Northern Uganda

Nutrition Survey in IDP Camps Gulu District, Northern Uganda

Action Against Hunger (ACF-USA)June 2005

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ACKNOWLEDGEMENTS

ACF-USA would like to acknowledge the help and support from the following people, without whomthis survey would not have been conducted.

Thanks to OFDA for their financial support in conducting the survey.

Thanks to the District Department of Health Services (DDHS) for their agreement to let us conduct thesurvey and for their support of our activities within the District.

Thanks to all the Camp Leaders, Zonal Leaders, and selected camp representatives who assisted usin the task of data collection.

Thanks to the survey teams who worked diligently and professionally for many hours in the hot sun.

Last and not least, thanks to the mothers and children, and their families who were kind enough to co-operate with the survey teams, answer personal questions and give up their time to assist us.

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TABLE OF CONTENTSI EXECUTIVE SUMMARY .......................................................................................................................... 6

I.1 OBJECTIVES............................................................................................................................................. 6I.2 RESULTS.................................................................................................................................................. 6I.3 RECOMMENDATIONS ............................................................................................................................... 6

II INTRODUCTION ........................................................................................................................................ 8

II.1 NORTHERN UGANDAN CONTEXT............................................................................................................. 8II.2 GULU DISTRICT IDP CAMPS.................................................................................................................... 8II.3 ACF-USA ACTIVITIES IN GULU DISTRICT .............................................................................................. 9

III OBJECTIVES........................................................................................................................................... 9

IV METHODOLOGY ................................................................................................................................... 9

IV.1 SURVEY DESIGN ...................................................................................................................................... 9IV.2 THE NUTRITIONAL ANTHROPMETRIC SURVEY....................................................................................... 10IV.3 TRAINING OF THE NUTRITION SURVEY TEAMS...................................................................................... 10IV.4 DATA COLLECTION AND MEASUREMENT TECHNIQUES......................................................................... 11

IV.4.1 Children from 6 to 59 months:...................................................................................................... 11IV.4.2 Children less than 6 months: ........................................................................................................ 11

IV.5 MORTALITY........................................................................................................................................... 12IV.6 CUT-OFF GUIDELINES AND FORMULAS USED ........................................................................................ 12

IV.6.1 Weight for Height Index................................................................................................................ 12IV.6.2 MUAC........................................................................................................................................... 13

IV.7 SURVEY IMPLEMENTATION.................................................................................................................... 13IV.8 CONSTRAINTS........................................................................................................................................ 13

V RESULTS.................................................................................................................................................... 14

V.1 AGE AND GENDER DISTRIBUTION OF CHILDREN 6 TO 59 MONTHS.......................................................... 14V.2 WEIGHT FOR HEIGHT INDEX (W/H) OR ACUTE MALNUTRITION ........................................................... 15

V.2.1 Acute Malnutrition in Z-scores ..................................................................................................... 15V.2.2 Acute Malnutrition in Percentage of Median ............................................................................... 16

V.3 MUAC ANALYSIS ................................................................................................................................. 17V.4 MEASLES VACCINATION COVERAGE..................................................................................................... 17V.5 NUTRITION INFORMATION ON INFANTS UNDER 6 MONTHS .................................................................... 18

V.5.1 Evaluation of the prevalence of malnutrition ............................................................................... 18V.5.2 Feeding practices.......................................................................................................................... 18V.5.3 Mortality ....................................................................................................................................... 19

VI DISCUSSION.......................................................................................................................................... 19

VII RECOMMENDATIONS........................................................................................................................ 21

VIII APPENDICES......................................................................................................................................... 23

VIII.1 APPENDIX 1: LOCAL EVENTS CALENDAR TO CALCULATE AGE IN MONTHS...................................... 23VIII.2 APPENDIX 2: CLUSTER SELECTION, GULU CAMPS 2005..................................................................... 25

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LIST OF TABLES

TABLE 1 GAM AND SAM BY AGE GROUP IN Z-SCORES, GULU DISTRICT, UGANDA, JUNE 2005........................... 6TABLE 2 ACUTE MALNUTRITION BY AGE GROUP IN % OF THE MEDIAN, GULU DISTRICT, UGANDA, JUNE 2005. .. 6TABLE 3 ACUTE MALNUTRITION CUT-OFF FOR DEFINITION OF POPULATION NUTRITIONAL STATUS...................... 12TABLE 4 MUAC CUT-OFFS FOR DEFINITION OF MALNUTRITION STATUS............................................................... 13TABLE 5 MORTALITY RATE CUT-OFF FOR DEFINITION OF STATUS OF THE POPULATION......................................... 13TABLE 6 AGE AND GENDER DISTRIBUTION 6-59 MONTHS, GULU DISTRICT, UGANDA, JUNE 2005. ..................... 14TABLE 7 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORES, GULU DISTRICT, UGANDA, JUNE 2005....... 15TABLE 8 WEIGHT FOR HEIGHT AND OEDEMA DISTRIBUTION, GULU DISTRICT, UGANDA, JUNE 2005................... 15TABLE 9 GAM AND SAM BY AGE GROUP IN Z-SCORES, GULU DISTRICT, UGANDA, JUNE 2005......................... 15TABLE 10 GAM AND SAM DISTRIBUTION BY GENDER IN Z-SCORES, GULU DISTRICT, UGANDA, JUNE 2005 ...... 15TABLE 11 WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN PERCENTAGE OF MEDIAN, GULU DISTRICT, UGANDA,

JUNE 2005. .................................................................................................................................................... 16TABLE 12 GAM AND SAM BY AGE GROUP IN PERCENTAGE OF MEDIAN, GULU DISTRICT, UGANDA, JUNE 2005.

