Sudan Multiple Indicator Cluster Survey 1995

Publication date:

II · 1·:•.•.• . •,•,•,•,•>:·:·:·:·:·:·:·:·:·:·:·:.:.:.:.:.:.:.;.,.: .• :.:.:.:.:.: . ,•,•,•,•:•:•,•,•:•,•:•,•,•,•,•: I I I l,.,., . , . ·m;·············, . ,.,.,.,.,.,.,., . ,., . , . ·.················t····\ I I I I I I I 1995 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 TABLE OF CONTENTS CHAPTER 1. SUDAN SYNOPSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I CHAPTER 2. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 CHAPTER 3. SURVEY DESIGN AND METHODOLOGY . . . . . . . . 3 Sampling . . . . . . . . . . . . . . . . . . . 3 Map of Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CHAPTER 4. PLANNING AND PREPARATION . . . . . . . . . . . . . . . . . . . 7 Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Training . . . . . . . . . 7 CHAPTER 5. IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . 8 CHAPTER 6. DATA ANALYSIS AND FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Control of Diarrhoeal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 Acute Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Vitamin A Deficiency (V AD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Universal Salt Iodization (USI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Protein Energy Malnutrition (PEM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Basic Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Access to Safe Drinking Water . . . . . . . 22 Access to Sanitary Means of Excreta Disposal . . . . . . . 24 I I I !I II II II !I I I I I I I I I I I I I I Table I . Table 2. Table 3. Table 4. Table 5. Table 6. Table 7. Graph I. Table 8. Table 9. Table 10. Table 11 . Table 12. Table 13. Table 14. Table 15. Graph 2. Table 16. Table 17. Table 18. Table 19. Table 20. Table 21. Table 22. Table 23 . SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 LIST OF TABLES AND GRAPHS Age distribution of children under I 0 years, by zone and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Age distribution of children under two years, by zone and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Distribution of children under five years of age surveyed, by zone and sex . . . . . . . . . . . . . . . . . . . . . . 6 Distribution of children 6 - I 0 years of age surveyed, by zone and sex . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Vaccination coverage among children 12-23 months surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . 9 Diarrhoeal incidence in the last 2 weeks among children under the age of two and five years. . . . . . . I 0 Treatment of diarrhoea among the under-fives in per cent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . II ORT Use-rate among children under five years of age with diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . 12 Amount of liquid given to children under fives surveyed during diarrhoea in per cent . . . . . . . . . . . . 13 Amount of food given to children under fives surveyed during diarrhoea in per cent . . . . . . . . . . . . . 13 Person who treated diarrhoea among the under-fives surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . 14 Attitude on breast-feeding during Diarrhoea among children less than 2 years surveyed. . . . . . . . . . . 15 Duration of breast-feeding among children under fives stopped breast-fed surveyed in per cent. . . . . 15 Incidence of diarrhoea among children surveyed by status of breast-feeding in per cent. . . . . . . . . . . . 16 Incidence of ARI in the last 2 weeks among under-fives surveyed in per cent . . . . . . . . . . . . . . . . . . . 17 ARI symptoms among children under 5 years surveyed which lead to mothers seeking treatment . . . 18 Coverage of vitamin A among children aged 12-23 months surveyed . . . . . . . . . . . . . . . . . . . . . . . . . 18 Consumption of iodized salt among households surveyed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Nutrition status among children under-five years surveyed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Primary school attendance among boys 6-10 years surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . 21 Primary school attendance among girls 6-10 years surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . 22 Source of drinking water in households surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Source of domestic water in households surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Treatment of drinking water in households surveyed in per cent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Accessibility to type of sanitation facility in per cent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii CHAPTER 1. SUDAN SYNOPSIS The Sudan is the largest country in Africa with a land mass of2.5 million square kilometers. The last National Census conducted in 1993 cited a population of 19.47 million in the North and 4.3 million in the South. The northern areas are fairly arid, barring the areas along the banks of the River Nile which are extremely fertile. The southern part of the country enjoys a tropical/equatorial climate and is potentially arable land. Temperatures are high with a maximum daily temperature between 29.4 and 46.1 degrees centigrade. The annual average rainfall is less than 50 mm in the far North, between 127 and 254 mm in Khartoum and between 760 and 1720 mm in the South. The country is divided into 26 administrative states, with a State government responsible for each state. For the purpose of the survey, the country was divided into seven geographical zones (see page 4) The population density is concentrated at 163 per sq. km. in the state housing the capital, Khartoum, and unevenly