Transcript Title

From Relief to Self-Reliance
Meru North SMART survey
Validation Report
Monitoring and Evaluation
Anastacia Maluki
amaluki@internationalmedical
corps.org
©2012
International
Corps of International Medical Corps and should not be reproduced without prior written consent. This material is protected
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BACKGROUND INTRODUCTION
• Meru North district :Igembe South, Igembe North, Tigania West and
Tigania East.
• The population is relatively static and densely populated with an
annual growth rate of 2.8%.
– estimated population of 740,035 people (Igembe 471,836 and
Tigania 268,199 with an average proportion of 16.7% children
under 5 years
• 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.
• The district comprises of six livelihood zones namely;
– marginal mixed farming (Majority of the population)
– mixed farming food crops
– mixed farming: Tea/dairy
– rain fed cropping
– rain fed tea/dairy
©2012 International Medical Corps
Map of Meru District
©2012 International Medical Corps
Rationale for conducting a survey
• To gauge the performance of the HINI
•
•
•
•
package.
Inform future programming in the district.
To evaluate the extent and severity of
malnutrition among children aged 6-59
months.
Analyse the possible factors contributing to
malnutrition .
Recommend appropriate interventions.
©2012 International Medical Corps
Objectives
• To estimate the current prevalence of acute
malnutrition in children aged 6-59 months and to
compare the overall nutritional changes with
previous GAM and SAM
• To estimate the retrospective crude and under
five death rates and morbidity among under five
children and as well compare with previous CMR
and U5MR.
• To estimate Measles, BCG vaccination and
Vitamin A supplementation for children 9-59
months and 6-59 months respectively
©2012 International Medical Corps
Objectives (2)
• To assess the current food security situation of
the surveyed population, prevalence of some
common diseases (Diarrhea, Fever, and Cough)
and to identify factors likely to have influenced
malnutrition in young children
• To assess child and infant care and feeding
practices among caretakers with children 0-23
months
• To establish the situation of water and sanitation,
appropriate hygiene practices including hand
washing among caretakers
©2012 International Medical Corps
Methodology Anthropometric and Morterlity
Data entered on ENA software
Anthropometric sample
Retrospective Mortality sample
Estimated prevalence
7.2
0.98
Desired precision
3
0.5
Design effect
1.5
1.5
Recall period
90 days
Average household size
5
Percent of under five children
17
Percent of non-respondent
3
3
Households to be included
628
563
Children to be included
466
Population to be included
Recall period since 2nd Jan, 2012
©2012 International Medical Corps
5
2732
Methodology –IYCN (2)
• Indicators calculated were:
–
–
–
–
Timely initiation of breastfeeding (children 0-23 months),
Exclusive breastfeeding under 6 months,
Timely complementary feeding, and
Continued breastfeeding at 1 year.
• The sample size for children between 0-23 months was
730
• The number of children reached per cluster was given
by dividing 730 by 37 giving 20 children per cluster.
• Getting children below 6 months in a cluster was quite
a challenge and therefore purposive sampling was used
where no children of that age group were found in the
cluster.
©2012 International Medical Corps
Description of sampling methods
• Number of clusters to be surveyed was 37
=(726/ 20 (Household to be reached per day))
• A total of 6 survey teams :
– 1 team leader
– 3 enumerators
• Data was collected for 6 days (37/6).
©2012 International Medical Corps
Data collection Tools
• Questionnaire A (Household) - primary
caretakers
• Questionnaire B (anthropometry ) – 6-59
months
• Questionnaire C (IYCF) - 0-23 months
• Questionnaire D (Mortality) - all HH members
• Focus Group Discussion (FGD) guide qualitative data.
©2012 International Medical Corps
Training
• The team was trained for 3 days (26th-28th March,
2012):
–
–
–
–
–
nutrition survey objective
anthropometric measurements
interviewing techniques
completion of questionnaires
standardization test will be done
• pre-test was done on 29th March 2012
• Data collection begun on the 30th March, 2012–
6th, April, 2012.
©2012 International Medical Corps
Data Entry and Analysis
• SMART/ENA for Anthropometric and mortality
data analysis.
