Yemen

Nutritional Anthropometric and Retrospective Mortality Survey, Children 6 to 59 Months: Taiz District, Mountainous, Hills & Valleys and Coastal Plain Ecological Zones - Final Report

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Date: from 19th April to 4th May 2014

Executive summary:

Taiz Governorate is located in the southwestern part of the Republic of Yemen, bordering the Red Sea to the west, Hodeida and Ibb governorates to the north, Lahij to the south, and Al-Dhale governorate to the east. Its surface area is about 10 462 km2. Taiz is Yemen’s most populous governorate, with an estimated 2,839,206 people – 12.15% of the country’s population (2011 population projection based on 2004 census). About 81% of the population is rural while 19% is urban; 48% is male and 52% is female. Taiz’s population growth rate is 2.47%. Current population density is estimated at 26 inhabitants /km2.

The governorate contains of two main ecological zones / livelihood zones: the mountainous zone, where agriculture (Qat growing) is the main livelihood project, and the lowland coastal plain close to the Red Sea, where cultivation of sorghum, millet, vegetables, and fruit in addition to fisheries work.

Taiz governorate has insufficient social services in areas including health; poor road infrastructure; as well as water shortages and high food prices. Further deterioration has taken place since May 2011, when Taiz experienced incidents of civil unrest and armed conflict. These security incidents have limited access for the humanitarian community.

Administratively Taiz is divided into 23 districts, 3 urban (Muzaffar, Qahera and Salah), and 20 rural (Al Taziha, Saber Al Moadm, Mashra.a and Hdnan, Al Msrakh, Jabal Habashi, Mawasit, Al Maafr, Ashammaitin, Mauza.a, Al Wazeia, Al Makha, Dhubab, Maqbana, Sharhab Al Rawna, Sharhab Al Salam, Khadder, Same.a, Aselow, Hiffan and Mawiah). There are 1877 villages, within 329 Ozla.

Survey date: 19th of April to 4th of May, 2014.

This nutritional survey was conducted as part of the 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 eight teams, six supervisors, six data enterers and one survey coordinator.

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 2,839,206 people. 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 41, 34 and 32 clusters were selected from Mountains, valleys & hills and coastal plain 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 820, 680 and 704 household were visited 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.

Malnutrition: The global acute malnutrition (GAM) rate (weight for height <-2 Z score or oedema) was 17.4% (95% CI: 14.6 - 20.6) and severe acute malnutrition (weight for height <-3 or oedema) rate was 3.3% (95% CI: 2.0 - 5.3) among the Lowland ecological zone. And GAM rate of 11.8% (95% CI: 9.7 - 14.3) and SAM rate of 1.6% (95% CI: 0.9 - 2.8) with no oedema case reported among the Mountainous zones. Mixed zone of hills and valleys reported GAM of 12.3% (9.7 - 15.4 95%C.I.) and SAM of 1.6% (0.8 - 3.3 95% C.I.).The results indicate critical nutrition levels in Lowland and serious nutrition levels in Mountainous and mixed zones according to WHO classification. The confidence interval ranges do overlap between the coastal and mixed zone, illustrating that statistically non- significant difference in the rates of acute malnutrition between the ecological zones. Mountainous zone does not overlap although it is slightly with other two zone indicating same nutritional situation.

Chronic malnutrition or “stunting”, indicating long term poor nutrition was at high levels in all areas- 45.5% (95% CI 40.7- 50.4) and 55.4% (95% CI 49.0 - 61.7) in Lowland and Mountainous and 39.9% (95%CI 34.2 - 45.9) zones respectively.

Mortality: The crude and under-five mortality rates were 0.27 (95% CI: 0.16 -0.48) and 0.14 (95% CI: 0.02 – 1.03) in coastal while 0.24 (0.13 – 0.42) and 0.00 in mixed zone and 0.19 (0.12 – 0.31) and 0.00 in Mountainous zone respectively. Both crude and under-five rates fall below the emergency thresholds of 1/10,000/day and 2/10,000/day respectively according to SPHERE standards.

Measles vaccination coverage rates were found higher in high land followed by mixed and lowland with 89.5%, 78.2% and 73.8% respectively. Penta3/Polio coverage at 75% in high and mixed area while coastal reported 65.9%. Vitamin A coverage considered below for the three zones.

