UNICEF/CDC/WHO Elderly Assessment in Government Controlled Areas of Donetsk and Luhansk oblasts and Non- Government controlled areas of Donetsk

UNICEF/CDC/WHO Elderly Assessment in Government Controlled Areas of Donetsk and Luhansk oblasts and Non- Government controlled areas of Donetsk April 2016 Nutrition Sub-Cluster of the Health and Nutrition Cluster Кластерная группа по питанию Кластера здравоохранения и питания https://www.humanitarianresponse.info/operations/ukraine/nutrition

Introduction Previous assessments in Donbass region have shown older people: Make up the largest percentage of people affected by the conflict Are one of the most vulnerable groups Humanitarian response has been slow to identify and address their needs A recent assessment by HelpAge International in the Donbass region suggested there may be cases of malnutrition in older persons and difficulties for older persons to access healthcare services and medications for non-communicable diseases No comprehensive assessments done of older people s health and dietary needs

Assessment Goal Collect information on health and nutrition in order to help design and inform emergency interventions of the key partner agencies working in the health and nutrition sectors. Specifically, provide advice on the requirements for adapted and targeted assistance for older men and women >60 years living in the government controlled areas (GCAs) of Donetsk and Luhansk oblasts and non-government controlled areas (NGCAs) of Donetsk oblast and to monitor the degree to which these groups are accessing such services.

Methods Quantitative (NGCAs and GCAs) Cross-sectional household survey Qualitative (GCAs only) Focus group discussions This was presented in a previous presentation and will not be discussed here

NGCA Sampling Frame Electoral precincts with population data in non-government controlled areas (NGCAs) of Donetsk oblast Last updated October 2015

NGCA Sample Selection Multi-stage sampling procedure 1) Cluster randomized sample Electoral precincts were primary sampling units Clusters selected probability proportional to size (PPS) 25 clusters were selected

NGCA Sample Selection Multi-stage sampling procedure 2) Systematic random sampling to choose households Chose 2 random starting points in the cluster, conducted ½ of the interviews for that cluster from each starting point Apartment buildings Apartment building randomly selected Apartment unit randomly selected as starting point using a random number Chose every other apartment Private houses Private house randomly selected as starting point Chose every other house after random starting point

Inclusion Criteria 1) Person > 60 years at the time of the survey 2) Current resident of one of the randomly selected clusters and households 3) Consented to participate in the survey NOTE: Included all elderly persons, not only internally displaced persons (IDPs)

Survey Administration GCA Sample Size of 750 elderly persons 31 Clusters of 24 Households 24 Clusters in Donetsk oblast, 7 clusters in Luhansk oblast Data collection was conducted from 30 January to 13 February 2016 9 trained data collectors NGCA Sample Size of 418 elderly persons 25 Clusters of 16 Households Data collection was conducted from 21 February to 5 March 2016 5 trained data collectors

Survey Topics Questions Household and individual demographics, income Access to humanitarian assistance Chronic diseases and access to medications Food intake and food insecurity Dependency (Ability to perform daily activities) Psychological distress Anthropometry Measurements Body Mass Index Mid-upper arm circumference

Questionnaire-Demographics and Income Education Age Sex Living situation IDP status Number of people in household Pension Total income

Questionnaire-Humanitarian Assistance Registered to receive assistance Receipt of aid Cash/Vouchers Food Non-food Transportation assistance

Questionnaire-Health and Healthcare Seeking Chronic Diseases Hypertension Diabetes Cardiovascular diseases Chronic lung diseases Taking medications regularly Acute Respiratory Infection Sought care Reason for not seeking care

Questionnaire-Nutrition and Food Insecurity Nutrition Foods eaten yesterday Number of meals eaten yesterday Number of times food group eaten in past week Individual dietary diversity Calculated based on the Women s Dietary Diversity Score (WDDS) developed by the Food and Agriculture Organization (FAO) of the United Nations 1 Food Insecurity Household Hunger Scale developed by the Food and Nutrition Technical Assistance Project III (FANTA) 2 1. Guidelines for Measuring Household and Individual Dietary Diversity. FAO. 2013 2. Household Hunger Scale: Indicator Definition and Measurement Guide. FANTA III. 2011

Questionnaire-Dependency Help with bathing Help getting dressed Help using the toilet Help with moving from bed to chair Incontinence Help with eating Someone to care for you Classified as independent, moderately dependent, and severely dependent Katz Index of Independence in Activities of Daily Living 1-3 1. Katz S, Ford A, Moskowitz R, et al. Studies of illness and the aged. The Index of ADL: A standardized measure of biological and psychosocial function. JAMA, 185(12), 1963. 2. Katz S, Down T, Cash H, et al. Progress in the development of the index of ADL. The Gerontologist. 10(10), 1970. 3. Katz S. Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. JAGS. 31(12) 1983.

