Kajiado Nutrition Survey May 2011Final report Survey... · 2018. 3. 23. · Kajiado County Integrated Nutrition and food security survey report (May 2011) 6 1.0 INTRODUCTION 1.1 Background

May 2011

Report compiled by: Yedideyah Consultancy

Firm

This integrated nutritional survey was conducted from 18th to 22nd April 2011 in three districts of Kajiado County, specifically Kajiado North, Kajiado Central and Kajiado South. A total of 766 children 6-59 months and 556 caretakers from 594 households were assessed for their nutritional status, morbidity, immunization status, vitamin A supplementation and de-worming, In addition, a total of 312 children 0-24 months were assessed for infant and young child nutrition. Mortality data and causes of deaths were further obtained from 884 households. The survey results showed a Global Acute Malnutrition (GAM) rate of 8.6% (95% CI: 6.7-11.0 CI), Severe Acute Malnutrition (SAM) rate of 0.9% (95% CI: 0.5-1.8 CI); and under five mortality rate of 0.3/10,000/day (95% CI: 0.10-0.94) and crude mortality rate of 0.23 (95% CI: 0.08-0.60). Prevalence of stunting at 19.7 %( 95% CI: 15.7-24.6) and underweight prevalence 12.1% (95% CI: 9.8-14.9). About 36% of children 6-59 months were reported to be ill two weeks prior to the survey period. Another 39.2% of these children had not received vitamin A supplementation. Nearly 75% of households do not treat water before consumption. On average children 6-24 months consumed 3 meals similar to older household members. The GAM level signify an alert situation with aggravating factors such as morbidity, poor water and sanitation practices, low meal frequencies and irregular sources of income. To prevent the nutritional status from getting worse, it is highly recommended that;

1. Continue support for community IMAM programs especially in rural areas 2. Scale up WASH program to cover all areas of the county especially in the rural and semi-urban areas 3. Scale up Vitamin A supplementation and measles campaign in the county 4. Support income generating activities especially among the population workforce ( 20-40 years) 5. Support community nutrition education for caregivers (men and women) with emphasis on infant and young child nutrition

and good health seeking behavior. 6. Support projects related to agriculture and livestock

Ministry of Public health and Sanitation

Ministry of Medical Services

Kajiado County Integrated Nutrition and food security survey report (May 2011)

2

Acknowledgements This Integrated Nutrition and Food Security Survey was implemented by Mercy-USA for Aid and

Development with financial support from UNICEF and in collaboration with MOPHS/MOMS

Technical advice and support in conducting the survey and reporting was provided by Emily Teshome (Lead Consultant) and Jedidah Wanjiku (Technical Assistant) from Yedideyah Consultancy Firm

The survey Coordinators, Irene Bosire and Susan Wako from Mercy – USA, are highly acknowledged for coordinating the entire survey.

Important contributions of Mercy -USA field staff are appreciated for organizing the survey logistics.

This study could not have been completed without the tireless efforts of the data collectors, data entry clerks, field guides and Kajiado county community members that provided valuable information compiled

in this report.


3

Table of Contents Acknowledgements ....................................................................................................................................... 2 1.0 INTRODUCTION .................................................................................................................................. 6

1.1 Background Information ..................................................................................................................... 6 1.2 Survey Objectives ............................................................................................................................... 7

1.2.1 Overall Objective ................................................................................................................................. 7 1.2.2 Specific Objectives .............................................................................................................................. 7 2.0 SURVEY METHODOLOGY ................................................................................................................. 7

2.1 Training ............................................................................................................................................... 8 2.2 Sampling methodology ....................................................................................................................... 8 2.3 Data collection procedures .................................................................................................................. 8 2.4 Data Analysis ...................................................................................................................................... 9 2.5 Quality control .................................................................................................................................... 9 2.6 Study limitations ............................................................................................................................... 10

3.0 RESULTS AND DISCUSSION ........................................................................................................... 11 3.1 Demographic characteristics of the study household ........................................................................ 11 3.2 Nutritional status of children under five years old (6-59 months) .................................................... 12 3.4 Mortality in Children and Adults ...................................................................................................... 14 3.5 Health, Water and Environmental sanitation .............................................................................. 14 3.6 Infant and young Child Nutrition (0-24 months) .............................................................................. 20 3.7 Household Food Consumption patterns and dietary diversity Score ................................................ 23 3.8 Household food security ................................................................................................................... 24 3.9 Socio-economic status ...................................................................................................................... 28 3.10 community participation and government/ NGO support ............................................................... 29

4.0 RECOMMENDATIONS ...................................................................................................................... 31 Figures Figure 1: Seasonal calendar for Greater Kajiado District ............................................................................. 6 Figure 2: Trends of Rainfall in Greater Kajiado District .............................................................................. 6 Figure 3: Distribution of Study population by gender (N=2968) ............................................................... 11 Figure 4: Reasons for not attending school (n=87) ..................................................................................... 12 Figure 5: Distribution of nutritional status of 6-59 months by sex (N=776) .............................................. 13 Figure 6: Prevalence of illness episodes among 6-59 months old children in April 2011 (N=339) ........... 14 Figure 7: Preferred Health Care Assistance (N=292) ................................................................................. 15 Figure 8: Distribution of Sources of water by household (N=594) ............................................................ 18 Figure 9: Proportion of breastfeeding children (0-24 months) consuming addition fluids (N=298) .......... 21 Figure 10: Meal frequencies by age category ............................................................................................. 23 Figure 11: Distribution of food items consumed by household members (N=594) .................................... 24 Figure 12: Prevalence of food group consumption by household (N=594) ................................................ 24 Figure 13: Main source of household foods (N=594) ................................................................................. 25 Figure 14: Coping strategy used by households in Kajiado county ( N=594) ............................................ 27 Tables Table 1: Summary results ............................................................................................................................. 5 Table 2: Distribution of sample divisions by districts .................................................................................. 7 Table 3: Distribution of focus group discussions held by livelihood ............................................................ 9 Table 4: Plausible check for anthropometric data ....................................................................................... 10 Table 5: Prevalence of acute and chronic malnutrition for children 6-59 months using WHO 2006 and NCHS standards .......................................................................................................................................... 13


4

Table 6: Nutritional status of caretakers (15-49 years) by physiological status. ........................................ 13 Table 7: Immunization, vitamin A supplementation and de-worming status ............................................. 17 Table 8: Distribution of Vitamin A supplementation by survey district .................................................... 17 Table 9: Breastfeeding practices ................................................................................................................. 20 Table 10: Distribution of child age by number of meals consumed using 24 hour recall .......................... 22 Table 11: Average ration size received per household ............................................................................... 25 Table 12: Distribution of food aid by district ............................................................................................. 26 Table 13: Wealth group characteristics ....................................................................................................... 28 Table 14: Distribution of livestock sizes ..................................................................................................... 29 Abbreviations

ALRMP - Arid Lands Resource Management Programme ANC - Ante-Natal Clinic ASAL - Arid and Semi-Arid Lands CMR - Crude Mortality Rate CSB - Corn Soya Blend CSI - Coping Strategy Index DSG - District Steering Group ENA - Emergency Nutrition Assessment FGDs - Focus Group Discussions GAM - Global Acute Malnutrition GOK - Government of Kenya HAZ - Height-for-Age Z-score IMAM - Integrated Management of Acute Malnutrition ITNs - Insecticide-Treated mosquito Nets MOA - Ministry of Agriculture MOMS - Ministry of Medical Services MOPHS - Ministry of Public Health and Sanitation MOH - Ministry of Health MUAC - Mid-Upper Arm Circumference PLW - Pregnant and Lactating Women SAM - Severe Acute Malnutrition SD - Standard Deviation U5MR - Under Five-Mortality Rate U5s - Children less than five years old WAZ - Weight-for-Age Z-score WHZ - Weight-for-Height/length Z-scores WHO - World Health Organization


5

Table 1: Summary results

Indicator May 2011 N % (95% CI)