...................................................................................................................................................................... 16TABLE 13 GAM AND SAM DISTRIBUTION BY GENDER IN % OF THE MEDIAN, GULU DISTRICT, UGANDA, JUNE

2005 .............................................................................................................................................................. 17TABLE 14 MUAC DISTRIBUTION IN UNDER-5 POPULATION, GULU DISTRICT, UGANDA, JUNE 2005. ................... 17TABLE 15 MEASLES VACCINATION COVERAGE, GULU DISTRICT, UGANDA, JUNE 2005. ..................................... 17TABLE 16 AGE AND GENDER DISTRIBUTION OF INFANTS MORE THAN 49.0 CM HEIGHT, GULU DISTRICT, UGANDA,

JUNE 2005 ..................................................................................................................................................... 18TABLE 17 PREVALENCE OF ACUTE MALNUTRITION AMONG INFANTS MORE THAN 49.0CM HEIGHT, GULU DISTRICT,

UGANDA, JUNE 2005..................................................................................................................................... 18TABLE 18 LONGITUDINAL COMPARISON OF ACF SURVEY WASTING RESULTS IN Z-SCORES, GULU DISTRICT,

UGANDA, JUNE 2005..................................................................................................................................... 19

LIST OF FIGURES

FIGURE 1 DEMOGRAPHICS OF SURVEY SAMPLE (AGE AND SEX), GULU DISTRICT, UGANDA, JUNE 2005. ........... 14FIGURE 2 WEIGHT FOR HEIGHT DISTRIBUTION IN Z-SCORES, GULU DISTRICT, UGANDA, JUNE 2005. ................. 16

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List of Acronyms

ACF-USA Action Against Hunger-USACHW Community Health WorkersCI Confidence IntervalDDHS District Department of Health ServicesGAM Global Acute MalnutritionIDP Internally Displaced PersonsLRA Lord’s Resistance ArmyMOH Ministry of HealthMUAC Mid-Upper Arm CircumferanceNGO Non-Governmental AgenciesNRM National Resistance MovementOCHA United Nations Office for the Coordiantion of Humanitarian AffairsSAM Severe Acute MalnutritionSFC Supplementary Feeding CentersSCF Save the ChildrenTFC Therapeutic Feeding CentersUNICEF United Nations Children’s FundWFP World Food ProgrammeW/H Weight for HeightWHO World Health Orgainzation

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I EXECUTIVE SUMMARY

I.1 Objectives

• To evaluate malnutrition rates in children 6-59 months.• To estimate the malnutrition in infants below 6 months.• To evaluate the retrospective mortality rate among the IDP population. • To estimate the measles immunization coverage among children 9 to 59 months.• To make recommendations for program implementation as may be necessary.

I.2 Results

Table 1 GAM and SAM by Age Group in Z-scores, Gulu District, Uganda, June 2005.

Z scores 6-59 months (n=976) 6-29 months (n=445)Global Acute Malnutrition (W / H <-2 Z-scores and/or oedema)

4.1%(2.6% - 6.4%)1

5.2%(2.7% - 9.3%)

Severe Acute Malnutrition (W / H <-3 Z-scores and/or oedema)

1.2%(0.5% - 2.8%)

1.6%(0.4% - 4.6%)

Table 2 Acute Malnutrition by Age Group in % of the median, Gulu District, Uganda, June 2005.

% of the median 6-59 months (n=976) 6-29 months (n=445)Global Acute Malnutrition(H / A <-2 Z-scores)

3.1%(1.8% - 5.2%)

3.8%(1.8% - 7.6%)

Severe Acute Malnutrition (H / A <-3 Z-scores)

0.8%(0.2% - 2.2%)

0.9%(0.1% - 3.6%)

According to the MUAC measurements:

0.9% of the children were detected as malnourished 1.3% were at risk of malnutrition

The mortality rate for the total population is 0.8 / 10.000 person / dayThe proportion of total deaths that are under-5 years is 31.0%

Measles vaccination coverage is 83.1% (vaccination verified by a health card) and an additional16.0% claimed vaccination but could not be proven by a health card.

Of the 85 infants less than 6 months surveyed, 3.6% were acutely malnourished.88.2% receive only breast milk as their nourishment while the remaining 11.8% received breast milkand some other course of nourishment.

I.3 Recommendations

Continuation of the activities concerning treatment of severe and moderate acute malnutrition,and of surveillance activities (home visitor program and active case finding in the community).

Strengthening community involvement in prevention activities, such as breast feeding supportgroups, community based discussion groups and peer to peer learning.

1 Confidence interval at 95%.

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Promotion of balanced diet and kitchen gardens among the feeding center beneficiaries throughactivities such as distribution of gardens seeds, cooking demonstrations, and identification ofdiverse diets in coordination with food security programs.

Strengthening of mother and child health activities through the health centers, including activitiesto encourage early accessing of health services, regular attendance at the health centers forgrowth monitoring, vaccination and child health screening.

Continuation of nutrition surveillance though annual nutrition surveys, and strengthen the existingsurveillance system to identify areas of higher acute malnutrition concentrations and targetinterventions appropriately

Continuation of the water and sanitation activities in the camps to ensure better access to cleanwater and promote proper hygiene conditions in the camps in order to reduce morbidity andresulting malnutrition.

Continue food distribution and monitoring of the food security situation in order to predict andprevent any change in living conditions that could damage the nutrition status of the population.

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II INTRODUCTION

II.1 Northern Ugandan Context

The war in Northern Uganda has been ongoing for 18 years. Initially rooted in the turmoil of the 1980’scivil war that ended with the victory of President Yoweri Museveni’s National Resistance Movement(NRM) government, the conflict has since been transformed by Joseph Kony’s Lord’s ResistanceArmy (LRA) into a brutally violent war in which civilians in the northern districts are the main victims.Approximately 1.6 million people have been internally displaced. The Acholi region of Uganda(Kitgum, Pader, and Gulu Districts) has seen an increase in the intensity of insurgency since 1996.This has resulted in people moving, spontaneously or under the direction of the Government, intocamps protected by the Uganda People’s Defense Forces (UPDF).

Population estimates vary widely. According to the most recent figures the total population of GuluDistrict is estimated at 700,7742 but, according to the 2002 census, the population of the district was468,407. A census is currently being undertaken to accurately define the population. At the time ofthis survey, the population residing in officially recognized Internally Displaced Persons (IDP) campsin Gulu District was estimated to be around 570,774 compared to 355,003 in 2004. Of these, 45,976are resident in 4 camps that are inaccessible due to security risks.

