Wajir West and North Integrated Nutrition and Mortality survey

preliminary results

Islamic Relief Worldwide –Kenya

25th July-6th August 2012

OBJECTIVES OF THE SURVEYOVERAL OBJECTIVE: The overall goal of the survey was to

determine the prevalence of acute malnutrition of children between 6-59 months of age

Specific survey objectives Determine the prevalence of acute malnutrition in the children

aged 6-59months. Determine the Crude and under five mortality rates of the

entire population Determine the morbidity rates in children aged 6-59 months. Estimate the coverage of immunization (measles,DPT1&3/

OPV1&3), and Vit A supplementation amongst children aged 6-59 months.

Estimate the coverage of women supplemented with iron folate in their last pregnancy

Assess household food security and WASH practices. Assess IYCN practices

AREA SURVEYED

• The sampling frame was drawn from the population of three Divisions in Wajir North (Gurar, Bute and Buna) and five divisions in Wajir West (Eldas, Griftu, Hadado, Ademasajida, and Arabajahan).

Sampling DesignSampling was 2 stages.

• The first stage

– Assignment of clusters based on proportion to population size (PPS) ENA for SMART software used. (42 villages/clusters)

• The second stage, – selection of the households was done using Simple random

method.– The village elders gave the list of the households – In cases where the villages had huge number of

households, segmentation was done; the population was subdivided in to equal segments and one segment was randomly selected using SRM, the household were then listed, and the required households (18) selected from the list by simple random method.

INDICATOR SURVEY VALUE

ACCEPTABLE VALUE/RANGE

COMMENT

Digit preference - WEIGHT 3 (0-5 Excellent, 5-10 good, 10-20 , acceptable and > 20 problematic)

Excellent

Digit preference - HEIGHT 7 Good

Design Effect W/H 1.37

Design effect Mortality 2.0

WHZ ( Standard Deviation) 1.02 (<1.1 Excellent, <1.15 Good, <1.20 , acceptable and >1.20 problematic) Excellent

WHZ (SKEWNESS) 0.00 <±1.0 Excellent, <±2.0 Good, <±3.0 Acceptable >±3.0 Problematic . Excellent

WHZ (KURTOSIS) -0.13 <±1.0 Excellent,<±2.0 Good, <±3.0 Acceptable, >±3 Problematic Excellent

PERCENTAGE OF FLAGSWHZ: 1.3%, HAZ: 4.0 %, WAZ: 0.9 %

Less than 3% - 5% of the entire sample Acceptable range

AGE DISTRIBUTION (%)

Group 1: 06-17 months 23.3% 20% - 25% Within acceptable ranges. Recall (calendar of event) was used in 33.0% of the cases to estimate ages of

children 0-23 months

Group 2: 18-29 months 27.1% 20% - 25% Group 3: 30-41 months 25.2% 20% - 25% Group 4: 42-53 months 15.3% 20% - 25%

Group 5: 54-59 months 9.1% 10.0%

Plausibility check

INDICATOR SURVEY VALUE

ACCEPTABLE VALUE/RANGE COMMENT

Age ratio: (6-29): (30-59) MONTHS

1.02 The value should be around 1.0 Acceptable

SEX RATIO 1.11 0.8 – 1.2 ACCEPTABLE

SEX RATIO p VALUEp-value = 0.129 >0.1 Excellent, >0.05 Good, >0.001

Acceptable <0.000 ProblematicExcellent

OVERAL SURVEY QUALITY12.0 % 0-5 = Excellent; 5-10= Good ,10-15

=Acceptable >15= ProblematicAcceptable

Plausibility Check continues………

Demographic characteristics

Demographic characteristics (Mortality) N

Total number of HH sampled 740

Total population sampled 4821

Total under five sample 962

Anthropometrics children 6-59 months

Males 423

Females 380

Sex Ratio 1:1

PLW 482

Malnutrition rates INDEX INDICATOR November

2011N=764

July2012

N=793

Statistical significanc

e of two survey

(Chi square)

WHO 2006

GAM: W/H < -2 z and/or Oedema

27.9% [22.7- 33.7]

14.6% (11.9-17.8)

P=0.000

SAM: W/H < -3 z and/or Oedema

5.6% [3.6- 8.8]

2.3% ( 1.3- 4.0)

P=0.011

Prevalence of stunting: H/A <-2

5.8% [3.9-8.5]

