1. ©2012 International Medical Corps Isiolo SMART survey May 2012 Validation Report From Relief to Self-Reliance Monitoring and Evaluation Anastacia Maluki amaluki@internationalmedical corps.org All content in this document is the property of International Medical Corps and should not be reproduced without prior written consent. This material is protected by copyright. ©2012 International Medical Corps. Materials may not be reproduced without International Medical Corps’ prior written consent.

2. ©2012 International Medical Corps BACKGROUND INTRODUCTION Isiolo district is in Eastern Province of Kenya and covers an area of 25,605 Km2 Isiolo is classified as 100% ASAL The survey area covered 5 administrative divisions of Isiolo District namely: – Isiolo East, Central, Ol donyiro, Merti and Cherab Estimated total population of 104, 223 inhabitants, with an annual growth rate of 3.6% p.a. – The estimated Under-5 target population of the survey is 15.4% The district receives a bimodal rainfall : – short rains, which are most reliable, in mid-October to December while the long rains in mid-March to June

3. ©2012 International Medical Corps Map of Isiolo District

4. ©2012 International Medical Corps Rationale for conducting a survey To gauge the performance of the HINI package. Inform future programming in the district. To evaluate the extent and severity of malnutrition among children aged 6-59 months. Analyse the possible factors contributing to malnutrition. Recommend appropriate interventions.

5. ©2012 International Medical Corps Objectives To estimate the current prevalence of acute malnutrition in children aged 6-59 months and to compare the overall nutritional changes with previous GAM and SAM To estimate the retrospective crude and under five death rates and morbidity among under five children and as well compare with previous CMR and U5MR. To estimate Measles, BCG vaccination and Vitamin A supplementation for children 9-59 months and 6-59 months respectively

6. ©2012 International Medical Corps Objectives (2) To assess the current food security situation of the surveyed population, prevalence of some common diseases (Diarrhea, Fever, and Cough) and to identify factors likely to have influenced malnutrition in young children To assess child and infant care and feeding practices among caretakers with children 0-23 months To establish the situation of water and sanitation, appropriate hygiene practices including hand washing among caretakers

7. ©2012 International Medical Corps Methodology Anthropometric and Morterlity Data entered on ENA software Anthropometri c sample Retrospective Mortality sample Rationale Estimated prevalence15.7 %0.12 INTEGRATED HEALTH AND NUTRITION SMART SURVEY ISIOLO DISTRICT, April 2011 Desired precision40.3 Decided in conjunction with the Estimated Malnutrition prevalence of 15.7% Design effect1.5 anticipate malnutrition prevalence is quite different in the 5 divisions Recall period 90 days it gave reasonable level of precision and an estimate that is close enough to the current situation. Recall period since 2 nd Feb, 2012 Average household size5.5 INTEGRATED HEALTH AND NUTRITION SMART SURVEY ISIOLO DISTRICT, April 2011 Percent of under five children14.8 Current Population estimates from DSO Office- Isiolo Percent of non-respondent33 Anticipate low level of non-response as there are no major events taking place / displacement/ conflicts Households to be included702 174 Children to be included519 Population to be included 929.

8. ©2012 International Medical Corps Methodology –IYCN (2) Indicators calculated were: – Timely initiation of breastfeeding (children 0-23 months), – Exclusive breastfeeding under 6 months, – Timely complementary feeding, – Minimum dietary diversity, – Minimum acceptable diet, – Minimum meal frequency and – continued breastfeeding at 1 year. The sample size for children between 0-23 months was 546 16 The number of children reached per cluster was given by dividing 546 by 36 giving 16 children per cluster. Where children below 6 months were not found purposive sampling was applied to get them.

9. ©2012 International Medical Corps Description of sampling methods 36 Number of clusters to be surveyed was 36 =(702/ 20 (Household to be reached per day)) A total of 6 survey teams : – 1 team leader – 3 enumerators Data was collected for 6 days (36/6).

10. ©2012 International Medical Corps Data collection Tools Questionnaire A (Household) - primary caretakers Questionnaire B (anthropometry ) – 6-59 months Questionnaire C (IYCF) - 0-23 months Questionnaire D (Mortality) - all HH members Focus Group Discussion (FGD) guide - qualitative data.

