Christian Mission Aid CMA - Action Against Hunger

5.I. EXECUTIVE SUMMARY.I.1. ContextAthoc: Baidit and Jalle II Payams are located in South Bor County in the Jonglei Upper Nile Region. The Countycomprises of six payams namely: Jalle, Baidit, Makuach, Anyidi, Kolnyang and Bor town. The river Mabor Golcuts across the county and provides grazing areas, water and fishing points. The Nile River on the eastern sideof the County offers good fishing opportunities and grazing areas for cattle. The area is generally flat and madeof black cotton and sandy soils. The inhabitants belong to the Dinka Bor clan.The County faced the last insecurity incident in 2000 when the militia group made aerial bombardments inAnyidi, Makuach and Jalle payams; unspecified number of people was injured and properties were destroyedduring the incident. During the recent years, apart from sporadic cattle raids in the location, security has beenrelatively stable.The NGO’s operating in the location are: CMA, WHO, FAO, CRS, Southern Sudan Agricultural revitalizationProgram (SARP), Penykou Agency for Relief and Development (PARAD), WFP and CARE. CMA operates sixPrimary Health Care Units (PHCUs) and one Primary Health Care Center (PHCC) that provides in-patientservices and tuberculosis clinic. The PHCU’s are located in Tong, Makol cuei, Akuei Deng, Apoor, Mathiang,and Kolmarek. There are three non-functional PHCUs located in Kuei, Yolmuchel and Jalle II. CRS, FAO andSARP provide capacity building in fishing. WFP provides relief food; the last distribution was done in April 2005.WHO provides polio vaccinations services. CARE and PARAD implement water project, while GTZ isimplementing road rehabilitation and dyke construction projects supported by WFP.Households have access to potable water from borehole facilities; however, in some locations, households gettheir water from unsafe sources, such as swamps and rivers. A few latrines were observed mainly in church,local authority and health centre compounds. Waste disposal in both payams is poor.Food stocks were not observed in most of the visited households during the time of survey. According to thecommunity, the last harvest in October/ November 2004 was poor as compared to 2003 harvest due to laterains, heavy wind and attack from birds. This concurs with STARBASE 2004 report, which estimated that poorhouseholds in Bor were to experience a 15- 20% food deficit. The most affected are the pure small-scale cropfarming households. The community reported that the maize harvested last October had been depleted andwere surviving on the little sorghum harvested in November 2004 and on wild food. The last WFP distributionwas done in April 2005 and the community reported that these have been exhausted as well.Majority of families seek medical attention from local traditional healers first and only consult at the PHCC/Uwhen the condition is severe. Hygiene and sanitary practices are generally poor in the community; there is highprevalence of diarrhoeal diseases as reported by CMA..I.2. JustificationACF-USA conducted a nutritional survey in Padak in May 2002 which revealed GAM and SAM rates of 37.7%and 6.6%, respectively. In March 2003, the nutrition survey by TEARFUND showed malnutrition rates of 20.8%GAM and 2.4% SAM. The ANA report 2004/5 indicates that food security in Bor will be relatively stable due tomarket access, fishing opportunities, and enhanced income. However, poor households are likely to experiencefood deficits due to declined household production and low purchasing power.In May this year, CMA reported 17 cases of severe malnutrition in its PHCC and raised this concern with ACF-USA; consequently, a nutritional survey was carried out.

6.I.3. Objectives• To evaluate the nutritional status of children aged 6 to 59 months.• To estimate the measles immunisation coverage of children aged 9 to 59 months.• To identify groups at higher risk to malnutrition: age group and sex..I.4. MethodologyA two-stage 30 by 30 cluster survey methodology was applied. This sample size was taken to provide theestimates of the prevalence of malnutrition with a 95 % confidence interval. This sampling frame covered allvillages falling within Baidit and Jalle II payams. In each cluster, households were randomly selected andsurveyed. All the children 6 to 59 months of age belonging to the same family, defined as a woman and herchildren, were included in the survey.Data collected during the survey included the following variables:- For the children: age, sex, height, weight, oedema, MUAC, measles vaccination.- Qualitative information to capture food security situation, child care practices, nutrition, and health andsanitation situation were collected through focus group discussions, individual interviews andobservation method.

