NUTRITIONAL ANTHROPOMETRIC AND MORTALITY SURVEY

FINAL REPORT

WAJIR EAST DISTRICT

NORTH EASTERN PROVINCE, KENYA

17th - 30th November 2011

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Acknowledgements Special thanks are expressed to; .

• ECHO for the continued financial support to Save the Children Nutrition program and for funding this survey.

• Provincial administration, ALRMP, Ministry of Agriculture, Ministry of Health and District Development Office through their respective district focal persons for the necessary expertise during the entire survey period.

• Survey team (supervisors, team leaders, enumerators and drivers) for their tireless efforts to ensure that the survey was conducted professionally and on time.

• Community members who willingly participated in the survey and provided the information needed.

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Table of contents

Contents Acknowledgements ........................................................................................................................................... 2

Table of contents ............................................................................................................................................... 3

List of figures .................................................................................................................................................... 4

List of tables ...................................................................................................................................................... 4

List of abbreviations and acronyms .................................................................................................................. 5

Executive summary ........................................................................................................................................... 6

1 Introduction ............................................................................................................................................. 10

1.1 Survey Objectives .......................................................................................................................... 12

2 Methodology ........................................................................................................................................... 13

2.1 Sample size .................................................................................................................................... 13

2.2 Sampling procedure: selecting households and children ............................................................... 14

2.3 Case definitions and inclusion criteria ........................................................................................... 14

2.3.1 Children’s data .......................................................................................................................... 14

2.3.2 Mortality data ............................................................................................................................ 15

2.3.3 Causes data ................................................................................................................................ 16

2.4 Nutritional Status Cut-off Points ................................................................................................... 16

2.4.1 Weight-for-height (WFH) and MUAC – Wasting among Children .......................................... 16

2.4.2 Weight-for-age (WFA) – Underweight ..................................................................................... 16

2.4.3 Height-for-age (HFA) – Stunting .............................................................................................. 17

2.5 Questionnaire, training and supervision ........................................................................................ 17

2.6 Data analysis .................................................................................................................................. 18

3 Results ..................................................................................................................................................... 19

3.1 Anthropometric results (based on WHO standards 2006): ............................................................ 19

3.2 Mortality results (retrospective over 94days prior to interview) ................................................... 23

3.3 Children’s morbidity...................................................................................................................... 24

3.4 Vaccination Results ....................................................................................................................... 25

3.5 Micronutrient supplementation and de-worming........................................................................... 25

4 Discussion ............................................................................................................................................... 25

4.1 Nutritional status ........................................................................................................................... 25

4.2 Mortality ........................................................................................................................................ 29

4.3 Causes of malnutrition ................................................................................................................... 29

5 Conclusions ............................................................................................................................................. 32

6 Recommendations and priorities ............................................................................................................. 33

7 Appendicies ............................................................................................................................................. 34

7.1 Appendix 1: Plausibility Report .................................................................................................... 34

7.2 Appendix 2: Assignment of Clusters ............................................................................................. 34

7.3 Appendix 3: Result Tables for NCHS growth reference 1977 ...................................................... 36

Annex 3: survey questionnaire .................................................................................................................... 39

7.4 Annex 5: calendar of events ............................................................................................................ 1

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List of figures Figure 1: Map of Wajir East district................................................................................................................ 10

Figure 2: Livelihood zones.............................................................................................................................. 11

Figure 3: Seasonal timeline ............................................................................................................................. 11

Figure 4: Population age and sex pyramid ...................................................................................................... 20

Figure 5: Distribution of WFH Z-scores for sampled children ....................................................................... 21

Figure 6: Type of health care sought ............................................................................................................... 24

Figure 7: Stabilization centre admissions ........................................................................................................ 26

Figure 8: Nutrition survey trends 2004-2011 .................................................................................................. 28

Figure 9: Women’s nutritional status .............................................................................................................. 28

Figure 10: Mortality trends 2009-2011 ........................................................................................................... 29

Figure 11: Proportion of children 0-23 months put to the breast within 1 hour of birth ................................. 30

Figure 12: proportion of children exclusively breastfed ................................................................................. 30

Figure 13: Minimum dietary diversity (n=212) .............................................................................................. 31

Figure 14: Minimum meal times for children 6-8 months (n=29) .................................................................. 31

Figure 15: Minimum meal times for breastfed children 6-23 months (n=226) ............................................... 31

Figure 16: Minimum meal times for non-breastfed children 6-23 months (n=11) .......................................... 32

Figure 17: Main current water sources ............................................................................................................ 32

List of tables Table 1: Results Summary ............................................................................................................................. 7

Table 2: WFP food basket commodities ......................................................................................................... 12

Table 3: Sample size calculation ..................................................................................................................... 14

Table 4: Mortality Thresholds ......................................................................................................................... 17

Table 5: General Characteristics of Study Population and Households ............................................... 19

Table 6: Acute malnutrition definitions .......................................................................................................... 19

Table 7: Distribution of age and sex of sample ............................................................................................... 19

Table 8: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex 20

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema ........ 21

Table 10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores ..................... 21

Table 11: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex .............. 21

Table 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema ...................... 22

Table 13: Prevalence of underweight based on weight-for-age z-scores by sex ............................................. 22

Table 14: Prevalence of underweight by age, based on weight-for-age z-scores ............................................ 22

Table 15: Prevalence of stunting based on height-for-age z-scores and by sex .............................................. 23

Table 16: Prevalence of stunting by age based on height-for-age z-scores ..................................................... 23

Table 17: Mean z-scores, Design Effects and excluded subjects .................................................................... 23

Table 18: Mortality rates ................................................................................................................................. 23

Table 19: Prevalence of reported illness in children in the two weeks prior to interview (n=491) ................. 24

Table 20: Symptom breakdown in the children in the two weeks prior to interview (n=491) ........................ 24

Table 21: Vaccination coverage: BCG for 6-59 months and measles for 9-59 months .................................. 25

Table 22: Vaccination coverage: Pentavalent and Oral polio Vaccine for 6-59 months ................................. 25

Table 23: Micronutrient supplementation and de-worming: ........................................................................... 25

Table 24: TSFP missed distributions .............................................................................................................. 26

Table 25: Comparison of nutrition survey results based on MUAC 2009-2011: ............................................ 28

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List of abbreviations and acronyms ALDEF Arid Lands Development Focus ALRMP II - Arid Lands Resource Management Project II APHIA - Aids Population Health Integrated Assistance Project ASAL - Arid and Semi-Arid Lands CDR - Crude Death Rate CI - Confidence Interval CMR - Crude Mortality Rate CSB - Corn Soya Blend ENA - Emergency Nutrition Assessment EPI - Extended Programme of Immunization GAM - Global Acute Malnutrition GFD - General Food Distribution HAZ - Height-for-Age Z-score HINI High Impact Nutrition Interventions HSNP - Hunger Safety Net Project KFSSG Kenya Food Security Steering Group L/HAZ - Length/ Height for Age –Z-score MOH - Ministry of Health MUAC Mid-Upper Arm Circumference OPV - Oral Polio Vaccine OTP - Out-patient Therapeutic Program SAM - Severe Acute Malnutrition SC - Stabilization Centre SD - Standard Deviation SFP - Supplementary Feeding Programme SMART Standardized Monitoring and Assessment of Relief and Transitions U5MR - Under Five-Mortality Rate UNICEF - United Nations Children’s Fund URTI - Upper Respiratory Tract Infection WAZ - Weight-for-Age Z-score WFP - World Food Programme WHM - Weight for Height Median WHO - World Health Organization WHZ - Weight-for-Height/length Z-scores

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Executive summary Wajir East district, also Wajir east constituency is one of the 8 districts within the larger Wajir County. The district currently comprises of 6 divisions namely Wajir Bor, Tarbaj, Kutulo, Central, Mansa and Khorofharar. The district lies around 3° north of the Equator and borders Somalia to the East, Wajir South to the South, Wajir West to the West, Wajir North to the North West and Mandera Central District to the North. The district, measuring approximately 14,471 km², is one of the districts gazetted as Arid and Semi-Arid Lands of Kenya (ASAL). Wajir town is the district headquarters and is the largest urban town in Wajir County. The population is currently estimated at 226,086 persons. The main livelihood activity in the district is pastoralism and being predominantly arid, the district experiences chronic food insecurity and high incidences of malnutrition. Predictable rainy and dry seasons can no longer be counted upon to provide adequate dry season grazing and water for pastoral populations, whose resilience is increasingly eroded by broader economic factors in the region. Food aid continues to be a key source of food for a majority of the population. Save the Children has been present in Wajir east since 2009 with interventions in nutrition (treatment of the acutely malnourished, nutrition surveillance and promotion of infant and young child feeding), health (capacity building and health systems strengthening for maternal and child health), Water, Hygiene and Sanitation (WASH) and food security and livelihoods. Save the Children in collaboration with the Ministry of Health and on behalf of the district steering group undertakes annual nutrition surveys (before the long rains) to monitor the nutrition situation. This survey was undertaken in November to evaluate the nutrition status of the population in the context of a severe drought. Survey objectives The specific objectives of this survey were to estimate:

1. The prevalence of acute and chronic malnutrition in children aged 6-59 months; 2. The nutrition status pregnant women and mothers with children <5 years; 3. The crude and under five mortality rate and causes of death; 4. The proportion of households with access to improved water and sanitation; 5. Infant and young child feeding (IYCF) practices; 6. The coverage and content of the general food distribution; 7. The food access and dietary diversity at household level; 8. The Coverage of measles and BCG vaccination among target children; 9. The Coverage rate of Vitamin A. supplementation and de worming; 10. The Morbidity rates of children 6-59 months 2 weeks prior to the survey; 11. To recommend appropriate interventions based on the survey findings;

Area covered The survey was conducted from 17th – 30th November, 2011 and covered the 6 administrative divisions of Wajir East District namely: Central, Wajir Bor, Kotulo, Khorofharar, Mansa and Tarbaj. Methodology Two different sampling methodologies were applied. Emergency Nutrition Assessment (ENA) for Standardized Monitoring of Relief and Transition (SMART) was used to calculate Anthropometry and mortality samples while IYCF multi survey sampling calculator was used to calculate for IYCF sample. Probability of Proportion to Population Size (PPS) was used to identify clusters within a study area after collecting population data from all villages/ sub location that were considered as clusters.

