Tana River County SMART Survey

Conducted by:International Medical Corps and Ministry of Public Health and Sanitation

Services

With support from UNICEF KCO

Type of the survey: SMART18th to 24th February, 2012

Martin Meme – Consultant Nutritionist

Survey Implementation Dates

Survey Team Training: 5 days (13th - 17th February 2012) including anthropometric survey standardization, piloting, adjustment of survey tools and logistics

Data Collection: 7 days (18th-24th February 2012)

Survey Background • Tana River County comprises of 3 districts (Tana North, Tana

River and Tana Delta) covering an area of 180,385 km².• County comprises of 3 livelihood zones (Marginal mixed

farming, Mixed farming and Pastoral).• Food security situation in the county was at ‘Stressed Phase’

with the status rated at ‘Alert and Deteriorating’ (ALRMP Drought Early Warning Bulletin - January 2012).

• This survey therefore served to assess the nutritional situation in the county to gauge the performance of HINI and inform future programming

Objectives of the survey

1. To evaluate the nutritional status of children aged 6 to 59 months2. To assess the nutritional status of pregnant and lactating mothers

aged 15-49 years3. To estimate the measles and polio immunization coverage for children

aged 9 to 59 months4. To estimate the crude and under-five mortality rates5. To estimate the systematic treatment (vitamin A supplementation and

de-worming coverage)6. To identify factors likely to have influenced the nutritional status of

young children7. To estimate the prevalence of some common illnesses (e.g. measles,

diarrhea, malaria, and ARI)

Objectives of the survey cont..

8. To estimate the impact and coverage of general food distribution and feeding programs

9. To establish the current household food security situation10. To establish the situation of water and sanitation11. To assess the percentage of mothers accessing MCH

facilities and the level of exclusive breastfeeding of children under six months

12. To estimate the iron /folate coverage among mothers

Sampling MethodologyParameter Anthropometric Sample Mortality Sample

SMART (2-stage cluster sampling with PPS design)

Estimated prevalence 13.3 0.36

Desired precision 4 0.3

Design effect 2 2

Recall period 90 days

Average household size 6 6

% underfives 15

% non-response 3 3

Households included 719 639

Children included 603

Population to be included 3717

Anthropometric sample higher therefore used in both surveysIYCF sample size = 409 children (IYCF multi survey sampling calculator)

Plausibility check

Indicator Survey valueAcceptable value/range

Interpretations/Comments

Digit preference score - weight5 0-<=20 Good

Digit preference - height8 0-<=20 Good

WHZ ( Standard Deviation)1.02 0-<1.2 Excellent

WHZ (Skewness)0.08 <±3.0 Excellent

WHZ (Kurtosis)-0.17 <±3.0 Excellent

Percent of flags2.3 0%-10% Excellent

Overall Survey Score11% (including 4% overall age-distribution score)

Age distribution (%)

Group1 6-17 mo22.7

Group 2 19-29 mo26.5

Group 3 30-41 mo23.8

Group 4 42-53 mo20.0

Group 5 54-59 mo7.0

Age Ratio : G1+G2/G3+G4+G51.0

Overall Sex Ratio 1.1 0.8-1.2 Excellent

Nutrition status- Wasting (WHZ)by Sex (WHO 2006)

Alln =862

Boysn = 449

Girlsn = 413

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

116 (13.5%)(11.3-16.0 95% C.I.)

71 (15.8%)(12.7-19.5 95% C.I.)

45 (10.9%)(38.6-13.6 95% C.I.)

Prevalence of Moderate Acute Malnutrition (MAM)(<-2 z-score and >=-3 z-score, no oedema)

89 (10.3%)(8.5-12.5 95% C.I.)

54 (12.0%)(9.6-14.9 95% C.I.)

35 (8.5%)(6.3-11.2 95% C.I.)

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

27 (3.1 %)(2.3-4.2 95% C.I.)