8high incidences of malaria and diarrhoeal diseases. The combined effect of disease and low food intake rapidlydeteriorated the nutritional status especially among the under 5 year olds.A retrospective mortality survey has been implemented alongside the nutritional survey. Unfortunately, the datacollected was not satisfying, and can be attributed to the methodology that was used. As a result, this indicatoris reported in this the present survey..I.6. Recommendations.I.6.1. Programmatic• A therapeutic feeding program should be immediately implemented to cover the South Bor County, to treatand reduce the risk of mortality among the severely malnourished children. Co-ordination with and amonghumanitarian agencies on ground should be initiated; technical support should be offered by ACF-USA.• Deeper analysis of the health situation should be undertaken by CMA, while enhancing the coverage of itsprimary health care services in the area, ensuring increased access and utilization by the population. ThePHCU’s in Kuei, Yolmuchel and Jalle II should be re-established.• Further assessment and monitoring of the food security situation should be carried out; meanwhile, generalfood aid must be promptly delivered by WFP. Existing food security programs and initiatives should becontinued while further developing its impact potentials.• Capable agencies should support South Bor with projects to increase safe water sources (such as boreholeinstallation) and basic sanitary facilities..I.6.2. On Methodology• To implement in the future surveys the SMART methodology for the collection of data and the analysisof the retrospective mortality rate..II. INTRODUCTIONBaidit and Jalle II Payams are located in South Bor County in the Jonglei Upper Nile Region. The Countycomprises of six payams namely: Jalle, Baidit, Makuach, Anyidi, Kolnyang and Bor town. The river Mabor Golcuts across the county and provides grazing areas, water and fishing points. The Nile River in the eastern sideof the County offers good fishing opportunities and grazing areas for cattle. The area is generally flat and madeof black cotton and sandy soils. The inhabitants belong to Dinka Bor clan.The County faced the last insecurity incident in 2000 when the militia group made aerial bombardments inAnyidi, Makuach and Jalle payams; unspecified number of people was injured and properties were destroyedduring the incident. During the recent years, apart from sporadic cattle raids in the location, security has beenrelatively stable.Several NGO’s are operating in South Bor, covering programs such as primary health care, food security, waterand sanitation, fisheries, livestock health, and road rehabilitation/construction, among others

9In May 2002, ACF-USA conducted a nutritional survey in Padak, which revealed GAM and SAM rates of 37.7%and 6.6%, respectively. Again in March 2003, the nutritional survey by TEARFUND showed persistently highmalnutrition rates of 20.8% GAM and 2.4% SAM. By the end of the 2004, assessment reports (ANA andSTARBASE), indicated that food security in Bor will be relatively stable due to market access, fishingopportunities and enhanced income. However, poor households are likely to experience food deficits due todeclined household production and low purchasing power. A 15- 20% food deficit was projected in 2005, andthe most affected would be the small-scale crop farming households.In the month of May alone, CMA reported 17 cases of severe malnutrition in its PHCC and raised this concernwith ACF-USA. Consequently, a nutritional survey was carried out to determine the current nutritional situationin the area..III. OBJECTIVES• To evaluate the nutritional status of children aged 6 to 59 months.• To estimate the measles immunisation coverage of children aged 9 to 59 months.• To identify groups at higher risk to malnutrition: age group and sex..IV. METHODOLOGYThe survey was conducted in Athoc: Baidit and Jalle II Payams of South Bor County in the Jonglei Upper Nileregion, from 14 th - 30 th June 2005..IV.1. Type of Survey and Sample SizeThe target population of the survey was children 6-59 months of age.The total population of the 30 accessible villages in Baidit/Jalle II payams was estimated at 41,728, giving atarget population of 8,345 children (calculated as 20% of the total population). A two-stage cluster samplingmethodology was used, composed of 30 clusters of at least 30 children in each cluster.Qualitative information to capture food security, childcare practices, nutrition, and health and sanitation situationwas collected through focus group discussion, individual interview and observation methods..IV.2. Sampling MethodologyA two-stage cluster sampling was used:• At the first stage, 30 clusters were randomly selected. Using a random draw, villages were chosen froma list of accessible villages and the clusters assigned accordingly. (See appendix 1 for village list andestimated population). The probability of selection was proportional to the village population size. Eachcluster included a minimum of 30 children.

