CARE INTERNATIONAL SOMALIA NUTRITION SMART SURVEY … · CHILD IMMUNIZATION, VITAMIN A...
Transcript of CARE INTERNATIONAL SOMALIA NUTRITION SMART SURVEY … · CHILD IMMUNIZATION, VITAMIN A...
CARE INTERNATIONAL – SOMALIA
NUTRITION SMART SURVEY
FINAL REPORT
LASCANOD DISTRICT, SOOL REGION, SOMALIA
OCTOBER 2019
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ACKNOWLEDGEMENT
Care Somalia would like to acknowledge all those who were involved directly or
indirectly in the nutrition SMART survey conducted in Lascanod District. In
particular, CARE Somalia M&E department is appreciated for planning, coordination,
provision of field logistics and supervision during data collection. Special gratitude
is also extended to;
• OFDA for their financial support to carry out the SMART survey in Lascanod
District
• CARE Somalia nutrition program and the M&E staff for facilitating recruitment
of survey teams, training, supervision and data collection
• The Ministry of Health for their involvement in SMART survey protocol
validation and planning
• The district and village administrators in Lascanod for facilitating entry of
teams to carry out surveys
• The enumerators for their commitment and team work in collecting quality
data as evidenced by the plausibility report
• The community and all caregivers in the sampled households for welcoming
the teams and accepting to participate in the survey
• Epistat consultants for their technical expertise in conducting the SMART
survey
Report compiled by: Epistat Research Consultants
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Table of Contents
ACKNOWLEDGEMENT .................................................................................... i
LIST OF TABLES ........................................................................................ iii
LIST OF FIGURES ....................................................................................... iii
ACRONYMS AND ABBREVIATIONS ..................................................................... iv
EXECUTIVE SUMMARY .................................................................................. v
1.0 INTRODUCTION ..................................................................................... 8
1.1 Background ....................................................................................... 8
1.2 Justification of the Survey ..................................................................... 9
1.3 Survey Objectives ............................................................................... 9
1.3.1 Specific Objectives ........................................................................ 9 1.4 Survey Area ...................................................................................... 9
1.5 Survey Timing .................................................................................... 9
2.0 METHODOLOGY .................................................................................... 10
2.1 Study Design .................................................................................... 10
2.2 Target Group.................................................................................... 10
2.3 Data and Data Collection Methods ........................................................... 10
2.4 Sample Size Determination ................................................................... 11
2.4.1 Anthropometry Sample Size ............................................................. 11 2.4.2 Summary of sampling methods .......................................................... 13
2.5 Organization of the survey .................................................................... 14
2.5.1 Recruitment and Composition of survey teams ....................................... 14 2.5.2 Training of the survey teams ............................................................ 14 2.5.3 Field Data Collection ..................................................................... 14
2.6 Data Management .............................................................................. 14
2.6.1 Data Quality Control ...................................................................... 14 2.6.2 Data Collection Tools ..................................................................... 15 2.6.3 Data Entry and Analysis .................................................................. 15
3.0 RESULTS ............................................................................................ 16
3.1 Summary of survey completeness ........................................................... 16
3.2 Anthropometric results (WHO Growth Standards 2006) .................................. 16
3.2.1 Distribution by age and sex of sample ................................................. 16 3.2.2 Prevalence of wasting (WHZ) based on SMART flags ................................. 17 3.2.3 Prevalence of acute malnutrition by MUAC ........................................... 19 3.2.4 Prevalence of underweight (WAZ) ...................................................... 21 3.2.5 Prevalence of Stunting (HAZ) ........................................................... 21 3.2.6 Mean z-score, Design Effect and excluded subjects ................................. 22
3.3 Child Morbidity and Immunization Coverage ............................................... 22
3.3.1 Retrospective child morbidity ........................................................... 22 3.3.2 Health seeking behaviour ................................................................ 23 3.3.3 Child immunization, Vitamin A supplementation, and deworming ................ 24
4.0 CONCLUSION ....................................................................................... 25
5.0 RECOMMENDATIONS .............................................................................. 26
6.0 ANNEXES............................................................................................ 27
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LIST OF TABLES
Table 1: Summary of survey results ......................................................... v
Table 2: Survey target group ............................................................... 10
Table 3: Data and collection methods .................................................... 10
Table 4: Sample size determination ...................................................... 11
Table 5: Summary of survey completeness .............................................. 16
Table 6: Distribution of age and sex of sample ......................................... 16
Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores
(and/or oedema) and by sex ............................................................... 18
Table 8: Distribution of acute malnutrition and oedema based on weight-for-height
z-scores........................................................................................ 19
Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-
scores and/or oedema ...................................................................... 19
Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or
oedema) and by sex ......................................................................... 20
Table 11: Prevalence of underweight based on weight-for-age z-scores by sex ... 21
Table 12: Prevalence of stunting based on height-for-age z-scores and by sex .... 22
Table 13: Mean z-scores, Design Effects and excluded subjects ..................... 22
LIST OF FIGURES
Figure 1: Somalia seasonal calendar ...................................................... 10
Figure 2: Population age and sex pyramid ............................................... 17
Figure 3: Distribution of WHZ z-scores for the observed population (curve) ....... 18
Figure 4: Prevalence of acute malnutrition by age, based on MUAC cut offs and/ or
oedema ........................................................................................ 20
Figure 5: Common illnesses reported ..................................................... 23
Figure 7: Health and seeking behavior ................................................... 24
Figure 8: VAS, Deworming and Measles coverage ....................................... 25
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ACRONYMS AND ABBREVIATIONS
AIMWG Assessment and Information Management Working Group
CHAST Children Hygiene and Sanitation Transformation
CI Confidence Interval
CLTS Community Led Total Sanitation
DEFF Design Effect
ENA Emergency Nutrition Assessment
FSL Food Security and Livelihoods
FSNAU Food Security and Nutrition Analysis Unit
GAM Global Acute Malnutrition
GMS Grams
HAZ Height for Age Z-score
HAZ Height for Age Z-Score
HHs Households
IDP Internally Displaced Persons
IPC Integrated Phase Classification
IYCF/N Infant and Young Child Feeding/Nutrition
LCL Lower Confidence Limit
M&E Monitoring and Evaluation
MAM Moderate Acute Malnutrition
MUAC Mid Upper Arm Circumference
OFDA Office of Foreign Disaster Assistance
OTP Outpatient Therapeutic Program
PHAST Participatory Hygiene and Sanitation Transformation
PLW Pregnant and Lactating Women
PPS Probability proportional to size
SAM Severe Acute Malnutrition
SD Standard Deviation
SMART Standardized Monitoring and Assessment of Relief and Transitions
UCL Upper Confidence Limit
USAID United States Agency for International Development
WASH Water, Sanitation and Hygiene
WAZ Weight for Age Z-Score
WHO World Health Organization
WHZ Weight for Height Z- Score
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EXECUTIVE SUMMARY
CARE International received a grant from OFDA/USAID to carry out humanitarian
assistance in Bari, Galgadud, Mudug, Nugaal, Sanaag, Sool, and Togdheer regions of
Puntland, Galgadud and Somaliland. The interventions started on October 1st 2018
and ended on 30th September 2019. In order to understand the prevailing situation
for targeted humanitarian response, CARE conducted a nutrition SMART survey in
Lascanod District, Sool Region from 17th -31st October 2019. The overall objective of
this survey was to assess the nutrition situation in Lascanod district and determine
the outcome of integrated nutrition and health programs running in the area.
