emergency nutrition assessment final report · annex 1: kutupalong results of 2x2 tests of...
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 1
EMERGENCY NUTRITION ASSESSMENT FINAL REPORT
COX’S BAZAR, BANGLADESH
OCTOBER 22 - NOVEMBER 27 2017
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ACKNOWLEDGEMENTS
The Emergency Nutrition Assessment in Cox’s Bazar, Bangladesh was conducted on behalf of the Nutrition
Sector by Action Against Hunger In collaboration with the Government of Bangladesh, the United Nations
High Commissioner for Refugees, the World Food Programme, the United Nations Childrens’ Fund, Save
the Children, and the Centers for Disease Control and Prevention. The assessment was funded by the
United Nations High Commissioner for Refugees, the United Nations Childrens’ Fund, and the European
Commission Humanitarian Aid and Civil Protection, however the opinions expressed in this report may not
reflect the official opinion of these organizations.
Action Against Hunger wishes to thank the Government of Bangladesh and the local governments of Cox’s
Bazar, Ukhia, and Teknaf for their support in making this assessment a reality.
Action Against Hunger also thanks the persons surveyed for their availability and flexibility, without which
the results of this assessment could not have been possible. Family members and their measured children
are warmly thanked for their cooperation and for welcoming survey teams into their homes for data
collection.
Action Against Hunger also thanks the community volunteers and community leaders for their collaboration
in identifying survey areas and households during data collection.
Special thanks and gratitude to the survey teams who made the assessment possible through their
professionalism and dedication in the field.
Coordination team:
Leonie Toroitich-Van Mil, Nutrition Head of Department, Action Against Hunger, Bangladesh
Mohammad Lalon Miah, Survey Manager, Action Against Hunger, Bangladesh
Alexandra Humphreys, Flying Survey Manager, Action Against Hunger
Technical support:
The Emergency Nutrition Assessment Technical Working Group
Eva Leidman, Epidemiologist, CDC Emergency Response and Recovery Branch
Oleg Bilukha, Associate Director of Science, CDC Emergency Response and Recovery Branch
Blanche Greene Cramer, EIS Officer, CDC Emergency Response and Recovery Branch
Aimee Summers, Epidemiologist, CDC Emergency Response and Recovery Branch
Emilie Robert, Health and Nutrition Technical Advisor, Action Against Hunger, France
Claudia Grigore, Mobile Data Collection Officer at CartONG
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................................................................................................................................. 2
TABLE OF CONTENTS ..................................................................................................................................... 3
LIST OF TABLES .............................................................................................................................................. 7
LIST OF FIGURES .......................................................................................................................................... 10
ACRONYMS ................................................................................................................................................. 11
EXECUTIVE SUMMARY ................................................................................................................................ 13
OBJECTIVES ............................................................................................................................................. 13
METHODOLOGY ...................................................................................................................................... 13
RESULTS .................................................................................................................................................. 14
1. INTRODUCTION ................................................................................................................................... 15
1.1 CONTEXT ........................................................................................................................................... 15
1.1.1 Geography and Demography ..................................................................................................... 15
1.1.2 Displacement and the Camps .................................................................................................... 16
1.1.3 Food Security and Livelihoods ................................................................................................... 18
1.1.5 Water, Sanitation, and Hygiene ................................................................................................. 19
1.1.6 Health ......................................................................................................................................... 20
1.1.7 Nutrition ..................................................................................................................................... 22
1.1.8 Infant and Young Child Feeding Practices .................................................................................. 22
1.1.9 Protection................................................................................................................................... 23
1.1.10 Humanitarian Actors ................................................................................................................ 23
1.2 Survey Justification ........................................................................................................................... 26
1.3 Survey Objectives .............................................................................................................................. 27
1. METHODOLOGY .................................................................................................................................. 29
2.1 Type of Survey and Target Population .............................................................................................. 29
2.2 Sample Size Calculation .................................................................................................................... 29
2.3 Sampling ............................................................................................................................................ 32
2.3.1 Cluster Selection ........................................................................................................................ 32
2.3.2 Household Selection .................................................................................................................. 33
2.3.3 Selection of Individuals to Survey .............................................................................................. 34
2.4 Collected Variables............................................................................................................................ 35
2.4.1 Demography & Mortality .................................................................................................... 35
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2.4.2 Anthropometry .......................................................................................................................... 35
2.4.3 Morbidity ................................................................................................................................... 35
2.4.4 Infant and Young Child Feeding ................................................................................................. 36
2.4.5 Receipt of Services ..................................................................................................................... 36
2.5 Indicators and Cut-offs ...................................................................................................................... 37
2.5.1 Mortality Indices ........................................................................................................................ 37
2.5.2 Anthropometric Indices ............................................................................................................. 38
2.5.3 Anaemia ..................................................................................................................................... 40
2.6 Questionnaire, Training, and Supervision ......................................................................................... 41
2.6.1 Questionnaire ............................................................................................................................ 41
2.6.2 Training ...................................................................................................................................... 41
2.6.3 Supervision ................................................................................................................................. 42
2.7 Data Management ............................................................................................................................ 42
2.8 Ethical Considerations ....................................................................................................................... 43
2.9 A Note on Interpretation .................................................................................................................. 43
3. RESULTS ................................................................................................................................................... 46
3.1 Kutupalong Refugee Camp................................................................................................................ 46
3.1.1 Data Quality ............................................................................................................................... 46
3.1.2 Demography and Mortality ........................................................................................................ 48
3.1.3 Prevalence of Acute Malnutrition by WHZ ................................................................................ 50
3.1.4 Prevalence of Acute Malnutrition by MUAC .............................................................................. 52
3.1.5 Prevalence of Acute Malnutrition WHZ vs. MUAC .................................................................... 54
3.1.6 Low MUAC in Women ................................................................................................................ 55
3.1.7 Low MUAC in Infants .................................................................................................................. 55
3.1.8 Prevalence of Chronic Malnutrition ........................................................................................... 56
3.1.9 Prevalence of Underweight ....................................................................................................... 56
3.1.10 Prevalence of Anaemia ............................................................................................................ 57
3.1.11 Prevalence of Morbidity........................................................................................................... 58
3.1.12 IYCF Indicators .......................................................................................................................... 59
3.1.13 Receipt of Services ................................................................................................................... 62
3.1.14 Care-seeking Behaviour ........................................................................................................... 64
3.2 Makeshift Settlements ...................................................................................................................... 68
