Type of the survey: SMART 18th to 24th February, 2012 Tana River County SMART Survey Conducted by: International Medical Corps and Ministry of Public Health and Sanitation Services With support from UNICEF KCO Type of the survey: SMART 18th to 24th February, 2012 Martin Meme – Consultant Nutritionist

Survey Implementation Dates Survey Team Training: 5 days (13th - 17th February 2012) including anthropometric survey standardization, piloting, adjustment of survey tools and logistics Data Collection: 7 days (18th-24th February 2012)

Survey Background Tana River County comprises of 3 districts (Tana North, Tana River and Tana Delta) covering an area of 180,385 km². County comprises of 3 livelihood zones (Marginal mixed farming, Mixed farming and Pastoral). Food security situation in the county was at ‘Stressed Phase’ with the status rated at ‘Alert and Deteriorating’ (ALRMP Drought Early Warning Bulletin - January 2012). This survey therefore served to assess the nutritional situation in the county to gauge the performance of HINI and inform future programming

Objectives of the survey To evaluate the nutritional status of children aged 6 to 59 months To assess the nutritional status of pregnant and lactating mothers aged 15-49 years To estimate the measles and polio immunization coverage for children aged 9 to 59 months To estimate the crude and under-five mortality rates To estimate the systematic treatment (vitamin A supplementation and de-worming coverage) To identify factors likely to have influenced the nutritional status of young children To estimate the prevalence of some common illnesses (e.g. measles, diarrhea, malaria, and ARI)

Objectives of the survey cont.. 8. To estimate the impact and coverage of general food distribution and feeding programs 9. To establish the current household food security situation 10. To establish the situation of water and sanitation 11. To assess the percentage of mothers accessing MCH facilities and the level of exclusive breastfeeding of children under six months 12. To estimate the iron /folate coverage among mothers

SMART (2-stage cluster sampling with PPS design) Sampling Methodology Parameter Anthropometric Sample Mortality Sample SMART (2-stage cluster sampling with PPS design) Estimated prevalence 13.3 0.36 Desired precision 4 0.3 Design effect 2 Recall period 90 days Average household size 6 % underfives 15 % non-response 3 Households included 719 639 Children included 603 Population to be included 3717 Anthropometric sample higher therefore used in both surveys IYCF sample size = 409 children (IYCF multi survey sampling calculator)

Plausibility check Indicator Survey value Acceptable value/range Interpretations/ Comments Digit preference score - weight 5 0-<=20 Good Digit preference - height 8 WHZ ( Standard Deviation) 1.02 0-<1.2 Excellent WHZ (Skewness) 0.08 <±3.0 WHZ (Kurtosis) -0.17 Percent of flags 2.3 0%-10% Overall Survey Score 11% (including 4% overall age-distribution score) Age distribution (%) Group1 6-17 mo 22.7 Group 2 19-29 mo 26.5 Group 3 30-41 mo 23.8 Group 4 42-53 mo 20.0 Group 5 54-59 mo 7.0 Age Ratio : G1+G2/G3+G4+G5 1.0 Overall Sex Ratio 1.1 0.8-1.2

Nutrition status- Wasting (WHZ) by Sex (WHO 2006) All n =862 Boys n = 449 Girls n = 413 Prevalence of Global Acute Malnutrition (GAM) (<-2 z-score and/or oedema) 116 (13.5%) (11.3-16.0 95% C.I.) 71 (15.8%) (12.7-19.5 95% C.I.) 45 (10.9%) (38.6-13.6 95% C.I.) Prevalence of Moderate Acute Malnutrition (MAM) (<-2 z-score and >=-3 z-score, no oedema) 89 (10.3%) (8.5-12.5 95% C.I.) 54 (12.0%) (9.6-14.9 95% C.I.) 35 (8.5%) (6.3-11.2 95% C.I.) Prevalence of Severe Acute Malnutrition (SAM) (<-3 z-score and/or oedema) 27 (3.1 %) (2.3-4.2 95% C.I.) 17 (3.8%) (2.6-5.5 95% C.I.) 10 (2.4%) (1.2-4.9 95% C.I.)

Prevalence of Wasting (WHZ) by Age (Months) Total No. Severe Wasting (<-3 z-scores) Moderate Wasting (>= -3 -<-2 z-scores) GAM (<-2 z-scores) 6-17 195 6 (3.1) 16 (8.2) 22 (11.3) 18-29 229 5 (2.2) 23 (10.0) 28 (12.2) 30-41 205 7 (3.4) 17 (8.3) 24 (11.7) 42-53 173 5 (2.9) 22 (12.7) 27 (15.6) 54-59 60 4 (6.7) 11 (18.3) 15 (25.0) 862 27 (3.1) 89 (10.3) 116 (13.5)

Prevalence of Underweight (WAZ) by Sex All (N = 859) Boys (N= 448) Girls (N= 411) Prevalence of Underweight (<-2 z-score ) 234 (27.2%) (23.3-31.5 95% C.I.) 132 (29.5%) (25.4-33.8 95% C.I.) 102 (24.8%) (19.2-31.4 95% C.I.) Prevalence of Moderate Underweight (<-2 z-score and >=-3 z-score) 174 (20.3%) (17.6-23.2 95% C.I.) 99 (22.1%) (18.9-25.7 95% C. 75 (18.2%) (13.7-23.9 95% C.I.) Prevalence of Severe Underweight (<-3 z-score) 60 (7.0 %) (4.8-10.1 95% C.I.) 33 (7.4%) (4.4-12.2 95% C.I.) 27 (6.6%) (4.5-9.5 95% C.I.)