10• At the second stage, i.e. the selection of the households within each cluster, the standard WHOmethodology was used: a pen was spun while being at the central point of the selected cluster, defininga random direction. All the children 6-59 months of age included in the households encountered in thatdirection were measured..IV.3. Data CollectionDuring the anthropometric survey, for each selected child 6 to 59 months of age, the following information wasrecorded (See appendix 2 for anthropometric questionnaire):• Age: recorded with the help of a local calendar of events (See appendix 4 for calendar of events)• Gender: male or female• Weight: children were weighed without clothes, with a SALTER balance of 25kg (precision of 100g).• Height: children were measured on a measuring board (precision of 0.1 cm). Children less than 85cmwere measured lying down, while those greater than or equal to 85cm were measured standing up.• Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measuredchildren (precision of 0.1cm).• Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to bothfeet.• Measles vaccination: assessed by checking for measles vaccination on EPI cards and askingcaretakers.• Household status: for the surveyed children, households were asked if they were permanent residents,temporarily in the area, or displaced..IV.4. Indicators, Guidelines, and Formulas Used.IV.4.1. Acute Malnutrition‣ Weight-for-Height IndexFor the children, acute malnutrition rates were estimated from the weight for height (WFH) index valuescombined with the presence of oedema. The WFH indices are compared with NCHS 3 references. WFH indiceswere expressed both in Z-score and percentage of the median. The expression in Z-score has true statisticalmeaning and allows inter-study comparison. The percentage of the median on the other hand is commonly usedto identify eligible children for feeding programs.Guidelines for the results in Z-score:• Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of thechild.• Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema.• Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema.Guidelines for the results expressed in percentage according to the median of reference:• Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs.• Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema.• Global acute malnutrition is defined by WFH

11‣ Children’s Mid-Upper Arm Circumference (MUAC)The weight for height index is the most appropriate index to quantify wasting in a population in emergencysituations where acute forms of malnutrition are the predominant pattern. However the mid-upper armcircumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC isonly taken for children with a height of 75 cm and more. The guidelines are as follows:MUAC < 110 mmMUAC ≥ 110 mm and

12land cultivated depends on available farm labour and tools. Most households have few malodas, pangas andsickles; this limits the amount of land that can be cultivated. Returnees have introduced Jembes, which residentcommunities have been receptive to.For most of the year, the Dinka Bor diet consists of sorghum, fish, goat meat and milk. Maize is consumed to alimited extent. Milk is added to the sorghum/maize diet depending on its availability. Fish and goat meat areserved as stews. During the “hunger gap” period, the community depends on wild leaves, lalop, water lily,barter trading in which goats and grass are exchanged for grains, as well as from WFP relief food. Sale offirewood to NGO’s and food for work are also practised.Food stocks were not observed in most of the visited households during the time of survey. According to thecommunity, the last harvest in October/ November 2004 was poor as compared to 2003 harvest due to laterains, heavy wind and attack from birds. This concurs with STARBASE 2004 report, which estimated that poorhouseholds in Bor were to experience a 15- 20% food deficit. The most affected are the pure small-scale cropfarming households. The community reported that the maize harvested last October had been exhausted by thetime of survey and they are now surviving on the little sorghum harvested in November 2004 and on wild food.The last WFP distribution was done in April 2005. The total number of beneficiaries was 13,758 with 50%rations provided for residents and 100% rations for returnees; this was estimated to last for 44 and 30 days,respectively. The food consisted of cereals 152.35 mt, pulses 17.25mt, CSB 10.9 mt, oil 10.719 mt and salt 1.5mt. Each returnee household received; cereals 81kg, pulses 9kg, CSB 9kg, oil 5.4kg and salt 0.92 kg. Eachresident household received; cereals 60kg, pulses 7kg, CSB 3kg, oil 4.35kg and salt 0.53kg. These have beenexhausted.The rivers Magol Bior and Nile provide fishing opportunities, although access is limited due to lack ofappropriate fishing gear, canoes, and presence of crocodiles and hippos. FAO and CRS through SARP arecurrently implementing a capacity building project in fishing. FAO provides training in fishing methods andprocessing, in boat construction and marketing. In fish processing, FAO has introduced smoked fish, sun driedsalty fish and wet salty fish although low access to salt hinders local fishermen from gaining from this programfully. Five shops along the Nile River have been established where fish and fishing equipment such as twinesare sold on cost recovery basis. SARP offers training in technical, business skills and is overseeing theconstruction of fishing school.Livestock kept by the community include cattle, sheep, goat, and chicken. Cattle are kept as a source of milk, fortrading purposes and payment of dowry. On special occasions, cattle, goat and sheep are slaughtered toprovide meat. Milk produced by cow is 2 litres per day during the rainy season and 0.5 litres per day during thedry season. The cattle are usually moved to the cattle camps between the month of May and November. Atpresent, little livestock is kept by households due to massive cattle raids from 1991 to 1994 and sporadically tothis time. The average number of cattle per household is 60-300 for the rich, 5-15 for the middle class and 0-4for the poor; majority of the community is in the middle class. CARE supports veterinary services in the areathrough SRRC on a cost recovery basis..V.3. HealthCMA operates 6 Primary Health Care Units (PHCU’s), one Primary Health Care Centre (PHCC) and atuberculosis clinic. The PHCU’s are located in Tong, Makol cuei, Akuei Deng, Apoor, Mathiang, and Kolmarek,while there are three non-functional PHCUs located in Kuei, Yolmuchel and Jalle II. The services are managedby an expatriate Doctor and 3 Nurses together with 15 community health workers (CHW’s), 1 medical assistant,2 Nurses, 2 Laboratory assistants, 2 Pharmacy assistants and 36 support staff. MEDAIR, which used to operatein the location, trained all technical local staff. 60 Trained birth Attendants assist in the maternal child healthcare while 4 other community health promoters deliver health education to the community.Morbidity reports in the PHCC indicate that malaria, diarrhoea and respiratory infections are the leading causesof consultations. Other reported diseases are skin diseases, malnutrition, intestinal parasites and eye infections.Screening for TB cases is carried out at the centers, and positive cases are referred for treatment in the TBclinic in Baidit. Other services provided are regular EPI (measles, polio, BCG, and DPT) and maternal childhealth care.

