Republic of Yemen Ministry of Public Health and Population Taiz Governorate Health Office Nutrition Survey of Taiz Governorate 2016 May 2016 Final Report 1 Contents Page 1. Executive Summary 7 2.Taiz Context 9 3. Methodology 10 3.1 Setting 10 3.2 Study and sampling design 11 3.3 Sampling Procedure (The second stage) 12 3.4 Survey Population and Data Collection Process 13 3.5 Measurement Standardization and Quality Control 14 3.6 Data Entry and Analysis 15 4. Assessment Results 17 4.1 Household Characteristics 17 4.2 Food Security 21 4.3 Child Nutrition 25 4.3.1 Distribution of U5 children 25 4.3.2 Wasting (WHZ) Indicators 26 4.3.3 Oedema and WHZ Indicators 28 4.3.4 Underweight (WAZ) Indicators 29 4.3.5 Stunting (HAZ) Indicators 31 4.3.6 MUAC Indicator of Children 36 4.4 Child Morbidity and Immunization 41 4.5 Infant and Young Child Feeding (IYCF) Practices 42 4.6 Child Mortality 43 4.7 Mid-Upper Arm Circumference (MUAC) Measurement for 44 Women 4.8 Discussion and variable associations 45 5. References 48 2 3 Acronyms TC: Taiz City THL: Taiz Highland TLL: Taiz Lowland HHs: Households YER: Yemeni Rial WHZ: Weight-for-height-z score WAZ: Weight-for-age-z score HAZ: Height-for-age-z score MUAC: Mid Upper Arm Circumference GAM: Global Acute Malnutrition MAM: Moderate Acute Malnutrition SAM: Severe Acute Malnutrition 95% CI: 95% Confidence Interval FT: Fisher Test SD: Standard Deviation U5: Under Five U5MR: Under Five Mortality Rate CMR: Crude Mortality Rate MDGs: Millennium Development Goals SDGs: Sustainable Development Goals BF: Breastfeeding MDD: Minimum Dietary Diversity MMF: Minimum Meal Frequency MAD: Minimum Acceptable Diet IYCF: Infant and Young Child Feeding 4 List of Tables Table 1: Key indicators of the nutritional survey of Taiz Governorate Table 2. Parameters used in the Sample Size Determination Table 3. Chronology of Activities in Taiz Governorate Table 4: Household Characteristics Table 5: Distribution of HHs Income Quintiles by zone Table 6: HHs Food Security Indicators by zone Table 7: Descriptive Statistics of Some Food Security Indicators by zone Table 8: FCHDDSIPC indicators by income quintiles and zone Table 9: FCS Classification indicator by income quintile and zone Table 10: CS Type indicator by income quintile and zone Table 11: Distribution of U5 children by age group, gender and zone Table 12: Prevalence of Wasting (WHZ) by gender and zone (6-59 months) Table 13: Prevalence of wasting by age group and zone Table 14: Distribution of WHZ and Oedema (6-59 months) Table 15: Prevalence of Underweight (WAZ) by gender and zone (6-59 months) Table 16: Prevalence of Underweight by age group and zone Table 17: Prevalence of Stunting (HAZ) by gender and zone (6-59 months) Table 18: Prevalence of Stunting by age group and zone Table 19: Prevalence of MUAC by gender and zone (6-59 months) Table 20: Prevalence of MUAC by age group (6-59 months) and zone Table 21: Mean z-scores, Design Effects and excluded subjects by zone Table 22: Child Morbidity 6-59 by gender and zone Table 23: IYCF Indicators Table 24: U5MR for all children by zone (365 days recall time) Table 25: U5MR of male children by zone Table 26: U5MR of female children by zone Table 27: Nutrition status of women aged 15-49 years measured by MUAC Table 28: Mapping the statistical significant associations between malnutrition status of children and some socio-economic and health indicators List of Figures Figure (1): TC (WHZ) Figure (2): THL (WHZ) 5 Figure (3): TLL (WHZ) Figure (4): TC (WAZ) Figure (5): THL (WAZ) Figure (6):TLL (WAZ) Figure (7): TC (HAZ) Figure (8): THL (HAZ) Figure (9): TLL (HAZ) Figure (10): TC Population Pyramid Figure (11): THL Population Pyramid Figure (12): TLL Population Pyramid Figure (13): The malnutrition status by gender and zone Figure (14): The malnutrition status by by zone 6 1. Executive Summary A SMART survey was conducted from …. to …. 2016 in three zones namely TC, TLL and THL in Taiz Governorate (details about districts in each zone are shown on the methodology section). A total of 1458 HHs were surveyed and a variety of HH characteristics information were collected. Data were also collected from 1708 U5 children and 2338 women on the reproductive age 15- 49 years. The survey was designed and aimed at updating information about the nutritional status of children and women and more precisely: 1. To investigate some of the HHs living conditions that may – directly or indirectly – affect the nutritional status of children and women. 2. To evaluate the HHs food security situation. 