Prevalence of Stunting (HAZ) by Sex All (N = 860) Boys (N= 448) Girls (N= 412) Prevalence of Stunting (<-2 z-score ) 287 (33.4%) (24.8-43.2 95% C.I.) 153 (34.2%) (25.6-43.8 95% C.I.) 134 (32.5%) (23.2-43.5 95% C.I.) Prevalence of Moderate Stunting (<-2 z-score and >=-3 z-score) 197 (22.9%) (18.3-28.2 95% C.I.) 109 (24.3%) (19.4-30.1 95% C. 88 (21.4%) (15.9-28.1 95% C.I.) Prevalence of Severe Stunting (<-3 z-score) 90 (10.5 %) (6.4-16.7 95% C.I.) 44 (9.8%) (5.7-16.4 95% C.I.) 46 (11.2%) (6.7-18.0 95% C.I.)

Prevalence of Wasting by MUAC All (N= 863) Boys (N=449) Girls (N= 414) Moderate acute malnutrition (MUAC 11.5 - <12.5cm) (36) 4.2% (15) 3.3% (21) 5.1% Severe acute malnutrition (MUAC <11.5cm) (12) 1.4% (7) 1.6% (5) 1.2% Total Wasted (MUAC < 12.5cm (48) 5.6 % (22) 4.9% (26) 6.3% At risk (MUAC 12.5 - <13.5cm) (171) 19.8% (80) 17.8% (91) 22.0%

Child Morbidity N=579 (67.4%)

Zinc Supplementation during Last DD Episode Management of last DD Episode (N=68) % Oralite/ORS (n=25) 36.8 Other home-made liquid: porridge, soup e.t.c. (n=18) 26.5 Zinc + ORS (n=6) 8.8 Home-made salt/sugar solution (n=3) 4.4 Zinc tablets (n=1) 1.5 Other (n=15) 22.1

Immunization, Vitamin A Coverage and Deworming Measles 9-59 MONTHS (N=820) Yes by card Yes by Recall Not immunized Don’t know 564 (68.8%) 170 (20.7%) (89.5%) 77 (9.4%) 9 (1.1%) OPV 1 (N=863) 686 (79.5%) 145 (16.8%) (96.3%) 26 (3.0%) 6 (0.7%) OPV 3 (N=863) 642 (74.4%) 149 (17.3%) (91.7%) 62 (7.2%) *(4.6% drop out) 10 (1.2%) Vitamin A coverage (6-11 months N=99) None Once Twice 30 (30.3%) 48 (48.5%) (69.7%) 18 (18.2%) Vitamin A coverage (12-59 months N=762) 161 (21.1%) 289 (37.9%) (78.9%) 258 (33.9%) Dewormed (>=24 months N=536) No 80 (14.9%) 196 (36.6%) (48.5%) 215 (40.1%) 45 (8.4%)

Water and Environmental Sanitation Characteristic % Yes Access to toilet facility (N=775): No 252 (32.5) 523 (67.5) Main sources of drinking water (N=779): Protected well River Tap Public pan Borehole Canal 200 (25.7) 184 (23.6) (13.0) 92 (11.8) 83 (10.7) 36 (4.6) Appropriate Drinking water treatment (N=779): Not appropriate (17.9) 639 (82.1)

Washing of hands

Estimated feeding programs point coverage Estimated point Coverage by WHZ (%) Comments/Analysis Supplementary Feeding Programme (SFP) 38.2% 34 eligible children out of 89 in the sample who should have been in SFP Therapeutic (OTP) 63.0% Commendably high ( 17 out of 27 children who should have been in OTP)

Nutritional status of Women by MUAC % Pregnant and lactating women MUAC <21cm (N= 458) 26 5.7 Non-pregnant and non-lactating women MUAC <21cm (N=149) 6 4.0 Total MUAC <21cm (N=573) 32 5.3

Maternal Health-Care n % Yes Received iron/folate supplementation (N=757) NO 467 290 61.7 38.3 Mothers took iron/folate for 90 or more days (N=464) 11 2.4 Attended ANC (N=765) No 676 89 88.4 11.6 Supervised medical care Where last delivery took place (N=755) Unsupervised medical care 177 578 23.4 76.6

