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INTEGRATED HEALTH AND NUTRITION SURVEY
GREATER TANA RIVER DISTRICT
By
MINISTRY OF PUBLIC HEALTH AND SANITATION
And
INTERNATIONAL MEDICAL CORPS (IMC)
With Support from UNICEF
December 2010
Submitted to:
The International Medical Corps (IMC)
Nairobi
Report compiled by:
Martin Meme
Consultant Nutritionist
Department of Foods, Nutrition & Dietetics
Kenyatta University
P.O. Box 43844 (00100)
Nairobi
Cell: 0722-306607
Email:
TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS......EXECUTIVE SUMMARY ……………………………………………………………………...
1.0 INTRODUCTION …………………………………………………………………………...
1.1 Background to the Survey and Rationale………………………………………......
1.2 Objectives …………………………………………………………………………………...
2.0 METHODOLOGY ……………………………………………………………………......
2.1 Geographic Target Area and Population Group……………………………………......
2.2 Type of Survey......
2.3 Sampling Methodology and Sample Size ………………………………………………..
2.4 Data Collection Tools and variables measured......
2.4.1 The Household Questionnaire......
2.4.2 Child (6-59 months old) and maternal questionnaire......
2.4.3 Under 6 months old questionnaire......
2.4.4 Mortality questionnaire......
2.4.5 Baby Friendly Hospital Initiative (BFHI) questionnaire......
2.4.6 Focus group discussion (FGD) guide......
2.5 Training and Supervision…………………………………………………………………
2.6 Data Entry and Analysis......
2.7 Nutritional Status Cut-off Points......
2.7.1 Weight-for-height (WFH) and MUAC – Wasting for Children …………………......
2.7.2 Weight-for-age (WFA) – Underweight ……………………………………………......
2.7.3 Height-for-age (HFA) – Stunting ………………………………………………………..
2.7.4 Maternal MUAC …………………………………………………………………………..
2.8 Data Quality Control......3.0 RESULTS AND DISCUSSIONS ………………………………………………………...
3.1 Demographic Characteristics of Study population and Households……………......
3.2 Nutritional Status of Children 6-59 Months ……………………………………………...
3.2.1 Overall Prevalence of Global Acute Malnutrition (WHO Standards)………………..
3.2.2 Prevalence of Acute malnutrition by MUAC......
3.2.3 Prevalence of Underweight by Weight-for-age Z-scores (WHO-GS)……………….
3.2.4 Prevalence of Stunting by height-for-age (HFA) z-scores (WHO-GS)…………......
3.3 Adult Nutritional Status ………………………………………………………………......
3.4 Mother to Mother Care groups (MMCGs) and Maternal Health......
3.5 Access to Health Facilities......
3.6 Child Feeding, Care and Health ……………………………………………………….....
3.6.1 Infant and young Child Feeding Practices ……………………………………………
3.6.2 Child Immunization, Vitamin A Supplementation and Deworming ……………......
3.6.3 Child Morbidity …………………………………………………………………………....
3.6.4 Supplementary and Therapeutic Feeding Programme Coverage ……………….....
3.6.5 Insecticide Treated Mosquito Nets (ITN) Holding Rates and Utilization …………...
3.7 Water, Sanitation and Hygiene Practices………………………………………………...
3.8 Household Food Security Indicators ……………………………………………………..
3.8.1 Sources of income………………………………………………………………………..
3.8.2 Food Aid …………………………………………………………………………………..
3.8.3 Household Dietary Diversity and Food Sources ……………………………………...
3.9 Association between GAM and Important Public Health variables......
3.10 Mortality …………………………………………………………………………………....
4.0 CONCLUSIONS AND RECOMMENDATIONS ………………………………………... / 4
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LIST OF TABLES
Table1: Maternal MUAC Cut-off Points …………………………………………………….
Table 2: Age and sex distribution of sample children ……………………………………..
Table 3: Overall prevalence of acute malnutrition by WFH z-scores (WHO-GS)......
Table 4: OverallChild nutritional status based on MUAC…......
Table 5: Prevalence of underweight by weight-for-age z-scores (WHO-GS)………......
