CARE INTERNATIONAL – SOMALIA

NUTRITION SMART SURVEY

FINAL REPORT

LASCANOD DISTRICT, SOOL REGION, SOMALIA

OCTOBER 2019

i

ACKNOWLEDGEMENT

Care Somalia would like to acknowledge all those who were involved directly or

indirectly in the nutrition SMART survey conducted in Lascanod District. In

particular, CARE Somalia M&E department is appreciated for planning, coordination,

provision of field logistics and supervision during data collection. Special gratitude

is also extended to;

• OFDA for their financial support to carry out the SMART survey in Lascanod

District

• CARE Somalia nutrition program and the M&E staff for facilitating recruitment

of survey teams, training, supervision and data collection

• The Ministry of Health for their involvement in SMART survey protocol

validation and planning

• The district and village administrators in Lascanod for facilitating entry of

teams to carry out surveys

• The enumerators for their commitment and team work in collecting quality

data as evidenced by the plausibility report

• The community and all caregivers in the sampled households for welcoming

the teams and accepting to participate in the survey

• Epistat consultants for their technical expertise in conducting the SMART

survey

Report compiled by: Epistat Research Consultants

ii

Table of Contents

ACKNOWLEDGEMENT .................................................................................... i

LIST OF TABLES ........................................................................................ iii

LIST OF FIGURES ....................................................................................... iii

ACRONYMS AND ABBREVIATIONS ..................................................................... iv

EXECUTIVE SUMMARY .................................................................................. v

1.0 INTRODUCTION ..................................................................................... 8

1.1 Background ....................................................................................... 8

1.2 Justification of the Survey ..................................................................... 9

1.3 Survey Objectives ............................................................................... 9

1.3.1 Specific Objectives ........................................................................ 9 1.4 Survey Area ...................................................................................... 9

1.5 Survey Timing .................................................................................... 9

2.0 METHODOLOGY .................................................................................... 10

2.1 Study Design .................................................................................... 10

2.2 Target Group.................................................................................... 10

2.3 Data and Data Collection Methods ........................................................... 10

2.4 Sample Size Determination ................................................................... 11

2.4.1 Anthropometry Sample Size ............................................................. 11 2.4.2 Summary of sampling methods .......................................................... 13

2.5 Organization of the survey .................................................................... 14

2.5.1 Recruitment and Composition of survey teams ....................................... 14 2.5.2 Training of the survey teams ............................................................ 14 2.5.3 Field Data Collection ..................................................................... 14

2.6 Data Management .............................................................................. 14

2.6.1 Data Quality Control ...................................................................... 14 2.6.2 Data Collection Tools ..................................................................... 15 2.6.3 Data Entry and Analysis .................................................................. 15

3.0 RESULTS ............................................................................................ 16

3.1 Summary of survey completeness ........................................................... 16

3.2 Anthropometric results (WHO Growth Standards 2006) .................................. 16

3.2.1 Distribution by age and sex of sample ................................................. 16 3.2.2 Prevalence of wasting (WHZ) based on SMART flags ................................. 17 3.2.3 Prevalence of acute malnutrition by MUAC ........................................... 19 3.2.4 Prevalence of underweight (WAZ) ...................................................... 21 3.2.5 Prevalence of Stunting (HAZ) ........................................................... 21 3.2.6 Mean z-score, Design Effect and excluded subjects ................................. 22

3.3 Child Morbidity and Immunization Coverage ............................................... 22

3.3.1 Retrospective child morbidity ........................................................... 22 3.3.2 Health seeking behaviour ................................................................ 23 3.3.3 Child immunization, Vitamin A supplementation, and deworming ................ 24

4.0 CONCLUSION ....................................................................................... 25

5.0 RECOMMENDATIONS .............................................................................. 26

6.0 ANNEXES............................................................................................ 27

iii

LIST OF TABLES

Table 1: Summary of survey results ......................................................... v

Table 2: Survey target group ............................................................... 10

Table 3: Data and collection methods .................................................... 10

Table 4: Sample size determination ...................................................... 11

Table 5: Summary of survey completeness .............................................. 16

Table 6: Distribution of age and sex of sample ......................................... 16

Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores

(and/or oedema) and by sex ............................................................... 18

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

z-scores........................................................................................ 19

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

scores and/or oedema ...................................................................... 19

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

oedema) and by sex ......................................................................... 20

Table 11: Prevalence of underweight based on weight-for-age z-scores by sex ... 21

Table 12: Prevalence of stunting based on height-for-age z-scores and by sex .... 22

Table 13: Mean z-scores, Design Effects and excluded subjects ..................... 22

LIST OF FIGURES

Figure 1: Somalia seasonal calendar ...................................................... 10

Figure 2: Population age and sex pyramid ............................................... 17

Figure 3: Distribution of WHZ z-scores for the observed population (curve) ....... 18

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

oedema ........................................................................................ 20

Figure 5: Common illnesses reported ..................................................... 23

Figure 7: Health and seeking behavior ................................................... 24

Figure 8: VAS, Deworming and Measles coverage ....................................... 25

iv

ACRONYMS AND ABBREVIATIONS

AIMWG Assessment and Information Management Working Group

CHAST Children Hygiene and Sanitation Transformation

CI Confidence Interval

CLTS Community Led Total Sanitation

DEFF Design Effect

ENA Emergency Nutrition Assessment

FSL Food Security and Livelihoods

FSNAU Food Security and Nutrition Analysis Unit

GAM Global Acute Malnutrition

GMS Grams

HAZ Height for Age Z-score

HAZ Height for Age Z-Score

HHs Households

IDP Internally Displaced Persons

IPC Integrated Phase Classification

IYCF/N Infant and Young Child Feeding/Nutrition

LCL Lower Confidence Limit

M&E Monitoring and Evaluation

MAM Moderate Acute Malnutrition

MUAC Mid Upper Arm Circumference

OFDA Office of Foreign Disaster Assistance

OTP Outpatient Therapeutic Program

PHAST Participatory Hygiene and Sanitation Transformation

PLW Pregnant and Lactating Women

PPS Probability proportional to size

SAM Severe Acute Malnutrition

SD Standard Deviation

SMART Standardized Monitoring and Assessment of Relief and Transitions

UCL Upper Confidence Limit

USAID United States Agency for International Development

WASH Water, Sanitation and Hygiene

WAZ Weight for Age Z-Score

WHO World Health Organization

WHZ Weight for Height Z- Score

v

EXECUTIVE SUMMARY

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

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

Puntland, Galgadud and Somaliland. The interventions started on October 1st 2018

and ended on 30th September 2019. In order to understand the prevailing situation

for targeted humanitarian response, CARE conducted a nutrition SMART survey in

Lascanod District, Sool Region from 17th -31st October 2019. The overall objective of

this survey was to assess the nutrition situation in Lascanod district and determine

the outcome of integrated nutrition and health programs running in the area.

