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SQUEAC REPORT
Chalbi District, Marsabit County,Kenya
Samuel Kirichu, October 2013
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ACKNOWLEDGEMENTS
This assessment was carried out with the participation of many partners at different levels who
are highly acknowledged.
Much appreciation goes to the Ministry of Health for the direct participation during the
entire exercise. Special, mention is due to the DHMTs, Nurses, CHEWs and CHWs who
were involved during the entire assessment in data collection, compilation and analysis.
The Chalbi Concern Worldwide Team who included Kassim Lupao and Leonard Kariama
are highly appreciated for their active participation during the entire process
Special gratitude goes to the members of the community who included the community
leaders, religious leaders, caregivers, beneficiaries and the traditional healers and
traditional birth attendant for accepting to provide the information once they were visited
by the assessment team.
Many acknowledgements are due to the National Nutrition Information Working Group
for their technical inputs before, during and after the assessment.
Last but not least, I appreciate the support offered by Joseph Njuguna the Survey Assistant
who spent tireless nights in entering, analysing and collating the data collected on daily
basis in addition to the supervisory roles that he played throughout the assessment period.
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EXECUTIVE SUMMARY
Chalbi (Marsabit North) District is one of the 5 districts in Marsabit County, in Northern Kenya. The
district is currently part of the North Horr Sub-County. The district boarders Ethiopia to the North,
North Horr District to the North West, Loyangalani District to the South West, Marsabit Central and
Laisamis to the South, Sololo to the East and Isiolo County to the South East. The district has an
estimated population of 32,0001 where the proportion of the under 5 years old is 13%. The major
livelihood in the district pastoralism which accounts to approximately 85%2 with the major livestock
being cattle and goats though camels are also kept. The district receives bimodal rainfall pattern
with long rain received in March to May and short rains between October and December.
Since October 2011, Concern Worldwide has been supporting the Ministry of Health in scaling up of
High Impact Nutrition Interventions (HiNi) for improved nutrition in children and women in Chalbi
District. The goal is to contribute to reduction in mortality and chronic malnutrition in children aged
0 to 5 years. The interventions are in line with the priorities outlined in the nutrition sector
partnership framework which supports scaling up of HiNi, supporting the MoH to deliver essential
nutrition services through cost effective and feasible interventions in prevention of malnutrition.
Among the key activates include the integrated management of acute malnutrition. Currently
Concern Worldwide is supporting 7 facilities in Chalbi out of the 8 facilities which are available in the
district
The August 2013 SMART Survey conducted in the area by Concern Worldwide and the Ministry of
Health found that the Global Acute Malnutrition Rate was 15.9% which was classified as critical and
the Severe Acute Malnutrition Rate was found to be 3.4%. However, the Integrated Management of
Acute Malnutrition (IMAM) monthly data was recording low admission in the same period. For
instance, the Outpatient Therapeutic Program (OTP) registered only 21 admissions Between May
and August while the Supplementary Feeding Program (SFP) registered only 108 admissions
between June and August 2013. With this in mind it was recommended by the SMART Survey that a
coverage assessment be done in the area to identify the specific barriers to both programs. The Map
below shows the prevalence of GAM in Marsabit County
This coverage assessment applied the SQUEAC Methodology. The methodology is semi-quantitative
implying that it uses both qualitative and quantitative approaches. The SQUEAC Methodology is
designed to be conducted in three phases which include Stage 1, Stage 2 and Stage 3. Stage 1
involves identifying areas of low and high coverage as well as reasons for coverage failure using
routine program data, any other existing data and qualitative data. Stage 2 involves, confirming the
location of areas of high and low coverage and the reasons for coverage failure identified in stage 1.
This is done using the small studies, small surveys and small-area surveys. Stage 3 involves providing
an estimate of overall program coverage using Bayesian techniques. The SQUEAC methodology was
designed to be low resource in terms of financial and human resources. The coverage assessment
was conducted between 24th September, 2013 and 18th October, 2013. In total, there were 16
participants who were involved in the collection of the both qualitative and quantitative data. The
participants were all drawn from the Ministry of Health and included 2 DHMT members, 1 PHO, 3
1KNBS
2August, 2013 SMART Survey Report by Concern Worldwide
4 | P a g e
OTP Nurses, 3 CHEWs and 7 community health workers among other local guides who also
participated during the small and wide area survey. In addition, 2 program staff participated in the
assessment.
The coverage assessment established that the SAM Coverage in Chalbi District was 20.2% (10.7%-
35.2%) which is below the 50% recommended by the SPHERE standards for ASAL program.
Additionally, the MAM coverage was found to be 29.7% (20.2% - 41.4%) which is also below the
targeted 50%. The results above show that both the SAM and the MAM coverages were low and
below the SPHERE Standards. The major barrier to both the SAM and MAM coverage were Poor
Community Level Activities, Poor Service Delivery at SDP and Health Management, Misconception
about the IMAM Program, Knowledge of Malnutrition, Poor Health Seeking Behaviour, Distance,
Cultural Factors/Festivals, Stigmatization, RUTF Side Effects.
Based on the finding of the study, the following recommendations were developed: Implementation
of the community strategy, Increase awareness of malnutrition and program in the community,
Involvement of key actors in the community in the nutrition program, Improve the integration of
health services delivery at the SDPs, Scale up outreach services in the district, Improve service
delivery at all levels, Improve supervision and monitoring at the facility and community level, Issue
adequate ration to cover beneficiaries in times of festivities, Conduct regular mass screening and
active case findings, Capacity building to health workers during supervision visits, Active involvement
of all health workers during distribution days
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CONTENTS 1.0 INTRODUCTION ---------------------------------------------------------------------------------------------------- 7
1.1 CONTEXT --------------------------------------------------------------------------------------------------------- 7
1.2 IMAM PROGRAM IN CHALBI DISTRICT, MARSABIT COUNTY ---------------------------------------- 9
2.0 OBJECTIVES ---------------------------------------------------------------------------------------------------------- 9
3.0 METHODOLOGY ---------------------------------------------------------------------------------------------------- 9
4.0 RESULTS ------------------------------------------------------------------------------------------------------------- 10
4.1 Outpatient Therapeutic Program (OTP) ----------------------------------------------------------------- 10
4.1.1 Program Data Analysis --------------------------------------------------------------------------------- 10
4.1.1.1 Admission Trends ------------------------------------------------------------------------------------ 10
4.1.1.2 MUAC on Admission -------------------------------------------------------------------------------- 11
4.1.1.3 Exit Trends -------------------------------------------------------------------------------------------- 12
4.2 Supplementary Feeding Program (SFP) ------------------------------------------------------------------ 14
4.2.1 Program Data Analysis --------------------------------------------------------------------------------- 14
4.2.1.1 Admission Trends ------------------------------------------------------------------------------------ 14
4.2.1.2 MUAC on Admission -------------------------------------------------------------------------------- 15
4.2.1.3 Exit Trends -------------------------------------------------------------------------------------------- 15
4.3 Hypothesis Testing and Small Area Survey -------------------------------------------------------------- 16
4.3.1 Outpatient Therapeutic Program (OTP) ----------------------------------------------------------- 17
4.3.2 Supplementary Feeding Program (SFP) ----------------------------------------------------------- 18
5.0 Summary of Barriers, Boosters and Recommendation -------------------------------------------------- 29
Outpatient Therapeutic Program – Barriers and Boosters ------------------------------------------------------- 29
Barriers: ------------------------------------------------------------------------------------------------------------------- 29
Boosters: ------------------------------------------------------------------------------------------------------------------ 31
Supplementary Feeding Program – Barriers and Boosters ------------------------------------------------------- 32
Barriers: ------------------------------------------------------------------------------------------------------------------- 32
Boosters: ------------------------------------------------------------------------------------------------------------------ 33
SFP Histogram: ----------------------------------------------------------------------------------------------------------- 33
SFP Concept Map: ------------------------------------------------------------------------------------------------------- 34
Recommendations --------------------------------------------------------------------------------------------------------- 35
Action Points----------------------------------------------------------------------------------------------------------------- 35
6.0 Appendices --------------------------------------------------------------------------------------------------------- 37
6.1 SQUEAC Coverage Survey, Chalbi Kenya, Concern WW --------------------------------------------- 37
6.2 Questionnaire for Caretakerswith cases not in the program --------------------------------------- 37
6.3 SQUEAC Coverage Survey, Chalbi Kenya, Concern WW --------------------------------------------- 40
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6.4 Questionnaire for Care takerswith cases not in the program -------------------------------------- 41
6.5 List of Participants--------------------------------------------------------------------------------------------- 43
6.6 Map of Chalbi -------------------------------------------------------------------------------------------------- 44
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1.0 INTRODUCTION
1.1 CONTEXT
Chalbi (Marsabit North) District is one of the 5 districts in Marsabit County, in Northern Kenya. The
district is currently part of the North Horr Sub-County. The district boarders Ethiopia to the North,
North Horr District to the North West, Loyangalani District to the South West, Marsabit Central and
Laisamis to the South, Sololo to the East and Isiolo County to the South East. The district has an
estimated population of 32,0003 where the proportion of the under 5 years old is 13%. The major
livelihood in the district pastoralism which accounts to approximately 85%4 with the major livestock
being cattle and goats though camels are also kept. The district receives bimodal rainfall pattern
with long rain received in March to May and short rains between October and December.
