Attachments
EXECUTIVE SUMMARY
Abyan governorate is located in the south of the country, bordering the Gulf of Aden in the south, with an area of 16,442 square kilometers and a population of 476,242. The governorate contains of two main ecological zones the coastal region and the highlands.
Abyan experienced a devastating catastrophe as Ansar al-Shari’a and government forces vied for control of the region during 2011 and the first half of 2012. Reports indicate that nearly 150,000 people fled their homes in Abyan to the neighbouring Aden and Lahj governorates when fighting began. In early May 2012 the Yemeni Army began a major offensive to wrestle control of the province from militants and captured it after a month of heavy fighting. The government and aid agencies are currently assessing needs in Zinjibar and the surrounding area. The priorities after the “very heavy destruction” would be water, shelter, food, sanitation and power. Meanwhile, UN agencies, the government, and local and international NGOs have set up a working group, headed by Minister of Public Works, which is providing technical assistance to aid planners regarding how best to conduct assessments of damaged property. WFP, the UN Children’s Fund (UNICEF), the UN Office for the Coordination of Humanitarian Affairs (OCHA) and the World Health Organization (WHO) drafted an Abyan and the South Inter-Agency Response Plan, which is partly intended to encourage the return of displaced families. WFP conducted a general food distribution for 15,000 displaced households within Abyan and provide three months of food rations to encourage around 10,000 families currently displaced in Aden to return to their homes in Abyan.
The 2012 WFP-CFSS reported that 19.9%, 29.7%, 49.7% are severely, moderately, and "severe and moderate" food insecure in Abyan governorate respectively. Furthermore, as Abyan has been particularly badly affected in early 2012, the governorate reported reduced access to food by 28 percent of its populations as a result of insecurity. The survey, reported the following malnutrition prevalence: GAM: 10.1%, SAM: 3.3%, underweight: 25.8%, and stunting: 32.8%. According to Nutrition cluster strategy 2012/Yemen, Abyan falls within the serious zone (GAM from 10 – 14.9%).
Between 22 December 2012 and 3 January 2013, MoPHP, UNICEF, IOM and IRC conducted two inter-agency nutrition surveys using the Standardized Monitoring and Assessment for Relief and Transition (SMART) methodology covering the Conflict Directly Affected and Indirectly Affected districts in Abyan Governorate of Yemen. This was a Yemen Nutrition Cluster initiative to establish and monitor the levels of acute malnutrition, stunting and underweight among children aged 6-59 months in the different livelihood/ ecological zones, identify some of the factors associated with malnutrition, and inform on the appropriate responses.
Using a two-stage Probability Proportionate to Population Size (PPS) sampling methodology, 42 clusters in the Conflict Directly Affected and Indirectly Affected districts were randomly selected for both anthropometric and mortality assessments.
The calculated sample sizes in the Conflict Directly Affected and Indirectly Affected districts using ENA for SMART software were 892 and 960 households respectively for assessing both the anthropometry and mortality.
The nutritional situation in the Conflict Directly Affected and Indirectly Affected districts is shown in table 1 below. It is clear that Abyan has different pattern of malnutrition than that have seen in other governorates (e.g. Hodeidah, Hajjah etc.) but similar to neighbouring Aden. This pattern is represented by a ‘normal’ stunting, ‘serious’ underweight and ‘critical’ wasting. In the Conflict Directly Affected districts the Global Acute Malnutrition (GAM) rate was 16.1 per cent (95% CI: 13.5 – 19.2), with Severe Acute Malnutrition (SAM) 2.8 per cent (95% CI: 2.0 – 4.0). GAM and SAM rates in the Conflict Indirectly Affected districts were 11.3 per cent (95% CI: 9.0 – 14.2) and 1.9 per cent (95% CI: 1.2 – 3.2), respectively. According to WHO categorization, these rates indicate that the nutrition situation in Abyan Conflict Directly Affected districts is critical (which equal to GAM rates ≥ 15% per cent) and in the Conflict Indirectly districts is serious (which equal to GAM rates between 10 -14 per cent).