The survey applied the Standardized Monitoring and Assessment of Relief and

Transition (SMART) methodology involving the two-stage cluster sampling approach

targeting 34 clusters and 16 households per cluster. The survey targeted 447 children

from 534 households for the anthropometric survey as determined by ENA for SMART

(July 19, 2015). Eventually, the survey reached 650 children from 543 households

achieving a coverage of 145.4% and 101.7% for the children and households

respectively. The reported prevalence of global acute malnutrition remains of

serious threshold at 10.2 % (7.2 – 14.3 95% C.I.) with severe acute malnutrition

prevalence of 0.9 % (0.4 - 2.0 95% C.I.). A summary of the key findings is presented

in the table below;

Table 1: Summary of survey results

SUMMARY OF SURVEY RESULTS, OCTOBER 2019

INDICATOR N n % 95% CI

ANTHROPOMETRIC RESULTS (6-59 MONTHS) WHO 2006

Wasting (WHZ)

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

636 65 10.2% 7.2 – 14.3

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

59 9.3% 6.4 – 13.2

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

6 0.9% 0.4 - 2.0

Prevalence of GAM by MUAC

Prevalence of global malnutrition (< 125 mm and/or oedema)

650 15 2.3% 1.2 – 4.4

Prevalence of global malnutrition (< 125 mm and >= 115 mm, no oedema)

15 2.3% 1.2 – 4.4

Prevalence of global malnutrition (< 115 mm and/or oedema)

0 0.0% 0.0 – 0.0

Underweight (WAZ)

Prevalence of underweight (<-2 z-score) 648 38 5.9% 3.8 – 8.9

vi

Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)

34 5.2% 3.3 – 8.3

Prevalence of severe underweight (<-3 z-score)

4 0.6% 0.2 – 1.6

Stunting (HAZ)

Prevalence of stunting (<-2 z-score) 641 22 3.4% 2.0 – 5.8

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

22 3.4% 2.0 – 5.8

Prevalence of severe stunting (<-3 z-score)

0 0.0% 0.0 – 0.0

CHILD IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND DEWORMING

Measles immunization( 9-59 months) –( Card and Recall)

621 271 43.6% 39.8 – 47.6

Vitamin A supplementation coverage children 6-59 months

650 191 29.4% 26.0 -33.0

Deworming for Children (12-59 months) in the last 6 months

571 182 31.9% 28.2 – 35.8

CHILD MORBIDITY AND HEALTH SEEKING BEHAVIOR

Prevalence of reported illness (6-59 months) 14 days mothers/caregivers recall

650 197 30.3% 26.9 – 34.0

Fever 123 62.4% 55.3 – 69.2

Cough 115 58.4% 51.2 – 65.3

Diarrhea 54 27.4% 21.3 – 34.2

Skin infections 12 6.1% 3.2- 10.4

Eye infections 6 3.1% 1.1 – 6.

Other illnesses 12 6.1% 3.2 -10.4

Health seeking for sick children 95 48.2 41.1-55.4

Main location of health seeking –Public health facilities

95 53 55.8% 45.2 – 66.0

The survey findings revealed a serious nutrition situation in the district based on

WHO thresholds (10-14%). The prevalence of underweight and stunting were both

low according to WHO thresholds recording 5.9 % (3.8 - 8.9 95% C.I.) and 3.4 % (2.0

- 5.8 95% C.I.) respectively. Morbidity rates in the survey were low with (30.3%) of

the children reportedly ill 2 weeks prior to the survey. fever was the most dominant

illness at (62.4%). The health seeking behavior of caregivers was also below average

(48.2%) with most visiting public health facilities (55.8%) to seek assistance in the

treatment of their children. Vitamin A supplementation (29.4%), Measles (43.6%) and

Deworming (31.9%) also recorded poor coverage with all falling below the 80% WHO

target. Based on these findings, the following actions were recommended to improve

health and nutrition service delivery in Lascanod district;

vii

1. CARE should continue implementing all components of CMAM program and

scale up community mapping for outreach locations and collaborative

outreach health care services in hard to reach locations. The implementation

should integrate all key components in each treatment centre. Attention

should be given to notable ‘pockets of malnutrition’ in Bocame, Xidh xidh and

Goljano villages.

2. Strengthen Maternal, Infant and Young Child nutrition to address the

associated long term impacts of malnutrition on mothers and children.

3. Intensify immunization campaigns in coordination with key stakeholders in

the district to promote Vitamin A supplementation, immunization and

deworming to meet global coverage targets. It should be conducted by

implementing partners through static and mobile facilities to improve

coverage.

4. Enhance WASH programs to include hygiene and sanitation approaches such

as PHAST (Participatory Hygiene and Sanitation Transformation), CHAST

(Children Hygiene and Sanitation Transformation) and CLTS (Community Led

Total Sanitation). This recommendation is based on diarrhoeal diseases and

field observation on lack of sanitation facilities in some of the villages.

5. Enhance awareness on importance of health records among caregivers and

collaborate with other partners and the MoH to support documentation of

healthcare delivery services especially births and immunization coverage.

Most births in Lascanod were reported by recall.

6. Conduct integrated Knowledge, attitudes, practices and behavior survey to

understand factors influencing health seeking behaviors and health service

utilization in the district. Education levels, socio-economic factors, physical

and cultural beliefs are likely to influence health seeking behavior and health

service utilization of caregivers in the community.

8

1.0 INTRODUCTION

1.1 Background

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

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

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

development, small-scale enterprise development, primary school education,

teacher training, adult literacy and vocational training. CARE Somalia is currently

operational in the northern regions of Puntland and Somaliland1.

Lascanod District is one the four districts (Agnabo, Hudun and Taleh) making up the

larger Sool region. Sool shares the western border with Ethiopia. The population

estimates of Sool region is 327,428 with Lascanod district having a population of

75,4362. The region is inhabited by people from the Somali ethnic group with Harti

Darod, Habar Jeclo, and Habar Younis forming the dominant sub clans. The

population is segmented into urban, rural, nomads and IDPs with nomads forming

the bulk of the population. Pastoralism and trade are the major sources of livelihood

for the residents.

