South Sudan
NUTRITIONAL ANTHROPOMETRIC SURVEY
CHILDREN UNDER 5 YEARS OLD
ALEK SOUTH, ALEK NORTH, ALEK WEST, GOGRIAL AND RIAU PAYAMS,
GOGRIAL WEST COUNTY, WARRAP STATE, BAHR EL GHAZAL
17TH JANUARY – 9TH FEBRUARY, 2007
Edward Kutondo- NSP Manager
Beatrice Otieno - Nutritionist
Imelda V. Awino - Nutritionist
1
ACKNOWLEDGMENTS
¾
The UK Department for International Development (DFID) for funding the survey,
¾
Sudan Relief and Rehabilitation Commission (SRRC) in Gogrial West County, for ensuring smooth
progress of the whole exercise,
¾
The entire survey team for their sedulous attitude and boundless determination through out the survey,
¾
Finally to parents and caretakers, local authorities, and community leaders with whose assistance the
survey objectives were realized.
2
TABLE OF CONTENTS
.I. EXECUTIVE SUMMARY.....................................................................................................................................4
.I.1. INTRODUCTION ................................................................................................................................................4
.I.2. OBJECTIVES ....................................................................................................................................................4
.I.3. METHODOLOGY ...............................................................................................................................................4
.I.4. SUMMARY OF FINDINGS ...................................................................................................................................5
.II. INTRODUCTION ................................................................................................................................................9
METHODOLOGY ..................................................................................................................................................10
.II.1. TYPE OF SURVEY AND SAMPLE SIZE ..............................................................................................................10
.II.2. SAMPLING METHODOLOGY ............................................................................................................................10
.II.3. DATA COLLECTION .......................................................................................................................................11
.II.4. INDICATORS, GUIDELINES, AND FORMULA’S USED ..........................................................................................11
.II.4.1. Anthropometry .....................................................................................................................................11
.II.4.2. Mortality ...............................................................................................................................................12
.II.5. FIELD WORK ................................................................................................................................................12
.II.6. DATA ANALYSIS ............................................................................................................................................13
.III. RESULTS OF THE QUALITATIVE ASSESSMENT.......................................................................................13
.III.1. SOCIO- DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS .................................................................13
.III.2. FOOD SECURITY ..........................................................................................................................................14
.III.3. HEALTH ......................................................................................................................................................18
.III.4. WATER AND SANITATION ..............................................................................................................................20
.III.5. MATERNAL AND CHILD CARE PRACTICES .......................................................................................................21
.III.6. EDUCATION .................................................................................................................................................22
.III.7. ACTIONS TAKEN BY NGO’S AND OTHER PARTNERS ......................................................................................22
.IV. RESULTS OF THE ANTHROPOMETRIC SURVEY......................................................................................24
.IV.1. DISTRIBUTION BY AGE AND SEX. ..................................................................................................................24
.IV.2. ANTHROPOMETRICS ANALYSIS .....................................................................................................................25
.IV.2.1. Acute Malnutrition, Children 6-59 months of Age ..............................................................................25
.IV.2.2. Risk of Mortality: Children’s MUAC....................................................................................................26
.IV.3. MEASLES VACCINATION COVERAGE .............................................................................................................27
.IV.4. HOUSEHOLD STATUS ..................................................................................................................................27
.IV.5. COMPOSITION OF THE HOUSEHOLDS ............................................................................................................27
.V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY.....................................................................28
.VI. CONCLUSION ................................................................................................................................................28
.VII. RECOMMENDATIONS..................................................................................................................................30
.VIII. APPENDIX ....................................................................................................................................................31
.VIII.1. SAMPLE SIZE AND CLUSTER DETERMINATION .............................................................................................31
.VIII.2. ANTHROPOMETRIC SURVEY QUESTIONNAIRE .............................................................................................33
.VIII.3. HOUSEHOLD ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE
SHEET/HOUSEHOLD) .............................................................................................................................................34
.VIII.4. ENUMERATION DATA COLLECTION FORM FOR A DEATH RATE CALCULATION SURVEY (ONE SHEET/CLUSTER)....35
.VIII.5. CALENDAR OF EVENTS IN GOGRIAL WEST COUNTY.....................................................................................36
.VIII.6. FOOD MARKET PRICES IN ALEK MARKET, GOGRIAL WEST COUNTY, FEBRUARY 2007....................................38
.VIII.7. GOGRIAL WEST COUNTY MAP. ..................................................................................................................39
3
.I. EXECUTIVE SUMMARY
.I.1. Introduction
Gogrial West County is situated in Warrap State, Southern Sudan’s Bahr-el-Ghazal region. It borders Unity
State, Wau, Twic, Tonj, Aweil East and South Counties to the North East, South West, North, East and West
respectively.
The county counts 116.8161 inhabitants. The predominant denizens of Gogrial West County are the Dinka
ethnic group of the Aguok sub clan whose predominant livelihood activity is agro-pastoralism.
Gogrial West County is subdivided into payams, bomas and villages. Administratively, the commissioner is in
charge of the county while chiefs and administrators govern villages, bomas and payams respectively. The nine
administrative payams in the County are Alek South, Alek North, Alek West, Gogrial, Kuac North, Kuac South,
Riau, Akon North and Akon South.
The county is under the jurisdiction of the GoSS.
The area lies within the Western flood plain zone. It is a flat terrain whose soil structure is mainly sandy with
pockets of loam clay soil.
A number of seasonal rivers exist in the region (Malualawien and Nyantit rivers are the main ones). They
provide fishing grounds to the community during certain times of the year.
FEWSNET November 2006 report, indicated good production in the highlands while flooding negatively affected
lowland crops in Gogrial County. It also revealed that an unknown number of households were displaced due to
inter-ethnic conflicts in early 2006.
Reports tentatively estimated that up to 20% of the county's population may have been affected by the
insecurity. According to FEWSNET December 2006 - January 2007, the potential arrival of large numbers of
returnees from Northern Sudan could strain local capacities, sources of food and labor opportunities. Moreover,
the insecurity also interrupted some cultivation activities in the area.
At the beginning of the year 2005, ACF-USA undertook an exploratory/rapid assessment that detected critical
malnutrition rates necessitating the opening of targeted feeding programs. However, due to the reduced
admissions the program was closed after seven months. A survey conducted by ACF-USA between February
and March 2006 further revealed GAM and SAM rates of 23.9% [20.0% -28.2%] and 4.2% [2.6% -6.6%] in Zscores (NCHS reference, at 95% confidence interval) respectively. Such prevalence indicated the need to reopen feeding program, and ACF-USA implemented them from May 2006.
.I.2. Objectives
ƒ
ƒ
ƒ
ƒ
To evaluate the nutritional status of children aged 6 to 59 months.
To estimate the crude mortality rate through a retrospective survey.
To estimate the measles immunization coverage of children aged 9 to 59 months.
To determine immediate, basic and underlying factors influencing the nutrition situation of the community.
.I.3. Methodology
The SMART methodology was applied for both the anthropometric and retrospective mortality surveys.
All the accessible villages in Alek South, Alek North, Alek West, Riau and Gogrial payams were included in the
survey design.
From the SRRC population figures, the target population2 was calculated after which larger villages were divided
evenly into sub villages with a target population size not greater than 250. This data was then entered into
Nutrisurvey for SMART software (December 2006 version) from where planning was done.
Retrospective mortality data was collected alongside the anthropometric data.
1
2
Source: Acting SRRC Gogrial West County
estimated at 20% of the entire population
4
Further, qualitative data was gathered through observation and households interviews through structured
questionnaires. The data focused on food security, water and sanitation, child care services as well as
accessibility and utilization of health care services.
.I.4. Summary of Findings
The region has been one of the most affected by the two decades of conflict in South Sudan. As a
consequence, agricultural production and access to local and external markets had markedly deteriorated. A
number of areas around Gogrial town, and between Wau and Gogrial town, are believed to be mined.
The county has enjoyed relative peace following the signing of CPA in January, 2005 which has enabled the
resumption of economic activities and resettlement of returnees. However, episodes of inter-clan fighting
between the Aguok and Apuk sub clans have been reported in August, September, November 2006, several
episodes of fighting were reported. The disarmament exercise was successfully carried out in the county
between November and December 2006.
During the survey period, the security situation was calm with no insecurity incident being reported.
General information
Both the availability and accessibility to potable water in Gogrial West County is generally below the
recommended SPHERE and SOH standards3. Despite the fact that there are numerous hand pumps in the
county, most of them are in poor condition. The few functional ones can hardly meet the needs of the entire
populace. Because of the long queues and the enormous walking distances to these water points, most people
resort to consumption of water from shallow wells and stagnant pools. Through observation and interviews
during the survey it was noted that, the water is consumed untreated by most of the populace unmindful of the
harm it poses to their health. This predisposes the community to the risk of contracting water borne diseases.
Hygiene and sanitation situation in Gogrial West County is deemed to be in a poor state owing to the fact that
very few latrines were observed during the assessment period. The latrines that were observed were mainly
found in administrative compounds and in Alek and Gogrial town. Consequently, human waste was
indiscriminately disposed off, a practice which further precipitates the risk of infection. It was also observed that
cooking utensils and water containers were not kept clean while child care practices were also generally below
standard as most children were observed eating without first cleaning their hands.
Despite the free health services proffered in the county, the health seeking behavior of the community is not up
to date since medical attention is sought so late when the disease has progressed to critical stages. Results
from interviews conducted with the health personnel on ground confirmed that most people prefer taking their
sick ones to the traditional healers locally known as kunjurs, as a first resort and only go to the health facilities
should the disease persist. However this situation is slowly changing with the continuous health education
especially in the towns where people have began to realize the significance of conventional treatment and timely
intervention.
According to the NCA Health supervisor; malaria, malnutrition and pneumonia are the leading causes of
morbidity and mortality in the surveyed community. Anemia and diarrhea are also common, a situation which
can be ascribed to poor sanitation and minimal food intake. During the survey period there was an outbreak of
meningitis which is believed to be endemic in the region during the dry season.
Regardless of the fact that last season harvest was better compared the previous year, most of those
households interviewed reported to have depleted their food stocks or had very little reserves; ascribed to the
sale of grains and brewing of beer to acquire income to purchase other items. To cope, most households
reduced the number of meals per day with wild fruits and vegetables being important supplements.
The agencies intervening in the area are listed below:
ACF-USA runs nutrition programs (SFC and TFC-HT) in the county since May 2006.
3
Sphere standards on water access and quantity include; Average water use for drinking, cooking and personal hygiene per
person per day is 15 litres, Queuing time not more than 15 minutes and safe water is available on regular basis.
5
NCA is involved in the provision of primary health care services and education activities in Gogrial West County.
The health services are provided in collaboration with the Ministry of Health, whereby NCA is responsible for
provision of medical and drug supplies. They run 1 PHCC situated in Alek South Payam and 11 PHCUs each
located in Keet, Atukuel, Mandeng, Malual Ajak, Mankuac, Anguoth, Panliet, Ayuang, Malualawien, Bau, and
Pakor villages.