The district experiences poor health and nutrition outcomes which are mainly attributed to poor
access to critical health services. Other major factors contributing to high malnutrition rates in the
district include chronic and acute food insecurity due to erratic or poor rainfall, poor dietary
diversity and low purchasing power due to eroded capacity by seasons of successive droughts, and
also worthy to note is suboptimal child care and feeding practices and poor practices related to
hygiene and sanitation, cultural beliefs and low access to essential health services also plays a major
role in nutritional status of children in this district. For instance, various nutrition surveys done in the
district and the former larger Marsabit district have shown high malnutrition rate. A SMART Survey
conducted in May 2011 showed a GAM rate of 27.4% which was very critical while a SMART Survey
conducted in June 2012 showed a GAM rate of 10.7% which was serious and in August 2013 the
GAM rate was found to be 15.9% which again was classified as critical.
The August 2013 SMART Survey conducted in the area by Concern Worldwide and the Ministry of
Health found that the Global Acute Malnutrition Rate was 15.9% which was classified as critical and
the Severe Acute Malnutrition Rate was found to be 3.4%. However, the Integrated Management of
Acute Malnutrition (IMAM) monthly data was recording low admission in the same period. For
instance, the Outpatient Therapeutic Program (OTP) registered only 21 admissions Between May
and August while the Supplementary Feeding Program (SFP) registered only 108 admissions
between June and August 2013. With this in mind it was recommended by the SMART Survey that a
coverage assessment be done in the area to identify the specific barriers to both programs. The Map
below shows the prevalence of GAM in Marsabit County
3KNBS
4August, 2013 SMART Survey Report by Concern Worldwide
8 | P a g e
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1.2 IMAM PROGRAM IN CHALBI DISTRICT, MARSABIT COUNTY
Since October 2011, Concern Worldwide has been supporting the Ministry of Health in scaling up of
High Impact Nutrition Interventions (HiNi) for improved nutrition in children and women in Chalbi
District. The goal is to contribute to reduction in mortality and chronic malnutrition in children aged
0 to 5 years. The interventions are in line with the priorities outlined in the nutrition sector
partnership framework which supports scaling up of HiNi, supporting the MoH to deliver essential
nutrition services through cost effective and feasible interventions in prevention of malnutrition.
Among the key activates include the integrated management of acute malnutrition. Currently
Concern Worldwide is supporting 7 facilities in Chalbi out of the 8 facilities which are available in the
district.
2.0 OBJECTIVES
The following were the objectives of the coverage assessment
1. To identify the barriers and the boosters which influence the OTP coverage
2. To determine the OTP program Coverage
3. To build the capacity of MoH staff on program coverage methodology
4. Develop feasible recommendations to improve the coverage and performance of IMAM
program
3.0 METHODOLOGY
This coverage assessment applied the SQUEAC Methodology. The methodology is semi-quantitative
implying that it uses both qualitative and quantitative approaches. The SQUEAC Methodology is
designed to be conducted in three phases which include Stage 1, Stage 2 and Stage 3. Stage 1
involves identifying areas of low and high coverage as well as reasons for coverage failure using
routine program data, any other existing data and qualitative data. Stage 2 involves, confirming the
location of areas of high and low coverage and the reasons for coverage failure identified in stage 1.
This is done using the small studies, small surveys and small-area surveys. Stage 3 involves providing
an estimate of overall program coverage using Bayesian techniques. The SQUEAC methodology was
designed to be low resource in terms of financial and human resources.
The coverage assessment covered the entire Chalbi District. The district has a projected population
of 32,000 where approximately 6,000 are children under the age of 5 years. The coverage
assessment was implemented by the MoH with the technical and logistical support from Concern
Worldwide.
The coverage assessment was conducted between 24th September, 2013 and 18th October, 2013. In
total, there were 16 participants who were involved in the collection of the both qualitative and
quantitative data. The participants were all drawn from the Ministry of Health and included 2 DHMT
members, 1 PHO, 3 OTP Nurses, 3 CHEWs and 7 community health workers among other local guides
who also participated during the small and wide area survey. In addition, 2 program staff
participated in the assessment.
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4.0 RESULTS
4.1 Outpatient Therapeutic Program (OTP)
4.1.1 Program Data Analysis
The routine program data which was analysed included the admissions, MUAC on admission,
MUAC on defaulting, program performance data which included the defaulters and the in-
program deaths. This data was used to detect any trends which would later be explored and the
existing trends explained. Additionally, a calendar of seasonal events in Chalbi was developed in-
order to establish if there was any relationship between the program data and in particular the
admissions and the defaulters with the seasonal calendar.
4.1.1.1 Admission Trends Figure 1: Admission Trends
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Key
Diarrhoea ++ + ++ + + + ++ ++ + + + ++ ++ +++ - Severe
++ - Moderate
+ - Low
Blank – No
Food Prices +++ ++ ++ + + ++ +++ +++
Migration +++ + + + + + + + + +++ +++ +++ +++
Cultural
Festivals
++ ++ + +++ + + + + + +++ +++ ++ ++
Dry Season + + ++ +++ ++ + ++ +++ ++
The above figure shows the trends in admission overtime. In precise, the figure presents the
trends of admission between September 2012 and August, 2013. According to the figure, the
highest number of admissions was made in the month of January 2013, while the least number
of admissions were made in the month of December 2012. On the general trend of the
admissions, the results show that there was a general decline in the number of admissions from
February 2013 till July 2013. The data precisely shows that between May and August, 2013 there
were only 21 new admission that were made in program despite a nutrition survey done at the
same period showing a SAM prevalence of 3.4% and a GAM rate of 15.9%. The low number of
admission in this period points to a low coverage in the area. Further, comparing between the
admission trends and the seasonal calendar, the results show no relationship between the two
and hence concluding that the admissions trends in Chalbi do not follow the seasonal calendar.
