care international somalia nutrition smart …...table 1: summary of main survey results summary of...

CARE INTERNATIONAL – SOMALIA

NUTRITION SMART SURVEY

FINAL REPORT

BADHAN DISTRICT, SANAG REGION, SOMALIA

OCTOBER 2019

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ACKNOWLEDGMENT

CARE Somalia would like to pleasantly acknowledge the support of everyone who was

involved in successful execution of the SMART survey in Badhan District, Sanaag Region.

The following played a key role;

▪ OFDA for their financial support to carry out the SMART survey

▪ Ministry of Health for their help in survey planning, coordination and

implementation

▪ Community leaders for good reception and provision of household lists for their

villages

▪ Parents and caretakers for availing their children for assessment as well as for

providing other relevant data for the study

▪ Somalia Cluster’s Assessment and Information Management Working Group for

their technical review and validation of the survey protocol and results.

▪ Care Somalia staff for the management of personnel, logistics planning and field

implementation of the survey

▪ Field supervisors and data collectors for their hard work and dedication during

data collection

Report compiled by:

Epistat Research Consultants

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TABLE OF CONTENTS

ACKNOWLEDGMENT ................................................................................ I

LIST OF TABLES .................................................................................... III

LIST OF FIGURES .................................................................................. IV

LIST OF ANNEXES .................................................................................. IV

ACRONYMS AND ABBREVIATIONS ................................................................ V

EXECUTIVE SUMMARY ............................................................................. VI

1.0 INTRODUCTION ................................................................................ 1

1.1 Background .................................................................................. 1

1.2 Health and nutrition situation ............................................................ 2

1.3 Justification of the survey ................................................................ 2

1.4 Survey objectives ........................................................................... 3

1.4.1 Specific Objectives .................................................................... 3

1.5 Survey location and timing ................................................................ 3

2.0 METHODOLOGY ................................................................................ 4

2.1 Study design ................................................................................. 4

2.2 Target group ................................................................................ 4

2.3 Data and data collection methods ....................................................... 4

2.4 Sample size determination ................................................................ 5

2.4.1 Anthropometry sample size .......................................................... 5

2.4.2 Summary of sampling methods ...................................................... 6

2.5 Organization of the survey ................................................................ 6

2.5.1 Recruitment and Composition of survey teams ................................... 6

2.5.2 Training of the survey teams ........................................................ 7

2.5.3 Field Data Collection ................................................................. 7

2.6 Data Management .......................................................................... 7

2.6.1 Data Quality Control .................................................................. 7

2.6.2 Data Collection Tools ................................................................. 8

2.6.3 Data Entry and Analysis .............................................................. 8

3.0 RESULTS- BADHAN DISTRICT ................................................................. 9

3.1 Anthropometric Results.................................................................... 9

3.1.1 Distribution by age and sex .......................................................... 9

3.1.2 Prevalence of Wasting (WHZ) ...................................................... 10

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3.1.3 Prevalence of Acute Malnutrition by MUAC ...................................... 12

3.1.4 Prevalence of Underweight (WAZ) ................................................ 14

3.1.5 Prevalence of Stunting (HAZ) ...................................................... 15

3.1.6 Mean z-scores, Design Effects and excluded subjects ......................... 16

3.2 Child morbidity and immunization coverage ......................................... 16

3.2.1. Child Morbidity ..................................................................... 16

3.2.2 Health seeking behaviour .......................................................... 17

3.2.3 Child immunization, vitamin a supplementation, and deworming ........... 18

4.0 CONCLUSION ................................................................................. 20

5.0 RECOMMENDATIONS ......................................................................... 21

6.0 ANNEXES ...................................................................................... 22

LIST OF TABLES

Table 1: Summary of Main Survey Results ..................................................... vi

Table 2: Survey target group ..................................................................... 4

Table 3: Data and collection methods .......................................................... 4

Table 4: Sample size determination ............................................................ 5

Table 5: Summary of survey completeness .................................................... 9

Table 6: Distribution of age and sex of sample ............................................... 9

Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or

oedema) and by sex ............................................................................. 11

Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z-

scores .............................................................................................. 12

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores

and/or oedema ................................................................................... 12

Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema)

and by sex......................................................................................... 13

Table 11: Prevalence of underweight based on weight-for-age z-scores by sex ....... 14

Table 12: Prevalence of stunting based on height-for-age z-scores and by sex ........ 15

Table 13: Mean z-scores, Design Effects and excluded subjects ......................... 16

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LIST OF FIGURES

Figure 1: Badhan Seasonal Calendar ............................................................ 3

Figure 1: Age and sex pyramid ................................................................. 10

Figure 2: Distribution of WHZ z-scores for the surveyed population ..................... 11

Figure 3: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or

edema ............................................................................................. 14

Figure 4: Common illnesses reported ......................................................... 17

Figure 5: Health seeking behavior ............................................................. 17

Figure 6: Vitamin A Supplementation, Deworming and measles vaccination ........... 19

LIST OF ANNEXES

Annex 1: List of sampled clusters ............................................................. 22

Annex 2: Badhan District Plausibility report ................................................. 23

Annex 3: Badhan District Standardization test report ...................................... 24

Annex 4: Badhan District calendar of events, 2019 ......................................... 27

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ACRONYMS AND ABBREVIATIONS

AIMWG Assessment and Information Management Working Group

CHW Community Health Worker

CI Confidence Interval

CMAM Community Management of Acute Malnutrition

DEFF Design Effect

ENA Emergency Nutrition Assessment

FSNAU Food Security and Nutrition Analysis Unit

GAM Global Acute Malnutrition

HAZ Height for Age Z-score

HH/s Household/s

IDPs Internally Displaced Persons

IMCI Integrated Management of Childhood Illnesses

IPC Integrated Phase Classification

IYCF Infant and Young Child Feeding

KAP Knowledge, Attitudes and Practices

LCL Lower Confidence Limit

MIYCN Maternal, Infant and Young Child Nutrition

MOH Ministry of Health

MUAC Mid Upper Arm Circumference

ODK Open Data Kit

OFDA Office of Foreign Disaster Assistance

OTP Outpatient Therapeutic Programme.

PPS Probability proportional to size

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring and Assessment of Relief and

Transitions

TEM Technical Error of Measurement

TSFP Targeted Supplementary Feeding Program

UCL Upper Confidence Limit

VAS Vitamin A Supplementation

WASH Water, Sanitation and Hygiene

WAZ Weight for Age Z-Score

WHO World Health Organization

WHZ Weight for Height Z- Score

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EXECUTIVE SUMMARY

CARE has been providing emergency relief and lifesaving assistance to the Somali people

since 1981. Since then, its programs have evolved to include water and sanitation, Food

security and livelihood, Nutrition and Education. CARE Somalia is currently operational

in the northern regions of Puntland and Somaliland1. The nutrition program being

implemented in 21 villages of Badhan and Lascanod Districts aims to address high

malnutrition rates through treatment of Acutely Malnourished Children, pregnant and

lactating women, referral and treatment of severely malnourished cases with medical

complication as well as community based IYCF programs for improving IYCF practices

in the community.

