Nutrition Survey report IDP camps, Apac district, Northern Uganda. 19th to 27th of April 2006.

Transcription

1 Nutrition Survey report IDP camps, Apac district, Northern Uganda 19th to 27th of April 2006.

2 Table of content SUMMARY...3 RECOMMENDATIONS INTRODUCTION SITUATION SURVEY OBJECTIVES METHODOLOGY SURVEY METHODOLOGY DATA COLLECTED DATA ANALYSIS TRAINING AND SUPERVISION RESULTS ANTHROPOMETRIC RESULTS...9 Distribution of age and sex of the children...9 Distribution of malnutrition in z-score...10 Distribution of malnutrition in percentage of the median...11 Mid upper arm circumference (MUAC) MORTALITY RESULTS VACCINATION RESULTS...12 Measles immunization coverage...12 Vitamin A coverage PROGRAM COVERAGE DISCUSSION...13 RECOMMENDATIONS...14 ACKNOWLEDGEMENTS...14 APPENDIX...14 Table 1: Results summary...3 Table 2: Distribution of age and sex...9 Table 3: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)...10 Table 4: Prevalence of acute malnutrition by age based on w/h in z-scores and oedema...11 Table 5: Distribution of acute malnutrition and oedema based on weight-for-height z-scores...11 Table 6: Prevalence of acute malnutrition based on the percentage of the median and/or oedema...11 Table 7: Prevalence of malnutrition by age, based on w/h in % of the median and oedema...11 Table 8: MUAC distribution according to nutritional status...12 Table 9: Mortality rates...12 Table 10: Measles immunization coverage...12 Table 11: Vitamin A coverage...13 Table 12: Children attending the SFC program...13 Table 13: Results summary...13 Figure 1: ACF s SFC attendance... 6 Figure 2: Population age and sex pyramid Figure 3: Z-score distribution weight for height

3 Summary The survey took place in the IDP camps of Apac district, in northern Uganda from the 19 th to 27 th of April It was following up a survey done in February 2005, with the objective to evaluate the evolution of the nutritional status of this population, and do recommendations accordingly. A two-stage random cluster sampling method was used. This sampling provides a representative estimate of malnutrition prevalence with 95% confidence. The results obtained are summarized in the table bellow: Table 1: Results summary Age groups Indicators Z scores Global Acute Malnutrition 4.4% (2.8% - 6.8%) 4.7% (2.9% - 7.2%) 6-59 months Z scores Severe Acute Malnutrition 1.4% (0.5% - 3.0%) 0.8% (0.2% - 2.3%) % of the median Global Acute Malnutrition 3.0% (1.7% - 5.2%) 3.7% (2.2% - 6.0%) % of the median Severe Acute Malnutrition 1.3% (0.5% - 2.9%) 0.6% (0.1% - 2.0%) Z scores Global Acute Malnutrition 7.0% (4.2% %) 8.3% (5.1% %) 6-29 months Z scores Severe Acute Malnutrition 1.7% (0.5% - 4.6%) 1.4% (0.3% - 4.4%) % of the median Global Acute Malnutrition 4.7% (2.4% - 8.5%) 6.5% (3.7% %) % of the median Severe Acute Malnutrition 1.7% (0.5% - 4.6%) 0.9% (0.1% - 3.7%) Crude retrospective mortality (last 3 months): 0.47/10,000/day [ ] Crude retrospective mortality of the under 5 years: 0.37/10,000/day [ ] Measles vaccination coverage: with a card to prove = 53.9%; without a card =32.7%. Vitamin A supplementation=71.0% The malnutrition rates show that the nutritional situation is not alarming but requires monitoring, due to the fragile balance of the food security of the IDP population and to fragile security context in the area. Several years ago, northern Apac was the food basket of both Lira and Apac, but the insecurity arising for the past years had a negative impact on land access and agricultural production. Unfortunately, there is no data available about the food security yet, the NGO activities being too recent there. The major cause of malnutrition is not the access to food in term of quantity, but in term of variety. The diet of the IDP population is mainly composed of beans and posho 1, and little vegetable. The second cause of malnutrition is improper access to health care, which is translated here in the poor vaccination coverage. 1 Corn flour meal 3