Questionnaire-Psychological Condition Nervous Hopeless Restless or fidgety Depressed Everything is an effort Worthless Kessler K6 Psychological Distress Scale 1-2 Scale previously pilot tested and validated in Ukraine 1. Kessler R, Andrews G, Colpe L, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine. 32(60), 2002. 2. Kessler R, Barker P, Colpe L, et al. Screening for serious mental illness in the general population. Archives of General Psychiatry. 60(20), 2003.

Questionnaire-Anthropometry Arm-demi span (as proxy for height) and weight used to calculate body mass index (BMI) Mid-upper arm circumference (MUAC)

Household Survey Results

Demographic Characteristics GCA (N=758) NGCA (N=418) Gender n (%) n (%) Male 266 (35.1) 140 (33.5) Female 492 (64.9) 278 (66.5) Age (years) 60-70 371 (48.9) 181 (43.3) >70 387 (51.1) 237 (56.7) Mean (SD) 71.8 (8.2) 72.7 (8.3) Median (IQR) 70.4 (64.5-78.1) 73.4 (65.1-78.4) Respondent Self 695 (92.7) 390 (93.3) Proxy 63 (8.3) 28 (6.7) Education level Incomplete secondary school 177 (23.4) 100 (23.9) Complete secondary school 177 (23.4) 143 (34.2) Professional secondary education 285 (37.6) 133 (31.8) Incomplete or complete higher education or above 119 (15.7) 42 (10.1)

Demographic Characteristics GCA (N=758) NGCA (N=418) Living situation (n, %) Own house or apartment (no fee) 740 (97.6) 400 (95.7) Other 18 (2.4) 18 (4.3) Total # of people in household Mean (SD) 2.1 (1.1) 2.1 (1.1) Median (IQR) 2 (1-2) 2 (1-2) Total # of people >60 years in household (n, %) 1 386 (50.9) 201 (48.1) 2 361 (47.6) 202 (48.3) 3 11 (1.5) 15 (3.6) Living Situation Living alone 238 (31.4) 123 (29.4) Living only with another person(s) over 60 308 (40.6) 172 (41.2) Living with people under 60 212 (28.0) 123 (29.4)

Socioeconomic Characteristics GCA Donetsk (N=592) GCA Luhansk (N=166) GCA Total (N=758) NGCA (N=418) Ukrainian Government Pension Eligibility Registered to receive pension from Ukrainian Government, n (%) 592 (100) 166 (100) 758 (100) 372 (89.0) N=592 N=166 N=758 N=372 Received pension last month from Ukrainian Government, n (%) Amount of pension received last month from Ukrainian Government (UAH) 590 (99.7) 166 (100) 756 (99.7) 80 (21.5) N=590 N=166 N=756 N=60 Mean (SD) 1676.0 (784.3) 1549.1 (533.0) 1647.3 (736.9) 1985.5 (1093.9) Median (IQR) 1350 (1230-1800) 1300 (1228-1700) 1342 (1230-1800) 1500 (1200-2750)

Socioeconomic Characteristics NGCA (N=418) DNR Pension Eligibility Registered to receive pension, n (%) N=418 Received pension last month, n (%) N=409 409 (97.9) 402 (98.3) Amount of pension received last month from DNR N=356 Mean (SD) Median (IQR) Received pension from Ukrainian government and DNR last month, n (%) 1244.5 (707.5) UAH 3360.1 (1910.2) RUB* 930 (815-1407) UAH 2512 (2200-3800) RUB* 77 (18.4) *Exchange Rate 2.7:1

Socioeconomic Characteristics GCA Donetsk (N=592) GCA Luhansk (N=166) GCA Total (N=758) NGCA (N=418) Resident of household currently working, n (%) 155 (26.2) 34 (20.5) 189 (24.9) 72 (17.2) Total amount of household income N=529 (UAH) Mean (SD) Median (IQR) Total household income per capita (UAH) N=140 (UAH) N=669 (UAH) 3090.7 (1768.8) 2661.9 (1216.5) 3000.8 (1677.5) 2723 (1500-4000) 2500 (1470-3400) 2650 (1500-3813) N=339 2713.5 (2049.2) UAH 7326.5 (5532.9) RUB* 2222 (1185-3498) UAH 6000 (3200-9444) RUB* Mean (SD) Median (IQR) 1663.6 (734.1) 1530.6 (565.3) 1635.7 (704.2) 1450 (1250-2000) 1325 (1210-1770) 1400 (1250-1953) 1474.8 (1087.6) UAH 3982.0 (2936.5) RUB* 1111 (852-1675) 3000 (2300-4522) RUB* *Exchange Rate 2.7:1