The survey applied the Standardized Monitoring and Assessment of Relief and
Transition (SMART) methodology involving the two-stage cluster sampling approach
targeting 34 clusters and 16 households per cluster. The survey targeted 447 children
from 534 households for the anthropometric survey as determined by ENA for SMART
(July 19, 2015). Eventually, the survey reached 650 children from 543 households
achieving a coverage of 145.4% and 101.7% for the children and households
respectively. The reported prevalence of global acute malnutrition remains of
serious threshold at 10.2 % (7.2 – 14.3 95% C.I.) with severe acute malnutrition
prevalence of 0.9 % (0.4 - 2.0 95% C.I.). A summary of the key findings is presented
in the table below;
Table 1: Summary of survey results
SUMMARY OF SURVEY RESULTS, OCTOBER 2019
INDICATOR N n % 95% CI
ANTHROPOMETRIC RESULTS (6-59 MONTHS) WHO 2006
Wasting (WHZ)
Prevalence of global malnutrition (<-2 z-score and/or oedema)
636 65 10.2% 7.2 – 14.3
Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)
59 9.3% 6.4 – 13.2
Prevalence of severe malnutrition (<-3 z-score and/or oedema)
6 0.9% 0.4 - 2.0
Prevalence of GAM by MUAC
Prevalence of global malnutrition (< 125 mm and/or oedema)
650 15 2.3% 1.2 – 4.4
Prevalence of global malnutrition (< 125 mm and >= 115 mm, no oedema)
15 2.3% 1.2 – 4.4
Prevalence of global malnutrition (< 115 mm and/or oedema)
0 0.0% 0.0 – 0.0
Underweight (WAZ)
Prevalence of underweight (<-2 z-score) 648 38 5.9% 3.8 – 8.9
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Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)
34 5.2% 3.3 – 8.3
Prevalence of severe underweight (<-3 z-score)
4 0.6% 0.2 – 1.6
Stunting (HAZ)
Prevalence of stunting (<-2 z-score) 641 22 3.4% 2.0 – 5.8
Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)
22 3.4% 2.0 – 5.8
Prevalence of severe stunting (<-3 z-score)
0 0.0% 0.0 – 0.0
CHILD IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND DEWORMING
Measles immunization( 9-59 months) –( Card and Recall)
621 271 43.6% 39.8 – 47.6
Vitamin A supplementation coverage children 6-59 months
650 191 29.4% 26.0 -33.0
Deworming for Children (12-59 months) in the last 6 months
571 182 31.9% 28.2 – 35.8
CHILD MORBIDITY AND HEALTH SEEKING BEHAVIOR
Prevalence of reported illness (6-59 months) 14 days mothers/caregivers recall
650 197 30.3% 26.9 – 34.0
Fever 123 62.4% 55.3 – 69.2
Cough 115 58.4% 51.2 – 65.3
Diarrhea 54 27.4% 21.3 – 34.2
Skin infections 12 6.1% 3.2- 10.4
Eye infections 6 3.1% 1.1 – 6.
Other illnesses 12 6.1% 3.2 -10.4
Health seeking for sick children 95 48.2 41.1-55.4
Main location of health seeking –Public health facilities
95 53 55.8% 45.2 – 66.0
The survey findings revealed a serious nutrition situation in the district based on
WHO thresholds (10-14%). The prevalence of underweight and stunting were both
low according to WHO thresholds recording 5.9 % (3.8 - 8.9 95% C.I.) and 3.4 % (2.0
- 5.8 95% C.I.) respectively. Morbidity rates in the survey were low with (30.3%) of
the children reportedly ill 2 weeks prior to the survey. fever was the most dominant
illness at (62.4%). The health seeking behavior of caregivers was also below average
(48.2%) with most visiting public health facilities (55.8%) to seek assistance in the
treatment of their children. Vitamin A supplementation (29.4%), Measles (43.6%) and
Deworming (31.9%) also recorded poor coverage with all falling below the 80% WHO
target. Based on these findings, the following actions were recommended to improve
health and nutrition service delivery in Lascanod district;
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1. CARE should continue implementing all components of CMAM program and
scale up community mapping for outreach locations and collaborative
outreach health care services in hard to reach locations. The implementation
should integrate all key components in each treatment centre. Attention
should be given to notable ‘pockets of malnutrition’ in Bocame, Xidh xidh and
Goljano villages.
2. Strengthen Maternal, Infant and Young Child nutrition to address the
associated long term impacts of malnutrition on mothers and children.
3. Intensify immunization campaigns in coordination with key stakeholders in
the district to promote Vitamin A supplementation, immunization and
deworming to meet global coverage targets. It should be conducted by
implementing partners through static and mobile facilities to improve
coverage.
4. Enhance WASH programs to include hygiene and sanitation approaches such
as PHAST (Participatory Hygiene and Sanitation Transformation), CHAST
(Children Hygiene and Sanitation Transformation) and CLTS (Community Led
Total Sanitation). This recommendation is based on diarrhoeal diseases and
field observation on lack of sanitation facilities in some of the villages.
5. Enhance awareness on importance of health records among caregivers and
collaborate with other partners and the MoH to support documentation of
healthcare delivery services especially births and immunization coverage.
Most births in Lascanod were reported by recall.
6. Conduct integrated Knowledge, attitudes, practices and behavior survey to
understand factors influencing health seeking behaviors and health service
utilization in the district. Education levels, socio-economic factors, physical
and cultural beliefs are likely to influence health seeking behavior and health
service utilization of caregivers in the community.
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1.0 INTRODUCTION
1.1 Background
CARE has been providing emergency relief and lifesaving assistance to the Somali
people since 1981. Its main program activities since then have included projects in
water and sanitation, sustainable pastoralist activities, civil society and media
development, small-scale enterprise development, primary school education,
teacher training, adult literacy and vocational training. CARE Somalia is currently
operational in the northern regions of Puntland and Somaliland1.
Lascanod District is one the four districts (Agnabo, Hudun and Taleh) making up the
larger Sool region. Sool shares the western border with Ethiopia. The population
estimates of Sool region is 327,428 with Lascanod district having a population of
75,4362. The region is inhabited by people from the Somali ethnic group with Harti
Darod, Habar Jeclo, and Habar Younis forming the dominant sub clans. The
population is segmented into urban, rural, nomads and IDPs with nomads forming
the bulk of the population. Pastoralism and trade are the major sources of livelihood
for the residents.