3.2.1 Data Quality ............................................................................................................................... 68
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3.2.2 Demography and Mortality ........................................................................................................ 70
3.2.3 Prevalence of Acute Malnutrition by WHZ ................................................................................ 72
3.2.4 Prevalence of Acute Malnutrition by MUAC .............................................................................. 74
3.2.5 Prevalence of Acute Malnutrition WHZ vs. MUAC .................................................................... 76
3.2.6 Low MUAC in Women ................................................................................................................ 77
3.2.7 Low MUAC in Infants .................................................................................................................. 77
3.2.8 Prevalence of Chronic Malnutrition ........................................................................................... 78
3.2.9 Prevalence of Underweight ....................................................................................................... 78
3.2.10 Prevalence of Anaemia ............................................................................................................ 79
3.2.11 Prevalence of Morbidity........................................................................................................... 80
3.2.12 IYCF Indicators .......................................................................................................................... 81
3.2.13 Receipt of Services ................................................................................................................... 84
3.2.14 Care-seeking Behaviour ........................................................................................................... 86
3.3 Nayapara Refugee Camp ................................................................................................................... 89
3.3.1 Data Quality ............................................................................................................................... 89
3.3.2 Demography and Mortality ........................................................................................................ 91
3.3.3 Prevalence of Acute Malnutrition by WHZ ................................................................................ 93
3.3.4 Prevalence of Acute Malnutrition by MUAC .............................................................................. 95
3.3.5 Prevalence of Acute Malnutrition WHZ vs. MUAC .................................................................... 97
3.3.6 Low MUAC in Women ................................................................................................................ 98
3.3.7 Low MUAC in Infants .................................................................................................................. 99
3.3.8 Prevalence of Chronic Malnutrition ........................................................................................... 99
3.3.9 Prevalence of Underweight ..................................................................................................... 100
3.3.10 Prevalence of Anaemia .......................................................................................................... 100
3.3.11 Prevalence of Morbidity......................................................................................................... 101
3.3.12 IYCF Indicators ........................................................................................................................ 103
3.3.13 Receipt of Services ................................................................................................................. 106
3.3.14 Care-seeking Behaviour ......................................................................................................... 108
4. DISCUSSION ........................................................................................................................................... 110
4.1. The Malnutrition Landscape .......................................................................................................... 110
4.2. Underlying Causes of Malnutrition ................................................................................................ 113
4.3 Receipt of Services .......................................................................................................................... 115
4.4 Limitations of the Assessment ........................................................................................................ 116
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5. Conclusion and Recommendations....................................................................................................... 117
Annex 1: Kutupalong Results of 2x2 Tests of Statistical Significance per Epi Info Software .................... 119
Annex 2: Makeshift Settlements Results of 2x2 Tests of Statistical Significance per Epi Info Software .. 120
Annex 3: Nayapara Results of 2x2 Tests of Statistical Significance per Epi Info Software ....................... 121
Annex 4: Survey Team Training Schedule ................................................................................................. 122
Annex 5: Makeshift Settlements Cluster Determination .......................................................................... 125
Annex 6: Survey Questionnaire ................................................................................................................ 126
Annex 7: Cluster Control Form .................................................................................................................. 136
Annex 8: Anthropometric Measurement Form Children .......................................................................... 137
Annex 9: Anthropometric Measurement Form Women .......................................................................... 138
Annex 10: Event Calendar ......................................................................................................................... 140
Annex 11: Referral Form ........................................................................................................................... 143
Annex 12: Kutupalong Refugee Camp Plausibility Check ......................................................................... 144
Annex 13: Makeshift Settlements Plausibility Check ................................................................................ 154
Annex 14: Nayapara Refugee Camp Plausibility Check ............................................................................ 167
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LIST OF TABLES
Table 1: Summary of Key Indicators, Cox’s Bazar, November 2017 ........................................................... 14
Table 2: Health Facilities Existing Prior to August 25th, 2017 in Ukhia and Teknaf, Cox’s Bazar, Bangladesh
Ministry of Health and Family Welfare 2017* ............................................................................................ 21
Table 3: Stabilization Centres and Outpatient Therapeutic Programmes Operating in Kutupalong Refugee
Camp During Survey Data Collection .......................................................................................................... 24
Table 4: Stabilization Centres and Outpatient Therapeutic Programmes Operating in the Makeshift
Settlements During Survey Data Collection ................................................................................................ 24
Table 5: Stabilization Centres and Outpatient Therapeutic Programmes Operating in Nayapara Refugee
Camp During Survey Data Collection .......................................................................................................... 25
Table 6: Overview of Reported Representative Estimates of Global Acute Malnutrition for Rakhine State
and Cox’s Bazar since 2015 ......................................................................................................................... 27
Table 7: Sample Size Calculation Parameters Anthropometry ................................................................... 30
Table 8: Cut-offs for the Indices for Weight-for-Height z-score (WHZ), Height-for-Age z-score (HAZ), and
Weight-for-Age z-score (WAZ) according to WHO reference 2006 ............................................................ 38
Table 9: WHO Classification for Severity of Malnutrition by Prevalence among Children Under Five ...... 39
Table 10: WHO Cut-off Values for Anthropometric Measurements Using MUAC to Assess Moderate and
Severe Acute Malnutrition .......................................................................................................................... 39
Table 11: IPC classification Acute Malnutrition by MUAC .......................................................................... 40
Table 12: WHO Cut-off Values for Prevalence of Anaemia based on Haemoglobin Measurement .......... 40
Table 13: WHO Classification of Public Health Significance of Anaemia and Iron Deficiency in Populations
based on Haemoglobin Measurement ....................................................................................................... 40
Table 14: KTP Households and Children 6-59 months Planned vs. Surveyed ............................................. 46
Table 15: KTP Median z-score ± Standard Deviation for WHZ, HAZ, and WAZ .......................................... 47
Table 16: KTP Overall Data Quality per ENA Plausibility Check .................................................................. 47
Table 17: Demographics of Kutupalong Refugee Camp ............................................................................. 48
Table 18: KTP Distribution of Age and Sex Children 6-59 months .............................................................. 49
Table 19: KTP Prevalence of Acute Malnutrition per WHZ and/or Oedema, WHO Reference 2006 ......... 51
Table 20: KTP Prevalence of Acute Malnutrition by Sex per WHZ and/or Oedema, WHO Reference 2006
.................................................................................................................................................................... 51
Table 21: KTP Prevalence of Acute Malnutrition by Age per WHZ and/or Oedema, WHO Reference 2006
.................................................................................................................................................................... 52
Table 22: KTP Prevalence of Acute Malnutrition by MUAC ........................................................................ 53
Table 23: KTP Low MUAC in Women 15-49 Years ...................................................................................... 55
Table 24: KTP Low MUAC in Infants 0-5 Months ........................................................................................ 56
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Table 25: KTP Prevalence of Chronic Malnutrition by HAZ, WHO Reference 2006 .................................... 56
Table 26: KTP Prevalence of Underweight by WAZ, WHO Reference 2006 ............................................... 57
Table 27: KTP Prevalence of Anaemia in Children 6-59 months per WHO ................................................. 57
Table 28: KTP Two-week Prevalence of Diarrhoea, Cough, and Fever in Children 6-9 Months ................. 59
Table 29: KTP Infant and Young Child Feeding Indicators .......................................................................... 60