Household income per capita in $/day Socioeconomic Characteristics Household income per capita ($/day) GCA Donetsk (N=528) n (%) GCA Luhansk (N=140) n (%) GCA Total (N=668) n (%) NGCA Total (N=339) n (%) <$2/day $2-$3/day $3-$4/day >$4/day 280 (53.0) 86 (61.4) 366 (54.8) 228 (67.3) 162 (30.7) 37 (26.4) 199 (29.8) 69 (20.4) 57 (10.8) 15 (10.7) 72 (10.8) 16 (4.7) 29 (5.5) 2 (1.4) 31 (4.6) 26 (7.7)

IDP Status GCA Total (N=758) NGCA Total (N=418) Displaced due to conflict (n, %) 13 (1.7) 8 (1.9) Permanent residence left from (n, %) N=13 N=8 Donetsk oblast 8 (61.5) 8 (100) Luhansk oblast 2 (15.4) 0 (0) Other/Don t know 3 (23.1) 0 (0) Length of displacement, months Mean (SD) 16.2 (5.6) 15 (4.6) Median (IQR) 19 (12-19) 14 (12-19)

Assistance Donetsk Luhansk Registered to receive additional assistance from the state, humanitarian or volunteer organizations GCA Total NGCA n/n (%) n/n (%) n/n (%) n/n (%) All respondents 33/592 (5.6) 43/166 (25.9) 76/758 (10.0) 359/418 (85.9) IDPs 4/11 (36.4) 2/2 (100) 6/13 (46.2) 4/8 (50.0) Received humanitarian assistance in the last 3 months, all respondents N=592 n (%) N=166 n (%) N=758 n (%) N=418 n (%) Any kind of assistance 17 (2.9) 32 (19.3) 49 (6.5) 347 (83.0) Cash vouchers/coupons 2 (0.3) 1 (0.6) 3 (0.4) 1 (0.2) Food assistance 12 (2.0) 30 (18.1) 42 (5.5) 347 (83.0) Non-food assistance 6 (1.0) 3 (1.8) 9 (1.2) 4 (1.0) Transportation 0 (0) 0 (0) 0 (0) 1 (0.2)

Organizations Providing NGCA with Food Assistance (N=347) n % Akhmetov Foundation Red Cross Russian Government Church Other 340 98.0 7 2.0 6 1.7 1 0.3 3 0.9

Health and Healthcare Seeking

Percentage Prevalence of Chronic Disease 100 90 80 70 60 50 40 30 20 10 0 Any Chronic Disease Hypertension Diabetes Cardiovascular Chronic Lung Chronic Disease GCA NGCA

Percentage Percentage Prevalence of Chronic Disease by Sex GCA NGCA 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 Chronic Disease Chronic Disease Men Women Men Women

Percentage Percentage Prevalence of Chronic Disease by Age 100 90 80 70 60 50 40 30 20 10 0 GCA 100 90 80 70 60 50 40 30 20 10 0 NGCA Chronic Disease 60-70 Years >70 Years Chronic Disease 60-70 Years >70 Years

GCA Prevalence of Chronic Disease by Age and Sex 60-70 Years >70 Years Total Men (N=153) Women (N=218) Men (N=113) Women (N=274) Men (N=266) Women (N=492) Prevalence of chronic diseases Any chronic condition Hypertension Diabetes Cardiovascular disease Chronic lung disease 83 (54.3) 161 (73.9) 65 (57.5) 205 (74.8) 148 (55.6) 366 (74.4) 57 (37.3) 127 (58.3) 43 (38.1) 161 (58.8) 100 (37.6) 288 (58.5) 11 (7.2) 20 (9.2) 5 (4.4) 33 (12.0) 16 (6.0) 53 (10.8) 51 (33.3) 115 (52.8) 49 (43.4) 158 (57.7) 100 (37.6) 273 (55.5) 13 (8.5) 20 (9.2) 14 (12.4) 13 (4.7) 27 (10.2) 33 (6.7)

