South Sudan

NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OLD

RESULTS SUMMARY

WUDIER PAYAM, LONGUCHOK COUNTY, UPPER NILE STATE.

27TH AUGUST TO 16TH SEPTEMBER 2006

Action Against Hunger – USA (ACF-USA)

South Sudan

Onesmus Muinde- Assistant CMN Joseph Nganga - Nutritionist. Imelda .V. Awino - Nutritionist.

Deborah Morris - Program Assistant.

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ACKNOWLEDGMENTS

ACF - USA acknowledges the important support and assistance of the following:

Department for International Development (DFID) for funding the nutrition assessment. Sudan Relief and Rehabilitation Commission (SRRC), both in Lokichoggio and Wudier Payam for

facilitating the work in the field.

Oxfam GB Wudier and Lokichoggio for their overwhelming support in terms of accommodation and upkeep.

Mothers, caretakers, local community and community leaders without whose support and cooperation

the survey would not be a success.

The surveyors for their commitment and hard work that saw the successful completion of the survey.

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TABLE OF CONTENTS .I. EXECUTIVE SUMMARY.....................................................................................................................................5 .I.1. INTRODUCTION ..............................................................................................................................................5 .I.2. METHODOLOGY..............................................................................................................................................5 .I.3. SUMMARY OF FINDINGS................................................................................................................................6 .I.4. RESULTS OF THE NUTRITION SURVEY .......................................................................................................7 .I.5. DISCUSSION....................................................................................................................................................7 .I.6. RECOMMENDATIONS ....................................................................................................................................8 .II. INTRODUCTION ................................................................................................................................................9 .III. OBJECTIVES OF THE SURVEY ....................................................................................................................10 .IV. METHODOLOGY............................................................................................................................................10 .IV.1. TYPE OF SURVEY AND SAMPLE SIZE ................................................................................................................10 .IV.2. SAMPLING METHODOLOGY..............................................................................................................................11 .IV.3. DATA COLLECTION..........................................................................................................................................11 .IV.4. INDICATORS, GUIDELINES, AND FORMULA’S USED ............................................................................................11

.IV.4.1. Acute Malnutrition.............................................................................................................................11

.IV.4.2. Mortality ............................................................................................................................................12 .IV.5. FIELD WORK...................................................................................................................................................13 .IV.6. DATA ANALYSIS ..............................................................................................................................................13 .V. RESULTS OF THE QUALITATIVE ASSESSMENT ........................................................................................13 .V.1. SOCIAL DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS.....................................................................13 .V.2. FOOD SECURITY ..............................................................................................................................................15 .V.3. HEALTH...........................................................................................................................................................17 .V.4. WATER AND SANITATION..................................................................................................................................18 .V.5. MOTHER AND CHILD CARE PRACTICES ..............................................................................................................19 .V.6. NGO ACTIVITIES..............................................................................................................................................21 .VI. RESULTS OF THE ANTHROPOMETRICS SURVEY....................................................................................22 .VI.1. DISTRIBUTION BY AGE AND SEX.......................................................................................................................22 .VI.2. ANTHROPOMETRICS ANALYSIS ........................................................................................................................22

.VI.2.1. Acute Malnutrition, Children 6-59 months of Age.............................................................................22

.VI.2.2. Risk of Mortality: Children’s MUAC ..................................................................................................25 .VI.3. MEASLES VACCINATION COVERAGE.................................................................................................................25 .VI.4. HOUSEHOLD STATUS ......................................................................................................................................26 .VI.5. COMPOSITION OF THE HOUSEHOLDS ...............................................................................................................26 .VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ...................................................................26 .VII.1. MORTALITY RATE ..........................................................................................................................................26 .VIII. CONCLUSION ..............................................................................................................................................27 .IX. RECOMMENDATIONS...................................................................................................................................28 .X. APPENDIX .......................................................................................................................................................29 .X.1. SAMPLE SIZE AND CLUSTER DETERMINATION....................................................................................................29 .X.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE. ...................................................................................................30 .X.3. HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/HOUSEHOLD).................................................................................................................................................31 .X.4. ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/CLUSTER). .........32 .X.5. CALENDER OF EVENTS –WUDIER PAYAM AUGUST 2006 ......................................................................33 .X.6. MAP OF WUDIER PAYAMS, LONGUCHOK COUNTY (POPULATION SIZE: 22,942) ...................................................35

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LIST OF TABLES

TABLE 1: MUAC GUIDELINES .....................................................................................................................12 TABLE 2: DISTRIBUTION BY AGE AND SEX ...................................................................................................22 TABLE 3: WEIGHT FOR HEIGHT DISTRIBUTION BY AGE IN Z-SCORE ................................................................23 TABLE 4: WEIGHT FOR HEIGHT VS. OEDEMA ................................................................................................23 TABLE 5: GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN Z-SCORE......................................24 TABLE 6: NUTRITIONAL STATUS BY SEX IN Z-SCORE....................................................................................24 TABLE 7: DISTRIBUTION OF WEIGHT/HEIGHT BY AGE IN PERCENTAGE OF THE MEDIAN ...................................24 TABLE 8: WEIGHT FOR HEIGHT VS. OEDEMA.................................................................................................25 TABLE 9: GLOBAL AND SEVERE ACUTE MALNUTRITION BY AGE GROUP IN PERCENTAGE OF THE MEDIAN........25 TABLE 10: MUAC DISTRIBUTION ................................................................................................................25 TABLE 12: HOUSEHOLD STATUS .................................................................................................................26 TABLE 13: HOUSEHOLD COMPOSITION ........................................................................................................26

LIST OF FIGURES FIGURE 1: SOURCES OF LIVELIHOOD ...........................................................................................................14 FIGURE 2: SOURCES OF INCOME..................................................................................................................14 FIGURE 3: CROPS GROWN...........................................................................................................................15 FIGURE 4: SOURCES OF DRINKING WATER....................................................................................................18 FIGURE 5: HUMAN WASTE DISPOSAL............................................................................................................19 FIGURE 6: FEEDING BETWEEN 6-29 MONTHS................................................................................................20 FIGURE 7: DISTRIBUTION BY AGE AND SEX IN WUDIER PAYAM.......................................................................22

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.I. EXECUTIVE SUMMARY

.I.1. INTRODUCTION

Longuchok County is composed of 6 Payams namely Wudier, Longuchok 1, Darjo, Guelguk (formally Chotbora), Pamach and Malual with a total of 18 Bomas (3 Bomas located in each Payam). Wudier Payam lies within Longuchok County in Upper Nile State and it is bordered by Maban Payam to the West, Longuchok 1 payam to the south, Darjo Payam to the north and Chotbora to the East. Wudier Payam is generally flat and is crisscrossed by rivers and deep swamps which are mainly seasonal and also acts as main source of water for the cattle and some members of the community who live far from the drilled boreholes. The area is made up of fertile sandy black cotton soil. The community is mainly agro-pastoralists (farming maize as a major crop and rearing average number of cattle). According to the WFP food security and livelihoods updates of May 2006, the 2005 rains were untimely and most people had not planted, as a result most households in Upper Nile including Longuchok County were facing acute food shortages due to deteriorating food security situation. Notably the last WFP food drop in the location was in November 2005. This occasioned early exhaustion of food stocks with limited access to market and the community were reported to be mainly relying on various coping mechanisms such as consumption of wild foods for survival. Correspondingly, 19 cases of severe malnutrition among under-fives had been treated at MSF-Holland PHCC in Wudier between the month of April and July 2006 (MSF-H). Additionally, there were reports of non-facilitated returnees coming back to Longuchok County, mainly from Ethiopia (Dima and Panyadur refugee camps) and from North. The returnees mostly settle in Wudier and Darjo Payams and are integrated in the locations’ communities and exert pressure on the already plagued food resources as they establish themselves, further exacerbating the food insecurity situation in the area. Finally, according to both Servants Heart and MSF H, no nutrition surveys have been conducted in the location in the recent past. Given the above reasons, ACF USA decided to implement a nutritional survey in the region in order to detect the actual nutritional situation.

An anthropometrics nutritional survey was carried out in Wudier payam by ACF-USA from 27th August to 11th September 2006, with the following objectives:

To evaluate the nutritional status of children aged 6 to 59 months. To estimate the measles immunisation coverage of children aged 9 to 59 months. To estimate the crude mortality rate through a retrospective survey. To determine predisposing factors influencing the nutrition situation of the community.