Demographic data Total number of households assessed for nutrition and food security situation 594 Total number of Children (6-59 months) assessed for nutritional status 776 Total number of people in household assessed for mortality 4446 Total number of children ( under five ) in household assessed for mortality 1133 Average household size ( SD) 5.7 (SD± 2.1) Malnutrition GAM according to weight for height index in Z score or presence of oedema (WHO) 67 8.6 (6.7 - 11.0 ) SAM according to weight for height index in Z score or presence of oedema (WHO) 7 0.9 (0.5 - 1.8 ) Global Acute Malnutrition (NCHS) 62 8.0 (6.2-10.4.) Severe acute malnutrition (NCHS) 5 0.6 (0.2-2.1) Presence of Oedema 0 0 Global Acute Malnutrition for children 6-59 months by MUAC <12.5cm 41 5.3 (4.0-7.0) Severe Acute malnutrition for children 6-59 months by MUAC <11.5cm 3 0.4 (0.1-1.2) Proportion of children stunted (HAZ <-2) 153 19.7 (15.7 - 24.6 ) Proportion of children underweight (WAZ<-2) 94 12.1 (9.8 - 14.9 ) Proportion of female caretakers (15-49 years) malnourished ( <21cm) (N=556) 12 2.2 Mortality Under five mortality 3 0.30 (0.10-0.94) Crude mortality 9 0.23 (0.08-0.60) Health, water and Sanitation Children ill within the last two weeks (N=776) 292 37.6 Proportion of children with diarrhoea in two weeks prior to the survey 43 5.5 Proportion of children with ARI in two weeks prior to the survey 183 23.3 Proportion of children with fever and chills like Malaria in the two weeks prior to the survey 51 6.7 Proportion of children supplemented with Vitamin A within 6 months prior to the survey 458 60.8 Proportion of children immunised against measles 9-59 months 697 90.1

Children de-wormed in the past 6 months (24-59 months) (N=622) 225 36.2 Households with mosquito nets (N=594) 376 63.3 Access to safe drinking water ( treated water) N= 594 147 24.7 Average quantity of water(litres) per household per day (Mean SD) 40.8 SD±37.5 Access to toilet facility( N=594) 367 61.8 Infant and Young child feeding practices 0-24 months (N= 312)

• Given Colostrum (N=312) 232 74.4 • Given pre-lacteals within first 3 days (N=312) 263 84.3 • Exclusive breastfeeding (0-6 months) (N=75) 11 14.7 • Currently still breastfeeding (N=298) 227 76.2

Complementary feeding practices (6-24 months) • Children <6 months mean number of times/day n=15 (Mean SD) 4.07 SD± 2.30 • Children 6-8.9 months mean number of times/day n=35 (Mean SD) 2.60 SD±1.19 • Children 9-23.9 months mean number of times/day n=176 (Mean SD) 3.03 SD±1.20

Household food security/ Food aid Children (6-59 months) enrolled in selective feeding programs (N=776) 39 5.1 Household receiving general food rations in last 1 month (N=594) 45 7.6 Days food ration lasted ( Mean SD) 5.4 SD±9.2 HH consuming at least 3 meals (N=594) 409 68.9


6

1.0 INTRODUCTION

1.1 Background Information The Greater Kajiado comprises of three districts; Kajiado North, Kajiado Central and Loitoktok districts. It covers a total area of 21,900.9 Square kilometers, with an estimated population of 687,312 out of which 137,466 are children under five years old1. There are five different livelihoods namely; Pastoral, Agro pastoral, Pastoral/Leasing, Mixed farming and Formal employment/Casual waged labor/Business.

Figure 1: Seasonal calendar for Greater Kajiado District

Short Rains in Loitokitok Long Rains in Loitokitok This period is dry and dusty- with high temp Jan-Feb March - April -May Jun-July - Aug-Sept Oct - Nov - Dec Harvesting of beans Long Rains in Kajiado Central/North Short Rains in Kajiado Central/North &potatoes

The area is characterized by two rainy seasons that vary within the three districts, as shown in figure 1. The area saw a failure in the second season rainfall for 2010, as well as first season rainfall for the year 2011 (see Figure 2).

Figure 2: Trends of Rainfall in Greater Kajiado District

0

20

40

60

80

100

120

140

160

180

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Rainf

all a

mou

nt (m

m)

2003-2008

2010

2011

Kajiado County continues to receive food aid through WFP. March 2011 recorded 46,300 beneficiaries receiving a 75% ration, including maize, sorghum, pulses, CSB and vegetable oil. Most health facilities in the county run a supplementary feeding program whereby they distribute vegetable oil and CSB. This however excludes Namanga division and Mashuru location.

The average prices of maize, beans and posho, though higher than normal since January 2011, were reported to stabilize, at Ksh. 28, 100 and 30 per Kg respectively. For example, beans price is abnormally high compared to a long term mean of Ksh. 46/kg. Again price fluctuation for basic/staple food items contributes towards household food insecurity.

1 Kenya National Bureau of Statistics, 2010 Census


7

On the other hand, availability of milk at household level is on upward trend, with an average of 2.1L recorded across all livelihood zones. Also, livestock prices were on upward trend with most markets characterized by low livestock volumes and high prices. However, there was no crop income from most of the rain-fed crop growing areas, owing to the fact that there was total crop failure in the previous season2. This indicates a difference in household food security in the different livelihoods, with crop growing areas having less capability of obtaining food as compared to pastoralists; this is considering the fact that only a small proportion is receiving general food ration. No disease outbreak was recorded in the month of March 2011.

1.2 Survey Objectives

1.2.1 Overall Objective Establish the extent and severity of acute malnutrition, understand the causes and provide information for nutrition, food security and other related interventions

1.2.2 Specific Objectives 1. To estimate the current prevalence of acute malnutrition in children aged 6-59 months. 2. To estimate the current prevalence of acute malnutrition for pregnant and lactating women. 3. To estimate the retrospective crude and under five death rates and morbidity among under five

years children in the survey area. 4. To estimate Measles, Oral Polio vaccination and ‘Vitamin A’ supplementation for children 9-59

months and 6-59 months respectively. 5. To compare the overall nutritional changes with the previous GAM and SAM (2009 and 2011). 6. To assess the current food security situation of the surveyed population.

2.0 SURVEY METHODOLOGY Quantitative and qualitative methods were used to collect primary information while secondary data was collected from various sources such as locally available reports and relevant web-links. The primary data included anthropometric measurement, mortality data and structured interview with household respondents, most preferably caretakers to the targeted children. Local leaders and community members provided qualitative information through the focus group discussions. The actual primary data collection was conducted between 18th and 22nd April 2011 in the three districts of Kajiado County, which hold a total of seventeen administrative divisions (see table 1). Clusters surveyed were derived from these divisions. A list of specific clusters for this study is appended in annex 7 Table 2: Distribution of sample divisions by districts

Districts Divisions Total population Total U5 children % (N)

Kajiado North Magadi, Ngong, Isinya, Kitengela, Olturoto

387,538 77,507

Kajiado Central Central, Namanga, Bissil, Enkorika, Mashuru, Kinyewa

162,278 32,455

2 Arid Lands Resource Management Project II, Drought Monitoring Bulletin, March 2011.


8

Loitoktok Kimana, Lenkisim, Rombo, Entonet, Kuku, Mbirikani

137,496 27,499

2.1 Training Before the start of data collection, 6 teams were recruited and trained for the survey. Each team comprised of a team leader and two enumerators. Three supervisors- two from MOMS/MOPHS and one partner agency (Concern Worldwide) - were trained on how to collect qualitative data and supervise the data collection teams. The teams and their supervisors were trained on the objectives of the survey, instrument, interview techniques, questionnaire familiarization, anthropometric measurements and use of codes and recording of answers. A practical field experience was conducted after the classroom training; this was to pre-test the questionnaire and enable the interviewers to practically learn how to take anthropometric measurements of children and caretakers, conduct interviews and fill questionnaires. Pre-testing was performed on 18 households, which facilitated some changes on the questionnaire structure and calendar of events. Additionally, a team of four data clerks (precisely, 3 from Mercy –USA and 1 from ALRMP) were trained on how to use ENA for SMART and SPSS for Window data entry databases. Annex 1 provides a list of all the survey team members and respective clusters) the survey consultant trained and closely supervised all teams and offered technical support in the whole process during the survey.

2.2 Sampling methodology In order to obtain the required clusters and sample sizes for household interviews and mortality, ENA for SMART planning tool was used. The study subjects were selected using the two-stage cluster sampling methodology. The following parameters were used to calculate and determine sample size; Children under five = 137, 466, Estimated prevalence (June 2009 survey) = 11.5%, desired precision 3% and design effect of 2. This yielded 866 children under five years old and given a household size of 5 persons, about 578 households were selected for the survey. Mortality sample size was also determined using the following parameters; Children under five = 137, 466 and Population size = 638, 132; the prevalence for U5MR=0.56% and CMR=0.47%. To obtain the sample size; a desired precision ± = 0.30/10,000/day and design effect = 2.0 was used; this yielded a sample size of 4424 persons and 884 households.