dispersed among the other 25 States. The civil strife in the South has been the cause of a large displaced population in the Northern States. These, together with the remaining population in the Southern States, are the people who are most vulnerable, and in dire need of food, shelter, health services and basic education. Poor information networks and lack of proper data present large difficulties in dealing with these problems. A limited infrastructure for provision of health facilities exists in most areas throughout the country. However, morbidity and mortality rates, especially from preventable diseases, are still unacceptably high. The health and education facilities in the South continue to deteriorate as a result of the prolonged civil war. Southern Sudan has experienced civil strife since 1955, with some interludes of peace. The Pan Arab Project for Child Development (PAPCHlLD) surveys conducted in 1993, indicated under-five mortality rate at 107 per 1000 live births. Diarrhoea related deaths among the under fives are estimated to constitute about 30% of total under-five mortality, whilst acute respiratory infections are responsible for about 34%. Malaria and other immunizable diseases contribute to the remaining. The situation is further complicated by malnutrition. The PAPCHILD survey indicated that 33% of under-fives were stunted, 13% suffered from wasting and 34% were underweight. Deficiencies in micro-nutrients such as VitA and Iodine together with complications of childhood diseases such as poliomyelitis, tetanus and meningitis, have resulted in a large number of disabled/crippled or mentally retarded children. In the South, drinking water is largely obtained from the surrounding rivers, and consumed without purification, continues to spread water-borne diseases. Of the 146,888 cases of dracunculiasis reported globally in 1996, Sudan has the highest number at 114,772 (Guinea worm wrap-up # 64). I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiiiiiiii CHAPTER 2. INTRODUCTION The World Summit Declaration of 1990 identified 27 goals for the well-being of women and children to be attained by the year 2000. The Dakar Consensus under the organization of the OAU adopted 13 of these as Mid-Decade goals to be achieved by the year 1995. The mid-decade goals are therefore an integral and critical part of those objectives endorsed by the World Summit for Children. Paragraph 34 (v) of the Plan of Action states that "each country should establish appropriate mechanisms for the regular and timely collection, analysis and publication of data required to monitor relevant social indicators related to the well-being of children . which record the progress being made toward the goals set forth in this Plan of Action and corresponding National Plans of Action". Following this, the Federal Ministry of Health, Republic of Sudan, in collaboration with UNICEF and WHO, launched a National Programme of Action called "The Sudan Mid-Decade Goals Project Plan of Action" (SMDGPPA). This programme identifies strategies and priorities for achieving the 13 mid- decade goals (endorsed by the OAU) in Sudan by 1995. These goals are listed in the appendix. During a midterm review in 1993, it was decided to delay some of these goals to 1997. In 1995, the Multiple Indicator Cluster Survey was adopted in Sudan as a tool tor training people at State level to collect certain service indicators which would allow for rapid assessment of progress toward specific set goals. This rapid survey technique is a modification of the universally approved "EPI Cluster Survey Technique." The survey design allows for low cost and rapid production of data at various levels, which makes it useful as a monitoring tool at state/local level. It also allows for sub-national planning and regular monitoring. It aims to provide a more speedy and all-encompassing view of the current status of women and children with regard to monitoring the progress of the essential indicators targeted for the Decade goals. It is hoped that this document will serve as a valuable and enduring national mechanism and as a central reference point for future monitoring of indicators in a systematic manner at sub-national or state level in achieving the Decade and Summit Goals. 2 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii CHAPTER 3. SURVEY DESIGN AND METHODOLOGY The Multiple Indicator Cluster Survey is an adaptation of the EPI Cluster Survey sampling method which was introduced in 1974, by the World Health Organization. The EPI survey was intended to address the very limited objective of estimating immunization coverage rates. Over the years, the design has been used for other purposes. While it is widely acclaimed for its low cost, simplicity and ease of operation, there have been various criticisms leveled at the technique - mainly dealing with the issues of bias and reliability. These have been overcome by various modifications to the design. These modifications are laid out in the Draft Handbook for Multiple Indicator Surveys. The above named handbook was used as a guideline to develop an operational manual for use in the Sudan. The survey design consists of a series of questionnaire modules designed to provide data for some service indicators. These include vaccine coverage, vitamin A status, salt iodization, ORT use in diarrhoea, malnutrition, educational attainment, and the availability of water supply and sanitation facilities. The questionnaire modules have been adapted for use in the Sudan. The survey design offers a rapid, dependable, low-cost and easily replicable system for monitoring progress. Because the questionnaire is simple, and