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The target population for the anthropometric survey was children aged 6-59 months while that for IYCF was children 0-24 months. The total sample size of households was arrived at by collating both the Anthropometry, IYCF and Mortality samples. The final sample size was 574 households from 34 clusters. Data was collected on anthropometry, morbidity, vaccination and de-worming status, Vitamin A supplementation, hygiene and sanitation practices, IYCF, food security and livelihoods. This data was triangulated with feeding programme data to help in the interpretation of results.

Retrospective information on mortality was collected using the current household census method, with a recall period of 94 days, from all households visited including those without children under the age of five. A total of 578 households were visited and 791 children from 6 to 59 months were assessed for anthropometry and other indicators. The final analysis was on 775 children after exclusion of 16 records. Anthropometric and mortality data were analyzed using the ENA software beta version May 2011. IYCF data was analysis on Excel and Qualitative and quantitative data was analyzed using the EpiInfo/ ENA software. Main survey results

Table 1: Results Summary

Characteristic % ( 95% CI)

GAM (WFH <-2 Z score or presence of oedema) - WHO 2006 30.6% (25.8 - 35.8 )

SAM (WFH <-3 Z score or presence of oedema) - WHO 2006 7.6 % (5.3 - 10.7)

Prevalence of GAM by MUAC (<12.5cm) 5.1% [3.7-6.9]

Proportion of children sick two weeks prior to survey 62%

Proportion of caretakers seeking medical care when child is ill 76.9%

BCG Scar 95.6%

Measles immunization (card and confirmation) 95.4%

OPV1 immunization (card and confirmation) 97.5%

OPV3 immunization (card and confirmation) 97.3%

Vitamin A supplementation coverage (>12 month) -1 time 58.1%

Vitamin A supplementation coverage (>12 month) -2 times 11%

Vitamin A supplementation coverage (6-11 months)- 1 time 64.1%

Proportion of children >1 year de-wormed 1 time 28.1% [12.5-23.7]

Proportion of children >1 year de-wormed 2 time2 5.9%

Iron-folate Supplementation for pregnant mothers 13.2%

Appropriate hand-washing with soap/ash 43.5%

Proportion of children 6-59 months supplemented with Zinc the last time they had diarrhoea

5.9%

IYCF Key Indicator - Timely Breast-feeding Initiation 73.4%

IYCF Key Indicator - Exclusive Breastfeeding 28.6%

IYCF Key Indicator - Minimum Dietary Diversity 3.8%

IYCF Key Indicator - Minimum Feeding Frequency 9.1%

Crude mortality rate (deaths/10000/day) 0.12 (0.05-0.32)

Under-five mortality rate (deaths/10000/day) 0.11 (0.01-0.87)

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Conclusion:

In light of the above findings, the prevalence of Global Acute Malnutrition (GAM) rates in this survey is considered “critical” with GAM of 30.6% (25.8 - 35.8) and SAM 7.6 % (5.3 - 10.7). These rates indicate an increase in malnutrition as compared with the April nutrition survey conducted in the district which showed a GAM of 22.8% (19.0% - 27.2% 95% C.I) and SAM of 4.3% (2.8% - 6.6% 95% C.I). Further analysis with the CDC calculator indicates a 0.0316 probability (96.8%) that the prevalence rates in the November survey is higher than that in April 2011 hence indicating a worsening situation. The deteriorating malnutrition situation of Wajir East was further compounded by increased child morbidity as 62% of the children were reported to have been ill in the 2 weeks prior to the survey, with diarrhoea, fever with chills and vomiting accounting for the major symptoms. In addition, the persistent low coverage of Vitamin A supplementation, de-worming and poor hygiene and sanitation continue to aggravate the situation. The food security situation remains poor with the food aid interventions (GFD, BSFP and TSFP) remaining inadequate due to frequent pipeline breaks and issues with accessibility due to the rains. Both crude and under five mortality rates are below emergency levels, however there is need to urgently address the above issues to prevent the situation worsening further. Recommendations Immediate

� Continue with the treatment of acute malnutrition and childhood illnesses among children in the district through strengthening the health and nutrition outreach teams

� Identify more effective means to scale up community mobilization activities through the empowerment of the community in the detection and referral of acutely malnourished children less than 5 years.

� Maximize use of existing interventions (BSFP, Health and nutrition outreach) to improve the Vitamin A supplementation and De-worming rates.

� Conduct mass chlorination of the boreholes and promote household water treatment to make drinking water safer for use.

� Continue the health outreaches in locations inaccessible to health facilities to offer a comprehensive package of services.

� Save the Children through its health and nutrition programmes should consider strategies to promote iron and zinc supplementation as part of the comprehensive package of high impact health and nutrition interventions.

Medium term

� Strengthen continuous nutrition surveillance through regular nutrition assessments and ongoing MUAC screening (early warning system). Consider undertaking a more robust surveillance system to establish the true peak of malnutrition so that interventions are more tailored to have impact.

� Promote behaviour change related to hygiene and sanitation to reduce the incidence of diarrhoea and other water borne diseases

� Strengthening of MoH capacities to manage malnutrition and childhood illnesses. There is need for continued advocacy and support both at the national and district level to be able to achieve this.

� Diet diversity is an issue in the district that may be contributing to the high chronic and acute malnutrition levels. Availability of a diverse range of foods is problematic in many parts of the districts and hence it is important to establish any limiting nutrients from the existing diets and develop strategies to meet the missing micronutrients.

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� There is need for more Integrated health, nutrition and food security programming to address the underlying causes of malnutrition and this should be emphasized as the county governments begin to develop their strategies.

Long term

� Viable WATSAN interventions � There is need for promoting rain water harvesting technologies to boost water

storage and increase availability � Disaster risk reduction strategy in programming. This includes but not limited to

strategic destocking, educating the community on disaster risk management and encouraging the communities to establish pasture range reserve /reseeding to avoid mass losses of animals during drought.

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1 Introduction Wajir East district is one of the 8 districts within the larger Wajir County. The district currently comprises of 6 divisions namely Wajir Bor, Tarbaj, Kutulo, Central, Mansa and Khorofharar. The district lies around 3° north of the Equator and borders Somalia to the East, Wajir South to the South, Wajir West to the West, Wajir North to the North West and Mandera Central District to the North. The district, measuring approximately 14,471 km², is classified as arid within agro-ecological zone six and is characterised by long dry spells and short rainy seasons. Wajir town is the district headquarters and is the largest urban town in Wajir County. The population is predominantly Muslim and of Somali ethnicity, and is divided into clans, with community elders being in charge of daily affairs. Fai is the predominant clan and other clans include Masare, Garre, Degodia, Murule, Ogaden and Ajuran. The survey area covered all six divisions of the district (Fig 1). The current estimated population living in this area is 226,0861.

Figure 1: Map of Wajir East district

Geography Wajir East District is a featureless plain, which is prone to flooding during the rainy season. The district has some seasonal swamps and perennial river beds/drainage lines (‘laghas’) that flow in the rainy season. These serve as dry season grazing zones and also allow some cultivation when it rains. The area receives bimodal rains with the onset of the long rains in April. The months succeeding the long rains, June to September, are very dry but vegetation continues to thrive because the lower temperatures reduce the rate of evaporation. The short rains fall from September/October to December. The average annual rainfall is 250-300mm and quantitatively, it rains more during the short rains than during the long rains2. However the rains have become increasingly unpredictable and erratic. The topography of the district is a slightly elevated plateau, which lies between 150-200m above sea level. The mean annual temperature of the district is 29°C and ranges from 28°-39°C. The district lies within the sahelian climatic region, which is characterized by long dry spells and short rainy seasons. In the classification of areas by aridity, the district is categorized as Zone VII (i.e. 100% Arid with cyclic droughts).

1 Current Estimates from DDO’s Office- Wajir Town based on 2009 census

2 District Development Office- Summary document for Key Investment Opportunities in Wajir East District

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Livelihoods

Figure 2: Livelihood zones

In Wajir East District 70% of the population solely depends on livestock for their livelihood. The main form of land use is nomadic pastoralism which is seen as the most efficient method of exploiting the rangelands hence pastoral activities are practised all over the district. As shown in the adjacent map, most of the area covers the Pastoral Camel Zone (Eastern Bush land) where predominantly camel herding occurs. Small pockets of agro-pastoral activity are found in Tarbaj and Wajir Bor divisions. The crops cultivated include maize, sorghum, beans, cowpeas (kunde)

3, tomatoes, sweet pepper and pawpaw. In addition, small-scale irrigated horticulture is emerging in peri-urban areas (kitchen gardens) with crops such as watermelon, pawpaw, lemons and vegetables thriving4. There are peri-urban and urban settlements in the district’s Central Division which has the highest population density of 27 persons per sq. km. This is due to the fact that Wajir town is the county headquarters with government offices, markets, employment opportunities (formal/waged labour) and Small and Medium Enterprises (SMEs). Other peri-urban/urban settlements can be found in and around the divisional headquarters which serve as market centres and watering points. These have grown steadily as a result of people who have ‘dropped out’ of the pastoralist lifestyle following recurrent shocks. Other pull factors that have also encouraged settlement include free primary education, school feeding programmes, better access to healthcare, increased water points and markets in urban/semi-urban settings.

Current Climatic Conditions and Food Security Persistent incidences of drought and their increasing unpredictability in the province in recent years have continued to threaten the livelihoods of many pastoralists subjecting them to food insecurity (due to the short recovery phase between droughts), high malnutrition rates (above the emergency thresholds of 15%) and increased disease burden. In 2011, the district, including the rest of the ASALS suffered severe drought conditions, which further eroded the already diminishing livelihoods causing critical food insecurity, lack of water and high malnutrition rates. The October – December 2011 short rains came as expected with above normal rainfall performance reported in most parts of the province. Whilst the rains have brought relief in increased water availability and pasture, they also signalled a shift in needs due to the flooding and the ensuing reduced accessibility to most parts of the districts. Figure 3: Seasonal timeline Short Dry Spell (Jilaal)

Long Rainy Reason (Gu’)

Long Dry Spell (Hagai)

Short Rainy Season (Deyr)

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

Migration, Conflicts, Watering of Livestock, Pressure on boreholes

Pasture Surveys, mating season, Planting

Livestock diseases, Labour Demand

Calving, Kidding Period

Migration, Conflict

3 District Steering Group Combined Report for Wajir North, East, West and South Districts-Rapid Assessment and Sectoral Report on

the Impact of the Short Rains in the District- January 2009. 4 Ministry of Agriculture- Wajir East Food and Crop Situation Report-April 2009

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Humanitarian interventions in Wajir East district

Save the Children has been implementing programmes in Wajir East district since August 2009. Our current integrated approach; Nutrition, Health, Food security and Livelihoods Support programmes, aim to address the underlying causes of malnutrition through strengthening health systems, treatment for acute malnutrition and enhancement of house hold food security and livelihoods in the medium term while at the same time linking these to long term livelihood strategies. The World Food Programme (WFP) through Arid Lands Development Focus (ALDEF) has been carrying out general food distribution (GFD) in this area. The GFD food basket provides a 75% ration scale of 2,100Kcal/person, the daily per capita energy requirement5 and is as follows:

Table 2: WFP food basket commodities

Commodity Ration Sizes

Cereals 10.35kgs Pulses 1.80 kgs CSB 1.20 kgs Vegetable Oil 0.60 kgs

The Ministry of special programmes through the District Commissioner’s office occasionally supplies food to the region and this is usually divided equally among the divisions. School feeding programme is also available in all government schools which is run by WFP. Other actors on the ground include: OXFAM GB supporting ALDEF administratively to implementing Hunger Safely Net Programme (HSNP) and water and sanitation programmes. Kenya Red Cross society undertaking emergency relief operations Aids Population Health Integrated Assistance project (APHIA II) has been supporting the MoH in combating HIV /AIDS and in matters related to reproductive health.