14
12
5
2
21
8
13
7
3 3
8 7
0
5
10
15
20
25
No. Admissions
Average Number
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4.1.1.2 MUAC on Admission Figure 2: MUAC on Admission
Since September 2012 till August 2013, there were only 29 admissions which were made using
MUAC. Of the 29 admission made, 8 were made with a MUAC of 11.0 cm. the median MUAC on
admission in Chalbi for the OTP program was found to 11.1 which is an indication of early
admission. However, there were still some late critical admissions (13%) which were made with
a MUAC of less than 10.6 cm. Early admission into the OTP program is a good indicator for early
seeking behaviour through there is also evidence for poor seeking behaviour as demonstrated
by the late critical admission.
Further, it is also worth noting that in the review period (September 2012 – August 2013) there
were 110 admissions in the entire district. As indicated above, 29 admissions were made using
the MUAC implying that the remainder 81 admissions were made using the weight-for-height z-
score. None of the admissions in the entire period was made using oedema. The low proportion
of admissions using the MUAC would point to low community activities since the MUAC Tape is
the tool which is used at the community level for screening.
Table 1: Screening Data by Month
# Screened # Reported to OTP # Admitted
Sep-12 0 0 0
Oct-12 9 0 0
Nov-12 5 2 2
Dec-12 8 0 0
Jan-13 2 0 0
Feb-13 0 0 0
Mar-13 29 0 0
Apr-13 0 0 0
May-13 13 0 0
Jun-13 0 0 0
Jul-13 36 0 0
Aug-13 0 0 0
Total 102 2 2
The above shows the summary of the number of children screened at the community in the
period between September 2012 and August, 2013. In total, there were 102 children who were
5 5
4
3
8
0 0 0
1
3
0
1
2
3
4
5
6
7
8
9
11.4 11.3 11.2 11.1 11 10.9 10.8 10.7 10.6 >10.5
Nu
mb
er
of
Ad
mis
sio
ns
MUAC on Admission
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screened by the community health workers, of whom only 2 were reported to the OTP program
and admitted. The above data shows very low community screening of the children under the
age of 5. For instance with only 102 children in a whole year in a district with approximately
6000 children means that only about 1.7% of the children were reached. The above data is a
good pointer to low community activities by the community health workers (CHWs). In total,
there are 54 who are being supported by Concern Worldwide and another 6 being supported by
the Chalbi DHMTs. Thus in total, there are 60 CHWs in the district but comparing the output with
this number means that either community level screening is not available in almost the entire
district or it very low.
4.1.1.3 Exit Trends Figure 3: Exit Trends over Time
The exit trends above show that the cure rate was high and above the SPHERE recommendation
of 75% between September 2012 and February 2013. Soon after that, there was a decline in the
cure rate till May 2013 when again an upward trend was recorded till August 2013. Between
March and May, 2013 the cure rate was below the SPHERE threshold and hence considered low.
The reduced cure rate in the district in this period was mainly attributed to the increased
defaulting rates. The increased defaulting rate was mainly attributed to staff absenteeism during
this period as some of them had gone for leave leaving the facility closed down or being
operated by a facility based CHW.
0.0
15.0
30.0
45.0
60.0
75.0
90.0
105.0
Pe
rce
nt
Average % Cured
Average % Defaulters
Average % Deaths
Average % Non-respondants
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Table 2: Discharged Cured after # of Weeks of Admission to OTP
Week of Discharge Number Discharged as Cured Proportion Discharged
1 1 1.4%
2 2 2.9%
3 0 0.0%
4 1 1.4%
5 4 5.7%
6 6 8.6%
7 1 1.4%
8 2 2.9%
9 2 2.9%
10 5 7.1%
11 4 5.7%
12 9 12.9%
13 14 20.0%
14 1 1.4%
15 6 8.6%
16 12 17.1%
The table above presents the total number of OTP cases discharged in the program as cured. In
total, 70 children were exited from the OTP program as cured from the period between
September 2012 and August 2013. The Kenya IMAM Guideline by the MoH recommends that a
child admitted should be discharged from the program after a minimum of two months.
However, according to the above data, about 21% of all those discharged as cured were made
before the two months period. This is an indication of existence of early discharged from the
program. Early exits may lead to either re-admissions or the beneficiaries may keep off from the
program and this may promote negative perception in the community about the program.
Additionally, about 60% of those discharged had been in the program for more than 12 weeks.
This implies that the length of stay in the OTP program was pretty long and this may affect the
program negatively at the community level.
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4.2 Supplementary Feeding Program (SFP)
4.2.1 Program Data Analysis
The routine program data analysed included the admissions, MUAC on admission, MUAC on
defaulting, program performance data which included the defaulters and the in-program deaths.
This data was used to detect any trends which would later be explored and the existing trends
explained. Additionally, a calendar of seasonal events in Chalbi was developed in-order to
establish if there was any relationship between the program data and in particular the
admissions and the defaulters with the seasonal calendar.
4.2.1.1 Admission Trends Figure 4: Admission Trends
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Key
Diarrhoea ++ + ++ + + + ++ ++ + + + ++ ++ +++ - Severe
++ - Moderate
+ - Low
Blank – No
Food Prices +++ ++ ++ + + ++ +++ +++
Migration +++ + + + + + + + + +++ +++ +++ +++
Cultural
Festivals
++ ++ + +++ + + + + + +++ +++ ++ ++
Dry Season + + ++ +++ ++ + ++ +++ ++
The figure above presents the trends of the admissions in the SFP program from September
2012 to August 2013. The figure indicates that from February 2013 till August 2013, there was a
downward trend in the number of admissions. This may be attributed to the reduced community
level activities in the area at this period as noted during the qualitative data collection.
Additionally, in this period there were three health facilities which had been closed for almost
three months as a result of health workers being on leave. This was also complicated by the fact
that all the seven facilities in Chalbi had only one staff though this was worked on in the month
of August when the number of staffs was increased to two per facility. The month of September
2012 registered the highest number of admissions throughout the entire year. On the other side,
the month of August 2013 registered the least number of admissions. A comparison between
the admission trends and the calendar of local events showed that there was no relationship
between the seasonal calendar and the admission trends. The failure of the seasonal calendar
and the admission trends to have a relationship acts as a barrier to the program
0
20
40
60
80
100
120
No. Admissions
Average number
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4.2.1.2 MUAC on Admission Figure 5: MUAC on Admission
The above show the number of admissions made against each MUAC measurement. According
to the program data, the median MUAC on admission for the SFP program for Chalbi was 12.3
which is a pointer of early admissions in the SFP program. However, the data also points to some
late critical admission which also indicates late health seeking behaviours.
In the period between September 2012 and August 2013, there were 520 admissions in the SFP
program where 172 were made through the MUAC and this represents 33.1% of all the
admissions made on that period. The low number of admissions using MUAC may point to low
community screening.
4.2.1.3 Exit Trends Figure 6: Exit Trends over Time
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Key
Diarrhoea ++ + ++ + + + ++ ++ + + + ++ ++ +++ - Severe
++ - Moderate
+ - Low
Blank – No
Food Prices +++ ++ ++ + + ++ +++ +++
Migration +++ + + + + + + + + +++ +++ +++ +++
Cultural
Festivals
++ ++ + +++ + + + + + +++ +++ ++ ++
Dry Season + + ++ +++ ++ + ++ +++ ++
49
34
22
14
27
6 5 3 4 8
0
10
20
30
40
50
60
12.4 12.3 12.2 12.1 12 11.9 11.8 11.7 11.6 11.5
Nu
mb
er
of
Ad
mis
sio
ns
MUAC on Admission
0.0
15.0
30.0
45.0
60.0
75.0
90.0
105.0
Pe
rce
nta
ges Average % Cured
Average % Defaulters
Average % Deaths
Average % Non-respondants
16 | P a g e
The cure rate for the SFP program in Chalbi from the month of September and February 2013
was below the 75% as recommended by the SPHERE standards. This was mainly contributed by
the high proportion of non-responses and defaulters in the same period. This may have been
attributed directly to increased migration and cultural festivals. However, from the month of
March 2013, through the month of May there was an increased cure rate in the area which once
again decreased till the month of August though this was still above the 75% threshold as
recommended by SPHERE standards. The high defaulter rate in this period was mainly
attributed to a number of factors which includes migration, increased cultural festivals,
increased work load at household which includes water tracking as a result of the dry season. A
comparison between the season events calendar and the exit trends showed that there was a
relationship between the two which is a booster to the program.