4 Recommendations Continue to support the existing activities addressing the problem of acute malnutrition: (screening, surveillance and treatment) Continue to monitor the nutritional status of the population by making annual assessment. Making the promotion of healthy balance diet by making demonstration, giving seeds, and emphasize on healthy and hygiene practices. Continue the distribution of tools and seeds and encourage the food security team to work in more camps. Put a priority to access to health service for pregnant, breast feeding mothers and children. 4

5 1-Introduction 1.1 Situation Apac district has become increasingly affected by the 18-year civil war in northern Uganda during the last two years. Numbers of Internally Displaced People (IDPs) have increased since In fear of constant LRA attacks in the north, many people moved south towards Lake Kyoga and settled within villages in that area, settlements also known as gazetted camps. However, a large majority stayed in the region, to be eventually driven into permanent camps due to the deterioration of the security situation along the northern border. The nutrition assessment evaluates the nutrition and mortality situation of Apac district in the northern part of Uganda. The district has five counties, which are further sub-divided into 23 sub-counties. Pader district is Apac s neighbour in the north, Gulu in the North West, Kitgum in the north east, Masindi in the west and Nakasongola in the south. On the east side, there is Lira district, and most of the administrative decisions take place here. Apac covers an area of 6,684 square kilometers and the altitude lies between 1,350 and 1,500 meters above sea level. Around ninety percent of the district s population lives in rural areas and the balance is staying in an urban-based. The population of Apac district is estimated at around 676,244 people in 2002, while the number of displaced people is estimated at 121,189 according to DDMC on May 2005 (latest figures). According to the district, the density of the population was 115 persons/square kilometer in The people of Apac are Lango by tribe and Luo is the common language. The offices of many non governmental organizations (NGOs) like Action against Hunger are based in Lira town. Here are the NGOs working in Apac district and their principal activities: Agriculture and food security: UNFAO = United Nations Food and agriculture organization URCS= Uganda Red Cross Society ACF-USA CEASOP = collaboration effort to alleviate social problems VEDCO = volunteer efforts for development concerns CESVI = Cooperazione e sviluppo ASDI = Agency for Promoting Sustainable Development Initiatives Health (including HIV) and nutrition ACF-USA UNICEF CESVI MSF-H = Médecins sans frontière - Holland Water and sanitation UNICEF CESVI CPAR= Canadian physicians for aid and relief ACF-USA MSF-H Shelter, resettlement and NFI URCS UNICEF 5

6 Education UNICEF SCiU= Save the Children in Uganda Protection CARITAS PATH= PATH ministries international UNICEF CADOVIC Coordination OCHA = office for the coordination of humanitarian affairs (See Acronyms in annex.) ACF-USA is the only NGO working in nutrition in the camps. 2 SFC are currently in place, for beneficiaries who are moderately malnourished. These centers distribute food rations and educate families in proper nutrition and healthcare. As this report is being written, there is 3 news SFC program being open and to add CBC programs. The attendance of these centers since their implementation is presented in the following graph: Figure 1: ACF s SFC attendance SFC admission number - July 2005 to April Otwal Acokara 50 0 Jul- 05 Aug- 05 Sep- 05 Oct- 05 Nov- 05 Dec- 05 Jan- 06 Feb- 06 Mar- 06 Apr- 06 To ensure that recovered beneficiaries remain healthy, our teams at these centers attempt to determine the causes of moderate malnutrition and to correct them through programs in water-and-sanitation and food security or by alerting a medical NGO of the need for medical interventions. We also help prevent malnutrition in developing communities through child-growth monitoring. We work with health centers and other relief organizations to find children who are malnourished, and we take random samples of entire communities to identify undernourished populations. When we determine that our aid is warranted, we sometimes go house-by-house examining all the children in town to find those in need of nutritional care. We determine this by measuring upper-arm circumference or the ratio of height to weight and comparing these measurements to the standards of healthy children. Finally, in all our nutritional programs we educate and train mothers and fathers in the importance of good nutrition for their growing children. We train local medical staff on how to recognize and treat malnutrition. We also educate community leaders in the importance of nutritional monitoring. 6