Health and Nutrition Situation

Since 2018, CARE implemented Nutrition, health and FSL services in Badhan and

Lascanod covering a total of 21 villages. The CARE nutrition program aimed at

addressing the high malnutrition rates through treatment of Acutely Malnourished

Children under 5, pregnant and lactating women, referral and treatment of

complicated cases of SAM and improved IYCF practices amongst the community

through community based IYCF programs. The program covered 4 fixed sites in

Lascanod. The SMART survey was intended to complement the last FSNAU Post Deyr

2018 survey by adopting the same approach of obtaining the specific GAM rate at

district level and complementing the livelihood estimate of FSNAU. This enabled

CARE to establish its baseline GAM for programming purposes as programs continue

into 2020.

Supported by OFDA/USAID grant, CARE provided humanitarian assistance in Bari,

Galgadud, Mudug, Nugaal, Sanaag, Sool, and Togdheer regions of Puntland, Galgadud

and Somaliland from October 2018 to October 2019. The project provided temporary

employment, protection services, basic health services and treatment services for

acutely malnourished children and pregnant and lactating women. The communities

also benefitted from WASH services through provision of safe water, hygiene

promotion and kits to vulnerable households. The project aimed a total reach of

1 https://www.care-international.org/where-we-work/somalia 2 https://reliefweb.int/sites/reliefweb.int/files/resources/Population-Estimation-Survey-of-Somalia-PESS-2013-2014.pdf

9

247,671 people for assistance; equivalent to 22% of the population in IPC 3 and 4 in

these regions3 as of 2018.

In September 2019, CARE conducted IYCF KAP endline survey in Sool and Sanag

regions. The survey reported exclusive breastfeeding rate of 75.8%, this is above

both national rate (33%) and Somaliland rate (56%) according to 2016 FSNAU

assessment. The report shows that 84% of children were timely introduced to

complementary feeding, however, continued breastfeeding at 1 year was slightly

above average (58. 4%).The reported minimum dietary diversity (4.5%) was below

the national (15%) and Somaliland estimates (7%).

1.2 Justification of the Survey

The SMART survey was meant to complement the FSNAU livelihood assessments

estimates by providing district specific GAM rates. The results will also be used by

CARE to determine the baseline GAM for continuation of programs into 2020.

1.3 Survey Objectives

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

malnutrition among children 6-59 months in Lascanod District.

1.3.1 Specific Objectives

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

aged 6 – 59 Months.

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

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

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

recall

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

Using assessment for action approach clearly indicating the finding,

recommendations actions, timelines and responsibility and monitoring.

1.4 Survey location

The survey was conducted in Somalia’s Lascanod District located in Sool Region.

1.5 Survey Timing

The survey took place in October 2019. This falls period falls in post Gu season as shown in

Figure 1 below.

3 https://reliefweb.int/job/3305148/terms-reference-tor-smart-survey-sool-and-sanag-regions-drought-response-and-recovery

10

Figure 1: Somalia seasonal calendar4 2.0 METHODOLOGY

2.1 Study Design

This survey used a cross-sectional study design applying the two-stage cluster

sampling approach based on the probability proportional to population size (PPS).

The first stage involved the selection of clusters/villages while the second stage

involved the selection of households to be surveyed through simple random

sampling.

2.2 Target Group

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

table below provides a summary of targeted groups for each indicator.

Table 2: Survey target group

Key Indicators Targeted Population

Prevalence of acute malnutrition Children 6-59 months

Child morbidity and health seeking Children 6-59 months

Vitamin A supplementation Children 6-59 months

Measles immunization Children 9-59 months

Deworming Children 12-59 months

2.3 Data and Data Collection Methods

Table 3: Data and collection methods

Data and collection methods

Anthropometric Data

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

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

children 6-59 months (Annex IV)

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

Weight - Standardized SECA scales were used

4 FEWSNET

11

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

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

to 24 months were measured in standing position

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

6-59 months were measured on the left arm to the nearest 0.1cm or 1.0 mm

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

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

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

A supplementation in the past one year.

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

recall period for all the children 6-59 months

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

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

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

in all children aged 9-59 months in the survey

Deworming - Supplementation with deworming tablets was assessed in children

12-59 months in the survey.

2.4 Sample Size Determination

2.4.1 Anthropometry Sample Size

The sample size for anthropometric survey was calculated using ENA for SMART 2011

(July 9, 2015 version) using Sool population parameters as shown below.

Table 4: Sample size determination

Population Parameter

Lascanod District Sool Region

Rationale/Source

Estimated prevalence

10.8%

Somalia June-July 2019 surveys, FSNAU. Lascanod (Sool) reported a GAM of 10.8% (8.2-14.1). Hawd pastoral estimates used for Lascanod

Desired precision 3.5

Reasonable precision in consideration of estimated GAM and associated resources

Design effect 1.36

Lascanod applied 1.36 obtained from the Hawd Pastoral survey

Average household size

4.8 Somalia June-July 2019 surveys, FSNAU

Percent of under five children

20%

Adjusted from the Somalia June-July 2019 surveys, FSNAU of 27.2% for Lascanod (Sool)

12

Percent of non-respondent

3% Anticipated Non-Response Rate

Children to be included

447

Sample sizes (Households)

534

Clusters 34

No. of households per cluster

16

13

Number of Households per Cluster

The number of households to be completed per day were determined by considering

the time available to conduct the survey after consideration of time spent on

travelling, initial introduction, breaks, administering questionnaire in each

household and time spent to move from one household to the next.

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

After exclusion of the travelling time, the initial introduction and selection of

household and lunch break, the amount of time left to conduct the survey was 7

hours. The amount of time spent to conduct the survey in one household was 25

minutes (20 minutes for interviews and 5 for moving from one household to the

next), therefore, the total number of households’ representative of a cluster was

16.8 ≈ 16 (rounded down in first stage of sampling) as detailed below;

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

▪ Average return travel time for each cluster: 1 hours

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

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

▪ Average time in the household: 20 minutes

▪ Breaks: 1 lunch/prayer break of 0.5 hours

𝑛ℎℎ =(9−1−0.5−0.5)60min

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

Number of Clusters for Lascanod District

The number of clusters was determined by dividing the total household sample by

16 households representative of a cluster i.e. No. of clusters =534/16 = 33.3, this

was rounded up to 34 clusters. Therefore, 34 clusters were sampled based on

population proportion to size for Lascanod District. Tukaraq village was excluded

from the sampling frame based on security concerns.