The health units provide treatment of common ailments, health education, HIV/AIDS and EPI programs. These
services are free save for the registration and admission fee which are 100 and 200 Sudanese Dinnars
respectively. The PHCC acts as a referral centre to the PHCUs, and offers MCH and in-patient services with a
bed capacity of 30. The organization is in the process of setting up a laboratory and for that matter, a laboratory
technician has already been trained. They are also involved in training activities for the health personnel such as
CHWs, TBAs, EPI and MCH staff; village health committees for PHCUs and Management committees for
PHCCs. The CHWs and MCH were trained for 9 months in 2004 and had a refresher course in 2006. Plans are
underway to train more MCH and CHWs in the course of the year.
In education, the organization has four main activities namely; support of primary schools, school construction,
teacher training and adult literacy. They initially supported 14 primary schools, however only 5 schools are
currently supported through provision of scholastic materials such as books and pens among others. The other
9 schools are taken care of by the Government. One school has been targeted for construction in Alek whereas
the teacher training program is intended to wind up as soon as the Government opens up a teacher training
centre in Kuajok. In addition, a women centre whose aim is to curb the low enrolment and literacy levels among
females, offers cookery and dressmaking lessons; this has led to the initiation of a primary school which has so
far reached class two.
FARM AFRICA, whose aim is to eradicate poverty by improving the livelihoods of farmers and herders in
marginalized areas mainly incorporates innovative approaches in development to ensure that people live in
sustainable situations using natural resources. Their program in the location includes animal health, agriculture,
water, community development, research and policy. Animal health main activities are provision of veterinary
inputs, improving productivity and disease surveillance. The agriculture component is concerned with improving
farming methods, empowering local blacksmiths and encouraging dry season cropping. They also give farm
inputs to vulnerable groups such as returnees and those affected by inter clan fighting. In the sector of water,
the agency partners with SUPRAID to drill new boreholes, rehabilitate broken ones through the existing water
management teams and also explore alternatives to boreholes such as shallow wells. Research and policy
which is the key area in the organization, aims at creating models in agriculture and other sectors that are able
to meet the community needs in one package. These models can in future be used for up scaling of projects by
the Government and other agencies. At the moment the agency is in the process of gathering information on
research and policy at Government level and sensitizing the community on policy issues. They also intend to
initiate action oriented research for example that which would reduce the women work load in the community.
Finally, the community development aspect tries to capture the other needs of the community which are not met
by the agency’s interventions; as such models like village development committees have been initiated.
SUPRAID is an indigenous organization whose main activity is drilling of new bore holes in the county. Because
of their capacity, they are at times contracted by NGOs to drill boreholes.
SC-UK is involved in education, HIV/AIDS and child protection programs in Gogrial West County. Under
education, they have a teacher training targeting those aged 12-21 years. They also support primary schools in
terms of scholastic materials and construction of physical facilities. They are currently supporting a total of 9
primary schools in the county; one school each in Akon South, Kuac North and South payams and 2 schools
each in Akon North, Riau and Gogrial payams. In addition they also conduct work shops with local education
authorities who assist in community mobilization.
The HIV/AIDS program is mainstreamed and integrated into the education program.
WVI in Gogrial West County is operating a number of programs including food security which is currently
implemented in Ajiep with the main activities being demonstration farms, ox plough training, and tree planting.
The food aid program is carried out in collaboration with WFP, and they have currently moved from general food
distribution (except for returnees and the vulnerable) to food for assets while in Health and Nutrition, the agency
is at the moment running an SFP and one PHCC in Ajiep.
6
RESULTS
The anthropometric nutritional survey included a total of 642 children. The data of 4 of them were excluded as
they presented incoherencies. The table below relies on the analysis of the data of 638 children.
Table 1: Results of the Anthropometrics Survey
4
REFERENCE
INDICATOR
Global Acute Malnutrition
W/H< -2 z and/or edema
NHCS
Severe Acute Malnutrition
W/H < -3 z and/or edema
Global Acute Malnutrition
W/H < 80% and/or edema
% Median
Severe Acute Malnutrition
W/H < 70% and/or edema
Global Acute Malnutrition
W/H< -2 z and/or edema
Z-scores
Severe Acute Malnutrition
W/H < -3 z and/or edema
WHO
Global Acute Malnutrition
W/H < 80% and/or edema
% Median
Severe Acute Malnutrition
W/H < 70% and/or edema
Total crude retrospective mortality (last 3 months) /10,000/day
Under five crude retrospective mortality /10,000/day
By card
Measles immunization coverage
According to caretaker5
(N= 590, children >=9 months old)
Not immunized
Z-scores
RESULTS
(n=638)
19.0%
(15.3 - 22.7)
0.9%
(0.1 - 1.8)
7.8%
(5.4 - 10.2)
0.2%
(0.0 - 0.5)
19.0%
(15.1 - 22.8)
2.8%
(1.3 - 4.4)
4.1%
(2.2 - 5.9)
0.2%
(0.0 – 0.3)
0.58 [0.28– 0.89]
0.97 [0.28–1.65]
3.9%
17.1%
79.0%
Discussion
WVI and ACF-USA have undertaken numerous nutrition surveys in the region since the year 2004. The latest
assessments were conducted in the previous year that revealed GAM and SAM rates 23.9% [95% C.I: 20.0% 28.2%] in Z-score survey done by ACF-USA assessment between February and March 2006. This yeas
malnutrition rates are lower as compared to last year results, which could be attributed to impact of ACF-USA
nutrition treatment program in the region. However, the current GAM rate of 19.0% [ 95% C.I: 15.3%-22.7%] in
z-scores is still above emergency threshold and could be attributed to a number of multifaceted factors such as;
decline in food security, disease and poor health seeking patterns, water and deplorable sanitation practices,
inappropriate feeding and child care practices and insecurity. These can be summarised as follows:
Food Insecurity:
The food insecurity situation in the location could be attributed to various shocks such as livestock diseases,
lack of appropriate and adequate fishing and farming equipment, lack of labor and human diseases. The main
coping strategies adopted by most of the households were: eating fewer meals, consumption of wild fruits and
vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and
alcohol. These may decline over time further exacerbating food insecurity and in the long run may result to
adverse health and malnutrition.
Disease prevalence and poor health seeking patterns:
4
The rates are expressed with a 95% confidence interval.
When no EPI card was available for the child at the household, measles vaccination information was collected according to
the caretaker
5
7
Despite free health services offered by the health agency on ground (NCA), the health seeking behaviour of the
community is still wanting. Most of the community sought treatment when the disease had already progressed
into serious phases. Belief in traditional healers in this community is rampant as evidenced by the presence of
various magical paraphernalia as observed in most of the homes visited. This has contributed to the current rate
of malnutrition as some community members seek health services as the last resort, making their bodies
compromised by diseases.
Deplorable Water and Sanitation situation:
To meet their water requirements, some of the community members fetch water for drinking and household
consumption from sources such as unprotected well and swamps. Unfortunately, water from these sources is
not treated by majority before drinking. This coupled with the poor hygiene and sanitation in the area,
predisposes the community to diarrhoeal and water borne ailments, especially during the wet season when the
waste and feacal matter is swept back into these water sources and as a results of these diseases that
compromise the health status of the community members resulting to malnutrition especially the under fives.
Inappropriate child care and feeding practices:
Women are engaged in many household activities and thus have very little time for nurturing the children, which
apparently poses a risk on the nutritional status of the exclusively breastfed children. Moreover, the weaning
foods were predominantly the family meal of kuon made from sorghum while other foods such as milk and meat
products were minimally consumed. This consequently leads to poor nutrient intake, and ultimately induces poor
nutrition state of the children.
Security and safety:
The county is still believed to be mined, which limits people’s movement to certain areas. Further, the
continuous episodes of inter clan fighting between the Aguok and Apuk sub clans have continuously been
reported in the county since 2004 hence predisposing the local community to higher risk of food insecurity. This
is because the community is forced to run for their lives thus productive time that could have been spent in tilling
and preparing land for cultivation is spent either in fighting or defending the community. However, as could be
observed in some of these villages, such as Mankuac and Mangok, the community was gradually coming back
and had started settling and it is hoped that with time, the community will be able to bounce back to its normal
livelihood activities.
Recommendations
The above emergency level GAM rate among children aged 6-59 months as depicted by the results signify a life
precarious nutrition situation in Gogrial West County. This has been closely attributed to a bleak food security
situation (access and availability) and diseases as well as various underlying factors discussed above. This is
therefore an indicator that the causal factors responsible for the prevailing state need to be nipped from the bud
before anything untoward happens. Timely interventions are thus inevitably necessary to bolster the community
from the probable effects of malnutrition. Additionally reconstructive and long term measures also need to be put
in place in order to prevent future recurrence of the same, and ultimately ensure that malnutrition is alleviated.
The following recommendations have therefore been put forth by ACF-USA:
Food Security
ƒ To continue the food distribution to the returnees, displaced and other highly vulnerable households.
ƒ To develop new strategies of food for agriculture and food for assets.
ƒ Besides action oriented researches, to explore possibilities of empowering the community to initiate
livelihood activities through the village development committees.
Health
ƒ To carry on with targeted feeding programs for the management of both severely and moderately
malnourished children, and increase their coverage.
ƒ To maintain the existing health initiatives with special focus on MCH and EPI.
Water and Sanitation
8
ƒ
ƒ
ƒ
ƒ
To forge ahead and implement the alternative to boreholes initiative by offering training and technical
support to the community on how to dig shallow wells, dams and rain harvesting, all of which will
ensure sustainability with a cost advantage.
To partner with other agencies involved in water activities to rehabilitate some of the existing
dysfunctional boreholes within the county.
To support latrine construction using locally available materials and furnish the community with the
required technical skills while at the same time encouraging community participation to ensure their
utilization.
To enhance health and hygiene promotion activities within the county by educating the community on
the significance of personal hygiene, human waste disposal and water treatment methods.
Security and safety
ƒ To carry on with the de-mining activities especially in Gogrial town and its environs which are believed
to be heavily mined.
.II. INTRODUCTION
Gogrial West County which is administered by the GoSS is situated in Warrap State, Southern Sudan’s Bahr-elGhazal region. It borders Unity State, Wau, Twic, Tonj, Aweil East and South Counties to the North East, South
West, North, East and West respectively. The county which has a populace of 116,8166 is further subdivided
into payams, bomas and villages. The nine administrative payams in the County are Alek South, Alek North,
Alek West, Gogrial, Kuac North, Kuac South, Riau, Akon North and Akon South.
The county is majorly inhabited by people of the Dinka ethnicity, specifically the Dinka Bahr el Ghazal clan
belonging to Aguok sub clan. Just like the other populace of Bahr el Ghazal region, the Gogrial West County
residents are mainly agro-pastoralists, although fishing and trade are also important sources of livelihood.