7 Access to health services remains limited in northern Apac, with only two camps having a health centre within a 2 km distance; other camps population has to walk at least 6 km to reach a clinic. CESVI ran a mobile clinic previously in all camps, however due to a lack of funding this has now ceased. Safe drinking water is restricted, with many people accessing shallow wells, protected and unprotected springs for usage. The total number of safe water sources is extremely low and does not achieve acceptable coverage for the population. Food insecurity levels may heighten since the conflict directly affects agricultural activities. Due to intensified insecurity, people have limited access to land. CINS and URCS have distributed seeds and tools in some camps; the numbers of households that plant are still to be determined and monitored. There are currently no general food distributions in the region. This is the second nutritional assessment and household survey done in the IDP camps in Apac to assess living conditions. 1.2 Survey Objectives To assess the nutritional status of children 6-59 months in IDP camps of Apac To assess the retrospective mortality To assess the measles immunization and Vitamin A supplementation coverage To assess the feeding practices of children under 6 months. 2- Methodology 2.1 Survey Methodology The assessment was done with the cluster sampling method. The technique is a two stage measuring 30 children in 30 clusters (30 x 30), which allows analyzing the results with a 95% confidence interval. The target population is children 6-59 months. Stage 1- Cluster Selection The cluster is a geographical unit used to divide the population. The smallest geographical unit should be used here they were IDP camps in Lira district. Clusters to be surveyed were selected by using the Nutrisurvey. For the survey to be representative of the population, the selection probability of each camp is proportional to its population. The list of clusters selected is available in annex. Stage 2 Household Selection Households to be surveyed were selected randomly in each cluster by using the EPI method. At the centre of the identified cluster, a pencil or bottle was set on the ground and spun. The direction to which it pointed determined the direction to be followed by the surveying team. The team walks in the direction indicated by the pen, from the centre to the edge of the village. At the edge of the village spin the bottle again, until it points into the village and walk along this second line counting each house on the way. The first house to be surveyed was randomly chosen, through the use of a bag of random numbers. The main house was use in case of a family having many houses. All the children aged 6-59 months living in the household were included in the nutritional survey. The following house to be surveyed was the door to the right closest to the previously visited house. If the team reached the end of the camp before the sample number was reached, they returned to the center of the camp and repeat the procedure in another direction until the sample was complete. If there 7

8 was more than one cluster per camp, teams shared the camp in order to avoid overlaps, and moved in different directions. All household selected by the sampling method was also surveyed for the retrospective mortality questionnaire, whether or not they had children eligible for the survey. 2.2 Data collected 1- Anthropometric data Age: Registered in months for children 6-59 months; if the mother did not know the exact date birth, then the supervisor tried to remember the season with important events. Gender: Female/Male Weight: Registered in kilograms to the nearest 100g and measured with a Salter Scale. Height: Measured in cm to the nearest millimeter with a wooden height board. MUAC: Measured with ACF bracelet on the left arm and in cm to nearest mm. Edema: The thumb pressure technique for three seconds was implemented bilaterally, beginning at the feet of surveyed children and moving up towards limbs. Measles: Recorded according to vaccination card availability. The following code was developed - (1) if a child has a card and has been vaccinated, (2) if the child has not been vaccinated, and (3) if the caretaker confirms that the vaccine has been received, but has no card to prove it. Vitamin A: Recorded as received in the last month. SFC: if the child is in a supplementary feeding center s program. If not, then if the child was fitting the criteria of admission, the team supervision would refer the child to the nearest SFC. Acute malnutrition rates were estimated from the weight for height (WFH) index values combined with the presence of edema for the children 6-59 months measured. The WFH indices are compared with National Center of Health Statistics (NCHS) reference curve, based on a population of healthy children. WFH indices are expressed both in Z-scores and percentage of the median. The expression in Z-scores is statistically reliable for comparisons of different studies. The percentage of the median is more operationally feasible in identifying children who fit the admittance criteria for nutrition programs. Z-score and % median systems do not classify the same children as malnourished 2. The guidelines for the results expressed in Z-scores are as follows: o Severe malnutrition is defined by WFH < -3 SD and/or bilateral edema on the lower limbs o Moderate malnutrition is defined by WFH < -2 SD and -3 SD and no edema. o Global acute malnutrition is defined by WFH < -2 SD and/or bilateral edema The guidelines for the results expressed in percentage according to the median of reference: o Severe malnutrition is defined by WFH < 70 % and/or bilateral edema on the lower limbs o Moderate malnutrition is defined by WFH < 80 % and 70 % and no edema. o Global acute malnutrition is defined by WFH <80% and/or existing bilateral edema The measurement of the mid-upper arm circumference (MUAC) is use to as a malnutrition indicator ass fallow: MUAC < 110 mm MUAC 110 mm and <120 mm MUAC 120 mm and <125 mm MUAC 125 mm and <135 mm MUAC 135 mm severe malnutrition and high risk of mortality moderate malnutrition and moderate risk of mortality high risk of malnutrition moderate risk of malnutrition "adequate" nutritional status 2 Prudhon, Claudine. Assessment and Treatment of Malnutrition in Emergency Situation. Action Contre La Faim. 8

