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Nutrition and Mortality Survey in
Al-Baidha Governorate
Yemen
24 – 29 /October/2015
Ministry of Public Health and Population
Al-Baidha Governorate Health Office
United Nations Children’s Fund (UNICEF)
Nutrition and Mortality Survey Report
Al-Baidha Governorate, Yemen
24 – 29 /October/2015
ACKNOWLEDGEMENTS
The Yemen Ministry of Public Health and Population (MoPHP)/ Al-Baidha Governorate Public Health and Population Office, in collaboration with UNICEF Yemen Country Office and UNICEF Sana’a Zone, acknowledge the contribution of the various stakeholders in this survey.
The UNICEF Yemen Country Office provided technical support, employing SMART methodology. The survey plan has been prepared by Nutrition Department of MOPHP, the Survey Manager was provided by Taiz GHO and field supervisors were provided by the central MoPHP and Taiz and Dhamar GHOs. Survey enumerators, team leaders and data entry team were provided by GHO of Al-Baidha. The data analysis was completed by the FMF consultant while report writing was made by the HAD consultant. UNICEF YCO provided the overall technical advices especially on sampling, questionnaire and the guideline.
Al-Baidha Governorate Public Health and Population oversaw 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 EU Humanitarian Aid and Civil Protection (ECHO); 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
CI Confidence Interval
CMAM Community Management of Acute Malnutrition
DHS Demographic Health Survey
ENA Emergency Nutrition Assessment
FHS Family Health Survey
GAM Global Acute Malnutrition
HAZ Height for age z-score
HDDS Household diet diversity Scoring
IPC Integrated food security phase Classification
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
WFP-CFSS World food programme- Comprehensive Food Security Survey
Table of contents
Executive summary .......................................................................................................................................... 1
Introduction / background ................................................................................................................................. 4
Assessment objectives ..................................................................................................................................... 5
Methodology ..................................................................................................................................................... 6
Sampling Design and Sample Size Determination ...................................................................................... 6
Sampling Procedure: .................................................................................................................................... 6
Survey Population and Data Collection Process ......................................................................................... 9
Measurement Standardization and Quality Control ..................................................................................... 9
Data Entry and Analysis ............................................................................................................................. 10
Data Entry Verification and Cleaning ......................................................................................................... 11
Results ............................................................................................................................................................ 12
Household Characteristics of Study Population: ........................................................................................ 12
Morbidity, Immunization Status of the U5 children: .................................................................................... 14
Infant and young child feeding (IYCF) practices: ....................................................................................... 15
Nutrition Status ........................................................................................................................................... 17
Mortality: ..................................................................................................................................................... 19
Discussion and variable association .............................................................................................................. 21
Levels of Malnutrition: ................................................................................................................................. 21
Morbidity and Malnutrition Levels: .............................................................................................................. 23
Child Feeding and Malnutrition Levels ....................................................................................................... 24
Nutrition Status and Food consumption based on household dietary diversity ......................................... 24
Water and sanitation with Nutrition situation: ............................................................................................. 25
Recommendations: ........................................................................................................................................ 25
Annexes .......................................................................................................................................................... 27
Annex 1: Al-Baidha Governorate Nutrition Survey Questionnaire ................................................................. 28
Annex 3: Al-Baidha Governorate Nutrition Survey Team, October 2015 ...................................................... 38
Annex 4.: Al-Baidha Nutrition Survey Standardization Test Report for Evaluation of Enumerators ............. 40
Annex 5: job descriptions for Survey Teams (Extracted from SMART Training Materials) ....................... 41
Annex 6: Al-Baidha Governorate Assessment Quality Checks ..................................................................... 44
Annex 7: Cluster Sampling for Al-Baidha Nutrition Survey ............................................................................ 45
Annex 8: Age Conversion Tables for Al-Baidha Nutrition Survey ................................................................. 46
Annex 9: Calendar of Events for Al-Baidha Nutrition Survey for Reference in Age Estimation. .................. 47
1
Executive summary
Between 24 and 29 October 2015, MoPHP and Al-Baidha Governorate Public Health and Population Office supported by UNICEF conducted a nutrition and mortality survey in Al-Baidha Governorate using the Standardized Monitoring and Assessment for Relief and Transition (SMART) methodology mainly to assess the levels of acute malnutrition among children aged 6-59 months, to assess levels of stunting and underweight, to identify some of the factors associated with malnutrition, estimate the under-five and crude death rates, and inform on the appropriate responses.
Using a two-stage Probability Proportionate to Population Size (PPS) sampling methodology, 30 clusters were randomly selected for both anthropometric and mortality assessments. A minimum of 14 households per cluster were randomly selected and assessed. A total of 444 households were surveyed, covering a total of 622 children aged 6-59 months.
The nutritional situation is shown in table 1 below. The Global Acute Malnutrition (GAM) rate was 6.0 per cent (95% CI: 4.1 – 8.7), with Severe Acute Malnutrition (SAM) 0.5 per cent (95% CI: 0.2 – 1.5). According to WHO categorization, these rates indicate that the nutrition situation in Al-Baidha Governorate is ‘poor’ which is between 5 - 9.9 per cent. However, with the current aggregating factors and the ongoing armed conflict there, Al-Baidha is classified as ‘serious’.
Underweight and stunting were ‘serious’ with 22.0 per cent (95% CI: 17.1 – 27.9) and 34.6 per cent (95% CI: 29.3 – 40.4) respectively. No significant different between both genders in GAM, underweight and stunting.
The main sources of drinking water in the Governorate are unprotected open well and water tanker with levels of 26.8 per cent and 24.3 per cent respectively. Majority of households latrine type was pour flush with level of 72.5 per cent.
There is high prevalence of common disease, as recorded two weeks prior to the survey (diarrhoea, acute respiratory infection (ARI) and fever prevalence). Vitamin A coverage is lower than the Sphere Standard’s recommendation of 95 per cent coverage (25.2 per cent). About 18 per cent of children aged 0-6 months was being exclusive breastfed. Among children 12 to 15 months of age, 53.7 per cent still on breastfeeding and only 16.6 per cent of children aged 6-23 months met the recommended minimum dietary diversity.
There is no statistically significant relationship between acute malnutrition and feeding patterns, with
vitamin A supplementation, or with cough or fever, but diarrhoea has shown relation to underweight.
Minimum diet diversity among children aged 6-23 months has shown close relation with stunting
while food consumption based on household dietary diversity has shown relation with underweight.
The crude death rate found is 0.33 per 10000 per day, while the under-five (U5) death rate is 0.12
per 10000 per day and both are within the acceptable levels of less than 1 /10,000/day.
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Specific recommendations include:
Immediate Interventions
Develop detailed integrated response micro-plan articulating district level humanitarian needs.
Strengthen and expanding CMAM services to reach all health facilities and outreach services where acute malnutrition is high as in Mukayras, Nati’, Al-Sawadityah and Al-A’rsh.
CMAM services should adhere to the CMAM protocol (ensuring systematic treatment and full consideration of moderate acute malnutrition management) that should be integrated with infant feeding, hygiene promotion and food security interventions.
To promote appropriate IYCF practices (early initiation of breastfeeding, exclusive and sustained breastfeeding for 2 years and promotion of appropriate complementary feeding practices for children aged 6 to 24 months) along with micronutrient supplementations and deworming.
Accelerate the integration of IYCF counselling into all CMAM services delivered by both fixed and mobile clinics.
Intensive social mobilisation campaigns on IYCF feeding and caring practices through behaviour change / communication interventions mainly in the following areas; timely introduction of complementary food and continue breastfeeding up to two years, along with Vitamin A supplementation, micronutrient supplements, and promotion of safe sanitation and hygienic practices including hand washing with soap as well as safe disposal of children’s excreta, diarrhoea prevention measures and appropriate management of ARI among young children.
Medium term Interventions
The nutrition package that includes the management of acute malnutrition, the growth monitoring and promotion (GMP), IYCF counselling, and supplementation with micronutrients for child and mother should be entered to the minimum official service list at the governorate level to assure provision of this package by all working health facilities.
Continued support for longer term water development and sanitation programmes throughout the governorate, with community mobilization activities to promote safe sanitation and hygienic practices.
Exploring new initiatives to promote small scale income generating projects, draw lessons learnt and replicate the successful projects.
Promote improved latrine use and other hygiene services like Community Led Total Sanitation (CLTS) strategy.
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Table 1: Summary of Nutrition Survey in Al-Baidha governorate, October 2015
Indicator N % 95% CI
Child Malnutrition Total number of households assessed for children 444/ 448 99.1
Mean household size 8.6
Total number of children assessed (6-60 months) 622/624 99.6
Number of children less than 6 months 74/698 10.6
Child sexofU5 children
Males (boys) 346 49.7
Females (girls) 350 50.3
Global acute malnutrition (WHZ<-2 z-score or oedema) 37 6.0 4.1 - 8.7
Moderate acute Malnutrition (-2 >z-score >=-3, no oedema)
34 5.5 3.6 - 8.2
Severe acute Malnutrition (WHZ<-3 z score or oedema) 3 0.5 0.2 - 1.5
Oedema 0 0 0.0-0.0
Chronic malnutrition (H/A<-2 z score) 212 34.6 29.3 - 40.4
Moderate chronic Malnutrition(-2 >z-score >=-3) 147 24.0 20.5 - 28.0
Severe chronic Malnutrition (H/A<-3 Z score) 65 10.6 7.5 - 14.8
Underweight prevalence (W/A<-2 Z score) 136 22.0 17.1 - 27.9
Moderate underweight(-2 >z-score >=-3) 106 17.2 13.3 - 21.9
Severe underweight (W/A<-3 z score) 30 4.9 3.2 – 7.3
Child Morbidity Children reported with suspected measles within one month prior to assessment
14 2.0 1.0 - 3.1
Children reported with diarrhoea in 2 weeks prior to assessment 288 41.5 37.8 - 45.2 Children reported with ARI within 2 weeks prior to assessment 324 46.7 43.0 - 50.4 Children reported with fever in 2 weeks prior to assessment 340 49.0 45.3 - 52.7 Immunization and Supplementation Status Children aged 9 – 59 months immunised against measles Total 303 51.4 47.4 - 55.5 Confirmed by vaccination cards 187 31.7 28.0 - 35.5 Confirmed by recall 116 19.7 16.5 - 22.9
Children who have received 3 doses of polio vaccine 279 45.0 41.1 - 48.9
Children reported to have received vitamin A supplementation in last 6 months
156 25.2 21.8 - 28.6
Child Feeding Exclusive breastfeeding under 6 months 13 18.3 9.3 - 27.3 Continued breast feeding at one year 29 53.7 40.4 – 67.0 Continued breast feeding at two years 7 25.9 9.4 - 42.5 Minimum diversity diet at 6-23 months 34 16.6 11.5 - 21.7 Mortality 0-5 Death Rate (U5DR) as deaths/10,000/ day 0.12 0.02-0.93
Crude Death Rate (CDR) as deaths/10,000/ day 0.33 0.20-0.54
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Introduction / background
Al- Baidha Governorate is located in the central part of the country With an area of 9,314 square kilometres and divided into 20 districts, Al Baidha is bordered by Abyan, Lahj and AlDhale’ in the south, Dhamar and Ibb in the west, Shabwah and Abyan in the east, and Shabwah, Mareb and part of Sana’a in the north. Rada’a district is the largest in terms of area with almost one third of the Governorate area, while DhiNa’im district is the smallest. Al Baidha is one of the governorates with greatest poverty in Yemen.