NGCA Prevalence of Chronic Disease by Age and Sex 60-70 Years >70 Years Total Men (N=69) Women (N=112) Men (N=71) Women (N=274) Men (N=140) Women (N=278) Prevalence of chronic diseases Any chronic condition Hypertension Diabetes Cardiovascular disease Chronic lung disease 39 (56.5) 85 (75.9) 48 (67.6) 137 (82.5) 87 (62.1) 222 (79.9) 24 (34.8) 71 (63.4) 34 (47.9) 114 (68.7) 58 (41.4) 185 (66.6) 5 (7.3) 11 (9.8) 8 (11.3) 15 (9.0) 13 (9.3) 26 (9.4) 23 (33.3) 63 (56.3) 39 (54.9) 114 (68.7) 62 (44.3) 177 (63.7) 6 (8.7) 5 (4.5) 5 (7.0) 10 (6.0) 11 (7.9) 15 (5.4)

Use of Medications Donetsk N=592 Luhansk N=166 GCA Total N=758 NGCA Total N=418 Regular use of medications n/n (%) n/n (%) n/n (%) n/n (%) Any chronic conditions 287/392 (73.2) 118/122 (96.7) 405/514 (78.8) 206/309 (66.7) Hypertension 219/292 (75.0) 93/96 (96.9) 312/388 (80.4) 166/238 (69.8) Diabetes 38/55 (69.1) 13/14 (92.9) 51/69 (73.9) 25/37 (67.6) Cardiovascular disease 180/266 (67.7 92/107 (86.0) 272/373 (72.9) 138/221 (62.4) Chronic lung disease 21/39 (53.9) 11/21 (52.4) 32/60 (53.3) 5/16 (31.3) Primary Reason for not taking medications regularly, any condition N=151 n (%) N=25 n (%) N=176 n (%) N=142 n (%) Not prescribed to take regularly 32 (21.2) 5 (20.0) 37 (21.0) 29 (20.4) Can t access pharmacy 0 (0) 1 (4.0) 1 (0.6) 1 (0.7) Availability of medication at pharmacy 1 (0.7) 0 (0) 1 (0.6) 0 (0) Cost of medication 62 (41.1) 6 (24.0) 68 (38.6) 85 (59.9) Other 62 (41.1) 15 (60.0) 77 (43.8) 37 (26.1) Unknown 2 (1.3) 0 (0) 2 (1.1) 0 (0)

Using medications regularly for all conditions; n/n (%) Not using medications for any condition because too expensive; n/n (%) Not using medications for any condition for other reasons; n/n (%) Household income per capita ($/day) <$2/day $2-$3/day $3-$4/day >$4/day Living Situation GCA NGCA GCA NGCA GCA NGCA 162/252 (64.3) 83/166 (50.0) 41/252 (16.3) 51/166 (30.7) 49/252 (19.4) 32/166 (19.3) 99/139 (71.2) 33/51 (64.7) 13/139 (9.4) 7/51 (13.7) 27/139 (19.4) 11/51 (21.6) 28/45 (62.2) 5/10 (50.0) 5/45 (11.1) 4/10 (40.0) 12/45 (26.7) 1/10 (10.0) 12/19 (63.2) 11/20 (55.0) 2/19 (10.5) 5/20 (25.0) 5/19 (26.3) 4/20 (20.0) Living alone 107/170 (62.9) 43/97 (44.3) 26/170 (38.2) 36/97 (37.1) 37/170 (34.3) 18/97 (18.6) Living only with another person(s) over 60 149/207 (72.0) 72/122 (59.0) 18/207 (8.7) 23/122 (18.9) 40/207 (19.3) 27/122 (22.1) Living with people under 60 82/137 (59.9) 52/90 (57.8) 24/137 (17.5) 26/90 (28.9) 31/137 (22.6) 12/90 (13.3)

Health Care Seeking Donetsk N=592 Luhansk N=166 GCA Total N=758 NGCA N=418 Acute respiratory disease two week prevalence n (%) n (%) n (%) n (%) 129 (21.8) 30 (18.1) 159 (21.0) 55 (13.1) Among those with acute respiratory disease, sought care at a health clinic n/n (%) n/n (%) n/n (%) n/n (%) All respondents 29/129 (16.5) Respondents with one or more chronic conditions Primary Reason for not seeking care, acute respiratory 22/94 (23.4) 13/30 (43.3) 13/26 (34.6) 42/159 (26.4) 35/120 (29.2) 11/55 (20.0) 9/44 (20.5) N=100 N=17 N=117 N=44 Can t access the clinic 4 (4.0) 2 (11.8) 6 (5.1) 1 (2.3) Cost of clinic visit 11 (11.0) 1 (5.9) 12 (10.3) 6 (13.6) Didn t feel it was necessary 29 (29.0) 9 (52.9) 38 (32.5) 13 (29.6) Other/Don t know 56 (56.0) 5 (29.4) 61 (52.1) 24 (54.5)

