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SCI - Borno State - SMART Survey FINAL Report
SCI - Borno State - SMART Survey FINAL Report
MORTALITY SURVEY
FINAL REPORT
July 2019
Save the Children International
Acknowledgements
Save the Children International (SCI) would like to acknowledge the important contribution
of the following towards the success of the survey:
SCI staff and management in the MEAL and nutrition sections for the leadership, guidance
and oversight. SCI administration and security units who provided logistical support through
vehicles and security arrangements. The survey teams who worked tirelessly during training
and data collection. The community leaders who allowed the survey teams to work without
hindrance. Mothers, caregivers, fathers and children who graciously took part in the survey.
2
Table of contents
Acknowledgements……………………………………………………………………………2
Executive summary……………………………….………………………..…………...….…..7
1. Introduction……………..…………………………..…..…………...……….…….....14
1.1 Background………………………………………………….……………………………14
1.2 Survey Justification………………………………………………………………………..15
1.3 Survey Objectives…………………………………………………………………..…….16
2. Methodology…….……………………….……………………………….….…..........17
2.1 Survey design…….…………………………………………….……….….….………......17
2.2 Sample size determination…….….………………………………….….…….…......…....17
2.3 Survey target population…………………………………….…………………….….......13
2.4 Sampling procedure….………………………....…...................................................................14
2.4.1 Selecting clusters……………………………………………………………………….18
2.4.2 Selecting households and children…………………………………………………...…18
2.5 Survey implementation……….……………………………………………………...…....18
2.5.1 Questionnaire and training……………………………………………………………..18
2.5.2 Data collection and supervision……………………………………………………..….19
2.5.3 Data cleaning and analysis…………………………………………………………...….19
2.5.4 Data collection tools…………………………………………………………………....19
2.5.5 Case definitions, inclusion criteria and classification…………………………………...20
2.6 Limitations…………………………………………………………………………….......21
2.7 Classification of malnutrition……………………………………………………………..21
3. Results…….…………………….………………………………………..……....…....23
3.1 Household characteristics and demographics………….…………………….……..…..24
3.1.1 Response rates……………………………………………………………………….....24
3.1.2 Data quality…………………………………………………………………………..…24
3.1.3 Age and sex ratio in children 6-59 months…………………………….………..……..24
3.2 Anthropometric results (based on WHO standards 2006)……...….. ……………......25
3.3 Mortality results………………………………………………………………………...31
3.4 Children’s morbidity …………………………………………………………………..31
3.5 Measles vaccination and Vitamin A supplementation ………..………………………..32
3.6 Infant and young child feeding (IYCF)……………………………………………….....33
3.7 Women of reproductive age……………………………………………….………......34
4. Discussion………………….…………………..…………………………...….….…..36
5. Conclusion ………………………………………………………………………...…37
6. Recommendations……………………………………………………………………37
Annex 1 List of individuals who participated in the survey………………………………….39
Annex 2 Assigned clusters………………………………………………………...……….....40
Annex 3 Survey questionnaire…………………………………………………….…………41
Annex 4 Standardisation test report………………………………………….….………… 45
Annex 5 Survey local calendar of events………………………………………...…………. 48
Annex 6 Plausibility report for anthropometry………………………………………….…..51
3
List of tables
Table 1 Child Health, Nutrition and Morbidity…………………….…………………………9
Table 2 Infant and Young Child Feeding……………………………….……………………..10
Table 3 Women of reproductive age (15-49 years) ………………………..……………….10
Table 4 Mortality……………………………………………………...…………………...…10
Table 5 Sample size calculation………………………………………….………………...…17
Table 6 Classification of malnutrition using WHO 2006 Growth Standards………….……21
Table 7 Classification of public health significance for children under 5 years of age………22
Table 8 MUAC cut-off’s for women of reproductive age………………………..……….…23
Table 9 Minimum dietary diversity for women (MDD-W) ……………...……………….…23
Table 10 Survey response rates………………..……………………………………….……24
Table 11 Overall survey data quality…………………………………..…………….…….…24
Table 12 Distribution of age and sex of sample…………………………….………..………25
Table 13 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or
oedema) and by sex……………..………………………………………………………....…25
Table 14 Prevalence of acute malnutrition disaggregated by LGA……………..………...….26
Table 15 Weighted prevalence of global acute malnutrition………………………………...26
Table 16: Prevalence of acute malnutrition by age, based on weight-for-height z-scores
and/or oedema……………………………………………………………………………….26
Table 17: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and
by sex…………………………………………………………………………..…………….27
Table 18 Prevalence of acute malnutrition by age, based on MUAC cut off's and/or
oedema…………………………………………………………………………………….…28
Table 19 Prevalence of underweight based on weight-for-age z-scores by sex………….….28
Table 20 Prevalence of underweight by age, based on weight-for-age z-scores…………….29
Table 21 Prevalence of stunting based on height-for-age z-scores and by sex………...……29
Table 22 Prevalence of stunting by age based on height-for-age z-scores……………….….30
Table 23 Mean z-scores, Design Effects and excluded subjects…………………………..…31
Table 24 Mortality rates, Borno SMART Survey, July 2019…………………………………31
Table 25 Prevalence of reported illness in children in the two weeks prior to interview
(n=590)………………………………………………………………………………….……31
Table 26 Measles vaccination and Vitamin A supplementation vaccination coverage……….33
Table 27 Infant and Young Child Feeding results……………………………………….……33
4
List of figures
Figure 1 Trend of SAM admissions in SCI operational areas of Borno state,
June 2018-July 2019…………………………………………………………………………..15
Figure 2: Weight-for-Height z-scores………………………………..………………..……...27
Figure 3: Height-for-age z-scores……….……………………….………………….….……..30
Figure 4: Proportion of children who sought treatment for illness….…….…………….…..32
Figure 5: Health-seeking behaviour…………………………………………………………..32
Figure 6: Complementary feeding for children 6-23 months..…….……………………...….34
Figure 7: Minimum dietary diversity for women 15-49 years…………….………………….34
Figure 8: Dietary diversity for women 15-49 years……………………………….……....….35
Figure 9: Proportion of malnutrition by pregnancy and lactation status…………………….35
5
List of acronyms
