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NUTRITIONAL ANTHROPOMETRIC SURVEY FINAL REPORT IDP CAMPS AND RESETTLEMENT AREAS OF GULU & AMURU DISTRICTS, NORTHERN UGANDA MAY 2007 Funded by:

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NUTRITIONAL ANTHROPOMETRIC SURVEY

FINAL REPORT

IDP CAMPS AND RESETTLEMENT AREAS OF GULU & AMURU DISTRICTS, NORTHERN UGANDA

MAY 2007

Funded by:

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ACKNOWLEDGMENTS We would like to extend our appreciation to the Gulu & Amuru District Director of Health Services for fully supporting the nutrition survey and involving two of their staff in the survey. We would like to thank all of the AAH management team for their assistance in preparing and conducting the survey. Without the support of logistics and administration at both capital and base levels, the survey would not have been possible. We further appreciate the management team members that took the time to participate in the survey. The involvement of AAH-Canada further broadened our understanding of the SMART methodology and was warmly welcomed. We appreciate all of the team members from the office and field that spent two long weeks conducting the survey. Their dedication and hard work helped ensure the accuracy and reliability of the data. Further thanks to all of the drivers that ensured the teams’ safe delivery to and from the field. Special thanks are extended to all of the camp and village leaders that welcomed and willingly assisted the teams in their home communities. Without their support and sensitization to the community, finding the houses and finding families at home would have been impossible. Finally, we offer much thanks to the individual families that patiently allowed us to weigh and measure their children and provided vital information for the survey.

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Table of content

I EXECUTIVE SUMMARY ............................................................................................................................................ 4 II INTRODUCTION .......................................................................................................................................................... 8 III OBJECTIVES .......................................................................................................................................................... 9 IV METHODOLOGY................................................................................................................................................. 10

IV.1 Type of Survey and Sample Size ......................................................................................................10 IV.2 Data Collection ...................................................................................................................................10 IV.3 Indicators, Guidelines, and Formula’s Used ...................................................................................11

IV.3.1 Acute Malnutrition .........................................................................................................................11 IV.3.2 Mortality ..........................................................................................................................................12

IV.4 Field Work ...........................................................................................................................................12 IV.5 Data Analysis......................................................................................................................................12

V RESULTS OF THE ANTHROPOMETRIC SURVEY ............................................................................................ 12 V.1 Anthropometry ...................................................................................................................................12

V.1.1 Distribution by Age and Sex .........................................................................................................13 V.1.2 Anthropometric Analysis ..............................................................................................................13

V.2 Measles Vaccination Coverage.........................................................................................................15 V.3 Household Status and composition.................................................................................................16

VI RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY ................................................................. 16 VII DISCUSSION ......................................................................................................................................................... 17 VIII RECOMMENDATIONS ....................................................................................................................................... 18 IX APPENDIX ............................................................................................................................................................. 19

IX.1 Sample Size and Cluster Determination ..........................................................................................19 IX.2 Anthropometric survey questionnaire .............................................................................................20 IX.3 Household enumeration data collection form for a death rate calculation survey (one sheet/household) .............................................................................................................................................21 IX.4 Calendar of events in AMURU & GULU districts.............................................................................22

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I EXECUTIVE SUMMARY Lying 332 km from the national capital Kampala, Gulu district has traditionally been widely acknowledged as the regional capital of the northern region. Up to May 2006, Amuru was part of Gulu District but has then been upgraded as an entire District. The 2 districts cover an area of 11,732 sq km, comprised of open water and swamps (180 km²), arable land (10,301 km²), national parks and games reserves (982 km²) and forest coverage (371 km²). Security and displacement The war in Northern Uganda has been ongoing for twenty years. Initially rooted in a popular rebellion against President Yoweri Museveni’s National Resistance Movement (NRM) government, the conflict has since been transformed by Joseph Kony’s Lord’s Resistance Army (LRA) into a brutally violent war in which civilians in the northern districts are the main victims. Approximately 1.9 million people have been internally displaced. The Acholi region of Uganda (Kitgum, Pader, and Gulu Districts) has seen an increase in the intensity of insurgency since 1996. This has resulted in people’s displacement, spontaneously or under the direction of the Government, into camps protected by the Uganda People’s Defense Forces (UPDF). The conflict in Northern Uganda is often referred to as the forgotten war. Funding for relief and development activities has never been proportional to the needs. However, in the last two to three years, an increase in international attention has been followed by an increase in the amount of international funds designated to humanitarian projects in Northern Uganda war affected districts. Besides funding, the peace talk on going since August 2006 led to a significant improvement of the security situation. This improvement of security conditions motivated the beginning of a returning process for IDP’s to their villages of origin, improving their access to land for gardening. However, people showed still traumatize by the war and most of them still feared to return back where the government army (UPDF) can not provide them security. Weather Amuru & Gulu districts climate consists in wet and dry seasons. The average rainfall received is 1,500 mm per annum with a monthly rainfall average varying between 14 mm in January and 230 mm in August. The wet season extends from April to October with peaks in May, August and October. The dry season starts in November and lasts up to March. Population The district has a population of 479,496 according to the 2002 population census. Gulu is a multi-ethnic district although some 85 percent of the people are from the Acholi ethnic group. Other ethnic groups represented are the Langi, Madi and Alur. The main languages spoken are Luo, English, Swahili, Madi, Lugbara, Luganda, Acholi and Kinubi. Infrastructure Gulu can be accessed by road and air. The national railway line also extends to the district although it is not actually functional. The district has a 415 km feeder road network and a 600 km community road network Mobile Telephones Network (MTN) and Uganda telecom networks are covering the districts. Gulu district has four main hospitals and five health sub-districts (HSD). The hospitals are Anaka District Hospital, Gulu Referral Hospital, St. Mary’s Lacor Hospital (Missionary founded) and a private independent Hospital. Agriculture remains the major economic activity in Gulu district. Over 90 percent of the population in the district engages and benefits from agriculture activities. Agriculture contributes 45 percent of the Gross Domestic Product (GDP). Some 10,301 km² are cultivated but insecurity has rendered big chunks of the district no-go areas. Among the cash crops grown are rice, tobacco, cotton, groundnuts, sun flowers and sesame. The staple foods are finger millet, sorghum, cassava, sweet potatoes, pigeon peas, beans, cowpeas, bananas, soy beans and maize.