13The health seeking practice of the community is still poor. People tend to first seek health care from traditionalhealers before going to the PHCU’s. When recovery in the health unit is not immediate, patients are usuallyreluctant to continue with medication..V.4. Water and SanitationPotable water is accessed from the 125 borehole facilities present in the Athoc Payam, installed by UNICEF,CARE and Pride Africa; CARE is in the process of handing over the water project to PARAD. However, in somelocations, households still depend on water from swamps, pools and rivers due to the inaccessibility toboreholes. Boiling of drinking water is generally not practiced, and the families interviewed stated that boilingchanges the taste of the water. Few latrines were observed mainly in the church, local authority and healthcentre compounds and there is general non-acceptance of using latrines among the population; for the majority,open defecation is practiced..V.5. Mother and Childcare PractisesMost mothers report to be exclusively breastfeeding infants in their first 6-12 months; the belief that earlyweaning causes children to wet while sleeping at night is common. The infants are breastfed on demand whilethe rest of the children are fed three meals per day comprising of milk, porridge, fish and sorghum. Hygieneduring breastfeeding and food preparation was observed to be poor. The quantity and quality of food served tochildren during hunger gap is low with priority given to the husband and visitors followed by children and elders..V.6. Actions Taken by NGO’s and other PartnersThe following table summarizes NGO activities in the area:Table 2 Agencies intervention in Athoc: Jalle 2 and Baidit PayamsAgencyActivitiesWFP • Targeted Food Aid distribution and monitoringCMA • Offers health services in the locationWHO • Polio vaccinationFAO, CRS andSARPCARE• Capacity building in fishing.• Veterinary support through SRRC, Borehole drilling, seed distribution andfarmer training. Handing over water project to PARAD and Agriculture toCRS.GTZ • Road rehabilitation and dyke construction.

14.VI. RESULTS OF THE ANTHROPOMETRICS SURVEY.VI.1. Distribution by Age and Sex916 children have been measured during the survey.Table 3 Distribution by Age and SexAGE(In months)BOYS GIRLS TOTALN % N % N %SexRatio06 – 17 125 43.9 160 56.1 285 31.1 0.7818 – 29 108 52.2 99 47.8 207 22.6 1.0930 – 41 96 52.7 86 47.3 182 19.9 1.1242 – 53 70 53.0 62 47.0 132 14.4 1.1354 – 59 44 40.0 66 60.0 110 12.0 0.67Total 443 48.4% 473 51.6% 916 100% 0.94The overall sex ratio of 0.94 allows the validation of the sample selection, since it lies within the acceptedbenchmark range of 0.80 - 1.20.Figure 1 Distribution by Age and SexFigure 1: Distribution by age and sex, Athoc payams, 200554-5942-53Age in mont30-41BoysGirls18-2906-17-60% -40% -20% 0% 20% 40% 60%PercentageThere is a slight over representation of the 6-17 months and under representation of 42-53 months age groups.This can be attributed to ages given by parents (caretakers) during the survey being approximate and aresubject to strong recall bias. Dates of birth were not known and a local calendar of events had to be used toestimate the ages.