With financial support from the Office of Foreign Disaster assistance (OFDA), CARE

Somalia conducted a SMART survey in Badhan District in October 2019. The goal of the

survey was to determine a district representative prevalence of acute malnutrition in

Badhan district. The survey was also a follow up to the last FSNAU Post Deyr 2019 survey

and its findings will be used to inform for baseline/continuation of the project beyond

2019

The SMART survey adopted a cross-sectional study design applying two-stage cluster

sampling based on the probability proportional to population size (PPS). The first stage

involved the selection of 36 clusters/villages by the ENA software while the second

stage involved the selection of 16 households in each of the sampled clusters to be

surveyed through simple random sampling. The survey targeted 522 children from 564

households for the anthropometric survey as determined by ENA for SMART (July 19,

2015 update). Eventually, a total of 552 households from 36 clusters were surveyed

with 689 children 6-59 months included in the survey. The key findings of the survey

are shown in the table below;

Table 1: Summary of Main Survey Results

SUMMARY OF SURVEY RESULTS, OCTOBER 2019

INDICATOR N n % 95% CI

ANTHROPOMETRIC RESULTS (6-59 MONTHS) WHO 2006

Wasting (WHZ)

Prevalence of global malnutrition

(<-2 z-score and/or oedema)

678 91 13.4 10.5 – 17.0

Prevalence of moderate malnutrition (<-2

z-score and >=-3 z-score, no oedema)

80 11.8 9.0-15.4

1 https://www.care-international.org/where-we-work/somalia

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Prevalence of severe malnutrition (<-3 z-

score and/or oedema)

11 1.6 0.9 – 2.8

Prevalence of GAM by MUAC

Prevalence of global malnutrition (< 125

mm and/or oedema)

689 24 3.5 2.1-5.8


mm and >= 115 mm, no oedema)

22 3.2 1.9-5.4


mm and/or oedema)

2 0.3 0.1-1.2

Underweight (WAZ)

Prevalence of underweight (<-2 z-score) 685 90 13.1 11.0-15.6

Prevalence of moderate underweight (<-2

z-score and >=-3 z-score)

86 12.6 10.5-14.9

Prevalence of severe underweight (<-3 z-

score)

4 0.6 0.2-1.5

Stunting (HAZ)

Prevalence of stunting (<-2 z-score) 673 83 12.3 9.9-15.3

Prevalence of moderate stunting (<-2 z-

score and >=-3 z-score)

69 10.3 8.3-12.7

Prevalence of severe stunting (<-3 z-

score)

14 2.1 1.2-3.6

CHILD IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND DEWORMING

Measles immunization( 9-59 months) –(

Card and Recall)

660 420 63.6 58.5-69.2

Vitamin A supplementation coverage

children 6-59 months

689 454 65.9 62.3- 69.3

Deworming for Children (12-59 months) in

the last 6 months

615 252 41.0 37.2-45.0

CHILD MORBIDITY AND HEALTH SEEKING BEHAVIOR

Prevalence of reported illness (6-59

months) 14 days mothers/caregivers

recall

689 256 37.2 33.6-40.8

Fever 224 87.5 82.8-91.3

Cough 172 67.2 61.1-72.9

Diarrhea 40 15.6 11.4-20.7

Skin infections 10 3.9 1.9-7.1

Eye infections 1 0.4 0.01-2.7

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Other illnesses 24 9.4 6.1-13.6

Health seeking for sick children 129 50.4 44.1-56.7

Main location of health seeking –Private

health facilities

129 36 37.2 28.9-46.2

The findings revealed a nutrition situation which is serious as evidenced by the GAM

prevalence of 13.4% (10.5 – 17.0 95% C.I.) based on the WHO emergency thresholds.

Based on the survey findings, the following actions were recommended to improve

delivery of health and nutrition services in Badhan District;

1) CARE Somalia should continue with nutrition services in Badhan District and scale

up to uncovered locations in order to address the serious levels of malnutrition.

Outreach services need to be considered in volatile or hard to reach areas.

2) Screening for malnourished cases by MUAC at the community level needs to be

enhanced. This will help contain the situation and avoid at risk cases getting

malnourished, while also having moderately malnourished cases treated early.

3) The indicators for Deworming, Vitamin A supplementation and immunization

performed below the WHO targets. There is therefore nee to scale up community

activities to promote the uptake of vitamin A and deworming, as well as promoting

the uptake of other immunization services.

4) Strengthen the routine Vitamin A supplementation and deworming. This should be

given more priority to improve the indicators considering the stability in the area,

coverage and access to the health facilities.

5) Enhance health facility documentation. A training can be conducted on the health

facility staff on documentation of routine activities. This can be accompanied by

periodic data audits and verification exercises.

6) Considering the effect malnutrition has on the younger children, there is need to

strengthen the MIYCN activities in the district, with a key focus on Exclusive

breastfeeding and complimentary feeding, while also improving on poor practices

such as bottle feeding. A significant proportion of 38.5% of the children in the KAP

survey conducted in the area had been bottle fed.

7) A capacity assessment should be done on the public health facilities, including the

lower levels of care in the community with a view of promoting customer service

and promoting services access.

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1.0 INTRODUCTION

1.1 Background

Badhan district is among the four administrative districts of Sanaag region located on

the north eastern tip of Somaliland neighboring Sool and Togdheer regions. The

population of Sanaag region is estimated at 270,367 (UNDP 2005)2. More than 79% of

the population live in the rural areas predominantly practicing pastoral as the main

source of livelihood with pockets of agro-pastoral areas. Over the years, the region has

experienced recurring droughts and floods which depleted livestock herds adversely

and resulted in urban migration. Approximately, 5,000 people from the region were

displaced due to riverine and flash floods in May 20193. Most of the affected internally

displaced persons (IDPs) have left rural areas in Sanaag, Lower Shabelle, Bakool and

Bay to areas within or outside their region Political instability surrounding

administrative ownership of the region between Somaliland and Puntland remain a huge

challenge to the security and overall humanitarian effort in Badhan District and the

entire Sanaag region.

CARE has been providing emergency relief and lifesaving assistance to the Somali people

since 1981. Its main program activities since then have included projects in water and

sanitation, sustainable pastoralist activities, civil society and media development,

small-scale enterprise development, primary school education, teacher training, adult

literacy and vocational training. CARE Somalia is currently operational in the northern

regions of Puntland and Somaliland4.

Since 2018 CARE has been implementing Nutrition, health and FSL services in Badhan

and Lascanod covering 21 villages. The CARE nutrition program aimed to address the

high malnutrition rates through treatment of Acutely Malnourished Children under 5,

pregnant and lactating women, referral and treatment of complicated cases of SAM and

improving IYCF practices amongst the community through community based IYCF

programs.