Table 6: Prevalence of stunting by height-for-age z-scores (WHO-GS)………......
Table 7: Overall adult nutritional status by MUAC …………………………………………
Table 8: Impact of MMCGs and access to healthcare by district......
Table 9: Child morbidity ……………………………………………………………………..
Table 10: Sources of water and treatment of drinking water ……………………………..
Table 11: Quantities of food aid received by households …………………………………
Table 12: Association between GAM and other variables ………………………………..
Table 13: Underfive and crude mortality rates ………………………………......
LIST OF FIGURES
Figure 1: Distribution of W/H Z-scores for sampled children......
Figure 2: Access to health facilities......
Figure 3: Types of pre-lacteals given to infants......
Figure 4: Child weaning age ………………………………………………………………....
Figure 5: Food groups taken by children in the previous 24 hours...... …......
Figure 6: Immunization, vitamin A supplementation and de-worming Coverage......
Figure 7: Household income sources......
Figure 8: Food groups taken by households in the previous 24 hours......
Figure 9: Household food sources (24 hour recall)......
Figure 10: Household coping mechanisms………………………………………………….
LIST OF APPENDICES
Appendix 1: Plausibility check for Greater Tana river district......
Appendix 2: Local events calendar......
Appendix 3: Survey Tools...... / 18
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ACRONYMS AND ABBREVIATIONS
ACF- Action Against Hunger
ALRMP- Arid Lands Resource Management Programme
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
With an area of 38,782 km² the Greater Tana River is an arid and semi-arid district in the Coast province of Kenya. Its only permanent source of water (Tana River) traverses the northern border of the district, which makes the inhabitant community heavily reliant on seasonal rivers during the wet season and their river beds (laga) for water during the dry season. There are three main livelihood zones in the larger district namely, Marginal Mixed Farming (which accommodates 49% of the population), Pastoral (14%) and Mixed Farming (37%). Many parts of the district receive erratic and poorly distributed rains. It is estimated that 72% of the greater district’s population live below the poverty line, therefore, do not have access to adequate food and consequently partly rely on relief food aid and charitable donations[1]. The district had been on Emergency Operations Programme (EMOP) since September 2004 which has since May 2009 been phased out and replaced with the Protracted Relief and Recovery Operations (PRRO). The PRRO consists of five programmes namely; the School Meals programme (SMP), Supplementary Feeding Programme (SFP), Protection Ration (PR), General Food Distribution (GFD) and Food for Assets (FFA). The current caseload for the PRRO is a total of 58,400 persons, with 42,700 beneficiaries on GFD and 15,700 beneficiaries for FFA. Following the near-failure of the short rains of 2010, most parts of the greater district deteriorated into a general alert food security status. Prior to the conduct of this survey and according to the Early Warning System (EWAS), the mixed farming livelihood zone was at alert but stable status, the pastoral livelihood zone at alert/alarm status and the marginal mixed farming livelihood zone at alert (the latter two clearly indicating a worsening food security trend).
The International Medical Corps–Kenya (IMC-Kenya)had been implementing a 10-month UNICEF-funded Essential Nutrition Action (ENA) in Tana River from April to December 2010. The project comprised of a Supplementary Feeding Program (SFP), an Outpatient Therapeutic Programme (OTP), an Infant and Young Child Feeding programme (IYCF), Baby Friendly Hospital Initiative (BFHI), Mother to Mother Support Groups (M2MsGs), Vitamin and Mineral Supplementation, Immunization and Community Health/Nutrition Education (CHNE) projects. The implementation concept revolved around supporting the relevant Government of Kenya line ministries (Ministry of Public health and Sanitation (MoPHS) and Ministry of Medical Services (MoMS)) by enhancing their technical and logistical capacity to undertake the planned activities and achieve their set goals and objectives as outlined in the 6th Annual Operation Plan (AOP 6) in health-care service provision. In order to build the capacity to manage acute malnutrition at the health facility and community levels, IMC has facilitated trainings for health workers on management of acute malnutrition, Integrated Management of Childhood Illnesses (IMCI), Infant and Young Child Feeding practices (IYCF) and Baby Friendly Hospital Initiatives (BFHI). These training sessions were designed to improve the quality of service delivery and ensure adherence to the World Health Organization (WHO) and United Nations Children Fund (UNICEF) standards and national policy guidelines. Community Health Workers (CHWs) had been trained on community mobilization and sensitization, active case finding, follow-up and mentorship of pregnant and lactating women to promote better nutritional practices and effect positive behavioural change.