The years between 1996 and 2002 were characterized by fluctuating insecurity. In June 2002 thesecurity situation in Gulu District, and in most of Northern Uganda, drastically changed for the worseagain as the LRA rebels flooded from Sudan en masse following the beginning of operation “Iron Fist”in March 2002. The situation in Northern Uganda worsened in 2003 with an unprecedented expansionof LRA attacks away from its traditional areas of operation. The beginning of 2004 saw an increase inthe frequency and intensity of LRA attacks on IDP camps, ambushes, looting, and abductions. In2005, the attacks have continued, but at a much reduced pace. Due to persistent insecurity, access toland is poor and looting of food stocks has increased. The general atmosphere is one of heightenedfear.

II.2 Gulu District IDP Camps

Water and Sanitation: General sanitation is poor and is aggravated by the fact that people live in densely confined areaswithin the security of the camps. Access to safe water is very dire, with the estimated amount of safewater per person per day standing at 5.5 l/p/d according to an ACF - USA survey carried out in May2005 (the SPHRE standards recommend a minimum of 15 l/p/d in emergencies). Latrine coveragefluctuates among camps though in general, there is a need for improved services. This generally poorenvironmental situation is a cause for concern, especially since morbidity and then malnutrition arecorrelated to quality of water and sanitation facilities.

Food Security:Food eaten in most households is not diverse with most meals composed of World Food Program(WFP) food rations. WFP has been distributing food aid to the IDP camps in 1996. Plot sizes foragriculture are reducing – the current average is estimated at 0.7 acres3 compared to 1.25 acres in2003 and 2.2 acres in 2002. The majority of the IDP population experiences a hunger gap centered inMay, June, and July due to the cultivation calendar. However, there is evidence that it has extendedinto August and beyond for some locations.

Humanitarian Assistance: The major factor restricting relief work in Gulu District is insecurity. Agencies are often unable to reachcamps because of insecurity with some camps routinely cut-off from services. As shown by carefulanalysis of access, camps in Gulu District have been reachable over 70% of the time for the last year.An issue is the regularity of access, which impedes planning and only allows for “hit and run” types of

2 According to WFP statistics October, 20043 Action against Hunger food security team estimation

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operations, which are not suited to the structural issues at play. The conflict in Northern Uganda isoften referred to as the forgotten war. Funding for relief and development activities has not beenproportional to needs. In the last one to two years however, an increase in international attention hasserved to increase the amount of international funds earmarked for projects in Gulu District, and otherdistricts in Northern Uganda.

II.3 ACF-USA Activities in Gulu District

ACF-USA has been operational in Gulu District since 1996 implementing nutrition, water andsanitation programs. Currently ACF-USA supports 16 Supplementary Feeding Centers (SFC’s)integrated in the Health Centers spread throughout the District, and 2 Therapeutic Feeding Centers(TFC’s) – one in Gulu Municipality Hospital and one in Anaka camp Hospital. A home visiting programhas been developed in October 2003, for the active research of malnutrition cases in the camps. Inparallel, the Health Centers staff has been trained in the prevention and detection of malnutrition forchildren coming in for health consultation, and health/nutrition education is being provided at thecommunity level by CHW in 9 camps. ACF also supports home treatment for severe malnutrition in 6camps, where children unable to be treated in a TFC can receive ready to use therapeutic food. ACFhas been monitoring the nutrition situation of the camp populations since 1998, and the presentsurvey is part of this ongoing surveillance. The first ACF survey in 1998 measured alarmingly highmalnutrition and mortality rates. The rates reduced in 1999 and since then have remained within aconsistent range regarded as an alert situation by international agencies. Other agencies have alsoconducted surveys in the area; such as Save the Children who found GAM of 7.7 in the 13 newlygazetted IDP camps at the end of last year.

III OBJECTIVES

• To evaluate malnutrition rates in children 6-59 months.• To estimate the malnutrition in infants below 6 months.• To assess the feeding and weaning practices for children less that 6 months.• To evaluate the retrospective mortality rate among the IDP population. • To estimate the measles immunization coverage among children 9 to 59 months.• To make recommendations for program implementation as may be necessary.

IV METHODOLOGY

IV.1 Survey Design

The survey was undertaken in officially recognized camps in the Gulu district. Since the last surveywas undertaken, the government of Uganda has officially recognized more camps. Some campspreviously that were small or “off-shoots” of other camps have now been gazetted. Even though, thereare 53 officially recognized camps, according to Action against Hunger workers in the field, not allcamps contain people. Therefore, 44 camps were included in the cluster selection. Four of thesecamps are not accessible at all due to security constraints, and therefore, were not included in thecluster selection since they could not be visited.

The methodology used was the internationally recognized two-stage cluster sampling processcomprising of a random selection of 900 children for the survey, aged 6-59 months (recognized as

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being particularly vulnerable and often used as a sample representing the whole population).Anthropometric measurements were used as indicators for the nutritional status of the population.

Furthermore, information on infant feeding practices was collected to better understand and shapeguidelines for future program interventions, specifically in mother and child health.