CARE International received a grant from OFDA/USAID to carry out humanitarian

assistance in Bari, Galgadud, Mudug, Nugaal, Sanaag, Sool, and Togdheer regions of

Puntland, Galgadud and Somaliland. The interventions happened over 1-year period

from October 2018 to September 2019. The project provided temporary employment,

treatment services for acutely malnourished children and pregnant and lactating

women, basic health services, protection services, safe water to communities including

hygiene promotion as well as provision of WASH Non-Food Items (mainly hygiene kits)

2 UNDP population Figure - 2005 3 Food and Nutrition Analysis Post Gu 2019, Technical Report No xI. 50, august 18, 2019 4 https://www.care-international.org/where-we-work/somalia

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to vulnerable households. The project aimed a total reach of 247,671 people for

assistance; equivalent to 22% of the population in IPC 3 and 4 in these regions5.

1.2 Health and nutrition situation

Sanaag region has consistently recorded serious GAM levels. Based on the FSNAU

assessments conducted in the region, the Post Deyr in 2017 recorded a GAM rate of

13.8%, with 12.6% recorded in a similar assessment in 2018. The post Gu 2019 recorded

a GAM rate of 15.8% (11.6-21.1) which showed a deteriorating nutrition situation. In the

absence of large-scale humanitarian assistance, food security is expected to rapidly

deteriorate to emergency IPC Phase 4 in Northern Inland Pastoral, East Golis Pastoral

of Sanaag6.

CARE Somalia, with the support of the ministry of health Puntland are supporting Infant

and Young Child Feeding (IYCF) programming at all levels of the nutrition system in

order to have an integrated and comprehensive approach of delivering basic nutrition

services. With financial support from OFDA/USAID, CARE has been supporting 18 sites

covering 14 villages through 2 mobile teams and 2 static sites.

A baseline IYCF survey was conducted in September 2018 in Sool and Sanag region in

our areas of operation (Badhan, Ceelafweyn, Erigavo, Lascanod). The IYCF end line

study was conducted in Bari, Sool and Sanag region (Bosaso, Badhan, Ceelafweyn,

Erigavo, Lascanod and Taleh) in September 2019. The survey findings showed that

exclusive breastfeeding was at 75.8%, while 84% of the children 6-8 months had been

introduced to complimentary foods on a timely manner. Only 29.6 had continued

breastfeeding beyond 2 years with 58.4% breastfeeding beyond one year. Dietary

diversity was low at 4.5% with a meal frequency of 63%.

1.3 Justification of the survey

CARE had been implementing Nutrition, health and FSL services in Badhan District

aimed to address the high malnutrition rates through treatment of Acutely Malnourished

Children below 5 years of age, pregnant and lactating women, referral and treatment

of complicated cases of SAM and improving IYCF practices amongst the community

through community based IYCF programs.

To understand malnutrition situation, CARE planned and conducted the first SMART

survey to determine district representative prevalence of acute malnutrition in Badhan

5 https://reliefweb.int/job/3305148/terms-reference-tor-smart-survey-sool-and-sanag-regions-drought-response-and-recovery 6 SOMALIA Food Security Outlook, June 2019 to January 2020

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district. The survey was also a follow up to the last FSNAU Post Deyr 2019 survey report.

The findings of this survey will also be used by CARE to inform for baseline and

continuation of the project into 2020.

1.4 Survey objectives

The overall objective of this survey was to assess the prevalence of acute malnutrition

among children 6-59 months in Badhan District.

1.4.1 Specific Objectives

i) To estimate the current prevalence of acute malnutrition among children aged

6 – 59 Months.

ii) To estimate the coverage of measles vaccination (9-59 months), Vitamin A

supplementation (6-59 months) and deworming (12-59 months)

iii) To assess common morbidity among children 6-59 months based on a 2 weeks’

recall

iv) To draft actionable and localized recommendations based on the findings. Using

assessment for action approach clearly indicating the finding, recommendations

actions, timelines and responsibility and monitoring.

1.5 Survey location and timing

The survey was conducted in Somalia’s Badhan District located in Sanag Region in

October 2019. The survey timing fell on post Gu season as shown in Figure 1 below.

Figure 1: Badhan Seasonal Calendar

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2.0 METHODOLOGY

2.1 Study design

The SMART survey adopted a cross-sectional study design applying two-stage cluster

sampling based on the probability proportional to population size (PPS). The first stage

involved selection of clusters/villages by the ENA software while the second stage

involved the selection of households to be surveyed through simple random sampling.

2.2 Target group

Based on the objectives of this study, the survey targeted children age 6-59 months.

Table 2: Survey target group

Key Indicators Targeted Population

Prevalence of acute malnutrition Children 6-59 months

Child morbidity and health seeking Children 6-59 months

Vitamin A supplementation Children 6-59 months

Measles immunization Children 9-59 months

Deworming Children 12-59 months

2.3 Data and data collection methods

Table 3: Data and collection methods

Data and collection methods

Anthropometric Data

Age - Health cards and birth certificates were used to determine precise age of the

child. Local calendar of events was used in the absence of documentation for children

6-59 months

Sex – Was recorded as either ‘f’ for female or ‘m’ for male

Weight - Standardized SECA scales were used

Height - Standard height boards were used for taking length and height. Children less

than 24 months were measured lying down and children greater than or equal to 24

months were measured in standing position

MUAC – Was taken using standardized and MOH approved MUAC tape. All children 6-

59 months were measured on the left arm to the nearest 0.1cm or 1.0 mm

Bilateral oedema - All children were checked for oedema; minimal thumb pressure

was applied to the top of the feet for about 3 seconds

Vitamin A supplementation – All children 6-59 months were assessed for Vitamin A

supplementation in the past one year.

Prevalence of child morbidity – this was assessed based on a 2 weeks (14 days) recall

period for all the children 6-59 months

5

Health seeking behavior – For all the children reported ill, the caregivers were

assessed on if and where they sought assistance for their sick children

Measles vaccination – Measles vaccination either by recall or by card was assessed in

all children aged 9-59 months in the survey

Deworming - Supplementation with deworming tablets was assessed in children 12-

59 months in the survey.

2.4 Sample size determination

2.4.1 Anthropometry sample size

The sample size for anthropometric survey was determined using ENA for SMART

software (July 9, 2015 version). As shown below, the population parameters for Badhan

Districts, Sanaag region were used to obtain the number of children and households to

be included in the survey.

Table 4: Sample size determination

Population Parameters Value Rationale/Source

Estimated Prevalence of

GAM (%) 15.8%

Somalia June-July 2019 surveys, FSNAU.

East Golis (Sanag) reported a GAM of

15.8% (11.6-21.1)

Desired precision 4 Reasonable precision in consideration of

estimated GAM and associated resources

Design Effect 1.5 Was adjusted due to high DEFF 2.9

reported for East Golis survey

Children to be included 522

Average HH Size 5.3 Somalia June-July 2019 surveys, FSNAU

% Children under 5s 20%

Adjusted from the Somalia June-July

2019 surveys, FSNAU of 26.8% for East

Golis (Sanag)

%Non-response Households 3% Anticipated Non-Response Rate

Households to be included 564

Number of households per cluster

The number of households to be completed per day in each cluster was determined

according to the time each team could spend conducting the survey excluding travel

time to the field and back, initial introduction and breaks.