11. ©2012 International Medical Corps Training The team was trained for 3 days (14 th -16 th May, 2012): – nutrition survey objective – anthropometric measurements – interviewing techniques – completion of questionnaires – standardization test was done pre-test was done on 17 th May 2012 Data collection begun on the 18 th May, 2012– 23 th, April, 2012.

12. ©2012 International Medical Corps Data Entry and Analysis SMART/ENA for Anthropometric and mortality data analysis. All the other quantitative data was entered and analyzed in the SPSS (Version 15.0) computer package

13. ©2012 International Medical Corps Findings: Demographic Characteristics DEMOGRAPHYNumber Number of HH surveyed 700 Number of children 6-59 months surveyed704 Number of children 0-23 months surveyed for IYCN 554 Average number of persons per HH 5.9 S.D = 2.5 Average number of children (0-6 months ) per HH 0.2 S.D=0.4 Average number of children (6-59 months ) per HH 1.2 S.D = 0.8 Most of the children aged 0-23 months for IYCN were not included in the anthropometric measurement. They were purposively sampled.

14. ©2012 International Medical Corps Distribution of age and sex of 6-59 months. overall male: female ratios were within the expected range of 0.8 – 1.2 21% of children aged 0-23 were purposively sampled for IYCN indicators this explains why there are more children in the age category 6-17 months. Boys Girls Total Ratio AGE (months) no.% % %Boy:girl 6-1710042.013858.023833.80.7 18-299763.05737.015421.91.7 30-416944.88555.215421.90.8 42-536758.34841.711516.31.4 54-592455.81944.2436.11.3 Total35750.734749.3704100.01.0

15. ©2012 International Medical Corps Prevalence of acute malnutrition based on weight-for-height z- scores (and/or oedema) and by sex Boys were more malnourished than girls but it was not significantly. P value for the GAM rate was 0.842 All n = 699 Boys n = 353 Girls n = 346 Prevalence of global malnutrition (<-2 z-score and/or oedema) (77) 11.0 % (8.5 - 14.2 95% C.I.) (46) 13.0 % (9.6 - 17.5 95% C.I.) (31) 9.0 % (5.9 - 13.4 95% C.I.) Prevalence of moderate malnutrition ( =-3 z- score, no oedema) (53) 7.6 % (5.7 - 10.0 95% C.I.) (29) 8.2 % (5.4 - 12.3 95% C.I.) (24) 6.9 % (4.7 - 10.1 95% C.I.) Prevalence of severe malnutrition (<-3 z-score and/or oedema) (24) 3.4 % (2.2 - 5.3 95% C.I.) (17) 4.8 % (2.9 - 7.8 95% C.I.) (7) 2.0 % (0.9 - 4.7 95% C.I.)

16. ©2012 International Medical Corps Prevalence of acute malnutrition based on MUAC cut off's and/or oedema Nutritional StatusMUAC CriteriaNumber Percentage 2012 Percentage 2011 Severe malnutrition <11.5cm40.5% 1.4% Moderate malnutrition >=11.5 and <12.5cm 273.8 % 3.4% At risk of malnutrition >=12.5 and <13.5cm 11716.6% 17.3% Satisfactory nutritional status >=13.5cm55679 % 77.5% TOTAL 704100% GAM 3.8%

17. ©2012 International Medical Corps Prevalence of underweight based on weight-for-age z-scores by sex Boys are more underweight than girls and this is significant. P. value =0.0126 All n = 696 Boys n = 351 Girls n = 345 Prevalence of underweight (<-2 z-score) (116) 16.7 % (13.7 - 20.2 95% C.I.) (73) 20.8 % (17.1 - 25.1 95% C.I.) (43) 12.5 % (8.8 - 17.4 95% C.I.) Prevalence of moderate underweight ( =-3 z- score) (100) 14.4 % (11.7 - 17.5 95% C.I.) (61) 17.4 % (14.1 - 21.2 95% C.I.) (39) 11.3 % (7.8 - 16.1 95% C.I.) Prevalence of severe underweight (<-3 z-score) (16) 2.3 % (1.3 - 4.1 95% C.I.) (12) 3.4 % (1.8 - 6.3 95% C.I.) (4) 1.2 % (0.4 - 3.1 95% C.I.)