Each team comprised the following:Supervisor/Interviewer (1)Measurers (2) Driver (1) and appropriate vehicle

Each team was equipped with: Anthropometric Data Collection Form 6-59 months (1) Anthropometric Data Collection Form under 6 months (1) Mortality Data Collection Form total population (1) Verbal Questions Form to determine Cause of Death (1) Weight For Height Index Chart (1) Random Number Table (1) TFC/SFC referral forms (10) MUAC Tapes (3) Height board (1) Scale (1) Weighing Pants (3)

IV.2 The Nutritional Anthropmetric survey

The nutritional anthropometric survey was conducted using random two-stage cluster sampling. With aconfidence interval of 95%, a total of 30 clusters with 30 children aged 6-59 months in each weremeasured in order to obtain valid estimates of acute and chronic malnutrition, both global and severe. For the survey, the population of each camp was estimated using the current figures from DDHS andWFP. From this, the number of children aged 6-59 months were estimated as a proportion of the totalpopulation. The cumulative population of these children was then calculated, and the samplinginterval determined. Clusters were then allocated, and each survey entity had an equal chance ofbeing randomly selected. The data collected in the field was age (with reference to birth certificates and local calendars ifnecessary); sex; weight (with a Salter scale of 25 kg for children with a precision of 100g); height (with 1mm precision). Children < 2 years (< 85cm) were measured lying down and children > 2 years (>=85cm)measured standing up. The presence of bi-lateral oedema on the feet, (by applying a constant pressureduring 3 seconds) was verified as well as mid-upper arm circumference (MUAC) with 1mm precision. Data analysis was performed using Epi-Info 5 and Epinut software. Weight-for-height was used as ameasure of wasting, and height for age used as a measure of stunting. Both indices were calculatedusing the National Center for Health Statistics (NCHS) global reference standards. The presence ofbilateral pitting oedema was considered in the definition of severe acute malnutrition as being indicativeof Kwashiorkor.

IV.3 Training of the Nutrition Survey Teams

All surveyors were fully trained at a workshop conducted by the Medical coordinator and 2 Nutritionprogram managers of AAH. The staff used in the survey had previous experience of conductingnutrition surveys with AAH in this district. The workshop included discussions on the objectives of thesurveys, training in the methodologies of each stage of the surveys and the undertaking of practicemeasurements at an AAH supported SFC site, alongside a briefing on nutrition and malnutrition.Identification of acute malnutrition was performed on the spot. The children identified were registeredfor follow-up.

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IV.4 Data Collection and Measurement Techniques

IV.4.1 Children from 6 to 59 months:

• Age: Recorded in months. If the mother/caretaker knows the birth date, determination of the age is simple and the statedage is recorded in the questionnaire. If the caretaker is unsure, the age can be determined byinformation from vaccination cards. In cases where documentation of the age of the child is notavailable, age (month and year of birth) is determined using a calendar of local events asreference (Appendix 2).

• Gender: Recorded as Male or Female.• Weight: Recorded in kilograms to the nearest 0.1kg.

Children are weighed by using a 25kg hanging scale graduated by 0.1kg. The scale is hooked toa stick held by the 2 surveyors with the frame of the scale at eye level. The child is undressed andplaced in the weighing pants. When the child is steady, a surveyor reads and records themeasurement to the nearest 100grams.

• Height: Recorded in centimeters to the nearest 0.1cm.Children above the age of 2 years (more or equal 85 cm) are measured standing using an ACFmeasuring board; the ones below the age of 2 years are measured lying down. Each child’sshoes must be removed and he/she must be bareheaded. The child’s head, shoulder blades,buttocks, calves and heels must touch the board while the child looks straight-ahead.

• MUAC: Recorded in centimeters to the nearest 0.1cm.MUAC is measured on the left arm only, at the mid-point between the elbow and the shoulder.The arm’s muscles should be relaxed and the elbow bent. A special MUAC measuring tape isplaced around the arm, and after gently tightening, the measurement is read in the window.

• Oedema: Recorded as present/absent. In order to determine the presence of oedema, normal thumb pressure is applied to the middletop of both feet for 3 seconds. If a shallow print persists on both feet once the pressure isremoved, then the child presents oedema. Due to the clinical definition of nutrition relatedoedema, only children with bilateral oedema are recorded as having oedema for the purpose of anutrition survey.

• Measles Immunization Status: Recorded as “yes with a health card to prove it”, “yes withoutcard to prove it”, and “no”.

This data is collected only for children between 9 and 59 months, which is the vaccination periodrecommended by the national protocol.

IV.4.2 Children less than 6 months:

The following data was recorded on a separate questionnaire. • Age: Recorded in months.• Gender: Recorded as Male or Female• Height: Recorded as centimeters to the nearest 0.1cm.• Weight: Recorded as kilograms to the nearest 0.1kg.• Feeding practices: The feeding practices of infants can help explain the nutritional status of

children less than 6 months of age. Important questions to ask the mother are whether the child isexclusively breastfed, having breast milk plus other kind of food/drinks (even just water), onlyweaning food, or only family meal rations.

The study of the nutritional status of children below 6 months of age helps complete the nutritionalpicture. It also adds information regarding low birth weight such as the possible reasons why and theage when malnutrition may begin.

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IV.5 Mortality

The calculation of the mortality rate requires: the number of people living in the household at the day of the survey. the number of people alive in the household 3 months ago. the number of deaths in the household in the previous 3 months. for the ones who died within the recall period, the age and the presumed cause of mortality is

recorded. the number of people who migrated out of the household within this recall period.

In order for the mortality rate calculations to be valid, the total number surveyed must be over 5000. Inthe case of a 30x30 nutrition survey, there are not enough children surveyed to make the calculationof an Under 5 mortality rate statistically valid. The sample size taken of approximately 900-1200children below 5 years is not representative for this data. It is possible, however, to calculate theproportion of deaths among children under 5 years, as well as the cause of death, in order to adddetail to the understanding of the nutrition situation.

Since the total population in the survey area is approximately 5000, it is possible to estimate themortality rate for the total population with enough confidence.

IV.6 Cut-off Guidelines and Formulas Used

IV.6.1 Weight for Height Index4

The weight for height index expresses the weight of a child in relation to height. It highlights anyevidence of thinness or wasting in a child, and is an indicator of the child’s present and immediatenutritional status (acute malnutrition).

There are two main units for expressing malnutrition rates in a population: Z-score or percentage ofthe median. The percentage of the median method is used for admission to nutritional centers,whereas the Z-scores are the internationally recognized expression for the results of nutritionalsurveys as they are more statistically precise. The results will be presented in both Z-scores andpercentage of median. They are also compared to the internationally recognized reference populationstandard5.

Table 3 Acute Malnutrition cut-off for definition of population nutritional status.