2.4.2 Summary of sampling methods

First stage Cluster sampling

This stage involved the selection of 34 clusters in Lascanod district using the ENA for

SMART software based on population proportion to size (PPS) (see Annex II). An

updated list of all villages/clusters with their respective population sizes was used.

Second stage sampling

The second stage of sampling involved the selection of 16 households in each of the

sampled clusters. This selection was done using simple random sampling using the

household listing and random number generator mobile application. Segmentation

was applied for the densely populated clusters (more than 200 households) and

14

clusters with sparsely distributed followed by simple random sampling of

households.

2.5 Organization of the survey

2.5.1 Recruitment and Composition of survey teams

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

recruiting 6 survey teams, composed of 1 team leader and 2 data collectors. In total,

18 enumerators were recruited for this survey. The selection process considered key

factors such as the level of education, previous experience in conducting surveys,

the ability to read and communicate in English and undoubted fluency in Somali

dialects.

2.5.2 Training of the survey teams

A 4-day training was conducted for all teams before data collection. The training

was conducted in Lascanod town and mainly focused on anthropometric

measurements, survey teams, field procedures translation and back-translation of

the questionnaires, data recording using ODK and second stage sampling. The third

day included a standardization test using 10 healthy children 6-59 months to assess

the precision and accuracy of enumerators in taking anthropometric measurements.

The results of this exercise are available in Annex III.

The survey pre-test was conducted in 3 purposively selected non-sampled villages

around Lascanod town; Jaama Laaye, Farxaskulle and Daami. The results from the

pilot test were analyzed, feedback shared and the notable gaps addressed

sufficiently before teams proceeded to the field for data collection.

2.5.3 Field Data Collection

The process of data collection was conducted over a period of 6 days with rigorous

coordination by CARE Lascanod and close supervision by the consultant and MoH

representative. Data was collected by 6 teams using ODK mobile platform.

2.6 Data Management

2.6.1 Data Quality Control

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

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

▪ 4-day comprehensive training including standardization and pilot test

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

Health representative, consultant, the CARE program staff

▪ Distribution of enumerator strengths across the teams

▪ Calibration and standardization of the survey equipment

▪ Use ODK platform to collect and organize data

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

15

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

before proceeding to the field

▪ Adequate logistic planning during field work

2.6.2 Data Collection Tools

The data collection tools for use were guided by SMART methodology

(anthropometry) and the Somalia AIMWG for additional variables. A combined tool

data collection including the additional variables on child morbidity and

immunization coverage was used in ODK format.

2.6.3 Data Entry and Analysis

The anthropometric data collected using ODK was uploaded into ENA for SMART 2011

software (July 9, 2015 version) for quality checks, review and analysis. Child

morbidity and immunization data was organized and reviewed using MS Excel and

consequently analysed using to Epi Info version 7. Descriptive analysis was performed

for this survey.

16

3.0 RESULTS

3.1 Summary of survey completeness

The survey targeted 447 children aged 6-59 months from 534 households in 34

clusters across Lascanod District. The proportion of households and children

surveyed exceeded the target as shown in the table below;

Table 5: Summary of survey completeness

Planned Surveyed % Achieved

Households 534 543 101.7%

Clusters 34 34 100%

Anthropometry U5s 447 650 145.4%

3.2 Anthropometric results (WHO Growth Standards 2006)

The global acute malnutrition (GAM) is defined as <-2 z scores weight-for-height

and/or oedema and severe acute malnutrition (SAM) is defined as <-3z scores weight-

for-height and/or oedema). All exclusions of z-scores were determined by applying

SMART flags (WHZ -3 to 3; HAZ -3 to 3; WAZ -3 to 3)5 which are based on the observed

survey mean.

The survey reached 650 children (310 boys: 340 girls) aged 6-59 months in the

sampled households where measurements of weight, height, MUAC and oedema were

taken to determine their nutritional status. The anthropometry data was analysed

using ENA for SMART 2011 (July 9th, 2015 version) and recorded an excellent overall

data quality score of 8% (see Annex I). The weight of children was taken with

minimal clothing and factored in the analysis where the average weight of the cloth

was 200 grams.

3.2.1 Distribution by age and sex of sample

Out of the 650 surveyed children in the anthropometric survey, 310 were boys while

340 girls. With a sex ratio of 1.1 (p-value = 0.239) it is evident boys and girls were

equally represented in the survey. Similarly, there was no statistical difference in

the age ratio of 6-29 months to 30-59 months old (0.83, p-value = 0.774) since the

expected value falls around 0.85.

Table 6: Distribution of age and sex of sample

Boys Girls Total Ratio

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

6-17 74 47.1 83 52.9 157 24.2 0.9

18-29 68 49.3 70 50.7 138 21.2 1.0

30-41 76 48.4 81 51.6 157 24.2 0.9

42-53 60 43.8 77 56.2 137 21.1 0.8

54-59 32 52.5 29 47.5 61 9.4 1.1 5 https://smartmethodology.org/survey-planning-tools/smart-methodology/

17

Total 310 47.7 340 52.3 650 100.0 0.9 The distribution by age and sex is presented in the graph below which shows no difference

in representation.

Figure 2: Population age and sex pyramid

3.2.2 Prevalence of wasting (WHZ) based on SMART flags

The prevalence of acute malnutrition was determined based on weight-for-height z-

scores of <-2 and or oedema. Extreme values of WHZ below or above the SMART flag

ranges of WHZ -3 to +3 were excluded in consideration of the observed mean. Based

on the inclusion and exclusion criteria, 636 children were included in the final

analysis for GAM after 12 children with z-scores out of range and 2 not available

were excluded. The 2 missing WHZs are of 2 disabled children whose heights were

not recorded.

The prevalence of Global Acute Malnutrition (GAM) based on WHZ in Lascanod

district was 10.2% (7.2 – 14.3 95% C.I.) while that of Severe Acute Malnutrition (SAM)

was 0.9 % (0.4 - 2.0 95% C.I.). According to WHO standards (10-14%), this GAM rate

renders severity of malnutrition in the population serious6. The prevalence of

malnutrition is likely to worsen during the October 2019-January 2020 according to

food security outlook. FEWSNET’s October 2019 report shows that Sool region will

remain in IPC Phase 3 (Crisis) until January 2019. The situation is expected to

improve in February – May 2019 due to anticipated improved harvest and livestock

herds as a result of the October – December, Deyr rains7.

