Attachments
Dates of the survey: 17th – 28th May, 2014
EXECUTIVE SUMMARY
The governorate of Hajja is situated 120 km North West of Sana'a with an area of 8,228 square km. Hajja is bordered by Saudi Arabia and Sa’ada Governorate in the north, Amran Governorate in the east, Mahaweet and Hodeida governorates in the south, and the Red Sea with part of Hodeida coastal area in the west.
Administratively Hajja has 31 districts, Abs (the largest district), Aflah AlSham, Aflah AlYaman, AlJameema, AlMaghraba, AlMahabesha, AlMoftah, AlShaghadera, AlShahel, Aslam, Bakeel AlMeer, Bani AlA'waam, Bani Qais AlTawr, Hajja, Hajja City, Harad, Hayran, Khairan AlMoharraq, Kohlan Afar, Kohlan AlSharaf, Kuaidena, Kushar, Mabyan, Midi, Mustaba, Najra, Qarah, Qufl Shammar, Shares, Wadhra , and Washha (the smallest district), as shown in Figure 1. There are more than 3800 villages, within more than160 Ozlas Hajja Governorate is the fifth populous governorate in the country, with an estimated 1,880,839 inhabitants. The governorate contains of two main ecological zones / livelihood groups: the lowland zone and the mountainous zone.
Qat cultivation is the main agriculture activity of people living in mountains zone while animal breeding and grazing and fishing is main activity for people in the lowland.
Agriculture and grazing are the main activities of the people in this governorate. Whereas Qat is grown in the mountain areas, farmers in the plain lands between the mountains and the Saudi Arabian border in the north (Tihama) concentrate on fruit and vegetable. Mostly sheep and goats but also cattle and camels are bred in the governorate. Fishing is another source of income on the coastline of the Red Sea.
Climate and rains: In mountains, the climate is temperate in summer and cold in winter, while in the Lowland the climate is tropical hot and humid in summer session and temperate in winter. The eastern part of the governorate is the highest rained with monsoon rains during summer.
Socio-political situation: Since 2009, Hajja was affected by the conflict in the neighbor governorate, Sa’ada during the 6th war between the government and Houthies group during while thousands of IDPs left their homelands in Sa’ada to stay in many settlements in Hajja and Amran governorates. In 2012, new conflict raised within some of Hajja districts between tribes living in these districts and Houthies groups which was resulted in new internally displacement to other districts within WFP comprehensive food security survey in comparison to 2011, overall food insecurity fell by about 8 percent in 2014. While 41.1 percent of the population was food in secure in 2014, there are significant differences in food insecurity between governorates. Sa’ada governorate, which was surveyed for the first time, was found to have the country’s most food insecure regions. Nearly 70 percent of the population there are food insecure, of which more than 40 percent are severely food insecure. In another five governorates – Lahej, Hajja, Shabwa, Ad Daleh and Al Bayda – more than half of all their populations are food insecure. Al Mahra, Hadramout and Aden governorates, meanwhile, are among the least food insecure, with less than 10 percent of people having poor or borderline food consumption.
1.1 Survey objectives:
Ministry of public health and planning (MOPHP) conducted the survey in Hajja as follow up survey to see the trends of malnutrition over the whole district.
Objectives
- To evaluate the global and severe acute malnutrition rates among children aged 6-59 months in the 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.
Survey date: 17th to 28th of May, 2014.
This nutritional survey was conducted as part of the bi-yearly 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 seven teams, seven supervisors, seven 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 Hajja governorate.
2. Methodology:
Population figures used in the sampling of the survey were provided by MOPHP for the year of 2014. The total population was estimated at 1924916 people of which 327,534 were estimated to be less than five years of age. This estimation was done based on the proportion of children less than five years found during the period of the survey, which was estimated at 17% of the total population.
In this survey, amulti-stage cluster sampling method was used. 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. A total amount of 36 and 35 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. Nevertheless numbers of children surveyed per cluster total of 579 and 644 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 with 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 eight 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.
Clusters were selected using SMART software during the planning stage as mentioned above based on the population numbers of each villages or area to be covered by the survey 35 & 36 clusters were selected randomly for lowland and highland zones respectively as mentioned above and number of households to be visited daily was decided and agreed by the team.