Table 30: KTP Receipt of Immunizations and Food/Nutrition Assistance .................................................. 63
Table 31: KTP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Diarrhoea .... 65
Table 32: KTP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Cough .......... 65
Table 33: KTP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Fever ........... 66
Table 34: MS Households and Children 6-59 months Planned vs. Surveyed ............................................. 68
Table 35: MS Median z-score ± Standard Deviation for WHZ, HAZ, and WAZ ........................................... 69
Table 36: MS Overall Data Quality per ENA Plausibility Check ................................................................... 69
Table 37: Demographics of the Makeshift Settlements ............................................................................. 70
Table 38: MS Distribution of Age and Sex, Children 6-59 months .............................................................. 71
Table 39: MS Prevalence of Acute Malnutrition per WHZ and/or Oedema, WHO Reference 2006 .......... 73
Table 40: MS Prevalence of Acute Malnutrition by Sex per WHZ and/ or Edema, WHO Reference 2006. 73
Table 41: MS Prevalence of Acute Malnutrition by Age per WHZ and/ or Edema, WHO Reference 2006 74
Table 42: MS Prevalence of Acute Malnutrition by MUAC ......................................................................... 75
Table 43: MS Low MUAC in Women 15-49 Years ....................................................................................... 77
Table 44: MS Low MUAC in Infants 0-5 Months ......................................................................................... 78
Table 45: MS Prevalence of Chronic Malnutrition by HAZ, WHO Reference 2006..................................... 78
Table 46: MS Prevalence of Underweight by WAZ, WHO Reference 2006 ................................................ 79
Table 47: MS Prevalence of Anaemia in Children 6-59 months per WHO.................................................. 79
Table 48: MS Two-week Prevalence of Diarrhoea, Cough, and Fever in Children 6-59 Months ................ 81
Table 49: MS Infant and Young Child Feeding Indicators ........................................................................... 82
Table 50: MS Receipt of Immunizations and Food/Nutrition Assistance ................................................... 85
Table 51: MS Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Diarrhoea ..... 86
Table 52: MS Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Cough ........... 87
Table 53: MS Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Fever ............ 87
Table 54: NYP Households and Children 6-59 months Planned vs. Surveyed ............................................ 89
Table 55: NYP Median z-score ± Standard Deviation for WHZ, HAZ, and WAZ .......................................... 90
Table 56: NYP Overall Data Quality per ENA Plausibility Check .................................................................. 90
Table 57: Demographics of Nayapara Refugee Camp ................................................................................ 91
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Table 58: NYP Distribution of Age and Sex, Children 6-59 months ............................................................ 92
Table 59: NYP Prevalence of Acute Malnutrition in Nayapara Refugee Camp per WHZ and/or Oedema,
WHO Reference 2006 ................................................................................................................................. 94
Table 60: NYP Prevalence of Acute Malnutrition by Sex per WHZ and/or Oedema, WHO Reference 2006
.................................................................................................................................................................... 95
Table 61: NYP Prevalence of Acute Malnutrition by Age per WHZ and/or Oedema, WHO Reference 2006
.................................................................................................................................................................... 95
Table 62: NYP Prevalence of Acute Malnutrition by MUAC ....................................................................... 96
Table 63: NYP Low MUAC in Women 15-49 Years ...................................................................................... 99
Table 64: NYP Low MUAC in Infants 0-5 Months ........................................................................................ 99
Table 65: NYP Prevalence of Chronic Malnutrition by HAZ, WHO Reference 2006 ................................. 100
Table 66: NYP Prevalence of Underweight by WAZ, WHO Reference 2006 ............................................. 100
Table 67: NYP Prevalence of Anaemia in Children 6-59 months per WHO .............................................. 101
Table 68: NYP Two-week Prevalence of Diarrhoea, Cough, and Fever in Children 6-59 Months ............ 102
Table 69: NYP Infant and Young Child Feeding Indicators ........................................................................ 104
Table 70: NYP Receipt of Immunizations and Food/Nutrition Assistance ................................................ 107
Table 71: NYP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Diarrhoea .. 108
Table 72: NYP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Cough ........ 109
Table 73: NYP Two-week Recall of Care-seeking Behaviour for Children 6-59 Months with Fever ......... 109
Table 74: Comparison of Malnutrition Indicators and Cut-offs Across all Three Surveys ........................ 110
Table 75: Comparison of Key Indicators and Across all Three Surveys .................................................... 115
Table 76: Comparison of Key Indicators and Across all Three Surveys .................................................... 116
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LIST OF FIGURES
Figure 1: Map of Sixty-four Districts in Bangladesh with Cox’s Bazar in Red, Wikipedia Commons, 2009 15
Figure 2: Refugee Sites by Population and Location Type, ISCG, October 22nd, 2017 ................................ 17
Figure 3: KTP Age Distribution of Children 6-59 months ............................................................................ 49
Figure 4: KTP Distribution of the WHZ of the Sample Compared to the WHO 2006 Reference ................ 50
Figure 5: KTP Prevalence of Acute Malnutrition by Age per MUAC ........................................................... 53
Figure 6: KTP Prevalence of Acute Malnutrition WHZ vs. MUAC ............................................................... 54
Figure 7: KTP 24-Hour Recall of Consumption of Liquids in Children 6-23 Months ................................... 61
Figure 8: KTP 24-Hour Recall of Food Group Consumption in Children 6-23 Months ................................ 62
Figure 9: MS Age Distribution of Children 6-59 months ............................................................................. 71
Figure 10: MS Distribution of the WHZ of the Sample Compared to the WHO 2006 Reference ............... 72
Figure 11: MS Prevalence of Acute Malnutrition by Age per MUAC .......................................................... 75
Figure 12: MS Prevalence of Acute Malnutrition WHZ vs. MUAC .............................................................. 76
Figure 13: MS 24-Hour Recall of Consumption of Liquids in Children 6-23 months .................................. 83
Figure 14: MS 24-Hour Recall of Food Group Consumption in Children 6-23 Months .............................. 84
Figure 15: NYP Age Distribution of Children 6-59 months.......................................................................... 92
Figure 16: NYP Distribution of the WHZ of the Sample Compared to the WHO 2006 Reference .............. 93
Figure 17: NYP Prevalence of Acute Malnutrition by Age per MUAC ......................................................... 97
Figure 18: NYP Prevalence of Acute Malnutrition WHZ vs. MUAC ............................................................. 98
Figure 19: NYP 24-Hour Recall of Consumption of Liquids in Children 6-23 Months ............................... 105
Figure 20: NYP 24-Hour Recall of Food Group Consumption in Children 6-23 Months ........................... 106
Figure 21: The Population Influx of Rohingya Refugees during the Emergency Assessment ................... 112
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ACRONYMS
ACF Action Against Hunger - Action Contre la Faim
ARI Acute Respiratory Infection
BF Breastfeeding
BSFP Blanket Supplementary Feeding Programme
CDC Centers for Disease Control and Prevention
CDR Crude Death Rate
CI Confidence Interval
CMAM Community Management of Acute Malnutrition
CMAM-I Community Managemnt of Acute Malnutrition- Infants
DEFF Design Effect
DHS Demographic and Health Survey
FAO Food and Agriculture Organization
FSL Food Security and Livelihoods
GAM Global Acute Malnutrition
GBV Gender Based Violence
GFD General Food Distribution
HAZ Height-for-Age z-score
HH Household
IFRC International Federation of Red Cross and Red Crescent
IGA Income Generating Activity
IOM The International Organization for Migration
IYCF Infant Young Child Feeding
IPC Integrated Food Security Phase Classification
IRC International Rescue Committee
ISCG Inter Sector Coordination Group
IYCF Infant and Young Child Feeding
KTP Kutupalong Refugee Camp
MAD Minimum Acceptable Diet
MAM Moderate Acute Malnutrition
MHCP Mental Health and Care Practices
MICS Multiple Indicator Cluster Survey
MMD Minimum Dietary Diversity
MMF Minimum Meal Frequency
MMR Maternal Mortality Ratio
MNP Micronutrient Powder
MoHFW Ministry of Health and Family Welfare
MR Measles-Rubella
MS Makeshift Settlements
MSF Medecins sans Frontieres
MUAC Mid-Upper Arm Circumference
NGO Non-Governmental Organization
NRR Non-Response Rate
NYP Nayapara Refugee Camp
OCHA United Nations Office for the Coordination of Humanitarian Affairs
OCV Oral Cholera Vaccine
OPV Oral Polio Vaccine
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OR Odds Ratio
OTP Outpatient Therapeutic Programme
PLW Pregnant and Lactating Women
PPS Population Proportional to Size
PSU Primary Sampling Unit
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SARPV Social Assistance and Rehabilitation for the Physically Vulnerable
SC Stabilization Centre
SD Standard Deviation
SENS Standard Expanded Nutrition Survey
SFP Supplementary Feeding Programme
SHED Society for Health Extension and Development
SMART Standardized Monitoring and Assessment of Relief and Transition
SRS Simple Random Sampling
SSU Secondary Sampling Unit
TSFP Targeted Supplementary Feeding Programme
UNFPA The United Nations Population Fund
UNHCR UN High Commissioner for Refugees
UNICEF United Nations Childrens’ Fund
WASH Water, Sanitation, and Hygiene
WAZ Weight-for-Age Z-score
WFP World Food Programme
WHO World Health Organization
WHZ Weight-for-Height Z-score
WSB Wheat Soy Blend
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EXECUTIVE SUMMARY
This emergency nutrition assessment was composed of three population representative SMART
surveys within Cox’s Bazar, Bangladesh. The aim of the assessment was to understand the
nutrition status of the Rohingya living within Kutupalong Refugee Camp, Nayapara Refugee
Camp, and the Makeshift Settlements of Ukhia and Teknaf upazilas. Data collection took place
from October 22nd to November 27th, 2017.
OBJECTIVES The principal objective was the evaluation of the nutritional status among Rohingya children 6-59
months within the three survey areas, as well as to provide salient nutrition and nutrition-sensitive
data to inform an effective humanitarian response to the Rohingya Crisis in Cox’s Bazar.