1.1 Survey Objectives

The survey was undertaken from 17th to 30th November 2011 and was carried out in partnership with MoH. This survey aimed to provide updated information on the nutrition situation in the context of the severe drought. The specific objectives of this survey were to estimate:

• The prevalence of acute and chronic malnutrition in children aged 6-59 months; • The nutrition status pregnant women and mothers with children <5 years ; • The crude and under five mortality rate and causes of death; • The proportion of households with access to improved water and sanitation; • Infant and young child feeding practices • The coverage and content of the general food distribution; • The food access and dietary diversity at household level; • The Coverage of measles and BCG vaccination among target children; • The Coverage rate of Vitamin A supplementation, de worming, zinc

supplementation and iron folate supplementation; • The Morbidity rates of children 6-59 months 2 weeks prior to the survey; • To recommend appropriate interventions based on the survey findings;

5 Based on UNHCR/UNICEF/WFP/WHO Guidelines for Food and Nutrition Needs in Emergencies

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2 Methodology

2.1 Sample size

Two different sampling methodologies were applied; Emergency Nutrition Assessment (ENA) for Standardized Monitoring of Relief and Transition (SMART) was used to calculate Anthropometry and mortality samples while IYCF multi survey sampling calculator was used to calculate for IYCF sample. A 2 stage cluster sampling method with Probability of Proportion to Population Size (PPS) was used to identify clusters within a study area after collecting population data from all villages that were to be considered as clusters.

The required sample size was calculated on the nutritional status for children 6-59 months and on the Crude Mortality Rate (CMR) for the household sample. Sample size for infants and young children (0-5 months) was calculated separately using IYCF sampling calculator calculating sample size for each of the IYCF indicators. The sample size for the survey was calculated and adjusted for absentees and refusals using previous results of surveys conducted in the district. Sample size for anthropometry was calculated using the ENA for SMART software which gave 589 children. IYCF sample size was calculated using the multiple survey sample size calculation considering current rates of the most critical IYCF indicators to be considered (Timely initiation of breast feeding, Exclusive breast feeding, continued breast feeding, minimum dietary diversity and minimum meal frequency). The highest from IYCF sample size (Timely initiation of breast feeding) was considered which was 7856. It was then assumed that 80% of these children would be captured in the overall anthropometry sample. Thus, 20% (157) of the 785 was added to the anthropometry sample to account for the remaining age group making the total sample of children 746. In order to calculate number of households to visit during the survey, the number of children was divided by 1.3 (number of children/household) based on previous surveys giving rise to 574 HH. Parameters used in the determination of mortality and anthropometry data (20% U5) 1) The estimated prevalence of malnutrition is 22.8 %7) 2) The design effect is 2 and the standard margin of error is 5% (95% CI). 3) The number of children less than 5 years per household is estimated at 1.38 4) The average number of persons per household is 6 and 1 mother per household. Sample size for mortality was calculated based on the April 2011 survey showing death rate of 0.18/10,000/day, a desired precision of 0.3, design effect of 2, non-response rate of 3% and 90 days recall period. This was keyed in to ENA for SMART with family size of 6 and gave a sample size of 1,859 people and 319 households. To calculate the number of clusters to visit, the total sample for anthropometry, IYCF and mortality was used. The sample giving the highest number of household was the anthropometry sample which gave 574 households. These were divided by the number of households to be reached per day (17) giving a total of 34 clusters.

6 Rates of IYCF indictors for Wajir East /South and Mandera central was based on Save the Children KPC

survey Sept 2011. 7 GAM rates April 2011 Wajir East survey 8 From the April 2011 Wajir East nutrition survey

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The table below summarizes the sample size calculation. Table 3: Sample size calculation

Sample of IYCF

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Sample of Anthro

Total sample of children

# of HH

10

to visit

# of HH for mortality

Sample size considered

# of HH/ cluster

# of clusters

157 589 746 574 319 574 17 34

2.2 Sampling procedure: selecting households and children

The second sampling stage comprised of the household selection. Only the randomly sampled villages were assessed during data collection. In the selected village, the Expanded Programme on Immunization (EPI) method was applied in order to determine the starting point. At the center of the village, a pen was spun to determine the starting direction. The team then moved to the periphery along the pointed direction. At the end of the village, the pen was re-spun and a direction obtained. Just like the first stage, the survey team moved along the pointed direction but this time counting all households in that direction to the edge. A table of random numbers was used to determine the first household. Mortality and anthropometric questionnaires were administered accordingly and subsequent households determined by going to the next house to the right. In villages with more than one cluster, the village was subdivided and the centre of each subdivision determined and households selected as described above. In a cluster that was sparsely populated, all the households in the cluster were visited. A household was defined as a group of people who lived together and shared a common cooking pot. In polygamous families with several structures within the same compound but with different wives having their own cooking pots, the structures were considered as separate households and assessed separately. All children aged 6-59 in every household visited were included in the anthropometric survey and 0-24 month category included in IYCF survey. In cases where there was no eligible child, a household was still considered part of the sample and its mortality data were collected. If a respondent was absent during the time of household visit, the teams left a message and re-visited later to collect data for the missing person, with no substitution of households allowed. The teams visited the nearest adjacent village (not among those sampled) to make up for the required number of households if the selected village yielded a number below 22 children and 17 households, following the SMART methodology8.

2.3 Case definitions and inclusion criteria

2.3.1 Children’s data

Anthropometric data:

Age: the age of the child was recorded based on a combination child health cards, the mothers’/caretakers’ knowledge of the birth date and use of a calendar of events for the district developed in collaboration with the survey team.

Sex: it was recorded whether a child was male or female.

9 This is based on IYCF multiple survey sample size calculation using Step-by-Step guide. This is 20% of

the IYCF sample calculated as the remaining 80% is expected to be covered with Anthropometry sample. 10 Number of households to be visited is calculated number children divided by 1.3 for all the districts based

on previous surveys. 8SMART (2006): Measuring Mortality, Nutritional Status and Food Security in Crises Situations: SMART METHODOLOGY

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Bilateral oedema: normal thumb pressure was applied on the top part of both feet for 3 seconds. If pitting occurred on both feet upon release of the fingers, nutritional oedema was indicated.

Weight: the weights of children were taken with minimal or light clothing on, using UNICEF Salter Scales with a threshold of 25kgs and recorded to the nearest 0.1kg.

Length/height: children were measured bareheaded and barefooted using wooden UNICEF height boards with a precision of 0.1cm. Children under the age of two years were measured while lying down (length) and those over two years while standing upright (height). If child age could not be accurately determined, proxy heights were used to determine cases where height would be taken in a supine position (<87cm) or in an upright position (≥87cm). Height rods with a marking at 87cm were used to assist in determining measuring position.

Mid Upper Arm Circumference (MUAC): the MUAC of children was taken at the midpoint of the upper left arm using a MUAC tape and recorded to the nearest 0.1cm.

Retrospective morbidity of children: The caretaker with the child at the time of the survey was asked to recall if the child had any illness in the 2-weeks prior to the survey.

Vaccination status and coverage: For all children 6-59 months, information on Penta valent 1 and Oral polio Vaccine (OPV) 1 and Penta valent 3 and OPV 3 and measles vaccination was collected using health cards and recall from caregivers. The vaccination coverage was calculated as the proportion of children immunized based on records and recall. BCG: For all children 6-59 months, the information was collected by checking whether the characteristic BCG scar was present or not. Vitamin A supplementation status: For all children 6-59 months of age, information on Vitamin A supplementation was collected using the child welfare cards and recall from caregivers. Information on how many times the child had received supplementation in the last 6 months was collected. Vitamin A capsules were also shown to the mothers to aid in recall. De-worming status: Information was solicited from the care takers as to whether their child/children 6-59 months had been de-wormed in the last 3 months. A local calendar of events was used to refer to 3 months recall period. Programme coverage For all children 6-59 months of age, the caretakers/mothers were asked to state whether the child was enrolled in a supplementary feeding program (SFP), an outpatient feeding program (OTP) and Blanket Supplementary Feeding programme (BSFP) at the time of the survey. Children found to be malnourished based on MUAC measurements were referred to the nearest health facility for treatment.

Infant and Young Child feeding (IYCF) Data on IYCF was collected from children aged 0-24 months and was based on mothers recall of feeding practices including a 24 hour dietary recall.

2.3.2 Mortality data

Retrospective mortality data was collected using the current household census method in all the visited households, including those with no children aged less than five years old.

The recall period was 94 days with the reference period being the last 10 days of IDD at the end of August. Information was collected on the age and sex of the household members, their residence status, the number of household members present within the recall period, the number of persons who arrived or left, and the number of births and deaths over the recall period. The presumed causes of death were recorded based on the following case definitions:

• Diarrhea (watery stool >3/24H);

16

• Bloody diarrhea;

• Measles (fever with rash);

• Fever;

• Lower respiratory tract infection (fever, cough, chest pin, difficulty breathing);

• Malnutrition;

• Injury;

• Other (specify);

• Unknown;

2.3.3 Causes data

Secondary data on causes of malnutrition was mainly obtained from previous surveys undertaken in the area. Primary data on the causes of malnutrition was obtained from interviewing mothers/caretakers of children based on the household questionnaire that contained questions of water sources and hand washing practice, main sources of food and income, use of mosquito nets, dietary diversity and nutritional status of mothers/caretakers. The questionnaires were based on the national guidelines for nutritional assessments in Kenya, and modified slightly to collect context specific data for Wajir East. Data was collected from 578 households. Government officials and other NGOs working in the area were visited to provide information on the on-going interventions in the area.

