25. May, 2017

The Nutrition causal analysis conducted by ACF with support from DFID started in January 2017 in Nangere LGA, Yobe state, Northeastern Nigeria and ended in May with a technical workshop consiting of stakeholders from MDAs, INGOs, National and Local NGOs on Monday 8th and Tuesday 9th May 2017 to:

-          Evaluate the preliminary Link NCA results

-          Evaluate the preliminary Link NCA recommendation

-          Improve the quality of Link NCA result and recommendation 

 The following hypothesised risk factorsfrom the UNICEF framework of malnutrition causality were considered and rated by experts in the preliminary workshop:

Technical experts individually rated the 22 original causal hypotheses from 1 (hypothesis believed to contribute marginally to under-nutrition) to 5 (hypothesis believed to be a major contributor to under-nutrition).

Hypothesis 1: Non-optimal breastfeeding practice for children up to 6 months (Validated)

 

4.82

Hypothesis 2: Young child non-optimal feeding practices (Validated)

 

4.50

Hypothesis 3: Poor nutritional status among pregnant and lactating women (Validated)

 

4.75

Hypothesis 4: Inadequate child health care (Validated)

 

4.50

Hypothesis 5: Poor child psychosocial practices and lack of psychosocial network (Revised)

 

4.50

Hypothesis 6: Weakness of the health system (Validated)

 

4.46

Hypothesis 7: Poor utilization and access to health services (Revised)

 

4.50

Hypothesis 8: Pregnancy (bellow 18) (Revised)

 

3.96

Hypothesis 9: Short birth interval (Revised)

 

4.57

Hypothesis 10: Inadequate access to water in quality and quantity (Validated)

 

4.57

Hypothesis 11: Non optimal water management/water chain (Revised)

 

4.79

Hypothesis 12: Poor hygiene practices (Revised)

 

4.54

Hypothesis 13: Inadequate management of human and animal excreta (Validated)

 

4.57

Hypothesis 14: Inadequate management of solid waste (Validated)

 

4.43

Hypothesis 15: Difficulties to manage water for crops and livestock (Validated)

 

4.46

Hypothesis 16: Limited access to food (quality/quantity) (Validated)

 

4.43

Hypothesis 17: Limited food availability (quality and quantity) (Validated)

 

4.50

Hypothesis 18: Sub-optimal food and other sources of incomes management (household level) (Revised)

4.39

Hypothesis 19: Emergency coping strategies (Validated)

 

4.61

Hypothesis 20: High maternal household workload (Validated)

 

4.75

Hypothesis 21: Poor women empowerment (Validated)

 

4.79

Hypothesis 22: High illiteracy rates among parents (Validated)

 

4.82

Average note

4.56

 

Hypotheses 1, 11, 21, 22, were mostly considered as major hypotheses and hypotheses 8 and 18 as minor hypotheses by the technical experts. Original hypotheses mainly got a high confidence note, with an average rating score of 4.56.

CLASSICAL DESIGN

1. Designing the NCA

2. Identify causal hypothesis at stake.

3. Participatory ranking of hypothesis.

4. Validation of results.

BACKGROUND OF STUDY

Nangere Local Government Area (LGA) is one of the 17 LGAs located in Yobe State. Nangere LGA borders Positikum LGA to the East, Fune LGA to the North East, Jakusko to the North, Bauchi State to the West and Fika LGA to the South. The LGA has an estimated population of 151,344 persons1 spread over a geographical area of 1,183km². The LGA has a total of 11Wards (Chukuriwa, Dawasa, Kukuri, Watinani, Dudduye, New Nangere, Tikau, Dazigau, Chilariye, Degubi and Langawa Darin) with headquarters located in Sabon Gari Nanger (Sabon Garin). There are a total of 461 villages in Nangere LGA. The main crop and livestock markets is also located in Potiskum and Dawasa markets. 