Additionally, the assessment aimed to:
Estimate demographic characteristics of the households
Estimate crude death rate and under five death rate in the past three months
Measure anthropometric indicators among children 0-59 months and women 15-49 years
Determine the prevalence of anaemia per haemoglobin and morbidity per two-week recall
Estimate infant and young child feeding indicators
Assess immunisation coverage and the receipt of services
METHODOLOGY The survey of Kutupalong Refugee Camp (October 22nd to 28th) selected households using simple
random sampling among those residing within the camp. Household lists were provided by
UNHCR (n=2,621) as well as household enumeration lists (n=2,174) created the week prior to
data collection. The total estimated population of Kutupalong Refugee Camp was 24,499. The
survey of the Makeshift Settlements (October 29th to November 20th) selected households using
two-stage cluster sampling among refugees residing outside of Kutupalong and Nayapara
Refugee Camp. 96 clusters were drawn with a planned 14 households per cluster. The total
estimated population of the Makeshift Settlements was 720,902. The survey of Nayapara Refugee
Camp (November 20th to 27th) selected households using simple random sampling among those
residing within the camp. Household lists provided by UNHCR (n=3,709) as well as household
enumerations lists (n=5,206) created the week prior to data collection. The total estimated
population of Nayapara Refugee Camp was 38,997.
Analysis of the data was conducted using ENA for SMART software (version 9th July 2015), Stata
Version 13 and EPI info 7.2.10. The anthropometric data was cleaned by ENA for SMART
software following SMART flag recommendations (+/- 3 of the survey’s observed median).
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RESULTS The prevalence of GAM in children 6-59 months per WHZ were above the 15% WHO emergency
threshold in Kutupalong and the Makeshift Settlements, with Nayapara falling just below the same
cut-off (see table 1 below). In all three sites, stunting in children 6-59 months was above the 40%
critical threshold, and anaemia in children 6-59 months was above the 40% threshold for high
public health significance. Indicators of low MUAC for women 15-49 years and infants 0-5 months
although inferential, are of concern. Two-week recall of diarrhoea, acute respiratory infection, and
fever indicate a high disease burden in children under five. Breastfeeding is common but exclusive
breastfeeding is very low. The malnutrition status of the Rohingya at the time of assessment
constituted a serious public health emergency in need of additional humanitarian support.
Although there exist contextual differences between the three surveys and population subsets,
the overall findings suggest a context of persistently high acute and chronic malnutrition
in the Rakhine State of Myanmar, where, following the violence on August 25th, 2017 acute
malnutrition rapidly deteriorated among the Rohingya in the Rakhine State as well as
across the border in Cox’s Bazar.
Table 1: Summary of Key Indicators, Cox’s Bazar, November 2017
Indicator Sample Kutupalong RC
Makeshift Settlements
Nayapara RC
% 95% CI % 95% CI % 95% CI
% Children
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1. INTRODUCTION
1.1 CONTEXT
1.1.1 Geography and Demography
Located in the southeast of Bangladesh in the Chittagong Division, Cox’s Bazar is one of
Bangladesh’s sixty-four districts (zilas). Named after the town of Cox’s Bazar, it is bordered by
Chittagong District to the North, Bandarban District and the Myanmar border to the East, and the
Bay of Bengal to the West. Cox’s Bazar is known for having one of the world’s longest natural sea
beaches and for being prone to severe weather events such as cyclones. Cox’s bazar is located
in the tropical monsoon region, which is characterized by high temperature, heavy rainfall, and
high humidity. Despite being characterized by the tropical climate “wet” and “dry” seasons, the
Bangla calendar is divided into six seasons: summer (Grisma), rainy (Barsa), autumn (Sarat), late
autumn (Hemanta), winter (Shhit), and spring (Basanta), with an average annual temperature of
32.8 °C (91.0 °F). Earthquakes and related tsunamis are additional natural threats to the region.
Cox’s Bazar is itself comprised of the eight sub-districts (upazilas) including Ukhia and Teknaf,
which host virtually the entire Rohingya population displaced within Bangladesh.
Figure 1: Map of Sixty-four Districts in Bangladesh with Cox’s Bazar in Red, Wikipedia
Commons, 2009
Officially known as The Republic of the Union of Myanmar, Myanmar is a sovereign State and the
second largest country by area in the Southeast Asian region. In the 2016 United Nations
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Development Index Report, Myanmar ranked 146 out of 188 countries and territories1. Within
Myanmar, the majority of the Rohingya live in the western coastal State of Rakhine (one of the
poorest States in Myanmar) which sits across the Naf River from Cox’s Bazar. According to the
World Bank, the poverty rate of Myanmar as a whole is 37.5% while in the Rakhine State the
poverty rate is 78.0%2. Access to education, health services, and adequate nutrition are low in
Rakhine State. Rakhine State has an insufficient number of trained physicians per capita and
some of the lowest immunisation rates in the country. A 2015 SMART Survey conducted in
Maungdaw and Buthidaung Townships of Rakhine State reported emergency levels of acute
malnutrition. The previously concerning situation is believed to have deteriorated significantly due
to recent violence and displacement. In Bangladesh, basic services available prior to the
population movements from Myanmar have been severely strained.
1.1.2 Displacement and the Camps
Ongoing waves of violence have sent Rohingya over the border into Bangladesh since the early
1970s. Most recently, attacks on police posts and the subsequent backlash in northern Rakhine
in October 2016 saw an influx of 87,000 Rohingya persons displaced into Bangladesh by July of
20173. Attacks on police posts and the subsequent backlash in northern Rakhine on August 25th,
2017 caused an estimated 603,000 Rohingya persons to flee to Bangladesh from Myanmar, by
the commencement of this assessment4. These influxes joined an estimated 125,000 Rohingya
who had arrived in Bangladesh during earlier waves of violence. These estimates are based on
official data provided by the Inter Sector Coordination Group (ISCG) the main coordination body
for humanitarian agencies in Cox’s Bazar.
1 UNDP (2016) Human Development Report 2 World Bank (2014) Ending Poverty and Boosting Shared Prosperity in a Time of Transition 3 Ibid. 4 ISCG 22 Oct 2017 Situation Report: Rohingya Refugee Crisis
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 17
Figure 2: Refugee Sites by Population and Location Type, ISCG, October 22nd, 2017
Kutupalong Refugee Camp (KTP) is located in the Ukhia upazila of Cox’s Bazar. The first of two
government-run UNHCR-supported camps established in 1992, Kutupalong Refugee Camp was
created in response to a large influx of Rohingya at the time. The camp adopted the name of the
pre-existing small town and market of Kutupalong. Kutupalong Refugee Camp is bordered by the
Kutupalong Makeshift Settlements to the west and south, and by the Raja Palong rural area to
the north and east. The estimated population within Kutupalong Refugee Camp was 24,499 at
the beginning of the Kutupalong Refugee Camp Survey (October 22nd, 2017).
Nayapara Refugee Camp (NYP) is located in the Teknaf sub-district (upazila) of Cox’s Bazar. The
second of two government-run UNHCR-supported camps established in 1992 due to a large influx
of Rohingya at the time. Nayapara Refugee Camp is bordered by the Nayapara Makeshift
Settlements to the north. The estimated population within Nayapara Refugee Camp was 38,997
at the beginning of the Nayapara Refugee Camp Survey (November 20th, 2017).
The makeshift and spontaneous settlements (MS) include all refugee settlements in Ukhia and
Teknaf sub-districts outside of the two official refugee camps (Kutupalong and Nayapara) and
excluding Rohingya who have been absorbed into host communities. The two largest makeshift
sites were originally Kutupalong Makeshift (which borders Kutupalong Refugee Camp) and
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 18
Balukhali Makeshift, but the rapid expansion of these sites has blurred borders and created new
colloquial distinctions. Built on previously forested land with stretches of rice paddy, these informal
settlements lacked basic infrastructure including water points, health facilities, and roads. The
newest development is the designation of a 3,000-acre piece of land known as Kutupalong
Extension, which stretches from Kutupalong Makeshift to Balukhali Makeshift Settlements, to host
new arrivals. This expansive area has been further divided into “zones” known as “AA”, “BB”,
“CC”, etc. The estimated population of all makeshift and spontaneous settlements was 720,902
at the beginning of the Makeshift Settlements Survey (October 29th, 2017).
