Report on Integrated Health and Nutrition Survey

REPORT ON INTEGRATED HEALTH AND NUTRITION SURVEY

IN LARGER MERU NORTH COUNTY OF KENYA.

FINAL REPORT

(April, 2012)

Anastacia Maluki,

International Medical Corps

Monitoring and Evaluation officer

ACKNOWLEDGEMENTS

I take this opportunity to thank UNICEF for the financial support they provided to conduct this survey.

Special thanks are expressed to: the Survey co-ordinators (DNO), Team leaders, team members, data entry clerks, International Medical Corps staff members and drivers for their tireless efforts to ensure that the survey was a success.

I am also indebted to the district administrators, local leaders and community members who willingly participated in the survey and provided the information needed.

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

LIST OF APPENDICES

ACRONYMS AND ABBREVIATIONS

EXECUTIVE SUMMARY

1.0 BACKGROUND INTRODUCTION

1.1 Rationale for conducting a survey

1.2 Objectives:

2SURVEY METHODOLOGIES

2.1 Sampling Methodology and Sample Size

2.2 Description of sampling frame (including source of population data)

2.3 Description of sampling methods

2.4 Data to be collected, and data collection methods and tools

2.5 Data collection Tools and Variables Measured

2.6 Training and Supervision

2.7 Data Entry and Analysis

2.8 Nutritional Status Cut-off Points

2.9 Survey data validation process

2.10 Survey Limitations

2.11 Good Practice

3. RESULTS

3.1 TARGET POPULATION DEMOGRAPHIC CHARACTERISTICS

3.2 ANTHROPOMETRIC RESULTS (BASED ON WHO STANDARDS 2006)

3.3 ADULT NUTRITIONAL STATUS

3.4 MATERNAL HEALTH CARE INFORMATION.

3.5 CHILD FEEDING, CARE AND HEALTH

3.6 SUPPLEMENTARY AND THERAPEUTIC FEEDING PROGRAMME COVERAGE

3.7 INSECTICIDE TREATED MOSQUITO NETS (ITN) HOLDING RATES AND UTILIZATION

3.8 WATER, SANITATION AND HYGIENE PRACTICES

3.9 HOUSEHOLD FOOD SECURITY

3.10 MORTALITY RESULTS

4. CONCLUSION

5 .RECOMMENDATIONS

6. APPENDICIES

LIST OF TABLES

LIST OF FIGURES

LIST OF APPENDICES

ACRONYMS AND ABBREVIATIONS

ACF- Action Against Hunger

AOP- Annual operation Plan

ARI- Acute Respiratory Infection

BFHI- Baby friendly Hospital Initiative

CED- Chronic Energy Deficiency

CHNE- Community-based Health/Nutrition Education

CI- Confidence Interval

CMAM- Community-based management of Acute Malnutrition

CMR- Crude Mortality Rate

CSB- Corn Soya Blend

DDS- Dietary Diversity Score

EMOP- Emergency Operation Programme

ENA- Emergency Nutrition Assessment

EWAS- Early warning System

FAO- Food and Agriculture Organization

FANTA- Food and Nutrition Technical Assistance

FFA- Food for Assets

FGD- Focus Group Discussion

GCM- Global Chronic Malnutrition

GFD- General Food Distribution

GAM- Global Acute Malnutrition

GOK- Government of Kenya

GS- Growth Standards

HFA- Height-for-Age

ICNP- Integrated Community Nutrition Programme

IMAM- Integrated management of Acute Malnutrition

IMC- International Medical Corps

IMCI- Integrated Management of Childhood Diseases

ITN- Insecticide Treated Nets

IYCF- Infant and Young Child Feeding

KCO- Kenya Country office

KEPI- Kenya Expanded Programme on Immunization

MMCG- Mother to Mother Care Groups

MoMS- Ministry of Medical Services

MoPHS-Ministry of Public Health and Sanitation

MUAC- Mid-Upper Arm Circumference

NCHS- National Centre for Health Statistics

NGO- Non-Governmental Organization

OJT-On-the-Job Training

OPV- Oral Polio Vaccine

PPS- Probability Proportional to Population Size

PR- Protection Ration

PRRO- Protracted Relief and Recovery Operation

SAM- Severe Acute Malnutrition

SCM- Severe Chronic Malnutrition

SD- Standard Deviation

SFP- Supplementary Feeding Programme

SMART- Standardized Monitoring and Assessment of Relief and Transitions

SMP- School Meals Programme