Globally, over 35% of under-five deaths are attributed to child undernutrition. The North East region of Nigeria has the highest acute malnutrition caseloads in the country. The national nutrition and health survey conducted in 20152 revealed Global Acute Malnutrition(GAM) and Severe Acute Malnutrition(SAM) prevalence(WHZ<-2SD) among children less than five years in Yobe State was at 10.9% and 2.0% respectively.

The SMART-AAH survey findings revealed prevalence of Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) based on Weight for Height Z-scores (WHZ<-2SD and/or oedema) among children aged (6-59 months) in the surveyed areas of Nangere LGA was 14.6% (11.4-18.6 95% CI)and 2.6% ( 1.5- 4.4 95% CI) respectively.

The prevalence of stunting and underweight among children aged (6-59 months) was at 68.3% (63.0-73.2 95% CI) and 51.6% (46.0-57.1 95% CI) respectively. The prevalence of Stunting and underweight were above WHO thresholds13.The prevalence of stunting indicates that more than one in every two children were exposed to undesirable consequences of stunted growth and retardation.

METHODOLOGY

The sample size of the quantitative survey was design following the NCA methodology. A preliminary sample was designed with ENA, and then the final sample size was design according to the target population by household to be surveyed for the main indicators.

The risk factors survey used a random cluster sampling method and clusters were selected with ENA accordingly to the Proportion Population Size (PPS).

The selection of households was done following a two-stage or a three-stage cluster sampling method accordingly to the size of the cluster.

Size of the household was recorded for each family visited. The NCA being exclusive, only families with at least one child under 59 months were fully interviewed. Sample size targeted was 530 households within 30 clusters.

Among these 30 clusters, 5 were randomly selected for the qualitative survey. They were selected with a random selection formula in Excel. Due to security issues and bad weather conditions, only one cluster was visited for the qualitative enquiry. The population of the cluster was homogeneous and representative of the studied area and quality findings were gathered. However, the study presents some important limitations and the results are not representative of other areas or of other communities.

The RFS questionnaire was divided in six sections with different targets: household level, child 0-23, child 0-59, main caregiver, anthropometric measurement of 6-59 months children and observation part.

29 core indicators, 17 optional indicators and 11 local indicators were used to design the questionnaires. These indicators were chosen from the Link NCA indicators guidelines. Unfortunately, some of those data were not collected or do not meet quality criteria and could not be used.

FGD methodology and life story interviews were used for the qualitative component. One week was spent in each village. FGDs topics were “understanding of malnutrition-perception of good nutrition”, “health status”, “FSL status”, “WASH situation and main issues”, “Care practices behaviours” and “Protection”.

FGDs welcomed mothers and grandmothers of children less than 59 months in different group sessions. Some other FGD was organised in each village with fathers and grandfathers of children less than 59 months.

Interviews were done with key informants and mothers of undernourished children.

A seasonal and historical calendar was design for each villages and communities participated to rating exercises of the main hypothesis.

The Link NCA is based on the triangulation between scientific literature, quantitative data and NCA qualitative findings. Following the final technical workshop, the Link NCA report will be finalized.

These hypothesised risked factors were rated by participants in the final technical workshop:

Risk factors: confidence note and rating

Risk Factors

NCA Analyst rating

Average group confidence note

Final rating (validated during the workshop)

Comment from working group

1

Major

3.00

Major

 

2

Major

3.00

Major

 

3

Major

2.60

Major

 

4

Important

3.00

Major

Bad health child practices can lead to undernutrition and in this local context, it do

5

Minor

2.80

Minor

 

6

Important

3.00

Important

 

7

Major

3.00

Major

 

8

Minor

2.40

Minor

 

9

Important

2.80

Important

 

10

Major

3.00

Major

 

11

Important

2.80

Major

The water management is link to hygiene practices et quantity of water

12

Major

3.00

Major

 

13

Major

3.00

Major

 

14

Minor

2.40

Minor

 

15

Important

2.60

Important

 

16

Major

3.00

Major

 

17

Major

3.00

Major

 

18

Minor

2.40

Important

There is a real situation sub-optimal incomes with a big impact of the seasonality