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Objectives of the survey A nutritional survey was conducted in Gulu & Amuru districts in April 2007.

• To evaluate the nutritional status of children aged 6 to 59 months. • To estimate the measles immunization coverage of children aged 9 to 59 months. • To estimate the crude mortality rate through a retrospective survey.

Methodology In order to be able to compare 2007 nutritional data with those collected during the last years surveys, and as it appeared that nutritional status of the people in Gulu and Amuru districts could be assumed equivalent, the survey was conducted jointly for both districts. Targeted population remained the IDP’s, as considered as the most vulnerable. Compared with 2006 survey, transit and resettlement camps and villages of return were included in the survey in order to follow the population in its returning process. The Smart methodology was applied for the calculation of the sample size: 32 cluster of 22 children. The sampling frame covered all accessible IDP camps, including resettlement and transit camps and villages. In each cluster, households were randomly selected and surveyed using the EPI method. All the children aged between 6 and 59 months of the same family, defined as all inhabitants using the same cooking pot, were included in the survey. A retrospective mortality survey over the period from January 1st up to the date of the survey (3 months and half) was undertaken alongside the anthropometric survey, using SMART methodology. Nutrition and mortality data were analyzed using Nutrisurvey version December 2006 software. Summary of the findings As a transition to a complete return from camps, authorities organized several resettlement and transit camps in Gulu and Amuru districts, An average of 25% of the population had already returned or joined transit camps in both Gulu & Amuru while in Lira over 79% is no longer in the displaced camps in March 2007. In Gulu and Amuru most people in transit or returning process were still linked with some humanitarian assistance provided in the camps (as access to health facilities, education, and access to clean water is questionable in villages, returning areas and transit camps). Results of the survey Table 1: Results for Gulu & Amuru Districts

Index INDICATOR RESULTS (n =763)

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

3.1 % [1.8% - 4.5%] Z-scores

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

0.4 % [0.0% - 0.8%]

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

2.1 % [1.0% - 3.2%]

NCHS

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

0.0% [0.0%-0.2%]

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

3.5 % [2.1% - 5.0%] Z-scores

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

0.8 % [0.2% - 1.4%]

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

1.0 % [0.3% - 1.8%]

WHO

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

0.0% [0.0%-0.2%]

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Total crude retrospective mortality (last 3.5 months) /10,000/day Under five crude retrospective mortality /10,000/day

0.30 [0.11-0.48] 0.20 [0.00-0.43]

Measles immunization coverage on children >=9 months old (n= 739)

By card According to caretaker1 Not immunized

47.8% 41.4% 10.8%

Table 2: Nutritional Surveys – Gulu/Amuru Districts - Main results since 2003

May 2003 (n=900)

June 2004 (n=1072)

June 2005 (n=976)

June 2006 (n=934)

April 2007 (n=763)

Global Acute Malnutrition (W/H <-2 Z-scores2 and/or oedema)

6.7% (4.6% - 9.5%)3

4.6% (3.0% - 6.8%)

4.1% (2.6% - 6.4%)

4.3% (2.7% - 6.7%)

3.1% (1.8% - 4.5%)

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

1.3% (0.7% - 2.4%)

0.8% (0.3% - 2.2%)

1.2% (0.5% - 2.8%)

0.3% (0.0% - 1.5%)

