NUTRITION ASSESSMENT REPORT BURHAKABA PASTORAL AND AGROPASTORAL LIVELIHOOD SYSTEMS BURAHAHKABA DISTRICT BAY REGION, SOMALIA

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1 NUTRITION ASSESSMENT REPORT BURHAKABA PASTORAL AND AGROPASTORAL LIVELIHOOD SYSTEMS BURAHAHKABA DISTRICT BAY REGION, SOMALIA Food Security Analysis Unit (FSAU/FAO) World Vision International (WVI) Ministry of Health (MOH) Green Hope Somalia Association for Rehabilitation and Development (SARD) Burhakaba Organization for Community Development (BOCD) MAY 27

2 Table of Contents ACKNOWLEDGEMENTS EXECUTIVE SUMMARY... 4 SUMMARY OF FINDINGS INTRODUCTION OBJECTIVES METHODOLOGY ASSESSMENT RESULTS DISCUSSION RECOMMENDATIONS APPENDICES REFERENCES. 41 2

3 Acknowledgement The Nutrition Surveillance Project of the Food Security Analysis Unit (FSAU) acknowledges the participation of World Vision (WVI), Green Hope, Somalia Association for Rehabilitation and Development (SARD), Ministry of Health (MOH) and Burhakaba Organization for Community Development (BOCD) in the Burhakaba District Nutrition Assessment. FSAU provided technical support including the assessment coordinators and three supervisors and financed the cost of transport, supervisors, enumerators and data entry clerks. World Vision provided supervisors, nurses and helped in identification of enumerators while Green Hope, BOCD and SARD provided some of the assessment supervisors and enumerators. Special thanks goes to the mothers, caregivers, leaders and the community as a whole in Burhakaba district for their cooperation, time and for providing information individually and in focus group discussions that helped the survey team to get a better understanding of the nutrition situation in the area. Comments from partners in Bay Region, local community and members of the Nutrition Working Group in Nairobi on the preliminary results are also highly appreciated. FSAU also express sincere appreciation to the assessment team for their high level of commitment demonstrated during all stages of this assessment. 3

4 EXECUTIVE SUMMARY Burhakaba is the largest district amongst the five districts of Bay region in Southern Somalia and has two dominant livelihood zones; the Southern Inland Pastoral (camel, sheep and goats) and the Agro- Pastoral (camel cattle and sorghum). According to FSAU Post Deyr 6/7 analysis the food security situation in Burhakaba district indicated improvement from the Acute Food and Livelihood Crisis in Gu 6 to the current classification of Chronically Food Insecure following two consecutive good rainy seasons and the subsequent bumper harvests and improved water and pasture access. The integrated analysis of the nutrition situation conducted in January 27 classified Burhakaba District to be in the Serious phase. In some cases improvement in food security does not always translate into improved nutrition and hence the need to determine the prevailing nutrition situation in the district. Past assessments in the district have largely been based on administrative boundaries, but due to the fact that different livelihood systems have varying ability to withstand shocks affecting nutrition and food security, FSAU has adapted an approach of livelihood-based assessments. FSAU in collaboration with WVI, MOH, SARD, BOCD and Green Hope conducted two nutrition assessments in Burhakaba district in May 27 based on dominant livelihood systems; Agro-pastoral and Pastoral. Using a 3 by 3 cluster sampling methodology, a sample of 912 children aged 6-59 months and/or less than 11cm were assessed from Agro Pastoral and 94 from the Pastoral Livelihoods respectively. The main objective of the survey was to determine the level of wasting and oedematous malnutrition among children below five years, possible factors that may be contributing to malnutrition, dietary diversity, morbidity and mortality rate in the two livelihood systems in the district. Findings from the two assessments indicated a critical nutrition situation with Agro-Pastoral livelihood recording a relatively lower Global Acute Malnutrition rate (GAM) of 15.6% ( ) and Severe Acute Malnutrition Rate (SAM) of 3.3% ( ) while the Pastoral livelihood recorded a GAM of 16.2% ( ) and SAM of 3.9% ( ). However as the confidence interval ranges overlap between the two assessments there is no statistically significant difference between the nutrition situations in the two livelihood zones. Since the past nutrition assessment were conducted based on administrative boundaries, it is not feasible to directly compare the results. Based on the inter-grated nutrition analysis carried out in January 27, Burhakaba district was classified as facing a serious nutrition situation and hence the current findings show deterioration. The crude mortality rate for both assessments was above 1.3/1,/day, indicating an alert situation. The reportedly main causes of death were diarrhoea, malaria and ARI Morbidity levels in the two livelihood zones in the two weeks prior to the assessment were reported to be high. Overall, about 37.7% and 35.8% of the children from agro-pastoral and pastoral livelihood zones respectively were reported to have suffered from one or more of the assessed communicable diseases in the two weeks prior to the assessment. ARI, diarrhoea and suspected malaria recorded the highest prevalence of reported diseases as shown in the table. Rapid Diagnostic test for malaria done at the same time indicated 8.7% and 16.6% of the agro-pastoralist and pastoralist respectively as having tested positive to malaria (Plasmodium falciparum). Morbidity was significantly associated with malnutrition particularly for pastoral livelihood (p<.5). The high morbidity may partly be explained by limited health facilities in the district making them inaccessible to majority of the rural population. Inaccessibility of health facilities may further explain why the majority (>54%) of the households with sick children two weeks prior to the assessment did not seek any health assistance. At the same time, WHO reported high incidences of AWD with 535 cases with CFR of 9.5% reported in the district from January to 18 th May 27. The high morbidity also be explain by poor sanitation with >9% of the households do not have access to sanitation facilities and low access to safe water with less than ten percents obtaining water from protected sources. This may have lead to increased diarrhoea diseases. The coverage of the health programmes; Vitamin A supplementation, measles vaccination and polio immunization, were far below the recommended coverage of 95% (Sphere 4

