Design
All children aged 6–59 months living in the 1655 households and one caregiver per household enrolled in a nutrition programme provided by Save the Children in 2017 were included in the study. The nutrition programme was provided in three IDP camps in three different districts in Somalia. One caregiver from each of 1655 households answered a questionnaire on hygiene and feeding practices. At the same time, based on standard criteria in the questionnaire, naturalistic observations of caregivers’ hygiene practices were performed by the data collectors. Mid-Upper-Arm Circumference measurement was carried out for 2370 children [16]. Ethical approval was obtained from the Research and Ethics Review Committee of the Ministry of Health, South Central Somalia (D-nr: MoH& HS/DGO/0129/2017).
Setting
The three selected IDP camps are located in the districts of Baidoa, Dharkenley and Dayniile. The camps in Dharkenley and Dayniile districts in the Benadir region were established in the twenty-first century. The selected IDP camp in the district of Baidoa in Bay region was established in the 1990s. Together they represent approximately 600,000 of the 1.1 million total Somali IDP population. The caregivers and the children in this study were living in the IDP camps in traditional houses, in so-called “aqals” built of straw or plastic with shared water supply and latrines. Goats, cattle, chicken, dogs roamed throughout the camps.
Participants
As per the inclusion criteria, 1655 caregivers and 2370 children were included in the study. Caregivers and any of their children aged 6–59 months enrolled in a nutrition programme provided by Save the Children in 2017 were included. As part of the study’s ethical guidelines, Community Nutrition Volunteers’ (CNVs) observations which identified children with malnutrition and diseases such as pneumonia, malaria, measles or AIDS or with weights < 2500 g and the severely malnourished or ill were referred to health facilities for treatment and care [17]. The study used, ideally, vaccination cards to determine children’s ages. If there was no vaccination card or the caregiver did not recall their children’s dates of birth, a seasonal calendar was used as a tool to estimate age by mapping back through monthly changes in weather (rainfall or temperature) and agricultural activities.
Questionnaire
The WHO Infant and Young Child Feeding Counselling (IYCF) questionnaire adopted by the research department of Save the Children, South Central Somalia was inspired by several other interrogative tools [18,19,20]. It was written first in English, then translated into Somali and back-translated into English as a built-in control to reduce bias [21]. The questions were pre-tested on 10 IDPs to ensure validity [15] before back-translation into English [21]. The feeding questions were, after pre-testing, adapted to the Somali context with regards to the specific foods available in South Central Somalia. The questions consisted of 98 closed and open yes/no or multiple-choice response alternatives in the following sections: demographic information on caregivers and households; household hunger; hygiene practices and observations; child feeding practices; and, infant and young child feeding (IYCF) knowledge and attitudes. For further details see a summary of the content of each section of the questionnaire in Appendix. Child anthropometry in terms of Mid-Upper Arm circumference [16] is included in the questionnaire as a subsection and described below.
Anthropometry
Malnutrition is divided into three measurements of the nutritional situation in a population; Moderate Acute Malnutrition (MAM), Severe Acute Malnutrition (SAM) and Global Acute Malnutrition (GAM). MAM and SAM are % of children below the anthropometric thresholds in a population and GAM is the sum of those. A GAM value of more than 10% indicates an emergency [22]. Humanitarian agencies use Mid-Upper-Arm Circumference as a anthropometric thresholds for admitting children with malnutrition to feeding programmes. The mid-point between the tip of the shoulder and the tip of the elbow is identified and then measured [23]. The cut-offs used by WHO to classify a child as MAM is a Mid-Upper-Arm Circumference between 110 mm and 125 mm, less than 110 mm is classified as SAM [16, 22]. A cut-off of point of 110 mm was used for SAM in this study. In some other studies where the Mid-Upper-Arm Circumference was measured the cut-offs has been increased from 110 mm to 115 mm to define SAM. This to ensure that children between are not missed out from management of malnutrition [22, 24, 25].
Data collection
Twenty data collectors were recruited from rosters in the Mogadishu and Baidoa Save the Children offices. They were all professional data collectors with years of experience of gathering data for periodic monitoring and research projects. They received 2 days’ additional training before commencing their work for this study. This training was carried out at the end of July 2017 by the Save the Children research manager in the Save the Children office in Mogadishu. The training focused on administering the study questionnaire and how to make naturalistic observations. Intra-examiner reliability was established among the data collectors by a thorough discussion and testing of the questionnaire at the training sessions [15]. During the training, an online link to the questionnaire was distributed. The data collectors worked with Save the Children Community Nutrition Volunteers (CNV), who carried out the Mid-Upper-Arm Circumference measurements. The data collectors and CNVs gathered and recorded data 7 days a week throughout the month of August 2017.
The data collectors made one house visits to each of the 1655 households participating in the study. During the visit, data collectors provided verbal information about the twofold aim of the study, the design and assurances that participants could withdraw from the study without consequences at any time. The data collectors gained verbal consent from the guardians of the children. Informed consent was thus obtained from all 1655 caregivers and consent for the children involved before the data gathering began [17]. During the visit to the household, data collectors gave out appointment times and locations for the Mid-Upper Arm Circumference measurement and the completion of the questionnaire. It was at this visit that data collectors collected observational data on hygiene. Using naturalistic observation the real-life environment created by the household member’s behaviour was observed [15]. Household hygiene practices and environment were observed for an hour without providing advice to the caregivers. Corrective measures were suggested after the observation. Data collectors evaluated the presence of human faeces, garbage, and animal droppings (Appendix). By asking caregivers if their household experienced hunger often, rarely/sometimes or never during the past month/30 days, data collectors assessed hunger levels within the household [18]. The data collectors asked the caregivers to bring the child/children to the appointment at set time and place.
On the day of the appointment, to collect data at each IDP camp, data collectors and CNVs set up a collection centre in one of the ‘aqals’ in the IDP camp. CNVs set up their equipment for the anthropometric Mid-Upper-Arm measurements. At each appointment a CNV conducted the anthropometric Mid-Upper-Arm Circumference measurement/s of the child/children. The children turned up in a piece of cloths, or pants and a shirt. Children were examined in a standing position with their left/right arm hanging freely at their side. Because the arm measurement needed to be taken with a bare shoulder and arm, CNVs asked caregivers to remove any shirts with sleeves. For weak and young children, measurements were taken while in a recumbent position [16]. The procedure took approximately 10 min including information. Together with the caregiver and their child/children, the data collectors filled out the questionnaire. This process took approximately 30 to 45 min. The data collectors sent the completed questionnaires, including observations and anthropometric Mid-Upper-Arm Circumference measurement data, to the online server at Save the Children on a daily basis.
Analysis
The information gained from the three districts (Baidoa, Dharkenley, and Dayniile) was entered into Stata© statistical software (StataCorp LLC™) [26], cleaned and analyzed using mean (m), standard deviation (SD) and percentage (%). The Chi-squared test (Pearson chi-squared), a non-parametric method for ordinal data, was used to analyze the differences between children aged 6–24 months and those aged 25–59 months for the classification of malnutrition and between the groups in each of the Baidoa, Dharkenley and Dayniile districts. Statistical significance was set at 0.05 [15].