2.3 Data collection procedures Similar to all integrated nutrition surveys conducted in Kenya, the assessment tools recommended by MOPHS and MOMS were used in this survey but with minimum adjustment to the household questionnaire to suit the needs of the district ( see Annex 2). Children’s data included age, sex, morbidity, immunization status, vitamin A supplementation, de-worming, anthropometric (weight, height MUAC) and presence of oedema. The nutritional status of caregivers (15-49 years) was assessed by taking MUAC measurement using the adult MUAC tape. To assess both crude and under five mortality rates, retrospective mortality data was collected from 884 households including households without children aged 6-59 months. Data collected include total persons per household (both above and under five persons), total deaths (all and under fives) from 15th of February to 15th of April 2011 (on average 90 recall days) See Annex 4 for mortality checklist. Causes of death in each household were also recorded.


9

Household information collected included household size, main occupation, school attendance for children between 5-17 years (boys and girls), household water sources and consumption, access to toilet facilities, use of mosquito net, infant and young child feeding practices, food consumption patterns and dietary diversity. All households enumerated for anthropometry in each cluster also provided household food security information, and sources of food, asset ownership, source of income, use of coping mechanisms and delivery of relief food. Coping strategy was determined and calculated as per The WFP Coping Strategies Index Field methods manual. In order to verify and validate the quantitative data collected through the structured questionnaires, qualitative data was collected through FGDs, of which clusters were randomly selected in each of the divisions based on the livelihood zones of the communities ( see annex 3 for FGD checklist). A total of 21 FGDs composed of between 8 and 12 people were conducted, however 1 group (women) from pastoral livelihood had 6 people; in each zone focus group discussions were conducted consisting of either men alone or women alone while 2 groups were mixed -consisting of both men women.

Table 3: Distribution of focus group discussions held by livelihood

Livelihood Type of focus group No. of FGDs held (8-12 members)

Crop farming Women 1 Pastoralists Men

Women Mixed

4 3 1

Agro- pastoralist Men Women

4 3

Semi- urban Men Women Mixed

2 2 1

2.4 Data Analysis In this study, there were four main sets of data gathered and analyzed in different statistical packages, these were; 1. Mortality data that was entered in excel and analyzed in ENA for SMART soft to determine death rates. The excel software was later used to determine the causes of death 2. Content analysis was performed for the qualitative data, precisely Focus group discussions and key informants, in a systematic way to establish patterns, trends and relationships from the information gathered. 3. Household data was keyed-in and analyzed in the SPSS for Windows version 11 software and 4. The ENA for SMART software was used for calculating nutritional indices. The software has WHO standards as the default settings and NCHS references. This study used WHO standards 2006 to present the actual nutritional status based on anthropometric data. 2.5 Quality control The survey teams were thoroughly trained and keenly observed during a pre-testing conducted on 18 households. In addition, the lead Consultant, assisted by experienced survey supervisors conducted close monitoring of household interviews, anthropometric measurements and recording throughout the survey period. During the data collection sessions, all anthropometric measurements were checked twice before


10

recording. At the end of every day, all the questionnaires were checked and any errors or omissions were sorted out immediately by team leaders and supervisors. Missing information necessitated the households to be re-visited. Close supervision of data entry was done by lead consultant on daily basis and data validated before actual analysis. Age of children was verified by health cards, however there was limitations related to age verification ( see section 2.6 for details) and for adults by use of national identity cards- in the absence of cards, a local calendar of event ( Annex 6) formulated by the local staff members was used to give estimates of the birth month and year. During data analysis, the ENA for SMART software flagged off anthropometric extremes (check of z-scores for plausible report from mean range -3.0 to +3.0). Potentially incorrect or out of range values like Sex, age, height or weight and respective z-scores were excluded from the analysis. Percentage of values flagged off with WHO flags was 0.1%. Summary report of plausible checks is presented in table 3. Triangulation of data was done to verify the findings of the quantitative data; this was done by collecting information through focus group discussions, key informants and observation. A field procedure guideline was also provided to the teams’ leaders and supervisors for reference (Annex 5).

Table 4: Plausible check for anthropometric data

Indicator Survey value Acceptable value/range

Interpretations

Digit preference - weight 5 0-10 Good

Digit preference - height 10 0-10 Acceptable

WHZ ( SD) 1.14 0.8-1.2 Acceptable

HAZ (SD) 1.13 0.8-1.2 Acceptable

WAZ (SD) 1.01 0.8-1.2 Acceptable

Percent of flags 0.1%

Age distribution (%)

Group1 6-17 0.99 0.8- 1.2 good

Group 2 19-29 0.91 0.8- 1.2 good

Group 3 30-41 1.09 0.8- 1.2 acceptable

Group 4 42-53 0.96 0.8- 1.2 good

Group 5 54-59 0.94 0.8- 1.2 good

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

0.98 0.8- 1.2 good

Sex Ratio P=0.773 Boys and girls equally represented

2.6 Study limitations This study encountered a large number of caregivers that were illiterate and hence could not determine the exact data of birth for their children. In addition, the survey teams (majority of who were from the ministry of health) found out that there was improper recording of child’s age. Although the teams verified age by use of a calendar of event and age charts, still care should be taken while interpreting age data. Notably, this concern was mentioned in the 2009 nutrition survey.


11

3.0 RESULTS AND DISCUSSION

3.1 Demographic characteristics of the study household The sampled 594 households of Kajiado County population constitute 2968 persons, of which 49.1 Percent are males and 50.9 Percent females. Children under five years obtained in this study were 800 (395 males and 405 female). On average, the mean household size was 5.7 (SD± 2.1) with a minimum of 2 people and a maximum of 14 people living in the same household. Several studies have shown that larger and poorer families in rural areas do not always have enough to eat because an increase in family size means a decrease in per capita calories in-take. An analysis of the age distribution indicated that there were more children below five years when compared to other age groups. Among the over five year olds, there were more persons in the age category between 20-40 years when compared to the older (>40 years) generation; inferring a good representation of the workforce in the county. Even so, the population pyramid is a typical representation of a developing country where the older generation are less and reversibly more of the younger generation (<10 years). This phenomenon implies a high dependency ratio and as such acquired resources are thinly distributed resulting to inadequacy especially for basic needs. The study population distribution is in figure 3.

Figure 3: Distribution of Study population by gender (N=2968)

About 88% of the under five year old children had their own mothers for caretaker, whereas another 4.9% had extended family relations such as stepmothers or other relatives. Some 3.9% of the children had grandmothers as caretakers and another 0.2% was adopted. The remaining 3% did not respond to this question. Regarding occupation of household members, out of the 1992 persons over five years, majority 60.8% were schools going children or college students, 10.7% were housewives, 15% casual laborers while another 8.1% engaged in petty trade. Among other occupations reported were livestock herding, domestic help, permanent employment, agriculture, sex worker (1 respondent) and selling charcoal/firewood.


12

Again, the study showed that 859 children were eligible for school going (5-18 years old), out of which (777) 90.5% were already enrolled and the rest did not attend school. The majority of respondents reported that the school going children did not go to school because either they had not been enrolled in primary school or simply did not attend due to lack of fees (for details refer to Figure 4). This was mainly so for children supposed to join higher levels or secondary education. Low school participation rate is often associated with poverty (typical of poor rural or urban poor settings) and sometimes ignorance by illiterate parents. Although this study did not look at the literacy level of study parents it is possible that irregular source of income (mentioned above) could simply not sustain the education level of most children in secondary school where parents are expected to pay fees.

Figure 4: Reasons for not attending school (n=87)

4.3

34.8

1.4 1.44.3

7.2

20.3

2.9 2.9 4.310.1

5.8

0.05.010.015.020.025.030.035.040.0

Percen

t of schoo

l age

children

3.2 Nutritional status of children under five years old (6-59 months) 3.2.1 Acute and chronic malnutrition

This survey found the prevalence of Global Acute Malnutrition (GAM) for Kajiado County to be 8.6 (95%CI 6.7-11.0) and Severe Acute Malnutrition (SAM) 0.9 (95% CI 0.5-1.8); overall boys appeared to be more acutely malnourished 9.2 % (95% CI 6.4 - 12.9) than girls 8.1 % (95% CI 5.5 - 11.9) although there was no significant difference, given that the confidence intervals are overlapping. Accordingly, the prevalence for stunting prevalence (<-2 z-score) was 19.7 % (95% CI 15.7 - 24.6) and prevalence of severe stunting (<-3 z score) at 2.3 % (95% CI 1.2 - 4.5). In this survey the stunting rates are much lower than that reported in 2009 by 33.9% (95% CI 28.0 – 40.3 95% CI). This difference is highly significant and perhaps could have been caused by age recall bias in 2009; this challenge was addressed and corrected in this study. In addition, the prevalence of underweight is 12.1 % (95% CI 9.8 - 14.9) and severe underweight is 1.0 % (95%CI 0.5 - 2.1) similarly, this findings are much lower than those obtained in 2009 survey at 25.6% (20.3 – 31.6 95% CI). The comparison of the nutritional status based on NCHS and WHO 2006 standards is represented in table 4.


