س 000– س 000: دون ممارسة إطعام األطفال بين سن 0 إلى 00 شلر خالل الـ 00 ساعة الماضية )يتر فارغا لألطفال بعمر أكبر من 00 شلرا(

رقم الطفل االسم األول عمر الطفل C024b C024a هل تناول الطفل أمس أيا من المجموعات الغذائية أدناه. ابدئي بسؤال اليوم من الوقت الذي استيقظ فيه الطفل صباح أمس وحتى نومه في للطفل )باألشهر( المساء. اتركي األم تتذكر وعندما تنتهي قم بذكر المواد أدناه )كما سبق 1 = نعم 2 = ال3 األم التعرف أعاله( هل رضع الطفل من ثدي أمه كم عدد C025j C025i C025h C025g C025f C025e C025d C025c C025b C025a خالل الـ 24 المرات التي ساعة الماضية؟ عصيدة أو كبد أو كلى أو رضع فيها أي أغذية أحيانا ال تكون شبيسة أو قلب أو أحشاء دبا أو جزر أو الطفل و عدد مصنوعة من هناك رضاعة خبز أو أرز الحليب أو أخرى. بطاطا حلوة أي فواكه المرات التي الفول أو مباشرة لكن لبن أو مكرونة الجبن أو أي لحوم بقر جوفها أصفر أو أو أعطى فيها الفاصوليا أو األم يستخرج من أو أي غذاء الزبادي أو أو غنم أو برتقالي. خضراوات أية الطفل لبن ماء معبأ و حليب البازيليا أو الثدي ويعطى مصنوع من الحقين أو ماعز أو بيض أي خضراوات أخرى لم مشروبات أو األم خالل الـ بدون سكر أطفال العدس أو للطفل بطريقة الحبوب. األيسكريم دواجن. ورقية داكنة تذكر في أغذية أخرى 24 ساعة الفول أخرى. بطاطا أو الثريب اسماك الخضرة. الخانة الماضية؟ السوداني أو 1 = نعم بيضاء أو أية )الثرابة(. طازجة أو مانجو أو باباي السابقة. أي بقوليات 2 = ال أغذية درنية مجففة أو ناضجة. أخرى. أخرى. معلبة. .1

Annex 2: Hajjah Governorate Mortality Survey Questionnaire, 27 Aug- 9 September 2015

مسح الحالة التغذوية والوفيات في محافظة حجة، أغسطس5102م استمارة رصد أفراد األسرة خالل فرتة 531 يوم من اتريخ املسح)منوذج 2( مديرية املسح: ______احلي: ______التاريخ: ______رقم العنقود: _____رقم الفريق:

______رقم استبيان األسرة: ______طبقة املسح: ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

اجلنس )ذكر التحق أثناء غادر أثناء فرتة ولد أثناء فرتة تويف أثناء فرتة سبب موقع م االسم )اختياري( العمر ابلسنوات أو أنثى( فرتة531 يوم 531 يوم 531 يوم 531 يوم الوفاة الوفاة 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 هام: يتم تسجيل كل األفراد املوجودين حاليا كل ومن التحق ابألسرة أو غادرها أو توىف أو ولد خالل 09 يوم من اتريخ املسح

رموز أسباب الوفاة 5 = اإلسهال 1 = سوء التغذية 2 = احلمى 6= العنف / بسبب الصراعات 3= احلصبة 7= أخرى )حدد( 4 = مشاكل يف التنفس رموز مواقع الوفاة

5 = يف املوقع احلال 2= أثناء اهلجرة =3 يف آخر مكان سكن فيه 4 = أخرى )حدد(

Annex 3: Hajjah Governorate Nutrition Survey Team, 27 Aug-9 September 2015

No Name Title 1 Dr.Akram Nasar 2 Tayhan Hodaees Nabeeh Madkoor 3 Team Heads 4 AbdulKhaliq Almedhwahee 5 Ibraheem Ajlan 6 Yahea Meqdam 7 Kawkab Atta 8 Elham Sharaf aldeen 9 Haifa Alhosaeenee 10 Montaha Dahshoosh 11 thikra Gadeel 12 Maryam Alhosam 13 Mona Otaeefa 14 Hanna Otaeefa 15 Ghada Almaswaree Enumerators 16 Eshraq Alwashalee 17 Nora Abo Nokhra 18 Fattema Alnaseery 19 Yosra Albormee 20 Ebtessam Almarwanee 21 Rasha Alsakeea'a 22 Huda Albahree 23 Hayat Alossam 24 Khayreyah Altalee 25 Mohameed Alforas 26 Abdulmalik Alqossee 27 Zaeed Almoshekee Field supervisors 28 Mohameed Alsaqaf 29 Nabeel Zeiad 30 Dr.Fahed AlNadharee Survey manager 31 Dr. Waleed Shamsan Logistic 32 waleed almadhaji Technical assistant- UNICEF 33 Nagib Abdulbaqi Technical advisor- UNICEF 34 Nassar Al-Alashwal Sampling 35 Farouk Abdurrahman Al-Qadasi Data analysis 36 Dr. Huda Ali Al-Najjar Survey Report writer 37 Hadhramee Hadee 38 Yossof Ala'azee Data entry 39 Mohamed Ali Sa'asa'ah 40 Ameen Albaqa'a