ARI A-cute Respiratory Infection
CI- Confidence Interval
ENA- Emergency Nutrition Assessment
FAO- Food and Agricultural Organisation
GAM- Global Acute Malnutrition
HAZ- Height-for-age z-score
IYCF- Infant and young child feeding
IPC- Integrated phase classification
LGA- Local government area
MAM- Moderate acute malnutrition
MDD-W Minimum dietary diversity for women
MUAC Mid upper arm circumference
NBS National Bureau of Statistics
OTP Outpatient therapeutic care programme
PPS Probability proportional to size
SAM- Severe acute malnutrition
SCI- Save the Children International
SFP- Supplementary feeding programme
SMART- Standardised Monitoring and Assessment for Relief and Transitions
UNICEF- United Nations Children’s Fund
WAZ- Weight-for-age z-score
WHO- World Health Organisation
WHZ- Weight-for-height z-score
6
Executive Summary
Introduction
Given the prevailing acute food security situation and high malnutrition prevalence observed
in the previous survey, it is necessary to update the nutrition and mortality indicators by
determining the prevalence of acute malnutrition and mortality as well as to investigate factors
related to malnutrition. According to the 2018 SMART Nutrition and Mortality Survey
conducted in Kaga, Jere, Konduga and Magumeri LGAs in Borno State, the prevalence of global
acute malnutrition (GAM) was 15.7% (12.2-20.0, 95% C.I), with a severe acute malnutrition
(SAM) prevalence of 4.2% (2.9-6.1, 95% C.I). The crude death rate was 0.79 deaths per 10,000
per day (0.52-1.20, 95% C.I), with an under 5 death rate of 1.60 deaths per 10,000 per day
(0.83-3.07, 95% C.I). However, due to the persistent on-going conflicts in the areas, it is
necessary to also continue monitoring the mortality trends, and as such, this survey will also
measure the mortality rates.
The overall objective of the survey was to determine the magnitude and severity of
malnutrition and retrospective mortality rates amongst the population in the accessible
communities of the 4 LGAs (Kaga, Jere, Konduga and Magumeri) in Borno State within the
areas in which Save the Children is operational.
Specific objectives
Methodology
The Standardized Methodology for Assessment in Relief and Transitions (SMART) which
applies a two-stage cluster sampling was used. At the first stage, 48 clusters were selected
from the list of accessible communities using sampling with probability proportional to size
(PPS). At the second stage, 10 households in each cluster were selected using simple random
sampling.
A total of 397 children aged 6-59 months from 480 households in 48 clusters were sampled
for anthropometric measurements. The mortality assessment was conducted concurrently in
the 480 households.
7
Additional information was collected in the 480 households visited to provide more insight
into possible risk factors associated with the high acute malnutrition prevalence (morbidity,
infant and young child feeding and women of reproductive age).
ENA-for-SMART calculated a required sample size of 477 households. It was estimated that
a single team was able to complete 10 households within a day, therefore the survey design
was 48 x 10 (48 clusters each with 10 households). A list of accessible communities and their
population was entered in ENA-for-SMART, from which the 48 clusters were assigned baded
on sampling with probability proportional to size (PPS). Households within the cluster were
selected using simple random sampling. In all sampled households, all children below 5 years
and all women aged 15-49 years were surveyed.
8
Summary of findings
Table 1 Child Health, Nutrition and Morbidity
INDICATOR n/N % (95% C.I)
1
To be interpreted with caution.
9
Traditional healer 4/315 1.3 (0.0-2.8)
Other 28/315 8.9 (2.1-15.6)
Measles vaccination (9-59 months)
By card 90/555 16.2 (10.6-21.8)
By recall 182/593 30.7 (22.3-39.0)
Vitamin A supplementation
By recall 421/590 71.4 (60.8-81.9)
Table 2 Infant and Young Child Feeding
INDICATOR n/N % (95% C.I)
Introduced to solid foods at 6 months (6-8 months) 7/37 18.9 (5.7-32.1)
Continued breastfeeding at 1 year (12-15 months) 67/72 93.1 (86.9-99.2)
Continued breastfeeding at 2 years (20-23 months) 5/20 25.0 (0.5-49.5)
Consumption of iron-rich foods (6-23 months) 42/211 19.9 (13.7-26.1)
Mean dietary diversity score (6-23 months) 2.9 (2.5-3.2)
Minimum meal frequency (6-23 months) >= 4 times 21/211 10.0 (5.3-14.6)
Minimum dietary diversity (6-23 months) >= 4 food groups 39/211 18.5 (11.6-25.3)
Minimum acceptable diet (MAD) children 6-23 months 4/211 1.9 (0.0-4.2)
Table 4 Mortality
INDICATOR Deaths/10,000/day
(95% C.I)
Crude death rate (deaths per 10,000 per day) 0.83 (0.55-1.27)
Under 5 death rate (deaths per 10,000 per day) 1.88 (0.92-3.82)
10
Discussion
With respect to quantitative result, the comparison between 2018 and 2019 refers to the 2
SMART surveys conducted by SCI in accessible communities within the SCI area of operation.
Stunting was also of major concern as it was also above the critical category of WHO
classification and was higher than in 2018. In Nigeria, 37 percent of children under 5 years are
stunted. Nigeria has the highest number of children under 5 years with chronic malnutrition
(stunting or low height-for-age) in sub-Saharan Africa at more than 11.7 million, according to
the most recent Demographic and Health Survey. The prevalence of stunting increases with
age, peaking at 46 percent among children 24–35 months. While stunting prevalence has
improved since 2008 (41 percent), the extent of acute malnutrition (wasting or low weight-
for-height) has worsened, from 14 percent in 2008 to 18 percent in 2013 among children
under 5 years3.
2
https://reliefweb.int/sites/reliefweb.int/files/resources/WFP%20Nigeria-2019%20EFSA%20Report%20-
%20Final%20Version%20to%20be%20shared.pdf
3
https://www.usaid.gov/sites/default/files/documents/1864/Nigeria-Nutrition-Profile-Mar2018-508.pdf
11
The prevalence of underweight also increased in 2019 compared to 2018. A significant
proportion of children reported having experienced diarrhoea, fever or acute respiratory
infection in the preceding 2 weeks. Most children sought treatment from government
clinics/hospitals followed by pharmacies and private clinics. Measles vaccination coverage was
quite low both by recall and confirmation with card, while Vitamin A supplementation
coverage was quite high.