Z-scores % of MedianAcute Malnutrition <-3 z-scores <70%Moderate Malnutrition <-2 and >=-3 z-scores <80% and >=70%Global Malnutrition <-2 z-scores <80%

4 SPHERE, Project. Minimum Standards in Nutrition in Nutrition and Food Aid. Humanitarian Charterand Minimum Standards in Disaster Response. Geneva, 2002.5 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years.United States. Vital Health Statistics. 165, 11-74.

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IV.6.2 MUAC

MUAC can be used without reference to age or height between 6 and 59 months, and is a particularlysuccessful way in identifying children with a high mortality risk. The standards used by ACF are:

Table 4 MUAC cut-offs for definition of malnutrition status.

MUAC6

Severe Malnutrition <110mmModerate Malnutrition >=110mm and <120mm At risk of malnutrition >=120mm and <125mmAdequate Nutritional Status >=125 mm

Mortality

The calculation of the death rate is as follow: Death rate (DR) = ____n_____

[(n+N+M)+N]/2

where: n= the number of deaths in the recall periodN= the number of people alive at the day of the surveyM= the number of people who migrated within the recall period.

Mortality rate (MR) = (DR x 10,000)/number of days in the recall periodMR is expressed per 10,000 per day.

Table 5 Mortality rate cut-off for definition of status of the population

Total Population Population Under 5 yearsAlert 1/10,000/day 2/10,000/dayEmergency 2/10,000/day 4/10,000/day

For this survey the recall period was three months; therefore, the number of days in the recall periodwas 90 days (3 months).

IV.7 Survey Implementation

The survey was conducted from May 31st- June 17th 2005 with a total of 12 field days of datacollection. It was implemented in 26 out of 53 recognized IDP camps.

IV.8 Constraints

Security constraints limited movement to and in the field, and most importantly limited the timeavailable per day to conduct the survey. Sometimes camps had to be revisited if there was notenough time to complete the days work. In addition, due to ACF’s policy of travelling unaccompaniedby military escort, plans sometimes had to be changed at the last minute.

6 MUAC Index and Cut-offs, ACF-USA Guidelines and Protocols, 2004.

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V RESULTS

V.1 Age and gender distribution of children 6 to 59 months

The total sample size was 985. After flagging and cleaning bad data, the measurements for 976children were included in analysis.

Table 6 Age and Gender Distribution 6-59 months, Gulu District, Uganda, June 2005.

Boys Girls TotalAge groups(in months) N % N % N %

Sex ratio

06-17 92 45.8 109 54.2 201 20.6 0.8418-29 125 51.2 119 48.8 244 25.0 1.0530-41 112 47.5 124 52.5 236 24.2 0.9042-53 101 46.5 116 53.5 217 22.2 0.8754-59 45 57.7 33 42.3 78 8.0 1.36

TOTAL 475 48.7 501 51.3 976 100 0.95

The distribution of sex shows a slight imbalance with more girls than boys. However, the sex ratioequals to 0.95, which maintains that selection was done randomly.

Figure 1 Demographics of Survey Sample (Age and Sex), Gulu District, Uganda, June 2005.

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

6-17

18-29

30-41

42-53

54-59

Distribution of the sample by age and gender

BoysGirls

The age distribution by sex shows some imbalances, in particular within the 6-17 month and the 54-59month age group. The reason for this is not clear. Nevertheless, the period intervals within the agegroups used in the standard analysis are not equal, and therefore, the lower representation of childrenis an artifact.

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V.2 Weight for Height Index (W/H) or Acute Malnutrition

V.2.1 Acute Malnutrition in Z-scores

Table 7 Weight for Height Distribution by Age in Z-scores, Gulu District, Uganda, June 2005.

SevereMalnutrition Moderate Malnutrition No malnutrition

W/H <-3 Z-score W/H >=-3 and <-2 Z-score W/H >=-2 Z-score

OedemaAge

groups(in

months)N

N % N % N % n %06-17 201 3 1.5 3 1.5 194 96.5 1 0.518-29 244 1 0.4 13 5.3 228 93.4 2 0.830-41 236 1 0.4 1 0.4 232 98.3 2 0.842-53 217 0 0.0 9 4.1 207 95.4 1 0.554-59 78 0 0.0 2 2.6 75 96.2 1 1.3Total 976 5 0.5 28 2.9 936 95.9 7 0.7

Table 8 Weight for Height and oedema distribution, Gulu District, Uganda, June 2005.

W / H < -2 Z scores W / H >= -2 Z scoresMarasmic Kwashiorkor KwashiorkorYES 0 0.0% 7 0.7%

Marasmus No MalnutritionOedemaNO 33 3.4% 936 95.9%

Both marasmus and kwashiorkor type of malnutrition were found in the sample.

Table 9 GAM and SAM by Age Group in Z-scores, Gulu District, Uganda, June 2005.

6-59 months (n=976) 6-29 months (n=445)Global Acute Malnutrition 4.1%

(2.6% - 6.4%)75.2%

(2.7% -9.3%)Severe Acute Malnutrition 1.2%

(0.5% - 2.8%)1.6%

(0.4% - 4.6%)

The Chi square test reveals that the difference of malnutrition among both age groups is significant(p<0.05). The 6-29 months and 30-59 months old groups have statistically the same relative risk ofbeing malnourished.

Table 10 GAM and SAM distribution by gender in Z-scores, Gulu District, Uganda, June 2005

Boys GirlsN % n %

Severe Acute Malnutrition 8 1.7% 4 0.8%Global Acute Malnutrition 26 5.5% 14 2.8%No Malnutrition 449 94.5% 487 97.2%Total 475 100.0% 501 100.0%

According to the Chi square test (p=0.034), boys are at higher relative risk of malnutrition than girls(Relative Risk: 1.96, Confidence interval at 95%: 1.04 – 3.71).

7 Confidence interval at 95%.

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Figure 2 Weight for Height Distribution in Z-scores, Gulu District, Uganda, June 2005.