Gogrial West County has enjoyed relative peace following the signing of CPA in January 2005, which has
enabled the resumption of economic activities and resettlement of returnees; however there has been insecurity
in some parts of the county since 2005 due to inter-clan conflicts between Gogrial West and Gogrial East
counties causing displacement and disruption of livelihoods. Similarly due to the insecurity, crop production was
low while some did not cultivate at all in the affected locations7. The most recent incidents were reported in the
month of September 2006.
The county which is located in the Western flood plain zone is characterized by a flat terrain whose soil structure
is mainly sandy with pockets of loam clay soil. A number of seasonal rivers exist in the region with Rivers
Malualawien and Nyantit providing fishing grounds to the community to supplement their food demands during
certain times of the year.
FEWSNET November 2006 reported good production in the highlands while flooding negatively affected lowland
crops in Gogrial County. It further confirmed the fact that, an unknown number of households were displaced by
inter-ethnic conflicts in early 2006 and the insecurity interrupted cultivation activities of some of the remaining
non-displaced households. Reports tentatively estimated that up to 20% of the county's population may have
been affected by the insecurity. According to FEWSNET December 2006 - January 2007, the potential arrival of
large numbers of returnees from Northern Sudan could strain local capacities, sources of food and labour
opportunities.
At the beginning of the year 2005, ACF-USA undertook an exploratory/rapid assessment that detected critical
malnutrition rates necessitating the opening of targeted feeding programs. However, due to the reduced
admissions, the program was closed after seven months. A survey conducted by ACF-USA between February
and March 2006 further revealed much higher GAM and SAM rates of 23.9% [20.0% -28.2%] and 4.2% [2.6% 6
7
Source: Acting SRRC Gogrial West County, population figure of assessed payams.
WFP Sudan Annual Needs Assessment report 2007
9
6.6%] in Z-score at 95% confidence interval accordingly. This necessitated the re-opening of the feeding
programs in the county in May 2006.
Due to the recent and prevailing conditions as well as the need to assess the impact of the nutrition programs
that were put in place following the high GAM and SAM rates a nutritional survey was conducted in Gogrial
West County between 17th January and 9th February 2007.
METHODOLOGY
.II.1. Type of Survey and Sample Size
The anthropometric survey has been done with the SMART8 methodology. The target population is the 6-59
months old age group.
Selection of accessible villages was done using a map of the area (Appendix VIII.9) and the administrative
information given by the SRRC.The Gogrial West County population is estimated at 116,8169 , from this figure a
target population of 23,32 children10 was calculated. The larger villages were divided evenly into sub villages
with a target population size not greater than 250. This data was then entered into Nutrisurvey for SMART
software, (December 2006 version) from where planning was done.
A total of 34 clusters were assigned in proportion to target population size utilizing a design effect of 2,
prevalence 28.2% and precision 4.3%.
A retrospective mortality survey was done along with the anthropometric one, utilizing SMART methodology.
Besides, both formal and informal interviews, observation and structured questionnaires were used to obtain
qualitative information so as to determine the immediate, underlying and basic causes of malnutrition within the
location.
.II.2. Sampling Methodology
A two-stage cluster sampling method was used:
♦
At the first stage, the sample size was determined by inputting necessary information into the
Nutrisurvey software for both anthropometric and mortality surveys. The information included estimated
population sizes, estimated prevalence rates of mortality and malnutrition, the desired precision and
design effect. The prevalence’s were derived from the nutrition survey conducted in the location early
last year while the design effect was taken to be 2 in both cases. The anthropometric and the mortality
survey sample sizes were divided by 1.511 and 612 respectively to get the number of household to be
visited. The anthropometric survey results revealed more households; as such a sample size of 826 was
adopted. 34 clusters were then randomly selected by inputting the sub village names and the revised
target population sizes into Nutrisurvey software, which automatically assigned clusters (See appendix
VIII.3). Each cluster comprised of 16 households.
♦
At the second stage, selection of households within each cluster was done. The team began by dividing
the village into sub villages accordingly with the help of the surveyors. The EPI methodology was used
whereby a pen was spun from the centre of the village to randomly choose a direction. The team then
walked in the direction indicated, to the edge of the village. At the edge of the village the pen was spun
again, until it pointed into the body of the village. The team then walked along this second line counting
each house on the way. Using simple balloting, the first house to be visited was selected at random by
drawing a number between one and the number of households counted when walking. All children aged
8
Standardized Monitoring and Assessment in Relief and Transition
Source: Acting SRRC Gogrial West County, population figure of assessed payams.
10
20% of the entire population
11
Average under 5 population per household
12
Average population per household
9
10
6-59 months in each household were included in the nutritional survey. If there was more than one wife
in the household13, each wife was considered separately regardless of whether they were cooking
together. If there were no children in a household, the house remained a part of the “sample” that
contributed zero children to the nutritional part of the survey. All children aged 6-59 months were
measured and the mortality questionnaire completed; the subsequent households were then chosen by
proximity. In villages where the houses were closely packed together, the next house on the right was
chosen until a total of 16 households were surveyed. However in cases where the villages were spreadout, the house with the door closest to the last house surveyed was considered. The household was
recorded on the nutritional data sheet as having no eligible children. The mortality questionnaire was
administered to all selected households, whether they counted eligible children or not.
.II.3. Data Collection
Four selected surveyors were subjected to a standardization test to ascertain their capability in taking accurate
and precise measurements, so as to minimize errors during data collection (see appendix VIII.2).
For each selected child, information was collected during the anthropometric survey using an anthropometric
questionnaire. The information included (See appendix VIII.4):
•
•
•
•
•
•
•
•
Age: recorded with the help of a local calendar of events (See appendix VIII.7).
Gender: male or female
Weight: children were weighed without clothes, with a SALTER balance of 25kg (precision of 100g).
Height: children were measured on a measuring board (precision of 0.1cm). Children less than 85cm
were measured lying down, while those greater than or equal to 85cm were measured standing up.
Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured
children (precision of 0.1cm).
Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both
feet.
Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking
caretakers.
Household status: for the surveyed children, households were asked if they were permanent residents,
temporarily in the area, displaced or returnee.
.II.4. Indicators, Guidelines, and Formula’s Used
.II.4.1. Anthropometry
For the children, acute malnutrition rates were estimated from the weight for height (WFH) index values
combined with the presence of oedema. The WFH indices are compared with the NCHS14 and the 2005 WHO
references.
The indexes are presented in both NCHS and WHO references, but currently, only the NCHS reference is used
at field level for identification of malnourished cases. The WHO reference indexes are mentioned for
information.
WFH indices are expressed in both Z-score and percentage of the median. The expression in Z-score has true
statistical meaning, and allows inter-study comparison. The percentage of the median on the other hand is
commonly used to identify eligible children for feeding programs.
Guidelines for the results expressed in Z-score:
• Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the lower limbs of the
child.
• Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema.
• Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema.
13
A household refers to a mother and her children
NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital
Health Statistics. 165, 11-74.
14
11
Guidelines for the results expressed in percentage of median:
• Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the lower limbs
• Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema.
• Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema
¾ Children’s Mid-Upper Arm Circumference (MUAC)
The weight for height index is the most appropriate index to quantify wasting in a population in emergency
situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm
circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC
measurements are presented for all children form 6 to 59 months, divided by height groups, as MUAC is a
malnutrition indicator in children taller that 65 cm in some protocols, and children taller than 75 cm in others.
The guidelines are as follows:
MUAC < 110 mm
MUAC ≥ 110 mm and <120 mm
MUAC ≥ 120 mm and <125 mm
MUAC ≥ 125 mm and <135 mm
MUAC ≥ 135 mm
severe malnutrition and high risk of mortality
moderate malnutrition and moderate risk of mortality
high risk of malnutrition
moderate risk of malnutrition
adequate’ nutritional status
.II.4.2. Mortality
Mortality data was collected using Standardized Monitoring and Assessment of Relief and Transitions (SMART)
methodology. A prevalence of 0.4 and precision of 0.6% were used during planning. The crude mortality rate
(CMR) is determined for the entire population surveyed for a given period. The CMR is calculated using
Nutrisurvey for SMART software for Emergency Nutrition Assessment.
The formula below is applied:
Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2),
Where:
a = Number of recall days (90)
b = Number of current household residents
c = Number of people who joined household
d = Number of people who left household
e = Number of births during recall
f = Number of deaths during recall period
The result is expressed per 10,000-people / day.
The thresholds are defined as follows15:
Total CMR:
Alert level:
Emergency level:
1/10,000 people/day
2/10,000 people/day
Under five CMR:
Alert level:
Emergency level:
2/10,000 people/day
4/10,000 people/day
.II.5. Field Work
Three teams of three surveyors each executed the fieldwork. All the surveyors participating in the survey
underwent a 4-day training, which included standardization exercise and a pilot survey. Qualitative data was
collected alternately by the ACF-USA staff with the help of the qualitative data supervisor who acted as a
15
Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition,
ACC / SCN, Nov 95.
12
translator. ACF-USA staff supervised all the teams in the villages. The survey (including training, planning, data
collection and travelling) lasted for a period of 22 days.
.II.6. Data Analysis
Data processing and analysis for both anthropometric and mortality were carried out using Nutrisurvey for
SMART software (December 2006 version).
Excel was used to carry out analyses on MUAC, measles immunization coverage, household status and
composition.
Qualitative data was analyzed using SPSS (Statistical Package for Social Sciences) version 10.0.
.III. RESULTS OF THE QUALITATIVE ASSESSMENT
.III.1. Socio- demographic Characteristics of the Respondents
Gogrial West County was one of the regions worst affected by the two decades of conflict in South Sudan.
Agricultural production as well as access to local and external markets had markedly deteriorated as livelihoods
were put at a deplorable state. Reportedly, a number of areas around Gogrial town and between Wau and
Gogrial area are believed to be mined, reflecting the past hostilities between SPLM and GOS in these areas.
Unconfirmed reports indicated that someone was blown off after a land mine exploded in Manalom village, near
Gogrial town during the time of the assessment. Episodes of inter clan fighting between the Aguok and Apuk
sub clans have continuously been reported in the county since 2004.The latest incidence being in September
2006 when skirmishes broke out between the two clans in Mankuac village, at Gogrial East border, during which
five women were seriously injured.
Alongside the anthropometric survey, qualitative information was gathered on 50 households using structured
questionnaires, observation and interviews. Of all the households, 49 (98%) and 1 (2%) of the respondents were
residents and IDPs respectively. Majority 42 (84%) were females with only a minimal 8 (16%) representing the
males, who in most cases were left behind when their female counterparts went to collect grass for thatching
houses. The absence of males could be ascribed to the fact that the prevailing peace in the region has caused
most men to move to town areas to seek involvement in developmental and livelihood activities such as trade,
employment by government or agencies, among others. As such it was the females who were mostly left behind
to tend to the young ones and perform domestic chores.