.I.2. METHODOLOGY

A two-stage 30 by 30 cluster survey methodology was applied. From the entire population figure of 22,9421, 20% of the population was sampled to represent the children who are under five years of age (<5 years =4,579). 30 clusters were assigned to all the accessible villages in Wudier payam. In each cluster, households were randomly selected and surveyed. All the children aged between 6 and 59 months of the same family, defined as a woman and her child, were included in the survey. Alongside the anthropometric survey, a retrospective mortality survey (over the past three months) was undertaken in Wudier payam using SMART methodology. Qualitative data was also collected through observation and the use of questionnaires. The information sought was mainly on food security, water and sanitation, accessibility and utilization of health care services as well as child care practices.

1 Wudier SRRC secretary August 2006

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.I.3. SUMMARY OF FINDINGS

Wudier Payam has 3 Bomas namely Gier, Gambel and Wanken and is inhabited by the Nuer tribe who are the majority, followed by the Burun and Buldit tribe. The Payam is made up of 28 villages. The SRRC secretary reported the current security situation to be normal within the location. Successful disarmament exercise in the location was carried out by the SPLA in February 2006. Reportedly, in the year 2005, the GOS headquarter was in Wudier but after signing of the CPA, it was moved to Longuchok 1 Payam in March 2006 necessitating the commissioner’s movement too, nevertheless, there is a stable prevailing political stability2. The last insecurity incident in the area occurred on 15th May 2006 whereby the county’s commissioner was ambushed on his way to Guelguk from Wudier resulting to death of one person. Later, 7 people were killed and two wounded when the commissioner called for back-up security3. During the assessment period, three international NGO’s were working within Wudier Payam namely Oxfam GB, VSF Belgium and MSF-Holland and one indigenous NGO; Servants Heart. Main activities of the mentioned NGOs are as follows:

Oxfam GB: Public Health Program with emphasis on Health education, water and sanitation. So far, they have constructed 4 functional boreholes within Wudier village and are targeting to construct 6 more boreholes within Wudier Payam. In the health education and sanitation program that they initiated in May 2005, they recruited and trained more than 48 village hygiene motivators (VHM) working within the Payam. MSF Holland: Run a PHCC that offers health services to the community which range from preventive services to curative services. Run 3 outposts in Chotbora, Darjo and Longuchok 1 where they have outreach services after every 10 days VSF Belgium: Offer mainly curative services to the livestock. Servants Heart: Offer support to the Wudier Primary School through provision of school uniforms.

Preventive services are offered by both MSF-H at the PHCC and Oxfam GB within the community. These efforts are seen in the gradual behaviour change among the community, however, latrines were observed in few households and human waste was mainly disposed off in the open fields susceptible to flooding, hence, easily predisposing the community to diarrhoeal infections. According to observations made during the assessment, community health seeking behaviour is generally satisfactory. Interviews with households and with nurse in charge of MSF-H clinic revealed that most community members seek medical attention at the clinic as opposed to traditional healers. Borehole water is generally accessible to community around Wudier centre where the four functional boreholes are located. Most of the villages which are far from these water points rely heavily on river and swamp water puddles that forms during the rainy season. During the assessment period most of the household had cultivated crops mainly maize while sorghum, millet and groundnuts were cultivated in few households. Food security situation is not expected to improve with exhaustion of the current crop of green maize that the community is mainly relying on at this period. Residents in the payam depend on long distance trade between Wudier and Ethiopian, and Guelguk markets located approximately 6-8 days and 3 days away respectively. Most commodities, especially food are delivered from these markets and battered with livestock in the community particularly during the dry season. However, during the rainy season, accessibility to these markets is limited by the surrounding rivers and swamps.

2 Wudier SRRC secretary September 2006 3 Wudier SRRC secretary September 2006

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.I.4. RESULTS OF THE NUTRITION SURVEY

A total of 931 children were measured during the nutritional survey, however only 922 children were finally included in the analysis. Nine records were excluded from the analysis due to aberrant data. The result of the anthropometrics survey, shown in the table below, indicates Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) of 6.7%[4.6%-9.6%] and 0.5%[0.1%-1.9%] which are below the emergency threshold of rates 15% and 4% respectively.

AGE GROUP INDICATOR RESULTS

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

6.7% [4.6%-9.6%] Z-score

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

0.5% [0.1%-1.9%]

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

4.1% [2.5%-6.5%]

6-59 months (n =922 ) % Median

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

0.2% [0.0%-1.4%]

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

9.4% [6.1%-14.0%] Z-score

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

1.0% [0.2%-3.6%]

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

6.7% [3.9%-10.9%]

6-29 months (n =481 )

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

0.4% [0.0%-2.7%]

Total crude retrospective mortality (last 3 months) /10,000/day* Under five crude retrospective mortality /10,000/day Percentage of children under five amongst deaths recorded

0.72[0.31-1.31] 0.12[-0.13-0.36]

5.88% Measles immunization coverage on children >=9 months old (n=845)

By card According to caretaker4

Not immunized

0.8% 9.6%

89.6% * Important note: the mortality results presented here are reflecting the data collected in the community. They are surprisingly low, and might be biased by the reticence form the population to speak about death issues. The crude mortality rates are given here as an indicator only.

.I.5. DISCUSSION

The Z- score analysis of the anthropometric data unveiled a global acute malnutrition (GAM) of 6.7 % [4.6 % - 9.6 %] and severe acute malnutrition (SAM) of 0.5 % [0.1 % - 1.9 %] at 95% confidence interval. There was no significant difference in the prevalence of malnutrition between the boys and girls (Chi square = 0.02, p>0.05). All the sexes were at equal risk 1.04 (0.64 – 1.68) of being malnourished. However, in comparison to the age groups of 6-29 and 30-59 months, the risk of being malnourished of children aged 6-29 months was 2.43 (1.41 – 4.18) times more than those aged between 30-59 months. This implies that children aged between 6-29 months are at a higher risk of exposure and suffering from malnutrition because of a number of reasons that come with the intermediary weaning period such as compromised quality and quantity of weaning foods and increased susceptibility to childhood diseases. The retrospective mortality data analysis showed that during the assessment period, the crude mortality rate of the location was at 0.72[0.31-1.31] at 95% CI. The under five crude mortality rate was 0.12[-0.13-0.36] with under-five population being 1(5.88%) of the total population. As can be deduced from these results, both crude

4 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker.

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mortality rates for adults and children are below the alert and emergency levels of 1/10,000 people/day and 2/10,000 people/day and 2/10,000/day and 4/10,000/day respectively. This survey in Wudier in Longuchok County reveals the lowest malnutrition rates ever experience in Upper Nile State of South Sudan. The low GAM and SAM rate could be explained by the following factors: Improved food security: Though it was reported that in the beginning of the year most of the community had minimal access to adequate foods; the rains in the region performed superbly well improving the food access. The survey was conducted during harvest time and the community had already started to harvest maize and had access to wide variety of vegetables. The improved pasture as a result of good rains too improved the livestock milk yield enabling the most of the children to have adequate milk resulting to good nutrition status. Access to health care: The availability of MSF-H health facilities in the County has greatly influenced the heath status of the population; most of the maladies affecting the community could be easily treated in the health facility. The presence of MSF-H nutrition treatment program in the location has contributed positively to the nutrition status detected as malnourished children could easily be nutritionally managed in the MSF-H PHCC. Child Care: Children were well initiated into breastfeeding upon birth, continue to be breastfed and introduced to weaning foods in a timely manner. Some of the complimentary feeds given to children include cows or goats’ milk, porridge made from ground maize and locally grown vegetables. The availability of these complementary foods in the community ensured that the children were well fed on a nutritious diet enhancing their nutrition status. Water Access: Though, majority of the population got their water for household consumption from swamps and rivers, OXFAM GB have already constructed a total of 4 functional boreholes in Wudier Center with a target of building 6 more borehole outside Wudier centre in the Payam. They have trained village health motivators (VHMs) to maintain the boreholes as well as create awareness to the community on acceptable hygienic practices and construction of toilets/latrines for human waste disposal. This has increased access to portable water in Wudier significantly reducing the risk of water borne diseases which can influence the nutrition status of the children.

.I.6. RECOMMENDATIONS

The Global Acute Malnutrition is below the emergency level and alert level. However, this does not in totality imply absence of malnutrition but rather indicates that there is need to curb immediate and underlying causes through long-term impact interventions to enhance the current nutrition situation and diminish any chances of deterioration. In this regard; ACF-USA recommends the agencies in the location to continue implementing their current activities and in long run the nutrition situation will remain at manageable levels. The Measles vaccination coverage is very low, it is highly recommended that routine EPI activities be started in the location as measles outbreaks can significantly influence the nutrition status of the under fives.

