aweil county is located in northern bahr el ghazal state of

ACF-USA Nutrition Survey, Aweil East County, Southern Sudan, June 2010 1

Anthropometric and Retrospective Mortality Survey

Aweil East County,

Northern Bahr el Ghazal State Southern Sudan

June 2010


Acknowledgement

Action Against Hunger would like to express its deep gratitude for the support given during the Anthropometric and retrospective Mortality Survey 2010 in Aweil East County.

We would like to thank ACF-USA staff, particularly the support team without which the survey wouldn’t have been possible.

Furthermore, we would like to thank the survey teams, for their endurance, dedication and team spirit which enabled survey to reach the end successfully. Thanks also to all drivers who ensured timely and safe movement of the survey teams.

A special thanks to the SSRRC of Aweil East County for providing vital information on the geographical areas.

We finally like to say many thanks to the individual families who pleasantly allowed the survey teams measure their children and provided the survey team with the information required to make it a success.


Table of Contents

Executive Summary ....................................................................................................................................................... 51. Introduction ......................................................................................................................................................... 72. Objectives of the survey ...................................................................................................................................... 83. Survey Methodology ............................................................................................................................................ 8

3.1 Type of Survey ............................................................................................................................................. 83.2 Sampling methodology ................................................................................................................................ 83.3 Training and Data Collection ........................................................................................................................ 93.4 Anthropometric survey .............................................................................................................................. 103.5 Mortality survey ......................................................................................................................................... 103.6 Food Security and Livelihood, Water and Sanitation ................................................................................. 103.7 Data Quality Control Assurance ................................................................................................................. 113.8 Field Exercise .............................................................................................................................................. 113.9 Data Entry and Analysis ............................................................................................................................. 11

4. Guidelines and Formulae used .......................................................................................................................... 114.1 Acute Malnutrition ..................................................................................................................................... 114.2 Mortality .................................................................................................................................................... 12

5. Survey Constraints ............................................................................................................................................. 126. Results: Anthropometry and Retrospective Mortality ....................................................................................... 12

6.1 Anthropometric analysis (WHO Standards, 2006) ..................................................................................... 134.2 Vaccination Coverage ................................................................................................................................ 144.4. Mortality .......................................................................................................................................................... 143.5 Child Morbidity .......................................................................................................................................... 15

7. Results on Qualitative data ................................................................................................................................ 157.1 Socio- demographic characteristics of the respondents ............................................................................ 157.2 Food Security and Livelihoods ................................................................................................................... 167.3 Health ......................................................................................................................................................... 177.4 Water and Sanitation ................................................................................................................................. 197.5 Maternal and Child Care Practices ............................................................................................................. 20

8. Discussion .......................................................................................................................................................... 219. Conclusion and Recommendations ................................................................................................................... 2210. Annexes .......................................................................................................................................................... 23


Abbreviations

ACF-USA Action Contre la Faim- USA (Action Against Hunger-USA) BSFP Blanket Supplementary Feeding Program CMR Crude Mortality Rate ENA Emergency Nutrition Assessment EPI Expanded Program on Immunization FGD Focus Group Discussion GAM Global Acute Malnutrition GFD General Food Distribution IDP Internally Displaced People INGO International Non Governmental Organization IOM International Organization for Migration MAM Moderate Acute Malnutrition MOH Ministry of Health MUAC Mid Upper Arm Circumference NCHS National Center for Health Statistic OTP Outpatient Therapeutic Program PHCC Primary Health Care Center PHCU Primary Health Care Unit SAM Severe Acute Malnutrition SFP Supplementary Feeding Program SMART Standardized Monitoring and Assessment of Relief and Transitions SSRRC Southern Sudan Relief and Rehabilitation Commission TFP Therapeutic Feeding Program UNICEF United Nations Children’s Fund U5MR Under Five Mortality Rate WFH Weight for Height WFP World Food Program WHO World Health Organization WVI World Vision International


Executive Summary

Aweil County is located in Northern Bahr el Ghazal state of Southern Sudan. Aweil East County is one of the five counties that make up the state of Northern Bahr el Ghazal in Southern Sudan. Its borders include Gogrial West County to the east, Southern Kordofan to the north-east, Southern Darfur to the north, and Aweil South County to the south. The County consists of the seven administrative payams of Malualbai, Baac, Madhol, Mangartong, Mangok, Yargot and Wunlang running from north to south. The current population of Aweil East County is estimated at 180,948.

According to April and May 2009 National Baseline Household Survey, the incidence of poverty (calculated at an income of 72.9 SDG per person per month) in Southern Sudan range from one fourth in Upper Nile to three fourths in Northern Bahr el Ghazal. This makes Northern Bahr el Ghazal is one of the poorest and most food insecure state in Southern Sudan. Aweil East/Northern Bahr el Ghazal is traditionally an agro-pastoralist region with cattle ownership being the primary determinant of wealth and status.

The topography of Aweil East makes it prone to flooding during rainy seasons. The County lies in the western flood plain livelihood zone which is prone to seasonal flooding; especially in August and September. The flat terrain and sandy and clay soils contribute to this flooding pattern. The fact that sanitation and waste disposal is very poor in the region and especially in Aweil East, the population is always susceptible to Acute Watery Diarrhea.

Poverty, food insecurity, insufficient heath services and high child morbidity, poor infant and child feeding practices, low immunization coverage and high vulnerability to Acute Watery Diarrhea aggravate each other subjecting Aweil East to a vicious cycle of malnutrition.

An anthropometric and retrospective mortality survey was conducted between 13th and 25th

The sampling frame included all the 7 payams of Aweil East County. The survey used SMART methodology, 40 clustered were sampled in the survey that included 475 households for anthropometric data and 598 households for mortality data. The results are summarized by Table 1 below.

June 2010. The survey was aimed at assessing the prevalence of acute malnutrition in children aged 6-59 months, estimating the crude and under five mortality rate, estimating the coverage of measles among targeted children and identifying some of the underlying causes/factors contributing to malnutrition in Aweil East.

Table 1: Results Summary, Aweil East, June 2010

INDEX INDICATOR RESULTS1

NCHS (1977)

(n=649)

Z- scores

Global Acute Malnutrition W/H< -2 z and/or oedema

23.1% [17.9% - 28.3%]

Severe Acute Malnutrition W/H < -3 z and/or oedema

1.5% [0.6% - 2.5%]

% Median

Global Acute Malnutrition W/H < 80% and/or oedema

13.9% [9.6% - 18.2%]

Severe Acute Malnutrition W/H < 70% and/or oedema

0.0 % [0.0% - 0.2%]

WHO (2006) (n=649)

Z-scores

Global Acute Malnutrition W/H< -2 z and/or oedema

23.1% [17.9% - 28.3%]

Severe Acute Malnutrition W/H < -3 z and/or oedema

3.2% [1.6% - 4.8%]

1 Results in brackets are expressed at 95% Confidence Interval


MUAC (n=645)

Height >65 cm

Global Acute Malnutrition (<125mm)

9.0% [6.8% -11.2%]

Severe Acute Malnutrition (<115mm)

1.9% [0.8% - 2.9%]

Mortality

Total crude retrospective mortality (last 91 days) /10,000/day

0.39 [0.18-0.82]

Under five crude retrospective mortality (last 91 days) /10,000/day

0.16 [0.02-1.17]

As shown by the findings of this survey, it is demonstrably rear that the population of Aweil East is in need of support and malnutrition is still at emergency level. A small improvement was seen when the result of this survey are compared to a similar survey that was done at the same time in the previous year. It is believed that effort of many agencies in the County working on health, food aid, food security and livelihoods and nutrition are privy to this progress. However, measured against the complexity of food security, health and nutrition challenges in the county, a double measure of effort is required to have meaningful impact on the population.