Figure 7: MUAC on Defaulting
On defaulting, there were 47 defaulters throughout the entire period. Out of the total
defaulters, 19 defaulted with a MUAC of greater than or equal to 12.5 which is indicative of late
defaulting. However, there were also a number of early and critical defaulters also noted among
the defaulters which is becomes a barrier to the SFP program.
4.3 Hypothesis Testing and Small Area Survey
After the review of the program data and the qualitative data, two hypotheses were set. The
first hypothesis was set by the team which was investigating the OTP coverage while the second
was set by the team which was investigating the SFP coverage. These hypotheses were
independent of each other and hence the OTP team proceeded to the field to conduct a Small
Area Survey in order to test the hypothesis. This was also the case for the SFP team.
19
9
6 5
2 3
1 2
0
2
4
6
8
10
12
14
16
18
20
≥12.5 12.4 12.3 12.2 12.1 12 11.9 11.8
Nu
mb
er
of
De
fau
lte
rs
MUAC on Defaulting
17 | P a g e
4.3.1 Outpatient Therapeutic Program (OTP)
After the review of the program data and the qualitative data, the OTP team developed the
following hypothesis “Program Awareness is High in Villages Served by CHWs”. In order to test
the above hypothesis, three villages serviced with a CHW and three villages not served by a CHW
were selected. These villages were sampled purposively and the sample size for testing the
above hypothesis was 10 for each village. The target respondents for the small area survey were
the caregivers of the children aged between 6 and 59 months in the selected villages. The
targeted 10 caregivers from the sampled villages were selected randomly from a list which was
developed by teams once they arrived in the field. An in-depth interview was conducted with
the caregivers of the selected households. The assessment teams were given a sachet of plumpy
nut and a MUAC tape. These were also used to test whether the caregiver knew about the
program. The following were the finding of the small area survey:
Table 3: Hypothesis 1 Data
Village n Aware of IMAM
Program
Not Aware of IMAM
Program
Villages with CHWs – El Gade 10 10 0
Villages with CHWs - Kalacha 10 10 0
Villages with CHWs - Maikona 9 9 0
Total 29 29 0
In order to confirm the hypothesis or fail to accept the hypothesis, the LQAS method was used
as described in the equation below:
Equation 1: LQAS
Where
d – Decision rule
n – Total number of respondents interviewed
p – Coverage standard set for the area (50% for ASAL programs according to
SPHERE)
Using the above formula we obtain:
Since the caregivers in the villages with a CHW who were found to be aware of the program
was 29 which is greater than the decision value of 14, then we confirm the hypothesis that
program awareness was high in villages served with a CHW.
On the other hand, a second hypothesis was tested which stated that “villages not served by a
CHW has low program awareness”. Using similar methodology as with the first hypothesis, 10
caregivers from 3 villages not served by CHWs were chosen at random from a list developed by
the survey team once they were in the village. The following data was received:
18 | P a g e
Table 4: Hypothesis 2 Data
Village n Aware of IMAM
Program
Not Aware of
IMAM Program
Villages without CHWs – El Gade 10 6 4
Villages without CHWs - Kalacha 10 9 1
Villages without CHWs - Maikona 10 8 2
Total 30 23
Using the LQAS formula the following was obtained :
Since 23 is greater than 15, then the hypothesis that in villages not served by CHWs was low
was not confirmed and hence deducing that villages which are served by CHWs have high
program awareness.
The above results therefore imply there was high program awareness in the district.
4.3.2 Supplementary Feeding Program (SFP)
After the review of the program data and the qualitative information for the SFP program, the
following hypothesis was set : «program coverage was high in villages close to service delivery
points (<5 km or < 1 hour) «. To test the hypothesis, 3 villages close to a service delivery point
and three villages far from service delivery points were sampled purposively. In the sampled
villages, a house to house screening of all children between 6 and 59 months was done. The
reason for using this method was to find nearly all or all children who were MAM cases in the
community. The case definition for MAM was children with a MUAC of above 11.4 cm but
below 12.5 cm. The MUAC Tool was the tool which was used for screening the children. A short
questionnaire was applied to the caregivers who had active children not in the program. The
following data was obtained from the small area survey :
Table 5: Hypothesis 3 Data
Village n Covered Not Covered
Near Villages– (El Gade, Kalacha and Maikona) 14 7 7
In order to confirm the hypothesis or fail to accept the hypothesis, the LQAS method was used
as described in the equation below:
Equation 2: LQAS
Where
d – Decision rule
n – Total number of respondents interviewed
p – Coverage standard set for the area (50% for ASAL programs according to
SPHERE)
Based on the above data, the following was obtained:
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Since 7 is not greater than 7, the hypothesis that program coverage was high in villages close to
a service delivery point was rejected and hence implying that there was low coverage in villages
close to service delivery points.
The final hypothesis stated that “program coverage was low in villages far from service delivery
points”. The following was the data which was obtained from the villages which were selected
from far distances from service delivery points:
Table 6: Hypothesis 4 Data
Village n Covered Not Covered
Far Villages– (El Gade, Kalacha and Maikona) 11 3 8
The decision rule in this case was found to be 5 as outlined below:
Based on the above data the hypothesis that villages far from service delivery points have low
coverage was confirmed.
Therefore based on the small area survey, it was established that the SFP program coverage
was low in all areas of the district.
The Assessment Team together with a Local Guide (Extreme Left) during Small Area Survey
20 | P a g e
1.1 WIDE AREA SURVEY
5.1.1 Introduction
Before proceeding to the wide area survey, the team both for SAM and MAM developed the
prior distribution. Four methods were applied when developing the prior and these included: (1)
weighted barriers and boosters (2) Unweighted barriers and boosters (3) concept map and (4)
histogram. Each of the methods and results are described below:
5.1.1.1 Weighted Barriers and Boosters
In this method, all the barriers and boosters which were identified in stage 1 and 2 were
weighted such that every barrier was given a percentage in which the participant thought that it
affected the program. In the same was each booster was also given a score depending on how
the participant thought that the booster impacted on the program. The scale which was used
ranged between 1% and 5% where 5% was the highest score and 1% was the least score. The
table below presents the weighted barriers and boosters for both the OTP and SFP programs.