13

Table 5: Prevalence of acute and chronic malnutrition for children 6-59 months using WHO 2006 and NCHS standards

Level of prevalence WHO 2006 (N=776)

% (95% CI)

NCHS standards N=773

% (95%CI) Prevalence of Global Acute Malnutrition (<-2 z score and /or oedema

8.6 (6.7-11.0) 8.0 (6.2-10.4.)

Prevalence of Severe Acute Malnutrition (<-3 z score and /or oedema

0.9 ( 0.5-1.8) 0.6 (0.2-2.1)

3.2.2 Nutritional status of 6-59 months children by sex Although more boys were noted to be more malnourished than girls at 9.2 %( 6.4 - 12.9 95% C.I.) and 8.1 % (5.5 - 11.9 95% C.I.) respectively this difference was not significant. It is therefore possible that both boys and girls are posed to similar risk factors of malnutrition. Figure 5: Distribution of nutritional status of 6-59 months by sex (N=776)

3.2.3 Nutritional status of children (12-59 months) and adults (15-49 years ) by MUAC

Analysis of nutritional status determined by MUAC indicated that 41 children had a MUAC measurement of below 125mm and only 3 children had a MUAC measurement of less than 115mm giving a prevalence of 5.3%(95%CI: 4.0-7.0) and 0.4% (95%CI:0.1-1.2) respectively. In addition, out of 556 caregivers (15-49 years), only 12 (2.2%) were found to have a MUAC measurement of < 21 cm (details in table 5). Further analysis to determine nutritional status of caregivers based on age indicated that out of the 44 caregivers reported to be at risk of malnutrition (21-22.9cm) about 61.5% of them were caregivers aged below 24 years and breastfeeding children 6-24 months.

Table 6: Nutritional status of caretakers (15-49 years) by physiological status.

Caretaker physiological status <18.4cm 18.5-20.9cm 21-22.9cm >23cm Total n % n % n % n %

Current pregnant 1 0.2 2 0.4 1 0.2 34 6.3 38


14

Breast feeding (<6 months) 0 0.0 2 0.4 11 2.0 59 10.6 72 breastfeeding (6-24months) 0 0.0 2 0.4 17 3.1 154 27.7 173 breastfeeding (above 24 months) 0 0.0 2 0.4 4 0.7 23 4.1 29 pregnant and Breast feeding 0 0.0 0 0.0 0 0.0 2 0.4 2 Not pregnant/not breastfeeding 0 0.0 3 0.5 11 2.0 228 41.0 242 Total 1 0.2 11 2.0 44 7.9 501 90.1 556

3.4 Mortality in Children and Adults Out of 884 households sampled for mortality data, a total of 4446 household members and 1133 children under five years were recorded. Of these households, 3 children under five years and 9 adults were reported to have died over a 90-day recall period, yielding a specific under five mortality rate of 0.30 (95% CI 0.10-0.94)/10,000/day and crude mortality rate of 0.23 (95% CI 0.08-0.60). These death rates were lower than what was reported in the 2009 survey. The limitation on this assessment was that the interviewees were not willing to provide information on deaths especially for children; therefore care should be taken while interpreting this data. The causes of deaths for adults were found out to be; accident, old age and other unknown causes; for the under five children, causes were vomiting, diarrhoea and other unknown causes.

3.5 Health, Water and Environmental sanitation 3.5.1 Episodes of illness for children (6-59 months) Common ailments of young children are various. This survey looked at the common ailments that affected the study children 6-59 months two weeks prior to the survey period. All 6-59 months old children were screened for illnesses, out of which 292 (37.6%) were reported to be ill two weeks prior the survey period. Common ailments were diseases of respiratory system, fever with chills like malaria, diarrhea and vomiting. Other illnesses reported include eye infections, boil, stomach ache; one case each of bloody diarrhea and measles were also reported. Some children had more than one illness, with 2.4% having a combination of watery diarrhea and vomiting. This led to a total of 339 illnesses being recorded in this survey, as shown in figure 6. The prevalence of illnesses compares well with MOPHS/MOMS records. Figure 6: Prevalence of illness episodes among 6-59 months old children in April 2011 (N=339)

12.7

5.3

15.6

54

0.3

2.7

3.2

2.1

0.6

0.3

2.4

0.9

0 20 40 60

Watery Diarrhoea

Vomiting

Fever with chills like malaria

Fever with cough and difficulty in …

Measles

Eye infection

skin infections

Stomachache

Toothache

bloody diarrhoea

others

ear infection

Percent

Common

Illne

sses


15

3.5.1 Health seeking behaviors In order to understand the care practices and management of a sick child, the health seeking behavior of the caretakers was also established. Majority of the caretakers 138 (47.3%) reported to have to have taken their children to the nearest public health facilities and 25.0% to private clinic/pharmacy; others bought drugs from the nearest pharmaceutical stores/kiosks, while a small proportion (1.4%) sought for assistance from a traditional healer. It was however noted that about a quarter of the caretakers (28.1%) did not seek for any health care assistance for the sick child. Still, out of the 43 children that had watery diarrhoea only 1(one) child was treated using zinc, while 20 (46.5%) received oralite solution. An even smaller proportion (0.2%) of children received home- made solution made from sugar and salt while the rest received milk, tea, porridge or just plain water. These coverage of children with diarrhoea and supplemented with zinc is way below coverage the recommended 80%. Figure 7 presents information on preferred health care options; but it is worth noting that some respondents sought for health assistance from more than one source, this largely depended on the accessibility and severity of the illness. Figure 7: Preferred Health Care Assistance (N=292)

1.4

25.0

5.1

47.3

3.1

28.1

2.1

0.3

0.0 10.0 20.0 30.0 40.0 50.0

traditional healer

Private clinic/pharmacy

Shop/kiosk

public clinic/hospital

Mobile clinic

No assistance sought

Local herbs

NGO/FBO

Percent

Additional information from the focus group discussions revealed that different health seeking behaviors vary with type of livelihoods. Caretakers from semi urban livelihoods reported preference of ‘government health facility as it is cheap, however some especially those with no money, seek no assistance, while others visit a nabii (prophet) for prayers, others go for herbs from waganga (herbalists)’- this is a custom in Maasai land. Others opt for private clinics ‘private clinics offer better services as opposed to government facilities’. ‘Our number one preference is the traditional medicine-Ndipilikwa/Silale- which is more effective and has no side effects such as vomiting. It is also affordable when there is no money, and readily available, given that health facilities are far away and roads are unreliable. Sometimes we have to wait for market days to take the children to hospital due to unreliable means of transport,’ caretakers from pastoralist livelihood. They added that health facility is visited only when no improvement is seen with traditional medicine; still, others who think they may be bewitched visit witchdoctors. ‘We take the children to CHWs since they are nearby, thus we are served faster, also handled well. Some visit private clinics due to good medicine provided. We opt for traditional medicine as first option


16

because government health facilities are far away and most children die on the way to the hospital’, caretakers from agro pastoralist livelihood. Another option was to visit a pastor for spiritual intervention (prayers), according to caretakers from farming livelihood. Hence the findings of this study regarding health seeking behavior should be taken into consideration and proper guidance provided when counseling caregivers on the care of a sick. 3.5.2 Malaria Prevention and Control This study revealed 376 (63.3%) of the households have a mosquito net. Only 18.3% of them admitted to have treated the nets, out of which 24.6% had treated the nets less than a month ago, and 42.1% between 1-6 months ago; 23.2% had treated their nets more than six months ago, while the rest could not remember when the nets were treated. Use of the mosquito nets varied among members of the households. About 28.3% caretakers said that the nets are used by children less than 5 years, 20.5% said by mothers only. It was noted that most households (30.8%) had everyone sleeping under the nets, while the rest did not use the nets at all. Additional information obtained from the focus group discussions to explain and support these findings indicated that some people do not use the nets because; ‘some are ignorant of net usage or their importance, others have no beds to put the nets on’, caretakers from semi urban livelihood. ‘House design does not allow us to put the nets-they are easily destroyed by smoke; some mothers do not attend ANCs hence are not given the nets, others are not aware of free ITN issuance in government facilities. Nets are worn out and not replaced, while other people visit private clinics which do not give free nets’, caretakers from pastoral livelihood.