52%
60%
46%
50%
40%
30%
20%
8%
2%
10%
0%
op
Cr
g
in
m
r
fa
ism
al
r
so
pa
ro
Ag
tty
Pe
de
tra
er
th
O
Figure 1: Sources of Livelihood
The county is predominantly inhabited by the Dinka ethnic group, specifically the Dinka Bahr el Ghazal clan
belonging to the Aguok sub clan who are mainly agro-pastoralists with crop farming as an important source of
13
livelihood. The survey results confirmed this fact, as more than half 26(52%) of households interviewed were
agro pastoralists with 23(46%) being crop farmers as shown in Figure 1 above. However, as at the time of
assessment, most of the cattle were at the toic (cattle camp) and thus nutritional benefits derived from livestock
were minimal. Even though the qualitative analysis does not reveal any returnees, FEWSNET December 2006
projects that a substantial number of IDPs and returnees are expected back with a large percentage expected to
settle in Warrap state. A total of 25,400 IDPs and returnees are expected back during the year16.
Most 29(58%) of the households rely on petty trade; majorly sale of alcohol and grass for their income so as to
meet other household demands.
60%
58%
50%
40%
28%
30%
20%
14%
12%
10%
10%
0%
Livestock
sale
Crops sale Petty trade
Firewood Remittance
collection
Figure 2: Sources of Income
Other sources of income entailed the sale of livestock, crops, firewood and remittance as shown in figure 2
above. Sale of alcohol by the community is rampant as observed during the assessment. The local brew was
made using sorghum which in the long run may have led to depletion of the existent stocks. Additionally, most
community members were observed to start taking the brew early in the morning and thus productive time was
adversely wasted.
.III.2. Food Security
Gogrial West County in the western flood plain zone is characterized by flat terrain mainly covered with sandy
soil amid pockets of loam and black cotton soil. According to FEWSNET December 2006 report, food security
gains made in this zone are likely to be lost should large scale population returns occur. These will be
compounded by chronic vulnerability of some households, impact of structural food deficits as well as targeting
problems between returnees and their hosts.
As at the time of assessment, private production 39(78%) was the predominant source of food in most
households as the last harvest was carried out towards the end of the year. 22(44%) of the community bought
their food from the local markets using income acquired through petty trade, remittance and sale of firewood and
grass. Notably, majority of the surveyed population 46(92%) planted crops during the last planting season with a
negligible number 4(8%) of households having not planted anything due to lack of labour and social instability.
Of the households that had cultivated food crops, most of them 33(71.7%) had cultivated relatively smaller farm
sizes of approximately 0.5 feddans17, most likely due to lack of tools and other farm inputs. Comparatively, the
16
17
Warrap state OCHA ,GOSS AND NGO meeting held at Kuajok on 31st January 2007
One feddan is a local measure of land equivalent to 4200.833 sq meters (1.038 acres)
14
last seasons harvest was better 27(58.7%) than that of the previous year (2005). Nevertheless, some 41(89.1%)
of the respondents reported harvests that were below their expectations and attributed this to lack of rain
31(75.6%), insects 2(4.9%), diseases and pests infestation 3(7.3%). Other problems that led households not to
harvest what they expected accounted for 16(39%), these included lack of manure, lack of labour, destruction of
crops by livestock and interclan fighting. This concurs with FEWSNET December reports indicating that the year
2006 crop production in the entire Western Flood Plain zone was better than that of the previous year. The
report further indicates that the performance of off -farm production such as wild foods was relatively good and
this concurs with observations during the survey period.
Sorghum was the predominant crop cultivated by most 44(95.7%) of the households with maize, beans and
vegetables grown to a minimal extent. Findings further indicated that there is a bit of crop diversification in the
community with some 17(37%) households having planted other crops such as tobacco, pumpkin, groundnuts
and simsim as illustrated in the figure 3 below.
95.7%
100%
90%
80%
70%
60%
50%
40%
30%
37.0%
28.3%
10.9%
20%
10%
0%
ze
ai
M
4.3%
um
gh
r
So
s
an
Be
s
le
ab
t
ge
Ve
et
ill
M
8.7%
r
he
Ot
Figure 3: Types of crops grown
FARM Africa, which implements a food security program within the county, cited the presence of strigger weeds
which greatly affects sorghum production and the agency is currently working on ways through which this
problem can be dealt with. To curb the problem of low sorghum yields as a result of unreliable rain patterns, the
agency has initiated strategies such as seed priming whereby sorghum seeds are soaked overnight before
planting to ease germination. Sorghum transplanting is another strategy in which sorghum is first planted in
seed beds just before the rains begin, and then transplanted immediately the rains begin. The program is also
trying to empower local blacksmiths to be able to produce farm tools such as malodas and jembes. Dry season
cropping is being encouraged besides the rain-fed farming, which is typical in most parts of South Sudan, with
vegetables being planted along the river banks. With all these innovative approaches, it is hoped that the
sorghum yields are likely to increase in future.
Despite improved harvests, most 22(44%) households reported that the food stocks would last for at most three
months while an almost similar proportion 17(34%) had already depleted their food stocks and were relying on
wild fruits and vegetables 7(41.2%), kinship 3(17.6%), sale of firewood 5(29.4%) and other means 10(58.8%)
such as sale of grass and local brew. Nonetheless, despite this improvement, structural food deficits are still
expected by a segment of poor households that is chronically food insecure starting in April 2007. Typically, the
structural deficits occur anytime between April and August, commonly known as the hunger gap season18.
Figure 4 below shows the various coping mechanisms adopted by the respondents.
18
FEWSNET December 2006
15
80%
60%
58.8%
41.2%
40%
20%
29.4%
17.6%
0%
Wild food
collection
Kinship
Sale of
firewood
Other
Figure 4: Coping Mechanisms
Majority of the households’ meal comprised mainly of sorghum, wild fruits such as chum, tamarind (chue) and
wild vegetables such as anyuer and akuor, as these were reportedly consumed daily. Additionally, dried fish;
locally known as madeja, was consumed by some 18(36%) of the households whereas milk was consumed by
very few 5(10%) of the households and notably, the little milk available was only fed to younger children. This
was because most of the cattle were at the cattle camp during this time of the year. This attests to the
FEWSNET January 2007 report that vindicate that the households in the Western Flood Plain Livelihood Zones
were consuming sorghum supplemented by groundnuts, sesame, fish and wild foods. The report further
elaborates that less milk was being consumed as cattle were moved to grazing areas away from homesteads.
Figure 5 below illustrates the foods frequently consumed during the survey period.
100%
90%
42%
36%
10%
2%
its
fru
es
bl
ta
ge
ve
ild
W
sh
Fi
t
ea
M
ilk
M
m
hu
rg
So
ild
W
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure 5: Foods most frequently consumed
The last WFP food distribution in the location which was done through WVI was reported to be August 2006 by
the households interviewed with no household having received any food aid in the preceding three months. This
affirms the WFP new food distribution strategy for South Sudan of food distribution to the chronically food
insecure during April-July hunger season, for resettlement and re-integration activities and food for the local
population receiving returnees19.
19
Southern Sudan Food Security Update (FEWSNET) December 2006
16
The Aguok and Apuk of the Dinka ethnic community own a variety of livestock as depicted in the results in which
35(70%) admitted that they own livestock. 22(62.9%) owned cows or chicken, 20(57.1%) had goats with
4(11.4%) owning sheep. Significantly, the cows, goats and sheep were at the cattle camp “toic” with only the
chicken found in the homes as observed. The major benefits derived from the livestock by the community
included milk 20(57.1%) especially in the wet season, food on special occasions 15(42.9%), payment of dowry
14(40.0%), sale 8(22.9%) and use of livestock as a symbol of wealth 1(2.9%). Other benefits obtained from the
livestock accounted for 20(57.1%) and mainly included manure and eggs as demonstrated in Figure 6 below.
Most respondents 46(92%) reported that livestock were sold or bought at the local markets. This could be due to
the existence of vibrant markets both within the county and in the neighbouring areas.
In the past five years, the number of livestock owned has tremendously declined as reported by 23(65.7%) of
the households. This declination could be due to persistent insecurity that has led to cattle raiding, sale of
livestock, and payment of dowry not to mention slaughter of animals for food. Livestock diseases and lack of
adequate pastures may have also contributed significantly to this scenario. According to FARM Africa, the most
common livestock diseases in the county are Anthrax, Haemorrhagic septicaemia, Contagious bovine
pleuropneumonia, contagious caprine pleuropneumonia and Mange, hence their disease surveillance program
targets prevention of these diseases and management of outbreaks.
60%
57.1%
50%
57.1%
42.9%
40.0%
40%
30%
22.9%
20%
10%
2.9%
le
Sa
y
wr
Do
od
Fo
ilk
M
er
th
lth
O
ea
fW
lo
bo
m
Sy
0%
Figure 6: Benefits derived from livestock
A number of vibrant markets exist in Gogrial West County such as at Alek and Gogrial averagely being
approximately less than an hour walk for most 35(70%) of the households. These markets sell food and non
food items. Some of the food items found in most markets include sorghum, maize, pulses, milk, oil, vegetable,
sugar, wheat, salt, and fish. Cash purchases are increasing within the county as households reported to
purchase a variety of commodities from the market. Foodstuffs commonly purchased included sorghum, sugar,
fish, maize, rice and other such as salt (see food list and their prices are attached in appendix VIII.8). Worth
mentioning is the introduction of a new currency, the pound, in Sudan on January 9, 2007. The new currency
was established as a result of the north-south peace agreement signed in January 2005 and replaces the
dinnar, which was introduced in 1992. The establishment of a new and common currency is expected to have a
positive impact on the collection of market data and monitoring of markets, especially in southern Sudan, which
has been problematic in the past due to the use of different currencies in different markets and states. This
applies to all market data that was collected starting 1995 to 2006.20 20 FEWSNET January 2007
17
It is paramount to note that various seasonal rivers are extant in the region with Rivers Malualawien and Nyantit
providing fishing grounds to the community to supplement their food demands during certain times of the year
especially between March and May as reported by the households. According to the findings, only 14(28 %) of
the community had access to fishing grounds. This could be associated with the fact that most rivers are
seasonal hence dry up when rain stops as was the case during the survey. Of those who had fishing grounds,
only 4(28.6 %) practiced fishing, half of whom said they harvested enough fish. Those who did not practice
fishing cited a number of reasons such as lack of adequate and appropriate fishing equipment and lack of labor
as reported by 3(30%) and 7(70%) of the respondents correspondingly. Men offer the most significant skill and
labour in fishing as in the Dinka community, fishing activity is mainly reserved for males therefore the notable
absence of men in the representative households interviewed explains the low fishing practice in those
households. Half of the respondents who did fishing said they used nets, while a similar proportion used other
fishing tools such as baskets locally known as athoy; only 1(25%) said they used hooks for fishing. The results
further indicated that the most common fish preservation methods used amongst this community was drying as
revealed by all the respondents. This was evidenced by the availability of dried fish, madeja in most local
markets.