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.II. INTRODUCTION

Map 1: Upper Nile state Longuchok County is composed of 6 Payams namely Wudier, Longuchok 1, Darjo, Guelguk (formally Chotbora), Pamach and Malual with a total of 18 bomas (3 Bomas located in each Payam). Longuchok borders Mawuit,

community is mainly agro-

06 necessitating the commissioner’s movement too, nevertheless, there is a stable prevailing olitical stability5.

Mabaan and Luakapiny as shown in the map 1 above. Wudier Payam is generally flat and is crisscrossed by rivers and deep swamps which are mainly seasonal and also acts as main source of water for the cattle and some members of the community who live far from the drilled boreholes. The area is made up of fertile sandy black cotton soil. The pastoralists (farming maize as a major crop and rearing average number of cattle). The SRRC secretary reported the current security situation to be normal within the location. Successful disarmament exercise in the location had been carried out by the SPLA in February 2006. Reportedly, in the year 2005, the GOS headquarter was in Wudier but after signing of the CPA, it was moved to Longuchok 1 payam in March 20p

5 Wudier SRRC secretary September 2006

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The last insecurity incident in the area occurred on 15th May 2006 whereby the county’s commissioner was ambushed on his way to Guelguk from Wudier resulting to death of one person. Later, 7 people were killed and two wounded when the commissioner called for back-up security6. According to the WFP food security and livelihoods updates of May 2006, the 2005 rains were untimely and most people had not planted, as a result most households in Upper Nile including Longuchok County were facing acute food shortages due to deteriorating food security situation. Notably the last WFP food drop in the location was in November 2005. This occasioned early exhaustion of food stocks with limited access to market and the community were reported to be mainly relying on various coping mechanisms such as consumption of wild foods for survival. Correspondingly, 19 cases of severe malnutrition among under-fives had been treated at MSF-Holland PHCC in Wudier between the month of April and July 2006 (MSF-H). Additionally, there were reports of non-facilitated returnees coming back to Longuchok County, mainly from Ethiopia (Dima and Panyadur refugee camps) and from North. The returnees mostly settle in Wudier and Darjo Payams and are integrated in the locations’ communities and exert pressure on the already plagued food resources as they establish themselves, further exacerbating the food insecurity situation in the area. Finally, according to both Servants Heart and MSF H, no nutrition surveys have been conducted in the location in the recent past. Given the above reasons, ACF USA decided to implement a nutritional survey in the region in order to detect the actual nutritional situation. Given the above reasons, ACF USA decided to implement a nutritional survey in the region in order to detect the actual nutritional situation

.III. OBJECTIVES OF THE SURVEY

An anthropometrics nutritional survey was carried out in Wudier Payam by ACF-USA from 27th August to 11th September 2006, with the following objectives:

To evaluate the nutritional status of children aged 6 to 59 months. To estimate the measles immunisation coverage of children aged 9 to 59 months. To estimate the crude mortality rate through a retrospective survey. To determine predisposing factors influencing the nutrition situation of the community

.IV. METHODOLOGY

.IV.1. Type of Survey and Sample Size

The target population assessed included children of age 6-59 months. The total population of the 28 accessible villages in Wudier Payam was estimated at 22,9427, giving a target population of 4579 children (calculated as 20% of the total population). A two-stage cluster sampling methodology was used. A retrospective mortality survey (over the past three months) using SMART8 methodology was undertaken alongside the anthropometric survey. Qualitative data was also obtained using both observation and questionnaires. Systematic sampling method was used, and the qualitative questionnaire was administered in every 5th household in the 10 out of 30 clusters covered. A total of 50 households were interviewed on the following topics; food security, water and sanitation, accessibility and utilization of health care services as well as child care practices.

6 Wudier SRRC secretary September 2006 7 Wudier SRRC population figures 8 Standardized Monitoring And Assessment Of Relief And Transitions

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.IV.2. Sampling Methodology

A two-stage cluster sampling was used:

• At the first stage, 30 clusters were randomly selected. Using a random draw, villages were chosen from a list of accessible villages, and the clusters assigned accordingly (Appendix 1)9. The probability of selection was proportional to the village population size. Each cluster included a minimum of 30 children.

• At the second stage, that is, the selection of the households within each cluster, the standard EPI

methodology was used: a pen was spun while being at the central point of the selected cluster, defining a random direction. All the children 6-59 months of age belonging to the households encountered in that direction were measured.

.IV.3. Data Collection

Quality of the data collected was ensured by meticulous enumerator training and close expert supervision during the actual survey for consistency, completeness and clarity of the questionnaires. During the time of the survey, anthropometric measurements, for each selected child aged 6 to 59 months were made so as to capture and record the following child survival indicators. (Appendix 2)10

• Age: recorded with the help of a local calendar of events (Appendix 5)11 • Gender: male or female • Weight: children were weighed without clothes, with a Salter scale of 25kg (precision of 100g). • Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm

were measured lying down, while those greater than or equal to 85cm were measured standing up. • Mid-Upper Arm Circumference: MUAC measurements were taken at mid-point of left upper arm for all

the children included in the survey (precision of 0.1cm). • Bilateral pitting oedema: assessed by the application of normal thumb pressure on dorsal side of both

feet for at least 3 seconds. • Measles vaccination: assessed by verifying 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 returnee. The retrospective mortality survey information, which was also collected in households with no children aged less than five years captured the following information:

• The number of household members the day of the survey • The number of people present during the recall period, • The number of deaths and the age group of the deceased persons over the last three months, • The number of births over the preceding three months, • The number of persons, who left or arrived in the last three months,

.IV.4. Indicators, Guidelines, and Formula’s Used

.IV.4.1. Acute Malnutrition

Weight for Height Index This measure is objective, repeatable and has low variability; and is used as an indicator of severe current and past malnutrition. For target population (children aged between 6 to 59 months), acute malnutrition rates were approximated from the weight for height (WFH) index values combined with the existence of oedema. The WFH indices are

9 Villages in Wudier payam and corresponding estimated population figures). 10 Anthropometric Questionnaire 11 Calendar of events

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compared with NCHS12 references. WFH indices were expressed in both Z-score and percentage of the median. The expression in Z-score has true statistical meaning, and allows inter-study comparison. WHZ is a more statistical correct indicator for malnutrition as besides the actual and the median measurement it takes into account the standard deviation of the specific measurement. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs.

Guidelines for the results expressed in Z-score:

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 of median:

Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs Moderate malnutrition is defined by WFH [≥ 70 % and < 80 %] and no oedema. Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema

Mid-Upper Arm Circumference (MUAC)

In emergency situations, the weight for height index is the most appropriate index to quantify wasting amongst the existing population where acute forms of malnutrition are the prime pattern. Nevertheless, mid-upper arm circumference (MUAC) is a significant tool for rapid screening of children at a higher risk of mortality. MUAC is a good predictor of mortality as research has shown that MUAC is closely correlated with mortality. The table below illustrates the guideline: Table 1: MUAC Guidelines MUAC < 110 mm Severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm Moderate malnutrition and moderate risk of mortality MUAC ≥ 120 mm and <125 mm High risk of malnutrition MUAC ≥ 125 mm and <135 mm Moderate risk of malnutrition MUAC ≥ 135 mm Adequate nutritional status

.IV.4.2. Mortality

SMART methodology was used to collect the mortality data .The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. This is calculated using Nutrisurvey for SMART software for Emergency Nutrition Assessment. The formula below is applied:

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

a = Number of recall days (90) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period

The result is expressed per 10,000-people / day. The thresholds are defined as follows13:

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

Under five CMR:

Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

.IV.5. Field Work

The survey was executed by a group of ten surveyors under the supervision of three ACF-USA staff. The surveyors were grouped into three teams consisting of three people to collect the anthropometric data and retrospective mortality data concomitantly; and one to collect the qualitative data. It is worth noting that the ten surveyors were trained for three days during which a pilot study was carried out. Each team collected anthropometric data from a minimum of 30 eligible children per cluster. The entire survey including training and pilot survey lasted 21 days with the actual survey running between 1st and 11th September 2006. During this time, a total of 15 accessible villages were clustered and a total of 931 children aged between 6-59 months were assessed. Due to the presence of deep rivers and deep swamps in the area (see appendix for the map), the ACF-USA team sought consent to send the survey teams to collect data while closely supervising them which included scrutinizing measurements taken, feedback and appraisals with an objective of eliminating errors in the data collected.

.IV.6. Data Analysis

Anthropometric data entry and analysis were carried out using EPI-INFO 5.0 software, EPINUT 2.2 Program, while household mortality data was analysed using Nutrisurvey software as specified in SMART methodology. Qualitative data was analyzed using SPSS (Statistical Package for Social Sciences) to derive relevant descriptive statistics.