For households where all family members were reported to use nets. ‘Some people keep the nets under mattresses to protect themselves from the aggressive bed bugs that attack them at night; sometimes the people do not even sleep in beds-they sleep outside the house as they cannot put up with the bed bugs in the house!’, caretakers from agro pastoral livelihood.

It was also found that some people do not visit hospitals due to religious reasons thus they do not receive any nets; ‘others do not use since the nets were not available especially for children above five years old -who were born before the program offering nets started’, caretakers from farming livelihood.

Given these findings, the policy of providing mosquito nets to vulnerable groups ought to be reviewed and appropriate counseling provided for proper utilization of the nets by deserving members of the family. Community campaigns should be supported and enhanced to ensure that the vulnerable groups such as pregnant mothers and children under five years use the nets at household level.

3.5.4 Immunization, vitamin A supplementation and de-worming status

Out of the 800 under five children screened, 674 of them were of the age category 9-59 months old and eligible for measles vaccination out of which 607 of the children had their immunization status affirmed either by recall or by health card. The coverage rate of 90.1% for measles is above the recommended EPI 80% . Even so about 9.6% of the caretakers said that their children had not received measles vaccination while another 0.3% did not know the measles immunization status for their children. This study reported


17

one case of measles ( see section 3.5.1), it is therefore possible that the reported case could be among the non- vaccinated group of children- hence the need to scale up measles vaccination campaigns. Table 6 presents the immunization status for these children. Table 7: Immunization, vitamin A supplementation and de-worming status

Yes Yes Total Card % Recall % %

Measles (n=674) 409 60.7 198 29.4 90.1 OPV1 (n=749) 528 70.5 211 28.2 98.7 OPV3 (n=743) 506 68.1 213 28.7 96.8 De-worming status (n=622) 70 11.3 155 24.9 36.2 Vitamin A supplementation (n=753)

Yes %

• No dose 295 39.2 • One dose 311 41.3 • Two doses 88 11.7 • Three doses or more 59 7.8

It was found that the prevalence rates for measles, OPV1 and OPV3 were above the recommended EPI coverage cut-off point of 80%, at 97.9% and 95.5% respectively. About 61.4% of the under five years had received vitamin A supplementation within the last one year. Children that have not received vitamin A supplementation have a low chance of survival as they face a risk of mortality from measles, diarrhea and other infections. The distribution of vitamin A supplementation varied with districts. Table 7 below shows the coverage of the distribution by district. The northern district appeared to have the highest number of children without vitamin A supplementation. Whereas, Kajiado South recorded the lowest number of two doses. Table 8: Distribution of Vitamin A supplementation by survey district (N=753)

District Total

Kajiado central Kajiado north Kajiado south

Vitamin A doses per year

No dose 63 157 75 295 One dose 74 152 85 311 Two doses 27 54 7 88 More than three doses 8 46 5 59

Total 172 409 172 753 Vitamin A and Iron supplementation for caregivers Out of 274 breastfeeding mothers interviewed during this study, a total of 148 (54.0%) said that they had received vitamin A supplementation. Also caregivers were asked if in their last pregnancy they had received any iron supplements. Out of 341 respondents 42.1% said that they had received iron pills, 0.2% iron sprinkles, 0.2% iron syrup and 5.1% said that they had received another form of iron supplements. This study was not able to establish the other type of iron supplements as it was merely relying on respondents re-call.


18

De-worming status Regarding de-worming status, only a small proportion (36.2%) of the children had been de-wormed, while for another 3.7% of the children, the caretakers did not know their de-worming status. Again worm infestation in children can produce nutritional deficiencies and anemia. Poor personal hygiene, consumption of unclean water and general environmental sanitation are very good vehicles for worm infestation. Lack of knowledge (due to low literacy level) by caretakers on how worms are transmitted and treated may also contribute to the low de-worming coverage. Notably, in this study it was found that rarely do health workers record the de-worming status in the health card neither is the caregiver informed whenever de-worming tablets are administered to the child. Given these findings, it is essential that the health care system is reviewed and de-worming campaigns initiated in the county. 3.5.5 Water safety and adequacy

Common water points for this population included; dams, unprotected wells, tap water, springs and boreholes found within or near 594 study households. Overall, tap and borehole water was reported to be the most common sources of water with 40.6% and 35.4% households respectively.

Figure 8: Distribution of Sources of water by household (N=594)

Unsafe water mainly from unprotected wells, dam, laga3, shallow pans was also utilized by about 6.1% of the households. Figure 8 shows the comparison between sources for water for drinking and general households use. Among the districts, Kajiado North had the highest number of people fetching water from taps and boreholes, with 168(28.3%) and 97(16.3%) respectively. Asked whether water is treated before consumption, majority of the respondents 446(75.1%) reported that they drink water without any treatment. A small percentage of respondents 100(16.8%) use boiling as a way of cleaning drinking water, 47(7.9%) use chemicals, and the rest filter/sieves. Unavailability of safe water and poor hygiene condition at household level is one of the underlying causes of malnutrition, as malnutrition is multi-causal. Consumption of untreated water could also be the cause of waterborne diseases such as diarhoea among the young children.

3 Local name for seasonal rivers

0

50

100

150

200

250

300

numbe

r of h

ouseho

lds

General Household use

Drinking


19

The distances to water point was not seen as an impediment to accessing water as majority (39.4%) of household members walk a proxy distance of less than 10 minutes to water point, while another 31.1% walk for 10-30 minutes to the water point. However, a considerable proportion (6.2%) reported spending between 60-120 minutes to the water point. It was also found that the majority (47.6%) spend less than 10 minutes at the water point; another 28.3% spend between 10-30 minutes. Majority (28.4%) of the households reported to use 60 liters of water per household per day. About 27.2% reported to use 40 liters, 16% used 80litres per household per day while 6.7% used 20litres; this translates to an average of 7-14litres (estimating household size of 5.7 persons) per person per day. This amount of water is not adequate because WHO recommends 20 liters per person in a day. However, the challenge faced in this community is that majority of the people (57.8%) have to buy water for their household use, while the remaining 42.2% of the households did not have to buy water as most were natural sources. For those who buy, the prices ranged between 1-30 shillings; while a few reported paying as much as 50 or 60 shillings per 20litre jerrican. Others said they contribute monthly, with the reported amounts ranging between 50-500 shillings per month.

3.5.6 Toilet accessibility, hygiene and environmental sanitation

Access to toilet facility was determined to assess hygiene and environmental sanitation. Out of 594 households, 367 (61.8%) have access to a toilet facility; this include pit latrines and ventilated improved toilets. Only one household had a flush toilet. The alternative methods that were used include bush, near the rivers, cat method. Others used neighbors’ or nearby hospital latrines. Some households claimed to have a latrine, yet when asked what type it was, they were referring to a bucket or basin as their toilet, in this case the faeces is disposed off at the nearest garbage area. The focus group discussions confirmed that majority of the people do not have access to latrines/toilets to dispose off their fecal waste. In semi urban areas, ‘some use latrines, though most latrines are full hence not in use, others use flying toilets, throw into the road or dustbins; children’s waste is disposed off by throwing into the toilets, while some people throw it into the dumping site or into dustbins to be discarded together with other wastes’. ‘Majority of the people use the bush, while some dispose the waste behind the house. Those near the town centre use toilets. For the children, it is either thrown into the toilet for those who access them, thrown into the bush or left in the open for dogs and chicken to clear out’ caretakers from pastoral livelihood.

‘Some people use the dispensary latrines’ caretakers from agro pastoralist livelihood but residing near health centers

When asked about hygiene practices when handling the child after defecation, the focus group discussions gave different responses based on the different livelihood zones. It was found out that among the pastoralist most people use unhygienic ways to clean the child after defecation; ‘some people use leaves, others old cloth, old mattresses or just empty hands, others use maize cobs while just about 10% use tissue paper’, caretakers from pastoral livelihoods.