Based on the findings of this survey, the following are recommended:

> Increased coverage of TFP.

> Promotion of the importance of immunization of children. This can be achieved through health education sessions at OTP, PHCU, PHCC and community level.

> Among other health interventions, provision of bed nets and promotion of their use to reduce the incidence of malaria is highly recommended. Malaria is persistently prevalent among children under the age of five years

> The community in this location is used to continuous food distribution from agencies like WFP and partners. While this is done to save people from large-scale starvation, it is recommended that more focus be given to developing the capacity of the community to increase farming activities (supporting increased household food production) that will have a remarkable contribution to food security of the population and hence reduced prevalence of under-nutrition, especially among the <5 children, pregnant and lactating mothers of Aweil East.

> Provision of seeds and tools, including agricultural training on improved farming techniques and plant protection as well as diversification of income sources through various income generating activities is highly recommended

> Increase the number of adequate and safe water schemes through construction, rehabilitation and training on operation and maintenance, especially in highlands and lowlands which are lagging behind as all the boreholes are concentrated in the midlands only.

> Recent effort in supporting the community in latrine construction and use at the household level and distribution of slabs for latrines has seen increased interest by some community members. This needs to continue in tandem with hygiene community hygiene promotion.


1. Introduction

Aweil East County is one of the five counties that make up the state of Northern Bahr el Ghazal in Southern Sudan. The county consists of the seven administrative Payams of Malualbaai, Baac, Madhol, Mangartong, Mangok, Yargot and Wunlang running from north to south. Population figures for the total population of the county are estimated at 180,948.

Northern Bahr el Ghazal is traditionally an agro-pastoralist region, and cattle ownership remains the primary determinant of wealth and status. Livestock are sold for cash, traded for other products, form marriage dowries and act as a source of milk and meat.

However, given that up to seventy percent of the population does not own any cattle, and over forty percent do not own any livestock at all, the majority of the population is reliant on a more diversified livelihoods base. Agriculture is commonly undertaken during the annual cropping season, although generally at a subsistence level that covers barely 3-6 months worth of the household’s staple food requirements. Very poor and poor households (those with no or few livestock) undertake a range of seasonal and year-round livelihoods activities including: grass and firewood collection; charcoal burning; casual labor; fishing; petty trade; and wild food collection as coping mechanisms. These households tend to be heavily reliant on cash income, wild food collection and daily purchasing to meet their needs as they lack the asset base to make long term investments.

The population of Aweil East County has seen a high influx of returnees in the previous year, with an estimated 24% of all returnees in Northern Bahr El Ghazal State having settled in Aweil East. From March to May 2009 Northern Bahr el Ghazal State recorded 18,335 spontaneous returnees into the state. Additionally, an estimated 56% of Northern Bahr El Ghazal’s Internally Displaced People (IDP) population is currently settled in Aweil East. However, there had been no more report of returnees as per 2010 according to the SSRRC office in the County.

According to the 2009/2010 Annual Needs and Livelihood Assessment, about 4 million people in south Sudan were found to be food insecure due to last year drought which didn’t make the crops do well. Again Aweil East was said to be among the 4 Counties which were said to be having severe hunger. One of these counties was Aweil East County. In addition, though regular market assessments by ACF have shown that currently food prices are not very high for staple food items and the cost of livestock. The situation is still hard.

A rapid water and sanitation assessment in Aweil East County conducted in March 2009 by ACF showed that only 24% of the population has access to clean water. It also demonstrated that while some households show interest in having latrines, however they don’t have slabs for use on them; the sanitation coverage rate in Aweil East is almost negligible.

The community is currently facing a very serious hunger gap due to the fact that last year’s harvest was poor yielding as a result of concurrent drought, floods and crop pest infestations. This early onset of the hunger season and an increased reliance on market purchases adds particular pressures onto the most vulnerable households who lack livestock and other assets. The delayed rains this year are also hampering planting which will result in a shorter growing season in which to plant or re-plant seeds in hopes of obtaining good yields.

Aweil East County is a subject of chronic level of acute malnutrition, above the emergency threshold. The combination of food insecurity, lack of access to clean water and sanitation facilities, disease outbreaks, and poor child care practices and inadequate health facilities have a negative impact on the nutrition status of children under five years of age.

Nutrition and retrospective mortality surveys are undertaken annually in Aweil East County by ACF in order to estimate malnutrition and mortality rates in this county so as to give early warning to the stakeholders. There are several UN agencies, international NGOs (INGO), and Ministries operating in Aweil East to help with basic infrastructural needs such as health clinics and schools, and to assist the general population in livelihoods and food security, water and sanitation, health and nutrition needs. Table 2 below shows some of the key partners working in Aweil East.


Table 2: UN Agencies, NGOs and INGOS Operating in Aweil East County

NGO/UN Agency Activity IOM Returnee monitoring, food security, WASH WFP G FD, BSFP, Food for Training UNICEF Nutrition, education, child survival, WASH FAO Food Security and surveillance World Vision International Nutrition, food aid, emergency response Save the Children Alliance Education, child protection vocational training IRC Medical treatment and child survival programs AMURT International Food security, education and WASH Mercy Corps Food security, economic recovery and development, cash for work VSF SWISS Livestock surveillance, vaccination, outbreak reporting, and restocking TearFund Health Christian Solidarity International Health

2. Objectives of the survey

• To assess the prevalence of acute malnutrition in children aged 6-59 months • To estimate the crude and under five mortality rate • To estimate measles immunization coverage of children 9-59 months • To estimate crude mortality rate through a retrospective survey • To determine immediate, underlying and basic causes of malnutrition

3. Survey Methodology

3.1 Type of Survey

Standardized Monitoring and Assessment of Relief and Transitions (SMART) was employed to determine the sample size in the implementation of anthropometric and mortality survey. Children aged 6-59 months formed the target population or sampling frame for anthropometric part of the survey. In addition to the two survey tools, a qualitative questionnaire was administered in the households. Focus group discussion was done with the selected key informants from the community to support the findings.

3.2 Sampling methodology

Two stage cluster sampling methods were used for anthropometric and retrospective mortality surveys data collection. Those were segmentation and probability proportion to size.

Sample size for anthropometric and retrospective mortality surveys were calculated using ENA for SMART November 2008 version. The data that was entered in the software include estimated prevalence of malnutrition and mortality rate, desired precision, design effect, percentage of U5 children, average household size and recall period in days. The two sample sizes of anthropometric and mortality were increased by 10% and 5% respectively to take care of the non-responsive households or unforeseen circumstances.

First Stage


Table 3: Sample size calculation for anthropometric and retrospective mortality surveys

Data entered in ENA software Anthropometric

survey Retrospective

mortality survey Estimated prevalence 25 0.4 +-Desired precision 5 0.3 Design effect 2 2 Recall period in days 91 Percent of under five children 22.7 Percent of non responsive households 10 5 Sample size 576 3,752

Anthropometric survey; with the estimated prevalence of 25%, desired precision of 5%, design effect of 2 and, a 10% added to the sample size for non-responsive, a sample size of 576 children was arrived at for anthropometric survey. A total of 15 households were visited in one day per cluster. All children of 6-59 months found in all the 15 households per cluster were measured since the sampling units were households. At the end of the survey, 683 children were measured in 40 clustered villages.