5 24) as shown in the table. Dietary diversity was good with the majority (>84%) of the households in the two livelihoods, reportedly consuming four or more food groups in the twenty four hours prior to the assessment. This has positive impact on the nutrition situation and a reflection of improved food security as reported in the FSAU Post Deyr 6 assessment. Purchase and own food production were the main food sources and majority of the assessed households reported the main source of income being the sale of either crop/crop-products or animals/animal-products for agro-pastoral and pastorals respectively. Poor feeding practices persist with over half of the children aged 6 24 months (59.2% from pastoral and 53.6% from agropastoral livelihood) were Agro Pastoral pastoral SUMMARY OF THE BURAHAKABA DISTRICT ASSESSMENT FINDINGS reportedly still Indicator N % (CI) N % (CI) breastfeeding at the time of assessment with over Total number of households surveyed Mean household size SD= SD=2. 73% of the children Total number of children assessed Global Acute Malnutrition (WHZ<-2 or oedema) having been introduced ( ) ( ) to foods other than Severe Acute Malnutrition (WHZ<-3 or oedema) breast milk before the ( ) ( ) recommended age of 6 Oedema months. This is an Global Acute Malnutrition (WHM<8% or oedema) ( ) ( ) indication of a suboptimal childcare practices. The essential role played by breast milk was evident in the assessment, particularly in the pastoral livelihood where malnutrition was significantly related with breastfeeding. The children who were not breastfeeding at the time of the assessment were about.69 times more likely to be malnourished than those breastfeeding (p=.1). Malnutrition equally affected the younger (6-29 months) and older children (3-59 months) with no statistical difference between the two categories (p>.5). A summary of findings is provided in the table. Severe Acute Malnutrition (WHM<7% or oedema) (1. 3.) Proportion of malnourished pregnant women (MUAC 23.). Proportion of severely malnourished pregnant women (MUAC 2.7) Proportion of children reported to have diarrhea in 2 weeks prior to assessment Proportion of children reported to have ARI within two weeks prior to assessment Children reported to have a febrile illness in 2 weeks prior to assessment Suspected measles within one month prior to assessment Malaria prevalence by RDT (plasmodium falciparum) (N=55) N= ( ) ( ) ( ) ( ) Children (9-59 months) immunised against measles ( ) Children who have ever received polio vaccine ( ) Children who received vitamin A supplementation in last 6 months Proportion of children 6-24 months who are breastfeeding Children (6-24 months) introduced to other foods before 6 months Proportion of households who consumed 3 food groups Proportion of households who consumed 4 food groups Under five Death Rate (U5DR) as deaths/1,/ day ( ) ( ) ( ) ( ) ( ) (1. 3.) (N=83) N= ( ) ( ) ( ) ( ) ( ) ( ) ( ) (15. 2.) ( ) ( ) ( ) ( ) 1.84 ( ) 2.81 ( ) Crude Death Rate (CDR) as deaths/1,/ day 1.31 ( ) 1.88 ( ) 5

6 The assessment team makes the following recommendations on both short- and long-term basis; 1. Enhance delivery of basic health services through intensification of EPI, and mobile clinics services and establishment of more health posts and maternal health clinics in rural areas to provide relevant health services. 2. Rehabilitation and treatment of severely and moderately malnourished children through outreach and community-based mechanisms to reach malnourished children in the interior villages. Vulnerable households should be targeted for distribution of selected nutritious food such as pulses and other products reach in micronutrients (minerals and vitamins) to enhance nutrition quality of the diets. 3. Training of various community groups (women, girls,) on both prevention and treatment of acute malnutrition is essential in both management of current malnutrition and prevention of recurrent cases. 4. Promotion of production and consumption of vegetables, fruits, chicken/eggs which are cheap sources of vitamins, minerals and protein is vital to enhancing food and nutrition situation as well as economic empowerment. 5. In order to break the vicious cycle of malnutrition and morbidity, there is a need to intensify nutrition and health education targeting children care givers with messages on breastfeeding, child-feeding, health-seeking behaviour and hygiene & sanitation. 6. Rehabilitation of existing water sources such us, water catchments, boreholes and wells, construction of new ones and establishment of mechanism for routine water treatment/chlorination to enhance water quality particularly during the dry season that recorded peak of AWD prior to the assessment. 7. Provision of sanitary facilities including large scale building of latrine in the district for appropriate disposal of human excretal waste. This should be coupled with awareness on the need to use such facilities. 8. Measures for boosting security in the district to increase access by humanitarian actors. 6