16Figure 2 Weight for Height in Z-Score Distribution, Athoc, 2005Figure 2. Weight for Height Z - score distribution, Athoc, 2005.30252Percentag 0e15ReferenceSexCombined1050-5-4-3-2-10 1 2 3 4 5Z -ScoreThere is a significant displacement of the sample curve to the left of the reference curve, indicating a poorernutritional situation in this population than in the reference one. The mean Z-score of the sample is –1.76. Thestandard deviation of the curve, equal to 0.90, lies within the accepted benchmarks (0.80 – 1.20): it shows thatthe sample is representative of the population.Table 6 Global and Severe Acute Malnutrition by age group in Z-score6-59 months (n = 916) 6-29 months (n =492)Global acute malnutrition 39.3% [34.7%- 44.1%] 39.4% [33.2%- 46.0%]Severe acute malnutrition 5.9% (4.0%- 8.6%] 8.1% [5.1% -12.5%]Statistical comparative analysis of malnutrition rates for children 6-29 months and 30-59 months of age indicatethat there is no significant difference (p>0.05) between the two age groups. The 6-29 and 30-59 months agegroups have equal chances of being malnourished.

17Table 7 Nutritional Status by Sex in Z-scoreNutritional statusDefinitionBoysGirlsN % N %Severe malnutritionWeight for Height < -3 and/oroedema32 7.2 22 4.7Moderate malnutrition -3 ≤ W/H < -2 and no oedema 156 35.2 150 31.7Normal -2 ≤ W/H and no oedema 255 57.6 301 63.6TOTAL 443 48.4% 473 51.6%The statistical analysis shows that there is no significant difference in the prevalence of malnutrition betweenboys and girls (p>0.05). Both boys and girls present equal chances of becoming malnourished.‣ Distribution of Malnutrition in Percentage of the MedianCut-offs for acute malnutrition expressed in percentage of the median are commonly used in determiningadmission criteria in feeding centres.Table 8 Distribution of Weight/Height by age in percentage of the medianAGE(In months)N< 70%N %≥ 70% & < 80%N %≥ 80%N %OedemaN %06-17 285 13 4.6 87 30.5 185 64.9 0 0.018-29 207 1 0.5 45 21.7 161 77.8 0 0.030-41 182 0 0.0 42 23.1 140 76.9 0 0.042-53 132 0 0.0 38 28.8 94 71.2 0 0.054-59 110 0 0.0 28 25.5 82 74.5 0 0.0TOTAL 916 14 1.5% 240 26.2% 662 72.3% 0 0.0%Table 9 Weight for height vs oedemaOedemaYESNO< -2 SD ≥ -2 SDMarasmus/Kwashiorkor0 0.0%Marasmus254 27.7%Kwashiorkor0 0.0%No malnutrition662 72.3%Table 10 Global and Severe Acute Malnutrition by age group in percentage of the median6-59 months (n = 916) 6-29 months (n = 492)Acute global malnutrition 27.7% [23.6%-32.2%] 29.7% [24.0%-36.0%]Global and Severe AcuteMalnutrition by age group inpercentage of the median1.5% [0.6%-3.3%] 2.8% [1.2%-6.1%]Statistical comparative analysis of malnutrition rates for children aged 6-29 months and 30-59 months indicatethat there is no significant difference (p>0.05).