the sample size manageable, the survey can be conducted, data analyzed and results released within a short period. Sampling According to the latest National Census, carried out in 1993, the Sudan is estimated to have a total population of23.8 million, of which 4.3 million people live in the south of the country. This total includes about 3.5 million children under five and about 4 million children between the ages of 6 and 10 yrs. The total population is distributed among approximately 3.5 million households (HH) in the North, and 0.7 million households (HH) in the South. The above statistics were used as the population basis for the sampling process for the Multiple Indicator Cluster Survey ( 1995). The sampling units used to collect the data for the selected indicators were HH. A household means the group of people who usually live and eat together. For the purpose of the survey, the country was divided into 7 zones as shown on the map (page 4 ). In each of the seven zones, systematic random sampling was used to select 30 clusters. 50 HH were selected in each cluster, to make a total of 1500 HH per zone. The 1500 selected HH were surveyed in each of the Northern six zones, but in the southern zone, only 1350 HH were actually surveyed, as the remaining were found to be inaccessible. 3 _X- I I I I I I I I I I I I I I I I I I I I I Map of Sudan LIBYA CHAD CENTRAL AFRICAN REPUBLIC ZAIRE EGYPT SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 ETHIOPIA UGANDA :i oi • Nairobi l ~~--------------------~----------~----~~ Sample zones: Northern -Northern - Nahr Al-Niel Darfur -Northern -Western -Southern Eastern - Red Sea - Kassala - Gadarif Khartoum Kordofan -Northern -Western -Southern Central - White Nile - Gezira - Sennar -Blue Nile South - all 10 southern states 4 I I I I I I I I I I I I I I I I I I I I \~ SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Table 1. Age distribution of children under 1 0 years, by zone and sex 0-4 yrs 6-10 yrs ZONE Population #HH Male Female Male Female Northern 1,229,740 211,360 82,410 79,910 83,550 82,770 Eastern 2,658,130 498,370 197,190 199,940 217,090 212,320 Khartoum 3,252,410 530,740 212,010 204,920 210,270 209,950 Central 5,272,710 857,190 412,180 400,800 425,150 404,280 Kordofan 2,696,740 462,120 221,250 222,350 243,870 234,410 Darfur 4,357,380 768,700 373,450 372,170 417,580 388,990 Total North 19,467,110 3,328,480 1,498,490 1,480,090 1,597,510 1,532,720 Total South 4,321,788 665,656 327,710 263,243 445,793 333,301 GRAND TOTAL 23,788,898 3,994,136 1,826,200 1,743,333 2,043,303 1,866,021 Table 2. Age distribution of children under two years, by zone and sex ZONE 0-11 mos Male Female 12-23 mos Male Female Northern 32,020 16,360 15,660 26,630 13,700 12,930 Eastern 68,800 34,760 34,040 59,350 29,920 29,430 Khartoum 82,590 42,320 40,270 67,080 34,260 32,820 Central 148,630 76,480 72,150 129,860 65,730 64,130 Kordofan 84,930 42,710 42,220 61,230 30,110 31,120 Darfur 115,850 59,150 56,700 118,430 59,700 58,730 Total North 532,820 271,780 261,040 462,580 233,420 229,160 Total South 79,946 43,383 36,563 84,528 47,381 37,147 GRAND TOTAL 612,766 315,163 297,603 547,108 280,801 266,307 5 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICA TOR CLUSTER SURVEY 1995 Table 3. Distribution of children uncler five years of age surveyed, by zone and sex ZONE US surveyed male 0/o female 0/o Northern 1,051 525 49.95 526 50.05 Eastern 1,305 714 54.71 591 45 .29 Khartoum 1,437 774 53.86 663 46.14 Central 1,524 780 51.18 744 48.82 Kordofan 1,631 786 48.19 845 51.81 Darfur 1,403 735 52.39 668 47.61 Total North 8,351 4,314 51.66 4,037 48.34 Total South 1,484 733 49.39 751 50.61 GRAND TOTAL 9,835 5,047 51.32 4,788 48.68 Table 4. Distribution of children 6 - I 0 years of age surveyed, by zone and sex ZONE 6-10 years Male 0/o Female % Northern 916 424 46.29 492 53 .71 Eastern 856 493 57.59 363 42.41 Khartoum 1,106 554 50.09 552 49.91 Central 1,102 590 53.54 512 46.46 Kordofan 1,127 589 52.26 538 47.74 Darfur 848 438 51.65 410 48.35 Total North 5,955 3,088 51.86 2,867 48.14 Total South 834 448 53.72 386 46.28 GRAND TOTAL 6,789 3,536 52.08 3,253 47.92 6 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiiiiiiii CHAPTER 4. PLANNING AND PREPARATION UNICEF, the Central Bureau of Statistics and the University of Khartoum were involved with the Ministry of Health in the planning and preparation of the first multiple indicator cluster survey in Sudan. A member of each of these institutions was sponsored by UNICEF to attend regional workshops on MI CS, and a committee was formed to oversee the 1995 MICS. Questionnaire Following the guidelines for model questionnaires laid out in the Draft Handbook for Multiple Indicator Surveys, the questionnaire for Sudan was prepared in English and then translated into Arabic. This was done jointly by UNICEF, the Ministry of Health, University of Khartoum, Central Bureau of Statistics, the relevant sections in the Ministry of Higher Education and the National Department of Water Supply. The model questionnaire for measuring the Mid-Decade Goals asks for the minimum information necessary to measure the chosen indicators. Short, specific questions using simple, everyday words are asked. One question is asked at a time. There is a clear flow from question to question, and a layout that makes it easy to administer. It provides all the information needed to calculate estimates of each indicator. It has instructions to interviewers that are clear and easy to distinguish from the questions to respondents. It is as easy as possible for interviewers to use, while ensuring that the data obtained is accurate. The translated questionnaire was