9 2- Mortality A 3-month retrospective survey assessed the levels of mortality in communities. Identifying number of household members now and three months ago provided identification of movement in and out of the camps, birth and the deaths that occurred within the last 3 months. The questionnaire was filled even in the houses where no children were eligible for anthropometric measurements. The formula below is applied: Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), where: a = Number of recall days (90) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period The result is expressed per 10,000-people / day. 2.3 Data Analysis Data processing and analysis were carried out using Nutrisurvey software for anthropometric and mortality data. Excel program was use for other data. 2.4 Training and supervision 6 teams of 3 persons each were constituted. 6 persons among them already participated in the previous survey. All the others people were choose for their experience in undertaking a nutritional survey or of taking anthropometric measurements. They were trained on survey methodology and measurement techniques by the project manager, and the home visiting officer. A practice pilot survey was done on the field, and the results obtained were analyzed and validated thanks to the Nutrisurvey software. The survey took place from the 19 th to the 27 th April 2006 without interruption. 3- Results 3.1 Anthropometric results Distribution of age and sex of the children Table 2: Distribution of age and sex Age groups Boys Girls Total Ratio no. % no. % no. % Boy: girl 6-17 months months months months months Total

10 Figure 2: Population age and sex pyramid 140 numbers of children boys girls months months months months months Distribution of malnutrition in z-score Table 3: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) All n = to 29 months n = 432 Prevalence of global malnutrition (<-2 z-score and/or oedema) 4.7% (2.9% - 7.2%) 3 8.3% (5.1% %) Prevalence of severe malnutrition (<-3 z-score and/or oedema) 0.8% (0.2% - 2.3%) 1.4% (0.3% - 4.4%) The Chi square test shows that the risk to be acutely malnourished is similar for both sex (p=0.05, at 95%). An the other hand, the analysis of the malnutrition prevalence per age group reveals that the 6-29 months old present a much higher risk to be malnourished (Relative risk=7.6, Confidence interval = , at 95%). Figure 3: Z-score distribution weight for height 3 Confidence interval at 95%. 10

11 The mean of the curve is -0.28, and the standard deviation is.096 (it should be between 0.80 and 1.10), which shows that the sample is of adequate quality. Table 4: Prevalence of acute malnutrition by age based on w/h in z-scores and oedema. Moderate Severe wasting wasting Normal Age Oedema Total (<-3 z-score) (>= -3 and <-2 z- (> = -2 z score) (months) score ) No. % No. % No. % No. % Total Table 5: Distribution of acute malnutrition and oedema based on weight-for-height z-scores <-2 z-score >=-2 z-score Oedema present Marasmic kwashiorkor 2 (0.2 %) Kwashiorkor 3 (0.3 %) Oedema absent Marasmic 37 (4.1 %) Normal 858 (95.3 %) Distribution of malnutrition in percentage of the median Table 6: Prevalence of acute malnutrition based on the percentage of the median and/or oedema ALL n = months n = 432 Prevalence of global acute malnutrition (<80% and/or oedema) 3.7% (2.2%-6.0%) 6.5% (3.7%-10.9%) Prevalence of severe acute malnutrition (<70% and/or oedema) 0.6% (0.1%-2.0%) 0.9% (0.1%-3.7%) Table 7: Prevalence of malnutrition by age, based on w/h in % of the median and oedema Moderate Severe wasting Normal Age Total wasting (<70% median) (> =80% median) (months) no. (>=70 and <80%) Oedema No. % No. % No. % No. % Total