6 https://www.who.int/nutrition/nlis_interpretation_guide.pdf 7 Somalia Food Security Outlook http://fews.net/east-africa/somalia/food-security-outlook/october-2019

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

6-17

18-29

30-41

42-53

54-59

Month

s

Age and Sex Distribution

Boys Girls

18

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

All n = 636

Boys n = 301

Girls n = 335

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

(65) 10.2 % (7.2 - 14.3 95% C.I.)

(30) 10.0 % (6.4 - 15.2 95% C.I.)

(35) 10.4 % (7.2 - 14.9 95% C.I.)

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

(59) 9.3 % (6.4 - 13.2 95% C.I.)

(28) 9.3 % (5.9 - 14.3 95% C.I.)

(31) 9.3 % (6.2 - 13.5 95% C.I.)

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

(6) 0.9 % (0.4 - 2.0 95%

C.I.)

(2) 0.7 % (0.2 - 2.8 95%

C.I.)

(4) 1.2 % (0.5 - 2.9 95%

C.I.)

The prevalence of oedema is 0.0 % The surveyed population was graphically plotted against the WHO reference population as

shown in the figure below with a resulting mean of -0.66 and a standard deviation of ±1.06.

The recorded SD was within the acceptable range of 0.8-1.2, indicative of plausible

results. With the observed mean lesser than the reference mean (0), the Lascanod

curve deviated to the left indicating the surveyed population was undernourished in

comparison to the reference population.

Figure 3: Distribution of WHZ z-scores for the observed population (curve)

19

No cases of oedema were observed during the survey. However, 12 children were reported

to be marasmic (1,9%).

Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z-scores <-3 z-score >=-3 z-score Oedema present Marasmic kwashiorkor

No. 0 (0.0 %)

Kwashiorkor No. 0

(0.0 %)

Oedema absent Marasmic No. 12 (1.9 %)

Not severely malnourished No. 636 (98.1 %)

The analysis of acute malnutrition was further done by age groups for both severe

and moderate wasting. Children 18-29 months and 54-59 months’ group were the

most affected by moderate wasting at 12.0% and 15.8% respectively. Severe wasting

was generally low across the groups;

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Severe wasting

(<-3 z-score) Moderate wasting

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

Normal (> = -2 z score)

Oedema

Age (mo)

Total no.

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

6-17 155 2 1.3 10 6.5 143 92.3 0 0.0

18-29 133 2 1.5 16 12.0 115 86.5 0 0.0

30-41 154 0 0.0 14 9.1 140 90.9 0 0.0

42-53 137 2 1.5 10 7.3 125 91.2 0 0.0

54-59 57 0 0.0 9 15.8 48 84.2 0 0.0

Total 636 6 0.9 59 9.3 571 89.8 0 0.0

3.2.3 Prevalence of acute malnutrition by MUAC

Empirical evidence corroborate the efficacy of MUAC measurement as an indicator

of mortality risk associated with wasting in children 6-59 months8. MUAC is commonly

used in community screening and admission of children 6-59 months into feeding

programs based on the WHO recommended cut-offs of 115mm and 125 mm to define

severe and moderate malnutrition respectively9. This is owed to the fact that MUAC

assessment is easier to conduct and very affordable.

8 Chiabi, A., Mbanga, C., Mah, E., Nguefack Dongmo, F., Nguefack, S., Fru, F., ... & Fru III, A. (2016). Weight-for-height z score and mid-upper arm circumference as predictors of mortality in children with severe acute malnutrition. Journal of tropical pediatrics, 63(4), 260-266. 9 Myatt, M., Khara, T., & Collins, S. (2006). A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food and nutrition bulletin, 27(3_suppl3), S7-S23.

20

MUAC measurements of all sampled children 6-59 months were taken. The

prevalence of GAM (< 125 mm and/or oedema) by MUAC was 2.3% (1.2 – 4.4 95%

C.I.). There were no cases of severe malnutrition.

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

n = 650 Boys

n = 310 Girls

n = 340

Prevalence of global malnutrition (< 125 mm and/or oedema)

(15) 2.3 % (1.2 - 4.4 95%

C.I.)

(7) 2.3 % (1.1 - 4.4 95%

C.I.)

(8) 2.4 % (1.0 - 5.7 95%

C.I.)

Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)

(15) 2.3 % (1.2 - 4.4 95%

C.I.)

(7) 2.3 % (1.1 - 4.4 95%

C.I.)

(8) 2.4 % (1.0 - 5.7 95%

C.I.)

Prevalence of severe malnutrition (< 115 mm and/or oedema)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

The distribution of GAM by MUAC as classified by age demonstrated that children 6-

17, 18-29 and 54-59 months were the most affected by moderate malnutrition.

Similarly, the same age groups were the most wasted by WHZ z-scores.

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

21

3.2.4 Prevalence of underweight (WAZ)

Underweight is a composite indicator that reflects both wasting (low weight for

height ratio) and stunting (low height for age). Essentially, weight for age measures

the child’s body weight relative to their age10. The analysis of the prevalence of

underweight (WAZ) involved 648 children after exclusion of 2 children with z-scores

out of range. The survey recorded an underweight prevalence of 5.9 % (3.8 - 8.9 95%

C.I.) while the prevalence of severe underweight was 0.6 % (0.2 - 1.6 95% C.I.).

According to WHO standards (<10%), the prevalence of underweight in Lascanod

district is considered low. From the findings, more boys compared to girls were

underweight as shown below;

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

n = 648 Boys

n = 309 Girls

n = 339

Prevalence of underweight (<-2 z-score)

(38) 5.9 % (3.8 - 8.9 95%

C.I.)

(26) 8.4 % (5.3 - 13.0 95% C.I.)

(12) 3.5 % (1.9 - 6.4 95%

C.I.)

Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)

(34) 5.2 % (3.3 - 8.3 95%

C.I.)

(23) 7.4 % (4.5 - 12.0 95% C.I.)

(11) 3.2 % (1.7 - 6.2 95%

C.I.)

Prevalence of severe underweight (<-3 z-score)

(4) 0.6 % (0.2 - 1.6 95%

C.I.)