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Sample

There is a slight displacement of the sample population curve to the left of the reference curveindicating that the nutritional status of the under 5 population is only slightly less well off than anadequately nourished population. The mean Z-score of -0.20 statistically confirms the graphical results. The standard deviation is 0.99,which indicates that the distribution is satisfactory, and the data is representative of the population (itshould stay it the range 0.80 – 1.20).

V.2.2 Acute Malnutrition in Percentage of Median

Table 11 Weight for Height Distribution by Age in Percentage of Median, Gulu District, Uganda, June 2005.

SevereMalnutrition Moderate Malnutrition No malnutrition

W/H <-3 Z-score W/H >=-3 and <-2 Z-score W/H >=-2 Z-score

OedemaAge

groups(in

months)N

N % N % N % n %06-17 201 1 0.5 3 1.5 196 97.5 1 0.518-29 244 0 0.0 10 4.1 232 95.1 2 0.830-41 236 0 0.0 2 0.8 232 98.3 2 0.842-53 217 0 0.0 6 2.8 210 96.8 1 0.554-59 78 0 0.0 1 1.3 76 97.4 1 1.3Total 976 1 0.1 22 2.3 946 96.9 7 0.7

Table 12 GAM and SAM by Age Group in Percentage of Median, Gulu District, Uganda, June 2005.

6-59 months (n=976) 6-29 months (n=445)Global Acute Malnutrition 3.1%

(1.8% - 5.2%)3.8%

(1.8% - 7.6%)Severe Acute Malnutrition 0.8%

(0.2% - 2.2%)0.9%

(0.1% - 3.6%)

Statistically, there is no significant difference between the malnutrition rates of children 6-29 monthsand 30-59 months (p<0.05).

17

Table 13 GAM and SAM distribution by gender in % of the median, Gulu District, Uganda, June 2005

Boys GirlsN % n %

Severe Acute Malnutrition 4 0.8% 4 0.8%Global Acute Malnutrition 17 3.6% 13 2.6%No Malnutrition 458 96.4% 488 97.4%Total 475 100.0% 501 100.0%

The analysis of the malnutrition distribution by gender in % of the median does not reveals significantdifference between boys and girls, on the relative risk to be malnourished (p=0.37).

V.3 MUAC Analysis

The MUAC analysis is done on children more than 75.0cm height. The sample counts 793 children.

Table 14 MUAC distribution in under-5 population, Gulu District, Uganda, June 2005.

Total 75 >= Height< 90 cm

Height >=90cmMUAC Nutritional meaning

N % n % n %<110mm Severe malnutrition 0 0.0 0 0.0 0 0.0

>=110 and <120mm Moderate malnutrition 7 0.9 7 1.7 0 0.0>=120 and <125mm At risk of malnutrition 10 1.3 9 2.2 1 0.3

>=125mm No malnutrition 776 97.9 398 96.1 378 99.7Total 793 100.0 414 100.0 379 100.0

According to the MUAC measurements, 0.9% of the children are malnourished, and 1.3% are at risk.

V.4 Measles Vaccination Coverage

According to the National Protocol, children above the age of 9 months receive measles vaccination.Therefore, the analysis is done on the 9-59 months age group, which represents 929 children.

Table 15 Measles Vaccination Coverage, Gulu District, Uganda, June 2005.

Status N %Yes: vaccinated and proven by health card 772 83.1%No 8 0.9%Unsure: not proven by health card 149 16.0%

At least 83.1% of the eligible children are vaccinated against measles, which conforms with the WHOrecommendations (80%) to prevent an outbreak.

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V.5 Nutrition Information on Infants under 6 months

V.5.1 Evaluation of the prevalence of malnutrition

85 infants are included in the analysis. The distribution of the sample is as follows:

Table 16 Age and gender distribution of infants more than 49.0 cm height, Gulu District, Uganda, June2005

Age Boys Girls Total0 –1 months 4 9 131 –2 months 5 5 102 – 3 months 4 8 123 – 4 months 11 11 224 - 5months 6 8 145 – 6 months 6 8 14

Total 36 49 85

As 2 of these children are less then 49.0 cm height, their nutritional index cannot be calculated (thestandards start at 49.0 cm), and hence, they are considered malnourished. Both children are less than1 month old, and their weights are 2.9 and 3.0 kg respectively. They are not malnourished.

The anthropometric analysis on the 83 other children is:

Table 17 Prevalence of acute malnutrition among infants more than 49.0cm height, Gulu District, Uganda,June 2005.

Z-score % of the medianGlobal acute malnutrition 3 3.6% 4 4.8%

Severe acute malnutrition 3 3.6% 3 3.6%

The sample used is not representative of the total population of infants of the age group. Therefore,no confidence interval can be calculated.

V.5.2 Feeding practices

The mothers of the infants surveyed have been questioned on the diet of their infants.• 85 of them were lactating. The breastfeeding rate is 100%• 75 of them were not providing any other food than breast milk. The exclusive breast

feeding rate is 88.2%• Among the 10 children who receive milk and other food/drink, 1 is 2 months old, 2 are 3

months old, 4 are 4 months old, and 3 are 5 months old.

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V.5.3 Mortality

Total population at the day of the survey: 4233< 5 years old: 1060>= 5 years old: 3173

Total population 3 months before the survey: 4330Number of migrants who arrived within the recall period: 124Number of migrants who left within the recall period: 190

Number of deaths: 31< 5 years old: 13>= 5 years old: 18

Mortality rate: [31 / ((4233+4330)/2)]*10 000 / 90 = 0.8

The retrospective mortality rate on the last 3 months is 0.8/10,000/day.

% of under five in the population: 25.0%% of deaths in total population that are under five: 31.0%

VI DISCUSSION

Since 1998, when the rates of malnutrition were alarming, the situation has improved tremendously.As reported in the following table, the rates of GAM have shown a steady decrease since 2001, andmalnutrition rates continue to decrease this year.

Table 18 Longitudinal Comparison of ACF survey wasting results in Z-scores, Gulu District, Uganda,June 2005.

