Standardised Expanded Nutrition Survey (SENS) Final report - Makpandu Refugee Settlement Western Equatoria South Sudan (Survey conducted: 1-5 October 2018)
UNHCR and WVI carried out a rapid nutrition survey in Makpandu from 1 to 5 October 2018.
The overall aim of the survey was to assess the nutrition situation among the refugee population and to monitor the progress of the current nutrition interventions.
The survey was based on the UNHCR Standardized Expanded Nutrition Survey (SENS) guidelines for refugee populations (version 2, 2013). Only the anthropometric and health module of SENS http://sens.unhcr.org/ were carried out due to access limitations.
A cross-sectional survey was conducted using simple random sampling. Households were physically labelled with unique numbers per block. To reduce non-response rate and ensure results were representative of people actually living in the settlement at the time of the survey, empty households1 , as verified through neighbours were not be labelled and thus not be included in the sampling frame. A random household sample was drawn from the actual number of physically verified household before the survey. Children 6-59 months were included in the survey.
A total of six survey teams composed of three members each: one team leader/questionnaire enumerator and two anthropometric measurers carried out the data collection. A three day training was carried out from 25 to 27 September 2018 by UNHCR. Data collection lasted five days. The survey teams were supported by a World Vision International (WVI) supervisor on ground and coordinated remotely by the UNHCR Nutrition and Food Security Officer throughout the duration of data collection.
Data collection was carried out using paper questionnaires. The data was entered daily into ENA for SMART software (version July 9th, 2015) https://smartmethodology.org/. Data validation was carried out on a daily basis by the UNHCR survey coordinator which allowed for daily feedback to the WVI supervisor and onward to the team leaders. Data analysis was undertaken using ENA for SMART July 9th 2015 version for anthropometric indices and Epi info version 7.
Results from the survey showed a Global Acute Malnutrition (GAM) prevalence of 5.3%, with 0.9% severe acute malnutrition (SAM). This is classified as poor according to the WHO classification as it falls between 5-9%2 . Compared to 2017, the GAM prevalence showed increase trend from 3.3% to 5.3% and SAM prevalence from 0% to 0.9% in 2018 but not being statistically significant. This increase, however, is indicative of likely deterioration if the causes of undernutrition are not addressed.
The prevalence of global stunting of 21.1% in 2018 indicates a poor situation according to WHO classification as it is above the acceptable standard of <20%. This should, however, be interpreted with caution due to the age estimation limitation. 44% of the children 6-59 months did not have a reliable age documentation.
The coverage of Targeted Supplementary Feeding Program (TSFP) and Therapeutic Feeding Program (TFP) using both admission criterion did not meet the recommended standard of >90%. This indicates the need to strengthen active case finding, referral and enrollment into the nutrition programme in Makpandu.
The coverage of measles vaccination and vitamin A supplementation was below the target coverage of ≥95% and ≥90% respectively indicating the need to strengthen and maintain both the routine and campaign vaccination/supplementation interventions.
Almost a third of children 6-59 months reported to have had diarrhea in the last two weeks prior to the survey indicating a high morbidity rate requiring improved health services provision, and strengthening of community based preventive interventions on hygiene, sanitation and child care practices. Three quarters of these sought medical care at the Makpandu PHCC.
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 Infant and Young Child Feeding (IYCF) practices, health and sanitation at household level are recommended to facilitate optimal nutrition. This to be accomplished through adequate food assistance, 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.
The overall nutrition situation in Makpandu settlement is classified as poor as the GAM prevalence of 5.3% falls between 5-9%3 . The GAM prevalence showed increased trend from 3.3% in 2017 to 5.3% in 2018. The prevalnce of severe acute malnutrition (SAM) increased to 0.9% from 0% in 2017. Although the increase in GAM prevalence from 3.3% to 5.3% in 2018 was not statistically significant (p>0.05) the prevalence range moved from “acceptable” level to “poor” level indicating a likely deteriorating situation.
