South Sudan

Standardised Expanded Nutrition Survey (SENS) Final report - Gorom Refugee Camp South Sudan (Survey conducted: 17-20 September 2018)



UNHCR and ACROSS carried out the nutrition survey in Gorom refugee camp from 17 to 21 September 2018.
The overall aim of the survey was to assess the nutrition situation among the refugee population and to monitor ongoing programme interventions.
The survey was based on the UNHCR Standardized Expanded Nutrition Survey (SENS) guidelines for refugee populations (version 2, 2013). Following four modules of SENS were used (1. anthropometric and health, 2.
Anaemia, 3. IYCF, and 4. Food Security). Modules 5. Water Sanitation and Hygiene and 6. Mosquito net coverage were not carried out as access limitations required for module prioritization. The camp has a WASH monitoring system in place and no blanket mosquito net distribution was carried out within the year.
UNHCR population figures from ProGres were used to determine the total population and that of children 6-59 months for survey planning purposes. At the end of August 2018 the Gorom refugee population was 2203 individuals. 393 (17.8%) of these were children under five years.
An exhaustive survey was conducted in relation to children as the total population size of Gorom camp was below 2,500 people rendering sampling unnecessary. All children aged 6-59 months in the camp were surveyed.
A total of six survey teams composed of four members each (one team leader, one haemoglobin measurer, one anthropometric measurer/translator and one anthropometric/haemoglobin measurement assistant were included in each survey. A standardized training lasting five days, which included a standardization test was provided. Data collection lasted five days. The survey teams were supported by a team of 2 supervisors and 1 coordinator who roved between the teams duration the data collection.
Mobile phone questionnaires using Open Data Kit (ODK) android software was used for data collection for all the modules. Data validation was carried out on a daily basis by the survey coordinator, which allowed for daily feedback to the survey teams. Data analysis was carried out using ENA for SMART July 9, 2015 version for anthropometric indices and Epi info version 7 for all the other data.
Under the various forms of malnutrition, the survey results showed a prevalence of Global Acute Malnutrition (GAM) of 4.0%. This falls within the acceptable category GAM prevalence <5% according to WHO classification.
The prevalence of global stunting among children aged 6-59 months was 17.1% which is within the acceptable WHO range of <20%. Total anaemia prevalence among children aged 6 to 59 months reported 55.2% and among women of reproductive aged between 15-49 years (non-pregnant) was 56.9%. Both categories are classified as of high public health significance as are above 40%. Despite of reducing trends in the prevalence of anaemia compared to the results of SENS 2017 (anaemia was 71.0% and 66.2% among children and women), the high prevalence of anaemia among children aged 6-59 months and non pregnant women aged 15-49 years remains a key concern.
Under infant and young child feeding practices, the proportion of children aged 0-23 months that had timely initiation of breastfeeding within the first hour of delivery was 84.6%.The rate of exclusive breast feeding for the first six months of life was 93.3%. The proportion of children aged 6 to 8 months that were introduced to solid and semi-solid foods on time was 66.7%. 17% of the surveyed children aged 0-23 months were bottle fed and the same proportion also received infant formula. The results above indicate positive gains in terms of breastfeeding practices. Appropriated practices around complementary feeding remain sub optimal indicating the need to continue strengthening the IYCF program to improve feeding practices.
The household diet diversity score (HDDS) reported 4.8 out of 12 food groups. Majority of the refugees (78.5%) in Gorom refugee camp reported to have used negative coping strategies within the last month pre the survey to fill the food assistance gap.

19.7% of children had dieahroea during the last two weeks prior to the SENS survey, compared to 12.8% reported in SENS 2017.
Maintenance of a comprehensive nutrition program, strengthening of preventative activities including the provision of adequate household food intake, appropriate caring practices with support and promotion of optimal IYCF practices, health and sanitation at household level are recommended to facilitate optimal nutrition. This to be accomplished through adequate food assistance, support, promotion and protection of infant and young child feeding practices, improved health services, adequate water and sanitation and the expansion of livelihood activities in addition to the treatment of malnourished persons.

Interpretation of results:

  • The overall nutrition situation is classified as acceptable as the GAM prevalence is 4%1 . In 2017 the GAM prevalence was 5% among children 6-59 months. The reduction from 5.0% to 4.0% in 2018 was not statistically significant (p>0.05) but indicates that the acute malnutrition situation is on a downward trend.
    This was also the case for severe acute malnutrition.

  • The 17.1% prevalence of global stunting is acceptable according to WHO standard2 but should be interpreted with caution due to the age estimation limitation. 10% of the children 6-59 months had no reliable age documentation. Stunting prevalence remained the same in 2018 compared 2017 as the reduction was not statistically significant (p>0.05). In 2017 stunting among children 6-59 months was 17.6%.

  • The TFP coverage using MUAC was 100%. The coverage for TSFP was below standard using both the MUAC and WHZ scores criterion. Most of the cases identified with acute malnutrition based on the WHZ scores did not meet the MUAC cut off of <125mm. This indicates the need to strengthen case finding, including innovative ways of identifying cases that are acutely malnourished based on WHZ scores.

