Nutritional Anthropometric and Retrospective Mortality Survey, Children 6 to 59 months: Low Land and Mountainous Ecological Zones Lahj Governorate, Yemen - Final Report

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Executive Summary

Lahij governorate is one of the twenty one governorates in Yemen, covering a total area of 13,046 km2 which makes it the fifth largest governorate in Yemen by its total area. Lahij Governorate is located 320 km southwest of the Capital City of Sana’a and 30 km to the east of the City of Aden. Al-Houta is the capital city of Lahij and is considered a crossing point to and from many governorates. Al-Houta is also a favorite stopover for tourists, because of the presence of vital facilities, administrative centers and markets. Sultan Abdali Palace is considered to be the most prominent architectural landmark of Houta city. The condition of the road to Al-houta and the inter district roads are generally good.

Lahij governorate borders Abyan governorate in the East, Taiz governorate to the Southeast, AlBaidha governorate to the Northwest and Aden governorate to the South. The governorate is subdivided into 15 districts (muderiah).

Demography: The total population of Lahij governorate is estimated to be 869, 2531 with a sex distribution of 50% (435028) females and 50% (434225) males. The average family size is estimated to be 7 persons per household. According to health office information, 793,964 (91%) of the total population live in the rural areas.

Topography: The topography of Lahj varies from high mountains reaching 2500m above sea level as part of As-Sarat mountainous range, to fertile valleys, such as Wadi Tuban, which is one of the most fertile Wadis in Yemen. The Mountainous Areas of Lahj are rich in natural resources for environmental tourism such as: The Forest of Irf-Maqatirah and areas in the mountains of Yafi'a, which grows some of the finest Yemeni coffee. The villages of Yafi'a also are characterized with their own architectural features, such as the reliance on stone and their high rise floors. Islamic landmarks in the governorate include the Al-Nour Mosque in Al-Mousat. There are still annual pilgrimages to various tombs in the different areas of Lahj Governorate to pay tribute to respected Islamic notables of the past.

Climate: The governorates climate varies according to the topography of the terrain. In the coastal plains the temperature can rise in the summer to 32oC, where the mean temperature in the winter comes down to 20 oC. The coastal plains also witness rainfall in the winter and autumn. However, in the mountainous highlands, rainfall is witnessed in the spring and summer seasons.

Agriculture: The total cultivated area in the Governorate of Lahj is 60,000 feddans. The most popular wadis are Wadi Tuban, Wadi Wirzan, Wadi Yahr, Wadi Saba and Wadi Al-Rruja’a. Along the banks of Wadi Tiban, a number of recent dams were constructed. Since Wadi Tiban is characterized by a semi-tropical climate this fills the gardens of Lahj Governorate with vegetables, fruits, various types of grain and long fiber cotton and with the lovely scents of blossoms and flowers.

Food security status: WFP cluster food security survey (CFSS) conducted in 2014 classified Lahij as food insecure area, more than half of its population suffer from food insecurity. Prevalence of global acute malnutrition was at the critical level.

Survey date: 14th to 26th of June, 2014

This nutritional survey was conducted as part of the biyearly nutritional monitoring system of the MOPHP intervention areas. The survey was conducted in collaboration with MOPHP at local and national levels and with technical and financial support from UNICEF. Data collection was completed by six teams, six supervisors, six data enterers and one survey coordinator.

Area of coverage: This survey has been carried out in the two ecological zones, representing Mountains and Costal areas of Lahij governorate.

1.1 Survey objectives:

The main purpose of the survey was to assess the nutrition situation of the Lowland and Mountainous communities. The final outcome of the survey would be to make recommendations for the purposes of guiding the design and implementation of an appropriate response in Lahij governorate.

  • To evaluate the global and severe acute malnutrition rates among children aged 6-59 months in Taiz Governorate.
  • To identify groups at higher risk of malnutrition: age group, gender.
  • To estimate the mortality rate and cause of death among children less than 5 years of age over the preceding three months.
  • To estimate the crude mortality rate and cause of death among the population over 5 years of age for the preceding three months.
  • To estimate vaccination coverage Pentavalent3/ Polio3, measles and vitamin A supplementation.
  • To estimate the prevalence of disease in the two week prior to the survey i.e. acute respiratory infections (ARIs), Diarrhoea, fever and measles.
  • To collect relevant food security, water and sanitation, and care practices information on the surveyed population.
  • To make possible recommendations concerning further programs.

2. Methodology:

In Lahij governorate, districts are subdivided in to sub-districts; which are further divided into villages. The universe that the samples were drawn was based on the complete list of ‘villages’ in all the fifteen districts and the best available population estimates of the selected villages obtained from the central population office.

