©2012 International Medical Corps Meru North SMART survey Validation Report From Relief to Self-Reliance Monitoring and Evaluation Anastacia Maluki amaluki@internationalmedical

©2012 International Medical Corps

Meru North SMART surveyValidation Report

From Relief to Self-Reliance

Monitoring and EvaluationAnastacia Maluki

[email protected]

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.


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


Map of Meru District


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.


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


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


Methodology Anthropometric and MorterlityData entered on ENA software Anthropometric sample Retrospective Mortality sample

Estimated prevalence 7.2 0.98

Desired precision 3 0.5

Design effect 1.5 1.5

Recall period 90 days

Average household size 5 5

Percent of under five children 17

Percent of non-respondent 3 3

Households to be included 628 563

Children to be included 466

Population to be included 2732

Recall period since 2nd Jan, 2012


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

• 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.


Description of sampling methods

• 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).


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.


Training• The team was trained for 3 days (26th-28th March,

2012):– nutrition survey objective– anthropometric measurements– interviewing techniques– completion of questionnaires– standardization test will be done

• pre-test was done on 29th March 2012• Data collection begun on the 30th March, 2012–

6th, April, 2012.


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


Findings: Demographic CharacteristicsDEMOGRAPHY Number

Number of HH surveyed 740

Number of children 6-59 months surveyed 709

Number of children 0-23 months surveyed for IYCN 731

Average number of persons per HH 5.7 S.D = 2.3

Average number of children (0-6 months ) per HH 0.2 S.D=0.4

Average number of children (6-59 months ) per HH 1.1 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.


Distribution of age and sex of 6-59 months.

Boys Girls Total Ratio

AGE (months)

no. % no. % no. % Boy:girl

6-17 131 54.1 111 45.9 242 34.1 1.2

18-29 112 49.1 116 50.9 228 32.2 1.0

30-41 47 47.5 52 52.5 99 14.0 0.9

42-53 43 49.4 44 50.6 87 12.3 1.0

54-59 27 50.9 26 49.1 53 7.5 1.0

Total 360 50.8 349 49.2 709 100.0 1.0

• 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.


Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex

Alln = 692

Boysn = 348

Girlsn = 344

Prevalence of global malnutrition (<-2 z-score and/or oedema)

(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 (<-2 z-score and >=-3 z-score, no oedema)

(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)

(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


GAM 12.6%

Prevalence of acute malnutrition based on MUAC cut off's and/or oedema

Nutritional Status MUAC Criteria Number Percentage

Severe malnutrition <11.5cm 21 3%

Moderate malnutrition >=11.5 and <12.5cm

67 9.6 %

At risk of malnutrition >=12.5 and <13.5cm

190 27.3%

Satisfactory nutritional status >=13.5cm 419 60.1 %

TOTAL 697 100


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

Alln = 705

Boysn = 358

Girlsn = 347

Prevalence of underweight(<-2 z-score)

(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(<-2 z-score and >=-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)

(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.)


Prevalence of stunting based on height-for-age z-scores and by sex

Alln = 702

Boysn = 357

Girlsn = 345

Prevalence of stunting(<-2 z-score)

(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(<-2 z-score and >=-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


Nutrition Status of caregivers of < 5 year old children: n=697

Pregnant Lactating Not pregnant nor lactating TotalMaternal physiological status

0.0

2.0

4.0

6.0

8.0

10.0

12.0

3.3

4.8

11.4

6.9

Nutrition Status of caregivers of < 5 year old children:

% MUAC<21

Perc

enta

ges o

f car

egiv

ers


Vaccination coverage Measles

n=651 OPV 1n=697

OPV 3n=697

Deworming (12-59 Months)N=603

YES

with cardn=279

With Recall from mothern=275

with cardn=360


with cardn=347


with cardn=91


% 42.9 42.2 51.6 46.2 49.8 46.1 15.1 28

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%


Vaccination coverageVitamin 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 %


Symptom breakdown in the children in the two weeks prior to interview (n=309)

Symptoms 6-59 months

Cough 50.0 %

Malaria 21.9%

Diarrhoea 11.3 %

Measles 2.3 %

Other 14.5 %

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


Zinc Supplementation during Last DD EpisodeManagement 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


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

Tap w

ater

River

Unprotec

ted w

ell

Borehole

Protec

ted w

ell

Wate

r bowser Lak

e

Public pan Dam

Rain W

ater

Others0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.033.2 32.0

14.6

8.56.5

3.70.7 0.3 0.3 0.0 0.2

31.731.6

14.09.6

6.23.4 0.8 1.8 0.3 0.3 0.3

Household water uses

General use Drinking

Water Sources

perc

enta

ge U

sage


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.

67%

30%

3%

Nothing Boiling Add chemicals


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

1 2 3 4 50.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

4.4

24.1

70.7

0.7 0.0

8.8

25.1

65.7

0.3 0.1

Frequency of meals intake in households.

usual meal frequencyDay preceeding survey

Frequency of meals intake

Perc

enta

ge o

f hou

seho

ld


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


Summary of findingIndicators % ( 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) 53Continued breastfeeding upto 2 years (n=643) 89.7Minimum dietary diversity (6-23 months) 3.2Consuming 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 HDDS 3.2At 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=373 85.2%

Toilet coverage (n=630) 85.4% of caregivers wash hands with soap (n=479) 64.9%


Plausibility checkIndicator Survey value

Acceptable value/range

Interpretations/Comments

Digit preference score - weight 5 <10 Excellent

Digit preference - height 5 <10 Excellent

WHZ ( Standard Deviation) 1.13 0.8-1.2 Good

WHZ (Skewness) -0.10 -1 to +1 Excellent

WHZ (Kurtosis) -0.33 -1 to +1 Excellent

Percent of flags WFH 2.4 <3% Excellent

Overall Survey Score 12%

Age distribution (%)

Group1 6-17 mo34.1 20%-25%

Group 2 18-29 mo 32.2 20%-25%

Group 3 30-41 mo 14.0 20%-25%

Group 4 42-53 mo12.3 20%-25%

Group 5 54-59 mo7.5 20%-25%

Age Ratio : G1+G2/G3+G4+G5 1.0 Ard 1.0

Overall Sex Ratio 1.02 0.8-1.2 Excellent


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


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 .


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.


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.


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.

Documents

©2012 International Medical Corps Meru North SMART survey Validation Report From Relief to Self-Reliance Monitoring and Evaluation Anastacia Maluki amaluki@internationalmedical