Risk factors of anaemia and iron deficiency in Somali children and women: Findings from the 2019 Somalia Micronutrient Survey.

There are limited data on the prevalence of anaemia and iron deficiency (ID) in Somalia. To address this data gap, Somalia's 2019 micronutrient survey assessed the prevalence of anaemia and ID in children (6-59 months) and non-pregnant women of reproductive age (15-49 years). The survey also collected data on vitamin A deficiency, inflammation, malaria and other potential risk factors for anaemia and ID. Multivariable Poisson regressions models were used to identify the risk factors for anaemia and ID in children and women. Among children, the prevalence of anaemia and ID were 43.4% and 47.2%, respectively. Approximately 36% and 6% of anaemia were attributable to iron and vitamin A deficiencies, respectively, whereas household possession of soap was associated with approximately 11% fewer cases of anaemia. ID in children was associated with vitamin A deficiency and stunting, whereas inflammation was associated with iron sufficiency. Among women, 40.3% were anaemic, and 49.7% were iron deficient. In women, ID and number of births were significantly associated with anaemia in multivariate models, and approximately 42% of anaemia in women was attributable to ID. Increased parity was associated with ID, and incubation and early convalescent inflammation was associated with ID, whereas late convalescent inflammation was associated with iron sufficiency. ID is the main risk factor of anaemia in both women and children and contributed to a substantial portion of the anaemia cases. To tackle both anaemia and ID in Somalia, food assistance and micronutrient-specific programmes (e.g. micronutrient powders and iron supplements) should be enhanced.

Anemia among pregnant women in internally displaced camps in Mogadishu, Somalia: a cross-sectional study on prevalence, severity and associated risk factors.

BACKGROUND: Anemia in pregnancy is a serious global public health problem in most developing countries and a major cause of maternal morbidity and mortality. Somalia which already had very high maternal mortality ratio of 829 per 100,000 live births, pregnant women in internally displaced camps (IDPs) remain at most exposed. The aim of the study was to determine the prevalence, severity and associated risk factors of anemia among pregnant women in internally displaced camps in Mogadishu, Somalia. METHODS: A community based cross-sectional study was conducted among 383 households in the most IDP settled districts in Mogadishu. Every pregnant mother in these sampled households who was voluntarily consented was targeted. A sample of blood was also taken by pricking the fingertip and inserted into hemoglobin meter. Those with Hb < 11 g/dl from hemoglobin meter had been taken another sample of 3 cc blood and put into EDTA tube for CBC analysis to identify the type of anemia. Data on risk factors were collected using structured pretested questionnaire via an interview. Collected data was coded and entered in SPSS- Version 22 for analysis. Descriptive analysis, bivariate chi-square and multivariate logistic regression were done. RESULTS: The overall prevalence of anemia among study participants was 44.4% (95%CI: 39.5-49.3%), where severe and moderate anemia were 11.8 and 47.0% respectively. In addition all anaemic cases were microcytic hypochromic anemia. Young maternal age, low Family income, fewer/zero parity, being at third or second trimesters, lack of ANC attendance during pregnancy, lack of iron supplementation during pregnancy, taking tea immediately after meal during pregnancy, lower/zero frequency of daily meat and vegetables consumption during pregnancy were associated risk factors of anemia. CONCLUSION: The anemia prevalence from this study was severe public health problem. Several factors were found to be associated with anemia during pregnancy. Measures has to be taken to curb the problem by including them mass iron supplementation and health education towards identified risk factors.

"Change-makers in midwifery care": Exploring the differences between expectations and outcomes-A qualitative study of a midwifery net-based education programme in the Somali region.

OBJECTIVE: The aim of this study is to explore midwifery educators' expected outcomes in the net-based master's programme, the programmes' realised outcomes and the reported difference regarding the increased choices for the graduates and the effect on their agency. DESIGN: In this case study, we focused on a net-based master's programme in sexual and reproductive health in Somalia. Somalia suffers from a shortage of skilled birth attendants and there is a need for building up the capacity of midwifery educators. SETTING AND PARTICIPANTS: Data was collected in focus group discussions at the start of the programme and eight months after the students graduated. The data were analysed through the lens of the choice framework, which is based on the capability approach. FINDINGS: Findings show that many of the graduates' expectations were met, while some were more difficult to fulfil. While the midwives' choices and resource portfolios had improved because of their role as educators, the social structure prevented them from acting on their agency, specifically in regards to making changes at the social level. Several of the positive developments can be attributed to the pedagogy and structure of the programme. CONCLUSION: The flexibility of net-based education gave the midwifery educators a new educational opportunity that they previously did not have. Students gained increased power and influence on some levels. However, they still lack power in government organisations where, in addition to their role as educators, they could use their skills and knowledge to change policies at the social level.

Iodine intake in Somalia is excessive and associated with the source of household drinking water.