2.4 Nutritional Status Cut-off Points

The following nutritional indices and cut-off points were used in this survey:

2.4.1 Weight-for-height (WFH) and MUAC – Wasting among Children

The prevalence of wasting (a reflection of the current health/nutritional status of an individual) are presented as global acute malnutrition (GAM) and severe acute malnutrition (SAM) using weight-for-height (WFH) z-scores and MUAC indices. The results on wasting were presented as global acute malnutrition (GAM) and severe acute malnutrition (SAM):

� Children whose WFH z-scores fell below -2 standard deviations from the median of the WHO standards (WHO-GS) or had bilateral oedema were classified as wasted (to reflect GAM)

� Children whose WFH z-scores fell below -3 standard deviations from the median of the WHO-GS or had bilateral oedema were classified as severely wasted (to reflect SAM)

Like weight for height, MUAC is used to quantify wasting in a population. The guidelines used are as follows: MUAC <11.5 cm severe acute malnutrition and high risk of mortality MUAC ≥11.5 cm and <12.5cm moderate acute malnutrition and moderate risk of mortality MUAC≥12.5 cm and <13.5 cm high risk of malnutrition MUAC≥13.5 cm adequate nutritional status A cut-off point of <12.5cm MUAC was used to denote GAM among the underfives.

2.4.2 Weight-for-age (WFA) – Underweight

The measure of underweight gives a mixed reflection of both the current and past nutritional experience by a population and is a very useful tool in growth monitoring.

� Children whose WFA z-scores fell below -2 standard deviations from the median of the WHO-GS or had bilateral oedema were classified as underweight

17

� Children whose WFA z-scores fell below -3 standard deviations from the median of the WHO-GS or had bilateral oedema were classified as severely underweight.

2.4.3 Height-for-age (HFA) – Stunting

Height-for-age is a measure of linear growth and therefore an unequivocal reflection of the cumulative effects of past nutritional inadequacy and/or illness episodes.

� Children whose HFA z-scores fell below -2 standard deviations from the median of the WHO-GS were classified as stunted (to reflect Global Stunting)

� Children whose HFA z-scores fell below -3 standard deviations from the median of the WHO-GS were classified as severely stunted.

Mortality Indices The Crude Death Rate is defined as the number of people in the total population who died between the start of the recall period and the time of the survey. It is calculated using the following formula. The result was expressed per 10,000 people / day. Crude Mortality Rate (CMR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period Table 4: Mortality Thresholds

Total population CMR Under-five population U5MR Alert level: 1/10,000 people/day 2/10,000 children/day

Emergency level: 2/10,000 people/day 4/10,000 children/day

2.5 Questionnaire, training and supervision

Questionnaire The standard nutrition survey questionnaire as recommended in the nutrition guidelines was adapted to include additional information on the high Impact nutrition interventions. The IYCF questionnaire as recommended in the CARE IYCF step by step guide was used to collect information on IYCF. The questionnaire was developed in English and the enumerators trained on the questionnaire. During the training session, the enumerators translated the questionnaires as they would ask during data collection and an agreed way of asking the questions during data collection was agreed upon. The questionnaires were not translated into Somali language however, all interviews were conducted in Somali language. The questionnaire was pre-tested a day before the actual survey began and the final questionnaire used is annexed in the report. Survey teams and supervision The survey was executed by 6 teams each comprising of 1 team leader and 2 anthropometric measurers. Four of the team leaders were from Ministry of Health (MOMS/MOPHS), 1 from Arid Lands Resource Management Project (ALRMP) and one from the District development Office. The survey was led and supervised by trained staff from Save the Children UK. The anthropometric measurers were recruited from the district and spoke the local language as well as English. The measurers were required to be literate and at least have completed high school to participate in the study. The team leaders were practitioners either in health, food security and nutrition and were sourced from the government and

18

Save the Children. The survey was supervised by the nutrition technical specialist from save the Children UK. Training Training for the survey teams was undertaken by Save the Children staff (the nutrition technical specialist). The training was undertaken for 3 days and covered an introduction to nutrition and nutrition assessments, the survey objectives, anthropometric measurements, household selection procedures, data collection and interviewing skills and the survey questionnaire. The anthropometric standardization exercise, as recommended by the SMART methodology was undertaken with 10 children, each measurer taking measurements on each child twice. Each enumerator was closely observed and guided by supervisors and manually given a score of competence based on performing measurements with accuracy and precision. After the class room training, practical field experience was conducted to pre-test the questionnaire, take anthropometric measurements of children and caretakers, conduct interviews and fill questionnaires; pre-testing exercise was performed on 12 households. The pre-testing exercise facilitated some changes on the structure of the questionnaire. In addition, a team of data clerks who were trained on the operation of ENA for SMART for the data entry and these were closely supervised by the M&E officer from Save the Children.

2.6 Data analysis

Anthropometric and mortality data entry and processing was done using the ENA for SMART software Beta version May 2011 where the World Health Organization Growth Standards (WHO-GS) data cleaning and flagging procedures were used to identify outliers which enabled data cleaning as well as exclusion of discordant measurements from anthropometric analysis. The SMART/ENA software generated weight-for-height, height-for-age and weight-for-age Z scores to classify them into various nutritional status categories using WHO9 standards and cut-off points. IYCF data was analysed in Excel using guidance from the Infant and Young Child Feeding Practices collecting and using data: a step- by- step guide. All the other quantitative data were entered and analysed in the ENA EPI 3.5.3 version.

9WHO 2006

19

3 Results Table 5: General Characteristics of Study Population and Households

Number of children 6-59 months surveyed 791

Number of children 6-59 months analysed 775

Number of anthropometry data excluded using Plausibility Check 16

Household Census:

Number of total population surveyed for mortality 3499

Number of children under five surveyed for mortality 946

Number of HH covered in the mortality survey 578

Number of persons who joined the household during the recall period

50

Number of persons who left the household during the recall period 104

Number of under five children who joined the household during the recall period

5

Number of under five children who left the household during the recall period

7

Number of births during the recall period 16

DEMOGRAPHY

Number of persons per HH 3499/578= 5.92 Number of children per HH 946/578= 1.54 % of children under five in the population 27%

3.1 Anthropometric results (based on WHO standards 2006): Table 6: Acute malnutrition definitions

WFH z-score MUAC

Global Acute Malnutrition < -2 SD and/or oedema <12.5 CM and/or Oedema

Moderate Acute Malnutrition < -2 SD and -3≥ SD ≥11.5cm and <12.5cm

Severe Acute Malnutrition < -3 SD and/or oedema <11.5cm and /or oedema

Exclusion of z-scores from Observed mean SMART flags: WHZ -3.0 to 3.0; HAZ -3 to 3; WAZ -3 to 3 Table 7: Distribution of age and sex of sample

Boys Girls Total Ratio

AGE (mo) no. % no. % no. % Boy:girl

6-17 94 53.1 83 46.9 177 22.4 1.1 18-29 86 52.4 78 47.6 164 20.7 1.1 30-41 74 44.8 91 55.2 165 20.9 0.8 42-53 90 47.9 98 52.1 188 23.8 0.9 54-59 55 56.7 42 43.3 97 12.3 1.3 Total 399 50.4 392 49.6 791 100.0 1.0

20

Figure 4: Population age and sex pyramid

The overall sex ratio was 1.0 (p-value = 0.803) indicating that both boys and girls were

equally represented. The overall age distribution (p-value = 0.238) was as expected, however, the overall sex/age distribution (p-value = 0.032) indicated a significant difference. There was an over representation of children 30-59 months (age ratio of 6-29 months to 30-59 months was 0.76 and the value should be 1.0). This may be attributed to the difficulty in estimating actual ages of children due to absence of health cards. Age estimation was mainly done through use of the events calendar. Table 8: Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by

sex

All n = 775

Boys n = 392

Girls n = 383

Prevalence of global malnutrition (<-2 z-score and/or oedema)

(237) 30.6 % (25.8 - 35.8 95% C.I.)

(127) 32.4 % (26.5 - 38.9 95% C.I.)

(110) 28.7 % (23.1 - 35.1 95% C.I.)

Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)

(178) 23.0 % (19.8 - 26.5 95% C.I.)

(95) 24.2 % (19.5 - 29.8 95% C.I.)

(83) 21.7 % (17.4 - 26.7 95% C.I.)

Prevalence of severe malnutrition (<-3 z-score and/or oedema)

(59) 7.6 % (5.3 - 10.7 95% C.I.)

(32) 8.2 % (5.3 - 12.4 95% C.I.)

(27) 7.0 % (4.7 - 10.5 95% C.I.)

The prevalence of oedema is 0.0 %

21

Table 9: Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema

Severe wasting

(<-3 z-score)

Moderate wasting

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 171 14 8.2 33 19.3 124 72.5 0 0.0 18-29 159 13 8.2 41 25.8 105 66.0 0 0.0 30-41 162 10 6.2 28 17.3 124 76.5 0 0.0 42-53 187 9 4.8 56 29.9 122 65.2 0 0.0 54-59 96 13 13.5 20 20.8 63 65.6 0 0.0 Total 775 59 7.6 178 23.0 538 69.4 0 0.0

Table 10: Distribution of acute malnutrition and oedema based on weight-for-height z-scores

<-3 z-score >=-3 z-score

Oedema present Marasmic kwashiorkor No. 0

(0.0 %)

Kwashiorkor No. 0

(0.0 %) Oedema absent Marasmic

No. 59 (7.6 %)

Not severely malnourished No. 716 (92.4 %)

Figure 5: Distribution of WFH Z-scores for sampled children

Table 11: Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex

All n = 790

Boys n = 398

Girls n = 392

Prevalence of global malnutrition (< 125 mm and/or oedema)

(86) 10.9 % (8.5 - 13.8 95% C.I.)

(44) 11.1 % (7.6 - 15.7 95% C.I.)

(42) 10.7 % (7.7 - 14.6 95% C.I.)

Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)

(64) 8.1 % (6.1 - 10.6 95% C.I.)

(33) 8.3 % (5.5 - 12.2 95% C.I.)

(31) 7.9 % (5.4 - 11.4 95% C.I.)

Prevalence of severe malnutrition (< 115 mm and/or oedema)

(22) 2.8 % (1.8 - 4.3 95% C.I.)