April 98 March 99 March 01 May 03 June 04 June 05Wasting Gulu

Eastcamps

GuluWest

camps

GuluEast

camps

GuluWest

camps

GuluEast

camps

GuluWest

camps

GuluDistrictcamps

GuluDistrictcamps

GuluDistrictcamps

Global 15.7 11 6.4 4.9 6.7 7.7 6.7 4.5 4.195% CI 11.5-21.2 7.4-16 4.4-9.2 3.1-7.4 4.6-9.5 5.4-10.7 4.6-9.5 3.0-6.8 2.6 - 6.4Severe 2.5 2.3 1.6 0.5 1 1.8 1.3 0.8 1.295% CI 1.0-5.6 0.8-5.4 0.7-3.3 0.1-1.9 0.3-2.6 0.8-3.6 0.7-2.4 0.3-2.2 0.5 - 2.8

In the sample, 3.6% of the children less than 6 months of age were malnourished. In 2004, no infantsbelow the age of 6 months were malnourished. However, those results must be taken cautiously asthe sample was not representative of the population.

The mortality rate was determined to be 0.8/10,000 per day (it was 1.2/10,000 per day in the 2004survey). According to international agreed upon standards, this is below the cause for alert.Of the deaths that occurred within the population 31.0% were in the under-5 age group. This agegroup represents 25% of the sample. Fever was reported commonly as a cause of death, as well asdiarrhea. 83.1% of the eligible under 5 population has been vaccinated against measles with a health card asproof. An additional 16% also reported vaccination but do not have the health card to prove it. Thisrate exceeds the 80% recommended by the WHO to prevent an outbreak.

20

Last year, only 47% of the households could produce the vaccination card, and 50% declared thattheir children had been vaccinated without any documentation to prove it. There is an improvement inboth the vaccination and card conservation rate.

This improvement in both malnutrition rates and retrospective mortality can be put in relation with thefact that rebel activity as a whole has decreased this year compared to the previous years. The results are compiled from camps that were accessible to the ACF teams. Therefore, it has to betaken into account that the situation in inaccessible camps might be different since they are not ableto regularly access services. Some of the camps (Bibia, Atiak, Ome-1 and Ome-2) that were notvisited due to security problems had other actors present. In Atiak, Save the Children operates a SFC,which provides support for the population and the malnourished children. Beneficiaries in Amurufrequently come from Ome-1 and Ome-2. When the security situation allowed, water-sanitation andfood security activities have been conducted in Bibia by ACF. From these activities, it is felt that thesituation should be drastically different, but it is not possible to be accurate about the state of thepopulation at this time.

However, there is much still to be done, and with the decrease in rates, the underlying causes ofmalnutrition should be strongly addressed.

Child feeding:In both the surveys and program work, ACF identified that children are most vulnerable at the time ofweaning. In addition, mothers do not space their children adequately, and hence there is a large riskfor the older children to become malnourished due to the mother either suddenly weaning the olderchild or showing less attention due to the increased workload of the new born baby. In the present survey, 100% of the mother were breastfeeding their baby, but 88.2% claimed toexclusively breastfeed their children. This percentage is encouraging, but has to be taken carefully.Indeed, during program work, it is frequently seen that whilst mothers may be exclusively breastfeed,they may not be doing so as frequently or for a long enough duration to meet the baby’s needs. Manymothers in the camps are very young, and due to the change in social structure caused by moving into the camps, there is often very little support and advice from the community.

Of the 10 children who were not exclusively breastfed some were as young as 2 months old. WHOrecommends that mothers should exclusively breastfeed their children for the first 6 months. Indeed,the risk of disease and subsequent malnutrition is great in children this young when given uncleanwater or inappropriate foodstuffs.

Food access:WFP provides rations to all the camps included in the survey. In the newly gazetted camps, therations are 50% of the recommended daily intake, and in the other camps, they are 78%. Onlyextremely vulnerable individuals receive 100% rations. The produce from gardens supplements these rations when the security situation allows. In times ofinsecurity this is the only food available to the households. This year, the harvest has been particularlypoor implying that the population was extremely reliant on this food supply.

Water and sanitation:The official figures still state that water coverage is 5.6l per person per day and latrine coverage is 50persons to one latrine, which is will below the recommended Sphere standards of 15l and 20 peoplerespectively (these figures may change after the recent registration of IDPs, correct as of March2005).

21

Management of acute malnutritionACF continues to work in 16 IDP camps in Gulu, to detect and treat moderate and severemalnutrition. The admission figures on the last 12 months are:

Jun-04

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

TOTAL

SFC 1785 1252 1449 1592 1672 1677 664 971 925 1077 1611 1161 15836TFC 125 130 80 56 62 69 44 33 34 57 58 86 834HT 41 74 75 27 50 60 33 24 33 26 40 26 509 The figures above indicate that we have treated 17,179 children over the last year in the Gulu District.

IDP Pop. 550,000U 5 Pop (at 20%) 110,000

Estimated affected pop. fromfeeding center attendance 15.6%

The above figures show that the total number of children treated over the period of one yearcorrespond to about 15.6% of the under 5 population. This figure is not inconsistent with a 4% GAM rate. A nutrition survey gives a picture of the situation ata given time. Allowing for a theoretical 100% coverage, and for an average treatment period of 3months (equal to theoretical duration of stay of patients in SFC’s), a 4% GAM rate will translate into ayearly caseload representing 16% of the population. After adjusting for relapses and lower actualcoverage, the 15.6% observed in Gulu is consistent with this prediction.

Therefore, great attention must be paid to both malnutrition rates and to the absolute caseloads intowhich they translate over a time period. This is applicable to the situation above, but also to places ofhigh population density (typically urban slums, such as Lagos or Nairobi) where even low rates willmechanically translate in caseloads superior to areas typically described as nutritional emergencies. Strengthening of home treatment programs may help to address the rising severe malnutrition ratesfor those who fit the criteria. In addition, home visiting activities and tracing of defaulters can help toensure that children can be treated before becoming severely malnourished and are at a high risk ofdeath.