1.1.3 Food Security and Livelihoods
The Rakhine State of Myanmar is characterized as one of the least developed States in the
country, with 78.0% of the Rakhine State population falling below the poverty line5. A 2011 food
security assessment conducted in northern Rakhine State by the World Food Programme (WFP)
noted a deteriorating food security situation with the share of severely food insecure households
increasing from 38% in 2009 to 45% in 20116. The general population of Rakhine State is largely
dependent on agriculture and fishing as sources of food and income. Rice is the main crop in the
region, although coconut and nipa palm are also cultivated. Fishing is a major source of income,
with most production transported to and sold in Yangon. Women generally tend small livestock
such as chickens, and goats, while men herd larger animals such as buffalo and cattle. The
vending of timber, bamboo, and fuel collected from the mountains also contribute to income
generation. In the Final Report of the Advisory Commission on Rakhine State released this year,
the environment in Rakhine State was described as one of “protracted conflict, insecure land
tenure, and lack of livelihood opportunities”7. This has negatively affected local economies and
reduced opportunities for livelihoods and income generating activities (IGAs). Barriers to trade,
livelihood opportunities, and health services for Rohingya in Rakhine have led to the use of
negative coping mechanisms; including reduced meal frequency and relying on food purchased
on credit.
In Cox’s Bazar, Rohingya refugees are living in overcrowded conditions with few legal means for
IGAs. The Rohingya are largely not allowed to work or move out of the camps, and are
increasingly putting themselves at risk in order to access food, fuel, and other basic needs. These
risks include moving outside of designated areas to collect firewood, reduction of food intake, and
survival sex8. In addition, recent reports suggest that many Rohingya refugees are relying on
some sort of informal assistance or borrowing to meet basic needs. These practices ultimately
affect household safety and food security, while increasing tensions within the affected population
and in relation to host communities9. Small-scale vending by the Rohingya is informal and illegal.
Traders are largely from the host community, with a small margin being Rohingya refugees who
5 World Bank (2014) Ending Poverty and Boosting Shared Prosperity in a Time of Transition 6 WFP (2011) Food Security Assessment Northern Rakhine State Myanmar 7 Advisory Commission on Rakhine State (2017) Towards a Peaceful, Faire, and Prosperous Future for the People of Rakhine 8 OXFAM (2017) Rapid Protection, Food Security, and Market Assessment 9 Ibid.
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 19
arrived prior to 2007. Small-scale agriculture and animal husbandry is difficult to achieve given
overcrowding and lack of available land.
In a November 2017 OXFAM report released just prior to the conclusion of this assessment, more
than 80% of focus group respondents relied on dry food assistance from NGOs as their primary
food source. Despite this indication of high reliance on food assistance, 50% of interviewed
traders witnessed humanitarian food assistance being re-sold, with reports that funds from re-
sold assistance is being directed to buying fresh foods, medicine, and other basic needs10. In the
same assessment, focus group participants reported being able to access on average 11-12 food
groups before arriving in Bangladesh, but consuming 3-4 food groups now. Several assessments
have concluded that markets within the camps are well functioning with good capacity to meet
increases in demand11. In the same OXFAM assessment, 92% of those interviewed said ‘lack of
money’ was the main constraint of populations to access markets and 73% of those interviewed
during the IRC assessment said money was their most pressing need12.
1.1.4 Water, Sanitation, and Hygiene
The water, Sanitation, and Hygiene (WASH) context of Rakhine State is underdeveloped, with
poor access to clean water and sanitation facilities. In a 2009 Multiple Indicator Cluster Survey
(MICS), Rakhine State was found to have some of the poorest WASH indicators in Myanmar, with
only 57.7% of the population using an improved source of drinking water13, while an estimated
58% of households in rural Myanmar do not have improved toilet facilities, often relying on open
pit latrines14. The survey also reported that an estimated 20% of households in rural Myanmar
were without available soap and water to support adequate handwashing practices. The lack of
adequate WASH infrastructure and practices in Rakhine State are further exacerbated by frequent
natural hazards such as storms and floods.
In Cox’s Bazar, insufficient WASH facilities across camps and makeshift sites were aggravated
by the Barsa rains in September and October 2017. Poor sanitation facilities, insufficient latrines,
and poor drainage have increased risks of diarrhoeal and other waterborne disease outbreaks in
the crowded camps. In settlements that emerged spontaneously, virtually no access to potable
water or sanitation facilities existed prior to the influx. In other areas water points were hastily
erected. The Cox’s Bazar WASH sector reported (ISCG WASH Sector Situation Report- 5
November) that 4,637 tubewells with hand-pumps had been installed. However infrastructure
surveys found over 30% of waterpoints needing immediate rehabilitation/replacement15. A multi-
sector needs assessment conducted by IRC on October 7th, 2017 in Teknaf and Ukhia as well as
two neighbouring upazilas found that 25% of families reported drinking water was inconsistently
available, and 31% had practiced open defecation16. Furthermore, some WASH facilities are
constructed precariously on steep inclines, which can be dangerous at night and in the event of
rain. There are serious concerns about latrines that were constructed too close to water points,
10 Ibid. 11 Ibid. 12 IRC (2017) Undocumented Myanmar Nationals Influx to Cox’s Bazar, Bangladesh 13 UNICEF (2009) Myanmar Multiple Indicator Cluster Survey 14 USAID (2015-16) Myanmar Demographic and Health Survey 15 ISCG WASH sector Situation report, 5th November 2017 16 IRC (2017) Undocumented Myanmar Nationals Influx to Cox’s Bazar, Bangladesh
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 20
latrines that are difficult to desludge due to location, and the extensive practice of open defecation
in the newest sites17.
1.1.5 Health
Access to health services in Rakhine State is low compared to Myanmar at large. The World
Health Organization (WHO) recommends 22 health workers per 10,000 people. In Rakhine State,
the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) Humanitarian
Needs Overview 2018 reported that there are currently 5 health workers per 10,000 people,
compared to the national average of 16 health workers per 10,000 people18. The Rakhine State
also has some of the lowest immunisation rates in the country with just 41% of children having all
basic vaccination coverage19,20. As of 2016, less than 19% of women were giving birth in a
professional health facility and skilled providers attended less than 1 in 3 births21. Myanmar’s
maternal mortality ratio (MMR) was 282 / 100,000 live births in 2014, making it one of the worst
in the region; Rakhine State’s MMR was even higher at 314 / 100,000 live births22. The 2015-16
Myanmar DHS reported that in Rakhine State 62% of children 6-59 months and 55% of women
15-49 suffered from anaemia (Hb
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 21
below facilities have virtually no ambulances or other vehicles to use for outreach or mobility of
services.
Table 2: Health Facilities Existing Prior to August 25th, 2017 in Ukhia and Teknaf, Cox’s
Bazar, Bangladesh Ministry of Health and Family Welfare26 2017* *This list is not exhaustive, as it does not include all charitable and faith-based hospitals and clinics
Within the camps and settlements, a high burden of acute respiratory infections (ARI) have
persisted, particularly among children less than five years of age27. Inadequate vaccination
coverage, vector control measures, and water and sanitation conditions contribute to an
environment where communicable diseases can easily spread. A WHO report released October
11th, 2017 concluded that the affected population is at high risk of outbreaks of a host of diseases
including cholera, hepatitis E, dysentery, dengue, chikungunya, Japanese encephalitis, malaria,
scrub typhus, as well as scabies28. Dengue hemorrhagic fever is one of the leading causes of
death among children under ten years in Myanmar29. Measles is endemic to both Myanmar and
Bangladesh, with measles being the fifth leading cause of death among children under five years
in Bangladesh30. Measles outbreaks among the Rohingya population have been reported in Cox’s
Bazar in both 2016 and 2017.
