SMART Survey Preliminary Results Ministry of Public Health and Population Hadhramout Governorate Health Office Supported by UNICEF Hadhramout Governorate 24 November – 9 December 2018

Executive Summary Between 24 November and 9 December 2018, a Nutrition and Mortality Survey conducted in the two zones of Hadhramout, the Coastal Zone and the Valleys & Desert Zone. In the Coastal Zone, a total of 630 households have been approached with absence and refusal rate of 0.95%. In the Valleys & Desert Zone, a total of 615 households have been approached with absence and refusal rate of 0.49%. All nomadic settlements were excluded from the frames oin both zones before identifying the clusters. Six teams carried out the survey in 14 working days.

Executive Summary The plan for the Coastal Zone is to do the survey in 42 clusters. The plan for the Valleys & Desert Zone is to do the survey in 42 clusters. One cluster dropped due to an accident happened for the survey team vehicle in which team members injured and the vehicle extremely damaged. The selection of clusters followed PPS. Primary sampling units in the sampling frames are villages in in rural settings and Haras in cities as previously presented in the survey protocol

Executive Summary The planned number of households per cluster is 15 HHs in each survey zone. The selection of households at the cluster level followed the SRS method after households listing. Segmentation was considered for large clusters. The selection of sample segments were made randomly using PPS.

Summary of Key Anthropometric Findings - Coastal Zone In the Coastal Zone, number of children in the surveyed HHs was 638 children distributed as the following: 93 children aged 0 to less than 6 months. 91 of them were measured for their weight. 545 children aged 6 to less than 60 months. 542 of them were measured for their height and weight. Levels of GAM and SAM based on Weight-for-Height and the presence of bilateral oedema among children aged 6 – 59 months were found as 12.5% (9.5 - 16.3 95% CI) and 1.5% (0.8 - 2.7 95% CI) respectively. No oedema case was found

Summary of Key Anthropometric Findings - Coastal Zone Levels of GAM and SAM based on MUAC and the presence of bilateral oedema among children aged 6 – 59 months were found as 2.6% (1.6 - 4.1 95% CI) and 0.6% ( 0.2 - 1.7 95% CI) respectively. No oedema case was found Combined GAM and SAM based on admission criteria of WHZ and/or MUAC and/or oedema were found as 13.3% (10.7 - 16.4 95% CI) and 1.8% (1.0 - 3.4 95% CI) respectively.

Summary of Key Anthropometric Findings - Coastal Zone levels stunting and severe stunting among children aged 6 – 59 months were found as 22.7% (17.7- 28.6 95% CI) and 6.1% (4.1 - 9.0 95% CI) respectively. Levels of underweight and severe underweight among children aged 0 – 59 months were found as 21.2% (17.0 - 26.2 95% CI) and 5.0% (2.7 - 8.8 95% CI) respectively. Summary findings have excluded extreme values (SMART Flags +/- 3SD from the observed mean). Interpretation of measurements is based on WHO Growth Standards 2006.

Summary of Key Anthropometric Findings - Valleys & Desert Zone In the Valleys & Desert Zone, number of children in the surveyed HHs was 696 children distributed as the following: 82 children aged 0 to less than 6 months. All of them were measured for their weight. 612 children aged 6 to less than 60 months. 610 of them were measured for their height and weight. 2 children aged 60 months and above who have been measured for their height and weight. Levels of GAM and SAM based on Weight-for-Height and the presence of bilateral oedema among children aged 6 – 59 months were found as 8.5% (6.6 -10.7 95% CI) and 0.8% (0.4 - 1.9 95% CI) respectively. No oedema case was found

Summary of Key Anthropometric Findings - Valleys & Desert Zone Levels of GAM and SAM based on MUAC and the presence of bilateral oedema among children aged 6 – 59 months were found as 2.5% (1.5- 4.0 95% CI) and 1.0% ( 0.5 - 2.1 95% CI) respectively. No oedema case was found Combined GAM and SAM based on admission criteria of WHZ and/or MUAC and/or oedema were found as 9.5% (7.4 - 12.1 95% CI) and 1.6% (0.9 - 3.0 95% CI) respectively.