pre-tested in the community around Khartoum, with respondents similar to the respondents in the survey sample. This was done to identify problem areas, misinterpretations and cultural objections to the questions. Training A team of federal supervisors were trained by the committee during a one-day training period. Following this, the supervisors conducted a pilot survey in one cluster in the Khartoum state. These officers were then sent to each zone in order to train field supervisors and surveyors . The training, which followed guidelines on instructions to interviewers in Section 2.2 of the Draft Handbook for Multiple Indicator Surveys, lasted two days. It consisted of an explanation of the questionnaire and the methodology involved in conducting the survey, e.g., interviewing techniques, obtaining co-operation from respondents and maintaining standard procedures. The federal supervisors stayed in their allocated zone through the course ofthe survey. 7 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiii CHAPTER 5. IMPLEMENTATION One of the objectives of the survey conducted in March/ April 1995 was to monitor progress of some indicators targeted for the mid-decade goals. This has been the first Multiple Indicator Cluster Survey organized as a national survey in the Sudan. Data collection was carried out by the federal and state ministries of Health in their respective zones. Health workers and local (state) ministries of Health staff were employed as interviewers after receiving 2 days of training on the procedures to be employed. According to the designed plan, each cluster in the northern zones which consists of 50 HH was supposed to be surveyed by one team with two interviewers in one day. In each zone, six teams were recruited, thus it was targeted to finish within 5 working days. Realizing that the terrain in the South is relatively more difficult, instead of six, nine teams were recruited to cover all Government accessible areas in the ten southern states which have been determined as one unit of survey or equivalent to one zone of the North. It was targeted to finish the whole area in the South covering 1500 HH within four days. The field situation, however, did not allow the teams to move as scheduled. Several constraints were encountered, such as transportation problems, unexpected rain, poor road condition between clusters, uncertain schedule of flights and other difficulties. Even in the South the teams discovered that two selected clusters were not accessible at that time due to insecurity. As a result only 1350 HH were covered in the South instead of 1500. Due to the above operational difficulties, the duration of the survey was much longer than planned. This has resulted more man days involved and inflated the financial requirement for the field activities. The next Multiple Indicator Cluster Survey should consider and accommodate the operational aspects in a more flexible way. Overall, the operational activities in the field of this survey was completed within 6 months. 8 I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 iiiiiiiiiiiiiiiiiiiiiiii CHAPTER 6. DATA ANALYSIS AND FINDINGS Immunization Morbidity and mortality rates of children under five due to immunizable diseases still remain high, and efforts are underway to sustain and increase the immunization coverage all over the country. At more than 80%, the Northern and Khartoum zones have all achieved a fairly high coverage of dose 1 (DPT/OPV). The Central zone at 74.75% comes next. The Eastern zone has the lowest coverage at 50.80%. Throughout the country, it is fairly obvious that the 2nd and 3rd doses of the DPT/OPV vaccination have not covered as many as the 1st dose. In Darfur, only 28.62% of children between the ages 12 - 23 months were covered by dose 3. Total measles coverage for the North is 49.49%. In the Southern zone, the DPT/OPV vaccination coverage with dose 1 was 57.76%, whereas with dose 3 it dropped to 32.85%. The coverage with measles vaccine is 41.16%. Khartoum has the highest coverage with reference to all the above five antigens. Table 5. Vaccination coverage among children 12-23 months surveyed in per cent Population No. DPT/OPV Source ZONE 12-23 months surveyed 1 2 3 Measles Card Northern 26,630 176 83.36 75.57 67.05 65.91 59.09 Eastern 59,350 250 50.80 44.40 41.60 40.80 35.20 Khartoum 67,080 285 83.16 79.65 64.91 70.88 53.68 Central 129,860 297 74.75 68.69 62.63 58.92 44.11 Kordofan 61,230 289 59.17 48.10 32.53 40.48 35.99 Darfur 118,430 269 51.30 41.64 28.62 32.34 33.09 Total North 462,580 65.50 57.91 47.83 49.49 41.32 Southern 84,528 277 57.76 46.93 32.85 41.16 39.35 GRAND 547,108 64.30 56.21 45.52 48.20 41.02 TOTAL With regard to the MDG , the above table indicates that much work needs to be done in the Eastern, Kordofan and Darfur zones, for the 80% achievement target to be realized throughout the country. 