Table 7: Weighted Barriers for the OTP Program
S. No BERRIERS SOURCE METHOD WEIGHTS
1 Poor knowledge of malnutrition in the community
(5/7)
W11111, C1111111,
M11111, R1, D11
IGDs11, SSI, SI,
SAS111
4%
2 Perception of malnutrition NOT as a Health
problem (3/7)
C1111, M, R111 , O11 IGDs11SSI1, O1 3%
3 Poor Health Seeking Behavior (3/7) S1, W111111, C1111,
A1, R1
IGDs1, SSI11 2%
4 Sharing of RUTF at Household Level by other
children and family members (6/7)
D111, B1111, C1111 SI1, SSI1, SI1 4%
5 Perception of IMAM program as a food program
rather than a health program (7/7)
C1111, R1111, A111,
D11, B111, H111,
W111111
IGDs11, SSI11,
SI11111 4%
6 Lack of confidence by caregivers that RUTF is
adequate for the child (4/7)
D1, B111 SI11 3%
7 Child refuses to take RUTF (2/7) D1, B11 SI11 3% 8 RUTF side effects such as diarrhea and vomiting
(2/7)
D1, B1 IGDs1, SI1 1%
9 Competing task of caregivers (6/7) H1111, W111, C11111,
D11, B11
SI11, IGDs1 4%
10 Nomadic lifestyle of the community (6/7) D11, B111111, H11111,
W11111
SI11, SSI1, IGDs1 4%
11 Long distance to Health facility (4/7) D1, B111, A11 SI11, SSI1 3% 12 No regular mass screening in the villages (7/7) H1111, W111, S1, A1,
R1
SSI11 5%
13 Few village volunteers in the community (3/7) W1111, H111, C111 SSI1, IGDs1 3% 14 Lack of proper sensitization prior to activity (3/7) A1, R1, D1 SSI11, SI1 2% 15 Little or no involvement of local leaders and key
actors in the community (5/7)
A11111, H111, W1111 O1, SSI1111 1%
16 Stigmatization (4/7) H1, A1111, C1 SSI11, IGDs1 3% 17 Absenteeism of Health Workers (Shortage of
health workers) (2/7)
D1, B11, C1 SI11, IGDs1 2%
18 Extra expectations of the caregivers from program
such as receiving food (6/7)
C111111, M11, R11,
A11, D11, B1
IGDs11, SSI11,
SI11 3%
21 | P a g e
19 Perception by CHWS’ Monthly Motivation as a
Salary and thus seen as very low and sometimes
the already existing CHWs sabotage the
community activities in demanding for more
money
W111111, S1, H111111 SI1, SSI1 3%
20 The existing CHWs mainly spend their time
in the facility rather than in the community O
1111111
, S111 O
1
, SSI111 2%
21 Negative attitude by the community towards
the CHWs H
11 SSI1 2%
22 Poor documentations, Recoding and
Accuracy of Data O
1111111
, S1 O
1
, SSI1 3%
23 Shortage of CHWs and CHEWs in the area,
there are 60 CHWs being supported by
Concern Worldwide and DHMTs while there
are more than 400 villages in the vast districts
S1
, H1
, W111111 O1, SSI11 4%
24 5/8 Areas do not have community Units while
3 of the existing Community Units are not
functional
S1
, W1 SSI
11 4%
25 Unstandardized allowances by partners on the
ground (Some give more allowances than
others hence sabotaging the activities)
S1 SSI
1 1%
26 Cultural festivals which are almost monthly in
the district such as “Festivities of Fetching
Firewood in October” among others
W1
, H1
, S1 SSI
111 4%
27 Negative attitude towards the program.
Community members thinks that the program
is benefiting from them rather than them
benefiting from the community
W1111
, H1111
, S1 SSI
111 2%
28 Sale of Plamynut by Health Workers O1
, H1 SI
1
, O1 1%
29 Low quality supervision of facilities by
DHMTs and poor monitoring of community
level activities
W111
,O1
, H1 SSI
111 3%
30 Few or no IEC materials at the health
facilities O
1 O1 1%
31 Poor integration of Health services W1
, H1
, S1 SSI
111 1% 32 Sale of RUTF by the beneficiaries SSI
111 1% 33 Inactive CHWs W
1
, H1
, S1 SI
1
, O1 3%
34 Incitement of community by inactive CHWs W1
, S1 SSI
111 2%
Key
Source
Health Workers Elders Program Staffs Chief/Administration
CHW/CHEW
Observation
TBAs/Traditional Healers Caregivers Religious Leaders Defaulters Program data
HH Heads/ Men
Beneficiaries
W
E
S
A
H
O
T
C
R
D
PD
M
B
22 | P a g e
Method
Informal Group Discussions
Semi Structured Interviews
Simple Interviews
Observation Check List
Small Area Survey
IGIs
SSI
SI
O
SAS
The above table lists all the barriers which were identified during the coverage assessment in
Chalbi. Each barrier has been given a score which it was thought to affect the program. The
process of scoring the barriers and boosters was exhaustive as the program staff, program
implementers, CHWs, CHEWs and the DHMTs members were all involved in this process.
Table 8: Weighted Boosters for the OTP Program
S. No BOOSTERS SOURCE METHODS WEIGHTS
1 Good knowledge of malnutrition in the
community (2/7)
M11, R111111,
A111111, D1111
FGDs1, SSI11,
SI1 2%
2 Positive perception of IMAM services (4/7) C111111, M111,
R111111, A111, B111
FGDs11, SSI111 2%
3 Good Health Seeking behavior (4/7) W111111, H111 SSI11 3%
4 High cure rate (6/7) PD1, R1 PD1, SSI1 3%
5 Early admission(6/7) PD1 PD1 3%
6 Integrated services at the facility level (6/7) S1, W111111 S1, SSI1 5% 7 Increased number of health workers (6/7) S1, W111111 S1, SSI1 4% 8 Consistent supply of nutritional commodities
(6/7)
S1,O1, W111111 S1, O1, SSI1 3%
9 On the Job Training (6/7) S1, W111111 S1, SSI1 3%
10 High program awareness in the community S1,O1, SAS 4%
Using the weighted barriers and boosters, the estimated prior was determined as 20.5%. This
was done as shown below
5.1.1.2 Un-weighted Barriers and Boosters
In this method, all the barriers and boosters were listed and each given an equal score of 1%.
This implies that all the barriers were countered as were the boosters. In this case, there were
34 barriers and 10 boosters. Using this method, the total number of barriers was subtracted
from 100% and then the total number of boosters was added on 0%. The barriers were
subtracted from 100% since that’s the optimal coverage a program can reach while the boosters
were added to 0% since that the least a program can reach. Then the average of the two was
taken and this yielded to a prior mode of 38%
Prior weighted
= ((0%+32%) + (100%-91%))/2=20.5%
23 | P a g e
5.1.1.3 Histogram
In this method, the assessment participants who included the program staff, program
implementers, CHWs, CHEWs and members of the DHMTs were asked to develop the most
probable histogram that would reflect the OTP program. The following was developed:
Figure 8: A Snapshot of the Histogram Developed by the OTP Assessment Team
5.1.1.4 Concept Map
The final method involved developing a concept map which tried to relate the barriers and
boosters as obtained in stage 1 and 2 of this process. Using the concept map the number of
positive and negative were counted and then the total number of positive was added to 0% and
the number of negative was subtracted from 100% then the average was identified as 20%. The
following is a snapshot of the OTP Concept Map:
Prior Unweighted
= ((0%+10%) + (100%-34%))/2=38.0%
24 | P a g e
Using the above four methods, the overall OTP prior mode was determined as 25.6%
The same procedure used for determining the OTP prior mode was also used to determine the
SFP mode. In this case, the prior mode from SFP was determined as 42.9%. The weighted
barriers and boosters, concept map and the histogram for the SFP program are appended in this
report.