Mortality survey; the sample size for mortality survey was 3,752 with an average size of 6 person per household (3,752/598). Mortality data was collected in 15 households per cluster to achieve the calculated sample size and the survey objectives. Probability proportion to size (PPS) together with segmentation was used to randomly select households/sampling units in the field. All villages in the County were included in the sampling frame as there were no inaccessible areas reported.

Segmentation was used depending on the size of the village. Villages with large sizes were segmented while the ones of small sizes were assessed completely .After drawing the list of the households with the help of village leaders, systematic random sampling (SRS) was used by calculating the sampling intervals to randomly select the households to be visited in the village. The sampling intervals differed depends on the size of the village.

Second stage

In all the selected households, every child of 6-59 months was included for the anthropometric survey. If there was more than one wife in the household and they cook differently, they were considered to be separate households but if they eat from the same cooking pot, then they were considered as single household. In the last household, all eligible children were measured no matter what number was required in each cluster. Households without <5 years old children were also included in the survey as they contribute to mortality survey even if they lack children for anthropometric survey.

Ages of the children were determined with the help of calendar of events, birth and immunization cards if available. However, many mothers were not able to produce those cards as it was claimed to have either lost or left in their previous village.

Mortality was administered in all the households selected and with adult person present.

Qualitative data was collected using a designed cross-sectional questionnaire. Unlike anthropometric and mortality surveys, the qualitative questionnaire was administered in every third household of the same cluster alongside anthropometric and mortality surveys. Formal and informal interviews, observation and structured questionnaires were used to obtain qualitative information so as to determine the immediate, underlying and basic causes of malnutrition within the surveyed Payams of the County.

3.3 Training and Data Collection

During this period, anthropometric, mortality and qualitative data was gathered under supervision. A training of 26 enumerators was undertaken and it was ensured that the enumerators were well versed with anthropometric measurements, survey methodology and interviewing skills. A lot of practical exercises were undertaken to ensure “hands on” experience on various survey procedures. Five teams made up of 1 supervisor, and 3 enumerators were formed. Standardization and pilot tests formed part of the training.


3.4 Anthropometric survey

The anthropometric questionnaire was administered to all eligible children till a target of 15 households per cluster was obtained. In instances where the village was assessed completely and the target number of households was not achieved, the teams moved to the next village which was not clustered and repeat all the selection methods to complete the day work. Apart from anthropometric measurements, other data collected include;

3.5 Mortality survey

Mortality survey data was collected from 15 households in each cluster whether there were eligible children for anthropometric survey. One ninety one days recall period was used to collect the data using the visit by the President to Aweil town in March as a reference occasion. Mortality Standard questionnaire was administered to the respondents to collect the data.

3.6 Food Security and Livelihood, Water and Sanitation

Food security and livelihoods, and water and sanitation data were collected from the same households that provided mortality data. This was meant to provide complementary information to that of Global Acute Malnutrition rates. Information was collected during the anthropometric survey using a pre-structured qualitative questionnaire.

Food security and livelihoods information included:

Main livelihood: Information was sought on what they consider to be their main livelihood(s) Main source of income: Information was sought on what they consider to be their main source(s) of income Current month’s food source: Information was sought on what is the household’s main food source(s) for the

current month Sufficiency of main food sources: Information was sought to determine if household thought their main

sources of food were sufficient Coping strategies: Information was sought on what the household does when it’s food stocks decline in order

to determine coping mechanisms Current food stock: Information was sought on how long their current food stock would last Food adequacy: Information was sought on what the household thought can be done to ensure enough food

for household consumption Crops cultivated: Information was sought on what crops were cultivated or will be cultivated this planting

season Feddans cultivated: Information was sought on how many feddans of land the household cultivated or

planned to cultivate this planting season Livestock owned: Information was sought on which type of livestock the household owned Fishing: Information was sought on whether the household was engaged in fishing, and why not if the

response was ‘no’.

Water and sanitation information included:

Current water source: Information was sought on what is the household’s current water source(s) Time to water source: Information was sought on how many minutes it took to go to the water source and

back. This was to determine the time it took to obtain water. Times per day collecting water: Information was sought on how many times a day water was collected Water collection container: Information was sought on what type of container was used to actually collect the

water in. Water storage container: Information was sought n what type of container was used to store the water once

it arrived at the household.


3.7 Data Quality Control Assurance

The use of an anthropometric standardization and cluster control sheet, thorough training of the 5 teams (each consisting of 1 supervisor, 1 enumerator and 2 measurers), and close supervision by the ACF Survey team manager was aimed at minimizing errors and increasing the quality of data collected.

The data collection exercise was undertaken under the general supervision of ACF-USA South Sudan team. The field work was undertaken in a number of phases as outlined below:

Meeting of local authorities and agencies on ground so as to elaborate the teams’ mission in the area. Gathering of information on the villages that make up the entire County with the relevant population figures. Collection of background information including accessibility and security of the area. Field data collection Plans for results dissemination

3.8 Field Exercise

The training was followed by a field exercise in a village not selected for the surveys. The methodology was tested; precision and the accuracy of the data collection were assessed as well as measurement techniques. Additionally all the data collection forms were tested during the exercise. The exercise was successful and the actual survey started a day after that.

3.9 Data Entry and Analysis

Anthropometric and mortality data processing and analysis was conducted using SMART/ENA software November 2008 version. Extreme value flags and WHO verification guidelines were used to identify Z-score values where there was a strong likelihood that some of the data items were incorrect; these data were not used in the analysis. The food security, water and sanitation data entry was entered and analyzed in SPSS version 11.5.

4. Guidelines and Formulae used

4.1 Acute Malnutrition

Weight for Height Index: Weight for height index was used to identify wasted children. It measures short term effect either from lack of food intake or illness, which reflects the recent past and current situation of the area. It is useful particularly when it becomes difficult to determine the exact age of the child as the case in most rural past of developing countries.

Acute malnutrition rate was estimated using weight for height index and bilateral pitting edema. Results were expressed both in z-score and percentage of median using NCHS reference and WHO standards. Besides having true technical meaning; z-score express malnutrition rate more precisely and allow for inter study comparison. On the other hand, the percentage median estimate weight deficit more accurately and commonly used in determining eligible children for targeted feeding programs.

The following guidelines were thus used in expression of results in z-score and percentage of median:

SAM was defined by WFH <-3SD and/or existing bilateral edema

Results expressed in Z-score

MAM was defined by WFH <-2SD and >=-3 SD and no edema GAM was defined by <-2 SD and/or existing of bilateral pitting edema

SAM was defined by WFH < 70% and/or existing bilateral edema

Guideline for results expressed in percentage of median

MAM was defined by WFH < 80% and >= 80% and no edema GAM was defined by < 80% and/or existing of bilateral pitting edema


Children’s Mid Upper Arm Circumference (MUAC): MUAC is a useful tool for rapid screening of children under five years of age. Taken accurately, MUAC measurements can be a good predictor of mortality in emergencies.