22.4% (19.0-26.3)

P=0.000

Prevalence of underweight: W/A <-2

13.7% [9.8-18.8]

19.1% (16.0-22.6)

P=0.045

% with Oedema 0.0% 0.5% P=0.084

Malnutrition rates disaggregated by sex

Sex INDICATOR

November2011

N=764

July2012

N=793

Statistical significance

of two survey (Chi

square)

Boys GAM: W/H < -2 z and/or

Oedema

(109) 28.2%

(22.7-34.6)

( 69) 16.5% (13.1-20.7) P=0.000

SAM: W/H < -3 z and/or Oedema

( 25) 6.5% ( 3.9-10.6)

( 11) 2.6% ( 1.5- 4.6) P=0.005

Girls

GAM: W/H < -2 z and/or Oedema

(104) 27.5% (21.4-34.6)

( 47) 12.5% ( 9.5-16.3) P=0.000

SAM: W/H < -3 z and/or Oedema

( 18) 4.8% ( 2.7- 8.4)

( 7) 1.9% ( 0.7- 5.0) P=0.016

Boys Prevalence of stunting: H/A <-2

( 31) 8.0% ( 4.7-13.4)

(101) 25.0% (20.2-30.4) P=0.000

Girls ( 13) 3.4% ( 2.2- 5.3)

( 72) 19.6% (15.4-24.6) P=0.000

Boys Prevalence of underweight: W/A <-2

( 57) 14.7% ( 9.9-21.3)

( 81) 19.4% (15.4-24.1) P=0.049

Girls ( 48) 12.6% ( 8.7-17.9)

( 70) 18.7% (14.8-23.4) P=0.008

Malnutrition trends for the last three surveys

Nutrition status of < 5 by MUAC

Indicator

Nov 2011

(N=764)%

July 2012(N=793)

%

Statistical significance

of two survey (Chi

square)Prevalence Severe Acute Malnutrition (SAM): MUAC < 11.5 CM and/or Oedema

1.6 0.9 P = 334Not significant

Prevalence of Global Acute Malnutrition (GAM): MUAC < 12.5 cm or edema

7.6 3.0 P = 002Significant

At risk MUAC ≥12.5 and <13.5 cm

21.6 15.8 P = 022Not significant

CHILD MORBIDITY RATES

41.3% of HH had children who had been sick two weeks to the survey No bloody diarrhea cases reported

MORTALITY RATES TRENDS

IndicatorMay 2011

Nov 2011

July 2012

Total CRUDEMORTALITY RATE

(Number/10,000/day)

0.70[0.50-0.98]

1.02[0.72-1.43]

0.49% [0.27-0.89]

UNDER FIVEMORTALITY RATE (Number/

10,000/day)

1.15[0.71-1.86]

1.71[0.91-3.16]

1.02% [0.51-2.03]

• Mortality rates are within normal ranges

Management of diarrhea cases

16.3% of HH had children with watery diarrhea No bloody diarrhea cases reported

IMMUNIZATION COVERAGE

VaccineNovember

2011%

July2012

%

OPV1/Pentavalent 1: CARD No report50.3

OPV1/Pentavalent 1: Mother recall No report

44.2

OPV1/Pentavalent 3 : CARD 48.0% 47.9

OPV1/Pentavalent 3: Mother recall 42.5%

42.4

Measles immunization coverage >= 9 months old children

VITAMIN A SUPPLEMENTATION COVERAGEAGE GROUP NO. OF

TIMESJuly

2012 (%)

6-59 (n=803) Once 59.46-11 (n=72) Once 56.912-59 (n=731)

Once 59.6

As the children grow older and are not being immunized, the defaulter for Vitamin A increases

The recall period for Vitamin A supplementation was six months (since January 2012)

Other High Impact Nutrition Intervention Indicators

HINI INDICATORSJuly

2012%

Nov 2011%

% 1-5 years old children de-wormed last three months

(n=241) 33.0 49.6

%<5s supplemented with zinc last time they had diarrhea

(n=1)1.9 0.0

% of women supplemented with iron for 90 days in their last pregnancy

(n=315) 53.2 52.6

Nov 2011 reported de-worming for last 6 months thus

not comparable

To establish whether the child was given Zinc was very hard during the survey since mothers are not aware of different types of drugs and therefore there is need to educate the mothers the importance of it.