Summary of Key Anthropometric Findings - Valleys & Desert Zone levels stunting and severe stunting among children aged 6 – 59 months were found as 22.4% (16.9 - 29.2 95% CI) and 5.9% (3.9- 8.8 95% CI) respectively. Levels of underweight and severe underweight among children aged 0 – 59 months were found as 17.5% (13.5 - 22.4 95% CI) and 2.6% (1.5 - 4.5 95% CI) respectively. Summary findings have excluded extreme values (SMART Flags +/- 3SD from the observed mean). Interpretation of measurements is based on WHO Growth Standards 2006.

Lahj Governorate map The Valleys & Desert Zone The Coastal Zone

Overall and specific objectives Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Governorate and key determinants Specific Objectives: To assess levels of acute malnutrition by WHZ criteria among children aged 6 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess levels of acute malnutrition by MUAC criteria among children aged 6 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To determine the combined acute malnutrition in children aged 6 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess levels of stunting among children aged 6 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. Note:

Overall and specific objectives Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Hadhramout Governorate and key determinants Specific Objectives: To assess levels of underweight among children aged 0 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the routine polio vaccination coverage among children aged 3 to 59 months, measles vaccination coverage among children aged 9 to 59 months and vitamin A supplementation coverage within the last 6 months prior to survey among children aged 6 to 59 months in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the level of acute malnutrition among women at child bearing age (15 to 49 years) in Coastal Zone and Valleys & Desert Zone Zone of Hadhramout Governorate. Note:

Overall and specific objectives Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Hadhramout Governorate and key determinants Specific Objectives: To assess the food consumption scoring (FCS) in past 7 days in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the mean coping strategy index (CSI) of households in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the household practice of a set of stress, crisis and emergency coping strategies in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the household head losing of income sources in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate due to the current conflict crisis. Note:

Overall and specific objectives Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Hadhramout Governorate and key determinants Specific Objectives: To assess the monthly household expenditure of households in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the education level of household caregivers in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the main household drinking water source, the quality classification of the water sources and the cleanness of drinking water storage in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the household latrine type and the quality classification of sanitation facilities in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. Note:

Overall and specific objectives Overall Objective: The overall objective of the survey was to assess the current nutrition situation in Hadhramout Governorate and key determinants Specific Objectives: To assess the practice of handwashing with water and soap (or soap alternatives) by household care giver after toilet and before the meal in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate. To assess the crude and under-five mortality rates in Coastal Zone and Valleys & Desert Zone of Hadhramout Governorate using the recall periods of 98.5 and 106.5 days respectively. Note:

Sample Size: Lahj Governorate – Coastal Zone Number of HH planned Number of HH surveyed % surveyed /planned Number of children 6-59 months planned Number of children 6-59 months surveyed 630 624 99.0% 488 545 (542 measured) 112% (111% for measured) Number of clusters planned Number of clusters surveyed % clusters/ planned 42 100%

Sample Size: Lahj Governorate – Valleys & Desert Zone Number of HH planned Number of HH surveyed % surveyed /planned Number of children 6-59 months planned Number of children 6-59 months surveyed 630 612 97.1% 488 615 (612 measured) 126% (125% for measured) Number of clusters planned Number of clusters surveyed % clusters/ planned 42 41 97.6%

Plausibility Check – Coastal Zone  

Plausibility Check – Valleys & Desert Zone  

Age and Sex Distribution (Table 3.1) Coastal Zone  AGE (mo) Boys (n) % Girls (n) Total (n) Ratio (Boy:Girl) 0-5 53 57.0 40 43.0 93 14.6 1.3 6-17 65 48.5 69 51.5 134 21.0 0.9 18-29 71 53.4 62 46.6 133 20.8 1.1 30-41 57 44.9 70 55.1 127 19.9 0.8 42-53 47 41 88 13.8 54-59 32 50.8 31 49.2 63 9.9 1.0 Total 325 50.9 313 49.1 638 100

Age and Sex Distribution (Table 3.1) Valleys & Desert Zone  AGE (mo) Boys (n) % Girls (n) Total (n) Ratio (Boy:Girl) 0-5 40 48.8 42 51.2 82 11.8 1.0 6-17 81 55.5 65 44.5 146 21.0 1.2 18-29 76 50.3 75 49.7 151 21.8 30-41 66 49.6 67 50.4 133 19.2 42-53 60 48.4 64 51.6 124 17.9 0.9 54-59 31 53.4 27 46.6 58 8.4 1.1 Total 354 51.0 340 49.0 694 100