0.4% (0.0% - 0.8%)

Measles vaccination coverage: Confirmed by Card Not conformed by Card

38.3% 61.7%

47% 53%

83.1% 16.0%

63.9% 32.8%

47.8% 41.4%

The results of the last 3 annually surveys show a general slight improvement in the prevalence of Global Acute Malnutrition, as compared to the rates found in the previous years: Rates of malnutrition have notably decreased. Immunization rates are acceptable as well, showing a good coverage for the prevention of outbreaks, and also reveal an acceptable level in health access. Many mothers couldn’t provide EPI cards as most of the time they were burnt or lost. Acute malnutrition in the surveyed areas is of low magnitude and low intensity, which makes the population slightly vulnerable to potential shocks. The current nutritional situation in Gulu and Amuru districts can be explained by the following factors:

Health Access and Water and Sanitation: Gulu and Amuru districts have good coverage of health facilities compared with other affected districts in Northern Uganda. Access to water improved although sanitation remains a concern (poor hygiene conditions in most camps and high level of promiscuity…). Such a situation could still lead to high incidence in some communicable diseases within the camps. Both districts have good number of facilities and health workers in the mains camps (with the exception of transit camps and villages), and IDP’s developed copying mechanisms in order to access health services (as moving to the main camps to access them). It has been noticed that in most cases the distance from return or transit areas to the main camps were from 1 to 20 km.

Food Security: The improvement of the security situation helped ensuring people a better access to

lands. Relief organizations as ACF, CICR, etc., provided seeds to support cultivation activities. General food distributions (GFD) from WFP were still ongoing. Following the improvement of the situation, World Vision and Save the Children phased out from their nutritional programs end 2006 and beginning 2007.

Nutrition and Health Education: Nutritional and health education messages are commonly provided

among mothers who attend nutritional programs and at lower level in communities: proper breastfeeding and weaning practices, well balanced diets, food safety, etc. However, to strengthen nutritional education and hygienic promotion is still needed for the entire population of Gulu and Amuru districts.

1 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker. 2 NCHS reference. 3 Confidence interval at 95%

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Recommendations In order to improve and sustain the nutrition status of the surveyed communities, ACF recommends the following: Health and nutrition:

Integration of nutritional curative activities in the existing health facilities to ensure sustainability Capacity building of the MoH structures (DDHS, health facilities) on the management of acute

malnutrition (identification of cases and treatment of severely malnourished children). Rehabilitation of health facilities in returning areas and villages. Conduction of EPI campaigns whenever necessary in parallel with systematic routine immunization

activities to ensure all children are vaccinated against childhood diseases. Increase the number of medical staff in health facilities as well as access to drugs and equipments.

Water and Sanitation:

Increase the access to proper water by constructing/rehabilitating boreholes in transit and returning areas.

Improve the quality of water in earth pans by introducing methods to filter water affordable and sustainable for the community.

Continue with sanitation programs such as water protection and education. Nutrition and health education:

Strengthen nutrition education activities in the districts, focusing on the improvement of the quality of food prepared from locally available foods.

Coordinate with Water & sanitation programs to provide hygiene promotion sessions to the communities.

Continue with health promotion programs in communities to improve nutritional and hygienic practices.

Food Security: Establish food for work programs as only vulnerable people in communities would receive food

distribution resulting with proper targeting. Device ways of enhancing food security for pastoralist communities especially improving grazing lands,

establishing market for the livestock’s and improving crop cultivation especially along the rivers.