12 Mid upper arm circumference (MUAC) Table 8: MUAC distribution according to nutritional status Height btw 65 Height btw 75 MUAC (mm) and 75 cm and 90 cm Height > 90 cm Total N % N % N % N % < % 3 0.8% 0 0.0% % 110<=MUAC< % % 0 0.0% % 120<=MUAC< % % 0 0.0% % 125<=MUAC< % % % % >= % % % % Total % % % % The MUAC analysis indicates that 3.4% of the children above 75 cm height are fitting the criteria for acute malnutrition, according to ACF protocols. 3.2 Mortality results All households visited were questioned about the demographics data and events that occurred during the past 3 months (90 days) person were present at the time of the survey. Out of them, 953 were under 5 children (29.7%). 41 births were recorded 14 deaths occurred, 3 of them affecting under 5 children 228 people left the household, 30 of tem being under 5 children 42 people joined the household, 27 of them being under 5 children. Table 9: Mortality rates CMR (total deaths/10,000 people / day): 0,47 ( % CI) U5MR (deaths in children under five/10,000 children under five / day): 0,37 ( % CI) 3.3 Vaccination results Measles immunization coverage It is assessed for children from 9 months old, according to the WHO protocols. Table 10: Measles immunization coverage number % Has been vaccinated with card Has not been vaccinated Has been vaccinated without card Total More than half of the 900 children included in the survey received a measles vaccine with proof of a vaccination card. WHO recommendation to prevent outbreak is a coverage over 80%: the coverage measured during the survey is not satisfying. 12

13 Vitamin A coverage Vitamin A is an essential micronutrient. Because the liver stores rather large amounts of retinol (vitamin A s metabolite), deficiency states typically take several months to develop. The more serious manifestations of vitamin A deficiency include impaired vision that can lead to blindness. Out of the 900 children, there has been 71% who received supplement of vitamin A in the last months. This rate seems a little bit high; the teams probably not ask if the supplement has been given in the last month since the results of last year was 43,7% of the children who had received a vitamin A supplement during the last month. Table 11: Vitamin A coverage number % Yes No total Program coverage Table 12: Children attending the SFC program number % Yes 46 5 No total % of the 900 children surveyed are part of the SFC s program. 4- Discussion The main results of the present survey are displayed in as follows: Table 13: Results summary Age groups Indicators Z scores Global Acute Malnutrition 4.4% (2.8% - 6 8%) 4.7% (2.9% - 7.2%) 6-59 months Z scores Severe Acute Malnutrition 1.4% (0.5% - 3.0%) 0.8% (0.2% - 2.3%) % of the median Global Acute Malnutrition 3.0% (1.7% - 5.2%) 3.7% (2.2% - 6.0%) % of the median Severe Acute Malnutrition 1.3% (0.5% - 2.9%) 0.6% (0.1% - 2.0%) Z scores Global Acute Malnutrition 7.0% (4.2% %) 8.3% (5.1% %) 6-29 months Z scores Severe Acute Malnutrition 1.7% (0.5% - 4.6%) 1.4% (0.3% - 4.4%) % of the median Global Acute Malnutrition 4.7% (2.4% - 8.5%) 6.5% (3.7% %) % of the median Severe Acute Malnutrition 1.7% (0.5% - 4.6%) 0.9% (0.1% - 3.7%) Crude retrospective mortality (last 3 months): 0.47/10,000/day [ ] Crude retrospective mortality of the under 5 years: 0.37/10,000/day [ ] 13