Information from the household interviews indicated that nearly 99.6% of the caregivers claimed to wash hands after visiting the toilet, before eating, after cleaning the child’s faeces, before cooking and before eating food. It is clear that the caregivers were very much conversant with the personal hygiene messages. Only a very small proportion (0.4%) reported not to wash hands. Again majority ( 56.8%) of the caregivers reported that they use soap and water to wash hands, another 12.6% use water only while the remaining proportion use water and ash and other traditional materials. Additional information obtained


20

from the focus group discussion to verify these data indicated that most caregivers use unhygienic ways to dispose of faces as well as they do not often wash hands as reported. This misreporting is much more linked to caregivers providing knowledge information rather than actual practice.

‘Majority do not clean child after defecation, neither do they clean their hands because water is scarce and expensive. A few clean the child using newspapers; others use tissue papers’, caretakers from semi urban livelihood.

Men and women in the same livelihood were found to give conflicting information on whether caretakers wash their hands after handling the child. In the semi urban livelihood, men said that all caretakers do not wash their hands, while women claimed that 50% do it.

Similarly, pastoralist men claimed that only 10% of caretakers clean their hands due to scarcity of water, yet the women said that 80% of them do clean hands. The agro pastoralist men also said that ‘10% of the caretakers clean their hands while 90% do not clean their hands-‘they use grass instead’. In this same livelihood, women claimed that 100% do clean their hands after handling the child. The crop farmers also reported that majority (80%) do wash their hands with water and soap.

3.6 Infant and young Child Nutrition (0-24 months) 3.6.1 Breastfeeding Practices

The actual infant and young child feeding practices were assessed by asking the caretakers if the child was ever breastfed; out of 312 children 0-24 months, 95.5% were breastfed while the remaining 4.5% were never breastfed. The various reasons given include lack of milk, did not want to breastfeed and medical advice. Only one caretaker did not know whether the child was ever breastfed, this was a foster parent to the child. Of those breastfed, 21.5% were initiated within the first hour of birth while 3.7% did not know the time of initiation-these were probably caretakers and not the true mothers to these children. Of those who ever breastfed, 76.2% were still breastfeeding; it was also found out that 14.7% of the children were exclusively breastfed. This figure is lower than that reported in 2009 survey ( at a prevalence of 29.2%); this is probably because in 2009 the IYCF assessment tool had not yet been refined and there is a likelihood that the caretakers reported on knowledge rather than what was actually practiced.

Table 9: Breastfeeding practices

Characteristic Number Percent (%) Ever breastfed (n=312) 298 95.5 Initiated in 1 hr (n=298) 175 58.7 Initiated after 1 hour and less than 24hrs (n=298) 99 33.2 Exclusively breastfed (n=75) 11 14.7 Still breastfeeding (n=298) 227 76.2 From the focus group discussions, it was found out that some mothers do not breastfeed their children alongside complementary feeding. This is mainly due to failure to produce breast milk; ‘When milk dries up we have to introduce other foods’, caretakers from pastoralist livelihood.


21

The study also found out that some caregivers introduce the complementary foods because they consider it ‘Good for their health’ women caregivers from pastoral livelihood. Men from this same livelihood said that the reason is because ‘the women do not know the importance of breastfeeding’.

Other respondents from agro pastoralist livelihood said that the failure is due to mother being malnourished or sick, hence too weak to continue breastfeeding. ‘Mothers have to introduce other complementary foods to infants because they are away from home for casual labor’ Caretakers from semi-urban livelihood said.

3.6.2 Additional fluids consumed by children 0-24 months on continuous breastfeeding (N= 298)

In this study, breastfeeding children of age category 9-23.9 months received more of the additional fluids. The type of these fluids and respective proportions are presented in figure 9 below. Other fluids included both natural and artificial juices often given to these children as snacks.

Figure 9: Proportion of breastfeeding children (0-24 months) consuming addition fluids (N=298)

16.3

0.7 2.4 0 0.3 3.1

15.3

1

10.2

0.7 2.7

10

50.5

2.4

46.4

3.1

32.5

0

10

20

30

40

50

60

Perce

nt of chil

dren

0‐24

mon

ths

3.6.3 Complementary feeding practices (0-24 months)

Information obtained from caretakers regarding the number of times the children 0-24 months with continued breastfeeding fed on solid and semi-solid foods to make him/her full indicate that on average children less than 6 months consumed about 4 meals (SD± 2.28) while the 6-8.9 months received 2.6 ((SD± 1.19) and children 9-23.9 months consumed on average 3 meals similar to the rest of household members. Table 6 provides detailed information. The findings of this study are in-line with the national IYCN recommended proportion of breastfeeding children receiving minimum times or more of foods in a day (2 times for infants 6-8 months, 3 or more times for other breastfed children and 4 or more times for non-breastfed children. It is however, worrying to see that at least 15 children below 6 months were receiving foods and yet are supposed to be on breast milk alone.


22

Table 10: Distribution of child age by number of meals consumed using 24 hour recall (N=226)

Age category 1-2 meals 3 meals 4 meals .> 5 meals Mean (SD)

<6 months (n=15) 4 (2.2%) 3 (1.3%) 1 (0.4%) 6 (2.6%) 4.07 (± 2.28)

6-8.9 months (n=35) 19 (8.4%) 12 (5.3%) 1 (0.4%) 3(1.3%) 2.60 (± 1.19)

9-23.9 months (n=176) 55 (24.5%) 78 (34.5% 28 (12.4%) 15 (6.6%) 3.03 (± 1.20)

Additional information from the focus group discussions indicated that complementary feeding practices vary with type of livelihood. The poorest feeding practice was noted in semi-urban and pastoral areas; ‘Children are fed one to two times per day because at times the children are away from home visiting neighbors; other times the child is not fed because the caretaker just does not give the food or even eat it up themselves’ caretakers from pastoralist livelihood.

‘They are fed only once per day due to scarcity of food i.e. no money to buy food’; ‘It is because the child cries a lot due to hunger- they are not satisfied by breast milk alone’ Caretakers from semi urban livelihood.

‘It is because of poverty’ men from agro pastoral area; ‘We do not get enough money from our husbands’, women caretakers from agro pastoralist livelihood said.

Another group said that the children are fed 3 times a day, saying that they believe ‘This is enough for them’ women caretakers from agro pastoralist livelihood.

In order to know the diversity of complementary foods given to the infants, the focus group discussions were asked what they fed them on. It was found out that in all the livelihoods, most of them had a variety of foods every day, including mashed potatoes, matoke, pumpkin, ripe bananas, pawpaw and uji- (mostly maize flour) -only caretakers from agro pastoralist livelihood reported adding wimbi and millet to the maize flour for uji.

There were, however, some exceptions; ‘We only feed them with Ugali and sukuma wiki as no other food is available due to poverty’, caretakers from semi urban livelihood. Some of them reported giving CSB and vegetable oil when it is available (from the supplementary feeding program). Others reported giving ‘omena’ (Dagaa) to the children (pastoralist livelihood).

‘We add cream or oil to their food; the children get a chance to eat meat when a goat or sheep dies, said caretakers from agro pastoral livelihood.

It was clear that vegetables are not part of the complementary foods for majority of the caretakers: only those from farming livelihood reported giving vegetables to the children.

3.6.3 Mothers workload and child care practices This study went further to find out if mothers provide quality time for child care. Qualitative information obtained through focus group information indicated that cross cutting all the livelihoods, mothers are usually too busy to stay at home and take care of infants and young children.


23

‘mothers are busy with other chores like grazing or looking for water’ caretakers from pastoralist livelihood.

‘The mothers are busy with other household chores or away from home to do casual work’, caretakers from semi urban livelihood.

‘Mothers are busy with other household chores and fending for other family members; they are overworked and too tired to take care of the young children’. Others said that ‘The men are not supportive’, caretakers from agro pastoralist livelihood. Evidently, heavy workload is the main cause of inadequate time for child care. Hence, poor parental care for infants and young children in the study communities may have contributed towards child infections and malnutrition.