Clusters and Household selection:

Clusters were selected at the random with the probability of being selected proportional to the size of the population in the districts of the governorate using the ENA software and household were selected when the survey teams visited the selected cluster location and met village leaders. The team leader explained the purpose of the survey and survey procedures. After obtaining the initial permission of village leaders and participation from each household was requested.

A total amount of 37 and 33 clusters were selected from Mountains and costal zones respectively using SMART software. As the house hold considered as the primary sampling unit number of children to be included was estimated to provide reasonable estimates of the prevalence of malnutrition with at least 95% confidence. A total of 538 and 554 household were visited from mountains and coastal respectively for data collection. The same method was applied for the retrospective mortality survey. All household including those without children less than 5 years of age were included for mortality survey. The sampling methodology follows the SMART guidelines.

Anthropometric and mortality data were analysed using ENA software and house hold using SPSS. Anthropometrics data were put in relation to the World Health Organization (WHO) reference population for indices calculation and the National Centre for Health Statistics (NCHS) reference for comparative value.


There were six survey teams each consisting of three enumerators, one team leader. The enumerators have been involved in previous nutrition surveys and possessed a practical experience.

A six days training was conducted including one day piloting for the enumerators prior to the actual field work. Standardization test was conducted using SMART to assess the techniques of the enumerators.

Anthropometrics result:

Weight-for-height z-scores (WHZ) were calculated to give the prevalence of acute malnutrition or wasting. Wasting can be assessed by comparing a child’s weight with the weight that would be expected from a healthy child of the same height. For the purposes of this report, prevalence of malnutrition according to WHO 2006 Growth Standards which are more internationally representative are presented. For purposes of comparing previous trend data and across countries, prevalence according to the NCHS 1977 reference population is presented in the appendix.

A z-score is a measure of how far the child deviates from the mean NCHS or WHO record for his age or height, and therefore a measure of how well he is growing compared to the ‘norm.’ As seen in figure 3.1 below, wasting is defined as <-2 z-scores (global acute malnutrition), whereas severe wasting is defined as <-3 z-scores (severe acute malnutrition).

The level of global acute malnutrition (GAM) found in Lowland Zone is 17.1% (13.6 – 21.4 95%C.I.), which classifies as ‘critical’ as per the WHO categorization of the severity of the situation, while in the Mountainous Zone, the GAM rate is 7.5% (5.3 – 10.7 95%C.I.), which is classified as ‘Poor’ according to the WHO categorization. The GAM level among the Lowland households was significantly higher than the Mountainous households (p<0.003).

Comparison between the WHO GAM rate of 2012 and 2014 for coastal , Statistically there is nonsignificant difference between 23.0% (19.4 -27.1 95%CI) and 17.1% (13.6 – 21.4 95%CI) using the “overlapping confidence interval test” and as well the statistical test using “two-survey” calculator shows p= 0.394.

Mountains GAM rates for the same period 2012 and 2014, 14.3% (11.0 -18.3 95%CI) and 7.5% (5.3 -10.7 95%CI) respectively shows significant difference as the confidence interval is not overlapping and using “two -survey” calculator p=0.0004 which confirm the statistical test of the confidence.

Prevalence of stunting, 30.5 % (25.2 - 36.3 95%CI) and 39.1 % ((33.5 - 45.1 95%CI) with severe stunting 6.0 %(4.2 - 8.4 95%CI) and 12.4 %(9.2 - 16.5 95%CI) in low land and high land respectively. Severe stunting tends to be higher in the age group from 18 to 41 months in mountains while it appears from 6-17 & 30-41 month in coastal areas; this could be attributed to the nutritional patterns in both communities.

Stunting prevalence remain high, however in comparison with 2012 prevalence was decreased from 35.1% (30.5 - 40.1 95%C.I) to 30.5% (25.2 - 36.3 95%C.I) in the Coastal area while in the mountain decreased from 46.9% (42.2 – 51.7 95%C.I) to 39.1% (33.5 – 45.1 95%C.I.) which is non- significant since there is overlapping confidence interval for both coastal and mountain zones.

According to WHO classification, the prevalence of chronic malnutrition (stunting) in highland and low land communities would be considered to be serious (39.1% and 30.5%). The prevalence of Global stunting and severe stunting found in the Lowland (30.5% and 6.0%, respectively) is lower than mountains.

Underweight prevalence is 33.0 %( 27.8 - 38.6 95% C.I.), and 29.5 % (24.0 - 35.7 95% C.I) with severe underweight 6.6 %( 4.4 - 9.7 95% C.I.), and 6.1 %( 4.1 - 9.2 95% C.I.), in low land and high land respectively. Rates remain high and above the WHO cut-off with 30% in low land. Underweight in comparison with 2012 was remains at same level since it is non-significant statistically with 40.2% (35.3 – 45.3 95%CI) in 2012 to 33.0 %( 27.8 - 38.6 95% C.I.) 2014 in low land and from 41.0% (35.6 – 46.5 95% C.I.) in 2012 to 29.5 % (24.0 - 35.7 95% C.I) in high land.