Infant and Young Child Feeding
Infant and young child feeding results were generally poor. A low proportion of children had
been introduced to solid foods between 6 to 8 months, showing very late introduction to
solid foods. Although continued breastfeeding was very high at 1 year, it was very low at 2
year. A low proportion of children 6-23 months had consumed iron-rich foods. Minimum
dietary diversity was only met by less than a fifth of children, while a very low proportion met
the minimum acceptable diet.
Mortality
Crude death rate and under 5 death rate were below the emergency threshold, despite acute
malnutrition being very high. This was the same trend observed in 2018 and the results in
both surveys are also very similar in terms of both indicators.
Conclusion
The nutrition situation in the SCI operational areas of Borno state is at a critical level and
has deteriorated as the results show. The concern is particularly with respect to acute and
chronic malnutrition, as well as infant and young child feeding.
Recommendations
Child Health, Nutrition and Morbidity
Given the critical prevalence of acute malnutrition, there is a need to scale up the
integrated management of acute malnutrition, ensuring that the services are accessible
to the whole population, and to incorporate a targeted supplementary feeding
component given the large MAM caseload which the findings highlight.
Integration of existing nutrition services and programmes with the health programmes
is essential to facilitate linkages which will guarantee that children have access to a
comprehensive package of health and nutrition services, including vaccination,
supplementation and treatment.
Given the gap which exists between classification of acute malnutrition by WHZ and
MUAC, it is important to set up a system whereby there is a way to screen at-risk
children at the second stage using WHZ. This will ultimately increase programme
coverage.
A SQUEAC assessment to investigate the barriers to optimal CMAM coverage is
recommended in targeted LGAs.
12
Infant and Young Child Feeding
The assessed IYCF indicators were generally poor in terms of continued breastfeeding,
complementary feeding and dietary diversity, which calls for a scaling up of efforts to
improve IYCF practices through the use of community-based approaches to spread
appropriate messages through platforms such as religious gatherings and other
community groupings.
Recent KAP studies should be reviewed in the context of this survey’s results, with a
view to implementing the strategies recommended which are applicable.
13
1. Introduction
1.1 Background
The ongoing conflict in the North East parts of Nigeria continues to increase population
displacements, restrict income-generating opportunities, limit trade flows and escalate food
prices. As a result of the reduced access and availability of food, local and internally displaced
persons (IDPs) populations in worst-affected areas of Borno, Yobe and Adamawa states
continue to experience food gaps. According to the Integrated Phase Classification (IPC)
analysis, most households in southern Yobe, northern Adamawa and Borno states worst
affected by the insurgency will continue facing Crisis (IPC Phase 3) and Emergency (IPC Phase
4) until September 20194. According to Food and Agriculture Organization (FAO), 6.4% of
the population of Borno are Internally Displaced Persons (IDPs) and another 3.4% are refugee,
which increases their vulnerability to food security, health and nutrition services. In addition,
at least 35% of the resident households in Borno State have an IDP or returnee in household5.
The nutrition situation in Borno State has been classified as serious according to the Nutrition
in Emergency Sector Working Group which noted that the prevalence of Global Acute
Malnutrition (GAM) increased from 6% in 2010 to 11.5% in 2015, with the peak being in 2012
when the prevalence of GAM was estimated as 13.8% 6. In addition, the National Nutrition and
Health Survey conducted in 2018 showed the prevalence of global acute malnutrition as
10.6%7 which is classified as serious. However, a SMART Survey conducted by Save the
Children International (SCI) in its operational areas 8 in Borno in August 2018 showed a critical
nutrition situation with the prevalence of global acute malnutrition estimated as 15.7% 9. The
same survey also found poor infant and young child feeding indicators, particularly exclusive
breastfeeding, complementary feeding and dietary diversity.
Figure 1 below is an analysis of the trend of admissions for severe acute malnutrition between
June 2018 and July 2019 shows that the admissions peaked in July in both 2018 and 2019,
which reflects the seasonal nature of acute malnutrition, given that this coincides with the
beginning of the rainy season, where food stocks are expected to be at their lowest.
4
http://fews.net/west-africa/nigeria
5
Food Security, Livelihood and Vulnerability Assessment Report (2016) by FAO and NBS
6
http://fscluster.org/sites/default/files/documents/nutrition_in_emergency_sector_response_plan_nigeria_draft_1_.pdf
7
https://www.unicef.org/nigeria/media/2181/file
8
Konduga, Jere, Magumeri and Kaga Local Government Authorities (LGAs)
9
SMART Survey Report, Save the Children, Borno 2018
14
Trend in SAM admissions in SCI operational areas of
Borno state, June 2018-July 2019
1200
Number of SAM admissions
1099
1000 993 966
800 761 792
600 622
567
460 495
400 388
347 375 336
295
200
Month
Figure 1 Trend of SAM admissions in SCI operational areas of Borno state, June 2018-
July 2019
The nutrition situation in the North East has further been aggravated by high food insecurity,
sub optimal infant and young children feeding practices such as untargeted/uncontrolled infant
formula distribution, negative coping strategies, increasing spread of endemic diseases, low
coverage of programs targeting children with moderate acute malnutrition, limited dietary
diversity, loss of livelihoods, disruption of access to quality water and optimal sanitation,
population displacement and destruction of housing, compromising the privacy necessary for
breastfeeding; and the poor and deteriorating health care system 10. An assessment of the
drivers of malnutrition conducted by SPRING in 2017 revealed that some of the key
contributing factors to high malnutrition included poor child feeding practices in addition to
other household, agricultural and WASH behaviours. The review recommended targeted,
multi-channel and high quality social behaviour communication interventions incuding
information and communication at household level ad mother support groups dapated to the
local context11.
