EXECUTIVE SUMMARY INTRODUCTION
A stratified, cluster nutrition survey was conducted in the Sahrawi refugee camps (Wilayas: Laayoune, Awserd, Smara, Dakhla and Boujdour) located near Tindouf, Algeria. The survey took place in March to May 2019, with the overall aim of establishing a detailed mapping of the current nutritional profile of the population. Findings of the survey were used to produce recommendations to improve the nutritional status and health of the Sahrawi refugees.
The surveyed used a stratified two-stage cluster sampling design. A total of 421 clusters were randomly allocated to each stratum using probability proportional to size based on available estimates used for humanitarian programming and using the quarter (barrio) as the sampling unit in this first stage. In the second stage, nine households2 were randomly selected from within each cluster, following the updated EPI method of proximity selection.
Two population groups were included in each survey; children aged 0-59 months and women of childbearing age (15-49 years). For all children surveyed, standard anthropometric, measles vaccination status, presence of diarrhoea in the previous two weeks and feeding practices, as well as health-seeking behaviours, during diarrhoea episodes were collected. Infant and young child feeding indicators were collected for children 0-35 months. For women, Body Mass Index (BMI) was obtained to assess the risk of chronic metabolic diseases.
Peripheral blood was obtained in children and women, to assess haemoglobin using a portable photometer (HemoCue® 201+). At the household level the Food Consumption Score (FCS) and the Household Dietary Diversity Score (HDDS) -both food security indicators-, as well as coping mechanisms, were obtained in all surveyed households. In addition, we obtained reported Non-Communicable Diseases (NCDs) and household water and sanitation data.
A total of 1,728 households were visited. Most households agreed to be surveyed 97.2% (1,944 children and 2,463 women). Key indicators obtained in these surveys are summarised in Table 1 below.
Nutritional status in children 6-59 months– Anthropometric indicators and anaemia
The overall prevalence of Global Acute Malnutrition (GAM), assessed using weight-for-length/height z-score (WHZ) <-2 and/or oedema, was 7.6%, ranging from 3.8% in Laayoune to 11.5% in Smara. The GAM prevalence in Smara was significantly higher than all other strata. Similar prevalence estimates were found when GAM was defined as Mid-Upper Arm Circumference (MUAC) <12.5 cm and/or oedema. GAM prevalence has significantly worsened since 2016. The stunting prevalence was 28.2%, ranging from 27.4% in Smara to 30% in Dakhla. Stunting prevalence has significantly worsened since 2016.
Overall, 50.1% of children aged 6-59 months suffer from anaemia. The most common types of anaemia being mild (24.2%) and moderate (24.1%), and severe anaemia was low (1.7%). There are not significant differences in the anaemia prevalence between strata. Anaemia prevalence has significantly worsened since 2016.
Infant and young child feeding (IYCF) practices
The proportion of children aged <24 months ever breastfed was high at 85.4%. Among infants aged <6 months the proportion who are exclusively or predominantly breastfed was 50.4% and 63.7%, respectively.
Breastfeeding was reportedly initiated in the first hour in 58% of the children aged <24 months. Continuation of breastfeeding at 12 and 24 months was 74.2% and 28.3%, respectively. The mean duration of breastfeeding was 20.7 months. The prevalence of bottle-feeding in children aged <24 months was 21.4%.
Adequate introduction of solid, semi-solid and soft foods between the ages of 6-8 months was reported in 64.8% of children that age. Only 31.9% of all children aged 6-23 months had a minimum acceptable diet (an IYCF summary indicator). The proportion of children aged 6-23 months reporting consumption of iron-rich or iron-fortified foods was 59.5%.
Diarrhoea, feeding patterns and health seeking behaviour
Overall, 10.4% children aged 0-59 months reported to have presented diarrhoea in the previous two weeks (did not differ significantly between strata). Feeding practices during diarrhoea were poor, with only 28.7% of children being offered more fluids and more than half (61.1%) having their feeding intake reduced. Health seeking behaviours among caregivers were also low, with only 44.4% and 34.7% of children with diarrhoea being taken to the health centre or given oral rehydration, respectively.