26 Bangladesh Ministry of Health and Family Welfare http://facilityregistry.dghs.gov.bd/search.php 27 WHO (2017) Public Health Situation Analysis and Interventions Bangladesh/Myanmar 28 WHO (2017) Public Health Situation Analysis and Interventions Bangladesh/Myanmar 29 WHO (2008) Joint Plan of Action on Dengue 30 WHO (2005) World Health Report
Health Facility types Number of Health Facilities
Location Capacity
District Hospital 1 Cox’s Bazar City 250 beds
Upazila Health Complex 1 Ukhia 50 beds
Union Health Centres 2 Ukhia Outpatient
Union Sub-centres 4 Ukhia Outpatient
Community Clinics 15 Ukhia Outpatient
NGO Clinics 3 Ukhia Outpatient
Upazila Health Complex 1 Teknaf 50 beds
Hospital 1 Teknaf 10 beds
Union Health Centres 4 Teknaf Outpatient
Union Health & Family Welfare Centres
2 Teknaf Outpatient
Union Sub-centres 2 Teknaf Outpatient
Community Clinics 13 Teknaf Outpatient
NGO Hospitals/Clinics 3 Teknaf Outpatient
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 22
1.1.6 Nutrition
Rakhine State has the worst nutritional status among children under five in all of Myanmar,
according to the 2015-16 Myanmar DHS, reporting that 38% of children less than age five years
were chronically malnourished, 14% were acutely malnourished, and 34% were underweight. The
results of two 2015 SMART Surveys conducted by Action Against Hunger in Maungdaw and
Buthidaung Townships of Rakhine State reported GAM prevalence of 19.0% [14.7-24.2]31 and
15.1% [11.8-19.2], and SAM prevalence of 3.9% [2.4-6.4] and 2.0% [1.1-3.6], respectively. These
prevalencesare likely influenced by the widespread poverty and periodic conflict, which have
created a protracted malnutrition context in Rakhine State.
SMART Surveys conducted by Action Against Hunger in Kutupalong and Nayapara Refugee
Camps in November 2016 indicated moderately high GAM prevalences of 12.7% [10.0-16.1] and
12.5% [9.7-16.1] and SAM prevalences of 0.7% [0.2-1.9] and 0.5% [0.1-1.7] respectively.
Screenings and rapid assessments prior and post August 25th, 2017 reported GAM prevalences
exceeding emergency levels among new arrivals3233, and Outpatient Therapeutic Programmes
(OTPs) were reporting an 8-fold increase in admissions34.
1.1.7 Infant and Young Child Feeding Practices
The 2009 Myanmar MICS Survey reported 44% of women initiating breastfeeding during the first
hour of birth, and an extremely low exclusive breastfeeding rate of 1.3% for infants 0-5 months in
Rakhine State35. The 2015-16 Myanmar DHS found that infants in Rakhine State have the lowest
rates of timely initiation of breastfeeding at 37%, and were the most likely to receive prelacteal
feeding (introduction of something other than breastmilk prior to initiating breastfeeding). The
2015 SMART Survey conducted by Action Against Hunger in Maungdaw and Buthidaung
Townships of Rakhine State reported very low rates of children 6-23 months achieving a minimum
acceptable diet (MAD) (achieving both minimum dietary diversity and minimum meal frequency)
of 8.3% and 3.3%, respectively.
There is concern that the multi-day journey to Cox’s Bazar and introduction into overcrowded
camps with poor WASH infrastructure will have very negative consequences for Rohingya infants
and young children. Although a SENS Survey conducted by Action Against Hunger in Kutupalong
Refugee Camp and Nayapara Refugee Camp in November-December 2016 showed relatively
high rates of timely initiation of breastfeeding (93.4% and 92.9%) and stable rates of exclusive
breastfeeding (89.7% and 77.3%) the low rates of minimum acceptable diet (11.3% and 10.6%),
respectively, remains concerning. In contrast, according to the 2014 Bangladesh DHS, the
national rate of exclusive breastfeeding among Bangladeshi nationals was just 55%36. The rapid
influx of new arrivals has brought new concerns for the IYCF status for Rohingya infants and
young children as a whole.
31 95% Confidence Interval 32 Nutrition Rapid SMART survey Balukhali Makeshift Settlement, May 2017 33 Nutrition Rapid SMART survey Shamlapur Demarcated Areas, May 2017 34 Action Against Hunger Programme data 35 UNICEF (2009) Multi Indicator Cluster Survey 36 USAID (2014) Bangladesh Demographic and Health Survey
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 23
1.1.8 Protection
The November 2017 rapid assessment by OXFAM identified key threats to protection for
Rohingya living in Cox’s Bazar; including lack of lighting, restricted movement for women,
firewood collection, and increased gender-based violence (GBV)37. The lack of lighting at night
leaves women vulnerable to assault and sexual violence and children vulnerable to kidnapping
and human trafficking. Women fleeing Myanmar often did not bring their burqas, putting pressure
on them to stay within the shelters until nightfall for reasons of modesty. This has directly affected
women’s access to WASH facilities--as indicated by reports of women consuming less food and
water in order to reduce their need to leave their shelter during the day--and restricted the ability
of female-headed households to access markets. Firewood collection for cooking fuel requires
family members to venture into the forests, with numerous accounts of sexual assault and
kidnappings. GBV is a growing concern as overcrowding and vulnerable portions of the population
are at increased risk. There have been reports of women being approached by “foreigners” and
recruited for “jobs” outside of the camps only to disappear, in addition to accounts of daughters
being married off younger than normal or men taking a second wife for economic or protection
purposes. High levels of stress and ongoing protection concerns highlight the need to strengthen
services for mental health and care practices (MHCP)38.
1.1.9 Humanitarian Actors
A well-rounded interpretation of the malnutrition context is strengthened by an understanding of
the humanitarian assistance landscape during the assessment data collection period. The
services and programmes most directed at the treatment and prevention of acute malnutrition
among children 6-59 months include stabilization centres (SCs), outpatient therapeutic
programmes (OTPs), targeted supplementary feeding programmes (TSFPs), and blanket
supplementary feeding programmes (BSFPs). SCs function for the treatment of acute malnutrition
with medical complications. OTPs function for the treatment of severe acute malnutrition without
medical complications. TSFPs function for the treatment of moderate acute malnutrition. BSFPs
function to prevent acute malnutrition in general. These key programmes are further strengthened
by IYCF-E support, deworming services, immunisation campaigns, and micronutrient
supplementation interventions.
Table 3 below shows the SCs and OTPs that were in operation during the entire course of the
survey in Kutupalong Refugee Camp (October 22nd to 28th). This list is not exhaustive, as it does
not capture SCs and OTPs that may have begun operations after the beginning of data collection.
As shown, there was one confirmed SC and one confirmed OTP implemented by ACF-UNHCR
operating during that period. With an estimated population of 24,499 at the commencement at the
survey, and estimating 14.5% of the population were children 6-59 months per the Kutupalong
Refugee Camp survey results, there were two programmes or 1 programme for every 1,776
37 OXFAM (2017) Rapid Protection, Food Security, and Market Assessment 38 WHO Report
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 24
children 6-59 months capable of treating severe acute malnutrition. In addition, there was
one TSFP and one BSFP implemented by ACF-WFP.
Table 3: Stabilization Centres and Outpatient Therapeutic Programmes Operating in
Kutupalong Refugee Camp During Survey Data Collection
Activity Target Location N Implementing
Organization (s)
SC Children 6-59
months Kutupalong Refugee
Camp 1 ACF-UNHCR
Total Number of Stabilization Centres 1 -
OTP Children 6-59
months Kutupalong Refugee
Camp 1 ACF-UNHCR
TOTAL Number of Outpatient Therapeutic Programmes 1 -
Table 4 below shows the SCs and OTPs that were in operation during the entire course of the
survey in Makeshift Settlements (October 29nd to November 20th). This list is not exhaustive, as it
does not capture SCs and OTPs that may have begun operations after the beginning of data
collection. As shown, there were four confirmed SCs and thirty-one confirmed OTPs implemented
by various humanitarian actors operating during that period. With an estimated population of
720,902 at the commencement at the survey, and estimating 18.3% of the population were
children 6-59 months per the Makeshift Settlements survey results, there were 35 programmes
or 1 programme for every 3,769 children 6-59 months capable of treating severe acute
malnutrition. In addition, there were eleven TSFPs and thirteen BSFPs implemented by various
humanitarian actors.