Nutrition

Percentage Types of Foods Eaten Yesterday 100 80 60 40 20 0 Type of Food GCA NGCA

Number of food groups consumed yesterday Dietary Diversity GCA (N=758) NGCA (N=418) Mean (SD) 4.5 (1.2) 4.5 (1.3) Median (IQR) 5 (4-5) 5 (4-5) Consumption of ironrich foods yesterday, n (%) Consumption of Vitamin A rich foods yesterday, n (%) 596 (78.6) 298 (71.3) 699 (92.2) 396 (94.7)

Days Ate Food in Past Week GCA (N=758) NGCA (N=418) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Cereals White/yellow potatoes Vegetables Fruits Eggs Meat/fish Milk/milk products Peas/beans 6.8 (0.9) 7 (7-7) 6.9 (0.6) 7 (7-7) 5.9 (1.7) 7 (5-7) 6.1 (1.5) 7 (5-7) 5.8 (1.7) 7 (5-7) 5.8 (1.5) 7 (5-7) 2.1 (2.3) 2 (0-3) 1.7 (2.1) 1 (0-3) 1.7 (1.7) 1 (0-3) 1.9 (1.7) 2 (1-3) 3.4 (2.4) 3 (2-6) 3.2 (2.3) 3 (1-5) 2.8 (2.6) 2 (0-5) 2.3 (2.2) 2 (0-3) 1.1 (1.7) 0 (0-2) 1.3 (1.5) 1 (0-2)

Number of Days Mean Number of Days Foods Eaten in Past Week 7 6 5 4 3 2 1 0 Cereals White/yellow potatoes Vegetables Fruits Eggs Meat/fish Milk/milk products Type of Food Peas/beans GCA NGCA

Dietary Diversity by Household Income per capita in $/Day Number of food groups consumed yesterday, mean (SD) GCA (N=366) Household income per capita in $/day <$2/day $2-$3/day $3-$4/day >$4/day Total NGCA GCA NGCA GCA NGCA GCA NGCA GCA (N=228) (N=199) (N=69) (N=72) (N=16) (N=31) (N=26) (N=668) NGCA (N=339) 4.2 (1.3) 4.3 (1.2) 4.7 (1.1) 4.6 (1.1) 4.8 (1.1) 4.5 (1.2) 5.4 (1.0) 5.6 (1.0) 4.5 (1.2) 4.5 (1.2) Consumption of ironrich foods yesterday, n (%) Consumption of Vitamin A rich foods yesterday, n (%) 251 (68.6) 327 (89.3) 150 (65.8) 217 (95.2) 176 (88.4) 190 (95.5) 69 (79.7) 64 (92.3) 61 (84.7) 70 (97.2) 11 (68.8) 15 (93.4) 30 (96.8) 30 (96.8) 25 (96.2) 26 (100) 518 (77.5) 617 (92.4) 241 (71.1) 322 (95.0) Days eaten in past week, mean (SD) Fruits 1.8 (2.4) 1.6 (2.4) 2.9 (2.7) 1.8 (2.1) 2.5 (2.4) 2.1 (2.3) 3.7 (2.6) 3.5 (2.7) 2.3 (2.5) 1.8 (2.5) Meat 3.1 (2.4) 3.1 (2.5) 3.9 (2.3) 3.2 (2.1) 3.8 (2.6) 3.7 (2.3) 5.5 (2.1) 5.0 (2.0) 3.5 (2.4) 3.3 (2.4) Milk 2.4 (2.6) 1.8 (1.9) 3.6 (2.7) 2.9(2.5) 3.1 (2.2) 1.7 (1.8) 3.1 (2.5) 3.5 (2.3) 2.9 (2.6) 2.1 (2.1)

Food Security GCA (N=758) NGCA (N=418) Food insecurity in n (%) (95%CI) n (%) (95%CI) past 30 days Little or no hunger 740 (97.6) 95.1-98.9 416 (99.5) 98.0-99.9 Moderate hunger 16 (2.1) 1.0-4.6 2 (0.5) 0.1-2.0 Severe hunger 2 (0.3) 0.0-1.1 0 N/A Mean (SD) Median (IQR) Mean (SD) Median (IQR) Number of meals eaten yesterday 3.4 (1.0) 3 (3-4) 3.4 (0.9) 3 (3-4)