The total amount of time available to work in a day was 9 hours (8:00 am – 5:00 pm).

After exclusion of the travelling time, the initial introduction and household and lunch

break, the amount of time left to conduct the survey was 7 hours. The amount of time

6

to be spent conduct the survey in one households was 25 minutes. The details below

were taken into consideration when performing this calculation based on the Badhan

District context:

▪ Departure from the base at 8:00 am and back at 5:00 pm.

▪ Average return travel time for each cluster: 1 hours

▪ Duration for initial introduction and selection of households: 0.5 hours

▪ Time spent to move from one household to the next: 5 minutes

▪ Average time in the household: 20 minutes

▪ Breaks: 1 lunch/prayer break of 0.5 hours

𝑛ℎℎ =(9−1−0.5−0.5)60min

20+5 = 16.8 households (this is rounded down to 16).

Based on this calculation, 16 households were planned per village/cluster to be included

in the survey.

Number of Clusters for Badhan District

The number of clusters for Badhan district was determined by dividing the total

households sample and 16 households (representing one cluster) i.e. number of clusters

=564/16 = 35.3, this was rounded up to 36 clusters.

2.4.2 Summary of sampling methods

First stage Cluster sampling

The first stage involved the selection of 36 clusters in Badhan district using the ENA for

SMART software based on population proportion to size (PPS). This was done using most

recent list of villages with their population sizes.

Second stage sampling

The second stage involved selection of 16 households in each of the 36 sampled clusters.

With the assistance of village leaders, household listing was done on the survey day

followed by simple random sampling using a random number generator mobile

application. Clusters with households above 200 or sparsely populated were segmented

before applying simple random selection of the households.

2.5 Organization of the survey

2.5.1 Recruitment and Composition of survey teams

Care Somalia, with the guidance of the consultant developed the criteria for recruiting

7 survey teams, composed of 1 team leader and 2 data collectors. In total the survey

recruited 21 enumerators to form 7 teams each composed of 3 persons. The selection

process considered key factors such as the level of education, previous experience in

7

conducting surveys, the ability to read and communicate in English and undoubted

fluency in Somali dialects.

2.5.2 Training of the survey teams

The survey teams were trained over a period of 4 days in Garowe town. The training

mainly focused on anthropometric measurements, survey teams, field procedures

translation and back-translation of the questionnaires, data recording using ODK and

second stage sampling. On day 3, standardization test was conducted using 10 healthy

children (6-59 months) to determine enumerators’ precision and accuracy in recording

measurements.

The pre-test was conducted on the fourth day in two non-sampled villages; Badhan-

30ka and Dhanaha. The results from the pre-test were analyzed, feedback shared and

the identified gaps addressed appropriately for each team prior to data collection and

final team formation.

2.5.3 Field Data Collection

The implementation of field data collection was conducted for 7 days. Data was

collected using ODK mobile application. Each team used one mobile phone with two

back-up phones. Close Supervision of the teams was done by the survey consultant,

CARE staff and MOH representative. At the end of each day’s data collection, the survey

manager reviewed all questionnaires for completeness, errors and corrections done

prior to sending the data to the server. Plausibility checks were done on a daily basis

and feedback given to the teams.

2.6 Data Management

2.6.1 Data Quality Control

To ensure data quality, the following measures were put in place;

▪ Review and validation of the protocol and report by the AIMWG

▪ 4-day comprehensive training including standardization and pilot test

▪ Field supervision of the survey teams during data collection by the Ministry of

Health representative, consultant, the CARE program staff

▪ Distribution of enumerator strengths across the teams

▪ Calibration and standardization of the survey equipment

▪ Use ODK platform to collect and organize data

▪ Use of Cluster Control forms for survey outcome for every sampled household

▪ Daily plausibility checks and sharing feedback with the teams every morning

before proceeding to the field

▪ Adequate logistic planning during field work

8

2.6.2 Data Collection Tools

The SMART methodology approved anthropometry tool was used. The guidance of the

Somalia AIMWG was applied designing the additional variables tool. The final tool

combined anthropometry and additional variables (child morbidity, deworming,

measles and vitamin A coverage).

2.6.3 Data Entry and Analysis

The ODK collected was exported into MS Excel, organized and subsequently analyzed.

The anthropometric data was uploaded into ENA for SMART 2011 software (July 9, 2015

version) for quality checks and analysis. Data obtained from additional variables was

reviewed and analyzed using EPI Info 7.

9

3.0 RESULTS- Badhan District

The anthropometric survey in Badhan district targeted 522 children 6-59 months from

564 households. The process of determining clusters led to an adjustment of the

households to 576 households were sampled, after which 5527 households were

surveyed with a cumulative total of 689 children. The summary of the survey

completeness is shown in the table below;

Table 5: Summary of survey completeness

CLUSTERS HOUSEHOLDS CHILDREN 6-59 MONTHS

Planned 36 Planned 564 Planned 522

Surveyed 36 Surveyed 552 Surveyed 689

% surveyed 100% % surveyed 97.9% % surveyed 130%

3.1 Anthropometric Results

All the children aged 6-59 months in the sampled households were included in the

anthropometric survey. This involved taking their requisite measurements (age, sex,

weight, height, MUAC and oedema) to determine their nutritional status based on the

different anthropometric indices.

3.1.1 Distribution by age and sex

There were a total of 689 children in the survey. Among the children, 357 were boys

while 332 were girls hence achieving a boy: girl ratio of 1.1. This shows an equal

representation of both sexes as evidenced by the resulting p-value = 0.3421. The age

ratio of children 6-29 months (younger children) to children 30-59 months (older

children) was 1.02 (The value should be around 0.85). Despite this value showing a

significant difference (p-value = 0.016), the ration was near the expected value of 1.02

the representation of younger and older children in the survey was acceptable.

Table 6: Distribution of age and sex of sample

Boys Girls Total Ratio

AGE (mo) no. % no. % no. % Boy:girl

6-17 91 51.1 87 48.9 178 25.8 1.0

18-29 94 55.3 76 44.7 170 24.7 1.2

30-41 78 49.7 79 50.3 157 22.8 1.0

42-53 74 51.0 71 49.0 145 21.0 1.0

54-59 20 51.3 19 48.7 39 5.7 1.1

Total 357 51.8 332 48.2 689 100.0 1.1

7 There were 24 absent households absent across the 36 clusters

10

The age and sex distribution is further presented in the graph below, showing an equal

representation of boys and girls in the survey.

Figure 2: Age and sex pyramid

3.1.2 Prevalence of Wasting (WHZ)

Global acute malnutrition (GAM) was defined as <-2 z-scores weight-for-height and/or

oedema and severe acute malnutrition (SAM) was defined as <-3 z-scores weight-for

height and/or oedema.