It considered is one of the highest tribal violence Governorate; the frequent tribal violence in Al- Baidha contributes to a lack of basic services locally.
Similar to the neighbouring governorates agriculture and livestock is the main stay complemented by petty trade and commercial activities around the capital and district towns. Although the economic income from Qat is high its expansion is encroaching the agricultural land which is a threat due to crop and livestock production. This is clearly reflected under the continued decline of local crop production and to the food and nutrition security of the vulnerable segment of the population.
Continued insecurity and fighting between different factions affected the overall economic development and daily life of the people.The conflict is seriously disrupting livelihoods and income options in the country in a number of ways. The airstrikes and conflicts have damaged essential infrastructure including markets, roads, bridges, hospitals, schools, residential houses, power stations, and water lines. Markets are not functioning in more than half of the governorates located in the western half of the country where prices of essential food and non-food commodities have escalated by over 40 percent compared to the pre-crisis levels.
The Governorate is facing scarcity in the water resources while in some areas, drought is commonly
exist. In many cases, IDP families are living in caves where drinking water sources stagnant pools. Lack
of clean water and fragile sanitation situation is leading to some increased prevalence of diseases like
acute diarrhea. Water and sanitation situation is in its worst level and access to portable water is a big
challenge for many people in the Governorate. The food shortage and the increase of its price is
affecting the food consumption and household dietary diversity.1
1 Acute food insecurity analysis worksheet of Al-Baidha Governorate. May, 2015.
Figure (1): Al-Baidha governorate-Yemen Map
5
Assessment objectives
The overall objective of the survey was to establish the nutrition situation in Al-Baidha Governorate, determine some of the factors influencing malnutrition.
Specific objectives were:
1. To estimate the level of acute malnutrition (wasting), stunting and underweight among children aged 6-59 months in Al-Baidha Governorate.
2. To identify factors influencing nutrition status of the children in Al-Baidha Governorate including disease prevalence, income status, drinking water cleanness, latrine type, and access to food.
3. To estimate the prevalence of some common diseases (suspected measles, diarrhoea, fever and ARI) in Al-Baidha Governorate.
4. To estimate the measles and polio vaccination and vitamin A supplementation coverage among children in Al-Baidha Governorate.
5. To assess distribution of baby milk gifts in surveyed households in Al-Baidha Governorate.
6. To determine some IYCF indicators (Exclusive breastfeeding, continued breastfeeding at 1 and 2 years, and minimum dietary diversity (MMD) in Al-Baidha Governorate.
7. To estimate the crude and under-five mortality/death rates in Al-Baidha Governorate.
6
Methodology
Sampling Design and Sample Size Determination
A cross-sectional survey was conducted between 24 and 29 October 2015 in Al-Baidha Governorate.
Using a two-stage Probability Proportionate to Population Size (PPS) sampling methodology, 30
clusters were randomly selected for the survey. The cluster sampling methodology was selected in
view of lack of an exhaustive updated list of household details.
A sample size of 395 households was calculated using ENA for SMART software based on the
estimated parameters shown in Table 2. The calculated sample size for mortality was about 342
households, hence the sample calculated for anthropometry was considered for mortality as well.
A minimum of 14 households per cluster were recommended for assessing the anthropometry and
mortality. A total of 448 households were surveyed reaching a total number of 698 under 5 children
among which 624 children aged 6-59 months.
Table 2. Parameters used in the Sample Size Determination
Anthropometry Mortality
Number of clusters 30 Number of clusters 30
Probability 0.05 Probability 0.05
T 2.045 T 2.045
Expected prevalence (p)
6.3
Estimated crude death rate (CDR) per 10000/day 0.27
Relative desired precision (d) 3
Relative desired precision (d) per 10000/day 0.2
Design Effect (DEFF) 2 Design Effect (DEFF) 1.5
n (children 6 – 59 months) 549 Recall period in days (RP) 150
Average household size 8.5 n (population) 2824
% of U5 in population 18.7 Average household size 8.5 Proportion of 6 - 59 months in U5 population 0.9 % Non response 3
% Non response 3
n (households) 395 n (households) 342
Households per cluster 14 Households per cluster 12
Sampling Procedure:
The ENA for SMART software was used in the random selection of the 30 core clusters from the sampling frame, including four reserve clusters. The sampling frame consisted of an exhaustive list of villages and the estimated population size for each. In this case, all villages were accessible and were included in the sampling frame, thus giving them an equal chance of being selected.
Before selection of clusters, all areas where conflict is existed or areas that are not accessible have been removed from the frame. The eluded areas are:
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1- Al-ZaherDistrict: Al-Habaj Al-A’la, Al-Habaj Al-Asfal, Aina, Al-Salb, Al-hanakah, Al-Madhbai, Al-Samlan, DheMakhshab, and allvillages of Al-ZaherOzla.
2- Al-Sawma’ah District: Zones of Dhamrah, Al-Qa’a, Al-Haid and DheMjenan.
3- Maswarah District: All villages in ozlas of Al-Tarthor, Baihan Al-Dawlah, Dathran Al Elwi, Dammaj, Sha’ban, and Maswarah.
4- Mokairas District: Bait Ja’di, Amnahar, Al-Aber, Amlili, Samaitah, Al-Kareesh, Al-hajlah, Al-Madloh, Al jaradi, Al-Qariah, AhlObaid, Bait Abdulkhaeq, Saber, Al Mahwa, Al Sinan, Haid Al-Meshiam, Al-Adi, Al-Wadi Al-Ghol, Al-haid, Al Mohammed, Mansab, Al Honaish Al-Dohr, Al-Araq, Al Shomaila, Al-marjalah, Saleh mohammed Sama’, Al Sofian Sama’, Al-Omairi, Sakin Mohammed Qasem, Al Saiar, malhoos, Blas, Al-Mohoq, Sakin Al-Shehri, Al-Atfah, Rahbah Al-Yousfi, Kareesh, Amheed, and Al-Hamah.
5- Nate’ District: Al villages of Maswar Al Dabashozla.
6- Sabah District: Al-Ghareerah and Al-Mansorah.
7- Walad Rabie’ District: Thah, Al qadri Al-Sofla, Al-Aghas, Al-Sarah, Jarba, Al-Jeef, Rawdhat Al-Hejr, Rawdhat Al-Athaba, Jarem, and Al-Joshm.
Upon reaching the cluster, the survey teams, with the help of an elder or the guide, requested the
residents’ permission to assess the areas. The purpose of the survey was explained and the process of
random selection of a representative sample from the cluster was also elaborated.
Once granted permission to continue with the survey, the team head started the process of the random selection the sampled households by identification of the borders of the cluster, the centre, and important landmarks. The team head is one who should decide about the appropriate method to randomly select household as per a standard decision tree he has trained on.
The first and the best option is look (or do) an updated list of households and then randomly select them from that list either in systematic or simple manner. Segmentation of the large cluster and listing of households in one randomly selected segment before doing the random selection of household from that list is the second appropriate method. The last option in that decision tree which is used in the difficult clusters is the modified EPI random walking method.
The Modified EPI methodology involved identifying the centre of the cluster or the segment, where they had to spin a pen to randomly select the direction to take to the edge/periphery of the cluster. The team walked to the edge of the cluster. From the edge of the cluster, the team had to spin the pen again aiming to randomly get a direction to follow to the other extreme edge of the cluster. In case the pen pointed towards outside of the cluster boarders, the teams were to spin the pen multiple times till the pen pointed to any of the directions towards the cluster. Once a new direction was obtained, the team counted all the households along the randomly selected direction, gave each household a number, and then randomly selected the first household to be interviewed from the numbered households (for example, household number 7 in the households numbered 1 to 10, in the
Figure (2): The modified EPI method used for
selection of households
8
figure (2)).
Same direction was followed to select the subsequent household for interview, going for next nearest household on the right side and following the selected direction, until the required minimum number of households and children had been assessed (Ref: Figure (2) indicating the household selection process– Figure adopted from the SMART Methodology Guideline).
In case the team assessed all households to the edge of the cluster and did not reach the required number of households, the team would repeat the process again i.e. start from the cluster centre to randomly select another direction, then walk to the edge, then spin the pen again and count the households to the edge of the cluster. Then randomly pick the first household for interview, and then go the next nearest household, to the right hand side, till the required number of households were interviewed.
In case of absence of members or children of the randomly selected house during the interview time,
an appointment was made by the survey team to return back before leaving the cluster.
9
Survey Population and Data Collection Process
The survey population for the anthropometry is children aged 6 months to less than 60 months, while population for the mortality assessment is everyone living in the household including those joined or lift the household and also those born or died within the recall period. All ages are rounded down to the nearest year
The activities undertaken in the entire survey period are summarised in table 3, below. As Al-Baidha Governorate has already a qualified SMART survey field teams participated in SMART and non-SMART surveys in the past, the survey manager has planned for only two days refresher training focusing on anthropometry, filling of questionnaire, and the field procedures before commencing the data collection phase. The data collection was completed in five days by seven teams (Ref: Annex 3: Al-Baidha Nutrition Survey Team).