(3) 1.0 % (0.3 - 3.0 95%

C.I.)

(1) 0.3 % (0.0 - 2.2 95%

C.I.)

3.2.5 Prevalence of Stunting (HAZ)

Stunting is a chronic form of malnutrition characterized by impaired growth and

development. It results when a child experiences long-term nutritional deprivation

which in turn leads to delayed mental development, poor school performance and

reduced intellectual capacity11. Evidence suggests the potential risk of small women

to deliver infants with low birth weight which contributes to intergenerational cycle

of malnutrition as infants of low birth weight tend to be smaller as adults12.

The analysis of stunting included 641 children after 7 children with z-scores out of

range and 2 not available were excluded. The findings showed a stunting prevalence

of 3.4 % (2.0 - 5.8 95% C.I.) with no children severely stunted. According to WHO

thresholds (<20%), the prevalence of stunting was low in the district.

10 http://www.searo.who.int/entity/health_situation_trends/data/Underweight_text/en/ 11 Dewey, K. G., & Begum, K. (2011). Long‐term consequences of stunting in early life. Maternal & child nutrition, 7, 5-18. 12 Sumarmi, S. (2016). Maternal short stature and neonatal stunting: an inter-generational cycle of malnutrition.

22

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

n = 641 Boys

n = 303 Girls

n = 338

Prevalence of stunting (<-2 z-score)

(22) 3.4 % (2.0 - 5.8 95%

C.I.)

(16) 5.3 % (2.8 - 9.7 95%

C.I.)

(6) 1.8 % (0.6 - 5.0 95%

C.I.)

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

(22) 3.4 % (2.0 - 5.8 95%

C.I.)

(16) 5.3 % (2.8 - 9.7 95%

C.I.)

(6) 1.8 % (0.6 - 5.0 95%

C.I.)

Prevalence of severe stunting (<-3 z-score)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

(0) 0.0 % (0.0 - 0.0 95%

C.I.)

3.2.6 Mean z-score, Design Effect and excluded subjects

The table below provides a summary of the mean z-scores, SD, DEFF, z-scores not

available and z-scores out of range for each of the three assessed indices. This

information provides a summary of quality of data, heterogeneity of each indicator

and useful in planning future surveys.

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

scores ± SD Design Effect (z-score < -2)

z-scores not available*

z-scores out of range

Weight-for-Height 636 -0.66±1.06 2.10 2 12

Weight-for-Age 648 -0.59±0.90 1.76 0 2

Height-for-Age 641 -0.23±0.86 1.58 2 7

3.3 Child Morbidity and Immunization Coverage

3.3.1 Retrospective child morbidity

The occurrence of common childhood illnesses was assessed among children aged 6-

59 months. The caregivers were probed based on 14 days’ recall whether their

children had fallen ill and the type of illness suffered. One third, (30.3%) of the

children experienced some form of illness over the 2 - weeks’ recall period. From

the findings, fever (62.4%) was the dominant illness followed by cough and diarrhea

at 58.4% and 27.4% respectively. Other reported illnesses are as shown in the Figure

5 below.

23

Figure 5: Common illnesses reported

Regarding other illnesses, vomiting (16.7%), stomatitis (16.7%) and meningitis

(16.7%) were the most common illnesses specified by caregivers. Other specified

illnesses are as shown below.

3.3.2 Health seeking behaviour

The health seeking behavior of caregivers whose children were reportedly ill over

the recall period was assessed. Out of those interviewed only (48.2%) of the

caregivers sought assistance. Health service utilization among caregivers was higher

in public health facilities (55.8%) followed by private clinics (30.5%) and

pharmacies/chemist (6.3%). It is apparent most caregivers who sought assistance

preferred medical (formal) over traditional and religious (non-formal) interventions

in the treatment of their children.

62.40%58.4%

27.4%

6.1%3.1%

6.1%

0%

10%

20%

30%

40%

50%

60%

70%

Fever Cough Diarrhoea Skininfection

Eyeinfection

Others

Type of illness

24

Figure 6: Health and seeking behavior

3.3.3 Child immunization, Vitamin A supplementation, and deworming

Immunization coverage for measles was assessed among children aged 9-59 months

based on both recall and health record documentation. The survey findings

established an overall proportion of children vaccinated against measles was 43.6 %

with 37.5% based on recall and 6.1% verification by card. In essence, measles

coverage was below average rendering the population more vulnerable to infections

due to the high number of unvaccinated children. Similarly, Vitamin A

supplementation and deworming were also low at 29.4% and 31.9% respectively.

Therefore, based on the WHO recommended coverage of 80%, it is evident from the

findings Vitamin A supplementation, deworming and immunization coverage in

Lascanod district are low hence the need for a scale up to meet public health

significance levels. Evidence has shown the efficacy of Vitamin A supplementation

in the control of child morbidity and mortality in children13.

13 Beaton, G. H., Martorell, R., Aronson, K. J., Edmonston, B., McCabe, G., Ross, A. C., & Harvey, B. (1993). Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries.

3.2%

6.3%

30.5%

55.8%

1.1%

3.2%

0% 10% 20% 30% 40% 50% 60%

Health seeking behavior

Traditional healer

Religious leaders

Public healthfacilities/hospital

Private clinic

Phamarcy/chemist

CHW/CommunityNutrition worker

25

Figure 7: VAS, Deworming and Measles coverage

4.0 CONCLUSION

The Lascanod district SMART survey recorded a GAM prevalence of 10.2 % (7.2 - 14.3

95% C.I.). This is a serious GAM prevalence according to WHO emergency thresholds

(10-14%). Despite this study being a district survey, the serious levels of malnutrition

are similar to the recent FSNAU assessments done in June-July in Sool Region that

recorded a GAM prevalence of 10.8% (8.2-14.1). With this GAM prevalence, there is

need for concerted efforts to scale up nutrition interventions that aim at prevention

and treatment of acute malnutrition to abate the levels from reaching critical. The

reported prevalence of malnutrition by MUAC of 2.3% was below the Gu 2019

prevalence (4%). The prevalence of underweight and stunting were both low

according to WHO thresholds recording 5.9 % (3.8 - 8.9 95% C.I.) and 3.4 % (2.0 - 5.8

95% C.I.) respectively.