9 I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Control of Diarrhoeal Diseases Dehydration and loss of essential salts are the major causes of mortality from diarrhoeal diseases. In combating the problem, the use of low cost approach and effective of Oral Rehydration Therapy has been the prime intervention to reach the goal for decreasing mortality due to diarrhoea related illnesses. The Technical Guidelines for Monitoring Mid-Decade Goals is recommending three major strategies for reduction of mortality due to diarrhoea: 1. ORT (increased fluid) and continued feeding should be practiced in every family; 2. Every child seeking care outside the home should receive ORS; 3. Every health provider and health facility both government and private should offer correct case management for diarrhoea; Table 6. Diarrhoeal incidence in the last 2 weeks among children under the age of two and five years. ZONE Under 2 surveyed w. diarrhoea(%) Under 5 surveyed w. diarrhoea(%) Northern 395 32.66 1,051 25.02 Eastern 587 36.29 1,305 29.89 Khartoum 581 35.28 1,437 26.17 Central 581 39.24 1,524 27.10 Kordofan 601 32.95 1,631 23.73 Darfur 459 40.74 1,403 28.37 Total North 37.31 27.04 Southern 618 56.80 1,484 40.97 GRAND TOTAL 40.07 29.35 It is evident from the above table that levels of children suffering from diarrhoea is fairly high, especially in the South. A recent survey indicated that children aged 0-4 years suffer an average of seven episodes of diarrhoea per year. In the North, the under-twos in the Central and Kordofan zones seem to be in the worst situation with the prevalence rate at around 40%. 10 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 The table indicates that 37.31% children under two in the North and 56.80% children under two in the South were suffering from diarrhoea in the two weeks preceding the survey. Meager access to clean water and inadequate sanitation facilities together with poor personal hygiene are the major causes of diarrhoeal diseases. Prior to 1993, Oral rehydration Therapy (ORT) was defined as the administration of oral rehydration salts and or recommended home fluids. It is now changed and is defined as increased intake of acceptable fluids, which include plain fluids available in the home. (Technical Guidelines for Monitoring Mid- Decade Goals). Examples of recommended home fluids: cereal based porridge like sorghum, rice, maize, millet etc. with salt in it; breast milk, yoghurt drink, soups etc. Table 7. Treatment of Diarrhoea among the under-fives in per cent Treatment ZONE Nothing ORS Home Fluid Drug Other Unknown Northern 26.62 22.81 12.17 28.52 5.70 4.18 Eastern 37.18 27.69 6.15 10.26 12.05 6.67 Khartoum 25.80 10.11 18.09 36.70 3.72 5.59 Central 30.27 4.60 23.00 28.33 7.99 5.81 Kordofan 18.09 10.85 32.04 25.06 10.34 3.62 Darfur 28.39 9.80 8.04 24.87 19.10 9.80 Total North 28.41 11.85 16.56 25.48 11.12 6.59 Total South 18.91 34.87 4.77 32.73 8.72 0.00 GRAND TOTAL 26.21 17.17 13.84 27.16 10.57 5.07 In most of the northern zones, the use of drugs for treating diarrhoea seems to be a preferred method, as contrasts with the South which might be due to poor supply of drugs in those areas. It is evident from the above table that the use of ORS falls drastically short of the target goal of 80% in all zones. II I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 In recent years, WHO and UNICEF have been placing greater emphasis on an increased volume of fluid intake. When given with continued feeding, the food can provide the required salt and carbohydrate or protein (needed to transport the salt and water into the body) and the composition of the fluid itself is therefore less important (provided certain harmful fluids are avoided).Continued feeding is not only critical for its role in rehydration but is also most important for the child's nutritional well-being. Based on this, water is considered to be an accepted home fluid provided feeding is continued. (Technical Guidelines for Monitoring Mid-Decade Goals). If we consider home fluid as a form of ORT, the picture looks a little higher, as the graph (below) shows, but total ORT usage is still at the rate of28.4% in the North, and 39.6% in the South. Graph 1. ORT Use-rate among children under five years of age with diarrhoea ORT USE RATE(%) Target Kordofan Northern Eastern Khartoum Central Darfur Total North Total South 0 10 20 30 40 50 60 70 80 12 I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Table 8. Amount of liquid given to children under fives surveyed during diarrhoea in per cent ZONE #of cases increased as it is decreased stopped Northern 263 35.74 52.09 8.75 3.42 Eastern 390 32.05 61 .79 4.62 1.54 Khartoum 376 40.43 46.01 12.50 1.06 Central 413 46.49 46.00 5.81 1.69 Kordofan 387 38.76 44.96 13.95 2.33 Darfur 396 19.85 63.82 14.32 2.01 Total North 34.99 53.18 9.99 1.84 Total South 608 47.86 41.12 10.36 0.66 GRAND TOTAL 37.96 50.39 10.08 1.57 It is interesting to note that in the majority of cases of diarrhoea in the North , liquid is either continued to be given to the child at the same rate (53 .18%) or liquid intake is increased (34.99%) rather than decreased (9.99%). In the South, some 41% of children suffering from diarrhoea continue to be given liquids at the normal rate. A larger number (47.86%) have an increased liquid intake, whilst some 10% are given less liquids. Table 9. Amount of food given to children under fives surveyed during diarrhoea in per cent ZONE #of cases increased as it is decreased stopped Northern 263 13 .31 65.78 14.83 6.08 Eastern 390 11.28 64.62 11.54 12.56 Khartoum 376 7.18 54.79 34.31 3.72 Central 413 4.84 57.14 30.75 7.26 Kordofan 387 11.37 52.97 29.72 5.94 Darfur 396 13 .32 64.57 18.59 3.52 Total North 9.61 59.77 24.27 6.35 Total South 608 27.14 49.34 20.56 2.96 GRAND TOTAL 13.66 57.36 23.41 5.57 13 I I I I I I I I :I II II I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Where food is concerned, table 9. shows that on average in the North, the majority of mothers/caretakers continue to give the child food at the same rate (59.77%). It seems that reducing intake offood during diarrhoea is still practiced (24.27%), only 9.61% increase the food intake. While in the South 27.14% of the children suffering from diarrhoea have their food intake increased, 20.56% have a reduced food intake, and 9.34% are given food at the same rate. Table 10. Person who treated diarrhoea among the under-fives surveyed in per cent ZONE #of