The survey made exclusions using the SMART flags (WHZ -3 to 3) based on the observed

mean. This is as recommended by the SMART methodology for small scale surveys. The

final sample used for the determination of GAM was 678 children after 11 children were

excluded with z-scores out of range.

Based on the WHZ, the analysis recoded a Global Acute Malnutrition (GAM) rate of 13.4

%( 10.5 - 17.0 95% C.I) and a SAM prevalence of 1.6 %( 0.9 - 2.8 95% C.I.). According the

to the WHO standards, the results indicate a serious nutrition situation in the district.

Boys in the survey were evidently more malnourished than the girls, as depicted by

their respective GAM prevalence in different thresholds.

-100 -80 -60 -40 -20 0 20 40 60 80 100

6-17

18-29

30-41

42-53

54-59

Girls Boys

11

Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex

The graphical presentation of the surveyed population shows a resulting mean of -0.79

and a standard deviation of ±1.04. The deviation of the population curve to the left

indicates a population with a poorly nourished population, as compared to the WHO

reference population.

Figure 3: Distribution of WHZ z-scores for the surveyed population

All

n = 678

Boys

n = 353

Girls

n = 325



(91) 13.4 %

(10.5 - 17.0

95% C.I.)

(59) 16.7 %

(11.9 - 23.0

95% C.I.)

(32) 9.8 %

(6.6 - 14.5

95% C.I.)

Prevalence of moderate

malnutrition

(<-2 z-score and >=-3 z-score, no

oedema)

(80) 11.8 %

(9.0 - 15.4

95% C.I.)

(54) 15.3 %

(10.6 - 21.6

95% C.I.)

(26) 8.0 %

(4.8 - 13.1

95% C.I.)

Prevalence of severe malnutrition


(11) 1.6 %

(0.9 - 2.8 95%

C.I.)

(5) 1.4 %

(0.6 - 3.3 95%

C.I.)

(6) 1.8 %

(0.9 - 3.7 95%

C.I.)

12

The survey did not record any oedema case, with only 1.7% of the children classified as

marasmic. This is shown in the table below;

Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z-

scores

<-3 z-score >=-3 z-score

Oedema present Marasmic kwashiorkor

No. 0

(0.0 %)

Kwashiorkor

No. 0

(0.0 %)

Oedema absent Marasmic

No. 12

(1.7 %)

Not severely malnourished

No. 677

(98.3 %)

The analysis of wasting by age groups showed that younger children were more affected

by malnutrition more than the older children for both severe and moderate wasting.

This is the group on transition from exclusive breast feeding and complementary

feeding, hence more vulnerable to the effects of inadequate nutrition. The findings

may also indicate poor child care practices within this group.

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores

and/or oedema

Severe

wasting

(<-3 z-score)

Moderate

wasting

(>= -3 and <-2

z-score )

Normal

(> = -2 z

score)

Oedema

Age

(mo)

Tota

l no.

No. % No. % No. % No. %

6-17 176 3 1.7 23 13.1 150 85.2 0 0.0

18-29 166 2 1.2 17 10.2 147 88.6 0 0.0

30-41 153 5 3.3 20 13.1 128 83.7 0 0.0

42-53 144 1 0.7 13 9.0 130 90.3 0 0.0

54-59 39 0 0.0 7 17.9 32 82.1 0 0.0

Total 678 11 1.6 80 11.8 587 86.6 0 0.0

3.1.3 Prevalence of Acute Malnutrition by MUAC

In children aged 6-59 months, the Mid-Upper Arm Circumference (MUAC), with simple

cut-offs of MAM (>=115 mm to <125 mm) and SAM (<115 mm has shown to be a better

13

predictor of mortality risk that is associated with malnutrition8. MUAC is used to monitor

malnutrition trends and for admission and discharge in nutrition programmes since its

measurements can be done easily, quickly and affordably

The analysis of GAM by MUAC involved all the 689 children in the survey. This was in

consideration of the MUAC cut offs applied in Somalia, where GAM is defined as MUAC

<125mm and SAM defined as MUAC <115 mm. The results showed a GAM prevalence of

3.5 % (2.1 - 5.8 95% C.I.) and a SAM prevalence of 0.3 % (0.1 - 1.2 95% C.I.). Girls and

boys in the survey were equally malnourished.

Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema)

and by sex

All

n = 689

Boys

n = 357

Girls

n = 332


(< 125 mm and/or oedema)

(24) 3.5 %

(2.1 - 5.8 95%

C.I.)

(11) 3.1 %

(1.5 - 6.2 95%

C.I.)

(13) 3.9 %

(2.0 - 7.6 95%

C.I.)


malnutrition

(< 125 mm and >= 115 mm, no

oedema)

(22) 3.2 %

(1.9 - 5.4 95%

C.I.)

(10) 2.8 %

(1.4 - 5.4 95%

C.I.)

(12) 3.6 %

(1.8 - 7.3 95%

C.I.)

Prevalence of severe malnutrition

(< 115 mm and/or oedema)

(2) 0.3 %

(0.1 - 1.2 95%

C.I.)

(1) 0.3 %

(0.0 - 2.1 95%

C.I.)

(1) 0.3 %

(0.0 - 2.3 95%

C.I.)

Further analysis of the wasting by MUAC based on the age groups shows that younger

children 6-17 months and 18-29 months were most affected by malnutrition with most

of the severely acutely malnourished children falling in the 6-17 months category. This

may be indicative of a gap in infant and young child nutrition, where the children

transitioning from exclusive breastfeeding to complimentary feeding may not be getting

adequate nutrition. The findings indicate poor IYCF practices in the district.

8 Chiabi, Andreas, et al. "Weight-for-height z score and mid-upper arm circumference as predictors of mortality in children with severe acute malnutrition." Journal of tropical pediatrics63.4 (2016): 260-266

14

Figure 4: Prevalence of acute malnutrition by age, based on MUAC cut offs and/or

edema

3.1.4 Prevalence of Underweight (WAZ)

Underweight refers to inadequate weight relative to age and is measured using weight-

for-age z-scores (WHO 2006). A child can have a low weight-for-age because they are

short, thin or a bit of both and therefore underweight is considered a composite

indicator for stunting and wasting9.

The analysis of underweight involved 685 children after 4 children were excluded with

z-scores out of range. The survey recorded an underweight prevalence of 13.1 %(11.0 -

15.6 95% C.I.) with a severe underwiehgt prevalence of 0.6 % (0.2 - 1.5 95% C.I.). This

indicates an alert nutrition situation based on the WHO classification of underweight10.

Boys in the survey had a higher prevalence of underweight than girls, with a 0.0%

underweight prevalence in girls. This is detailed in the table below;

Table 11: Prevalence of underweight based on weight-for-age z-scores by sex

All

n = 685

Boys

n = 356

Girls

n = 329

Prevalence of underweight

(<-2 z-score)

(90) 13.1 %

(11.0 - 15.6

95% C.I.)

(60) 16.9 %

(13.3 - 21.1

95% C.I.)

(30) 9.1 %

(6.7 - 12.3

95% C.I.)

9 Tanya K and Carmel D. the relationship between wasting and stunting, policy programming and research implications, 1915-1918. "Technical Briefing Paper 12.4 (July 2014): 8-9 10 Alert/medium 10-19.9

15


underweight

(<-2 z-score and >=-3 z-score)

(86) 12.6 %

(10.5 - 14.9

95% C.I.)

(56) 15.7 %

(12.4 - 19.8

95% C.I.)

(30) 9.1 %

(6.7 - 12.3

95% C.I.)

Prevalence of severe

underweight

(<-3 z-score)

(4) 0.6 %

(0.2 - 1.5

95% C.I.)

(4) 1.1 %

(0.4 - 3.0

95% C.I.)

(0) 0.0 %

(0.0 - 0.0

95% C.I.)

3.1.5 Prevalence of Stunting (HAZ)

Stunting is defined as a slowing or halting of linear growth or ‘linear growth faltering’.

This is commonly identified by a child falling off the standard growth trajectory

compared to their age as described by the WHO growth standards11. A child is classified

as stunted when their height-for-age is more than two standard deviations below the

WHO Child Growth Standards median.

After exclusion of 16 children whose measurement were out of range, a total of 673

children were included in the analysis of stunting. The survey recording a low stunting12

prevalence of 12.3 %( 9.9 - 15.3 95% C.I.). Boys and girls in the survey were equally

stunted as shown in the table below;

Table 12: Prevalence of stunting based on height-for-age z-scores and by sex

All

n = 673

Boys

n = 348

Girls

n = 325

Prevalence of stunting

(<-2 z-score)

(83) 12.3 %

(9.9 - 15.3

95% C.I.)

(48) 13.8 %

(10.3 - 18.2

95% C.I.)

(35) 10.8 %

(7.6 - 15.0

95% C.I.)

Prevalence of moderate stunting

(<-2 z-score and >=-3 z-score)

(69) 10.3 %

(8.3 - 12.7

95% C.I.)

(38) 10.9 %

(8.1 - 14.6

95% C.I.)

(31) 9.5 %

(6.7 - 13.4

95% C.I.)

Prevalence of severe stunting

(<-3 z-score)

(14) 2.1 %

(1.2 - 3.6 95%

C.I.)

(10) 2.9 %

(1.7 - 4.9

95% C.I.)

(4) 1.2 %

(0.5 - 3.1

95% C.I.)

11 Tanya K and Carmel D. the relationship between wasting and stunting, policy programming and research implications, 1915-1918. "Technical Briefing Paper 12.4 (July 2014): 8-9) 12 WHO classification of stunting , Low <20%

16

3.1.6 Mean z-scores, Design Effects and excluded subjects

The table below presents a summary of the three anthropometric indices as analysed

in the survey. The total number of children 6-59 months included in the survey was 689.

Exclusions were made before analysis for each anthropometric index using the smart

flags, which are based on the observed mean. The final sample used in analysis of

wasting, (WHZ), underweight (WAZ) and stunting (HAZ) is provided in the table below,

with the corresponding mean and the design effect for each index. The standard

deviation for all the indices was within the acceptable range of 0.85 - 1.2 indicating

quality measurements. Details are shown in the table below;

Table 13: Mean z-scores, Design Effects and excluded subjects

Indicator n Mean z-

scores ± SD

Design Effect

(z-score < -2)

z-scores not

available*

z-scores out

of range

Weight-for-Height 678 -0.79±1.04 1.51 0 11

Weight-for-Age 685 -0.89±0.97 1.00 0 4

Height-for-Age 673 -0.69±1.13 1.11 0 16

* contains for WHZ and WAZ the children with oedema.

3.2 Child morbidity and immunization coverage

3.2.1. Child Morbidity

Morbidity data was collected retrospectively based on a two week recall period. All the

caregivers were asked whether their child had suffered any illness and the type of

illness two weeks prior to the survey. The findings of the survey show that 37.6% of the

children in the survey had suffered at least one illness two weeks prior to the survey.

Fever and cough were the predominant illnesses, suffered by 87.5% and 67.2% of the

sick children respectively. The other illnesses reported in the survey are shown in the

graph below;

17

Figure 5: Common illnesses reported

3.2.2 Health seeking behaviour

To assess the health seeking behaviour, caregivers were asked what they did the last

time their child was sick. A notable proportioning (49.6%) of the caregivers did not seek

any type of assistance when their child was ill. This may be as a result of the caregivers’

assumption that the illness was not serious enough to warrant any external assistance.

Most of the caregivers who sought assistance preferred private clinics (37.2%) and public

health facilities (27.9%). The other places where the caregivers sought assistance are

shown in the figure below;

Figure 6: Health seeking behavior

87.5%

67.2%

15.6%

3.9%0.4%

9.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FEVER COUGH DIARRHOEA SKIN INFECTION EYE INFECTIONSOTHER ILLNESES

I LLNESSES REPORTED

0% 5% 10% 15% 20% 25% 30% 35% 40%

Private clinic

Public health facilities/hospital

Phamarcy/chemist

Shop

CHW/Community Nutrition worker

Traditional healer

Religious leaders

37.2%

27.9%10.1%

10.1%

9.3%

3.1%

2.3%Health Seeking Behaviour

18

3.2.3 Child immunization, vitamin a supplementation, and deworming

WHO recommends that Children be supplemented with Vitamin A at 6 months and

subsequently at 6 months’ intervals until a child reaches 5 years old13. Deworming at

least biannually using single doses of albendazole (400 mg) or mebendazole (500 mg) is

recommended as a public health intervention for all young children 12–23 months of

age, preschool children 1–4 years of age, and school-age children 5–12 years of age14.

To assess the coverage of vitamin A supplementation and deworming, the caregivers

were shown vitamin A (6-59 months) and deworming tablets (12-59 months), which was

meant to aid them recall if their children had received such in the past 12 months and

past 6 months respectively. Measles vaccination was also assessed in all children 9-59

months in the survey based on the EPI card or on recall where the cards were not

available.

The survey findings show that 65.9% of the children 6-59 months had been

supplemented with vitamin A in the past 12 months, while less than half (44.9% of the

children 12-59 months had been dewormed 6 months prior to the survey. More than half

(63.6%) of the children 9-59 months in the sample had been immunized against measles

with only 4.4% being verified by the EPI card. The routine program data in the district

reported a measles coverage of 62.2%15, which is similar to the coverage found in the

survey. The performance of Vitamin A, deworming and also measles fall below the WHO

recommended coverage of 80%, hence the need to put in place measures for scale up

to achieve the desired public health significance.

13 www.who.int/nutrition/publications/vitamins_minerals/en/index.html 14 Deworming and adjuvant interventions for improving the developmental health and well-being of children in low- and middle-income countries: a systematic review and meta-analysis 15 EPI coverage, Badhan district

19

Figure 7: Vitamin A Supplementation, Deworming and measles vaccination

65.9%

44.9%

63.6%

0%

10%

20%

30%

40%

50%

60%

70%

Vitamin A (6-59 months) Deworming (12-59 months) Measles (9-59 months)

Vaccination and Immunization

20

4.0 conclusion

The nutrition situation in Badhan district is serious as evidenced by the GAM prevalence

of 13.4% (10.5 – 17.0 95% C.I.) based on the WHO emergency thresholds. A nutrition and

food security assessment had been conducted in East Golis (Sanaag) where Badhan

district is included, which showed a GAM of 15.8% (11.6-21.1). The area has consistently

recorded serious nutrition levels based on the GAM prevalence from the FSNAU

assessments. The Post Deyr Food security and nutrition assessment conducted in 2017

recorded a GAM rate of 13.8%, with 12.6% recorded in a similar assessment in 2018.

GAM prevalence by MUAC was low 3.5% (2.1- 5.8 95% CI) as compared to the prevalence

by WHZ. This is expected as MUAC is more sensitive at high specificity levels than WHZ

for identifying children at high risk of death. It is worth noting that MUAC and WHZ do

not always identify the same children as having SAM hence the difference in the

prevalence of malnutrition by the 2 criteria16. The 2 criteria should be used in

management of acute malnutrition, with MUAC being the most effective for screening

children at the community level.

Based on the SMART survey results, the younger children (6-29 months) were the most

affected by acute malnutrition as compared to the older children. Malnutrition at such

an early age can be attributed to the fact that infants have high nutrient requirements

and are more susceptible to infection especially at this age when they are being

introduced to solid and semi-solid foods. The high rates of wasting in this group may be

suggestive of inadequate nutrition and care practices within this group, hence a need

to enhance child care practices through MIYCN programs in the district. The prevalence

of underweight was alert at 13.1% (11.0 - 15.6 95% C.I.) while the prevalence of stunting

was low at 12.3% (9.9 – 15.3, 95% C.I).

The assessment of child morbidity showed a morbidity rate of 37.6%, with the main

illnesses reported being fever and cough at 81.5% and 67.2% respectively. It is however

concerning that almost half (49.6%) of the caregivers with sick children did not seek

any kind of assistance when the children were sick. This may be due to factors like the

caregivers not prioritizing some illnesses, distance to the health facilities or the

caregivers not well informed on when and where to seek assistance when the child is

sick. Private facilities were the most preferred by the caregivers (37.2%) as compared

to the public health facilities (27.9%). The cost associated with the private facilities,

and the low preference to public health facilities may be a contributing factor for some

caregivers not seeking treatment for their sick children.

Although vitamin A supplementation was below the WHO recommended threshold of

80%, it was commendable that 65.9% of the children had been supplemented at least

16 Grellety E, Golden MH. Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr. 2016;2:10.

21

once in the past 12 months. Deworming was low at 44.9% for children 12-59 months

while measles vaccination was 63.6%. measles vaccination was majorly confirmed by

recall, hence the need to improve on the documentation of vaccinations through the

EPI program, as well as documenting the births, which will help in timely and effective

immunizations. There is a need to improve the awareness on immunizations and

vaccinations so as to reach levels which can bring a public health significance.

5.0 Recommendations

1) CARE Somalia should continue with nutrition services in Badhan District and scale

up to uncovered locations in order to address the serious levels of malnutrition.

Outreach services need to be considered in volatile or hard to reach areas.

2) Screening for malnourished cases by MUAC at the community level needs to be

enhanced. This will help contain the situation and avoid at risk cases getting

malnourished, while also having moderately malnourished cases treated early.

3) The indicators for Deworming, Vitamin A supplementation and immunization

performed below the WHO targets. There is therefore nee to scale up community

activities to promote the uptake of vitamin A and deworming, as well as promoting

the uptake of other immunization services.

4) Strengthen the routine Vitamin A supplementation and deworming. This should be

given more priority to improve the indicators considering the stability in the area,

coverage and access to the health facilities.

5) Enhance health facility documentation. A training can be conducted on the health

facility staff on documentation of routine activities. This can be accompanied by

periodic data audits and verification exercises.

6) Considering the effect malnutrition has on the younger children, there is need to

strengthen the MIYCN activities in the district, with a key focus on Exclusive

breastfeeding and complimentary feeding, while also improving on poor practices

such as bottle feeding. A significant proportion of 38.5% of the children in the KAP

survey conducted in the area had been bottle fed.

7) A capacity assessment should be done on the public health facilities, including the lower

levels of care in the community with a view of promoting customer service and promoting

services access.

22

6.0 Annexes

Annex 1: List of sampled clusters

Village name Population size Cluster Number

Badhan-Geeldoora 1 1272

1

Badhan-Geeldoora 2 2

Badhan-Waaberi 1 2915

3

Badhan-Waaberi 2 4

Badhan-Horseed 1 3074

5

Badhan-Horseed 2 6

Badhan-Horseed 3 7

Badhan-Iftin 1 2385

8

Badhan-Iftin 2 9

Badhan-Iftin 3 10

Mindigale 1 2862

11

Mindigale 2 12

Ceelbuh 1 2385

13

Ceelbuh 2 14

Ceelbuh 3 15

Rad 1 1590

16

Rad 2 17

Laako 1166 18

Cawsane 1 2385

19

Cawsane 2 20

Gumar 1219 21

Xarka-Dheere 636 22

Mindhicir 1272 23

Haylaan 1 2385

24

Haylaan 2 25

Haylaan 3 26

Caadsaaran 1590 27

Dooxadheer 1060 28

Faracad 689 29

Hadaftimo 1 4134

30

Hadaftimo 2 31

Hadaftimo 3 32

Gurmalle 398 33

Qoyan 636 34

Gooraan 795 35

Habarshiro 1113 36

23

Badhan-Golis 1034 RC

Jiicanyo 636 RC

Bendersamo 636 RC

Hadaftimo 4134 RC

Badhan-30ka 530 Pretest

Dhanaha 795 Pretest

Annex 2: Badhan District Plausibility report

Plausibility check for: SOM_102019_CARE_BADHAN.as

Standard/Reference used for z-score calculation: WHO standards 2006

(If it is not mentioned, flagged data is included in the evaluation. Some parts of this plausibility

report are more for advanced users and can be skipped for a standard evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5

(% of out of range subjects) 0 5 10 20 0 (1.6 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 0 (p=0.341)

Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 4 (p=0.016)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (5)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20

0 2 4 10 2 (10)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (6)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20

. and and and or

. Excl SD >0.9 >0.85 >0.80 <=0.80

0 5 10 20 0 (1.04)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 0 (0.14)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 0 (-0.17)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001

0 1 3 5 0 (p=0.054)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 6 %

The overall score of this survey is 6 %, this is excellent.

24

Annex 3: Badhan District Standardization test report

Standardisation test results Precision Accuracy OUTCOME

Weight subjects

mean SD

max

Technical

error TEM/m

ean

Coef of

reliability

Bias from

superv

Bias from

median result

# kg kg kg TEM (kg) TEM (%) R (%)

Bias (kg)

Bias (kg)

Supervisor 10 12.

7 2.5

0.2 0.07 0.6 99.9 - 0.81

TEM acceptable R value good Bias reject

Enumerator 1 10

12.7

2.5

0.1 0.06 0.5 99.9 -0.01 0.81


Enumerator 2 10

12.7

2.4

0.2 0.05 0.4 99.9 0 0.81


Enumerator 3 10

12.7

2.5

1.5 0.36 2.9 97.9 -0.01 0.81 TEM reject

R value acceptable Bias reject

Enumerator 4 10

12.7

2.5

0.7 0.18 1.4 99.5 -0.04 0.77 TEM poor R value good Bias reject

Enumerator 5 10

12.7

2.4

0.1 0.02 0.2 100 0 0.81 TEM good R value good Bias reject

Enumerator 6 10

12.7

2.5

0.1 0.03 0.2 100 0 0.81 TEM good R value good Bias reject

enum inter 1st 6x10

12.7

2.4 - 0.13 1 99.7 - -

TEM acceptable R value good

enum inter 2nd 6x10

12.7

2.4 - 0.23 1.8 99.1 - - TEM poor R value good

inter enum + sup 7x10

12.7

2.4 - 0.16 1.3 99.5 - -

TEM acceptable R value good

TOTAL intra+inter 6x10 - - - 0.25 2 98.9 -0.01 0.8 TEM reject

R value acceptable Bias reject

TOTAL+ sup 7x10 - - - 0.23 1.8 99.1 - - TEM poor R value good

Height subjects

mean SD

max

Technical

error TEM/m

ean Coef of

Bias from

superv Bias from result

25

reliability

median

# cm cm cm TEM (cm) TEM (%) R (%)

Bias (cm)

Bias (cm)

Supervisor 10 92.

3 10.7

3.8 0.91 1 99.3 - -1.11 TEM poor R value good Bias good

Enumerator 1 10

93.2

10.4

19.1 4.33 4.6 82.6 0.93 -0.19 TEM reject

R value reject Bias good

Enumerator 2 10 92

11.3 1 0.35 0.4 99.9 -0.24 -1.35 TEM good R value good Bias good

Enumerator 3 10

92.4 11 1 0.31 0.3 99.9 0.07 -1.04 TEM good R value good Bias good

Enumerator 4 10

91.7

11.5

3.5 0.97 1.1 99.3 -0.57 -1.69 TEM poor R value good Bias good

Enumerator 5 10

92.4

10.9

0.8 0.19 0.2 100 0.14 -0.97 TEM good R value good Bias good

Enumerator 6 10

91.9

10.1

10.1 2.28 2.5 94.9 -0.39 -1.5 TEM reject R value poor Bias good

enum inter 1st 6x10 92

10.8 - 1.62 1.8 97.7 - - TEM reject

R value acceptable

enum inter 2nd 6x10

92.6

10.7 - 2.56 2.8 94.2 - - TEM reject R value poor


92.3

10.6 - 1.91 2.1 96.6 - - TEM reject

R value acceptable

TOTAL intra+inter 6x10 - - - 2.96 3.2 92.3 -0.01 -1.12 TEM reject R value poor Bias good

TOTAL+ sup 7x10 - - - 2.75 3 93.3 - - TEM reject R value poor

MUAC subjects

mean SD

max

Technical

error TEM/m

ean

Coef of

reliability

Bias from

superv

Bias from

median result

# mm mm

mm

TEM (mm) TEM (%) R (%)

Bias (mm)

Bias (mm)

26

Supervisor 10 144

.7 10.6

4.5 1.76 1.2 97.3 - -0.29 TEM good

R value acceptable Bias good

Enumerator 1 10

146.4

10.9 25 5.83 4 71.2 1.64 1.35 TEM reject

R value reject

Bias acceptable

Enumerator 2 10

141.6 11 10 2.91 2.1 93.1 -3.07 -3.35 TEM poor R value poor Bias good

Enumerator 3 10

143.1

10.6 8 1.96 1.4 96.6 -1.57 -1.85 TEM good


Enumerator 4 10

145.6

10.4 10 4.25 2.9 83.3 0.89 0.6 TEM reject


Enumerator 5 10

145.2

12.3 6 1.9 1.3 97.6 0.49 0.2 TEM good


Enumerator 6 10

146.3

13.1 23 6.23 4.3 77.4 1.59 1.3 TEM reject

R value reject

Bias acceptable

enum inter 1st 6x10

144.8

11.9 - 4.61 3.2 85.1 - - TEM reject

R value reject

enum inter 2nd 6x10

144.6

10.8 - 5.21 3.6 76.6 - - TEM reject

R value reject


144.7

11.2 - 4.48 3.1 84 - - TEM reject

R value reject

TOTAL intra+inter 6x10 - - - 6.48 4.5 67.3 -0.01 -0.29 TEM reject


TOTAL+ sup 7x10 - - - 5.99 4.1 71.4 - - TEM reject R value reject

27

Annex 4: Badhan District calendar of events, 2019

Badhan District Calender of Events

MONTH SEASONS 2014 2015 2016 2017 2018 2019

January

Diraac

57 45 33 21 9

Mawlid War between

alshabab and

puntland

Campaing

Period for

presidency

Tukoraq war

Farmajo visited

Jubaland president

Puntland

election

February 56 44 32 20 8

Death of Prof

Mohamed Tobeel

Daalo airline

explossion

Farmajo

election

March 55 43 31 19 7

Many immigrants

from yemen

Magclay war

Sima drought

Election of

Hassan Khayre

(Prime

minister

April

GU

54 42 30 18 6

Explossion in

Garowe killing UN

staff

Heavy rains

and flooding

Sima drought Tukoraq

war

May 53 41 29 17 5

Sima drought Tukoraq war

Ramadhan

June 52 40 28 16 4

Ramadhan Ramadhan Ramadhan Tukoraq war

Ramadhan

Idd Ul fitri

28

July

Xagaa

51 39 27 15 3

Dabshid Somalia Prime

Minister visited

Puntland

August 50 38 26 14 2

Jubaland

presidential

elections

Idd ul fitri

Garacad Port

Started

September 49 37 25 13 1

Idd al Adha Idd Al Adha Idd Al Adha Idd Al Adha

October

Deyr

48 36 24 12 0

War between

Puntland and

Galmudug

Scobe?Zoobe

(Bomb attack)

Abdiwali Ali visited

Badhan

November 59 47 35 23 11

Qandala war

December 58 46 34 22 10

Bosaso airport

rebuild

Mowlid Mowlid Mowlid

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