Health and Nutrition Situation
Since 2018, CARE implemented Nutrition, health and FSL services in Badhan and
Lascanod covering a total of 21 villages. The CARE nutrition program aimed at
addressing the high malnutrition rates through treatment of Acutely Malnourished
Children under 5, pregnant and lactating women, referral and treatment of
complicated cases of SAM and improved IYCF practices amongst the community
through community based IYCF programs. The program covered 4 fixed sites in
Lascanod. The SMART survey was intended to complement the last FSNAU Post Deyr
2018 survey by adopting the same approach of obtaining the specific GAM rate at
district level and complementing the livelihood estimate of FSNAU. This enabled
CARE to establish its baseline GAM for programming purposes as programs continue
into 2020.
Supported by OFDA/USAID grant, CARE provided humanitarian assistance in Bari,
Galgadud, Mudug, Nugaal, Sanaag, Sool, and Togdheer regions of Puntland, Galgadud
and Somaliland from October 2018 to October 2019. The project provided temporary
employment, protection services, basic health services and treatment services for
acutely malnourished children and pregnant and lactating women. The communities
also benefitted from WASH services through provision of safe water, hygiene
promotion and kits to vulnerable households. The project aimed a total reach of
1 https://www.care-international.org/where-we-work/somalia 2 https://reliefweb.int/sites/reliefweb.int/files/resources/Population-Estimation-Survey-of-Somalia-PESS-2013-2014.pdf
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247,671 people for assistance; equivalent to 22% of the population in IPC 3 and 4 in
these regions3 as of 2018.
In September 2019, CARE conducted IYCF KAP endline survey in Sool and Sanag
regions. The survey reported exclusive breastfeeding rate of 75.8%, this is above
both national rate (33%) and Somaliland rate (56%) according to 2016 FSNAU
assessment. The report shows that 84% of children were timely introduced to
complementary feeding, however, continued breastfeeding at 1 year was slightly
above average (58. 4%).The reported minimum dietary diversity (4.5%) was below
the national (15%) and Somaliland estimates (7%).
1.2 Justification of the Survey
The SMART survey was meant to complement the FSNAU livelihood assessments
estimates by providing district specific GAM rates. The results will also be used by
CARE to determine the baseline GAM for continuation of programs into 2020.
1.3 Survey Objectives
The overall objective of this survey was to assess the prevalence of acute
malnutrition among children 6-59 months in Lascanod District.
1.3.1 Specific Objectives
i) To estimate the current prevalence of acute malnutrition among children
aged 6 – 59 Months.
ii) To estimate the coverage of measles vaccination (9-59 months), Vitamin A
supplementation (6-59 months) and deworming (12-59 months)
iii) To assess common morbidity among children 6-59 months based on a 2 weeks’
recall
iv) To draft actionable and localized recommendations based on the findings.
Using assessment for action approach clearly indicating the finding,
recommendations actions, timelines and responsibility and monitoring.
1.4 Survey location
The survey was conducted in Somalia’s Lascanod District located in Sool Region.
1.5 Survey Timing
The survey took place in October 2019. This falls period falls in post Gu season as shown in
Figure 1 below.
3 https://reliefweb.int/job/3305148/terms-reference-tor-smart-survey-sool-and-sanag-regions-drought-response-and-recovery
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Figure 1: Somalia seasonal calendar4 2.0 METHODOLOGY
2.1 Study Design
This survey used a cross-sectional study design applying the two-stage cluster
sampling approach based on the probability proportional to population size (PPS).
The first stage involved the selection of clusters/villages while the second stage
involved the selection of households to be surveyed through simple random
sampling.
2.2 Target Group
Based on the objectives of this study, the survey targeted children 6-59 months. The
table below provides a summary of targeted groups for each indicator.
Table 2: Survey target group
Key Indicators Targeted Population
Prevalence of acute malnutrition Children 6-59 months
Child morbidity and health seeking Children 6-59 months
Vitamin A supplementation Children 6-59 months
Measles immunization Children 9-59 months
Deworming Children 12-59 months
2.3 Data and Data Collection Methods
Table 3: Data and collection methods
Data and collection methods
Anthropometric Data
Age - Health cards and birth certificates were used to determine precise age of
the child. Local calendar of events was used in the absence of documentation for
children 6-59 months (Annex IV)
Sex – Was recorded as either ‘f’ for female or ‘m’ for male
Weight - Standardized SECA scales were used
4 FEWSNET
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Height - Standard height boards were used for taking length and height. Children
less than 24 months were measured lying down and children greater than or equal
to 24 months were measured in standing position
MUAC – Was taken using standardized and MOH approved MUAC tape. All children
6-59 months were measured on the left arm to the nearest 0.1cm or 1.0 mm
Bilateral oedema - All children were checked for oedema; minimal thumb
pressure was applied to the top of the feet for about 3 seconds
Vitamin A supplementation – All children 6-59 months were assessed for Vitamin
A supplementation in the past one year.
Prevalence of child morbidity – this was assessed based on a 2 weeks (14 days)
recall period for all the children 6-59 months
Health seeking behavior – For all the children reported ill, the caregivers were
assessed on if and where they sought assistance for their sick children
Measles vaccination – Measles vaccination either by recall or by card was assessed
in all children aged 9-59 months in the survey
Deworming - Supplementation with deworming tablets was assessed in children
12-59 months in the survey.
2.4 Sample Size Determination
2.4.1 Anthropometry Sample Size
The sample size for anthropometric survey was calculated using ENA for SMART 2011
(July 9, 2015 version) using Sool population parameters as shown below.
Table 4: Sample size determination
Population Parameter
Lascanod District Sool Region
Rationale/Source
Estimated prevalence
10.8%
Somalia June-July 2019 surveys, FSNAU. Lascanod (Sool) reported a GAM of 10.8% (8.2-14.1). Hawd pastoral estimates used for Lascanod
Desired precision 3.5
Reasonable precision in consideration of estimated GAM and associated resources
Design effect 1.36
Lascanod applied 1.36 obtained from the Hawd Pastoral survey
Average household size
4.8 Somalia June-July 2019 surveys, FSNAU
Percent of under five children
20%
Adjusted from the Somalia June-July 2019 surveys, FSNAU of 27.2% for Lascanod (Sool)
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Percent of non-respondent
3% Anticipated Non-Response Rate
Children to be included
447
Sample sizes (Households)
534
Clusters 34
No. of households per cluster
16
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Number of Households per Cluster
The number of households to be completed per day were determined by considering
the time available to conduct the survey after consideration of time spent on
travelling, initial introduction, breaks, administering questionnaire in each
household and time spent to move from one household to the next.
The total amount of time available to work in a day was 9 hours (8:00 am – 5:00 pm).