14 Measles vaccination coverage: with a card to prove = 53.9%; without a card =32.7%. Vitamin A supplementation=71.0% The malnutrition rates show that the nutritional situation is not alarming but requires monitoring, due to the fragile balance of the food security of the IDP population and to fragile security context in the area. Several years ago, northern Apac was the food basket of both Lira and Apac, but the insecurity arising for the past years had a negative impact on land access and agricultural production. Unfortunately, there is no data available about the food security yet, the NGO activities being too recent there. The major cause of malnutrition is not the access to food in term of quantity, but in term of variety. The diet of the IDP population is mainly composed of beans and posho, and little vegetable. The second cause of malnutrition is improper access to health care, which is translated here in the poor vaccination coverage. Recommendations Continue to support the existing activities addressing the problem of acute malnutrition: (screening, surveillance and treatment) Continue to monitor the nutritional status of the population by making annual assessment. Making the promotion of healthy balance diet by making demonstration, giving seeds, and emphasize on healthy and hygiene practices. Continue the distribution of tools and seeds and encourage the food security team to work in more camps. Put a priority to access to health service for pregnant, breast feeding mothers and children. Acknowledgements Action Against hunger would like to thank the ministry of health and the DDHS for letting us undertaking this nutritional survey. We give a special thanks to World Food Program and UNICEF for the funding of the survey. Many thanks to the camp leaders who tried to make our work easier. Thanks to the project coordinator of MSF-Holland for sharing statistics of the TFC. Lastly, thanks to the surveyors who made this survey possible by their hard and conscientious work. Of course, a grateful thanks to ACF staff in Lira base who made all in their power to make this survey a successful one. Appendix 14

15 Appendix 1: Assignment of Clusters Geographical unit Population size Assigned cluster Abock Acimi Acokara , 4, 5 Adit Ajaga , 8 Alibi Aloni Anyomolyec , 12 Bar Rio Iceme Itubara Ngai Trading center , 17, 18, 19 Ojwi-Abela , 21 Onekgwok Otwal Trading Center , 24 Otwal Railway , 26, 27 Alito , 29, 30 Opeta Aleka Ader

16 Appendix 2: Anthropometry questionnaire CAMP NAME CLUSTER DATE TEAM # SUPERVISOR # HH Child Date of birth Age Sex Weight (kg) Height (cm) Oedema MUAC (mm) Measles 4 Vitamin 5 SFC TFC A 4 Yes w/card=1, No=2, Yes w/ no card=3 5 Yes=1, No=2 16

17 Appendix 3: Mortality questionnaire CAMP CLUSTER DATE # HOUSEHOLD TEAM SUPERVISOR HH Member Present now Present at beginning of recall period (3 months) Sex Date of birth/ age in years Born during recall period? (3 months) Died during recall period? (3 months) Total Current HH members total Current HH members - < 5 years Current HH members who arrived during recall (exclude births) Current HH members who arrived during recall - < 5 years Past HH members who left during recall (exclude deaths) Past HH members who left during recall - < 5 years Birth during recall Total deaths Death < 5 years 17

18 Appendix 4: List of acronyms: WFP = World Food Program SP = Samaritan s Purse - Uganda COOPI = COOPerazione Internationale FAO = Food and Agriculture Organization CPAR = Canadian Physicians for Aid and Relief DETREC = DEvelopment TRaining and REsearch Centre HA = Hunger Alert URCS = Uganda Red Cross Society MSF-H = Medecins Sans Frontières - Holland CCF = Christian Children s Fund ALF = Alice Labol Foundation UPHOLD = Uganda Program for Human and Holistic Development GED = German Emergency Doctors NWMT = NorthWest Medical Teams PAG = Pentecostal Assemblies of God IRC = International Rescue Committee CEASOP = Collaboration Effort to Alleviate Social Problems ANCC = All Nations Christian Care WCH = War Child Holland CPA = Concern Parents Association TPO = Transcultural Psychosocial Organisation CCSO =Community Coping Support Organization LFI = Lightforce Rescue International RRC = Rachele Rehabilitation centre SA = Salvation Army CORD-U = Cooperation for Regional Development NRC = Norwegian Refugee Council OHCHR = UN office of the high commissioner for the human right UNHCR = UN High Commissioner for Refugees OCHA = UN Office for the Coordination of Humanitarian affairs NACWOLA = National Community of Women Living With Aids 18