(11) 2.8 % (1.4 - 5.5 95% C.I.)

(11) 2.8 % (1.4 - 5.6 95% C.I.)

22

Table 12: Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema

Severe wasting

(< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal (> = 125 mm )

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 177 15 8.5 34 19.2 128 72.3 0 0.0 18-29 164 5 3.0 23 14.0 136 82.9 0 0.0 30-41 165 1 0.6 4 2.4 160 97.0 0 0.0 42-53 188 1 0.5 1 0.5 186 98.9 0 0.0 54-59 96 0 0.0 2 2.1 94 97.9 0 0.0 Total 790 22 2.8 64 8.1 704 89.1 0 0.0

Table 13: Prevalence of underweight based on weight-for-age z-scores by sex

All n = 784

Boys n = 397

Girls n = 387

Prevalence of underweight (<-2 z-score)

(222) 28.3 % (24.5 - 32.5 95% C.I.)

(110) 27.7 % (22.4 - 33.7 95% C.I.)

(112) 28.9 % (24.4 - 34.0 95% C.I.)

Prevalence of moderate underweight (<-2 z-score and >=-3 z-score)

(180) 23.0 % (19.8 - 26.4 95% C.I.)

(87) 21.9 % (17.6 - 27.0 95% C.I.)

(93) 24.0 % (19.9 - 28.7 95% C.I.)

Prevalence of severe underweight (<-3 z-score)

(42) 5.4 % (3.9 - 7.4 95% C.I.)

(23) 5.8 % (3.8 - 8.8 95% C.I.)

(19) 4.9 % (3.0 - 8.1 95% C.I.)

Table 14: Prevalence of underweight by age, based on weight-for-age z-scores

Severe underweight (<-3 z-score)

Moderate underweight

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 173 11 6.4 34 19.7 128 74.0 0 0.0 18-29 161 14 8.7 40 24.8 107 66.5 0 0.0 30-41 165 5 3.0 42 25.5 118 71.5 0 0.0 42-53 188 8 4.3 48 25.5 132 70.2 0 0.0 54-59 97 4 4.1 16 16.5 77 79.4 0 0.0 Total 784 42 5.4 180 23.0 562 71.7 0 0.0

23

Table 15: Prevalence of stunting based on height-for-age z-scores and by sex

All n = 765

Boys n = 387

Girls n = 378

Prevalence of stunting (<-2 z-score)

(131) 17.1 % (13.7 - 21.1 95% C.I.)

(68) 17.6 % (13.9 - 22.0 95% C.I.)

(63) 16.7 % (12.6 - 21.8 95% C.I.)

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

(94) 12.3 % (9.9 - 15.2 95% C.I.)

(52) 13.4 % (10.5 - 17.0 95% C.I.)

(42) 11.1 % (8.0 - 15.2 95% C.I.)

Prevalence of severe stunting (<-3 z-score)

(37) 4.8 % (3.3 - 7.1 95% C.I.)

(16) 4.1 % (2.5 - 6.7 95% C.I.)

(21) 5.6 % (3.5 - 8.6 95% C.I.)

Table 16: Prevalence of stunting by age based on height-for-age z-scores

Severe stunting

(<-3 z-score)

Moderate stunting

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Age (mo)

Total no.

No. % No. % No. %

6-17 169 9 5.3 25 14.8 135 79.9 18-29 154 10 6.5 15 9.7 129 83.8 30-41 160 8 5.0 26 16.3 126 78.8 42-53 187 10 5.3 20 10.7 157 84.0 54-59 95 0 0.0 8 8.4 87 91.6 Total 765 37 4.8 94 12.3 634 82.9

Table 17: Mean z-scores, Design Effects and excluded subjects

Indicator n Mean z-

scores ± SD

Design Effect (z-

score < -2)

z-scores not

available*

z-scores out of range

Weight-for-Height

775 -1.45±1.04 2.22 1 15

Weight-for-Age 784 -1.42±1.00 1.49 0 7 Height-for-Age 765 -0.80±1.23 1.76 0 26 * contains for WHZ and WAZ the children with oedema.

3.2 Mortality results (retrospective over 94days prior to interview)

Mortality was assessed using the current household census method. The mortality results were as shown below: Table 18: Mortality rates

CMR (total deaths/10,000 people / day): 0.12 (0.05-0.34) (95% CI) U5MR (deaths in children under five/10,000 children under five / day): 0.11 (0.01-0.87) (95% CI) There were a total of 4 deaths 3 of which were adults and 1 a child less than 5 years. The main causes of death among adults were largely unknown and for under five years was reported as due to fever.

24

The mean household size was calculated as 6 people (mode =5, with a range of 2 to 15)

3.3 Children’s morbidity

Data on morbidity of children was collected with a recall period of 2 weeks prior to the date of the interview. A total of 492 children (62%) were found to have been ill in the period of 2 weeks preceding the survey. Table 19: Prevalence of reported illness in children in the two weeks prior to interview (n=491)

6-59 months

Prevalence of reported illness

62.1% (55.8 – 67.9 95% CI)

Table 20: Symptom breakdown in the children in the two weeks prior to interview (n=491)

6-59 months* Diarrhoea 53.6% Vomiting 36.5% Fever with chills like malaria 37.7%

Fever, cough, difficulty in breathing 33.6%

Intestinal Parasite 3.3%

Eye infections 1.0% Skin infections 2.4% Accident 0.2% Stomachache 2.0% Toothache 0.2%

Others 2.6% *Children may have had one or more symptoms during the recall period.

Diarrhea was the most prevalent illness reported in over half of all the children ill in the 2 weeks prior to the survey. The other prevalent illnesses included Vomiting, Malaria and respiratory tract infections. It is worth noting that the survey was undertaken during the rainy season when diarrheal diseases, malaria and respiratory tract infections are more prevalent. Of the children who were sick, 62.2% had sought treatment from a public clinic as shown below. Figure 6: Type of health care sought

Health seeking behaviour

1.4% 2.7%9.0%

1.2%

62.2%

0.4%

23.1%

0.0%

20.0%

40.0%

60.0%

80.0%

1.4% 2.7% 9.0% 1.2% 62.2% 0.4% 23.1%

Traditional

healer/She

Communit

y health

Private

clinic/

Shop/kios

k

Public

clinic

Mobile

clinic

No

assistance

25

3.4 Vaccination Results

Table 21: Vaccination coverage: BCG for 6-59 months and measles for 9-59 months

BCG n=790

Measles (with card)

n=790

Measles (with card or confirmation from

mother) n=790

YES

(755) 95.6 % (90.8 -97.9 95%

C.I.)

(296) 37.5% (27.5 -48.7 95%

C.I.)

(740) 93.7 % (89.2-96.4 95% C.I.)

Table 22: Vaccination coverage: Pentavalent and Oral polio Vaccine for 6-59 months

Penta 1/OPV1 (with card or confirmation from

mother) n=790

Penta 3/OPV 3 (with card or confirmation from

mother) n=790

YES

(772) 97.7 % (91.3-99.4 95% C.I.)

(771) 97.6 % (91.4-99.4 95% C.I.)

3.5 Micronutrient supplementation and de-worming

Table 23: Micronutrient supplementation and de-worming:

Micronutrient type/De-worming N=

Vitamin A supplementation for Children U5 790 (549) 69.5% (53.5-81.9 95% C.I.))

Vitamin A supplementation 6-11 months (once) 91 (59) 64.1% Vitamin A supplementation 12-59 months (once) 699 (407) 58.1% Vitamin A supplementation 12-59 months (twice) 699 (77) 11.1% Zinc supplementation for Diarrhoea management

790 (46)5.9%

Iron Folate supplementation for pregnant mothers

13.2%

De-worming for children 12-59 months Dewormed once Dewormed twice

700 (266) 38.1% (47) 8.4%

The results above indicate that the coverage for Vitamin A, Zinc and Iron supplementation and de-worming are suboptimal.

4 Discussion

4.1 Nutritional status

The prevalence of Global Acute Malnutrition is 30.6% (25.8 – 35.8 95% CI) and Severe Acute Malnutrition at 7.6% (5.3 – 10.7 95% CI). These rates indicate an increase in malnutrition as compared with the April 2011 nutrition survey conducted in the district which showed a GAM of 22.8% (19.0% - 27.2% 95% C.I) and SAM of 4.3% (2.8% - 6.6% 95% C.I). Further analysis with the CDC calculator indicates a 0.0316 probability (96.8%)

26

that the prevalence rates in the November survey is higher than that in April 2011 hence indicating a worsening situation.

The survey was undertaken during the short rains which came after the severe drought experienced in 2011. The period of the survey was considered as a difficult period as most of the settlements were faced with flooding following the heavy rains that came after the prolonged dry spell and hence prior to the survey, many areas were inaccessible by road. This affected the food supply (both markets and food aid) and the rains also increased the incidence of diseases like diarrhoea which may have contributed to the increase in levels of malnutrition. An analysis of admission trends into the stabilization centre (SC) also support the results with increased admissions recorded in November. Figure 7: Stabilization centre admissions

Admissions SC Wajir District Hospital

12 12 12 14

32 30

2016

2718

55

0

10

20

30

40

50

60

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Wajir D/Hosp

It is also worth noting that at the time of the survey, there was a pipeline breakage for the targeted supplementary feeding programme (TSFP) for up to 4 months in some places and this may also have contributed to the increase in the levels of malnutrition as newly malnourished children were not accessing treatment. This situation saw a number of children deteriorating further and being referred to the out-patient Therapeutic Programme (OTP) and SC as shown below. Table 24: TSFP missed distributions

SITE Transfers from TSFP to OTP

No. of missed distribution

Reasons for missing distribution

Number of affected beneficiaries

KATOTE 7 1 Lack of CSB 259

DUNTO 3 2 Lack of CSB 73

GUNANA 0 3 Poor roads due to rains

90

BASANICHA 2 4 Poor roads due to rains

188

JAIJAI 3 3 Lack of CSB 101

MEIGAG 2 3 Lack of CSB 114

LANBIB 2 3 due to poor roads and of lack of CSB

56

SITAWARIO 2 4 due to poor roads and of lack of CSB

38

QARSA 0 5 due to poor roads, of lack of CSB and security reasons

207

KONTON 0 8 Security reasons 124

HALANE 0 3 Lack of CSB 203

ABDIAZIZ 2 2 Lack of CSB 100

27

BERJAMAL 4 2 Lack of CSB 235

WARGADUD 12 4 due to poor roads and of lack of CSB

72

KAJAJA 2 14 3 Lack of CSB 176

KAJAJA1 13 4 Lack of CSB 113

GOTADE 19 2 Lack of CSB 151

HASSAN YAROW 8 1 Lack of CSB 100

HARAGAL 5 2 Theft cases- Community members broke the CSB store

124

BERJANAI 6 4 Poor roads due to rains

118

MASHINBEN 0 4 due to poor roads and of lack of CSB

75

KOM 1 $ 2 3 0 Lack of CSB 294

Total 107 3,011

At the time of the survey, there were a number of interventions aimed at preventing excess mortality from lack of food, disease and malnutrition and some of the programmes that were under implementation included:

• Treatment of acute malnutrition

• Blanket supplementary feeding programme for Children 6-59 months and Pregnant and lactating women

• Supporting the health system through health outreaches to provide medical care to remote settlements

• Cash transfers through the hunger safety net project

• Destocking and distribution of meat to vulnerable populations

• Food aid distribution from various players

• Hygiene and sanitation interventions

Nutrition surveys in the past have been undertaken during the peak of the hunger gap period which is assumed to be during the first quarter of the year as shown in the table below. In the recent past, no nutrition surveys have been undertaken during the last quarter of the year and hence it is difficult to tell if the changes seen are typical of the season. However, surveys conducted in the whole of the larger Wajir district (now county) in the month of October in 2004 and 2005 as shown in figure 8 below revealed similar trends with GAM rates above 30% (NCHS 1977 reference tables). There is need to investigate further the nutrition trends and establish peak periods of malnutrition to tailor nutrition interventions appropriately.

28

Figure 8: Nutrition survey trends 2004-201111

Results based on MUAC also indicated an increase in GAM and SAM though not statistically significant as shown below:

Table 25: Comparison of nutrition survey results based on MUAC 2009-2011: Divisions covered June 2009 April 2010 April 2011 Nov 2011

Tarbaj, Kotulo,

Central, Wajir Bor

GAM (MUAC< 12.5 cm) 12.0% 5.4% 4.6% 8.0%

SAM(MUAC<11.5 cm) 1.5% 0.8% 0.2% 2.8%

In this survey, the nutritional status of women was also assessed as it is known that nutrition status of mothers has a bearing on the nutrition status of their children. A MUAC assessment of all women caretakers aged 15-49 years was undertaken and 34.5% of the women had a low nutrition status with MUAC <21cm. A majority of the mothers (71%) were either pregnant or lactating.

Figure 9: Women’s nutritional status

Current women's physiological status

14.10%

24.20% 25.00%

0.40%

29.00%

7.30%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Curr

ently

pre

gnant

Bre

astf

eedin

g

(<6m

onth

s

infa

nt)

Bre

astf

eedin

g

(6-2

4m

onth

s)

Pre

gnant

and

bre

astf

eedin

g

Not

pre

gnant/

not

bre

astf

eedin

g

bre

astf

eedin

g

(>24m

onth

s)

Series2

11 The surveys undertaken from 2004 to 2008 covered the whole of Wajir county and were reported using

NCHS 1977 reference tables.

29

4.2 Mortality

The mortality rates were estimated based on the current household census method with a 94 day recall. The Crude mortality rate (CMR) for this survey was 0.12 (0.05-0.32 95% CI) and the Under 5 mortality rate (U5MR) was 0.11 (0.01-0.87 95% CI). The CMR and U5MR were normal for this area as shown in the trend below.

Figure 10: Mortality trends 2009-2011

4.3 Causes of malnutrition

The nutrition survey was undertaken during the short rains in November, following a period of drought. The period immediately preceding the survey was characterised by flooding in most parts following the heavy rains that started in October. At the time of the survey, the rains were said to be average to above average and it was predicted that the district would received good rainfall during the short rains season.

Malnutrition in amongst children in mandera west was affected by the following factors:

Health status:

a) Morbidity:

High morbidity rates were reported with 62% of children reporting having been ill in the last 2 weeks before the survey. The main causes of illness were diarrhoea (53.6%), Fever with chills like malaria (37.7%), Vomiting (36.5%) and respiratory infections characterised by fever, cough and difficulty breathing at 33.6%. Over three quarters of the children (76.9%) were taken for treatment when they fell sick with 62.2% seeking treatment from public clinics. The disease patterns in the community were said to be typical for the season with diarrhoea accounting for most of the outpatient and inpatients among children under five years in most health facilities.

Vaccination, Micronutrient supplementation and De-worming coverage

The immunization coverage for BCG (95.6%), Measles (93.7%) and Pentavalent/OPV 3 (97.6%) were good and above the MOH target of 80% and also indicated an improvement compared to the rates reported in the April survey. These 4 vaccines are used in the survey as proxy for the immunization coverage at population level. The measles campaign held earlier in the year, the malezi bora campaigns and the integrated outreaches supported by Save the Children have helped improve the immunization coverage. These strategies should continue to be supported to keep the coverage high and should also be used to improve the micronutrient supplementation coverage. There was an improvement in Vitamin A coverage at 69.5% compared to a rate of 19.4% reported in the April 2011 survey. The coverage for de-worming also improved from 17.8% in April to 46.5% in November 2011. The iron folate supplementation for pregnant women was 13.2% and Zinc supplementation in the treatment for diarrhoea was 5.9%. given the high incidences of diarrhoea at the time of the survey, it is important to improve the coverage for Zinc supplementation. The coverage for Iron folate and Zinc

30

supplementation can be improved if these supplies were made consistently available at the health facilities given the focus of these in the High Impact Nutrition Interventions (HINI) and also considering health care seeking practices can be said to be good as they have further been enhanced by regular outreaches.

Infant and Young Child Feeding (IYCF) Infant and young child feeding is a continuum of critical nutrition and health practices that begin during pregnancy and continue through at least the first two years of life. The sharpest increase in malnutrition occurs between 6 and 24 months of age, the time when children grow most rapidly. Appropriate IYCF includes timely initiation of breastfeeding within 1 hour of birth, exclusive breastfeeding for the first 6 months, complementary feeding after 6 months with continued breastfeeding upto 2 years, and improved feeding during and after illness. In this survey, the IYCF practices were considered to be sub-optimal and likely to contribute to the high malnutrition rates. Timely initiation of breastfeeding: Of all the children 0-23 months included in the survey, 73.4%) were put to the breast within one hour of birth against a district target of 80% as shown in the graph below.

Figure 11: Proportion of children 0-23 months put to the breast within 1 hour of birth

Timely intiation of Breastfeeding

73.4%72.1%

73.9%

65.0%

70.0%

75.0%

80.0%

85.0%

1 HR %

HINI

1 HR % 73.4% 72.1% 73.9%

HINI 80.0% 80.0% 80.0%

0-23 months Male Female

Exclusive Breastfeeding: Exclusive breastfeeding was reported to be low with only 28.6% of mothers reporting to have exclusively breastfed their children in the last 24 hours. Figure 12: proportion of children exclusively breastfed

Exclusive Breastfeeding Rates

28.6%20.0%

42.1%

0.0%

20.0%

40.0%

60.0%

EBF %

HINI

EBF % 28.6% 20.0% 42.1%

HINI 50% 50% 50%

0-5 Months Male Female

31

Dietary diversity and frequency of feeding were low with only 6.6% of children 6-23 months feeding at least 3 times a day and 3.8% of children 6-23 consuming food from at least 3+ food groups as shown below. Figure 13: Minimum dietary diversity (n=212)

Minimum Dietary Diversity

3.8% 5.5% 1.9%0.0%

50.0%

100.0%

4+ fd grps%

HINI

4+ fd grps% 3.8% 5.5% 1.9%

HINI 80% 80% 80%

6-23 months Male Female

Figure 14: Minimum meal times for children 6-8 months (n=29)

Fed atleast twice breastfed 6-8 month

17.2% 9.1%22.2%

0.0%

50.0%

100.0%

2-3 times %

HINI

2-3 times % 17.2% 9.1% 22.2%

HINI 80% 80% 80%

6-8 Months Male Female

Figure 15: Minimum meal times for breastfed children 6-23 months (n=226)

6-23 months fed at least 3 times

6.6% 11.0% 12.1%

0.0%

50.0%

100.0%

3+ times %

HINI

3+ times % 6.6% 11.0% 12.1%

HINI 80% 80% 80%

6-23 months Male Female

32

Figure 16: Minimum meal times for non-breastfed children 6-23 months (n=11)

6-23 non breastfed fed more than 4 times

9.1%0.0%

9.1%

0.0%

50.0%

100.0%

4+times %

HINI

4+times % 9.1% 0.0% 9.1%

HINI 80% 80% 80%

6-23 months Male Female

Water and Sanitation The main sources of water for a majority of the population were unprotected wells, private and public dams. A few of the households were harvesting rain water as shown below:

Figure 17: Main current water sources

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Fre

quencie

s

River

Water

tap

...

Bor

ehole

Unp

rotect..

Pro

tected

well

Pub

lic pan

Dam

Rain ha

rves

...

Water Sources

Main Current Water Sources

River

Water tap kiosk

Borehole

Unprotected well

Protected well

Public pan

A majority of the respondents (67.1%) said they took less than 30 minutes to and from their water sources while 22.2 % reported to having taken between 30minutes to 1 hour. Only 40% of the respondents reported to owning a toilet facility and of those, 22% were Ventilated Improved Pits and 15% were traditional pit latrines. This indicates poor human waste disposal methods that have the potential to contaminate the open water sources leading to diarrhoea and other water borne diseases.

5 Conclusions In light of the above findings, the prevalence of Global Acute Malnutrition (GAM) rates in this survey is considered “critical” with GAM of 30.6% (25.8 - 35.8) and SAM 7.6 % (5.3 - 10.7). These rates indicate an increase in malnutrition as compared with the April nutrition survey conducted in the district which showed a GAM of 22.8% (19.0% - 27.2% 95% C.I) and SAM of 4.3% (2.8% - 6.6% 95% C.I). Further analysis with the CDC calculator indicates a 0.0316 probability (96.8%) that the prevalence rates in the November survey is higher than that in April 2011 hence indicating a worsening situation.

33

The deteriorating malnutrition situation of Wajir East was further compounded by increased child morbidity as 62% of the children were reported to have been ill in the 2 weeks prior to the survey, with diarrhoea, fever with chills and vomiting accounting for the major symptoms. In addition, the persistent low coverage of Vitamin A supplementation, de-worming and poor hygiene and sanitation continue to aggravate the situation. The food security situation remains poor with the food aid interventions (GFD, BSFP and TSFP) remaining inadequate due to frequent pipeline breaks and issues with accessibility due to the rains. Both crude and under five mortality rates are below emergency levels, however there is need to urgently address the above issues to prevent the situation worsening further.