7 1. Introduction Burhakaba is the largest district amongst the five districts of Bay region in Southern Somalia. It is located between Baidoa to the west, Wanlaweyn to the east, Dinsor to the southwest, Jalalaqsi to the northeast and Qoryoley to the south. According to the UNDP population estimate of 25, the district has a population of 128,393 (UNDP 25). The main livelihoods in the district are Southern Inland Pastoral (camel, sheep and goats) and the Agro-Pastoral (camel cattle and sorghum) see map. According to FSAU Post Deyr 6/7 analysis the food security situation in Burhakaba district indicated improvement from the Acute Food and Livelihood Crisis in Gu 6 to the current classification of Chronically Food Insecure following two consecutive good rainy seasons and the subsequent bumper harvests. Due to availability of water and pastures, the district has often been a recipient of many animals from other parts of Southern Somalia faced with drought condition. This creates pressure on existing natural resources and sometimes results to conflict due to competition for limited resources. Owing to the security limitations, a comprehensive nutrition assessment in the district has not been done in the recent years. However, the nutrition assessments conducted in Burhakaba Town in August 1999 recorded a very critical GAM of 28.% and SAM of 6% while the district nutrition assessment carried out in August 2 recorded a similar nutrition situation with a GAM of 22.2% and SAM of 4.1%. Nutrition data from WVI managed health facility and the three sentinel sites established in 26 by FSAU to monitor the nutrition situation in the district have often recorded a fluctuating trend of malnutrition pointing to the precarious nutrition situation in the district (See Chart). The inter-grated nutrition analysis carried during the post Deyr 6/ 7 classified the nutrition situation in the district as serious Distribution of Acutely M alnourished Children in the sentinel Sites in Burahakaba District Baale Dubai Bisigcade Burhakaba Ceasing the opportunity of eased security situation in the district, FSAU and partners 1 conducted two nutrition assessments in Burhakaba district in May 27 based on dominant livelihood zones; Agropastoral and Pastoral (See map) to determine the nutrition situation and identify the possible underlying factors. 1 WVI, Green Hope, SARD, BOCD and MOH 7

8 2. ASSESSMENT OBJECTIVES The overall objective of the two livelihood-based assessments was to establish the extent and severity of malnutrition, determine the causes of malnutrition and to monitor the trends of malnutrition in Burhakaba district. Specific Objectives were: 1. To determine the level of malnutrition and nutritional oedema among children aged 6-59 months or with height/length of cm in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 2. To determine the level of malnutrition among women aged years in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 3. To identify factors influencing nutrition status of the children in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 4. To determine the prevalence of some common diseases (measles, diarrhoea, febrile illnesses and ARI) in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 5. To determine the measles and polio vaccination and Vitamin A supplementation coverage among in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 6. To assess child feeding and care practices in the two livelihood groups of Pastoral and Agropastoral in Burhakaba district. 7. To determine the crude and under-five mortality rates in the two livelihood groups of Pastoral and Agro-pastoral in Burhakaba district. 8

9 3. METHODOLOGY Two cross-sectional assessments were conducted among the pastoral and agro-pastoral in Burhakaba district. Two-stage cluster (3 by 3) sampling methodology was used to select 3 children aged 6-59 months and height/length of cm from each of the 3 clusters in each livelihood. A list of all settlements/villages/towns within each of the two assessed livelihoods in the district with their respective populations as based from UNDP population estimates for 25 (with verification from assessment team) formed a sampling frame and used to construct cumulative population figures for the assessment area from which 3 clusters were randomly drawn for each livelihood zone (Appendix 4). Retrospective mortality data was collected from 3 households in each cluster from each livelihood including even those that did not have children aged 6-59 months. Both qualitative and quantitative data collection techniques were used. Quantitative data was collected through a standard household questionnaire for nutrition assessment (appendix 1a) and a standard mortality questionnaire (appendix 2). Quantitative data collected included household characteristics; child anthropometry, morbidity; vitamin A supplementation, measles and polio immunization coverage; dietary diversity; and water and sanitation. Qualitative data was collected by an interagency team comprising of assessment supervisors and coordinators through focus group discussions and key informant interviews to provide further understanding of possible factors influencing nutritional status. A four-day training of enumerators and supervisors was conducted covering interview techniques, sampling procedure, inclusion and exclusion criteria, sources and reduction of errors, taking of measurements (height, weight and MUAC), standardisation of questions in the questionnaire, levels of precision required in measurements, diagnosis of oedema and measles, verification of deaths within households, handling of equipment, and the general courtesy during the assessment. Standardisation of measurement and pre-testing of the questionnaire and equipment were carried out in a village within the vicinity of Baidoa town. Quality of data was also ensured through (i) monitoring of fieldwork by coordination team, (ii) crosschecking of filled questionnaires on daily basis and recording of observations and confirmation of measles, severe malnutrition and death cases by supervisors. All households sampled were visited and recorded including empty ones (iii) daily review was undertaken with the teams to address any difficulties encountered, (iv) progress evaluation was carried out according to the time schedule and progress reports shared with partners on regular basis, (v) continuous data cleaning and plausibility checks (vi) monitoring accuracy of equipment (weighing scales) by regularly measuring objects of known weights and (vii) continuous reinforcement of good practices. All measurements were loudly shouted by both the enumerators reading and recording them to reduce errors during recording. Household and child data was entered, processed (including cleaning) and analysed using EPI6 software. Mortality data was entered and crude and under five mortality rates generated in Nutrisurvey software. Plausibility checks were carried out to as means of verifying the quality of the data focusing on the standard deviation, skewness, and kurtosis and whether there was age clumping and digit preferences (Appendix 5). 9