This was also the case for the prevalence of SAM.
The prevalence of global stunting was 21.1 % (12.2 - 33.8 C.I.). This indicates a poor level according to WHO classification and is above the acceptable standard of <20%.
This should however be interpreted with caution due to the age estimation limitation. 66% of the children 6-59 months did not have a reliable age documentation.
The enrolment coverage of Targeted Supplementary Feeding Program (TSFP) and Therapeutic Feeding Program (TFP) was low and did not meet the recommended standard of >90%. This indicates the need to strengthen active case finding, referral and enrollment in nutrition programme through screening at the community level in Makpandu.
The coverage of measles vaccination and vitamin A supplementation was also slightly below the target coverage of ≥95% and ≥90% respectively indicating the need to strengthen and maintain both the routine and campaign vaccination/supplementation interventions.
Almost a third of children 6-59 months reported to have had Diarrhoea in the last two weeks prior to the survey (32.9% vs. 24.5% in 2017 showed increased trend) indicating a high morbidity rate which is possibly one of the contributing factors for the increasing trends in GAM and SAM prevalence in 2018 requiring continued health services provision, and strengthening of community based preventive interventions on hygiene, sanitation and child care practices. Three quarter of these sort medical care at the Makpandu PHCC.
Recommendations and priorities
Maintain a 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 WVI).
Ensure all 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 (WVI). Maintain 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 WVI).
Conduct a two-step MUAC and WHZ scores (for children with MUAC at risk) screening monthly at the BSFP site and the PHCC triage area in Makpandu to ensure both high MUAC and WHZ score coverage (WVI). This to be coupled with mapping of the settlement location malnourished cases are identified from, to allow complementary prevention interventions to be put in place.
Continue strengthening the capacity of the nutrition program, in terms of provision of adequate staff and training to ensure quality provision of both curative and preventative components (UNHCR, WFP, UNICEF and WVI).
- Strengthen the prevention of malnutrition components including IYCF and community outreach education aspects to stop malnutrition from occurring in the first place. (UNHCR, UNICEF and WVI).
- Conduct quarterly mass MUAC screening to monitor the evolution of the nutrition situation in Makpandu settlement. (WVI).
- Ensure regular monitoring and supervision, quarterly joint monitoring and yearly program performance evaluations in Makpandu to assess performance progress and formulate recommendations for any identified gaps. (UNHCR, WFP, UNICEF and WVI).
- Undertake a follow up annual nutrition survey to analyze trends and facilitate program impact evaluation. (UNHCR, WVI, WFP and UNICEF).
Food security related
- Food assistance providing the minimum recommended dietary requirements (2100kcal/person/day) is critical to ensure basic nutrition provision. Until April 2018 the ration provided in Makpandu settlement provided 1582 kcal/p/d (75%) of the recommended calories which is insufficient. Following the introduction of the hybrid food and cash model systematic post distribution monitoring to be carried out to ensure the cash component is contributing to the intended food assistance requirements. In addition to this prepositioning of 2019 supplies to be carried out at the beginning of the year to avoid pipeline breaks (UNHCR, WVI and WFP).
- Continue the routine joint monthly food basket monitoring on site and ensure Makpandu inclusion in the country post distribution monitoring at the household level (UNHCR, WVI and WFP).
- Expand the coverage of sustainable food security and livelihood solutions in Makpandu settlement to complement the provided food assistance (UNHCR, WFP and WVI).
- Maintain and strengthen the provision of comprehensive primary health care programme for refugees and host populations in Yambio. (UNHCR and WVI).
- UNICEF, WVI and UNHCR to ensure that Expanded Programme on Immunization (EPI) and Vitamin A supplementation campaigns and routine programmes are strengthened to increase coverage to acceptable standards.
- Adequate clean water provision to be maintained in 2019. In addition to this hygiene promotion and latrine coverage strengthening to reduce the diarrhea caseload to be ensured. (UNHCR and WVI).