In order to continue monitoring the health and nutrition situation in the SCI operational areas
in Borno State, another SMART survey was proposed by SCI. The results of the proposed
SMART Survey will be critical for planning and making evidence-based decision, for the
ultimate goal of reaching the most in need.
10
https://www.humanitarianresponse.info/en/operations/nigeria/document/nutrition-and-food-security-surveillance-north-eastnigeria-
%E2%80%93-0
11
https://www.spring-nutrition.org/publications/reports/assessing-drivers-malnutrition-nigeria
15
acute malnutrition (SAM) prevalence of 4.2% (2.9-6.1, 95% C.I). The crude death rate was
0.79 deaths per 10,000 per day (0.52-1.20, 95% C.I), with an under 5 death rate of 1.60 deaths
per 10,000 per day (0.83-3.07, 95% C.I). However, due to the persistent on-going conflicts in
the areas, it is necessary to also continue monitoring the mortality trends, and as such, this
survey will also measure the mortality rates.
16
2 Methodology
2.1 Survey design
The survey followed a cross-sectional survey design and used the two-stage cluster sampling
method based on the SMART methodology.
Table 5 Sample size calculation, Borno State SMART Survey, July 2019
Parameters for Value Assumptions Based on Context
Anthropometry13
Estimated Prevalence of GAM 20.0 Upper limit of 2018 SMART Nutrition and
(%) Mortality Survey Report
± Desired Precision (%) 4.5 Rule of thumb as recommended by SMART for a
prevalence of GAM of 15-20%
Design Effect (if applicable) 1.2 SMART Survey, August 2018 – Save the Children
Children to be Included 397 As calculated from ENA
Average HH Size 5.9 SMART Survey, August 2018 – Save the Children
% Children Under 5 17.4 SMART Survey, August 2018 – Save the Children
% Non-response HH’s 10 An increase from 5% in the 2018 SMART Nutrition
and Mortality Survey Report given that there was a
higher than expected non-response rate.
Households to be Included 477 As calculated from ENA
Parameters for Mortality Value Assumptions based on context (add
reference)
Estimated Death Rate 1.20 Upper limit of 2018 SMART Nutrition and
/10000/day Mortality Survey Report SMART surveys, start
with global norms
± Desired precision / 10 000 / 0.6 Precision based on SMART guidance
day
Design Effect (if applicable) 1.2 SMART Survey, August 2018 – Save the Children
Recall Period in days 90 Based on 3 month recall period
Population to be included 1859 As calculated from ENA
Average HH Size 5.9 SMART Survey, August 2018 – Save the Children
% Non-response of Households 10 An increase from 5% in the 2018 SMART Nutrition
and Mortality Survey Report given that there was a
higher than expected non-response rate.
Households to be included 350 As calculated by ENA
Sample sizes were therefore calculated separated for anthropometry and mortality. Given
that the anthropometry sample size was larger, this was taken as the final sample size for the
survey in order to fulfil both objectives.
12
www.smartmethodology.org
13
Kaga, Mafa, Konduga, Magumeri and Jere LGAs
17
2.3 Survey Target Population
Anthropometric indictors were assessed for children aged 6 to 59 months based on the WHO
2006 standards. In each sampled household, all children were measured. Age was obtained
from the official age documentation, either the birth certificate or child health card. In this
case, the date of birth was recorded. In the event that the official document was not available,
the age in months was estimated using the local calendar of events. IYCF practices were
assessed by interviewing the mothers or primary caregivers of children aged 6 to 23 months.
Morbidity for the preceding 14 days (diarrhoea, acute respiratory infection and fever) was
assessed for 6-59 months. Vitamin A supplementation and measles vaccination coverage were
applied to children 6-59 and 9-59 months respectively. The mother/caregiver recall, and the
child health card were used for measles vaccination. For Vitamin A supplementation, only the
mother/caregiver recall was used. The main respondent was an adult woman responsible for
preparing food for the household. For the women questionnaire, all women of reproductive
age (15-49 years) were interviewed for the assessment of minimum dietary diversity for
women (MDD-W) as well as measurement of mid upper arm circumference (MUAC).
18
which included 3 days classroom training, 1-day standardization test and 1-day pilot test. The
training curriculum included the following key topics: survey objectives, survey team
organization, roles and responsibilities, sampling and selection, anthropometric
measurements, interviewing techniques, questionnaire familiarization and mobile data
collection. The standardisation test involved a total of 10 measurers who measured a total of
10 children twice. The objective was to measure accuracy, which was measured by the
difference between individual measurements and the supervisor measurement or the median
of the team’s measurements. Precision was measured by comparing the fisrt and second
measurements for the same child and measurer. Results of the test are displayed in Annex 4.
The scores for height and MUAC were satisfactory. However, the scores for weight were
poor. This was corrected by an additional training session with the team. The pilot test was
conducted by all the survey teams in a settlement which was within Maiduguri town and
outside the survey sample. This enabled the teams to familiarize themselves with sampling and
household selection as well as the questionnaire and measurement methods.
Each team collected data for a total of 8 days with each team completing 10 households per
day. The supervisors ensured that there was quality control in the field. The Survey Consultant
provided overall supervision.
Android mobile phones were used for data entry using the Kobo collect application. Each of
the survey teams had 2 mobile phones. The questionnaires were designed using excel form
designer and uploaded on the SCI server.
19
Module 3: Mortality- Household census for determination of crude and under 5 death rate.
Households (HH): A household was defined as a group of people who normally live together and
eat from the same pot and resources.
Birth date or age in months for children 6-59 months: the exact date of birth (day, month, and
year) was recorded from birth certificates or child health cards. A local calendar of events (Annex 5)
was used in the absence of official documentation, and the age in months was recorded.
Age of women 15-49 years: The reported age was recorded in years.
Weight of children 6-59 months: measurements were taken to the nearest 0.1kg using an
electronic scale (SECA scale).
Height/Length of children 6-59 months: children’s height or length was taken to the nearest
0.1cm using a wooden height board. Children less than 2 years were measured lying down, while those
greater than or equal to 2 years were measured standing up.
Oedema in children 6-59 months: Bilateral oedema was assessed by applying gentle thumb
pressure on to the tops of both feet of the child for a period of three seconds and thereafter observing
for the presence or absence of an indent.