.V. RESULTS OF THE QUALITATIVE ASSESSMENT

During the assessment curried out by ACF-USA in Wudier Payam, a household qualitative assessment was done in 50 households which were residing in Wudier at the time of survey, whereby, systematic sampling methodology was employed. The assessment was carried out to determine the following aspects; food security, water and sanitation, accessibility and utilization of health care services as well as child care practices all of which explain the factors affecting the nutritional status of population at any particular time. Data which was then analyzed in SPSS was interpreted in the following findings:

.V.1. Social Demographic Characteristics of the Respondents

Longuchok County where Wudier Payam is located borders Ethiopia and therefore cross-border movements were apparent. However during the time of survey minimal movement of population was reported with almost all people being residents and only marginal number being returnees (96)14 and internally 1815 displaced persons (IDPs). Although the household qualitative survey indicated no presence of IDPs, the marginal numbers of IDPs (SRRC did not have official figures) as implied in households included in anthropometric assessment were associated with movement of few members of the Nuer community on the edge of Maban county border into Wudier area as a caution to flee from previous low- scale ethnic tensions between Burun and Nuer tribe experienced mid of the year 2006. Nevertheless, most other movements observed in community were not associated with permanence of stay and were temporal.

13 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95. 14 SRRC returnee population figure 15 Anthropometric survey results.

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Figure 1: Sources of Livelihood

SOURCES OF LIVELIHOOD IN WUDIER PAYAM

4%0%

16%

4%

84%

0%

PASTORALISM FISHING CROP FARMING EMPLOYMENT AGROPASTORALIST PETTY TRADE

LIVELIHOODS

PERCEN

TAG

E

During the assessment carried out within Wudier payam, all the respondents were females. It is worthwhile to note that Wudier payam, in Longuchok County is an area inhabited by the Nuer Tribe being the majority, followed by the Burun Tribe, Dinka and the Buldit respectively. The qualitative household survey revealed that most of the residents of the Payam (84%) are agro pastoralists implying that they grew crops besides rearing livestock and this can be illustrated by the chart above. Few households (18%) cultivate crops solely without rearing of livestock. Similarly, these livelihoods are emphasized by the chart below which indicates that 68 % and 64% of the populations’ major sources of income are from the sale of crops and livestock respectively, further showing the communities providence to be mainly from agro pastoralist. Figure 2: Sources of Income

SOURCE OF INCOME IN WUDIER PAYAM

4% 2%

64% 68%

52%

8%0%

PERMANENT JOB SALE OFLIVESTOCK

PETTY TRADE REMMITANCE

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.V.2. Food Security

Food security refers to the availability of adequate and safe foods to meet all the nutritional requirements of all the household members at all times. WFP reports indicate that the food security situation in most of the areas within Upper Nile region was unstable due to shocks experienced during 2005 affecting food availability. The shocks most often reported were human sickness, IDPs/returnees late arrival, drop in farm gate prices, and floods. The main coping mechanisms were to eat fewer meals per day, collect wild food, eat less preferred foods and go entire day without eating16. Nonetheless, during the assessment period in Wudier payam, Longuchok County it was established that the area had had ample rainfall and relatively predictable rainfall pattern with the rains having commenced on May 2006 and were still expected to prolong till the beginning of October the same year. These rains enabled the community to plant maize and millet besides other crops with minimum delays, therefore, at the time of assessment the community heavily relied on crop of green maize which matured earlier. This directly impacted on nutritional status of the community thus the low global acute malnutrition rate [GAM of 6.7 %( 4.6 % - 9.6 %)] in the area. All households (100.0%) cultivated crops during the last growing season. Findings further reveal that the community mainly grows maize, besides millet for sustenance. Other crops grown include sorghum, beans, vegetables, cassava, groundnuts, tobacco and pumpkins. The figure 3 below illustrates that among all respondents who cultivated all (100%) planted maize, 37 (75.5 %) millet, 23 (46.9%) sorghum and 36 (73.5 %) other food crops (groundnuts, pumpkin and tobacco) respectively. 56.5% reported that in the current period they had and still expected abundance of main crops as compared to the last harvesting season ending January 2006 where yields were low. However, the community cited floods, birds, monkeys and insects as constant cause of flagging crop production. According to the interviewed households, provision of tools 43(95.6%), seeds 20(44.4%) as well as control of pests and wild animals will directly contain deterioration of crop production. The sizes of the land used for cultivation averaged at half feddan17 1 to 2 feddan, and greater than 2 feddan in 27(55.1%), 16(32.7%) and 6(12.2%) of the households included in the survey correspondingly. Cultivation of small portions of land could be attributed to lack of farming implements and the uncertainty of some farming fields being immensely flooded and not claimable in the rainy season. Figure 3: Crops grown

CROPS GROWN IN WUDIER PAYAM

10 0 %

4 6 . 9 0 %4 2 . 9 0 %

10 . 2 0 %

7 5 . 5 0 %

10 . 2 0 %

7 3 . 5 0 %

MAIZE SORGHUM BEANS VEGETABLES MILLET CASSAVA OTHERS

Close scrutiny of the amount of stocks available for consumption until the period of the next harvest revealed that despite the community having enough maize to feed on currently, there will be no buffer stocks to last

16 Annual Needs Assessment (ANA, February 2006.) 17 Local Unit Size of Land Measuring 4200 Meters Square.

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beyond this time and could herald a temporary food insecurity situation in the coming months. This is supported by survey revelation that current food stocks would last for one month, three months and six months in 8.0%, 40.0% and 34% of all the households surveyed respectively amongst those that had food stocks. The current major diets consumed within surveyed households and are synonymous with the community are composed of maize 48(96.0%), milk 44(88.0%), okra 6(12.0%) and a variety of locally produced vegetables such as Neet, Kudra, 47(94.0%) and to a lesser extent sorghum and millet. The area is only accessible to long distant markets which are outside the Payam but found in Ethiopia and Guelguk which are approximately 3 days walk from Wudier. Before the rainy season of 2006, the community depended on long distance traders, who brought food which they bartered for the livestock owned by the community. Sale of livestock was one factor attributed to declining livestock within the community. The assessment established that all the households had livestock such that 41(82.0%), 49(98.0%), 39(78.0%) 15(30.0%) and 13(26.0%) of household owned cows, goats, chicken, donkeys and sheep respectively. Most of the livestock were at home. Nevertheless, 8(16.0%) of the households reported that their livestock had increased, while majority 34 (68.0%) reported that their livestock herds had tremendously declined. The decline was attributed to benefits derived from the livestock such as sale of livestock as a food security shocks stabilization measure, use of livestock for dowry payment and livestock diseases. This is evident from the results which indicates that 48(96%) and 39(78%) of the households used cattle to pay dowry and selling for food respectively while also benefiting from milk production as indicated in the results [42(84%) of the households]. As compared to the previous five years, the community termed period between the year 2001 and 2002 as being bad in terms of food security within households and this was attributed to the prolonged drought with the best harvest averaging to 2 sacks of 50 kilograms maize in the households of respondents interviewed to assess food security situation. The situation was further worsened by fighting within Wudier payam between the GoS18 and SPLA19 followed by the fighting between SPLA and SPDF20 between 2000 stretching to 2002. On the other hand, the best year was 2003 when the yields averaged 7 sacks of 100 kilogram maize compared to the 2 sacks of 50 kilograms maize in 2001 and 2002. This good yield was attributed to adequate rainfall, peace and relatively larger portions of land to till. It is worth noting that peace ensured increased man power due to the arriving returnees coupled with good environment for working. Assessment established that fishing activity was not common at the time mainly due to flooding and reduced fish at fishing point. Thus, of all the households interviewed 45(90.0%) had fishing grounds, however, only 7(14%) of the interviewed households practiced fishing at the time of assessment. Results findings further show that the reduced fishing activity could be attributed to flooding 22(48.9%), lack of enough fish at fishing points 24(53.3%) a lack of fishing equipment 15(33.3%) and lack of labour 9(20.0%). Nevertheless, fishing activity is expected to increase between the months of October and December, the time during which majority of community does fishing. VSF-Belgium primarily offers veterinary services in Longuchok County including Wudier Payam and also HIV/AIDS education activities among the community. The activities which are implemented through community animal health workers (CAHWs), who have been trained by the organization, are community animal health management which encompasses surveillance, vaccination, treatment of livestock, training of community on cold chain management, creation of awareness in public health within the community. Besides this the organisation is also offering education on HIV/AIDS prevention on the premise of preventing negative spiral effects on household economy associated with the households with persons afflicted with HIV. These effects include sale of livestock to cater for medical expenses leaving the households without food security safety nets or source of livelihoods. Some of the common livestock diseases as reported by the VSF-B Veterinary doctor were: haemorrhagic Septicaemia, rinderpest, river flukes, worms, contagious bovine pleural-pneumonia (CBPP) for cows and contagious caprine pleural-pneumonia for goats. The causes of livestock diseases range from bacterial, viral and parasitic infections as well as parasites to other underlying causes like floods, hunger,

18 GoS- Government of South Sudan 19 SPLA- Sudan’s People Liberation Army 20 SPDF- Sudan’s People Defence Force

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drought and poor management. In the recent months no outbreak had been reported in the location. VSF –Belgium has 25 community animal health workers (CAHWs) in the entire Longuchok County. They have been given initial two weeks training and undergo refresher training every six months or one year.

