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Interagency Nutrition Survey Among Syrian Refugees in Jordan: Preliminary Results - Oct 12, 2016

An overview of the 3rd nutrition survey conducted in Jordan among Syrian refugees, focusing on prevalence rates of malnutrition, IYCF practices, food security, and access to health services. The use of SENS and SMART methodologies, objectives, methodology details including sampling design, and sample size calculation are discussed to assess the current nutrition situation. Preliminary results highlight concerns and key findings, emphasizing the importance of data quality and standardization.

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Interagency Nutrition Survey Among Syrian Refugees in Jordan: Preliminary Results - Oct 12, 2016

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  1. Interagency Nutrition Survey Amongst Syrian Refugees in Jordan PRELIMINARY RESULTS Amman, OCTOBER 12th 2016

  2. Outline 1. Introduction 2. Objectives 3. Methodology 4. Results 5. Recommendations

  3. INTRODUCTION

  4. Why an Interagency Nutrition Survey Amongst Syrian Refugees in Jordan? 3rdnutrition survey 1. Oct.-Nov. 2012  Host communities & Za’atari camp 2. April-May 2014  Host communities & Za’Atari camp 3. Sept.-Oct. 2016   Host communities, Za’atari camp and Azraq camp • Follow-up nutrition survey (Host communities and Za’Atari camp) Baseline nutrition survey (Azraq camp) WFP food vouchers have decreased since 2014 Concerns about the availability of age-appropriate food for children aged 6 to 23 months A greatly increased risk of acute malnutrition in new arrivals • • • • •

  5. Why use of SENS and SMART Methodologies? The UNHCR SENS Guidelines are aimed at UNHCR health and nutrition coordinators and partners to standardize the way annual nutrition surveys are conducted ; • • Nutrition •Anaemia • IYCF • Food Security • WASH • Mosquito Net • Nutrition • Mortality • Food Security SMART  A standardized, simplified field survey methodology which produces a snapshot of the current situation on the ground. •

  6. Surveys using SENS/SMART Rigorous standardization of field procedures Data quality checks To improve data quality, facilitate data collection and data sharing, electronic data collection in the field Use of mobile data collection methods (smartphones/ODK) • • • Consistent and reliable survey data is collected and analysed •

  7. OBJECTIVES

  8. Specific objectives of the survey Estimate the prevalence of acute malnutrition (wasting), chronic malnutrition (stunting) and underweight among Syrian refugee children aged 6-59 months in Jordan; Estimate the prevalence of acute malnutrition among women of reproductive age (15-49 years) based on Mid-Upper Arm Circumference (MUAC) in the Syrian refugee population in Jordan; • • Investigate IYCF practices among Syrian refugee children 0-23 months in Jordan; Define the current state of food security among Syrian refugees in Jordan; Determine access to key health services, use of improved hygiene facilities and indicators of health status (children 0-59 months and women). • • •

  9. METHODOLOGY

  10. Target population Anthropometric Measurements  All children from 6 to 59 months (weight, height, MUAC and edema) and all women from 15 to 49 years (MUAC) in selected households • IYCF practices  All children from 0 to 23 months in selected households • Food security  All selected households • Child morbidity  All children from 0 to 59 months in selected households •

  11. Methodology Survey Design • Cross-sectional household survey Sampling Design • Two stage cluster sampling representative for the survey area  Stage 1: Cluster Selection →PPS method (ENA software) →UNHCR registration data (ProGress)  Stage 2: Household Selection →Camps: Households listing (IRD, IMC & SCJ CHWs)  Systematic Random Sampling →Host Communities: UNHCR registration data  Simple Random Sampling

  12. Assumptions for the sample size calculation (E.g. Za’atari camp) Parameters for Anthropometry Value Assumptions based on context The prevalence of Global Acute Malnutrition (GAM) for Za’atari Camp from the Interagency Nutrition Survey amongst Syrian refugees in Jordan and conducted in August 2014 is used for calculation of sample size. To be on the safe side, the upper limit of the confidence interval was chosen (1.2% [0.5-3.3% 95% CI]). Estimated Prevalence of GAM (%) 3.3% The general purpose of this survey is to assess current nutrition situation in children under the age of five years and women of reproductive age and assist in monitoring the effectiveness and coverage of interventions. From a practical point of view, this means the level of precision needed for sample size calculations is high in order to allow valid comparisons between 2014 and 2016. Since the GAM prevalence is lower, a precision of ±2.5% was chosen. 2.5% ± Desired Precision As nutrition outcomes are known to generally create relatively low design effects, the choice was made to use a 1.5 design effect to inflate the sample size and compensate the possible heterogeneity between clusters. 1.5 Design Effect Children to be included Average Household Size % of Children Under Five years old 320 4.1 Data were taken from the DAG team Data were taken from the DAG team 19.0% It is expected to have 3% non-response rate which refers to the number of basic sampling units that are not able to be reached due to the following reasons: refusal, accessibility, security reasons, absentees, etc. 3% % Non-Response Households Households to be included 471

