1. ©2012 International Medical Corps Meru North SMART survey 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 Meru North district :Igembe South, Igembe North, Tigania West and Tigania East. The population is relatively static and densely populated with an annual growth rate of 2.8%. – estimated population of 740,035 people (Igembe 471,836 and Tigania 268,199 with an average proportion of 16.7% children under 5 years Rainfall is bimodal with long rains expected from mid-March to May and the short rains expected from mid-October to late November. Short rains are most reliable. The district comprises of six livelihood zones namely; – marginal mixed farming (Majority of the population) – mixed farming food crops – mixed farming: Tea/dairy – rain fed cropping – rain fed tea/dairy

3. ©2012 International Medical Corps Map of Meru 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 softwareAnthropometric sampleRetrospective Mortality sample Estimated prevalence7.20.98 Desired precision30.5 Design effect1.5 Recall period 90 days Average household size55 Percent of under five children17 Percent of non-respondent33 Households to be included628 563 Children to be included466 Population to be included 2732 Recall period since 2 nd Jan, 2012

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, and – Continued breastfeeding at 1 year. The sample size for children between 0-23 months was 730 20 The number of children reached per cluster was given by dividing 730 by 37 giving 20 children per cluster. Getting children below 6 months in a cluster was quite a challenge and therefore purposive sampling was used where no children of that age group were found in the cluster.

9. ©2012 International Medical Corps Description of sampling methods 37 Number of clusters to be surveyed was 37 =(726/ 20 (Household to be reached per day)) A total of 6 survey teams : – 1 team leader – 3 enumerators Data was collected for 6 days (37/6).

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 (26 th -28 th March, 2012): – nutrition survey objective – anthropometric measurements – interviewing techniques – completion of questionnaires – standardization test will be done pre-test was done on 29 th March 2012 Data collection begun on the 30 th March, 2012– 6 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 surveyed740 Number of children 6-59 months surveyed709 Number of children 0-23 months surveyed for IYCN731 Average number of persons per HH5.7S.D = 2.3 Average number of children (0-6 months ) per HH0.2S.D=0.4 Average number of children (6-59 months ) per HH1.1S.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. BoysGirlsTotalRatio AGE (months) no.% % % Boy: girl 6-1713154.111145.924234.11.2 18-2911249.111650.922832.21.0 30-414747.55252.59914.00.9 42-534349.44450.68712.31.0 54-592750.92649.1537.51.0 Total36050.834949.2709100.01.0 overall male: female ratios were within the expected range of 0.8 – 1.2 Most of the children aged 6-29 months for IYCN were purposively sampled and this explains why they are many children between these age groups.

15. ©2012 International Medical Corps Prevalence of acute malnutrition based on weight-for-height z- scores (and/or oedema) and by sex All n = 692 Boys n = 348 Girls n = 344 Prevalence of global malnutrition (<-2 z-score and/or oedema) 7.8 % (54) 7.8 % (5.2 - 11.6 95% C.I.) (34) 9.8 % (4.6 - 19.5 95% C.I.) (20) 5.8 % (3.3 - 10.0 95% C.I.) Prevalence of moderate malnutrition ( =-3 z-score, no oedema) 6.6 (46) 6.6 % (4.0 - 10.8 95% C.I.) (30) 8.6 % (3.8 - 18.2 95% C.I.) (16) 4.7 % (2.6 - 8.2 95% C.I.) Prevalence of severe malnutrition (<-3 z-score and/or oedema) 1.2 % (8) 1.2 % (0.5 - 2.8 95% C.I.) (4) 1.1 % (0.6 - 2.4 95% C.I.) (4) 1.2 % (0.2 - 6.2 95% C.I.) Boys were more malnourished than girls but it was not significantly. P value for the GAM rate was 0.208

16. ©2012 International Medical Corps Prevalence of acute malnutrition based on MUAC cut off's and/or oedema Nutritional StatusMUAC CriteriaNumberPercentage Severe malnutrition <11.5cm213% Moderate malnutrition >=11.5 and <12.5cm 679.6 % At risk of malnutrition >=12.5 and <13.5cm 19027.3% Satisfactory nutritional status >=13.5cm41960.1 % TOTAL 697100 GAM 12.6%

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 extremely significant. P. value =0.004 All n = 705 Boys n = 358 Girls n = 347 Prevalence of underweight (<-2 z-score) 14.2 % (100) 14.2 % (11.5 - 17.4 95% C.I.) (65) 18.2 % (13.9 - 23.4 95% C.I.) (35) 10.1 % (7.0 - 14.4 95% C.I.) Prevalence of moderate underweight ( =-3 z-score) (85) 12.1 % (9.7 - 14.9 95% C.I.) (54) 15.1 % (11.4 - 19.7 95% C.I.) (31) 8.9 % (5.8 - 13.5 95% C.I.) Prevalence of severe underweight (<-3 z-score) 2.1 % (15) 2.1 % (1.3 - 3.6 95% C.I.) (11) 3.1 % (1.5 - 6.1 95% C.I.) (4) 1.2 % (0.4 - 3.0 95% C.I.)