.V.3. Health

Health, a state of spiritual, social, mental, physical and psychological well being of an individual and not just the mere absence of a disease is a key aspect in determining an individual’s nutritional status. MSF-Holland started giving medical services in Wudier in 2004 and currently runs a PHCC within the Payam (Appendix 6)21. The PHCC is managed by 4 medical experts, 5 community health workers (CHWs), two nurses and a skilled laboratory technician; all under close monitoring and supervision of medical co-ordinator. There are also 3 other outpost (PHCUs), found in Darjo, Longuchok 1, and Beneshowa manned by trained (CHWs) and are served by the PHCC as a referral centre. MSF-H offer services that range from preventive to curative to both inpatient and outpatients and have laboratory services that perform microscopy screening. The curative services include treatment of common morbidities such as malaria (especially in the wet season), diarrhoeal diseases, kalazaar and brucellosis; perform minor surgeries and deliveries, run a TB program that by then had a total of 23 patients and malnutrition screening and if need be home based feeding (had 2 people in the Month of August 2006). The preventive services offered range from antenatal care, tetanus immunisation, prophylaxis for TB contacts, malaria prevention, STI contact and prevention and hygiene promotion mainly offered to patients within the PHCC. The clinic conducts deliveries and also has trained traditional birth attendants (TBAs) who do deliveries in the community. With regards to household morbidity, the assessment revealed common illnesses and conditions to be malaria, fever, respiratory tract infections and diarrhoea diseases as shown by the results. In addition to these the MSF-H public clinic also confirmed other morbidities in the community as Kalazaar and brucellosis with common causes of mortality so far being Kalazaar, Tetanus and Tuberculosis. Using MUAC as a major screening tool for malnutrition, the clinic reported a total of 7, 1 and I cases of severe malnutrition amongst children less than five years of age recorded in the months of June, July and August respectively in Wudier payam; 4 cases of moderate malnutrition in the months of June and July. Similarly a total of 66,35 and 22 cases of diarrhoeal diseases either with bloody, mucous or watery diarrhoea in the months of June, July and August 2006 respectively were recorded amongst the children less than five years of age. In early August one adult death was reported in the clinic. However, there were no reported deaths of under-fives. The clinic has adequate supply of drugs as reported by the medical expert. Similarly, it also receives food rations in form of sorghum, oil and wheat from World Food Program and uses it to feed its in-patients. However, all the food had been exhausted by the time of assessment after completion of the last supply received in the month of August. Nevertheless, the clinic looked forward to deliveries in September 2006. The assessment unveiled low measles immunisation coverage in the location. According to the anthropometric data analysis, 757 (89.6%) of the children under-fives included in survey had not been immunised against measles. The last measles outbreak had been reported to have occurred between November 2004 and April 2005 with 31 reported cases and 7 deaths22. Further reports also indicated that only one measles case had been diagnosed, treated and discharged in the last three months. Despite the foregoing, no particular intervention was put in place and therefore the current situation needs to be reversed to counter any possible outbreak of measles by implementing both routine and mass immunisation. In the months of June, July and August the outpatient figures stood at 945, 738 and 820 patients correspondingly. The Wudier PHCC serves a total of 22,94223 persons within the immediate environs. This

21 Map of Wudier payam 22 Source: WHO Program Officer Wudier 23 Wudier payam total population. Source: Wudier payam SRRC secretary

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translates to 1:22,942 and is below the recommended SPHERE and SPLM Secretariat of Health (SOH) standards which requires that one PHCC should serve 50,000 and 80,000 people respectively. It is worth noting that the PHCC is a referral unit for the three mentioned outposts. Findings from the assessment further revealed that the entire population first sought medical care from the PHCC run by MSF-H and at most, it takes about five days from some villages to walk to the health facility during the rainy and dry seasons respectively. This community practice (prompt care and attendance at the PHCC), coupled with the fact that most maladies afflicting under fives are attended to promptly when accessibility is good, could explain the relatively low [6.7%(4.6%-9.6%)] Global Acute Malnutrition (GAM) in the area.

.V.4. Water and Sanitation

Data about the location’s water and sanitation was also collected through the questionnaires and observation and this was analyzed through SPSS. Findings reveal that majority of the population 40(80 %) get their water for drinking from the rivers and 5(10%) from the boreholes while; majority of the households 9(18%) and 36(72%) got their water for household consumption from swamps and rivers respectively. This can be seen from the illustration below. Figure 4: Sources of drinking water.

0%

10%

20%

30%

40%

50%

60%

70%

80%

PERCENTAGE

SOURCE

SOURCE OF DRINKING WATER IN WUDIER PAYAM

PERCENTAGE 6% 80% 10% 8%

SWAMP WATER RIVER BOREHOLE RAIN WATER

The values in the chart above corroborate a situation where majority of community members consume unsafe water exposing them to waterborne infections and diarrhoeal diseases. Susceptibility to the aforementioned diseases is further exacerbated by community’s widespread practice of disposing off human waste haphazardly as reflected by the results of the 50 households interviewed in the location. The findings reveal that the community mainly disposed the human waste in the bushes 47(94 %) compared to 3(6%) (See figure 5) who disposed the waste in the toilets/latrines. From observation, it was quite evident that the households and bushes were nearby swamps and rivers which happen to be amongst the community water sources for drinking and household consumption. Most of waste is thus redirected back to the water sources especially in rainy season hence making the water points agents of variety of waterborne infections which as explained above are the major causes of morbidity and mortality .

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Figure 5: Human waste disposal.

TOILET , 6%

BUSHES , 94%

Other activities that further aggravate the situation as could be seen from observation include human bathing and washing of dirty linen and utensils alongside river banks, stagnant pools and swamps. Oxfam GB runs a Public Health program in Wudier with a number of components which include water and sanitation. The objective of the water and sanitation project is to provide clean water to as many people as possible as per the sphere standards24. In a bid to attain their objective, they have already constructed a total of 4 functional boreholes in Wudier center with a target of building 6 more borehole outside Wudier centre in the payam. They have 48 trained persons (Village Health Motivators) to maintain the boreholes. Furthermore, the health motivators create awareness to the community on acceptable hygienic practices (hand washing, use of dish racks, clean environment) and construction of toilets/latrines for human waste disposal. The Oxfam’s program has been implemented on pilot basis with total community participation whereby most households in the community within Wudier centre has been supplied with a bucket and a lid in addition to two separate cups as an initiative of promoting safe water storage and consumption. According to the organization, this initiative is planned to be applied in the entire Payam and eventually Longuchok County. It is also noteworthy that the community tends to move from settlements in search of water points for livestock in the dry season and for this reason Oxfam GB –Wudier has constructed two boreholes with livestock trunks as a pilot for the provision of water to the livestock.

.V.5. Mother and Child care practices

Initiation of breastfeeding upon birth, exclusive breastfeeding for the first four to six months, on-demand breastfeeding, and appropriate weaning of children are fundamental practices considered to preventing vulnerability of children to malnutrition as they ensure availability of essential nutrients at their time of rapid growth and development. In most communities in southern Sudan, most of the mothers including the expectants are expected to perform all the household chores as part of cultural expectations. From the findings of the assessment, the initiation of breastfeeding to infants upon birth is well practiced. Of the 50 households interviewed, 43 (86.0%) initiated breastfeeding immediately after birth while 7(14.0%) initiated breastfeeding after one day. However, breastfeeding on demand was a rare practices with only 13(27.1%) being able to do so. The reason why majority of mothers were not able to breastfeed on demand could be a consequence of mothers attending to other chores. On the other hand, exclusively breastfeeding was relatively practiced in the community with 25 (50.0 %) and 16(32.0%) of the interviewed households introducing other foods at 4-6 months and above 6 months respectively. Using these aforementioned statistics as a reflection of the community’s way of life, and in comparison to general child feeding practices in most communities in Sudan, it can be presumed that the community has relatively fair infant feeding practises explaining the low rates of malnutrition. However, general observations and interviews revealed that the common food introduced to the children below 4 months of age are cows/goats milk whose nutritive content is not readily available as would be that of breast milk in the not well developed digestive capability of these children’s’ systems. This denies them of essential growth nutrients and also