MUAC of children 6-59 months and women 15-49 years: MUAC was measured at the mid-
point of the left upper arm between the elbow and the shoulder and taken to the nearest 1mm using
a standard tape.
Measles vaccination in children 9-59 months: measles vaccination was assessed by checking for
the measles vaccine on the child health card if available or by asking the caregiver to recall if no child
health card was available or if it was not recorded.
Vitamin A supplementation in last 6 months in children 6-59 months: whether the child
received a vitamin A capsule over the past six months was recorded using recall from the
mother/caregiver.
Morbidity: Retrospective morbidity was assessed using recall for the past 2 weeks.
Diarrhoea: Diarrhoea was defined as three loose stools or more in 24 hours. Caregivers were asked
if their child had suffered episodes of diarrhoea in the past two weeks.
Fever (without cough): Fever was assessed through a two-week recall, defined as fever in the
absence of respiratory symptoms (cough) in children 6-59 months. This indicator is a proxy for
suspected malaria.
Acute Respiratory Infection (ARI): Cough, breathing difficulties, chest in-drawing, rapid breathing.
Crude death rate: Number of deaths from all causes per 10,000 people per day
20
Under five death rates: Number of deaths among children under five from all causes per 10,000
people per day
2.6 Limitations
The estimation of age was a challenge given that 87% of children did not have an official
age document to confirm the date of birth. However, the local calendar of events was
used to estimate the age in months. It must be noted that recall bias cannot be
excluded under such circumstances.
In a few of the communities, particularly in Gajigana and Ngamdu, due to the longer
distances, as well as security protocols, the target number of households could not be
achieved. However, sufficient children were surveyed, and the number of households
met the minimum number given that a contingency had been made based on the 10%
additional households anticipated for non-response.
The sample size was calculated based on children 6-59 months. For indicators
requiring sub-groups which are small, particularly the IYCF section, results must be
interpreted with caution given the larger width of the confidence interval.
Children between 0-5 months were not included in the sample, and therefore early
initiation of breastfeeding, exclusive breastfeeding and bottle feeding could not be
calculated. This was an oversight during questionnaire design.
The survey results cannot represent the whole of Borno state, as the sampling frame
only included accessible communities within the areas of operation of SCI in 4 LGAs
of Borno state (Kaga, Konduga, Magumeri, and Jere LGAs).
21
Table 7 Classification of public health significance for children under 5 years of
age14
Prevalence % Very High Medium Low Very low
High
Wasting ≥15 10-<15 5-<10 2.5-<5 <2.5
Stunting ≥30 20-<30 10-<20 2.5-<10 <2.5
Continued breastfeeding at 1 year: Proportion of children 12–15 months of age who were fed
breast milk during the previous day.
Introduction of solid, semi-solid or soft foods: Proportion of infants 6–8 months of age who receive
solid, semi-solid or soft foods during the previous day.
Children ever breastfed: Proportion of children born in the last 24 months who were ever breastfed.
Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who were fed
breast milk during the previous day. Commented [MO1]: replace with ----a day preceding the survey
Consumption of iron-rich or iron-fortified foods: Proportion of children 6-23 months of age who
received an Iron-rich food or Iron-fortified food that is specially designed for infant and young children
or that is fortified in the home during the previous day.
Minimum dietary diversity: Proportion of children 6-23 months of age who receive foods from 4 or
more food groups during the previous day.
Minimum meal frequency: Proportion of non-breastfed children 6-23 months who received at least
4 full meals during the previous day.
Minimum acceptable diet: Proportion of children 6-23 months who received at least 4 full meals
and at least 4 of the food groups during the previous day.
14
(UNICEF/WHO/World Bank, 2018), Levels and trends in child malnutrition-Joint Malnutrition Estimates
15 (WHO, 2010), Indicators for assessing infant and young child feeding practices
22
Under nutrition in women of reproductive age:
16
(FAO/FANTA/USAID, 2019. Minimum Dietary Diversity for Women-A Guide to Measurement.
23
3. Results
3.1 Household characteristics and demographics
3.1.1 Response rates
A total of 726 households were interviewed, which was 90% of the planned 480 households
(Table 10). The total survey population was 2,787, giving an average household size of 6.5.
The number of children aged 6-59 months was 593, which was 149% of the target of 397.
24
6-17 88 56.1 69 43.9 157 26.5 1.3
18-29 84 57.9 61 42.1 145 24.5 1.4
30-41 68 48.2 73 51.8 141 23.8 0.9
42-53 57 48.7 60 51.3 117 19.7 0.9
54-59 18 54.5 15 45.5 33 5.6 1.2
Table 14 contains a disaggregated analysis by LGA in order to get an idea of the LGAs in which
acute malnutrition was highest, which may be classified as “hot spots”. The prevalence of
acute malnutrition was highest in Magumeri, followed by Konduga, then Kaga, and was much
lower in Jere. It is important to note that the survey was not representative with respect to
LGAs as the sampling frame included accessible settlements within the operational areas of
the 4 LGAs and was not a stratified survey. The figures represented in the table are therefore
only indicative.
25
Table 14 Prevalence of acute malnutrition disaggregated by LGA
LGA Global acute Moderate acute Severe acute
malnutrition (GAM) malnutrition (MAM) malnutrition (SAM)
n/N % (95% C.I) n/N % (95% C.I) n/N % (95% C.I)
Jere 28/189 14.8 (9.5-22.4) 21/189 11.1 (6.7-17.9) 7/189 3.7 (1.6-8.3)
Konduga 22/91 24.2 (13.6-39.2) 14/91 15.4 (8.1-27.1) 8/91 8.8 (1.8-33.7)
Kaga 31/144 21.5 (15.0-29.9) 26/144 18.1 (11.4-27.5) 5/144 3.5 (1.7-7.0)
Magumeri 45/159 28.3 (21.0-36.9) 30/159 18.9 (12.8-26.9) 15/159 9.4 (5.2-16.4)
Table 15 shows the weighted prevalence using the 4 LGAs as strata. The calculated
weighted prevalence of GAM was 23.6%, which was slightly higher than the survey GAM
prevalence of 21.1%.