Only one caregiver responded the child was given a drug other than ORS and it is assumed was zinc

Nutrition Status of caregivers of < 5 year old children

INDICATORNov 2011

%

July 2012

%

% Women Pregnant and lactating 65.8 81.4

% women with MUAC <21cm 11.8 2.4

% Lactating and pregnant mothers with MUAC <21cm

11.4 1.9

INFANT AND YOUNG CHILD FEEDING PRACTICES

Indicator NNov

2011 %N

July2012

%BREASTFEEDING PRACTICESExclusive breastfeeding rates (0-5 months) 55 67.3 225 59.6Early initiation of breastfeeding (within an hour) 377 48.8 552 60.1Meal diversityProportion of children who consumed solid, semi-solid or soft foods during previous day (6-8 months)

32 75.0 30 63.3

Minimum diet diversity (breast fed and non breast fed) (from ≥ 3 food groups during the previous day) 6-23 months

237 0 327 16.8

Minimum diversity (breast fed) (from ≥ 3 food groups during the previous day) 6-23 months 208 0 262 14.5

Minimum diet diversity (non- breast fed) (from ≥ 4 food groups during the previous day) 6-23 months

29 0 65 0

Continued breastfeeding at 2years (20-23 Months)

37 57.1 96 56.3

IYCN ……..

MINIMUM MEAL FREQUENCY N

Nov 2011

% N

July 2012

%Minimum meal frequency (all) (2+ meals

for breastfed 6-8 month, 3+ for breastfed 9-23 months and 4 times for non-

breastfed children)

237 54 327 86.0

Minimum meal frequency ( breast fed) At least twice a day for 6-8 months and 3+

times a day for 9-23 months old208 51.4 262 61.4

Minimum meal frequency (non breast fed) (4+ times a day of children 6-23 months)

29 72.4 65 24.6 Consumption of solids, semi solid and soft foods for children 6-8m very low; although they

are timely introduced to complementary foods most of them are given milk alone or milk and tea in combination.

Meal Diversity for non breast fed children is very low………majority are taking 2 meals (solids/semisolid and liquids (milk and tea) and none consumed more than 3 meals in a day for both Nov 2011 and July 2012

FOOD SECURITYINDICATORS

Main sources of livelihood 88.2% of HH owned livestock 0.4% engaged in farming previous planting season

Main HH source of food

% HOUSEHOLD FOOD CONSUMPTION

Consumption of meals the previous day was similar to normal days showing the community is in its best in terms of meal frequency

Household dietary diversity score

Dietary score (N=611)

July 2012

%

Low dietary score (3 food groups) (n=26) 4.3

Medium dietary score (4-5 food groups) (n=379) 62.0

High dietary score (6+ food groups) (n=206) 33.7

Mean dietary diversity score (N=611) 5.2

Least consumed food groups 0.8% of households consumed fruits(n=5) 0.0% consumed fish (n=0) 9.2% of households consumed vegetables (n=56)

Availability is the problem for the above three food groups

Water and sanitation

% of households by sources of drinking water Majority 75 % of households get water from unsafe sources

92.1% of households don’t treat drinking water

Proportion of households consuming > 15 L/P/P/D =14.1% Protected shallow well and borehole= safe water sources

HAND WASHING PRACTICES %

24.4% of caregivers use soap to wash their handsNote: the respondents with children who can go to bushes were not included in “after cleaning child buttom”

Access to latrine

Most of improved latrines were constructed by organization like IRK, Mercy

corps etc

Conclusion There is significant difference in Wasting (GAM (p=000) and Stunting (p=000) in

comparison with November 2011 and July 2012 surveys rates attributed (by MOH, IRK and arid lands) to Increased intervention since last year after May report which indicated GAM rate at 27.5%.

The interventions included:- Increased coverage of acute malnourished children through TSFP, integrated outreaches

conducted by IRK/ MOH on weekly basis and provision of general food distribution whereby majority 96% (last three months) of household survey reported to have received food aid consistently since last year September.