In a nut shell, the food insecurity in the location could be attributed to various shocks such as livestock diseases,
lack of appropriate and adequate fishing and farming equipment, lack of labour and human diseases. The main
coping strategies adopted by most of the households were eating fewer meals, consumption of wild fruits and
vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and
alcohol. Despite the numerous fall-back strategies in the community, some of them are not sustainable and
would make the households poorer as they may deprive people of their livelihoods or result to poor health. This
is especially when cattle are sold and sorghum used to brew beer. These may decline over time further
exacerbating food insecurity and in the long run may result to adverse health and malnutrition.
.III.3. Health
Disease prevalence is one of the immediate causes of malnutrition, therefore lack of and inaccessibility to health
care services are key issues when trying to define the nutritional situation unearthed by the results in Gogrial
West County. Provision of health care in the surveyed locations is largely undertaken by NCA in collaboration
with the ministry of Health. The agency is responsible for medical and drug supply while the Government
remunerates the staff. Initially there used to be 11 PHCUs and one PHCC. However 4 PHCUs have since been
closed down due to lack of staff as such, only 9 PHCUs are functional at present. The PHCC is run by a medical
assistant and supported by two nurses. Good enough, two more nurses have already been trained and are
expected to join in the running of the PHCC in the course of the year. The PHCUs on the other hand are each
headed by a Community Health worker. TBAs and EPI staff are also attached to every health unit. Other than
timely and general supervision, NCA also provides drugs to the health centres every month. The
NCA/Government run health units provide both preventive and curative services; these include treatment of
common ailments, health education and EPI services. The PHCC which acts as a referral centre to the PHCUs
additionally offers HIV/AIDS program, MCH and inpatient services with a bed capacity of 30. There were no
laboratory services during the time of the survey; however the structure had been set up. According to the
information gathered from the NCA health supervisor, there was already a trained laboratory technician, thus
provision of laboratory services is likely to commence soon.
According to the NCA health supervisor, the health facilities are well utilized with monthly attendance rates
ranging from 1000 to 2000 patients. She further reported that despite the fact that health services were free; the
health seeking patterns of the community is deplorable, as majority seek medical attention when it is too late.
Belief in traditional healers in this community is rampant as evidenced by the presence of various magical
paraphernalia as observed in most of the homes visited. However she noted that health seeking patterns have
greatly improved in the recent past, a situation which she attributed to the persistent health education.
Provision of EPI services are done routinely in the PHCC; however the health supervisor reported that despite
the vigorous health education given, most mothers in this community still do not recognize the significance of
immunization and as such some fail to avail their children for vaccination, while those whose children have been
vaccinated do not keep the cards well and end up loosing them. These two factors have proved to be major
challenges when trying to verify whether a child has been immunised or not. This could elucidate the low (21%)
measles coverage unveiled by the results. To curb the problem of enormous walking distances to get children
18
immunized in the PHCC, the agency organizes frequent outreach EPI activities through the PHCUs. These
outreach activities are usually organised on monthly basis with the last one being conducted in the month of
December.
Reportedly, all the health units provide general health talks every morning and to individual patients depending
on the prevailing condition. Of importance is the MCH clinic where the pregnant and lactating mothers are
advised on appropriate child care practices. Nonetheless, due to limited staff who most of the time are
overwhelmed, individualised health education is greatly hampered. Growth monitoring is done in the PHCC and
the malnourished children are referred to the ACF-USA feeding program. Additionally, HIV/AIDS health
education program is also existent in the PHCC and is conducted every Monday. The program utilizes audio
visual equipments which are in both English and Dinka languages.
Health care service provision in Gogrial West County is greatly hampered by the challenge of limited staff. Out
of the 24 trained Community Health Workers, only 14 are currently working. Similarly, the EPI staffs most of who
are demoralised since they have not been paid for some time. Pointedly, it is the lack of staff that prompted the
closure of four PHCUs run by NCA as the CHWs in charge of these health units had reportedly gone to Kuajok
to look for money. The issue of non payment of salaries has reportedly caused most staff to move out and seek
alternative sources of income. This has further been aggravated by the fact that the government payroll has not
been revised to include new entrants, but still include names of ghost workers. The government through the
Ministry of Health thus need to act swiftly to salvage this important sector.
The common diseases, as reported by the NCA health supervisor, were Malaria, Respiratory Tract Infections
(RTIs), mostly pneumonia and diarrhoeal diseases. Malnutrition was also said to be common especially among
the young children. Reportedly, this was due to the fact that most of the households in the community prepare
food late at night and hence children are not fed adequately. Malaria, which apparently is the leading cause of
morbidity was said to be common during all seasons. Results of the analysis attest to this fact. This could
probably be due to lack of mosquito nets as was discovered through interviews with households and
observations. The high prevalence of pneumonia especially among children could be ascribed to the fact that
most children were left uncovered or wore very minimal clothing as observed in the households visited. Such
was the case regardless of the nippy weather especially during the early morning hours. Most household were
also observed to be lacking adequate bedding to guard them against the cold during the night. On the other
hand the many cases of diarrhoeal infections are most likely precipitated by consumption of untreated well and
swamp water as well as poor sanitation as illuminated by the results. The figure 8 beneath shows some of the
common diseases mentioned by the respondents.
100%
80%
60%
90%
76%
40%
42%
20%
0%
ia
ar
al
M
14%
ea
ho
r
a
Di
r
ve
Fe
Is
RT
10%
er
th
O
Figure 7: Common causes of morbidity
During the survey period, there was a meningitis outbreak reported in the county and its environs and was said
to have started on 22nd January. According to the NCA health supervisor there were a total of 7 cases reported
in the PHCC, 2 of whom passed on. She however noted that following reports from an inter-agency meeting that
was held in Kuajok on 31st January, the situation had been contained and was being monitored. She also
revealed that they were planning a mass Meningitis immunization exercise to be held in the whole county as
soon as the necessary logistical issues were sorted out. The aim would be to curb the endemic occurrence of
meningitis in this region during this time of the year, which in most cases results in many casualties.
19
From the discussion above, it is eminent that a lot more still needs to be done in a bid to enhance the health
status of the community. The existing health facilities in Gogrial West County cannot adequately meet the needs
of the entire population and the high numbers of returnees expected in the county in future. Assuming that all
the residents in the assessed payams in Gogrial West County, which is currently approximated at 116,81621
people, use the PHCC located in Alek as a referral centre, it translates to a ratio of 1:116816 persons. This falls
short of the recommended SPHERE and SOH standards which advocate for one PHCC against 50,000 and 80,
000 respectively.
.III.4. Water and Sanitation
Despite the presence of a number of registered hand pumps in Gogrial West County, the water situation is still
plagued as most of the hand pumps are dysfunctional. The few that are in good order can hardly meet the need
of the populace. As such, accessibility and availability of potable water is still below SPHERE22 standards, which
recommends not more than 15 minutes queuing time and 250 persons per hand pump. Reliable sources
indicated that out of 256 registered boreholes in this county only a third are functional. As a result of the long
walking distances and queues at the water points, some people prefer getting water from shallow wells and
swamps as reported by 26% and 10% respectively. Because of the difficulty in accessing water, most
households, at the time of the survey were found to use very little water for household consumption with more
than half of the respondents reporting that they consume an average of 30-40 litres per day as shown in figure
9 below. For instance, presuming that each household has an average of 6 persons, this therefore translates to
5-7 litres per person per day, which falls below the initial average recommended 15 litres per person per day.
Worse still, more than half 40(80%) of the respondents admitted that they drunk untreated water with only
10(20%) saying that they either filtered or sieved water before drinking. This practice, coupled with poor hygiene
and sanitation in the area predisposes the community to diarrhoeal and water borne ailments, especially during
the wet season. Children are usually the first culprits of such infections and the worst hit owing to their under
developed immunity and eventually succumb to effects of malnutrition. Save the children-UK which used to
carry out borehole drilling and repairs in the county have so far handed over to FARM Africa. Driven by the fact
that agriculture and livestock requires water, the agency intends to partner with SUPRAID to drill more and
repair some of the extant boreholes using the existing water management teams. Since borehole drilling is an
expensive venture, they are also exploring the possibility of empowering the community to embark on
alternatives to boreholes specifically shallow protected wells, digging dams and rain harvesting. These
approaches would not only ensure sustainability but would also prove to be relatively cheap when it comes to
maintenance.
2% 4% 4%
28%
12%
50%
10-20litres
21-30litres
51-60litres
>60litres
31-40litres
41-50litres
Figure 8 : Average daily water consumption
21
Source: Acting SRRC Gogrial West County
Sphere(2004) standards on water access and quantity include; Average water used for drinking, cooking and personal
hygiene per person per day is 15 liters, Queuing time not more than 15 minutes, one hand pump with a flow rate of 16.6
Litres/minute for a maximum of 500 persons and safe water availability on regular basis.
22
20
Hygiene and sanitation practices in the representative sample surveyed in Gogrial West County seemed to be
quite unsatisfactory. To begin with latrine use was rare; virtually all the households interviewed did not have
access to a toilet facility, save for those that were observed in NGOs, administrative offices and in town centres.
Saddening, majority of the population therefore admitted that they disposed off human waste haphazardly
unmindful of the negative health repercussions it may inflict on their health. This reprehensible practice is further
aggravated by the cultural belief that prohibits latrine use among the Dinka community. Similarly the stools of
young children were gotten rid off by throwing outside the yard as reported by all the respondents who had
children. Nonetheless, the various reactions drawn from the respondents as they tackled this question during
the interviews clearly proved that they were aware that this practice was not right, thus signifying that health
education has had some impact in trying to change the attitudes of this community.
It is pretty good to note that majority 46(92%) acknowledged hand washing before meals with only a negligible
proportion saying it was not practiced. With this not withstanding, it was observed that personal hygiene was
generally not up to standard as most children presented with unclean faces and were seen eating with frowzy
hands. Moreover the wild fruits were largely consumed unwashed by most people. Cooking utensils and water
containers were not properly cleaned and were left in the open thus risking contamination by house flies and
dogs. Poor hygiene and sanitation is linked to the prevalence of diarrhoeal infections.
.III.5. Maternal and Child care practices
Causes of malnutrition in developing countries are often characterized by complex, multidimensional and
interrelated factors. Inappropriate child care practices, being one of the underlying causes of malnutrition need
to be overemphasized in trying to capture the possible causes of malnutrition unearthed by the survey results.
This is because children less than five years of age, in most instances are not able to perform most tasks by
themselves, including eating. Their nutritional status is of particular concern since the early years in life are
crucial for optimal growth and development. Expectant and lactating women are also of concern as their
physiological state warrants them to consume additional nutrients to cater for the elevated requirements.