10 4. ASSESSMENT RESULTS 4.1 Household Characteristics of Study Population The two livelihood-based nutrition assessments covered a total of 1814 children aged 6-59 months and with height of cm from total of 895 households. This included 912 children from 458 households from agro-pastoral livelihood and 92 children from 437 households from pastoral livelihood zones. The mean household size for agro-pastoral was 6. (SD=2.) persons while that of pastoral was 5.8 persons (SD=2.). The other household characteristics by livelihood are presented in Table 4.1 below. Table 4.1: Household Characteristics Characteristics Agro-pastoral Pastoral N % N % (CI) Total Households Household size (Mean): 6. SD= SD=2. Mean No of Underfives 2.1 SD= SD=.9 Residential Status Resident Recently Displaced IDP Long term IDP Hosting IDP Proportion of households hosting IDP ( ) 3.7 (2.2 6.).2 (. 1.4) The results showed that over 95% of the assessed households were local residents with rest being either recently displaced or long term IDPs. Qualitative information during the time of assessment reported observation of groups of displaced families returning to Mogadishu while others complained that their previous area of residence have been occupied by other people. At the time of the assessment, 5.9% and 5.5% of the households from agropastoral and pastoral respectively were reportedly hosting IDPs. The impact of the IDPs on the household included increased food sharing, increased expenditure on food and constraint on living condition in the order of importance as shown in the table. In order to cope with the impact of the IDPs, households hosting IDPs had resulted to increased borrowing or purchase on credit, dependence on remittance, increased sale of assets and reduction in meal sizes. The major source of income for the assessed households in the pastoral and agro-pastoral livelihoods were sale of animal and animal products (83.8%); and sale of crops (5.7%) respectively as expected. Other sources of income are as shown in the table ( ) 4.5 ( ) (4. 8.6) ( ) Impact of IDP hosting) N=27 N=24 Increased Food sharing Increased Food expenditure Constraint on living condition ( ) 22.2 ( ) 18.5 ( ) Coping with IDP Impact N=27 N=24 Increased Borrowing/Credit Increased demand on Remittance Increased Sale of assets/produce Reduced meal size Main source of Income Crop sales Animal and its products sales Casual labour Petty Trade Salaries/wages Remittances Others ( ) 4.7 ( ) 14.8( ) 3.7 (.1 19.) 5.7 ( ) 34.9 ( ) 8.5 ( ) 4.6 (2.9-7.).9 (.3-2.4).2 ( (. -1.4) ( ) 54.2 ( ) 5. ( ) 41.7 ( ) 37.5 ( ) 6.2 (4.2-9.) 83.8 ( ) 6.6 ( ) 2.5 ( ).2 (. -1.5).7 (.2-2.2) 1

11 4.2 Health Water and Environmental Sanitation Water Access and Quality Water catchments were the main water sources for both the agro-pastoralist (77.1%) and pastoralist (63.2%). Other sources of water included shallow wells, bore holes and seasonal streams. Most of these water sources are located at recommended distance of less than 5 metres. The results also showed that most (>8%) of the households owned insufficient number (1-4) of water storage containers with capacity of 2 litres limiting their capacity to store water (Table 4.2). Sphere recommends a minimum of 2 water collecting containers in addition to enough clean water storage containers to ensure there is always water in the households. On storage situation, most households, stored water in covered container which is a good practice to protect from contamination at the household level. Table 4.2: Water Access and Quality Source of Water Water catchments Protected wells/bore holes Open Shallow wells Others Water Source distance <5m 51-1Km 1-Km >3Km Number of clean water storage containers 1-2 containers 3-4 containers 4 5 containers > 5 containers Method of Water storage Covered containers Open containers Constricted neck-end (Ashuun) Agro-pastoral (N=464) Pastoral (N=43) N % N % (CI) ( ) 1.7 ( ) 7.4 ( ) 6.7 ( ) 16.2 ( ) 17.5 ( ) 5.7 ( ) 57.2 ( ) 33.2 ( ) 7.2 ( ) 2.4 ( ) 59.6 ( ) 25.8 ( ) 14.6 ( ) ( ).5 (.1 1.8) 33.6 ( ) 2.7 ( ) 66.1 ( ) 14.4 ( ) 14.4 ( ) 5. ( ) 6.2 ( ) 3. ( ) 7.3 ( ) 2.3 ( ) 54.5 ( ) 31.1 ( ) 14.1 ( ) Sanitation and Hygiene Practices The results revealed that the most of the households in the district irrespective of livelihood zones had no access to sanitation facilities for human waste disposal. The majority of the assessed households; agro-pastoral (82.1%) and pastoral (92%) were using bushes for human waste disposal. For the few household with access to sanitary facilities, they were mainly using traditional pit latrine. The distribution of the sanitary facilities is shown in table 4.3 below. 11