Table 4: Stabilization Centres and Outpatient Therapeutic Programmes Operating in the
Makeshift Settlements During Survey Data Collection
Activity Target Location N Implementing
Organization (s)
SC Children 6-59
months
Ukhia Upazila Health Complex, Teknaf Upazila
Health Complex 2 MoHFW
Kutupalong MS 1 MSF
Leda MS 1 IOM
Total Number of Stabilization Centres 4 -
OTP Children 6-59
months
Balukhali MS 3 ACF, SHED
Chakmarkul 1 ACF
Hakimpara 3 ACF, Concern Worldwide
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 25
Jamtoli 2 Concern Worldwide, Save
the Children
Kutupalong MS* 4** ACF, SARPV
Leda 2 ACF
Moynarghona 1 ACF
Shamlapur 2 ACF
Thangkhali 2 ACF, Concern Worldwide
Unchiprang 2 SARPV, SHED
Zone AA 1 ACF
Zone BB 2 ACF
Zone CC 1 ACF
Zone DD 1 ACF
Zone NN 2 ACF, Concern Worldwide
Zone PP 1 Save the Children
Zone SS 1 ACF
TOTAL Number of Outpatient Therapeutic Programmes 31 -
*One OTP in Kutupalong MS began operating on October 31st, 2017, two days after the Makeshift
Settlements survey data collection had begun
**Includes one mobile OTP
Table 5 below shows the SCs and OTPs that were in operation during the entire course of the
survey in Naypara Refugee Camp (November 20th to 27th). This list is not exhaustive, as it does
not capture SCs and OTPs that may have begun operations after the beginning of data collection.
As shown, there was no SC and one confirmed OTP implemented by ACF-UNHCR operating
during that period. With an estimated population of 38,997 at the commencement at the survey,
and estimating 13.5% of the population were children 6-59 months per the Nayapara Refugee
Camp survey results, there were two programmes or 1 programme for every 2,632 children 6-
59 months capable of treating severe acute malnutrition. In addition, there was one TSFP
and one BSFP implemented by ACF-WFP.
Table 5: Stabilization Centres and Outpatient Therapeutic Programmes Operating in
Nayapara Refugee Camp During Survey Data Collection
Activity Target Location N Implementing
Organization (s)
SC Children 6-59
months Nayapara Refugee Camp 0 -
Total Number of Stabilization Centres 0 -
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 26
OTP Children 6-59
months Nayapara Refugee Camp 1 ACF-UNHCR
TOTAL Number of Outpatient Therapeutic Programmes 1 -
In addition to the above services, several campaigns occurred across all camps and settlements
in Ukhia and Teknaf prior to or during the assessment:
Measles vaccination campaign conducted Nov 18th - 30th (MoHFW, WHO, UNICEF,
IOM, MSF IFRC, Save the Children).
Oral Cholera Vaccine (OCV) vaccination campaign with first round conducted on Oct 10th
targeting all persons over one year of age. and the second round Nov 4th targeting children
12 months-59 months (MoHFW, WHO, IOM, UNHCR)
Nutrition Action Week was conducted Nov 10th - 26th (MoHFW, UNICEF, Nutrition Sector)
with the aim of administering vitamin A capsules to children 6-59 months, deworming
children 24-59 months, and screening and referring SAM, MAM, and at-risk cases.
1.2 Survey Justification
The most recent surveys from the Rakhine State of Myanmar as well as camps and settlements
within Cox’s Bazar show high prevalences of acute malnutrition (see table 6 below). Screenings
and rapid assessments in Cox’s Bazar indicated GAM prevalences exceeding emergency levels
among new arrivals. OTPs reported an 8-fold increase in admissions after August 25th, 2017.
Furthermore, the overcrowding in the camps and strained water and sanitation infrastructure was
likely increasing the vulnerability of children under five. Due to the rapid influx of refugees and
mass displacement, overcrowding, overstretched resources, and lack of available data on the
malnutrition status of the population, the Nutrition Sector agreed to conduct an emergency
nutrition assessment. The Nutrition Sector organised the emergency nutrition assessment
technical working group; members of which included ACF, CDC, UNHCR, UNICEF, WFP, and
Save the Children.
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 27
Table 6: Overview of Reported Representative Estimates of Global Acute Malnutrition for
Rakhine State and Cox’s Bazar since 2015
N Survey Date Country Location GAM by
WHZ 95% CI
Survey Type
Source
1 May 2017 Bangladesh Balukhali Makeshift 21.2% [15.7-28.1] SMART ACF, Nutrition Sector
2 May 2017 Bangladesh Leda Makeshift 14.6% [9.8-21.2] SMART ACF
3 May 2017 Bangladesh Shamlapur 19.6% [14.2-26.5] SMART ACF, Nutrition Sector
4 Feb 2017 Bangladesh Ukhia & Teknaf (host communities)
11.3% [9.1-14.0] SMART ACF
5 Nov 2016 Bangladesh Kutupalong RC 12.7% [10.0-16.1] SENS ACF, UNHCR
6 Nov 2016 Bangladesh Nayapara RC 12.5% [9.7-16.1] SENS ACF, UNHCR
7 2015-2016 Myanmar Rakhine State 13.9% - DHS MoH, USAID
8 Dec 2015 Bangladesh Kutupalong RC 12.5% [9.5-16.2] SENS ACF, UNHCR
9 Dec 2015 Bangladesh Nayapara RC 13.1% [9.9-17.0] SENS ACF, UNHCR
10 Dec 2015 Bangaldesh Kutupalong Makeshift 20.1% [16.3-24.4] SMART ACF, MSF
11 Oct 2015 Myanmar Maungdaw, Rakhine 19.0% [24.1-14.7] SMART ACF
12 Oct 2015 Myanmar Buthidaung, Rakhine 15.1% [19.2-11.8] SMART ACF
1.3 Survey Objectives
This emergency nutrition assessment aimed to determine the nutrition status of Rohingya children
under five in the Ukhia and Teknaf Upazilas of Cox’s Bazar, as well as select indicators of
demography and mortality, anthropometry, morbidity, IYCF, and receipt of health services.
Demographic data collected during the assessment was expected to assist humanitarian actors
in the planning and targeting of humanitarian interventions. The assessment was designed to
provide estimates separately for registered refugees, unregistered refugees who arrived prior to
August 25th, 2017, and unregistered refugees who arrived post August 25th, 2017.
The specific objectives of the assessment were as follows:
Demography
To estimate the household demographic composition in terms of age and sex
distribution, proportion of pregnant and lactating women
To estimate household demographic composition by arrival subset
To estimate crude death rate and under five death rate in the past three months
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 28
Anthropometry
To measure the prevalence of acute malnutrition in children 6-59 months
To measure the prevalence of stunting in children 6-59 months
To measure the prevalence of underweight in children 6-59 months
To measure the prevalence of low mid-upper arm circumference (MUAC) (
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 29
To determine the enrollment of children 6-59 months in OTPs
To determine the enrollment of children 6-59 months in BSFPs
To determine the proportion of children 6-59 months that have received micronutrient
powder since August 25th, 2017
1. METHODOLOGY
2.1 Type of Survey and Target Population
All three surveys were cross sectional household surveys conducted using the SMART
(Standardized Monitoring and Assessment in Relief and Transitions) Survey design for
anthropometric data. While survey teams surveyed every selected household regardless of
household demographics, the target population for anthropometric indicators were children 0-59
months and women 15-49 years.
For Kutupalong Refugee Camp, households were selected by Simple Random Sampling (SRS)
among those residing within the camp regardless of registration status. The Primary Sampling
Unit (PSU) was the household. Household lists included a UNHCR registered refugee list
(n=2,621 households) as well as household enumeration lists created to capture unregistered
persons and new arrivals (n=2,174 households). Newly arrived households were enumerated the
week preceding data collection. Total sampling frame population size 24,449. There were no
exclusions due to inaccessibility.
For the Makeshift Settlements, households were selected using two-stage cluster sampling
among refugees residing in Ukhia and Teknaf Upazilas, yet outside of Kutupalong Refugee Camp,
Nayapara Refugee Camp, and host communities. The PSU was the cluster, and the Secondary
Sampling Unit (SSU) was the household. Rohingya refugees that were absorbed by the host
communities were excluded from the assessment due to difficulties in locating them, as well as
ethical concerns. Total sampling frame population size 720,902 based on ISCG population
estimates updated October 26th, 2017. There were no exclusions due to inaccessibility, however,
as some areas not included in the sampling frame became populated after survey planning was
complete, and therefore were excluded by default.