Quantitative data were collected by means of a household questionnaire for nutrition survey and a
mortality survey question, adopted from the SMART Methodology guidelines (Ref: Annex 1: Al-Baidha
Nutrition Survey Questionnaire and Annex 2: Al-Baidha Mortality Form). Although all under five
children were involved in the survey for questions related to morbidity, only children aged 6 to less
than 5 years were included in the measurement of height, weight and MUAC and questions related to
vaccination and vitamin A supplementation, while children aged 0 to 24 months were included for
questions related to IYCF practices. The age estimation was based on birth or immunization card
details.
Retrospective mortality data were collected from all randomly selected households, irrespective of
presence or absence of children aged 6-59 months. A recall period of 135 days prior to the survey was
used.
Table 3: Chronology of Activities in the Al-Baidha Nutrition Survey
Action Period
Preparation: Contacting local authority, survey team identification
training material preparation
10 – 14 October 2015
Refresher training of survey teams 17 – 22 October 2015
Data collection and data entry 24 – 29 October 2015
Data cleaning and analysis (row table and slides) 7-15 December 2015
Preparing the first report (report of findings) 7 January 2016
Presentation of the findings 10 January 2016
Receiving comments 11-15 January 2016
Finalizing and circulating the final report 30 January 2016
Measurement Standardization and Quality Control
Six survey teams underwent rigorous standardisation test procedures using 10 children aged 6 - 59 months. This exercise was conducted at the training place aimed at assessing the accuracy and precision of the survey teams for purposes of enhancing the survey data quality. The weak team members were identified and the common mistakes made were identified and addressed (Ref: Annex 4: Al-Baidha Nutrition Survey Standardization Test Report, showing team performance and how errors were rectified/ addressed). Further field testing of survey tools and exercise on data collection, including household selection and interview steps and familiarization of questions was conducted, and field level challenges and common mistakes identified and discussed. The field test was
10
conducted in a village near to Al-Baidha town considering that the village was not one of the randomly selected clusters. Only five out six trained teams were selected to do the survey. Each team was composed from 3 female surveyors and one male team head.
Beside training, data quality was ensured through (i) monitoring of fieldwork by field technical supervisors; (ii) crosschecking of filled questionnaires on a daily basis, recording of observations and daily de-briefing and discussion; (iii) confirmation of measles, severe malnutrition especially oedema cases and death cases by supervisors; (iv) daily entry of anthropometric data; (v) doing the plausibility check in daily basis for the overall quality scoring and identification each team quality using 10 scoring criteria (statistical tests), plus ensuring each team was given feedback on the quality of previous day’s data before the start of a new day; (v) daily equipment calibration, (vi) additional check done at the data entry level to enable entry only of relevant possible responses and measurements; (vii) continuous reinforcement of good practices.
Clear job descriptions were provided to the teams before commencing the data collection to ensure appropriate guidance in delivering the assigned tasks (Annex 5: Survey Team Job Description). Field team head had to review the questionnaire and verify the accuracy of the details before the teams leave a household, thus minimizing possibility of incomplete data (missing variables) and outliers.
Data Entry and Analysis
The data in the filled questionnaires and mortality forms were entered to an Excel sheets that were formulated for the purpose of the survey supported with all required self-check formulas as well as converting dates from Hijri to Gregorian. The anthropometrical data then were copied to ENA for SMART for interpretation to z scores as well as creation of the final plausibility check report and results of nutritional anthropometry status tables and curves. Similarly, the data of mortality were transferred to ENA for the analysis purposes and getting out the final death results with population pyramid.
The remaining household variables and child-related variables (feeding practices and morbidity) were analysed using SPSS. Running and tabulation of all variable frequencies was carried out as part of data cleaning. The nutrition indices (z-scores) for Weight for Height (wasting), Height for Age (stunting) and Weight for Age (underweight) were generated and compared with WHO 2006 Growth Standards. Children/cases with extreme z-score values were flagged and investigated and appropriately excluded in the final analysis if deviating from the observed mean (SMART flags).
The classification used for wasting levels was a follows:
W/H < -3 Z-Scores or oedema = Severe acute malnutrition
W/H -3 Z-Scores to < -2 Z-Scores = Moderate acute malnutrition
W/H < -2 Z-score or oedema = Global/total acute malnutrition
W/H -2Z-Scores = Normal
The classification used for Stunting levels was a follows:
H/A < -3 Z-Scores = Severe stunting
H/A -3 Z-Scores to < -2 Z-Scores = Moderate stunting
H/A < -2 Z-score = Stunting Prevalence rates
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H/A -2Z-Scores = Normal
The classification used for Underweight levels was a follows:
W/A < -3 Z-Scores = Severe Underweight
W/A -3 Z-Scores to < -2 Z-Scores = Moderate underweight
W/A < -2 Z-score = Underweight Prevalence Rates
W/A -2Z-Scores = Normal
Frequencies and cross-tabulations were used to give percentages, means and standard deviations in the descriptive analysis and presentation of general household and child characteristics.
Data Entry Verification and Cleaning
Four team members shared the work of data entry, and then each member would review the work done by another colleague before merging the data on a daily basis.
About 10 per cent of the entered questionnaires were randomly drawn using the Random Number table of ENA software. These drawn questionnaires were revised for accuracy of entry in the electronic database. The quality of data entry was accepted if accuracy was not less than 95 per cent.
The uniqueness of IDs of both household questionnaire and mortality sheet was also reviewed for any repeating during data entry.
For anthropometry data, all flagged records were also reviewed by means of revisiting original questionnaires.
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Results
Household Characteristics of Study Population:
As shown in table (4) below, majority of surveyed households were residents (96 per cent), while 4.1 per cent were internal displayed people. The gender of household head is largely male (98 per cent).
The main income source for household heads is causal2 work that was found in about almost half of households while working in farms is the second main income source as shown in table (4). During the last 4 months, 53.4 per cent of household heads have partially lost their income and 13 per cent have totally lost their income.
Regarding drinking water, the “water from unprotected open well” was the main source for 27 per cent of households (figure 3). Among those who are not use bottled water for drinking, only 2. 5 per cent do treating drinking water, mainly by boiling (60 per cent) then by filtering with clothes (30 per cent). About 59 per cent of the households store drinking water in clean containers.
As shown in table (4), about 72.5 per cent of households use flush or pour flush toilets while 19 percent of households reported defecation in open.
The assessment of food consumption level in Al-Baidha Governorate has been made using the 12 food groups HDDS and classified using the new IPC criteria3. It was found that around 69 per cent of households is classified as normal or stressed with HDDS between 5 and 12 in compare to 7 percent which classified as emergency or catastrophe with HDDS between 0 and 2.
2 Temporary work is daily wage based work such as work in construction, on others’ farms, etc. 3 Household food consumption indicator study: summary recommendations for the integrated food security phase classification acute reference table for house hold group classification. This summary brief was prepared by L.Glaeser (FANTA) , C. Hillbruner (FEWS NET), A. Mathiessen (WFP Vulnerability Analysis and Mapping [VAM]), and L. Olivera (IPC Global Support Unit [GSU]. 2015
26.824.3 23.4
18
5.9
0.9 0.2 0.2 0.20
5
10
15
20
25
30
35
40
Figure (3): Main drinking water source of houesholds in Al- Baidha (%)
Water from unprotectedopen well Water tanker
Water from protected openwellHouse connected pipedwaterUnprotected surface water(Wadi, springs, etc.)Bottled water
House connected yard pipedwaterWater from uncoveredrainwater harvesting tankOther
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Table 4: Household Characteristics
N %
Total Households 444/448 99.1
Household size (Mean): 8.6
Mean No of children Under-fives 1.6
Mean No of children under 6 months 0.17
Sex of Household Head: Male 435 98.0 Female 9 2.0
Residence Rural
358
80.6
Urban 86 19.4 HH Resident or IDPs
Resident 426 95.9 IDP 18 4.1
Presence of IDPs families in resident HH 16 3.6
Main Source of Income:
Casual worker 220 49.5 Farmer working in his farm. 69 15.5 Own a small scale business 45 10.1 Public / mix sector employee 39 8.8 Medium or small private sector employee 10 2.3 Own a medium scale business 9 2.0 In security or military forces 9 2.0 Social insurance 9 2.0 Large private sector employee 2 .5 Casual worker 32 7.2 Farmer working in his farm. 220 49.5 Own a small scale business 69 15.5 Other 45 10.1
During the last 4 months, was the income of head of household affected?
Ordinary income has not been lost 149 33.6 Income has partially been lost 237 53.4 Income has totally been lost 58 13
Household latrine type
Flush/pour flush latrine 322 72.5 Defecation in open 82 18.5 Open pit latrine 30 6.8 Simple covered pit latrine 10 2.3
Food consumption based on household dietary diversity
Normal or stressed 307 69.1 Crisis 106 23.9 Emergency or catastrophe 31 7.0
14
Morbidity, Immunization Status of the U5 children:
A high prevalence of common diseases was recorded as reflected in table (5) below. During the two weeks prior to the survey, the recorded prevalence of diarrhoea among U5 children was 42 per cent, the prevalence of ARI as described by coughing or breathing difficulty was 47 per cent and the prevalence of fever two weeks prior to the survey was 49 per cent. Suspected measles4 during the last month was 2 per cent.
As shown in table (5), the coverage for the third dose of polio vaccination is low with a proportion of 45 per cent. Thirty two per cent of children aged 9 months to below 60 months vaccinated for measles were confirmed by vaccination cards while the rest 20 per cent by recall. During the previous six months, only around one fourth of the surveyed children had received vitamin A supplement. The above immunization coverage and vitamin A supplementation coverage are lower than the Sphere Standards recommended of 95 per cent coverage.
Table 5: Morbidity and Immunization N %
Morbidity:
Proportion of children with diarrhoea within 2 weeks prior to assessment 288 41.5
Proportion of children with ARI within two weeks prior to assessment 324 46.7
Proportion of children with fever within two weeks prior to assessment 340 49.0
Suspected measles within one month prior to assessment 14 2.0
Immunization:
Children (9-59 months) immunised against measles:
Total 303 51.4
Confirmed by vaccination cards 187 31.7
Confirmed by recall 116 19.7
Children who have ever received routine polio 3 vaccine 279 45.0
Supplementation:
Children who received vitamin A supplementation in last 6 months 156 25.2
4 The suspected measles is defined as having rash and fever in addition to at least one of: cough, sore throat, or conjunctivitis.