Table 16 clearly reveals that wasting was highest in the 6-17 age group, followed by the 18-
29 age group, followed by the 18-29 age group. This finding is consistent with the observation
that acute malnutrition affects younger children more than older children.
The survey and WHO WHZ curves are shown in Figure 2. The survey curve was to the left
of the WHO curve, indicating a higher prevalence of malnutrition than the WHO standard
population.
26
Figure 2 Weight-for-Height z-scores
Table 17: Prevalence of acute malnutrition based on MUAC cut off's (and/or
oedema) and by sex
All Boys Girls
n = 593 n = 315 n = 278
Prevalence of global (75) 12.6 % (37) 11.7 % (38) 13.7 %
malnutrition (10.2 - 15.6 (8.6 - 15.8 (10.2 - 18.1
(< 125 mm and/or oedema) 95% C.I.) 95% C.I.) 95% C.I.)
Prevalence of moderate (55) 9.3 % (29) 9.2 % (26) 9.4 %
malnutrition (7.1 - 12.0 (6.5 - 12.9 (6.8 - 12.8
(< 125 mm and >= 115 mm, no 95% C.I.) 95% C.I.) 95% C.I.)
oedema)
Prevalence of severe (20) 3.4 % (8) 2.5 % (12) 4.3 %
malnutrition (2.1 - 5.4 (1.2 - 5.3 (2.2 - 8.2
(< 115 mm and/or oedema) 95% C.I.) 95% C.I.) 95% C.I.)
Acute malnutrition for MUAC was also higher for younger children, and this is consistent with
the observation that MUAC identifies a higher proportion of younger children, who are at a
higher risk of mortality (Table 18).
27
Table 18 Prevalence of acute malnutrition by age, based on MUAC cut off's
and/or oedema
Severe Moderate Normal Oedema
wasting wasting (> = 125 mm )
(< 115 mm) (>= 115 mm
and < 125
mm)
Age Tota No. % No. % No. % No. %
(mo) l no.
6-17 157 15 9.6 33 21.0 109 69.4 0 0.0
18-29 145 5 3.4 13 9.0 127 87.6 0 0.0
30-41 141 0 0.0 9 6.4 132 93.6 0 0.0
42-53 117 0 0.0 0 0.0 117 100.0 0 0.0
54-59 33 0 0.0 0 0.0 33 100.0 0 0.0
Total 593 20 3.4 55 9.3 518 87.4 0 0.0
The prevalence of underweight was much higher among younger children than older children
(Table 20).
28
Table 20 Prevalence of underweight by age, based on weight-for-age z-scores
Severe Moderate Normal Oedema
underweight underweight (> = -2 z
(<-3 z-score) (>= -3 and <-2 score)
z-score )
Age Tota No. % No. % No. % No. %
(mo) l no.
6-17 149 34 22.8 51 34.2 64 43.0 0 0.0
18-29 144 28 19.4 40 27.8 76 52.8 0 0.0
30-41 137 20 14.6 37 27.0 80 58.4 0 0.0
42-53 115 7 6.1 24 20.9 84 73.0 0 0.0
54-59 33 1 3.0 8 24.2 24 72.7 0 0.0
Total 578 90 15.6 160 27.7 328 56.7 0 0.0
29
Figure 3 Height-for-age z-scores
A summary of the mean z-scores, design effects and excluded subjects is shown in Table 23.
For WHZ, the SD was 1.15, which is acceptable given that the expected range for good quality
of data is below 1.20. The design effect was 1.24, with 3 z-scores unavailable and 8 out of
range. The final survey design effect was close to the planned figure of 1.2, indicating that the
homogeneity was similar to what was observed in the last survey.
30
Weight-for- 582 -1.01±1.15 1.24 3 8
Height
Weight-for-Age 578 -1.78±1.17 1.73 1 14
Height-for-Age 550 -1.96±1.34 1.76 2 41
* contains for WHZ and WAZ the children with edema.
31
Health-seeking behaviour for children 6-59 months
Of those who sought treatment, the highest proportion sought treatment from a government
clinic/hospital (47.6%), with 26.3% seeking treatment from a pharmacy, and 15.2% from a
private clinic (Figure 5).
Health-seeking behaviour
Other 8.9
Friend/relative
Pharmacy
Private clinic
Government…
32
Table 26 Measles vaccination and Vitamin A supplementation vaccination
coverage
Measles Measles Vitamin A
(with confirmation (with card or (with confirmation
from card) confirmation from from
N=555 mother/caregiver) mother/caregiver)
N=593 N=590
(90) 16.2% (182) 30.7% (421) 71.4%
(10.6-21.8, 95% C.I.) (22.3-39.0, 95% C.I.) (60.8-81.9, 95% C.I)
About a fifth (19.9%, 13.7-26.1, 95% C.I) of children between 6 to 23 months had consumed
iron-rich foods. The mean dietary diversity score for the 6-23 months age group was 2.9 (2.5-
3.2, 95% C.I). The proportion of children of the same age group meeting the minimum dietary
diversity was only 18.5% (11.6-25.3, 95% C.I). The proportion who met the minimum
acceptable diet (MAD) was only 1.9% (0.0-4.2, 95% C.I). The results show poor infant and
young child feeding practices, although they must be interpreted with caution given the lower
precision as a result of the lower sample sizes for smaller age categories.
There was a high consumption of grains, roots and tubers (90.9%), other fruits/vegetables
(75.5%), and legumes/nuts (55.6%). Consumption of vitamin A-rich fruits and vegetables
(18.2%), flesh foods (21.7%), dairy products (16.1%) and eggs (6.3%) was very low (Figure 6).
33
Complementary feeding, 6-23 months
100 90.9
80 75.5
56.6
60
%
40
21.7
18.2 16.1
20
6.3
0
Grains, Legumes or Vitamin A Other fruits Flesh foods Eggs Dairy
roots and nuts rich fruits and products
tubers and vegetables
vegetables
CATEGORY
Consumption of cereals, roots and tubers (99.85) and other vegetables (84.5%) was very high
as well as the consumption of dark green leafy vegetables (78.7%) and pulses (72.8%).