Cases Health Mother Traditional Other Don't know worker healer Northern 263 49.43 25 .10 0.76 1.52 23.19 Eastern 390 22 .56 35.13 1.03 3.85 37.44 Khartoum 376 45.48 26.33 0.27 0.00 27.93 Central 413 32.93 36.32 1.45 0.24 29.06 Kordofan 387 31.27 49.10 2.07 1.29 16.28 Darfur 396 14.32 51.01 6.53 0.50 27.64 Total North 28.83 39.75 2.61 1.01 27.80 Total South 608 49.34 26.81 6.09 0.00 17.76 GRAND TOTAL 33.57 36.76 3.41 0.78 25.48 Most of the cases are treated either by the mother or the health worker. The survey shows that the role of traditional healer and other is not significant in treating children with diarrhoea. This suggests that training and health education are required to promote ORT use to mothers and health workers. Another important factor is mother's attitude on breast-feeding during diarrhoea. The survey shows that more than 80% of mothers both in the North and the South continue to breast-feed their babies during their bouts of diarrhoea. Only 1.82% in the North and 3.40% in the South stopped breast-feeding, with others decreasing the numbers or duration of feeds as shown in table 11. 14 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Table 11. Attitude on breast-feeding during Diarrhoea among children less than 2 years surveyed. # ofUnder2 Breast-feeding (%) ZONE Breast-fed % with Diarrhoea Continued Stopped Decreased Northern 358 32.12 82.61 4.35 13.04 Eastern 466 37.55 78.86 3.43 17.71 Khartoum 487 33 .06 83.85 1.86 14.29 Central 479 39.67 83.68 1.05 15.27 Kordofan 529 33 .08 82.29 2.86 14.85 Darfur 413 41.65 75.00 0.58 24.42 Total North 37.46 80.70 1.82 17.48 Total South 550 58.91 83.95 3.40 12.65 GRAND TOTAL 40.61 81.39 2.16 16.45 Table 12. Duration of breast-feeding among children under fives stopped breast-fed surveyed in per cent. #of Under 5 Age in months when breast-feeding was stopped in per cent ZONE stopped breast-fed 0 <6 6-11 12- 17 18- 24+ Northern 615 3.90 1.46 5.04 17.89 71.71 Eastern 760 12.11 3.03 6.58 22.63 55.66 Khartoum 893 1.57 2.02 8.62 18.14 69.65 Central 997 1.20 1.60 5.62 18.96 72.62 Kordofan 1,038 7.03 0.39 2.60 19.08 70.91 Darfur 882 0.23 0.68 2.83 15.53 80.73 Total North 3.38 1.41 4.97 18.40 71.84 Southern 789 13.94 1.01 2.66 10.65 71.74 GRAND TOTAL 4.90 1.35 4.64 17.28 71.83 The figures show that the level of breast-feeding (at least up to 12 months) in most states is still around the 95% mark. At 99.09 %, the Central zone has the highest number of breast-fed children . The Eastern zone, however, shows a marked difference in pattern, with only 84.87% of the infants being breast- fed up to 12 months and a mere 55.66% up to 24 months. 15 I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 In the South 71.74% of the children are breast-fed up to 24 months. Furthermore, all the above data relating to breast-feeding has provided no statistics on supplementary feeding. It is suggested that the new questionnaire for the second Multiple Indicator Cluster Survey ask whether the child is exclusively breast-fed or is provided with supplementary feeding. An additional analysis was made on the incidence of diarrhoea among children who are still breast- fed and among those who are no longer breast-fed. It is believed that those who are breast-fed should have been less likely to suffer from diarrhoea rather than those who are not breast-fed. However, this survey revealed an inconsistent result especially in the South as shown in the table below. Table 13. Incidence of diarrhoea among children surveyed by status of breast-feeding in per cent. Breast-fed Not Breast-fed ZONE #under 2 Diarrhoea No Diarrhoea #under 2 Diarrhoea No Diarrhoea Northern 358 32.12 67.88 37 37.84 62.16 Eastern 466 37.55 62.45 121 31.40 68.60 Khartoum 487 33.06 66.94 94 46.81 53.19 Central 479 39.67 60.33 102 37.25 62.75 Kordofan 529 33.08 66.92 72 31.94 68 .06 Darfur 413 41.65 58.35 46 32.61 67.39 Total North 37.46 62.54 36.42 63.58 Total South 550 58.91 41.09 68 39.71 60.29 GRAND TOTAL 40.61 59.39 36.78 63.22 This has been taken as a useful lesson learned from the first experience in conducting a Multiple Indicator Cluster Survey in the Sudan to improve the quality of questionnaire as well as the questioning technique. 16 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Acute Respiratory Infections In Sudan, Acute Respiratory Infections (ARI) have been contributing significantly to the mortality rates in children. Recent records indicate that nationally 21% ofunder-five mortality is attributed to ARI. Table 14. Incidence of ARI in the last 2 weeks among under-fives surveyed in per cent. ZONE #of Under-five With ARI symptoms Without ARI symptoms Northern 1,051 39.11 60.89 Eastern 1,305 36.48 63.52 Khartoum 1,437 45.86 54.14 Central 1,524 47.44 52.58 Kordofan 1,631 44.45 55.55 Darfur 1,403 33.57 66.43 Total North 41.39 58.61 Total South 1,484 41.17 58.83 GRAND TOTAL 41.35 58.65 Cough is the most common symptom as one of the criteria for diagnosing ARI. The incidence rate of ARI symptoms for the North and the South is at around the 41% mark. That is to say that almost half the national population of children under five showed signs of ARI in the two weeks preceding the survey. Nose- block, fast breath, fever are recognized as other symptoms for diagnosing ARI. Mothers and care-takers usually will seek treatment for the child when the child is suffering from disturbing symptoms. As far as ARI is concerned, fever is the most common symptom which lead the mothers and care-takers seek help, as shown in table 15. In the North, 42.84% of ARI cases seek treatment due to suffering from fever and similarly 54.34% of ARI cases in the South. Very few mothers or caretakers seek treatment for loss of appetite. About 20% of mothers or caretakers in the North and some 15% in the South seek help for fast breath. Even lesser numbers seek help for nose blocks. 