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 The Yemen Ministry of Public Health and Population (MoPHP)/ Hodeidah Governorate Public Health and Population Office, in collaboration with UNICEF Yemen Country Office and UNICEF Hodeidah Zone, acknowledge the contribution of the various stakeholders in this survey. The UNICEF Yemen Country Office provided technical support, employing SMART methodology. The Survey Manager was provided by Taiz GHO and field supervisors were provided by the central MoPHP and Amran and Dhamar GHOs. Survey enumerators, team leaders and data entry team were provided by GHO of Hajjah. The data analysis and report writing were made by two FMF consultants. UNICEF YCO provided the overall technical assistance especially on sampling, questionnaire and the guideline. The Hodeidah Governorate Public Health and Population over saw the political and logistical arrangements for the survey, ensuring its smooth operation. The Nutrition survey was supported financially by UNICEF under a grant from the UK Department for International Development (DfID); this support is greatly appreciated. The contribution of local authorities in ensuring the survey teams’ security during fieldwork and in providing office facilities is gratefully appreciated. The data could not have been obtained without the co-operation and support of the communities assessed, especially the mothers and caretakers who took time off from their busy schedules to respond to the interviewers. Their involvement and cooperation is highly appreciated. UNICEF and MoPHP also express their sincere appreciation to the entire assessment team for the high level of commitment and diligence demonstrated during all stages of the assessment to ensure high quality of data collected, and the successful accomplishment of the exercise. 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 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 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 Annex 7: Tables of Weighted Finding of Nutritional Status .................................................................................. 48 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, Mountainous and Lowland of Hajja Governorate in 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