17 (3.8%)(2.6-5.5 95% C.I.)

10 (2.4%)(1.2-4.9 95% C.I.)

Prevalence of Wasting (WHZ) by Age

Age

(Months)

Total

No.

Severe Wasting(<-3 z-scores)

Moderate Wasting(>= -3 -<-2 z-scores)

GAM (<-2 z-scores)

6-17 195 6 (3.1) 16 (8.2) 22 (11.3)

18-29 229 5 (2.2) 23 (10.0) 28 (12.2)

30-41 205 7 (3.4) 17 (8.3) 24 (11.7)

42-53 173 5 (2.9) 22 (12.7) 27 (15.6)

54-59 60 4 (6.7) 11 (18.3) 15 (25.0)

Total 862 27 (3.1) 89 (10.3) 116 (13.5)

Prevalence of Underweight (WAZ) by Sex

All(N = 859)

Boys(N= 448)

Girls(N= 411)

Prevalence of Underweight(<-2 z-score )

234 (27.2%)(23.3-31.5 95% C.I.)

132 (29.5%)(25.4-33.8 95% C.I.)

102 (24.8%)(19.2-31.4 95% C.I.)

Prevalence of Moderate Underweight(<-2 z-score and >=-3 z-score)

174 (20.3%)(17.6-23.2 95% C.I.)

99 (22.1%)(18.9-25.7 95% C.

75 (18.2%)(13.7-23.9 95% C.I.)

Prevalence of Severe Underweight (<-3 z-score)

60 (7.0 %)(4.8-10.1 95% C.I.)

33 (7.4%)(4.4-12.2 95% C.I.)

27 (6.6%)(4.5-9.5 95% C.I.)

Prevalence of Stunting (HAZ) by Sex

All(N = 860)

Boys(N= 448)

Girls(N= 412)

Prevalence of Stunting(<-2 z-score )

287 (33.4%)(24.8-43.2 95% C.I.)

153 (34.2%)(25.6-43.8 95% C.I.)

134 (32.5%)(23.2-43.5 95% C.I.)

Prevalence of Moderate Stunting(<-2 z-score and >=-3 z-score)

197 (22.9%)(18.3-28.2 95% C.I.)

109 (24.3%)(19.4-30.1 95% C.

88 (21.4%)(15.9-28.1 95% C.I.)

Prevalence of Severe Stunting(<-3 z-score)

90 (10.5 %)(6.4-16.7 95% C.I.)

44 (9.8%)(5.7-16.4 95% C.I.)

46 (11.2%)(6.7-18.0 95% C.I.)

Prevalence of Wasting by MUAC

All(N= 863)

Boys(N=449)

Girls(N= 414)

Moderate acute malnutrition(MUAC 11.5 - <12.5cm)

(36) 4.2% (15) 3.3% (21) 5.1%

Severe acute malnutrition(MUAC <11.5cm) (12) 1.4% (7) 1.6% (5) 1.2%

Total Wasted(MUAC < 12.5cm

(48) 5.6 % (22) 4.9% (26) 6.3%

At risk(MUAC 12.5 - <13.5cm) (171) 19.8% (80) 17.8% (91) 22.0%

Child Morbidity N=579 (67.4%)

Zinc Supplementation during Last DD Episode

Management of last DD Episode (N=68) %

Oralite/ORS (n=25) 36.8

Other home-made liquid: porridge, soup e.t.c. (n=18) 26.5

Zinc + ORS (n=6) 8.8

Home-made salt/sugar solution (n=3) 4.4

Zinc tablets (n=1) 1.5

Other (n=15) 22.1

Immunization, Vitamin A Coverage and DewormingMeasles 9-59 MONTHS (N=820) Yes by card

Yes by RecallNot immunized

Don’t know

564 (68.8%)170 (20.7%) (89.5%)

77 (9.4%)9 (1.1%)

OPV 1 (N=863)