The nutritional status of the population surveyed in the camps is acceptable, but the population in theIDP camps remains highly dependent on humanitarian assistance. Malnutrition still remains a concernfor a high number of children.

VII Recommendations

Continuation of the activities concerning treatment of severe and moderate acute malnutrition,and of surveillance activities (home visitor program and active case finding in the community).

Strengthening community involvement in prevention activities, such as breast feeding supportgroups, community based discussion groups and peer to peer learning.

Promotion of balanced diet and kitchen gardens among the feeding center beneficiaries throughactivities such as distribution of gardens seeds, cooking demonstrations, and identification ofdiverse diets in coordination with food security programs.

Strengthening of mother and child health activities through the health centers, including activitiesto encourage early accessing health services, regular attendance at the health centers for growthmonitoring, vaccination, and child health screening.

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Continuation of nutrition surveillance though annual nutrition surveys, and strengthening theexisting surveillance system to identify areas of higher acute malnutrition concentrations andtarget interventions appropriately.

Continuation of the water, and sanitation activities in the camps to ensure better access to cleanwater, and to promote proper hygiene conditions in the camps in order to reduce morbidity andresulting malnutrition.

Continue food distribution, and monitoring of the food security situation in order to predict andprevent any changes in living conditions that could damage the nutrition status of the population.

VIII APPENDICES

VIII.1 Appendix 1: Local Events Calendar to Calculate Age in Months

Gulu District, Uganda June 2000- May 2005MONTH ANNUAL NATIONAL EVENTS ANNUAL LOCAL EVENTS

2000 2001 2002 2003 2004 2005

JANUARY 1st New Year26th Victory Day 52 40

28 16 4

FEBRUARY Clearing field ,opening sch GuludeclaredEbola free51

3927 15 Peace Talks 3

MARCH 8th Women's Day PresidentialElections inUganda 50

38 26 142

APRIL Easter

Beginning ofWet Season49

Beginningof WetSeason37

Beginning ofWet Season25

Beginning of Wet Season 13 Beginning of Wet Season1

MAY 1st Labor Day 48 36 24 12 ACF Nutrition Survey0-1

JUNE 3rd Martyrs day9th Heroes Day

NationalReferendumheld 59

47Increase inRebelactivity35

23 11

JULY Harvest of maize / beansHarvest 1stseason crops58

Harvest 1stseason crops46

Burning ofAlero &Marawobi34

Harvest 1stseason crops22

Harvest 1st season crops 10

AUGUST Assumption Day 57 45Release ofwomen/children inAtiak 33

21Christmas in Aug. in Pece Stadium 9

SEPTEMBER Weeding of second season 56 44Population

Census32

208

OCTOBER 9th Independence Day

Ebolaoutbreak inGulu55

43 31 197

24

NOVEMBER Harvest of maize / beansPrayers inKeyo Hills54

Prayer inKeyo Hills 42

Prayer inKeyo Hills

30Prayer in

Keyo Hills 18 Prayer in Keyo Hills 6

DECEMBER 25th Christmas Day26th Boxing Day

Death of Dr.Lukwiya53

41 29

Cease fire/Peace talksbetween LRAandgovernment17

Peace Talks end; Musevi declares war LRAat Pece 5

VIII.2 Appendix 2: Cluster selection, Gulu camps 2005

Village No. Camps Estimated TotalPopulation

E. 6-59 mths (20%)ESTIMATED

E. 6-59 mthsCUMULATED

Number Attributed Cluster

1 Acet 24,191 4838 4838 1 4838 1,22 Agung 1,799 360 5198 4839 5198 3 Alero 17,037 3407 8605 5199 8605 34 Amuru 42,841 8568 17174 8606 17174 4,55 Anaka 27,119 5424 22597 17175 22597 6,76 Aparanga 2,284 457 23054 22598 23054 7 Awach 15,704 3141 26195 23055 26195 88 Awer 18,967 3793 29988 26196 29988 99 Awere 18,916 3783 33772 29989 33772 10

10 Cwero 9,763 1953 35724 33773 35724 1111 Koch Goma 10,850 2170 37894 35725 37894 12 Lalogi 19,122 3824 41719 37895 41719 1213 Olwal 12,162 2432 44151 41720 44151 1314 Olwiyo 1,875 375 44526 44152 44526 15 Ongako 8,420 1684 46210 44527 46210 1416 Opit 24,244 4849 51059 46211 51059 1517 Pabbo 54,163 10833 61891 51060 61891 16,17,1818 Pagak 10,180 2036 63927 61892 63927 1919 Paicho 14,208 2842 66769 63928 66769 2020 Palaro 10,124 2025 68794 66770 68794 21 Palenga 10,269 2054 70848 68795 70848 2122 Parabongo 11,294 2259 73106 70849 73106 23 Patiko Ajulu 13,502 2700 75807 73107 75807 2224 Purongo 9,043 1809 77615 75808 77615 2325 Unyama 11,848 2370 79985 77616 79985 26 Wii Anaka 1,878 376 80361 79986 80361 27 Wia Nono 2,362 472 80833 80362 80833 2428 Alokolum 11,881 2376 83209 80834 83209

29 Awor 9,632 1926 85136 83210 85136 2530 Bobi 22,762 4552 89688 85137 89688 2631 Coo-pe 11,732 2346 92034 89689 92034 2732 Dino 6,009 1202 93236 92035 93236 33 Keyo 7,033 1407 94643 93237 94643 2834 Koro Abili 9,191 1838 96481 94644 96481 35 Koro Lapainat 19,687 3937 100418 96482 100418 2936 Lolim 2,480 496 100914 100419 100914 37 Lugore 5,653 1131 102045 100915 102045 3038 Palukere 1,350 270 102315 102046 102315 39 Pawel 4,323 865 103180 102316 103180 40 Odek 3,876 775 103955 103181 103955

Total 519,774 103955

Observation: We have not included Ome 1, Ome 2, Atiak, and Bibia as they are not accessible due to security reasons. Ome 1 7830Ome 2 7845Atiak 24,768Bibia 5883District 649,774