Moreover, due to the inter relationship between birth weight, breast feeding and malnutrition, additional nutrients
are thus essential. In Gogrial West County, just like in most parts of South Sudan this category of individuals
with special needs are not exempted from the usual tedious duties; neither did they consume adequate and
nutritious foods to meet their accelerated nutrient needs. Instead they were seen indulging in nerve cracking
tasks such as cutting and transporting large bundles of grass, pounding sorghum among others. In the long run,
they ended up depleting even the meagre nutrient reserves, as they ate only once a day.
The survey results have generally vindicated satisfactory early infant feeding practices in Gogrial West
community. Commendably, more than half 44(93.6%) of the mothers interviewed initiated breastfeeding
immediately after birth, 45(95.7%) of whom breastfed their children on demand. Exclusive breastfeeding was
highly regarded in the community as unveiled by the results. More than half 31(64.6%) of the mothers
interviewed commenced weaning after six months of age which is the recommended weaning period by WHO.
Thereafter, beast milk continued to form an important component of food fed to children between 6-29 months.
Even though malnutrition is said not to affect milk production both in terms of the quality and quantity, most
lactating mothers engaged in activities outside the home such as fetching water, firewood and grass collection,
alcohol brewing hence spent very little time with the children. When they came back, they were either too tired
or too busy to appropriately breastfeed their children. Unfortunately, this practice poses a risk on the nutritional
status of the young exclusively breastfed children.
It is a known fact that breast milk is the perfect food for infants as it contains all the necessary nutrients required
for growth and development in the very initial stages of life. However, as a child develops, breast milk needs to
be supplemented with other foods to take care of the increased nutrient requirements. The weaning foods apart
from being palatable should be balanced so as to provide the child with the necessary growth factors. In the
surveyed households the predominant weaning food mainly comprised of food eaten by everyone and was
made from sorghum locally known as kuon as reported by 37(75.5%) of the respondents. This could be ascribed
to the fact that it was the beginning of the dry season thus most cattle had been driven to the wet lowlands
(cattle camps) locally known as toic, as such milk availability was limited as only 18(36.7%) fed their young ones
on milk.
21
The frequency of feeding among the young children was greatly hampered by the limited food stocks and the
involvement of mothers in other household chores outside the home. This implied that the children were either
left hungry or under the care of older children who at times consumed most of the food while the young ones
remained hungry or consumed very little. It was also a common practice in most households that food is served
in a common bowl where both the younger and older children ate together. This practice may have negative
consequences on the nutritional status of the younger children as they are unable to keep pace with the older
children who eventually ate the larger portion. Nevertheless majority of the households interviewed 35(71.4%)
reported that they fed their young children twice a day. These two servings are not adequate since children have
small stomachs thus require small but frequent meals.
.III.6. Education
Education in Gogrial West County is currently receiving support, both from the Government and NGOs. Save
the Children-UK has various educational activities within the county. They have a teacher training program
whereby they do phase training and in -service teacher training which lasts for four years. Additionally, the
agency also has an education management training aspect which mainly targets head teachers and supervisors
at the county level whose aim is to impart them with management skills so as to improve the quality of
education. There is also the intensive English course which targets the Arabic trained teachers, to enable them
learn English, which is the main language of instruction. Further, the organization also runs accelerated learning
program, which is a four level course fitting in the curriculum of primary 1 up to 8. The programs utilize the
syllabus developed by the Sudan secretariat of Education. No school fee is charged in these learning facilities
as the services are absolutely free. The agency also extends support to primary schools in terms of scholastic
materials such as text books, pens, rubbers, rulers among others. During the time of the survey the agency was
supporting 9 schools in Gogrial West County; one school each in Akon South, Kuac North and Kuac South
payams and 2 schools each in Akon, Riau and Gogrial payams. Additionally they also engage in construction of
primary schools and so far two permanent structures have been constructed each in Ajiep and Akon payams.
Workshops are conducted with local education authorities who do community mobilization.
NCA on the other hand supported 14 primary schools initially by giving them scholastic materials. However at
the time of the survey they were only supporting 5 schools as the rest were being supported by the Government.
According to the education officer, the agency also does construction of schools and is planning to begin
construction of one primary school in Alek this year. The teacher training program which is intended to close
once the government sets up a teacher training college in Kuajok is currently being conducted in three phases.
Similarly there is also an adult literacy program in place with cookery and dress making being some of the
courses offered. According to the agency, a primary school has been initiated out of it and has so far reached
primary two.
Non payment of salaries to some teachers by the government is posing a great challenge to the education
system in Gogrial West County as reported by the agencies on ground. This has been occasioned by poor
teacher regularization hence there are teachers who exist in the government payroll but do not offer services.
This has caused loss of morale among the active teachers leading to poor service provision and late reopening
of schools. According to the Ministry of Education calendar for South Sudan, there are supposed to be three
terms every year running from April, however due to lack of water and food most schools delay in reopening. It
was reported that this year schools are likely to reopen in June as opposed to April. This means that a lot of
learning time is lost as the community tries to cope with the devastating effects of the hunger gap period. More
over, it was also noted by the two agencies proffering education that the exercise of nationalizing positions by
most NGOs has impacted negatively on the education sector. The few skilled personnel who are able to read,
speak and write in English are absorbed in other sectors thus putting education sector at a halt.
.III.7. Actions Taken by NGO’s and Other Partners
Underneath are the different NGOs and SINGOs and their areas of interventions in Gogrial West County:
ACF-USA implements targeted feeding (SFC and TFC-HT) programs in the county. A TFC and a distribution
centre for the severely and moderately malnourished children respectively are operational in Alek centre. The
programs that started off in May 2006 targeted 250 and 1300 patients in the TFC and SFP accordingly. The
22
program has so far registered a total of 224 and 700 severely and moderately malnourished children. The
January 2007 reports indicate that there were a total of 32 and 127 children on Therapeutic and Supplementary
Feeding programs correspondingly, all of whom were children below five years of age.
NCA is involved in the provision of primary health care services and education activities in Gogrial West County.
The health services are provided in collaboration with the Ministry of Health, whereby NCA is responsible for
provision of medical and drug supplies while the Government remunerates staff. They run 1 PHCC situated in
Alek South Payam and 11 PHCUs each located in Keet, Atukuel, Mandeng, Malual Ajak, Mankuac, Anguoth,
Panliet, Ayuang, Malualawien, Bau, and Pakor villages. However, 4 PHCUs have been closed down since early
this year due to lack of staff (CHWs). The medical assistant is in charge of the PHCC while the PHCUs are
supervised by Community Health Workers (CHWs).
Among the curative and preventive services proffered in the health units include, treatment of common ailments,
health education, HIV/AIDS and EPI programs. These services are free save for the registration and admission
fee which are 100 and 200 Sudanese Dinnars respectively. The PHCC which acts as a referral centre to the
PHCUs in addition offers MCH and in-patient services with a bed capacity of 30. The organization is in the
process of setting up a laboratory and for that matter, a laboratory technician has already been trained. They are
also involved in training activities for the health personnel such as CHWs, TBAs, EPI and MCH staff; village
health committees for PHCUs and Management committees for PHCCs. The CHWs and MCH were trained for
9 months in 2004 and had a refresher course in 2006. Plans are underway to train more MCH and CHWs in the
course of the year.
On education, the organization has four main activities namely; support of primary schools, school construction,
teacher training and adult literacy. They initially supported 14 primary schools, however only 5 schools are
currently supported through provision of scholastic materials such as books and pens among others. The other
9 schools are taken care of by the Government. The schools use the syllabus developed by Sudan Secretariat
of Education (SOE) with English being the main language of instruction. One school has been targeted for
construction in Alek whereas the teacher training program is intended to wind up as soon as the Government
opens up a teacher training centre in Kuajok. In addition, a women centre whose aim is to curb the low
enrolment and literacy levels among females, offers cookery and dressmaking lessons; this has led to the
initiation of a primary school which has so far reached class two.
FARM AFRICA, whose aim is to eradicate poverty by improving the livelihoods of farmers and herders in
marginalized areas mainly incorporates innovative approaches in development to ensure that people live in
sustainable situations using natural resources. The main program areas the agency is concerned with include
animal health, agriculture, water, community development, research and policy. Animal health main activities
are provision of veterinary inputs, improving productivity and disease surveillance. The agriculture component is
concerned with improving farming methods, empowering local blacksmiths and encouraging dry season
cropping. They also give farm inputs to vulnerable groups such as returnees and those affected by inter clan
fighting. In the sector of water, the agency partners with SUPRAID to drill new boreholes, rehabilitate broken
ones through the existing water management teams and also explore alternatives to boreholes such as shallow
wells. Research and policy which is the key area in the organization, aims at creating models in agriculture and
other sectors that are able to meet the community needs in one package. These models can in future be used
for up scaling of projects by the Government and other agencies. At the moment the agency is in the process of
gathering information on research and policy at Government level and sensitizing the community on policy
issues. They also intend to initiate action oriented research for example that which would reduce the women
work load in the community. Finally, the community development aspect tries to capture the other needs of the
community which are not met by the agency’s interventions; as such models like village development
committees have been initiated.
SUPRAID is an indigenous organization whose main activity is drilling of new bore holes in the county. Because
of their capacity, they are at times contracted by NGOs to drill boreholes.
SC-UK is involved in education, HIV/AIDS and child protection programs in Gogrial West County. Under
education, they have a teacher training program whose activities include; phase training, in-service teacher
training, education management training, intensive English course and accelerated learning, which is a four
level course targeting those aged 12-21 years. They also support primary schools in terms of scholastic
materials and construction of physical facilities. They are currently supporting a total of 9 primary schools in the
23
county; one school each in Akon South, Kuac North and South payams and 2 schools each in Akon North, Riau
and Gogrial payams. In addition they also conduct work shops with local education authorities who assist in
community mobilization. The HIV/AIDS program is mainstreamed and integrated into the education program.
WVI in Gogrial West County is operating a number of programs including food security which is currently
implemented in Ajiep with the main activities being demonstration farms, ox plough training, and tree planting.
The food aid program is carried out in collaboration with WFP, and they have currently moved from general food
distribution (except for returnees and the vulnerable) to food for assets while in Health and Nutrition, the agency
is at the moment running an SFP and one PHCC in Ajiep.
UNMAS whose main responsibility is to assess and monitor global land mine threat carries out de-mining
activities within the county especially around Gogrial town.
.IV. RESULTS OF THE ANTHROPOMETRIC SURVEY
A total of 642 children were measured, however due to incoherent data in four records, only 638 records were
subjected to analysis.
.IV.1. Distribution by Age and Sex.
Table 2: Distribution by Age and Sex
Age groups
(months)
06 – 17
18 – 29
30 – 41
42 – 53
54 – 59
Total
BOYS
N
68
74
47
61
60
310
GIRLS
%
43.9
54.0
46.1
47.7
51.7
48.6
N
87
63
55
67
56
328
TOTAL
N
%
155
24.3
137
21.5
102
16.0
128
20.1
116
18.2
638
100.0
%
56.1
46.0
53.9
52.3
48.3
51.4
Sex
Ratio
0.8
1.2
0.9
0.9
1.1
0.9
Age groups in month
The table above demonstrates that there is only a slight variation between the two sexes in the sample
population structure.