Moderate or Severe Hunger GCA (N=18) NGCA (N=2) n % n % Income per capita ($/day) N=14 N=2 <$2/day 13 92.9 1 50.0 $2-$3/day 1 7.1 1 50.0 $3-$4/day 0 0 0 0 >$4/day 0 0 0 0 Living Situation N=18 N=2 Living alone 7 38.9 1 50.0 Living only with another person(s) over 8 44.4 0 0 60 Living with people under 60 3 16.7 1 50.0 Number of food groups consumed 3.4 (1.5) 3 (0) yesterday 1, mean (SD) Days eaten in past week, mean (SD) Fruits 1.7 (2.9) 0 Meat 1 (1.1) 4.5 (4.5) Milk 0.8 (1.4) 0 BMI, mean (SD) 28.5 (4.9) 39.1 (1.2)

Dependency/Activities of Daily Living

Dependency GCA (N=758) NGCA (N=418) Requires help with activities n (%) 95%CI n (%) 95%CI Bathing 111 (14.6) 12.0-17.8 85 (20.3) 15.8-25.7 Getting dressed 62 (8.2) 6.6-10.2 57 (13.6) 11.0-16.8 Going to the toilet 46 (6.1) 4.6-7.9 51 (12.2) 9.5-15.5 Moving from bed to chair 44 (5.8) 4.3-7.9 46 (11.0) 8.0-15.0 Leak urine or feces 139 (18.3) 14.4-23.0 98 (23.4) 19.1-28.4 Eating 20 (2.6) 1.7-4.1 30 (7.2) 4.6-11.1 Dependency Independent 664 (87.6) 84.6-90.1 345 (82.7) 79.1-85.8 Moderate dependency 48 (6.3) 4.4-9.0 25 (6.0) 4.0-8.9 Severe dependency 46 (6.1) 4.6-8.0 47 (11.3) 8.6-14.6

Dependency Someone to help if person needs help with 1 or more activities No Yes, but not every day Yes, every day, part of the time Yes, every day, all of the time GCA (N=186) NGCA (N=130) n (%) 95%CI n (%) 95%CI 31 (16.7) 11.5-23.6 32 (24.6) 15.6-36.6 55 (29.6) 24.3-35.4 16 (12.3) 7.9-18.6 18 (9.7) 6.0-15.3 10 (7.7) 3.6-15.6 82 (44.1) 37.2-51.2 71 (54.6) 43.4-65.4

Percentage Prevalence of Dependency by Age 30 25 20 15 Severe dependency Moderate dependency 10 5 0 60-70 Years >70 Years 60-70 Years >70 Years GCA NGCA

Percentage Prevalence of Dependency by Sex 20 18 16 14 12 10 8 Severe dependency Moderate dependency 6 4 2 0 Male Female Male Female GCA NGCA

Psychological Distress

Psychological Distress GCA (N=711) NGCA (N=396) n (%) 95%CI n (%) 95%CI Felt most or all of the time in past 30 days Nervous 286 (40.2) 35.3-45.4 162 (40.9) 34.1-48.1 Hopeless 170 (23.9) 20.4-27.9 137 (34.6) 28.5-41.2 Restless/Fidgety 252 (35.4) 29.2-42.2 178 (44.9) 37.6-52.6 Depressed 233 (32.8) 27.0-39.2 139 (35.1) 29.8-40.8 Everything is an effort 245 (34.5) 28.7-40.7 158 (39.9) 33.3-46.8 Worthless 151 (21.2) 17.1-26.0 89 (22.5) 18.0-27.6 Suffers from serious psychological distress 239 (33.6) 28.0-39.7 168 (42.5) 36.1-49.2 Mean (SD) Median (IQR) Mean (SD) Median (IQR) Kessler K6 Score 9.7 (6.7) 8 (4-15) 11.4 (6.8) 12 (6-16)

Psychological Distress GCA NGCA Income per capita ($/day) n/n % n/n % <$2/day 130/344 37.8 92/216 42.6 $2-$3/day 56/185 30.3 29/67 43.3 $3-$4/day 24/72 33.3 8/16 50.0 >$4/day 6/30 20.0 10/25 40.0 Living Situation Lives alone 84/234 35.9 63/123 51.2 Lives with people >60 only 85/289 29.4 60/163 36.8 Lives with people <60 70/188 37.2 45/109 41.3 Dependency Independent 191/642 29.8 125/341 36.7 Moderately Dependent 27/41 65.9 15/22 68.2 Severely Dependent 21/28 75.0 28/32 87.5 BMI, mean (SD) (N=158) 29.0 (6.2) 30.5 (6.8)