6 Recommendations and priorities Immediate

� Continue with the treatment of acute malnutrition and childhood illnesses among children in the district through strengthening the health and nutrition outreach teams

� Identify more effective means to scale up community mobilization activities through the empowerment of the community in the detection and referral of acutely malnourished children less than 5 years.

� Maximize use of existing interventions (BSFP, Health and nutrition outreach) to improve the Vitamin A supplementation and De-worming rates.

� Conduct mass chlorination of the boreholes and promote household water treatment to make drinking water safer for use.

� Continue the health outreaches in locations inaccessible to health facilities to offer a comprehensive package of services.

� Save the Children through its health and nutrition programmes should consider strategies to promote iron and zinc supplementation as part of the comprehensive package of high impact health and nutrition interventions.

Medium term

� Strengthen continuous nutrition surveillance through regular nutrition assessments and ongoing MUAC screening (early warning system). Consider undertaking a more robust surveillance system to establish the true peak of malnutrition so that interventions are more tailored to have impact.

� Promote behaviour change related to hygiene and sanitation to reduce the incidence of diarrhoea and other water borne diseases

� Strengthening of MoH capacities to manage malnutrition and childhood illnesses. There is need for continued advocacy and support both at the national and district level to be able to achieve this.

� Diet diversity is an issue in the district that may be contributing to the high chronic and acute malnutrition levels. Availability of a diverse range of foods is problematic in many parts of the districts and hence it is important to establish any limiting nutrients from the existing diets and develop strategies to meet the missing micronutrients.

� There is need for more Integrated health, nutrition and food security programming to address the underlying causes of malnutrition and this should be emphasized as the county governments begin to develop their strategies.

Long term

� Viable WATSAN interventions

34

� There is need for promoting rain water harvesting technologies to boost water storage and increase availability

� Disaster risk reduction strategy in programming. This includes but not limited to strategic destocking, educating the community on disaster risk management and encouraging the communities to establish pasture range reserve /reseeding to avoid mass losses of animals during drought.

7 Appendicies

7.1 Appendix 1: Plausibility Report

Plausibility check for: Nutrition_surveydatabase_Nov2011_WE.as

Standard/Reference used for z-score calculation: WHO standards 2006 (If it is not mentioned, flagged data is included in the evaluation. Some parts of this

plausibility report are more for advanced users and can be skipped for a standard

evaluation)

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-10 >10

(% of in-range subjects) 0 5 10 20 0 (1.9 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 0 (p=0.803)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000 (Significant chi square) 0 2 4 10 0 (p=0.238)

Dig pref score - weight Incl # 0-5 5-10 10-20 > 20 0 2 4 10 0 (3)

Dig pref score - height Incl # 0-5 5-10 10-20 > 20 0 2 4 10 4 (11)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >1.20 0 2 6 20 0 (1.04)

Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (0.09)

Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0 0 1 3 5 0 (-0.15)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000 0 1 3 5 1 (p=0.030)

Timing Excl Not determined yet

0 1 3 5

OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 5 %

At the moment the overall score of this survey is 5 %, this is excellent.

7.2 Appendix 2: Assignment of Clusters

Geographical unit Population size Cluster

Barwaqo 3270

Kalkacha 2453 1

Bagdad 818

Bangal 818

Bulla Hewa 818

Wagberi1 2020

35

Wagberi2 2020 2

Bulla Kom 1515

Maalim Salad 1515 3

Lanbib 1010

Abdiaziz 1010

Meigag 1010

Hodhan 2759

Shalete 2759 RC

Godrahma 1839

Bulla Majina 1839

Jogoo 6833 4, RC

Bulla Isiolo 2000 5

Makoror 8221 6, 7, 8

God- Ade 6706 9, RC, 10

Bulla power 5364

Halane 1341

Township 7382 11, 12, 13

Alimao 4282

Bulla Gadud 1071

Tarbaj 11339 14, 15, 16, 17

Haragal 1620

Katote 3240

Dambas 9037 18

JaiJai 1004

Elben 12197 19

Dunto 8913 20, 21, 22, 23

Mansa 10201 24

Ogoralle 2292

Burmayo 2344 25

Sarman 7742 26

Wajir Bor 4591 27

Arbaqaranso 2754 RC

Sitawario 918 28

Handaki 918

Riba 6451 29, 30, 31

Qarsa 2764 32, 33

Krof Harar 11450

Dowyare 2938 34

Kotulo 8888

El Kotulo 6244 RC, 35, 36

Lafaley 3638 37

Jowhar 3358

Dasheq 5579 38, 39

Wargadud 3682

Hungai 6467 40

Kajaja1 2274

Kajaja2 2274

36

7.3 Appendix 3: Result Tables for NCHS growth reference 1977

Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and by sex

All n = 781

Boys n = 396

Girls n = 385

Prevalence of global malnutrition (<-2 z-score and/or oedema)

(222) 28.4 % (24.0 - 33.3 95% C.I.)

(121) 30.6 % (24.8 - 37.0 95% C.I.)

(101) 26.2 % (20.9 - 32.3 95% C.I.)

Prevalence of moderate malnutrition (<-2 z-score and >=-3 z-score, no oedema)

(199) 25.5 % (21.7 - 29.6 95% C.I.)

(106) 26.8 % (21.5 - 32.8 95% C.I.)

(93) 24.2 % (19.1 - 30.0 95% C.I.)

Prevalence of severe malnutrition (<-3 z-score and/or oedema)

(23) 2.9 % (1.8 - 4.8 95% C.I.)

(15) 3.8 % (2.4 - 6.0 95% C.I.)

(8) 2.1 % (0.9 - 4.8 95% C.I.)

The prevalence of oedema is 0.0 % Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema

Severe wasting (<-3 z-score)

Moderate wasting

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 171 7 4.1 35 20.5 129 75.4 0 0.0 18-29 161 10 6.2 50 31.1 101 62.7 0 0.0 30-41 165 1 0.6 37 22.4 127 77.0 0 0.0 42-53 187 1 0.5 51 27.3 135 72.2 0 0.0 54-59 97 4 4.1 26 26.8 67 69.1 0 0.0 Total 781 23 2.9 199 25.5 559 71.6 0 0.0

Distribution of acute malnutrition and oedema based on weight-for-height z-scores

<-3 z-score >=-3 z-score

Oedema present Marasmic kwashiorkor No. 0

(0.0 %)

Kwashiorkor No. 0

(0.0 %) Oedema absent Marasmic

No. 23 (2.9 %)

Not severely malnourished No. 758 (97.1 %)

Prevalence of acute malnutrition based on MUAC cut off's (and/or oedema) and by sex

All n = 790

Boys n = 398

Girls n = 392

Prevalence of global malnutrition (< 125 mm and/or oedema)

(790) 100.0 %

(0.0 - 0.0 95% C.I.)

(398) 100.0 %

(0.0 - 0.0 95% C.I.)

(392) 100.0 %

(0.0 - 0.0 95% C.I.)

Prevalence of moderate malnutrition (< 125 mm and >= 115 mm, no oedema)

(0) 0.0 % (0.0 - 0.0 95% C.I.)

(0) 0.0 % (0.0 - 0.0 95% C.I.)

(0) 0.0 % (0.0 - 0.0 95% C.I.)

Prevalence of severe (790) 100.0 (398) 100.0 (392) 100.0

37

malnutrition (< 115 mm and/or oedema)

% (0.0 - 0.0 95% C.I.)

% (0.0 - 0.0 95% C.I.)

% (0.0 - 0.0 95% C.I.)

Prevalence of acute malnutrition by age, based on MUAC cut off's and/or oedema

Severe wasting (< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal (> = 125 mm )

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 177 177 100.0 0 0.0 0 0.0 0 0.0 18-29 164 164 100.0 0 0.0 0 0.0 0 0.0 30-41 165 165 100.0 0 0.0 0 0.0 0 0.0 42-53 188 188 100.0 0 0.0 0 0.0 0 0.0 54-59 96 96 100.0 0 0.0 0 0.0 0 0.0 Total 790 790 100.0 0 0.0 0 0.0 0 0.0

Prevalence of acute malnutrition based on the percentage of the median and/or oedema

n = 781

Prevalence of global acute malnutrition (<80% and/or oedema)

(136) 17.4 % (14.0 - 21.4 95%

C.I.) Prevalence of moderate acute malnutrition (<80% and >= 70%, no oedema)

(134) 17.2 % (13.9 - 21.0 95%

C.I.) Prevalence of severe acute malnutrition (<70% and/or oedema)

(2) 0.3 % (0.0 - 1.9 95%

C.I.)

Prevalence of malnutrition by age, based on weight-for-height percentage of the median

and oedema

Severe wasting

(<70% median)

Moderate wasting

(>=70% and <80% median)

Normal (> =80% median)

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 171 0 0.0 29 17.0 142 83.0 0 0.0 18-29 161 2 1.2 32 19.9 127 78.9 0 0.0 30-41 165 0 0.0 21 12.7 144 87.3 0 0.0 42-53 187 0 0.0 32 17.1 155 82.9 0 0.0 54-59 97 0 0.0 20 20.6 77 79.4 0 0.0 Total 781 2 0.3 134 17.2 645 82.6 0 0.0

Prevalence of underweight based on weight-for-age z-scores by sex

All n = 785

Boys n = 398

Girls n = 387

Prevalence of underweight (<-2 z-score)

(286) 36.4 % (31.9 - 41.2 95% C.I.)

(144) 36.2 % (30.0 - 42.8 95% C.I.)

(142) 36.7 % (31.5 - 42.2 95% C.I.)

Prevalence of moderate underweight

(236) 30.1 % (26.5 - 33.9

(115) 28.9 % (23.7 - 34.7

(121) 31.3 % (26.9 - 36.0

38

(<-2 z-score and >=-3 z-score) 95% C.I.) 95% C.I.) 95% C.I.) Prevalence of severe underweight (<-3 z-score)

(50) 6.4 % (4.7 - 8.6 95% C.I.)

(29) 7.3 % (5.0 - 10.5 95% C.I.)

(21) 5.4 % (3.5 - 8.4 95% C.I.)

Prevalence of underweight by age, based on weight-for-age z-scores

Severe underweight (<-3 z-score)

Moderate underweight

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Oedema

Age (mo)

Total no.