Consumption of other Vitamin-A rich vegetables and fruits (16.2%), dairy products (19.6%)
and flesh foods (33.3%) were particularly low (Figure 8).
34
Dietary diversity for women 15-49 years
120
99.8
100 84.5
72.8 78.7
80
60
%
33.3
40 26.8
19.6 16.2 17.3
20 5.6
0
Food category
Nutritional status was analysed using the less than 210mm (severe malnutrition) and 210-
229mm (moderate malnutrition) cut-off value for MUAC (Figure 9). There was no significant
difference between the different categories in terms of malnutrition.
35
4. Discussion
With respect to quantitative result, the comparison between 2018 and 2019 refers to the 2
SMART surveys conducted by SCI in accessible communities within the SCI area of operation.
The analysis of the trend of admissions for SAM over the period June 2018 to July 2019 shows
that the admissions were highest in the month of July in both 2018 and 2019, with the peak
coinciding with the peak of the hunger season. This partly explains the prevalence being very
high. It would be expected that, due to this seasonality aspect, the prevalence would be lower
during the period after the harvest, as the SAM admissions show. Apart from the seasonality
factor, it must be noted that, according to the Nigeria Nutrition in Emergency Sector
Strategic Response Plan 2017-2018, a rapid SMART assessment conducted in April 2016 by
Action Against Hunger in the LGAs of MMC and Jere revealed a GAM rate of 19.1% and SAM
rate of 3.1% (April 2016). Nutrition assessments undertaken in April- June 2016 in some LGAs
in Borno state also showed that there were pockets with extremely high acute malnutrition
rates which included Konduga LGA (16.4% GAM and 5.0% SAM). The same report also
indicated that the state of malnutrition in the North East of Nigeria is related to high food
insecurity, sub optimal infant and young children feeding practices negative coping strategies,
increasing spread of endemic diseases, low coverage of programs targeting children with
moderate acute malnutrition, limited dietary diversity, loss of livelihoods, disruption of access
to quality water and optimal sanitation, population displacement and destruction of housing,
compromising the privacy necessary for breastfeeding; and the poor and deteriorating health
care system. Some of these factors were investigated in the report and are discussed below.
Stunting was also of major concern as it was also above the critical category of WHO
classification and was higher than in 2018. In Nigeria, 37 percent of children under 5 years are
stunted. Nigeria has the highest number of children under 5 years with chronic malnutrition
(stunting or low height-for-age) in sub-Saharan Africa at more than 11.7 million, according to
the most recent Demographic and Health Survey. The prevalence of stunting increases with
age, peaking at 46 percent among children 24–35 months. While stunting prevalence has
improved since 2008 (41 percent), the extent of acute malnutrition (wasting or low weight-
for-height) has worsened, from 14 percent in 2008 to 18 percent in 2013 among children
under 5 years.
36
quite low both by recall and confirmation with card, while Vitamin A supplementation
coverage was quite high.
Mortality
Crude death rate and under 5 death rate were below the emergency threshold, despite acute
malnutrition being very high. This was the same trend observed in 2018 and the results in
both surveys are also very similar in terms of both indicators.
5. Conclusion
The nutrition situation in the SCI operational areas of Borno state is at a critical level and
has deteriorated as the results show. The concern is particularly with respect to acute and
chronic malnutrition, as well as infant and young child feeding.
6. Recommendations
Child Health, Nutrition and Morbidity
Given the critical prevalence of acute malnutrition, there is a need to scale up the
integrated management of acute malnutrition, ensuring that the services are accessible
to the whole population, and to incorporate a targeted supplementary feeding
component given the large MAM caseload which the findings highlight.
Integration of existing nutrition services and programmes with the health programmes
is essential to facilitate linkages which will guarantee that children have access to a
comprehensive package of health and nutrition services, including vaccination,
supplementation and treatment.
Given the gap which exists between classification of acute malnutrition by WHZ and
MUAC, it is important to set up a system whereby there is a way to screen at-risk
children at the second stage using WHZ. This will ultimately increase programme
coverage.
A SQUEAC assessment to investigate the barriers to optimal CMAM coverage is
recommended in targeted LGAs.
37
appropriate messages through platforms such as religious gatherings and other
community groupings.
Recent KAP studies should be reviewed in the context of this survey’s results, with a
view to implementing the strategies recommended which are applicable.
38
Annex 1 List of individuals who participated in the survey
39
Annex 2 Assigned clusters
40
Annex 3 Survey questionnaire
1
2
3
4
5
6
7
8
9
10
11
12
List all members who have left the households since the start of the recall period
1 Y
2 Y
3 Y
4 Y
List all members who died since the start of the recall period
1 Y
2 Y
3 Y
4 Y
Was anyone pregnant at the start of the recall period? YES ( ), NO ( ). If yes, how many? ( )
41
(Mobile data entry)
Count the numbers from the print-based mortality module
Number Number Number Number Number Number Number Number Number
of current of current of current of current of past of past of of of
household household household household household household births deaths deaths
members members members members members members during during (under
(total) (under 5 who who who left who left recall recall 5 years)
years) arrived arrived during during during
during during recall recall recall
recall recall (exclude (exclude
(under 5 deaths) deaths)
years) (under 5
years)
1
2
3
42
4. Infant and Young Child Feeding-IYCF Practices (6 – 23 Months)
Did your child eat any of the following food groups in the PAST 24-HOURS (1=Yes, 2=No)
1. Grains, roots, tubers (bread, rice, 1.A. Porridge, bread, noodles or other foods made from
potato) rice, corn, maize, sorghum, millet, white potatoes, yam,
cassava
2. Legumes or nuts (lentils) Beans, peas, other lentils, nuts (peanuts) or seeds
(pumpkin seed, spinach seed, jackfruit seed) or any foods
made from these (
3. Dairy products (milk, yoghurt, Milk (tinned, powdered or fresh animal milk) yogurt,
cheese) cheese or other milk products
4. Flesh foods (meat, fish, poultry, A. Liver, kidney, heart or other organ meats or blood-
liver/organ meat) based foods
B. Meat such as beef, pork, lamb, mutton, rabbit, game,
chicken, duck, pigeon other birds
C.. Fresh or dried fish, shellfish or seafood like shrimp (
5. Vitamin A rich fruits and vegetables Pumpkin, carrots, squash, sweet potatoes, sweet peppers;
(carrot, pumpkin, orange sweet potato, any dark green leafy vegetables such as spinach, pumpkin
mango, papaya, dark green leafy leaf, ripe mangoes, cantaloupe, ripe papaya (dried peach,
vegetables, long beans) and 100% fruit juice made from these items
6. Egg Eggs from chickens, duck, guinea fowl or any other egg
7. Other fruit and vegetables (banana, Cabbage, tomato, onion, eggplant, cucumber , long bean,
apples, pineapple, watermelon, eggplant, garlic
onion, cucumbers, tomatoes)
8. Any oil, fats, butter, ghee or foods made with any of these
9. Any sugary foods such as chocolates, sweets, candies, pastries, cakes, biscuits or just sugar
10. Any lipid based nutrient supplement (LNS) like Plumpy nut, Plumpy sup; any other specialized
nutritious foods like fortified blended foods (FBFs) or high energy biscuits (HEBs) like WSB+/++ or WFP
biscuits
43
5. Women of reproductive age (15-49 years)
Consumed = 1
Not consumed = 0
White roots and tubers (potato, white/red sweet potato, yam, radish)
Vitamin A rich vegetables, roots and tubers (orange/yellow sweet potato, sweet
pumpkin, carrot etc.)