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 in the greater Tana River district between 12th and 17th December 2010. The main objective of the survey was to evaluate the extent and severity of malnutrition among children aged 6-59 months and to elucidate possible factors contributing to malnutrition and recommend appropriate interventions as well as 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.
Overall, the surveyed households had, on average, 6.1 (SD 2.3) members and yielded 983 underfives and 703 eligible primary childcare givers (15-49 years old) whose nutritional status was assessed. The findings showed a global acute malnutrition (GAM) rate of 10.9% (z-scores <-2 standard deviations and/or oedema) and a severe acute malnutrition (SAM) rate of 2.1% (1.2-3.7 CI) by WHO-GS. The overall prevalence of GAM denotes a ‘serious’ situation in the community according to WHO benchmarks. According to the WFH z-scores index, the weight-for-height percentage median (WFHM) index (NCHS references) gave the expected lower rates for both GAM (5.9% 4.3-8.0 CI) and SAM (0.7% 0.3-1.8 CI) rates. MUAC findings showed 17.1% (14.8-19.7 CI) of the underfives at risk of malnutrition (12.5cm-<13.5CM). The overall prevalence of chronic energy deficiency (CED) among women was 10.5% (8.4-13.1 CI) while 1.4% (0.7-2.7 CI) of them suffered from severe CED, with the prevalence among the ssampled 105 pregnant mothers of 29.5% (21.2-39.3 CI) being statistically higher (P<0.01) than that (7.2% 5.3-9.6 CI) of the 598 non-pregnant women. Gestational malnutrition leads to low birth weights and may ultimately culminate in poor child growth and development, thus there is an urgent need to address high rates of malnutrition among pregnant women. The prevalence of underweight among the underfives was 24.8% (21.8-28.0 CI) with 5.7% (4.4-7.4 CI) of the children being severely underweight. The prevalence of global chronic malnutrition (GCM) stood at 32.5% (28.8-36.2 CI) while severe chronic malnutrition (SCM) rate was 11.1% (9.3-13.3 CI). The results also showed that though not significantly, more boys than girls suffered from both GCM and SCM. Both the crude mortality rate (CMR) of 0.36 deaths/10,000/day and the underfive mortality rate (UFMR) of 1.01 deaths/10,000/day did not reach the threshold for ‘Alert’ status.
Overall, less than one third (27.8%) of the mothers were aware of mother to mother care groups (MMCGs) and a similarly low proportion (28.1%) of those who were aware reported being members of the groups, with more mothers (26.2%) being members in Tana Delta district than in both Tana River district’s 19.4% and Tana North district (5.9%). Ironically, on the whole, and in spite of the reported high level of MCH clinic attendance, three quarters (75.2%) of the mothers reported having delivered at home with assistance from traditional birth attendants (TBAs) with only about one fifth (22.1%) delivering their babies in health facilities. Only half (50.3%) of the children delivered at home were taken for medical attention within the recommended 2-week period. Slightly more than one third (67.7%) of the mothers, overall, reported having received vitamin A supplementation following their last delivery. On average it took people in the district 73.3 (Sd 101.1) minutes to reach the nearest health facility, which is more than twice the SPHERE[3] recommendation of 30 minutes. After birth 63.0% of the infants were put on the breast within the first hour of birth, 83.7% given colostrum during the first 3 days of birth, but 51.1% were given pre-lacteals during the first 3 days, a practice that hospital delivery would help curb. Child breastfeeding fell short of the ‘on-demand’ rule for most of the children (90.2%) indicated as having been breastfed less than 12 times during the preceding day. Although exclusive breastfeeding rate (computed among infants who had not received pre-lacteals and were not on other foods) stood at 36.3%, early weaning was practised for more than two thirds (67.3%) of the rest of the children who been weaned by the first month of birth, with only 5.5% weaned at the WHO recommendation of 6 months. Although the overall maintenance of breast feeding stood at 77.4%, the children’s complementary diets were poor, with 60.2% of the children thriving on low diversity diets coupled with relatively low (not on-demand) feeding at a frequency at 2.8 (SD 1.1) meals per day for the 6-9 month olds and 3.0 (SD 0.9) times those aged 9-23 months.