The reported child morbidity showed that (30.3%) of the children had fallen sick two

weeks prior to the survey with the most dominant illnesses being fever (62.4%),

cough (58.4%) and diarrhea (27.4%). Of much concern is the health seeking behaviour

where more than half of the caregivers with sick children did not seeking any form

of medical assistance. Those who sought assistance mostly visited public health

facilities (55.8%) and private clinics (30.5%).

29.40%31.90%

43.60%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Vitamin A coverage (6-59months)

Deworming coverage (12-59months)

Measles coverage (9-59months)

Immunizations and Vaccination

26

Vitamin A supplementation of children 6-59 months and deworming recorded low

coverage of (29.4%) and (31.9 %) respectively. Similarly, measles coverage by both

card and recall was also very low with only (43.6%) being immunized. The coverage

of Vitamin A supplementation, deworming and measles are below the 80% WHO

target.

5.0 RECOMMENDATIONS

1. CARE should continue implementing all components of CMAM program and

scale up community mapping for outreach locations and collaborative

outreach health care services in hard to reach locations. The implementation

should integrate all key components in each treatment centre. Attention

should be given to notable ‘pockets of malnutrition’ in Bocame, Xidh xidh and

Goljano villages.

2. Strengthen Maternal, Infant and Young Child nutrition to address the

associated long term impacts of malnutrition on mothers and children.

3. Intensify immunization campaigns in coordination with key stakeholders in

the district to promote Vitamin A supplementation, immunization and

deworming to meet global coverage targets. It should be conducted by

implementing partners through static and mobile facilities to improve

coverage.

4. Enhance WASH programs to include hygiene and sanitation approaches such

as PHAST (Participatory Hygiene and Sanitation Transformation), CHAST

(Children Hygiene and Sanitation Transformation) and CLTS (Community Led

Total Sanitation). This recommendation is based on diarrhoeal diseases and

field observation on lack of sanitation facilities in some of the villages.

5. Enhance awareness on importance of health records among caregivers and

collaborate with other partners and the MoH to support documentation of

healthcare delivery services especially births and immunization coverage.

Most births in Lascanod were reported by recall.

6. Conduct integrated Knowledge, attitudes, practices and behavior survey to

understand factors influencing health seeking behaviors and health service

utilization in the district. Education levels, socio-economic factors, physical

and cultural beliefs are likely to influence health seeking behavior and health

service utilization of caregivers in the community.

27

6.0 ANNEXES

Annex I: Plausibility Report

Plausibility check for: SOML_201910_CARE_LAASCANOD.as Standard/Reference used for z-score calculation: WHO standards 2006

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

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

evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

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

(% of out of range subjects) 0 5 10 20 0 (1.9 %)

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

(Significant chi square) 0 2 4 10 0 (p=0.176)

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

(Significant chi square) 0 2 4 10 0 (p=0.774)

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

0 2 4 10 2 (8)

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

0 2 4 10 0 (7)

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

0 2 4 10 2 (8)

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

. and and and or

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

0 5 10 20 0 (1.06)

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

0 1 3 5 0 (0.16)

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

0 1 3 5 1 (-0.26)

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

0 1 3 5 3 (p=0.001)

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 8 %

The overall score of this survey is 8 %, this is excellent.

28

Annex II: Sampled Clusters

Geographical unit Population size Cluster

Adhicadeye 640 1

Tuulo samakaab 850 2

Yagori 820 RC

kalax 140 laasadaar 860 3

Balli hadhac 600 4

Dhumay 600 5

Dhagax iskuraw 310 Dhabansaar 400 Xidh xidh 720 6

Higlada 480 Karin gorfood 1200 7,8

Bocame 5210 RC,9,10,11,12

Buulal 210 Qabri bayax 380 13

Qoriley 3900 14,15,16,RC,17

Afgooye 240 Goljano 740 18

Shululux 850 RC

Yeyle 990 19

Yaaheel 50 20

hadhwanaag 120 Dalyare 590 Ganbadhe 740 21

Kabaalka xargaga 590 22

Saaxa gebo gebo 450 23

Xalxaliye 60 Canjiid 240 Dabataad 730 24

Dharkeyn 912 25

Kalabeydh 4100 26,27,28,29,30

Saaxdheer 600 31

Dan 400 32

Fardhidin 750 33

Karindabeylweyn 739 34

29

Annex III: Standardization Test Report

Standardisation test results

Precision Accuracy OUTCOME

Weight subjects Mean SD max Technical error TEM/mean

Coef of reliability

Bias from superv

Bias from median result

# Kg kg kg TEM (kg) TEM (%) R (%) Bias (kg) Bias (kg)

Supervisor 10 13.1 2.4 0.2 0.07 0.5 99.9 - 1.24 TEM acceptable R value good Bias reject

Enumerator 1 10 13.2 2.4 0.4 0.12 0.9 99.7 0.05 1.28 TEM poor R value good Bias reject

Enumerator 2 10 13.1 2.3 0.7 0.17 1.3 99.5 -0.05 1.19 TEM poor R value good Bias reject

Enumerator 3 10 13.1 2.3 0.7 0.19 1.5 99.3 -0.05 1.19 TEM poor R value good Bias reject

Enumerator 4 10 13.1 2.4 0.2 0.09 0.7 99.9 -0.02 1.22 TEM acceptable R value good Bias reject

Enumerator 5 10 13.2 2.4 0.5 0.14 1.1 99.7 0.02 1.26 TEM poor R value good Bias reject

Enumerator 6 10 13.1 2.4 0.5 0.13 1 99.7 0.01 1.25 TEM poor R value good Bias reject

enum inter 1st 6x10 13.1 2.3 - 0.11 0.8 99.8 - - TEM acceptable R value good

enum inter 2nd 6x10 13.2 2.4 - 0.17 1.3 99.5 - - TEM acceptable R value good

inter enum + sup 7x10 13.1 2.3 - 0.13 1 99.7 - - TEM acceptable R value good

TOTAL intra+inter 6x10 - - - 0.2 1.6 99.2 0 1.23 TEM acceptable R value good Bias reject

TOTAL+ sup 7x10 - - - 0.19 1.5 99.3 - - TEM acceptable R value good

Height subjects Mean SD max Technical error TEM/mean

Coef of reliability

Bias from superv

Bias from median result

# Cm cm cm TEM (cm) TEM (%) R (%) Bias (cm)

Bias (cm)

Supervisor 10 93.7 7.9 1.6 0.57 0.6 99.5 - 1.21 TEM acceptable R value good Bias poor