3.7 Household Food Consumption patterns and dietary diversity Score Caretakers in the 594 households assessed were asked about the frequency of intake of foods and drinks that children 6-59 months and other household members ate or drank within the last 24 hours (from morning of the previous day to the time they woke up in the morning of the survey day). Figure 10 shows the distribution of the number of meals consumed at household level and how this varies between different age groups. Only a very small proportion of children (24.5%) under five years were found to have taken foods and drinks more than 4 times in the previous 24 hours. Again 46.6% of the families usually take 3 meals daily. Of interest about 6.4% of children 6-23 months old had consumed only 1 meal in the previous 24 hours, and another 24.1% received 2 meals, which indicates inadequate food intake for this age group. Figure 10: Meal frequencies by age category

7296

70

10

97

251

102

6

157

375

313

0

100

200

300

400

<2 meals 3 meals 4‐5 meals 6 or more meals

Freq

uencies

6‐23 24‐59 >5 years

Regarding household dietary diversity, on average, most households (97%) were found to have consumed cereal based food such as ugali, githeri and Uji made out of maize flour. It was found that only a small proportion of households had consumed fruits and vitamin A-rich fruits and vegetables; also tubers, legumes, eggs and meat were notably not popular among the households. Figure 11 presents the various types of food items consumed within 24 hours of the interview date.


24

Figure 11: Distribution of food items consumed by household members (N=594)

4.7 6 7 9.2 9.518.3 23.5 29.2 32.2

47 54.6 59.7 65.7 70.484.4

97

0

20

40

60

80

100

120

Percen

t

The study found out that on average 44% of children 6-59 months consumed 4-5 food groups in a span of 24 hours and about 10% consumed more than 6 food categories. This proportion is much lower than the recommended national target of 70% for children 6-23 months that are expected to consume at least 3 or 4 food groups in a day. Figure 12 presents the prevalence of food group consumption as reported by caretakers. Figure 12: Prevalence of food group consumption by household (N=594)

30.7 40.8 9.9

33.5 46.4 11.3

35.2 48.3 11.4

0%

20%

40%

60%

80%

100%

Low DDS ( <3 foods) Medium DDS ( 4‐5 foods) High DDS (>6 foods)

6‐23 24‐59 >5 years

3.8 Household food security 3.8.1 Household food sources Most of the households got their food from the market (97%) while a considerable amount of milk, eggs and meat ( 24%) were from own production; a very small proportion of cereals (0.5%) and fats/oils (0.2%) were obtained from free relief food. This is just a small fraction (0.6%) out of the 6.1% who had claimed to have received food aid in the last 3 months, (see section 3.8.2.) and most probably the only proportion of respondents with some relief food. All fruits and most vegetables were bought from the market, this findings support the information obtained from Ministry of Agriculture indicating that due to


25

poor rainfall, majority of the households were purchasing vegetables from the local markets. Figure 13 have details of the sources of the other foods.

Figure 13: Main source of household foods (N=594)

93.1 99.6 98.8 100 99.7 97.1 98.3 99.5 99.468.4

98.2 100 95.7 99.7

0.8 1.2 1.4 2.3 0.5

21.4

0.7 1.9 0.3

Percen

t

Food group

Market Own productionMarket and own production Gifts and relatvies and friendsFood for assets Food for relief

3.8.2 General food distribution

Regarding general food distribution, this study found out that 36 (6.1%) out of the 594 households assessed had received food aid in the last 3 months; out of these, 19.4% had received it within the last 1 month, 38.8% between 1-2 months and the majority (41.7%) in more than 2 months ago. Table 11 shows the main foods received and the average amounts received per person per household.

Table 11: Average ration size received per household

Type of food Average amount (kg) received per person Maize 16.9 Beans 3.1 Oil 1.2 CSB 0.7

Other foods received include salt, sugar, sorghum and rice. The amounts of food items received per person per month varied and more or less depended on the donor agency. Table 12 shows the number of households that received food aid in each of the districts, majority of which were from Kajiado North; they received food aid from Agro German, GOK, MIDI, NIA or Compassion; the small proportion who received food aid in Kajiado Central had received it from church and while those from Kajiado South received from Agro German. Most of this food was consumed by household members and a small proportion shared with it with kins. Only 1 (one) household was reported to have sold half a kilogram of the food (specifically maize) in the market. No food was bartered for other items, neither was any saved for seed.


26

Table 12: Distribution of food aid by district

Food last received Kajiado Central Kajiado North Kajiado South Total (%) <1 month - 7 - 7 (19.4) 1-2 months 3 11 - 14 (38.9) >2 months - 12 2 15 (41.7) Total 3 30 2 36 (100)

‘Most of it is utilized by family members while part is shared out-it is our culture to share with those who have nothing’, caretakers from farming livelihood.

This mode of food aid utilization is a clear indicator that the need for relief food was high at household level. The alternative sources of food when the food aid did not last for a month were buying and borrowing, while others stayed without food. Most holds reported that they had bought maize flour, beans, sugar, rice, wheat flour, vegetables and fruits.

Information on relief food supply from the focus group discussions revealed that there were differences in the amounts of food items received with some claiming dissatisfaction from the same; ‘Each household receives 4 kilograms of cereal per month, which is hardly enough to last for a month, furthermore only 2% of the population benefits from this food; there is a haphazard distribution of the food at the chief’s office, also the beans do not cook completely hence we do not fully utilize them. We sometimes sell part of the food to buy vegetables’ caretakers from semi urban livelihood.

‘Each household receives 10 kilograms each of beans, rice and sorghum to last for one month; most of it is utilized by family members while some is shared with neighbors and friends who do not have any; some is sold to pay the maize millers and buy sugar or salt. For the CSB and vegetable oil (which is given to targeted individuals), it is given as per instructions but sometimes it is shared amongst other children’, caretakers from pastoral livelihood.

3.8.3 IMAM programs

This survey endeavored to assess the coverage of nutrition interventions by finding out how many of the assessed children were also currently enrolled in the programs. Out of the 776 children aged 6-59 months, only 18 were enrolled in a supplementary feeding program, while another 21 were in a therapeutic feeding program, giving an estimated coverage of 35% and 80% for SFP and OTP respectively.

Progress reports from Mercy-USA Nutrition program that mostly covered the Kajiado North and parts of Central, indicated that by end of April 2011, 187 Pregnant and lactating women and 633 children under five years were still enrolled in the supplementary program. In addition, a total of 163 severely malnourished children were receiving treatment in the out-patient program and only 1 child with severe malnutrition and medical complication was still admitted in the in-patient therapeutic program. On the same note, reports from Concern Worldwide -agency supporting MOPHS/MOMS to implement IMAM program in Kajiado central and south showed that by end of April 2011 a total of 98 children under five years were admitted in OTP and no child was admitted in the In-patient program. Also, in the supplementary feeding program there were 449 children under five years and 100 pregnant and lactating .


27

In Kajiado county there are 137, 466 children under five years old. The findings of this study showed that the total prevalence of malnutrition as GAM is 8.6% (95%CI: 6.7-11.0) and SAM is 0.9% (0.5-1.8). Based on these findings the number of severely malnourished children expected to be enrolled in Therapeutic feeding programs is estimated at 618 (estimates based on 50% coverage). While for the moderately malnourished children it is estimated at 5,292 children (estimates based on 50%). These figures outwardly mark out the need for continuous support for IMAM program through the health facility in the county.

3.8.4 Coping strategies Index

As indicated in the figure 14, on average 54.8% of the households limited the variety of foods and similarly swapped consumption for less preferred cheaper foods (54.6%). This was followed by households reducing number of meals in a day (48.9%), worrying about food (48.9%) and purchase food on credit (48.6%). These coping strategies were categorized as least severe and moderate during the focus group discussion. Results also showed that a few proportion of the households used the severe and very severe coping strategy. Example of the severe coping strategies included consumption of seed stocks, individual migration out of the area and sending households to eat elsewhere. While the very severe CS included consumption of toxic plants, households migrate out of the area, abandonment of children and family. Figure 14: Coping strategy used by households in Kajiado county ( N=594)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Have you ever worried that your household did not have enough food

Skip food consumption for an entire day

Limited the variety of food

Feed working members at expense of non‐working

Borrow food from a friend or relative

Consume wild foods (normal wild food)

Consume toxic/taboo foods ( Acacia, bitter fruit etc)

Send household members to eat elsewhere

Begging or engaging in degrading jobs

Household migration out of the area

Sale of milking livestock

Disintegration of families

Part of family migrate with livestock looking for grazing

Relative Frequency Never Relative Frequency Hardly ( Once per week)

Relative Frequency Sometimes ( Twice per week) Relative Frequency Often ( 3‐6 times per week)

Relative Frequency Every day (All the time) ( 3‐6 times per week)


28

3.9 Socio-economic status

3.9.1 Sources of income

In this study, respondents were asked to list their household sources of income for the previous three months in the order of importance. Majority said that the main source of household income was waged labour (40.4%), followed by sale of livestock at 17.5%, then petty trade 15.3%. income from sale of livestock products and salary considerably contributed towards income for some of the households; whereas a considerable 8.8% had no source of income at all. Among sources recorded as others include cash for work, selling charcoal, firewood, ration food or fish and hiring out land.