12 Table 4:3 Sanitation & Hygiene Access to Sanitation facility Flush toilets VIP Traditional pit latrine /Open pit Designated Area No latrine at all (Bush) Use of washing agent Soap Shampoo Ash Plant extract materials None Method of food storage: Put in a pot besides fire Covered container Suspended in a rope/hooks Don t store Others Agro-pastoral Pastoral N % (CI) N % (CI) (.5-3.) 7.6 ( ) 7.9 ( ) 1.1 (.4-2.7) 82.1 ( ) 7.7 ( ) 11.6 ( ) 6.6 ( ) 2.8 ( ) 8.3 ( ) 13.3 ( ) 33.6( ) 1.5 ( ) 41.5 ( ) 1.1 (.4 2.7) The results also revealed that the majority of the household s were using different types of washing detergent with the largest proportion (7.7% agropastoral and 63.2% pastorals) using soap. Other washing detergents used included shampoo, plant extracts and ash. However, 8.3% of agro-pastorals and 2.4% of the pastoralists were not using any washing agent. On food storage, most households kept food in covered containers (.1 1.8) 3.9 ( ) 2.7 ( ).9 (.3 2.3) 92. ( ) 63.2 ( ) 5.5 ( ) 3.9 ( ) 7.1 (4.9 1.) 2.4 ( ) 14.2 ( ) 13.5 ( ) 8. ( ) 64.3 ( ) a. Morbidity, immunization and Health Seeking Behaviour and Child care High morbidity Table 4.4: Health seeking behaviour rates were reported Agro-pastoral Pastoral in the two Child fell sick N % N % livelihoods of Proportion ill ( ) ( ) pastoral (35.8%); Where health service sought agro-pastoral Public health facilities ( ) (.7 6.) (37.7%). For the Private pharmacy/clinic ( ) ( ) children who fell Traditional healers ( ) ( ) sick within two Own medication ( ) ( ) weeks prior to the No assistance sought ( ) ( ) assessment, more Night Blindness than half (>54%) months (.4-2.7) 3.7 (.2 2.2) did not seek for 6 years 3.7 (.2 2.1) 4.9 (.3 2.5) medical assistance. None ( ) ( ) The remaining sought for medical services from traditional healers, private pharmacy/clinic, public facilities or use own medication (Table 4.4). The incidence of reported diarrhoea in within two weeks prior to the assessment was high with pastoral and agro-pastoral recording 15.5%; and 13.4% respectively. Incidences of the reported ARI and febrile illnesses (suspected malaria) were also equally high (>17%) both livelihoods (Table 4.5). A rapid diagnostic test for malaria 2 conducted concurrently in the district reported malaria 2 Tests using Para checks conducted in collaboration with UNICEF 12

13 prevalence of 8.7% for agro-pastoral and 16.6% for pastoral livelihood having tested positive for Plasmodium falciparum among the sampled population. Furthermore, WHO reported 535 cases of AWD with CFR of 9.5% in Burhakaba district from January to 18 th May 27. The peak period for AWD in the district was in the month of April. Table 4.5:1 Morbidity, measles immunisation, polio vaccination and vitamin A supplementation Agro-pastoral Pastoral Incidence of major child illnesses N % (CI) N % (CI) Proportion of children with diarrhoea in 2 weeks ( ) ( ) prior to assessment Proportion of children with ARI within 2 weeks prior to assessment ( ) ( ) Children with suspected malaria in 2 weeks ( ) ( ) prior to assessment Children tested positive for malaria (RDT) ( ) ( ) Suspected measles within one month prior to ( ) ( ) assessment Immunization Coverage Children (9-59 months) immunised against ( ) ( ) measles Children who have ever received polio vaccine ( ) ( ) Children who received vitamin A ( ) ( ) supplementation in last 6 months The coverage for the three health programmes were all far below the recommended coverage of 95% (Sphere 24) as shown in table 4.5 in the two livelihood zones. 13

14 4.2.3 b Child feeding Table 4.5:2 Child Feeding Practices Is child breastfeeding? Yes No Breastfeeding frequency (N=81) 1-2 times 3-6 times On demand Age stopped breastfeeding (N=278): - 5 months 6-11 months months More than 18 months Introduction of Complementary feeding (N=259) - 3 months 4 5 months 6 months 7 or more months Feeding frequency (n=259): Once 2 times 3 4 times 5 or mores times recommended by Facts for Life (22). Agro-pastoral Pastoral N % N % ( ) 46.4 ( ) 1. (.1 3.7) 31.8 ( ) 67.2 ( ) 1.2 ( ) 43.4 ( ) 4.4 ( ) 6. ( ) 51.7 ( ) 21.8 ( ) 22.6 ( ) 3.9 ( ) 17. ( ) 39.9 ( ) 39.9 ( ) 3.1 ( ) ( ) 4.8 ( ).5 (. 2.9) 33.3 ( ) 66.1 ( ) 1. ( ) 6.8 ( ) 25.4 ( ) 3.9 (.8 7.7) 54.4 ( ) 26.1 ( ) 12.9 ( ) 6.6 ( ) 7.5 ( ) 34.6 ( ) 5.3 ( ) 7.5 ( ) Over half (53-57%) of the children aged 6-24 months were breastfeeding at the time of the assessment with most (>66%) of them breastfed on demand. Exclusive breastfeeding was minimal with the majority (>7%) of the children having been introduced to complementary foods before the recommended first six months (WHO). In addition, the majority of the children were fed 3-4 times in a day and only 3-7% was fed 5 or more times as 4.3 Household Food Security Food Consumption As shown on figure 4.3, cereals provided the bulk of the food in the household diet for both the agropastorals and pastorals with the cereal-based diets having been consumed by all the assessed households. Other food items frequently consumed were milk (>84%), oil/fat (>77%) and sugar (86%) as tea. Although meat consumption was low, it was relatively higher among the pastoral households (22%) than in agropastoral (18.5%) as expected. Consumption of other food groups (fruits, vegetables, eggs, roots and fish were very low in the two livelihoods as shown in the figure below. 14

