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 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 Medium Term Interventions: ....................................................................................................................................2 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 3: Hajjah governorate Nutrition Survey Team, 27 Aug-9 September 2015 ............................................... 42 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 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 in Hajja Governorate of 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). There was high prevalence of common disease, as recorded during the survey (diarrhea, Acute Respiratory Infection (ARI) and fever prevalence are the reported cases 2 weeks before the survey while measles was one month before the survey (table 1 ) below . Vitamin A coverage was lower than the Sphere Standards recommendation of 95 per cent coverage (Lowland Zone – 75.1 per cent; Mountains – 68.2 per cent). 1 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. In Mountainous zone, continued breast feeding at one year was 87.9 per cent and become 60 per cent at two years and 16.8 per cent of 6-23 children in Lowland zone are on