THE FEDERAL REPUBLIC OF SOMALIA Somali Micronutrient Survey 2019 Xog la helaa talo la helaa - Information for better decisions SOMALIA MICRONUTRIENT SURVEY – 2019 SOMALIA MICRONUTRIENT SURVEY 2019 FINAL REPORT – AUGUST 2020 Recommended Citation: Ministry of Health FGS, FMS, Somaliland, UNICEF, Brandpro, GroundWork. Somalia Micronutrient Survey 2019. Mogadishu, Somalia; 2020. SOMALIA MICRONUTRIENT SURVEY – 2019 Government Partner Funding agencies KINGDOM OF BELGIUM Implementing agency i SOMALIA MICRONUTRIENT SURVEY – 2019 TABLE OF CONTENTS INVESTIGATORS AND INSTITUTIONAL AFFILIATIONS ......................................................... x ACKNOWLEDGEMENTS .................................................................................................... xi ABBREVIATIONS ............................................................................................................. xii EXECUTIVE SUMMARY ...................................................................................................... 1 1. INTRODUCTION ........................................................................................................... 9 1.1. Nutritional situation of young children and women in Somalia ............................... 9 1.2. Rationale for the survey ............................................................................................ 9 1.3. Research goal .......................................................................................................... 10 1.4. Primary objectives ................................................................................................... 10 1.5. Secondary objectives ............................................................................................... 11 1.6. Implementation of the SMS 2019 ........................................................................... 11 2. METHODOLOGY ........................................................................................................ 12 2.1. Survey design ........................................................................................................... 12 2.2. Survey participants .................................................................................................. 13 2.3. Sample size determination ...................................................................................... 13 2.4. Primary outcomes ................................................................................................... 15 2.5. Ethical considerations ............................................................................................. 15 2.6. Field work and data collection ................................................................................ 16 2.6.1. Instrument pre-testing, training of survey teams, and field testing ........ 16 2.6.2. Community mobilization and sensitization .............................................. 18 2.6.3. Selection of PSUs ...................................................................................... 18 2.6.4. Changing security status and replacement PSUs ..................................... 19 2.6.5. Household listing and random selection of households .......................... 19 2.6.6. Field work (interviews) ............................................................................. 19 2.6.7. Field work (anthropometry and phlebotomy) .......................................... 21 2.6.8. Cold chain and processing of blood samples ............................................ 22 2.6.9. Supervision of fieldwork ........................................................................... 22 2.7. Definitions of indicators and specimen analysis ..................................................... 22 2.7.1. Anthropometric indicators ....................................................................... 22 2.7.2. Urinary iodine and drinking water iodine concentrations ....................... 23 2.7.3. Blood specimens ....................................................................................... 24 2.7.4. Analysis of iodine in salt ........................................................................... 26 2.8. Data management and analysis .............................................................................. 26 2.8.1. Data entry ................................................................................................. 26 2.8.2. Data monitoring ........................................................................................ 26 2.8.3. Data analysis ............................................................................................. 26 2.8.4. Case definitions of key indicators and nutritional deficiencies ................ 27 ii SOMALIA MICRONUTRIENT SURVEY – 2019 3. RESULTS .................................................................................................................... 29 3.1. Response rates for households, children, and women ........................................... 29 3.2. Household Characteristics ....................................................................................... 31 3.2.1. Demographic characteristics .................................................................... 31 3.2.2. Displacement and relocation .................................................................... 33 3.2.3. Agricultural activities and livestock ownership ........................................ 36 3.2.4. Household financial access and remittances ............................................ 36 3.2.5. Cooking fuel and household lighting ........................................................ 38 3.2.6. Water and sanitation ................................................................................ 38 3.2.7. Bednet ownership and use ....................................................................... 40 3.2.8. Food insecurity ......................................................................................... 42 3.2.9. Salt iodine concentration .......................................................................... 44 3.2.10. Drinking water iodine concentration ........................................................ 45 3.2.11. Bouillon cube use and consumption ........................................................ 48 3.3. Children ................................................................................................................... 50 3.3.1. Characteristics .......................................................................................... 50 3.3.2. Low birthweight ........................................................................................ 51 3.3.3. Recent illness and treatment .................................................................... 53 3.3.4. Infant and young child feeding indicators ................................................ 53 3.3.5. Consumption of vitamin and mineral supplements ................................. 55 3.3.6. Stunting ..................................................................................................... 59 3.3.7. Wasting ..................................................................................................... 62 3.3.8. Underweight ............................................................................................. 65 3.3.9. Mid-upper arm circumference ................................................................. 68 3.3.10. Malaria ...................................................................................................... 71 3.3.11. Anemia, iron deficiency, and iron deficiency anemia .............................. 71 3.3.12. Vitamin A deficiency ................................................................................. 78 3.3.13. Zinc deficiency .......................................................................................... 80 3.3.14. Hemoglobinopathies ................................................................................ 81 3.4. All Women ............................................................................................................... 83 3.4.1. Characteristics .......................................................................................... 83 3.4.2. Educational attainment ............................................................................ 84 3.4.3. Supplement consumption ........................................................................ 88 3.4.1. Coffee and tea consumption .................................................................... 89 3.4.2. Dietary diversity ........................................................................................ 89 3.5. Non-pregnant women ............................................................................................. 91 3.5.1. Anthropometry ......................................................................................... 91 3.5.2. Malaria ...................................................................................................... 95 3.5.3. Anemia, iron deficiency, and iron deficiency anemia .............................. 95 3.5.4. Vitamin A deficiency ............................................................................... 102 3.5.5. Folate and Vitamin B12 deficiencies....................................................... 102 3.5.6. Median urinary iodine concentration ..................................................... 104 iii SOMALIA MICRONUTRIENT SURVEY – 2019 3.6. Pregnant women ................................................................................................... 106 3.6.1.