15 Fig Distribution of Food Groups Consumed by Households % hhs Pastoral Agropastoral Cereals Meat Eggs Roots Vegetables Fruits Pulses Milk Oils Sugar Fish Miscellanous Food Groups As may be Table 4.6. Households main source of food expected the Agro-pastoral Pastoral main sources of Main source of food n % n % food for the Own production ( ) ( ) majority (>95%) Purchasing ( ) ( ) of assessed Gifts from friends (.8 3.6) 2.5 (.1 1.8) households were Food Aid 4.9 (.3 2.4) purchase and Bartered 4.9 (.3 2.4) 4.9 (.3 2.5) Borrowed 1.2 (. 1.4) 2.5 (.1 1.8) own production. Gathering 2.4 (. 1.4) 2.5 (.1 1.8) This applies where the two livelihoods are interdependent in that agro-pastorals produce cereal for their own consumption as well as sell the surplus in order to buy other food types including milk while pastorals use meat/milk/ghee from their livestock and sell the rest to buy cereals and other food types Dietary Diversity Five food groups were reportedly most frequently consumed in 41.9% (mean=4.9) among the agropastorals while pastorals mostly (34.6% mean=4.7) consumed four food groups. As shown in Fig 4.3.2, large majority (>84%) of the households in the two livelihood consumed diversified diets 3 in 24 hours prior to the assessment. Fig Household Dietary diversity among different LZs 1 8 % FGPs 4 or more FGPs Pastoral Agropastoral 3 Composed of at least four food groups based on a total of 12 FAO food groups. 15

16 Table 4.7. Household Food Consumption and Dietary diversity Agro-pastoral Pastoral n % n % No of food groups consumed 1 food group 2 food groups 3 food groups 4 food groups 5 food groups 6 food groups 7 food groups 8 food groups 9 food groups 1 food groups (.3-2.4) 4.4 ( ) 1.5 ( ) 26. ( ) 27.1 ( ) 17.7 ( ) 7.6 ( ) 3.1 ( ) 2.6 ( ).2 (. 1.4) ( ) 8.2 ( ) 34.6 ( ) 33.9 ( ) 17.6 ( ) 2.5 ( ).2 (. 1.5).2 (. 1.5) No. Having Diversified Diet 1-3 food groups 4 food groups Mean HDDS 4.9 (SD=1.6) 4.7 (SD=1.1) Formal and informal support Table 4.8 Formal and Informal support received by households Agropastoral (N=458) Pastoral (N=437) Informal support n % n % Received: Yes No Type of social support N=27 N=28 Zakat Remittances from abroad Remittances from Somalia Gifts Loans Formal support Received: Yes No Type of formal support N=24 N=11 Free Food aid Supplementary food Food for Work (Multiple responses accepted) The assessment results revealed between 5-6% of the assessed households in Burhakaba district had received informal support in forms of remittances from abroad, gifts, zakat from better off households and loans. Distribution of the different types of social support is shown in table 4.8. Formal support was reportedly received by even fewer number of household (2-5%) and was mainly in form of free food aid, supplementary food and food for work. Although there is no SFP in the district, some malnourished children may be getting services from the neighbouring districts such as Baidoa, Dinsor and QansahDere. Food aid is mainly distributed by WFP & partners. 16

17 4.4 Nutrition Status Malnutrition by Livelihoods Table 4.9: Summary of Malnutrition rates by Livelihood systems Malnutrition rates given in table 4.9. Agro-pastoral Pastoral No % (CI) No % (CI) Global Acute Malnutrition (<-2 Z score or oedema) ( ) Severe Acute Malnutrition (<-3 Z score or oedema) ( ) Oedema 3.3 (..7 GAM (WHM<8% /oedema) SAM (WHM<7% /oedema) ( ) (1. 3.) Stunting (HAZ < -2) ( ) Underweight (WAZ < -2) ( ) ( ) ( ) ( ) (1. 3.)) ( ) ( ) The results from the two assessments indicate a critical nutrition situation with Agro-pastoral livelihood recording a relatively lower rate with a GAM of 15.6% ( ) and a SAM of 3.3% ( ) while Pastoral recorded a GAM of 16.2% ( ) and SAM of 3.9% ( ). A summary of the findings for malnutrition rates is % Fig a Burhakaba Agro-pastoral WHZ distribution Curve - May' WHZ Reference Sex Combined Boys Girls % Fig b Burhakaba Pastoral WHZ Distribution Curve M ay' 7 Reference Sex Combined Boys Girls WHZ Overall, the distribution of the weight-for-height scores in the two assessments (agro-pastoral, mean=-.92; median=-1.4; SD=1.23, skewness=.75) as well as pastorals (mean=-.73; median=-.87; SD=1.42, skewness=.74) were skewed towards the left depicting a poorer nutrition situation according to international (WHO) standards (Fig 4.4.1a/b). The stunting and underweight levels among the agro-pastorals were 33.2% and 38.3% respectively while the pastorals recorded stunting rate of 43% and underweight rate of 4.3% 17