Enumerator 1 10 93.5 8.2 2.4 0.75 0.8 99.2 -0.19 1.01 TEM poor R value good Bias poor

Enumerator 2 10 92.5 7.9 2 0.67 0.7 99.3 -1.18 0.03 TEM poor R value good Bias good

Enumerator 3 10 94 7.1 18 4.12 4.4 66.5 0.26 1.46 TEM reject R value reject Bias reject

30

Enumerator 4 10 93.4 8.1 2 0.68 0.7 99.3 -0.26 0.94 TEM poor R value good Bias poor

Enumerator 5 10 93.7 8.2 4 1.03 1.1 98.4 -0.02 1.19 TEM reject R value acceptable Bias poor

Enumerator 6 10 93.2 8 1.3 0.43 0.5 99.7 -0.46 0.75 TEM acceptable R value good Bias poor

enum inter 1st 6x10 93.5 7.7 - 2.5 2.7 89.4 - - TEM reject R value reject

enum inter 2nd 6x10 93.3 7.9 - 0.73 0.8 99.2 - - TEM acceptable R value good

inter enum + sup 7x10 93.4 7.8 - 1.52 1.6 95.1 - - TEM reject R value acceptable

TOTAL intra+inter 6x10 - - - 2.58 2.8 88.9 -0.31 0.94 TEM reject R value reject Bias poor

TOTAL+ sup 7x10 - - - 2.41 2.6 90.4 - - TEM reject R value poor

MUAC subjects Mean SD max Technical error TEM/mean

Coef of reliability

Bias from superv

Bias from median result

# Mm mm mm TEM (mm) TEM (%) R (%)

Bias (mm)

Bias (mm)

Supervisor 10 156.8 12.2 8 2.89 1.8 94.4 - 4.75 TEM poor R value poor Bias reject

Enumerator 1 10 156.1 11 16 4.8 3.1 80.8 -0.6 4.15 TEM reject R value reject Bias reject

Enumerator 2 10 153.8 11.7 10 3.47 2.3 91.2 -3 1.75 TEM reject R value poor Bias acceptable

Enumerator 3 10 150.2 10.3 12 4.28 2.8 82.7 -6.55 -1.8 TEM reject R value reject Bias good

Enumerator 4 10 156.9 12.6 8 3.46 2.2 92.4 0.15 4.9 TEM reject R value poor Bias reject

Enumerator 5 10 153.8 11.7 9 3.69 2.4 90 -3 1.75 TEM reject R value reject Bias acceptable

Enumerator 6 10 151.4 10 11 3.81 2.5 85.6 -5.4 -0.65 TEM reject R value reject Bias good

enum inter 1st 6x10 154 11.3 - 3.95 2.6 87.8 - - TEM reject R value reject

enum inter 2nd 6x10 153.4 11.3 - 5 3.3 80.4 - - TEM reject R value reject

inter enum + sup 7x10 154.1 11.4 - 4.38 2.9 84.9 - - TEM reject R value reject

TOTAL intra+inter 6x10 - - - 5.99 3.9 71.7 -3.07 2.12 TEM reject R value reject Bias poor

TOTAL+ sup 7x10 - - - 5.82 3.8 73.9 - - TEM reject R value reject

31

Annex IV: Calendar of Events

LAASCANOD SMART SURVEY 2019, CALENDAR OF EVENTS

MONTH SEASONS 2014 2015 2016 2017 2018 2019

January 57 45 33 21 9

Diraaac ( Dry season)

Restaurant attack in Liido

Doorashii Barlamaanka Somalia

Sanadka cusub

Doorashii Puntland Sanadka Cusub Drought of sima Booqashadii farmaajo and rape and killing asha ilyas in Galkacyo

February 56 44 32 20 8

IGADmeeting in moadisho

Dabaaldagii Mowliidka, Daalo airline explosiion and farmajo election

Doorashadi Farmaajo

agreement between qayad and Baharsame

March 55 43 31 19 7

Death of former Somalia PM, Death of Pf. Mohamed Tubeel

Magclay war and hottest month of jiilaal

Dagaalkii Suuj iyo Garmaal,and selection of primenister Hassan Ali Khayre

Puntlant state treasurer killed in Galkacyo

April Gu 54 42 30 18 6

32

Garisa Collage attack

Explossion in Garowe killing UN staff

Soondheere and outbreak of acute water diarhea at sool, sanaa,and togdheer

Iclaaminti dagaal ka dhana alshabab

Dagaalkii Tuko raq

beginning of GU season

Heavy rains-Flooding

May 52 41 29 17 5

Soon dheere and Soamliland indepence day

Soon dheere and independence day of somaliland

Bilowgii Bisha Ramadan and somaliland independence Day.

Bilowgii Bishii Ramdan and Somaliland Independence Day

Maalinka dhalinyada Somalia

Maalinka dhalinyada Somalia

Maalinka dhalinyada Somalia

Maalinka dhalinyada Somalia

June 52 40 28 16 4

Bilowgii Bishii Ramadan

Bilowgii Bishii Ramadan

Idd fitri Idd Fitri, June 26th

26-Jun 26-Jun somali republic day Afurur millitary base attacked

July

Xagaa

51 39 27 15 3

Kowdii Luuliyo and idd fitr

Kowdii Luuliyo Kowdii Luuliyo( union nation day)

Kowdii Luuliyo

death MP sado ali Idd Fitri, Dabshid

August 50 38 26 14 2

Aasaaska Puntland Aasaaska Puntland Aasaaska Puntland Aasaaska Puntland

Soon fur and election of jubaland

Conflict between Rerbiciidya & Dhulbahanite and mid of xagaa season

Idd Adha

September 49 37 25 13 1

33

Idd ADHA Bishii Sakada Idd Adha

idd Adha Carafa

October

Deyr

48 36 24 12 0

islamic year Bishii Sakada soobe Explosion celebration of 21st october for miletry conducted addministrion of somalia

Burtinle Mayor election and lack of Dayr rain

Drought

November 59 47 35 23 11

Duufaanihii 2013 Bishii Sakada and death of former somali journalism called awke

Fighting between puntland & Golmudug

Drought and presidential of Somaliland

December 58 46 34 22 10

campaign kii doorashooyinka Puntalnd

mawliid Day ( celebration of birth prophet mohamed)

mawliid Day ( celebration of birth prophet mohamed)

Drought