Conclusion:

Comparing the WHO GAM rate of 2012 and 2014 for both highlands and coastal Statistically there is no significant difference between 2012 & 2014 GAM rates in Coastal areas 15.1% (12.6 -18.0 95%CI) and 17.4% (14.6 - 20.6 95%CI) using the “overlapping confidence interval test” and as well the statistical test using “two-survey” calculator shows p= 0.390.

Mountains GAM rates for the same period 2012 and 2014, 9.4% (7.4 -11.9 95%CI) & 11.8% (9.7-14.3 95%CI) respectively shows no significant difference since the overlapping of confidence is there, using “two -survey” calculator with p=0.271 which confirm the statistical test of the confidence.

Prevalence of acute malnutrition using MUAC is remaining acceptable for the three zones and remains below 15% since there is no clear recommended standard.

Stunting remains critical problem in the governorate as the overall prevalence of stunting is exceeded 40% in 2014 with slight changes from 2012. The rates of 2014 decreased slightly compared to 2012 45.5% / 49.1% in coastal areas and deteriorated slightly in the mountain comparing rate of 2014 by 2012, 55.5%/51.5% respectively.

Mortality rates remain almost same compared with last year survey which is below the emergency level of less than 2 deaths/10,000 children / day) and 1 death/ 10,000 children / day as shown above in the previous table in the mortality section.

Morbidity trends considered high in all zone specially fever and acute respiratory infections which related to the prevalence of malnutrition.

Vaccination coverage of measles needs to be improved in coastal and hills/valleys zones to reach the recommended EPI coverage of above 80%.Mountain zone coverage within the recommended level at >80%. Vitamin A coverage remain poor and below the recommended standards at >85%.

Percentage of children who ate 4 food groups or more was found 20.7%, 17.7% and 12.1% in low land, mixed and Mountainous respectively. Majority of children eats one or two groups which is not meeting the WHO recommendation.

Infant and young child feeding practices need to be strengthened through on-going educational program conducted by the community based volunteers who were supported by MOPHP and other national or international organization working to Taiz governorate.

Majority of the population have no access for clean safe water, they are using water from unprotected open well in the hand percentage of houses using open pit latrines and open defection is big as well which might worsen the public heath situation. Water and sanitation remain one of the major components aggravating the underlying causes of malnutrition therefore improvement of the situation is recommended through scaling up the available WASH services in the governorate at the community and health facilities.

Coping strategies: Food security status remain a concern with majority of households tried to find ways to cope with the situation. Coping strategies used by the communities’ i.e. lowering meal size and reduction of meal portion due to increase in food prices with limited income sources. Eighty per cent of household assessed in the three zones reported that they borrowed money (dept.) to survive.

Conclusion:

The findings from the survey shows critical situation in the coastal areas and this need to give priority to these areas when designing the intervention and even special focus to the pockets reported high rates among the coastal areas. The situation in mountains and hills and valleys zones remains serious and close monitoring is warranted.

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.

Recommendations:

These recommendations are based on the findings of the survey data. Although the nutrition situation for the whole governorate is below the emergency threshold at 15% but remains alerting while remain critical in the coastal area. Therefore, recommendations are generated as below to address wasting and under nutrition issues.

  • To continue treatment of acute malnutrition through functioning TFC/OTP and SFP in Taiz governorate , to ensure needs are covered.

  • Scale-up the CMAM program to reach the communities far from the catchment area of the health facilities to ensure equity for non-reached malnourished children.

  • Continue advocate and strengthening out –reach component of CMAM to improve the active and adaptive case finding system for early detection and referral of malnourished children as well defaulter tracing.

  • Initiate blanket feeding program using plumpy’doz or other products for children from 6 to 36 to mitigate elevated malnutrition rates to complement existing treatment program to tackle the stunting high rates (preventative programs).

  • Promote infant and young child feeding (IYCF) practices , by using C4D program to disseminate related nutritional messages to targeted communities and beneficiaries - Strengthen the multi-sectoral integration of programmes in the community and within the health facilities to target the management of childhood morbidities in the particular focusing on prevention and treatment targeting the different age groups - Strengthen EPI routine programme coverage in collaboration with MOPH.