Nutrition Assessment in Gulu Municipality Gulu District, Northern Uganda. Action Against Hunger (ACF-USA) July 2004

Transcription

1 Nutrition Assessment in Gulu Municipality Gulu District, Northern Uganda Action Against Hunger (ACF-USA) July 2004 A

2 INTRODUCTION 1. Northern Ugandan Context The war in Northern Uganda has been ongoing for eighteen years. Initially rooted in a popular rebellion against President Yoweri Museveni s National Resistance Movement (NRM) government, the conflict has since been transformed by Joseph Kony s Lord s Resistance Army (LRA) into a brutally violent war in which civilians in the northern districts are the main victims 1. Approximately 1.5 million people have been internally displaced. The Acholi region of Uganda (Kitgum, Pader, and Gulu Districts) has seen an increase in the intensity of insurgency since This has resulted in people moving, spontaneously or under the direction of the Government, into camps protected by the Uganda People s Defence Forces (UPDF). According to the most recent 2002 census the total population of Gulu District is 468,407. At the time of this survey the population residing in officially recognised Internally Displaced Persons (IDP) camps in Gulu District was estimated to be around 355, However, figures from May 2004 detail that 439,000 IDPs are present in Gulu District, with a displacement rate of 94% 3. The years between 1996 and 2002 were characterised by fluctuating insecurity. In June 2002 the security situation in Gulu District, and in most of Northern Uganda, drastically changed for the worse again as the LRA rebels flooded from Sudan en masse following the beginning of operation Iron Fist in March Iron Fist was designed by the Ugandan military to chase the LRA from their strongholds in Southern Sudan. IDP camps were attacked, looted, and often burnt. The situation in Northern Uganda worsened in 2003 with an unprecedented expansion of LRA attacks away from its traditional areas of operation. The beginning of 2004 has seen an increase in the frequency and intensity of LRA attacks on IDP camps, ambushes, looting, and abductions. Due to persistent insecurity, access to land has decreased and looting of food stocks has increased. The general atmosphere is one of heightened fear. 2. Gulu Municipality Gulu Municipality is a spread out and diverse geographic area. It encompasses anything from mini-villages set in an agricultural setting to apartment buildings in the economic downtown area. According to the 2002 census there are approximately 113,000 people in the Municipality; however, it can be assumed that the population size is actually quite larger than that. An increase in insecurity in the last year has caused inhabitants of Gulu District to shift some, if not all, of their family members to the more secure Municipality. Moreover, those persons who used to live on the edges of the Municipality have at times edged closer to the center for security reasons. ACF-USA has been operational in Gulu District since May 1997 implementing nutrition, water and sanitation programs. In Gulu Municipality, currently ACF-USA supports 2 Supplementary Feeding Centres (SFCs) integrated into two hospitals in the Municipality, and supports 1 Therapeutic Feeding Centres (TFC). ACF has been monitoring the nutrition situation of the IDP camp populations since 1998 with the most recent Gulu District IDP camp survey completed in June This, however, is the first nutrition survey conducted exclusively within the population of Gulu Municipality. 1 Behind the Violence: Causes, Consequences and the Search for Solutions to the War in Northern Uganda, Refugee Law Project Working Paper No.11, February Kampala, Uganda. 2 WFP Population Figures, Gulu, Uganda. April Uganda Monthly Report, FEWS Net, May B