15
Infant and young child feeding (IYCF) practices:
Exclusive breastfeeding:
The overall prevalence of exclusive breastfeeding among children aged below 6 months was 18.3 per cent. Figure (4) below shows that exclusive breastfeeding among girls was 18.8 per cent and it was among boys 17.9 per cent but no significant difference.
Continued breastfeeding at one year:
The overall prevalence of continued breast feeding at one year was 53.7 per cent. Figure (5) below
shows that continued breast feeding at one year was 54 per cent among both boys and girls.
17.9% 18.8%
82.1% 81.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Male Female
Figure(4): Prevalence of exclusive breastfeeding by gender
No
Yes
53.6% 53.8%
46.4% 46.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Male Female
Figure(5): Prevalence of continued breastfeeding at one year by gender
No
Yes
16
Continued breast feeding at two years:
The overall prevalence of continued breast feeding at two year was 26 per cent. Figure (6) below
shows that continued breast feeding at two years among boys and girls was 20 per cent and 33 per
cent respectively but without significant difference.
Minimum diversity diet (MMD) in 6 – 23 months children
The minimum dietary diversity score was calculated as the proportion of children 6-23 months of age
who received foods from four or more out of the seven food groups5 during the previous day. Only
around one out of five children aged 6-23 months are on proper diversified/ complementary feeding.
Figures (7a),(7b) show minimum dietary diversity as a higher among boys (21 per cent) than girls (12.4
per cent). However, there was no significance difference.
5 The seven food groups used are: (Grain, roots, tubers), (Legumes and nuts), Dairy products (milk, yogurt, cheese), Flesh foods (meat, fish poultry and liver/organ meats), eggs, Vitamin-A rich fruits and vegetables and Other fruits and vegetables.
20.0%33.3%
80.0%66.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Male Female
Figure(6): Prevalence of continued breastfeeding at two years by gender
No
Yes
21%
79%
Figure 7a: MDD among boys
Good dietarydiversification
Poor dietarydiversification
12.4%
87.6%
Figure 7 b: MDD among girls
Good dietarydiversification
Poor dietarydiversification
17
Characteristics of the children assessed
The ratio of boys to girls was 1.0 as shown in table (6), implying representativeness of the sample collected during the survey. Overall age ratio of 6-29 months to 30-59 months was as expected with no significant differences between age groups and both gender.
Nutrition Status
Below is a summary of the anthropometry results. Data quality was validated using the Plausibility check tool of ENA for SMART software. The overall scoring of the plausibility check of the survey data is 2% which is categorized as excellent (Ref: Annex 6 for the Assessment Quality Check).
Acute Malnutrition
There is a slight shift to the left of the study population when compared with the reference population, as per the graphs shown (implying presence of malnutrition). The interpretation was made based on the 2006 WHO Growth Standards.
The level of wasting with oedema – also known as global acute malnutrition (GAM) – found is 6.0 per cent which classified as ‘poor’ as per the WHO categorization of the severity. The severe acute malnutrition (SAM) was 0.5 per cent. Details are shown in table (7). The proportion of the acute malnourished boys (6.9 per cent) was slight higher to that of girls (5.1 per cent) but without significant difference. There’s no single oedema case identified in this survey.
Table 7: Acute Malnutrition (Wasting) Rate
All n = 619
Boys n = 303
Girls n = 316
Prevalence of global malnutrition
(<-2 z-score and/or oedema)
(37) 6.0 %
(95% CI: 4.1 - 8.7)
(21) 6.9 %
(95% CI: 4.2 - 11.2)
(16) 5.1 %
(95% CI: 3.0 - 8.4)
Prevalence of moderate malnutrition
(<-2 z-score and >=-3 z-score
(34) 5.5 %
(95% CI: 3.6 - 8.2)
(19) 6.3 %
(95% CI: 3.6 - 10.8)
(15) 4.7 %
(95% CI: 2.8 - 7.9)
Prevalence of severe malnutrition
(<-3 z-score and/or oedema)
(3) 0.5 %
(95% CI: 0.2 - 1.5)
(2) 0.7 %
(95% CI: 0.2 - 2.7)
(1) 0.3 %
(95% CI: 0.0 - 2.4)
The prevalence of oedema is 0.0 %
Table 6: Distribution of Age and Sex of the sample
Boys Girls Total Ratio
AGE (mo) no. % no. % no. % Boy: girl
6-11 31 49.2 32 50.8 63 10.1 1.0
12-23 73 47.7 80 52.3 153 24.5 0.9
24-35 78 54.5 65 45.5 143 22.9 1.2
36-47 68 48.2 73 51.8 141 22.6 0.9
48-59 56 45.2 68 54.8 124 19.9 0.8
Total 306 49.0 318 51.0 624 100.0 1.0
18
Providing on current situation and status of contributing factors including the continuation of conflict
and the scarcity of water, poor sanitation, high food prices, availability and prices of fuels and cooking
gases, deterioration of income, availability and access for main food commodities, GAM in Al-Baidha
can be classified as ‘serious’.
Chronic Malnutrition Rates:
Stunting prevalence as shown in table (8) is 34.6 per cent.
There is also overall shift to the left of the study population
deviating from the reference population. The prevalence of
severe stunting is 10.6 per cent. The statistical details of the
stunting rates are as shown in table (8) below. This stunting
level is between 20 per cent and 39.9 per cent which
classified as ‘serious’ as per the WHO (2000) categorization of
the severity. The proportions of the chronic malnourished for
boys and girls are (35 per cent and 34 per cent respectively)
and no significant difference.
Table 8: Chronic Malnutrition (Stunting) Rate
All n = 612
Boys n = 300
Girls n = 312
Prevalence of stunting(<-2 z-score ) (212) 34.6 %
(95% CI: 29.3 - 40.4)
(105) 35.0 %
(95% CI: 27.9 - 42.8)
(107) 34.3 %
(95% CI: 27.7 - 41.6)
Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)
(147) 24.0 %
(95% CI: 20.5 - 28.0)
(77) 25.7 %
(95% CI: 20.3 - 31.8)
(70) 22.4 %
(95% CI: 17.4 - 28.5)
Prevalence of severe stunting (<-3 z-score)
(65) 10.6 %
(95% CI: 7.5 - 14.8)
(28) 9.3 %
(95% CI: 5.9 - 14.4)
(37) 11.9 %
(95% CI: 7.8 - 17.7)
Underweight Rates:
Underweight prevalence as per child gender is shown in table (9). The rate is 22.0 per cent with severe underweight of 4.9 per cent. The statistical details of the underweight prevalence are shown in the table (9) below.
The above underweight rate is between 20 per cent and 29.9 per cent which is classified as ‘serious’ as per the WHO (2000) categorization. The proportion of the underweight boys (23 per cent) was than that of the girls (21 per cent) but without significant difference.
19
Table 9: Underweight Rate
All n = 618
Boys n = 303
Girls n = 315
Prevalence of underweight (<-2 z-score )
(136) 22.0 %
(95% CI: 17.1 - 27.9)
(69) 22.8 %
(95% CI: 17.5 - 29.1)
(67) 21.3 %
(95% CI: 15.0 - 29.2)
Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)
(106) 17.2 %
(95% CI: 13.3 - 21.9)
(55) 18.2 %
(95% CI: 14.0 - 23.2)
(51) 16.2 %
(95% CI: 11.5 - 22.3)
Prevalence of severe underweight (<-3 z-score)
(30) 4.9 %
(95% CI: 3.2–7.3)
(14) 4.6 %
(95% CI: 2.5 –8.4)
(16) 5.1 %
(95% CI: 2.9–8.7)
Mortality:
The crude death rate is 0.33 per 10,000 per day. The rate is higher among males than females (0.50 and 0.17 respectively).The under-five death rate is 0.12 per 10,000 per day which can be reported as below 0.1 per 10,000 per day. These rates are within acceptable levels of WHO categorization. However, 11.1 per cent of death caused by violence is a concern.
Table 10: Mortality data
U5 Total
Total HHs surveyed
Total Population assessed in HHs 547.5 3573.5
Number who joined the HHs 97 708
Number who left the HHs 85 719
Number of births 0 0
Number of deaths 1 15
Mortality rate (per 10,000 per day)
Under-five
Crude
0.12
0.33
Population Pyramid:
Information about household members during the previous 135 days was collected. The resulting
population pyramid is shown here. The population distribution by age shows almost equal number of
the men and women throughout the age groups (0.9 males: 1 Females).
20
21
Discussion and variable association
Levels of Malnutrition:
Levels of different types of malnutrition in Al-Baidha Governorate are summarized in figure (8) below.
This survey found an overall GAM prevalence in Al-Baidha Governorate is 6.0 percent which is lower than national one (16.3 per cent) and classified as “poor” according to WHO categorization of the severity, but as a matter of fact it is considered as “serious” as based on current situation and contributing factors whereas escalated conflict and airstrikes have damaged essential infrastructure including markets, roads, bridges, hospitals, schools, residential houses, power stations, and water lines. Markets are not functioning in more than half of the Governorate where prices of essential food and non-food commodities have escalated by over 40 percent compared to the pre-crisis levels6, disrupting the health services and other livelihoods activities. Health care facilities face increasing shortages of essential medicines and supplies, frequent disruptions in power supply and lack of fuel for generator.
GAM rate is higher than that found by the WFP-CFSS conducted in April 2014 (4.4 per cent). On other hand it is close to that found by the WFP-CFSS conducted in December 2011 (6.3 per cent).
In this survey, no significant differences were found in wasting (7 per cent for boys and 5 per cent for girls).
6 Market Watch , WFP-VAM. March-April 2015
6.0%
34.6%
22.0%
5.5%
24.0%
17.2%
0.5%
10.6%
4.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Wasting Stunting Underweight
Fig (8): Prevalence of diffrent types of malnutrition among U5
children in Al-Baidha Governorate- Oct.2015
Severe+Moderate
Moderate
Severe
22
6.3%
13.6%
4.4% 6%
42.6%35.6%
42.1%
34.60%
23.9%
29.5%
18.3%
22.0%
WFP-CFSSDecember 2011
DHs February2014
WFP-CFSS April2014
SMARTSeptember
2015
Fig. (9): Trends of malnurtition in Al-Baidah Governorate 2011-2015
GAM Stunting Underweight
Stunting level of 35per cent in Al-Baidha is lower than that of the WFP-CFSS conducted in 2011, 2014 ( 42.6 Per cent and 42.1 respectively) and it is lower than the national one (46.5 percent) as shown by DHS 2014. The Stunting level in Al-Baidha is classified as ‘serious” based on the WHO classification of severity. Severe stunting of 11 per cent in this survey is lower than that found in WFP-CFSS 2014 (17 per cent).