24 SPHERE STANDARDS: One water point to serve a maximum number of 500 persons

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exposes them to waterborne infections at a time they are most vulnerable25. The continued exposure of children below 4 months to these feeds which are normally prepared in less acceptable hygienic environment is a predisposing factor in residual malnutrition apparent in children aged between 6-29months old. This could explain why the children aged 6-29 months are 2.43 (1.41 – 4.18) times more of being malnourished than those aged between 30-59 months. Findings further indicate that a number of children 47(95.9 %) aged 6-29 months continue being fed on breast milk, with a similar number 47(95.9 %) fed on cows or goats milk, 7 (14.3 %) on porridge (mainly prepared from ground maize), 8 (16.3%) on vegetables like kudra and neet26, while 5(10.0%) feed on normal household diet composed of maize, locally grown vegetables and milk. Furthermore, children who are aged 30 months and above are mainly fed on cows or goats milk 41(85.4%), vegetables 34(70.8%), common household diet ascida27 25(52.1%), breast milk 27(56.3%) while only 6(12.5%) are fed on porridge. These being the foods available at the time of assessment, they could further be the reason of low malnutrition rates of [6.7 %( 4.6%- 9.6%)] and [0.5 %( 0.1%-1.9%)] Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) respectively as expressed in Z-scores. It also indicates that variety of nutrients consumed in the child’s meals complement the maize diet that was predominant at the time. 32 (64.0%) of the interviewed households indicate that mothers feed their children twice while 15(30.0 %) do so more than two times in a day. Figure 6: Feeding between 6-29 months

95.90% 95.90%

14.30% 16.30% 10.40%

BREASTMILK

COW/GOATSMILK

PORRIDGE VEGETABLE OTHERFOODS

During the assessment period, there were four schools offering primary education. Currently, the schools which are supported by Servants Heart are located in Wichluak, Gambel, Wudier centre and Wanken villages. At the moment, they use the New Sudan syllabus. Wudier primary school, which is about ten minutes walk from Wudier Centre, was started in September 2002 by GARDOS, who trained teachers for a duration of three weeks and thereafter the trained teachers subsequently trained others who teach at the other three schools. Wudier primary school has classes that run from class one to five and plans are underway for gradual expansion. It has four physical classrooms built by the community and some of the children learn under trees. Currently the school has a total number of 526 pupils (182 girls, 344 boys) with ten trained teachers. Besides giving teachers incentives, Servants Heart also sponsors the teachers for refresher courses the last one being in April 2006. Apart from refresher trainings to the teachers, Servants Heart also offers school uniform

25 SCN report, 2004 26 A variety of traditional locally grown vegetables 27 A traditional meal prepared with maize flour and water

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to the pupils the last supply being in June 2006 where they supplied the school with 390 each of t-shirts, shorts, cups and spoons. UNICEF on the other hand sponsors the school with learning material with the last supplies having been made in May 2006. Before 2005, WFP supported school feeding programme for the pupils but the program is no longer running. The other schools in the payam are supported by Wudier primary school through provision of text books and training of their teachers. Generally the pupils’ response to school is good and the reported drop outs of children were attributed to responsibility endowed to them in taking cattle to the cattle camps, lack of school uniform and learning materials and early girl marriages.

.V.6. NGO activities

During the undertaking of the survey, four international NGO’s were found to be undertaking activities in the location and these were as follows:

Oxfam GB: Runs a Public Health Program with emphasis on health education, water, hygiene and sanitation. Activities carried out include construction of boreholes within Wudier payam and Longuchok County, training of village health motivators (VHM), hygiene and sanitation promotion through hygiene promoters on issues such as latrine construction and use, dish racks use and clean environment. MSF Holland: Run a PHCC that offers health services to the community which range from preventive services to curative services. VSF Belgium: Activities range from disease surveillance of livestock, vaccination of livestock, treatment of animals, creating awareness on the use of hand dug wells, training of community animal health workers, creation of awareness on public health and even HIV/AIDS and capacity building of the community by training the community on management of resources. Servants Heart: Offer education and health services in Longuchok County. In Wudier payam the main activity is education (through supplying the school with uniform, training of teachers and refresher course and provision of incentives to the teachers)

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.VI. RESULTS OF THE ANTHROPOMETRICS SURVEY

In the nutrition assessment implemented in Wudier a total of 931 children were measured, however, only 922 children were finally included in the analysis after exclusion of 9 data records that were erroneous.

.VI.1. Distribution by Age and Sex

Table 2: Distribution by Age and Sex

BOYS GIRLS TOTAL AGE (IN MONTHS) N % N % N %

Sex Ratio

06 – 17 131 50.4 129 49.6 260 28.2 1.02 18 – 29 118 53.4 103 46.6 221 24.0 1.15 30 – 41 60 50.0 60 50.0 120 13.0 1.00 42 – 53 91 49.2 94 50.8 185 20.1 0.97 54 – 59 67 49.3 69 50.7 136 14.8 0.97 Total 467 50.7 455 49.3 922 100.0 1.03

The sex ratio above; 1.03 is acceptable. Figure 7: Distribution by age and sex in Wudier payam.

- 6 0 % - 4 0 % - 2 0 % 0 % 2 0 % 4 0 % 6 0 %

P ERCENTAGES

0 6 - 17

18 - 2 9

3 0 - 4 1

4 2 - 5 3

5 4 - 5 9

DISTRIBUTION BY AGE AND SEX, WUDIER-SEPTEMBER 2006

Boys Gir ls

.VI.2. Anthropometrics Analysis

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

Distribution of Acute Malnutrition in Z-Scores

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Table 3: Weight for Height distribution by age in Z-score

< -3 SD ≥ -3 SD & <- 2 SD ≥ -2 SD OedemaAge group (In months) N

N % N % N % N % 06-17 260 5 1.9 32 12.3 223 85.8 0 0.0 18-29 221 0 0.0 8 3.6 213 96.4 0 0.0 30-41 120 0 0.0 2 1.7 118 98.3 0 0.0 42-53 185 0 0.0 10 5.4 175 94.6 0 0.0 54-59 136 0 0.0 5 3.7 131 96.3 0 0.0

TOTAL 922 5 0.5 57 6.2 860 93.3 0 0.0

Table 4: Weight for height vs. Oedema

Weight for height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor 0 0.0%

Kwashiorkor 0 0.0%

Oedema NO Marasmus

62 6.7% No malnutrition

860 93.3% The analysis above indicates no cases of marasmic-kwashiorkor were identified amongst the 922 children included in the analysis. Of the identified malnutrition cases, all 62 (6.7%) were marasmic. Figure 8: Z- scores distribution Weight for Height, Wudier payam.

WEIGHT FOR HEIGHT Z-SCORE DISTRIBUTION, WUDIER-SEPTEMBER 2006

0

5

10

15

2 0

2 5

- 5 - 3 - 1 1 3 5

Z - SC OR E

Reference populat ionWudier populat ion

The graph above indicates a slight displacement of the sample curve to the left side of the reference curve. This shift of the curve to the left indicates that the investigated population (Wudier Payam) was relatively malnourished compared to the reference population. The mean of the sample is – 0.68, instead of 0.0 in the reference population.

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The standard deviation of the sample is 0.96, which is comprised in the 0.80 – 1.20 interval, showing that the Weight for Height in Z-score of the sample is following a Normal law, and is therefore representative of the population.

Table 5: Global and Severe Acute Malnutrition by age group in Z-score

6-59 months (n = 922)

6-29 months (n =481)

Global acute malnutrition

6.7% [4.6%-9.6%]

9.4% [6.1%-14.0%]

Severe acute malnutrition

0.5% [0.1%-1.9%]

1.0% [0.2%-3.6%]

The relationship between children aged 6-29 and 30-59 months has a significant difference (Chi square= 11.10, p<0.05) as revealed by the statistical comparative analysis results of malnutrition. As can be deduced from the results children aged 6-29 months are 2.43 (1.41 – 4.18) times more of being malnourished than those aged between 30-59 months. This implies that they are at a higher risk of exposure and suffering from malnutrition and this could be attributed to various reasons evident in the intermediary weaning period such as compromised quality and quantity of weaning foods, susceptibility to childhood diseases and infections which has a cyclical relationship with malnutrition and just by the mere fact that some of them could already be suffering from malnutrition, increasing the exposure thus furthering chances of morbidity.

Table 6: Nutritional Status by Sex in Z-score

Boys Girls Nutritional status

N % N % Severe malnutrition 5 1.1 0 0.0 Moderate malnutrition 27 5.8 30 6.6 Normal 435 93.1 425 93.4 TOTAL 467 50.7 455 49.3

As per the statistical analysis carried out, the results reveal that there is no statistical difference in the prevalence of malnutrition between the boys and girls (Chi square = 0.02, p>0.05). All the sexes were at equal risk 1.04 (0.64 – 1.68) of being malnourished.