5.1.2 Sampling
Using the SQUEAC Calculators based on the averaged prior which had been obtained through
four methods, the sample sizes for both programs were calculated using the formula below:
Further, in order to determine the number of villages which would yield the required sample size
for both programs, the following formula was used
Averaged Prior = (20.5%+38.0%+24.0% + 20.0%)/4 = 25.6%
Averaged Prior = (44.5%+42.5% + 41.0% + 43.5%)/4 = 42.9%
25 | P a g e
Table 9: Sample Size for Wide Area Survey
OTP SFP
Averaged Mode 25.6% 42.9%
Alpha 6.0 13.1
Beta 17.6 17.5
Precision 14% 12%
Sample Size 16 34
SAM Prevalence using MUAC5 2% 4.5%
Average Village Population 450 450
Proportion of Under-5 13% 13%
Number of Villages Required 14 14
5.1.3 Results of Wide Area Survey
The wide area survey was done using a two stage sampling approach. The first stage sampling
involved the selection of the villages. The 14 villages required to meet the sample size was done
through spatial systematic sampling. This was done though sampling systematically, two villages
within a catchment area of each of the seven facilities. All the villages in each facility were listed
and then two villages sampled systematically. In the second stage sampling, a complete
enumeration of the sampled village was done. This involved screening of all the children aged
above 6 months and below 5 years. This was done in order to capture nearly all or all the active
SAM and MAM cases in the sampled villages. This method worked well particularly for the MAM
cases who would be hard to identify through active case finding. The screening of the under-five
was done though the MAUC tape and pitying of oedema. At the end of the wide area survey, no
oedema case was found and hence all the active cases found during this exercise were through
the MUAC measurement. The following is the results of the wide are survey:
Table 10: Wide Area Survey Results – OTP Program
Chalbi
Total SAM 18
SAM Covered 3
SAM Not Covered 15
Calculated Sample Size 16
Likelihood 16.7%
Prior 25.6%
Alpha 6.0
Beta 17.6
Point Coverage 20.2% (10.7% - 35.2%)
Z - Test z = 0.51, p = 0.613
In total, there were 18 SAM cases that were identified during the wide area survey, out of which
3 were in the program and 15 were not in the program. Combining the results of the prior
distribution and the likelihood distribution using conjugate analysis, a posterior estimate of
20.2% (10.7%-35.2%) was obtained. This implies that the overall OTP coverage is Chalbi District is
5 Chalbi Community Based Surveillance Report October 2012
26 | P a g e
20.2% which is below the SPHERE recommended coverage for ASAL area which is 50%. This
implies that the OTP coverage in Chalbi low and this was mainly attributed to low community
level activities, poor service delivery at the service delivery points and weak health management
systems. The graphical representation of the coverage is shown below:
Figure 9: OTP Posterior Estimate
A further, analysis of the caregivers of the children who were found not to be in the program in
stage three was done and the following were the reasons as to why their children were not in
the program.
Figure 10: Reasons for Non-Coverage identified in Stage 3 – OTP Program
6
1
2
1
3
1
1
0 1 2 3 4 5 6 7
None Awareness of Malnutrition
None Awareness of Program
Too Far
Mother Feels Ashamed or Shy about Coming
The amount of Food was too Little to Justify Coming
Health Worker not Available
The Child Does not Get Healed
27 | P a g e
The above show that among the cases who were not in the program at stage 3 of the
assessment, 6 of them were due to lack of awareness about the malnutrition, 3 of them thought
that the amount of ratio was too little to justify coming to the program while 2 were because the
services were very far.
The following table presents the results of the wide area survey for the SFP program
Table 11: Wide Area Survey Results – SFP Program
Chalbi
Total MAM 39
MAM Covered 8
MAM Not Covered 31
Calculated Sample Size 34
Likelihood 20.5%
Prior 42.9%
Alpha 13.1
Beta 17.5
Point Coverage 29.7% (20.2% - 41.4%)
Z - Test z = 1.93, p = 0.0541
During stage 3, 39 MAM cases were identified out of whom 8 were in the program and 31 were
not in the program. This implies that the likelihood estimate was 20.5%. Using conjugate
analysis, a posterior estimate of 29.7% (20.2%-41.4%) was obtained, which implies that for every
10 MAM cases in Chalbi, 3 are in the program. The coverage was found to be low and even
below the recommended coverage value by the SPHERE standards. This was mainly attributed to
the low community level activities and poor service delivery at the service delivery points. The
graphical representation of the coverage is shown below:
Figure 11: SFP Posterior Estimate
28 | P a g e
A further, analysis of the caregivers of the children who were found not to be in the program in
stage three was done and the following were the reasons as to why their children were not in
the program.
Figure 12: Reasons for Non-Coverage identified in Stage 3 – SFP Program
At stage 3, the greatest barrier to the SFP program was identified as none awareness of
malnutrition. This was followed by none awareness of the program and also stigma was
mentioned as a barriers as well as distance.
The OTP Team Brainstorming of the Qualitative Data
14
7
3
2
1
3
1
1
1
0 2 4 6 8 10 12 14 16
None Awareness of Malnutrition
None Awareness of Program
Too Far
No Time/Too Busy
The Mother Cannot Carry More than One Child
Mother feels ashamed or shy about coming
The amount of food was too little to justify coming
The mother does not think the program can help…
Health woker was not available
29 | P a g e
5.0 Summary of Barriers, Boosters and Recommendation
Outpatient Therapeutic Program – Barriers and Boosters
Barriers:
S. No BERRIERS SOURCE METHOD WEIGHTS
1 Poor knowledge of malnutrition in the community
(5/7)
W11111, C1111111,
M11111, R1, D11
IGDs11, SSI, SI,
SAS111
4%
2 Perception of malnutrition NOT as a Health
problem (3/7)
C1111, M, R111 , O11 IGDs11SSI1, O1 3%
3 Poor Health Seeking Behavior (3/7) S1, W111111, C1111,
A1, R1
IGDs1, SSI11 2%
4 Sharing of RUTF at Household Level by other
children and family members (6/7)
D111, B1111, C1111 SI1, SSI1, SI1 4%
5 Perception of IMAM program as a food program
rather than a health program (7/7)
C1111, R1111, A111,
D11, B111, H111,
W111111
IGDs11, SSI11,
SI11111 4%
6 Lack of confidence by caregivers that RUTF is
adequate for the child (4/7)
D1, B111 SI11 3%
7 Child refuses to take RUTF (2/7) D1, B11 SI11 3% 8 RUTF side effects such as diarrhea and vomiting
(2/7)
D1, B1 IGDs1, SI1 1%
9 Competing task of caregivers (6/7) H1111, W111, C11111,
D11, B11
SI11, IGDs1 4%
10 Nomadic lifestyle of the community (6/7) D11, B111111, H11111,
W11111
SI11, SSI1, IGDs1 4%
11 Long distance to Health facility (4/7) D1, B111, A11 SI11, SSI1 3% 12 No regular mass screening in the villages (7/7) H1111, W111, S1, A1,
R1
SSI11 5%
13 Few village volunteers in the community (3/7) W1111, H111, C111 SSI1, IGDs1 3% 14 Lack of proper sensitization prior to activity (3/7) A1, R1, D1 SSI11, SI1 2% 15 Little or no involvement of local leaders and key
actors in the community (5/7)
A11111, H111, W1111 O1, SSI1111 1%
16 Stigmatization (4/7) H1, A1111, C1 SSI11, IGDs1 3% 17 Absenteeism of Health Workers (Shortage of
health workers) (2/7)
D1, B11, C1 SI11, IGDs1 2%
18 Extra expectations of the caregivers from program
such as receiving food (6/7)
C111111, M11, R11,
A11, D11, B1
IGDs11, SSI11,
SI11 3%
19 Perception by CHWS’ Monthly Motivation as a
Salary and thus seen as very low and sometimes
the already existing CHWs sabotage the
community activities in demanding for more
money
W111111, S1, H111111 SI1, SSI1 3%
20 The existing CHWs mainly spend their time
in the facility rather than in the community O
1111111
, S111 O
1
, SSI111 2%
21 Negative attitude by the community towards
the CHWs H
11 SSI1 2%
22 Poor documentations, Recoding and
Accuracy of Data O
1111111
, S1 O
1
, SSI1 3%
23 Shortage of CHWs and CHEWs in the area,
there are 60 CHWs being supported by
Concern Worldwide and DHMTs while there
S1
, H1
, W111111 O1, SSI11 4%
30 | P a g e
are more than 400 villages in the vast districts
24 5/8 Areas do not have community Units while
3 of the existing Community Units are not
functional
S1
, W1 SSI
11 4%
25 Unstandardized allowances by partners on the
ground (Some give more allowances than
others hence sabotaging the activities)
