Final report October 2019-March 2020 Grand Bassa, Grand Cape Mount, Rural Montserrado, Rivercess, and Sinoe Counties 2 ACKNOWLEGEMENTS The Link NCA in Grand Bassa, Grand Cape Mount, Rural Montserrado, Rivercess, and Sinoe Counties was commissioned by the Liberian Wash Consortium and funded by Irish Aid. The study was conducted by Link NCA Analyst, Grace Heymsfield, under the supervision of Lenka Blanárová, Senior Nutrition Assessment Coordinator, Action Against Hunger UK, and the study’s focal points: Tom Health (Action Against Hunger France WASH Technical Adviser) and Michael Slewion Doe (Consortium Coordinator), with valuable contributions from the pool of Technical Advisors at Action Against Hunger, France, namely Fabienne Rousseau, Xuan Phan and Janis Differt; Tekar Jallah-Bundor, Action Against Hunger Liberia Nutrition and Health Program Manager, and Mohamed Takoy, Action Against Hunger Liberia Country Representative. The Link NCA team wishes to express their thanks to all those who have contributed to this study and/or facilitated its development, in particular the qualitative and quantitative study teams for their expertise and sense of humor.1 A special thank you to: • G. Tarnue Brooks, Action Against Hunger M&E Officer, for his constant encouragement and immense support co-managing the Risk Factor Survey; • Two additional team members who ‘Linked’ both stages of the study, propelling the study forward with their qualitative and quantitative experience: Paul Sahr Johnson & Joseph N. Davis- Qualitative Research Assistants, Quantitative Supervisors; To Dr. Annette Brima- Davis, Director, Nutrition Division, and Mameni Linga Morli, National SUN Focal Point, for their support of the study, as well as the Grand Cape Mount, Grand Bassa, Montserrado, Rivercess, and Sinoe County Health Teams, for their tireless efforts and partnership. To local authorities for their dedication in the fight to improve health and food security and their unwavering support over the course of the study, and residents of sampled towns for their hospitality and genuine collaboration. To all technical experts who attended the Link NCA technical workshops, for sharing their expertise and hence contributing to the high quality of the study. A special thank you to Jeffrey Rozelle for technical advice and GIS support. To all residents of sampled towns for their hospitality and genuine collaboration. This study would not have been possible without the exceptional work and commitment of all people involved. 1 Full listing of team members in Annex F. 3 ABBREVIATIONS AAH / ACF Action Against Hunger / Action Contre la Faim ANC Antenatal Care ARI Acute Respiratory Infections CFSNS The Comprehensive Food Security and Nutrition Survey CHA Community Health Assistant CI Confidence Interval CMAM Community Management of Acute Malnutrition DHS Demographic and Health Survey ECHO European Civil Protection and Humanitarian Aid Operations ENA Emergency Nutrition Assessment FAO Food and Agriculture Organization FGD Focus Group Discussion FSL Food Security and Livelihoods GAM Global Acute Malnutrition gCHV General Community Health Volunteer GCM Global Chronic Malnutrition GoL Government of Liberia HAZ Height for Age z-score HH Household HHS Household Hunger Scale HDDS Household Dietary Diversity Score HIES Household Income and Expenditure Survey HQ Headquarters IDDS Individual Dietary Diversity Score IYCF Infant and Young Child Feeding Link NCA Link Nutrition Causal Analysis LMH Last Mile Health LNNMS Liberia National Nutrition And Mortality Survey LR Livelihood Zone MAHFP Months of Adequate Household Food Provisioning MAM Moderate Acute Malnutrition MCSP Maternal Child Survival Program MIS Malaria Indicator Survey MUAC Mid-Upper Arm Circumference NGO Non-Governmental Organization OTP Outpatient Therapeutic Programme PLW Pregnant and Lactating Woman PNC Postnatal Care PPS Probability Proportionate to Size rCSI Reduced Coping Strategy Index RFS Risk Factor Survey RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition SCI Save The Children SFP Supplementary Feeding Programme SSI Semi-Structured Interview SMART Standardized Monitoring for Assessment in Relief & Transitions TBA Traditional Birth Attendant 4 TTM Trained Traditional Midwife UNICEF United Nations’ Children’s Fund USAID United States Agency for International Development WASH Water, Sanitation and Hygiene WaST Concurrent Wasting and Stunting WFP World Food Programme WHO World Health Organization WHZ Weight for Height z-score FIGURES Figure 1: Map of the study area [in blue] Figure 2: Study area by region [Region 1- Green, Region 2- Blue, Region 3- Grey] Figure 3: Predominant Livelihood Zones, Liberia Figure 4: Summary of key barriers to health care in study zone Figure 5: Example diarrhea treatment pattern [Grand Bassa] Figure 6: Example