Few data on iodine status in Somalia are available, but it is assumed that deficiency is a public health problem due to the limited access to iodized salt. We aimed to describe the iodine status of the population of Somalia and to investigate possible determinants of iodine status. A national 2-stage, stratified household cluster survey was conducted in 2009 in the Northwest, Northeast, and South Central Zones of Somalia. Urinary iodine concentration (UIC) was determined in samples from women (aged 15-45 y) and children (aged 6-11 y), and examination for visible goiter was performed in the Northwest and South Central strata. A 24-h household food-frequency questionnaire was conducted, and salt samples were tested for iodization. The median UICs for nonpregnant women and children were 329 and 416 µg/L, respectively, indicating excessive iodine intake (>300 µg/L). The prevalence of visible goiter was <4%. The coverage of salt iodization was low, with a national average of 7.7% (95% CI: 3.2%, 17.4%). Spatial analysis revealed localized areas of relatively high and low iodine status. Variations could not be explained by food consumption or salt iodization but were associated with the main source of household drinking water, with consumers of borehole water having a higher UIC (569 vs. 385 µg/L; P < 0.001). Iodine intake in Somalia is among the highest in the world and excessive according to WHO criteria. Further work is required to investigate the geochemistry and safety of groundwater sources in Somalia and the impact on human nutrition and health.

Lack of patient risk counselling and a broader provider training affect malaria control in remote Somalia Kenya border: Qualitative assessment.

Effectiveness of providing health education solely via mass media and the providers' targeted training in malaria control needs further exploration. During pre-epidemic season, we conducted a qualitative study of 40 providers and community leaders using focus groups, comprehensive semi-structured interviews and consultation observations. Interviews were transcribed, coded and analysed for major themes. Community leaders believe that they can acquire malaria from contaminated water, animal products, air or garbage. Consequently, they under-utilise bed nets and other protective measures due to perceived continued exposure to other potential malaria sources. Practitioners do not provide individualised health counselling and risk assessment to patients during sick visits, leading to a range of misconceptions about malaria based on limited knowledge from rumours and mass media, and a strong belief in the curative power of traditional medicine. Providers overdiagnose malaria clinically and underutilise available tests due to time constraints, and the lack of training and resources to correctly diagnose other illnesses. Subsequently, misdiagnoses lead them to question the efficacy of recommended treatments. Promoting counselling during clinical encounters to address patient misconception and change risky behaviour is warranted. Wider-ranging ongoing training could enable providers to properly diagnose and manage differential diagnoses to manage malaria better.

Outbreak of beriberi among African Union troops in Mogadishu, Somalia.

CONTEXT AND OBJECTIVES: In July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies. DESIGN, SETTING, AND PARTICIPANTS: The illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness. RESULTS: From April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported. CONCLUSIONS: An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources.

The consumption of khat and other drugs in Somali combatants: a cross-sectional study.

BACKGROUND: For more than a decade, most parts of Somalia have not been under the control of any type of government. This "failure of state" is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control-to our knowledge the first account on this topic. METHODS AND FINDINGS: Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e.g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%-57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%-76.5%), followed by smoking cannabis (10.7%, 99% CI 0%-30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%-24.4%), drinking alcohol (5.3%, 99% CI 0%-13.8%), inhaling solvents (1.8%, 99% CI 0%-5.1%), and eating hemp seeds (0.6%, 99% CI 0%-2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets. CONCLUSIONS: Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.

Khat use as risk factor for psychotic disorders: a cross-sectional and case-control study in Somalia.

BACKGROUND: Little is known about the prevalence of khat-induced psychotic disorders in East African countries, where the chewing of khat leaves is common. Its main psycho-active component cathinone produces effects similar to those of amphetamine. We aimed to explore the prevalence of psychotic disorders among the general population and the association between khat use and psychotic symptoms. METHODS: In an epidemiological household assessment in the city of Hargeisa, North-West Somalia, trained local interviewers screened 4,854 randomly selected persons from among the general population for disability due to severe mental problems. The identified cases were interviewed based on a structured interview and compared to healthy matched controls. Psychotic symptoms were assessed using the items of the WHO Composite International Diagnostic Interview and quantified with the Positive and Negative Symptoms Scale. Statistical testing included Student's t-test and ANOVA. RESULTS: Local interviewers found that rates of severe disability due to mental disorders were 8.4% among males (above the age of 12) and differed according to war experiences (no war experience: 3.2%; civilian war survivors: 8.0%; ex-combatants: 15.9%). The clinical interview verified that in 83% of positive screening cases psychotic symptoms were the most prominent manifestations of psychiatric illness. On average, cases with psychotic symptoms had started to use khat earlier in life than matched controls and had been using khat 8.6 years before positive symptoms emerged. In most cases with psychotic symptoms, a pattern of binge use (> two 'bundles' per day) preceded the onset of psychotic symptoms, in contrast to controls of the same age. We found significant correlations between variables of khat consumption and clinical scales (0.35 to 0.50; p < 0.05), and between the age of onset of khat chewing and symptom onset (0.70; p <0.001). CONCLUSION: Evidence indicates a relationship between the consumption of khat and the onset of psychotic symptoms among the male population, whereby not the khat intake per se but rather early onset and excessive khat chewing seemed to be related to psychotic symptoms. The khat problem must be addressed by means other than prohibition, given the widespread use and its role in Somali culture.

Malnutrition: trials and triumphs.

Severe malnutrition is uncommon but often fatal, particularly in very young infants or when oedema is present. Another major contributor to mortality is undiagnosed infection. Three pilot studies have recently been performed in severely malnourished patients in therapeutic feeding centres in sub-Saharan Africa. In each, a practical management problem was addressed and a potential solution tested. Three conclusions were reached: young breastfeeding infants were best managed using a supplemented suckling technique; routine antibiotics from admission reduced mortality; and in adults with oedematous malnutrition, therapeutic diets with a lower-than-usual protein:energy ratio were effective in reducing mortality and permitting catch-up weight gain.