S1 SSI
1 1%
26 Cultural festivals which are almost monthly in
the district such as “Festivities of Fetching
Firewood in October” among others
W1
, H1
, S1 SSI
111 4%
27 Negative attitude towards the program.
Community members thinks that the program
is benefiting from them rather than them
benefiting from the community
W1111
, H1111
, S1 SSI
111 2%
28 Sale of Plamynut by Health Workers O1
, H1 SI
1
, O1 1%
29 Low quality supervision of facilities by
DHMTs and poor monitoring of community
level activities
W111
,O1
, H1 SSI
111 3%
30 Few or no IEC materials at the health
facilities O
1 O1 1%
31 Poor integration of Health services W1
, H1
, S1 SSI
111 1% 32 Sale of RUTF by the beneficiaries SSI
111 1% 33 Inactive CHWs W
1
, H1
, S1 SI
1
, O1 3%
34 Incitement of community by inactive CHWs W1
, S1 SSI
111 2%
31 | P a g e
Boosters:
S. No BOOSTERS SOURCE METHODS WEIGHTS
1 Good knowledge of malnutrition in the
community (2/7)
M11, R111111,
A111111, D1111
FGDs1, SSI11,
SI1 2%
2 Positive perception of IMAM services (4/7) C111111, M111,
R111111, A111, B111
FGDs11, SSI111 2%
3 Good Health Seeking behavior (4/7) W111111, H111 SSI11 3%
4 High cure rate (6/7) PD1, R1 PD1, SSI1 3%
5 Early admission(6/7) PD1 PD1 3%
6 Integrated services at the facility level (6/7) S1, W111111 S1, SSI1 5% 7 Increased number of health workers (6/7) S1, W111111 S1, SSI1 4% 8 Consistent supply of nutritional commodities
(6/7)
S1,O1, W111111 S1, O1, SSI1 3%
9 On the Job Training (6/7) S1, W111111 S1, SSI1 3%
10 High program awareness in the community S1,O1, SAS 4%
Key
Source
Health Workers Elders Program Staffs Chief/Administration
CHW/CHEW
Observation
TBAs/Traditional Healers Caregivers Religious Leaders Defaulters Program data
HH Heads/ Men
Beneficiaries
W
E
S
A
H
O
T
C
R
D
PD
M
B
Method
Informal Group Discussions
Semi Structured Interviews
Simple Interviews
Observation Check List
Small Area Survey
IGIs
SSI
SI
O
SAS
32 | P a g e
Supplementary Feeding Program – Barriers and Boosters
Barriers:
S. No BARRIERS SOURCE METHOD WEGHT
1 Migration of beneficiaries to other areas hence
affecting follow up
B111111 SSI1 1%
2 Long distance to service delivery points M111, B11, C11, E111 IGDs11, SSI11 2%
3 Water tracking O11 O1 1%
4 Lateness of outreach vehicles during outreach
days at the community hence some beneficiaries
go home unattended and get frustrated
O1 O1 1%
5 Failure to do mass screening on monthly bases in
the community
O111111, H111111 ,
W1111111, S1
O1, SSI11 5%
6 Poor or non-existence of active case finding by
CHWs in the community
C1111111, H1111111 IGDs1, SSI1 4%
7 Unclear roles and responsibility of CHWs and
CHEWs
H1, W1 SSI11 1%
8 Perception of monthly allowances for CHWs as
salary hence deemed as long
H1111111, W1 SSI11 1%
9 Negative attitude of CHW by community
members
C1 C1 1%
10 Preference of CSB over plumpy sup B11111 SSI1 2%
11 Sharing of CSB with family members 1%
12 Low involvement of key actors M1111111 IGDs1 1%
13 Low or no involvement and support from men E11111, A1 SSI11 2%
14 Poor understanding of malnutrition among men M1111111, E111, R1111,
T11111
IGDs1, SSI111 2%
15 Lack of program awareness especially among the
men
2%
16 Illiteracy and hence forgetting appointment dates B1111 SSI1 1%
17 Inadequate staff leading to heavy workload and
staff absenteeism
C1111, H1111 IGDs111, SSI1 2%
18 5/8 of the area don’t have community units and
the 3 which exist are not fully functional
S1, H111111 SSI111111 2%
19 Poor documentation O11111 O11111 1%
20 Cultural and religious festivities H1111, W11111, C1, O1 O1, SSI111, SI11 1%
21 Long waiting time at the facility O1, B1111, D11 O1, SSI11111,SI1 1%
22 Little supervision by the DHMTs W11 SSI11 2%
23 PHOs and CHEWs are not fully involved in the
outreaches and other nutritional activities
S111, H11, W11 IGDs111 2%
24 Stigmatization S111, H11, W11 IGDs111, C 2%
25 Fear of being reprimanded by the CHWs and
other Health Workers
S111 IGDs111 1%
26 Perception of the program as partner’s rather
than the Government
S111 IGDs111 2%
27 Selling of RUTF by the beneficiaries S111 IGDs111 1%
33 | P a g e
Boosters:
S. No BOOSTERS SOURCE METHODS WEIGHTS
1 Some levels of awareness by caregivers about
malnutrition
C1111111, R111, E1111,
T11, A11, B1111111, S1,
H1111111, W1111
IGD1, SSI11111, SI11 5%
2 Good perception towards the program by
community members particularly women
C1111111, R1111,
E1111111, B1111111,
H1111111, W11111
IGD1, SSI11111 3%
3 Good perception towards health workers B1111111, C1111111 IGD1, SSI1 3%
4 The services are rendered free of charge(No
cost incurred)
B1111111, H1111111 SSI11 3%
5 Adequate supply of plumpy sup, CSB, oil etc B1111111, H1111111,
W1111111
SSI111 2%
6 Regular nutritional assessment O1111111 O1 2%
7 Seminars for CHW and Health workers H1111111, W1111111 SSI11 3%
8 Regular outreach services O1111111 O1 2%
9 High cure rate PD PD1 3%
10 Integration of services at the facility level W1 SI1 2%
11 Increased in the number of Health workers S111, H11, W11 SSI111 3%
12 Awareness of the program is high among
caregivers
S111, H11, W11 IGDs 3%
SFP Histogram:
34 | P a g e
SFP Concept Map:
The SFP Team in the Process of Developing the Concept Map
35 | P a g e
Recommendations RECOMMENDATIONS RATIONALE
1 Implementation of the community strategy. This will
lead to increased community level activities.
The community strategy is not being implemented in the
district. Currently, there are only 3 community units rather
than 8 and the 3 CUs available are not even functional.
2 Increase awareness of malnutrition and program in the
community. This will help reduce the perception of the
IMAM program as a health program rather than a food
program.
There is generally low level of awareness of the malnutrition.