Annex 3: Hajjah Governorate Nutrition Survey Team, 27 Aug- 9 September 2015

م االسم الصفة 1 د.أكرم صالح نصار 2 تيهان ناصر قايد هديش نبيه أحمد مذكور 3 رؤساء الفرق 4 عبدالخالق أحمد المضواحي 5 إبراهيم محمد عجالن 6 يحي يحي زايد مقدام 7 كوكب عطاء حسين يعيش 8 غادة حسن المسوري 9 هيفاء علي ناصر الحسيني 10 خيرية عبدهللا حمود الطلي 11 إشراق صالح محسن الوشلي 12 هدى عبدهللا البحري 13 إلهام محمد مهدي شرف الدين 14 ذكرى سعد أحمد جعدل مريم أحمد علي الحسام 15 ماسحين 16 حياة محمد حسن العسام 17 هناء ناصر قايدعطيفة 18 فاطمة علي حسن النصيري 19 منى ناصر قايد عطيفة 20 نورا علي عايض أبو نخرة 21 يسرى أحمد محمد البرمي 22 منتهى علي دهوش 23 إبتسام عبده حمود المروني 24 رشاء علي يحي السكيع 25 محمد محسن أحمد الفراص 26 زيد علي يحي الموشكي 27 د.محمد طه السقاف المشرفين 28 نبيل حمود مسعد زياد 29 عبدالملك عبدهللا أحمد القسي 30 د. فهد عبدالعزيز النظاري مدير المسح 31 نجيب عبدالباقي المشرف الفني- اليونيسف 32 د. وليد محمد شمسان اشراف وإمداد 33 وليد سالم المدحجي الدعم الفني- اليونيسف 34 نصار األشول تصميم العينة 35 فاروق عبدالرحمن القدسي محلل البيانات 36 د.هدى علي النجار كاتب تقرير المسح 37 حضرمي هادي ناصر الحضرمي رئيس فريق مدخلي البيانات 38 يوسف صالح ناصر الغزي 39 محمد علي حمود صعصعة مدخلي البيانات 40 أمين يحي صالح البقع

Annex 4: job descriptions for Survey Teams (Extracted from SMART Training Materials)

Each survey team should be composed of at least 3 people. Including women in survey teams is highly recommended since they are usually more comfortable interacting with children. Generally, two surveyors are involved in anthropometric measurements while another one, the team leader, records the data on the forms. However, it is strongly suggested that each team member knows how to accomplish the tasks of his teammates, because unexpected events can happen and a change in the staff may be required.

All team members must have the following qualifications:  They should be able to write and read English or French (depending on the country where the survey takes place) and speak the local languages of the areas where the survey will be conducted.  They should have sufficient level of education, as they will need to read and write fluently and count accurately.  They should be physically fit to walk long distances and carry the measuring equipment.  They do not (necessarily) have to be health professionals. In fact, anyone from the community can be selected and trained as long as he meets the above criteria.

1. Survey Manager (or supervisor)

The manager guarantees the respect of the survey methodology; he has the responsibility for: 1- Gathering available information on the context and survey planning, 2- Selecting team members, 3- Training team members, 4- Supervision of the survey: Taking necessary actions to enhance the accuracy of data collected: 4.1 Visiting teams in the field and making sure that before leaving the field, each team leader reviews and signs all forms to ensure that no pieces of data have been left out; making sure that the team returns to visit the absent people in the household at least once before leaving the area. 4.2 It is particularly important to check cases of oedema, as there are often no cases of oedema seen during the training and some team members may therefore be prone to mistaking a fat child for one with oedema (particularly with younger children). The supervisor should note teams that report a lot of oedema, confirm measles and death cases, and visit some of these children to verify their status. 4.3 Ensuring that households are selected properly and, that the equipment is checked and calibrated each morning during the survey, and that measurements are taken and recorded accurately.

