AWEIL NORTH COUNTY SQUEAC ASSESSMENT REPORT BY MARCH 22, 2018 Report By: Jacqueline Macharia Acknowledgement This is an expression of gratitude towards the individuals and organizations that effortlessly supported the processes of this noble exercise. The 2017 SQUEAC in Aweil North County would not have been successful without their inputs. • The donor for funding the assessment • The Ministry of Health (MoH), State MoH and the County Health Department for their support and authorizing the assessment process within the community to proceed as planned • The entire Aweil North community for their patience, willingness to give information to the best of their knowledge when called upon and in allowing screening of their children. • Premiere Urgence Internationale (PUI) for providing some inputs used in triangulation being the nutrition partner in Aweil North • Concern worldwide for their inputs in planning for the assessment and mobilizing the community concerning the exercise. Thank you to the staff that went out of their way to assist during some processes for smooth running. i Table of Content Acknowledgement -------------------------------------------------------------------------------------------- i Abbreviations ------------------------------------------------------------------------------------------------ iv Executive Summary ----------------------------------------------------------------------------------------- v Introduction --------------------------------------------------------------------------------------------------- 1 1.1 Background ----------------------------------------------------------------------------------------------------------- 1 1.2 Shocks ------------------------------------------------------------------------------------------------------------------ 1 1.3 Health and Nutrition ----------------------------------------------------------------------------------------------- 2 1.4 Previous SQUEAC -------------------------------------------------------------------------------------------------- 3 1.5 Timing of the Assessment ----------------------------------------------------------------------------------------- 3 1.6 Justification ----------------------------------------------------------------------------------------------------------- 3 1.7 Objectives -------------------------------------------------------------------------------------------------------------- 3 1.8 Challenges ------------------------------------------------------------------------------------------------------------- 4 Methodology -------------------------------------------------------------------------------------------------- 4 2.1.1 Quantitative Data ---------------------------------------------------------------------------------------------- 4 2.1.1.1 Admission by Month ---------------------------------------------------------------------------------------------- 4 2.1.1.2 MUAC Admissions ------------------------------------------------------------------------------------------------ 6 2.1.1.3 Time to Default ----------------------------------------------------------------------------------------------------- 7 2.1.1.4 Length of Stay ------------------------------------------------------------------------------------------------------ 7 2.1.1.5 Discharge Outcomes ----------------------------------------------------------------------------------------------- 9 2.1.1.6 Documentation ----------------------------------------------------------------------------------------------------- 11 2.1.2 Qualitative Data ---------------------------------------------------------------------------------------------- 12 2.1.2.1 Barriers and Boosters -------------------------------------------------------------------------------------------- 13 2.2 Stage 2 ---------------------------------------------------------------------------------------------------------------- 20 2.2.1 Stage 2 Process ------------------------------------------------------------------------------------------------ 20 2.2.2 Case Definition ------------------------------------------------------------------------------------------------ 21 2.2.3 Prior Formation ---------------------------------------------------------------------------------------------- 22 2.2.3.1 Un-weighted Barriers and Boosters -------------------------------------------------------------------------- 22 2.2.3.2 Weighted Barriers and Boosters ------------------------------------------------------------------------------ 22 2.2.3.3 Concept Map ------------------------------------------------------------------------------------------------------- 23 2.2.3.4 Histogram Prior --------------------------------------------------------------------------------------------------- 23 2.3 Stage 3 ---------------------------------------------------------------------------------------------------------------- 24 2.3.1 Sample Size Calculation ------------------------------------------------------------------------------------ 24 2.3.2 Quantitative Sampling Framework --------------------------------------------------------------------- 24 2.3.3 Case Finding Methodology -------------------------------------------------------------------------------- 25 2.3.4 Quantitative Data Results --------------------------------------------------------------------------------- 25 2.3.5 Reasons for SAM Non-Attendance ---------------------------------------------------------------------- 26 Conclusion ------------------------------------------------------------------------------------------------------------ 27 Annexes ------------------------------------------------------------------------------------------------------- 28 Annex 1 Recommendations ------------------------------------------------------------------------------------------ 28 Annex 2: Wide Area Survey Results ------------------------------------------------------------------------------ 30 ii Annex 3: Point and Period Coverage ----------------------------------------------------------------------------- 31 Annex 4: List of Aweil North SQUEAC Participants -------------------------------------------------------- 31 Annex 5: Review of Selected Action Points Derived from the Previous SQUEAC ------------------- 32 Annex 6: Concept Map in the Context of Aweil North ------------------------------------------------------- 33 List of Figures Figure 1: Admissions over Time (Dec 16 – Nov 17) ------------------------------------------------------------------ 5 Figure 2: Total Admission by MUAC (Sep - Nov 17) ---------------------------------------------------------------- 6 Figure 3: MUAC ≥ 11.5 cm Admissions by Centre (Sep – Nov 17) ----------------------------------------------- 7 Figure 4: Time-to-Default (Sep - Nov 17) ------------------------------------------------------------------------------- 7 Figure 5: Length of Stay (Sep 17 - Nov 17) ----------------------------------------------------------------------------- 8 Figure 6: Discharge Outcomes over Time (Dec 16 – Nov 17) ------------------------------------------------------- 9 Figure 7: Admissions and Discharge by Payam (Dec 16 – Nov 17) ---------------------------------------------- 10 Figure 8: Example of a Register showing drastic changes in MUAC measurements, missing exit information and mixed up visit dates ----------------------------------------------------------------------------------- 11 Figure 9: Prior Mode based on BayesSQUEAC calculator at β(12.5,5.9) --------------------------------------- 23 Figure 10: Beta Binomial Conjugate Analysis using BayesSQUEAC calculator ------------------------------ 26 Figure 11: Reasons for SAM Non-Attendance ------------------------------------------------------------------------ 26 List of Tables Table 1: Distribution of OTP sites by Payam in Aweil North County ------------------------------------------- 10 Table 2: Barriers and Boosters ------------------------------------------------------------------------------------------- 13 Table 3: Stage 2 Results by Village ------------------------------------------------------------------------------------- 21 Table 4: LQAS Decision Rule Results --------------------------------------------------------------------------------- 21 Table 5: Weighted and Un-Weighted Barriers and Boosters ------------------------------------------------------- 22 Table 6: Single Coverage Estimate Results ---------------------------------------------------------------------------- 25 List of Equations Equation 1: Sample Size Calculation (SAM Cases) ----------------------------------------------------------------- 24 Equation 2: Sample Size Calculation (Number of Villages) ------------------------------------------------------- 24 iii Abbreviations CF: Community Facilitator CI: Confidence/Credible Interval CMAM: Community Management of Acute malnutrition CNV: Community Nutrition Volunteers CWW: Concern Worldwide FSNMS: Food Security and Nutrition Monitoring Survey GAM: Global Acute Malnutrition GFD: General Food Distribution HHP: Home Health Promoters IPC: Integrated Phase Classification KAP: Knowledge, Attitude and Practice LQAS: Lot Quality Assurance Sampling MTMSG: Mother to Mother Support Group MUAC: Mid-Upper Arm Circumference NBeG: Northern Bahr el Ghazal NGO: Non-Governmental Organization OPD: Outpatient Department OTP: Outpatient Therapeutic Program PHCC: Primary Health Care Centre PHCU: Primary Health Care Unit PUI: Premeire Urgence Internationale RUTF: Ready to Use Therapeutic Food SAM: Severe acute malnutrition SC: Stabilization Centre SMART: