South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEYCHILDREN UNDER 5 YEARS OLD

GALDORA AND PANAMDIT PAYAMS, (PAYUER) MALUT COUNTY, UPPERNILE REGION

FEBURUARY 23RD –MARCH 10TH, 2006

Onesmus Muinde NSP ManagerMonica Asekon-Nutritionist

Joseph Nganga -Nutritionist.Deborah Nyamorris – Program Officer

(ACF-USA)

2

ACKNOWLEDGMENTS

ACF-USA acknowledges the invaluable support and assistance of the following

-OFDA for funding the survey,

-MEDAIR both at Lokichoggio and field level for facilitating the work in the field, and accommodating the team.

-The Executive Commissioner and the SRRC in Malut for accommodating the team when they went to Malut.

-The deputy SRRC (Panamdit payam) for facilitating the work in the field.

-The local survey teams for working tirelessly in the hostile environment.

-Last but not least, thanks to the local community, particularly mothers/caretakers, for their cooperation.

3

TABLE OF CONTENTS.I. EXECUTIVE SUMMARY................................................................................................................................................ 5

.I.1. INTRODUCTION .............................................................................................................................................................. 5

.I.2. OBJECTIVES ................................................................................................................................................................... 5

.I.3. METHODOLOGY ............................................................................................................................................................. 5

.I.4. SUMMARY OF FINDINGS................................................................................................................................................. 6

.I.5. RESULTS ........................................................................................................................................................................ 7

.I.6. RECOMMENDATION’ ...................................................................................................................................................... 9

.II. INTRODUCTION ............................................................................................................................................................ 9

.III. METHODOLOGY ....................................................................................................................................................... 10

.III.1. TYPE OF SURVEY AND SAMPLE SIZE ......................................................................................................................... 10

.III.2. SAMPLING METHODOLOGY ....................................................................................................................................... 10

.III.3. DATA COLLECTION ................................................................................................................................................... 10

.III.4. INDICATORS, GUIDELINES, AND FORMULAS USED .................................................................................................... 11.III.4.1. Acute Malnutrition............................................................................................................................................. 11.III.4.2. Mortality ............................................................................................................................................................ 11

.III.5. FIELD WORK ............................................................................................................................................................. 12

.III.6. DATA ANALYSIS........................................................................................................................................................ 12

.IV. RESULTS OF THE QUALITATIVE ASSESSMENT .............................................................................................. 12

.IV.1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS .............................................................................. 12

.IV.2. FOOD SECURITY........................................................................................................................................................ 13

.IV.3. HEALTH .................................................................................................................................................................... 15

.IV.4. WATER AND SANITATION.......................................................................................................................................... 15

.IV.5. MOTHER AND CHILDCARE PRACTICES ...................................................................................................................... 16

.IV.6. EDUCATION............................................................................................................................................................... 16

.V. RESULTS OF THE ANTHROPOMETRICS SURVEY ............................................................................................ 17

.V.1. DISTRIBUTION BY AGE AND SEX ................................................................................................................................ 17

.V.2. ANTHROPOMETRICS ANALYSIS.................................................................................................................................. 18.V.2.1. Acute Malnutrition, Children 6-59 months of Age .............................................................................................. 18.V.2.2. Nutritional Status of Children below 6 months ................................................................................................... 20

FEEDING PRACTICES.................................................................................................................................................... 20.V.2.3. Risk to Mortality: Children’s MUAC .................................................................................................................. 21

.V.3. MEASLES VACCINATION COVERAGE.......................................................................................................................... 21

.V.4. HOUSEHOLD STATUS.................................................................................................................................................. 22

.V.5. COMPOSITION OF THE HOUSEHOLD ............................................................................................................................ 22

.VI. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ........................................................................ 22

.VII. DISCUSSION............................................................................................................................................................... 23

.VIII. RECOMMENDATIONS........................................................................................................................................... 24

.IX. APPENDIX.................................................................................................................................................................... 25

.IX.1. LIST OF VILLAGES, ESTIMATED POPULATION AND DISTANCES .................................................................................. 25

.IX.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE ........................................................................................................... 28

.IX.3. MORTALITY SURVEY QUESTIONNAIRE (CLUSTER ENUMERATION DATA COLLECTION FORM) .................................... 29

.IX.4. MORTALITY SURVEY QUESTIONNAIRE FORM (HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATHRATE CALCULATION SURVEY) ............................................................................................................................................. 30.IX.5. CALENDAR OF EVENTS IN PANAMDIT AND GALDORA PAYAMS................................................................................. 35.IX.6. ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN 6 MONTHS................................................ 37

4

LIST OF TABLESTABLE 1 ACUTE MALNUTRITION RATES IN Z-SCORE AND PERCENTAGE OF MEDIAN ................................................................ 7TABLE 2 AGENCY INTERVENTION IN GALDORA AND PANAMDIT PAYAMS .............................................................................. 16TABLE 3 DISTRIBUTION BY AGE AND SEX................................................................................................................................ 17TABLE 4 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORE ......................................................................................... 18TABLE 5 WEIGHT/HEIGHT VS. OEDEMA.................................................................................................................................. 18TABLE 6 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN Z-SCORE .............................................................. 19TABLE 7 NUTRITIONAL STATUS BY SEX IN Z-SCORE............................................................................................................... 19TABLE 8 DISTRIBUTION OF WEIGHT/HEIGHT BY AGE IN PERCENTAGE OF THE MEDIAN........................................................... 19TABLE 9 WEIGHT FOR HEIGHT VS. OEDEMA............................................................................................................................ 20TABLE 10 GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP, IN % OF THE MEDIAN ............................................ 20TABLE 11 AGE DISTRIBUTION OF THE UNDER 6 MONTHS......................................................................................................... 20TABLE 12 FEEDING PRACTICES ............................................................................................................................................... 21TABLE 13 MUAC DISTRIBUTION ............................................................................................................................................ 21TABLE 14 MEASLES VACCINATION COVERAGE ...................................................................................................................... 21TABLE 15 HOUSEHOLD STATUS .............................................................................................................................................. 22TABLE 16 HOUSEHOLD COMPOSITION .................................................................................................................................... 22

LIST OF FIGURESFIGURE 1 SOURCE OF LIVELIHOOD.......................................................................................................................................... 13FIGURE 2 CROPS GROWN ........................................................................................................................................................ 13FIGURE 3 COPING MECHANISMS FOR COMMUNITY LIVING IN GALDORA AND PANAMDIT PAYAMS........................................ 14FIGURE 4 DISTRIBUTION BY AGE AND SEX ............................................................................................................................. 17FIGURE 5 WEIGHT FOR HEIGHT INDEX IN Z-SCORE DISTRIBUTION......................................................................................... 18

5

.I. EXECUTIVE SUMMARY

.I.1. Introduction

Panamdit and Galdora (formally Koladar) Payams are located in Malut County, in the Northern Upper Nile State,in the Upper Nile region. Malut County comprises seven payams, namely: Panamdit, Galdora, Paloch, Thak,Wunamum, Takuach and Malut. The inhabitants of Panamdit and Galdora payams in which the anthropometricnutritional survey was undertaken, belong to the Dinka Tribe of Nyiel clan. The river Awilwil, which is seasonalcuts across the County and provides grazing areas, especially during the dry season. The White Nile River onthe northern side of the County offers good fishing opportunities, grazing areas for the cattle and means oftransport from Southern to Northern Sudan through Malut town. The area is generally flat and made of blackcotton soil.

The last insecurity incident, which Panamdit Payam faced, was in March 2005. During the incident in the Southof Payuer, several people were hurt and some lost their life. The fight was between SPLA and GOS militia. Thefight ended and there has not been any reported incident since. During the survey the security was generallystable. The area is under the new government of national unity.

Last year in April ACF-USA conducted a survey in this region that unveiled a Global Acute Malnutrition (GAM)rate of 28.1% in Z-scores [Confidence interval at 95%: 23.4%-33.3%] and Severe Acute Malnutrition rate (SAM)of 4.5% [2.6%-7.4%]. MEDAIR implemented a Therapeutic Feeding Center (TFC) from July to October 2005.Only few admissions were recorded in the TFC.

In February 2006, MEDAIR, the health organization operating in Payuer, indicated that the food insecurity hadintensified in the location which had resulted to having significantly high number of malnourished children in theirPHCC in Payuer. ACF-USA decided to conduct a nutritional survey in the location.

.I.2. Objectives

A nutritional survey was carried out in Galdoara and Panamdit Payams from 23rd February to 10th March 2006,with the following objectives:

• To evaluate the nutritional status of children aged 6 to 59 months.• To estimate the measles immunization coverage of children aged 9 to 59 months.• To identify groups at higher risk to malnutrition: age group and sex.• To estimate the crude mortality rate through a retrospective survey.• To assess the extent of household movement.

.I.3. Methodology

Based on the SRRC population figures, a two-stage cluster sampling survey methodology had been initiallyplanned for. However, the real population found on the ground on the first day of the survey established thatmost of the population had moved to another neighboring Malut Payam. Malut Payam is 12 hours walk fromPayuer airstrip where the team had camped; efforts to move to Malut Payam were hampered by lack oftransport.Therefore, the methodology chosen was an exhaustive sampling of all children from 6 to 59 months old.

A retrospective mortality survey (over the past three months), and qualitative survey on food security and healthsurvey was also conducted along with the anthropometric survey.

6

.I.4. Summary of Findings

MEDAIR is the only NGO operating in the location, and is also the main health provider organization in theregion. MEDAIR supports three PHCU’s and one Kalazar clinic; the PHCU’s are located in Payuer (Panamdit) inPanamdit Payam and in Thiangrial and Maker which are in Galdora Payam. The health units provide preventive,curative, and promotive services. Health seeking practices are of concern as most people seek medicalassistance as a last resort. However, this practice is gradually changing due to health education and healthservices by MEDAIR. The most common diseases are malaria, diarrhoea and respiratory tract infections, linkedto poor environmental health, poor hygiene and sanitary practices, and lack of safe drinking water in thecommunity. Kalazar also has a high prevalence in the area.

The households have no access to potable water. There are no boreholes in the location; the community drawswater from the seasonal rivers Awilwil and Yal, and the White Nile for household consumption. The majority ofthe households do not treat drinking water, thus the water consumed is not safe. Most of households carry outwashing (washing clothes and bathing) near riverbanks; hence, the water fetched for the households is only forcooking and drinking. MEDAIR has plans to drill boreholes in the next two months. There are very few latrinesin area; most of the households dispose of human waste in the open field.

The food security situation is deteriorating during this period of hunger gap. The hunger gap seems to have setin early due to erratic rains received last year and widespread destruction of sorghum by pest. The harvest ofsorghum was lower compared to that of the previous year. Most households had already exhausted their foodstock as sorghum stocks were not observed in most of the visited households during the time of the survey. Thehouseholds mainly relied on wild foods which included desert dates, wild rice, Adik and Agok (varieties of thewild grass) water lily, lalop and various roots. Due to the poor harvest experienced last year, many people havemoved to Malut town. They are in search of food from relatives in town, or of buying from Malut town (which hasaccess of food commodities from Renk through the White Nile). The last WFP distribution was done in January2006 and most households reported that they had exhausted the relief food stock.

The survey covered all the villages in Panamdit and Galdora payams, a total of 640 children were measuredduring the nutritional survey. Six records were excluded from the analysis because of aberrant data. The results indicate deteriorating nutrition situation in the location, the GAM is significantly above the emergencycut off of 15%, which indicates a critical nutrition situation.

High Global acute malnutrition rates in the region can be directly attributed to mainly to the current acuteshortage of food in the region. Poor child feeding practices, disease, poor hygiene and sanitation and lack ofsafe drinking water have also contributed to the present malnutrition rates.

7

.I.5. Results

Table 1 Acute Malnutrition rates in Z-score and percentage of Median

AGE GROUP INDICATOR RESULTS1

Global Acute MalnutritionW/H< -2 z and/or oedema 20.8%

Z-score Severe Acute MalnutritionW/H < -3 z and/or oedema 1.7%

Global Acute MalnutritionW/H < 80% and/or oedema 11.7%

6-59 months(n = 634)

% Median Severe Acute MalnutritionW/H < 70% and/or oedema 0.5%

Global Acute MalnutritionW/H < -2 z and/or oedema 23.9%

Z-scoreSevere Acute MalnutritionW/H < -3 z and/or oedema 2.1%

Global Acute MalnutritionW/H <80% and/or oedema 13.7%

6-29 months (n = 284)

% Median Severe Acute MalnutritionW/H <70% and/or oedema 0.7 %

Total crude retrospective mortality (last 3 months) /10,000/dayUnder five crude retrospective mortality /10,000/dayPercentage of children under five amongst death recorded

0.74 [0.43-1..6]21.11[0.29-1.93]

33.3%

Measles immunization coverageBy cardAccording to caretaker3

Not immunized

29.4%16.9%53.7%

The GAM rate is above emergency threshold of 15%, but SAM is less than the 4% benchmark as defined byWHO4. The analysis of the MUAC measurements for children aged one to 59 months or having a height greateror equal to 75 cm revealed that 0.2% of the children were severely malnourished and at high risk of mortality,while 0.9% were moderately malnourished. Children at risk of malnutrition were 19.1%.

The comparative analysis indicate that there is no significant difference in the risk of malnutrition betweenchildren aged 6-29 months and the ones aged 30-59 months (p>0.05). Similarly, there is no significant difference in the prevalence of malnutrition between boys and girls (p>0.05).

The crude mortality rate (CMR), 0.74/10,000/day, is below the alert level of 1/10,000/day5. Approximately 33.3%(7 out of 21 cases) of the individuals who died during the 3 months preceding the survey were children under 5years old. CMR for children below 5 years is 1.11/10,000/day.

The malnutrition revealed in the region can be linked to shortage of food, poor feeding practices, disease andpoor hygiene and sanitation and lack of safe water.

1 Exhaustive nutrition survey methodology was employed hence no confidence intervals given for the anthropometric data.2 Confidence interval at 95%3 When no EPI card was available for the child at the household, measles vaccination information was collected according tothe caretaker4 WHO classification of wasting prevalence in populations, 2000..

8

Shortage of foodThe hunger gap seems to have set in early. Due to erratic rains received last year, and widespread destructionof sorghum by pest, there was a poor harvest of sorghum (major crop), maize, and very little food stock carry-over to the year 2006, which has resulted to acute food shortage among the community. The householdsinterviewed reported minimal harvest of maize and sorghum in November/December. Most households hadalready exhausted their food stock, as sorghum stocks were not observed in most of the visited householdsduring the time of the survey. The households mainly relied on wild foods, which included desert dates, wild rice,Adik and Agok (varieties of the wild grass) water lily, lalop and various roots. This concurs with food securityanalysis data that revealed 91.4% of the households interviewed currently relied on wild foods and vegetables.Due to the poor harvest experienced last year many people have moved to Malut town in search of food fromrelatives in town and even to buy from Malut town, which has access of food commodities from Renk throughthe White Nile. The last WFP distribution was done in January 2006, and most households reported that theyhad exhausted the relief food stock. Availability and access to fish, milk and meat as sources of protein waslimited due to lack of fishing equipment, poor milk production, low economic power and cultural practices whichlimits people’s slaughter of livestock and therefore consumption of meat.

Poor feeding practicesMost mothers reported to exclusively breastfeed infants in their first 4-6 months which is good practise asrecommended by (WHO, 1991). The infants are breastfed on demand. The complementary diet is composed ofporridge (made from sorghum flour and add sugar). Milk is given separately. However, this is not adequatesince children are fed twice a day which is not enough to meet the daily nutritional requirements of a growingchild, and the nutrients in the diet is not balanced since sugar and sorghum are only rich in carbohydrates.Children 30 months of age and above are also fed two meals per day comprising of milk, porridge, fish soup andWalwal (traditional dish made from pounded sorghum) based on availability along side breastfeeding. Childrendo not have special foods, and usually feed on the normal family diet. Micronutrients such as Vitamin A, C andminerals such as iron, iodine and zinc also lack in the children diet. Hygiene during food preparation wasobserved to be poor. Generally the quantity and quality of food served to children is inadequate to meet theirincreasing nutritional requirements.

DiseaseMEDAIR PHCC health records show high incidence of Kalazar, malaria, acute respiratory infections, diarrhoealdiseases and eye infection. These diseases were also reported to be common in the household interviewed.Measles immunisation coverage estimated at 46.3% among children under-5 years is low, and makes themvulnerable to disease. Utilization of health services from the existing primary health care facilities is poorbecause of far distance; the only villages that can access the health facilities, are around Payuer and Thiangrial.This is even worse during the rainy season since most areas flood and become inaccessible. Diseases likediarrhoea depletes nutrients in the body and fluid balance eventually leading to rapid weight loss. Malariacauses high fever, loss of appetite and lowers efficiency of red blood cells resulting in poor food intake, weightloss and even mortality. The health-seeking practices, especially on drinking safe water, hygiene and sanitationare still poor.

Poor hygiene and sanitation Among the households interviewed, Majority have no access to potable water. There are no boreholes in thelocation; the community draws water from the seasonal river Awilwil and the White Nile for householdconsumption. The majority of the households do not treat drinking water, thus the water consumed is not safeand increases chances of getting water-borne diseases that causes malnutrition. Most of households’ carry outwashing (washing clothes and bathing) near the riverbanks, hence water fetched to the households is only forcooking and drinking. MEDAIR has plans to drill boreholes in the next two months. There are very few latrines inthe area; most of the households dispose off human waste in the open field. During the dry season there aremany flies that settle on them, then contaminate food in the households which increases the diarrheic diseaseprevalence. During the rainy season all the human waste is washed down to the same rivers that the communitydraw water from. The above practices promote high incidences of disease prevalence.

9

.I.6. Recommendation’

In conclusion, the nutrition situation is of concern. The current nutritional situation is caused by shortage of food,disease, poor feeding practices, and poor hygiene, sanitation and lack of safe potable water. The nutritionalsituation can be improved by addressing the following recommendations.

• Based on the results a supplementary feeding program should be immediately implemented to coverMalut County, to treat and reduce the risk of mortality among the moderately malnourished childrenrespectively by MEDAIR, MEDAIR should too continue to treat the severely malnourished children intheir PHCC.

• WFP to distribute to continue distributing food at 75% ration in the region as most of the populacelacked enough food supply in the entire period of hunger gap.

• MEDAIR to strengthen child feeding practices through nutrition education on infant feeding, such asexclusive breastfeeding for the first six months of a child’s life, provision of a variety of foods andfrequency of feeding for children of six months and above. Also to expand and promote regular growthmonitoring of under five aged children to detect malnutrition and ensure early intervention.

• MEDAIR and other capable agencies should support Malut County with projects to increase safe watersources such as borehole installation. The community also requires education on water treatment,usage and storage.

• MEDAIR to institute EPI campaign in the location to increase measles coverage.

.II. INTRODUCTION

Nutritional survey was carried out in Panamdit and Galdora (formally Koladar) Payams in Malut County in theNorthern Upper Nile State in the Upper Nile region. Malut County comprises of seven payams, namely:Panamdit, Galdora, Paloch, Thak, Wunamum, Takuach and Malut. The inhabitants of Panamdit and Galdorapayams belong to the Dinka Tribe of Nyiel clan. The river Awilwil, which is seasonal, cuts across the County andprovides grazing areas, especially during the dry season. The White Nile River on the northern side of theCounty offers good fishing opportunities, grazing areas for the cattle and means of transport from Southern toNorthern Sudan through Malut town. The area is generally flat and made of black cotton soil.

The last insecurity incident, which Panamdit Payam faced, was in March 2005. During the incident in the Southof Payuer several people were hurt and some lost their life. The fight was between SPLA and GOS militia. Therehas not been any reported incident since. During the survey the security was generally stable. The area is underthe new government of national unity.

STARBASE September 2005 report indicated that food gaps were expected during the hunger gap period in theUpper Nile State. MEDAIR reported there was shortage of food among the community, and also increase inmalnutrition cases of children visiting the PHCU. The last nutritional survey in the location was conducted byACF (USA) last year in April that unveiled a GAM of 28.1% [23.4%-33.3%] and SAM of 4.5% [2.6%-7.4%].MEDAIR intervened with a TFC in the location targeting severely malnourished children, which started from Julyto October 2005.ACF-USA decided to implement a nutritional survey in Panamdit and Galdora payams due to above informationto obtain the current nutritional situation.

10

.III. METHODOLOGY

The Nutritional survey in Panamdit and Galdora Payams in Malut County, Upper Nile State, the Upper Nileregion was conducted from 23rd February to 10th March 2006.

.III.1. Type of Survey and Sample Size

The target population of the survey was children 6-59 months of age. Based on the SRRC population figures, atwo-stage cluster sampling survey methodology had been initially planned for. However, the real populationfound on ground on the first day of the survey established that most of the population had moved out due tofood shortage. Therefore, an exhaustive survey was planned. It covered all the villages in Panamdit andGaldora payams.

Qualitative information collection was carried out along side anthropometric survey to capture food security,childcare practices, nutrition, and health and sanitation situation through individual household interview andobservation methods. A retrospective mortality survey (over the past three months) was also conducted,alongside the anthropometric survey.

.III.2. Sampling Methodology

An exhaustive survey was conducted, meaning that all the children 6-59 months of age in the two payams wereincluded in the survey. A household was defined by a mother and her children.

.III.3. Data Collection

During the anthropometric survey, for each selected child 6 to 59 months of age, the following information wasrecorded (See appendix 2 for the anthropometric questionnaire):

Age: recorded with the help of a local calendar of events (See appendix 5 for the calendar of events).Gender: male or female. Weight: children were weighed without clothes, with a SALTER weighing scale of 25kg (precision of 100g).Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm weremeasured lying down, while those greater than or equal to 85 cm were measured standing up.Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children(precision of 0.1cm).Bilateral Oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet.Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking caretakers.Household status: for the surveyed children, households were asked if they were permanent residents,temporarily in the area, displaced or returnees.

During the retrospective mortality survey, in all the visited households including those where there were nochildren less than five years old, the teams recorded all the current and retrospective demographic data over thepast 3 months: the number of household members, the number of people present within the recall period, thenumber of births and deaths over the last three months and the number of persons who arrive or left (Seeappendices 3 and 4 for the mortality questionnaires- enumeration data collection forms for households andclusters).

11

.III.4. Indicators, Guidelines, and Formulas Used

.III.4.1. Acute Malnutrition

Weight for Height IndexFor the children, acute malnutrition rates were estimated from the weight for height (WFH) index valuescombined with the presence of oedema. The WFH indices are compared with NCHS6 references. WFH indiceswere expressed in both Z-scores and percentage of the median. The expression in Z-scores has true statisticalmeaning and allows inter-study comparison. The percentage of the median on the other hand is commonly usedto identify eligible children for feeding programs.

Guidelines for the results expressed in Z-scores:Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the child.Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema.Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema

Guidelines for the results expressed in percentage according to the median of reference:Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs.Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema.Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema.

Children’s Mid-Upper Arm Circumference (MUAC)The weight for height index is the most appropriate index to quantify wasting in a population in emergencysituations where acute forms of malnutrition are the predominant pattern. However the mid-upper armcircumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC istaken on all children, even if it is an actual criterion of malnutrition for those whose height is 75cm and more.The guidelines are as follows:

MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of mortalityMUAC ≥ 120 mm and <125 mm high risk of malnutritionMUAC ≥ 125 mm and <135 mm moderate risk of malnutritionMUAC ≥ 135 mm normal or adequate nutritional status.

.III.4.2. Mortality

The crude mortality rate (CMR) is determined for the entire population surveyed for a given period.

The formula used for calculating the CMR according to ENA software is as follows:

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

Where: a = Number of recall days (period corresponds to 3 months (90 days) preceding the survey) 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 the recall period f = Number of deaths during recall period Therefore, CMR is expressed per 10,000-people / day.

6 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. VitalHealth Statistics. 165, 11-74.

12

The thresholds are defined as follows7:

Alert level: 1/10,000 people/dayEmergency level: 2/10,000 people/day

The proportion of deaths within the past three months among the under five years old is also calculated.

.III.5. Field Work

All surveyors who participated in the survey underwent a four -day training, which included a pilot survey. Threeteams of three surveyors each executed the fieldwork and one surveyor was trained in translating qualitativeinformation as the nutritionist recorded data on qualitative questionnaire.ACF-USA staff supervised all the teams in the villages. Accessibility to the whole county was limited since theteam was not able to get a vehicle while on ground. Due to this, the sampling frame only included two payamswhereby all the villages within the two payams were surveyed. The villages that were very far off were accessedby boat and by camping to a nearer village.

The survey, the training and traveling days, lasted for a period of 22 days.

.III.6. Data Analysis

Data processing and analysis were carried out using EPI-INFO 5.0 software and EPINUT 2.2 program. Mortalitydata was processed and analyzed using the Nutrisurvey software. Qualitative data was analyzed using SPPSS(Statistical package for social sciences).

.IV. RESULTS OF THE QUALITATIVE ASSESSMENT

.IV.1. Socio-demographic characteristics of the respondents

Qualitative data was collected during the period of survey, 35 households were interviewed comprehensively onfood security, hygiene and sanitation, nutrition and health; in the two surveys where the anthropometric datawas collected. All the respondents were residents with 29 (82.9%) being female while 6 (17.1%) were male.According to SRRC, a total number of 1,095 returnees and 350 IDP’s were reported to have arrived in theperiod between September 2004 and April 2005 in Panamdit payam. The returnees and IDP’s were comingfrom Khartoum as a result of the peace agreement signed recently. Current information on total number of IDP’sand returnees who had arrived in the location was not available at the time of the survey.Over half (57.3%) of the household interviewed had the source of livelihood as agro-pastoralist, 45.7% weresubsistence farmers while 2.9% depended on fishing as their major livelihood. The figure below shows differentlivelihood activities the community had.

7 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition,ACC / SCN, Nov 95.

13

54.3%

45.7%

2.9% 2.9% 2.9%

0%

10%

20%

30%

40%

50%

60%

Agro-

pastrolism

Subsistence

farm ing

Fishing Em ploym ent Pastolism

Livelihood activity

Figure 1. Source of livelihood

Perc

enta

ge

87.5%

56.3%

15.6%6.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Sorghum Maize Beans Vegetables

Crops

Figure 2. Crops grown

Perc

enta

geFigure 1 Source of Livelihood

.IV.2. Food Security

The community of Dinka are mainly agro-pastoralists. They keep livestock and grow crops at the same time.The major crop that is cultivated is sorghum, of the households that cultivated crops 87.5% grew sorghum,56.3% of them grew maize, and 15.6% cultivated beans. 6.3% cultivated vegetables mainly Okra and eggplantsas shown in Figure 2.

Figure 2 Crops Grown

14

91.4%

14.3%11.4%20.0%2.9%

42.9%

0%10%20%30%40%50%60%70%80%90%100%

W ild fruits W FP Kinship Sell cows Slaughter

cows

M ove to

another

location

Coping mechanisms

Figure 3: Coping mechanisms for commuinity living in Galdora and Panamdit payams

Maize is grown around the homestead and consumed green in good years, the short and medium term varietiesof Sorghum are harvested in August/ September. A ratoon (the crop that grows from the cut stems of theSorghum after the first harvest) Crop is harvested in November/December), the long–term variety is planted inAugust-September, and harvested in January/February. Other crops include groundnuts when the seed areavailable. However, poor rainfall in 2005 and pest infestation affected the October 2005 harvest, resulting in thecommunity carry over little grain into 2006. Reasons cited for the poor harvest are insect pest (shirap), (87.5%)lack of rains (53.1%), and bird attacks (21.1%). All households had exhausted stocks of the last harvest.Generally the harvests are small quantities even in a normal year as the community lacks agriculture tools andseeds. During a bad season, wild foods are consumed include desert dates, wild rice, Adik and Agok (Varietiesof the wild grasses) water lily, lalop and various roots. The dates, wild rice and roots are found in the forests andare gathered in dry season (January–April), While water lily is gathered from the Dirr River around April–May.The community gathers a variety of wild foods, and consumes them throughout the year, particularly hunger–gap period (January-April). Wild foods have become an important source of nutrition. Progressive years of poorcrop harvests have caused food shortages, and reduced food stocks. In the last months of 2005 and beginningof 2006, the community has had to turn to wild foods to grapple with hunger.

The hunger gap seems to have set in early due to erratic rains received last year and widespread destruction ofsorghum by pest resulting in poor harvest of sorghum (major crop) and maize and very little food stock carry-over to the year 2006. This has resulted to acute food shortage among the community. The householdsinterviewed reported minimal harvest of maize and sorghum in November/December. Most households had already exhausted their food stock as sorghum stocks were not observed in most of thevisited households during the time of the survey and mainly relied on wild foods which included desert dates,wild rice, Adik and Agok (varieties of the wild grass) water lily, lalop and various roots. However, this concurswith food security analysis data shown in Figure 3, that revealed 91.4% of the households interviewed currentlyrelied on wild foods and vegetables. Figure 3 Coping Mechanisms for Community Living in Galdora and Panamdit Payams

Also most people had moved to Malut town in search of food from relatives in town, and even to buy from Maluttown which has access of food commodities that come from Renk through the White Nile. WFP has in the pastbeen distributing food in the area, the last WFP distribution was done in January 2006 and most householdsreported that they had exhausted the relief food stock.

Fish is mostly consumed during the dry season (Jan-April). The fish consumed are mainly caught by the use oflocal nets, spear, cloths and hooks. According to the Starbase report of July 2005, the Dinka had been reportedthat they are not experienced and rely on more experienced Nuer, living as IDP’s, to do most of the fishing andexchange grain for fish with them. Majority of the population (85.3%) has fishing grounds however only 10% gotenough fish for household consumption. The methods that are mainly used are use of spears (46.4%), nets(39.3%), hooks (32.1%) and use of cloths (25%). At the time of the survey, Shilluk, who inhabit the opposite sideof river Nile, are more skilled in fishing and use the fish for trading with Payuer community. Despite their poorfishing skills, most of the Dinka households are able to access fish throughout the year although it is not enough

15

for the household. Fishing is limited due to lack of appropriate fishing gear, canoes and the presence of hipposin the river. This is because of lack of adequate and modern fishing equipment. Also, the onset of this year(2006) dry season has seen low river waters of the tributaries Awilwil and Yal limiting fishing to a few pointsalong the river. The Starbase report (July 2005) reports that trade is hampered because the community’s purchasing power isweak, and therefore, few people make their way to the garrisons’ towns like Malut and undertake casual work toacquire money to purchase basic items. In Payuer, the community main market is in Malut where they are ableto buy mainly Dura (mixture of varieties of sorghum), rice, sugar and oil, and also sell their livestock and thus,derive money to buy the food. Honey is gathered in the dry season, with household s consuming a small amountand rest is used for exchange for grain. Hunting also occurs in the dry season, but these foods account 1-2% ofthe household’s dietary requirements.

ANA report (February 2006) reported that the number of livestock owned per household has declined over theyears due to cattle raids due to localized conflict and lack of veterinary services. Majority of the householdscurrently own goats (90%), followed by chicken (63.3%) cows 26.7% and donkeys (16.7%) with majority ofanimals at home. 82.9% of households reported a decline in the number of cattle owned over the last five years,due to cattle lost in raids, animal diseases and sale of livestock to buy food. The cow population is very low, andmost people keep more of the goats and sheep, and some keep chicken and donkey. The main benefit gainedfrom livestock according to household interviewed is milk, dowry, barter trade and food on special occasions.The communities rarely sell their livestock. The milk yield is very low per animal especially during the dryseason; according to the household interviewed, the yield per animal is 250ml of milk that may not be adequate.The households without livestock rely on their neighbors. Access to meat as sources of protein is limited due tocultural practices, which limits people’s consumption of meat unless the man goes out to hunt wild animals. Theaverage number of cattle per household is 40-50 for the rich, 10-20 for the middle class and below 10 for thepoor; majority of the community is in the middle class. The main livestock diseases include haemorrhagesepticaemia, trypanomiasis, contagious borine pleuro pneumonia, rinderpest (Wet mouth and diarrhoea)mastitis and fluke/intestinal parasite.

.IV.3. Health

MEDAIR supports three PHCU’s and one Kalazar clinic; the PHCU’s are located in Payuer (Panamdit) inPanamdit Payam while Thiangrial and Maker are in Galdora Payam. These units had started in 2003 as mobileKalazar clinics operating from Payuer in Panamdit Payam. Payuer PHCU is the main referral center forcomplicated cases found in the other PHCU’s. The PHCU in Payuer is managed by one medical assistant, twoCHW, one female assistant, two Kalazar assistant, and two volunteers. The other two health units in Galdoraare each managed by two CHW’s. The health units provide preventive, curative, and promotive services. EPIImmunization services are also provided in all the health units. Health seeking practices are also of concern asmost people seek medical assistance as a last resort. However, this practice is gradually changing due to healtheducation and health services by MEDAIR. The most common diseases are Malaria, diarrhoea and respiratorytract infections linked to poor environmental health, poor hygiene and sanitary practices and lack of safedrinking water in the community. Kalazar also has a high prevalence in the area. The PHCC reported the maincauses of under 5 year old mortality are diarrhoea, Kalazar, Pneumonia and malaria. Drug supply is consistent.According to medical assistant, being a dry season with shortage of food and many flies diarrhoea andmalnutrition among the under five seem to be on increase, between January and February 2006 they haveadmitted 12 cases of severely malnourished children.

.IV.4. Water and Sanitation

The households have no access to potable water. There are no boreholes in the location. The community drawswater from the seasonal rivers Awilwil and Yal, and the White Nile for household consumption. The majority ofthe households do not treat drinking water thus the water consumed is not safe. Most of households carry outwashing (washing clothes and bathing), hence water fetched to the households is only for cooking and drinking.MEDAIR has plans to drill boreholes in the next two months. There are very few latrines in area; most of the

16

households dispose of human waste in the open field. During dry season the seasonal rivers dry up and thecommunity is forced to walk long distance to White Nile to fetch water.

.IV.5. Mother and Childcare Practices

Expectant mothers do not have special care and eat less food because they believe they have no space toaccommodate food. They are also not exempted from heavy work. The mothers increase the amount foodconsumed during the lactation period.

Most mothers reported to place the child on the breast immediately after birth, mothers too exclusivelybreastfeed infants in their first 4-6 months; The infants are breastfed on demand while the rest of the childrenare fed two meals per day comprising of milk, porridge, fish and Walwal (traditional dish made from poundedsorghum). Most mothers introduce complimentary feeding when the infant is 6 months of age and above.Children below one year of age are assisted to eat, while those above 18 months of age eat alone. Fish is fed tochildren above the age of 1 year and above. Children do not have special foods, and usually feed on the normalfamily diet. Most mothers continue to breastfeed their children up to the second year of the child’s’ life. Hygieneduring food preparation was observed to be poor. Food handling and storage practices are also poor. Generallythe quantity and quality of food served to children is inadequate.

.IV.6. Education

There no Primary and secondary schools in the area except in the former GoS town (Malut), so MEDAIR startedan English class to assist the community members who are interested in learning, reading and writing English. The following table summarizes NGO activities in the area:

Table 2 Agency intervention in Galdora and Panamdit Payams

Agency Activities

MEDAIR • Offers health services.• Trains community in English and how to read and write.

17

.V. RESULTS OF THE ANTHROPOMETRICS SURVEY

A total of 640 children were measured, but six were not included in the analysis because of incorrectmeasurements or records.

.V.1. Distribution by Age and Sex

640 children were measured during the survey.

Table 3 Distribution by age and sex

AGE(In months)

BOYS GIRLS TOTAL

N % N % N %

SexRatio

06 – 17 59 44.7% 73 55.3% 132 20.8% 0.8118 – 29 74 48.7% 78 51.3% 152 24.0% 0.9530 – 41 72 56.3% 56 43.8% 128 20.2% 1.2942 – 53 66 50.4% 65 49.6% 131 20.7% 1.0254 – 59 55 60.4% 36 39.6% 91 14.4% 1.53Total 326 51.4% 308 48.6% 634 100% 1.06

The overall sex ratio of 1.06 allows the validation of the sample selection, since it lies within the acceptedbenchmark range of 0.80-1.20.

Figure 4 Distribution by Age and Sex

-60% -40% -20% 0% 20% 40% 60% 80%

Percentage

06-17

18-29

30-41

42-53

54-59

Ag

e in

Mo

n

Distribution by Age and sex-Payuer 06

BOYSGIRLS

There is a slight over representation (14.4% instead of around 10%) of the 54-59 months and wellrepresentation (20.2% which is between 20-25%) of 30-41 months age groups. The over representation of the54-59 months age group can be attributed to ages given by parents (caretakers) during the survey which areapproximate, and are subject to strong recall bias. Dates of birth were not known and a local calendar of eventshad to be used to estimate the ages.

18

.V.2. Anthropometrics Analysis

.V.2.1. Acute Malnutrition, Children 6-59 months of Age

Distribution of Malnutrition in Z-score

Table 4 Weight for Height distribution by age in Z-score

< -3 SD ≥ -3 SD & < - 2 SD ≥ -2 SD OedemaAGE(In months)

N n % N % N % N %

06-17 132 2 1.5 30 22.7 100 75.8 0 0.0

18-29 152 4 2.6 32 21.1 116 76.3 0 0.0

30-41 128 2 1.6 24 18.8 102 79.7 0 0.0

42-53 131 1 0.8 17 13.0 113 86.3 0 0.0

54-59 91 2 2.2 18 19.8 71 78.0 0 0.0

TOTAL 634 11 1.7% 121 19.1 502 79.2% 0 0.0

Table 5 Weight/Height vs. Oedema

Weight for height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor0 0.0%

Kwashiorkor0 0.0%

OedemaNO Marasmus

132 20.8%No malnutrition502 79.2%

No case of kwashiorkor was found in the sample.

Figure 5 Weight for Height Index in Z-Score Distribution

Weight for Height Z-score distribution-Payuer 2006

0

5

10

15

20

25

30

-5 -4 -3 -2 -1 0 1 2 3 4 5

Z-score

Perc

en

ta

ReferenceSex Combined

19

There is a significant displacement of the sample curve to the left of the reference curve, indicating a poorernutritional situation in this population than in the reference one. The mean Z-score of the sample is –1.26. Thestandard deviation of the curve, equal to 0.91, lies within the accepted benchmarks (0.80 – 1.20): it shows thatthe sample is representative of the population.

Table 6 Global and Severe Acute Malnutrition by age group in Z-score

6-59 months (n = 634) 6-29 months (n =284)Global acute malnutrition 20.8% 23.9%

Severe acute malnutrition 1.7% 2.1%

Statistical comparative analysis of malnutrition rates for children 6-29 months and 30-59 months of age,indicate that, there is no significant difference (p>0.05, Chi square=3.04).

Table 7 Nutritional Status by Sex in Z-score

Boys GirlsNutritional statusN % N %

Severe malnutrition 7 2.1 4 1.3

Moderate malnutrition 70 21.5 51 16.6

Normal 249 76.4 253 82.1

TOTAL 326 51.4 308 48.6

The statistical analysis shows that there is no significant difference in the prevalence of malnutrition betweenboys and girls (p>0.05).

Distribution of Malnutrition in Percentage of the MedianCut-offs for acute malnutrition expressed in percentage of the median are commonly used in determiningadmission criteria in feeding centres.

Table 8 Distribution of Weight/Height by age in percentage of the median

AGE(In months) N

< 70%N %

≥ 70% & < 80%N %

≥ 80%N %

OedemaN %

06-17 132 1 0.8 21 15.9 110 83.3 0 0.0

18-29 152 1 0.7 16 10.5 135 88.8 0 0.0

30-41 128 0 0.0 13 10.2 115 89.8 0 0.0

42-53 131 0 0.0 11 8.4 120 91.6 0 0.0

54-59 91 1 1.1 10 11.0 80 87.9 0 0.0

TOTAL 634 3 0.5% 71 11.2% 560 88.3% 0 0.0%

20

Table 9 Weight for height vs. Oedema

Weight for Height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor0 0.0%

Kwashiorkor0 0.0%

OedemaNO Marasmus

74 11.7%No malnutrition560 88.3%

Table 10 Global and Severe Acute Malnutrition by age group, in % of the median

6-59 months (n = 634) 6-29 months (n = 284)

Acute global malnutrition 11.7% 13.7%

Severe acute malnutrition 0.5% 0.7%

.V.2.2. Nutritional Status of Children below 6 months

65 children below 6 months of age, present in the households at the time of the survey, were measured in orderto determine their nutritional status. These data are given as an indicator of the nutritional status of children inthis group of age, but they are not representative.

Table 11 Age distribution of the under 6 months

Age in month Females Males N %0 - - - -1 1 2 3 4.62 5 9 14 21.53 7 9 16 24.64 7 6 13 20.05 11 8 19 29.2

Total 31 34 65 100

Only 54 children were included in the anthropometric analysis, as some caretakers did not accept their infants tobe measured. According to the Weight for Height index in Z-score:

• there was no severely malnourished infants.• there was 1 moderately malnourished infant (1.9%).

According to the Weight for Height index in % of the median:• there was no severely malnourished infants.• there were 2 moderately malnourished infant (3.7%).

Feeding Practices

Breast milk was the main diet of all infants. 76.9 % of the mothers interviewed practised exclusively breastfedtheir infants, while 23.1% had begun complementary feeding before the child reaches 6 months old. None ofinfants were on exclusive weaning food. Complementary food was usually composed of sorghum porridge andgoat milk when available.

21

Table 12 Feeding practices

Feeding practices Frequency PercentageExclusive breastfeeding 50 76.9%Mixed feeding (breast milk and weaning food) 15 23.1%Exclusive weaning food 0 0.0%Total 65 100%

.V.2.3. Risk to Mortality: Children’s MUAC

As MUAC overestimates the level of under nutrition in children less than 1 year old, the analysis refers only tochildren having height equal to or greater than 75cm.

Table 13 MUAC distribution

MUAC (mm) < 75 cm height 75 – 90 cmHeight ≥ 90 cm height Total

< 110 2 2.6% 1 0.4% 0 0.0% 3 0.5%110≥ MUAC<120 4 5.1% 3 1.3% 2 0.6% 9 1.4%120≥ MUAC<125 5 6.4% 7 3.1% 6 1.8% 18 2.8%125 ≥ MUAC <135 28 35.9% 61 26.8% 32 9.8% 121 19.1%MUAC ≥ 135 39 50.0% 156 68.4% 288 87.8% 483 76.2%TOTAL 78 100.0% 228 100.0% 328 100.0% 634 100.0%

According to the MUAC measurement, 0.2% of the children are severely malnourished, and therefore, at highrisk of mortality, 0.9% are moderately malnourished and could easily slip into the severely malnourished group.18.9% are at risk to malnutrition. 80.0% had good nutrition status.

.V.3. Measles Vaccination Coverage

Measles vaccination is administered from the age of 9 months. Children 9-59 months of age were included inthe analysis. A total of 601 children were included in the analysis.

Table 14 Measles Vaccination Coverage

Measles vaccination N %

Proved by Card 176 29.4

According to the mother/caretaker 101 16.9

Not immunized 321 53.7

Total 598 100

Only 29.4% of the children were vaccinated against measles as proved by the card, and 16.9% were vaccinatedaccording to the mothers or caretakers. By then, at least 53.7% of the children were not immunized. This is verylow by WHO standards which require coverage of 80% to prevent outbreaks.

22

.V.4. Household Status

Table 15 Household Status

Status N %

Residents 402 85.5

Internally Displaced 8 1.7

Temporary Residents (on transit) 11 2.3

Returnee 49 10.4

Total 470 100

Only the households where children were measured were assessed on their status. The larger proportion of the surveyed families were residents 404 (85.5%) while 8 (1.7%) was internallydisplaced. 11 (2.3%) of the households were temporarily residing in the location, 50(10.4%) were returnees.There was a lot of movement of the population during the time of the survey.

.V.5. Composition of the Household

Table 16 Household Composition

Age group N %

0 to 59 months 691 23.8

Adults 2210 76.2

Total 2901 100.0

538 households were visited during the survey, including those where there were no eligible children for theanthropometric survey. The mean number of children under 5 years of age per household is 1.3 and the meannumber of the over 5 years of age per household is 3.8.

.VI. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

The crude mortality was calculated from the figures collected from families with or without children under 5 yearsof age.

There were a total of 2901 persons living at the day of the survey, 691 of them being children under the age of5. Over the three months preceding the survey, the following demographic changes were observed:

• 27 births.• 20 persons had arrived in the location, 5 being children under 5 years of age. • 501 people had left the location in the same period, 40 being children under 5 years of age.• 21 deaths were reported, 7 being deaths among the children under 5 years of age.

23

According to the above formula, the crude mortality rate is 0.74/10,000/day (Confidence interval at 95%: 0.43 –1.06), and the under five mortality rate is 1.11 (0.29 – 1.93).

.VII. DISCUSSION

The GAM rate is above emergency threshold of 15%, but SAM is less than 4% benchmark as defined by WHO8.The analysis of the MUAC measurements for children ages one to 59 months or having a height greater orequal to 75 cm revealed that 0.2% of the children were severely malnourished and at high risk of mortality, while0.9% were moderately malnourished. Children at risk of malnutrition were 19.1%.

The comparative analysis indicate that there is no significant difference in the risk of malnutrition betweenchildren aged 6-29 months and the ones aged 30-59 months (p>0.05). Similarly, there is no significant difference in the prevalence of malnutrition between boys and girls (p>0.05).

The crude mortality rate (CMR), 0.74/10,000/day, is below the alert level of 1/10,000/day9. Approximately 33.3%(7 out of 21 cases) of the individuals who died during the three months preceding the survey were childrenunder five years old. CMR for children below 5 years is 1.11/10,000/day.

The malnutrition revealed in the region can be linked to shortage of food, poor feeding practices, disease andpoor hygiene and sanitation and lack of safe water.

Shortage of food-The hunger gap seems to have set in early. Due to erratic rains received last year, and widespread destructionof sorghum by pest, there was a poor harvest of sorghum (major crop), maize, and very little food stock carry-over to the year 2006, which has resulted to acute food shortage among the community. The householdsinterviewed reported minimal harvest of maize and sorghum in November/December. Most households hadalready exhausted their food stock as sorghum stocks were not observed in most of the visited householdsduring the time of the survey, and the households mainly relied on wild foods which included desert dates, wildrice, Adik and Agok (varieties of the wild grass) water lily, lalop and various roots. This concurs with the foodsecurity analysis data that revealed 91.4% of the households interviewed currently relied on wild foods andvegetables. Due to the poor harvest experienced last year many people have moved to Malut town in search offood from relatives in town and even to buy from Malut town, which has access of food commodities from Renkthrough the White Nile. The last WFP distribution was done in January 2006 and most households reported thatthey had exhausted the relief food stock. Availability and access to fish, milk and meat as sources of protein waslimited due to lack of fishing equipment, poor milk production, low economic power and cultural practices whichlimits people’s slaughter of livestock and therefore consumption of meat.

Poor feeding practicesMost mothers reported to exclusively breastfeed infants in their first 4-6 months which is a good practise asrecommended by (WHO, 1991). The infants are breastfed on demand. Complementary diet is composed ofporridge (made from sorghum flour and add sugar). Milk is given separately. However, this is not adequatesince children are fed twice a day, which is not enough to meet the daily nutritional requirements of a growingchild and the nutrients in the diet is not balanced since sugar and sorghum are only rich in carbohydrates.Children aged 30 months and above are also fed two meals per day comprising of milk, porridge, fish soup andWalwal (traditional dish made from pounded sorghum) based on availability along side breastfeeding. Childrendo not have special foods, and usually feed on the normal family diet. Micronutrients such as Vitamin A, C andminerals such as iron, iodine and zinc also lack in the children diet. Hygiene during food preparation was

8 WHO classification of wasting prevalence in populations, 2000..

24

observed to be poor. Generally the quantity and quality of food served to children is inadequate to meet theirincreasing nutritional requirements.

DiseaseMEDAIR PHCC health records show high incidence of Kalazar, malaria, acute respiratory infections, diarrhoealdiseases and eye infection. These diseases were also reported to be common in the household interviewed.Measles immunisation coverage estimated at 46.3% among children under-5 years is low and makes them to bevulnerable to disease. Utilization of health services from the existing primary health care facilities is poorbecause of far distance; the only villages that can access the health facilities are around Payuer and Thiangrial.This is even worse during the rainy season since most areas flood and become inaccessible. Diseases likediarrhoea depletes nutrients in the body and fluid balance eventually leading to rapid weight loss. Malariacauses high fever, loss of appetite and lowers efficiency of red blood cells resulting in poor food intake, weightloss and even mortality. The health-seeking practices, especially on drinking safe water, hygiene and sanitationare still poor.

Poor hygiene and sanitation Among the households interviewed, majority have no access to potable water. There are no boreholes in thelocation. The community draws water from the seasonal river Awilwil and the White Nile for householdconsumption. The majority of the households do not treat drinking water, thus the water consumed is not safeand increases chances of getting water-borne diseases that causes malnutrition. Most of households’ carry outwashing (washing clothes and bathing) near the riverbanks, hence water fetched to the households is only forcooking and drinking. MEDAIR has plans to drill boreholes in the next two months. There are very few latrines inthe area; most of the households dispose off human waste in the open field. During the dry season there aremany flies that settle on them, then contaminate food in the households which increases the diarrheic diseaseprevalence. During the rainy season all the human waste is washed down to the same rivers that the communitydraws water from. The above practices promote high incidence of disease prevalence.

.VIII. RECOMMENDATIONS

In conclusion, the nutrition situation is of concern. The current nutritional situation is caused by the shortage offood, disease, poor feeding practices, and poor hygiene, sanitation and lack of safe potable water. Thenutritional situation can be improved by addressing the following recommendations.

• Based on the results a supplementary feeding program should be immediately implemented to coverMalut County, to treat and reduce the risk of mortality among the moderately malnourished childrenrespectively by MEDAIR, MEDAIR should too continue to treat the severely malnourished children intheir PHCC.

• WFP to distribute to continue distributing food at 75% ration in the region as most of the populacelacked enough food supply in the entire period of hunger gap.

• MEDAIR to strengthen child feeding practices through nutrition education on infant feeding, such asexclusive breastfeeding for the first six months of a child’s life, provision of a variety of foods andfrequency of feeding for children of six months and above. Also to expand and promote regular growthmonitoring of under five aged children to detect malnutrition and ensure early intervention.

• MEDAIR and other capable agencies should support Malut County with projects to increase safe watersources such as borehole installation. The community also requires education on water treatment,usage and storage.

• MEDAIR to institute EPI campaign in the location to increase measles coverage.

25

.IX. APPENDIX

.IX.1. List of Villages, estimated population and distances

PayamsVillagesEstimated distances from Payuer airstripTarget population (20% of the entire population)

PanamditPanamdit

2Hrs 30Min124

Panamdit2Hrs240

Mading50Min142

Malek5Min164

Wunlal30Min

13

Baijak40Min

42

Belgo2Hrs181

Wunbarkou2Hrs 15Mins

24

Nyayok2Hrs 40Mins

104

26

Atiapmoch6Hrs 30Mins

60

GaldoraAchoidok

7Hrs 30Mins93

Kuemwar9Hrs104

Wunkou11Hrs

64

Wunyok13Hrs

58

Wetkiech15Hrs

54

Wunlau17Hrs

26

Chuei15Hrs 30Mins

80

Thiangrial18Hrs

64

Wunliet20Hrs

40

Duki21Hrs164

Roorayik/Gor24Hrs

27

191

Chatony30Hrs

66

The survey done was exhaustive thus all children under five years met were included in the survey.

28

.IX.2. Anthropometric Survey Questionnaire

DATE: CLUSTER No:VILLAGE: TEAM No:N°.

Family N°.

Status

(1)

AgeMths

SexM/F

WeightKg

HeightCm

SittingHeightcm(2)

OedemaY/N MUAC

Cm

MeaslesC/M/N

(3)

12345678910111213141516171819202122232425262728293031Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident invillage (cattle camp, water point, visiting family…), 4= Returnee.Sitting Height is optional. To apply for ACF-USA survey. This data is for research Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles

29

.IX.3. Mortality survey questionnaire (Cluster enumeration data collection form)

Survey Payam: Village: Cluster number:

Current HHmember

Current HHmembers who

arrived during recall(exclude births)

Past HH memberswho left during

recall(exclude deaths)

Deathsduring recall

N

Total < 5 Total <5 Total < 5

Birthsduringrecall

Total < 51234567891011121314151617181920212223242526272829303132

30

.IX.4. Mortality Survey Questionnaire Form (Household enumeration data collection form for adeath rate calculation survey)

Survey Payam: Village: Cluster number:

HH number: Date: Team number:

1234567

IDHH memberPresent now

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

SexDate of birth/or age in yearsBorn during recall period?

Died during the recall period

1

2

3

4

31

5

6

7

8

9

10

32

11

12

13

14

15

16

33

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)

34

Past HH members who left during recall - < 5

Births during recall

Total deaths

Deaths < 5

.IX.5. Calendar of events in Panamdit and Galdora Payams

MONTH Seasons 2001 2002 2003 2004 200549 37 25 13JANUARY

ADUONG Cleaning sorghum forstorage

Abducted youngpeople who were

trained as soldiersCPA agreement

48 36 24 12FEBRUARYALEK BOR Cutting building material

s

59 47 35 23 11MARCH AKULDIT Making ropes for

buildingWFP dropped

food WFP dropped food

58 46 34 22 10APRIL BIEL DITBuilding tukuls Fighting between

Arabs and SPLAMEDAIR came andbuild compound and

started kalazaar

SPLA took somearmed people tosupport shilluk as

ACF nutritionsurvey

57 45 33 21 9MAY BIE THEIClearing land for

cultivation Hunger gap Antenop bombpayuer

56 44 32 20 8JUNE LALPlanting maize New sudan flag

brought to payuer55 43 31 19 7JULY HOR

BAKLEY Weeding maize Community ofPayuer raided Arab

cattleGarang dies

54 42 30 18 6AUGUSTKUONDOK Planting type of sorghum

called jackTwo commissionersof Akok and Payuer

fighting

SPLA capture Toritand people in

Payuer celebrate53 41 29 17 5SEPTEMBER

NYETH Harvesting green maize Fighting stops

52 40 28 16 4OCTOBER KOL Hunger gap-look forlalop and water lily Hunger gap Hunger gap Hunger gap Hunger gap

51 39 27 15 3NOVEMBERAKOCH DIT

Lay sorghum down ingarden to avoid birdeating

Dinka andUpper Nile hold

a conference

Dinka and Uppernileheld conference in

payuer

36

Christmascelebration, cold

month

Christmascelebration, cold

month

Christmascelebration, cold

month

Christmascelebration, cold

month

2DECEMBERAKOCH THEI

some sorghum that isdry is harvested,

celebrate Christmas Christmascelebration, cold

month

Christmascelebration, cold

month

Christmascelebration, cold

month

Christmascelebration, cold

month

.IX.6. Anthropometric Survey Questionnaire for Children less than 6 months

DATE: CLUSTER No:VILLAGE TEAM No:

N°.Family N°.

Age MthsSex

M/FWeight

KgHeight

CmFeeding practices*

1

2

3

4

38

5

6

7

8

9

39

10

11

12

13

14

40

15

16

17

18

19

41

20

21

22

23

24

42

25

26

27

28

29

43

30

31

* Exclusive beast feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food =3.