Stunting is found 35 per cent and 34 per cent for boys and girls respectively otherwise severe stunting is 9 per cent for boys and 12 per cent for girls but the differences were not significant.
Underweight is acting as a composite indicator for GAM and chronic malnutrition. Underweight level of 22 per cent is high even it is lower than the national one (39 per cent). It is slightly lower than that found in WFP-CFSS 2011 (23.9 per cent) and higher than that found in WFP-CFSS 2014 (18.3 per cent). Sever underweight of 4.9 per cent is slightly higher than that of WFP-CFSS 2014 (2.9 per cent). Underweight is found slight higher in boys (23 per cent) than that in girls (21 per cent) but the difference was not significant and severe underweight is the same rate for each boys and girls (5 per cent) .
Underweight is significant highest in age group of 24 to less than 36 months and is lowest in group of 12 to less than 24 months with 34.5 per cent and 13.2 per cent respectively, wasting is significant highest among those aged 6 to less than 12 months with 11.3 per cent and is lowest among those in their second year with 2.6 per cent, and stunting is significant highest among those aged 24 to less than 36 months and is lowest among those aged 6 to 12 months with 46.2 per cent and 15 per cent respectively.
23
There is a significant relation between underweight and number of children under five while other nutritional indicators has been shown no significant relation.
Vitamin A Supplementation, Polio, Measles vaccination and Malnutrition Levels:
It is notable that the vitamin A coverage with level of 25.2 per cent (supplementation six months prior to the survey) was lower than the recommended 95 per cent coverage (Sphere Standards, 2011). There was no relationship identified between vitamin A supplementation and the levels of either stunting, underweight or wasting.
Even though there was a low coverage of vaccination but there is a significant association between nutrition status and Polio and Measles vaccination as tables (11) and (12) show.
Table 11: Relation between child's nutritional status and Pentavalent 3 and Polio 3 vaccination in the past six months for children 6 – 59 months
Indicator Yes No Statistical significance
N % N %
Underweight 46 16.5 89 26.4 X2: 8.65, P- value =0.003, df 1
Severe Underweight 6 2.2 24 7.1 X2: 8.09, P- value =0.004, df 1
Wasting 9 3.2 28 8.3 X2: 6.88, P- value = 0.009, df 1
Table 12: Relation between child's nutritional status and Measles vaccination in the past six months for children 9 – 59 months
Indicator Yes No Statistical significance
N % N %
Underweight 48 15.9 82 28.9 X2: 14.13, P- value =<0.001, df 1
Severe Underweight 7 2.3 21 7.4 X2: 8.24, P- value =0.004, df 1
Stunting 95 31.7 113 40.5 X2: 4.90, P- value =0.027, df 1
Morbidity and Malnutrition Levels:
Table (13) shows that ARI and fever two weeks prior to the survey are higher than that found by DHS of 2014 in Al-Baidha except diarrhoea is close.
Table 13. Morbidity levels of Al-Baidha Governorate as found by DHS 2014 and SMART 2015
Survey Diarrhoea ARI Fever
DHS Feb. 2014 40% 38.8% 35%
SMART Sep. 2015 41.5% 46.7% 49%
24
The association between diarrhoea and either GAM or stunting was not seen but it has been seen for underweight (X2: 3.98, P< 0.05, df:1) and severe underweight (X2: 8.00, P< 0.01, df:1). ARI and fever were found to have no association with nutritional status.
Child Feeding and Malnutrition Levels
Exclusive breastfeeding:
Exclusive breastfeeding in the early months of life is correlated strongly with increased infant survival and lowered risk of illness, particularly from diarrhoeal disease 7. To achieve optimal growth, development and health, WHO recommends that infants should be exclusively breastfed for the first six months of life. Exclusive breastfeeding was found in this survey 18.3 per cent which is higher than national level of DHS 2014 with level 10.3 per cent but it still low as WHO defined that rate of EBF should be 50 per cent up to 89 per cent to be classified as a practice of “good” level.8
Continued breastfeeding:
The continued breastfeeding at one year was found as 54 per cent that dropped to 26 per cent at two years. Continuation of the breastfeeding gradually declined with age, however, continued breastfeeding at both one year and two years in Al-Baidha are much lower than the national ones (71.2 per cent and 45.3 per cent respectively as per the DHS 2014). Survey results show insignificant association of continuation of breastfeeding with malnutrition levels.
Dietary diversification and complementary feeding:
The food basket and proper complementary feeding for children 6-23 months of age was found to be very limited. Children do not get essential nutrients for healthy growth and development; this may include foods such as milk, meat, fruit, vegetables etc. This survey found that about only one third of the 6-23 months children are on minimum proper complimentary feeding/diversified food, i.e. they received foods from four or more food groups during the previous day according to the MDD score. The average dietary diversity score found is 2.4 (SD 1.21). It was found that children aged 6-23 months on properly diversified complementary feeding have lower prevalence of stunting with significant association (X2: 4.7, P< 0.01, df:1).
Nutrition Status and Food consumption based on household dietary diversity
Underweight was found to be lower among children from households with normal food consumption (X2: 10.1, P<0.05, df2).
7 The optimal duration of exclusive breastfeeding. Note for the Press No 7.Geneva, World Health Organization, 2001 8 WHO. Infant and young child feeding. A tool for assessing national practices, policies and programmes. Geneva. 2003
25
Water and sanitation with Nutrition situation:
Survey shows that higher prevalence of underweight and stunting was found among children living in households reported defecation in open comparing to other households using latrines (P < 0.05).
Recommendations:
Although mortality is still low, the serious levels of stunting and underweight in Governorate that are beyond the serious cut off as per WHO categorization as well as the GAM rates that are equal to the "poor" according to WHO classification i.e. between 5 - 9.9 per cent require an urgent intervention to address the situation a cross the Governorate.
The situation in Al-Baidha can go worse with the existence of multi-sectoral aggravating factors like high poverty rate (51.8%)9, poor feeding practices, high prevalence of communicable diseases and insufficient coverage of essential health services like immunization and micronutrient supplementation.
Below are the main immediate and medium-term recommended interventions:
Immediate Interventions
Develop detailed integrated response micro-plan articulating district level humanitarian needs.
Strengthen and expanding CMAM services to reach all health facilities and outreach services where acute malnutrition is high as in Mukayras, Nati’, Al-Sawadityah and Al-A’rsh.
CMAM services should adhere to the CMAM protocol (ensuring systematic treatment and full consideration of moderate acute malnutrition management) that should be integrated with infant feeding, hygiene promotion and food security interventions.
To promote appropriate IYCF practices (early initiation of breastfeeding, exclusive and sustained breastfeeding for 2 years and promotion of appropriate complementary feeding practices for children aged 6 to 24 months) along with micronutrient supplementations and deworming.
Accelerate the integration of IYCF counselling into all CMAM services delivered by both fixed and mobile clinics.
Intensive social mobilisation campaigns on IYCF feeding and caring practices through behaviour change / communication interventions mainly in the following areas; timely introduction of complementary food and continue breastfeeding up to two years, along with Vitamin A supplementation, micronutrient supplements, and promotion of safe sanitation and hygienic practices including hand washing with soap as well as safe disposal of children’s excreta, diarrhoea prevention measures and appropriate management of ARI among young children.
9 Yemen Poverty Assessment, World Bank. 2007
26
Medium term Interventions
The nutrition package that includes the management of acute malnutrition, the growth monitoring and promotion (GMP), IYCF counselling, and supplementation with micronutrients for child and mother should be entered to the minimum official service list at the Governorate level to assure provision of this package by all working health facilities.
Continued support for longer term water development and sanitation programmes throughout the Governorate, with community mobilization activities to promote safe sanitation and hygienic practices.
Exploring new initiatives to promote small scale income generating projects, draw lessons learnt and replicate the successful projects.
Promote improved latrine use and other hygiene services like Community Led Total Sanitation (CLTS) strategy.
27
Annexes
28
Annex 1: Al-Baidha Governorate Nutrition Survey Questionnaire
اليمنيةالجمهورية
وزارة الصحة العامة والسكان
بيضاءمكتب الصحة العامة والسكان بمحافظة ال
5102 أكتوبر، البيضاءمسح الحالة التغذوية والوفيات في محافظة
( 0استبيان األسرة )نموذج
واألشخاص العاملين فيه أوالً. يتم الشرح للساكنين في المسكن )البالغين منهم( عن المسح والتعريف بالجهة القائمة عليه
م.)أعضاء الفريق(، ثم بعد ذلك الحصول على الموافقة الشفهية منه
قةافمو
ال
نعم .1
انتقل إلى ال .2
النهاية
القرية/ الحارة العزلة لمديرية
تاريخ المقابلة سنـــــــــة شهر يوم
Ø 1 5 1 Ø 2
رب األسرة: اسم
فريق
المسح رقم
..........