18. ©2012 International Medical Corps Prevalence of stunting based on height-for-age z-scores and by sex Boys are more stunting than girls and this is not significant. P. value =0.281 All n = 689 Boys n = 348 Girls n = 341 Prevalence of stunting (<-2 z-score) (118) 17.1 % (14.7 - 19.9 95% C.I.) (71) 20.4 % (16.3 - 25.3 95% C.I.) (47) 13.8 % (10.4 - 18.0 95% C.I.) Prevalence of moderate stunting ( =-3 z-score) (91) 13.2 % (10.9 - 15.9 95% C.I.) (50) 14.4 % (10.9 - 18.7 95% C.I.) (41) 12.0 % (8.7 - 16.5 95% C.I.) Prevalence of severe stunting (<-3 z-score) (27) 3.9 % (2.6 - 5.8 95% C.I.) (21) 6.0 % (3.8 - 9.4 95% C.I.) (6) 1.8 % (0.8 - 3.6 95% C.I.)

19. ©2012 International Medical Corps Comparison of GAM rates in Isolo There has been good short rains which was experienced in the late 2011 which has led to improved pasture and livestock productivity. Kidding and lambing has also improved milk availability and food availability has also improved. This also followed BSFP interventions (Sept 2011-Feb 2012), out reaches have helped in reaching malnourished cases in far to reach areas..OJTs enhanced capacities of health workers and CHWs in active case finding. May 2012 (95% C.I.) April 2011 (95% C.I.) interpretation Prevalence of global malnutrition (<-2 z- score and/or oedema) 11.0 % (8.5 - 14.2 ) 15.7% [12.0 - 20.2] No Difference Prevalence of moderate malnutrition ( =-3 z-score, no oedema) 7.6 % (5.7 - 10.0 ) 13.1 % [9.6 - 17.5 ] No difference Prevalence of severe malnutrition (<-3 z-score and/or oedema) 3.4 % (2.2 - 5.3) 2.6% [1.8 - 3.7] p.value=0.0072 (significant)

20. ©2012 International Medical Corps Nutrition Status of caregivers of < 5 year old children: n=676 The main cause of maternal malnutrition was lack of balance diet and enough food especially for the pregnant and lactating mothers.

21. ©2012 International Medical Corps Vaccination coverage Measles n=644 OPV 1 n=704 OPV 3 n=704 Deworming (12- 59 Months) N=587 YES with card n=468 With Recall from mother n=144 with card n=530 With Recall from mother n=158 with card n=509 With Recall from mother n=162 with card n=266 With Recall from mother n=189 %72.722.475.322.472.32345.332.3 Overall % (2012) 95.197.795.377.6 Overall % 2011 91.496.494.341.0 Vaccination coverage was above National coverage of 80% except for deworming.Improved deworming attributed to improved HINI interventions through outreaches and creating awareness through M2MSG.

22. ©2012 International Medical Corps Vitamin A coverage Vitamin A 6-59 months N=704 Vitamin A 6-11 months N=117 Vitamin A 12-59 months ( received twice in the last 1 year) N=587 90.8%92.3%41.9 % 56.3% (2011) Vitamin A supplementation has improved through HINI interventions which are done through outreaches and OJT

23. ©2012 International Medical Corps Symptom breakdown in the children in the two weeks prior to interview (n=428) 60.8 % of the under-fives reported to have been sick. Majority (55.4%) of the HH reported seeking medical assistance for their sick child.

24. ©2012 International Medical Corps Zinc Supplementation during Last DD Episode Management of last DD Episode (N=46)% Oralite/ORS /Zinc 10.7 Home-made salt/sugar solution 6.5 Nothing 82.6 Low usage of zinc is because of shortage supply of zinc to the government hospitals

25. ©2012 International Medical Corps General and Domestic House hold water sources n=700 it takes an average 41.4 minutes to access main source of water and HH use an average of 80.1 litres of water per day.

26. ©2012 International Medical Corps Methods of Water treatment 68% of those who don’t treat water get water from safe sources ( tap water and protected well).

27. ©2012 International Medical Corps Frequency of meals taken in household meal frequency taken 2.6 (SD 0.7) On average the mean Individual Diet Diversity Score was 4.1 (SD 1.6) for the number of food groups consumed

28. ©2012 International Medical Corps HOUSEHOLD DIETARY DIVERSITY SCORE (HDDS) Diet Diversity Groups May 2012 %April 2011 % Low Diversity Groups (<=3 food groups) 35.416.0 Medium Diversity Groups (4-5 food groups) 4860.9 High Diversity Groups (>6 food groups) 16.523.2 With cereals being highly consumed (23%) and fish and sea (0.8%) products being least consumed.