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II INTRODUCTION Lying 332 km from the national capital Kampala, Gulu district has traditionally been widely acknowledged as the regional capital of the northern region. Up to May 2006, Amuru was part of Gulu District but has then been upgraded as an entire District. The 2 districts cover an area of 11,732 sq km, comprised of open water and swamps (180 km²), arable land (10,301 km²), national parks and games reserves (982 km²) and forest coverage (371 km²). Security and displacement The war in Northern Uganda has been ongoing for twenty years. Initially rooted in a popular rebellion against President Yoweri Museveni’s National Resistance Movement (NRM) government, the conflict has since been transformed by Joseph Kony’s Lord’s Resistance Army (LRA) into a brutally violent war in which civilians in the northern districts are the main victims. Approximately 1.9 million people have been internally displaced. The Acholi region of Uganda (Kitgum, Pader, and Gulu Districts) has seen an increase in the intensity of insurgency since 1996. This has resulted in people’s displacement, spontaneously or under the direction of the Government, into camps protected by the Uganda People’s Defense Forces (UPDF). The conflict in Northern Uganda is often referred to as the forgotten war. Funding for relief and development activities has never been proportional to the needs. However, in the last two to three years, an increase in international attention has been followed by an increase in the amount of international funds designated to humanitarian projects in Northern Uganda war affected districts. Besides funding, the peace talk on going since August 2006 led to a significant improvement of the security situation. This improvement of security conditions motivated the beginning of a returning process for IDP’s to their villages of origin, improving their access to land for gardening. However, people showed still traumatize by the war and most of them still feared to return back where the government army (UPDF) can not provide them security. Weather Amuru & Gulu districts climate consists in wet and dry seasons. The average rainfall received is 1,500 mm per annum with a monthly rainfall average varying between 14 mm in January and 230 mm in August. The wet season extends from April to October with peaks in May, August and October. The dry season starts in November and lasts up to March. Population The district has a population of 479,496 according to the 2002 population census. Gulu is a multi-ethnic district although some 85 percent of the people are from the Acholi ethnic group. Other ethnic groups represented are the Langi, Madi and Alur. The main languages spoken are Luo, English, Swahili, Madi, Lugbara, Luganda, Acholi and Kinubi. Infrastructure Gulu can be accessed by road and air. The national railway line also extends to the district although it is not actually functional. The district has a 415 km feeder road network and a 600 km community road network Mobile Telephones Network (MTN) and Uganda telecom networks are covering the districts. Gulu district has four main hospitals and five health sub-districts (HSD). The hospitals are Anaka District Hospital, Gulu Referral Hospital, St. Mary’s Lacor Hospital (Missionary founded) and a private independent Hospital. Agriculture remains the major economic activity in Gulu district. Over 90 percent of the population in the district engages and benefits from agriculture activities. Agriculture contributes 45 percent of the Gross Domestic Product (GDP). Some 10,301 km² are cultivated but insecurity has rendered big chunks of the district no-go areas. Among the cash crops grown are rice, tobacco, cotton, groundnuts, sun flowers and sesame. The staple foods are finger millet, sorghum, cassava, sweet potatoes, pigeon peas, beans, cowpeas, bananas, soy beans and maize.

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General sanitation is at poor level and people live in densely confined areas within the security of the camps. Access to safe water improved but remains lower than recommended by SPHERE standards (250 persons per water point); security situation regularly improved for the 2 last years. Access to land also improved and returning process started to villages and Parishes. ACF intervention ACF-USA has been operational in Gulu/Amuru Districts since May 1997 through nutrition, food security and water & sanitation programs. ACF-USA currently supports 16 Supplementary Feeding Centers (SFC) integrated in Health facilities spread throughout the two districts, one Therapeutic Feeding Centre (TFC), in Gulu Municipality Hospital and 6 community-based therapeutic care centers (OTP centers). A home visiting program has been operational since October 2003, devoted to the active research of the acutely malnourished cases in the camps surrounding the nutritional centers. In parallel, Health facilities staffs have been trained in prevention and detection of acute malnutrition, and health/nutrition education is being provided at community level by health educators and Community Health Workers in 16 camps. In 2006, attendance of each centre was as follow:

SFC: around 10863 admissions Gulu TFC: around 534 admissions OTP centers: around 633 admissions

Humanitarian interventions Many non-governmental organizations are present in both districts: Table 3: List of NGOs working in Gulu/Amuru districts and their field of activities

Activities NGOs working in Gulu/Amuru

Food security WFP, FAO, UNDP, COU, CCF, ACORD, COME, CRS, WVI, ACF, CPAR, NRC, CARITAS, HA, HPI, ACDI/VOCA, ICRC, SOS

Health and nutrition FAO, UNFPA, WFP, WHO, UNICEF, AEI, COME, CPA, FEED, HAU, HA, TASO,

UPHOLD, ICRC, ACORD, ACF, ACFIC, AMREF, AVSI, CPAR, CARE, CARITAS, CRS, CCF, MSF Swiss, MSF Spain, SCiU, SOS, WVI, CUO

Water and sanitation AMREF, CARE, UNICEF, MSF Spain, ICRC, ACF, AVSI, WVI, CPAR

Social services UNICEF, FEED, NOAH’S ARK, URCS, ICRC, AVSI, CPAR, NRC, SCIU, SOS, WVI, CCF, CARITAS, NA

Human rights and protection

UNOHCHR, UNICEF, CPA, HURIFO, LAP, ICRC, CARE, NRC, SOS, WCC, WCH, WVI, UHRC, AMNESTY COMMISSION, UNDSS, IOM, TSA, AC

Education and Child Care

AEI, UNICEF, CPA, FEED, GUSCO, URCS, UPHOLD, AVSI, CPAR, CARITAS, CCF, NRC, SCIU, SOS, WVI, INVISIBLE CHILDREN

Return and recovery UNDP, WFP, GUSCO, NUPI, ACORD, CARE, CRS, MSF, IOM, QPSW, SCIU, SOS, WVI, AMNESTY COMMISSION, ARC, WCH

III OBJECTIVES - To evaluate the nutritional status of children aged 6 to 59 months. - To estimate the measles immunization coverage of children aged 9 to 59 months. - To estimate the crude mortality rate through a retrospective survey.