Anthropometry

BMI (kg/m 2 ) GCA (N=488) Total NGCA (N=305) n (%) 95%CI n (%) 95%CI Underweight (<18.5) 7 (1.4) 0.6-3.2 2 (0.7) 0.0-5.1 Normal (18.5-24.99) 123 (25.2) 20.9-30.0 55 (18.0) 14.6-22.1 Overweight (25-162 (33.2) 29.5-37.2 107 (35.1) 30.0-52.4 29.99) Obese (>30) 196 (40.2) 35.8-44.7 141 (46.2) 40.1-52.4 Mean (SD) 29.1 (5.8) (95%CI) (28.5-29.6) Median (IQR) 28.8 (24.8-33.0) 29.8 (6.0) (29.2-30.5) 29.4 (26.0-33.1)

BMI (kg/m 2 ) GCA (N=169) Male NGCA (N=88) n (%) 95%CI n (%) 95%CI Underweight (<18.5) 1 (0.6) 0.0-4.5 1 (1.1) 0.2-8.2 Normal (18.5-24.99) 58 (34.3) 27.8-41.5 22 (25.0) 19.0-32.2 Overweight (25-67 (39.7) 33.1-46.6 33 (37.5) 28.4-47.6 29.99) Obese (>30) 43 (25.4) 19.4-32.6 32 (36.4) 27.4-46.4 Mean (SD) 27.2 (4.7) (95%CI) (26.5-27.9) Median (IQR) 26.7 (24.0-30.1) 38.0 (5.2) (27.0-29.1) 27.8 (24.9-31.1)

BMI (kg/m 2 ) GCA (N=319) Female NGCA (N=217) n (%) 95%CI n (%) 95%CI Underweight (<18.5) 6 (1.9) 0.8-4.6 1 (0.5) 0.0-3.7 Normal (18.5-24.99) 65 (20.4) 15.2-26.7 33 (15.2) 10.9-20.8 Overweight (25-95 (29.8) 25.1-35.0 74 (34.1) 27.2-41.8 29.99) Obese (>30) 153 (47.9) 42.2-53.7 109 (50.2) 42.2-58.2 Mean (SD) (95%CI) Median (IQR) 29.8 (25.6-33.7) 30.0 (6.0) (29.3-30.8) 30.6 (6.2) (29.6-31.5) 30.1 (26.8-33.9)

Conclusions and Recommendations

Discussion-Demographics/Income In both GCA and NGCA about 2/3 of the sample were female and 1/3 of the sample were males Life expectancy 66 years for males vs. 76 years for females About half of the sample was 60-70 years and half was >70 years Slightly larger proportion of people >70 years in NGCA areas (57% vs. 51%) Many people living in poverty 55% of people in GCA and 67% of people in NGCA living on <$2/day 85% of people in GCA and 88% of people in NGCA living on <$3/day Only 22% of people in NGCA who are registered to receive Ukrainian pension received it in the month preceding the survey, however almost all received DNR pension About 1/3 of the population (31% GCA and 29% NGCA) live alone

Discussion-Assistance Few households (about 10%) in GCA are registered to receive humanitarian assistance 5.6% of individuals in Donetsk, 25.9% in Luhansk Only 6.5% of households have received assistance in 3 months preceding survey Majority of households (about 86%) in NGCA are registered to receive humanitarian assistance 83% of households have received assistance in 3 months preceding survey All households (83%) that have received assistance received food assistance 98% received food assistance from Akhmetov Foundation Only 1 household received cash or voucher assistance, 4 households received nonfood assistance and 1 household received transportation assistance Low proportion of IDPs in both samples (<2% of the sample in GCA and NGCA)

Discussion-Nutrition Most common foods eaten are cereals/grains and white/yellow potatoes, and vegetables Mean number of food groups eaten in day preceding survey was 4.5 in GCA and NGCA 79% of people in GCA and 71% of people in NGCA consumed iron-rich foods in the day preceding the survey People living on <$2/day ate less fruits, milk, and meat About 2% of people in GCA and 0.5% of people in NGCA experienced moderate or severe hunger in the 30 days preceding the survey 93% of these people in GCA live on <$2/day 100% of people in both areas live on <$3/day Only 2 people in NGCA. One person had received food assistance.