• All the other quantitative data was entered
and analyzed in the SPSS (Version 15.0)
computer package
©2012 International Medical Corps
Findings: Demographic Characteristics
DEMOGRAPHY
Number
Number of HH surveyed
740
Number of children 6-59 months surveyed
709
Number of children 0-23 months surveyed for IYCN
731
Average number of persons per HH
5.7
S.D = 2.3
Average number of children (0-6 months ) per HH
0.2
S.D=0.4
Average number of children (6-59 months ) per HH
1.1
S.D = 0.8
Most of the children aged 0-23 months for IYCN were not
included in the anthropometric measurement. They were
purposively sampled.
©2012 International Medical Corps
Distribution of age and sex of 6-59 months.
Boys
Girls
Total
Ratio
AGE
(months)
6-17
no.
%
no.
%
no.
%
131
54.1
111
45.9
242
34.1
Boy:
girl
1.2
18-29
112
49.1
116
50.9
228
32.2
1.0
30-41
47
47.5
52
52.5
99
14.0
0.9
42-53
43
49.4
44
50.6
87
12.3
1.0
54-59
27
50.9
26
49.1
53
7.5
1.0
Total
360
50.8
349
49.2
709
100.0
1.0
• overall male: female ratios were within the expected
range of 0.8 – 1.2
• Most of the children aged 6-29 months for IYCN were
purposively sampled and this explains why they are many
children between these age groups.
©2012 International Medical Corps
Prevalence of acute malnutrition based on weight-for-height zscores (and/or oedema) and by sex
All
n = 692
Boys
n = 348
Girls
n = 344
Prevalence of global malnutrition
(<-2 z-score and/or oedema)
(54) 7.8 %
(34) 9.8 %
(20) 5.8 %
(5.2 - 11.6 (4.6 - 19.5 (3.3 - 10.0
95% C.I.)
95% C.I.)
95% C.I.)
Prevalence
of
moderate
malnutrition
(<-2 z-score and >=-3 z-score, no
oedema)
Prevalence of severe malnutrition
(<-3 z-score and/or oedema)
(46) 6.6 %
(30) 8.6 %
(16) 4.7 %
(4.0 - 10.8 (3.8 - 18.2 (2.6 - 8.2 95%
95% C.I.)
95% C.I.)
C.I.)
(8) 1.2 %
(4) 1.1 %
(4) 1.2 %
(0.5 - 2.8 (0.6 - 2.4 95% (0.2 - 6.2 95%
95% C.I.)
C.I.)
C.I.)
Boys were more malnourished than girls but it was not
significantly. P value for the GAM rate was 0.208
©2012 International Medical Corps
Prevalence of acute malnutrition based on MUAC cut off's
and/or oedema
Nutritional Status
MUAC Criteria
Number
Percentage
Severe malnutrition
<11.5cm
21
3%
Moderate malnutrition
>=11.5
<12.5cm
and 67
9.6 %
At risk of malnutrition
>=12.5
<13.5cm
and 190
27.3%
Satisfactory nutritional status
>=13.5cm
419
60.1 %
697
100
TOTAL
GAM 12.6%
©2012 International Medical Corps
Prevalence of underweight based on weight-for-age z-scores by
sex
All
n = 705
Prevalence of underweight
(<-2 z-score)
Boys
n = 358
Girls
n = 347
(100) 14.2 % (65) 18.2 %
(35) 10.1 %
(11.5 - 17.4 (13.9 - 23.4 (7.0 - 14.4
95% C.I.)
95% C.I.)
95% C.I.)
Prevalence
of
moderate (85) 12.1 %
(54) 15.1 %
(31) 8.9 %
underweight
(9.7 - 14.9 (11.4 - 19.7 (5.8 - 13.5
(<-2 z-score and >=-3 z-score)
95% C.I.)
95% C.I.)
95% C.I.)
Prevalence of severe underweight
(<-3 z-score)
(15) 2.1 %
(11) 3.1 %
(4) 1.2 %
(1.3 - 3.6 95% (1.5 - 6.1 95% (0.4 - 3.0 95%
C.I.)
C.I.)
C.I.)