18 4.4.2 Malnutrition by Sex in the two Livelihood zones Table 4.1 Distribution of children by nutritional status (WHZ-score or oedema) and child sex Nutrition status GAM (WHZ<-2 /oedema) SAM (WHZ<-3 /oedema) Agro-pastoral Pastoral Males Females Males Females n % n % n % n % ( ( ) ( ) ( ) ( ) ( ) ( ) ( ) Oedema 2.4 (.1 1.6) 1.2 (. 1.6) 2.4(.1 _1.7) In the agro-pastoral livelihood, out of the 912 children assessed 54.5% were boys and 45.5% girls; sex ratio 1.19) while among pastorals 51.7% of 92 children assessed were boys and 48.3% were girls; sex ratio 1.7). Overall, slightly higher proportion of boys than girls was malnourished in the two livelihoods zones as shown in table 4.1. Among the agro-pastorals 17.7% of boys were malnourished as compared to 13% of girls. Statistical analysis showed that boys from agro-pastoral livelihood were 1.2 times more likely to be malnourished than girls (p=.5). Similarly, 17.8% of boys from pastoral livelihood as compared to 14.4% of girls were malnourished but statistically both sexes were equally likely to be malnourished (p=.17) Malnutrition by Age in the three Livelihoods Table 4.11 Distribution of Acute Malnutrition (WHZ Scores) by Age Age Agro-pastoral Pastoral (months) SAM GAM SAM GAM (1.3%) 33 (14.3%) 4 (2.2%) 16 (8.8%) (3.1%) %) 12 (5.5%) 48 (22.1%) (6.3%) 19 (13.4%) 1 (4.8%) 34 (16.3%) (2.7%) 27 (14.4%) 3 (1.6%) 27 (14.3%) (5.1%) 21 (21.2%) 6 (5.6%) 21 (19.4%) Total 3 (3.3%) 142 (15.6%) 35 (3.9%) 146 (16.2) From the agro-pastoral livelihood, the proportion of malnourished children was highest in the months age category (21.2%) while children aged 3-41 months recorded the lowest number of malnutrition (13.4%). Among the pastoral, and 6-17 months age categories recorded the highest (21.1%) and the lowest (8.8%) proportion of malnourished children respectively. However, analysis of distribution of malnutrition between the breastfeeding age group 6-24 months and the months category showed no statistical difference both livelihood zones (p>.5). 18

19 4.5 Mortality A total of 4766 persons including 134 under fives from 92 agro-pastoral households were assessed for mortality. The crude and U5 mortality rates were 1.31 ( ) and 1.84 ( ) respectively among the agro-pastorals. Among the pastorals a total of 4547 persons inclusive of 1179 under five children from 94 households were assessed for mortality. The crude and U5 mortality rates were 1.88 ( ) and 2.81 ( ) respectively among the agro-pastorals. Table 4.12 Mortality among the Pastoral, Agro-pastoral Livelihood zones in Burhakaba district Agro-pastoral Pastoral U5 Total U5 Total Total HHs surveyed Total Population assessed in HHs Number who joined the HHs Number who left the HHs Number of births Number of deaths Mortality rate 1.84 ( ) 1.31 ( ) 2.81 ( ) 1.88 (.9 2.9) The under five mortality rates in the two livelihoods indicates an acceptable situation while the crude mortality rates in both livelihoods reflect an alert situation according international (WHO). to standards As shown on figure 4.4.2, diarrhoeal diseases, suspected malaria, ARI and birth related complications (poor birth outcome) Fig Causes of Mortality in U5s in Burhakaba district were the main reported factors associated with 16 under-five mortality 14 according respondents recall Pastoral Agropastoral Among the children aged 5 years and the adults, the reported causes of death included malaria, measles, anaemia, ARI, TB and diarrhoea Malaria/febrile Birth related complication Accident Diarrhoeal ARI Others Qualitative data A total of fifteen focus group discussions were held during the assessment focusing on food security, sanitation, water availability, health and childcare. Qualitative data indicated that the district has only one health centre located in Burhakaba town thus limiting access to health services for the majority of the rural population. This partly explains why care givers don t seek health care for their children when they are sick. Whenever the child or adult is sick they first use their own medication and traditional healer and may visit health centres when the condition has already deteriorated. Some rural villages are located in a distance of about 9 kilometres and yet in the midst of poor 19

20 infrastructure coupled with limited and expensive transport to take the sick people to Burhakaba town. It was also noted that mother start giving their children tea at the age of two to three months claiming that they are unable to produce enough milk for their young babies. Further it was observed that women are overburdened with work and hence do not have time to take care of their young children. By the age of four months young children are under the care of their siblings (who are also under age) as their mother go to work far away from their homes. In such cases mothers prepare tea to be taken by both the young child and other siblings. With the absence of the mother and responsible caretaker, young children are fed irregularly predisposing them to malnutrition. On food security, both livelihoods were reportedly food secure following bumper cereal harvest in the agro-pastoral areas and improvement of pastures and livestock condition in the pastoral livelihood zones. However, with the influx of the IDP and poor GU 7 rain received as of the time of the assessment it was anticipated that the food security situation would decline. Slight increase in milk consumption had been noted in pastoral areas with the on set of the Gu rains but this would depend on the ultimate outcome of the Gu rains and the crop production in the agro-pastoral areas. General sanitation in the district is poor with the majority of the households using bush for human faecal disposal which is a risk factor to watery diarrhoea during wet seasons when the faecal material is washed into the unprotected water sources. Water availability was reportedly favourable due to adequate Deyr 6 rainfalls and light rainfall received at the onset of GU 7. However water quality is of great concern and is often related with high diarrhoea episodes. 2

