1. 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

2. 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)

4. 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

5. 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 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)

6. 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

7. 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)

8. 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 (%)
Group mo
22.7
Group mo
26.5
Group mo
23.8
Group mo
20.0
Group mo
7.0
Age Ratio : G1+G2/G3+G4+G5
1.0
Overall Sex Ratio
1.1

9. 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%)
( % C.I.)
71 (15.8%)
( % C.I.)
45 (10.9%)
( % C.I.)
Prevalence of Moderate Acute Malnutrition (MAM)
(<-2 z-score and >=-3 z-score, no oedema)
89 (10.3%)
( % C.I.)
54 (12.0%)
( % C.I.)
35 (8.5%)
( % C.I.)
Prevalence of Severe Acute Malnutrition (SAM)
(<-3 z-score and/or oedema)
27 (3.1 %)
( % C.I.)
17 (3.8%)
( % C.I.)
(2.4%)
( % C.I.)

10. 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)

11. Prevalence of Underweight (WAZ) by Sex
All
(N = 859)
Boys
(N= 448)
Girls
(N= 411)
Prevalence of Underweight
(<-2 z-score )
234 (27.2%)
( % C.I.)
132 (29.5%)
( % C.I.)
102 (24.8%)
( % C.I.)
Prevalence of Moderate Underweight
(<-2 z-score and >=-3 z-score)
174 (20.3%)
( % C.I.)
99 (22.1%)
( % C.
75 (18.2%)
( % C.I.)
Prevalence of Severe Underweight (<-3 z-score)
60 (7.0 %)
( % C.I.)
33 (7.4%)
( % C.I.)
(6.6%)
( % C.I.)

12. Prevalence of Stunting (HAZ) by Sex
All
(N = 860)
Boys
(N= 448)
Girls
(N= 412)
Prevalence of Stunting
(<-2 z-score )
287 (33.4%)
( % C.I.)
153 (34.2%)
( % C.I.)
134 (32.5%)
( % C.I.)
Prevalence of Moderate Stunting
(<-2 z-score and >=-3 z-score)
197 (22.9%)
( % C.I.)
109 (24.3%)
( % C.
88 (21.4%)
( % C.I.)
Prevalence of Severe Stunting
(<-3 z-score)
90 (10.5 %)
( % C.I.)
44 (9.8%)
( % C.I.)
(11.2%)
( % C.I.)

13. Prevalence of Wasting by MUAC
All
(N= 863)
Boys
(N=449)
Girls
(N= 414)
Moderate acute malnutrition
(MUAC <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 <13.5cm)
(171) 19.8%
(80) 17.8%
(91) 22.0%

14. Child Morbidity N=579 (67.4%)

15. 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

16. Immunization, Vitamin A Coverage and Deworming
Measles 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%)

17. 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)

18. Washing of hands

19. 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)

20. 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

21. 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

22. 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%

23. 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%)

24. Breastfeeding practices

25. 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

26. 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

27. Mortality Crude mortality rates (CMR):
0.75/10,000/day [ % CI]*
Under 5 mortality rates (U5MR):
1.23/10,000/day [ % CI]*
Mortality rates below ‘alert’ threshold

28. 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 ).
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.

29. 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.

30. 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

31. 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.

32. 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

33. 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