After exclusion of the travelling time, the initial introduction and selection of
household and lunch break, the amount of time left to conduct the survey was 7
hours. The amount of time spent to conduct the survey in one household was 25
minutes (20 minutes for interviews and 5 for moving from one household to the
next), therefore, the total number of households’ representative of a cluster was
16.8 ≈ 16 (rounded down in first stage of sampling) as detailed below;
▪ Departure from the base at 8:00 am and back at 5:00 pm.
▪ Average return travel time for each cluster: 1 hours
▪ Duration for initial introduction and selection of households: 0.5 hours
▪ Time spent to move from one household to the next: 5 minutes
▪ Average time in the household: 20 minutes
▪ Breaks: 1 lunch/prayer break of 0.5 hours
𝑛ℎℎ =(9−1−0.5−0.5)60min
20+5 = 16.8 households (rounded down to 16)
Number of Clusters for Lascanod District
The number of clusters was determined by dividing the total household sample by
16 households representative of a cluster i.e. No. of clusters =534/16 = 33.3, this
was rounded up to 34 clusters. Therefore, 34 clusters were sampled based on
population proportion to size for Lascanod District. Tukaraq village was excluded
from the sampling frame based on security concerns.
2.4.2 Summary of sampling methods
First stage Cluster sampling
This stage involved the selection of 34 clusters in Lascanod district using the ENA for
SMART software based on population proportion to size (PPS) (see Annex II). An
updated list of all villages/clusters with their respective population sizes was used.
Second stage sampling
The second stage of sampling involved the selection of 16 households in each of the
sampled clusters. This selection was done using simple random sampling using the
household listing and random number generator mobile application. Segmentation
was applied for the densely populated clusters (more than 200 households) and
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clusters with sparsely distributed followed by simple random sampling of
households.
2.5 Organization of the survey
2.5.1 Recruitment and Composition of survey teams
Care Somalia, with the guidance of the consultant developed the criteria for
recruiting 6 survey teams, composed of 1 team leader and 2 data collectors. In total,
18 enumerators were recruited for this survey. The selection process considered key
factors such as the level of education, previous experience in conducting surveys,
the ability to read and communicate in English and undoubted fluency in Somali
dialects.
2.5.2 Training of the survey teams
A 4-day training was conducted for all teams before data collection. The training
was conducted in Lascanod town and mainly focused on anthropometric
measurements, survey teams, field procedures translation and back-translation of
the questionnaires, data recording using ODK and second stage sampling. The third
day included a standardization test using 10 healthy children 6-59 months to assess
the precision and accuracy of enumerators in taking anthropometric measurements.
The results of this exercise are available in Annex III.
The survey pre-test was conducted in 3 purposively selected non-sampled villages
around Lascanod town; Jaama Laaye, Farxaskulle and Daami. The results from the
pilot test were analyzed, feedback shared and the notable gaps addressed
sufficiently before teams proceeded to the field for data collection.
2.5.3 Field Data Collection
The process of data collection was conducted over a period of 6 days with rigorous
coordination by CARE Lascanod and close supervision by the consultant and MoH
representative. Data was collected by 6 teams using ODK mobile platform.
2.6 Data Management
2.6.1 Data Quality Control
To ensure data quality, the following measures were put in place;
▪ Review and validation of the protocol and report by the AIMWG
▪ 4-day comprehensive training including standardization and pilot test
▪ Field supervision of the survey teams during data collection by the Ministry of
Health representative, consultant, the CARE program staff
▪ Distribution of enumerator strengths across the teams
▪ Calibration and standardization of the survey equipment
▪ Use ODK platform to collect and organize data
▪ Use of Cluster Control forms for survey outcome for every sampled household
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▪ Daily plausibility checks and sharing feedback with the teams every morning
before proceeding to the field
▪ Adequate logistic planning during field work
2.6.2 Data Collection Tools
The data collection tools for use were guided by SMART methodology
(anthropometry) and the Somalia AIMWG for additional variables. A combined tool
data collection including the additional variables on child morbidity and
immunization coverage was used in ODK format.
2.6.3 Data Entry and Analysis
The anthropometric data collected using ODK was uploaded into ENA for SMART 2011
software (July 9, 2015 version) for quality checks, review and analysis. Child
morbidity and immunization data was organized and reviewed using MS Excel and
consequently analysed using to Epi Info version 7. Descriptive analysis was performed
for this survey.
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3.0 RESULTS
3.1 Summary of survey completeness
The survey targeted 447 children aged 6-59 months from 534 households in 34
clusters across Lascanod District. The proportion of households and children
surveyed exceeded the target as shown in the table below;
Table 5: Summary of survey completeness
Planned Surveyed % Achieved
Households 534 543 101.7%
Clusters 34 34 100%
Anthropometry U5s 447 650 145.4%
3.2 Anthropometric results (WHO Growth Standards 2006)
The global acute malnutrition (GAM) is defined as <-2 z scores weight-for-height
and/or oedema and severe acute malnutrition (SAM) is defined as <-3z scores weight-
for-height and/or oedema). All exclusions of z-scores were determined by applying
SMART flags (WHZ -3 to 3; HAZ -3 to 3; WAZ -3 to 3)5 which are based on the observed
survey mean.
The survey reached 650 children (310 boys: 340 girls) aged 6-59 months in the
sampled households where measurements of weight, height, MUAC and oedema were
taken to determine their nutritional status. The anthropometry data was analysed
using ENA for SMART 2011 (July 9th, 2015 version) and recorded an excellent overall
data quality score of 8% (see Annex I). The weight of children was taken with
minimal clothing and factored in the analysis where the average weight of the cloth
was 200 grams.
3.2.1 Distribution by age and sex of sample
Out of the 650 surveyed children in the anthropometric survey, 310 were boys while
340 girls. With a sex ratio of 1.1 (p-value = 0.239) it is evident boys and girls were
equally represented in the survey. Similarly, there was no statistical difference in
the age ratio of 6-29 months to 30-59 months old (0.83, p-value = 0.774) since the
expected value falls around 0.85.
Table 6: Distribution of age and sex of sample
Boys Girls Total Ratio
AGE (mo) no. % no. % no. % Boy:girl
6-17 74 47.1 83 52.9 157 24.2 0.9
18-29 68 49.3 70 50.7 138 21.2 1.0
30-41 76 48.4 81 51.6 157 24.2 0.9
42-53 60 43.8 77 56.2 137 21.1 0.8
54-59 32 52.5 29 47.5 61 9.4 1.1 5 https://smartmethodology.org/survey-planning-tools/smart-methodology/
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Total 310 47.7 340 52.3 650 100.0 0.9 The distribution by age and sex is presented in the graph below which shows no difference
in representation.