17 I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Table 15. ARI symptoms among children under 5 years surveyed which lead to mothers seeking treatment. ARI No Nose Fast ZONE cases appetite block breath Fever Duration Other Northern 411 1.70 24.57 23 .36 31.63 1.70 17.03 Eastern 476 2.10 9.66 21.43 34.03 4.20 28 .57 Khartoum 659 2.88 4.70 27.92 57.51 1.82 5.15 Central 723 1.80 4.98 16.87 53.11 12.17 11.06 Kordofan 725 2.62 32.69 17.24 32.00 6.90 8.55 Darfur 471 5.73 27.60 17.62 32.27 3.82 12.95 Total North 2.93 15.52 19.67 42.84 6.55 12.49 Total South 611 2.45 9.33 15.06 54.34 6.06 12.77 GRAND TOTAL 2.85 14.50 18.91 44.74 6.47 12.54 Vitamin A Deficiency (V AD) Available statistics on VAD show high prevalence rates among children, ranging between 0.4%- 2.8% for night blindness, 0.9%-3.0 for Bitot's spots and 0.2 -0.5% for corneal ulcers . Graph 2. Coverage of Vitamin A among children aged 12-23 months surveyed. COVERAGE OF VITAMIN A(%) AMONG CHILDREN 12-23 MONTHS 10 15 20 25 30 The survey committee realized that the age group surveyed was not completely correlated with the policy of vitamin A distribution in the Sudan. Vitamin A is administered targeting children between 6-23 months of age with one dose of vitamin A of 200,000 IU. Therefore, the survey should have shown a higher coverage if it would have been interviewing children more than 24 months instead of 12-23 months. In any case the result has been useful to compare the success or failure between states. Eastern zone has achieved the highest coverage in the North, while Central zone has been the lowest. Overall, the South achieved higher coverage than the North . This experience has been taken into consideration for improving the questionnaire for next Multiple Indicator Cluster Survey. 18 I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Universal Salt lodization (USI) In the Sudan, Iodine Deficiency Disorder (IDD) has been recognized as a public health problem since the 1950s. In the North, around 2.3 million people are estimated to be at risk ofiDD. Ofthese, 1.5 million are estimated to be in the Darfur zone. Studies conducted in the 1980s indicated high goitre prevalence. Total Goitre Rate (TGR) is estimated to be 20% nation-wide, with a wide variation as seen below. Red Sea states 13% Khartoum 17% Kordofan 68% Central 75% Darfur 87% A survey in the South in the 1970s revealed goitre prevalence rates of 10 - 30%. Universal Salt Iodization has been adopted as a national strategy to overcome the problem. Two main salt producers in Port Sudan with a capacity of producing about 80% of country requirement are preparing to produce iodized salt. In fact, iodized salt had not been available for most of the households at the time the survey was implemented. However, for the purpose of practicing the survey technique and methodology this indicator was included. Table 16. Consumption of iodized salt among households surveyed ZONE # of Household Yes o;o No o;o Northern 1,500 10 0.67 1,490 99.33 Eastern 1,500 9 0.60 1,491 99.40 Khartoum 1,500 6 0.40 1,494 99.60 Central 1,500 1 0.07 1,499 99.93 Kordofan 1,500 3 0.20 1,497 99.80 Darfur 1,500 1 0.07 1,499 99.93 Total North 0.26 99.74 Total South 1,350 1 0.07 1,349 99.93 GRAND TOTAL 0.23 99.77 19 I I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Protein Energy Malnutrition (PEM) In recent years, malnutrition (severe and moderate) has become an immense threat to children and women in the country nation-wide, as a result of natural disasters and the civil war in the South which caused displacement of large numbers of the population. This problem is intensified in the South. The PAP Child Surveys done in 1993 revealed that 34% of under-fives were under weight (weight for age), 13% suffered from wasting (weight for height), and 33% were stunted (height for age). The Multiple Indicator Cluster Survey, was using " weight for height" as the criteria to study the level of malnutrition. A child is considered moderately malnourished if his/her weight for height is less than 2 standard deviation of the median weight for height ofthe reference population for the same age and sex and severely malnourished if his/her weight for height is less than 3 standard deviation . Table 20. shows a total malnutrition level of 16.51% in the North. Of these, 5.97% are severely malnourished and 10.54% moderately malnourished. Table 17. Nutrition Status among children under-five years surveyed Nutrition Status ZONE # Under-5 surveyed Severe % Moderate 0/o Northern 907 88 9.70 166 18.30 Eastern 1,133 88 7.77 132 11.65 Khartoum 1,375 40 2.91 137 9.96 Central 1,422 93 6.54 124 8.72 Kordofan 1,550 76 4.90 138 8.90 Darfur 380 19 5.00 16 4.2 1 Total North 5.74 8.71 Total South 1,290 187 14.50 175 13.57 GRAND TOTAL 7.19 9.51 The Northern and Eastern States suffer the highest level of malnutrition with 28% and 19.42% respectively of their under-five population. Darfur appears to be the most well off state with respect to under-five malnutrition at an overall rate of9%. Of this, 5% are severely malnourished. In the South severe malnutrition is more prominent at the rate of 14.50% out of the overall malnutrition rate of28.07%. 