  • The coverage of measles vaccination and vitamin A supplementation was slightly below the target coverage of ≥95% and ≥90% respectively indicating the need to continue improving routine and campaign strategies.

  • 19.7% of children 6-59 months were reported to have had diarrhoea in the last two weeks prior to the survey indicating a morbidity caseload requiring continued health, water and sanitation services provision.
    In 2017 SENS around 12.8% of children were reported to have had diarrhoea in the last two weeks of survey.
    Total anaemia prevalence in children 6 to 59 months was 55.2% (with 1.3% being severe anaemia). The prevalence among women aged 15-49 years (non-pregnant) was 56.9% (with 3.2% being severe anaemia). The prevalence of anaemia among both categories is critical as it is above the 40% level of public health significance (WHO classification)3 . Analyis by age categories indicated that the prevalence of anaemia was higher among children aged 6-23 months (as high as 65.9%, with 2.2% being severe anaemia). The high prevance of anaemia among children aged 6-59 months and non-pregnant women aged 15-49 years remains a key concern in the camps. It requires to be addressed through multi-sectoral preventive and curative interventions.

  • The rate of exclusive breastfeeding of 93.3%, introduction of solid, semi-solid or soft foods 66.7%, and consumption of iron-rich or iron-fortified foods 67.0% improved greatly compared to 2017. The introduction of solid, semi-solid or soft foods and consumption of iron-rich or iron-fortified foods of remain sub optimal indicating the need for continued IYCF program strengthening to improve feeding practices.

  • Under food security: 100% of the HHs had a ration card; the household diet diversity score was 4.8 out of 12 food groups; most of the households reported using one or more of the negative coping strategies (borrowed cash or food 40.5%, sold assets 12.4%, reduced quantity or frequency of meals 42.9%, begged 9.0%, and engaged in potential risky or harmful activities 26.4%. Only a small proportion of the refugees in Gorom (21.4%) reported not using any of the negative coping strategies to fill the food assistance gap (a 70% of the recommended general food ration is provided per person per month). This group is likely to be benefiting from the complementary livelihood interventions in place. This however needs to be scaled up to increase the proportion to cover majority of the population.


Nutrition related

  • Continue the implementation of the comprehensive Community based Management of Acute Malnutrition (CMAM) program providing both therapeutic and supplementary feeding programs to facilitate the rehabilitation of identified acute malnourished children, pregnant and lactating women, people living with HIV/AIDS and TB patients on treatment. This to include active case finding and community mobilization. (UNHCR, UNICEF, WFP and ACROSS).

  • Ensure all the children aged U5 in the community screened and referred 6-59 months children identified with a MUAC less than 125mm get enrolled into the management of acute malnutrition programs through community outreach follow up at household level (ACROSS)

  • Community outreach, triage areas and nutrition centres to systematically screen and refer all persons with anaemia signs and symptoms (palmar pallor).

  • Ensure monthly blanket supplementary feeding programme for children 6-23 months, pregnant and lactating women using a fortified blended food or lipid based supplement to prevent malnutrition and to cover the nutrient gap these vulnerable groups have in light of a predominant grain based general food diet (UNHCR, WFP and ACROSS)

  • Conduct two step MUAC and WHZ scores (for children with MUAC at risk) screening during BSFP and at the health facilities’ triage areas to ensure both high MUAC and WHZ score coverage (ACROSS)

  • Continue strengthening the capacity of the nutrition facility in terms of provision of adequate staff and training to ensure quality provision of both curative and preventative components of nutrition (UNHCR, WFP, UNICEF and ACROSS)

  • Expand and strengthen preventative nutrition components including Infant and Young Child Feeding (IYCF) and community outreach education aspects to stop the various forms of malnutrition from occurring in the first place. (UNHCR, UNICEF and ACROSS)

  • Continue implementing the micronutrient reduction strategy to curb the high anaemia prevalence.

  • Conduct follow up quarterly mass MUAC screening to monitor the evolution of the nutrition situation at the community level. (ACROSS)

  • Ensure regular monitoring, quarterly joint monitoring and yearly program performance evaluations in all camps to assess performance progress and formulate recommendations for any identified gaps. (UNHCR, WFP, UNICEF and ACROSS).

  • Undertake a follow up annual joint nutrition survey to analyze trends and facilitate program impact evaluation in 2018. (UNHCR, ACROSS, WFP and UNICEF).

Food security related

  • Provision of a General Food Ration (GFR) providing the recommended minimum dietary requirements (2100kcal/person/day) and milling assistance (UNHCR, ACROSS and WFP).
  • Continue the routine joint monthly food basket monitoring on site and ensure the inclusion of the refugee camp in the post distribution monitoring at the household level to ensure that refugees receive their entitlement (UNHCR, ACROSS and WFP).
  • Expand the coverage of sustainable food security and livelihood solutions to allow diet diversity and to complement the general food distribution. This to include the promotion of all year-round production of micronutrient-rich foods or crops in home gardens, fruit trees and small animal husbandry. (UNHCR, WFP and ACROSS).