MUAC < 115m and/or edema Severe malnutrition and high risk of mortality MUAC Guidelines Definition

MUAC ≥ 115 mm and <125 mm Moderate malnutrition and risk of mortality MUAC ≥ 125 mm and <135 mm High risk of malnutrition MUAC ≥ 135 Adequate nutritional status

4.2 Mortality

SMART methodology was utilized in mortality data collection. A 91 days recall period was used in the survey. This was well remembered because it marked the visit by President of South Sudan to Aweil town in March. Obtained data was used to calculate the crude mortality rate. ENA (November 2000 version) was used in these calculations. To obtain the CMR, the formula below was applied:

Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where:

a = Number of recall days 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 was expressed per 10,000 people / day. Thresholds were defined as follows:

Total CMR- Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

Under five MR- Alert level: 2/10,000 people/day

Emergency level: 4/10,000 people/day

5. Survey Constraints

Access: During the planning phase of the survey, the SSRRC Secretariat in Aweil East County provided the information that all villages in the County were accessible. However, the experience of the survey teams was different as sometimes cars got stuck in mud for hours and this increased the logistics cost and support in the survey.

Recall bias: The population living at the far ends of the County was not able to remember with ease the visit of the President of South Sudan to Aweil town. This made it difficult to accurately determine ages of some children.

Supervision: Aweil East is a vast County and the survey comprised of five teams. It proved very difficult for the two ACF-USA supervisors to join all the teams at the same time as the clusters were scattered over the large area.

6. Results: Anthropometry and Retrospective Mortality

Data collection in this survey was conducted between 13th and 25th June 2010. The sampling frame included all the 7 payams of Aweil East County. The survey used SMART methodology, 40 clustered were sampled in the survey that included 475 households for anthropometric data and 598 households for mortality data. A total of 649 children were included in the final data analysis whose results are described in the sub-sections below.


6.1 Anthropometric analysis (WHO Standards, 2006)

Table 4: Distribution of age and sex of sample, Aweil East, June 2010

Age groups Boys Girls Total Ratio no. % no. % no. % Boy: Girl

6-17 months 85 57.0 64 43.0 149 22.8 1.3 18-29 months 82 49.1 85 50.9 167 25.6 1.0 30-41 months 77 47.8 84 52.2 161 24.7 0.9 42-53 months 61 53.5 53 46.5 114 17.5 1.2 54-59 months 31 50.0 31 50.0 62 9.5 1.0 Total 336 51.5 317 48.5 653 100.0 1.1

The distribution of age and sex group shows how far the total boy to girl ratio is within the defined range of 0.8-1.2. The sex ratio within the age groups in this population sample indicates a normal distribution.

Table 5: Prevalence of acute malnutrition by sex, Aweil East, June 2010

All

n = 649 Boys

n = 334 Girls

n = 315

Prevalence of global malnutrition (<-2 z-score and/or oedema)

23.1% (18.2% - 28.9%)

26.9% (20.6 - 34.4%)

19.0% (14.3 - 24.9%)

Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)

19.9% (15.1% - 25.7%)

21.9% (15.8% - 29.4%)

17.8% (13.1% - 23.7%)

Prevalence of severe malnutrition (<-3 z-score and/or oedema)

3.2% (1.9% - 5.4%)

5.1% (3.0 %- 8.6%)

1.3% (0.5% - 3.4%)

Table 6: Prevalence of acute malnutrition by age group, Aweil East, June 2010

Age groups Total no.

Severe wasting (<-3 z-score)

Moderate wasting (≥ -3 and <-2 z-score )

Normal ≥-2 z score)

Oedema

No. % No. % No. % No. % 6-17 months 148 10 6.8 32 21.6 106 71.6 0 0.0

18-29 months 165 3 1.8 39 23.6 123 74.5 0 0.0 30-41 months 160 3 1.9 28 17.5 129 80.6 0 0.0 42-53 months 114 3 2.6 17 14.9 94 82.5 0 0.0 54-59 months 62 2 3.2 13 21.0 47 75.8 0 0.0

Total 649 21 3.2 129 19.9 499 76.9 0 0.0

Table 7: Distribution of acute malnutrition and oedema based on weight-for-height z-scores, Aweil East, June 2010

<-3 z-score ≥ -3 z-score

Oedema present Marasmic kwashiorkor

0 (0.0 %) Kwashiorkor

0 (0.0 %)

Oedema absent Marasmic 21 (3.2 %)

Not severely malnourished 628 (96.8 %)

A comparison of the results based on the weight-for-height distribution curve of the survey population with the WHO Standards normal population is presented in Figure 9. The shift of the curve to the left with mean z-score of -1.24 (SD ±1.02) shows poor nutrition status of the population compare with WHO standard population.


Figure 1: Weight for Height in Z-scores compared to WHO population, Aweil East, June 2010

4.2 Vaccination Coverage

The table below show the immunization coverage among the under five children of 9-59months in the surveyed area. This information was either gotten from birth/vaccination cards and or recalled by the mother/caretaker.

Table 8: Measles vaccination coverage, Aweil East, June 2010

Population >=9 months N=619 Percent

Immunization by cards 32 5.2%

[3.4% - 6.9%]

Immunization by mother recall 135 21.8%

[18.6% - 25.1%]

Note immunized 452 73.0%

[69.5% - 76.5%]

Aweil East, as shown by Table 8 above, has extremely low immunization coverage. Out of 619 children of 9-59 months, only 167 children got immunized as indicated by cards and mothers/caretakers. This is less than half the number of reliable children in same age range.

4.4. Mortality

In the retrospective mortality survey, a 91 days recall period was used to collect mortality data. Visit in Aweil by South Sudan President in March was used as a reference occasion. Mortality survey questionnaire was administered to 588 households. As presented in Table 9 below, the households sampled comprised of 1.2 children < 5 years per household and an overall average of 5.3 persons per household. Data was collected from 15 households per cluster. The results found crude and under five mortality death rates of 0.38 (0.21-0.68) and 0.16 (0.03-0.88) respectively. All results were expressed with 95.CI. Mortality rates in this area, according to the results of this survey (Table10) were well under the emergency cut-off points (CMR of 2/10,000/day and U5MR of 4/10,000/day).

In spite of the low mortality rates shown by this survey it is important to note that he population in Aweil East is not always open on discussing about death, dead relatives or children as it is sometimes considered a taboo.


Table 9: Household Composition, Aweil East, June 2010

Age group N % Average per household Under 5 years 724 23.2 1.2 Adult 2395 76.8 4.1 Total 3119 100 5.3

Table 70: Mortality rate, Aweil East, June 2010

Demographic data Results Current residents in household 3119 Current residents <5 years in the household 724 People who joined the household 28 <5 years who joined the household 6 People who left the household 136 <5 years who left the household 16 Birth 46 Death 11 Death <5 years old 1 Recall period in days 91 CMR (death/10,000 people/day) 0.38 (0.21-0.68) U5MR (death in children<5 years/10,000/death) 0.16 (0.03-0.88)

3.5 Child Morbidity

A recall period of two weeks was used in morbidity data collection. Mothers/caretakers were asked whether their < 5 children had any kind of illness. About 44.5% of children were reported to have had no ailments. Among the illnesses reported, Malaria was leading with 24.5%, Diarrhea with 13.4%, Skin Infections with 12.8% and Coughing with 11.1%. Only 0.3% children reported to have been affected by Measles. Table 10 below summarizes the results.

Table 81: Illness in Children (6-59 Months old) 2 Weeks Prior to Interview, Aweil East, June 2010

Illness Proportion Cough 11.1% Diarrhea 13.4% Malaria 24.6% Measles 0.3% Skin infection 12.8% Worm 0.9% Others 9.0%

7. Results on Qualitative data

A qualitative questionnaire was administered to 85 households to collect information on food security and livelihoods, water and sanitation, child care practices and health. Information collected was supplemented by information collected from key informant interviews, focus group discussions, and observation.