SPSS- Statistical Package for Social Scientists

SSS- Small Scale Survey

TBA- Traditional Birth Attendant

UFMR- Underfive Mortality Rate

UK- United Kingdom

UNICEF- United Nations Children’s Fund

USAID- United States of America International Aid

WFA- Weight-for-Age

WFH- Weight-for-Height

WHO- World Health Organization

EXECUTIVE SUMMARY

This survey covered the greater Meru North district (Igembe South, Igembe North, Tigania West and Tigania East Districts), which is inhabited by people from Igembe and Tigania origins. The population in Meru North District is relatively static and densely populated with an annual growth rate of 2.8%. The district has an estimated 146,567 households with an average of 5 persons per house hold. It has an estimated population of 740,035 people (Igembe 471,836 and Tigania 268,199) and 123,770 children below 5 years (Igembe 75,494and Tigania 48,276).Giving an average proportion of 16.7% children under 5 years. The district comprises of six livelihood zones namely; marginal mixed farming, mixed farming food crops, mixed farming: Tea/dairy, rain fed cropping and rain fed tea/dairy. Majority of the population fall under marginal mixed farming.

In view of the need to gauge the performance of the Essential Nutrition Action (ENA) package and for informed future formulation and prioritization of appropriate interventions in the district, International Medical Corps in collaboration with the MoPHS and MoMS carried out a nutritional survey between 26th March and 6th April 2012.Training of enumerators took 4 days (26th-29th March, 2012) and data collection took place as from 30th March, 2012– 6th, April, 2012. The main objective of this survey was to establish the extent and severity of malnutrition and to provide data for use in monitoring the progression of the situation.The survey utilized the Standardized Monitoring of Relief and Transitions (SMART) methodology and also in accordance with both the National Guidelines for Nutrition and Mortality assessments in Kenya and the UNICEF-recommended nutritional survey key indicators. Both anthropometric and mortality data were collected simultaneously during the survey. A two-stage cluster sampling with probability proportional to size (PPS) design was employed for the integrated nutrition survey. Sample size was determined on the basis of estimated prevalence rates of malnutrition (GAM), desired precision and design effect) using the ENA for SMART software.. IYCF multi survey sampling calculator was used to calculate IYCF and Qualitative data was collected through: focus group discussions (FGDs), key informant interviews and general observations.

Overall, the surveyed households had, on average, 5.7 (SD 2.3) members per household. The findings showed a global acute malnutrition (GAM) rate of 7.8 % (5.2-11.6 CI), a severe acute malnutrition (SAM) rate of 1.2 % (0.5-2.8 CI) by WHO-GS. The overall prevalence of GAM in Meru North County reveals risky situation with aggravating factors in the community according to WHO benchmarks. Notably was the measles break out in the district just before the survey and high morbidity cases in coughing 50% and diarrhoea disease 11.3% which are considered as aggravating factors. Tigania East division was most afflicted by acute malnutrition where the prevalence of GAM stood at 11.7% (7.2-18.4 CI),this was followed by Igembe north 8.5%, Igembe south 6.8% and finally Tigania west 4.3%. The findings though are not statistically valid as the sample size are too small to represent a division. Both the crude mortality rate (CMR) of 0.24 (0.11-0.56 CI) deaths/10,000/day and the under-five mortality rate (UFMR) of 0.48 (0.14-1.59CI) deaths/10,000/day did not reach the threshold for ‘Alert’ status.