Additionally, the perception that the IMAM program is not a
health program is pretty high in the district
3 Conduct routine appetite tests and follow up visits. This
should be implemented in all the service delivery points
as outlined in the IMAM guidelines
There are cases of children refusing to take RUTF and mostly
appetite tests are not taken when a case is being admitted in
the program
4 Involvement of key actors in the community in the
nutrition program
Low involvement of key actors at the community level. This
includes the local administrators, religious leaders and the
TBA
5 Improve the integration of health services delivery at the
SDPs
In some facilities, the health services were not fully integrated
where the management of IMAM services would be left to
the CHWs
6 Scale up outreach services in the district Insufficient number of outreaches. There are currently 18
outreach sites in the district which are not covering the entire
area
7 Improve service delivery at all levels Evidence of poor service delivery which was mainly
attributed to staff absenteeism, lack of IEC material in most
facilities among other issues
8 Improve supervision and monitoring at the facility and
community level
There is low quality supervision in the district. There was
also poor documentation at almost all the facilities in the
district
9 Issue adequate ration to cover beneficiaries in times of
festivities
Beneficiaries fails to turn up during cultural festivities which
are very frequent in the district
10 Conduct regular mass screening and active case findings Mass screening and active case finding are not done regularly
11 Capacity building to health workers during supervision
visits
DHMTs do little monitoring during visits
12 Active involvement of all health workers during
distribution days
Most staff leave the distribution activity to CHWs
Action Points ACTION POINTS BY WHO BY WHEN MONITORING MONITORING
TOOLS
1 Mapping of areas to identify
possible/potential outreach sites
DHMT/CWW By Nov 2013 Monthly Report
2 Develop a calendar of religious /
cultural festivals
HW/DHMTs ,, ,, ,,
3 Budget training of CHWs, CHEWs,
and CHCs on community strategy
on existing CUs
DHMTs ,, Quarterly Annual work plan
4 Develop schedule for mass
screening/active case findings
HW ,, Monthly Summary reports
5 Develop Health education schedule HW ,, ,, Monthly report
6 Develop an OJT mentorship plan DHMTs ,, ,, OJT report/ report
book
7 Prepare a distribution monitor
rooster
HW ,, Weekly Reports
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8 -Establish functional community
units
-Conducting home visits/ ACF for
beneficiaries in the OTP program
-DHMTs, Program
staff
-CHW,CHEWs,
HW
-Within one
year
-Monthly
-Regularly
Reports
9 Creating awareness on malnutrition
in the community
HW, Elders,
Leaders
Immediately Weekly
10 Conducting appetite test on OTP
beneficiaries on every visit
HW, CHWs Strengthen the
existing
On every visit Ration card
11 Provision of IEC materials at health
facility
Ensuring that facilities are
operational at all time
-DHMTs, Program
staff
-Workers Self
commitment
Monthly Reports
12 -Supervision at facility level
-Supervision at community level
DHMTs, Program
Staff
-CHEWs
Immediately Monthly Reports
13 OJT on proper documentation DHMTs, Program
Staff
Immediately Monthly OJT Reports
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6.0 Appendices
6.1 SQUEAC Coverage Survey, Chalbi Kenya, Concern WW
District: ____________ Location:_________________ Village:____________ OTP
Site:______________
Team Number:_____________
Name of Child
Sex
M /F
Age
Mons.
MUAC
Oed.
Y/N
Covered
Y/N
If in the
program
whorefer
edthem ?
Time from
home to
OTP site
(one-way)
(hrs, min)
Total # of ChildrenScreened:__________________ # SAM:________ # in OTP:________
6.2 Questionnaire for Caretakerswith cases not in the program
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OTP site:____________ District:______________ Village:________
Team: _____________ Name of child: ______________
1. DO YOU THINK YOUR CHILD IS MALNOURISHED (sick, thin, have oedema
on both legs)?
� YES � NO
2. ARE YOU AWARE OF A PROGRAM WHICH CAN HELP malnourished children?
� YES � NO (stop)
If yes, which program(s)? ______________________________________
*********If answer to 1 OR 2 is NO-stop**********
3. WHY DID YOU NOT TAKE YOUR CHILD TO THAT PROGRAMME?
�too far (How long to walk? ……..hours)
�no time / too busy Specify the activity that make them busy this
season____________________________________________________
�mother sick
� the mother cannot carry more than one child
� the mother feels ashamed or shy about coming
�no other person who can take care of the other siblings
� the amount of food was too little to justify to come
� the child has been rejected. When? (This week, last month etc)________________
�the children of the others have been rejected
�my husband refused
�necessary to be enrolled at the hospital first
�carer does not think program can help her child (prefers traditional healer, etc.)
�other reasons: ___________________________________________________
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4. WAS YOUR CHILD PREVIOUSLY ADMITTED TO OTP/SFP
PROGRAM?
� YES � NO (=> stop!)
If yes, why is he/she stop going?
�default when?.................Why?..................
� discharged by the programme (when?........)
�because it was not recovering (when?........)
�other:___________________________________________
(Thank the carer)
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6.3 SQUEAC Coverage Survey, Chalbi Kenya, Concern WW
District: ____________ Location:_________ Village:________ SFP Site:______________
Team Number:_____________
Name of Child
Sex
M /F
Age
Mons.
MUAC
Covered
Y/N
If in the
program
whorefer
edthem ?
Time from
home to
SFP site
(one-way)
(hrs, min)
Total # of ChildrenScreened:_______________ # MAM:________ # in SFP:________
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6.4 Questionnaire for Care takerswith cases not in the program
SFP site:____________ District:______________ Village:________
Team: _____________ Name of child: ______________
1. DO YOU THINK YOUR CHILD IS MALNOURISHED (sick, thin )?
� YES � NO
2. ARE YOU AWARE OF A PROGRAM WHICH CAN HELP malnourished children?
� YES � NO (stop)
If yes, which program(s)? ______________________________________
*********If answer to 1 OR 2 is NO-stop**********
3. WHY DID YOU NOT TAKE YOUR CHILD TO THAT PROGRAMME?
�too far (How long to walk? ……..hours)
�no time / too busy Specify the activity that make them busy this
season____________________________________________________
�mother sick
� the mother cannot carry more than one child
� the mother feels ashamed or shy about coming
�no other person who can take care of the other siblings
� the amount of food was too little to justify to come
� the child has been rejected. When? (This week, last month etc)________________
�the children of the others have been rejected
�my husband refused
�necessary to be enrolled at the hospital first
�carer does not think program can help her child (prefers traditional healer, etc.)
�other reasons: ___________________________________________________
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4. WAS YOUR CHILD PREVIOUSLY ADMITTED TO OTP/SFP
PROGRAM?
� YES � NO (=> stop!)
If yes, why is he/she stop going?
�default when?.................Why?..................
� discharged by the programme (when?........)
�because it was not recovering (when?........)
�other:___________________________________________
(Thank the carer)
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6.5 List of Participants
Name Duty Station
Samuel Kirichu Coverage Assessment Expert, Assistant Project Manager – Survey and Survey
Joseph Njuguna Survey Assessment
Kassim Lupao Assistant Program Manager, Chalbi
Leonard Kariama Nutrition Project Officer - Chalbi
Isacko Umuro Orto
Wato Elema Gura
Vivika Mithika Nurse, Bubisa Dispensary
Hawo Mohamed Adan Community Health Extension Worker, Bubisa
Gilbert Mugo Nurse, El-Gade Dispensary
Richard Komen Public Health Officer, Kalacha
Adhano Abudho Adhi
Muhamed A Muhamud Community Health Worker, Hurri Hills Dispensary
ElemaIya
Alex Kimathi Nurse, Folore Dispensary
Issacko Adano Roba
Mishuna Diba Mamo
Elema Adano Adehe
Abshiro Halakhe Ali Community Health Worker, Maikona Dispensary
Guracha Halake
Luka G. Tume
The Assessment Team
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6.6 Map of Chalbi