The entire morality rate and under five were remains at the acceptable level with 0.17 (0.07-0.37 95%C.I.) and 0.10 (0.04 – 0.27 95% C.I.), under five mortality rate remain low with 0.00 and 0.15 (0.02-1.14 95%C.I.) in low land and high land respectively. Both rates were remains acceptable and at below level recommended by SPHERE standard with 0.8/ 10,000 person / day (crude mortality) and 2.1 / 10,000 children / day (under five mortality rate) in emergency setting. The recall period used to estimate the death rate was 90 days prior to survey date using local events to helps respondent in recalling.

Morbidity data were collected from all under five children two weeks prior to the survey day. Enumerators have the disease symptoms definition and record what has mentioned by respondent after matching it according to what has been mentioned during the training. Fever is the highest prevalence among surveyed children in lowland (52.7%) while Mountains reported (43.2%). Coastal areas reported high prevalence of ARIs compared with mountains with (49.6%/36.4%). Diarrhoea reported as third disease in terms of prevalence with 35.6% and 34.3% in low and high land respectively. Suspected measles cases were 3.6% and 3.9% in low and high land zones.

Percentage of children who were slept under mosquito net in the previous night to the survey day was found low with 30.8% and 35.7% in lowland and highland respectively. Coverage of feeding program were found low below three per cent in both. Since the SMART survey is not the proper method in evaluating the CMAM coverage, therefore semi-quantitative evaluation of access and coverage (SQUEAC) survey recommended to better estimate the coverage.

Vaccination coverage for Polio/Pentavalent found 78.6% and 75.6% and Measles 83.6% and 76.5%% followed by Vitamin A supplementation 43% and 35% in low land and highland. Vitamin A supplementation coverage was very low as the last campaign was conducted more than six months and this was confirmed by MoPHP. The coverage for the routine immunization remains below 80 per cent for Pent/Polio and over 80 per cent measles in low land.


Of the two ecological surveyed, Lowland presented a critical nutrition situation with GAM at 17.1% and SAM estimated at 1.8% which remains low and at acceptable level. The Mountainous zone presented poor nutrition situation with GAM and SAM estimates of 7.5% and 0.8%, respectively and in the presence of aggravating factors such as acute food insecurity, suboptimal vitamin A supplementation coverage, and childhood morbidity considered as high. Infant and young child feeding practices remain one of the challenges and great efforts needed to address it. Water and sanitation as well remains one of the most important factors as shown above the percentage of people who drinks water from unsafe sources as well the open defecation. WFP cluster food security survey (CFSS) conducted in 2014 classified Lahij as food insecure area, more than half of its population suffer from food insecurity. Prevalence of global acute malnutrition was at the critical level and this is meeting the finding from this SMART survey, therefore below recommendation generated.

Specific Recommendation:

  • To give priority to the low land zone as the prevalence of acute malnutrition is high and starts with pockets has higher GAM than the other in the same zone to prioritize interventions at the lowest level.
  • Strengthen/establish multi-sectoral programmes in the community and within the health facilities to target the management of childhood morbidities in the particular focusing on prevention and treatment.
  • Scale up of current Community based management of acute malnutrition (CMAM) program through use of mobile team to reach uncovered area specially pockets reported high prevalence of malnutrition. Intervention/scale up can goes beyond the health facility to the second and third level at the community to early identify and detect children with acute malnutrition for early treatment.
  • Promotion of infant and young child feeding (IYCF) practices among the care givers through dissemination of nutrition and health messages through use of the current working community volunteers, community health workers with focus on early initiation of breast feeding, exclusive breast feeding, complementary feeding and continuation of breast feeding to two years.
  • Strengthen the community out-reach component of CMAM to improve the active and adaptive case finding for early detection and referral as well defaulter tracing and community mobilization.

General Recommendation:

  • Improve micronutrient supplementation for Vitamin A through the routine and non-routine work as well the use of fortified salt by raising community awareness.
  • Blanket supplementary feeding targeting children below three years to prevent malnutrition using plumpy’doz as the youngest age group has high prevalence of malnutrition compared with other age groups.
  • Promote sanitation and hygiene practices especially hand washing practices and latrine use i.e. Community Led Total Sanitation (CLTS) as the percentage of hand washing before feeding children and before food preparation is poor as well people who were use open defecation found to be high in both communities.
  • Conduct proper SQUEAC survey to better estimate the coverage and effectiveness of ongoing CMAM program in the governorate.
  • Enhance the livelihood patterns through introduction of projects that promote the household income such as food voucher and income generation projects that suit their situation.
  • Improvement of health services in government health facilities as more than 70% in both communities seek treatment in public health facilities therefore provision of essential drugs and equipment is necessary to provide better services for all.