The first house is picked at random; thereafter houses are picked by proximity using modified EPI method described below.
Prevalence of global and severe acute malnutrition based on weight for height z-score considered the highest in coastal areas with GAM of 19.8% (16.6 - 23.4 95% C.I.) and SAM of 2.9% (1.8 - 4.5 95% C.I.) Compared with GAM of 9.2 % (6.2 -13.4 95% C.I.) and SAM of 1.0% (0.4 - 2.5 95% C.I.) in mountains areas. Global acute malnutrition in coastal areas remains critical as it exceeded the emergency threshold at >15% for this year 2014.The rates might increase following the seasonal patterns therefore, monitoring of the situation is warranted. Statistically there is significant difference in the prevalence between coastal and mountains p 0.0001.
Weighted prevalence of global acute malnutrition based on weight for-height z-scores (and/or oedema) is 11.8%. The weighted analysis is used to correct the bias of a non-representative sample. The distribution of the sample for each stratum is not proportional to the sample calculated for the entire population.
Prevalence of stunting are 44.1%(38.5-49.9 95%CI) and 53.2% (48.0-58.3 95%CI) with severe stunting 13.9%(11.0-17.4 95%CI) and 21.3%(17.5-25.8 95%CI) in low land and high land respectively. Rates of stunting remains high in both ecological zones. Prevalence of stunting and severe stunting considered the highest in mountinous areas than coastal whcih may be attributed to living conditions.
Mortality: The entire morality rate and under five were remains at the acceptable level, with CMR of 0.15 (0.07-0.29 95%C.I.) and 0.23 (0.12 – 0.46 95% C.I.) in low land and high land respectively and under five mortality rate remain low with 0.00 and 0.17(0.02-1.26 95%C.I.) in low land and high land as well 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.
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 with 53.3% and 56.6% among surveyed children in low and high land zones respectively, followed by Diarrhoea with 35.4% and 41.9% and acute respiratory tract infection (ARIs) with 31.3% and 41, 9% in low and high land respectively. Prevalence of Diarrhoea, fever and ARIs was the highest in highland ecological zone compared with coastal areas.
Measles coverage was 69.4% and 67.8% in low land and high land respectively. Penta3/Polio coverage was 61.5% and 59.7% in low land and highland. Vitamin A supplementation coverage was low as the last campaign was conducted more than six months.
Percentage of children under two years found still at breast feeding was acceptable with 80.6% and 73.8% in lowland and highland respectively. Consumption of food from 4-7 food groups on the previous day, majority of surveyed children were found relying on cereal, dairy product plus more than 60% receiving juice or sugared water while consumption of flesh food, eggs, dark green vegetables and fruits rich with vitamin A was very low.
Majority of interviewed household (>95%) were found to be headed by male with 90% and over among them were married and live with their spouse.
Main sources of income for the assessed household focused in four main sources. In low land zone the first source found to be temporary work (25.3%) followed by remittances (18.1%), Qat (12.4%), and others type of works (11.3%). High land main source is Qat (40%) followed by employee with fixed wage (20.5%), Temporary work (17%), and remittances (5.6%).
Main source of drinking water for assessed household; Open protected well (26.4%) is first source for low land while water from white tanker is for high land (33.5%), then open unprotected well (22.2%) as second source for low land, shallow un protected water (22.8%) the second source of high land, third (21.7%) in low land and piped water connected to the house (11.4%) in high land.
Recommendations:
These recommendations are based on the preliminary analysis/findings of the survey data. From the finding underlying causes are present, in terms of disease prevalence, low vaccine and micronutrient supplication coverage, poor sanitation, inadequate food security, poor feeding practices, in adequate health services. Therefore, recommendations are generated as below to address wasting and under nutrition issues.
Specific Recommendation:
- To give priority to the low land zone as the prevalence of malnutrition is high and find out which pockets has higher GAM than the other in the same zone to prioritize interventions at the disaggregate 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 un covered 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.
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.
- 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.
- 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.
- In depth investigation to find out why, there is high prevalence of wasting among the lowland children compared with their counter part in high land 19.8% to 9.2% as mentioned above, while the stunting rate is higher in mountain (53.2%) than low land (44.1%) although both are above 40%.
- Improvement of health services in government health facilities as the majority of people in both communities seek treatment there.