Distribution of Malnutrition in Percentage of the Median Percentages of the median cut off for acute malnutrition are commonly used as a determination criterion for admission in the feeding centres. The criteria commonly used are as follows:

• <70 % weight for their height are admitted in therapeutic feeding centres • 70 % – 79 % weight for their height is admitted in supplementary feeding centres.

Table 7: Distribution of Weight/Height by age in percentage of the median

< 70% ≥ 70% & < 80% ≥ 80% Oedema Age (In months)

N N % N % N % N %

06-17 260 1 0.4 23 8.8 236 90.8 0 0.0 18-29 221 0 0.0 5 2.3 216 97.7 0 0.0 30-41 120 0 0.0 1 0.8 119 99.2 0 0.0 42-53 185 0 0.0 3 1.6 182 98.4 0 0.0 54-59 136 0 0.0 2 1.5 134 98.5 0 0.0

TOTAL 922 1 0.1 34 3.7 887 96.2 0 0.0

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Table 8: Weight for height vs. oedema

Weight for height < -2 SD ≥ -2 SD

YES Marasmus/Kwashiorkor 0 0.0 %

Kwashiorkor 0 0.0 %

Oedema NO Marasmus

35 3.8 % No malnutrition 887 96.2 %

Table 9: Global and Severe Acute Malnutrition by age group in percentage of the median

6-59 months (n = 922)

6-29 months (n =481)

Global acute malnutrition

3.8 % (2.3% - 6.1%)

6.0 % (3.4% - 10.1%)

Severe acute malnutrition

0.1% (0.0% - 1.2%)

0.2% (0.0% - 2.3%)

.VI.2.2. Risk of Mortality: Children’s MUAC

Out of the 931 children assessed, 922 children were used in the analysis because of nine erroneous data records.

Table 10: MUAC Distribution

MUAC (mm) < 75 cm height >=75 – < 90 cm Height ≥ 90 cm height Total

MUAC < 110 3 1.4 % 1 0.4 % 0 0.0% 4 0.4% 110≥ MUAC<120 35 15.9% 5 1.9 % 0 0.0% 40 4.3% 120≥ MUAC<125 26 11.8 % 6 2.2 % 2 0.5% 34 3.7% 125 ≥ MUAC <135 61 27.7% 24 9.0 % 27 6.2% 112 12.1%

MUAC ≥ 135 95 43.2% 231 86.5% 406 93.3% 732 79.4% TOTAL 220 100.0% 267 100.0% 435 100.0% 922 100.0%

MUAC is a significant predictor of mortality amongst children who are 12 months and above (≥ 75cm).The analysis of MUAC of children whose heights are equal to or above 75 cm as illustrated in the table above indicates that; 1 (0.1 %) were severely malnourished and at high risk of mortality, 5 (0.7 %) were moderately malnourished with moderate risk of mortality, 59 (8.4 %) being at risk of malnutrition while 90.7 % were well nourished.

.VI.3. Measles Vaccination Coverage

Measles vaccination is usually administered to children at the age of 9 months and above. Thus of all the 845 children aged 9-59 months assessed, measles coverage was calculated in two ways dependent on whether the child is immunized or not. This is verified by the vaccination card or as stated by the mother or caretaker on whether the child is immunized or is not immunized. This will yield three percentages as illustrated in the table below.

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Table 11: Measles Vaccination Coverage

Measles Vaccination N % Proved by Card 7 0.8 According to the mother/caretaker 81 9.6 Not immunized 757 89.6 Total 845 100.0

From the table above, a total of 757 (89.6%) were found to not have been immunised indicating a very large percentage. The coverage is far below the international recommendation for measles vaccination coverage of 90%, which ensures herd immunity.

.VI.4. Household Status

Table 11: Household Status

Status N % Residents 572 90.5 Internally Displaced 18 2.8 Temporary Residents (on transit) 37 5.9 Returnee 5 0.8 Total 632 100

90.5 % of the households surveyed during the assessment were residents, 2.8 % of the population being internally displaced, 5.9 % and 0.8 % of the population being temporary residents and returnees respectively. There were minimal movements during the time of assessment.

.VI.5. Composition of the Households

Table 123: Household Composition

Age group N % Under 5 years 969 37.6 Adults 1609 62.4 Total 2578 100.0

During the assessment period, mortality data was collected from a total of 614 households. The mean number of children under 5 years of age per household was 1.6 and the mean number of adults per household was 2.6.

.VII. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY

.VII.1. Mortality Rate

Mortality data was collected from all the households in all accessible villages regardless of whether they had the target population or not and was used to calculate the crude mortality rate (CMR). Among the households interviewed, a total of 969 children aged less than five years of age and 1609 adults were alive at the time of the survey. The following demographic changes were observed over the three months preceding the survey:

2578 residents. 50 births. 66 people arrived in the location.

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209 persons left the location. 17 deaths were reported, one being a child under five years of age.

From the findings:

Crude mortality rate = 0.72 [0.31 – 1.13] /10,000/day. The under five mortality = 0.12 [0.0 - 0.36] /10,000/day

As can be deduced from the results above, both crude mortality rates for adults and children are below the alert and emergency levels of 1/10,000people/day and 2/10,000 people/day and 2/10,000/day and 4/10,000/day respectively. Important note: The mortality results presented here are reflecting the data collected in the community. They are surprisingly low, and might be biased by the reticence form the population to speak about death issues. The crude mortality rates are given here as an indicator only.

.VIII. CONCLUSION

An anthropometric nutritional assessment was implemented in Wudier Payam, Longuchok County by ACF- USA between 27th August and 17th September 2006. During the entire assessment period, questionnaires and observation methods were used to collect data. Anthropometric data for 922 children aged 6-59 months assessed during the survey was analysed in both Z – scores and percentage of median. Applying the SMART methodology, a total of 614 households were sampled for collection of mortality data and analysed in the Nutrisurvey software. Additionally, a total of 50 households were systematically sampled and interviewed to determine context specific factors associated with malnutrition in the area and included questions on food security, health, child care practices, and water and sanitation situation. The Z- score analysis of the anthropometric data unveiled a global acute malnutrition (GAM) of 6.7 % [4.6 % - 9.6 %] and severe acute malnutrition (SAM) of 0.5 % [0.1 % - 1.9 %] at 95% confidence interval. There was no significant difference in the prevalence of malnutrition between the boys and girls (Chi square = 0.02, p>0.05). All the sexes were at equal risk 1.04 (0.64 – 1.68) of being malnourished. However, in comparison to the age groups of 6-29 and 30-59 months, the risk of being malnourished of children aged 6-29 months was 2.43 (1.41 – 4.18) times more than those aged between 30-59 months. This implies that children aged between 6-29 months are at a higher risk of exposure and suffering from malnutrition because of a number of reasons that come with the intermediary weaning period such as compromised quality and quantity of weaning foods and increased susceptibility to childhood diseases. The retrospective mortality data analysis showed that during the assessment period, the crude mortality rate of the location was at 0.72[0.31-1.31] at 95% CI. The under five crude mortality rate was 0.12[-0.13-0.36] with under-five population being 1(5.88%) of the total population. As can be deduced from these results, both crude mortality rates for adults and children are below the alert and emergency levels of 1/10,000 people/day and 2/10,000 people/day and 2/10,000/day and 4/10,000/day respectively. This survey in Wudier in Longuchok County reveals the lowest malnutrition rates ever experience in Upper Nile State of South Sudan. The low GAM and SAM rate could be explained by the following factors: Improved food security: Though it was reported that in the beginning of the year most of the community had minimal access to adequate foods; the rains in the region performed superbly well improving the food access. The survey was conducted during harvest time and the community had already started to harvest maize and had access to wide variety of vegetables. The improved pasture as a result of good rains too improved the livestock milk yield enabling the most of the children to have adequate milk resulting to good nutrition status.

27

28

Access to health care: The availability of MSF-H health facilities in the County has greatly influenced the heath status of the population; most of the maladies affecting the community could be easily treated in the health facility. The presence of MSF-H nutrition treatment program in the location has contributed positively to the nutrition status detected as malnourished children could easily be nutritionally managed in the MSF-H PHCC. Child Care: Children were well initiated into breastfeeding upon birth, continue to be breastfed and introduced to weaning foods in a timely manner. Some of the complimentary feeds given to children include cows or goats’ milk, porridge made from ground maize and locally grown vegetables. The availability of these complementary foods in the community ensured that the children were well fed on a nutritious diet enhancing their nutrition status. Water Access: Though, majority of the population got their water for household consumption from swamps and rivers, OXFAM GB have already constructed a total of 4 functional boreholes in Wudier Center with a target of building 6 more borehole outside Wudier centre in the Payam. They have trained village health motivators (VHMs) to maintain the boreholes as well as create awareness to the community on acceptable hygienic practices and construction of toilets/latrines for human waste disposal. This has increased access to portable water in Wudier significantly reducing the risk of water borne diseases which can influence the nutrition status of the children.