Stunting rates in the Conflict Directly Affected and Indirectly Affected districts are 28.8 per cent (95% CI: 24.5 – 33.5) and 36.5 per cent (95% CI: 31.7 – 41.6) respectively with severe stunting of 7.2 per cent (95% CI: 5.6 – 9.1) and 12.1 per cent (95% CI: 9.1 – 16.0) respectively. Although these rates are below the critical levels of 40 per cent; the stunting rates especially in the Indirectly Affected districts should attract attention.
Underweight rate in the Conflict Directly Affected districts is 29.4 per cent (95% CI: 25.6 – 33.5), with severe underweight of 5.9 per cent (95% CI: 4.3 – 7.9) while the underweight and severe underweight rates in the Conflict Indirectly Affected districts are 29.3 per cent (95% CI: 24.8 – 34.3) and 6.1 per cent (95% CI: 4.2– 8.8), respectively. These rates are approaching the critical levels of 30 per cent, as per WHO categorization.
The two main sources of drinking water in the Conflict Directly Affected districts were house-connected piped water (47 per cent) and water tankers (28 per cent) while in the Conflict Indirectly Affected districts they were water tankers (40 per cent) and house-connected piped water (22 per cent). Around two thirds of Abyan population are having flush/pour flush latrine however, more households in the Conflict Indirectly Affected districts reported defecation in open compared to the Conflict directly Affected districts (14% vs. 3%). The main source of income is fixed monthly waged work (for around half of the population) followed by casual labour (for less than one fifth). Around half of the districts' population seeks health services from a public health facility when sick and nearly another half seeks private health services.
There was high prevalence of common disease, as recorded during the survey (diarrhea, Acute Respiratory Infection -ARI- and fever prevalence are the reported cases 2 weeks before the survey while measles was one month before the survey) as shown in table 1 below. The diarrhea prevalence in last two weeks prior to the survey is significantly much higher in the Conflict Directly Affected than Conflict Indirectly Affected districts and in urban than rural areas which may be related collapse of the water and sanitation networks as well as other services due to the conflict in these areas. Diarrhea prevalence is also much higher among children aged less than 36 compared to those who are 36 and above. Among children aged 6 to 24 months diarrhea prevalence was higher among children who were given more than one milk feed (other than breast milk) in the previous day to the survey which may be related to unhygienic preparation or administration of artificial milk. Having diarrhea found also to be significantly associated with GAM and underweight as repeated attacks of diarrhea may be associated to poor environmental sanitation which is known to be associated with tropical enteropathy with resultant poor nutrient absorption and considerable nutrient losses. The resulting nutritional deficiency causes impaired immunity and increased vulnerability to more infection resulting in a vicious cycle of infection and malnutrition.
Significantly higher ARI prevalence found to be associated with stunting. Vitamin A coverage of 38 per cent in the Conflict Indirectly Affected districts and of 39.0 per cent in the Conflict Directly Affected districts was much lower than the Sphere Standards recommendation of 95 per cent coverage. Furthermore, only 47 per cent of the children aged 9-59 months in the Conflict Indirectly Affected districts immunized against measles compared to 67 per cent in the Conflict Directly Affected districts. No association was found between vaccination or vitamin A supplementation and wasting, stunting, and underweight prevalence, or with any of the investigated morbidities.
A significant proportion of children ( around 88 per cent) do not receive the recommended number of meals (4 meals and above), as per UN-FAO recommendations.
However, neither the number of meals nor the number of feeds (other than breastfeeds) shows an effect on levels of stunting, GAM and SAM.
WASH is known to be an important factor related to both morbidities as well malnutrition. Overall only 60% of Abyan households drink water from clean containers (i.e. no algae seen) which found to be significantly higher in the Conflict Directly Affected than Conflict Indirectly Affected districts (66% vs. 50% respectively), and in urban than rural (70% vs. 56% respectively). Although diarrhea prevalence found to be slightly higher among households not using clean storage for drinking water the difference is not statistically significant. Furthermore, all household caretaker handwashing practices are significantly higher among Conflict Indirectly Affected districts except hand washing before child feeding and after disposal of child faces that found to be significantly higher among the Conflict Directly Affected districts.