Yes by cardYes by Recall

Not immunizedDon’t know

686 (79.5%)145 (16.8%) (96.3%)

26 (3.0%)6 (0.7%)

OPV 3 (N=863) Yes by cardYes by Recall

Not immunizedDon’t know

642 (74.4%)149 (17.3%) (91.7%)

62 (7.2%) *(4.6% drop out)10 (1.2%)

Vitamin A coverage (6-11 months N=99)

NoneOnceTwice

30 (30.3%)48 (48.5%) (69.7%)

18 (18.2%)

Vitamin A coverage (12-59 months N=762)

NoneOnceTwice

161 (21.1%)289 (37.9%) (78.9%) 258 (33.9%)

Dewormed (>=24 months N=536) Yes by cardYes by Recall

NoDon’t know

80 (14.9%)196 (36.6%) (48.5%)

215 (40.1%)45 (8.4%)

Water and Environmental Sanitation

Characteristic

%

YesAccess to toilet facility (N=775):

No

252 (32.5)

523 (67.5)

Main sources of drinking water (N=779): Protected well

RiverTap

Public panBorehole

Canal

200 (25.7)184 (23.6)101 (13.0)92 (11.8)83 (10.7)36 (4.6)

AppropriateDrinking water treatment (N=779):

Not appropriate

140 (17.9)

639 (82.1)

Washing of hands

Estimated feeding programs point coverage

Program Estimated point Coverage by WHZ (%)

Comments/Analysis

SupplementaryFeeding Programme (SFP)

38.2%

34 eligible children out of 89 in the sample who should have been in SFP

Therapeutic Feeding Programme(OTP)

63.0%

Commendably high ( 17 out of 27 children who should have been in OTP)

Nutritional status of Women by MUAC

n %

Pregnant and lactating womenMUAC <21cm (N= 458)

26 5.7

Non-pregnant and non-lactating womenMUAC <21cm (N=149)

6 4.0

TotalMUAC <21cm (N=573) 32 5.3

Maternal Health-Care

n %

YesReceived iron/folate supplementation (N=757)

NO

467

290

61.7

38.3

Mothers took iron/folate for 90 or more days (N=464) 11 2.4

YesAttended ANC (N=765)

No

676

89

88.4

11.6

Supervised medical care Where last delivery took place (N=755)

Unsupervised medical care

177

578

23.4

76.6

Household Food ConsumptionIndicator % households

Usual number of meals taken:Mean number of meals taken 2.70 (SD=0.5)

3 meals 70.0% *

2 meals 26.1% **

1 meal 2.6%

No. meals day preceding the survey:Mean number of meals 2.52 (SD=0.7)

3 meals 55.8% *

2 meals 36.1% ** *, **P<0.01

1 meal 6.4%

Did all household members take meals day preceding the survey?

YesNo

88.4%11.6%

Household Food Consumption cont..Indicator

Mean number of food groups consumed in household 3.7 (SD 1.3)

Household dietary diversity (N=609):Low dietary diversity (<4 food groups)

High dietary diversity (>=4 food groups)297 (48.8%)312 (51.2%)

Main 3 sources of food consumed previous day (N=760):Purchase

Own productionFood aid

462 (60.8%)148 (19.5%)121 (15.9%)

Breastfeeding practices

Complementary Feeding Practices – Frequency of Meals

Indicator n %

Breastfed 6-8 months old ≥ 2 times per day(N= 46)

37 80.4

Breastfed children 6-23 months old ≥ 3 times per day (N=270)

184 66.1

Non-breastfed children 6-23 months old≥ 4 times per day (N=48)

18 37.5

Breastfed children 6-8 months old ≥ 2 times + Breastfed children 6-23 months old ≥ 3 times + Non-breastfed children 6-23 months old ≥ 4 times per day (N= 364)