29. ©2012 International Medical Corps Maternal Health Care n=700 With a mean of 3.6 ANC visits. Despite the high ANC attendance only 37.7 % of mothers deliver at hospital. It takes a mean of 77 minutes to get to the nearest health facility.

30. ©2012 International Medical Corps MORTALITY May 2012April 2011 CMR (total deaths/10,000 people / day 1.15 (0.52-2.42) (95% CI) 0.12(0.05-0.29 95%cl) U5MR (deaths in children under five/10,000 children under five / day 0.62 (0.26-1.48) (95% CI) 0.27(0.07-1.08 95%CL) Main cause of death among the > 5 years was that people were killed 28%. For Under 5 years was ARI 25%, Neonatal death 25%, During delivery 25% and unknown 25%

31. ©2012 International Medical Corps Summary of finding Indicators% 2012% 2011 Timely initiation of breastfeeding (children 0-23 months) (n=552) 77.5%75.5 Exclusive breastfeeding under 6 months (n=170)76.5%58.5 Minimum dietary diversity (6-23 months) Consuming 3+ food groups (breastfed children) (n=335) n=221 66% Consuming 4+ food group (non-breastfed children) (N=46) n=22 48% Consuming 3+ or 4+ food group (breastfed and non-breastfed children) (n=381) n=243 64% Minimum meal frequency At least twice a day for 6-8 months (breastfed children) (n=75) 81% 3+ times a day for 6-23 months old (breastfed children) (n=335) 67% 4+ times a day of children 6-23 moths (non- breastfed children) (n=46) 17% Minimum meal frquency N=381 n=23261% Toilet coverage (n=700)56.7%52.2% % of caregivers wash hands with soap+water (n=700) 76.4%

32. ©2012 International Medical Corps Plausibility check IndicatorSurvey value Acceptable value/range Interpretations/ Comments Digit preference score - weight 5<10Excellent Digit preference - height 5<10Excellent WHZ ( Standard Deviation) 1.080.8-1.2Good WHZ (Skewness) -0.21-1 to +1Excellent WHZ (Kurtosis) -0.06-1 to +1Excellent Percent of flags WFH 0.7 %<3%Excellent Overall Survey Score 11% Age distribution (%) Group1 6-17 mo 33.8 %20%-25% Group 2 18-29 mo 21.9 %20%-25% Group 3 30-41 mo 21.9 %20%-25% Group 4 42-53 mo 16.3 %20%-25% Group 5 54-59 mo 6.1 %Ard 10% Age Ratio : G1+G2/G3+G4+G5 1.26Ard 1.0 Overall Sex Ratio 1.030.8-1.2Excellent

33. ©2012 International Medical Corps Conclusion Decrease in GAM rates from 15.7% to 11.0% this was greatly influenced by good short rains which was experienced in the late 2011 which has led to improved pasture and livestock productivity. Kidding and lambing has also improved milk availability and food availability has also improved. This also followed BSFP interventions (Sept 2011-Feb 2012), out reaches have helped in reaching malnourished cases in far to reach areas..OJTs enhanced capacities of health workers and CHWs active case Formation of mother-mother support groups from 4- 181 has increased IYCN components. EBF from 58% to 76.5%. Continuous OJT for health workers and community health worker has greatly improved HINI components especially for Vitamin A (56.3% 2011-90.8% 2012) supplementation and deworming (41% 2011-90.8% 2012).

34. ©2012 International Medical Corps Conclusion Decrease in food diversity was attributed to poor and damaged roads which lead to increase in market food prices and thus poor access to food.

35. ©2012 International Medical Corps Recommendations. Strengthen Community Led Total Sanitation and community awareness to increase toilet usage cover. 56.7% of households have access to toilet. Emphasis on the usefulness of hospital deliveries through mother to mother support group. Facilitate supply of zinc supplementation in the government hospitals. Improve coverage and reporting in deworming Treatment of drinking water through boiling. 66% of household reported that they do not treat water. Training of the community on appropriate hand washing. Only 76.4% of responded reported to wash hands with soap and water. Constitution of balanced diets using locally available foodstuffs (with continued agricultural diversification). 54.9 % of the children samples consumed low dietary diversity of less than four groups Infrastructural improvement to improve access to markets and facilitate general development in all areas of the County