54-59
42-53
BOYS
30-41
GIRLS
18-29
06-17
-60%
-40%
-20%
0%
20%
40%
60%
Figure 9 : Distribution by Age and Sex
24
There are slight imbalances in age distribution as illuminated by the diagram above, with most conspicuous
imbalance appearing in age group 30-41 months where there is slight under representation by about 4.1%.
Similarly in the age group 54-59 months there is some over representation of 8% more than the average of
10%. These disparities can be associated with recall bias by some of the caretakers in the two age categories.
The ages recorded were approximated by use of a local calendar of events.
.IV.2. Anthropometrics Analysis
.IV.2.1. Acute Malnutrition, Children 6-59 months of Age
¾
Distribution of Acute Malnutrition in Z-Scores
Table 3: Weight for Height distribution by age in Z-scores and /or oedema (NCHS Reference)
Age group
(In months)
N
06-17
18-29
30-41
42-53
54-59
TOTAL
155
137
102
128
116
638
≥ -3 SD & <- 2 SD
< -3 SD
≥ -2 SD
Oedema
N
%
N
%
N
%
N
%
3
0
0
0
2
5
1.9
0.0
0.0
0.0
1.7
0.8
33
30
8
19
25
115
21.3
21.9
7.8
14.8
21.6
18.0
119
106
94
109
89
517
76.8
77.4
92.2
85.2
76.7
81.0
0
1
0
0
0
1
0.0
0.7
0.0
0.0
0.0
0.2
Table 4: Weight for height vs. Oedema in z-scores (NCHS Reference)
Weight for height
YES
Marasmus/Kwashiorkor
0
0.0%
NO
Marasmus
120
18.8%
Oedema
≥ -2 SD
< -2 SD
1
Kwashiorkor
0.2%
No malnutrition
518
81.0%
Only one case (0.2%) of Kwashiorkor was found in the sample, the other cases of acute malnutrition are of the
Marasmic type.
Figure 10: Weight-for-Height Z-scores distribution, Gogrial West County-2007
25
The marked dislodgement of the sample curve to the left side of the reference curve, demonstrates a poor
nutritional situation of the surveyed population. The mean Z-score is 1.2 and standard deviation of 0.82 which is
within the acceptable range of 0.8–1.2. Therefore, the assessed sample can be said to have been
representative of the entire population.
Table 5: Global and Severe Acute Malnutrition in Z-scores in NCHS and WHO references
Global acute malnutrition
Severe acute malnutrition
WHO reference
19.0 %
(15.1% - 22.8%)
2.8 %
(1.3% - 4.4%)
NCHS reference
19.0 %
(15.3% - 22.7%)
0.9 %
(0.1% - 1.8%)
¾ Distribution of Malnutrition in Percentage of the Median
Cut-offs for acute malnutrition expressed in percentage of the median are commonly used in determining
admission criteria in feeding centres.
Table 6: Distribution of Weight/Height by age in percentage of the median and oedema (NCHS Reference)
≥ 70% & < 80%
< 70%
Age groups
(In months)
N
06-17
18-29
30-41
42-53
54-59
TOTAL
155
137
102
128
116
638
≥ 80%
Oedema
N
%
N
%
N
%
N
%
0
0
0
0
0
0
0.0
0.0
0.0
0.0
0.0
0.0
23
10
1
6
9
49
14.8
7.3
1.0
4.7
7.8
7.7
132
126
101
122
107
588
85.2
92.0
99.0
95.3
92.2
92.2
0
1
0
0
0
1
0.0
0.7
0.0
0.0
0.0
0.2
Table 7: Weight for height vs. Oedema in % of the median
YES
Oedema
≥ 80%
< 80%
Weight for height
Marasmus/Kwashiorkor
0
0.0%
NO
49
Marasmus
7.7%
1
Kwashiorkor
0.2%
No malnutrition
588
92.2%
Table 8: Global and Severe Acute Malnutrition in NCHS and WHO references in % of the median
Global acute malnutrition
Severe acute malnutrition
NCHS reference
7.8 %
(5.4% - 10.2%)
0.2 %
(0.0% - 0.5%)
WHO reference
4.1 %
(2.2% - 5.9%)
1.9%
(0.0% - 0.3%)
.IV.2.2. Risk of Mortality: Children’s MUAC
All 641 children were included in the MUAC analysis.
26
Table 9: MUAC Distribution
MUAC (mm)
< 110
110≥ MUAC<120
120≥ MUAC<125
125 ≥ MUAC <135
MUAC ≥ 135
TOTAL
>=75 – < 90 cm
height
0
0.0%
2
0.9%
12
5.5%
59
27.2%
144
66.4%
100%
217
< 75 cm height
3
12
9
33
48
105
2.9%
11.4%
8.6%
31.4%
45.7%
100%
≥ 90 cm height
0
0
6
35
275
316
0.0%
0.0%
1.9%
11.1%
87.0%
100%
Total
3
14
27
127
467
638
0.5%
2.2%
4.2%
19.9%
73.2%
100%
According to the MUAC criteria, 0.5% of children in the sample were severely malnourished and 2.2% moderately
malnourished.
.IV.3. Measles Vaccination Coverage
The survey results indicate very low measles immunization coverage as more than half (79.0%) of those
children measured had not been vaccinated against measles. Only a negligible number (3.9%) of the children
had EPI cards that could be used to confirm vaccination. This attests to information gathered from NCA that
most mothers fail to keep their cards safely for future use.
Table 10: Measles vaccination coverage
Measles vaccination
Proved by Card
According to the mother/caretaker
Not immunized
Total
N
23
101
466
590
%
3.9
17.1
79.0
100
.IV.4. Household Status
Table 11 below shows the household status of the surveyed population.
Table 7: Household status
Status
Residents
Internally Displaced
Temporary Residents (on transit)
Returnee
Total
N
427
4
23
5
459
%
93.0
0.9
5.0
1.1
100
The largest proportion of the surveyed population is resident in the location. The results show minimal
population movement during the period of assessment with the majority having settled in the county.
.IV.5. Composition of the Households
A total of 544 households were visited during the survey.
Table 8: Household composition
Age group
Under 5 years
Adults
Total
N
698
1940
2638
%
26.5
73.5
100.0
Average per Household
1.3
3.6
4.8
27
.V. RESULTS OF THE RETROSPECTIVE MORTALITY SURVEY
The crude mortality rate was calculated from the figures collected from all households surveyed. All the
households included in the anthropometric survey were considered for mortality data regardless of whether they
had children 6-59 months or not.
During the survey, a total of 2638 people were present in the assessed households. Of the total population 698
(26.5%) were children below the age of five years of age. 32 people had joined the various households within
the last three months while 108 had left.
On the same period, 31 births had taken place while the total deaths were 14, six of whom were for children
below five years. Thus the retrospective mortality rates are:
♦
♦
The crude mortality rate is 0.58 [0.28- 0.89] /10,000/day.
The under five mortality is 0.97 [0.28-1.65] /10,000/day.
.VI. CONCLUSION
Findings of the anthropometric analysis revealed GAM and SAM rates of 19.0% [15.3%-22.7%] and
0.9 %( 0.1%-1.8%) respectively in Z- score at 95% confidence interval. Analytically, the GAM rate is above the
emergency level of 15% and in turn calls for integrated and inter-agency intervention to curb any further decline
whereas the SAM is below the emergency level of 4%.
Over the preceding three months to the survey period, the mortality rates are 0.58 [0.28- 0.89] /10,000/day and
0.97 [0.28-1.65] /10,000/day respectively for total population and the under five years old age group. Both of the
aforementioned rates are below the alert levels.
WVI and ACF-USA have undertaken numerous nutrition surveys in the region since the year 2004. The latest
assessments were conducted in the previous year that revealed GAM and SAM rates 23.9% [95% C.I: 20.0% 28.2%] in Z-score survey done by ACF-USA assessment between February and March 2006. This yeas
malnutrition rates are lower as compared to last year results, which could be attributed to impact of ACF-USA
nutrition treatment program in the region. However, the current GAM rate of 19.0% [ 95% C.I: 15.3%-22.7%] in
z-scores is still above emergency threshold and could be attributed to a number of multifaceted factors such as;
decline in food security, disease and poor health seeking patterns, water and deplorable sanitation practices,
inappropriate feeding and child care practices and insecurity. These can be summarised as follows:
Food Insecurity:
The food insecurity situation in the location could be attributed to various shocks such as livestock diseases,
lack of appropriate and adequate fishing and farming equipment, lack of labour and human diseases. The main
coping strategies adopted by most of the households were: eating fewer meals, consumption of wild fruits and
vegetables, kinship support and buying using income from petty trade, sell of firewood, livestock, grass and
alcohol. These may decline over time further exacerbating food insecurity and in the long run may result to
adverse health and malnutrition.
Disease prevalence and poor health seeking patterns:
Despite free health services offered by the health agency on ground (NCA), the health seeking behaviour of the
community is still wanting. Most of the community sought treatment when the disease had already progressed
into serious phases. Belief in traditional healers in this community is rampant as evidenced by the presence of
various magical paraphernalia as observed in most of the homes visited. This has contributed to the current rate
of malnutrition as some community members seek health services as the last resort, making their bodies
compromised by diseases.
28
Deplorable Water and Sanitation situation:
To meet their water requirements, some of the community members fetch water for drinking and household
consumption from sources such as unprotected well and swamps. Unfortunately, water from these sources is
not treated by majority before drinking. This coupled with the poor hygiene and sanitation in the area,
predisposes the community to diarrhoeal and water borne ailments, especially during the wet season when the
waste and feacal matter is swept back into these water sources and as a results of these diseases that
compromise the health status of the community members resulting to malnutrition especially the under fives.
Inappropriate child care and feeding practices:
Women are engaged in many household activities and thus have very little time for nurturing the children, which
apparently poses a risk on the nutritional status of the exclusively breastfed children. Moreover, the weaning
foods were predominantly the family meal of kuon made from sorghum while other foods such as milk and meat
products were minimally consumed. This consequently leads to poor nutrient intake, and ultimately induces poor
nutrition state of the children.
Security and safety:
The county is still believed to be mined, which limits people’s movement to certain areas. Further, the
continuous episodes of inter clan fighting between the Aguok and Apuk sub clans have continuously been
reported in the county since 2004 hence predisposing the local community to higher risk of food insecurity. This
is because the community is forced to run for their lives thus productive time that could have been spent in tilling
and preparing land for cultivation is spent either in fighting or defending the community. However, as could be
observed in some of these villages, such as Mankuac and Mangok, the community was gradually coming back
and had started settling and it is hoped that with time, the community will be able to bounce back to its normal
livelihood activities.