The MUAC measurements of 715 eligible primary childcare givers (15-49 years old) were taken to assess their nutritional status.The survey findings showed that.2.2% (n=133) of caretakers had MUAC <21cm meaning that they are at risk of malnutrition or have chronic energy deficiency (CED). Overall, 87.7 % of mothers reported having attended MCH clinics and in spite of the clinic visit only 55.3 % of the women delivered in the hospital.

The findings indicate that practically all children (98.1%) were reported to have breastfed but only 53.3% were exclusively breastfed for 6 months.On average the mean food diversity was 2.8 (SD 1.8) given to children > 6 months. The findings showed that 64.2% of the children samples consumed low dietary diversity of less than four groups, a threat to optimal child growth and development while only 35.8% of the households had children >6 months who consumed 4 or more of the food group.Survey revealed that majority of the used tap water as their main source of water with 67% not treating water before drinking.85.4% of the HH had access to toilet facilities that they use.

The overall prevalence of GAM (7.8%) in Meru North County reveals poor nutritional status in the community according to WHO benchmarks. The study identified aggravating factors that had a negative bearing on optimal under-five nutritional status and their caregivers:

• Poverty and issues of who controls family income have a heavy contribution to household food security. Income sources are not diversified and therefore there’s over reliance on farm produce both as an income source and family food. Poverty has also made it difficult to access food from markets due to insufficient financial resources. Lack of water supply in many parts of Meru North districts especially in Igembe North division has led to infectious diseases spreading, causing childhood diarrhea, which leads to major malnutrition and subsequent death due to diarrheal dehydration
• Poor agricultural practices including cultivation of Miraa in most areas whose income does not translate into food security. This is further compounded by poor soil fertility as a result of poor farming practices and environmental degradation.
• Lack of access to food.Most major food and nutrition crises do not occur because of a lack of food, but rather because people are too poor to obtain enough food.
• Poor child and adult dietary profiles. Over-consumption of certain food group like cereals usually goes along with deficiencies in essential vitamins and minerals.
• High child morbidity prevalence reported to have affected 44.6% of the under-fives which was found to significantly affect child nutritional status;
• Poor IYCF practices including early weaning, low maintenance of breast feeding and poor feeding practices.
• Poor access to medical facilities some are too far for household to access. On average most health facilities are located 3.2 (SD 2.6) km away.
• Poor water sanitation status in the community with minimal treatment of unsafe drinking water at the household level increase vulnerability to infectious and water-borne diseases, which are direct causes of acute malnutrition.

Because malnutrition has many causes, only multiple and synergistic interventions embedded in true multisectoral programs can be effective. A variety of actions both immediate and long term solutions are needed:

• Addressing the poor access to essential health and nutrition services by strengthening the integrated outreach component- primarily focusing on regular medical outreach camps/mobile clinic. This will help to intensify active case finding of malnourished children and manage them accordingly.
• Strengthen programmes and strategies currently addressing infant and young child nutrition (IYCN) with a view to improving the protection, promotion, and support of optimal IYCF. Viable action points include:
• As the HINI program is rolled out there is need for continual monitoring of both facility and community based interventions to track progress while also documenting the process to assess the trends in the outcomes as well as impact indicators. Particular attention should go to improved maternal nutrition, iron/folate supplementation during the prenatal period and ensuring ORS/zinc support for diarrhoea.
• Strengthening of hygiene practices to reduce the incidence of diarrhoeal disease associated with contaminated water in the household including health education to educate the community on domestic treatment of drinking water and effective hand washing (soap/ash) after helping a child in the latrine, during food preparation and before child feeding. This should be backed-up with provision of free water treatment chemicals where feasible.
• Continued water trucking to areas affected by water stress by Ministry of Water and Irrigation and Kenya Red Cross especially in Igembe north District.
• Provision of water purification chemicals for water treatment at Household level
• Advocacy/public health campaigns on domestic water treatment such as boiling of drinking water and use of purification chemical to minimize risks of water-borne diseases, should be carried out.
• The Ministries of Public Health and sanitation and Medical services in collaboration with other stakeholders in the district to initiate and offer concrete support in the implementation of strong awareness campaigns and community based health and nutrition programs with special focus on infant and young child feeding practices, dietary diversification, food preparation and preservation, consumption of energy dense and micronutrient-rich foods and kitchen gardening. Women should be the prime targets of these. Nutrition messages should address strategies/ways of improving access to locally available and cheaper sources of fat, protein and micronutrients.