  13. Final Sample Sizes Parameters for Anthropometry Azraq Camp Host Communities Za’atari Camp Households to be included 471 435 753 10 10 9 Households/ cluster 48 48 88 Number of clusters Number of days required for data collection (8 teams) 6 days 6 days 11 days

  14. Training of survey teams Training of survey teams (5 days)  34 participants trained (32 recruited by SCJ + 2 persons from SCJ)  Theoretical sessions  3 days including 1 day for the use of smartphones (ODK)  Practical sessions (Anthropometric measurements, exercices, interviews, use of smartphones, etc.) • Standardization Test Pilot Test (Za’atari camp) • •  Selection of 32 persons based on Pre & Post-tests and standardization test results  8 teams

  15. Organogram of the survey Team Leader CHWs Team 1 Enumerator Supervisor 1 Team 2 2 measurers Team 3 Supervisor 2 Team 4 Team 5 Supervisor 3 Team 6 Team 7 Supervisor 4 Team 8

  16. Supervision Enumerators were assessed before the launch of the survey and continually throughout the data collection • Each Team Leader was responsible for the quality of her/his team • Each Supervisor was responsible of the quality for 2 teams • Each evening after the end of data collection  review of data quality by the Survey Consultant  HIGH QUALITY DATA •

  17. Fieldwork Plan Za’atari Camp   8 teams for 6 days (48 clusters)  5-6 supervisors (UNHCR, UNICEF, SCJ + CartONG)  1 supervision visit (MoH)  From the 3rdof Sept. to the 8thof Sept. • Azraq Camp   8 teams for 6 days (48 clusters)  4 supervisors (UNHCR, SCJ, CDC)  From the 17thof Sept. to the 24thof Sept. • Out of camp   8 teams for 11 days (88 clusters)  4-6 supervisors (UNHCR, SCJ, CDC, ACF-Canada + UNICEF)  From the 25thof Sept. to the 8thof Oct. •

  18. RESULTS

  19. Final Sample Sizes Number of children 6-59 assessed Number of children 6-59 planned Number of cluster planned Number of cluster surveyed Number of HH surveyed Number of HH planned Survey Area % % % 48 48 100% 471 441 93.6% 320 378 118.1% Za’atari Azraq 48 48 100% 435 436 100.2% 320 422 131.9% Host 88 88 100% 753 757 100.5% 337 493 146.3% Communities

  20. Data Quality Age-ratio (6-29/30-59 months) (value should be around 0.85)  Za’atari = 1.03  More younger children than older ones  Azraq = 0.82  Host Communities = 0.90 Sex-ratio  Za’atari = 1.2  Azraq = 1.0  Host Communities = 1.0 • • Quality of Age  Za’atari = 97% of exact DoB  Azraq = 87% of exact DoB  Host Communities = 99% of exact DoB • SD WHZ, HAZ and WAZ fall inside acceptable range (0.8-1.2) for all survey areas. •

  21. Data Quality Missing and flagged data Overall Data Quality Score Overall Sex Ratio Overall Age Distrib Skew ness WHZ Kurto sis WHZ Pois son Dist. DPS Weight DPS Height DPS MUAC SD WHZ Survey Area 7% Za’atari Azraq 3% Host communities 2% Excellent (Overall score 0-9) Good (Overall score 10-14) Acceptable (Overall score 15-24) Problematic (Overall score >25)

  22. NUTRITION STATUS OF CHILDREN

  23. Trend in Prevalence of Global, Moderate and Severe Wasting in Children 6-59 months (WHZ) Assessed by WHO 2006 Growth Standards 8 7 MAM SAM 6 5 4 2.7 3 1.9 1.8 2 1.2 2.4 0.8 1 1.9 1.8 0.9 0.8 0.3 0.3 0 2014 2016 2014 2016 2014 2016 Za'atari Camp Azraq Camp Host Communities

  24. Trend in Prevalence of Global, Moderate and Severe Stunting in Children 6-59 months (MUAC) Assessed by WHO 2006 Growth Standards 8 MAM SAM 7 6 5 4 3 2 1.5 1.4 0.6 0.8 1 0.4 1.4 0.8 0.9 0.0 0.2 0 2014 2016 2014 2016 2014 2016 Za'atari Camp Azraq Camp Host Communities