fever treatment pattern [Grand Bassa] Figure 7: Example cough treatment pattern [Grand Bassa] Figure 8: Household food allocation, as described in the qualitative inquiry, November-December 2019 Figure 9: Cycle of under-nutrition Figure 10: Percentage of children who consumed the 7 recommended food groups Figure 11: Livelihood zones [2017] and study counties Figure 12: Percentage of children under 5 years old surveyed per livelihood zone Figure 13: Months of inadequate food home provisioning, Risk Factor Survey Figure 14: Coping Strategies Classifications, Risk Factor Survey Figure 15: Percentage of children’s households engaged in coping strategies, Risk Factor Survey Figure 16: Water Sources, Risk Factor Survey Figure 17: Typical water decision-making tree in localities with multiple water points, as described by focus group participants during the qualitative inquiry, Rivercess [Region 3], November-December 2019 Figure 18: Point of use water treatment, households utilizing unprotected water sources, Risk Factor Survey Figure 19: Child defecation, Risk Factor Survey Figure 20: Workload Perception, Risk Factor Survey Figure 21: Decision-making involvement, Risk Factor Survey Figure 22: External support, Risk Factor Survey Figure 23: Historical Trends of Stunting Figure 24: Simplified causal pathway for Region 1 (Grand Cape Mount County) Figure 25: Simplified causal pathway for Region 2 (Grand Bassa and Montserrado Counties) Figure 26: Simplified causal pathway for Region 3 (Sinoe and Rivercess Counties) Figure 27: Simplified causal pathway for the entire study area (based on pooled data) LIST OF TABLES Table 1: Parameters of the quantitative study, by region Table 2: Qualitative sampling framework for the Link NCA qualitative survey, five selected counties in Liberia Table 3: Summary of community consultations during the Link NCA qualitative inquiry Table 4: List of hypothesized risk factors validated for field-testing during Initial Technical Workshop, including Technical Experts Rating Table 5: Seasonal calendar of main child illnesses in the study zone Table 6: Historical report, health changes 5 Table 7: Perception of risk related to certain birth-spacing/ pregnancy factors Table 8: Results of participatory exercises on meal composition Table 9: Perception of the risks associated with breastfeeding practices Table 10: Ideal meals, complementary feeding Table 11: Perception of the risks associated with childcare practices Table 12: Dominant livelihood zones in the study zone Table 13: Income Generating Activities (IGA), Region 1 Table 14: IGA, Region 2 Table 15: IGA, Region 3 Table 16: Income Generating Activities, by season Table 17: Barriers mentioned regarding agriculture Table 18: Mean livestock ownership: Risk Factor Survey, 95% CI Table 19: Barriers mentioned regarding choice to maintain livestock Table 20: Household expenses Table 21: Seasonal calendar, household expenses Table 22: 2019 CoD (Rainy season) in Link NCA Regions of Study Table 23: Summary of market access, Link NCA Regions Table 24: Town policies for water use, as described in qualitative inquiry, November- December 2019 Table 25: Perception of the risks associated with water quality Table 26: Sanitation/ hygiene laws, as described in the qualitative inquiry, November- December 2019 Table 27: Perception of the risks associated with certain sanitation/hygiene practices Table 28: Peak women workload, as described in qualitative inquiry, November- December 2019 Table 29: Peak men’s workload, as described in qualitative inquiry, November- December 2019 Table 30: Overview of decision-making powers within a household, as described in qualitative inquiry, November- December 2019 Table 31: Summary of anthropometric results, Risk Factor Survey Table 32: Number of cases by anthropometric deficiency, Risk Factor Survey Table 33: List of local terms used to describe different forms of undernutrition Table 34: Synthesis of the results of the exercise of the categorization of community risk factors Table 35: Summary of categorization of risk factors Table 36: Rating grid for the categorization of risk factors Table 37: Ideal Woman Exercise Table 38: Ideal Man Exercise PHOTOS Photo 1: Interactive indicators, Risk Factor Survey Photo 2: Team member defines EA with community mobilizer Photo 3: Participatory household spending exercise, Montserrado County Photo 4: Fermenting Cassava, Grand Bassa [Soaking, overlaid with palm leaves, packed for sale] Photo 5: Risk Factor Survey team river crossing, Grand Bassa Photo 6: Young fisherman pushes his canoe after being interviewed 6 TABLE OF CONTENTS ACKNOWLEGEMENTS ..................................................................................................................................................................................................