• Focus on programmes by ministry of agriculture that improve and sustain dietary diversity and consumption of micronutrient.-rich foods. And advising farmers on good farming methods .By improving agricultural yields, farmers could reduce poverty by increasing income as well as open up area for diversification of crops for household use.
• To address the issues of limited access to safe water, there is a need to establish water points in areas where water is inaccessible.
• MOH should increase access to health facilities in the rural parts of kenya by adding more health facilities or increasing CHW. These will improve hospital deliveries and access to medical services for those who cannot access the health facilities

1.0 BACKGROUND INTRODUCTION

Meru County is located in the Eastern province and constitutes 7 constituencies: Igembe, Ntonyiri, Tigania West, Tigania East, North Imenti, Central Imenti and South Imenti. The Larger Meru North District is made up of four districts namely: Igembe South, Igembe North, Tigania West and Tigania East Districts. Meru North covers an area of 4057 Km2 of which 833 Km2 is Meru National Park .It has an estimated population of 740,035 people (Igembe 471,836 and Tigania 268,199 )and 123,770 children below 5 years(Igembe 75,494and Tigania 48,276 ).Giving an average proportion of 16.7% children under 5 years [1]. The people of the district are mainly of Igembe and Tigania origins. Borans, Somalis, and others are also residents of the district.

The district lies within latitudes 0º 00’ and 0º 40’ North, and longitudes 37º 50’ East, with the southern boundary lying along the equator .Altitude ranges from 2,145m above sea level in the higher regions to 600m in the lower parts which cover the greatest land area (3/4 of total area). These low lying areas were designated as the Northern Grazing Areas (NGA) and are characterized by low and erratic rainfall. The soils are predominantly volcanic clay loams with patches of rock and black cotton soils. Rainfall amounts range from 380mm p.a. in the lower areas to 2500mm p.a. in the higher areas. Its spatial distribution is highly dependent on elevation, with the high altitude areas receiving the most amounts compared to the low-lying areas. Rainfall is bimodal with long rains expected from mid-March to May and the short rains expected from mid-October to late November. Short rains are most reliable.

Agro-ecological zones in the district range from LH2[2] (tea and dairy) to L6 (lowland grazing zones). LH2 zones cover a very small area while L6 covers the greatest area of the district. The district comprises of six livelihood zones namely; marginal mixed farming, mixed farming food crops, mixed farming: Tea/dairy, rain fed cropping and rain fed tea/dairy. Majority of the population fall under marginal mixed farming .Miraa is a major cash crop being farmed and is harvested throughout the whole year.

International Medical Corps with financial support from UNOCHA is supporting Ministry of Public Health and Sanitation and Ministry of Medical Services in scaling up of High Impact Interventions for improved maternal and child health in Meru North Districts. These interventions are in line with the priorities outlined in the nutrition sector partnership framework which supports scaling up of high impact interventions as well as supporting the Ministry of Health to deliver essential nutrition services. The overall strategy for International Medical Corps is to improve the technical and logistical capacity of the MoMS / MoPHS to deliver high-impact nutrition interventions through an integrated packageand promotion of iron enriched foodthat includes: Promotion of exclusive breastfeeding for the first six months of life; promotion of optimal complementary feeding for infants after the age of six months; Vitamin A Supplementation (2 doses per year for children aged 6-59 months); Zinc supplementation for diarrhea management; multiple micronutrients for children under five years; deworming for children (2 doses per year for children aged 12-59 months); iron-folic acid supplementation for pregnant mothers; prevention or treatment of SAM and MAM; promotion of improved hygiene practices including hand washing and promotion of the utilization of iodized salt.