18Table 11 Nutritional status by sex in percentage of medianNutritional statusDefinitionBoysGirlsN % N %Severe malnutrition Weight for Height < 70% or oedema 5 1.1 9 1.9Moderatemalnutrition70% ≤ Weight for Height < 80% 123 27.8 117 24.7Normal Weight for Height ≥80% 315 71.1 347 73.4TOTAL 443 48.4 473 51.6The statistical analysis shows also, as previously, that there is no significant difference in the prevalence ofmalnutrition between boys and girls (p>0.05). Both boys and girls present equal chances of becomingmalnourished..VI.2.2. Nutritional Status of Children below 6 months83 children aged below 6 months, present in the households at the time of the survey were measured in order todetermine their nutritional status. Among the under 6 months old, 51.8% (43) were boys and 48.2 % (40) weregirls.Table 12 Age distribution of the under 6 monthsAge in month N %0 - -1 12 14.52 18 21.73 17 20.54 24 28.95 12 14.5Total 83 100In the Z-score and percentage of median the analysis of the 83 children, only 67 children were included (somecaretakers did not accept their infants to be measured).According to the Weight for Height index in Z-score, there were no severely malnourished infants, 4 (6.0%) weremoderately malnourished, and 63 (94.0%) had good nutritional status. By Weight for Height index in percentageof the median out of the 67 children, 1(1.5%) infant was severely malnourished, 1(1.5%) moderatelymalnourished and 65 (97.0%) had good nutritional status.‣ Feeding PracticesBreast milk was part of the diet of all infants. 86.7 % of the mothers interviewed practiced exclusivebreastfeeding for their infants, while 13.3% had begun weaning before the child reaches 6 months old.Weaning food was usually composed of sorghum porridge and cow milk when available.

19Table 13 Feeding practicesFeeding practices Frequency PercentageExclusive breastfeeding 72 86.7%Mixed feeding (breast milk and weaning food) 11 13.3%Total 83 100%.VI.2.3. Risk to Mortality: Children’s MUACAs MUAC overestimates the level of under nutrition in children less than 1 year old, the analysis refers only tochildren having height equal to or greater than 75cm.Table 14 MUAC distributionCriteriaNutritional statusTotal75 to 90 cmheight90 to 115 cm heightN % N % N %=MUAC=MUAC=135 No malnutrition 383 53.6 112 40.0 271 62.4TOTAL 714 100 280 39.2 434 60.8According to the MUAC measurement, 0.7 % of the children are severely malnourished, and therefore, at highrisk of mortality, 7.0% are moderately malnourished and could easily slip into the severely malnourished group.38.7% are at risk to malnutrition..VI.3. Measles Vaccination CoverageMeasles vaccination is administered from the age of 9 months. Children 9-59 months of age were included inthe analysis. A total of 844 children were included in the analysis.Table 15 Measles vaccination coverageMeasles vaccination N %Proved by Card 273 32.3According to the mother/caretaker 344 40.8Not immunized 227 26.9Total 844 100Only 32.3% of the children were vaccinated against measles as proved by the card, and 40.8% were vaccinatedaccording to the mothers or caretakers. By then, at least 26.9% of the children were not immunized.

20.VI.4. Household StatusTable 16 Household StatusStatus N %Residents 589 98.5Internally Displaced 4 0.7Temporary Residents (ontransit)5 0.8Total 598 100The larger proportion of the surveyed families were residents 589 (98.5%), while 4 (0.7%) were internallydisplaced. 5 (0.8%) of the households were temporarily residing in the location. There was minimal movement ofthe population during the time of the survey..VI.5. Composition of HouseholdsTable 17 Household CompositionAge group N %0 to 59 months 999 29.6Adults 2376 70.4Total 3375 100.0598 households were visited during the survey. The mean number of under 5 year olds per household is 1.61(SD: 0.73) and the mean number of over 5 year olds per household is 3.84 (SD: 2.02)..VII. CONCLUSIONThe nutritional survey was undertaken in 2 of 5 payams of the South Bor County, sampling 916 children 6-59months of age. The analysis of the anthropometrics data showed that 39.3% of the children are acutelymalnourished, 5.9% of which are in the severe form. Among children 6-29 months of age, the GAM rate is39.4% while SAM is 8.1%. These rates are far above the critical threshold of 15% and 4%, respectively, andare the highest obtained from a nutritional survey in South Sudan in the most recent years:Table 18 GAM and SAM RatesGlobal acute MalnutritionSevere Acute MalnutritionMay 2002 March 2003 June 200537.7%20.8%39.3%(33.1% - 42.4%)(N/A)(34.7% - 44.1%)6.6%2.4%5.9%(4.5% - 9.4%)(N/A)(4.0% - 8.6%)