20 I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Basic Education The mid-decade goals for basic education are to increase the enrolment rate to 70%, completion rate to 75% and reduce the disparity of girl/boy ratio to 0.8 by 1995. In addition the literacy rate among population 15-45 years of age to be increased to 36%. Table 18. Primary school attendance among boys 6-10 years surveyed in per cent. ZONE Boys 6-10 yrs Not attending Class 1 Class 2 Class 3 Class 4 Northern 916 31.60 27.12 21.93 12.26 7.08 Eastern 856 41.18 20.69 17.65 14.00 6.49 Khartoum 1,106 28.88 25.27 23.83 16.43 5.60 Central 1,102 45.76 22.54 19.83 10.34 1.53 Kordofan 1,127 51.78 16.98 15.79 9.00 6.45 Darfur 848 43.61 26.03 15.53 10.96 3.88 Total North 42.53 22.95 18.43 11.70 4.40 Total South 834 37.95 37.28 14.51 6.92 3.35 GRAND TOTAL 41.53 26.08 17.57 10.65 4.17 It is clear from tables 2I and 22, that except for the Northern and Darfur zones, there is not very much disparity between the numbers of boys and girls who first enrol in Class I. In fact in classes 3 and 4 in the Northern zone, the percentage of female 6-10 years old is higher than that of male. In general, the overall rate of enrolment is very low in all zones, including Khartoum. The percentage of children who never attended school is rather high in most zones. Kordofan is in the worst position, with over 50% of school age children of 6 to I 0 years of age are not getting any formal education. It is quite disturbing that the percentage of children who actually attend class 4 is very small, 4.39% (male), 4.11% (female) in the North and 3.35 (male), 2.33% (female) in the South. It is clear that this is a result of children drop out from school and/or repetition. It is therefore, suggested that, the amended questionnaire for I996 includes questions related to these issues. This should provide a more comprehensive picture of the situation. 21 I I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Table 19. Primary school attendance among girls 6-10 years surveyed in per cent. ZONE Girls 6-10 yrs Not attending Class 1 Class 2 Class 3 Class 4 Northern 492 36.79 19.92 17.07 16.67 9.55 Eastern 363 50.69 18.18 15.43 10.74 4.96 Khartoum 552 35.33 23.55 20.83 12.86 7.43 Central 512 49.22 21.88 18.16 8.98 1.76 Kordofan 538 58.36 15.43 16.17 5.58 4.46 Darfur 410 53.17 21.22 14.88 7.81 2.93 Total North 49.25 20.34 16.95 9.35 4.11 Total South 386 41.71 37.05 13.47 5.44 2.33 GRAND TOTAL 47.90 23.32 16.33 8.65 3.79 Access to Safe Drinking Water It is very well documented that unsafe drinking water is responsible for a lot of the diseases especially diarrhoeal prevailing in the country. The primary aim of the water goal is to improve the populations' access to safe drinking water. Table 20. Source of drinking water in households surveyed in per cent ZONE #ofHH Main Well Rain/ Hafeer River Turaa Other Northern 1,500 57.87 12.80 0.00 24.67 0.67 4.00 Eastern 1,500 41 .73 41.07 1.47 4.07 9.27 2.40 Khartoum 1,500 86.93 0.73 0.00 2.67 0.00 9.67 Central 1,500 59.73 10.33 8.87 3.93 13.80 3.33 Kordofan 1,500 77.67 13.20 6.00 0.00 1.67 1.47 Darfur 1,500 43.07 48.67 8.27 0.00 0.00 0.00 Total North 59.90 22.81 5.25 3.61 5.22 3.22 Total South 1,350 11.11 13.11 7.41 49.19 0.07 19.11 GRAND TOTAL 51.77 21.19 5.61 11.21 4.36 5.87 22 I I I I I I :I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY I 995 Table 21. Source of Domestic Water in households surveyed in per cent. ZONE #ofHH Main Well Rain/ Hafeer River Turaa Other Northern 1,500 59.20 20.67 0.00 16.80 0.67 2.67 Eastern 1,500 43.00 41 .20 1.47 2.47 9.60 2.27 Khartoum 1,500 87.20 0.67 0.00 2.47 0.00 9.67 Central 1,500 59.60 7.47 8.87 3.87 16.87 3.33 Kordofan 1,500 77.60 11.40 4.93 0.07 3.33 2.67 Darfur 1,500 42.00 49.73 8.27 0.00 0.00 0.00 Total North 59.92 22.58 5.10 2.84 6.29 3.28 Total South 1,350 11.78 13.48 6.96 48.52 0.00 19.26 GRAND TOTAL 51.90 21.06 5.41 10.45 5.24 5.94 Table 22. Treatment of drinking water in households surveyed in per cent ZONE #ofHH Main Boiled Precipitated Filtered Other Northern 1,500 96.67 0.33 1.67 1.00 0.33 Eastern 1,500 93.07 0.13 5.93 0.20 0.67 Khartoum 1,500 98.80 1.07 0.00 0.07 0.07 Central 1,500 88.13 0.53 0.27 11.00 0.07 Kordofan 1,500 99.33 0.20 0.13 0.00 0.33 Darfur 1,500 99.20 0.73 0.07 0.00 0.00 Total North 95.22 0.54 1.10 2.94 0.20 Total South 1,350 65.33 0.96 27.33 6.30 0.07 GRAND TOTAL 90.24 0.61 5.47 3.50 0.18 23 I I I I I I I I I I I I I I I I I I I SUDAN MULTIPLE INDICATOR CLUSTER SURVEY 1995 Access to Sanitary Means of Excreta Disposal The primary aims of the sanitation goals are to improve the population's access to adequate sanitation facilities. Table 23. Accessibility to type of sanitation facility in per cent. ZONE #ofHH Pit latrine Syphon Private Common Other None Northern 1,500 66.07 3.67 9.47 0.00 0.00 20.80 Eastern 1,500 21.53 1.80 9.20 0.00 0.07 67.40 Khartoum 1,500 70.93 0.47 9.13 0.40 0.07 19.00 Central 1,500 50.40 0.73 4.80 0.00 0.13 43.93 Kordofan 1,500 36.13 4.40 4.40 0.00 0.53 54.53 Darfur 1,500 55.00 0.33 0.00 0.13 16.33 28.20 Total North 49.43 1.45 5.28 0.09 3.90 39.84 Total South 1,350 23.85 0.44 0.74 0.07 9.63 65.26 GRAND TOTAL 45.16 1.28 4.52 0.09 4.86 44.08 The pit latrine seems to be the most common facility available to the population in all zones except the Eastern and Southern . These two zones also stand out as having the largest percentage of people without a sanitary facility of any kind. This is a rather serious problem, as in this case, it is most likely that the open air is used for purposes of defecation and this gives rise to numerous problems. As the table shows, in Darfur, 16.33% of the population use "other" types of sanitary facilities, rather than 'none'. This presumably means it is a kind of sanitary facility, different from those listed above. It would be interesting to know what this "other" is since it is quite popular. Maybe this question could be addressed in the new questionnaire. 24

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