The districts experienced good rains late last year that improved pastures for the animals thus improved milk production and some farming was witnessed in some sites

DMOH reported that disease burden was high in 2010-2011 (60-70 patients/day) as compared to 2012 (30patients/day)

It was also reported that Fully immunized children coverage in 2010 was low-48% as compared to >50% currently (this was attributed to integrated outreaches conducted by IRK together with MOH)

IMAM-GFD linkage intervention which has improved since mid lat year When malnutrition is disaggregated by sex boys seems to be more malnourished but

looking further the statistical difference is not significant e.g. GAM July 2012 P= 0.0793 when boys and girls are compared

There is no significant difference in SAM (p=0.01) and underweight (p=0.05) since last year November 2011 survey

Mortality levels i.e. both crude rates and amongst under-fives remain at normal levels

Household Dietary Diversity has improved from 3.4 in Nov 2011 to 5.2 in July 2012

Recommendations• Nutrition

– Since malnutrition levels have shown improvement, (GAM from 27.9% -14.6%) the ongoing services should be strengthened and more emphasis should be geared towards ensuring all HINI indicators are improving as well. Thus IRK/MOH and donors should ensure that there is sustained funding for health and nutrition activities in the area.

– Morbidity cases have decreased especially diarrhea cases, looking at seasonality trends, it is expected that the cases will increase during the rainy season and thus there is need to prepare the health facilities with enough stocks of Zinc and sensitize communities on the importance of proper diarrhea management.

– Stunting levels: since this is long term deficiency emphasis should be put to address the shortfall through Optimal IYCF practices

• Vitamin A coverage– Low Vitamin A coverage- possible causes may be hard to reach areas

and poor practice of taking children for supplementation especially those above 12 months. possible solutions: strengthening of outreach services to hard to reach areas and ensuring good data capturing practices

– Malezi Bora campaigns should encourage supplementation to boost regular facility supplementation and thus concerted efforts are required from MOH and partners

Cont..• IMMUNIZATION COVERAGE

– Good immunization coverage for OPV/Pentavalent and Measles was realized and the practice need to be strengthened and maintained.

• IYCN– Consumption of solid food for children 6-8 months was poor from the

survey results (especially non breastfeeding)- possible reasons for poor practice: mothers are well informed of timely initiation of complementary feeds and are not encouraged to give energy dense and filling foods which are of solid or semisolid in nature and thus they rely on milk alone/ or tea. Possible solutions support community units (community health workers) and mother support groups so as to share the information with pregnant mothers and immediately after delivery.

– Dietary diversity for children 6-23 months especially for non breastfed children is poor with none getting nutrients from 4 or more food groups: Possible intervention: Intense nutrition education/promotion at the health facility and community level on the importance of Diet diversity for children 6-23 months.

Cont..• WASH

– Latrine coverage low- more sensitization on importance of latrine use and after effects of using the bushes as means of disposing human waste. Possible strategy is to use the CLTS approach

– Water treatment practice should be strengthened especially during rain season when human waste is washed to water pans and dam

– Per kapita water consumption according to sphere standards 2004 is not attained (14.1% (n=86) of households were able to attain the standard of >15litres per person/day and concerted efforts from concerned NGOS and government ministry should ensure the standards are achieved

– Hand washing practices before and after the four critical events should be promoted through various channels in the community e.g. mother support groups, community leaders meetings, local barazas

• FSL– Overreliance on food aid- the community should device new ways of

continuous supply of food by selling animals to mitigate food supply in times of droughts and food insecurity.

– Dietary diversity – the score is good although consumption of vegetables (9.6%), fish (0.0%) and fruits (0.8%) was very low followed by animal proteins food such as meats and eggs. The communities should be encouraged to have kitchen gardens for vegetable supply especially those in Wajir North in Gurar division

Cont..• District medical officers of health/MOH

– Ensure the social mobilization during Malezi bora activities is done on time to achieve high coverage of Vitamin A as well as ensuring adequate supply of Vitamin A capsules on time.

– Mothers who deliver at the health facilities or who come within a month after delivery to health facilities should be encouraged to breastfeed their children for the first six months and all health record of the children immunization status, Vitamin A and deworming captured in the mother child booklet for easy reference during surveys and other important health activities.

– De worming of children is very low. Possible causes: lack of supplies or hard to reach areas. Possible solutions: ensuring supplies are requested and availed in time for implementing partners eg IRK to collect and assist in supplementation during integrated outreaches. Mothers should also be sensitized on important of regular de worming of children less than five years

• IRK and Partners– To ensure each district has good monitoring of indicators, I suggest to

conduct at least one separate survey for the two district and if the results are similar then combined survey can continue.

– Finally during budgeting for surveys village guide should be considered as a priority as they help in ensuring quality data is captured by enumerators through minimizing resistance (if any)