18. ©2012 International Medical Corps Prevalence of stunting based on height-for-age z-scores and by sex All n = 702 Boys n = 357 Girls n = 345 Prevalence of stunting (<-2 z-score) 29.5 (207) 29.5 % (26.1 - 33.1 95% C.I.) (120) 33.6 % (28.3 - 39.4 95% C.I.) (87) 25.2 % (20.7 - 30.3 95% C.I.) Prevalence of moderate stunting ( =-3 z-score) (152) 21.7 % (19.0 - 24.6 95% C.I.) (82) 23.0 % (18.4 - 28.3 95% C.I.) (70) 20.3 % (16.7 - 24.4 95% C.I.) Prevalence of severe stunting (<-3 z-score) (55) 7.8 % (6.2 - 9.9 95% C.I.) (38) 10.6 % (7.9 - 14.2 95% C.I.) (17) 4.9 % (3.1 - 7.9 95% C.I.) Boys are more stunting than girls and this is extremely significant. P. value =0.009

19. ©2012 International Medical Corps Nutrition Status of caregivers of < 5 year old children: n=697

20. ©2012 International Medical Corps Vaccination coverage Measles n=651 OPV 1 n=697 OPV 3 n=697 Deworming (12-59 Months) N=603 YES with card n=279 With Recall from mother n=275 with card n=360 With Recall from mother n=322 with card n=347 With Recall from mother n=321 with card n=91 With Recall from mother n=229 %42.942.251.646.249.846.115.128 Measles coverage was quiet high,this is because there was a measles campaign going on during the survey. Both Measles and OPV were above National coverage of 80%

21. ©2012 International Medical Corps Vaccination coverage Vitamin A 6-59 months N=697 Vitamin A 6-11 months N=94 Vitamin A 12-59 months ( received twice in the last 1 year) N=603 65.6%58.5%66.7 %

22. ©2012 International Medical Corps Symptom breakdown in the children in the two weeks prior to interview (n=309) Symptoms6-59 months Cough50.0 % Malaria21.9% Diarrhoea11.3 % Measles2.3 % Other14.5 % 44.6% of the under-fives reported to have been sick and only 13.4% of mothers reported not to get any assistance when child was sick

23. ©2012 International Medical Corps Zinc Supplementation during Last DD Episode Management of last DD Episode (N=39)% Oralite/ORS 30.8 Zinc 15.4 Zinc + ORS 5.1 Home-made salt/sugar solution 12.8 Nothing 35.9

24. ©2012 International Medical Corps House hold water sources for general and domestic use it takes an average 41.75 minutes to access main source of water and HH use an average of 97.8 litres of water per day. A 20-litre jerrican costed on average Kshs 7.49

25. ©2012 International Medical Corps Methods of Water treatment Clearly the role of untreated water as the main cause of childhood diarrhoea and subsequent levels of acute malnutrition cannot be underestimated.

26. ©2012 International Medical Corps Frequency of meals taken in household meal frequency usually taken 2.7 (SD 0.6) while the one reported for the previous day prior to survey was 2.6 (SD 0.7) On average the mean Individual Diet Diversity Score was 4.1 (SD 1.5) for the number of food groups consumed

27. ©2012 International Medical Corps Mortality rates CMR (total deaths/10,000 people / day 0.24 (0.11-0.56) (95% CI) U5MR (deaths in children under five/10,000 children under five / day 0.48 (0.14-1.59) (95% CI) Main cause of death among the > 5 years was accidents while majority (75%) reported not to know the cause of death among the <5 year was