.IX. RECOMMENDATIONS

The Global Acute Malnutrition is below the emergency level and alert level. However, this does not in totality imply absence of malnutrition but rather indicates that there is need to curb immediate and underlying causes through long-term impact interventions to enhance the current nutrition situation and diminish any chances of deterioration. In this regard; ACF-USA recommends the agencies in the location to continue implementing their current activities and in long run the nutrition situation will remain at manageable levels. The Measles vaccination coverage is very low, it is highly recommended that routine EPI activities be started in the location as measles outbreaks can significantly influence the nutrition status of the under fives.

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.X. APPENDIX

.X.1. Sample Size and Cluster Determination.

VILLAGE TOTAL POPULATION

DISTANCE FROM WUDIER CENTRE

ACTUAL DISTANCE

POPULATION >5 YRS

CUMULATIVE FREQUENCY

INTERVAL CLUSTER

1 WUDIER 2982 5 minutes 5 minutes 596 596 0-596 1,2,3,4

2 WANKEN 2294 25 minutes 1 hr 30 minutes 458 1054 597-1054 5,6,7

3 THOARWAL 1835 2 hours 2 hours 367 1421 1055-1421 8,9

4 WICHLUAK 1605 4 hours 1.5 days 321 1742 1422-1742 10,11

5 KOTDEL 1605 I hour 3 hours 321 2063 1743-2063 12,13

6 DHOREBOR 1376 3 hours 3 hours 275 2338 2064-2338 14,15

7 THOTJIOK 1147 1 hour 3 hours 229 2567 2339-2567 16,17

8 TUEL 1147 2 hours 2 hours 229 2796 2568-2796 18

9 KOTPINY 917 3 hours 3 hours 183 2979 2797-2979 19

10 KIRGUOY 1147 2 hours 2 hours 229 3208 2980-3208 20,21

11 ROTJIOP 688 3 hours 3 hours 137 3345 3209-3345 22 12 LONGUCHOK 2 917 2 hours 2 hours 183 3528 3346-3528 23

13 TULUAL 688 1hr 30 min 1hr 30 min 137 3665 3529-3665 24

14 GAMBEL 917 3 hrs 30 min 4 hours 183 3848 3666-3848 25

15 GIER 1605 1 hour 2 hours 321 4169 3849-4169 26,27

16 BORBAR 1147 55 min 2 hours 229 4398 4170-4398 28,29

17 KUR 458 3 hr 30 min 3 hr 30 min 91 4489 4399-4489

18 ROTMUL 45 50 min 50 min 9 4498 4490-4498

19 MORYOL 43 2 hours 2 hours 8 4506 4499-4506

20 GOK 41 3 hr 30 min 3 hr 30 min 8 4514 4507-4514

21 NINDING 40 4 hours 4 hours 8 4522 4515-4522 30

22 WECHDENG 42 2 hrs 44 min 2 hrs 44 min 8 4530 4523-4530 23 JIONUBE 44 I hr 30 min I hr 30 min 8 4538 4531-4538

24 WANGCHUEY 41 1 hr 50 min 1 hr 50 min 8 4546 4539-4546

25 MANBUTUEY 40 3 hr 30 min 3 hr 30 min 8 4554 4547-4554

26 NGOTE 42 2 hr 30 min 2 hr 30 min 8 4562 4555-4562

27 KOATGAK 45 I hr 40 min I hr 40 min 9 4571 4563-4571

28 BILBUAR 44 I hour I hour 8 4579 4572-4579

The sampling interval is equal to total target population divided by number of clusters i.e. 4579/30 =152. Villages included in the clusters are shown in the table above. The random number drawn was 110 and lies between 001 and 152. The target population was more than 4500, thus necessitating application of the two stage cluster sampling method, whereby, a total of 931 children were included in the survey. The minimum number of children included in each cluster was 30. This was derived by dividing the sample size by the total number of clusters, that is 931/30 =31. A total of 930 children were included in the survey. 

30

.X.2. Anthropometric Survey Questionnaire.

ANTHROPOMETRIC SURVEY QUESTIONNAIRE

DATE: CLUSTER No: VILLAGE: TEAM No:

N°. Family N°.

Status (1)

Age Mths

Sex M/F

Weight Kg

Height Cm

Sitting Height cm(2)

Oedema Y/N

MUAC Cm

Measles C/M/N (3)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily

resident in village (cattle camp, water point, visiting family…), 4= Returnee. (2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research (3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles

31

.X.3. Household enumeration data collection form for a death rate calculation survey (one sheet/household).

Survey Payam: Village: Cluster number: HH number: Date: Team number:

1 2 3 4 5 6 7

ID HH member

Present now

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

Sex Date of birth/or age in years

Born during recall period?

Died during the recall period

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

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

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

32

.X.4. Enumeration data collection form for a death rate calculation survey (one sheet/cluster).

Survey Payam: Village: Cluster number: HH number: Date: Team number:

Current HH member

Current HH members who arrived during recall (exclude births)

Past HH members who left during recall (exclude deaths)

Deaths during recall N

Total < 5 Total <5 Total < 5

Births during recall

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

.X.5. CALENDER OF EVENTS –WUDIER PAYAM AUGUST 2006

MONTH 28 SEASONS 2001 2002 2003 2004 2005 2006 JANUARY PAYKEL

People take cattle to the cattle camps.

56 SPDF and SPLA hold a peace conference.

44 32 20. Comprehensive Peace Agreement signed.

8

FEBRUARY PAYREW

People rest.

55SPDF and SPLA joined ranks and called for ceasefire.

43 Palata tribe came looking for cattle pasture.

31 Someone murdered by the Maban tribe.

19. Wudier community request for a new commissioner.

7

MARCH PAYDIOK

People dig wells and construct tukuls.

54 Severe cholera outbreak and many children die

42

30. Commissioner and other community leaders attend a peace conference in Old Fangak.

18. Change of PHCU to PHCC and there were a lot of celebrations.

6

APRIL PAYNGUAN

Preparation of old and new gardens waiting for the rains.

53 The cholera outbreak continues

41 Fighting between Palata and Wudier community.

29 17. A measles outbreak killing many children.

MAY PAYDIECH

Planting of maize and millet begins.

52The cholera outbreak continues.

40 28 16. Celebration of inauguration of Dr.Garang as the SPLA leader. Health motivators trained by Oxfam GB in Wudier

JUNE PAYBAKEL

Weeding crops

51. Displacedpeople return to Wudier.

39

27 15

JULY PAYBAROW

Return cattle from the cattle camps.

50Severe famine and drought in Longuchok county

38. Mobilization of soldiers from Wudier to Yaboth army camp

26. Wudier and Maban community clash because of WFP food.

14 Arrival of Dr.J.Garang in Khartoum.

AUGUST PAYBADAK

Eat green maize. Planting of sorghum.

49Severe famine and drought in Longuchok county continues.

37 Sever flooding in Wudier in Darjo payams.

25. Nuer community compensate Maban community

13 The death of Dr.J.Garang

28 Corresponding Names of the Months in the Local Nuer Language.

34

SEPTEMBER Paybanguan

Harvesting of dry maize. Pentecost month.

48WFP assessment

36 24. Wudiercommunity revenge by killing 1 Maban in Wechdeng.

12 GOS and SPLA commanders meet in Longuchok I and people can now move freely

OCTOBER PAYWUAL

Storage of maize harvest. Cutting down trees for tukuls.

59 Fighting between militia and GOS in Wudier.

47 WFP food drops.

35 Servants Heart opens school in Wudier

23 11

NOVEMBER PAYWAULKEL

Fishing Preparation of clothes for Christmas

58. SPDF and SPLA soldiers clash in Wudier.

46

34 Lots of fish

22 10. Tournament in Wudier The last WFP food drop in Wudier.

DECEMBER PAYWALREW

Christmas celebrations

57 SPDF and SPLA soldiers clash in Wudier continues.

45 33 Severe outbreak of cattle disease

21 9More returnees in Wudier

35

.X.6. Map of Wudier payams, Longuchok County (Population size: 22,942) 29

29 SOURCE: WUDIER SRRC SECRETARY –AUGUST 2006.