3 Most of the international assistance targets the IDP population, and ACF wanted to know more about the nutritional status of the residents in order to elaborate specific recommendations, if need be. OBJECTIVES To evaluate malnutrition rates in children 6-59 months. To estimate the measles immunisation coverage among children 9 to 59 months. To evaluate the mortality rate for the total population and to determine the proportion of deaths in the under-five year population. To make recommendations for programme implementation as may be necessary. METHODOLOGY 1. Survey Design A standard 30x30 cluster sample was used, according to the population figures. The sampling universe used for cluster selection was the most recent 2002 census figures of Gulu Municipality broken down into divisions, wards, and sub-wards. The primary sampling stage was the selection of clusters (the cluster is the geographical unit used to divide the population for survey purposes). The second sampling stage was household selection within the clusters. The survey team went to the center of the defined cluster, using the random walk. From that central point, a random direction was chosen in which to begin the data collection by spinning a pencil. In the direction selected, the number of houses between the central point and the edge of the cluster was counted and, using the random number table, the first house to be visited at random was selected. The direction of each successive house was selected according to which household was to the right when the surveyor stood with his back close to the entrance of the recently surveyed house. Houses that were empty were either re-visited or messages were left with neighbours to inform the occupants to contact the survey team upon their return home. In each household, the primary eligibility criterion for children was age. Every eligible child between 6-59 months in the selected households was included in the data collection. If an eligible child was admitted in a Health Structure instructions were given to go and measure them at that location. Retrospective mortality data was collected from every household, including households that did not have any eligible children. 2. Data Collection and Measurement Techniques Many body parameters can be used to assess the nutritional status, however, there are some standard measurements used to calculate anthropometric indices. The age, weight, and height are the most commonly measured for nutrition surveys. The mid upper arm circumference (MUAC), prevalence of bilateral oedema, and measles immunisation status was also collected Anthropometric data Age: Recorded in months. If the mother/caretaker does not know the birth date, the age can be determined by information from vaccination cards, or from the calendar of local events. Gender: Recorded as Male or Female. Weight: Recorded in kilograms to the nearest 0.1kg. Children are weighed naked, by using a 25 kg hanging scale graduated by 0.1 kg. C

4 Height: Recorded in centimetres to the nearest 0.1 cm. Children aged more than 2 years old (more or equal 85 cm) are measured standing; the ones below this age/height are measured lying down. MUAC: Recorded in centimetres to the nearest 0.1 cm. MUAC is measured on the left arm only, at the mid-point between the elbow and the shoulder. A special MUAC measuring tape is placed around the arm and, after gently tightening, the measurement is read in the window. Oedema: Recorded as present or absent. In order to determine the presence of oedema, normal thumb pressure is applied to the middle top of both feet for three seconds. If a shallow print persists on both feet once the pressure is removed then the child demonstrates oedema. Due to the clinical definition of nutrition-related oedema only children with bilateral oedema are recorded as having oedema for the purpose of a nutrition survey. Measles Immunisation Status: Recorded as yes with a health card to prove it, yes without card to prove it, and no. This data is collected only on children between 9 and 59 months, which is the vaccination period recommended by the national protocol Mortality The calculation of the mortality rate requires: the number of people living in the household at the day of the survey; the number of people alive in the household 3 months ago; the number of deaths in the household in the previous three months. for the ones who died within the recall period, the age and the presumed cause of mortality is recorded. the number of people who migrated out of the household within this recall period. The retrospective mortality rate is calculated for the overall population. A percentage of the deaths that affected children below 5 years old is given. 3. Cut-off Guidelines and Formulas Used 3.1. Weight for Height Index 4 The weight for height index expressed the weight of a child in relation to height. It highlights any evidence of thinness or wasting in a child and is an indicator of the child s present and immediate nutritional status (acute malnutrition). The unit used for expressing malnutrition rates in a population is Z-score, and percentage of the median. The percentage of the median method is used for admission to nutritional centres, while Z-scores are the internationally recognised expression for the results of nutritional surveys, since they are more statistically precise. The results will be presented in both Z-scores and percentage of the median, and compared with the internationally recognised reference population standard 5. Z-scores % of the median Acute Malnutrition <-3 z-scores < 80% Moderate Malnutrition <-2 and >=-3 z-scores < 80% and >= 70% Global Malnutrition <-2 z-scores < 70% Table 1: Acute Malnutrition cut-offs for definition of population nutritional status. 4 SPHERE, Project. Minimum Standards in Nutrition in Nutrition and Food Aid. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva, NCHS: National Centre for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, D