التوقيع االسم
واألنثروبومتري األسرة
الوفيات
رئيس الفريق
بين فيما إذا كان هناك: غياب األسرة عند الزيارة األولى ويتطلب األمر زيارة ثانية .1 غياب طفل عند الزيارة األولى ويتطلب األمر زيارة ثانية* .2
.واألوديما حيث تستكمل عند حضوره األنثروبومترية* عند غياب الطفل، تستكمل كل بياناته عدا القياسات
ق. مالحظة: البيانات في الغالف هي لالستخدام الميداني واإلداري من قبل أعضاء الفري
هل األسرة مقيمة أم
نازحة؟
مقيمة. .1 نازحة .2
أو اسر نازحة؟ أسرةفي حال األسرة المقيمة. هل تقيم معكم
مقيمة فينبغي تعبئة بيانات أسرةنازحة تعيش مع أسرةفي حال وجود نعم .1
في استبيانين منفصلين عدا استمارة الوفيات فيجب ان تكون األسرتين
ال .2 ، وترفق مع استبيان األسرة المقيمة.لألسرتيناستمارة واحدة
29
الفريق )تستخدم إلدخال البيانات(يملئ من قبل رئيس
ال( 2نعم ، 1غياب األسرة حتى بعد الزيارة الثانية )
ال( 2نعم ، 1الموافقة )
رقم الفريق
رقم استبيان األسرة (2( أم نازحة )1األسرة مقيمة )
ال( 2نعم ، 1في حال األسرة المقيمة، هل تأوي أسرة نازحة )
س س س س ش ش ي ي تاريخ المقابلة Ø 1 5 1 Ø 2
(2( أم ريفية )1هل المنطقة حضرية )
رمز العزلة رمز القرية / الحارة رمز المحافظة رمز المديرية
رقم العنقود طبقة المسحز مر
-----------------------------------------------------------------------------------------------------------------
العمل المكتبي
التوقيع السنة الشهر اليوم االسم
إدخال البيانات
المراجعة
ترميز أخرى
المالحظات
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30
: بيانات عن األسرة )األحياء فقط والذين يعيشون حاليا في األسرة(000س
H001a األحياء فقط الذين يعيشون حاليا في األسرة تاريخ المسح( ةعدد أفراد األسر( العدد
H001b سنوات )األحياء فقط الذين يعيشون حاليا في األسرة تاريخ 5عدد األطفال أقل من
المسح(
العدد
H001c أشهر )األحياء فقط الذين يعيشون حاليا في األسرة تاريخ 6عدد األطفال أقل من
المسح(
العدد
: بيانات عن حال دخل األسرة000س – 000س
H002
نوع رب األسرة ما
ذكر .1
أنثى .2
H003
لرب األسرة؟ الرئيسيماهو العمل
موظف قطاع حكومي أو مختلط. .1
موظف في قطاع خاص كبير )مصانع وشركات كبيرة( .2
موظف في قطاع خاص متوسط أو صغير .3
موظف في قطاع ثالث )منظمات غير حكومية( .4
األمن أو الجيشفي .5
عامل باألجر اليومي. .6
صياد. /فالح يعمل في مزرعته .7
لديه عمل خاص صغير )بقاله صغيرة، بوفية، تاكسي، .......( .8
لديه عمل خاص متوسط )بيع جملة، بقالة كبيرة، معمل بالستيك، محطة .9
مياه، محطة بترول ....(
)مالك المصانع والشركات الكبيرة والعقارات(لديه عمل خاص كبير .11
ضمان اجتماعي )معاشات التقاعد(. .11
أخرى: تذكر ............................................................. .12
H004
خالل األربعة األشهر الماضية، هل تأثر دخل رب األسرة؟
المعتاد.لم يفقد راتبه أو دخله .1
فقد جزء من راتبه أو دخله. .2
فقد كل راتبه أو دخله. .3
31
: بيانات عن الماء واإلصحاح البيئي والنظافة000س –000س
H005
في منزلكم؟ )خيار واحد فقط( لمياه الشرب ماهو المصدر الرئيسي
.أنابيب مياه موصلة إلى البيت .1
.إلى فناء البيتأنابيب مياه موصلة .2
.بئر مفتوحة غير محمية .3
.بئر مفتوحة محمية .4
.خزان مغطى لحصاد مياه األمطار .5
.خزان مفتوح لحصاد مياه األمطار .6
سيارة نقل المياه )وايت ماء( .7
H007 الخ( ، كوثرشمالن، )حدة معبأةمياه صحية .8
الخ(، عين ماء جاري، محمية )واديمياه سطحية غير .9
عين ماء محمية .11
أخرى: تذكر ................................................ .11
H006a
إنتقل إلى ؟الشربهل تقومون بمعالجة الماء قبل
نعم .1
H007 ال .2
H007 ال أعرف .3
H006b
)خيار واحد فقط( لمياه الشربالمستخدمة الرئيسيةما هي طريقة المعالجة
غلي الماء قبل الشرب .1
استخدام الكلور .2
الترشيح عبر قماش نظيف .3
استخدام مرشح سيراميك أو رمل أو ما شابه )فلتر أو قطارة( .4
ترك الماء ساكنا قبل الشرب لترسيب الشوائب. .5
)شب الفؤاد(استخدام الشب .6
أخرى:تذكر ........................................................ .7
H007
: هل الوعاء الحاوي لمياه الشرب نظيف؟ لغرض الشربين المياه خزمن توفر نقاط ت تحقق:للمالحظة
(2ووجود الطحالب يعني رقم 1)عدم وجود طحالب يعني رقم
نعم. .1
ال. .2
32
H008
من توفر المرافق والممارسات تحقق -أين تتم عملية قضاء الحاجة )التبرز(؟ )اختر فقرة من التالي(
)سيفون أو دلو(. يتوفر فيه صب الماء للتنظيف الذاتي -مرحاض .1
.حفرة دون غطاء -مرحاض .2
)الجاف(. حفرة مغطاة بطريقة بسيطة -مرحاض .3
قضاء الحاجة في العراء )في الحقول مثال، الخ.( .4
أخرى:تذكر ........................................................ .5
خاص بحالة االستهالك الغذائي: 000س
H009
ساعة الماضية هل تم تناول أي من األغذية أو المجموعات الغذائية 24خالل الـ
أدناه.
نعم .1
ال .2
a. ، فتة، حبوب أخرى )ذرة، ذرة رفيعة، دخن، شعير(، ةبر، خبز، عصيد
من الحبوب مصنعة أرز، مكرونة، معجنات، أو أي منتجات
b. بطاط
c. )خضراوات )الخضراوات الورقية، الطماطم، الفلفل، جزر، دبا...... الخ
d. )فواكه )مانجو، عنب، ..... الخ
e. بقري، غنمي(، كبده، كالوي ، دواجنلحم(
f. بيض
g. )أسماك )طازجة ومجففة ومعلبة
h. ..... ،فاصوليا، عدس، بازيليا، فول
i. )..... ،مشتقات الحليب )لبن، جبن، زبادي، حقين
j. ).... ،زيوت/ دهون )سمن، زبدة، زيت نباتي
k. ،زبيب(سكر، عسل، فواكه مجففة )تمر
l. بهارات، شاي، بن
: هدايا من ألبان األطفال000س
H010
خالل الثالثين اليوم الماضية، هل حدث وأن حصلتم على عبوات ألبان أطفال بشكل مجاني؟
نعم .1
ال .2
33
شهراً في األسرة 00-6لألطفال في سن حالة التحصين وتزويد فيتامين )أ( : 000س –000س
سنوات في الجدول أدناه ابتداء باألصغر سنا( 0إلى أقل من 0)يجب تدوين كل األطفال من عمر
C011 C012a C012b C013 C014 C015
رقم
الطفل
االسم األول
للطفل
الطفلنوع
ذكر =1
= أنثى 2
تاريخ الميالد
)بالهجري أو الميالدي(
شهر (00إلى 0لألطفال من سن )
عمر الطفل
)باألشهر(
أشهر 6لألطفال بعمر
هل تم إعطاء فيتامين ، فأكثر
)أ( خالل الستة أشهر
الماضية ؟ )إظهار عينة(
= نعم1
= ال 2
= ال أعرف3
أشهر 6لألطفال بعمر
فأكثر
هل أخذ الطفل جرعة
لقاح الخماسي
؟3/الشلل3
= نعم1
= ال 2
أشهر فأكثر 0لألطفال بعمر
تطعيم الطفل ضد الحصبة هل تم
)حقنة في اليد اليسرى(؟
= نعم من البطاقة1
= نعم بالتذكر 2
= ال أعرف 3
= لم يطعم 4
سنـــــة شهر يوم . 1
سنـــــة شهر يوم . 2
سنـــــة شهر يوم . 3
سنـــــة شهر يوم . 4
سنـــــة شهر يوم . 5
سنـــــة شهر يوم . 6
سنـــــة شهر يوم . 7
-حول عمر الطفل: األمماذا قالت ......................................................................................................................................................................(: 1الطفل رقم ) ...........................................................................................(:...........................................................................2الطفل رقم ) ...........................................(:...........................................................................................................................3الطفل رقم ) ...........................................(:...........................................................................................................................4الطفل رقم ) ..........................................................................................................................(:............................................5الطفل رقم ) ...............................................(:.......................................................................................................................6الطفل رقم ) ...........................................(:...........................................................................................................................7الطفل رقم )
34
أشهر( 6شهر في األسرة )يترك فارغا لألطفال بسن أقل من 00-6طفال بين سن ألل جسمانيةالالقياسات : 000س –006 س
C016 C017 C018 C019
رقم
الطفل
)كما
سبق
أعاله(
االسم
األول
للطفل
الوزن )كيلو جرام( عمر الطفل )باألشهر(
= رافض 88.8
= غائب 99.9
الطول )سم(
= رافض 888.8
= غائب 999.9
أوديما( في كال القدمين.(التوذم
= نعم 1
= ال 2
= رافض 8
= غائب 9
قياس محيط الذراع
)سم()الميواك(
= رافض 88.8
= غائب 99.9
1.
. . .
2.
. . .
3.
. . .
4.
. . .
5.
. . .
6.
. . .
7.
. . .
35
سنوات( 0)كل األطفال تحت سن شهر في األسرة 00-0مراضة األطفال بين سن : 003س –000 س
C020 C021 C022 C023
رقم
الطفل
)كما سبق
أعاله(
الطفل عمر االسم األول للطفل
)باألشهر(
خالل اإلسهال
األسبوعين الماضيين
= نعم 1
= ال 2
سعال أو صعوبة في التنفس
خالل األسبوعين الماضيين
= نعم 1
= ال 2
الحمى خالل
األسبوعين الماضيين
= نعم 1
= ال 2
خالل الشهر الماضي )طفح جلدي + االشتباه بالحصبة
حمى + )سعال أو التهاب حلق أو التهاب الملتحمة(
= نعم 1
= ال 2
1.
2.
3.
4.
5.
6.
7.
36
شهرا( 00فارغا لألطفال بعمر أكبر من ساعة الماضية )يترك 00شهر خالل الـ 00إلى 0: دون ممارسة إطعام األطفال بين سن 000س –000 س
رقم
الطفل
)كما
سبق
أعاله(
االسم األول
للطفل
عمر الطفل
)باألشهر(
C024a C024b .بسؤال اليوم من الوقت الذي استيقظ فيه الطفل صباح أمس وحتى نومه في ابدئيهل تناول الطفل أمس أيا من المجموعات الغذائية أدناه
وعندما تنتهي قم بذكر المواد أدناه األم تتذكر اتركيالمساء.