7.1 Socio- demographic characteristics of the respondents

This survey revealed that the largest proportion (83.5%) of households is primarily residents of Aweil East. However, but the population also consists of returnees (8.2%), IDPs (4.7%), and temporary residents (3.5%).The status of each household was categorized by the household members themselves. Therefore, it is possible that they may consider themselves as residents rather than returnees, temporary residents or IDPs. This accounts for any discrepancies found in returnee percentages/figures found in other reports.


7.2 Food Security and Livelihoods

Aweil East County is mainly populated by the Dinka community who are predominantly agro-pastoralists. While cattle ownership remains the primary determinant of wealth and status, this survey showed that majority of the population are depending on crop farming (71.8%). As shown by Table 12, major livelihood activities include agro-pastoralism (22.4%), petty trade (3.5%), pastoralism and employment (1.2%). Petty trade (28.2%), sale of livestock (23.5%) and sale of crop (14.1%) are the main sources of income reported. The current month’s main sources of food are buying (43.5%), cultivation (23.5%), food aid (14.1%) and livestock (12.9%). A considerable number of people (17.6%) reported to have no sources of income.

Table 92: Main Livelihood Activities (n=85), Aweil East, June 2010

Livelihood Activity Percentage Crop farming 71.8% Agro-pastoralism 22.4% Petty trade 3.5%

Aweil East communities practice small scale farming mainly of cereals and pulses such as sorghum, maize, millet, groundnut and simsim. Majority of the population planted less than one feddan (36.5%) or between one and two feddans (40.0%) in this cropping season; see Figure 3. Most people who participated in the focus group discussion cited that floods in previous years, drought and Dhiach2

Figure 2: Number of Feddans to be planted in 2010, Aweil East, June 2010

frustrated farming activities in Aweil East. Lack of agricultural/farming equipment was identified as a hindrance to crop cultivation. Figure3. shows different sizes of land cultivated by farmers in the community.

During the survey, 81.2% of the respondents said they didn’t have sufficient food sources, 29.4% had food that will last for less than a month, 30.6% had food that will take them for the next one to three months and 18.8% had already finished the little they had while 16.5% said they had enough food sources. Most of the households’ main ways of getting additional food or coping with the shortage were found to be food distribution (29.4%), sale of livestock assets (15.3%), others (casual work & petty trade) (9.4%), food from relatives and borrowing contributed 8.2% each. Sale of personal assets, remittance from relatives, wild food collection, eating of immature crops and reduction of number of meals contribute 5.9% each.

2 A Dinka word referring to a kind of commonly found weed in Aweil East. It chokes cultivated crops hindering their growth and development.


Table 103: Sources of household food (n=85), Aweil East, June 2010

Source Percentage

Borrowing 8.2%

Receive money from relatives 5.9%

Ask for food from relatives 8.2% Food aid 29.4% Sell livestock assets 15.3% Sell personal assets 5.9% Wild food collection 5.9% Eat immature crops 5.9% Reduce number of meals 5.9%

Others (casual work and petty trade) 9.4%

According to the Table 13 above, most of the households survive through food aid (29.4%) from WFP, sell of livestock (15.3%), casual work and petty trade (9.4%). The effect of this will impact negatively on this year’s food production.

In this survey, most households (37.7%) were found to have no livestock while a similar proportion (37.7%) was found to own cattle. The second in livestock ownership were the households that owned goats (19.5%). Chickens (1.3%), donkeys (1.3%) and others (2.6%) are the least owned by the community. Table xx shows livestock ownership by the community.

Table 114: Livestock owned (n=77), Aweil East, June 2010

Type of livestock Percentage None 37.7% Cattle 37.7% Goat 19.5% Chicken 1.3% Donkey 1.3% Others 2.6%

Fishing activities in Aweil East routinely take place in March and April and then again from October to December of every year; though some people are able to carry on with fishing throughout the rest of the months of the year. The tools used for fishing include modern nets, hooks, or locally made fishing equipment like Thoi and Roke. There are not many household in Aweil East that fish and therefore fishing contributes minimally to livelihoods in this county. Survey results show that only 4.7% participate in fishing activities. Major hindrances, according to the community, are lack of access to fishing points (55.3%), lack of fishing equipment (21.2%) and lack of labor (17.6%).

Households were interviewed on the types of food they consumed within the previous 7 days preceding the survey. The food consumption patterns showed that the most commonly consumed foods were cereals (84.7%), milk and milk product (9.7%) and vegetables. The value of fruits in the diet is not known in the community and fruits are not sold in any market within the county.

Table 125: Most Commonly consumed Foods, Aweil East, June 2010

Food Proportion Cereals 84.7% Milk and milk products 9.7% Vegetables 5.6%

7.3 Health

Health services in Aweil East are supported by mostly NGOs and MoH. There are a total of 36 functional and 2 non functional health facilities in Aweil East. 2 Hospitals in Akuem and Gordhim are run by government and Ali


Arkanjelo3

The last vaccination campaign was done in June last year. Majority of children under five were found to have not been vaccinated due to long distances to travel while some of them were not vaccinated because mothers consider taking their children to health facility only when the child get sick. Figure 4 below shows the health-seeking behavior results of the survey.

. Two PHCCs (Malualkon and Malualbaai) and 8 PHCUs (Warawar, Bakou, Amethgolduang, Mangartong, Nyanlath, Adoor and two others) are run by IRC and MoH. Tear Fund is running 4 PHCUs, and Christian Solidarity International one PHCC in Mabil and two other PHCUs in the County. The government is running one PHCC in Wanyjok and 15 other PHCUs within the county. The two PHCUs are non functional due to lack of funding. Most of those health facilities are situated in the midlands leaving both the low and highlands with limited access to health care services.

Figure 3: First Place of Treatment when sick, Aweil East, June 2010

This survey results showed that majority of the population seek treatment at various places depending on the distance. This survey revealed that majority of the households seeks treatment at PHCC/Us (68.2%), the hospital (7.1%), pharmacy (10.6%) community health worker (5.9%) and about (1.2%) receive treatment from the relatives. Only 4.7% said they go to traditional healers first but (2.4%) have nowhere to sick treatment. In was evident that the proportion of people who are strong adherents to traditional believes and practices hinder many people from seeking treatment from health centres.

Most health units are located in the mid-land with no real facility in the far-low and high-lands. Therefore, key informants say that it is on average a 6-15 kilometer or two to three day walk to reach a health centers. This is supported by Figure 5 below that 54.1% say it takes more than 2 hours to reach a health facility, 24.7% say 1-2 hours and 12.9% they are more than or equal to 30 minutes and less than one hour. Only 8.2% say they are less than 30 minute walk.

3 A local NGO run by the Diocese of Rumbek


Figure 4: Distance covered to the nearest Health Facility, Aweil East, June 2010

Immunization rates continue to below in Aweil East County. This survey found that only 23.8% of children have received the BCG vaccination and 25.6% received the measles vaccine, confirmed by card and mother/caretaker. The EPI campaign that was done in the previous year seemed to have only benefited those near roads but children in the northern end of the County have not been reached. Reasons cited include not receiving the vaccines from MoH/ WHO. Currently, vaccination is carried out in PHCCs. However, mothers/caretakers are reluctant to walk for long distances to get their children vaccinated. They need to be convinced on the importance of the immunization to children

In the two weeks prior to the survey, over half the children surveyed had a reported illness (56.3%). The top two illnesses included malaria (24.6%) and diarrhea (13.3%) and skin infection (12.7%). This explain that both malaria and diarrhea cases have increased by 5.5% and 0.9% respectively compared to same time last year. Outbreaks of AWD were reported to have occurred in the month prior to this survey in Peth (Malualbaai Payam) of Aweil East County. Cholera/AWD is common among the habitants of lowlands in the County.