5 3.2. MUAC MUAC can be used without reference to age or height between 6 and 59 months, and is a particularly successful way in identifying children with a high mortality risk. The standards used by ACF are: 3.3. Mortality MUAC 6 Severe Malnutrition <110mm Moderate Malnutrition >=110mm and <120mm At risk of malnutrition >=120mm and <125mm Adequate Nutritional Status >=125 mm Table 2: MUAC cut-offs for definition of malnutrition status. The calculation of the death rate is as follows: Death rate (DR) = n [(n+n+m)+n]/2 where: n= the number of deaths in the recall period N= the number of people alive at the day of the survey M= the number of people who migrated within the recall period. Mortality rate (MR) = (DR x 10,000)/number of days in the recall period MR is expressed per 10,000 per day. Total Population Alert 1/10,000/day Emergency 2/10,000/day Table 3: Mortality rate cut-offs for definition of the status of the population 7. For this survey the recall period was three months; therefore, the number of days in the recall period was 90 days (3 months). 3.4 Data Analysis The statistical analysis was completed used the EPI 5 and EPINUT software. IMPLEMENTATION 1. Resources Data collection was conducted by 4 teams, each composed of three members: a supervisor and two measurers. For each team, the supervisor was an ACF-USA Gulu Nutrition Team staff member, while the two measurers were recruited in the community. A two-day training was done, including overview of methodology, measurement techniques, a standardisation of measurement exercises and a pilot survey. T Each team was equipped with: Anthropometric Data Collection Form 6-59 months (1) Anthropometric Data Collection Form under 6 months (1) Mortality Data Collection Form total population (1) 6 MUAC Index and Cut-offs, ACF-USA Guidelines and Protocols, SPHERE Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva, E

6 Verbal Questions to determine Cause of Death (1) Weight For Height Index Chart (1) Random Number Table (1) TFC/SFC referral forms (10) MUAC Tapes (3) Height board (1) Scale (1) Weighing Pants (3) 2. Survey Implementation The survey was conducted from July 16-23, 2004 with a total of 8 field days of data collection. It was implemented in 29 wards within the four divisions of Gulu Municipality. 3. Constraints encountered The data collection was found to be biased for one of the working teams. Therefore, the 6-59 month old child anthropometric analysis included only the work of the 3 remaining teams, in order to avoid misinterpretation. The general properties of a population distribution have nevertheless allowed the proper conduction of the analysis. Indeed, the nutritional status of a given population follows a Normal Distribution. Such a distribution is characterised by a standard deviation close to 1 (0.8 to 1.2 depending on the sampling), and a mean. The number of children included in the analysis was sufficient to obtain the mean of distribution for this population, and therefore, to statistically extrapolate to get the prevalence of acute malnutrition. The results presented are therefore representative. The retrospective mortality analysis includes the data collected from the 4 teams, after quality check. RESULTS 1. Children between 6 and 59 months old 1.1. Acute Malnutrition in Z-scores 6-59 months (n=948) Global Acute Malnutrition 3.3% (1.7%-4.9%) Severe Acute Malnutrition 0.4% (0.0% - 1.0%) Table 4: GAM and SAM in Z-scores, Gulu Municipality, Uganda. July F

7 Z-score Distribution: Weight for Height 25 % of population Ref erence Sex Combined Z-scores Figure 1: Weight for Height Distribution (6-59mths) in Z-scores, Gulu Municipality, Uganda. July The mean Z-score of indicates slight negative displacement of the sample population, representing a prevalence of slight malnutrition. The standard deviation is 0.93, which shows that the distribution is satisfactory Acute Malnutrition in Percentage of the Median 6-59 months (n=948) Global Acute Malnutrition 1.4% (0.4%-2.4%) Severe Acute Malnutrition 0.3% (0.0% - 0.8%) Table 5: GAM and SAM in % of the median, Gulu Municipality, Uganda. July MUAC Analysis The MUAC analysis is done on children more than 75.0 cm height. The sample includes 714 children. MUAC Prevalence <110mm 0.2% >=110 and <120mm 0.4% >=120 and <125mm 1.8% >=125mm 97.6% Total 100% Table 6: MUAC distribution in under-5 population, Gulu Municipality, Uganda. July According to the MUAC measurements, 0.1% of the children are at high risk of mortality. The malnutrition cases represent 0.6% of the sample Measles Vaccination Coverage Since measles vaccination commences at 9 months the analysis is done on children more than 9 months. Status Proportion G