Boys are more underweight than girls and this is extremely
significant. P. value =0.004
©2012 International Medical Corps
Prevalence of stunting based on height-for-age z-scores and by
sex
All
n = 702
Boys
n = 357
Girls
n = 345
Prevalence of stunting
(<-2 z-score)
(207) 29.5 % (120) 33.6 % (87) 25.2 %
(26.1 - 33.1 (28.3 - 39.4 (20.7 - 30.3
95% C.I.)
95% C.I.)
95% C.I.)
Prevalence of moderate stunting
(<-2 z-score and >=-3 z-score)
(152) 21.7 % (82) 23.0 % (70) 20.3 %
(19.0 - 24.6 (18.4 - 28.3 (16.7 - 24.4
95% C.I.)
95% C.I.)
95% C.I.)
Prevalence of severe stunting
(<-3 z-score)
(55) 7.8 %
(38) 10.6 % (17) 4.9 %
(6.2 - 9.9 (7.9 - 14.2 (3.1 - 7.9
95% C.I.)
95% C.I.)
95% C.I.)
Boys are more stunting than girls and this is extremely
significant. P. value =0.009
©2012 International Medical Corps
Nutrition Status of caregivers of < 5 year old children: n=697
Nutrition Status of caregivers of < 5 year old children:
12.0
11.4
Percentages of caregivers
10.0
8.0
6.9
6.0
4.8
4.0
% MUAC<21
3.3
2.0
0.0
Pregnant
Lactating
Not pregnant nor lactating
Maternal physiological status
©2012 International Medical Corps
Total
Vaccination coverage
Measles
n=651
OPV 1
n=697
OPV 3
n=697
Deworming
(12-59
Months)
N=603
YES
with
card
n=279
With
with
Recall
card
from
n=360
mother
n=275
With
Recall
from
mother
n=322
with
card
n=347
With
Recall
from
mother
n=321
with With
card Recall
n=91 from
mother
n=229
%
42.9
42.2
46.2
49.8
46.1
15.1
51.6
Measles coverage was quiet high ,this is because there was a
measles campaign going on during the survey. Both Measles
and OPV were above National coverage of 80%
©2012 International Medical Corps
28
Vaccination coverage
Vitamin A
6-59 months
N=697
Vitamin A
6-11 months
N=94
Vitamin A
12-59
months
(
received twice in the
last 1 year)
N=603
65.6%
58.5%
66.7 %
©2012 International Medical Corps
Symptom breakdown in the children in the two weeks prior
to interview (n=309)
Symptoms
6-59 months
Cough
50.0 %
Malaria
21.9%
Diarrhoea
11.3 %
Measles
2.3 %
Other
14.5 %
44.6% of the under-fives reported to have been sick and
only 13.4% of mothers reported not to get any assistance
when child was sick
©2012 International Medical Corps
Zinc Supplementation during Last DD Episode
Management of last DD Episode (N=39)
%
Oralite/ORS
30.8
Zinc
15.4
Zinc + ORS
5.1
Home-made salt/sugar solution
12.8
Nothing
35.9
©2012 International Medical Corps
House hold water sources for general and domestic use
Household water uses
35.0
33.2
31.7
32.0
31.6
percentage Usage
30.0
25.0
20.0
14.6
15.0
10.0
14.0
8.5 9.6
6.5 6.2
5.0
3.7
0.8
3.4
0.7
1.8
0.3
0.3
0.3
0.0
0.0
Water Sources
General use
it takes an average 41.75 minutes to access main source of
water and HH use an average of 97.8 litres of water per
day. A 20-litre jerrican costed on average Kshs 7.49
©2012 International Medical Corps
0.3
0.3
Drinking
0.2
Methods of Water treatment
3%
30%
Nothing
Add chemicals
67%
Clearly the role of untreated water as the main cause of
childhood diarrhoea and subsequent levels of acute
malnutrition cannot be underestimated.
©2012 International Medical Corps
Boiling
Frequency of meals taken in household
Frequency of meals intake in households.