No. % No. % No. % No. %

6-17 174 15 8.6 45 25.9 114 65.5 0 0.0 18-29 161 18 11.2 57 35.4 86 53.4 0 0.0 30-41 165 5 3.0 53 32.1 107 64.8 0 0.0 42-53 188 8 4.3 58 30.9 122 64.9 0 0.0 54-59 97 4 4.1 23 23.7 70 72.2 0 0.0 Total 785 50 6.4 236 30.1 499 63.6 0 0.0

Prevalence of stunting based on height-for-age z-scores and by sex

All n = 764

Boys n = 388

Girls n = 376

Prevalence of stunting (<-2 z-score)

(108) 14.1 % (11.1 - 17.8 95% C.I.)

(54) 13.9 % (10.8 - 17.7 95% C.I.)

(54) 14.4 % (10.3 - 19.6 95% C.I.)

Prevalence of moderate stunting (<-2 z-score and >=-3 z-score)

(86) 11.3 % (8.7 - 14.5 95% C.I.)

(46) 11.9 % (9.1 - 15.4 95% C.I.)

(40) 10.6 % (7.4 - 15.0 95% C.I.)

Prevalence of severe stunting (<-3 z-score)

(22) 2.9 % (1.8 - 4.5 95% C.I.)

(8) 2.1 % (1.0 - 4.3 95% C.I.)

(14) 3.7 % (2.3 - 6.0 95% C.I.)

Prevalence of stunting by age based on height-for-age z-scores

Severe stunting

(<-3 z-score)

Moderate stunting

(>= -3 and <-2 z-score )

Normal (> = -2 z score)

Age (mo)

Total no.

No. % No. % No. %

6-17 171 5 2.9 27 15.8 139 81.3 18-29 154 6 3.9 12 7.8 136 88.3 30-41 159 4 2.5 18 11.3 137 86.2 42-53 186 7 3.8 21 11.3 158 84.9 54-59 94 0 0.0 8 8.5 86 91.5 Total 764 22 2.9 86 11.3 656 85.9

Mean z-scores, Design Effects and excluded subjects Indicator n Mean z-

scores ± SD Design Effect (z-score < -2)

z-scores not available*

z-scores out of range

Weight-for-Height 781 -1.48±0.89 2.01 0 10

Weight-for-Age 785 -1.62±0.96 1.76 0 6 Height-for-Age 764 -0.65±1.20 1.72 0 27 * contains for WHZ and WAZ the children with edema.

39

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e o

f D

ivis

ion

N

am

e o

f V

illa

ge

C

luste

r N

o

Team

N

o

HH

No

D

ate

of

Inte

rvie

w

(dd

/mm

/yy)

Nam

e o

f In

terv

iew

er

Nam

e o

f T

eam

Lead

er

___/_

__

_/_

___

No

Curr

ent H

H m

em

bers

(N

am

e a

nd ID

)

Pre

sen

t in

HH

sin

ce (

10 d

ays b

efo

re

IDD

)

Age

(Indic

ate

in

M

onth

s

if <

5

then

circle

)

Sex

1=

Male

2=

Fem

ale

Pre

sent

no

w in

HH

(�

=Y

ES

X

= N

O)

In-

mig

ratio

n

Sin

ce

10 d

ays

befo

re ID

D t

o

date

(exclu

de

birth

s)

(�=

YE

S

X=

NO

)

Out-

mig

ratio

n

sin

ce 1

0 d

ays

befo

re ID

D to

date

(exclu

de

death

s)

(�=

YE

S

X=

NO

)

Birth

s s

ince

10 d

ays

befo

re ID

D

to d

ate

(�

=Y

ES

X

= N

O)

Die

d s

ince

10 d

ays

befo

re ID

D

to d

ate

(�

=Y

ES

X

= N

O)

Cause

of

death

*

1

2

3

4

5

6

7

8

9

10

11

SU

MM

AR

Y D

AT

A S

EC

TIO

N

*CA

US

ES

OF

DE

AT

H:

1=

Dia

rrh

oea (

min

imum

of 3 w

ate

ry s

tools

/24hrs

) 2=

Blo

od

y D

iarr

ho

ea;

3=

Measle

s (

feve

r w

ith r

ash

);

4=

Fe

ver;

5=

Lo

wer

resp

irato

ry tra

ct

infe

ctio

n (

feve

r, p

rod

uctive

cough, ch

est pa

in,

difficulty

bre

ath

ing)

6=

Maln

utr

ition;

7=

Inju

ry;

8=

Oth

er

(Sp

ecify)

;

9=

Unknow

n

Curr

ent H

H m

em

bers

tota

l

Curr

ent H

H m

em

bers

<5

y

Curr

ent H

H m

em

bers

who a

re m

ale

s

C

urr

ent H

H m

em

bers

who a

re f

em

ale

s

Curr

ent H

H m

em

bers

in-m

igra

tion to

tal

C

urr

ent H

H m

em

bers

in-m

igra

tion <

5y

P

ast H

H m

em

bers

out-

mig

ratio

n to

tal

P

ast H

H m

em

bers

out-

mig

ratio

n <

5y

Death

s t

ota

l

D

eath

s <

5y

Tota

l birth

s

41

WA

JIR

EA

ST

DIS

TR

ICT

NU

TR

ITIO

N S

UR

VE

Y 2

01

1:

WA

TE

R,

SA

NIT

AT

ION

AN

D H

YG

IEN

E P

RA

CT

ICE

S (

TW

O S

HE

ET

S P

ER

CL

US

TE

R)

Na

me

of

Div

isio

n

Nam

e o

f V

illa

ge

C

lus

ter

No

T

ea

m N

o

Date

of

Inte

rvie

w

(dd

/mm

/yy)

Nam

e o

f In

terv

iew

er

Nam

e o

f T

eam

Lea

de

r

___

_/_

___/_

__

_

HH

N

o.

2.1

W

hat is

your

household

main

curr

ent

wate

r sourc

e?

1=

Riv

er

2=

Wate

r ta

p/w

ate

r kio

sk

3=

Bore

hole

4=

Unpro

tecte

d w

ell

5=

Pro

tect

ed w

ell

6=

Public

pan-‘D

rip

’ 7=

Tanker

8=

Dam

- ‘H

arr

’ 9=

Laga

10=

Rain

harv

est

(fro

m the

roof)

11=

Oth

er

(specify)

2.2

W

hat is

the t

ota

l tim

e t

o a

nd fro

m

the c

urr

ent m

ain

w

ate

r sourc

e?

1=

less

than 3

0 m

in

2=

30 m

in-

1 h

our

3=

More

than 1

hour

2.3

W

hat do y

ou

do t

o w

ate

r befo

re

drinkin

g?

1=

Noth

ing

2=

Boili

ng

3=

Use o

f tr

aditio

nal

meth

ods

4=

Use

chem

icals

5=

filter/

sie

ve

6=

decant

(Mu

ltip

le

resp

on

ses)

2.4

D

oes y

our

household

have

access

to a

toile

t fa

cili

ty?

1=

Yes

2=

No

2.5

If

yes,

what

type o

f to

ilet

facili

ty?

1=

Tra

ditio

nal

pit latr

ines

2=

Ventila

ted

impro

ved p

it

latr

ine

3=

Flu

sh toile

t 4=

Oth

er

Specify

2.6

If

No,

where

do

you g

o/u

se?

(pro

be f

urt

her)

1=

Bush

2=

Open f

ield

3 =

Near

the r

iver

4 =

Behin

d the

house

5 =

Oth

er

(specify

)

2.7

H

ow

do y

ou

dis

pose o

f child

ren’s

fa

eces’?

1=

Bush

2=

Open fie

ld

3 =

Near

the

rive

r 4 =

Behin

d the

house

5=

Latr

ine

6 =

Oth

er

(specify

2.8

A

t w

hat tim

es d

o y

ou w

ash

your

hands?

(m

ult

iple

an

sw

ers

p

ossib

le)

1 =

After

defe

catio

n/v

isitin

g

toile

t?

2 =

Befo

re feedin

g t

he

child

?

3 =

Befo

re e

ating

4 =

Befo

re p

reparing food

5 =

When I thin

k th

ey

are

dirty

6 =

When w

ate

r is

ava

ilable

7=

Aft

er

cleanin

g c

hild

ren’s

bott

om

s

8=

Oth

er

(specify

)

2.9

W

hat do y

ou

use t

o c

lean

your

hands?

1=W

ate

r only

2 =

Wate

r and

soap

3=W

ate

r and

ash

4=

Oth

er

(specify

)

N/B

; Let

the r

esp

ond

en

t an

sw

er

the q

uestions a

nd o

nly

co

de w

ha

t th

ey

Sa

y; d

o n

ot assu

me

an a

nsw

er

befo

re a

skin

g the

qu

estio

n

7.4 Annex 5: calendar of events

2007 2008 2009 2010 2011

Jan 59

Jan 47 PEV

Jan 35

Jan 23 AWAR

SCHOOL OPENING

Jan 11

Feb 58

Feb 46 PEV

Feb 34

Feb 22

Feb 10

Mar 57 GUU

Mar 45 GUU

COALITION GOVERNMENT

Mar 33 GUU

Mar 21 DROUGHT

Mar 9 DROUGHT

Apr 56 GUU

Apr 44 GUU

Apr 32 GUU

Apr 20

Apr 8 DROUGHT

May 55

May 43

May 31

May 19

May 7

Jun 54 HAGAY

Jun 42 HAGAY

Jun 30 END OF MERLIN PGM

HAGAY

Jun 18

Jun 6 HAGAY

Jul 53 HAGAY

Jul 41 HAGAY

RAMADHAN

Jul 29 SCUK PROGM

HAGAY

Jul 17

Jul 5 HAGAY

Aug 52 HAGAY

RAMADHAN

Aug 40 HAGAY

IDD UL FITR

Aug 28 HAGAY

CENSUS(TIRCOB)

Aug 16 REFERENDUM

Aug 4 HAGAY

Sep 51 RAMAD

IDD UL FITR

Sep 39

Sep 27

Sep 15

Sep 3

Oct 50 DEYR

Oct 38

Oct 26 DEYR

Oct 14

Oct 2

Nov 49 DEYR

IDD ALHA

Nov 37 DEYR

IDD UL-ATHA

Nov 25 DEYR

Nov 13

Nov 1

Dec 48 DEYR

GENERAL ELECTIONS

Dec 36 DEYR

Dec 24 DEYR

Dec 12

2