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IV METHODOLOGY

IV.1 Type of Survey and Sample Size

A two-stage cluster sampling method was used. The anthropometric surveys target children aged between 6 and 59 months utilizing SMART methodology, which ensures accuracy and precision of data collected. Selection of accessible villages was done using a map of the area indicating administrative boundaries of the divisions and villages. Information on population figures for the divisions where AAH has programs activities was collected. The geographical units and their respective population were then inputted into the Nutrisurvey for SMART software December 2006 for planning the survey. The total population for all camps, resettlement sites, transit camps and villages is estimated 688,470 people, spread as follows:

368,238 people in Amuru district 320,232 people in Gulu district.

1. Cluster selection: At the first stage, the sample size was determined by inputting necessary

information into the Nutrisurvey software for both anthropometric and mortality surveys. The information included estimated population sizes (688470), estimated prevalence rates of mortality and malnutrition, the desired precision and design effect. Global malnutrition prevalence was expected at 7.5%, with 3% precision and design effect of 2. Hence the required sample size reached 591 children. In the mortality session, assumption was made on a prevalence of 1/10,000/day, desired precision of 0.4, and a design effect of 1.5, resulting in a sample size of 3086. Considering each team could survey 22 children per day, and in order to ensure a sufficient number of children, 32 clusters were selected ((591+10%)/22=30 clusters, 2 extra clusters taken for security of the data collection). List of selected clusters is available in appendix 1.

2. Children selection: At the second stage, selection of households to be visited within each cluster was

done. The EPI methodology was used whereby a pen was spun from the centre of the village to randomly choose a direction. The team then walked in the direction indicated, to the edge of the village. At the edge of the village the pen was spun again, until it pointed into the body of the village. The team then walked along this second line counting each house on the way. Using simple balloting, the first house to be visited was selected at random by drawing a number between one and the number of households counted when walking. In the selected household, all children aged 6-59 months in each household were included in the nutritional survey. If there was more than one wife (care taker) in the household4, each wife was considered separately regardless of whether they were cooking together. If there were no children in a household, the house remained a part of the “sample” that contributed zero children to the nutritional part of the survey. The household was recorded on the nutritional data sheet as having no eligible children.

The mortality questionnaire was only administered in households that were included in the anthropometric questionnaire and numbered correspondingly. Once the questionnaires were completed in the household, the next selected house to be visited is the one the closest on the right.

IV.2 Data Collection

Twelve data recorders were subjected to a standardization test to ascertain their capability in taking accurate and precise measurements, so as to minimize errors during data collection. For each selected child, information was collected during the anthropometric survey using an anthropometric questionnaire (See appendix II).

4 A household refers to a mother and her children

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The information included

• Household: each household visited was assigned a number. • Age: recorded with the help of a local calendar of events (See appendix v). • Gender: male or female • Weight: children were weighed without clothes, with a SALTER balance 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 was measured at mid-point of left upper arm for measured

children (precision of 0.1cm). • Bilateral Oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both

feet. • Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking

caretakers.

IV.3 Indicators, Guidelines, and Formula’s Used

IV.3.1 Acute Malnutrition

Weight for Height Index Acute malnutrition rates are estimated from the weight for height (WFH) index values combined with the presence of Oedema. The WFH indices are expressed in both Z-scores and percentage of the median, according to both NCHS5 and WHO references6. The complete analysis is done with the NCHS reference. The expression in Z-scores has mainly statistical meaning, and allows inter-study comparison. The percentage of the median, on the other hand, is used for the identification criteria of acute malnutrition in nutrition programs. Guidelines for the results expressed in Z-scores: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral Oedema on the lower limbs of the

child. • Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no Oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral Oedema. Guidelines for the results expressed in percentage of median: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral Oedema on the lower limbs • Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no Oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral Oedema.

Children’s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC measurements are significant for children with a height of 65 cm or one year and above. The guidelines are as follows: MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of 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

5 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74. 6 WHO reference, 2005

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IV.3.2 Mortality

Mortality data was collected using Standardized Monitoring and Assessment of Relief. The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The CMR 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 follows7: 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.4 Field Work

Four teams composed of two measurers, one data recorder and one mortality surveyor in each executed the fieldwork. They were recruited within the local communities and from ACF national staff. All the data recorders participating in the survey underwent 4-day training while the measurers were trained for 1 day, which included standardization exercise (for the data recorders) and a pilot survey. ACF-USA staff and MOH staff supervised all the teams in the villages. The survey (including training, and data collection and traveling) lasted for a period of 27 days.

IV.5 Data Analysis

Data processing and analysis for both anthropometric and mortality were carried out using Nutrisurvey for SMART software, December 2006 version using both NCHS and WHO references. Excel was used to carry out analyses on MUAC, measles immunization coverage, household status and composition.