األم التعرف 3= ال 2 = نعم 1هل رضع الطفل
من ثدي أمه
22خالل الـ
ساعة الماضية؟
كون ال تأحيانا
هناك رضاعة
مباشرة لكن لبن
األم يستخرج من
الثدي ويعطى
للطفل بطريقة
أخرى.
= نعم 1
= ال 2
كم عدد
المرات التي
فيها رضع
الطفل و عدد
المرات التي
أعطى فيها
الطفل لبن
األم خالل الـ
ساعة 22
الماضية؟
C025a C025b C025c C025d C025e C025f C025g C025h C025i C025j
أبماء مع
و بدون
سكر
حليب
أطفال
عصيدة أو
شبيسة أو
خبز أو أرز
أو مكرونة
أو أي غذاء
مصنوع من
الحبوب.
بطاطا
بيضاء أو أية
أغذية درنية
أخرى.
أي أغذية
مصنوعة من
الفول أو
الفاصوليا أو
البازيليا أو
العدس أو
الفول
السوداني أو
أي بقوليات
أخرى.
الحليب أو
الجبن أو
الزبادي أو
الحقين أو
األيسكريم
أو الثريب
)الثرابة(.
كبد أو كلى أو
قلب أو أحشاء
أخرى.
أي لحوم بقر
أو غنم أو
ماعز أو
دواجن.
اسماك
طازجة أو
مجففة أو
معلبة.
بيض
دبا أو جزر أو
بطاطا حلوة
جوفها أصفر أو
برتقالي.
أي خضراوات
ورقية داكنة
الخضرة.
مانجو أو باباي
ناضجة.
أي فواكه
أو
خضراوات
أخرى لم
تذكر في
الخانة
السابقة.
أية
مشروبات أو
أغذية أخرى
1.
2.
3.
4.
5.
6.
7.
37
Annex 2: Al-Baidha Governorate Mortality Survey Questionnaire
م5102اكتوبر، البيضاء مسح الحالة التغذوية والوفيات في محافظة
(2)منوذج يوم من اتريخ املسح 531رصد أفراد األسرة خالل فرتة استمارة
اجلنس )ذكر االسم )اختياري( مالتحق أثناء ابلسنواتالعمر أو أنثى(
يوم 531فرتةغادر أثناء فرتة
يوم 531ولد أثناء فرتة
يوم 531تويف أثناء فرتة
يوم 531سبب الوفاة
موقع الوفاة
1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19 20
يوم من اتريخ املسح 09هام: يتم تسجيل كل األفراد املوجودين حاليا و كل من التحق ابألسرة أو غادرها أو توىف أو ولد خالل
الوفاةرموز أسباب = سوء التغذية 1 اإلسهال= 5 = العنف / بسبب الصراعات 6 = احلمى 2 = أخرى )حدد(7 = احلصبة 3 = مشاكل يف التنفس 4
رموز مواقع الوفاة
= يف املوقع احلال 5 = أثناء اهلجرة 2 فيهسكن مكان = يف آخر 3 = أخرى )حدد( 4
: _____رقم الفريق: العنقودرقم : ___________ التاريخ: ______________احلي مديرية املسح: ____________
ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــطبقة املسح: : ___________استبيان األسرة ________ رقم
38
Annex 3: Al-Baidha Governorate Nutrition Survey Team, October 2015
No Name Title
1 Ali Alwi Al-Homigani
Team Heads
2 Mohammed Ali Al-Mukhlef
3 Ahmed Abdullah Al-Ma’den
4 Ali Hussein Saleh Al-greah
5 Mohammed Ali Saleh Allgasi
6 Saeed Mohammed Al-Harazi
7 Mona Mohammed Al-Mugahed
Enumerators
8 Najwa Ali Al-Nabegi
9 Zineb Ali Salem Al-rushdi
10 Soheer Gasem Al-Sobehi
11 Wafa Mohammed Al-Trki
12 Fardoos Naser Mohammed
13 Bdoor Saleh Al-Salami
14 Fnoon Nagi Al-ammaree
15 Nabeelah Ali Al-Melgmi
16 Nadiah Mohammed Al-Wahbee
17 Dlal Ali Salem Al-Rushdi
18 Fatoom Ali Drweesh
19 Zaboon Mohammed Al-Hanshali
20 Alta’af Ahmed Al-Muamri
21 Manal Nagib Al-Megtari
22 Afrah Ahmed Hussein
23 Kefaiah Ali Hadi Al-Musoa’a
24 Huda Omar Al-Galadi
25 Dr. Taha Ali Abdullwahed Al-Surori
Field supervisors 26 Dr.Mohammed Ali Al-fageeh
27 Dr. Ziad Ali Yahya
28 Dr. Adel Abdulmahammod Al-Absi
29 Dr. Fahad Abdulaziz Al-Nadaree Survey manager
30 Dr.Jalal Hussein Al-Zoaree Logistic
31 Nagib Abdulbaqi Ali Technical assistant- UNICEF
32 Faroog Abdulrahman Al-qadasi Data analysis
33 Huda Ali Al-Naggar Survey Report writer
34 Hadrmi Hadi Naser Al-Hadrmi
Data entry 35 Mohammed Hussein Al-Salmi
36 Esmaeel Mohammed Al-SAmaoee
37 Salah Mohammed Al-Rammah
39
Annex 3: Al-Baidha Governorate Nutrition Survey Team, October 2015
الصفة االسم م
علي علوي الحميقاني 1
رؤساء الفرق
محمد علي المخلف 2 احمد عبدهللا المعدن 3 علي حسين صالح القرعه 4 محمد علي سالم اللقاسي 5 سعيد محمد الحرازي 6 منى محمد المجاهد 7
ماسحين
نجوى علي النابقي 8 زينب علي سالم الرشدي 9
سهير قاسم الصبيحي 10 وفاء محمد التركي 11 فردوس ناصر محمد 12 بدور صالح السالمي 13 فنون ناجي العماري 14 نبيله علي الملجمي 15 نادية محمد الوهبي 16 دالل علي سالم الرشدي 17 فطوم علي درويش 18الحنشلي عبداإللهزبون محمد 19 الطاف احمد المعمري 20 منال نجيب المقطري 21 افراح احمد حسين مرزه 22 كفايه علي هادي المسوع 23 هدى عمر الجالدي 24 د/ طه علي عبد الرحمن السروري 25
مشرفين المسحعلي الفقيه د/ محمد 26 د/ زيد علي يحيى 27 د/ عادل عبد المحمود العبسي 28 مدير المسح د/فهد عبدالعزيز النظاري 29
مدير اإلمداد د/ جالل حسين الزوعري 30
اليونيسف -الدعم الفني نجيب عبد الباقي عبدالوهاب 31
القدسي عبد الرحمن فاروق 32 محلل البيانات
كاتب تقرير المسح النجارهدى علي د. 33
حضرمي هادي ناصر الحضرمي 34
مدخلين البيانات محمد حسين السالمي 35محمد السماوي إسماعيل 36 صالح محمد الرماح 37
40
Annex 4 : Al-Baidha Nutrition Survey Standardization Test Report for Evaluation of Enumerators
Standardisation test results Precision Accuracy OUTCOME
Weight subjects mean SD max Technical errorTEM/mean Coef of reliabilityBias from supervBias from medianresult
# kg kg kg TEM (kg) TEM (%) R (%) Bias (kg) Bias (kg)
Supervisor 10 14.3 2.3 0 0 0 100 - -0.39 TEM good R value good
Enumerator 1 10 14.4 2.3 0.1 0.04 0.3 100 0.1 -0.29 TEM acceptableR value goodBias poor
Enumerator 2 10 14.4 2.3 0.1 0.04 0.3 100 0.09 -0.31 TEM good R value goodBias acceptable
Enumerator 3 10 14.7 2.6 5.1 1.32 9 73.2 0.44 0.05 TEM rejectR value rejectBias reject
Enumerator 4 10 14.4 2.3 0.2 0.07 0.5 99.9 0.04 -0.35 TEM acceptableR value goodBias acceptable
Enumerator 5 10 14.4 2.3 1 0.23 1.6 99 0.07 -0.32 TEM rejectR value goodBias acceptable
Enumerator 6 10 14.3 2.3 0.1 0.05 0.3 100 0.03 -0.36 TEM acceptableR value goodBias good
enum inter 1st6x10 14.4 2.3 - 0.12 0.8 99.7 - - TEM acceptableR value good
enum inter 2nd6x10 14.5 2.4 - 0.76 5.2 89.8 - - TEM rejectR value reject
inter enum + sup7x10 14.4 2.3 - 0.41 2.9 95.4 - - TEM rejectR value acceptable
TOTAL intra+inter6x10 - - - 0.77 5.3 88.8 0.13 -0.28 TEM rejectR value rejectBias poor
TOTAL+ sup7x10 - - - 0.72 5 90.2 - - TEM rejectR value poor
Height subjects mean SD max Technical errorTEM/mean Coef of reliabilityBias from supervBias from medianresult
# cm cm cm TEM (cm) TEM (%) R (%) Bias (cm) Bias (cm)
Supervisor 10 99.3 9.1 0 0 0 100 - -1.73 TEM good R value good
Enumerator 1 10 98.8 9.2 0.9 0.27 0.3 99.9 -0.48 -2.21 TEM good R value goodBias good
Enumerator 2 10 98.7 9.4 1.1 0.33 0.3 99.9 -0.6 -2.33 TEM good R value goodBias good
Enumerator 3 10 98.9 9.2 0.6 0.25 0.3 99.9 -0.37 -2.1 TEM good R value goodBias good
Enumerator 4 10 99.1 9.2 1.4 0.47 0.5 99.7 -0.17 -1.9 TEM acceptableR value goodBias good
Enumerator 5 10 98.6 9 1 0.36 0.4 99.8 -0.62 -2.35 TEM good R value goodBias good
Enumerator 6 10 98.9 9.1 1 0.31 0.3 99.9 -0.38 -2.1 TEM good R value goodBias good
enum inter 1st6x10 98.9 9.1 - 0.45 0.5 99.8 - - TEM good R value good
enum inter 2nd6x10 98.8 9 - 0.43 0.4 99.8 - - TEM good R value good
inter enum + sup7x10 98.9 9 - 0.48 0.5 99.7 - - TEM good R value good
TOTAL intra+inter6x10 - - - 0.55 0.6 99.6 -0.43 -2.1 TEM acceptableR value goodBias good
TOTAL+ sup7x10 - - - 0.57 0.6 99.6 - - TEM acceptableR value good
MUAC subjects mean SD max Technical errorTEM/mean Coef of reliabilityBias from supervBias from medianresult
# mm mm mm TEM (mm) TEM (%) R (%) Bias (mm) Bias (mm)
Supervisor 10 152.7 7 0 0 0 100 - 2.7 TEM good R value good
Enumerator 1 10 151.4 8.5 7 2.36 1.6 92.3 -1.25 1.45 TEM acceptableR value poorBias good
Enumerator 2 10 150.4 7.7 12 3.1 2.1 83.8 -2.3 0.4 TEM poor R value rejectBias good
Enumerator 3 10 149.9 7.8 5 2.13 1.4 92.6 -2.85 -0.15 TEM acceptableR value poorBias good
Enumerator 4 10 149.4 7.6 7 2.29 1.5 91 -3.25 -0.55 TEM acceptableR value poorBias good
Enumerator 5 10 149.7 7.9 8 2.65 1.8 88.9 -3 -0.3 TEM acceptableR value rejectBias good
Enumerator 6 10 151.4 7.2 5 1.36 0.9 96.4 -1.35 1.35 TEM good R value acceptableBias good
enum inter 1st6x10 150.3 8.3 - 2.61 1.7 90 - - TEM acceptableR value poor
enum inter 2nd6x10 150.5 7.1 - 2.76 1.8 84.9 - - TEM poor R value reject
inter enum + sup7x10 150.7 7.6 - 2.9 1.9 85.6 - - TEM poor R value reject
TOTAL intra+inter6x10 - - - 3.59 2.4 78.2 -2.33 0.7 TEM rejectR value rejectBias good
TOTAL+ sup7x10 - - - 3.64 2.4 77.1 - - TEM rejectR value reject
Suggested cut-off points for acceptability of measurements
Parameter MUAC mmWeight Kg Height cm
individual good <2.0 <0.04 <0.4
TEM acceptable <2.7 <0.10 <0.6
(intra) poor <3.3 <0.21 <1.0
reject >3.3 >0.21 >1.0
Team TEMgood <2.0 <0.10 <0.5
(intra+inter)acceptable <2.7 <0.21 <1.0
and Total poor <3.3 <0.24 <1.5
reject >3.3 >0.24 >1.5
R value good >99 >99 >99
acceptable >95 >95 >95
poor >90 >90 >90
reject <90 <90 <90
Bias good <1 <0.04 <0.4
From sup if goodacceptable <2 <0.10 <0.6
outcome, otherwisepoor <3 <0.21 <1.4
from medianreject >3 >0.21 >1.4
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Annex 5: job descriptions for Survey Teams (Extracted from SMART Training Materials)