Figure 2: Population age and sex pyramid
3.2.2 Prevalence of wasting (WHZ) based on SMART flags
The prevalence of acute malnutrition was determined based on weight-for-height z-
scores of <-2 and or oedema. Extreme values of WHZ below or above the SMART flag
ranges of WHZ -3 to +3 were excluded in consideration of the observed mean. Based
on the inclusion and exclusion criteria, 636 children were included in the final
analysis for GAM after 12 children with z-scores out of range and 2 not available
were excluded. The 2 missing WHZs are of 2 disabled children whose heights were
not recorded.
The prevalence of Global Acute Malnutrition (GAM) based on WHZ in Lascanod
district was 10.2% (7.2 – 14.3 95% C.I.) while that of Severe Acute Malnutrition (SAM)
was 0.9 % (0.4 - 2.0 95% C.I.). According to WHO standards (10-14%), this GAM rate
renders severity of malnutrition in the population serious6. The prevalence of
malnutrition is likely to worsen during the October 2019-January 2020 according to
food security outlook. FEWSNET’s October 2019 report shows that Sool region will
remain in IPC Phase 3 (Crisis) until January 2019. The situation is expected to
improve in February – May 2019 due to anticipated improved harvest and livestock
herds as a result of the October – December, Deyr rains7.
6 https://www.who.int/nutrition/nlis_interpretation_guide.pdf 7 Somalia Food Security Outlook http://fews.net/east-africa/somalia/food-security-outlook/october-2019
-100 -80 -60 -40 -20 0 20 40 60 80 100
6-17
18-29
30-41
42-53
54-59
Month
s
Age and Sex Distribution
Boys Girls
18
Table 7: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex
All n = 636
Boys n = 301
Girls n = 335
Prevalence of global malnutrition (<-2 z-score and/or oedema)
(65) 10.2 % (7.2 - 14.3 95% C.I.)
(30) 10.0 % (6.4 - 15.2 95% C.I.)
(35) 10.4 % (7.2 - 14.9 95% C.I.)
Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)
(59) 9.3 % (6.4 - 13.2 95% C.I.)
(28) 9.3 % (5.9 - 14.3 95% C.I.)
(31) 9.3 % (6.2 - 13.5 95% C.I.)
Prevalence of severe malnutrition (<-3 z-score and/or oedema)
(6) 0.9 % (0.4 - 2.0 95%
C.I.)
(2) 0.7 % (0.2 - 2.8 95%
C.I.)
(4) 1.2 % (0.5 - 2.9 95%
C.I.)
The prevalence of oedema is 0.0 % The surveyed population was graphically plotted against the WHO reference population as
shown in the figure below with a resulting mean of -0.66 and a standard deviation of ±1.06.
The recorded SD was within the acceptable range of 0.8-1.2, indicative of plausible
results. With the observed mean lesser than the reference mean (0), the Lascanod
curve deviated to the left indicating the surveyed population was undernourished in
comparison to the reference population.
Figure 3: Distribution of WHZ z-scores for the observed population (curve)
19
No cases of oedema were observed during the survey. However, 12 children were reported
to be marasmic (1,9%).
Table 8: Distribution of acute malnutrition and oedema based on weight-for-height z-scores <-3 z-score >=-3 z-score Oedema present Marasmic kwashiorkor
No. 0 (0.0 %)
Kwashiorkor No. 0
(0.0 %)
Oedema absent Marasmic No. 12 (1.9 %)
Not severely malnourished No. 636 (98.1 %)
The analysis of acute malnutrition was further done by age groups for both severe
and moderate wasting. Children 18-29 months and 54-59 months’ group were the
most affected by moderate wasting at 12.0% and 15.8% respectively. Severe wasting
was generally low across the groups;
Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema Severe wasting
(<-3 z-score) Moderate wasting
(>= -3 and <-2 z-score )
Normal (> = -2 z score)
Oedema
Age (mo)
Total no.
No. % No. % No. % No. %
6-17 155 2 1.3 10 6.5 143 92.3 0 0.0
18-29 133 2 1.5 16 12.0 115 86.5 0 0.0
30-41 154 0 0.0 14 9.1 140 90.9 0 0.0
42-53 137 2 1.5 10 7.3 125 91.2 0 0.0
54-59 57 0 0.0 9 15.8 48 84.2 0 0.0
Total 636 6 0.9 59 9.3 571 89.8 0 0.0
3.2.3 Prevalence of acute malnutrition by MUAC
Empirical evidence corroborate the efficacy of MUAC measurement as an indicator
of mortality risk associated with wasting in children 6-59 months8. MUAC is commonly
used in community screening and admission of children 6-59 months into feeding
programs based on the WHO recommended cut-offs of 115mm and 125 mm to define
severe and moderate malnutrition respectively9. This is owed to the fact that MUAC
assessment is easier to conduct and very affordable.
8 Chiabi, A., Mbanga, C., Mah, E., Nguefack Dongmo, F., Nguefack, S., Fru, F., ... & Fru III, A. (2016). Weight-for-height z score and mid-upper arm circumference as predictors of mortality in children with severe acute malnutrition. Journal of tropical pediatrics, 63(4), 260-266. 9 Myatt, M., Khara, T., & Collins, S. (2006). A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food and nutrition bulletin, 27(3_suppl3), S7-S23.
20
MUAC measurements of all sampled children 6-59 months were taken. The
prevalence of GAM (< 125 mm and/or oedema) by MUAC was 2.3% (1.2 – 4.4 95%
C.I.). There were no cases of severe malnutrition.
Table 10: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex All
n = 650 Boys
n = 310 Girls
n = 340
Prevalence of global malnutrition (< 125 mm and/or oedema)
(15) 2.3 % (1.2 - 4.4 95%
C.I.)
(7) 2.3 % (1.1 - 4.4 95%
C.I.)
(8) 2.4 % (1.0 - 5.7 95%
C.I.)
Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)
(15) 2.3 % (1.2 - 4.4 95%
C.I.)
(7) 2.3 % (1.1 - 4.4 95%
C.I.)
(8) 2.4 % (1.0 - 5.7 95%
C.I.)
Prevalence of severe malnutrition (< 115 mm and/or oedema)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
The distribution of GAM by MUAC as classified by age demonstrated that children 6-
17, 18-29 and 54-59 months were the most affected by moderate malnutrition.
Similarly, the same age groups were the most wasted by WHZ z-scores.
Figure 4: Prevalence of acute malnutrition by age, based on MUAC cut offs and/ or oedema
21
3.2.4 Prevalence of underweight (WAZ)
Underweight is a composite indicator that reflects both wasting (low weight for
height ratio) and stunting (low height for age). Essentially, weight for age measures
the child’s body weight relative to their age10. The analysis of the prevalence of
underweight (WAZ) involved 648 children after exclusion of 2 children with z-scores
out of range. The survey recorded an underweight prevalence of 5.9 % (3.8 - 8.9 95%
C.I.) while the prevalence of severe underweight was 0.6 % (0.2 - 1.6 95% C.I.).