4.4 Deciding on how to overcome the problems encountered during the survey. Each problem encountered and decision made must be promptly recorded and included in the final report, if this has caused a change in the planned methodology. 4.5 Organizing data entry into ENA and checking any suspect data every evening, by using the appropriate sections of the plausibility report. 4.6 Organizing an evening “wrap up” session with all the teams together to discuss any problems that have arisen during the day7. 4.7 Ensuring that the teams have enough time to take appropriate rest periods and has refreshments with them. It is very important not to overwork survey teams since there is a lot of walking involved in carrying out a survey, and when people are tired, they may make mistakes or fail to include more distant houses selected for the survey. 5 Analyse and write the report.

2. Team Leader

Skills and required abilities: To be able to read, write and count; know the area to survey; be reliable and friendly. Tasks: 1. Ensures all forms and questionnaires are ready at start of day; 2. Ensures all equipment is ready at start of day; 3. Calibrates measurement instruments on daily basis; 4. Ensures all food/refreshments are ready at start of day; 5. Organises briefing meeting with his team before departure in morning; 6. Speaks with chief of village to explain the survey and its objectives, 7. Draws a map of the area to survey and use a random table; 8. Manages the households selection procedure; 9. Uses a local events calendar to estimate the age; 10. Calculates the Weight-for-Height ratio after taking anthropometric measurements; 11. Checks if the child is malnourished (checks for the presence of oedema); 12. Fills the anthropometric form; 13. Fills survey questionnaires when needed; 14. Fills the referral form if necessary; 15. Ensures that houses with missing data are revisited before leaving the field the same day;

7 This may not be possible if the survey area is large since the teams might be widely separated and remain in the field for several days. In that case, communication with teams in the field might often be very difficult; hence, each team leader must be sufficiently trained to be able to take decisions independently.

16. Checks that all forms are properly filled out before leaving the field. 17. Ensures that all the equipment is maintained in a good state; 18. Manages time allocated to measurements, breaks and lunch, 19. Ensures security of team members, 20. Note and report the problems encountered.

3. Measurers Skills and required abilities: To be able to read, write and count; know the area to survey; be reliable and friendly. Tasks: 1. Measures the height, weight and arm circumference (if included in the survey); 2. Assesses the presence of edema; 3. Uses a local events calendar to estimate the age; 4. Respects the time required for measurements, breaks and meals; 5. Takes care of the equipment; 6. Follows security measures.

The measurers must acquire some special skills and knowledge although they don’t have the primary responsibility for tasks that are related: 1. Know how to calculate the weight-for-height ratio; 2. Know how to select households for the survey; 3. Know how to check if a child is malnourished; 4. Learn how to make a reference for a malnourished child.

Annex 5: Hajjah Lowland assessment Quality Checks

Plausibility check for: Hajjah Lowland Sep 2015.as

Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report are more for advanced users and can be skipped for a standard evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of in-range subjects) 0 5 10 20 0 (1.0 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.868)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.345)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (4)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (6)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (3)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 0 (0.95)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (-0.05)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 1 (0.29)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.056)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 1 %

The overall score of this survey is 1 %, this is excellent.

Annex 6: Hajjah Mountainous assessment Quality Checks

Plausibility check for: Hajjah Mountains Sep 2015.as

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5 (% of out of range subjects) 0 5 10 20 0 (0.6 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 0 (p=0.265)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001 (Significant chi square) 0 2 4 10 2 (p=0.051)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (4)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (7)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20 0 2 4 10 0 (4)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20 . and and and or . Excl SD >0.9 >0.85 >0.80 <=0.80 0 5 10 20 5 (0.90)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (0.03)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6 0 1 3 5 0 (0.11)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001 0 1 3 5 0 (p=0.130)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 7 %

The overall score of this survey is 7 %, this is excellent.