Discussion-Health Around 70% of respondents have some type of chronic disease in both areas Women have higher prevalence of hypertension and cardiovascular disease About 79% of respondents in GCA and 67% in NGCA with a chronic condition take medications regularly for at least one condition Out of those who don t take medications for at least one chronic condition, about 40% in GCA and 60% in NGCA reported this was due to cost Most people do not have problems accessing healthcare 21% in GCA and 13% in NGCA reported an acute illness 26% in GCA and 20% in NGCA of those of those with an acute illness sought care Only 15% listed cost of care or access to the clinic as reasons for not seeking care in both areas

Discussion-Dependency About 12% of the sample in GCA and 17% of sample in NGCA had moderate or severe dependency People of older ages have a higher prevalence of dependency than those of younger ages In GCA about 46% of people and in NGCA about 37% of people who may need help with daily activities do not receive any help or do not receive help every day

Discussion-Psychological Distress 33% of people in GCA and 43% of people in NGCA reported suffering from severe psychological distress 70% of people in GCA and 80% of people in NGCA with moderate or severe dependency reported suffering from severe psychological distress

Discussion-Nutritional Status Undernutrition is not a major problem in this population Only 7 individuals in GCA (1.7%) and 2 individuals in NGCA (0.7%) had a BMI <18.5 kg/m 2 Only 25% of individuals in GCA and 18% of individuals in NGCA were in the normal BMI range 34% of men in GCA and 35% of men in NGCA had a normal BMI; compared to 20% of women in GCA and 15% of women in NGCA 75% of people in GCA and 81% of people in NGCA are overweight or obese Obesity is a major problem in this older population About 40% of people in GCA and 46% of people in NGCA are considered obese About 50% of women in both areas are considered obese

Recommendations 1. Provide psychosocial support services to all older individuals living in both areas if needed 2. Identify the people who are suffering from extreme hunger for targeted assistance 93% of those with moderate or severe hunger in GCA live on <$2/day 100% of those with moderate or severe hunger in both areas live on <$3/day 3. Modify food and voucher assistance in both areas to encourage healthier diets Distribution of food vouchers for people to buy fresh fruits and vegetables, meat, milk products, etc. 4. Engage in promotional activities on health and healthy diets in both areas Specifically targeting older women

Recommendations 5. Identify people who are not taking medications for chronic diseases regularly for targeted assistance 6. Identify and provide assistance to those who are moderately and severely dependent without everyday help 7. Do not limit humanitarian assistance in GCA areas to only internally displaced persons 8. Consider including cash/voucher assistance for purchasing medications for chronic diseases as part of humanitarian aid

Questions

MUAC (mm) GCA Total N=408 NGCA Total N=303 n (%) 95%CI n (%) 95%CI < 185 0 0 0 0 185-210 1 (0.3) 0.0-1.8 1 (0.3) 0.0-2.6 > 210 407 (99.8) 98.2-99.9 302 (99.7) 97.5-99.9 Mean (95%CI) 313.6 (309.2-318.0) Median (IQR) 310 (286-344) 307.0 (302.7-311.4) 304 (282-329)

MUAC (mm) GCA Male N=143 GCA Male N=88 n (%) 95%CI n (%) 95%CI < 185 0 0 0 0 185-210 0 0 0 0 > 210 143 100 88 100 Mean (95%CI) 305.4 (298.5-312.4) Median (IQR) 304 (286-328) 300.3 (293.5-307.1) 299 (281-321)

MUAC (mm) GCA Female N=265 NGCA Female N=215 n (%) 95%CI n (%) 95%CI < 185 0 0 0 0 185-210 1 (0.4) 0.0-2.8 1 (0.5) (0.0-3.5) > 210 264 (99.6) 97.2-99.9 214 (99.5) (96.5-99.9) Mean (95%CI) 317.9 (312.6-323.3) Median (IQR) 314 (288-350) 309.7 (303.7-315.8) 308 (282-332)

Response Rate Donetsk Luhansk GCA Total NGCA Total Households N=1,914 N=611 N=2,525 N=1,324 Absent 809 (42.3%) 355 (58.1%) 1164 (46.1%) 701 (52.9%) Refused 47 (2.5%) 62 (10.2%) 109 (4.3%) 14 (1.1%) No one over 60 523 (27.3%) 58 (9.5%) 581 (23.0%) 299 (22.6%) Consented 535 (28.0%) 136 (22.3%) 671 (26.6%) 310 (23.4%) Total Respondents over 60 in Consenting Households N=690 N=196 N=886 N=423 Absent 47 (6.8%) 5 (2.6%) 52 (5.9%) 4 (0.9%) Refused 57 (8.3%) 23 (11.7%) 80 (9.0%) 1 (0.2%) Interviewed 592 (85.8%) 166 (84.7%) 758 (85.6%) 418 (98.8%) Measured MUAC 352 (51.0%) 56 (28.6%) 408 (46.0%) 303 (71.6%) Measured Weight and Demispan 388 (56.2%) 100 (51.0%) 488 (55.1%) 305 (72.1%)