According to WHO standards (<10%), the prevalence of underweight in Lascanod
district is considered low. From the findings, more boys compared to girls were
underweight as shown below;
Table 11: Prevalence of underweight based on weight-for-age z-scores by sex All
n = 648 Boys
n = 309 Girls
n = 339
Prevalence of underweight (<-2 z-score)
(38) 5.9 % (3.8 - 8.9 95%
C.I.)
(26) 8.4 % (5.3 - 13.0 95% C.I.)
(12) 3.5 % (1.9 - 6.4 95%
C.I.)
Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)
(34) 5.2 % (3.3 - 8.3 95%
C.I.)
(23) 7.4 % (4.5 - 12.0 95% C.I.)
(11) 3.2 % (1.7 - 6.2 95%
C.I.)
Prevalence of severe underweight (<-3 z-score)
(4) 0.6 % (0.2 - 1.6 95%
C.I.)
(3) 1.0 % (0.3 - 3.0 95%
C.I.)
(1) 0.3 % (0.0 - 2.2 95%
C.I.)
3.2.5 Prevalence of Stunting (HAZ)
Stunting is a chronic form of malnutrition characterized by impaired growth and
development. It results when a child experiences long-term nutritional deprivation
which in turn leads to delayed mental development, poor school performance and
reduced intellectual capacity11. Evidence suggests the potential risk of small women
to deliver infants with low birth weight which contributes to intergenerational cycle
of malnutrition as infants of low birth weight tend to be smaller as adults12.
The analysis of stunting included 641 children after 7 children with z-scores out of
range and 2 not available were excluded. The findings showed a stunting prevalence
of 3.4 % (2.0 - 5.8 95% C.I.) with no children severely stunted. According to WHO
thresholds (<20%), the prevalence of stunting was low in the district.
10 http://www.searo.who.int/entity/health_situation_trends/data/Underweight_text/en/ 11 Dewey, K. G., & Begum, K. (2011). Long‐term consequences of stunting in early life. Maternal & child nutrition, 7, 5-18. 12 Sumarmi, S. (2016). Maternal short stature and neonatal stunting: an inter-generational cycle of malnutrition.
22
Table 12: Prevalence of stunting based on height-for-age z-scores and by sex All
n = 641 Boys
n = 303 Girls
n = 338
Prevalence of stunting (<-2 z-score)
(22) 3.4 % (2.0 - 5.8 95%
C.I.)
(16) 5.3 % (2.8 - 9.7 95%
C.I.)
(6) 1.8 % (0.6 - 5.0 95%
C.I.)
Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)
(22) 3.4 % (2.0 - 5.8 95%
C.I.)
(16) 5.3 % (2.8 - 9.7 95%
C.I.)
(6) 1.8 % (0.6 - 5.0 95%
C.I.)
Prevalence of severe stunting (<-3 z-score)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
(0) 0.0 % (0.0 - 0.0 95%
C.I.)
3.2.6 Mean z-score, Design Effect and excluded subjects
The table below provides a summary of the mean z-scores, SD, DEFF, z-scores not
available and z-scores out of range for each of the three assessed indices. This
information provides a summary of quality of data, heterogeneity of each indicator
and useful in planning future surveys.
Table 13: Mean z-scores, Design Effects and excluded subjects Indicator n Mean z-
scores ± SD Design Effect (z-score < -2)
z-scores not available*
z-scores out of range
Weight-for-Height 636 -0.66±1.06 2.10 2 12
Weight-for-Age 648 -0.59±0.90 1.76 0 2
Height-for-Age 641 -0.23±0.86 1.58 2 7
3.3 Child Morbidity and Immunization Coverage
3.3.1 Retrospective child morbidity
The occurrence of common childhood illnesses was assessed among children aged 6-
59 months. The caregivers were probed based on 14 days’ recall whether their
children had fallen ill and the type of illness suffered. One third, (30.3%) of the
children experienced some form of illness over the 2 - weeks’ recall period. From
the findings, fever (62.4%) was the dominant illness followed by cough and diarrhea
at 58.4% and 27.4% respectively. Other reported illnesses are as shown in the Figure
5 below.
23
Figure 5: Common illnesses reported
Regarding other illnesses, vomiting (16.7%), stomatitis (16.7%) and meningitis
(16.7%) were the most common illnesses specified by caregivers. Other specified
illnesses are as shown below.
3.3.2 Health seeking behaviour
The health seeking behavior of caregivers whose children were reportedly ill over
the recall period was assessed. Out of those interviewed only (48.2%) of the
caregivers sought assistance. Health service utilization among caregivers was higher
in public health facilities (55.8%) followed by private clinics (30.5%) and
pharmacies/chemist (6.3%). It is apparent most caregivers who sought assistance
preferred medical (formal) over traditional and religious (non-formal) interventions
in the treatment of their children.
62.40%58.4%
27.4%
6.1%3.1%
6.1%
0%
10%
20%
30%
40%
50%
60%
70%
Fever Cough Diarrhoea Skininfection
Eyeinfection
Others
Type of illness
24
Figure 6: Health and seeking behavior
3.3.3 Child immunization, Vitamin A supplementation, and deworming
Immunization coverage for measles was assessed among children aged 9-59 months
based on both recall and health record documentation. The survey findings
established an overall proportion of children vaccinated against measles was 43.6 %
with 37.5% based on recall and 6.1% verification by card. In essence, measles
coverage was below average rendering the population more vulnerable to infections
due to the high number of unvaccinated children. Similarly, Vitamin A
supplementation and deworming were also low at 29.4% and 31.9% respectively.
Therefore, based on the WHO recommended coverage of 80%, it is evident from the
findings Vitamin A supplementation, deworming and immunization coverage in
Lascanod district are low hence the need for a scale up to meet public health
significance levels. Evidence has shown the efficacy of Vitamin A supplementation
in the control of child morbidity and mortality in children13.
13 Beaton, G. H., Martorell, R., Aronson, K. J., Edmonston, B., McCabe, G., Ross, A. C., & Harvey, B. (1993). Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries.
3.2%
6.3%
30.5%
55.8%
1.1%
3.2%
0% 10% 20% 30% 40% 50% 60%
Health seeking behavior
Traditional healer
Religious leaders
Public healthfacilities/hospital
Private clinic
Phamarcy/chemist
CHW/CommunityNutrition worker
25
Figure 7: VAS, Deworming and Measles coverage
4.0 CONCLUSION
The Lascanod district SMART survey recorded a GAM prevalence of 10.2 % (7.2 - 14.3
95% C.I.). This is a serious GAM prevalence according to WHO emergency thresholds
(10-14%). Despite this study being a district survey, the serious levels of malnutrition
are similar to the recent FSNAU assessments done in June-July in Sool Region that
recorded a GAM prevalence of 10.8% (8.2-14.1). With this GAM prevalence, there is
need for concerted efforts to scale up nutrition interventions that aim at prevention
and treatment of acute malnutrition to abate the levels from reaching critical. The
reported prevalence of malnutrition by MUAC of 2.3% was below the Gu 2019
prevalence (4%). The prevalence of underweight and stunting were both low
according to WHO thresholds recording 5.9 % (3.8 - 8.9 95% C.I.) and 3.4 % (2.0 - 5.8
95% C.I.) respectively.