  25. Trend in Prevalence of Global, Moderate and Severe Stunting in Children 6-59 months 30 Assessed by WHO 2006 Growth Standards Moderate Stunting Severe Stunting 25 19.2 20 17.0 15 11.3 16.5 9.0 10 14.1 6.4 11 5 8.1 5.6 2.9 2.7 0.9 0.3 0.8 0 2014 2016 2014 2016 2014 2016 Za'atari Camp Azraq Camp Host Communities

  26. NUTRITION STATUS OF WOMEN

  27. Nutrition Status of Women (15-49 years) MUAC <230 mm Non pregnant and non- lactating women Pregnant women Lactating women Survey Area N % % % n n n [CI 95%] 5.7% [2.6-8.8] 5.4% [3.0-7.9] 4.7% [2.9-6.5] [CI 95%] 7.8% [0.9-14.8] 8.5% [0.7-16.3] 7.7% [1.6-13.8] [CI 95%] 1.7% [0.0-4.0] 7.6% [3.1-12.1] 419 14 4 2 Za’atari Azraq 434 14 4 9 Host Communities 668 22 5 0 0.0%

  28. Enrolment in ANC Programme Proportion of pregnant women attending ANC programme Survey Area N n % [95% CI] 52 52 71 51 41 54 98.1% [94.1-100.0] 78.8% [66.2-91.5] 76.1% [65.1-87.0] Za’atari Azraq Host communities

  29. IFA Supplementation Proportion of pregnant women taking iron-folic acid supplements Survey Area N n % [95% CI] 52 52 71 44 25 45 84.6% [75.3-93.9] 48.1% [32.9-63.3] 63.4% [50.9-75.8] Za’atari Azraq Host communities

  30. IYCF PRACTICES

  31. Timely Initiation of Breastfeeding (0-23 months) Proportion of children born in the past 24 months who were put to the breast within one hour of birth Survey Area N n % [95% CI] 179 188 229 99 95 85 55.3% [47.3-63.3] 50.5% [41.3-59.8] 37.1% [29.0-45.2] Za’atari Azraq Host communities

  32. “Prelacteal” Feeding in the first three days after delivery Proportion of children born in the past 24 months who received feeding in the first three days after delivery Survey Area N n % [95% CI] 174 75 43.1% [33.8-52.4] Za’atari Azraq 186 104 55.9% [46.7-65.1] Host communities 222 133 59.9% [51.6-68.2]

  33. Infant Formula after Delivering from the Health Personnel Proportion of mothers with children under 2 years who received infant formula after delivering from the health personnel Survey Area N n % [95% CI] 188 202 245 32 17 74 17.0% [10.4-23.7] 8.4% [3.8-13.0] 30.2% [21.9-38.5] Za’atari Azraq Host communities

  34. Exclusive Breastfeeding (0-5 months) Proportion of infants 0-5 months of age who are fed exclusively with breast milk Survey Area N n % [95% CI] 41 55 68 22 21 13 53.7% [39.9-67.4] 38.2% [21.0-55.4] 19.1% [8.8-29.4] Za’atari Azraq Host communities

  35. Introduction of Complementary Food (6-8 months) Proportion of infants 6-8 months of age who received solid, semi-solid or soft foods during the previous day Survey Area N n % [95% CI] 31 21 27 24 14 22 77.4% [63.1-91.8] 66.7% [42.8-90.5] 81.5% [66.6-96.4] Za’atari Azraq Host communities

  36. Minimum Meal Frequency Breastfed Children 6-23 months Non-breastfed children 6-23 months Children 6-23 months Survey Area N % % % n n n [CI 95%] [CI 95%] [CI 95%] 60.8% [47.0-74.5] 79.7% [68.0-91.3] 64.6% [55.4-73.8] 147 48 47 95 Za’atari 57.7% [44.3-71.1] 84.1% [75.0-93.2] 63.5% [54.9-72.1] Azraq 148 41 53 94 46.8% [33.4-60.2] 69.0% [59.1-78.9] 58.4% [49.7-67.2] Host communities 166 37 60 97

  37. Consumption of Iron Fortified Food (6-23 mois) Proportion of children 6-23 months of age who received iron-fortified food during the previous day Survey Area N n % [95% CI] 147 147 177 31 46 52 21.1% [15.1-27.1] 31.3% [22.8-39.8] 29.4% [22.4-36.4] Za’atari Azraq Host communities

  38. IYCF Counselling – Sessions about BF/CF Proportion of mothers with children under 2 years who attended a session about breastfeeding or infant feeding Survey Area N n % [95% CI] 189 80 42.3% [33.5-51.1] Za’atari Azraq 203 84 41.4% [32.6-50.2] Host communities 245 38 15.5% [9.9-21.1]