19

Important

2.80

Important

 

20

Minor

2.40

Minor

 

21

Minor

2.80

Important

The empowerment of woman have a direct impact on the financial healthiness of the household

22

Important

2.00

Major

The level of education mong parents have a direct impact of the empowerment of the parents

 RECOMMENDATIONS

BACKGROUND RECOMMENDATIONS

•Close cooperation between government and agencies
•Community level intervention (community power, knowledge, empowerment, porteur de savoir)
1. Emergency or development ? 
2. Nutritional security
3. Multisectoral approach: Integrated

FOOD SECURITY

Support farming and gardening:

•Fertilizer, seed, land, process of transformation
•Garden

Support raising:

•Cow and goat, sheet, chicken

Support women business

PROPOSITION

•Develop the household resilience and the community resilience to limit the accumulation of coping strategy
•Promote a coordination on agricultural education with an integrated approach (NUT-FSL-WASH)
•Increase the presence of local fertilizer
•Increase the accessibility to land
•Increase the access to seed (groundnuts, bennynuts, beans, soya beans)
•Increase the presence of garden (women) and maraichage, micro-gardening trainings and provision of inputs
•Trainings about pest management and provision inputs
•Support business to woman (material, management, cooperative)
•Increase the livestock for man and woman (knowledge about management, immunization) 
•Support the irrigation system (garden)
•Developing the agriculture for desert area
•Developing the micro-credit for farming, raising and business
•Developing farming and raising school
•Developing a double level strategies: household and community
 
WASH

Increase the access of water:

•HC
•Community level (crops, animals)
•Household 

Increase the access of soap:

Decrease the presence of excreta (management) and Improve the sanitation

Improve the hygiene practices 

PROPOSITION

•Construction and rehabilitation of water points
•Developing solar borehole, pomp well
•Developing community approach with employment access
•Developing community water management (both man and woman)
•Promote community projects and actors on hygiene practices (employment, certificate for professional skills)
•Community hygiene promotion
•Increase the management of animal and human excreta (local fertilizer): CLTS, latrine 
•Construction and rehabilitation of sanitation and bathing facilities
•Training water vendors and community leader on safe water chain
•Participatory hygiene and sanitation transformation (PHAST) mobilization
•Hygiene promotion delivered through door-to-door approach
•Increase the community management of waste 
 
NUTRITION & HEALTH

Breastfeeding practices and complementary feeding

Child Health care

Poor access and utilization of the health system

PROPOSITION

•Nutrition center: baby tent
•Ongoing training with the health worker about breastfeeding and complementary feeding
•Developing a community approach of the care practices and nutrition with the support of the birth attendance and local pharmacist
•Developing the knowledge about undernutrition among local doctor (traditional doctor)
•Participate in the change of behavior and diversification of the dietary at the multisectoral level
•Involve key community leader about undernutrition: Religious leader, teacher, village leader
•Sensitization men about undernutrition
•Involve the mother with undernourished children in community activities (agricultural group, WASH group, Health group)
•Involve the mother with undernourished children in income generating income
•Supporting the health center in term of recruitment, training, salary
•Supporting the health center in term of medicine supply, access to water
•Supporting the accessibility of health center with local ambulance
•Supporting the relationship between birth attendance and health center
•Supporting and train the local pharmacist
•Participate in the development of local medical knowledge
 
PROTECTION
•Developing school for adult (literacy center oriented on specific knowledge: farming, rising, water, business)
•Developing and support the access to school for children

Include Protection in each sector (empowerment)

Food security (raising, gardening, business), WASH (community group, worker), Nutrition/Health (birth attendance) 

 

Expert NCA: Ottavi Marie-Noëlle, ncaanalyst.ng@acf-international.org ; ottavimn@gmail.com

Focal Point : Fahad Zeeshan (Nut.Co) nutco.ng@acf-international.org

RFS study + SMART survey: Mutegi Kevin Murithi(Expert) ncaspecialist.ng@acf-international.org

Financement: DFID