V RESULTS OF THE ANTHROPOMETRIC SURVEY

V.1 Anthropometry

774 children between 6 and 59 months were measured during the survey. The data of 11 of them were excluded from the analysis, due to incoherence.

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

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V.1.1 Distribution by Age and Sex

Table 4: Distribution by age and Sex in Gulu & Amuru Districts

Boys Girls Total Age groups (months) n % n % n %

Sex ratio

06 - 17 94 43.3 123 56.7 217 28.4 0.8 18 - 29 101 54 86 46 187 24.5 1.2 30 - 41 79 50.3 78 49.7 157 20.6 1 42 - 53 76 49 79 51 155 20.3 1 54 - 59 21 44.7 26 55.3 47 6.2 0.8 Total 371 48.6 392 51.4 763 100 0.9 The proportion of boys to girls gives a sex ratio (G/B) of 0.9, which is acceptable. Figure 1: Distribution by Age and Sex

-60 -40 -20 0 20 40 60

percentage

06 - 17

18 - 29

30 - 41

42 - 53

54 - 59

age

grou

ps in

mon

ths

Distribution of age by sex in Gulu & Amuru districts

BoysGirls

V.1.2 Anthropometric Analysis

Distribution of Acute Malnutrition in Z-Scores

Table 5: Weight for Height distribution by age in Z-scores (NCHS Reference)

Severe wasting (<-3 z-scores)

Moderate wasting (>= -3 and <-2 z-

scores) No wasting

(> = -2 z scores) Oedema Age groups (in months) Total

n % n % n % n % 06 - 17 217 2 0.9 12 5.5 203 93.5 0 0 18 - 29 187 1 0.5 7 3.7 179 95.7 0 0 30 - 41 157 0 0 0 0 157 100 0 0 42 - 53 155 0 0 2 1.3 153 98.7 0 0 54 - 59 47 0 0 0 0 47 100 0 0 Total 763 3 0.4 21 2.8 739 96.9 0 0

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Table 6: Weight for height vs. Oedema in Gulu & Amuru Districts (NCHS Reference)

<-2 z-scores >=-2 z-scores

Oedema present Marasmic kwashiorkor 0 (0.0%)

Kwashiorkor 0 (0.0 %)

Oedema absent Marasmic 24 (3.1%)

Normal 739 (96.9 %)

Figure2: Z-scores distribution Weight-for-Height

The displacement of the sample curve to the left side of the reference curve indicates a slightly affected nutritional situation in the surveyed population. The mean Z-Scores of the sample is -0.27 and the Standard Deviation is 0.94. The SD is within the interval 0.80-.20, which shows that the sample is representative of the population. Table 8: Global and Severe Acute Malnutrition by Age group in Z-scores

NCHS Reference WHO Reference Global acute

malnutrition 3.1%

(1.8% - 4.5%) 3.5 %

(2.1% - 5.0%) Severe acute malnutrition

0.4% (0.0% - 0.8%)

0.8 % (0.2% - 1.4%)

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Distribution of Malnutrition in Percentage of the Median Table 9: Distribution of Weight/Height by age in % of the median in Gulu & Amuru Districts, (NCHS Reference)

Severe wasting (<-3 z-scores)

Moderate wasting (>= -3 and <-2 z-

scores) No wasting

(> = -2 z scores) Oedema Age groups (in months) Total

n % n % n % n % 06 - 17 217 0 0 12 5.5 205 94.5 0 0 18 - 29 187 0 0 4 2.1 183 97.9 0 0 30 - 41 157 0 0 0 0 157 100 0 0 42 - 53 155 0 0 0 0 155 100 0 0 54 - 59 47 0 0 0 0 47 100 0 0 Total 763 0 0 16 2.1 747 97.9 0 0

Table 10: Global and Severe Acute Malnutrition by Age group in % of the median

NCHS Reference WHO Reference Global acute

malnutrition 2.1 %

[1.0% - 3.2%] 1.0%

[0.3% - 1.8%] Severe acute malnutrition

0.0% [0.0% - 0.2%]

0.0% [0.0%-0.2%]

Risk of Mortality: Children’s MUAC

The data of all children whose height> 65cm are analyzed in the table below: Table 11: MUAC Distribution in Gulu & Amuru Districts

> 65 - < 75 cm >=75 – < 90 cm >=90 cm Total MUAC (mm)

n % n % n % n % < 110 4 2.2% 0 0.0% 0 0.0% 4 0.5% 110<= MUAC <120 25 13.8% 1 0.3% 0 0.0% 26 3.5% 120<= MUAC <125 10 5.5% 5 1.6% 1 0.4% 16 2.2% 125<=MUAC <135 53 29.3% 36 11.7% 5 2.0% 94 12.6% >= 135 89 49.2% 266 86.4% 249 97.6% 604 81.2% TOTAL 181 100.0% 308 100.0% 255 100.0% 744 100.0%

The MUAC analysis reveals that 4.0% of the children surveyed are fitting the criteria for acute malnutrition, according to ACF protocols.