7.4 Water and Sanitation

Most households in Aweil East County are using a combination of water sources for their households’ consumption. The main water source(s) cited in this survey were boreholes (77.6%) and rain water (12.9%). Rivers and unprotected wells are also some of the water sources (see Table 18). The source(s) of water used is dependent on many factors including seasonal availability, borehole breakdowns, lack of alternative water sources, and distance to the source. Borehole water is considered the only safe water supply and while 77.7% of the population is accessing this at some point, a large portion of the population is using unsafe water supplies. Below is the table showing current water sources to the community.

Table 16: Current Water Source, Aweil East, June 2010

Water source Percentage River 1.2% Lake 4.7% Borehole or hand pump 77.6% Unprotected well 3.5% Rain water 12.9%

The time it takes for household members to walk to and from the water source without including queuing time varies from village to village and is also dependent on the location of the water source in the community. More than half the households (52.9%) stated that it takes less than 30 minutes while others (35.3%) take 30 minutes to one hour and (11.8%) walk for more than one hour as shown in Table 18.


Table 17: Time to and from the water source (N=85), Aweil East, June 2010

Time Population Less than 30 minutes 52.9% 30 minutes to 1hour 35.3%

More than 1 hour 11.8%

The number of times water for consumption is collected by the household per day is sometimes determined by the distance from the source. Household duties allocation is also a factor to consider, water in the visited communities was fetched by women in most cases. Most households collect water between two (36.5%) and three (45.9%) times per day. Only 16.5% collect water more than three times a day. The most preferred container for water collection in the community is 20 litre jerry can (81.1%) and 10 litre jerry can.

Based on an average household size of 5.2 members, this amount of water equates to 6-8 liters/capita/day which is far below the SPHERE emergency standard of 15 liters/capita/day. There are several reasons that would contribute to this low daily per capita consumption rate; including distance to the water source, number of households sharing the daily water source, water scheme breakdowns, unreliable water supply, long queue time, and lack of containers for carrying and storing water.

Sanitation needs for Aweil East County were found inadequate. Only 4.7% of the households surveyed were found to have access to a latrine. Stool of children less than or equal to three years were primarily thrown outside the house compound (89.5%) with only 2.3% being thrown in a latrine. It is only 7.0% who bury it in the yard and a further 1.2% dispose of it in the river.

Health and hygiene practices for treating water prior to consumption were not observed or reported. However information on hand-washing practices and use of soup was sought. Over half of the households (52.9%) had soap in their homes at the time of the survey. As shown in Table 21, of the 52.9% households that had soap, only 2.4% washed before eating or feeding their children, and 2.4% washed after visiting latrine. Majority of households that had soap used it to wash clothes (91.8%). A considerable number of households (47.1%) did not have soap but reported that they buy it when need arises. Other alternatives used in place of soap were not assessed.

Table 19: Household Use for Soap (n=85), Aweil East, June 2010

Soap Use Population Washing of clothes 91.8% Before eating/feeding children 2.4% After visiting toilet 2.4% After cleaning child’s bottom 3.5%

Lack of adequate quality and quantity of water, proper sanitation, and good hygiene practices lead to the spread of diarrhea and other illnesses; and could be a factor in the reoccurrence of acute watery diarrhea/cholera outbreaks in Aweil East County since October 2008.

7.5 Maternal and Child Care Practices

Good child care practices and nutrition promotes growth and development in children. The UNICEF conceptual framework (1983) for malnutrition places care practices as one of the top three underlying causes of malnutrition; the other two being food security and health. Breastfeeding and complementary feeding practices are two major components of proper care practices.

This survey revealed that 81.5% of women initiated breastfeeding within one hour after delivery, only 8.1% reported to have breastfed their children after one day citing tiredness and sickness to be responsible for the delay. A 24-hour recall period was used in assessing the frequency of feeding and the types of food children were fed. Most of the children (44.7%) were reported to have eaten twice or thrice (32.9%) in the previous day while 15.5% ate three times and only 6.8% were fed once a day. It was further established that 65.3% of the children were said to have been fed on grain food (sorghum) while 42.1% were fed on dairy milk the previous day. Legumes, groundnuts (16.7%) and meat together with fish (13.2%) followed in that order.


No special food or feeding practices for pregnant mothers in the area covered by this survey. The community seemed not to be aware of the danger poor feeding and maternal care pose to the unborn child. Lack of support from household members was given as one of the reasons that leave pregnant mothers to still engage themselves in their field/farm tasks until and after delivery.

Figure 5: Number of times per day that children are fed, Aweil East, June 2010

8. Discussion

This survey found GAM rates of 23.1% [18.2-28.9%] and SAM rates of 3.2% [1.9-5.4%] (WHO 2005 standards). The GAM rate exceeds WHO emergency threshold (>15%) while SAM was below the emergency threshold (> 4%). This shows a considerable decrease compared with the findings of a similar survey that was conducted at the same time in the previous year. The June 2009 anthropometric survey found GAM and SAM rates of 29.8% [25.0-.35.2] and 7.8% [5.5-11.1] respectively (WHO 2005 Standards). Key indicators are pointing to the increase of moderate acute malnutrition that is considerably higher than the normal chronic emergency levels. The results could be linked to the following:

Poor food intake and insecurity: The community is already in a hunger gap and this is compounded by the fact that last year’s harvest was poor (as confirmed in discussions with key informants) as a result of drought and crop pest infestations. Inadequacy of food at the household level during this time of cultivation will make it difficult for the farmers to grow enough crops. Even if rain does well like this year, farmers still fear that it will be destroyed by Dhiach (weed), which they said can be gotten rid of by use of fertilizers. Majority of the people cultivate one to two feddans of land which produce little food that can take the household to January 2011, after which early hunger gap will set in. Use of local hand tools in cultivation is also another obstacle to crop production as it takes a lot of time to cultivate a small portion of land. Before harvesting time this year, the community is anticipating floods-between August and October which can also destroy crops before ripening. Fishing is done in the community but at a small scale as there is no enough fish in the mostly seasonal rivers in the County.

Increases in staple food prices, and decreased selling prices for livestock, are also affecting the food security situation and the ability of households to obtain sufficient food quantity. However, unlike in the June 2009 nutrition survey where 63.4% of households reported that their food stocks were already depleted, only 18.8% of the households this time said their food is already depleted; which is a big improvement. Additionally, 34.1% of the households stated that their food stocks will last for less than a month while 30.6% of the households will have their stocks taking them for one to three months. The combination of these factors might impact negatively on next year’s food security.

Disease prevalence: A heavy disease burden was is prevalent in Aweil East and contributes to persistent under nutrition, especially among the children under five years old. As found by this survey over half (56.3%) the children had a reported illness within 14 days prior to the survey. The top two illnesses included malaria (19.1%) and diarrhea (12.4%).

Survey results showed that a small percentage of children have been vaccinated in this county; 21.4% had BCG vaccination, 23.5% had measles vaccine. Extended Programs on Immunization (EPI) had not occurred by March 2010 to immunize children against the six killer diseases. Additionally, acute watery diarrhea (AWD)/cholera


outbreaks have been reoccurring since October 2008. In order to reduce the susceptibility of children in Aweil East to high rates of malnutrition scaling up immunization program and other interventions aimed at disease prevention among children will be very important for Aweil East and its neighboring Counties.