80.0
70.7
70.0
65.7
Percentage of household
60.0
50.0
40.0
usual meal frequency
Day preceeding survey
30.0
24.1 25.1
20.0
10.0
8.8
4.4
0.7
0.3
0.1
0.0
0.0
1
2
3
Frequency of meals intake
meal frequency usually taken 2.7 (SD 0.6) while the one
reported for the previous day prior to survey was 2.6 (SD
0.7) On average the mean Individual Diet Diversity Score
was 4.1 (SD 1.5) for the number of food groups consumed
©2012 International Medical Corps
4
5
Mortality rates
CMR (total deaths/10,000 people / 0.24 (0.11-0.56) (95% CI)
day
U5MR (deaths in children under 0.48 (0.14-1.59) (95% CI)
five/10,000 children under five /
day
Main cause of death among the > 5 years was accidents
while majority (75%) reported not to know the cause of
death among the <5 year was
©2012 International Medical Corps
Summary of finding
Indicators
% of women attended at least 1 Anc Visits (N=647)
Hospital Delivery (n=408)
% women supplemented with iron in there last
pregnancy (n=255)
% ( 95% CI)
92.8%
55.3%
34.6%
Timely initiation of breastfeeding (children 0-23 months)
(n=619)
Exclusive breastfeeding under 6 months (n=80)
Continued breastfeeding upto 2 years (n=643)
Minimum dietary diversity (6-23 months)
Consuming 3+ food groups (breastfed children) (n=317)
86.3
Consuming 4+ food group (non-breastfed children) (n=22)
31.9%
Consuming 3+ or 4+ food group (breastfed and nonbreastfed children) N=339 n=209
Minimum meal frequency HDDS
At least twice a day for 6-8 months (breastfed children)
(n=85)
3+ times a day for 6-23 months old (breastfed children)
(n=431) Medical Corps
©2012 International
4+ times a day of children 6-23 moths (non-breastfed
53
89.7
3.2
63.7%
61.7%
3.2
94.4%
85.2%
28.8%
Plausibility check
Indicator
Survey value
Acceptable
value/range
Interpretations/
Comments
Digit preference score - weight
5
<10
Excellent
Digit preference - height
5
<10
Excellent
WHZ ( Standard Deviation)
1.13
0.8-1.2
Good
WHZ (Skewness)
-0.10
-1 to +1
Excellent
WHZ (Kurtosis)
-0.33
-1 to +1
Excellent
Percent of flags WFH
2.4
<3%
Excellent
Overall Survey Score
12%
Age distribution (%)
Group1
6-17 mo
34.1
20%-25%
Group 2
18-29 mo
32.2
20%-25%
Group 3
30-41 mo
14.0
20%-25%
12.3
20%-25%
7.5
20%-25%
1.0
Ard 1.0
Group 4
Group 5
42-53 mo
54-59 mo
Age Ratio : G1+G2/G3+G4+G5
1.02
Overall
Sex Ratio
©2012
International Medical Corps
0.8-1.2
Excellent
Conclusion
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.
• FGD findings revealed that majority 75% of the
community was poor with only 25% categorized as rich.
• Majority 70.3% of the households purchase food
©2012 International Medical Corps
Conclusion
• 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.
• 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.
• most common foods consumed by the households &
children were Cereals and cereal products 24% least
consumed food were meat /fish/poultry product 1% .
• On average most health facilities are located 3.2 (SD 2.6)
km away .
©2012 International Medical Corps
Recommendation
Immediate Interventions
• strengthening the integrated outreach
component- to intensify active case findings of
malnourished children and manage the severaly
and moderately malnourished children.
• Strengthen programmes and strategies currently
addressing infant and young child nutrition (IYCN)
• Strengthen the HINI program especially maternal
nutrition, iron/folate supplementation during the
prenatal period and ensuring ORS/zinc support
for diarrhoea.
©2012 International Medical Corps
Recommendation
• Strengthening of hygiene practices to reduce the incidence
of diarrhoeal disease
• Continued water trucking to areas affected by water stress
by Ministry of Water and Irrigation and Kenya Red Cross
especially in the Igembe north area.
• Provision of water purification chemicals for water
treatment at Household level
• 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 .
Only 64.9% of the mothers reported washing hands with
soap.
©2012 International Medical Corps
Recommendation
Long-Term Interventions
• 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.
©2012 International Medical Corps