The reported child morbidity showed that (30.3%) of the children had fallen sick two
weeks prior to the survey with the most dominant illnesses being fever (62.4%),
cough (58.4%) and diarrhea (27.4%). Of much concern is the health seeking behaviour
where more than half of the caregivers with sick children did not seeking any form
of medical assistance. Those who sought assistance mostly visited public health
facilities (55.8%) and private clinics (30.5%).
29.40%31.90%
43.60%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Vitamin A coverage (6-59months)
Deworming coverage (12-59months)
Measles coverage (9-59months)
Immunizations and Vaccination
26
Vitamin A supplementation of children 6-59 months and deworming recorded low
coverage of (29.4%) and (31.9 %) respectively. Similarly, measles coverage by both
card and recall was also very low with only (43.6%) being immunized. The coverage
of Vitamin A supplementation, deworming and measles are below the 80% WHO
target.
5.0 RECOMMENDATIONS
1. CARE should continue implementing all components of CMAM program and
scale up community mapping for outreach locations and collaborative
outreach health care services in hard to reach locations. The implementation
should integrate all key components in each treatment centre. Attention
should be given to notable ‘pockets of malnutrition’ in Bocame, Xidh xidh and
Goljano villages.
2. Strengthen Maternal, Infant and Young Child nutrition to address the
associated long term impacts of malnutrition on mothers and children.
3. Intensify immunization campaigns in coordination with key stakeholders in
the district to promote Vitamin A supplementation, immunization and
deworming to meet global coverage targets. It should be conducted by
implementing partners through static and mobile facilities to improve
coverage.
4. Enhance WASH programs to include hygiene and sanitation approaches such
as PHAST (Participatory Hygiene and Sanitation Transformation), CHAST
(Children Hygiene and Sanitation Transformation) and CLTS (Community Led
Total Sanitation). This recommendation is based on diarrhoeal diseases and
field observation on lack of sanitation facilities in some of the villages.
5. Enhance awareness on importance of health records among caregivers and
collaborate with other partners and the MoH to support documentation of
healthcare delivery services especially births and immunization coverage.
Most births in Lascanod were reported by recall.
6. Conduct integrated Knowledge, attitudes, practices and behavior survey to
understand factors influencing health seeking behaviors and health service
utilization in the district. Education levels, socio-economic factors, physical
and cultural beliefs are likely to influence health seeking behavior and health
service utilization of caregivers in the community.
27
6.0 ANNEXES
Annex I: Plausibility Report
Plausibility check for: SOML_201910_CARE_LAASCANOD.as Standard/Reference used for z-score calculation: WHO standards 2006
(If it is not mentioned, flagged data is included in the evaluation. Some parts of this
plausibility report are more for advanced users and can be skipped for a standard
evaluation)
Overall data quality
Criteria Flags* Unit Excel. Good Accept Problematic Score
Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5
(% of out of range subjects) 0 5 10 20 0 (1.9 %)
Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.176)
Age ratio(6-29 vs 30-59) Incl p >0.1 >0.05 >0.001 <=0.001
(Significant chi square) 0 2 4 10 0 (p=0.774)
Dig pref score - weight Incl # 0-7 8-12 13-20 > 20
0 2 4 10 2 (8)
Dig pref score - height Incl # 0-7 8-12 13-20 > 20
0 2 4 10 0 (7)
Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20
0 2 4 10 2 (8)
Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20
. and and and or
. Excl SD >0.9 >0.85 >0.80 <=0.80
0 5 10 20 0 (1.06)
Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 0 (0.16)
Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6
0 1 3 5 1 (-0.26)
Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001
0 1 3 5 3 (p=0.001)
OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 8 %
The overall score of this survey is 8 %, this is excellent.
28
Annex II: Sampled Clusters
Geographical unit Population size Cluster
Adhicadeye 640 1
Tuulo samakaab 850 2
Yagori 820 RC
kalax 140 laasadaar 860 3
Balli hadhac 600 4
Dhumay 600 5
Dhagax iskuraw 310 Dhabansaar 400 Xidh xidh 720 6
Higlada 480 Karin gorfood 1200 7,8
Bocame 5210 RC,9,10,11,12
Buulal 210 Qabri bayax 380 13
Qoriley 3900 14,15,16,RC,17
Afgooye 240 Goljano 740 18
Shululux 850 RC
Yeyle 990 19
Yaaheel 50 20
hadhwanaag 120 Dalyare 590 Ganbadhe 740 21
Kabaalka xargaga 590 22
Saaxa gebo gebo 450 23
Xalxaliye 60 Canjiid 240 Dabataad 730 24
Dharkeyn 912 25
Kalabeydh 4100 26,27,28,29,30
Saaxdheer 600 31
Dan 400 32
Fardhidin 750 33
Karindabeylweyn 739 34
29
Annex III: Standardization Test Report
Standardisation test results
Precision Accuracy OUTCOME
Weight subjects Mean SD max Technical error TEM/mean
Coef of reliability
Bias from superv
Bias from median result
# Kg kg kg TEM (kg) TEM (%) R (%) Bias (kg) Bias (kg)
Supervisor 10 13.1 2.4 0.2 0.07 0.5 99.9 - 1.24 TEM acceptable R value good Bias reject
Enumerator 1 10 13.2 2.4 0.4 0.12 0.9 99.7 0.05 1.28 TEM poor R value good Bias reject
Enumerator 2 10 13.1 2.3 0.7 0.17 1.3 99.5 -0.05 1.19 TEM poor R value good Bias reject
Enumerator 3 10 13.1 2.3 0.7 0.19 1.5 99.3 -0.05 1.19 TEM poor R value good Bias reject