Child immunization for polio (88.4%), measles (92.1%), and vitamin A (82.6%) were commendably high and above the Kenya Expanded Programme on Immunization (KEPI) recommendation of 80% while more than half (57.5%) of the children had received de-wormers which is crucial in warding off the debilitating effects that helminthic infections cause among growing children. Militating against the high immunization rates, however, was a relatively high rate of morbidity where 60.4% of the under fives were reported having been sick during prior 2-week period, with most of them (28.8%) suffering from ARI, 13.8% from malaria and 11.8% from diarrhoea. The estimated point coverage for both SFP (10.8%) and OTP (5.6%) were very low and far below the project targets of 50%[1]. The insecticide treated mosquito net holding rate was 77.5%, with reported high utilization rate among underfives (96.4%) but low rates among pregnant women (50.0%) in a malaria endemic zone. Although the main drinking water sources were unsafe due to risk of contamination, more than four fifths (84.7%) of the households did not treat it before drinking at household level.
With very few (35.1%) households reported as receiving food aid and food purchase being the main source for most (71.3%) of them in the face of high market food prices, the main food stress coping mechanisms practised were indicative of reduced nutrient intake as was also borne out by poorly diversified household diets. Both the reported previous 24-hour mean frequency of taking meals as well as the proportion of members who had taken 3 meals the previous day were significantly lower than households normally did, strongly suggesting a current prevailing food deficit situation in the community.
The overall GAM prevalence in the Greater Tana River district of 10.6% (8.4-13.3 CI) is rated ‘serious’ according to WHO benchmarks[5,6][6] with the prevalence in certain sections of the larger district attaining ‘critical’ levels. Although both CMR and UFMR are below the threshold for an ‘alert’ status, this study identified a number of other aggravating factors with a negative bearing on optimal underfive child nutritional status and therefore an impediment to the on-going interventional activities in the district. Among these were:
High child morbidity prevalence reported to have affected 60.4% of the underfives which was found to significantly affect child nutritional status;
Poor child and adult dietary profiles coupled with low coverage of food aid distribution with poor IYCF practices including early weaning, low maintenance of breast feeding and poor feeding practices;
Low coverage of nutrition intervention programmes;
Lack of timely and appropriate child healthcare provision where more one fifth of the children born at home might have missed essential vaccinations;
Poor access to medical facilities and services;
Lack of conventional medical supervision for highly malnourished delivering mothers,
Poor hygiene, environmental and water sanitation status in the community with minimal treatment of unsafe drinking water at the household level and poor access to toilets
A prevailing food deficit situation that is set to deteriorate further before the onset of long rains expected in 3 months
In conclusion, the relatively high prevalence of GAM in addition to the aggravating factors listed above depict a situation set to fast deteriorate further in the near future unless the requisite food and non-food interventions are urgently put in place, which makes the following recommendations of the essence:
- Application of the WHO-GS WFH z-score index for a massive case-finding exercise in the community to help capture all deserving cases for SFP and OTP interventions;
- Up scaling of the general food aid distribution throughout the district and inclusion of all households with pregnant mothers and lactating children below 6 months in GFD;
- Provision of more mobile and outreach clinics in the far-to-reach areas of the district to complement existing facilities (plans should be put under way to consider putting up more health facilities to improve healthcare access by the population;
- Provision of adequate resources to enable full implementation of the Government’s Community Strategy to address nutrition and health issues in the district in a more comprehensive way;
- More emphasis need to be laid on community public health/nutrition education through various forums to improve child feeding and care, environmental, water and hygiene practices such as toilet holding and utilization, treatment of drinking water; and
- Speedy revival, completion and exploitation of the upcoming Tana River irrigation schemes to decisively improve food security in the larger district through agricultural diversification.
1.0
INTRODUCTION