3.9.2 Wealth Ranking

Focus group discussions were asked to divide themselves into different wealth groups and come up with the proportion of wealth groups. It was not easy to get an accurate estimate of wealth group characteristics and the breakdown between the wealth groups, as there was a big variation in the responses among the focus groups in the different livelihoods. Table 13 shows that livestock is the main form of asset for majority of the livelihoods except for farmers- whose mark of wealth is the size of land owned- and semi urbans whose mark of wealth is assets, activities engaged in or businesses owned.

Table 13: Wealth group characteristics

Livelihood Characteristics Rich/Better of Medium Poor

Semi urban % of total population 20 10 70

Assets Plots (rental), car Live in own house TVs, radios, beds

Live in rent houses Many children

Other activities Established businesses Give wage jobs

Salaried Work for the rich Do odd jobs

Local name Sonko/ Mbuyu Tusonko Mosmos Maskini

Pastoral % of total population 20 20 60

Livestock >100 cows (or 5-10 cows)*, 20 goats

20 cows (or 3-10 cows) 1 cow, 5 goats (or a few shoats, no cow)

Assets Many vehicles, shop, car Nothing

Other activities Good farmers->10 acres 10 acres farming land or working class

In animal selling business

Local name Ornasis Orkasis (Orkitkasis) Laisinak (Olaisinan)

Agro pastoral % of total population 30 30 40

Livestock >50 cows (or 5-10 cows) 5-30 cows (or 1-5cows) Nothing/ no income

Assets Big business, plots, car or large farm (1000 acres)

- Many children


29

Local name Orkasis No term, sometimes share with the poor

Olaisenani

Farming % of total population 10 35 55

Assets 50-100 acres land 20-50 acres <5 acres

3.9.3 Household assets, land and livestock sizes

The survey results show that the most common assets included; Farm inputs (specifically hoes, sickles and axes), household furniture (bed, chair/sofa sets), Radios, cell phones and paraffin stoves. Regarding farmland, only 29.8% of respondents reported to own farm, out of which 54.2% reported cultivating land sizes of one acre or less; another 26% reported to own farm sizes ranging between 1.5-3 hectares, 10.7% owned between 3.5 to 9 hectares, while 9.1% owned 10 or more hectares. On average, about 55.4% of the households reported to keep five or less livestock animals; see Table 14 for other details.

Table 14: Distribution of livestock sizes

Number(Range)

Cows (n=224 ) %

Camel (n=9) %

Sheep (n=222) %

Goats (n=250) %

Chicken (n=146) %

Donkeys (n=99) %

<5 59.3 55.5 41.8 38 47.9 89.9 5-10 25.9 33.3 28.4 25.6 34.9 7.1

11-20 4.5 11.1 11.7 16.4 9.6 3 21-50 8.5 Nil 10.4 12.8 4.8 Nil

51-100 0.9 Nil 6.3 6.4 0.7 Nil 101-200 Nil Nil 0.5 Nil 1.4 Nil

>200 0.9 Nil 0.9 0.8 0.7 Nil

Asked whether the animals had increased or decreased within the last season, 34.7% reported that the animals had increased and this was mainly due to new births; a few claimed they had bought more livestock. Whereas 6.1% said the animals declined because of selling or deaths caused by drought or diseases. Still, some (1.2%) said their livestock had all been wiped out, mainly due to deaths caused by drought.

3.10 community participation and government/ NGO support

When the focus group discussions were asked how they think the government and non governmental organizations can assist them recover from the current food insecurity, they said that ‘They can help us by providing clothes, finance our children’s education, make better the food relief supply as well as make water available for kitchen gardening. They can also help by establishing factories which can create job opportunities for the community’, caretakers from semi urban livelihood. They also said that they themselves can solve this problem by ‘Looking for employment such as any odd jobs available or ‘Kazi Kwa Vijana’ Initiative and cultivating land if water is available.


30

‘We have been discouraged on farming due to lack of rains but if boreholes are provided, we can assist ourselves by doing farm work and afforestation. We can also help raise funds for the boreholes construction’, caretakers from pastoralist livelihood said. They further said that the government and NGOs can assist them by restocking their dead cattle, creating market for farm produce, control of food prices, control of animal-human conflict, as well as construction of roads for easy access to the area. ‘They should also fight corruption, subsidize farm inputs, provide bursaries for our children’s school fees and put up school feeding programs. We, on the other hand, can assist ourselves by donating cattle to the poor and involve in income generating activities if financial assistance is provided’.

Those from agro pastoralist livelihood gave their views including, ‘providing tractors for tilling land and educate us on modern agriculture technology. There should also be control of fuel and food prices, provision of fuel-saving jikos and fighting FGM. We shall do our part by constructing food storage facilities and also wish that men could assist women’.

‘The government should assist us by buying the emaciated cattle from farmers, compensate us on the losses, and provide food for cash and planting trees. We should assist ourselves if we avoid selling green maize and beans as well as take care of the needy amongst us’, caretakers from farming livelihood said.


31

4.0 RECOMMENDATIONS Nutrition and health interventions Nutrition

• Continue Supporting MOPHS/MOMS to implement IMAM program • Specifically enroll all malnourished pregnant and lactating mothers of children below six months in

selective feeding programs. • Support MOPHS/MOMS to expand coverage of Community IMAM in areas not yet targeted • Continue targeted food distribution to poor and vulnerable households; review the food aid

distribution system to ensure the most vulnerable are protected. Health

• Support and streamline immunization and essential micronutrient supplementation implementation processes in the county in order to increase coverage; expecially for Vitamin A supplementation for under five years and breastfeeding mother and Iron for pregnant women

• Train and equip more community health workers on management of common ailments especially in areas where health facilities are situated far

• Support and continue mobile clinic services to reach out to communities not yet targeted. • Encourage the continued use of Insecticide Treated mosquito Nets (ITNs) and support distribution in

areas and or population not yet targeted. Also, replace ITNs to households with already old or torn nets.

Nutrition education

• Support the implementation of strong awareness campaigns and community education programme on infant and young child feeding practices, food preparation, and dietary diversity, consumption of protein and micronutrients rich food and vegetable gardening.

• Intensify and support the formation of women groups to be used as entry points for nutrition education program, Nutrition education messages passed to the women needs to focus the topics above and on improving access to cheaper sources of proteins and micronutrients. Include demonstration sessions as an integral part of the community training package

• Intensify community-based nutrition education programme to the general community including the male population who are the main decision makers.

• Intensify training in community health workers by using the OJT guide ( recently developed) for HINI,

Water and sanitation

• Continue supporting the government efforts in construction of safe water sources like protected water well and tapped water.

• Continue supporting the distribution of water purifiers • Support programmes that improve communities’ knowledge on hygiene and sanitation such as

community education programs, WASH programs in schools and communities.


32

Agricultural and livestock interventions

• Livestock being the most appropriate livelihood in terms of cultural preference, economic sustainability and environmental considerations, continue implementing animal health, increase access to dry season grazing areas by increased availability of water in areas with pasture potential, Increase opportunities for marketing of livestock.

• Continue support and promote water harvesting and irrigation programs. • Ensure households with malnourished children are included in all targeting exercises for food

security and income diversification interventions • Promoting kitchen or backyard gardening. The promotion package should include a community

education on the importance of consuming fruits and vegetables • Promote improved agriculture practices like water and soil conservation, crop diversification and

farming practices using ‘school gardening programs and/ or apply the best farmer model. • Support and promote seed stocking program • Support capacity building for farmers and livestock herders • Promote re-stocking exercise for the poor and very poor households at the same time encourage de-

stocking for communities and households with very large animal size Community economic empowerment

Empower women through supporting their income generating initiatives like small animal rearing, (chicken), animal oil production, vegetable gardening and petty-trade activities.

Promote more mother-focused income generation schemes for households that have under five old children to improve the nutritional status of children in particular and the household in general.

Monitoring and Evaluation

Support and continue strengthening early warning systems, nutrition and health monitoring and supervision systems both at the district level and community level in order to ensure that nutrition and health, water and sanitation and food security programs are implemented effectively.

Documents

Kajiado Nutrition Survey May 2011Final report Survey... · 2018. 3. 23. · Kajiado County Integrated Nutrition and food security survey report (May 2011) 6 1.0 INTRODUCTION 1.1 Background