3. To assess the nutritional status of U5 children and women aged 15- 49 years. 4. To assess the prevalence of infectious diseases, the immunization and Vitamin A coverage among children and follow the trends of IYCF practices. 5. To track any possible changes in U5MR trends. A two-staged cluster cross sectional study was conducted. The methods used, including sampling design and sample size determination were following SMART approach. The WHO Growth Standards and SMART flags of (±3SD) were used to calculate the nutritional situation of U5 children1,2. A cut-off of <-2SD) was used to calculate global acute malnutrition (GAM) of all nutritional indicators of children. Further, cut-off less than 22.2 cm for women and 12.5 cm for children to assess their MUAC nutritional status were used. The key indicators of the survey are shown on Table 1. Table 1: Key indicators of the nutritional survey in Taiz Governorate Indicators TC THL TLL Children Wasting (WHZ) Global 17.0% 14.5% 25.1% Severe 1.9% 1.7% 5.3% Underweight (WAZ) Global 38.1% 42.6% 48.8% Severe 8.9% 11.1% 15.9% Stunting (HAZ) Global 39.3% 49.4% 45.6% Severe 9.1% 16.7% 14.6% MUAC Global 8.3% 9.4% 11.7% 7 Severe 2.3% 2.1% 3.4% Oedema 0% 0% 0% U5MR per 10,000 per day 1.14 0.28 0.4 CMR per 10,000 per day 0.21 0.09 0.16 Still breastfeeding (6-24 months) 70.1% 67.3% 76.5% Exclusive breastfeeding < 6 months 25.0% 58.1% 11.9% Continued BF at 1 year (12–15 months) 87.5% 74.0% 80.4% Continued BF at 2 year (20-23 months) 50.0% 31.5% 54.7% MDD (6-23 months) 29.3% 27.5% 26.3% MMF (6-23 months) 50.9% 58.7% 55.4% MAD (6-23 months) 13.1% 13.0% 11.7% Proportion of children with diarrhoea within 2 45.1% 43.8% 27.4% weeks prior to assessment (6-59 months) Proportion of children with Cough Breathing 37.0% 36.9% 24.1% Difficulty (ARI) within 2 weeks prior to assessment (6-59 months) Proportion of children with Fever within 2 weeks 57.9% 62.3% 41.2% prior to assessment (6-59 months) Children immunized against measles (6-59 90.0% 88.6% 64.9% months) Children who have received 3 doses of polio 93.1% 91.1% 62.1% vaccine (6-59 months) Children reported to have received Vitamin A 91.2% 90.9% 77.9% supplementation in the last 6 months (6-59 months) Women Acute malnutrition among women Global 17.3% 19.0% 28.3% (WFP Yemen Classification) Severe 11.5% 12.4% 18.8% Acute malnutrition among Global 5.1% 7.7% 6.1% Pregnant women (WFP Yemen Severe 3.8% 6.7% 5.0% Classification) Acute malnutrition among Global 15.3% 21.4% 35.2% Lactating women (WFP Yemen Severe 17.9% 17.6% 36.2% Classification) With few exceptions, the above table marks the nutritional status of children in the three zones as critical and exceeding the emergency thresholds according to WHO categorization1. In general, the U5MR,s are high but more noticeably in TC zone. Exclusive breastfeeding varied enormously from one zone to another with the highest percentage in THL. Complementary food practices indicators are – into some extent – similar in the three zones. While 8 the highest prevalence rates of diarrhea and ARI are in TC and THL, the highest prevalence of fever in THL. More than 90% in TC and 88% in THL children were measles immunized and polio vaccinated. The situation is different with the TLL children where only 64.9% and 62.1% have been immunized against measles and polio. Vitamin A coverage is lower than 95% (the recommended coverage of Sphere Standards3) in all zones and more noticeably in TLL zone. The prevalence of acute malnutrition among women is mainly concentrated in TLL zone either on general or those who still lactating. In addition, statistical significant relationships between malnutrition status and some HHs characteristics, food security indicators and prevalence of diarrhea were found but it differ from one zone to another. Recommendations Rapid interventions should be implemented to alleviate more deterioration in the malnutrition disastrous situation in this governorate. The community-based programs should be enhanced to provide information and raise mothers awareness about the importance of breastfeeding practices and appropriate complementary feeding practices. Educate HHs about proper care and hygiene practices that could help in reducing the prevalence of infectious diseases. Efforts should be devoted to scale up the immunization and Vitamin A coverage specially in TLL zone. 2. Taiz Context Taiz Governorate is located in the southwestern part of the Republic of Yemen, bordering the Red Sea to the west, Hodaidah and Ibb governorates to the north, Lahj to the south, and Al-Dhale governorate to the east.