21The most relevant factors seen to have contributed to the current nutritional state among the under 5 years ofage population are the low access to food and to health services.The long dry spell and erratic rains of 2004 widely affected farming produce in many parts of the Upper Nileregion did not spare this area. Worsened by crops destruction from pests and strong winds, the householdsinterviewed reported minimal harvest of maize in October, which has been exhausted by the 1 st quarter of thisyear. During the time of survey, majority of the communities have been depending on limited sorghum stocksfrom the November harvest, and on wild foods. The Rivers Magol Bior and Nile are a source of fish, however,access is constrained by lack of tools and means for fishing – NGO’s such as FAO and CRS deliver programsand activities related to fishing, but its full potential is yet to be realized. Similarly, milk or meat from livestock ismeager, with majority of families owning maximum of 15 cattle to none. Moreover, although no significantmovement was observed during the time of survey, more than 5000 returnees were recorded in December2004, accordingly depleting the available food among the host families even more. WFP last carried out generalfood distribution in April, providing 50% ration for resident households and 100% ration for returnees; thesehave lasted for only a month.Health records show rising incidence of these conditions in the current period, but utilization of health servicesfrom the existing primary health care facilities is not practiced among the majority of the households surveyed.The health-seeking practices, especially on drinking safe water, hygiene and sanitation are unimproved.A retrospective mortality survey has been implemented alongside the nutritional survey. Unfortunately, the datacollected were not satisfying, which can be attributed to the methodology that was used. As a result, thisindicator is reported in this the present survey..VIII. RECOMMENDATIONSACF-USA recommends the following:Programmatic recommendations:• A therapeutic feeding program should be immediately implemented to cover South Bor County, to treat andreduce the risk of mortality among the severely malnourished children. Co-ordination with and amonghumanitarian agencies on ground should be initiated; technical support should be offered by ACF-USA.• Deeper analysis of the health situation should be undertaken by CMA while enhancing the coverage of itsprimary health care services in the area, ensuring increased access and utilization by the population. ThePHCU’s in Kuei, Yolmuchel and Jalle II should be re-established.• Further assessment and monitoring of the food security situation should be carried out; meanwhile, generalfood aid must be promptly delivered by WFP. Existing food security programs and initiatives should becontinued while further developing its impact potentials.• Capable agencies should support South Bor with projects to increase safe water source (such as boreholeinstallation) and basic sanitary facilities.Methodological recommendation:• To implement in the future surveys the SMART methodology for the collection of data and the analysisof the retrospective mortality rate.

22.IX. APPENDIX.IX.1. Sample Size and Cluster DeterminationVillages Distance from CMACOMPOUNDEstimatedpopulationTargetpopulationCumulative targetpopulationAttributed numbers Cluster Number ofclustersJalle II 2hrs 3302 660 164 1- 660 1, 2 2Makuach 1.5hrs 3538 708 1368 661- 1368 3, 4, 5 3Akuei Deng 4hrs 1060 212 1580 1369- 1580 6 1Liliir 4.5hrs 1188 238 1818 1581- 1818Akoi- Rial 4.25hrs 2093 419 2237 1819- 2237 7, 8 2Pamuom 3.25hrs 1138 228 2465 2238- 2465 9 1Maluak 3hrs 1224 245 2710 2466- 2710 10 1Mathiang 2hrs 1203 241 2951 2711- 2951 11 1Thontok 2.25hrs 1021 204 3155 2952- 3155Gameth 2.5hrs 1700 340 3495 3156- 3495 12 1Thoi – Bek 2.5hrs 1080 216 3711 3496- 3711 13 1Anya 1.75hrs 1252 250 3961 3712- 3961 14 1Kurkuot 1.5hrs 1280 256 4217 3962- 4217 15 1Wut – cuei 1.25hrs 1080 216 4433 4218- 4433 16 1Awuolthou 2hrs 1060 212 4645 4434- 4645 17 2Ayen 1hr 1230 246 4891 4646- 4891 18 1Cholanyang 0.75hrs 1135 227 5118 4892- 5118Lual leek 0.25hrs 2100 420 5538 5119- 5538 19, 20 2Apoor 0.75hrs 1235 247 5785 5539- 5785 21 1Pakeer 0.75hrs 2115 423 6208 5786- 6208 22 1Magok 0.75hrs 2012 402 6610 6209- 6610 23, 24 2Ayuira 1hr 1000 200 6810 6611- 6810Pagook 1.5hrs 1012 202 7012 6811- 7012 25 1Bongor 2hrs 1001 200 7212 7013- 7212 26 1Makol 3hrs 1201 240 7452 7213- 7452 27 1Chol Agoot 3.5hrs 1050 210 7662 7453- 7662Pabeu 2.5hrs 1150 230 7892 7663- 7892 28 1Panomahooth 2hrs 1010 202 8094 7893- 8094 29 1Pachalou 2.25hrs 707 141 8235 8095- 8235 30 1Malualbiol 2.5hrs 551 110 8345 8236- 8345Total 41728 8345 30

23The sampling interval is equal to target population divided by number of clusters i.e. 8345/30 =278. Villagesincluded in the clusters are shown in the table above. The random number drawn between 1 and 52 was165.The target population was greater than 4,500 hence the sample size was 900 children. A total of 916children were included in the survey.The number of children included in each cluster is sampling size/ number of clusters, which was 900/30 =30.