*Nutritional status in women of childbearing age (15-49years) – Anthropometric indicators and anaemia**
Overall, 5.8% of non-pregnant and non-lactating women of childbearing age were classified as underweight (BMI<18.5 kg/m2 ), 36.5% as overweight (BMI>25 and <30 kg/m2 ) and 29.6% as obese (BMI>30 kg/m2 ). The prevalence of overweight and obesity combined was 66.1%, ranging from 62.9% in Laayoune to 69.2% in Smara. Similar values of overweight and obesity prevalence were observed in 2016.
The prevalence of anaemia in non-pregnant women of reproductive age was 52.2%, ranging from 47.9% in Laayoune to 55.6% in Smara. There were no significant differences between strata. Pregnant presented similar anaemia prevalence estimates (55.1%) than their non-pregnant counterparts and lactating women presented higher anaemia prevalence (69.1%).
Food security indicators
Overall, the proportion of households classified as having an acceptable FCS was 60.3%, ranging from 57.2% in Laayoune to 62.9% In Dakhla. No significant differences were observed between strata. The mean FCS-based dietary diversity score (based on a 7-day recall) was 5.3 out of a maximum value of 7 food groups. The HDDS based on 24-hour recall was 8.2 out of a maximum value of 12 food groups. The proportion of women that reached the minimum dietary diversity was 60.3%. No significant differences between strata were observed for these indicators.
Overall, the mean value for the reduced Coping Strategies Index (rCSI) was 7.6, ranging from 6.2 in Smara to 9.4 in Laayoune. The strata of Smara presented observable lower rCSI values, but the difference did not reach statistical significance. The most common coping strategies used by the households were reliance on less preferred or less expensive foods, borrowing of food or rely on help from friends or relatives and limiting portion size at mealtimes.
Non-communicable diseases (NCDs)
Overall, the prevalence of reported adults (aged 25-64 years) having diabetes, high blood cholesterol, high blood pressure and cardio-vascular disease was 11.4%, 4.5%, 8.9% and 2.6%, respectively. In all Wilayas,
39.4% (95% CI 35.5; 43.5) of the households reportedly having an adult suffering either diabetes, high cholesterol or high blood pressure, displaying the societal exposure to NCDs.
Water, Sanitation and Hygiene (WASH) Indicators
Overall, 41.5% of households had their water provision meeting the UNHCR standards (20 litres/person/day).
There were significant differences between strata with the stratum of Dakhla presenting the highest estimates (78.0%). Almost half of the household reported satisfaction with the water supply (48.8%). On average households had their water tanks refilled every 31.4 days, ranging from 8.9 days in the stratum of Dakhla to 38.6 days in the stratum of Smara.
A large proportion of households (79.3%) reported the presence of soap. Basic hygiene practices such as washing hands before preparing or eating food was high (97.9%) with little differences between strata.
Most households reported having access to a latrine and only a very small proportion of households (0.5%) reported to engage in open defecation.
Coverage of Moderate and Severe Acute Malnutrition care programmes and measles vaccination
Overall, the point-coverage of Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM) treatment for children aged 6-59 months with acute malnutrition was low at 5.0% and 11.1%, respectively.
After including the children that were receiving MAM and SAM care but did not fit the case definition, periodcoverage remained low at 12.6% and 42.5% for MAM and SAM treatment, respectively.
Measles vaccination coverage for children 9-59 months was 94.0%, almost in line with the recommended Sphere standards at 95%.
The 2019 survey results, when compared with previous surveys, suggest a worsening of the nutrition of the Sahrawi population. There is a significant worsening in both GAM and stunting, which is significantly greater than in 2016. Both GAM and stunting prevalence are considered of poor public health significance, although in the stratum of Smara these are considered of serious public health significance.
Similarly, the prevalence of anaemia has increased in children aged 6-59 months and remain at similarly high levels among women of reproductive age when compared to 2016 prevalence estimates. The worsening anaemia prevalence in children has reversed past public health gains since 2010 that followed the introduction of special products like Chaila and Ghazala.
Sahrawi refugees are facing now a high risk of chronic diseases among adults, as determined by the prevalence of overweight and obesity among women of childbearing age and the high prevalence of reported NCDs among working age adults (aged 25-64 years).
Recommendations for action based on the findings of these surveys are provided in section VI of this report (see page 75).