29
.VII. RECOMMENDATIONS
The above emergency level GAM rate among children aged 6-59 months as depicted by the results signify a life
precarious nutrition situation in Gogrial West County. This has been closely attributed to a bleak food security
situation (access and availability) and diseases as well as various underlying factors discussed above. This is
therefore an indicator that the causal factors responsible for the prevailing state need to be nipped from the bud
before anything untoward happens. Timely interventions are thus inevitably necessary to bolster the community
from the probable effects of malnutrition. Additionally reconstructive and long term measures also need to be put
in place in order to prevent future recurrence of the same, and ultimately ensure that malnutrition is alleviated.
The following recommendations have therefore been put forth by ACF-USA:
Food Security
ƒ To continue the food distribution to the returnees, displaced and other highly vulnerable households.
ƒ To develop new strategies of food for agriculture and food for assets.
ƒ Besides action oriented researches, to explore possibilities of empowering the community to initiate
livelihood activities through the village development committees.
Health
ƒ To carry on with targeted feeding programs for the management of both severely and moderately
malnourished children, and increase their coverage.
ƒ To maintain the existing health initiatives with special focus on MCH and EPI.
Water and Sanitation
ƒ To forge ahead and implement the alternative to boreholes initiative by offering training and technical
support to the community on how to dig shallow wells, dams and rain harvesting, all of which will
ensure sustainability with a cost advantage.
ƒ To partner with other agencies involved in water activities to rehabilitate some of the existing
dysfunctional boreholes within the county.
ƒ To support latrine construction using locally available materials and furnish the community with the
required technical skills while at the same time encouraging community participation to ensure their
utilization.
ƒ To enhance health and hygiene promotion activities within the county by educating the community on
the significance of personal hygiene, human waste disposal and water treatment methods.
Security and safety
ƒ To carry on with the de-mining activities especially in Gogrial town and its environs which are believed
to be heavily mined.
30
.VIII. APPENDIX
.VIII.1. Sample Size and Cluster Determination
PAYAM
BOMA
VILLAGE
POPULATION
Gaikou
3846
Dhok
3000
Atokngar
2700
Areumac
1824
Keem
2100
Ngapathian
Alek South
Amom
3911
Jongar
2645
Atukuel
Rumkwel
3802
Lur
2607
Marial
Kuruec
Alek
4200
3574
Bulic
2280
Amoth
1630
Alek
4100
Mabiormun
3000
Panachier
2400
Alek-North
Malekngok
Dheng
2300
Marialmajock
1450
Malek
2500
Mankuac
Mayom
2745
Mangok
3200
A
B
C
D
A
B
C
A
B
C
A
B
A
B
A
B
C
D
A
B
C
A
B
C
D
A
B
C
A
B
C
D
A
B
C
A
B
A
B
A
B
C
D
A
B
C
A
B
A
B
A
B
A
B
A
B
C
A
B
C
WALKING
DISTANCES
2HRS
11/2HRS
21/2HR
1HR
40 MINS
3HRS
TARGET
POPULATION
769.2
600
540
364.8
420
782.2
21/2HRS
529
30 MINS
760.4
2 HRS
521.4
20 MINS
840
40MINS
714.8
2 HRS
456
20 MINS
326
5 MINS
820
3HRS
600
2HRS
480
21/2HRS
460
25MINS
290
1HR 20MINS
500
11/2HRS
549
41/2HRS
640
REVISED TARGET
POPULATION.
192
192
192
192
200
200
200
180
180
180
182
182
210
210
195
195
195
195
176
176
176
190
190
190
190
173
173
173
210
210
210
210
238
238
238
228
228
163
163
205
205
205
205
200
200
200
240
240
230
230
145
145
250
250
183
183
183
213
213
213
CLUSTER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
31
Nyokthiang
Alek-West
Alueth
Gogrial
Mankuac
2400
Achol
1500
Nyokthiang
2800
Mayen
2252
Ajieng
1820
Alueth
1850
Agok
3274
Wunriang
2695
Mandeng
Mandeng
3780
Wuntur
2430
Manalom
2110
Pancier
4191
Manyiel
3917
Panliet
Kunyuk
Maluil
4614
3267
Riau
Riangalei
Kueec
2812
2981
Anguoth
Malek
Acibut
TOTAL POPULATION
3940
4369
116816
A
B
A
B
A
B
C
A
B
A
B
A
B
A
B
C
A
B
C
A
B
C
D
A
B
A
B
A
B
C
D
A
B
C
D
A
B
C
D
A
B
C
A
B
C
A
B
C
A
B
C
D
A
B
C
D
6HRS
480
5HRS
300
4HRS
560
6HRS
450.4
41/2HRS
364
6HRS
370
4HRS
654.8
4HRS
539
41/2HRS
756
31/2HRS
486
2HRS
422
5HRS
838.2
51/2HRS
783.4
41/2HRS
922.8
5HRS
653.4
31/2HRS
562.4
51/2HRS
596.2
31/2HRS
788
4HRS
873.8
23363.2
240
240
150
150
186
186
186
225
225
182
182
185
185
218
218
218
179
179
179
189
189
189
189
243
243
211
211
209
209
209
209
195
195
195
195
230
230
230
230
217
217
217
187
187
187
198
198
198
197
197
197
197
218
218
218
218
23332
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
The clusters were automatically generated by Nutrisurvey December 2006 after inputting the revised target
population.
32
.VIII.2. Anthropometric Survey Questionnaire
DATE:
VILLAGE:
N°.
Family
N°.
Status
(1)
Age
Mths
Sex
M/F
Weight
Kg
Height
Cm
CLUSTER No:
TEAM No:
Sitting
Oedema
Height
Y/N
cm(2)
MUAC
Cm
Measles
C/M/N
(3)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily
resident in village (cattle camp, water point, visiting family…), 4= Returnee.
(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.
33
.VIII.3. Household enumeration data collection form for a death rate calculation
survey (one sheet/household)
Village:
Survey Payam:
HH number:
ID
Date:
1
2
HH
member
Present
now
Cluster number:
Team number:
3
Present at beginning of recall
(include those not present now
and indicate which members were
not present at the start of the
recall period )
4
5
6
7
Sex
Date of
birth/or
age in
years
Born
during
recall
period?
Died
during the
recall
period
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Tally (these data are entered into Nutrisurvey for each household):
Current HH members – total
Current HH members - < 5
Current HH members who arrived during recall (exclude births)
Current HH members who arrived during recall - <5
Past HH members who left during recall (exclude deaths)
Past HH members who left during recall - < 5
Births during recall
Total deaths
Deaths < 5
34
.VIII.4. Enumeration data collection form for a death rate calculation survey (one
sheet/cluster)
Survey Payam:
Village:
HH number:
N
Date:
Current HH
member
Total
<5
Current HH
members who
arrived during recall
(exclude births)
Total
<5
Cluster number:
Team number:
Past HH members
who left during
recall
(exclude deaths)
Total
<5
Births
during
recall
Deaths during recall
Total
<5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
35
.VIII.5. Calendar of events in Gogrial West County.
MONTHS
JANUARY
PANTOK/ NYIETH
FEBRUARY
PENROW/ KOL
SEASONS
Cattle take to Toics (cattle
camps)
Cut grass for thatching
Winnowing sorghum for
storage
Clearing farms
MARCH
PEN DIAK/ AKANYDIT
Clearing new farms
continue
Construct tukuls
Movement to water points
APRIL
PEN NGUAN/
AKANYTHI
Hunting
Fishing starts
Thatching tukuls.
MAY
PEN DHIECH/
ADUONG
JUNE
PEN DETEM/
ALETHBOR
JULY
PEN DHOROW/
AKOLDIT
AUGUST
PEN BET/ BILDIT
SEPTEMBER
PEN DHONGUAN/
BIELTHI
Rains begins
Cultivation of lands begins
Cows brought back home
from toics.
Cultivation continues
Weeding crops
Young men go for Ker
Begin planting maize and
sorghum.
Planting maize and
sorghum. Continues
Weeding sorghum
Hunger gap.
Men competition
Weeding maize and
groundnuts
Eating green maize.
Harvesting season
Court opens cases in
every payam
Eating green sorghum.
OCTOBER
PEN THIAR/ LAL
Harvesting continues
Tilling of new farms
NOVEMBER
PEN THIARTOK/
HORBEKLAI
Rain stops
Mudding tukuls
DECEMBER
PEN THIARKUROU /
KON
Christmas time
Celebration of good
harvest
2002
2003
2004
48
.
59
NCA opens EPI in
Gogrial West County
58
Alek airstrip opens
57
Cattle raiding by
Muralin in Gogrial West
County. GOS fight
SPLA in Tharkwen
56
James Lual raises New
Sudan flag in Alek
47
Spear master Mordit
dies
46
NCA opens PHCC in
Bau- Aweil
45
2005
36
35
Beginning of fight
between the Aguok
and Apuk clans.
34
Signing g of CPA
Gogrial town open to all
people
2006
12
24
23
NCA begins construction of
PHCC in Alek
22
Plane crashes in Aweil
airstrip
11
Meningitis out break
in Warrap state
10
ACF-USA conducts a
nutrition survey in the
County. SC-UK opens
a training institute in
Panliet
9
33
21
44
32
Returnees brought from
Khartoum by government.
ACF -US opens TFC IN Alek
20
SPLA defeats GOS in
Wintur
55
The late Dr Garang
visited Alek
43
31
19
SAF captures Gogrial
Town from SPLA
54
Relief food truck gets
stuck in river
Malualawien
42
Death of Deng Kong
30
18
41
Death of Kuec Mayarthe Executive chief
29
17
5
Death of Dr. John Garang
Salva Kiir sworn in
16
4
Machakos protocol
signed
53
52
40
28
GOS recapture Torit
from SPLA
51
39
27
38
26
37
25
50
Spear master Madut
Mell dies in Alek.
49
15
Lino (an intellectual) dies in
Nairobi and taken to Alek for
burial
14
ACF –USA TFC closes in
Alek
13
36
NCA opens a PHCC
in Alek
ACF-USA TFC
reopens in Alek
8
7
6
Commander Ayiang’s
son dies
3
2
1
.VIII.6. Food market prices in Alek market, Gogrial West County, February 2007.
COMMODITY
QUANTITY
Sugar
Maize flour
Beans
Maize
Lentil
Beef
Salt
Onions
Chicken
Fresh fish
Charcoal
Goat
cow
1 Kilogram
2 kilogram
1 kilogram
1 kilogram
1 kilogram
1 kilogram
50g
1 big bulb or 1 small bulb
1 Medium size
1 Medium size
Sack of 50 kilogram
1 medium size
1 medium size
PRICES IN SUDANESE
DINNAR
600
540
Not available
190
300
500
250
100/50
600
1000
1500
10,000
130, 000
38
.VIII.7. Gogrial West County Map.
39