Acute malnutrition by WHZ (Table 3.2) Coastal Zone   All n = 537 Boys n = 267 Girls n = 270 Prevalence of global malnutrition (<-2 z-score and/or oedema) (67) 12.5 % (9.5 - 16.3 95% C.I.) (40) 15.0 % (10.4 - 21.1 95% C.I.) (27) 10.0 % (6.8 - 14.5 95% C.I.) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) (59) 11.0 % (8.1 - 14.7 95% C.I.) (36) 13.5 % (9.4 - 19.0 95% C.I.) (23) 8.5 % (5.4 - 13.2 95% C.I.) Prevalence of severe malnutrition (<-3 z-score and/or oedema) (8) 1.5 % (0.8 - 2.7 95% C.I.) (4) 1.5 % (0.6 - 3.9 95% C.I.) (0.6 - 3.8 95% C.I.) The prevalence of oedema is 0.0 %

Acute malnutrition by WHZ (Table 3.2) Valleys & Desert Zone   All n = 602 Boys n = 309 Girls n = 293 Prevalence of global malnutrition (<-2 z-score and/or oedema) (51) 8.5 % (6.6 - 10.7 95% C.I.) (29) 9.4 % (6.4 - 13.5 95% C.I.) (22) 7.5 % (5.2 - 10.8 95% C.I.) Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema) (46) 7.6 % (5.8 - 9.9 95% C.I.) (26) 8.4 % (5.7 - 12.2 95% C.I.) (20) 6.8 % (4.4 - 10.3 95% C.I.) Prevalence of severe malnutrition (<-3 z-score and/or oedema) (5) 0.8 % (0.4 - 1.9 95% C.I.) (3) 1.0 % (0.3 - 3.0 95% C.I.) (2) 0.7 % (0.2 - 2.7 95% C.I.) The prevalence of oedema is 0.0 %

Acute malnutrition by MUAC (Table 3.5) Coastal Zone   All n = 542 Boys n = 271 Girls Prevalence of global malnutrition (< 125 mm and/or oedema) (14) 2.6 % (1.6 - 4.1 95% C.I.) (8) 3.0 % (1.4 - 6.0 95% C.I.) (6) 2.2 % (1.0 - 4.6 95% C.I.) Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema) (11) 2.0 % (1.2 - 3.4 95% C.I.) (5) 1.8 % (0.8 - 4.2 95% C.I.) Prevalence of severe malnutrition (< 115 mm and/or oedema) (3) 0.6 % (0.2 - 1.7 95% C.I.) (3) 1.1 % (0.4 - 3.3 95% C.I.) (0) 0.0 % (0.0 - 0.0 95% C.I.) The prevalence of oedema is 0.0 %

Acute malnutrition by MUAC (Table 3.5) Valleys & Desert Zone   All n = 609 Boys n = 312 Girls n = 297 Prevalence of global malnutrition (< 125 mm and/or oedema) (15) 2.5 % (1.5 - 4.0 95% C.I.) (7) 2.2 % (1.1 - 4.4 95% C.I.) (8) 2.7 % (1.4 - 5.1 95% C.I.) Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema) (9) 1.5 % (0.7 - 2.9 95% C.I.) (6) 1.9 % (0.9 - 4.1 95% C.I.) (3) 1.0 % (0.3 - 3.1 95% C.I.) Prevalence of severe malnutrition (< 115 mm and/or oedema) (6) 1.0 % (0.5 - 2.1 95% C.I.) (1) 0.3 % (0.0 - 2.3 95% C.I.) (5) 1.7 % (0.7 - 3.9 95% C.I.) The prevalence of oedema is 0.0 %

Underweight Z-scores (Table 3.7) Coastal Zone   All n = 626 Boys n = 318 Girls n = 308 Prevalence of underweight (<-2 z-score) (133) 21.2 % (17.0 - 26.2 95% C.I.) (79) 24.8 % (19.4 - 31.3 95% C.I.) (54) 17.5 % (12.7 - 23.8 95% C.I.) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) (102) 16.3 % (13.6 - 19.4 95% C.I.) (64) 20.1 % (16.2 - 24.7 95% C.I.) (38) 12.3 % (8.8 - 17.1 95% C.I.) Prevalence of severe underweight (<-3 z-score) (31) 5.0 % (2.7 - 8.8 95% C.I.) (15) 4.7 % (2.5 - 8.9 95% C.I.) (16) 5.2 % (2.5 - 10.3 95% C.I.)