24.IX.2. Anthropometric Survey QuestionnaireDATEVILLAGE:N°.12345678910111213141516171819202122232425262728293031FamilyN°.Status(1)TribeAgeMthsSexM/FWeightKgHeightcmCLUSTER No:TEAM No:SittingHeightcm (2)Oedema Y/NMUACmmMeaslesC/M/N(3)(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarilyresident in village (cattle camp, water point, visiting family…).(2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research.(3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against measles.

25.IX.3. Retrospective Mortality Survey QuestionnaireDATE:VILLAGE:CLUSTER No:TEAM No:FamilyN°.123456789101112131415161718192021222324252627282930TRIBE(1)Numberof < 5YearsalivetodayNumberof < 5yearsdead inlast 3monthsCAUSE(2)NUMBERof >= 5yearsalivetodayNumber ofdead >=5years inthe last 3monthsCAUSE(3)Number ofpeople alive inthe last 3months**(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarilyresident in village (cattle camp, water point, visiting family…).(2) Tribe: Nuer, Dinka, Shilluk. Murle.Cause: Diarrhoea (watery diarrhoea), 2=Bloody diarrhoea (Dysentery), 3=Measles, 4=Malaria, 5=TB, 6=Pneumonia, 7=Malnutrition, 8= Kala-Azar, 9=Accident (gunshot, snakebite…), 10=other(write presumed cause of death).

26.IX.4. Calendar of Events in Athoc: Jalle II and Baidit PayamsMONTHS SEASONS 2000 2001 2002 2003 2004 2005Christmas53 41 29 17 5JANUARY /celebrationsBombing stops GTZ arrival inPEITOK continue.PadakWinnow andstore sorghum.FEBRUARYPEIROUMARCHPEIDIAKAPRILPEI NGUANMAYPEI DHIECConstruction oftukuls.Clearance ofland.Land clearanceand cultivation.Start of rain andplanting ofmaize andsorghum.52 40 28 16Opening of newairstrip51 39 27 15TEARFUNDnutrition survey50 38 26 14 249 37 25 13 1ReturneesDroughtarrived in AthocJUNE48 36 24 12PEI DHETEM Weeding Flooding John Garang visitJULYPEI DHOROUAUGUSTPEI BETSEPTEMBERPEIDHONGUANWeedingScare birdsfrom attackingsorghum.Eating of greenmaize.Harvestsorghum. Littlerain.Good yield ofcrops59 47 35 23 11DroughtFlooding58 46 34 22 10Birds destroycrops57 45 33 21 9Poisonous fish Torit captured by FloodingSPLM

27OCTOBERPEI THEIRNOVEMBERPEITHIERUTOKDECEMBERPEI THIEHarvest maize.Recultivate.Heavy rain.Dry and storecereals. End ofheavy rain.Christmas,repair tukulsand marriageceremonies.56 44 32 20 8Torit recapturedby GOS55 43 31 19 7Peaceagreementsigned inMachakos54 18 6End ofTEARFUNDfeeding project

28.IX.5. Anthropometric Survey Questionnaire for Children Less than 6 months12345678910111213141516171819202122232425262728293031DATE:VILLAGE:N°.FamilyN°.AgeMthsSexM/FWeightKgCLUSTER No:TEAM No:Height Feeding practices*cm* Exclusive beast feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food=3.

29.IX.6. Padak Market Commodity PricesCommodity Quantity Price in Sudanese Dinar(SD)Sorghum 2kg 400.00Beans 0.5kg 225.00Maize 50kg 4200.00Milk 1litre 225.00Sugar 1kg 600.00Salt 0.25kg 50.00Cooking oil 1 litre 600.00Onions 3 pieces 100.00Soda 0.5 litre 300.00Fish(dry) Small size 100.00Fish(fresh) Small size 84.00Beef 1kg 300.00Bar soap 1 piece 50.00Omo 0.25kg 90.00Exchange rates: 1 Kshs = 3 SD, 1 US $ = 210 SD