  39. IYCF Counselling – Visit(s) at home Proportion of mothers with children under 2 years who received visit(s) at home to help with breastfeeding or infant feeding Survey Area N n % [95% CI] 189 203 245 153 101 35 81.0% [75.2-86.7] 49.8% [37.5-62.0] 14.3% [8.9-19.7] Za’atari Azraq Host communities

  40. CHILD MORBIDITY

  41. Diarrhea in the last two weeks Percentage of children with diarrhea in the last two weeks Survey Area N n % [95% CI] 419 81 19.3% [15.8-22.8] Za’atari Azraq 475 106 22.3% [17.8-26.8] Host communities 560 138 24.6% [20.2-29.0]

  42. FOOD SECURITY

  43. Duration of stay in Jordan as refugees Host communities (N=755) Azraq Camp (N=436) Za’atari Camp (N=441) n % N % n % 0 0 0 0 1 0.0% 0.0% 0.0% 0.0% 0.2% 82.5% 17.3% 0 0.0% 2.8% 50.9% 14.2% 9.2% 21.1% 1.8% 0 0 1 5 0.0% 0.0% 0.1% 0.7% 2.0% 62.8% 34.4% ≤ 1 month 1-3 months 4-6 months 7-12 months 13-24 months ≥ 2 years ≥ 4 years 12 222 62 40 92 8 15 474 260 364 76

  44. Main Source of cash/income • Za’atari  Food vouchers = 75.0%  Unskilled labour = 18.4%  Gift from family/relative = 2.3% Azraq  Food vouchers = 88.3%  Unskilled labour = 6.9%  Gift from family/relative = 2.7% • Host communities  Unskilled labour = 34.9%  Food vouchers = 24.2%  Monthly Financial Assistance (MFA) = 20.9% •

  45. Ration Card – Asylum Seeker Card Azraq Camp (N=436) Host communities (N=757) Za’atari Camp (N=441) Indicator % % % n n n [95% CI] [95% CI] [95% CI] 99.8% [99.3-100.0] Proportion of households with a ration card or asylum seeker card 440 436 100% 757 100% 99.8% [99.3-100.0] 90.5% [88.0-93.0] Proportion of households who are receiving food voucher from WFP 440 436 100% 685

  46. Value of the food vouchers from WFP Azraq Camp (N=435) Za’atari Camp (N=440) Host communities (N=679) Indicator % % % n n n [95% CI] [95% CI] [95% CI] 97.7% [95.1-100.0] 55.7% [51.2-60.1] 20 JOD/person/month 440 100% 425 378 2.3% [0.0-4.9] 44.3% [39.9-48.8] 10 JOD/person/month 0 0.0% 10 301

  47. Average number of days the food voucher lasts Za’atari Camp (N=439) Azraq Camp (N=436) Host communities (N=676) Indicator Mean [95% CI] Mean [95% CI] Mean [95% CI] n n n Average number of days the food voucher lasts (out of one month – August 2016) 16.7 19.7 16.7 438 435 676 [16.1-17.2] [18.8-20.6] [16.2-17.3]

  48. Main Source of Food Azraq Camp (N=436) Host communities (N=757) Za’atari Camp (N=441) n % n % n % Purchase from personal resources Purchase with cash given by charity Purchase at credit, borrowed Received as gift from charity Shared with hosts Humanitarian food aid Bartered against other goods Other 52 10 7 3 6 362 1 0 11.8% 2.3% 1.6% 0.7% 1.4% 82.1% 0.2% 0.0% 15 0 0 0 3 418 0 0 3.4% 0.0% 0.0% 0.0% 0.7% 95.9% 0.0% 0.0% 254 30 7 1 33 424 0 8 33.6% 4.0% 0.9% 0.1% 4.4% 56.0% 0.0% 1.0%

  49. Household Dietary Diversity Score Za’atari Camp (N=441) Azraq Camp (N=436) Host communities (N=757) Indicator Mean [95% CI] Mean [95% CI] Mean [95% CI] n n n 7.9 7.8 7.9 Average HDDS 441 436 757 [7.7-8.0] [7.7-8.0] [7.7-8.0]

  50. Host Communities Azraq Za'atari Spices, condiment and beverages 99.9 99.8 99.8 97.8 Sweets 96.1 85.0 98.7 Oils and fats 98.3 99.1 74.6 Milk and milk products 62.8 77.6 80.1 Nuts and seeds 72.7 77.3 6.1 Fish and seafood 5.0 8.6 42.1 Eggs 53.7 43.1 27.7 Meat 23.2 27.0 28.1 Fruits 29.6 34.2 93.6 Vegetables 92.9 92.1 37.4 White roots and tubers 49.5 41.5 99.7 Cereals 100.0 99.8 0.0 20.0 40.0 60.0 80.0 100.0

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