Enumerator 4 10 13.1 2.4 0.2 0.09 0.7 99.9 -0.02 1.22 TEM acceptable R value good Bias reject
Enumerator 5 10 13.2 2.4 0.5 0.14 1.1 99.7 0.02 1.26 TEM poor R value good Bias reject
Enumerator 6 10 13.1 2.4 0.5 0.13 1 99.7 0.01 1.25 TEM poor R value good Bias reject
enum inter 1st 6x10 13.1 2.3 - 0.11 0.8 99.8 - - TEM acceptable R value good
enum inter 2nd 6x10 13.2 2.4 - 0.17 1.3 99.5 - - TEM acceptable R value good
inter enum + sup 7x10 13.1 2.3 - 0.13 1 99.7 - - TEM acceptable R value good
TOTAL intra+inter 6x10 - - - 0.2 1.6 99.2 0 1.23 TEM acceptable R value good Bias reject
TOTAL+ sup 7x10 - - - 0.19 1.5 99.3 - - TEM acceptable R value good
Height subjects Mean SD max Technical error TEM/mean
Coef of reliability
Bias from superv
Bias from median result
# Cm cm cm TEM (cm) TEM (%) R (%) Bias (cm)
Bias (cm)
Supervisor 10 93.7 7.9 1.6 0.57 0.6 99.5 - 1.21 TEM acceptable R value good Bias poor
Enumerator 1 10 93.5 8.2 2.4 0.75 0.8 99.2 -0.19 1.01 TEM poor R value good Bias poor
Enumerator 2 10 92.5 7.9 2 0.67 0.7 99.3 -1.18 0.03 TEM poor R value good Bias good
Enumerator 3 10 94 7.1 18 4.12 4.4 66.5 0.26 1.46 TEM reject R value reject Bias reject
30
Enumerator 4 10 93.4 8.1 2 0.68 0.7 99.3 -0.26 0.94 TEM poor R value good Bias poor
Enumerator 5 10 93.7 8.2 4 1.03 1.1 98.4 -0.02 1.19 TEM reject R value acceptable Bias poor
Enumerator 6 10 93.2 8 1.3 0.43 0.5 99.7 -0.46 0.75 TEM acceptable R value good Bias poor
enum inter 1st 6x10 93.5 7.7 - 2.5 2.7 89.4 - - TEM reject R value reject
enum inter 2nd 6x10 93.3 7.9 - 0.73 0.8 99.2 - - TEM acceptable R value good
inter enum + sup 7x10 93.4 7.8 - 1.52 1.6 95.1 - - TEM reject R value acceptable
TOTAL intra+inter 6x10 - - - 2.58 2.8 88.9 -0.31 0.94 TEM reject R value reject Bias poor
TOTAL+ sup 7x10 - - - 2.41 2.6 90.4 - - TEM reject R value poor
MUAC subjects Mean SD max Technical error TEM/mean
Coef of reliability
Bias from superv
Bias from median result
# Mm mm mm TEM (mm) TEM (%) R (%)
Bias (mm)
Bias (mm)
Supervisor 10 156.8 12.2 8 2.89 1.8 94.4 - 4.75 TEM poor R value poor Bias reject
Enumerator 1 10 156.1 11 16 4.8 3.1 80.8 -0.6 4.15 TEM reject R value reject Bias reject
Enumerator 2 10 153.8 11.7 10 3.47 2.3 91.2 -3 1.75 TEM reject R value poor Bias acceptable
Enumerator 3 10 150.2 10.3 12 4.28 2.8 82.7 -6.55 -1.8 TEM reject R value reject Bias good
Enumerator 4 10 156.9 12.6 8 3.46 2.2 92.4 0.15 4.9 TEM reject R value poor Bias reject
Enumerator 5 10 153.8 11.7 9 3.69 2.4 90 -3 1.75 TEM reject R value reject Bias acceptable
Enumerator 6 10 151.4 10 11 3.81 2.5 85.6 -5.4 -0.65 TEM reject R value reject Bias good
enum inter 1st 6x10 154 11.3 - 3.95 2.6 87.8 - - TEM reject R value reject
enum inter 2nd 6x10 153.4 11.3 - 5 3.3 80.4 - - TEM reject R value reject
inter enum + sup 7x10 154.1 11.4 - 4.38 2.9 84.9 - - TEM reject R value reject
TOTAL intra+inter 6x10 - - - 5.99 3.9 71.7 -3.07 2.12 TEM reject R value reject Bias poor
TOTAL+ sup 7x10 - - - 5.82 3.8 73.9 - - TEM reject R value reject
31
Annex IV: Calendar of Events
LAASCANOD SMART SURVEY 2019, CALENDAR OF EVENTS
MONTH SEASONS 2014 2015 2016 2017 2018 2019
January 57 45 33 21 9
Diraaac ( Dry season)
Restaurant attack in Liido
Doorashii Barlamaanka Somalia
Sanadka cusub
Doorashii Puntland Sanadka Cusub Drought of sima Booqashadii farmaajo and rape and killing asha ilyas in Galkacyo
February 56 44 32 20 8
IGADmeeting in moadisho
Dabaaldagii Mowliidka, Daalo airline explosiion and farmajo election
Doorashadi Farmaajo
agreement between qayad and Baharsame
March 55 43 31 19 7
Death of former Somalia PM, Death of Pf. Mohamed Tubeel
Magclay war and hottest month of jiilaal
Dagaalkii Suuj iyo Garmaal,and selection of primenister Hassan Ali Khayre
Puntlant state treasurer killed in Galkacyo
April Gu 54 42 30 18 6
32
Garisa Collage attack
Explossion in Garowe killing UN staff
Soondheere and outbreak of acute water diarhea at sool, sanaa,and togdheer
Iclaaminti dagaal ka dhana alshabab
Dagaalkii Tuko raq
beginning of GU season
Heavy rains-Flooding
May 52 41 29 17 5
Soon dheere and Soamliland indepence day
Soon dheere and independence day of somaliland
Bilowgii Bisha Ramadan and somaliland independence Day.
Bilowgii Bishii Ramdan and Somaliland Independence Day
Maalinka dhalinyada Somalia
Maalinka dhalinyada Somalia
Maalinka dhalinyada Somalia
Maalinka dhalinyada Somalia
June 52 40 28 16 4
Bilowgii Bishii Ramadan
Bilowgii Bishii Ramadan
Idd fitri Idd Fitri, June 26th
26-Jun 26-Jun somali republic day Afurur millitary base attacked
July
Xagaa
51 39 27 15 3
Kowdii Luuliyo and idd fitr
Kowdii Luuliyo Kowdii Luuliyo( union nation day)
Kowdii Luuliyo
death MP sado ali Idd Fitri, Dabshid
August 50 38 26 14 2
Aasaaska Puntland Aasaaska Puntland Aasaaska Puntland Aasaaska Puntland
Soon fur and election of jubaland
Conflict between Rerbiciidya & Dhulbahanite and mid of xagaa season
Idd Adha
September 49 37 25 13 1
33
Idd ADHA Bishii Sakada Idd Adha
idd Adha Carafa
October
Deyr
48 36 24 12 0
islamic year Bishii Sakada soobe Explosion celebration of 21st october for miletry conducted addministrion of somalia
Burtinle Mayor election and lack of Dayr rain
Drought
November 59 47 35 23 11
Duufaanihii 2013 Bishii Sakada and death of former somali journalism called awke
Fighting between puntland & Golmudug
Drought and presidential of Somaliland
December 58 46 34 22 10
campaign kii doorashooyinka Puntalnd
mawliid Day ( celebration of birth prophet mohamed)
mawliid Day ( celebration of birth prophet mohamed)
Drought