For Nayapara Refugee Camp, households were selected by SRS among those residing within
the camp regardless of registration status. The PSU was the household. Household lists included
a UNHCR registered refugee list (n=3,709 households) as well as household enumeration lists
created to capture unregistered persons and new arrivals (n=5,206 households). Newly arrived
households were enumerated the four days preceding data collection. Total sampling frame
population size was 38,997. There were no exclusions due to inaccessibility.
2.2 Sample Size Calculation
Parameters used to calculate sample size for anthropometry and the evidence or working
assumptions which informed the decision, are summarized in table 7 below. All calculations were
made using ENA for SMART software (version 9th July 2015). The sample sizes were designed
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 30
to achieve adequate precision for estimates of acute malnutrition disaggregated for three
population subsets: registered refugees, unregistered refugees arriving prior to August 25th, 2017,
and unregistered refugees arriving post August 25th, 2017.
Table 7: Sample Size Calculation Parameters Anthropometry
Parameter Kutupalong Makeshift Nayapara Assumptions / Source of Information
Estimated GAM
Prevalence
18%
(13% GAM for 50% Pop) + (23% GAM for 50% Pop)
22%
(19% GAM for 25% Pop) + (23% GAM for 75% Pop)
24%
GAM for registered refugees estimated at 13% based on 2016 SENS data (see Table 6). GAM for unregistered refugees arriving prior to August 25 estimated at 19% based on 2017 SMART data. GAM for unregistered refugees arriving post August 25 estimated at 23% based on 2017 SMART data from Balukhali MS. GAM for Nayapara Refugee Camp updated to reflect the findings from Kutpualong refugee camp (the first survey completed). Registered camps estimated to host approximately 50% registered refugees and 50% new arrivals. Makeshift Settlements estimated to be 25% older arrivals and 75% newer arrivals based on estimates from ISCG.
± Desired Precision
5.3 3.25 4.25
Precision based on SMART guidelines, updated to allow for sufficient precision for three population groups: registered refugees, unregistered refugees arriving prior to August 25th, 2017 and unregistered refugees arriving post August 25th, 2017 (sub-populations of each sample).
Design Effect 1.0 1.3 1.0
Kutupalong and Nayapara surveys applied simple random sampling (DEFF of 1.0). Given the large number of clusters planned and no indication of large heterogeneity in the Makeshift Settlements a DEFF of 1.3 was assumed.
Sample Size Children 6-59
months 202 883 388 -
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 31
Average Household
Size
4.75
(5.2 for 50% Pop) + (4.3
for 50% Pop)
4.3 5.4
Average HH size for unregistered (4.3) based on full enumeration of households by UNHCR Oct 7-11, 2017. Average HH size for Kutupalong based on UNHCR registration data (4.75) and UNHCR enumeration Oct 7-11 (4.3). Average HH size for Nayapara based on results from Kutupalong survey (5.4).
% of Children under 5
16.5%
(14% of 50% Pop) + (19% of 50% Pop)
19% 16.1%
% of children under five for unregistered based on full enumeration of households by UNHCR Oct 7-11, 2017. % of children under five for Kutupalong based on UNHCR registration data and UNHCR enumeration Oct 7-11. % of children under five for Nayapara based on results from Kutupalong survey.
% Non-response
Rate 18% 10% 40%
Previous surveys (2015/2016) in the registered camps observed non-response rates between 4-7%. A higher non-response rate was used in anticipation of rapid population movement. In camps, enumeration of households would be conducted the week prior to data collection, while household lists would be updated the day prior in the Makeshift Settlements. Non-response rate for Nayapara based on results from the Kutupalong survey.
Sample Size (Households)
349 1,335 723 -
Parameter Kutupalong Makeshift Nayapara Assumptions / Source of Information
Estimated death rate per 10,000
/day
1.0 1.0 1.0 Absent data on mortality among this population, emergency levels of mortality were assumed.
± Desired precision
per 10,000/day
0.50 0.3 0.45
Precision is based on SMART guidance, updated to ensure reasonably precise estimates for three population groups: registered refugees, unregistered refugees arriving before August 25 and the new influx (arriving since August 25), sub-populations of each sample.
Design Effect
1.0 1.3 1.0 Surveys in the refugee camps applied simple random sampling. Given the large number of clusters planned and no indication of large
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 32
heterogeneity in mortality a DEFF of 1.3 was assumed.
Recall period in day
120 132 141
The end of Ramadan (June 25, 2017) was used as the beginning of the recall period. The midpoint of data collection was anticipated to be October 22, November 3, and November 12 for Kutupalong, Makeshift/spontaneous, and Nayapara respectively. The end of Ramadan is memorable and allows for an assessment before and after the influx.
Sample size (population)
1,281 4,576 1,345
Average HH Size
4.75
(5.2 for 50% Pop) + (4.3
for 50% Pop)
4.3 5.4
Average HH size for unregistered (4.3) based on full enumeration of households by UNHCR Oct 7-11, 2017. Average HH size for Kutupalong based on UNHCR registration data (4.75) and UNHCR enumeration Oct 7-11 (4.3). Average HH size for Nayapara based on results from Kutupalong survey (5.4).
% Non-response
Rate 18% 10% 40%
Previous surveys (2015/2016) in the registered camps observed non-response rates between 4-7%. A higher non-response rate was used in anticipation of rapid population movement. In camps, enumeration of households would be conducted the week prior to data collection, while household lists would be updated the day prior in the Makeshift Settlements. Non-response rate for Nayapara based on results from the Kutupalong survey.
Sample Size (Households)
329 1,183 415 -
2.3 Sampling
2.3.1 Cluster Selection
Only the Makeshift Settlements Survey applied a cluster sampling strategy. A sample size of
1,335 households was calculated based on the chosen parameters (see table 7 above).
According to the survey planning, it was estimated that if the teams departed their lodging at 7am
and returned at 6pm there would be 11 hours (660 minutes) available each day for data collection.
Travel to and from the survey sites would take approximately 3 hours (180 minutes). About 1 hour
(60 minutes) would be used for lunch and hydration breaks. In total, this left 7 hours (420 minutes)
to survey households. Little time would be necessary for orientation or introductions to local
leaders as one team member had arrived the day prior to make introductions, map the area, and
select the households. With an estimated 5 minutes walking between households and 25 minutes
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Action Against Hunger / Emergency Nutrition Assessment / Cox’s Bazar, Bangladesh / Oct - Nov 2017 33
of actual time spent surveying, it was estimated that 14 households could be surveyed in each
day of data collection.
Therefore, 1,335 households / 14 households per day = 95.4 clusters
The number of clusters was rounded up to 96 to achieve sufficient sample
Population estimates from each of the makeshift and spontaneous settlements was obtained from
the ISCG. The sampling frame included all Rohingya persons within these settlements regardless
of date of arrival. Clusters were assigned using population proportional to size (PPS) per ENA
software. Reserve clusters were not implemented as more than 80% of the sample size for
children was reached. A complete list of selected clusters is availabe in Annex 5.
For larger sites and sites with multiple clusters, segmentation was often used. The segmentation
method was also applied when the cluster contained more than 200 households. Often the most
efficient way to segment sites was to use blocks or sub-blocks. Block boundaries and estimated
populations per block used as segments were obtained in select sites from WFP as well as the
Bangladeshi military. Further division could be based on natural landmarks (canal, road, hill, etc.)
or public places (markets, schools, mosques, etc.).
In well-organised (generally older and more established) settlements population estimates could
be gathered from the UNHCR, ACF field staff, and the Bangladeshi Military. When possible, these
figures were triangulated between all three. Once segmented, clusters were selected using PPS.
In unorganised settlements (newer, less military or humanitarian presence) block designation
could be incomplete or nonexistent. In these cases, additional time was invested into
understanding the hierarchy of local community leaders (majis) who maintained lists of the
families they coordinated, and could therefore provide further population estimates. By
understanding the hierarchical structure of majis in a given area (head majis, sub-majis,
geographic delineations) it was possible to use majis as proxies for segments to carry out the
segmentation process. Reducing the likelihood of overlap was reinforced by mapping all maji
areas within natural boundaries such as canals, roads, and borders with established settlements.
Reducing the likelihood of gaps was reinforced by interviewing majis and asking if there were new
majis who had recently moved into the area or