However, only hand washing before meal and after meal was significantly associated with low diarrhea prevalence. Although, observed unavailability of soap at handwashing facility seems to be associated with higher diarrhea prevalence, the difference was not statistically significant. Of the household caretaker handwashing practice only hand washing before meal and before child feeding shows significant association with stunting. Having no flush/pour latrine found not to be associated with diarrhea or malnutrition.
Although both the Conflict Directly Affected and Indirectly Affected districts are having difficulty in accessing food, the Conflict Directly Affected districts were found to have significantly more vulnerable on different indicators e.g. 52%, 44%, 29%, and 34% the households reduced meal size, meal number, have members experienced to go to the bed hungry and reduced expenditure on health/education compared to 37%, 34%,20%,28% in Conflict Indirectly Affected districts respectively. The mean of the composite score for the five food insecurity indicators was also significantly higher in the Conflict Directly Affected than Conflict Indirectly Affected districts (2.3 vs. 2.0 respectively). Overall, the prevalence of all types of malnutrition found to be higher among food insecure households. However, this was only statistically significant for some food insecurity indicators e.g. GAM with reducing the size of meals because of the scarcity of resources, SAM and underweight with household member go the bed in night hungry because of not enough food, and stunting with borrowing food/money to purchase food or purchase food in credit.
Finally, about three fourths of the caretakers in Abyan have no formal education.
Although the prevalence of all types of malnutrition was higher among illiterate caretakers, this was only statistically significantly with stunting. Although there is no significant association was found between caretakers' education and morbidities, there is strongly significant association with poor child feeding, low vaccination coverage and vitamin A supplementation.
Recommendations As Abyan emerges from war, the humanitarian needs are high and should attract more attention both from government, CBOs/NGOs, and donor community. Although mortality is still low, the critical and serious levels of wasting and to some extent underweight require an urgent intervention to address the situation across the governorate with more focus on the Conflict Directly Affected district. The specific recommendations include:
Immediate Interventions
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Government along with development partners need to urgently restore security and basic services such as water, electricity and sanitation. As hundreds of internally displaced families have returned to their homes a general food distribution and provide food rations is important. Pre-positioned supplies in WASH, child protection and nutrition are important for response to reach the larger population.
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Rehabilitate and re-operationalize the destroyed health facilities to ensure proper delivery of health services especially nutritional services, vaccination and vitamin A supplementation.
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Develop detailed integrated response micro-plan articulating district level humanitarian needs, delivering response package, coverage and gaps to document the progress, advocacy and lessons learnt.
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Priority should be given to pockets of vulnerability especially in the Conflict Directly Affected areas through mobilizing outreach services to rapidly address the high GAM/SAM rates.
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Development of CMAM protocol, strengthen and expanding CMAM services to reach all the existed health facilities and outreach services. 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.
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Promote appropriate IYCF practices (especially promotion of appropriate complementary feeding practices for children aged 6 to 24 months) along with micronutrient supplementations and deworming. Accelerate the integration of IYCF counseling into all CMAM services delivered by both fixed and mobile clinics.
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Intensive social mobilisation campaigns on IYCF feeding and caring practices through behavior 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
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From the development point of view, there is an essential need for Yemen to be an active member in the global SUN movement.
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High level advocacy with the government and development partners to mobilise their commitment to fight malnutrition among U5 Yemeni children.
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Scaling up implementation of the national nutrition strategy and related action to address the high level of malnutrition in line with the lifecycle approach.
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Continued support for longer term water development and sanitation programmes throughout the governorate, with community mobilization activities to promote safe sanitation and hygienic practices.
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Follow up SMART nutrition survey and coverage survey in 2014 to track the progress on implementation of the response plan.
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Promote improved latrine use and other hygiene services like Community Led Total Sanitation (CLTS) strategy.
Other Recommendations
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Further investigation is needed to understand the causality tree behind high level of acute malnutrition among boys compared to girls found in this survey as well as earlier surveys e.g. in Hodeidah, Taiz, Hajja governorates.
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Undertaking full scale national nutrition and mortality survey.
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In a view of high malnutrition among illiterate mothers' children as well as poor child feeding practices and health indicators (e.g. vaccination, Vitamin A supplementation) found in this survey as well as previous surveys in Yemen, a focus on girls’ education is necessary in the long term battle against malnutrition as well as for broader development.