Annex 7: Tables of Weighted Finding of Nutritional Status

The weighted prevalence of GAM and SAM is 15.6 per cent and 2.6 per cent in rural Hajjah and 15.3 per cent and 0.8 per cent in urban areas, while levels are higher among boys (17.4 per cent and 2.5 per cent) than girls (13.8 per cent and 2.2 per cent). The overall GAM and SAM prevalence in Hajjah Governorate is 15.6 per cent and 2.4 per cent respectively. No Oedema case was reported in the each of the two zones. The weighted prevalence of stunting in Hajjah Governorate is 55.4 per cent with severe stunting of 20 per cent. Thus, the severity for Hajjah is classified as ‘critical’ as per WHO categorization. The prevalence of stunting in rural is 56.3 per cent with severe stunting of 20.9 per cent and in urban is 48.1 per cent with severe stunting of 12.1 per cent, and high as 64.9 per cent among children in the third year of age. Levels of stunting and severe stunting in boys are 57 per cent and 22.8 per cent and in girls are 54 per cent and 17.2 per cent respectively. The weighted prevalence of underweight in Hajjah Governorate is 45.9 per cent with severe underweight of 12.2 per cent. The prevalence of underweight in rural is 46.4 per cent with severe underweight of 12.7 per cent and in urban is 41.8 per cent with severe underweight of 7.7 per cent. Levels of underweight and severe underweight among boys are 48 per cent and 12.7 per cent and among girls are 43.9 per cent and 11.6 per cent respectively. Weighted rates are mentioned in the tables below with 95 per cent confidence intervals. Figures mentioned above and in tables below have been calculated after exclusion of SMART flags.

1: Stunting among children distributed per zone, residency place, gender, and age category

Stunting Weighted % 95% Conf Limits N Lower Upper Severe 223.06 20.9% 18.5% 23.5% Rural (n=1066.55) Moderate 377.81 35.4% 32.6% 38.4% Severe and moderate 600.87 56.3% 53.3% 59.3% Severe 15.86 12.1% 7.1% 19.1% Urban (n=131.02) Moderate 47.21 36.0% 27.7% 44.8% Severe and moderate 63.07 48.1% 39.3% 57.0% Severe 105.95 17.2% 14.4% 20.5% Girls (n = 614.55) Moderate 225.72 36.7% 32.9% 40.7% Moderate and severe 331.67 54.0% 49.9% 58.0% Severe 132.97 22.8% 19.5% 26.5% Boys (n = 583.02) Moderate 199.3 34.2% 30.4% 38.2% Moderate and severe 332.27 57.0% 52.9% 61.0% 6 - below 12 months (n = Severe 14.28 10.5% 5.7% 16.6% 134.47) Moderate 30.56 22.4% 15.9% 30.5% Moderate and severe 44.84 32.8% 25.1% 41.4% 12 - below 24 months (n = Severe 64.37 23.8% 18.7% 29.2% 270.84) Moderate 105.26 38.9% 33.0% 44.9% Moderate and severe 169.63 62.6% 56.6% 68.5% Severe 73.81 27.5% 22.3% 33.3% 24 - below 36 months (n = Moderate 99.16 36.9% 31.1% 42.9%

Stunting Weighted % 95% Conf Limits N Lower Upper 268.83) Moderate and severe 172.97 64.3% 58.3% 70.0% 36 - below 48 months (n = Severe 59.95 21.5% 16.9% 26.8% 278.41) Moderate 103.11 37.0% 31.3% 43.0% Moderate and severe 163.06 58.6% 52.6% 64.5% 48 - below 60 months (n = Severe 26.51 10.9% 7.4% 15.7% 242.88) Moderate 86.93 35.8% 29.8% 42.2% Moderate and severe 113.44 46.7% 40.2% 53.1% Severe 105.93 17.2% 14.3% 20.5% Lowland (n = 616.32) Moderate 220.42 35.8% 32.0% 39.7% Moderate and severe 326.35 53.0% 48.9% 56.9% Severe 132.99 22.9% 19.6% 26.6% Mountains (n = 581.25) Moderate 204.6 35.2% 31.3% 39.3% Moderate and severe 337.59 58.1% 53.9% 62.1% Severe 238.92 20.0% 17.7% 22.4% Hajjah (n=1197.57) Moderate 425.02 35.5% 32.8% 38.3% Severe and moderate 663.94 55.4% 52.6% 58.3%

2: Underweight among children distributed per zone, residency place, gender, and age category

Underweight weighted N % 95% Conf Limits Lower Upper Severe 136.28 12.7% 10.8% 14.9% Rural (n=1070.41) Moderate 360.47 33.7% 30.9% 36.6% Severe and moderate 496.75 46.4% 43.4% 49.4% Severe 10.14 7.7% 3.7% 13.5% Urban (n=131.95) Moderate 45.07 34.2% 26.1% 42.9% Severe and moderate 55.21 41.8% 33.2% 50.7% Severe 71.86 11.6% 9.3% 14.5% Girls (n = 617.34) Moderate 199.26 32.3% 28.6% 36.1% Moderate and severe 271.12 43.9% 40.0% 47.9% Severe 74.56 12.7% 10.2% 15.8% Boys (n = 585.02) Moderate 206.28 35.3% 31.4% 39.3% Moderate and severe 280.84 48.0% 43.9% 52.1% 6 - below 12 months (n = Severe 20.56 15.1% 9.7% 22.5% 136.61) Moderate 41.4 30.3% 22.5% 38.5% Moderate and severe 61.96 45.4% 36.8% 54.1% 12 - below 24 months (n = Severe 30.14 11.0% 7.5% 15.2% 274.7) Moderate 91.12 33.2% 27.6% 39.1% Moderate and severe 121.26 44.1% 38.1% 50.2% 24 - below 36 months (n = Severe 44 16.4% 12.2% 21.3% 268.83) Moderate 87.16 32.4% 26.8% 38.3% Moderate and severe 131.16 48.8% 42.6% 54.9% Severe 30.65 11.0% 7.7% 15.4% 36 - below 48 months (n = Moderate 98.51 35.4% 29.9% 41.4% 49