8 Vaccinated and proven by health card 53.5% Vaccinated but not proven by health card 41.6% Not vaccinated 4.9% Table 7: Measles Vaccination Coverage, Gulu Municipality, Uganda. July Approximately half (53.5%) of the eligible under-5 population has been vaccinated against measles with a health card as proof. 2. Mortality Total population at the day of the survey: 4610 Number of deaths: 53 Mortality rate: [53 / (( )/2)]*10000 / 90 = 1.2/10,000/day According to calculations using the previously detailed formula, the mortality rate for the total population is 1.2/10,000/day. Under-5 population: % of the total population Number of deaths: 18 34% of the total death cases Presumed causes of death <5 years >=5 years Accident % 12 34% Fever % 3 9% HIV/AIDS 1 5.6% 6 17% Tuberculosis 1 5.6% 2 6% Lower RTI 1 5.6% 2 6% Diarrhoea % 0 0% Bloody Diarrhoea 0 0.0% 1 3% Other % 3 9% Unknown % 6 17% Total % % Table 8: Presumed causes of Death, Gulu Municipality, Uganda. July DISCUSSION This is the first nutrition survey focusing on the population within Gulu Municipality in Gulu District. While ACF has been conducting nutrition surveys in Gulu District IDP camps since 1998, traditionally the municipality population has been excluded since it is has been argued that their living conditions, environment, and access to services are significantly different than those of the population living in the camps. Upon reflection on the large size of the Municipality population, co-joined with the increase in migrations into the municipality, it was agreed with the DDHS and other partners that an understanding of the nutrition situation within this sub-population of Gulu District was essential. ACF s survey of Gulu District IDP camps the month before revealed these results: 6-59 months Global Acute Malnutrition 4.6% (3.0% - 6.8%) Severe Acute Malnutrition 0.8% (0.3% - 2.2%) Table 9: Malnutrition rates 10 for Gulu District, ACF-USA Nutrition Survey, Uganda. June In comparison, the present survey found global acute malnutrition rates were low at 3.3%. 8 Accident includes car accident, fall, drowning, poisoning, burn, bite, sting, or other accidental injury. 9 Other for over 5years: Cancer, Old Age, Birth Complications 10 All malnutrition calculations with 95% confidence intervals H

9 MUAC rates are very low with only 0.2% severely malnourished and at elevated risk of mortality. The mortality rate was 1.2/10,000/day indicating the situation is cause for alert, but not an emergency. Since the conflict is chronic in nature, the mortality rate fits the context well. Moreover, the mortality rate in the IDP camps is 1.2/10,000/day. Since the mortality rates are similar, but the malnutrition rates differ, it further illustrates that the causes of death are primarily non-nutrition related. Even though the population in the Municipality has better access to services and care than the camp populations, the mortality rate is just as elevated. This suggests that there is a distinct set of conditions within the Municipality causing the elevated mortality rate. Of the deaths recorded, 34% were under five and yet the age group only represented 14% of the population. This proportion of deaths in the under-5 population is higher than normal and should receive further investigation and attention. Approximately half (53.5%) of the eligible under-5 population has been vaccinated against measles with a health card as proof. This rate is low, but another 41% of the parents claim their children are vaccinated without a card to prove it. This would bring the coverage to a satisfactory level. ACF-USA has been operating two SFCs within the Municipality for the last year; furthermore, there is also one ACF supported TFC and one hospital-based TFC (which previously received support from ACF). In addition, an active case-finding surveillance program increases program coverage. The combination of accessible feeding programs and an active surveillance program could decrease the acute malnutrition rates. In addition, there are other programs with food distribution as part of their activities that could increase access to food for vulnerable populations. For example, the school attendance rates are higher in the Municipality, consequently more of the vulnerable under-5 population has access to school feeding programs. RECOMMENDATIONS Programmatic Reinforcement of community involvement in activities of detection and prevention of acute malnutrition Implementation of health and nutrition education by Community Health Workers (CHWs) and home visitors, with an emphasis on weaning practices in order to target the nutritional status of the particularly vulnerable 6-29 month age group. Continuation of the activities concerning treatment of severe and moderate acute malnutrition for both resident and IDP populations Non-Programmatic Support continuation of programs (such as school feeding and HIV/AIDS support) involved in food distribution to vulnerable populations. Advocate to the MOH, and other key-implementing partners, the strengthening and broadening of health and nutrition education activities and campaigns. I