239 65.7

Complementary Feeding Practices – Dietary Diversity 6-23 months old

Indicator n %

Breastfed children consuming ≥ 3 food groups (N= 273)

126 46.2

Non-breastfed children consuming ≥ 4 food groups (N= 48)

14 29.2

Breastfed children consuming ≥ 3 food groups + Non-breastfed children consuming ≥ 4 food groups (N= 321)

140 43.6

Mortality

• Crude mortality rates (CMR):0.75/10,000/day [0.53-1.06 95% CI]*

• Under 5 mortality rates (U5MR):1.23/10,000/day [0.62-2.20 95% CI]*

Mortality rates below ‘alert’ threshold

Conclusions• This survey was conducted during the hunger-gap period that

precedes the onset of long rains in TRD.• Though both UFMR and CMR are low, the prevalence of GAM 13.5 is

beyond acceptable level according to WHO benchmarks and rated ‘Risky’.

• The prevalence of underweight in the County (27.2%) is above the average for Coast province (23.5%) but below the national average (16.1%) while that of stunting (33.4%) was below both that of Coast province (39.0%) and national average of 35.3% (KDHS 2008-2009).

• Underfive children in TRD county were faced with a high burden of morbidity (> 2/3rds sick) mainly due to ARI and malaria.

• Zinc supplementation dismally covering only 10% children during diarrhoea and attributed to erratic availability in medical facilities.

Conclusions cont...• Vitamin A supplementation and deworming coverage were

below WHO recommendation of 80%• WASH practices still poor in the county:

Less than 1/3rd households have access to toilets Less than 1/5th HHDs treat unsafe drinking waterAppropriate hand washing practised by only about 1/10th of the

childcare givers

• Coverage of selective feeding practices (particularly OTP) commendably high – but many factors militating potential gains

• Attendance to ANC high (more than 4/5th but more than ¾ of the mothers give birth without supervised medical care.

Conclusions cont...• IYCF Practices:

Breastfeeding practices (timely initiation, EBF and maintenance of b/feeding at 1 yr) good but low at 2 years (FGDs indicate socio-cultural and ignorance factors mainly responsible for non-compliance).

Although complementary feeding practices (frequency of meals) optimal for approximately 1/3rd of the children, qualitative analysis of the diet indicates poor dietary profiles for eligible children with more than half subsisting on poorly diversified diets.

• Food security status:Household food consumption during the survey’s conduct indicates

significant reduction in daily meal frequencyOnly about half households took highly diversified diets

Conclusions cont...

60% HHDs relying of food purchase as their major food source (a number of main food stress coping strategies practised apply to serious food deficit periods). FGDs discussants complained of high food prices in the market.

• FGDs and observations revealed a community readily embracing farming activities in the on-going irrigation scheme rehabilitation.

RecommendationsShort-term BY Who?

1 The following HINI components need improvement: Zinc supplementation during diarrheaVitamin A supplementationToilet access and useTreatment of drinking water by boilingTraining on appropriate hand washingCoverage of SFPMedical supervision of mothers during child birthContinued breastfeeding after 1 yearConstitution of balanced diets using locally available foodstuffs (diversification of agriculture)General health-promotive strategies e.g. use of ITNs

IMCUNICEFMOPHSMOAWHOAgro GermanPledge Action InternationalUNOPSWFP

2 Step up stop-gap measures to cushion community against current food-deficit situation before onset of long rains (GFD, FFA)

Red CrossWFPSamaritan Purse

Recommendations cont..Long-term BY Who?

3 Sustained rehabilitation of irrigation schemes with agricultural diversification, protection of schemes against destruction by wild animals and improved marketing of food products to further improve production in the county

MOAMOCDStakeholdersKWS

4 Initiation of small-scale irrigation projects in areas outside main scheme e.g. through drip irrigation

5 Infrastructural improvement to improve access to markets and facilitate general development in all areas of TRD county

MOPWLocal AuthoritiesCentral governmentOther stakeholders