Underweight weighted N % 95% Conf Limits Lower Upper 278.41) Moderate and severe 129.16 46.4% 40.4% 52.4% 48 - below 60 months (n = Severe 21.07 8.6% 5.4% 12.9% 243.81) Moderate 87.35 35.8% 29.7% 42.1% Moderate and severe 108.42 44.5% 38.0% 50.9% Severe 81.32 13.2% 10.7% 16.2% Lowland (n = 617.39) Moderate 227.91 36.9% 33.1% 40.9% Moderate and severe 309.23 50.1% 46.1% 54.1% Severe 65.1 11.1% 8.8% 14.0% Mountains (n = 584.97) Moderate 177.63 30.4% 26.7% 34.3% Moderate and severe 242.73 41.5% 37.5% 45.6% Severe 146.42 12.2% 10.4% 14.2% Hajjah (n=1202.36) Moderate 405.54 33.7% 31.1% 36.5% Severe and moderate 551.96 45.9% 43.1% 48.8%

3: Wasting among children distributed per zone, residency place, gender, and age category

Wasting weighted N % 95% Conf Limits Lower Upper Severe 27.12 2.6% 1.7% 3.7% Rural (n=1063.48) Moderate 138.8 13.1% 11.1% 15.3% Severe and moderate 165.92 15.6% 13.5% 18.0% Severe 1.07 0.8% 0.0% 4.2% Urban (n=131.95) Moderate 19.07 14.5% 8.9% 21.6% Severe and moderate 20.14 15.3% 9.5% 22.5% Severe 13.63 2.2% 1.3% 3.8% Girls (n = 614.41) Moderate 71.12 11.6% 9.2% 14.4% Moderate and severe 84.75 13.8% 11.2% 16.8% Severe 14.56 2.5% 1.4% 4.2% Boys (n = 581.02) Moderate 86.75 14.9% 12.2% 18.2% Moderate and severe 101.31 17.4% 14.5% 20.8% 6 - below 12 months (n = Severe 8.42 6.3% 2.6% 11.4% 134.47) Moderate 18.42 13.7% 8.2% 20.4% Moderate and severe 26.84 20.0% 13.7% 27.8% 12 - below 24 months (n = Severe 3.21 1.2% 0.2% 3.2% 270.84) Moderate 39.12 14.4% 10.4% 19.2% Moderate and severe 42.33 15.6% 11.4% 20.4% 24 - below 36 months (n = Severe 6.42 2.4% 0.8% 4.8% 268.83) Moderate 34.28 12.8% 8.9% 17.2% Moderate and severe 40.7 15.1% 11.2% 20.1% 36 - below 48 months (n = Severe 7.07 2.5% 1.0% 5.1% 278.41) Moderate 32.42 11.6% 8.0% 15.9% Moderate and severe 39.49 14.2% 10.2% 18.7% Severe 3.07 1.3% 0.3% 3.6% 48 - below 60 months (n = Moderate 33.63 13.8% 9.9% 19.0%

Wasting weighted N % 95% Conf Limits Lower Upper 242.88) Moderate and severe 36.7 15.1% 10.9% 20.4% Severe 23.54 3.8% 2.5% 5.8% Lowland (n = 614.18) Moderate 104.86 17.1% 14.2% 20.3% Moderate and severe 128.4 20.9% 17.8% 24.4% Severe 4.65 0.8% 0.3% 2.0% Mountains (n = 581.25) Moderate 53.01 9.1% 7.0% 11.8% Moderate and severe 57.66 9.9% 7.7% 12.7% Severe 28.19 2.4% 1.6% 3.4% Hajjah (n=1195.43) Moderate 157.87 13.2% 11.4% 15.3% Severe and moderate 186.06 15.6% 13.6% 17.8%