Vitamin A rich fruits (mango (ripe), papaya (ripe), water melon, black berry,
cantaloupe etc.)
Other fruits (banana, guava, jackfruit, lychee etc.
Dark green leafy vegetables (red amaranth, spinach, Indian spinach, water
spinach, sweet potato leaves etc.)
Fish and seafood (river fishes, sweet water fishes, marine fishes, fish eggs,
prawn, lobster, crab etc.)
44
Annex 4 Standardisation test results
STANDARDISATION TEST RESULTS
Weight subjects mean SD
Precision
# kg kg (TEM) Accuracy (Bias)
Supervisor 11 9.2 2.1 TEM poor Bias reject
Enumerator 1 11 9.2 2.1 TEM poor Bias reject
Enumerator 2 11 9.2 2.1 TEM poor Bias reject
Enumerator 3 11 9.3 2.2 TEM poor Bias reject
Enumerator 4 11 9.2 2.2 TEM reject Bias reject
TEM
Enumerator 5 11 9.3 2.2 acceptable Bias reject
Enumerator 6 11 9 2.2 TEM reject Bias reject
Enumerator 7 11 9.3 2.2 TEM poor Bias reject
Enumerator 8 11 9.2 2.1 TEM poor Bias reject
Enumerator 9 11 9.3 2.2 TEM poor Bias reject
enum inter 1st 9x11 9.2 2.1 TEM reject
TEM
enum inter 2nd 9x11 9.3 2.1 acceptable
inter enum + sup 10x11 9.2 2.1 TEM reject
TOTAL intra+inter 9x11 - - TEM reject Bias reject
TOTAL+ sup 10x11 - - TEM reject
45
Height subjects mean SD
Precision
# cm cm (TEM) Accuracy (Bias)
Supervisor 11 72.9 7.1 TEM poor Bias good
Enumerator 1 11 73.6 7.2 TEM poor Bias good
Enumerator 2 11 73.1 6.9 TEM reject Bias good
Enumerator 3 11 73.5 6.8 TEM poor Bias good
Enumerator 4 11 73.6 7 TEM poor Bias good
Enumerator 5 11 73.4 7.1 TEM reject Bias good
TEM
enum inter 2nd 9x11 73.6 6.7 acceptable
inter enum + sup 10x11 73.5 6.9 TEM reject
TOTAL intra+inter 9x11 - - TEM reject Bias good
TOTAL+ sup 10x11 - - TEM reject
46
MUAC subjects mean SD
Precision
# mm mm (TEM) Accuracy (Bias)
Supervisor 11 147.8 12.8 TEM reject Bias good
Enumerator 1 11 150.3 12.1 TEM poor Bias good
Enumerator 2 11 144 12.9 TEM reject Bias good
Enumerator 3 11 149.4 13.4 TEM reject Bias good
TEM
Enumerator 4 11 153.2 14 acceptable Bias poor
Enumerator 5 11 152 13.4 TEM reject Bias good
Enumerator 6 11 146.2 12.3 TEM reject Bias good
Enumerator 7 11 155.6 13.9 TEM reject Bias reject
Enumerator 8 11 154 11.9 TEM poor Bias poor
Enumerator 9 11 147.4 13.5 TEM reject Bias good
enum inter 1st 9x11 150.3 13.1 TEM reject
enum inter 2nd 9x11 150.2 13.6 TEM reject
inter enum + sup 10x11 150 13.2 TEM reject
TOTAL intra+inter 9x11 - - TEM reject Bias good
TOTAL+ sup 10x11 - - TEM reject
47
Annex 5 Survey local calendar of events
48
Eid El Fitr. Ramadan
Police fasting, Fire
Demostrations Disasters in
82 Chibok Kaga, Gajigana,
Gen. Buhari VP visits
Hike in Girls
May becomes 50 38 26 14 Maiduguri 2
Fuel Prices Released.
President Boko Haram
Ramadan
attack in
Magumeri
June Ramadan Ramadan Eid El Fitr. Eid El Fitr. Police Bomb Blast in
Chorela Demostrations Konduga (30
Outbreak Dead)
Claiming Female Corps
Many Lives Member
Released by
49 37 25 13 BH
1
49
September BH Eid El Adha. Eid El Eid El Adha. Harvest
Capture Death of Adha. Gwoza
Bama. Borno Attacks by
Attack of 58 Deputy 46 34 BH 22 10
Gwoza Governor
by BH
October Eid El Death of Eid El Kabr 13 Chibok Harvest
Adha. Eid Former Celebration Girls
Kabir Gov. of Kogi Released.
State. President
57 Ministrial 45 33 Buhari visit 21 9
Release by to Maiduguri
President
Buhari
50
Annex 6 Plausibility report for anthropometry
51