Underweight Z-scores (Table 3.7) Valleys & Desert Zone   All n = 690 Boys n = 353 Girls n = 337 Prevalence of underweight (<-2 z-score) (121) 17.5 % (13.5 - 22.4 95% C.I.) (68) 19.3 % (14.8 - 24.7 95% C.I.) (53) 15.7 % (11.3 - 21.5 95% C.I.) Prevalence of moderate underweight (<-2 z-score and >=-3 z-score) (103) 14.9 % (11.4 - 19.3 95% C.I.) (58) 16.4 % (12.1 - 21.8 95% C.I.) (45) 13.4 % (9.5 - 18.5 95% C.I.) Prevalence of severe underweight (<-3 z-score) (18) 2.6 % (1.5 - 4.5 95% C.I.) (10) 2.8 % (1.4 - 5.7 95% C.I.) (8) 2.4 % (1.2 - 4.7 95% C.I.)

Stunting Z-scores (Table 3.9) Coastal Zone   All n = 387 Boys n = 181 Girls n = 206 Prevalence of stunting (<-2 z-score) (122) 22.7 % (17.7 - 28.6 95% C.I.) (68) 25.4 % (19.6 - 32.2 95% C.I.) (54) 20.0 % (14.7 - 26.6 95% C.I.) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) (89) 16.5 % (12.5 - 21.6 95% C.I.) (49) 18.3 % (13.4 - 24.4 95% C.I.) (40) 14.8 % (10.6 - 20.4 95% C.I.) Prevalence of severe stunting (<-3 z-score) (33) 6.1 % (4.1 - 9.0 95% C.I.) (19) 7.1 % (3.9 - 12.6 95% C.I.) (14) 5.2 % (3.3 - 8.1 95% C.I.)

Stunting Z-scores (Table 3.9) Valleys & Desert Zone   All n = 606 Boys n = 310 Girls n = 296 Prevalence of stunting (<-2 z-score) (136) 22.4 % (16.9 - 29.2 95% C.I.) (81) 26.1 % (19.7 - 33.7 95% C.I.) (55) 18.6 % (13.1 - 25.7 95% C.I.) Prevalence of moderate stunting (<-2 z-score and >=-3 z-score) (100) 16.5 % (12.5 - 21.5 95% C.I.) (61) 19.7 % (14.8 - 25.7 95% C.I.) (39) 13.2 % (9.3 - 18.4 95% C.I.) Prevalence of severe stunting (<-3 z-score) (36) 5.9 % (3.9 - 8.8 95% C.I.) (20) 6.5 % (3.8 - 10.8 95% C.I.) (16) 5.4 % (3.4 - 8.6 95% C.I.)

Mean Z-scores, DEFF and Excluded Subjects (Table 3.13) - Coastal Zone Indicator n Mean z-scores ± SD Design Effect (z-score < -2) z-scores not available* z-scores out of range (SMART) Children aged 6 to 59 months Weight-for-Height 537 -0.76±0.06 1.40 4 Height-for-Age 538 -1.16±1.16 2.24 3 Children aged 0 to 59 months Weight-for-Age 626 -1.13±1.08 1.97 5 7 * contains for WHZ and WAZ the children with oedema.

Mean Z-scores, DEFF and Excluded Subjects (Table 3 Mean Z-scores, DEFF and Excluded Subjects (Table 3.13) - Valleys & Desert Zone Indicator n Mean z-scores ± SD Design Effect (z-score < -2) z-scores not available* z-scores out of range (SMART) Children aged 6 to 59 months Weight-for-Height 602 -0.66±0.97 1.00 2 8 Height-for-Age 606 -1.23±1.09 3.28 4 Children aged 0 to 59 months Weight-for-Age 690 -1.09±0.98 2.30 * contains for WHZ and WAZ the children with oedema.

Mortality Results – Coastal Zone Parameter Result Number of deaths during recall period 17 Recall period (days) 98.5 days CMR (total deaths/10,000 people / day): 0.39 (0.23-0.66 95% CI) U5MR (deaths in children under five/10,000 children under five / day) 0.33 (0.08-1.31 95% CI) Mean household size 7.9

Mortality Results – Valleys & Desert Zone Parameter Result Number of deaths during recall period 8 Recall period (days) 106.5 days CMR (total deaths/10,000 people / day): 0.13 (0.07-0.25 95% CI) U5MR (deaths in children under five/10,000 children under five / day) 0.14 (0.02-1.01 95% CI) Mean household size 9.3