Inadequate Water and Sanitation: As shown by this survey, only 58.9% of the population is accessing clean water through boreholes as a main water source, and 7% have access to proper latrines and sanitation. Hand-washing procedures are also low with only 15.5% washing hands before eating, 2.3% washing before feeding their children, and 1.5% washing after defecation. These low percentages can be contributed to distance and sources of water, functionality of water schemes and pumps, ability and knowledge to build latrines, and knowledge and implementation of proper hygiene practices. Lack of adequate quality and quantity of water, proper sanitation, and good hygiene practices leads to the spread of diarrhea and other illnesses; and is a key contributing factor in the reoccurrence of acute watery diarrhea outbreaks in Aweil East County. Diarrhea can lead to reduced food quantity intake and decreased nutrient absorption thereby contributing to a decline in nutrition status. Children are more vulnerable when it comes to hygiene-related infections.

Inappropriate maternal and child care practices: Poor child care practices in Aweil East County may be a contributing factor to high malnutrition rates. While there is good breastfeeding initiation after delivery, and prolonged breastfeeding duration primarily through the age of 18-24 months, complimentary feeding practices need to be improved. This survey reveals that only 15.4% of children are receiving foods at the proper age. The right quantity and quality of food is vital for the growth and development of children.

9. Conclusion and Recommendations

As shown by the findings of this survey, it is demonstrably rear that the population of Aweil East is in need of support and malnutrition is still at emergency level. A small improvement was seen when the result of this survey are compared to a similar survey that was done at the same time in the previous year. It is believed that effort of many agencies in the County working on health, food aid, food security and livelihoods and nutrition are privy to this progress. However, measured against the complexity of food security, health and nutrition challenges in the county, a double measure of effort is required to have meaningful impact on the population. Based on the findings of this survey, the following are recommended:

> Increased coverage of TFP.

> Promotion of the importance of immunization of children. This can be achieved through health education sessions at OTP, PHCU, PHCC and community level.

> Among other health interventions, provision of bed nets and promotion of their use to reduce the incidence of malaria is highly recommended. Malaria is persistently prevalent among children under the age of five years

> The community in this location is used to continuous food distribution from agencies like WFP and partners. While this is done to save people from large-scale starvation, it is recommended that more focus be given to developing the capacity of the community to increase farming activities (supporting increased household food production) that will have a remarkable contribution to food security of the population and hence reduced prevalence of under-nutrition, especially among the <5 children, pregnant and lactating mothers of Aweil East.

> Provision of seeds and tools, including agricultural training on improved farming techniques and plant protection as well as diversification of income sources through various income generating activities is highly recommended

> Increase the number of adequate and safe water schemes through construction, rehabilitation and training on operation and maintenance, especially in highlands and lowlands which are under-served as boreholes are concentrated in the midlands only.

> Recent effort in supporting the community in latrine construction and use at the household level and distribution of slabs for latrines has seen increased interest by some community members. This needs to continue in tandem with hygiene community hygiene promotion.


10. Annexes

Annex 1: Anthropometric Survey Questionnaire Anthropometric Survey Data Form

District/Village: _________________________ Date: _________________ Cluster number: _______ Team number: _______

Child No.

HH. No.

Sex (f/m)

Age in months

Weight (kg) + 0.1kg

Height (cm) + 0.1cm

Oedema (y/n)

MUAC (mm)

Vaccination Illness in the last 2 weeks, if any did the child has N/C/D/M/MS/SI/W/O

BCG Scar Present? (y/n)

Measles (c/m/n)

Vit A in the last 6 month (y/n)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Note: Administer in Households with Children aged between 6 – 59 months

1. Measles: C= according to EPI card, M=according to mother, N=not immunized against measles 2. N= Not sick C=Cough D=Diarrhoea [Episode of 3 or more watery stools per day] M= Malaria [Episode of fever with chills] MS = Measles [fever with cough, running nose and red eye] SI= Skin Infection [Episode of skin eruption or changes in skin appearance] O = Others


Annex 2: Household enumeration data collection form for death rate calculation (Household) Payam: Village: Cluster number: HH number: Date: Team number:

1 2 3 4 5 6 7

ID HH

member Present

now

Present at beginning of recall (include those not present now and indicate which members were not present at the start of

the recall period )

Sex Age in

years/months

Born during recall

period?

Died du the rec

perio

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20

Tally (these data are entered into Nutrisurvey for each household):

Current HH members – total Current HH members - < 5 Current HH members who arrived during recall (exclude births) Current HH members who arrived during recall - <5 Past HH members who left during recall (exclude deaths) Past HH members who left during recall - < 5 Births during recall Total deaths Deaths < 5


Annex 3: Enumeration data collection form for death rate calculation survey (Cluster) Survey Payam: Village: Cluster number: HH number: Date: Team number:

N Current HH

member

Current HH members who arrived during

recall (exclude births)

Past HH members who left during recall (exclude deaths)

Births during recall

Deaths during recall

Total < 5 Total <5 Total < 5 Total < 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32


Annex 4: Calendar of Events

MON

SEASONS 2005

2006

2007

2008

2009

2010

JANUARY

End of harvesting season for sorghum, first month after Christmas

53 41 29 17 5

Dinka /Misiriya war

FEB. End of cold and windy season

52 40 28 16 4

Dinka

/Misiriya.war SPLA/SAF fighting

In Malakal

MARCH

Increased hot and dry season, Trees shed leaves, mango season, Increased diarrhea and meningitis cases

51

39 27 15 3

Mengitis outbreak War btn Dinka l/Misiriya.Malong appointed governor of NBGS.

Issuance of arrest warrant

Omar came to Aweil town

APRIL

Preparation of land, Trees sprout leaves, Clouds gather Drizzles begin, moderate emperatures

Guinea filters

38 26 14 2

Creation of bomas/payams(SPLM)councils

Census. Peace conference

Dinka and Misiriya.

General elections

MAY Rains begin, SPLM day, start cultivation/ planting

49 37 25 13 1

SPLA/SAF Abyei fighting. Plane crash killed gov’t officials

Traditional chiefs’ conference in Bentiu.

JUNE SHAH

AR SITTA

Second cultivation/planting

48 36 24 12

Nhomlaau radio opened in malualkon

JULY

Weeding season(maize)

59

47 11

North-south road Construction begun. Local chiefs received sorghum to sell at cheap prices.

AUGUST

Harvesting of maize and wild vegetables such as okra and kudra. Heavy rains, many cases of malaria

58 46 34 22 10

Funeral of Dr. John Garang. Salva Kiir made first vice president

SEP. Eating green maize

57 45 33 21 9

OCT. Rain stops Comboni day.

56 44 32 20 8

Governor visited all

the counties in NBEG

NOV.

Christmas preparation. Smear houses with mud.

55 43 31 19 7

SPLA/SAF fought Madut appointed governor

Dinka /misiriya war

DEC. 54 42 30 18 6

CANS started


Annex 5: Qualitative Survey Questionnaire

Questions HH1 [ ]

HH2 [ ]

HH3 [ ]

HH4 [ ]

HOUSEHOLD CHARACTERSTICS 1 Status of the Household

1=Resident 2=IDP 3= temporarily resident 4=Returnee

2 What is your main livelihood activity/s? 1= Pastoralism 2= Fishing 3= Crop farming 4= Employment 5= Agro-pastoralist 6= Petty trade 7= Other (specify)

3 How many feddans of land did you cultivate/are you cultivating this year? 1= Less than one 2= One to two 3= Two to three 4= three to four 5= More than four.