21 5. Discussion Findings from the two livelihoods indicate a critical nutrition situation with Agro-pastoral livelihood recording a relatively lower rate with a GAM of 15.6% ( ) and a SAM of 3.3% ( ) while Pastoral recorded a GAM of 16.2% ( ) and SAM of 3.9% ( ). However as the confidence interval ranges overlap between the two assessments there is no statistically significant difference between the nutrition situations in the two livelihood zones. Since the past nutrition assessment were conducted based on administrative boundaries, it is not feasible to directly compare the current results with past assessments. However, the nutrition assessments conducted in Burhakaba Town in August 1999 recorded a very critical GAM of 28.% and SAM of 6% while the district nutrition assessment carried out in August 2 recorded a similar nutrition situation with a GAM of 22.2% and SAM of 4.1%. Other sources of Nutrition data including the sentinel sites established in 26 by FSAU and data from WVI MCH have often recorded a fluctuating trend of malnutrition pointing to the precarious nutrition situation in the district. The results from these assessments are also consistent with results from neighbouring/similar livelihood zones within Southern Somalia. Dietary diversity was good with the majority (>84%) of the households in the two livelihoods, reportedly consuming four or more food groups in the twenty four hours prior to the assessment. This has positive impact on the nutrition situation and a reflection of improved food security as reported in the FSAU Post Deyr 6 assessment. Good dietary diversity may have mitigated the nutrition situation in the district. However, continued insecurity and pressure from IDP such as increased food sharing and expenditure would have a negative impact on livelihood system and consequently on dietary diversity. Good dietary diversity is attributed to increased access to cereals from agro-pastoral areas in Bay region and milk from improved livestock conditions following good Deyr6/7 rains. Regarding the sources of food, purchase and own food production were the main food sources for the majority of the assessed households. As expected, the reported main sources of income were sale of crop/crop-products and animals/animal-products for agro-pastorals and pastoral respectively. Over half of the children aged 6 24 months (59.2% from pastoral and 53.6% from agro-pastoral livelihood) were reportedly still breastfeeding at the time of assessment with over 73% of the children assessed having been introduced to foods other than breast milk before the recommended age of 6 months. This is an indication of a sub-optimal childcare practices. Early cessation of breastfeeding and introduction of complementary foods deny a child the multiple health and nutrition benefits of breast milk. The essential role played by breast milk was evidenced in the assessment, particularly in pastoral livelihood where malnutrition was significantly related with breastfeeding with the children who were not breastfeeding at the time of the assessment being about.69 times more likely to be malnourished than those breastfeeding (p=.1). Infrequent feeding was also evidenced with less than 5% of the children being fed for the recommended minimum of five times. Malnutrition equally affected the younger (6-29 months) and older children (3-59 months) with no statistical difference between the two categories (p>.5). The reported morbidity in the two weeks prior to the assessment was high in both livelihood zones. Overall, about 37.7% and 35.8% of the children from agro-pastoral and pastoral livelihood zones respectively were reported to have suffered from one or more of communicable diseases during the two weeks prior to the assessment. ARI, diarrhoea and suspected malaria recorded the highest prevalence of reported diseases. Morbidity was significantly associated with malnutrition particularly for pastoral livelihood (p<.5). The high morbidity may partly be explained by limited health facilities in the district making them inaccessible to majority of the rural population. Inaccessibility of health facilities explains why the majority of the households with sick children two weeks prior to the assessment did not seek any health assistance. The coverage of the health programmes; Vitamin A 21

22 supplementation, measles vaccination and polio immunization (17-65%), were far below the recommended coverage of 95% (Sphere 24). The crude and U5 mortality rates were 1.31 ( ) and 1.84 ( ) respectively among the agro-pastorals while pastorals recorded a crude and U5 mortality rates of 1.88 ( ) and 2.81 ( ) respectively. The under five mortality rates in the two livelihoods indicates an acceptable situation while the crude mortality rates in both livelihoods reflect an alert situation according to international standards. Morbidity including diarrhoea, suspected malaria, ARI were the reported causes of deaths. The critical nutrition situation can be attributed to the high morbidity and poor child feeding practices, especially breastfeeding, which were both significantly related with malnutrition (p<.5). A further contributing factor is the outbreak of AWD in most part of southern Somalia. WHO reported 535 cases of AWD with CFR of 9.5% in Burhakaba district from January to 18 th May 27. The peak period for AWD in the district was in the month of April. AWD has negative impact on nutritional status and especially having occurred few weeks before the assessment may have exacerbated the nutrition situation as well as the mortality rates. In the assessment, 5.5% and 7.6% of the assessed households from Pastoral and Agro-Pastoral livelihoods, respectively, were reported to be hosting 1-1 IDPs who were mainly from Mogadishu. The fact that IDPs are more often vulnerable to malnutrition and the increased pressure on the host families may have also contributed to the critical nutrition situation. 6. Recommendations Although Burhakaba district livelihood systems have in the past withstood various shocks, continued pressure from both natural and man made crisis such as insecurity are constantly eroding the stability of these systems. Intervention efforts, therefore, need to be strengthened and broadened to address both immediate life saving needs in addition to developing longer term strategies to enhance the provision of basic services, sustainable strategies for livelihood support and social protection mechanisms. Specific recommendations on both short- and long-term basis include: 1. Enhance delivery of basic health services through intensification of EPI, and mobile clinics services and establishment of more health posts and maternal health clinics in rural areas to provide relevant health services. 2. Rehabilitation and treatment of severely and moderately malnourished children through outreach and community-based mechanisms to reach malnourished children in the interior villages. Vulnerable households should be targeted for distribution of selected nutritious food such as pulses and other products reach in micronutrients (minerals and vitamins) to enhance nutrition quality of the diets. 3. Training of various community groups (women, girls,) on both prevention and treatment of acute malnutrition is essential in both management of current malnutrition and prevention of recurrent cases. 4. Promotion of production and consumption of vegetables, fruits, chicken/eggs which are cheap sources of vitamins, minerals and protein is vital to enhancing food and nutrition situation as well as economic empowerment. 5. In order to break the vicious cycle of malnutrition and morbidity, there is a need to intensify nutrition and health education targeting children care givers with messages on breastfeeding, child-feeding, health-seeking behaviour and hygiene & sanitation. 6. Rehabilitation of existing water sources such us, water catchments, boreholes and wells, construction of new ones and establishment of mechanism for routine water treatment/chlorination to enhance water quality particularly during the dry season that recorded peak of AWD prior to the assessment. 22