Household Food Consumption Indicator % households Usual number of meals taken: Mean number of meals taken 2.70 (SD=0.5) 3 meals 70.0% * 2 meals 26.1% ** 1 meal 2.6% No. meals day preceding the survey: Mean number of meals 2.52 (SD=0.7) 55.8% * 36.1% ** *, **P<0.01 6.4% Did all household members take meals day preceding the survey? Yes No 88.4% 11.6%

Household Food Consumption cont.. Indicator Mean number of food groups consumed in household 3.7 (SD 1.3) Household dietary diversity (N=609): Low dietary diversity (<4 food groups) High dietary diversity (>=4 food groups) 297 (48.8%) 312 (51.2%) Main 3 sources of food consumed previous day (N=760): Purchase Own production Food aid 462 (60.8%) 148 (19.5%) 121 (15.9%)

Breastfeeding practices

Complementary Feeding Practices – Frequency of Meals Indicator n % Breastfed 6-8 months old ≥ 2 times per day (N= 46) 37 80.4 Breastfed children 6-23 months old ≥ 3 times per day (N=270) 184 66.1 Non-breastfed children 6-23 months old ≥ 4 times per day (N=48) 18 37.5 Breastfed children 6-8 months old ≥ 2 times + Breastfed children 6-23 months old ≥ 3 times + Non-breastfed children 6-23 months old ≥ 4 times per day (N= 364) 239 65.7

Complementary Feeding Practices – Dietary Diversity 6-23 months old Indicator n % Breastfed children consuming ≥ 3 food groups (N= 273) 126 46.2 Non-breastfed children consuming ≥ 4 food groups (N= 48) 14 29.2 Breastfed children consuming ≥ 3 food groups + Non-breastfed children consuming ≥ 4 food groups (N= 321) 140 43.6

Mortality Crude mortality rates (CMR): 0.75/10,000/day [0.53-1.06 95% CI]* Under 5 mortality rates (U5MR): 1.23/10,000/day [0.62-2.20 95% CI]* Mortality rates below ‘alert’ threshold

Conclusions This survey was conducted during the hunger-gap period that precedes the onset of long rains in TRD. Though both UFMR and CMR are low, the prevalence of GAM 13.5 is beyond acceptable level according to WHO benchmarks and rated ‘Risky’. The prevalence of underweight in the County (27.2%) is above the average for Coast province (23.5%) but below the national average (16.1%) while that of stunting (33.4%) was below both that of Coast province (39.0%) and national average of 35.3% (KDHS 2008-2009). Underfive children in TRD county were faced with a high burden of morbidity (> 2/3rds sick) mainly due to ARI and malaria. Zinc supplementation dismally covering only 10% children during diarrhoea and attributed to erratic availability in medical facilities.

Conclusions cont... Vitamin A supplementation and deworming coverage were below WHO recommendation of 80% WASH practices still poor in the county: Less than 1/3rd households have access to toilets Less than 1/5th HHDs treat unsafe drinking water Appropriate hand washing practised by only about 1/10th of the childcare givers Coverage of selective feeding practices (particularly OTP) commendably high – but many factors militating potential gains Attendance to ANC high (more than 4/5th but more than ¾ of the mothers give birth without supervised medical care.

Conclusions cont... IYCF Practices: Food security status: Breastfeeding practices (timely initiation, EBF and maintenance of b/feeding at 1 yr) good but low at 2 years (FGDs indicate socio-cultural and ignorance factors mainly responsible for non-compliance). Although complementary feeding practices (frequency of meals) optimal for approximately 1/3rd of the children, qualitative analysis of the diet indicates poor dietary profiles for eligible children with more than half subsisting on poorly diversified diets. Food security status: Household food consumption during the survey’s conduct indicates significant reduction in daily meal frequency Only about half households took highly diversified diets

Conclusions cont... 60% HHDs relying of food purchase as their major food source (a number of main food stress coping strategies practised apply to serious food deficit periods). FGDs discussants complained of high food prices in the market. FGDs and observations revealed a community readily embracing farming activities in the on-going irrigation scheme rehabilitation.

Recommendations Short-term BY Who? 1 The following HINI components need improvement: Zinc supplementation during diarrhea Vitamin A supplementation Toilet access and use Treatment of drinking water by boiling Training on appropriate hand washing Coverage of SFP Medical supervision of mothers during child birth Continued breastfeeding after 1 year Constitution of balanced diets using locally available foodstuffs (diversification of agriculture) General health-promotive strategies e.g. use of ITNs IMC UNICEF MOPHS MOA WHO Agro German Pledge Action International UNOPS WFP 2 Step up stop-gap measures to cushion community against current food-deficit situation before onset of long rains (GFD, FFA) Red Cross Samaritan Purse

Recommendations cont.. Long-term BY Who? 3 Sustained rehabilitation of irrigation schemes with agricultural diversification, protection of schemes against destruction by wild animals and improved marketing of food products to further improve production in the county MOA MOCD Stakeholders KWS 4 Initiation of small-scale irrigation projects in areas outside main scheme e.g. through drip irrigation 5 Infrastructural improvement to improve access to markets and facilitate general development in all areas of TRD county MOPW Local Authorities Central government Other stakeholders