V.2 Measles Vaccination Coverage

The source of information on immunization was either the child’s health card or the mother’s recall. A child was considered fully vaccinated if he had received the last dose of the EPI (from 9 months of age, according to the national protocol). It is important to mention however, that these results should be interpreted with caution since they are based on the caretaker’s recall, when no health card is available. Table 12: Measles Vaccination Coverage in all the divisions surveyed

Population >= 9 months 706 Immunized with card 44.9% Immunized without card 50.6% Not immunized 4.5%

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V.3 Household Status and composition

The table below gives an outline of households visited. Table 13: Household Status

N % Households with children <5 532 83.9% Households without children <5 102 16.1% Average nb of children <5 per household 1.4 22.9% Average nb of people per household 6.1 Total nb of household visited 634

The households without children under five were mainly the elderly and new wed homesteads. The empty houses were as a result of the returning process which is going on. Some people are moving to the resettlement camps, transit camps and villages in both Amuru and Gulu Districts. Some households were occupied only by children when parents had moved to the new places. Those children were alone for completing the school year 2006-2007 as many returning places don’t have schools. 90% of the households surveyed during anthropometry data collection were displaced and 10% were residents.

VI RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY The crude mortality rate was calculated from the figures collected from families with or without children under 5 years, over the past 3 months. Table 14: Demographic information

Current resident HH 3854 Current resident < 5 years old 864 People who joined HH 110 < 5 years old who joined HH 28 People who left HH 656 < 5 years old who left HH 84 Birth 35 Death 14 Death < 5 years old 2 CMR (deaths /10,000 people/day) 0.30 [0.11-0.48] U5MR (deaths in children<5/ 10000 / d )

0.20 [0.00-0.43] Both the crude and under-5 mortality rates were below the alert levels of 1/10,000 and 2/10,000 per day respectively.

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VII DISCUSSION This survey is part of a yearly monitoring. The results are displayed below together with the ones of previous years. Table 15: Nutritional Surveys – Gulu and Amuru Districts - Main results since 2003

May 2003 (n=900)

June 2004 (n=1072)

June 2005 (n=976)

June 2006 (n=934)

April 2007 (n=763)

Global Acute Malnutrition (W/H <-2 Z-scores8 and/or oedema)

6.7% (4.6% - 9.5%)9

4.6% (3.0% - 6.8%)

4.1% (2.6% - 6.4%)

4.3% (2.7% - 6.7%)

3.1% (1.8% - 4.5%)

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

1.3% (0.7% - 2.4%)

0.8% (0.3% - 2.2%)

1.2% (0.5% - 2.8%)

0.3% (0.0% - 1.5%)

0.4% (0.0% - 0.8%)

Measles vaccination coverage: Confirmed by Card Not conformed by Card

38.3% 61.7%

47% 53%

83.1% 16.0%

63.9% 32.8%

47.8% 41.4%

The results of the last 3 annually surveys show a general slight improvement in the prevalence of Global Acute Malnutrition, as compared to the rates found in the previous years: Rates of malnutrition have notably decreased. Immunization rates are acceptable as well, showing a good coverage for the prevention of outbreaks, and also reveal an acceptable level in health access. Many mothers couldn’t provide EPI cards as most of the time they were burnt or lost. Acute malnutrition in the surveyed areas is of low magnitude and low intensity, which makes the population slightly vulnerable to potential shocks. The current nutritional situation in Gulu and Amuru districts can be explained by the following factors:

Health Access and Water and Sanitation: Gulu and Amuru districts have good coverage of health facilities compared with other affected districts in Northern Uganda. Access to water improved although sanitation remains a concern (poor hygiene conditions in most camps and high level of promiscuity…). Such a situation could still lead to high incidence in some communicable diseases within the camps. Both districts have good number of facilities and health workers in the mains camps (with the exception of transit camps and villages), and IDP’s developed copying mechanisms in order to access health services (as moving to the main camps to access them). It has been noticed that in most cases the distance from return or transit areas to the main camps were from 1 to 20 km.

Food Security: The improvement of the security situation helped ensuring people a better access to

lands. Relief organizations as ACF, CICR, etc., provided seeds to support cultivation activities. General food distributions (GFD) from WFP were still ongoing. Following the improvement of the situation, World Vision and Save the Children phased out from their nutritional programs end 2006 and beginning 2007.

Nutrition and Health Education: Nutritional and health education messages are commonly provided

among mothers who attend nutritional programs and at lower level in communities: proper breastfeeding and weaning practices, well balanced diets, food safety, etc. However, to strengthen nutritional education and hygienic promotion is still needed for the entire population of Gulu and Amuru districts.