28. ©2012 International Medical Corps Summary of finding Indicators% ( 95% CI) % of women attended at least 1 Anc Visits (N=647)92.8% Hospital Delivery (n=408)55.3% % women supplemented with iron in there last pregnancy (n=255) 34.6% Timely initiation of breastfeeding (children 0-23 months) (n=619) 86.3 Exclusive breastfeeding under 6 months (n=80)53 Continued breastfeeding upto 2 years (n=643)89.7 Minimum dietary diversity (6-23 months)3.2 Consuming 3+ food groups (breastfed children) (n=317)63.7% Consuming 4+ food group (non-breastfed children) (n=22)31.9% Consuming 3+ or 4+ food group (breastfed and non- breastfed children) N=339 n=209 61.7% Minimum meal frequency HDDS3.2 At least twice a day for 6-8 months (breastfed children) (n=85) 94.4% 3+ times a day for 6-23 months old (breastfed children) (n=431) 85.2% 4+ times a day of children 6-23 moths (non-breastfed children) (n=21) 28.8% Minimum meal freq N=452 n=37385.2% Toilet coverage (n=630)85.4 % of caregivers wash hands with soap (n=479)64.9%

29. ©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) 1.130.8-1.2Good WHZ (Skewness) -0.10-1 to +1Excellent WHZ (Kurtosis) -0.33-1 to +1Excellent Percent of flags WFH 2.4<3%Excellent Overall Survey Score 12% Age distribution (%) Group1 6-17 mo 34.120%-25% Group 2 18-29 mo 32.220%-25% Group 3 30-41 mo 14.020%-25% Group 4 42-53 mo 12.320%-25% Group 5 54-59 mo 7.520%-25% Age Ratio : G1+G2/G3+G4+G5 1.0Ard 1.0 Overall Sex Ratio 1.020.8-1.2Excellent

30. ©2012 International Medical Corps Conclusion The study identified aggravating factors that had a negative bearing on optimal under-five nutritional status and their caregivers Poverty and issues of who controls family income have a heavy contribution to household food security. Income sources are not diversified and therefore there’s over reliance on farm produce both as an income source and family food. Poverty has also made it difficult to access food from markets due to insufficient financial resources. Lack of water supply in many parts of Meru North districts especially in Igembe North division has led to infectious diseases spreading, causing childhood diarrhea, which leads to major malnutrition and subsequent death due to diarrheal dehydration Poor agricultural practices including cultivation of Miraa in most areas whose income does not translate into food security. This is further compounded by poor soil fertility as a result of poor farming practices and environmental degradation. Lack of access to food.Most major food and nutrition crises do not occur because of a lack of food, but rather because people are too poor to obtain enough food. FGD findings revealed that majority 75% of the community was poor with only 25% categorized as rich. Majority 70.3% of the households purchase food

31. ©2012 International Medical Corps Conclusion Poor child and adult dietary profiles. Over-consumption of certain food group like cereals usually goes along with deficiencies in essential vitamins and minerals. High child morbidity prevalence reported to have affected 44.6% of the under-fives which was found to significantly affect child nutritional status; Poor IYCF practices including early weaning, low maintenance of breast feeding and poor feeding practices. Poor access to medical facilities some are too far for household to access. Poor water sanitation status in the community with minimal treatment of unsafe drinking water at the household level increase vulnerability to infectious and water-borne diseases, which are direct causes of acute malnutrition. most common foods consumed by the households & children were Cereals and cereal products 24% least consumed food were meat /fish/poultry product 1%. On average most health facilities are located 3.2 (SD 2.6) km away.

32. ©2012 International Medical Corps Recommendation Immediate Interventions strengthening the integrated outreach component- to intensify active case findings of malnourished children and manage the severaly and moderately malnourished children. Strengthen programmes and strategies currently addressing infant and young child nutrition (IYCN) Strengthen the HINI program especially maternal nutrition, iron/folate supplementation during the prenatal period and ensuring ORS/zinc support for diarrhoea.

33. ©2012 International Medical Corps Recommendation Strengthening of hygiene practices to reduce the incidence of diarrhoeal disease Continued water trucking to areas affected by water stress by Ministry of Water and Irrigation and Kenya Red Cross especially in the Igembe north area. Provision of water purification chemicals for water treatment at Household level The Ministries of Public Health and sanitation and Medical services in collaboration with other stakeholders in the district to initiate and offer concrete support in the implementation of strong awareness campaigns and community based health and nutrition programs. Only 64.9% of the mothers reported washing hands with soap.

34. ©2012 International Medical Corps Recommendation Long-Term Interventions Focus on programmes by ministry of agriculture that improve and sustain dietary diversity and consumption of micronutrient.-rich foods. And advising farmers on good farming methods.By improving agricultural yields, farmers could reduce poverty by increasing income as well as open up area for diversification of crops for household use. To address the issues of limited access to safe water, there is a need to establish water points in areas where water is inaccessible. MOH should increase access to health facilities in the rural parts of kenya by adding more health facilities or increasing CHW. These will improve hospital deliveries and access to medical services.