4 Which type/s livestock do you own? 1=None 2=Cows 3=Goats 4=Chicken 5=Donkey 6=Sheep 7=Others

FOOD SECURITY AND LIVELIHOOD 5 What is/are your main sources of income?

1=No income 2= Sale of livestock 3= Sale of livestock products 4= Sale of crops 5= Petty trading e.g. sale of firewood 6=Casual labour 7=Permanent job 8= Sale of personal assets 9= Remittance 10=Other(Specify)

6 What is/are the household’s main food source (s) in the current1=cultivation 2= Livestock 3= River(fishing)

month?

4=Buying 5= Food Aid 6= Wild food collection 7=Kinship 8= Other (specify)

7 Are your main sources of food sufficient for your household? 1=Yes (skip to qn 9) 2= No

8 If your answer is NO in question 7 above give reasons for insufficient food sources? (Note the answers in the field and code later for analysis- refer to the attached).

No Questions HH1 [ ]

HH2 [ ]

HH3 [ ]

HH4 [ ]

9 What do you do to get more food? 1=Borrow money 2=Receive money from relatives 3=Ask for food from relatives, friend, neighbours (no repayment) 4=Rely on food distribution (WFP, NGOs) 5=Sell livestock assets 6=Sell personal assets (other than livestock) 7=Send children away (to relatives, friends etc) 8=Wild food collection 9=Eat immature crops 10=Reduce number of meals 11= Others(specify)

10 How long will your currentl= less than a month 2= 1-3 months 3= 4-6 months

food stock last you?

4= more than 6 months 5= already completed.

11 Does this household do fishing? 1=Yes (skip to question 13) 2=No

12 If no, why? 1= Lack of fishing equipments 2= Lack of enough fish in the fishing points 3= Lack of labour 4= No access to fishing point 5=Other (Specify)


13 Which type of food group did consumed in this HH in 1= Meat and offal 2= Cereals (sorghum, maize etc)

the last 24 hour?

3= Milk and mil products 4= Beans, lentils and nuts. 5= Vegetables 6= Fruits 7= Fish 8= Egg 9= Spices, condiments and beverages 10= Sugar/Honey 11= Roots/tubers 12= Any other food

1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 [ ] 8 [ ] 9 [ ] 10[ ] 11 [ ]12 [ ]

1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 [ ] 8 [ ] 9 [ ] 10[ ] 11 [ ]12 [ ]

1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 [ ] 8 [ ] 9 [ ] 10[ ] 11 [ ]12 [ ]

1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 [ ] 8 [ ] 9 [ ] 10[ ] 11 [ ]12 [ ]

14 What is/ are your main1=River 2= Lake 3= Borehole/hand pump 4= Unprotected well 5= Surface run-off 6= Rain water 7=Swamp water 8= Seasonal spring

current water sources for drinking?

9= Laga 10= other (specify)

15 How long does it take to go to the main source of water, get water and back? 1= less than 30 minutes 2= 30 minutes –1 hour 3=more than 1 hour

No Questions HH1 [ ]

HH2 [ ]

HH3 [ ]

HH4 [ ]

16 How many times a day do you collect/fetch water? 1= 1time 2= 2 times 3= 3 times 4= More than 3 times

17 What type of container do you use to collect water? 1= Jerry can (10 liters) 2= Jerry can (20 liters) 3= Pot 4= Bladder 5= Other (specify)

18 Who usually collect water for the household? 1= Adult woman [15+] 3= Female child [under 15] 2= Adult man [15+] 4= Male child [under 15]

19 What treatment do you do to water before drinking? 1= None 2= Boiling 3= Use of traditional methods 4= Use chemicals/chlorine/PUR 5= filter/sieves

20 Does your household have access to improved toilet facility? 1=Yes 2= No (skip to question 22)

21 If no, where do you go/use (probe)? 1= Bush; 2=Open field 3=Near the river 4= Behind the house 5= Other(specify)

22 Do you have soap in the household? 1=Yes 2=No (go to question 24)

23 If yes, what do you use it for? 1= Before eating/feeding child 2= after using toilet 3= after cleaning a child’s bottom 4= before handling food/cook 5=Wash clothes 6=other (specify)’

HEALTH 24 When a member of your household is sick where does he/she first

1=Traditional healer 2=Community health worker 3=PHCC/U 4=Hospital 5=Relative/friend 6= Pharmacy 7= No assistance 8= Other(specify)

seek treatment?

25 How long does it take to walk to the nearest1= less than 30 minutes

health facility?

2= more or equal to 30 minutes and less than 1hr 3= more or equal to 1 hr and less than 2 hrs 4= more or equal to 2 hrs

26 Does your house hold have any insecticide treated mosquito bed nets? 1= Yes 2= No


Date: Cluster No: Team No: _________________ Payam : _______________ Village:_______________ Name of Head of HH: ____________________ Supervisor :__________________ Question 8; if your answer is NO in question 7 give reasons for insufficient food sources?

1=Not enough rain (drought) 2=Too much rain (flood) 3=Diseases killed livestock/destroyed crops 4=Pests killed livestock/destroyed crops 5=Insecurity 6=Livestock/crops stolen 7=Not enough livestock 8=Not enough land 7=Not enough fish in the rivers 8=Not enough people in household for production 9=Not enough materials (seeds, tools, equipment) for production 10=Do not have enough skill/training/education to increase production 11=Sickness (illness) or handicapped 12=Too young or too old 13O=Do not have enough money to buy food 14=Prices of food are too high 15=Lack of/inadequate income 16=Other (specify)

WFP food aid (FFR, FFW, FFE etc) - obtain information from WFP and SSRRC. Additional information to be gathered through key informant interviews and observation

Markets: Include how many markets are in the Payam; whether they sell food stuffs; food price changes Livestock: Where does the community buy or sell livestock; whether livestock are at home or in the cattle camps; milk availability Fishing: Probe whether there are any fishing grounds in the surveyed location and which months of the year the community does fishing. Water: Consider availability of portable water such as seeking to know how many boreholes/taps is in the area, how many are functional. Health care: Find out how many health facilities (PHCCs and PHCUs) are available in the surveyed area as well as additional information on health care seeking patterns.


Annex 6: Infant, Young child feeding practices and water and sanitation

SN Questions HH No___ Ch No__ 1 Does the youngest child (less than 24 months)

1= Yes 2 = No [go to question 3] ever breast feed?

2 When did you start breastfeeding your youngest child after birth (less than or equal to24 month)1. Immediate (within 1 hr) 2. More than 1 hour 3. One day 4. More than 1day 5.Others (specify)

?

3 Which type of the following food does the youngest childe (6 –23 months) eat yesterday1= grains, roots and tubers 2= legumes and nut

?

3= dairy products (milk, yogurt, cheese 4= flesh foods (meat, fish, poultry and liver/organ meats 5= egg 6= vitamin-A rich fruits and vegetables 7= other fruits and vegetables

4 4. How many times did you feed your younger child (6 – 23 months)1= Nil 2= Once 3=Twice 4= Thrice 5= more than 3 times

yesterday?

5 What happens with the stools of young children when they do not use the latrine or toilet facility1=children always use toilet or latrine

(less or equal to 36 months)?

2=thrown into toilet or latrine 3=thrown outside the yard 4=buried in the yard 5= Not disposed off or left on the ground 6= Wash in river or water point 7=No young children in the household 8=other (specify)

aweil county is located in northern bahr el ghazal state of

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