Each survey team should be composed of at least 3 people. Including women in survey teams is highly recommended since they are usually more comfortable interacting with children. Generally, two surveyors are involved in anthropometric measurements while another one, the team leader, records the data on the forms. However, it is strongly suggested that each team member knows how to accomplish the tasks of his teammates, because unexpected events can happen and a change in the staff may be required.
All team members must have the following qualifications:
They should be able to write and read English or French (depending on the country where the survey takes place) and speak the local languages of the areas where the survey will be conducted.
They should have sufficient level of education, as they will need to read and write fluently and count accurately.
They should be physically fit to walk long distances and carry the measuring equipment.
They do not (necessarily) have to be health professionals. In fact, anyone from the community can be selected and trained as long as he meets the above criteria.
1. Survey Manager (or supervisor)
The manager guarantees the respect of the survey methodology; he has the responsibility for:
1- Gathering available information on the context and survey planning,
2- Selecting team members,
3- Training team members,
4- Supervision of the survey: Taking necessary actions to enhance the accuracy of data collected:
4.1 Visiting teams in the field and making sure that before leaving the field, each team leader reviews and signs all forms to ensure that no pieces of data have been left out; making sure that the team returns to visit the absent people in the household at least once before leaving the area.
4.2 It is particularly important to check cases of oedema, as there are often no cases of oedema seen during the training and some team members may therefore be prone to mistaking a fat child for one with oedema (particularly with younger children). The supervisor should note teams that report a lot of oedema, confirm measles and death cases, and visit some of these children to verify their status.
4.3 Ensuring that households are selected properly and, that the equipment is checked and calibrated each morning during the survey, and that measurements are taken and recorded accurately.
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4.4 Deciding on how to overcome the problems encountered during the survey. Each problem encountered and decision made must be promptly recorded and included in the final report, if this has caused a change in the planned methodology.
4.5 Organizing data entry into ENA and checking any suspect data every evening, by using the appropriate sections of the plausibility report.
4.6 Organizing an evening “wrap up” session with all the teams together to discuss any problems that have arisen during the day10.
4.7 Ensuring that the teams have enough time to take appropriate rest periods and has refreshments with them. It is very important not to overwork survey teams since there is a lot of walking involved in carrying out a survey, and when people are tired, they may make mistakes or fail to include more distant houses selected for the survey.
5 Analyse and write the report.
2. Team Leader
Skills and required abilities:
To be able to read, write and count; know the area to survey; be reliable and friendly.
Tasks:
1. Ensures all forms and questionnaires are ready at start of day;
2. Ensures all equipment is ready at start of day;
3. Calibrates measurement instruments on daily basis;
4. Ensures all food/refreshments are ready at start of day;
5. Organises briefing meeting with his team before departure in morning;
6. Speaks with chief of village to explain the survey and its objectives,
7. Draws a map of the area to survey and use a random table;
8. Manages the households selection procedure;
9. Uses a local events calendar to estimate the age;
10. Calculates the Weight-for-Height ratio after taking anthropometric measurements;
11. Checks if the child is malnourished (checks for the presence of oedema);
12. Fills the anthropometric form;
13. Fills survey questionnaires when needed;
14. Fills the referral form if necessary;
15. Ensures that houses with missing data are revisited before leaving the field the same day;
10 This may not be possible if the survey area is large since the teams might be widely separated and remain in the field for several days. In that case, communication with teams in the field might often be very difficult; hence, each team leader must be sufficiently trained to be able to take decisions independently.
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16. Checks that all forms are properly filled out before leaving the field.
17. Ensures that all the equipment is maintained in a good state;
18. Manages time allocated to measurements, breaks and lunch,
19. Ensures security of team members,
20. Note and report the problems encountered.
3. Measurers
Skills and required abilities:
To be able to read, write and count; know the area to survey; be reliable and friendly.
Tasks:
1. Measures the height, weight and arm circumference (if included in the survey);
2. Assesses the presence of edema;
3. Uses a local events calendar to estimate the age;
4. Respects the time required for measurements, breaks and meals;
5. Takes care of the equipment;
6. Follows security measures.
The measurers must acquire some special skills and knowledge although they don’t have the primary responsibility for tasks that are related:
1. Know how to calculate the weight-for-height ratio;
2. Know how to select households for the survey;
3. Know how to check if a child is malnourished;
4. Learn how to make a reference for a malnourished child.
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Annex 6: Al-Baidha Governorate Assessment Quality Checks
Plausibility check for: Al-Baidha Oct 2015.as
Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility report
are more for advanced users and can be skipped for a standard evaluation)
Overall data quality
Criteria Flags* Unit Excel. Good Accept Problematic Score
Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5
(% of out of range subjects) 0 5 10 20 0 (0.5 %)
Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.631)
Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.165)
Dig pref score - weight Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (4)
Dig pref score - height Incl # 0-7 8-12 13-20 > 20
0 2 4 10 2 (9)
Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (5)
Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20
. and and and or
. Excl SD >0.9 >0.85 >0.80 <=0.80
0 5 10 20 0 (0.94)
Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (0.03)
Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (-0.01)
Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001
0 1 3 5 0 (p=0.114)
OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 2 %
The overall score of this survey is 2 %, this is excellent.
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Annex 7: Cluster Sampling for Al-Baidha Nutrition Survey
Cluster District Ozla Hara
1 Nata Aal Sodan Alflhah - Al-Hamra 2 Al-Soumah Aal Sayd Al-Aoulqyh 3 Al-Soumah Aal Obaid Al-Mashar 4 Al-Soumah Aouyn Al-Sabah 5 Thy Naam Al-Monqata Al-Monqata - Al-Monqata 6 Thy Naam Al-Rebad Albatehaa - Al-Zhra 7 Altfh Aal Abd Allh & Aal Hesham Al-Qaryh 8 Altfh Al-Qouym Hadharh - Al-Manah 9 Mokyras Mokyras Aal Majed 10 Mdynh Al-Baida Al-Baida Madynat Al-Biada - Azan 11 Al-Baida Aal Allbny Al-Mashra 12 Al-Baida Al-Dhahaky Al-Dhahaky 13 Al-Souadyh Aal Hasen Al-Khouah 14 Al-Souadyh Al Hady Bny Ouhb Abl - Al-Zogylyl 15 Radman Al-Aghoual Al-Olia Alkhrabh - Al-Gshh 16 Radaa Radaa Radaa - Harht Al-Qana 17 Radaa Radaa Radaa - Haarh Qaa Al-Sharaf 18 Radaa Radaa Al-Makleh 19 Al-Quryshyh Qyfh Al Mhan Yazyd Al-Zoub - Al-Rabah 20 Al-Quryshyh Qyfh Al- Mhan Lathhrh Wady Al-Nouash - Ayd Al-Aala 21 Ould-Rabai Qyfh Al- Mhdy Alabl Al-Shouahrh 22 Al-Arsh Al-Arsh Al-msla - Harht Al-Msla 23 Al-Arsh Al-Arsh Al-Harjh - Al-Synyaih 24 Al-Arsh Al-Arsh Al-Sudan 25 Sabah Sabah Qarn Qasd 26 Al-Ryashyh Jabl Al-Ryashyh Byt Al-Jalal 27 Al-Ryashyh Wady Al-Ryashyh Al-Mazoub 28 Al-Shryh Aal Ghonym Samadeh 29 Al-Malajm Aal Mnsour Al-Malajm Hejarh 30 Al-Malajm Thy Khyer Al-Moroah
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Annex 8: Age Conversion Tables for Al-Baidha Nutrition Survey
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Annex 9: Calendar of Events for Al-Baidha Nutrition Survey for Reference in Age Estimation.