8 NCHS reference. 9 Confidence interval at 95%

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VIII RECOMMENDATIONS In order to improve and sustain the nutrition status of the surveyed communities, ACF recommends the following: Health and nutrition:

Integration of nutritional curative activities in the existing health facilities to ensure sustainability Capacity building of the MoH structures (DDHS, health facilities) on the management of acute

malnutrition (identification of cases and treatment of severely malnourished children). Rehabilitation of health facilities in returning areas and villages. Conduction of EPI campaigns whenever necessary in parallel with systematic routine immunization

activities to ensure all children are vaccinated against childhood diseases. Increase the number of medical staff in health facilities as well as access to drugs and equipments.

Water and Sanitation:

Increase the access to proper water by constructing/rehabilitating boreholes in transit and returning areas.

Improve the quality of water in earth pans by introducing methods to filter water affordable and sustainable for the community.

Continue with sanitation programs such as water protection and education. Nutrition and health education:

Strengthen nutrition education activities in the districts, focusing on the improvement of the quality of food prepared from locally available foods.

Coordinate with Water & sanitation programs to provide hygiene promotion sessions to the communities.

Continue with health promotion programs in communities to improve nutritional and hygienic practices.

Food Security: Establish food for work programs as only vulnerable people in communities would receive food

distribution resulting with proper targeting. Device ways of enhancing food security for pastoralist communities especially improving grazing lands,

establishing market for the livestock’s and improving crop cultivation especially along the rivers.

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IX APPENDIX

IX.1 Sample Size and Cluster Determination

Geographical unit

Population size Clusters Geographical unit Population size Clusters

Acet 23761 1 langol 2981

Adak 5698 Lolim 749

Agung 2990 Lugore 6200

Alero 15777 2 Lukodi 3604

Alokolum 13602 3 Minakulu Okwir 425

Amuru 51233 4,5 Minakulu St-Thomas 4730 18

Anaka 24763 6 Mon Roc 3936

Aparanga 3200 Odek 5386

Atiak 26868 7 Olinga 1049

Atoo Hill 3417 8 Olwal 18057 19

Awach 16381 Olwiyo 2660

Awer 22523 9 Omee I (Lower) 7686

Awere (Gulu) 7250 10 Omee II (Upper) 3489 20

Awor 8494 Omel Lapem 2942

Bibiya 7134 Ongako 18025 21

Bira 2970 11 Opit 28535 22

Bobi 12839 Oroko 1286

Cet Kana 1332 Otong 3277

Copee 18058 12 Pabbo A 61229 23,24,25

Corner Agula 4002 Pagak 12664

Corner Nwoya 4056 Paicho 10219 26

Dino 6985 13 Palaro 6660

Guruguru 4325 Palenga 14677 27

Jeng-gari 7358 Palukere 1173

Kaladima 1887 Parabongo 16831 28

Keyo 8892 14 Patiko Ajulu 12038

Koch Goma 11761 Pawel 5294 29

Koro Abili 10680 15 Purongo 9860

Labongogali 10218 Tegot 556

Lacor 10840 16 Tetugu 17225 30

Lalogi 17986 17 Teyapadola 6991

Unyama 26868 31

Wii Anaka 1768 32

Wiyanono 2120

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IX.2 Anthropometric survey questionnaire

DATE: CLUSTER No: VILLAGE: DIVISION: TEAM No:

N°. Family N°.

Age Mths

Sex M/F

WeightKg

Height Cm

Oedemas Y/N

MUAC

Cm

Measles 0/1/2 (2)

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 2930

30

(1) Measles*: 2=according to EPI card, 1=according to mother, 0=not immunized against measles.

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

Survey Division: 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 )

SexDate 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

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IX.4 Calendar of events in AMURU & GULU districts

FEBUARY

Cleaning the field, opening school

62 50 38 26

23rd presidential election

14 2

MARCH

Women’s day Beginning of rainy season

61

Beginning of rainy season

49

Borlonyo attack massacre

37

Beginning of rainy season

25

Beginning of rainy season

13

Beginning of rainy season

1

APRIL

easter

60

Abduction of student of Lacor Seminor

48 36

Pope Benedict election

24

Election fo GULU LCI5 MAO

12

MAY

1st labour day

59 47 35 23

Amruru declared District .

11

JUNE

3RD marterys day, 9th heros day 58 46

Attack on Aboke girls 28 people killed and 7 abducted

34 22 10

JULY

Harvest of millet Burning of Alero and marawobi camp 57

Harvest 1st session

45

Harvest 1st session

33

Harvest 1st session

21

ceasation of hostility

9

AUGUST

Ascension day Release of women and children in atiak by LRA + Openning Gulu University

56

Death of former pdt IDI Amin DADA 44

Capturing of LRA brigadier Banya 32

Death of John Garange in a helicopter crash

20

peace talk in juba

8